The Journal of Pediatrics
Volume 149, Issue 1 , Pages 1-2.e1, July 2006

Making pediatrics residency programs family friendly: Views along the professional educational continuum

From the Division of General Pediatrics, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA.

Article Outline

 

The Federation of Pediatric Organizations Task Force on Women has made recommendations for improving work-life balance in the lives of pediatricians.1 Examined in the context of changes already underway in pediatric graduate medical education (GME), including duty hours regulations, the shift toward competency-based education, and trends toward higher acuity in children’s hospitals, these recommendations challenge the pediatric GME community to actively address the needs of women and families at a time of transformation and opportunity.

This essay looks at the Task Force recommendations through the eyes of a student about to start residency training, a second-year resident, junior faculty members seeking better work-life balance, and a program director engaged in strategic planning for the program. The authors started families at different stages of their careers and offer varied perspectives on the challenge of making residency training family friendly.

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What does it mean to be family friendly? 

The essence of family friendliness is flexibility. In recent years the federal government, labor unions, and Fortune 500 companies have implemented a number of options for making work environments family friendly, including gradual re-entry into the workplace after a leave of absence, job sharing, telecommuting, flex-time hours, the ability to work forty hours in fewer than five days, and help with care for elderly and disabled family members. Research indicates that adopting family friendly measures in the workplace leads to reduced absenteeism, greater productivity, enhanced recruitment and retention, and a perception of higher morale and commitment to the company.2, 3

Following the lead of those in other professions, pediatrics residency programs stand to benefit in similar ways by helping trainees achieve balance and satisfaction in both their personal and professional lives.

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Medical student perspectives: family friendliness and decisions about residency 

Over the past decade, achieving work-life balance has become a key goal for young physicians and a pivotal consideration in choosing a specialty. From 1996 to 2003, the percentage of graduating medical students choosing specialties with “controllable lifestyles” (characterized by physicians’ control of time spent on professional responsibilities) rose from 18% to 36% among women and from 28% to 45% among men.4 During the same period, controllable lifestyle accounted for 55% of the variability in specialty preference, after controlling for income, work hours, and duration of medical education.5 Concerns about work-life balance have become so central to career decisions that “lifestyle” specialties have earned their own nickname. Students wishing to pursue careers with controllable lifestyles can take the “E-ROAD” -– an acronym for emergency medicine, radiology, ophthalmology, anesthesiology, and dermatology.6 Residency programs for these specialties are among the most competitive in the nation. Within specialty fields, students compare individual programs. Most prefer those with built-in flexibility.7 Students tend to judge programs based on readily available information and may feel uncomfortable inquiring directly about the family friendliness of a given program. Students may selectively apply to programs that distribute explicit information about family leave policies, child care, part-time options, parent support groups, housing costs, family health benefits, and contingency plans for family emergencies. Among residents with children, many base their choice of residency program on external factors, such as the proximity of extended family. For others, a program’s inherent support structure - or lack thereof - is most critical in choosing a program.8

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Resident perspectives: challenges faced by housestaff with families 

Most residents begin training in their late twenties or early thirties, at a biologically ideal time for starting a family. Many who are otherwise ready choose to postpone having children, sensing that residency and parenting are incompatible. Delayed childbearing, especially for women, is associated with reduced fertility rates and higher perinatal mortality and morbidity.9, 10 To expect residents to finish training before starting a family is unreasonable and unfair.

Residents who raise children during residency face multiple obstacles as they try to meet the competing needs of children, spouses, patients, and colleagues. A concern for all working parents that can be particularly troublesome for residents is finding appropriate childcare. Some choose programs near extended family members or have one parent stay at home. Most other childcare options are too inflexible to accommodate residents’ extended hours, rotating schedules, and overnight call. When a child or childcare provider is ill, residents often have no choice but to burden their colleagues with additional work. The expense of childcare is also a significant problem. Annual childcare costs in Baltimore, Boston, Palo Alto, Philadelphia, San Francisco, and Seattle range from 35% to 40% of published annual gross salaries for pediatric interns.11, 12

The difficulty of balancing residency and parenting may place stress on resident marriages. Given the demands of residency and the limitations of childcare, spouses with relatively flexible work schedules may take on a disproportionate share of parenting responsibility: transporting children to and from school or daycare, attending medical appointments and parent-teacher conferences, and providing care when children are ill. This additional responsibility may limit spouses’ career success and personal time, leading to resentment, frustration, and interpersonal strain. The constant stress of balancing commitments to both training programs and families may have a negative impact on residents’ performance and well-being. It is essential that residency programs actively address the needs of residents with families during training.

