Do Family Leave Programs Affect Ophthalmology Resident Performance?

In medicine, the focus of wellness is, rightly, on the patients. Physicians, residents, and other care providers work long hours in settings that can be physically exhausting and mentally taxing so that their patients get the best care. Health care workers trade some of their comfort, and some of themselves, for the good of those they serve, because that’s what the job requires. 

However, there is a difference between making sacrifices and being deprived of common-sense workplace benefits. A spat of new research is considering the effects of this balance in medical residency. Researcher Divya Srikumaran, MD, ophthalmology specialist and vice chair of education at Johns Hopkins Wilmer Eye Institute, herself remembers weighing the pros and cons of having a child during the stressful years of residency and fellowship.

“The challenge that we face is, do we make these decisions to start a family in training, or do we defer them? When you start in training, you have a lot less control over your schedule, and you worry about the impact that it would have on your own training, the training of your classmates, and the cohort effect that you have,” she recalls.

Her experience is part of what promoted her and a team of researchers to find hard data demonstrating whether this guilt and concern is justified. Can taking parental leave during residency negatively affect physician performance — or could the study show that a generous family leave program actually benefits physicians?

Scoring Performance

This question is not without precedent. Previous research suggests that residents who take parental leave perceive that it may result in delayed program completion, loss of professional opportunities, and increased burden for coresidents — as well as the more direct consequence of missing out on valuable training.¹ It can be inferred that, for many, these fears lead to the decision to delay starting a family.

“Many of our residents are going through their training in medicine at a time that biologically coincides with when you can have children and have lower risk,” Dr Srikumaran explains. “When waiting till you’re much older to start, your family can increase the risk of complications from your pregnancy. We know advanced maternal age has an impact on the well being of the child, or it can have an increase in complications. There can be a greater rate of infertility and other problems. That’s well established in the literature.”

In a pair of JAMA Ophthalmology published studies from 2021 and 2022, Dr Srikumaran and colleagues show no significant differences in performance in those who took parental leave vs those who did not. In 2021, that team took into account Ophthalmic Knowledge Assessment Program [OKAP] scores for those who did and didn’t take family leave (P =.27), as well as the number of published works during residency (P =.19), and surgical volume by subspeciality, (P range =.11-.45).² 

The 2022 study considered OKAP percentiles and surgical volume again, and added research activity, average Accreditation Council for Graduate Medical Education (ACGME) milestones scores. This study shows no significant differences between female residents who took parental leave and residents who did not.¹  The men in that study were not independently evaluated for performance, having only taken a median of 2 weeks leave. 

Policies and Perceptions

In addition to residents’ own concerns about setbacks and delays, some report concerns about becoming the subject of bias by their program directors.¹ Indeed, in a prior survey, a majority of ophthalmology residents reported receiving negative feedback or actions regarding parenthood during training, and numerous surveys have found that program directors throughout the medical field perceive parental leave and childbearing to negatively affect resident scholarly activities, surgical and clinical skills, and even dedication to patient care.¹ 

Because each residency program, like any employer, has its own policy regarding parental leave, there are minimal protections in place to ensure that residents get the time they need for their leave, and that they get paid for it — this includes non-childbearing partners, as well.

“Partner leave is important in terms of providing support to a childbearing partner, or just being involved and present for their child,” Dr Srikumaran explains. “But I think this is something that, for women, it obviously comes up as a very biological problem as well as an emotional problem. I think that it is all very complex.”

As a result of constraining institutional policies, if residents do choose to take more time than their workplace offers, they often end up making additional sacrifices, such as using other types of leave or unpaid time, further burdening themselves and their families.

In these cases, it is possible that the pressures of resident work culture combine with perceived negativity around taking leave, resulting in poor mental health and burnout–a growing issue in care work and medicine. In a 2022 survey of residents of Ophthalmology and Vision Sciences at the University of Toronto, 72.7% of respondents reported feeling burned out from work at least several times a month, and 63.6% reported that having general mental health no better than “fair” or “good.”³

When it comes to policy, a recent glimmer of hope is a new ACGME mandate as of July 2022 that all programs offer 6 weeks of paid medical, parental, and caregiver leave to trainees.¹ This is a real sign of progress, considering that previously, the ACGME mandated only that all residency programs have written parental leave policies, but did not define the requirements.⁴ The policy was meant to ensure all students are entitled to parental leave, and that it is in accordance with state and local guidelines, but did not emphasize wellness or work-life balance in light of these seminal life events. 

