The ACGME’s New Paid Family and Medical Leave Policy: Just the Beginning

• ACGME
• COVID-19
• Family Leave
• Graduate Medical Education
• Pandemics
• Psychological Burn-out
• Policy
• Sick Leave

The COVID-19 pandemic has laid bare a problem that many people have managed behind the scenes for years: how to balance work and family caregiving responsibilities. While sharing family responsibilities between partners is becoming more common, women in particular continue to bear the brunt of the caretaking effort in many families.¹ For physicians, many of whom were already experiencing burnout before the pandemic, the extra burden of COVID-19-related work stress combined with fewer options for childcare and other support has made coping all but untenable. Even before the pandemic, the Association of American Medical Colleges reported in 2019 that “40% of women physicians scale back their medical practice, or leave the profession altogether, early in their careers. The primary reason? Family.”²

The profession has been slow to enact and implement policies that support medical students, residents-in-training, and attending physicians in balancing work and family responsibilities, including at the time of birth or in the course of adopting a child. Indeed, for far too long, medicine has turned a blind eye to the stress and often health-harming effects of training and work schedules that leave clinicians fending for themselves, often with serious consequences for professional satisfaction, health, and gender equity.³ Indeed, research shows that supportive paid leave policies are associated with a wide range of benefits for both workers and their families, including improving maternal physical and mental health, decreasing economic insecurity in the year after birth or adoption, promoting child health by encouraging breastfeeding and reducing parental stress, and reducing infant hospitalization and death.⁴

Notably, new policies enacted in the past 2 years have begun to address the problem, at least for residents. Back in 2014, the American Medical Association adopted a policy encouraging medical schools, residency programs, medical specialty boards, and the Accreditation Council for Graduate Medical Education (ACGME) to adopt family and medical leave policies. It was not until 2020, however, that the American Board of Medical Specialties (ABMS) promulgated a policy of relevance to family and medical leave. Specifically, the ABMS announced that as of July 2021, member boards must allow “a minimum of 6 weeks away once during training for purposes of parental, caregiver, and medical leave, without exhausting time allowed for vacation or sick leave and without requiring an extension in training.”⁵ Although the ABMS policy constituted an important first step forward in ensuring that residents and fellows are not penalized for taking time off for family or medical leave, it stopped short of requiring that residents or fellows-in-training be paid during the leave in question.

However, in early 2022, the ACGME took the family and medical leave policy for residents a step further. Under its new policy, all ACGME-accredited programs must offer residents and fellows 6 weeks of paid parental, caregiver, or medical leave. Residents and fellows are entitled to the leave from the day that they begin their program. Their health and disability benefits must be continued during the leave. The program must also provide residents with “accurate information regarding the impact of an extended leave of absence on the criteria for satisfactory completion of the program and on a resident’s/fellow’s eligibility to participate in examinations by the relevant certifying board(s)”.⁶ Requiring that the leave be paid is critical in that some residents may experience economic hardship if they lose salary to take advantage of leave time.⁴ ACGME-accredited residency training programs must ensure that they are in compliance with the new requirements, align their new policies with state and federal laws, and ensure that both incoming and existing trainees are informed about their rights. Furthermore, to implement the policy effectively, ACGME-accredited residency training programs should establish a culture in which trainees are encouraged to take the leave that they are entitled to. For example, a study of family medicine residency programs found that residents and faculty did not take all of the paid leave their programs offered.⁷ Notably, the American Academy of Family Physicians recommends that residency programs offer up to 12 weeks of paid leave and that the length of the leave be determined by the resident.⁸ See Table 1 for a comparison of policies.

Undergraduate medical education (UME) has yet to follow suit. A study published in February 2022 found that only a handful of allopathic medical schools include clear family and medical leave policies in their student handbooks.⁹ Since medical school and residency often coincide with the childbearing years, parental leave policies are especially crucial during both UME and graduate medical education. Absent institutional requirements for medical schools to create specific parental leave policies, medical students are at the mercy of their individual medical schools to provide leave in a way that does not significantly disrupt their education and potentially harm their careers.¹⁰ To address this problem, the Liaison Committee on Medical Education should include a review of family leave policies when accrediting medical schools.

Similarly, attendings and practicing physicians are subject to existing state and federal laws and to the generosity of their employer institution when they give birth, adopt a child, need to care for an ill or disabled parent or family member, or become ill themselves.¹¹ The United States continues to lag far behind other countries when it comes to the legal requirements for family and medical leave. The United States is 1 of only 7 countries that do not require paid parental leave. The average duration of family and medical leave among all other countries is 29 weeks.¹² The federal Family and Medical Leave Act of 1993 (FMLA) requires large employers (of 50 or more employees) to provide up to 12 weeks of leave without pay for the birth or adoption of a child or for serious illness of the employee or a family member. But for many workers, unpaid leave is not an option if it means foregoing their income. In addition, part-time workers and those employed for less than 12 months are not covered by the FMLA. States have begun to step into the void. Ten states and the District of Columbia now mandate paid family and medical leave. These state laws mandate that employers allow for an average of 6 to 12 weeks of leave but typically with only partial wage replacement.¹³

Physicians who live in states that have not enacted paid family and medical leave laws are subject to their institution’s discretionary policy and, depending on their workplace, the FMLA. A study of top-ranked hospitals and cancer centers found that the mean paid maternity and parental leave is 7.8 and 3.6 weeks, respectively, well below the 12-week paid family leave recommendation of the American Academy of Pediatrics and the mean of 18.6 weeks afforded by other Organisation for Economic Co-operation and Development countries.¹⁴ It is notable that most physicians are not afforded the leave time at the time of giving birth or adopting a child that the profession’s pediatric experts recommend.

Until Congress and state legislatures act to ensure that all workers, including physicians, are able to take the time that they need to care for themselves and their family members, the medical profession should continue to enact policies that support and protect the health and well-being of its workforce. Paid family and medical leave should not be deemed a job perk; it is fundamental to human flourishing. In health care, reasonable paid leave is crucial to treating medical professionals—including the next generation of doctors—humanely and with the respect they deserve, especially when they are contending with ever-growing challenges in their day-to-day work. Ensuring that all medical professionals have access to paid family and medical leave also moves the profession beyond its rhetoric regarding gender equity by walking the walk, not just talking the talk. The ACGME should be commended for its new policy. But it is only the first step. Paid family and medical leave policies should be required for medical students, residents, and existing physicians, and physicians should help to advocate for sound, health-promoting leave policies for all Americans.

• Received for publication July 18, 2022.
• Revision received September 6, 2022.
• Accepted for publication September 9, 2022.