Individuals in residency and fellowship training work long, often unpredictable hours, including nights and weekends, and residency training typically occurs during individuals' childbearing and child-rearing years. However, it is unclear how residents with children arrange child care that accommodates the 80-hour resident work week. Additionally, during the past 40 years, the proportion of women in medicine in the United States has increased dramatically. Historically, parental leave and child care have been considered women's issues, but they affect both men and women, especially for dual-professional and dual-physician couples. Additionally, residents often face repayment of educational debt while earning a limited salary, which can limit the affordability of child care options.
The lack of child care options for residents may have a broader impact on the training and growth of the physician workforce. Due to many factors, including the growth of an aging population and the limited number of entry positions into graduate medical education, a shortage of physicians (both generalists and specialists) is predicted for the United States within the next 10 years.1 Compounding this, a significant proportion of the physician population is working part-time. According to a national survey of 5704 physicians, 13% of US physicians work part-time, including 22% of female physicians and 9% of male physicians.2 Female physicians working part-time are more likely to be married and have young children.2
Similar trends in part-time employment are noted internationally as well. A study from Switzerland reported that the most prevalent career arrangement for a male physician with young children is full-time employment with a spouse unemployed or working less than half-time.3 However, the most common arrangement for a female physician with young children is 50% to 69% part-time employment with a full-time working partner.3 The authors suggest that in the era of physician shortages, availability of child care facilities in hospitals could encourage a higher work participation of physician mothers.3
A study of dual-physician marriages reported that as many as 87% of women and 59% of men arrange their work schedule to accommodate child care responsibilities.4 Among male and female surgeons married or partnered to another physician, nearly 40% reported that their career advancement had been slowed owing to child-rearing responsibilities. In addition, surgeons with a physician partner were twice as likely to miss work for sick-child care as surgeons with a nonphysician partner.5
Summary of the Literature
Literature searches reveal few reports of common child care arrangements during residency training, although a few studies illustrate the use of child care for residents in individual specialties. A 2001 survey of surgical residents found that 57% of respondents relied on their spouse for child care and only 11% used child care facilities; however, most respondents were male and many were married to stay-at-home spouses.6 A national survey of graduating pediatrics residents found that only 24% reported access to on-site child care at their training institution, 19% reported access to sick-child care, and 9% received subsidies for child care expenses. Almost 40% did not know if their training institution offered these programs.7 Among female residents with child care benefits available at their program, 23% took advantage of on-site child care, 50% used subsidized child care, and 64% used child care for sick children.7 Very few male residents reported either having been offered and/or using these options.7 Otolaryngology residents experiencing pregnancy during residency identified finding adequate child care coverage for on-call periods, ranging from 3 to 14 days per month, as the most significant postpartum stress indicator.8
Data suggest that on-site child care may contribute to an interest in a wider variety of specialty choices for women, and may facilitate women's career advancement. In a national survey of medical students, female students reported they would be more interested in a surgical career if child care were available at their hospital, either as a resident or attending physician.9 In a study conducted at Stanford University School of Medicine, women ranked a flexible work environment with regard to child or elder care, including access to available emergency child care on-site or near the medical center, as the highest priority and most important need to improve the career success and well-being of female faculty.10 Similarly, in a survey of male and female general surgery residency graduates, 79% recommended that employers provide child care facilities at work.6
On-site and near-site child care exists in some medical centers, but locations, hours, and services vary widely. In a survey of pediatrics department chairs, 59% indicated that on-site child care or assistance with finding child care was available at their institution, but 50% responded that demand for child care “always or almost always” exceeded availability.11 Only 13% offered sick-child care and 12% offered emergency child care.11
The Medical University of South Carolina was unable to find the necessary physical space or financial support to open a day care on campus, but instead developed a subsidy program for pediatrics residents to support day care costs at any local facility during the first 6 months of a child's life.12 Not surprisingly, all eligible residents took advantage of this opportunity.12 The Mayo Clinic opened a sick-child day care center after estimating that the hospital system was losing a half-day of work per employee per year owing to a lack of backup child care for ill children. They found that the saved workdays offset the day care center's operating costs.13 Although by no means comprehensive solutions to the complex issues surrounding child care, these examples illustrate the demand for and institutional benefits of increased support.
Child Care Survey Results
To assess the attitudes of clinical trainees regarding child care and to compare viewpoints among male and female residents with and without children, a survey was conducted of all Vanderbilt clinical residents and fellows in 2008. The survey was approved by the Vanderbilt University Institutional Review Board.
A total of 302 of 1113 residents (27%) participated in the survey, and residents were allowed to opt out of any question at their discretion. Most respondents shared household income with a significant other (78%; 235 of 302), and 37% (113 of 302) had children. The average age was 30 years, and 49% (148 of 301) were male. Among those without children, 24% (38 of 161) expected to have children before completion of residency.
The impact of a child on a family is demonstrated by our finding that in 99% (105 of 106) of couples with children, resident spouses worked outside the home before the birth or adoption of the first child, but only 51% (54 of 105) continued to work the same hours after the arrival of the first child. The remainder either continued the same job but at decreased hours (9%; 9 of 105), switched jobs to improve flexibility (11%; 12 of 105), or earned income at home (2%; 2 of 105). A significant proportion (27%; 28 of 105) of resident spouses reported they no longer worked outside the home after the first child's arrival.
