American College of Radiology Paid Family/Medical Leave Policy: A Call to Action for the House of Medicine

Abstract

The American College of Radiology (ACR) passed a historic paid family/medical leave (PFML) resolution at its April 2022 meeting, resolving that “diagnostic radiology, interventional radiology, radiation oncology, medical physics, and nuclear medicine practices, departments and training programs strive to provide 12 weeks of paid family/medical leave in a 12-month period for its attending physicians, medical physicists, and members in training as needed.” The purpose of this article is to share this policy beyond radiology so that it may serve as a call to action for other medical specialties. Such a PFML policy (1) supports physician well-being, which in turn supports patient care; (2) is widely needed across American medical specialties; and (3) should not take nearly a decade to achieve, as it did in radiology, especially given increasing physician burnout and the ongoing COVID-19 pandemic. Supported by information on the step-by-step approach used to achieve radiology-specific leave policies and considering current and normative policies at the national level, this article concludes by reviewing specific strategies that could be applied toward achieving a 12-week PFML policy for all medical specialties.

Introduction

In Washington DC on April 26, 2022, the American College of Radiology (ACR) passed a historic paid family/medical leave (PFML) resolution, resolving that “diagnostic radiology, interventional radiology, radiation oncology, medical physics, and nuclear medicine practices, departments and training programs strive to provide 12 weeks of paid family/medical leave in a 12-month period for its attending physicians, medical physicists, and members in training as needed.”¹ We believe that this new ACR policy should serve as a call to action for other medical specialties.

The PFML literature in medicine is limited. A 2018 JAMA survey of U.S. medical schools demonstrated a broad range of policies or lack thereof, with most offering <12 weeks of leave for their affiliated faculty and residents and many requiring the use of sick leave and vacation time.² A 2021 Radiology editorial called upon the American Board of Radiology (ABR) to enact a leave policy to allow residents in good standing to take 12 weeks of family/medical leave during residency (in addition to 4 weeks of vacation per year), sit for board examinations on time, and graduate without extension of training,³ which was affirmed by the policy the ABR subsequently implemented.⁴

A 2021 JAMA article⁵ then provided an update on medical specialty board PFML policies issued in response to an American Board of Medical Specialties (ABMS) mandate⁶ for written and accessible leave policies. This was subsequently followed by updated institutional requirements by the Accreditation Council of Graduate Medical Education (ACGME) mandating 6 weeks PFML for residents and fellows.⁷ A 2022 Clinical Imaging article, published just weeks before the passage of the ACR resolution, also focused on the issue of PFML, pointing out that unpaid FML may only be taken by those whose financial circumstances permit whereas PFML is a more inclusive policy, thus benefiting not only wellness but also diversity, equity, and inclusion.⁸

Although 12 weeks of PFML is nominal compared with some other countries or selected industries in the United States, this duration is consistent with the federal Family Medical Leave Act⁹ (FMLA, discussed hereunder and in Table 2, row 1) and is the minimum amount of paid leave endorsed by the American Public Health Association, the American Academy of Pediatrics, and the Pediatric Policy Council.¹⁰ Furthermore, PFML benefits society, practices, and departments, as well as individuals of all genders, ages, and stages of career and their family's well-being.⁸

For childbearing parents, PFML improves physical recovery from childbirth, which may include abdominal and pelvic surgery, and breastfeeding if pursued. For nonbirthing parents, studies have shown that PFML leads to closer relationships with their children, reduced household conflicts with their partners, and increased life satisfaction.^11,12

Irrespective of gender or age, PFML allows workers to take care of themselves and/or loved ones—including elder care—when ill or injured without also incurring financial insecurity and stress. Particularly important to medicine, PFML also ameliorates presenteeism (an employee being present at work while they are not well), which “is associated with on-the-job productivity losses and mistakes and represents a major component of total employer costs; on the job mistakes are particularly costly not only monetarily but also at the human level of pain and suffering when the job involves patient care.”¹³

There is also the business case for prioritizing physician well-being: a 2022 Mayo Clinic Proceedings article speaks of financial motivations, reporting, for example, that primary care physician (PCP) turnover, “results in approximately $979 million in excess health care expenditures for public and private payers annually, with $260 million attributable to PCP burnout-related turnover.”¹⁴

The passage of the 2022 ACR PFML policy was achieved by persistently building—step-by-step—on previous radiology-specific leave policies, as summarized in Table 1. These policies were modeled after and exist in the larger context of state and national recommendations, acts, and requirements related to physician well-being and affecting medical residents and other health care providers, as summarized in Table 2. But where and how to achieve this in other medical specialties? The possibilities include

Table 1.

