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ARTICLE |
a Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
b Department of Pediatrics, Wright State University School of Medicine, Dayton, Ohio
c Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan
d Pediatric Residency Program, Brown Medical School, Providence, Rhode Island
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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METHODS. We conducted Web-based anonymous surveys of 147 pediatric department chairs and 203 pediatric program directors. The chair's questionnaire asked about child care, lactation facilities, family leave policies, work-life balance, and tenure and promotion policies. The program director's questionnaire asked about family leave, parenting, work-life balance, and perceptions of "family-friendliness."
RESULTS. The response rate was 52% for program directors and 51% for chairs. Nearly 60% of chairs reported some access to child care or provided assistance locating child care; however, in half of these departments, demand almost always exceeded supply. Lactation facilities were available to breastfeeding faculty in 74% of departments, although only 57% provided access to breast pumps. A total of 78% of chairs and 90% of program directors reported written maternity leave policies with slightly fewer reporting paternity leave policies. The majority (83%) of chairs reported availability of part-time employment, whereas only 27% of program directors offered part-time residency options. Most departments offered some flexibility in promotion and tenure.
CONCLUSIONS. Although progress has been made, change still is needed in many areas in pediatric departments and training programs, including better accessibility to quality child care; improved lactation facilities for breastfeeding mothers; clear, written parental leave policies; and flexible work schedules to accommodate changing demands of family life.
Key Words: residency • faculty • education
Abbreviations: FOPO—Federation of Pediatric Organizations • PPD—pediatric program directors • RTFWP—Report of the Task Force on Women in Pediatrics • AMSPDC—Association of Medical School Pediatric Department Chairs • APPD—Association of Pediatric Program Directors • ABP—American Board of Pediatrics
During the past 4 decades, the percentage of women who have graduated from US medical schools has risen from 6.9% in 1966 to 47.1% in 2005.1 In 2000, the Future of Pediatric Education II Project Task Force published its landmark report, "Organizing Pediatric Education to Meet the Needs of Infants, Children, Adolescents and Young Adults in the 21st Century."2 The report's recommendations covered a wide range of issues regarding pediatric education and the pediatric workforce. Specifically, the report noted a critically low number of pediatric scientists and also noted the increase of women in pediatrics. The authors of Future of Pediatric Education II identified that to accommodate best the changing demographics of pediatrics and to encourage more women to enter academic medicine, strategies would be needed to promote the success of women in fellowship training and academia, including coordinated schedules, fair parental leave policies, quality child care, and flexibility in academic advancement. To address more fully and develop further these strategies, the Federation of Pediatric Organizations (FOPO) established the Task Force on Women in Pediatrics.2 This task force issued "The Report of the Task Force on Women in Pediatrics" (RTFWP), which made a series of recommendations that aim to improve issues of balancing work and family life, enhance productivity, and foster career advancement and individual fulfillment for women and men in pediatrics.3 The full report, available at www.fopo.org, is predicated on the conviction that "There are many reasons for addressing issues of family balance in the lives of pediatricians during training and practice, including concerns regarding productivity, career advancement, and individual fulfillment. The most compelling reason derives from the central responsibility of our profession. The commitment of pediatrics to the health and well-being of children and youth should encompass the families of those who choose to pursue careers in pediatrics."
Recommendations were made for the various levels of career development (from medical school training through senior-level career pediatricians) and involved actions by all 7 of the member organizations that constitute FOPO. Three broad areas of need were identified:
The Task Force charged all 7 FOPO member organizations to respond to the RTFWP in general, as well as charged individual member organizations with specific recommended actions. Two of the organizations that constitute FOPO, the Association of Medical School Pediatric Department Chairs (AMSPDC) and the Association of Pediatric Program Directors (APPD), initiated their responses through a survey of their membership to ascertain baseline practices that are relevant to the 3 broad categories that were identified in the RTFWP and summarized above. AMSPDC is composed of 147 pediatric department chairs in Canada and the United States. APPD's membership includes 203 pediatric program directors (PPD) as well as department chairs, assistant program directors, and others who are interested in residency education. This article describes the information that was obtained from these 2 separate surveys and provides recommendations for future actions.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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The APPD independently initiated its response to the RTFWP through a 22-question Web-based survey that addressed family leave, parenting, work-life balance, and perceptions of family-friendliness. All members of the APPD were asked to complete the survey via notification through the periodic APPD electronic Listserv newsletter. Only the responses from self-identified PPDs were used to ensure that each program was counted only once in the results. This research was approved by the institutional review board at Wayne State University.