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Junior faculty perspectives: mentors, models, and the need for institution-wide change 

Family friendly residency training cannot exist in isolation. Though we focus here on promoting work-life balance among trainees, to effect meaningful change, institutions must also address the needs of families further along the professional continuum. As residents move through training they look to faculty members as role models, scrutinizing their workload and lifestyles. Role models who enjoy work-life balance may be difficult to find, particularly among junior faculty. Promotion from the assistant to associate level is a steep climb that often occurs while faculty have young families. Traditional promotion criteria and timeframes tend to be inflexible and demanding. In order to fulfill their multiple professional commitments, faculty may bring work home or use vacation time to catch up on research and writing. From a resident’s perspective, a career in academic medicine may seem to promise long hours, low salaries relative to colleagues in practice, and constant pressure to juggle the requirements of academic advancement and having a family. To create authentically family friendly residency programs, departments of pediatrics must promote work-life balance for faculty, by offering part-time positions, flexible schedules, and individualized requirements for promotion.

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A program director’s perspective: looking to the future 

What matters to all of us in pediatric GME is delivering high quality training to prepare our graduates for the task of promoting children’s health. Quality training and family friendliness are not mutually exclusive. There are a number of ways for programs to become family friendly (Table; available at www.jpeds.com). Providing explicit information to applicants and developing support programs for residents with families are examples of readily implemented strategies that may have a small but important impact. Other approaches, including individualizing training schedules, offer greater promise - and a deeper set of challenges.

Table. Features of family friendly residency programs
Explicit promotion of work-life balance
•Clear communication with program applicants regarding family-related options and resources

•Educational programs and support systems to promote coping and time-management skills

•Access to faculty mentors and models for work-life balance

Expanded child care options
•On-site care

•Care for ill children

•Subsidized or low-cost child care

•Assistance with locating suitable care

Flexible training schedules
•Shared residency positions

•Part-time schedules

•Individualized timelines for completion of training

Institution-wide initiatives
•Flexible, individualized timelines for faculty promotion

•Stronger mentoring and development of formal support organizations for women and part-time faculty

Although part-time options and shared residency positions have been successful in pediatrics, according to recent data only one quarter of training programs offer part-time positions, and few residents take advantage of them.13, 14 For those who do train part-time, lower salaries, loss of benefits, and fear of overburdening colleagues are important concerns. A majority of residents suspect that arranging part-time training in their programs would be difficult or impossible. Colleagues of part-time residents, although supportive of flexible training options, report that offering part-time schedules results in heavier workloads and scheduling difficulties program-wide. Though part-time training strategies offer an obvious means of promoting work-family balance among residents, their real and perceived drawbacks limit both their popularity and utility.

In order for programs to accommodate part-time training or individualized training paths, hospitals and departments must rethink traditional assumptions about balancing service and education. Building flexibility into training calls for a re-engineering of pediatric care teams. Experiences with nurse practitioners in neonatal intensive care units in the late 1990s and with pediatric hospitalists in the early 2000s provide us with models that do not rely on residents as the sole providers of care. In this era of high acuity and complexity, to ensure maximal quality of care, teams must include members who are consistently present, rather than rotating at intervals. Allied health personnel are an ideal resource, not only for optimizing continuity and quality of care, but also for reducing dependency on residents as service providers, thereby promoting scheduling flexibility during training.

