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The Use of Parenting Electives in Pediatric Residency

Published:December 02, 2021DOI:https://doi.org/10.1016/j.acap.2021.11.017

      Abstract

      Background

      Financial considerations and the desire to not prolong training often influence residents’ parental leave length. Some residencies offer parenting electives. These primarily self-directed electives can extend parental time at home, support transition back to work, and allow residents to remain in training and be paid during these transitions.

      Objective

      Describe the prevalence and structure of parenting electives within pediatric residency programs from 3 geographic regions of the Association of Pediatric Program Directors (APPD).

      Methods

      All 66 pediatric residency program directors in the Western, Mid-America, and Northeastern regions of APPD were invited to participate in a phone interview regarding existence of and structure of their programs’ parenting elective.

      Results

      Thirty-six programs responded (55%). Of those, 24 (67% of responding programs) offer a specific parenting elective and an additional 5 (14%) offer a generic elective that can be tailored to new parents. Curricular elements shared by almost all programs offering specific parenting electives include self-reflective exercises, exploration of a community resource, and parenting articles/book review. Most programs incorporate clinic but not call into these electives.

      Conclusion

      Parenting electives are increasingly available in pediatric residency programs to support new resident parents. Sharing common curricular elements may help other programs implement and/or enhance this elective offering.

      Keywords

      What's New
      Parenting electives support new resident parents but are underdescribed in the literature. Our study found several residency programs offer elective experiences for new parents, with the majority of electives incorporating self-directed learning and clinic and the minority incorporating call.

      Background

      In November 2019, the American Academy of Family Physicians (AAFP) and the American Academy of Pediatrics (AAP) resolved to support a minimum of 12 weeks paid leave for parents of a newly born or adopted child, including physicians and residents.

      Resolution #99T 2020 Annual Leadership Forum TITLE: Paid Parental Leave and Mother/Baby-Friendly Workplaces Sponsored By: Section on Neonatal-Perinatal Medicine, Council on Community Pediatrics. Available at: https://apps.appd.org/pdf/AAP_ALF_Resolution_Nov2019.pdf. Accessed January 4, 2022

      The American Board of Pediatrics (ABP) in their Absences from Training Policy, requires 33 months of clinical training for “satisfactory” completion of general pediatrics residency,

      American Board of Pediatrics, Absences from training policy general pediatrics training irregularities | The American Board of Pediatrics (abp.org)

      allowing for 1 month/year to be used for vacation or leave, although this time is primarily used by residencies to support vacation. While the ABP states that the program director (PD) may submit a waiver for up to 8 additional weeks of elective training for family or medical leave,

      American Board of Pediatrics, Absences from training policy general pediatrics training irregularities | The American Board of Pediatrics (abp.org)

      the use of this waiver is variable from program to program. Previous research has shown that factors influencing resident's choice of parental leave length include the desire to not extend training or delay fellowship start, as well as financial considerations.
      • Stack SW
      • Jagsi R
      • Biermann JS
      • et al.
      Maternity leave in residency: a multicenter study of determinants and wellness outcomes.
      In popular culture, it is also recognized that parents may be returning to work, or entering the “fifth trimester,” before they are physically or emotionally ready and where tailed supports are often needed.
      • Brody LS.
      The Fifth Trimester: The Working Mom’s Guide to Style, Sanity, and Success After Baby.
      Further, there is the idea that parenting itself is training in pediatrics and time at home with children helps develop skills that can enhance residents’ pediatric training.
      • Pitt MB
      • Klein MD
      Parenting while becoming a pediatrician – an area ripe for study and improvement.
      ,
      • Wilder JL
      • Pingree EW
      • Hark CM
      • et al.
      Pediatric trainees as parents: perspectives on parenthood from pediatric resident parents.
      Due to these reasons, some residencies leverage parenting electives to allow residents to remain in training, continue to be paid, and maximize time at home with new children. However, there is a paucity of studies around this topic and none that describe the prevalence or structure of parenting electives.
      We conducted a survey-based study assessing the number of pediatric residency programs in 3 regions of the Association of Pediatric Program Directors (APPD) that had a parenting elective and what curricular elements were included in the elective.

      Methods

      Survey Administration

      We conducted a cross-sectional survey of pediatric program directors in 3 of the 8 regions of the APPD (Northeast, Mid-America, and Western) from January 2020 to January 2021. These regions were chosen because they offered a diversity of geography, program size, and program type and allowed for a more focused group of programs to target in order to ensure an adequate response rate. Email invitations were sent to all the pediatric program directors in these regions inviting them to participate in a phone interview about their programs’ parental leave policies and ways they help transition residents back to work. Phone interviews were conducted utilizing a prepiloted script and lasted approximately 30 minutes. Participants’ answers were recorded by the interviewer in RedCap. Email reminders were sent to nonresponders giving them an option to participate in the phone interview or in a web-based survey in lieu of the phone interview (also through RedCap) in order to offer flexibility of completion, though only one program ultimately chose to respond using the web-based survey. The Institutional Review Boards of the represented institutions deemed this study exempt.

