Health care industry struggles to keep pace with ‘tectonic shift’ in paid family leave
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For a growing number of Americans, 12 weeks of paid leave from work after the birth of a child, or to care for an ailing family member, is a standard benefit.
For many health care providers, including physicians and nurses, the reality of such paid leave is much different.
“Many physicians do not have paid leave available,” Santina Wheat, MD, MPH, vice chair of diversity, equity and inclusion in the department of family and community medicine at Northwestern University Feinberg School of Medicine, told Cardiology Today. “My own leave was a combination of short-term disability and vacation time.”
This cobbling together of other types of time off after childbirth is not an isolated anecdote. In 2019, Shannon B. Jeungst, PhD, certified rehabilitation counselor and assistant professor in the Department of Physical Medicine and Rehabilitation at the University of Texas Southwestern Medical Center, and colleagues published a study in JAMA Network Open revealing that attending physicians in the United States took a mean duration of 8 weeks’ paid maternity leave, whereas residents took a mean of 6 weeks. The math here would imply that many of these health care professionals had significantly less paid time than that. In fact, many had none.
However, the obstacles to taking leave do not end with insufficient paid time off. Stigma against taking time off is also common.
“The impact here is twofold. First, these women are miserable because they are being asked to choose between a healthy pregnancy and a job,” Pamela S. Douglas, MD, MACC, FASE, FAHA, Ursula Geller Professor of Research in Cardiovascular Diseases at Duke University and past president of the American College of Cardiology, told Cardiology Today. “Even when they do make that choice, they are then treated badly in ways minor and severe. We are making it very difficult for women to become cardiologists and have a full life with reasonable work-life harmony. That is a big negative for women, but it is also a big negative for men. We are making it difficult for people to live balanced healthy lives, and that can have a direct impact on patient care and safety.”
In a survey of more than 300 U.S. women cardiologists published in March in the Journal of the American College of Cardiology, Douglas and colleagues reported that more than half of respondents responded that pregnancy had an adverse career impact, with most respondents describing troubling or potentially illegal practices, including extra service requirements or a salary decrease. The survey, which examined experiences and policies specific to pregnancy and maternity leave in cardiology, also revealed significant health concerns, including 36.5% of women experiencing pregnancy complications, a rate that is much higher than the general population.
“Nationally, we need to start talking about some minimum standards,” Douglas said. “It has been difficult to get people to agree on that in the world of cardiology. The American Academy of Pediatrics has come out in favor of mandatory paid maternity leave. Cardiology is not ready for that yet, but I think we need to continue and to push. Women who are affected, their colleagues and men who are allies need to continue to push.”
“People can be resentful, make comments and try to negatively impact the careers of people who take leave,” Shikha Jain, MD, FACP, assistant professor of medicine in the division of hematology and oncology at the University of Illinois Cancer Center, said in an interview. “There are people who make others feel guilty or talk badly about people who get pregnant.”
Meanwhile, men who take leave face different kinds of stigma. The increasing participation by men in domestic activities in recent decades has not translated into increasing acceptance that they should have time off to care for a newborn, according to experts.
“Parental leave needs to apply to all parents, regardless of gender and whether or not a parent is the primary caregiver, for all of the reasons that parental leave is important,” Debra F. Weinstein, MD, executive vice dean for academic affairs at the University of Michigan Medical School and chief academic officer at Michigan Medicine, told Cardiology Today.
Eliminating stigmas surrounding family leave could be a positive step toward minimizing some pervasive inequities in health care, including the gender pay gap and the lack of women in decision-making positions.
However, there is another reason for health systems to offer extended paid leave to physicians and staff, according to Orli Cotel, a senior adviser for Paid Leave for the U.S. (PL+US), a 501(c)(3) nonprofit founded in 2016 with the aim of winning paid family and medical leave for working people in the United States.
That reason: Their bottom line.
“When Google increased their paid maternity leave, they saw a massive decrease in attrition,” Cotel said. “But it was not just about doing the right thing. It also helped their bottom line.”
Cotel suggested that administrators in the health care industry have been slow to catch on to the tech sector and other industries, which have learned one important lesson about providing benefits for staff: “Happy employees make good employees who produce results,” she said.
