Family and Medical Leave for Diagnostic Radiology, Interventional Radiology, and Radiation Oncology Residents in the United States: A Policy Opportunity
2021; Radiological Society of North America; Volume: 300; Issue: 1 Linguagem: Inglês
10.1148/radiol.2021210798
ISSN1527-1315
AutoresKirti Magudia, Thomas S.C. Ng, Shauna R. Campbell, Patricia Balthazar, Elizabeth H. Dibble, Comron Hassanzadeh, Neil Lall, E. Merfeld, Shadi A. Esfahani, Rachel Jimenez, Emma C. Fields, Johnson B. Lightfoote, Susan Ackerman, Elizabeth B. Jeans, Meridith J. Englander, Carolynn M. DeBenedectis, Kristin K. Porter, Lucy B. Spalluto, Lori A. Deitte, Reshma Jagsi, Elizabeth Kagan Arleo,
Tópico(s)Radiation Dose and Imaging
ResumoHomeRadiologyVol. 300, No. 1 PreviousNext Reviews and CommentaryFree AccessEditorialFamily and Medical Leave for Diagnostic Radiology, Interventional Radiology, and Radiation Oncology Residents in the United States: A Policy OpportunityKirti Magudia , Thomas S. C. Ng, Shauna R. Campbell, Patricia Balthazar, Elizabeth H. Dibble, Comron J. Hassanzadeh, Neil Lall, Emily C. Merfeld, Shadi A. Esfahani, Rachel B. Jimenez, Emma C. Fields, Johnson B. Lightfoote, Susan J. Ackerman, Elizabeth B. Jeans, Meridith J. Englander, Carolynn M. DeBenedectis, Kristin K. Porter, Lucy B. Spalluto, Lori A. Deitte, Reshma Jagsi, Elizabeth Kagan ArleoKirti Magudia , Thomas S. C. Ng, Shauna R. Campbell, Patricia Balthazar, Elizabeth H. Dibble, Comron J. Hassanzadeh, Neil Lall, Emily C. Merfeld, Shadi A. Esfahani, Rachel B. Jimenez, Emma C. Fields, Johnson B. Lightfoote, Susan J. Ackerman, Elizabeth B. Jeans, Meridith J. Englander, Carolynn M. DeBenedectis, Kristin K. Porter, Lucy B. Spalluto, Lori A. Deitte, Reshma Jagsi, Elizabeth Kagan ArleoAuthor AffiliationsFrom the Department of Radiology and Biomedical Imaging, University of California, 1700 4th St, Byers Hall, Suite 102, San Francisco, CA 94158 (K.M.); Departments of Radiology (T.S.C.N., P.B., S.A.E.) and Radiation Oncology (R.B.J.), Massachusetts General Hospital/Harvard Medical School, Boston, Mass; Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio (S.R.C.); Department of Diagnostic Imaging, Alpert Medical School of Brown University and Rhode Island Hospital, Providence, RI (E.H.D.); Department of Radiation Oncology, Washington University School of Medicine, St Louis, Mo (C.J.H.); Department of Radiology, Children's Healthcare of Atlanta, Atlanta, Ga (N.L.); Department of Radiology, Emory University, Atlanta, Ga (N.L.); Department of Human Oncology, University of Wisconsin School of Medicine, Madison, Wis (E.C.M.); Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Va (E.C.F.); Department of Radiology, Pomona Valley Hospital Medical Center, Pomona, Calif (J.B.L.); Department of Radiology and Radiological Science, Medical University of South Carolina, Charlestown, SC (S.J.A.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minn (E.B.J.); Department of Radiology, Albany Medical College, Albany, NY (M.J.E.); Department of Radiology, University of Massachusetts Medical School, Worcester, Mass (C.M.D.); Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (K.K.P.); Department of Radiology and Radiological Sciences, Vanderbilt University School of Medicine, Nashville, Tenn (L.B.S., L.A.D.); Department of Radiation Oncology, University of Michigan, Ann Arbor, Mich (R.J.); and Department of Radiology, New York-Presbyterian Hospital/Weill Cornell Imaging, New York, NY (E.K.A.).Address correspondence to K.M. (e-mail: [email protected]).Kirti Magudia Thomas S. C. NgShauna R. CampbellPatricia BalthazarElizabeth H. DibbleComron J. HassanzadehNeil LallEmily C. MerfeldShadi A. EsfahaniRachel B. JimenezEmma C. FieldsJohnson B. LightfooteSusan J. AckermanElizabeth B. JeansMeridith J. EnglanderCarolynn M. DeBenedectisKristin K. PorterLucy B. SpallutoLori A. DeitteReshma JagsiElizabeth Kagan ArleoPublished Online:Apr 13 2021https://doi.org/10.1148/radiol.2021210798MoreSectionsPDF ToolsAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookXLinked In IntroductionThe American Board of Medical Specialties recently announced that effective July 1, 2021, member boards with training programs of 2 years or more must "establish requirements for candidates to become eligible for Initial Certification, including standards for training" and have "policies that accommodate reasonable leaves of absence from residency and fellowship training for personal or familial needs" (1). In preparation for this mandate, the American Board of Radiology (ABR) solicited comments from diverse stakeholders in March 2021—including the Association of Program Directors in Radiology, the Association of Program Directors in Interventional Radiology, and the ABR Initial Certification Advisory Committee for Radiation Oncology—with regards to Residency Service-Time Requirement (2), including considerations of family and medical leave. These communications included an initial proposed policy suggesting that "Programs may grant up to six