We used descriptive statistics for most of the data presented. 
2 tests were used to compare categorical values. Statistical significance was considered present at P < .05. Stata 8 (Stata Corp, College Station, TX) was used for analysis of the AMSPDC data. SPSS 13.0 (SPSS, Chicago, IL) was used for the APPD data.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Area 1: Providing and Promoting Family-Friendly Environments
Infant/Child Care Provisions
Of the 75 department chairs, 59% reported availability of on-site or off-site child care facilities or assistance with locating quality child care for faculty in their department (Table 1). Availability of before- and after-school care, sick-child care, and back-up or emergency day care was more limited. For example, only 13% of department chairs reported that their institution had child care available for a mildly sick child, and only 12% had emergency or back-up child care options. Availability of child care was not associated with department size (P = .7).
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Department chairs reported that few programs offer scholarships or financial subsidization of child care costs (13%). Similar results were provided in the APPD survey: 4% of PPDs responded that their institution subsidizes child care costs for residents, and 2% stated that the institution paid for it.
Almost all infant/child care centers that were available through pediatric departments accepted children aged 6 months and older (94%); however, only 61% accepted them by 2 months of age (Table 2). Typically, child care centers accepted children until they were entering kindergarten.
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Lactation Facilities
A total of 74% of the AMSPDC respondents reported that their institutions offered lactation facilities, whereas 21% reported no designated space for breast pump use (5% were unsure). Breast pumps were provided by 57% of hospitals/departments for use by faculty and trainees; however, 30% did not provide breast pumps for faculty/trainee use (12% were unsure).
Family-Oriented Benefits to Parents Who Are Not in a Traditional Husband–Wife Union
Nearly one third of APPD survey respondents stated that their residency program's family leave policies and benefits extended to domestic partnerships (32%) or same-gender unions (31%); however, 39% of program directors responded that they did not know whether leave policies or benefits in their program extended to parents in nontraditional unions (not married).
Area 2: Flexibility in Scheduling and Progression Through Training and Career Paths
Leave Provisions
Of 75 AMSPDC respondents, 78% reported that their department has a written maternity policy and 61% reported that they had a written paternity leave policy. The majority (63%) of chairs responded that their department did not offer additional benefits for parental leave beyond those that are required by the Family Medical Leave Act (Table 3). Paid maternity leave ranged from only accumulated vacation and/or sick time (32%) to >12 weeks (17%). Paid paternity leave ranged from accumulated vacation and/or sick time (46%) to >12 weeks (7%).
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Part-Time Residencies
In the APPD survey, 73% of 106 PPDs reported that they did not offer part-time residency options, whereas 27% did. Among those who offered a part-time residency option, the average number of residents who have used that option in the past 10 years was <1 (0.95) with a range of 0 to 6.
Promotion and Tenure
Forty-nine percent of chairs responded that there had been no change in their tenure system in the past 10 years, 39% said that there had been changes, and 12% were unsure. As shown in Table 3, most pediatric departments have some flexibility with the promotion process, either by faculty-initiated ability to stop the "tenure" clock or by longer promotional processes for part-time faculty. In addition, a few chairs reported no firm promotion clock at their institution for clinical faculty. Only 5% of chairs responded that their institution has no flexibility in full-time equivalent or promotion and tenure for issues related to parenting, and 8% stated that there was no flexibility for issues related to the care of an ill or dependent family member.
