The challenges of pregnancy during residency

A recent study found female residents who became pregnant during residency had significantly lower peer evaluation scores.

Becoming pregnant during residency may negatively affect peer performance evaluations, a recent study found.

Of all internal medicine residents who trained from 2004 to 2014 at Mayo Clinic in Rochester, Minn., female residents who became pregnant during residency had significantly lower peer evaluation scores after pregnancy (a mean of 4.04 out of 5.0) compared to male residents whose spouse had been pregnant (mean of 4.16), according to results published in the June 2017 Journal of General Internal Medicine. Faculty evaluations, however, were not significantly different between groups.

Photo courtesy of Dr Oxentenko
Photo courtesy of Dr. Oxentenko.

ACP Hospitalist recently spoke about the findings with senior author Amy S. Oxentenko, MD, FACP, internal medicine residency program director, professor of medicine, and associate chair of the department of internal medicine at Mayo Clinic in Rochester, Minn.

Q: Why did you decide to study this issue?

A: In many training programs, evaluation scores of residents are important in determining the relative ranking within the residency class. This can have impact for end-of-residency awards or recognition, may impact program letters of recommendation for fellowship, and have other implications. We wondered, “What could be having any influence on ranking that might be preventing any group from being considered in the same fashion as other trainees?”

Q: Did the findings surprise you?

A: Having reviewed other literature, I was not entirely surprised. You would like to think you wouldn't find a difference. You would like to think that everybody would be evaluated based on the work that they're doing. However, maybe there is something important to be learned from this. It may be that following pregnancy for female residents, there is a bigger impact on their day-to-day clinical performance.

Q: What are the implications of the small but significant difference in peer evaluation scores that you discovered?

A: I don't question the statistical significance of it because with over 25,000 peer evaluations, we had a very large number of peer evaluations to compare. But is there a clinically or educationally meaningful difference? I think there probably is, but it would be hard to truly know unless you paired this with a qualitative study looking at all of the comments that trainees put in their peer evaluations of others.

Q: What are some possible reasons why female residents would receive lower peer evaluation scores after pregnancy?

A: There may be several reasons. A woman who comes back from a maternity leave may need to take time away from rounds or any clinical assignment if they're nursing in order to pump. Women also tend to carry a heavier burden of household responsibilities compared to male counterparts. For example, if the child is sick: Are women more apt to be the one to take the day off or leave early to go pick up that sick child compared to male colleagues? Might women be more fatigued after returning from maternity leave compared to male counterparts? Even though both groups might be getting up at night with newborns, the female residents may have more interrupted sleep and demands at night (especially if nursing), leading to them being more fatigued at work the next day. All of those things could be perceived by their peers in rating clinical performance.

Q: Why do you think this difference was apparent in peer evaluations but not in faculty evaluations?

A: I think peers on a team spend much more time with each other compared to faculty, who largely round with the residents but are intermittently present in the afternoon. Faculty complete their evaluations based on the residents presenting, their review of clinical notes, and overall assessment based on rounding observations, so they don't necessarily see what is happening in the afternoon, such as who is dividing up the work. These results would suggest that from the faculty's perception, there is no difference in what they observe in terms of how male versus female residents present on rounds, organize their notes, demonstrate their fund of knowledge, or any of the of the competency-based assessments.

Q: How do you think the peer treatment of pregnant residents has changed over time?

A: You would like to think there has been a change, and hopefully a positive change, because 20 or 30 years ago, pregnancy within training programs was much less common than it is today. In the past, trainees would oftentimes delay pregnancy until after they were done with training. I think there's been mentoring from others to impart, “If you're ready to start a family and it happens to be during your training, maybe you shouldn't delay,” because they've heard anecdotes of people who have delayed having children and then dealt with infertility issues or pregnancy-related complications.

Q: How has Mayo's residency program changed since this study?

A: Since we've done this study, our parental leave policy at our graduate school level has been enhanced. . . . Everyone gets a week of paid parental leave. For the female trainees who have a child during residency, they get the week of paid leave just like their male counterparts, but they are also eligible to get six weeks of paid short-term disability, allowing for up to seven weeks of paid leave, not including any additional paid vacation time or unpaid leave they want to add on. I think this shows a supportive environment. Within our residency, we've also created a protected pump room for those who want to nurse during residency, so it's convenient for them to break away from rounds to do that. And now that we evaluate in a milestone-based fashion, these differences seen in prior Likert-based scoring systems may not be as apparent or significant.