weeks Parental, Caregiver and Medical Leave during the residency" (2) (ABR, written communication, March 12, 2021; March 16, 2021; and March 17, 2021).We appreciate the ABR's efforts to seek feedback as it develops an updated policy. The purpose of this piece is to promote transparent discourse and to examine the nuanced issues pertaining to family and medical leave considerations within the broader context of Residency Service-Time Requirement (2) policies for diagnostic radiology (DR), interventional radiology (IR), and radiation oncology (RO) residents, with the shared goal of optimizing both the training of competent clinicians worthy of public trust as well as professional well-being and diversity, equity, and inclusion. Given the rationale provided below, we recommend that the ABR leave policy allow a resident who is in good standing to take 12 weeks of family and medical leave during residency (in addition to 4 weeks of vacation per year), to sit for the Core/Qualifying Examinations on time, and to graduate without extension of training, with additional leave to be considered by the program director on a case-by-case basis.Recent Family-friendly ABR PoliciesThe ABR has recently instituted multiple family-friendly policies for DR/IR/RO residents. These include:1. The 2019 Core Exam policy allowing "residents who are in or beyond their 32nd month of DR training to take the [Core] examination if (1) the program director attests that the resident is believed to have sufficient knowledge and experience, and (2) the candidate attests that he or she understands the potential consequences of taking the examination early. This policy change [allows for] up to a 4-month leave of absence, in addition to standard vacation and meeting time, during the first 3 years of radiology residency" [emphasis ours] (3,4).2. The 2020 Clinical Qualifying Exam policy for RO residents broadening eligibility from "until after completion of PGY-5/R4 year," representing completion of 48 months of residency, to now include "with approval of the program director, this option may be exercised after completion of 44 months of residency" (5).3. The 2020 Medical Physics and Cancer Biology Exam policy for RO residents broadening eligibility from "after completion of their PGY-4/R3 year," representing completion of 36 months of residency, to now include "with approval of the program director, this option may be exercised after completion of 24 months of residency" (5).4. The 2020 transition to a virtual examination format for the DR, IR/DR, and RO Core/Qualifying and Certifying Exams, in response to the COVID-19 global pandemic (6).5. Improved lactation accommodation in 2020 from 30 minutes for the Core/Qualifying Exam to an unspecified amount of additional break time that can be requested by a nursing mother (7).We commend the ABR for these policy changes that have benefitted all residents, particularly women and residents with families.Family and Medical Leave: Federal Law and within Medical OrganizationsThe 1993 Family and Medical Leave Act (FMLA) allows eligible employees to take 12 weeks unpaid, job-protected leave for the birth and care of a newborn, adopted child, or foster child, as well as for care of oneself or an immediate family member with a serious health condition (8). The U.S. Department of Labor considers medical residents to be employees under the FMLA (9). More recently, the Pediatric Policy Council and the American Academy of Pediatrics asked the federal government to pass the Family and Medical Insurance Leave Act to create a social insurance system enabling workers to take up to 12 weeks of paid leave to care for themselves or their families (10). The need for these policies, especially with respect to parental leave, are manifold. Paid parental leave is associated with numerous benefits including decreased infant mortality, decreased mother and infant rehospitalizations, decreased post-partum maternal depression, improved infant attachment and child development, decreased intimate partner violence, more timely pediatrician visits and immunizations, and increased breastfeeding initiation and duration (11,12). These concerns are no different for those still in medical training, and in fact, compared with women of a similar age, residents experience higher rates of obstetric complications (13). Availability of leave for all parents can also encourage more equitable parental involvement in childrearing (14–16).In March 2019, the Society of Chairs of Academic Radiology Departments "[pledged] to strive for departmental, institutional, and organizational change that provides 12 weeks of paid parental leave for eligible (as defined by the FMLA) faculty members of all genders" (17). The following month, in April 2019, the Association of Program Directors in Radiology published a statement of support for family leave as well, affirming that "under FMLA, eligible radiology residents of all genders have the right to take up to 12 weeks of unpaid