Parental leave in medical school: supporting students as parents

Context: The overlap between medical school, residency, andchildbearingpotentialincreasesthelikelihoodawoman will pursue parenthood within her, or her partner ’ s, medical training. Parental leave benefits mothers, fathers, and infants. Adequate parental leave promotes physical recovery, mental health, infant bonding, improved breastfeeding, appropriate childhood immunization, and familial engagement. Despite the risks and benefits, the United States does not have national paid maternity, paternity, or parental leave requirements. Complicating matters for medical trainees, parental leave policies are not well-de ﬁ ned within the undergraduate (UME) and graduate medical education (GME) realms. Signi ﬁ cant policy advancements are on the horizon for GME; however, medical schools are left without evidence to support policy formation. Objectives: This study aims to identify the presence and nature of maternal/paternal leave policies and procedures within UME. Given the authors ’ close association with osteopathic medical education, only osteopathic medical schools were considered to lay the framework for future study in UME. Methods: Investigators searched university websites for studenthandbooksoutliningrulesandpoliciessurrounding parental leave. The following terms were utilized to investigate these documents: “ parental, ” “ maternity, ” “ pater-nity, ” “ pregnant, ” “ pregnancy, ” and “ leave of absence ” (LOA). Administrative personnel were contacted, and subjective data were documented. A parental leave policy was defined as explicitly dedicated to expectant parents or those parents planning on adoption. Medical leave or other short-and long-term LOA policies were not considered a parental leave policy. Results: A total of 42 osteopathic medical schools were identified.

Women have become the majority in United States allopathic medical schools [1].For academic year 2020-2021, women comprised 51.5% of the student population, with 48,530 women enrolled in medical schools [1].The past decade has seen increasing enrollment of women in osteopathic medical colleges, with women making up 47.7% (n=15,088) of the medical student population in 2019-2020 [2].While the average age of a matriculating woman is 24 years [3], the mean age at which a woman typically gives birth in the United States is 26.9 years [4].The overlap between medical school, residency, and childbearing potential increases the likelihood that a woman will pursue parenthood within her medical training [5].Similarly, male medical students may wish to start a family within this critical time period.
Previous perspectives [5,6] affirm the benefits of maternity leave in both mothers and infants.Although mothers must physically recover from birth, women experience improved mental health with maternity leave [5,6].Maternal work hours have been linked to depression, parenting stress, and negative assessments of overall health [6].For infants, lack of an adequate maternity leave hinders breastfeeding and childhood immunization rates [6].For fathers, paternity leave increases engagement, caretaking, and bonding with an infant/child [5].Despite the risks and benefits, the United States does not have national paid maternity, paternity, or parental leave requirements.
Complicating matters for medical trainees, parental leave policies are not well-defined within the undergraduate (UME) and graduate medical education (GME) realms.Physician residents must combine leave hours (e.g., vacation, sick, and elective time), merge rotations that do not require a physical presence, or extend training if leave time set maximums [5].In a previous survey and study including 804 female resident respondents (126 mothers, 77 independent maternity leaves), length of leave was impacted by the desire to avoid prolongation of training time in 59 instances (27%, self-reported determinants not mutually exclusive), financial constraints in 27 (12%), newborn bonding in 26 (12%), and repercussions to professional working relationships in 24 (11%) [7].
Fortunately, significant policy advancements are on the horizon for GME.The American Board of Medical Specialties (ABMS) announced a new leave policy that started in July 2021 [8].This policy stipulates that during training, a one-time leave that is a minimum of 6 weeks may occur for parental, caregiver, and medical leave that does not require combining leave hours or extending time in training [8].
Much of the parental leave literature surrounding medical trainees falls within GME.With perspectives [5,7] calling on the Accreditation Council for Graduate Medical Education (ACGME) and ABMS policy evolution, we aimed to characterize the presence and nature of parental leave policies within osteopathic UME.

Methods
The Rocky Vista University (RVU) Institutional Review Board (IRB) considered this research exempt from IRB review and approval processes.We narrowed our focus to osteopathic medical schools to establish and characterize parental leave policies within a congruent UME population sharing similar philosophies in education, training, and practice.Main and branch campus colleges of osteopathic medicine were identified from the American Association of Colleges of Osteopathic Medicine (AACOM) directory (Table 1) [9].We conducted our data collection via two methods.We initially reviewed the student handbook and school policies of each osteopathic medical school obtained from university websites, utilizing the search terms "parental," "maternity," "paternity," "pregnant," "pregnancy," and "leave of absence" (LOA).In January 2021, we emailed each Student Affairs department individually, requesting information about parental leave policies that might exist outside of each school's respective student handbooks.One follow-up email was sent in February 2021 to the schools who had not yet responded.We defined a parental leave policy as explicitly dedicated to expectant parents or those parents planning on adoption.Medical leave or other short-and long-term LOA policies were not considered a parental leave policy.We preplanned policy classification into three groups: -Category 1: Clearly defined parental leave policy -Category 2: Vaguely defined parental leave policy -Category 3: No parental leave policy Subjective data from electronic communication with administrative personnel was documented in an attempt to describe parental leave policies more broadly in narrative form.