Although some health care institutions have come to terms with this reality, codifying protocols for at least 12 weeks of leave, many are not there yet. Until they do, many health care professionals will be left to struggle with insufficient time off to cope with domestic responsibilities.
‘Beacon of health’?
In a paper published in JAMA Network Open, researchers investigated 27 institutions regarding family leave protocols and reached similar conclusions as Jeungst’s research team. Their findings demonstrated that the mean duration of paid leave for mothers after childbirth was 7.8 weeks, with a range of 0 to 14 weeks. In addition, pay during leave for childbirth ranged from 0% to 100%. There were four institutions in the study that provided no paid leave for childbirth, while more than half of the institutions did not provide leave beyond the recovery time after childbirth.
Broad attempts have been made to rectify this situation. In April 2021, President Joe Biden introduced legislation that would provide federal funding for paid parental leave for all parents for up to 12 weeks. That law has yet to be passed.
However, Biden is not the only figure advocating for prolonged and codified leave. The American Academy of Pediatrics has long argued that a minimum of 12 weeks of paid parental leave can decrease infant mortality, promote parental bonding and increase on-time checkups and vaccination rates.
According to Cotel, the fact that health systems have failed to universally adopt this recommendation has caused myriad problems, not least of which is reduced employee well-being.
“You can’t be a beacon of health in your community if you do not provide basic health benefits to your employees,” she said.
Additionally, the failure of many health systems to provide leave bleeds into the doctor-patient relationship in a specific and potentially belittling way, Cotel said.
“Think about what it does to the morale of a doctor to tell their patients that they need to take 12 weeks off to recover from surgery or pregnancy, but they themselves are not even able to take that much time off,” she said.
Isabel Huang, MD, assistant professor of physical medicine and rehabilitation at the University of Texas Southwestern Medical Center, added that providing paid leave can greatly improve physician well-being and morale.
“Paid parental leave can significantly help a physician feel like a valued member of the system and help physicians live the self-care that we often counsel our own patients on,” she said.
Jain, meanwhile, called for a “culture change” from top to bottom in the medical industry.
“We are health care workers, we should be better than this,” she said. “We care for people, this is what we do. We should take care of ourselves and each other, as well, because it is the right thing to do.”
Whether, and how soon, this will happen remains to be seen. Clashes between employer and employee over salary and benefits are nothing new and may always exist. However, the larger concern surrounding paid leave in health care, for many experts, centers on clashes between personnel.
Avoiding stigma
For many, the primary reason the stigma against taking leave exists centers on the assumption that an absent provider will create an increased workload for colleagues.
However, Weinstein stressed that this should not be the employee’s problem, but the employer’s.
“Our co-workers should be protected from shouldering an unreasonable increase in workload because of reduced staffing that is generally predictable and often, though not always, associated with significant leave time,” she said. “This might be accomplished by staffing with capacity to address a predictable average level of individuals on leave. Avoiding a shift of extra work to colleagues is important for avoiding stigma.”
According to Jain, the challenges involved in taking paid leave differ at various stages of a health care professional’s career.
“If you are a trainee, the main barrier is that concerns will be raised about whether you will be able to adequately complete your training on time,” she said.
Trainees who do become pregnant and take time off may spend a significant portion of their early careers playing catch-up with their classmates and peers. This issue is of particular concern because most providers complete their medical training during their 20s and early 30s — peak childbearing years. It forces many to make hard choices at a young age in a situation that feels unwinnable.
Jain stressed that it could easily become a requirement that trainees are also provided time off for family leave, but many institutions have not yet implemented such provisions. “There are already times in medical training where there is down time,” she said. “It should be a no-brainer to also have paid leave.”
For established professionals who are further along in their careers, one important concern regarding leave is that that they will be burdening their colleagues with extra work while they are out.
The consequences of this stigma are obvious.
“Physician moms often come back early from leave,” Jain said, noting that she has heard anecdotal evidence of mothers returning as soon as 2 weeks postpartum, or without fully recovering from a cesarean section.
Again, data support these claims. Further findings from the Jeungst paper showed that among 844 physician mothers surveyed, 73% stated they did not consider the duration of their leave to be sufficient.