family leave" and the Association of Program Directors in Radiology "encourages program directors to make this right known to their trainees, as indicated by federal law, and to provide notice of any additional rights under relevant state family leave laws" (18). Multiple additional publications have recognized the necessity and importance of family and medical leave for medical trainees in general (19–22) and specifically for DR/IR/RO trainees and faculty (23–26).Shift toward Competency-based Training for ResidentsGiven the wide range in institutional and specialty board policies for family and medical leave (19,20), the American Board of Medical Specialties convened a joint workshop with the Accreditation Council for Graduate Medical Education in February 2020 that brought together more than 80 stakeholders, including the ABR, to discuss issues pertaining to offering appropriate family and medical leave for graduate medical education trainees (27). The discussion focused on moving from time-based training requirements to competency-based training, which has been an ongoing focus of the Accreditation Council for Graduate Medical Education since 1999 with the Milestones Project (28). Competency-based training affords flexibility to accommodate family and medical leave for trainees while balancing the duty of specialty medical boards to the public to ensure the clinical competence of graduating residents. The resultant American Board of Medical Specialties policy for all training programs with 2 years or more duration requires "a minimum of 6 weeks of time away from training for purposes of parental, caregiver and medical leave at least once during training, without exhausting all other allowed time away from training and without extending training" effective July 1, 2021 (1).Considerations Regarding Leave Policy Duration in DR/IR/ROThe ABR's initial proposed leave policy was written as follows with a request for collateral comments:"Programs may grant up to four weeks' vacation per training year. This allowance may be averaged over the training period and is not associated with a requirement to extend training in order to allow the individual to be considered eligible for Initial Certification. Programs may grant up to six weeks Parental, Caregiver and Medical Leave during the residency. This is defined as leaves of absence for personal or familial needs, including the birth and care of a newborn, adopted, or foster child ("parental leave"); care of an immediate family member (child, spouse or parent) with a serious health condition ("caregiver leave"); or the trainee's own serious health condition ("medical leave"). This allowance is not associated with a requirement to extend training to allow the individual to be considered eligible for Initial Certification and is in addition to the vacation allowance as defined" (ABR, written communication, March 12, 2021; March 16, 2021; and March 17, 2021).The above would limit DR/IR/RO residents to a single instance of no more than 6 weeks of family and medical leave for the entirety of residency training if candidates took the allotted 4 weeks of vacation per year, strived to obtain timely Initial Certification (Core and Certifying Examinations for DR/IR residents; Medical Physics Examination, Cancer Biology Examination, Clinical Radiation Oncology Examination, and Oral Certifying Examination for RO residents) (29–31), and aimed to graduate on time. This would be less family and medical leave than many DR/IR/RO residencies currently offer to their residents, and also less than what is allotted by some other medical specialty boards (25,32,33).The duration of allowable parental leave may have a profound impact on the future composition of the DR/IR/RO workforce, a workforce already known to be lagging in gender diversity. For instance, DR, IR, and RO had 28%, 18% and 37% female residents in 2020, respectively, compared with 46% across all graduate medical education specialties (34). Beyond training, compared with other specialties in medicine, DR has one of the lowest proportions of full-time faculty and chairs who are women, at 30% and 17%, respectively (35). For RO, the proportions of full-time faculty and chairs who are women are even slightly lower at 28% and 14%, respectively (36). Lastly, only 10% of IR faculty (40) and chiefs are women (M. J. Englander, written communication, March 2021).Constraining parental leave to less than the American Academy of Pediatrics recommended 12 weeks (10) has the potential to impact the recruitment of women to DR/IR/RO given that specialty training occurs during prime childbearing years (6-year training pathway for DR/IR, including a 1-year fellowship for DR, or 5-year training pathway for RO). While trainees can take the FMLA of up to 12 weeks, this may require an extension of training, possibly having reverberating personal and professional consequences. Delay in residency graduation would delay the start date of fellowship, which may