Results
Forty-two main and branch campus colleges of osteopathic medicine were identified (Figure 1).One of the 42 institutions (2.4%) did not have a student handbook available nor return email communication, while the remaining 41 schools had an available student handbook.Email responses were received from 17 schools (40.5%).Of note, our home institution was not contacted directly, because that information was readily available from previous institutional communications and policy development.Two of the 41 US osteopathic medical schools (4.9%) had an established parental leave policy in place (Category 1), whereas 39 (95.1%) did not (Category 3).Email responses indicated that expecting students were encouraged to follow short-or long-term LOA policies.
For both Category 1 parental leave policies, the common features included coordination with the Student Affairs departments, notification of preclinical or clinical education administrators, necessitation of supporting documents including physician letters, and modification of the student schedule or accommodations (i.e., retaking a semester, LOA, or additional time in the program) for missed work.

Discussion
A majority of US osteopathic medical schools do not have established paternity/maternity policies outlined in student handbooks.Without well-established policies, students must weigh family planning against extending the time necessary to complete his or her medical education.When requesting parental leave, students are advised to take a short-or long-term LOA.If a student requires a LOA during their medical education, it is unclear if the student may continue his or her education during leave (i.e., contribute to preclinical/clinical coursework during the LOA).If a student may not participate in the preclinical/clinical curriculum during this leave, the necessary requirements cannot be met, putting the student at a disadvantage and fragmenting his or her expected medical school trajectory.This not only applies to graduation deadlines, but also has lasting   impacts on future career planning, such as eligibility for audition rotations and residency applications.Depending on the LOA length, a student may be required to extend his or her training by a year, which is a financial and time-consuming burden.If a student arranges a shorter LOA (one not disrupting schedule/academic goals), the allocated time may not allow for appropriate healing after childbirth, bonding between infant and caregiver, or adjustment to parenthood.
Within GME, a survey study including 214 female resident respondents compared maternal and infant well-being outcomes in 25 maternity leaves.Compared with maternity leave lengths <8 weeks, residents with leave time >8 weeks were less likely to have postpartum depression (negative screen 70% vs. 33% with leave time <8 weeks) or burnout (negative burnout screen 38% vs. 33%), more likely to breastfeed longer (breastfeed ≥6 months 89% vs. 33%), and to have more satisfaction with parenthood (75% vs. 56%) [10].Establishing written, well-defined parental leave policies support not only residents but also their newborn and families [11].As GME and specialty societies issue consistent calls over accessible, clear, and detailed parental leave policies for residents, the same call must be extended to UME [12].
An independent review of student handbooks, websites, and policies was conducted in 2019 [13].Researchers evaluated 199 MD-and DO-granting institutions to describe the current parental leave policy in the US [13].Sixty-five schools mentioned parental leave in policy, including 25.2% of MD-granting institutions and 59.1% of DO-granting institutions [13].Of the 26 DO policies, only 30.8% included both the mothers and fathers, 0% addressed the academic year of the student, and 42.3% were included under a medical or personal LOA [13].Investigators confirmed the limited availability of a parental leave policy in the UME [13].In our present review, fewer parental leave policies were identified, which was likely a result of our parental policy definition centering on expectant parents and adoption while excluding medical and personal LOA policies.
Our institution, Rocky Vista University College of Osteopathic Medicine (RVUCOM), approved a pregnant and parenting student policy during our study period.This policy outlines student absences related to pregnancy and childbirth, addressing the return to academics after delivery and parental leaves.Students are encouraged to meet with Student Affairs to arrange an acceptable schedule.Enacting advanced policy measures protects students in their pursuit of both medical education and parenthood.Although time off for expectant parents is not guaranteed, this transition aims to foster a culture of institutional support and proper leave following childbirth.Furthermore, Colorado's Proposition 118 passed in 2020 authorizing paid family and medical leave for 12 weeks, with four additional weeks for pregnancy or childbirth complications for employees [14].Although medical students are not considered employees, the climate changes surrounding pregnancy and childbirth are significant, demonstrating our society's dedication to advancing parental leave practices.
Of note, two authors of this paper (S.R.O. and J.M.B.) had children during medical school prior to university implementation of the pregnant and parenting student leave policy.Continuing medical education in the postpartum period was a complicated matter.Medical leave time after childbirth ranged from 3 days to 8 weeks among our peers; alternatively, students elected to take a gap year.The decision to start a family during medical school was difficult, as each stage poses unique challenges for new parents.However, we appreciate the overlapping roles of a parent and physician and believe that the skills learned will benefit our careers as physicians.We gained empathy, strong communication skills, and time management techniques.As a patient or family member, we learned to advocate for ourselves and others, voicing concerns in a healthcare setting.Overall, the birth of our children benefited us both personally and professionally.We hope UME adopts policies to protect and support students who are starting a family.