Area 3: Issues Related to Balancing Family and Work and Considerations That Are Unique to Women in the Workforce
Stress Management
Most (95%) PPDs believed that it is the PPD's responsibility to monitor resident well-being. Greater than 90% of responding PPDs acknowledged that programs should be responsible for offering to their trainees guidance on stress reduction, time management, conflict management, and mental health. Fewer PPDs believed that residency programs should be responsible for offering guidance on financial planning (57%) and social activities (50%). Only 45% of PPDs responded that residency programs should offer guidance on child care.
Balancing Work and Family
In the AMSPDC survey, 40% of chairs responded that they offer formal instruction on issues of balancing family and work; 7% listed informal mentoring programs or interest groups. However, 52% did not offer formal instruction on balancing family and work.
Family-Friendly Rating
Forty-eight percent of PPDs reported that they would be in favor of a rating score with regard to family-friendliness of a residency training program, 23% would not, and 30% were unsure.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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The results of these 2 surveys indicate that change is needed in many areas, including better accessibility to quality child care; improved lactation facilities for breastfeeding mothers; clear, written parental leave policies; and flexible work schedules to accommodate changing demands of family life. In our study, only one third of medical institutions offered on-site child care despite the evidence demonstrating both its positive influence on work performance4 and importance for both mother and infant of maternal contact, particularly during the first year of life.5–8 In many institutions with child care options, demand almost always exceeded availability. Furthermore, child care for a mildly ill child or emergency/back-up child care options rarely were available. Given what is known about maternal stress and mothering6 as well as stress in employment performance, child care issues should be addressed more aggressively by most, if not all, academic medical complexes.
Supporting women to breastfeed through the first year of their infant's life is a high priority for pediatricians.9,10 Lactation facilities are 1 mechanism to help support continued nursing by working mothers. The 2005 revision of the American Academy of Pediatrics Policy Statement on Breastfeeding urges pediatricians to "encourage employers to provide appropriate facilities and adequate time in the workplace for breast-pumping."10 Nonetheless, 1 in 5 pediatric departments in our study currently do not offer lactation facilities to their faculty or trainees.
Given the age of the majority of pediatric residents (70% of whom are women) and junior faculty, childbearing is common during residency, fellowship, and the first stages of academic careers. Uncertainties of parental leave policies and cost of unpaid leave may be enormous sources of stress to parents. Navigating the waters of employment and child rearing, for which there are no written rules, is more complex for residents, fellows, and faculty. To be effective in counseling residents and faculty, academic leaders must be aware of existing policies related to family leave. If no written policies exist, then they should be developed and disseminated. Likewise, in our surveys, both the chairs and the PPDs reported very low levels of child care subsidization; child care costs may be a very real source of anxiety to residents who are parents. The United States differs from other industrialized nations in North America and Europe with regard to both child care subsidies and parent leave policies.11 Pediatric faculty and residents should encounter positive child care and parental experiences to enhance their effectiveness as advocates for patients and society. The benefits of subsidized child care should be determined independently for both faculty and residents or other trainees and compared with the potential negative impact of viewing this as an unequal or unfair benefit by employees who do not need access to child care. Given the financial vulnerability of trainees compared with most faculty, a need-based system that is open to all employees might be a possible solution.
Family, accommodations within the "tenure clock" vary widely between institutions, ranging from a few that offer no flexibility for parents, to those that have abolished the tenure clock altogether. Although the majority of institutions offer part-time employment options for faculty, not all do so and somewhat fewer seem to offer it for other dependent care. In addition, it is unclear how part-time options may effect faculty on who are different tracks (eg, research tracks, clinician tracks). Much has been written regarding tenure and part-time work and regarding parenting and tenure in the past decades.12 The huge range in current practices suggests that more work still is needed to address this substantial problem as increasing numbers of women enter medicine.