      Survey Content

      The phone interview script and survey were developed after literature search and iteratively revised after pilot testing with 3 current or former PDs at 3 institutions. The survey included 3 domains: presence or absence of a parenting elective, characteristics of a parenting elective if present, including who is allowed to participate and for how long, and finally, the curricular and clinical elements included. All questions were either multiple choice, choose all that apply, or open-ended. Participants were asked to share copies of their curriculum which were used for referencing to ensure accuracy of survey answers.

      Data Analysis

      Statistical analysis was descriptive in nature, with calculation of frequencies and percentages for categorical response variables. Membership data were obtained from the APPD as well as publicly available residency program websites.

      Results

      The overall survey response rate was 55% (36/66) with the response rate varying by region (Table 1).
      Table 1Survey Responses
      Total Number of Programs in RegionnPercent
      Total663655
       Northeast12867
       Mid-America251768
       Western291138
      Does your program offer a Parenting elective? (n = 36)Yes

      n (%)
      No

      n (%)
      Not officially but elective can be tailored

      n (%)
      24 (67%)7 (19%)5 (14%)
      How long has your program been offering elective? (n = 23)≤5 y

      n (%)
      ≥5 y

      n (%)
      12 (52%)11 (48%)
      Has anyone taken the elective who was not expecting or a new parent? (n = 22)Yes

      n (%)
      No

      n (%)
      Unsure

      n (%)
      12 (55%)10 (45%)0 (0%)
      How long is the elective? (n = 23)2 wk

      n (%)
      4 wk

      n (%)
      Other

      n (%)
      1 (4%)18 (78%)4 (17%)
      Twenty-four out of the 36 responding programs (67%) endorsed the presence of a specific parenting elective. Five programs (14%) did not have a specific parenting elective but offered an elective that could be tailored to new parents. Among programs with a specific parenting elective, 12 (50%) have been offering the elective for ≤5 years, and of these 12, 6 have been offering the elective for 1 year or less. In 55% of programs (12/22 with 2 programs not responding to this question), nonparents have also participated in the elective. Curricular elements shared by ≥90% of programs with a specific parenting elective included self-reflective exercises, parenting book review, reading parenting-based articles, and exploring a community resource (Figure). Most programs required clinic time during the elective but not call. Common curricular resources utilized, based on review of available programs’ curriculums, are listed in Table 2.
      Figure
      FigureCurricular elements utilized in parenting electives.
      Table 2Curricular Resources
      Books
      GeneralHeading Home with Your Newborn-Jana&Shu
      What to Expect the First Year-Murkoff
      Mommy Calls-Altmann
      The Baby Book-Sears
      BreastfeedingThe Breastfeeding Book-Sears
      New Mother's Guide to Breastfeeding-Meek
      SleepThe No-Cry Sleep Solution-Pantley
      Sleeping Through the Night-Mindell
      Healthy Sleep Habits, Happy Baby-Weissbluth
      Discipline1-2-3 Magic-Phelan
      Raising Your Spirited Child-Kurcinka
      Discipline that Lasts a Lifetime-Guarendi
      DadsNew Father: A Dad's Guide to the First Year-Brott
      Dad to Dad: Parenting Like a Pro-Hill
      VaccinesThe Vaccine Book-Sears
      PrematurityThe Premature Baby Book-Sears
      Preemies: The Essential Guide for Parents of Premature Babies-Linden
      OthersHappiest Baby on The Block-Karp
      Babies with Down Syndrome-Skallerup
      Siblings Without Rivalry-Faber & Mazlish
      The Fifth Trimester-Brody
      Articles
      Parenting in ResidencyThe Impact of Parental Leave on Extending Training-Mayo Clin Proc 2006
      Female Physicians: Balancing Career and Family-Acad Psychiatry 2004
      Juggling Work and Breastfeeding- Pediatrics, 2009
      A Mother's Gold-JAMA, 2021
      PostpartumWarning Signs of Health Problems After Birth-March of Dimes website
      Overview of the Postdelivery (Postpartum) Period-Merck Manuals website
      Lost Mothers: Maternal Mortality in the U.S.-NPR News website
      ColicColic-Peds in Review, 2012
      When Your Baby Won't Stop Crying-HelpGuide website
      Managing Infants Who Cry Excessively in the First Few Months of Life-BMJ 2011
      Feeding/SolidsStarting Solid Foods-Healthychildren.org
      Baby-Led Weaning-Parents.com
      CircumcisionCircumcision Policy Statement-Pediatrics September 2012
      Videos/Modules/Websites
      VideosHappiest Baby on the Block
      Birth and Beyond app-Gobal Health Media
      FirstDroplets.com-Stanford Medicine
      ModulesYale curriculum-Fatherhood, Colic, Breastfeeding, Formula Feeding, Attachment
      Mt. Sinai Parenting Curriculum
      AAP Prepared Presentations
      American Academy of Dermatology-birthmarks and newborn skin disease
      WebsitesDr. Milk
      MomMD
      CDC-Developmental Milestones
      Pathways.org