cause a subsequent delay to fellowship graduation or possibly the loss of the fellowship spot itself. Such a delay may also put a trainee at a disadvantage when applying for jobs, with potential financial repercussions in their career for years to come. This could incentivize residents to take less family and medical leave than they are entitled to under FMLA, potentially at the cost of their own wellness and the wellness of their family (38–40). Others may choose to delay pregnancy, even with the knowledge that age-related fertility decline may present significant fertility challenges, especially for female physicians (41–43).Currently, the ABR certification requirements dictate that DR trainees need to complete at least 32 months of clinical training and RO trainees need to complete 36 months of clinical training (27 months for both if on the Holman Research Pathway), within the Accreditation Council for Graduate Medical Education–defined 48-month residency training period (44,45). This framework has allowed many programs to offer a variety of rich experiences within the 12–16 months of available elective time, including mini-fellowships, extended research blocks, and nonclinical pursuits in Leadership and Global Health (46–50). Co-optation of this time for a 4-year Nuclear Radiology Pathway (51) and a 5-year integrated DR/IR program (52) has also been established. Accommodating 12 weeks of family and medical leave within this period would allow trainees to satisfy ABR certification requirements without graduation delay. We do acknowledge that the combined IR/DR training or the 4-year Nuclear Radiology pathway in their current forms may present less flexibility than DR and RO for elective time, potentially requiring more careful planning to accommodate family and medical leave.As previously described (53,54), any family and medical leave policy development should also be mindful of the following federal laws. Title VII of the Civil Rights Act of 1964 (42 U.S.C. 2000e and following) "prohibits practices that seem neutral but have a disproportionate impact on a protected group of people" (55,56). Moreover, according to the Pregnancy Discrimination Act (an amendment to Title VII), "Title VII is violated if a facially neutral policy has a disproportionate adverse effect on women affected by pregnancy, childbirth, or a medical condition related to pregnancy or childbirth" (57). Furthermore, the Americans with Disabilities Act of 1990 prohibits discrimination against a person with a disability, such as a postpartum woman with complications requiring additional time off (58). Lastly, Title IX prohibits sex discrimination in federally funded education programs, including residency programs (59).Recommended Revisions to the ABR's Initial Proposed Leave PolicyWe recognize that the American Board of Medical Specialties policy mandates "a minimum of 6 weeks of time away from training for purposes of parental, caregiver and medical leave" (1). However, in the spirit of the FMLA and compatible with the American Academy of Pediatrics, Society of Chairs of Academic Radiology Departments, and Association of Program Directors in Radiology statements in support of 12 weeks of parental leave (8,10,17,18), as well as with the ongoing shift toward competency-based training, we propose that the ABR policy allows a resident who is in compliance with clinical competency and Initial Certification requirements as well as is in good standing within their program to:1. Take 12 weeks of family and medical leave during the course of residency (in addition to 4 weeks of vacation per year), while still remaining eligible to both sit for the Core/Qualifying Examinations and to graduate without extension of training.2. Take additional family and medical leave if approved by the program director without extension of training (to be considered on a case-by-case basis), in keeping with the ABR Initial Certification requirements and Leaves of Absence policy currently in place (4,5,60–63).The normalization of parental, caregiver, and medical leave is long overdue in medicine. The above recommended policy would represent an opportunity for the ABR to be a trailblazer among medical specialties with an approach that maintains high standards of clinical training and truly promotes diversity, equity, and inclusion as well as physician well-being, all of which will ultimately positively impact patient care.Disclosures of Conflicts of Interest: K.M. Activities related to the present article: RFS representative to the Committee for Women of the ACR Commission for Women and Diversity; received money for travel/accommodations/meeting expenses from American Board of Medical Specialties (ABMS) and Accreditation Council on Graduate Medical Education (ACGME) for February 2020 parental leave workshop. Activities not related to the present article: has grants/grants pending with Society of Abdominal Radiology, and Radiological Society of North America R&E Foundation. Other relationships: disclosed no relevant relationships. T.S.C.N. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: is employed by Massachusetts General Hospital Physicians Organization; has grants/grants pending with MGH Imaging. Other relationships: disclosed no relevant relationships. S.R.C. Activities related to the present article: served as 2020-2021 Chair of the Association of Residents in Radiation Oncology (ARRO). Activities not related to the present article: disclosed no relevant relationships. Other relationships: disclosed no relevant relationships. P.B. Activities related to the present article: served as 2019-2020 President of the American Alliance of Academic Chief Residents in Radiology (ACR). Activities not related to the present article: disclosed no relevant relationships. Other relationships: disclosed no relevant relationships. E.H.D. disclosed no relevant relationships. C.J.H. disclosed no relevant relationships. N.L. disclosed no relevant relationships. E.C.M. disclosed no relevant relationships. S.A.E. Activities related to the present article: is a board member of American Association for Women in Radiology. Activities not related to the present article: disclosed no relevant relationships. Other relationships: disclosed no relevant relationships. R.B.J. disclosed no relevant relationships. E.C.F. disclosed no relevant relationships. J.B.L. disclosed no relevant relationships. S.J.A. disclosed no relevant relationships. E.B.J. disclosed no relevant relationships. M.J.E. disclosed no relevant relationships. C.M.D. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: has grants/grants pending with Association of Program Directors in Radiology (Jerome Ardnt grant); received payment for lectures including service on speakers bureaus from MRIonline. Other relationships: disclosed no relevant relationships. K.K.P. Activities related to the present article: serves as 2021 President of the American Association for Women in Radiology (AAWR) and is a member of American College of Radiology's Commission for Women and Diversity. Activities not related to the present article: received honorarium for lectures including service on speakers bureaus from Bracco Diagnostics (COVID advisory panel); holds stock/stock options in Pfizer. Other relationships: disclosed no relevant relationships. L.B.S. Activities related to the present article: served as the 2020 President of the American Association for Women in Radiology (AAWR) and is a member of the American College of Radiology's Commission for Women and Diversity. Activities not related to the present article: has grants/grants pending with NIH, CDC, DHHS, VA Office of Research and Development, VA Office of Rural Health, and Association of VA Hematology and Oncology (AVAHO); received honorarium for lectures including Brown University Department of Radiology and University of Iowa Department of Radiology. Other relationships: disclosed no relevant relationships. L.A.D. disclosed no relevant relationships. R.J. Activities related to the present article: received money for travel/accommodations/meeting expenses from American Board of Medical Specialties (ABMS) and Accreditation Council on Graduate Medical Education (ACGME) for February 2020 parental leave workshop. Activities not related to the present article: is a consultant for Greenwall Foundation; has received payment for expert testimony; has grants/grants pending with NIH, Doris Duke Foundation, Komen Foundation, Greenwall Foundation, and Blue Cross Blue Shield of Michigan; has received payment for lectures for many professional societies and academic institutions; holds stock/stock options in Equity Quotient. Other relationships: disclosed contract for an investigator initiated study with Genentech. E.K.A. Activities related to the present article: served as 2019 President of the American Association for Women in Radiology (AAWR) and is a member of American College of Radiology's Commission for Women and Diversity. Activities not related to the present article: is employed by Elsevier as Editor-in-Chief of Clinical Imaging; received honorarium for lectures including University of Alabama, Department of Radiology. Other relationships: disclosed no relevant relationships.AcknowledgmentsThe authors gratefully acknowledge legal review of the manuscript by Anne Yuengert, JD, Partner, Bradley Arant Boult Cummings LLP, Labor & Employment practice group, Birmingham, Alabama; review of the manuscript by Austin J Sim, MD, JD; and the support of Kaleigh Doke, MD, Laura Dover, MD, Virginia W. Osborn, MD, Amy Patel, MD, Yi Yang, MD, and Olga R Brook, MD.EndorsementsAmerican Association for Women in Radiology (AAWR) Board of Directors, Executive Board; Association of Program Directors in Radiology (APDR); Association for Directors of Radiation Oncology Programs (ADROP);Association of Program Directors in Interventional Radiology (APDIR); American College of Radiology (ACR),
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