The American College of Surgeons (ACS) recognizes that a successful surgical career should not preclude a surgeon’s choice to be a parent. Choosing to become a parent does not detract from one’s full professional commitment or ability to train as a surgeon. Surgical trainees who choose to have children (whether through a pregnancy of the surgeon or the surgeon’s partner, surrogacy, fostering, or adoption) have made an equivalent investment in their surgical careers as those individuals who choose not to have children. This issue is particularly pertinent to surgical trainees who have relatively long residency programs that occur during peak childbearing and family development years. The ACS is supportive of the health and well-being of surgical trainees and emphatically condemns imposition of punitive repercussions or bias toward those surgeons who choose to have children.
The ACS also recognizes that surgeons have increased rates of infertility and pregnancy complications as compared with the general population. Complications include conditions that affect both mother and fetus, such as spontaneous abortion, preterm delivery, growth restriction, and congenital abnormalities (Anderson and Goldman, 2020).
The ACS strongly supports adoption of the following guidelines for all institutions, residency programs, and their governing bodies.
The following guidelines offer ACS recommendations for a framework to support a pregnant surgical trainee or a surgical trainee attempting to become pregnant and workplace accommodations:
- The ACS encourages individualized assessment of requests for reasonable support for pregnancy-related conditions, in accordance with applicable federal and state laws. This includes but is not limited to prenatal appointments, reproductive technology, and treatment for infertility.
- Trainees should be given time off to attend necessary appointments for consultation, lab draws, and imaging.
- Trainees should be allowed to, but not forced to, use sick leave for relevant procedures.
- A residency or fellowship training program must ensure protected time for surgical trainees’ prenatal appointments (or the prenatal appointments of a childbearing partner)
- The ACS is supportive of the unique requirements of surgical trainees undergoing assisted reproductive technology (ART) treatment for infertility. The recommendations contained in this document are intended to extend to ART procedures, testing, and relevant appointments.
- The ACS encourages individualized assessment of requests for reasonable schedule and duty modifications based on pregnancy-related conditions in accordance with applicable federal and state laws.
- It is appropriate to consider accommodations to call schedule, duty hours, and operative schedule after 30 weeks of pregnancy including cessation of overnight call duties and 24-hour call shifts. Pregnant trainees should be allowed to take short breaks as needed.
- Pregnant trainees should avoid exposure to radiation in the operating room. Those in the first trimester of pregnancy should be excused from fluoroscopy cases given the high risk of radiation exposure.
- A complicated pregnancy may need additional modifications of the trainee’s schedule. There is significant variation in how pregnancy is experienced across individuals, thus differing flexibility may be necessary to provide needed support.
- The ACS supports the surgical trainee's ability to self-determine needed schedule and duty modifications with the program director.
The following guidelines offer ACS recommendations for a framework on parental leave policies. These guidelines also offer accommodations for non-birthing parents, as pregnancy and early infancy are important periods for all parents for infant bonding and/or supporting a birthing partner.
- Parental leave, including childbearing and non-childbearing parents. should be provided equally for individuals who are new parents through pregnancy, surrogacy, fostering, or adoption.
- Parental leave terms should be explicitly included in all resident and fellow contracts and should not be reserved for only those who may request parental leave terms.
- The trainee should inform the residency program director of an impending pregnancy or anticipated adoption in a timely fashion to allow for schedule changes to cover anticipated absence from professional duties and educational rotations.
- The ACS strongly endorses at least six weeks of paid parental leave for either or both parents, independent of vacation and sick leave.
- The residency or fellowship program is responsible for supporting the medical needs of the trainee and for ensuring the confidentiality of health care information.
- The residency or fellowship program should create a schedule that is flexible and equitable for the trainee to take leave, while accounting for those health care professionals who are affected by their absence.
- In accordance with the Family and Medical Leave Act of 1993 (FMLA), the ACS suggests that residency programs also may voluntarily allow new parents the opportunity to take a leave of absence for up to an additional six weeks (12 weeks total), acknowledging that an extended leave will likely require an extension of training time as required by the Surgical Specialty Boards and RRCs.
- Trainees should not be required to make up call coverage for the period of parental absence.
- Parental leave should not be a factor in decisions regarding trainee progression, trainee assessment and evaluation, access to leadership or research positions, and promotion or graduation.
The following guidelines offer ACS recommendations offer a framework in support of a breastfeeding trainee and workplace accommodations:
- Trainees who intend to breastfeed should be allowed flexibility to support expressing breast milk. Nursing mother break-time provisions is a patient protection in the Affordable Care Act of 2010, which amended Section 7 of the Fair Labor Standards Act, which requires covered employers to provide eligible employees with reasonable break time in a private, safe, and convenient place (other than a bathroom) to express milk for one year following the birth of a child. Access to a safe, hygienic, and convenient place for the storage of pumped milk also should be provided.
- The formalization of guidelines to support trainees who choose to pump at work is recommended. Individuals should have protected time several times per day and have clinic and operating adjustments without bias or penalty. For most individuals, expressing milk for 30-40 minutes every three to four hours provides sufficient milk for the infant. This accommodation also reduces the risk of developing engorgement, pain, or mastitis.
- Trainees should provide adequate notice prior to the need to express breast milk to allow for adequate intraoperative coverage.
- Postpartum depression is relatively common and can have negative consequences for maternal health and infant development. Consideration of postpartum mental health is important and trainees should be provided with timely, confidential, and accessible mental health support and given the time to attend any relevant appointments as needed.
Recommendation
The ACS urges each American Board of Medical Specialties (ABMS) Surgical Specialty Board, and each Accreditation Council for Graduate Medical Education Surgical Specialty Residency Review Committee (RRC) to:
- Provide clear and consistent policies regarding parental leave.
- Provide policies with the minimal appropriate allowances for parental leave time.
- Provide policies allowing parental leave time without requiring additional training time unless time away from training extends the six weeks prescribed in the FMLA.
The ACS also urges Surgical Specialty Boards and RRCs to collaborate in developing functionally similar policies that allow equitable application and individual impact across specialties and programs.
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