The theme of physician health and well-being cannot be thoroughly explored without introducing the complicated case of a resident physician who is pregnant. The issue is complicated because of the many interrelated, competing (and potentially conflicting) interests of the parties involved. These include the family and health interests of the resident and her fetus; the interests of others in the residency cohort who may have to cover for the pregnant resident and who may have ranked their own family interests secondary to their residency demands; and the interests of the program director who must balance the needs and interests of the pregnant resident with those of other residents and those of patients. Because of the annual matching program by which residents obtain their jobs and training positions, a resident's unexpected need for extended time off or for a reduced work schedule cannot be accommodated easily and may cause interruption in her training which may result in delayed completion of residency.
What policies do you think residency programs should adopt to balance these competing interests most fairly and effectively?
There is no doubt that this is a highly charged issue for all involved, but it is unfair to characterize it as a "pregnant resident" problem since that stigmatizes the individual who is most vulnerable. The days of residents being unmarried men living in the hospital are long gone and are not coming back nor should they. We should think of this in the context of the complex family issues all residents encounter. Sometimes I think faculty believe residents have no other life except to serve the program. Moreover we should not look at this situation as somehow unique because the individuals involved are residents. People in their twenties become fathers and mothers; it is what is supposed to happen. The better-run, most profitable corporations in this country have already figured out how to deal with this issue and retain productive employees, even those who have children.
The real issue is not policies but attitudes. While I agree that programs absolutely need clear policies, it is up to the educational leadership to create an environment that does not expect residents to be in reproductive limbo for the duration of training. As employers (we could argue whether residents are employees or students, but to do so would be missing the point), we have a legal and ethical responsibility to be supportive of the family needs of our residents. This is not an issue of training; it is an issue of who does the work. As program directors and faculty, we ought to be able to figure this out. Although, as the furor around the 80-hour week has so well demonstrated, it might not be easy. Yet, it is unfair to blame the residents for a system that we have created.
So the first policy is that residents have the right to pursue having children as they see fit in relation to their own situation. Ironic as it seems for those purported to be in the healing profession, faculty must give support to this notion and make it clear that the program will be supportive. Once it has been established that the program will find ways to support the resident, then it is important that clear policies be written so that everyone knows what to expect. The resident must take responsibility to notify the program administration as soon as possible about her pregnancy or that of a spouse if paternity leave is requested. This must apply to adoption as well. The program director and resident should discuss what rotations the resident should be on while pregnant and ways to accommodate the workload so as to not endanger mother or child. Although not entirely predictable, the duration of the time off should be specified. Most policies identify 6-8 weeks. There must be agreement on what type of leave will be used—vacation, sick leave, leave without pay, and whether any of this can be carry over from previous years. It is also helpful to review the resident's fringe benefits, especially if there is a chance that there might be complications for the mother or child. The resident must be notified by the program of the effect that time away may have on his or her Board eligibility. The program should also anticipate what steps it would take if there were complications and the leave period had to be extended. All policies must be in compliance with federal law. It is helpful to consult your institutional Graduate Medical Education office to be sure policies meet the legal requirements.
Setting policies is usually the easy part. For the resident taking leave, the experience will be shaped by the reaction of the program director, faculty, and peers. Setting the expectation that parental leave is acceptable is the first step. The real determinant of how a resident's leave will impact the program and the attitude of the other residents is how the program director makes up for the loss of the resident in the schedule. This problem cannot be left to the peer residents to solve. The program director and faculty must find a solution that does not simply shift the work to the remaining residents. This may involve reassignment of mid-level providers, temporarily rearranging services, or having faculty fill in. Whatever solution is chosen, acceptance will be determined by the expectations set initially.