A Chance for Meaningful Parental Leave During Residency

Last year, the ABMS–the umbrella consortium of medical specialties–waded into the established toxic mess of medical training schedules with a new mandate to provide trainees with a nonpunitive way to be parents, caretakers, or just sick:

Starting in July 2021, all ABMS Member Boards with training programs of two or more years duration will allow for a minimum of six weeks away once during training for purposes of parental, caregiver, and medical leave, without exhausting time allowed for vacation or sick leave and without requiring an extension in training. Member Boards must communicate when a leave of absence will require an official extension to help mitigate the negative impact on a physician’s career trajectory that a training extension may have, such as delaying a fellowship or moving into a full, salaried position.

6 weeks over the course of an entire residency may not seem like much given the vagaries of life, but it’s a better floor than many programs currently offer. A graduation delay sucks, and it’s the kind of punishment for living your life that causes many doctors to put off big milestones like starting a family. Medical training already takes a long time, and ~1 in 4 female physicians struggle with infertility (and in that study, 17% of those struggling would have picked a different specialty).

This issue is being addressed across medicine, but we’re going to discuss it in the context of radiology because I am a radiologist.

The American Board of Radiology’s recent attempt at how such language should look has drawn some ire on Twitter. Here is their email to program directors that’s been making the rounds:

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They proposed that a program “may” grant up to 6 weeks of leave over the course of residency for parental/caregiver/medical leave as a maximum without needing to extend residency at the tail end. The language here doesn’t even meet the ABMS mandate, which again states that a program “will” provide a “minimum” of 6 weeks (and explicitly states that said 6 weeks of leave shouldn’t be counted against regular sick time).

The ABR could have simply taken the straightforward approach of parroting the ABMS mandate. They could have–even better–taken the higher ground with an effort to trailblaze the first generous specialty-wide parental leave policy in modern medicine.

Instead, they have advocated for a maximum of six weeks, because any more and they feel they wouldn’t be able to “support the current length of required training.” As in, if a mom gets 3 months off to care for a newborn then the whole system falls apart.

I think they realized it would be prudent to ask for feedback first and then make the plan because a new softer blog post removes any specific language:

We need your input to develop a policy that appropriately balances the need for personal time including vacation as well as parental, caregiver, and/or medical leave with the need for adequate training. 

It is important to realize that the ABR is not restricting the amount of time an institution might choose to allow for parental, caregiver, and/or medical leave, nor are we limiting the amount of vacation a residency program might choose to provide. These are local decisions and the ABR does not presume to make these determinations. However, above a certain limit (not yet determined), an extension of training might be needed to satisfy the requirement for completion of the residency. 

Of course, in the original proposal, the ABR literally did want to limit program vacation (to 4 weeks, see above).

After the mishandling of the “ABR agreement” debacle and the initial we-can’t-do-remote-testing Covid pseudo-plan and now this, I hope the ABR will eventually come to the conclusion that stakeholders matter and that we can make radiology better by working together as a community.

Radiology is a “male-dominated” field, but it shouldn’t be. A public relations win here could make all the difference.

Plenty of Slack

I think there are more than six weeks of slack in our 4-year training paradigm, and it’s hard to argue otherwise.

When the ABR created the Core Exam and placed it at the of the PGY4/R3 year, they created a system where a successful radiology resident has proven (caveat: to the ABR) that they are competent to practice radiology before their senior year. It created a system where the fourth year of residency was opened up largely to a choose-you-own-adventure style of highly variable impact.

We have ESIR residents who spend most of their fourth-year doing IR, and we have accelerated nuclear medicine pathway residents that do a nuclear medicine fellowship integrated into their residency. There are folks early specializing into two-year neuroradiology fellowships during senior year, and others who take a bevy of random electives that they may never use again in clinical practice.1

We have many programs with a whole host of extracurricular “tracks” where residents might spend protected time every week doing research, quality improvement, or clinician-educator activities. I would know, I did all three during my residency. We have residents doing research electives and all kinds of other interesting things that may worthwhile but have no positive impact on their ability to practice radiology clinically, which is the primary purpose of residency training.

A hypothetical example: Take a research track resident with one half-day protected time every week for 40 weeks a year (say because of 8 weeks of night float and 4 weeks of vacation). That’s 20 days a year of reduced clinical activity. 20 working days is basically a month. If they have their R1 year to just focus on learning radiology before taking call, then over the next three years that resident would be “missing” 3 months of clinical time. But no one is seriously arguing that these tracks should postpone residency graduation.

