Reforms Needed in Nephrology Fellowship Programs to Support Pregnancy and Family Leave

It is well known that long and inconsistent working hours and night-call shifts can significantly affect physician trainees’ health, and these demands can have adverse effects on maternal and fetal health during pregnancy (1). Unfortunately, one in three medical and surgical fellows had unfavorable pregnancy outcomes during their training period (2). Beyond the physical and emotional toll during pregnancy, taking more than 6 weeks of leave from a fellowship program often results in an extension of the training period, which delays graduation and can affect one's level of compensation. It also delays board certification and can lead to difficulty matching into secondary fellowships.

What can be done to make it more conducive and appealing for individuals in medicine to choose nephrology fellowships? Do we have the right systems and policies in place to provide a supportive environment for individuals who become pregnant as well as for those who become caretakers with childcare needs? A recent survey-based study published in CJASN (3) sheds light on these important questions surrounding pregnancy and parenthood during nephrology fellowship.

Policies for parental leave vary across the globe, and the United States does not mandate paid parental leave. As the study demonstrated, nephrology fellows are often unaware of these policies even when they exist (3). Approximately three-fourths of fellows included in the study were unaware of Accreditation Council for Graduate Medical Education (ACGME) parental leave policies, and approximately 4 out of 10 respondents did not know about the duration of parental leave, accommodations for lactation, and access to subsidized childcare.

Surprisingly, one-fourth of the female fellows who took family leave reported experiencing “negative emotions” from fellow trainees upon return (4). Coverage of service obligations during leave is a topic of concern for co-fellows who are juggling their own shifts and responsibilities. Are financial incentives adequate motivators for trainees to cover for their colleagues while on leave? They may be for some, but they do not necessarily alleviate all concerns. Coordinating coverage results in additional shifts for the other fellows, worsening potential burnout and resulting in conflicting schedules with their other clinical and nonclinical responsibilities. However, if a system is built around sharing the coverage for the individual on leave among all nephrologists—both attendings and fellows-in-training—it may decrease the burden for everyone (4).

Additionally, individuals may have anxiety after a prolonged leave of absence, questioning their capabilities and ability to keep up with colleagues, resulting in poorer performance (5). With this in mind, a government initiative in the United Kingdom, called Springboard, aims to support individuals after prolonged leave and restore confidence when returning to practice. It offers a 2-day course for trainees who have taken time out of training for 3 months to 6 years, providing clinical and nonclinical practice support as well as a forum for sharing experiences (4, 5). Similar practical programs would be beneficial if made available in North America.

Medical trainees have work shifts lasting approximately 80 hours per week, and there are no special considerations during pregnancy per ACGME (3). Inconsistent and unconventional working hours pose an additional hindrance in the postpregnancy childcare phase. What may help with this? Should hospital facilities be required to offer in-hospital childcare or daycare centers for fellows/trainees? Some institutions have on-site childcare, but the demand is higher than hospitals can accommodate.

Women in Nephrology also offers a few suggestions to aid nephrologists returning from family leave. To improve participation at conferences, for example, Women in Nephrology suggests that nephrology conferences provide on-site childcare for parents attending the sessions, publicize the availability of breastfeeding/lactation areas at the meeting sites, and “allow infants in arms” during sessions (6).

The CJASN study's authors emphasize that programs should ultimately be advocating for their trainees (3). Specific recommendations include:

• Offering subsidized childcare for fellows

• Enacting clear policies for training programs

• Providing trainees with program-specific resources about pregnancy and parental leave policies, as well as national and local policies, early within their programs

• Mandating breastfeeding/lactation suites at every hospital

• Standardizing the duration for parental leave across the different governing bodies such as the American Board of Internal Medicine, ACGME, the American Board of Medical Specialties, and the Family and Medical Leave Act.

After overcoming societal, cultural, and socioeconomic factors that can influence pregnancy and its outcomes on health, a supportive workplace can enable fellows’ success both professionally and personally. We have an opportunity to create a safe and supportive environment for nephrology trainees who are or may become pregnant and for future trainees who are considering nephrology fellowships.

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