‘Things have changed’
First, it should be noted that although “things have changed” with regard to what is expected of men in terms of domestic contributions in the home, Jain noted that women still tend to shoulder the bulk of these duties.
“Men are doing more than they were 50 years ago,” she said. “But women still have an increased burden of domestic household work.”
Many women are forced to work “four shifts,” Jain added. One shift is professional work. The second covers domestic responsibilities. The third is advocacy, equity or citizenship work.
“Now, we have all of the ancillary and additional responsibilities brought about by COVID,” she said.
However, allowing more male physicians to take — and take longer — paternity leave could help alleviate that situation.
“If we can give paid paternal leave, we can offload some of that work,” Jain said.
Codified paternity leave would also make room for the understanding that care of children is not just the responsibility of the mother, and not just during the newborn period, according to Wheat.
“It might not just impact the stigma of leave but impact the stigma of the men in the workplace leaving for school functions, events or staying home when children are sick,” she added.
To that point, Cotel suggested that there are “vast benefits” to family equity.
“When fathers take paternity leave, their children see better outcomes in the near term and through high school,” she said.
According to Rita Hamad, MD, PhD, associate professor at the Institute for Health Policy Studies and the department of family and community medicine at the University of California, San Francisco, introducing or expanding paternity leave could also help address the “perceived discrimination” many new parents experience.
“In some parts of the medical field that are more male-dominated, encouraging a culture of paid leave among new fathers might help to reduce the challenges and perceived discrimination faced by new parents,” Hamad told Cardiology Today.
Again, the data support these individual anecdotes. In a paper published in JAMA Surgery, Castillo-Angeles and colleagues interviewed 40 surgery program directors in the United States, 28 of whom were male. A paternity leave duration of 1 week was allotted in 20 of these programs.
The interviews resulted in five major themes, as described by the authors:
- “Paternity leave policies are poorly defined by many programs and require self-initiation by residents.”
- “Residents often do not take the full amount of time offered for leave.”
- “Stigma against male residents taking parental leave is common and may be even greater than that facing women taking maternity leave.”
- “Paternity leave has little to no impact on colleagues’ workload owing to the brevity of time taken.”
- “Men desire longer leave than what they are currently offered and wish to receive equal time off compared with childbearing parents.”
“Making sure that paid leave is available to parents of all genders, including the childbearing and non-childbearing parent, is also important for same-sex couples,” Hamad said.
According to Weinstein, the lack of paid paternity leave contributes to another systemic problem within the health care industry.
“It also undermines professional opportunities and advancement for women,” she said.
One important byproduct of lost opportunities for women is the gender pay gap.
‘Handcuffed to the current system’
In a paper published in Health Care Management Review, researchers assessed 46 articles published since 2000 that included data related to physician pay. The findings were both sobering and unsurprising.
“Across almost all studies, female doctors earn significantly less than men, often tens of thousands of dollars less annually, despite similar demographic and work-related profiles,” they wrote. “This earnings gap is persistent across time, medical specialty, and country of practice.”
Huang suggested that in some cases, taking leave is not only unpaid, but also costly to the practitioner.
“Some physicians are even liable for the overhead costs of the practice, which results in a deficit during their leave,” she said.
According to Wheat, providing paid leave can help close the wage gap by allowing parents to stay within the workforce and not lose the hours of work that often compound the issue. “For some, it may also increase the likelihood that they return full time and continue to progress in lines for special projects and promotions,” she said.
Lower pay for similar work is just one component of the wage gap. In a paper published in JAMA Network Open, researchers looked at leadership positions in oncology. Among 6,030 total faculty, just 35.9% were women, according to the findings. In addition, women filled 21.7% of chair positions in medical oncology, 11.7% in radiation oncology and just 3.8% in surgical oncology.
“While we are seeing more women ascend to leadership positions, decision-makers in health care are still predominantly men,” Jain said.
Most estimates show that women make up less than one-fifth of medical school deans, for example, she added.
“The hierarchical structure perpetuates the same biases no matter how many women are in the workforce,” Jain said. “Because of perceptions that they will take leave for childbirth or carry the burden of child care once the children are grown, women are not being offered promotions, awards or collaborations.”