      Discussion

      In our study, we found there was an increasing number of programs in the Northeast, Mid-American, and Western regions of the APPD offering parenting electives. These electives allow residents to maximize time at home with a new child after leave while remaining in training and getting paid. Several studies have shown longer parental leaves result in benefits to maternal and infant health, including increased duration of breastfeeding.
      • Dagher RK
      • McGovern PM
      • Dowd BE.
      Maternity leave duration and postpartum mental and physical health: Implications for leave policies.
      ,
      • Gault B
      • Hartmann H
      • Hegewisch A
      • et al.
      Paid Parental Leave in the United States: What the Data Tell us About Access, Usage, and Economic and Health Benefits.
      ,
      • McGovern P
      • Dowd B
      • Gjerdingen D
      • et al.
      Mothers’ health and work-related factors at 11 weeks postpartum.
      Residents, and in particular, new resident parents, often take shorter medical leaves than what the family medical leave act (FMLA) allows or what is recommended by the American Academy of Pediatrics (AAP). The multicenter study by Stack et al showed that the median maternity leave length was 7 weeks with more residents taking 6 weeks of leave.
      • Stack SW
      • Jagsi R
      • Biermann JS
      • et al.
      Maternity leave in residency: a multicenter study of determinants and wellness outcomes.
      In the study by Cree-Green et al, mothers, and partners who had the opportunity to take a structured neonatal elective significantly increased time at home after becoming a parent compared to times prior to implementation of the elective.
      • Cree-Green M
      • Cree J
      • Urban K
      • et al.
      A structured neonatal parenting elective: an approach for parenting leave during residency.
      While parenting electives do not increase parental leave, the increased time at home involved in independent study can help facilitate transition back to work, breastfeeding, and parental bonding. In the recent study by Wilder et al, residents appreciated having the option of a parenting elective which allowed them to leverage “learning about newborn care and child development from one's own child”.
      • Wilder JL
      • Pingree EW
      • Hark CM
      • et al.
      Pediatric trainees as parents: perspectives on parenthood from pediatric resident parents.
      In our study, the curricular elements most utilized in parenting electives included self-reflective exercises, parenting book reviews, reading parenting-based articles, and exploring a community resource. Many programs offer the resident a list of approved activities to choose from to further increase flexibility and promote self-directed learning. Self-reflective exercises (example: writing an essay about how parenthood has changed them or what it is like to be a patient instead of a provider) have been shown to increase humanization in medicine.
      • Charon R.
      The patient-physician relationship. Narrative medicine: a model for empathy, reflection, profession, and trust.
      Reading a parenting book and writing a review and reading parenting-based articles also have the potential to help residents learn parenting advice not formally covered in residency. Exploring a community resource, such as getting a car seat inspected or going to a breastfeeding support group, helps residents learn about their local community, augmenting their skills both as a parent and referring pediatrician. Similar to community pediatric electives, these experiences are valuable as it has been shown that pediatricians exposed to the community during residency report greater participation in community activities later.
      • Minkovitz CS
      • Goldshore M
      • Solomon BS
      • et al.
      Community pediatrics training initiative workgroup. Five-year follow-up of community pediatrics training initiative.
      While a slight majority of programs in our study have had nonparents participate in parenting electives, given the potential benefits of this type of elective in enhancing pediatric training, this could be a future area of discussion and study.
      Finally, it was interesting to note that most programs included clinical responsibilities during the parenting elective, although most did this by including clinic time and not call. This approach makes sense as programs consider how best to use these electives to support a thoughtful return to work approach, including helping residents manage the often concurrent challenges of finding childcare services and lactation facilities, before having to return to busier clinical services. In a similar way, the Stanford Emergency Medicine Department created a specific return-to-work policy for new resident parents in 2017 which included no overnight shifts, no sick call, and no more than 3 shifts in a row to help smooth the transition back to clinical duties.
      • Gordon AJ
      • Sebok-Syer SS
      • Dohn AM
      • et al.
      The birth of a return to work policy for new resident parents in emergency medicine.
      As employers and residencies wrestle with how to best support new parents returning to work in the fifth trimester, these electives offer an intentional space for innovation and supports.
      This study answers the call recently laid out in the article by Pitt and Klein to “disseminate replicable approaches to address the challenges common to parent trainees.”
      • Pitt MB
      • Klein MD
      Parenting while becoming a pediatrician – an area ripe for study and improvement.
      We hope that disseminating this information will encourage programs who do not have a parenting elective to adopt one as well as to provide commonly utilized curricular resources.
      Our study has limitations including possible sampling bias from PDs who were more likely to respond if they personally knew the investigator(s). There could have also been response bias by PDs who were overall more interested in the topic or who already had certain policies and/or electives in place. While a priori sampling bias could be argued, the 3 regions are diverse not only geographically but by type and size of program. Finally, the study is limited by outcomes reported by program directors, who oversee but do not experience these electives. Future areas of study should examine the experience and perceived value of these electives and curricular activities from the perspective of trainees as well as the utilization and impact of these electives on overall leave outcomes.