We already have a system where there are minimum case requirements for residents to complete residency training. Last I checked, the ABR is certifying radiologists in the domain of clinical radiology, not their number of peer-reviewed publications or ability to do a sick root cause analysis.

Radiology residency may be four years after a clinical internship, but it’s clear that there is no standard radiology training program clinical “length” despite that fixed duration. Some residents are already doing far fewer months.

No one is adding up diagnostic work hours and saying you need 48 weeks/yr * 52 hours/wk * 4 years = 9,984 hours.

It’s not a thing, and it shouldn’t be.

Competency-based Assessment and Reasonable Limits

The core problem is that we have time-based residencies masquerading as a proxy for competency. You don’t magically become competent when you graduate. Competency is a continuum. Hiring trainees for a set number of years is convenient. It’s easy to schedule. It’s easy to budget. But it’s an artifact of convenience, not a mission-critical component of clinical growth.

There are R3 residents who are ready for the big leagues, and there are practicing doctors who should honestly move back down to the minors. No one is going to argue that a little more training makes you worse. But the logic that more is better gets us to the unsustainable current state of affairs, where doctors are accumulating more and more training to become hyper-specialized in the least efficient way possible while non-physician providers bypass our residency/fellowship paradigm to do similar jobs with zero training.

We all get better with deliberate practice. The question isn’t: is more better? The question is how much less is still enough for independent practice?

Obviously, the ABMS member boards like the ABR don’t exactly have the power to force institutions to change policies directly, and they probably don’t want to. But they do set the stage by mandating the criteria for board eligibility.

I would argue that the ABR should set a minimum threshold and no maximum. If a program is happy with that resident’s progress and they pass the Core Exam, then consider the boxes checked. Let everyone be treated with dignity and then give the programs the flexibility to compete in the marketplace of support.

When my son was born, I was able to take 4 days of sick time and then went straight into night float. That’s bullshit. You want to see motivation? Tell an expecting resident that if they’re a total champion that they can spend as much time as they need with their baby without delaying graduation.

Less than 6 weeks is unacceptable. And while a 6-week minimum is an improvement, I think the true minimum consistent with current training practices that should also have a chance of being implemented is three months.

I’d love to see six months or more. I don’t think that’s going to happen as a minimum, and there’s a very reasonable argument against it as underperforming residents really may need some of that time back. It would be nice to see language that demands 3 months, has no maximum, and strongly encourages programs to work with residents on a case-by-case basis to ensure they are ready for graduation with however much time they have.

But the first step is to have a minimum that doesn’t punish women who want to stay home with their infants until they’re done cluster feeding. Convince me otherwise.

Fairness

The ABR doesn’t use the language of “fairness” in their email, but I suspect the perception of fairness is at play. It’s almost always at play when older doctors consider policies that might benefit younger physicians. It’s the I-did-it-this-way-and-I’m-amazing-so-it-must-be-an-integral-part-of-the process. It’s the hazing.

Right now, some lucky residents across the country get varying degrees of time “off” thanks to PD support in the form of research electives, reading electives, and program staff simply looking the other way. We need to standardize a fair minimum that enables programs to provide a consistent humane process and not just put trainees solely at the mercy of their PDs and local GME office.

Yes, it’s true that if you allow parents time to be parents or people to take care of loved ones or people time to recover from illness that some residents will work fewer months than others. Every resident has their unique experience, but a policy change will also mean that every resident may not have a similar “paper” experience. That’s a fact.

Some people will say, that’s not fair. That it’s not fair to single residents or non-parents. That it’s not fair to the able-bodied. Or to those whose aging parents are healthy or have the resources to support themselves.

But let me provide a counterpoint:

I don’t think fairness means that every single resident has to have the exact same experience. They already don’t. I think fairness means we treat humans with the respect and compassion that every person deserves. I want to live in a world where everyone gets time to be a parent, even if yes, that world means that some doctors may have a career that is a few months shorter.

I think fairness means not punishing people when life happens just because making people jump through hoops makes it easier to check a box.

If you’re ready to practice, you’re ready.

If we need to reassess the validity of an exclusively time-based (instead of competency-based) training paradigm in order to do that, then let’s get to it.