Leave policies, Radiology-specific and from the American Board of Medical Specialties

Year	Organization	Policy
2019	SCARD	“SCARD members support the American Association for Women Radiologists and pledge to strive for departmental, institutional, and organizational change that provides 12 weeks of paid parental leave for eligible (as defined per the Family Medical Leave Act) faculty members of all genders.”²³
2020	APDR	“The APDR thus recognizes that under the FMLA, eligible^* radiology trainees of all genders have the right to take up to 12 weeks of unpaid family leave and encourages program directors to make this right known to their trainees, as indicated by federal law, and to provide notice of any additional rights under relevant state family leave laws.”²⁴
2020	ABMS	“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.”²⁵
May 18, 2021	ACR, Amended Resolution #48	ACR recommends that the ABR “allow a resident who is in good standing to take 12 weeks of family and medical leave during residency (in addition to 4 weeks of vacation per year), to sit for the Core/Qualifying Examinations on time, and to graduate without extension of training, with additional leave to be considered by the program director on a case-by-case basis.”²⁶
June 30, 2021	ABR	“Beginning with the 2021–2022 academic year, residents will be considered eligible for Initial Certification without an extension of training with ‘Time Off’ that does not exceed an average of eight weeks (40 workdays) per academic year over the duration of the residency.”⁴ 8 weeks/year × 4 year residency = 32 weeks max leave during residency (i.e., allowing 4 weeks' vacation/year × 4 years and a 12–16-week family/medical leave if needed
April 26, 2022	ACR	“Be it resolved, That the American College of Radiology (ACR) recommends that diagnostic radiology, interventional radiology, radiation oncology and nuclear medicine practices, departments and training programs strive to provide 12 weeks of paid family/medical leave in a 12-month period for its attending and trainee physicians as needed.”¹

ABMS, American Board of Medical Specialties; ABR, American Board of Radiology; ACR, American College of Radiology; APDR, Association of Program Directors in Radiology; FMLA, Family Medical Leave Act; SCARD, Society of Chairs of Academic Radiology Departments.

Table 2.

State and National Recommendations, Acts, and Requirements Affecting Medical Residents and Other Health Care Providers Affecting Well-being

Year	Organization/policy name	Specifics
1993	FMLA	“Entitles eligible employees of covered employers to take [12 weeks] unpaid, job-protected leave for specified family and medical reasons with continuation of group health insurance coverage under the same terms and conditions as if the employee had not taken leave”⁹
2019	Federal Employee Paid Leave Act	Provides “up to 12 weeks of paid parental leave to covered Federal employees in connection with the birth or placement (for adoption or foster care) of a child occurring on or after October 1, 2020.”¹⁹
3/18/2022	Dr. Lorna Breen Health Care Provider Protection Act	“This bill establishes grants and requires other activities to improve mental and behavioral health among health care providers. Specifically, the Department of Health and Human Services (HHS) must award grants to hospitals, medical professional associations, and other health care entities for programs to promote mental health and resiliency among health care providers. In addition, HHS may award grants for relevant mental and behavioral health training for health care students, residents, or professionals. Additionally, HHS must conduct a campaign to (1) encourage health care providers to seek support and treatment for mental and behavioral health concerns, and (2) disseminate best practices to prevent suicide and improve mental health and resiliency among health care providers.”²⁷

Medical specialty by medical specialty

American Medical Association (AMA)

ABMS and ACGME

Federal (or state) legislation.

Medical specialty by medical specialty

To achieve a PFML policy for all medical specialties, each of the additional 23 member boards under the ABMS could follow the step-by-step approach taken in radiology (summarized in Table 1):

Start with the Society of Chairs of Academic [insert medical specialty] Departments and present the SCARD statement (Table 1, row 1) as precedent

Then the Association of Program Directors in [insert medical specialty] and present the APDR statement (Table 1, row 2)

Then the American College of [insert medical specialty] and present the 2021 ACR policy (Table 1, row 4)

Then the American Board of [insert medical specialty] and present the ABR policy (Table 1, row 5)

Then the American College of [insert medical specialty] and present the related 2022 ACR policy (Table 1, row 6).

Advantage: each specialty works within its own individual specialty organizations. Disadvantage: this may take years. The passage of the 2022 ACR PFML policy took 5 years, from initiation of the idea and passage of the SCARD statement to passage of the 2022 ACR PFML policy, and 3 years of publishing articles before that to set the stage.^15
–17 Given the increasing physician burnout and persistent stressors, time is of the essence; thus, other possible strategies are considered hereunder.