      Conclusion

      Parenting electives can be a useful curricular offering for new resident parents both in their transition back to the workforce and in enhancing their pediatric training. Sharing commonly used curricular elements can help programs implement or enhance this important elective.

      Acknowledgments

      This project was unfunded.

      References

      1. Resolution #99T 2020 Annual Leadership Forum TITLE: Paid Parental Leave and Mother/Baby-Friendly Workplaces Sponsored By: Section on Neonatal-Perinatal Medicine, Council on Community Pediatrics. Available at: https://apps.appd.org/pdf/AAP_ALF_Resolution_Nov2019.pdf. Accessed January 4, 2022

      2. American Board of Pediatrics, Absences from training policy general pediatrics training irregularities | The American Board of Pediatrics (abp.org)

        • Stack SW
        • Jagsi R
        • Biermann JS
        • et al.
        Maternity leave in residency: a multicenter study of determinants and wellness outcomes.
        Acad Med. 2019; 94: 1738-1745https://doi.org/10.1097/ACM.0000000000002780
        • Brody LS.
        The Fifth Trimester: The Working Mom’s Guide to Style, Sanity, and Success After Baby.
        1st ed. Doubleday, New York, NY2017
        • Pitt MB
        • Klein MD
        Parenting while becoming a pediatrician – an area ripe for study and improvement.
        Acad Pediatr. 2021; 21: 925-926https://doi.org/10.1016/j.acap.2021.05.014
        • Wilder JL
        • Pingree EW
        • Hark CM
        • et al.
        Pediatric trainees as parents: perspectives on parenthood from pediatric resident parents.
        Acad Pediatr. 2021; 21: 934-942https://doi.org/10.1016/j.acap.2021.04.009
        • Dagher RK
        • McGovern PM
        • Dowd BE.
        Maternity leave duration and postpartum mental and physical health: Implications for leave policies.
        J Health Polit Policy Law. 2014; 39: 369-416
        • Gault B
        • Hartmann H
        • Hegewisch A
        • et al.
        Paid Parental Leave in the United States: What the Data Tell us About Access, Usage, and Economic and Health Benefits.
        Institute for Women's Policy Research, Washington, DC2014
        • McGovern P
        • Dowd B
        • Gjerdingen D
        • et al.
        Mothers’ health and work-related factors at 11 weeks postpartum.
        Ann Fam Med. 2007; 5: 519-527https://doi.org/10.1370/afm.751
        • Cree-Green M
        • Cree J
        • Urban K
        • et al.
        A structured neonatal parenting elective: an approach for parenting leave during residency.
        Acad Pediatr. 2020; 20: 595-599https://doi.org/10.1016/j.acap.2020.02.008
        • Charon R.
        The patient-physician relationship. Narrative medicine: a model for empathy, reflection, profession, and trust.
        JAMA. 2001; 286: 1897-1902https://doi.org/10.1001/jama.286.15.1897
        • Minkovitz CS
        • Goldshore M
        • Solomon BS
        • et al.
        Community pediatrics training initiative workgroup. Five-year follow-up of community pediatrics training initiative.
        Pediatrics. 2014; 134: 83-90https://doi.org/10.1542/peds.2013-3357
        • Gordon AJ
        • Sebok-Syer SS
        • Dohn AM
        • et al.
        The birth of a return to work policy for new resident parents in emergency medicine.
        Acad Emerg Med. 2019; 26: 317-326https://doi.org/10.1111/acem.13684