The new policies are just a start, but they will at least provide some equity within medical programs’ leave policies for the first time, according to Meghan Berkenstock, MD, associate professor of ophthalmology at the Johns Hopkins Wilmer Eye Institute.

“We found most of the places didn’t have a particular system associated with parental leave,” explains Dr Berkenstock. “There was no parental leave time. It was at the discretion of, usually, the program director, and so each division and each department, even within a school, does it completely differently.”

Dr Berkenstock co-authored a 2022 survey that explores not only the parental leave policies that exist among several ophthalmology programs, but also the attitudes of both ophthalmology residents and program directors toward parental leave and breastfeeding during residency.⁴ The survey shows that 87% of residents who took parental leave reportedly had not taken any time without pay, although it did not ask that respondents specify whether they used personal or vacation time in addition to their designated parental leave.⁴ Additionally, more than half of the respondents who had taken leave reported perceived negative feedback or actions in response to their leave, with nearly half (46.2%) of program directors reporting a perceived negative impact of leave on coresidents.⁴

Dr Berkenstock’s study also surveyed attitudes toward breastfeeding among ophthalmology residents. It found that, while all program directors were reportedly supportive of pumping in the workplace, half of responding residents felt they did not have enough time to do so.⁴ Dr Berkenstock suggests that this discrepancy calls for clear communication on both sides, in addition to the residents educating themselves on policy, as a first response.

“It requires a lot of collaboration between both the resident and the program director or associate program director,” Dr Berkenstock says. “If you, as the resident, feel like you are not getting what you need, go to HR, go to the Graduate Medical Education (GME) office looking at what the standards are now per the ACGME and also your institution, because if you feel like you’ve not gotten enough time, or you don’t have a safe place to pump, then that’s something the institution has to to deal with, and it’s in the bylaws. It’s pushing for that, because you might be the first one in your department to have this happen.”

Benefits Keep Ophthalmology in Good Health

Besides the mental welfare of students, another important reason that generous benefits are crucial in ophthalmology residency is because, over the past several decades, there has been a global decline in academic exposure to the discipline as a career in medical school curricula.⁵ In some cases, ophthalmology teaching has decreased or been eliminated in medical curricula, despite high need in the field due to a growing burden of related conditions and procedures.⁶ Ophthalmology is a unique career due to its offering a combination of medicine and surgery, but interventions are increasingly being trialed in order to reach students at as early as the high school level with education around careers in ophthalmology.⁵

Dr Berkenstock posits that parental leave and other benefits are likely to affect ophthalmology’s numbers, just as perceptions of burnout culture in medical disciplines impact enrollment, especially due to the high percentage of women who choose to practice it.

“More women are going into the specialty than ever before,” Dr Birkenstock explains. “We make up about 40 percent of the ophthalmology workforce, and that’s one of the points that we wanted to make: ‘Look, women make up half of a medical school class, and a lot of our childbearing years are spent being residents or fellows.’ With more of us going into it, this is not going to be a unique problem to a subset of residents. This is going to affect a lot of people, so we need to get with the program, and we need to do it now.”

Dr Srikumaran is hopeful about future change around parental leave, as she is witnessing it firsthand. She shared that her own practicing institution, Johns Hopkins University, recently instituted 12 weeks of paid parental leave for faculty, which includes the gestational parent and their partner. She sees the inclusion of other medical students and professionals in the future of her research, stressing that quality of life and student numbers are correlated with the success of the field of ophthalmology.

Rethinking Productivity

As for Dr Srikumaran, she decided to go forward with starting a family, delivering her child during her fellowship. Though she had worried about negative consequences at the time, when she returned, she realized her concerns were unfounded.

“In the grand scheme of things, I’m not sure that the few weeks that I missed was such a big deal, but it was quite stressful for me,” said Dr. Srikumaran. “I remember when I finished [my training], one of my faculty members had said to me, ‘Even with the time you took off, you had the highest numbers of all of your classmates.’”

Students who take leave are doing more than their fair share to make up for it performance-wise, she explains. These ambitious physicians work extra before and after their absences to prevent falling behind. What could their institutions do, then, to acknowledge that and ensure a high quality of life in their support?

“When you adjust for the time that people are present, they’re very productive. It’s just that they’re missing a little bit of time,” Dr Srikumaran says. “We can create an environment that is more supportive. It just requires a little more effort on the part of the program directors and resources from the program to make it happen.”