Residents with children were asked to indicate their current child care arrangement, allowing for more than 1 selection. Most used a child care facility (47%; 51 of 109). Other arrangements included a stay-at-home spouse (37%; 40 of 109), a nanny (25%; 27 of 109), or an extended family member (10%; 11 of 109). Extended family played a major role, with a number of families relocating after the trainee encountered difficulties managing child care. The monthly cost per child for facility-based child care varied, but nearly two-thirds reported ranges between $500 and $1,500. Only a few residents had school-aged children (7%; 8 of 109).
With the most common child care facility hours being Monday through Friday from 6 am to 6 pm (including Vanderbilt University day care, which serves the medical center and university), trainees arriving for work before 6 am (18%; 53 of 298), leaving at 7 pm or later (17%; 52 of 298), or working an average of 4 weekend days per month (42%; 125 of 299) would not be accommodated by most facilities, including Vanderbilt. Most respondents would change their current child care arrangement and enroll, or strongly consider enrolling, their child in hospital-based child care, especially if extended hours or drop-in emergency child care were available.
The most common “backup” child care plan for situations in which either the child or the regular caregiver is ill is for the “nontrainee” parent or spouse to stay home (45%; 45 of 101). Twenty-five percent (25 of 101) of respondents report staying home to care for a sick child themselves, which clearly has an impact on the hospital. Although 60% (64 of 106) reported that another trainee has never had to cover for them because child care was unavailable, 32% (34 of 106) reported needing coverage once in a year, and 7% (7 of 106) admitted to needing coverage once or twice a month.
At the time of the survey, 15% (12 of 80) of respondents with children were enrolled in Vanderbilt University child care services. When asked if respondents would switch to hospital-based child care services if they were equivalent to the trainee's current child care facility in quality, cost, and hours, 39% (31 of 80) would switch and 34% (27 of 80) would strongly consider it. If 24-hour flexible child care services were available, 46% (46 of 99) would consider using it for full-time care, and 45% (45 of 99) would consider using it for drop-in care as needed. Finally, when asked if hospital-based child care options would influence the choice between 2 otherwise equal residency programs, 71% (210 of 296) would rank the program with hospital-based child care higher. As expected, this effect was more significant among those with children than those without children (P < .001). However, we also found that men were just as likely as women to prefer programs with better child care availability (P > .05).
Conclusions and Recommendations
Residents and fellows are responsible for providing patient care at all hours of the day and night, resulting in an unpredictable schedule incongruent with the hours of most child care facilities. Extended-hour child care and 24-hour child care open for on-call emergencies could allow trainees to provide unhurried, high-quality patient care and could prevent stressful parenting crises. Availability of drop-in care would prevent the loss of work days for trainees who had no alternatives except to stay home. Additionally, child care facilities tend to be more affordable than independent child care arrangements, such as a nanny, although the hours are less flexible. By providing on-site child care with extended or emergency hours, more residents and fellows might be able to take advantage of affordable day care instead of hiring a nanny or having a nontrainee spouse stay home to ensure flexibility, which could allow spouses to continue to work or further their education if desired.
In summary, the literature indicates that lack of child care during their extended training and work hours is a major stress factor for physicians-in-training and practicing physicians, especially for women. Some women appear to seek part-time positions when confronted with child care and family care issues in their posttraining careers. Our institutional study found that on-site, extended-hour and/or drop-in child care is desired by both male and female residents and fellows.
We believe that hospital-provided, on-site (or near-site) child care would lead to improved workplace satisfaction by allowing trainees more frequent contact with their children, reducing stress and anxiety over scheduling, and potentially providing financial benefit to the hospital. On-site care would ease the transition from parental leave to return to work, potentially allowing for an earlier return if desired, and could facilitate and encourage breastfeeding and pumping among new mothers. Emergency child care would likely reduce the number of missed work days and decrease the burden of coverage on nonparent colleagues. On-site child care could also serve as a powerful recruiting tool for clinical programs seeking the best candidates.
Finally, by offering child care with extended hours, trainees could provide focused, unhurried patient care with the assurance that their own children are being cared for. For medicine to be a family-friendly as well as a gender-neutral playing field, child care and other family issues must be first recognized, and second, addressed in intentional and meaningful ways.
Rebecca A. Snyder, MD, MPH, is a General Surgery Resident, Department of Surgery, Vanderbilt University School of Medicine, and VA Quality Scholars Fellow, Veterans Health Administration, Tennessee Valley Healthcare System; Margaret J. Tarpley, MLS, is Senior Associate in Surgery, Vanderbilt University School of Medicine; Sharon E. Phillips, MSPH, is Assistant in Biostatistics, Department of Cancer Biostatistics, Vanderbilt University School of Medicine; and Kyla P. Terhune, MD, is Assistant Professor, Departments of Surgery and Anesthesiology, and Associate Program Director, General Surgery, Vanderbilt University School of Medicine.
Funding: This material is based upon work supported by the Office of Academic Affiliations, Department of Veterans Affairs, VA National Quality Scholars Program, and with use of facilities at VA Tennessee Valley Healthcare System, Nashville, Tennessee.