American Medical Association

The AMA could revise its 2014 policy, which currently “urges medical schools, residency training programs, medical specialty boards, the Accreditation Council for Graduate Medical Education, and medical group practices to incorporate and/or encourage development of leave policies, including parental, family, and medical leave policies, as part of the physician's standard benefit agreement,” with recommended components of leave policies to specify duration of leave and whether the leave is paid.¹⁸ A suggested update would read: “recommends that residency programs, specialty boards, and medical group practices incorporate into their family/medical leave policies a twelve-week paid minimum leave allowance.” (Changed or added words in italics).

Advantage: An AMA-endorsed PFML policy would be impactful and could influence over 190 state and specialty medical societies to adopt similar PFML. The AMA House of Delegates could also adopt a resolution directing AMA staff to advocate for legislation at the federal level. Disadvantage: A resolution passed at the AMA cannot mandate that other organizations adopt similar policies and may be perceived as a symbolic act (although sends a strong message).

American Board of Medical Specialties and Accreditation Council of Graduate Medical Education

The ABMS and ACGME recently established seminal policies promoting GME trainee access to PFML. The ABMS mandated⁶ written and accessible leave policies with a minimum of 6 weeks FML in training programs lasting 2 years or longer without exhausting vacation or sick leave and without extension of training.⁵ This led to improved member specialty board PFML policies for GME trainees.⁵ The ACGME went a step further by updating their institutional requirements (effective July 1, 2022) to require 6 weeks PFML from the start of training with at least 1 week of paid time off remaining.⁷

These policies are critical in promoting access of GME trainees to PFML. Given the influence of these national governing bodies, an update of policies to 12 weeks PFML would positively affect all GME trainees. Advantage: Promoting wellness of GME trainees will improve the resilience of our future physician workforce. Disadvantage: ABMS and ACGME policies are currently limited to GME trainees and thus are not applicable to physicians beyond training.

Federal (or state) legislation

In October 2020, the Federal Employee Paid Leave Act (FEPLA) made paid parental leave available to certain categories of federal civilian employees, and FMLA provisions were modified to provide up to 12 weeks of paid parental leave to eligible federal employees.¹⁹ In November 2021, Congress passed the Build Back Better Act (BBBA), which would have been the first federal enhancement of FML for private sector workers since the enactment of FMLA in 1993.²⁰ The BBBA passed by Congress did not go as far as initially proposed (12 weeks of paid leave)²⁰ and the Senate did not pass it.

What if federal (or state) legislation were to take a narrower approach, inspired by FEPLA and the Dr. Lorna Breen Bill (see Table 2, rows 4 and 5), with an act or bill specifically for health care providers at the national level? Such an act might be called, “Family/Medical Leave Act-Health Care Providers (FMLA-HCP).” Rationale: the government contributes ∼50% of all health care dollars to physician pay; 40% more is contributed by third-party payers that are themselves highly regulated by government and routinely follow the government's lead in pricing.²¹

Since the government contributes half of health care dollars that go to physician pay, does it not have a vested interest similar to federal employees, who have PFML? Advantage: such legislation would be broadly impactful. Disadvantage: the challenges of expanding from policy in a specialty medical sphere into public legislation at the national (or state) level.

In sum, there are advantages and disadvantages to pursuing a PFML policy one medical specialty at a time or at the level of the AMA, ABMS, ACGME or federal level. A combination of approaches may be necessary, and what is also necessary is actively advocating for this change. Although physicians prescribe self-care for their patients, they are often unable to prioritize their own health and needs. The 2022 ACR PFML policy sparks widespread change in a professional culture often disinclined to take care of its own and represents a major step toward prioritizing physician well-being and mitigating burnout.

This call to action is for advocacy for better working conditions to support the well-being of physicians. Subpar working conditions have plagued medicine for years; however, the COVID-19 pandemic amplified these issues, making prioritizing physician well-being more relevant than ever. It is time for the house of medicine to provide PFML to the people who provide family and medical care to our population.

[Postscript: On November 15, 2022, after submission (October 19, 2022) and acceptance (October 31, 2022) of this article, the AMA adopted policy recommending “that medical practices, departments and training programs strive to provide 12 weeks of paid parental, family and medical necessity leave in a 12-month period for their attending and trainee physicians as needed.” ²² N.B. The AMA-approved language is very similar (if not identical) to the ACR PFML resolution verbiage.¹]

Footnotes

Authors' Contributions

All authors contributed to the article conception. The first draft of the article was written by E.K.A. and all authors commented on previous versions of the article. All authors read and approved the final article.

Ethical Approval

This article did not involve human or animal subjects; thus, ethical approval was not applicable, nor is consent to participate or publish.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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