Moreover, when the men in leadership positions are looking for their own replacement — often after staying in said position for many years — they frequently pass the torch to another man.
“We need to take a hard look at this antiquated leadership structure,” Jain said. “Otherwise we will stay handcuffed to the current system, and we will lose strong women from important positions in our health care system.”
Given these circumstances, most employees tend to be on board with the advancement and adoption of universal paid leave policies. They understand the benefits to their careers, their families and the equitability of the health care system overall, according to experts. The people who need to be convinced, then, are not the employees but the employers.
‘Tectonic shift’
“Unfortunately, health care in recent decades has been run like a corporation rather than a system that is set up to take care of people,” Jain said.
This kind of thinking, in many ways, has led to the current situation with paid leave. According to Huang, many health system administrators and executives fail to recognize that providing better benefits to all employees can produce far-reaching advantages.
“Providing paid leave would create a greater level of job satisfaction and increase the retention rate of physicians in their hospital or health system, especially in the competitive market that we have today,” Huang said.
Cotel underscored this point by stressing that what executives in the tech sector learned — and what was replicated by Walmart, Target, Starbucks and other large national employers — is that when a valued and experienced employee quits, the resources required to find and train someone new are significant.
“Executives in many industries have learned that the cost-benefit of recruitment and talent retention vs. attrition helps their bottom line,” she said.
Hamad called on health care administrators to not only recognize this financial reality, but act on it.
“Employers can institute their own paid leave policies, and they should also lean into advocacy to encourage their state and federal policymakers to provide paid leave for all employees,” she said.
Douglas said paid leave policies should be considered part of what allows for a more diverse workplace, which benefits both providers and patients.
“If we treat people badly, we cannot expect people to want to join our profession,” Douglas said. “We are not diverse, which means we have an opportunity to improve our decisions and our care to the communities that we serve. This is all brand new, and cardiology is on the right path. The ACC is very much concerned about this issue, and groups like Women as One are also pushing for a pregnancy standard. We just need to keep pushing.”
As Cotel suggested, the tide is turning.
“There has been a tectonic shift in the last 5 years in terms of improvements in paid leave benefits across a number of industries,” she said. “If you are an employer and want to remain competitive in the marketplace, you no longer ask, ‘How can I afford to provide paid leave?’ The question is now, ‘How can I afford not to?’”
- References:
- Castillo-Angeles M, et al. JAMA Surg. 2022;doi:10.1001/jamasurg.2021.6223.
- Chowdhary M, et al. JAMA Netw Open. 2020;doi:10.1001/jamanetworkopen.2020.0708.
- Gulati M, et al. J Am Coll Cardiol. 2022;doi:10.1016/j.jacc.2021.12.034.
- Hoff T, et al. Health Care Manage Rev. 2021;doi: 10.1097/HMR.0000000000000290.
- Jeungst SB, et al. JAMA Netw Open. 2019;doi:10.1001/jamanetworkopen.2019.13054.
- Lu D, et al. JAMA Netw Open. 2021;doi:10.1001/jamanetworkopen.2021.8518.
- For more information:
- Orli Cotel can be reached at orli.cotel@gmail.com.
- Pamela S. Douglas, MD, MACC, FASE, FAHA, can be reached at pamela.douglas@duke.edu; Twitter: @pamelasdouglas.
- Rita Hamad, MD, PhD, can be reached at 995 Potrero Ave., Building 80, Ward 83, San Francisco, CA 94110; email: rita.hamad@ucsf.edu.
- Isabel Huang, MD, can be reached at 5201 Harry Hines Blvd, Dallas, TX 75235; email: remekca.owens@utsouthwestern.edu.
- Shikha Jain, MD, can be reached at 1818 West Taylor, Hematology/Oncology Clinic, Chicago, IL, 60612; email: sjain03@gmail.com.
- Santina Wheat, MD, MPH, can be reached at 2750 W North, Chicago, IL 60647; email: swheat@eriefamilyhealth.org.
- Deborah F. Weinstein, MD, can be reached at 7310B, Med Sci 1, 1301 Catherine St., Ann Arbor, MI 48109; email: dfwein@med.umich.edu; johnsoma@med.umich.edu.
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