The ABR is accepting feedback until April 15.

Physics is now just another Core Exam section

Probably the biggest news in radiology over the past year (at least for residents) was the announcement that the upcoming and all future ABR examinations were moving to an online remote/virtual format. That’s worked out pretty well so far.

One bit of nice unexpected news that was announced very quietly this week was that the ABR Core Exam, the first and only meaningful component of the radiology exam certification cycle, would no longer have a separately-graded physics section that could–by itself–prevent overall exam passage. Physics will still comprise an unchanged amount of the test but will be graded as just another section along with all the rest: a component for overall passage but not a section that examinees can “condition” and be forced to retake at a later time.

Holding physics somewhat apart was a holdover from the pre-Core Exam era when there was a completely separated dedicated physics exam.

The ABR made this decision during the grading process just last week. I’m sure that recent examinees would have really appreciated this information during their studies, but timing aside I fully support the ABR’s choice here. Strong move. What’s next?

Leadership and Resident Satisfaction

It’s residency Rank Order List season, and I thought I’d share a paper published in AJR from 2016 titled, “Radiology Resident’ Satisfaction With Their Training and Education in the United States: Effect of Program Directors, Teaching Faculty, and Other Factors on Program Success.”

It was a small study where the authors surveyed 217 radiology residents.

Of that group, 168/216 (77.8%) of residents were satisfied overall with their residency programs.

You’re always going to have some sour grapes, and it’s not possible from the data to figure out how much of that fraction might be related to noncontrollable factors like the city, the stresses of dealing with student loans, or other factors. But as the authors noted, that’s a big difference from the golden era:

This is lower than reported in similar previous national surveys conducted by the American College of Radiology, which reported a 97.8% level of job satisfaction of radiology trainees in 2003, and 97.6% level of job satisfaction in 1995.

Like with internet comments and product reviews, convenience surveys always lean toward the dissatisfied. But the data are still interesting because they can highlight the causes for dissatisfaction, even if they play an outsize role compared to the general community.

The three sub-categories with the greatest correlation with overall satisfaction were satisfaction with the program director and administrative office, daily workstation experience, and faculty.

So basically everything.

But of the three, the program director and administration were by far the most dominant. I suspect it’s more of a break not make scenario:

The factor with the greatest correlation to satisfaction with the program director and administrative office is how approachable and responsive the administration is to resident concerns.

A good program director may help make a program, but a bad one can definitely tank one.

A good PD is both a boss and an advocate. While not all trainee complaints are necessarily fixable (or even reasonable), accountability, transparency, and attentiveness aren’t something to take for granted in program leadership. Culture colors everything.

It might be impossible to change the culture of the hospital. It might be impossible to reduce RVU pressures on faculty or improve mediocre teachers. So the survey is actually good news because the program leadership is far more mutable.

There was one throwaway statistic they reference from a 2003 study that ties into the daily workstation experience/faculty components:

A survey with 132 junior radiologists revealed that 68% of the responders left academia after an average of 3.28 years because of low pay and lack of academic time.

That was almost 20 years ago, and the RVU pressure and lack of academic time have gotten worse since then. I wonder what that number is now.

My group is extremely stable, but I’ve seen a ton of turnover amounts young attendings in both academia and private practice. I don’t think enough practices of any variety are willing to allow for a Goldilocks approach between productivity and revenue.

The ABR dreams of a low-cost world

The February 2021 issue of the BEAM features a short article with the title, “Board, Staff Working Together to Control Expenses.

As the Board of Governors discussed these new [remote] exam tools, one of the perceived potential benefits was the intuitive opportunity to decrease costs and, by extension, reduce fees. However, there are persistent barriers to fee abatement at the time of this writing, including the absence of proven success of the new exam structure; a lack of dependable forecasts of the future steady-state expense structure; the inherent long-term nature of established financial obligations related to exam center equipment and leases; and the unexpected short-term development costs of the virtual exam platform software.

Proven success? Check.

Does any stakeholder believe that ~$50 million in cash reserves isn’t enough to deal with “a lack of dependable forecasts of the future steady-state expense structure” [sic]?

