The American Board of Medical Specialties (ABMS) establishes requirements for candidates to become eligible for Initial Certification. Effective July 1, 2021, a new parental leave policy will allow for a minimum of 6 weeks away from training for the purposes of parental, caregiver or medical leave at least once during training, while maintaining at least 2 weeks of vacation without extension of training. Currently, the American Board of Urology (ABU) stipulates that a urology resident must work at least 46 weeks during each year of residency to be eligible for board certification with extension of training if this requirement is not met. While the current ABU policy is more flexible than many other specialties, the new ABMS policy requires the ABU to reassess their requirements to ensure compliance.

The policy arrives as the demographics of urology residencies are changing. The recently published AUA 2019 census data elucidated several interesting findings regarding the current cohort of urology residents in the U.S. First, nearly 30% of current residents are women, which is significantly higher than the 9.9% of practicing women urologists. Additionally, the majority of residents (68%) and fellows (80%) reported being married or partnered, with 24.8% of residents and 46.3% of fellows identifying themselves as parents. Finally, the mean number of weeks taken off when a child was born during residency was 6.4 for females and 1.6 for males. Astoundingly, nearly 15% of residents and 28% of fellows reported that no parental leave was offered by their training program. With more women in the urology workforce and an increasing focus on well-being in residency training programs, a consensus statement detailing the implementation of the new ABMS policy for urology residencies is needed.

Urology residents face considerable challenges in family planning during their training. For example, perceptions of support from faculty and colleagues can limit the pursuit of parenthood during surgical training. In a survey of 2,188 general surgery residents, 30.4% of participants reported feeling unsupported by fellow co-residents in taking parental leave and 32.7% unsupported by faculty.¹ Unfortunately, these perceptions are not unfounded; surveys of program directors across a variety of surgical fields have revealed that many believe pregnancy during residency negatively impacts work performance.^2,3

The small size of many urology residency programs may further impact perceptions of parenthood due to a concern of work strain on co-residents. In a recent JAMA surgery article, one of the most commonly cited obstacles to taking leave amongst surgical residents was perceived “strain on residency program,” second only to “lack of universal leave policy” among surgical residents taking parental leave.¹ Finally, financial constraints may also dissuade residents from becoming pregnant or taking extended leave as neither the ABMS nor the ABU provide policy for unpaid vs paid leave, an issue universal to many American workers.

Whether influenced by social or academic pressures, financial challenges, or personal choices, many women will choose to defer pregnancy during medical school and residency training. Surgeons across specialties have an average of 1.4 biological children, compared to 2.6 in the average U.S. population.⁴ The average age of maternity has also been shown to be 8 years higher in female urologists when compared to the general population. This delay in pregnancy has likely led to the increased rates of assisted reproductive technology (ART) and pregnancy complication rates among women urologists. Whereas only 1% of the national population conceives via ART, 10.6% of women urologists reportedly conceive this way. Rates of pregnancy complications approached 25% among urologists, which was also significantly higher than the general population.⁵

The development of the new “ABMS Policy on Parental, Caregiver and Family Leave” was initiated following a report from the ACGME Council of Review Committee Residents in June 2019 in which members assessed prenatal work conditions, maternity leave policies and lactation considerations.⁶ The ABMS-proposed policy does allow for flexibility to create a parental, family or medical leave protocol that best suits the training required for their specialty and/or subspecialty. The requirement stipulates that a minimum of 6 weeks of parental leave be available for trainees, which is separate from allotted vacation time.

However, the American Board of Urology requires 48 calendar months (1 month = 4 weeks) of urology training, 12 of which must be in the capacity as chief resident in order to be eligible for board certification. In addition, a trainee can take off no more than 6 weeks of training in a single year without dispensation from the ABU to avoid possible extension of training. In response to these seemingly opposing policies, the ABU has proposed “averaging” the 46-week requirement over several years; specifically, 46 weeks may be averaged over the first 3 years of residency for a total of 138 weeks during the first 3 years and 92 during the last 2 years. This proposal would ensure adequate clinical time during the last 2 years of training, which are critical in achieving increased autonomy and in developing the surgical and leadership skills required for independent practice.

The above policy has the potential to enact significant positive change in urology training. The emphasis of well-being and mental health across residency programs has certainly encouraged the development of parental leave policies. However, certain challenges may arise in the implementation of these policies, including the issue of substitute coverage as well as that of paid vs unpaid parental leave and sources of funding if necessary. Further policies addressing paid leave status, the availability of lactation rooms, financial resourcing of replacement labor, and support for residents covering for those on leave will only further support this initiative and allow for trainees to achieve the flexibility that these policy changes intend to afford them.