Part-time residency training is offered in one quarter of the programs in our study, but, on average, <1 resident per program used this part-time option. This finding is consistent with other published data.13 Data that were obtained from national surveys that were conducted by the Accreditation Council for Graduate Medical Education and from the Graduate Medical Education Track/Fellowship and Residency Electronic Interactive Database system are similar to findings in our study. The Accreditation Council for Graduate Medical Education reported that in 2004–2005, there were 7795 total pediatric residents and 15 (<0.2%) were in part-time residency programs. In the Graduate Medical Education Track/Fellowship and Residency Electronic Interactive Database data for 2004–2005, 44 (22%) of 204 pediatric residency programs stated that they offer part-time or shared positions, compared with 27% of respondents in our survey, conducted in early 2006. It is unclear why such a seemingly family-friendly option is taken advantage of so infrequently. A variety of reasons might make the option less appealing, including increased time in training, financial issues and/or guilt of perceived increased workload on colleagues. Several mechanisms for part-time residency training or "shared" residencies have been described.13–15 Research into the effects, implementation, and barriers of part-time training on residency programs, individual residents, and institutions is needed. Furthermore, the resident who is a parent and does not want or is unable to work/train on a part-time basis may have a different set of stressors to contend with during training, including guilt of not being involved on a daily basis with child rearing. Efforts should be made to determine how best to support full-time resident parents to achieve both the maximum benefit of residency education and adequate time with their family.
The APPD survey results also highlight the variability among programs in the interpretation and adherence to the ABP requirements that a resident complete 33 months of residency. One month of absence is allowed each year by the ABP, including time spent on vacation, for parental leave, or for illness. For example a resident who starts on July 1, 2006, and finishes internship on June 30, 2007, would have completed 11 months if he or she took 3 weeks of vacation and 1 week during the winter holidays. A resident who is always present on his or her assigned rotations, except for designated vacations, typically completes 33 months of training during 3 years of residency. Any other time absent should be made up or formally waived by the ABP. Our results show that some PPDs adhere strictly to this rule; others do not. This may be because "block" rotations do not align perfectly with calendar months in many residency programs, allowing perhaps for different interpretations of rules for leave (eg, 1 month may or may not be counted as equivalent to 4 weeks).
Limitations
There are several limitations to the present study, including the 51% to 52% response rate to both surveys. Because this survey was anonymous, it is not possible to compare characteristics of pediatric departments or residency programs between respondents and nonrespondents. It therefore is possible that our data are not wholly representative of characteristics of family-friendly departments and residency programs because of response bias. Neither survey was constructed from previous qualitative research. Likewise, we did not conduct psychometric testing of the questions asked.
Implications
These data raise important questions regarding parenting for pediatric residents and faculty. Our data demonstrate a wide diversity in the presence of institutional policies and programs that focus on creating family-friendly environments for residents and faculty. Even when present, faculty and residents frequently do not take advantage of these unique opportunities. Understanding the feelings and attitudes toward the dual roles of parent and pediatrician would allow the pediatric community to understand more clearly family-friendly issues that involve child care and career progression. AMSPDC and APPD should take the lead in determining "best practices" for family-friendly academic departments and residency programs. To begin with, additional exploration of barriers, perceived and real, to developing family-friendly policies is needed.
Our surveys show the need for more accessible and flexible child care that not only allows but also encourages parent–child interaction and nurturing, universal accessibility to lactation facilities for breastfeeding mothers at work, and greater flexibility in training and academic career progression. Implementation of these initiatives does not require more research. Although some of the changes must have the commitment from the entire academic institution, change must begin somewhere. Where better to begin than within the departments and programs that are most concerned about children and families?
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FOOTNOTES |
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Address correspondence to Heather A. McPhillips, MD, MPH, Children's Hospital and Regional Medical Center, 4800 Sandpoint Way NE, Mailstop G0061, Seattle, WA 98105. E-mail: heather.mcphillips@seattlechildrens.org; or Ann E. Burke, MD, Wright State University School of Medicine, Dayton Children's Medical Center, One Children's Plaza, Department of Pediatrics, Dayton, OH 45404. E-mail: ann.burke{at}wright.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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