Another crucial step toward family friendliness involves completing the transition to competency-based education and certification. At present, when program graduates apply to take the American Board of Pediatrics certifying exam, program directors attest to their competence by verifying dates and completion of time in training. As the Task Force on Women notes, relying on measured competencies rather than fixed time in training would allow programs to individualize duration of training. High-stakes decisions about readiness for certification will require valid, reliable tools for assessing competency. The Task Force recommendations should inspire ongoing efforts to develop such tools. Combined with re-engineered patient care teams, following a truly competency-based model of training and evaluation would allow tremendous progress toward family friendliness.

Many of these suggestions and strategies may seem far out of reach. To be certain, the move toward family friendliness will require steps that are revolutionary rather than evolutionary. Though we belong to a field that focuses on caring for children and families, caring for our own families, historically, has not taken priority. The move to family friendliness will require a break with traditional assumptions and patterns and is likely to follow a difficult course. The pediatric GME community must rise to the challenge of promoting work-life balance, through debate and discussion, new priorities for GME funding, collaborative problem-solving, and advocacy. In the end, as the Task Force on Women makes clear, it is imperative that we align our training environments with the mission and values of our profession. As we work to promote the health and well-being of children and families, we must include our own.

References available at www.jpeds.com.

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References 

  1. Behrman RE , Arvin A , Berkowitz C , Dickson P , Freed GL , Jones MD , et al.   Federation of Pediatric Organizations Report of the Task Force on Women in Pediatrics . 2005; Available at http://www.fopo.org. Accessed November 29, 2005
  2. Bevan S , Dench S , Tamkin P , Cummings J . Family-friendly Employment (The Business Case) . DfEE Research Report . 1999;RR136; Available at http://www.employment- studies.co.uk/summary/summary.php?id=fambus. Accessed November 29, 2005
  3. Hammonds KH . Balancing Work and Family . Business Week . 1996; September 16, Available at http://www.businessweek.com/1996/38/b34931.htm. Accessed November 29, 2005
  4. Dorsey ER , Jarjoura D , Rutecki GW . The Influence of Controllable Lifestyle and Sex on Specialty Choices of Graduating U.S. Medical Students, 1996-2003 . Academic Medicine . 2005;80(9):791–796
  5. Dorsey ER , Jarjoura D , Rutecki GW . Influence of Controllable Lifestyle on Recent Trends in Specialty Choice by U.S. Medical Students . JAMA . 2003;290(9):1173–1178
  6. Rutecki GW  The Center for Bioethics and Human Dignity . Women Physicians and Lifestyle (What Are All Those Doctors Doing?) . 2005; February 04, Available at http://www.cbhd.org/resources/healthcare/rutecki_2005-02-04_print.htm. Accessed November 29, 2005
  7. Bond J , Galinsky E , Swanberg J . National Study of the Changing Workforce . New York: Fa milies and Work Institute; 1998;
  8. Rosenberg AR . Interviews with pediatric residents at Lucile Salter Packard Children’s Hospital at Stanford, University of California San Francisco, Seattle Children’s Hospital . 2005;
  9. Dunson D , Colombo B , Baird D . Changes with age in level and duration of fertility in the menstrual cycle . Human Reproduction . 2002;17(5):1399–1403
  10. Joseph K , Allen A , Dodds L , Turner L , Scott H , Liston R . The perinatal effects of delayed childbearing . Obstetrics and Gynecology . 2005;105:1410–1418
  11. Rosenberg AR . Personal communication with residency programs, program websites, and local child care centers . 2005;
  12. FREIDA Online: Fellowship and Residency Electronic Interactive Database. American Medical Association. Available at http://www.ama- assn.org/ama/pub/category/2997.html. Accessed November 29, 2005
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  14. Holmes AV , Cull WL , Socolar RR . Part-time Residency in Pediatrics (Description of Current Practice) . Pediatrics . 2005;116(1):32–37

 Conflicts of interest – None to disclose

PII: S0022-3476(06)00504-X

doi:10.1016/j.jpeds.2006.06.006

The Journal of Pediatrics
Volume 149, Issue 1 , Pages 1-2.e1, July 2006

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