Limitations
Unlike US ACGME training programs, robust published literature surrounding parental leave for medical students is lacking.While similarities may be drawn between medical students and residents, students are more vulnerable, which limit comparisons.Students are not employees and may not access employee benefits or insurance coverage.Handbooks may not reflect student advisement in practice; thus, collecting parental leave policy data from these resources limits our current research.Given the paucity of data, it is unclear whether a response rate of 40.5% among Student Affairs personnel provides an accurate representation of parental leave decisions.Furthermore, our research did not include US allopathic medical schools, limiting the generalizability to only osteopathic institutions.Having found only two US osteopathic medical schools with parental leave policies, we did not have robust categorization as prespecified.As schools begin to evolve policy around family matters, we are hopeful that this type of analysis may be made in the future.

Conclusions
Overlapping UME and childbearing years requires standardization of parental leave policies for medical students.Students expect clear, well-defined guidelines, scheduling flexibility, and approachable administrators who understand individual circumstances.ACGME-accredited residency programs and specialty organizations support standardized policies and protocols.Medical schools must follow suit, adopting parental leave options that do not disrupt students' schedules and creatively finding ways for students to continue their education (e.g., parental leave electives counting for educational credit).Melding parenthood and medicine creates a better worklife atmosphere with greater satisfaction for individuals assuming two simultaneously difficult roles.As medical schools adopt parental policies and encourage a familyfriendly environment, students may not have to choose between their medical education and family planning.Instead, trainees will be able to experience the joys of both medicine and parenting.
Research funding: None reported.Author contributions: All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; all authors drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Competing interests: None reported.
(AR) Lake Erie College of Osteopathic Medicine (PA) Rowan University School of Osteopathic Medicine (NJ) A.T. Still University of Health Sciences Kirksville College of Osteopathic Medicine (MO) Liberty University College of Osteopathic Medicine (VA) Sam Houston State University College of Osteopathic Medicine (TX) A.T Still University of Health Sciences School of Osteopathic Medicine in Arizona (AZ) Lincoln Memorial University -DeBusk College of Osteopathic Medicine (TN) Touro College of Osteopathic Medicine -New York (NY) Burrell College of Osteopathic Medicine at New Mexico State University (NM) Marian University College of Osteopathic Medicine (IN) Touro University College of Osteopathic Medicine -California (CA) California Health Sciences University College of Osteopathic Medicine (CA) Michigan State University College of Osteopathic Medicine (MI) Touro University Nevada College of Osteopathic Medicine (NV) Campbell University Jerry M. Wallace School of Osteopathic Medicine (NC) New York Institute of Technology College of Osteopathic Medicine (NY) University of the Incarnate Word School of Osteopathic Medicine (TX) Chicago College of Osteopathic Medicine of Midwestern University (IL) Noorda College of Osteopathic Medicine (UT) University of New England College of Osteopathic Medicine (ME) Des Moines University College of Osteopathic Medicine (IA) Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine (FL) University of North Texas Health Science Center at Fort Worth -Texas College of Osteopathic Medicine (TX) Edward Via College of Osteopathic Medicine -Auburn Campus (AL) Ohio University Heritage College of Osteopathic Medicine (OH) University of Pikeville -Kentucky College of Osteopathic Medicine (KY) Edward Via College of Osteopathic Medicine -Carolinas Campus (SC) Oklahoma State University Center for Health Sciences College of Osteopathic Medicine (OK) West Virginia School of Osteopathic Medicine (WV) Edward Via College of Osteopathic Medicine -Louisiana Campus (LA) Pacific Northwest University of Health Sciences College of Osteopathic Medicine (WA) Western University of Health Sciences College of Osteopathic Medicine of the Pacific (OR) Edward Via College of Osteopathic Medicine -Virginia Campus (VA) Philadelphia College of Osteopathic Medicine (PA) William Carey University College of Osteopathic Medicine (MS)

Figure 1 :
Figure 1: Flow diagram of inclusion, exclusion, and categorization of parental leave policy.