They continue (emphasis mine):

ABR senior leadership is committed to working with the board to control costs. We are optimistic that this is achievable as we close in on the “new normal,” but we don’t know the extent of potential cost reductions, nor when they might be achieved. The less visible infrastructure elements of board functions, ranging from cybersecurity to volunteer support, are critical to customer service for our candidates and diplomates, as well as fulfillment of our core mission. Despite these obstacles, the board members view themselves as responsible stewards of ABR resources, both financial and otherwise. In this vein, they consistently challenge each other, and the ABR staff, to reduce costs and, subsequently, fees, to the extent possible.

Transparency, transparency, transparency. Anything less is just self-love.

The ABR’s virtual Core Exam worked

Last year as the pandemic spiraled out of control, the ABR resisted–as they have for years–calls for disseminated exams away from their centers in Chicago and Tuscon. The lack of a foreseeable endpoint and pressure from advocates was finally enough for the ABR to make the switch. And to their credit, when the ABR came around, they went all the way: all exams are to be virtual from this point forward.

And guess what? It worked.

Apparently, it worked really well.

And I, for one, am not surprised.

People I’ve spoken to were overall very pleased with the remote experience. Were there rare technical difficulties? Sure. But reports are that the ABR was generally responsive and helpful in aiding candidates when issues cropped up, and multiple residents I spoke to gave ABR customer service high marks.

So while perhaps they shouldn’t have needed the worst pandemic in a century to make these changes, credit where it’s due: the ABR successfully pulled off the transition to at-home testing.

The ABR’s testing centers, though physically inconvenient, were always pretty nice compared with most commercial centers. But the ability to take the exam from a location of your choosing with no travel required and your choice of preferred snacks, clothing, thermostat settings, and bathroom is pretty nice. Having the exam over three days also probably helped with test-fatigue.

Future Fix Requests

There were a few complaints the ABR should address in future administrations:

  • Answer choice strikethrough. This was a common request, and it’s a common feature including one available on the USMLE exams that residents are all used to.
  • Cine clip optimization. This has been a longstanding complaint, but in this case, at least sometimes clips are presented in a separate window from the question and answer choices. They should be embedded the same way as normal images with easily controllable playback speed and the ability to manually scroll.
  • Remove the 30 question auto-lock. The need to lock previously seen questions makes perfect sense at the end of a 60-question block and whenever a candidate takes an optional break. But I’m not sure I buy any justification for auto-locking mid-section. This is a true functional change from prior exam administrations that has a negative impact on those who would like to review all related questions before moving on. It’s also difficult to know how much time to allot to question review when you break up 120 questions into 4 blocks instead of two, making time management more difficult.
  • Announce the section order. This was a big complaint I heard and one I agree completely with. For years the ABR has avoided publicizing the section order (e.g. Breast, then Cardiac, then GI) despite keeping it consistent across testing administrations. While people obviously aren’t supposed to discuss the exam, in the real world this has meant that candidates taking the exam later always know what sections are coming on which days, allowing them to cram most effectively. Unless every candidate has a randomized order, keeping this information semi-hidden in this setting just isn’t appropriate and should be a no-brainer to fix. Knowing you’re going to have ridiculous radioisotope safety microdetails on a specific day means you can prepare for that much more effectively and seriously jeopardizes the exam integrity. Again, this is not a new issue.

The Core Exam is still the Core Exam

Ultimately, the biggest complaint–no surprise–wasn’t the software but the test itself. It’s not as though the content magically became more on-point just because you got to wear pajamas.

If I were to limit myself to one content suggestion, it’s this:

I feel very strongly that the ABR’s reduction of physics and radiation safety to nonsense microdetails does our specialty a disservice. Residents constantly complain that the test material seems random and is not found in most review materials. This means either the Core Exam treats this material poorly or that the residents are studying the wrong information.

The problem is that this material is important. The ABR needs to make it clear what information candidates should know and release it as a packet of specific information like non-interpretive skills (NIS). In its current form, the combination of physics/radiation biology/radiation safety/nuclear medicine/RISE is a limitless almost black-box from which residents have no idea what to focus on or what material is high-yield. The end result is that most radiologists are taught low-yield or confusing information from physicists and end up with a poor understanding of these concepts. Candidates simply don’t really know what they should know and so don’t really know anything.

MR safety and contrast safety are included in the NIS study guide already (in addition to mission-critical information like the ACGME core competencies and how to create a “Culture of Safety”). The vast majority of the information I just described is also “non-interpretive” and needs to be included.