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Paid family/medical leave in radiology: The time is really now

      1. Paid family/medical leave in radiology: the time is really now

      Paid family/medical leave in radiology: now is the time. At the 2020 American College of Radiology (ACR) annual meeting, a paid family/medical leave resolution was deferred due to uncertainty surrounding the emerging COVID-19 pandemic. At the 2021 ACR annual meeting, ACR councilors passed the American Association for Women in Radiology (AAWR) amendment to resolution 48 in strong support of 12 weeks of family/medical leave for diagnostic radiology, interventional radiology, radiation oncology and nuclear medicine residents; the vote was 89.13% in the affirmative. The resolution itself was based on a 2021 Radiology editorial sponsored by 12 national organizations/societies
      • Magudia K.
      • Ng T.S.C.
      • Campbell S.R.
      • et al.
      Family and medical leave for diagnostic radiology, interventional radiology, and radiation oncology residents in the United States: a policy opportunity.
      ; however, it did not specify whether the leave was paid or unpaid. Thus, the next step is a normative paid family/medical leave resolution. Unpaid family/medical leave is an exclusive benefit that may only be taken by those whose circumstances permit. Paid family/medical leave is an inclusive policy that would benefit the wellness as well as the diversity, equity and inclusion of our specialty. Moreover, in contrast to the uncertainty of two years ago, it is certainly now clear that the last two years of COVID-19 have been ones in which more than ever, members of our specialty and beyond needed paid family/medical leave. So while we cannot turn back the clock, the time is really now to get a paid family/medical leave resolution enacted.

      2. Federal law: FMLA & FEPLA

      The Family and Medical Leave Act (FMLA) of 1993 provides eligible employees with up to 12-weeks of unpaid, job-protected leave per year for the care of a newborn or adopted child.
      Family Medical Leave Act of 1993. Pub L 103-3, 29 USC.
      While FMLA mandates leave, it does not mandate that the leave be paid. The Federal Employee Paid Leave Act (FEPLA) of 2019 gives federal workers access to up to 12 weeks of paid time off for the birth, adoption or placement of a new child.
      Women's and Fair Practices Departments. Federal Employee Paid Leave Act (FEPLA).
      However, while FEPLA mandates paid parental leave, it is only applies to federal employees and does not include paid leave for medical reasons. In fact, paid family/medical leave has been featured prominently in recent proposed federal legislation.
      • Donovan S.A.
      • Huston B.F.
      Build Back Better Act: universal comprehensive paid leave. Congressional Research Service.

      3. Paid family/medical leave benefits: societal, practices & departments, and individual

      3.1 Societal

      Paid family/medical leave is associated with numerous societal benefits (Table 1). These benefits include decreased infant mortality, mother and infant hospitalizations, societal expenditures related to health- and childcare costs, as well as work force absences.
      • Van Niel M.S.
      • Bhatia R.
      • Riano N.S.
      • et al.
      The impact of paid maternity leave on the mental and physical health of mothers and children: a review of the literature and policy implications.
      These benefits also include increased employee morale, job satisfaction, and productivity; notably, these differences are for both female and male workers.
      • Huang G.
      The business case for paid leave at your company. Forbes.
      • Hedlin S.
      How paid parental leave benefits men, too. Harvard Journal of Law & Gender.
      States and other countries that have implemented paid-leave policies have found significant reduction in the number of women leaving their jobs in the first year after giving birth—and an even greater reduction in those who leave after five years, suggesting that this early support has lasting effect.
      • Van Niel M.S.
      • Bhatia R.
      • Riano N.S.
      • et al.
      The impact of paid maternity leave on the mental and physical health of mothers and children: a review of the literature and policy implications.
      • Jones K.M.
      Paid family leave increases mothers' labor market attachment. Institute for Women's Policy Research.
      Table 1Overall societal paid family/medical leave benefits.
      DecreasedIncreased
      Infant mortalityBreastfeeding initiation & duration
      Infant & mother hospitalizationsTimely immunizations & pediatrician visits
      Post-partum depressionProductivity, loyalty, and morale
      Intimate partner violenceJob satisfaction
      Expenditures related to health- and childcare costs and work force absences

      3.2 Practices & departments

      There are multiple business advantages to a formal paid family/medical leave policy for practices and departments (Table 2).
      • Arleo E.K.
      Paid parental leave in radiology: the time is now-challenges, strategies, and the business case for implementation.
      First, a formal policy promotes consistency and fairness by avoiding subjective decisions on employees' personal situations. A formal policy also facilitates budgeting and preparing for absences by allowing practices to project and cover costs. Furthermore, a formal policy minimizes concerns over discussing and taking leave, leading to employees providing more advanced notice, permitting earlier and more optimal planning. The benefits of paid leave also include improved employee retention, morale and productivity. A paid family/medical leave policy may also serve as a strong recruitment tool leading to a potential competitive hiring advantage. Finally yet importantly, a formal inclusive family/medical leave policy supports same sex and adoptive parents as well as diversity, equity and inclusion goals.
      Table 2Top benefits of paid family/medical leave: Practices & departments and individuals.
      Practices and departmentsIndividuals
      Consistency and fairness: a formal policy avoids subjective decisions on employees' personal situations.Physical recovery from childbirth or a serious medical illness
      Facilitates budgeting and preparing for absencesBonding with a new child
      Diversity, equity & inclusion (including support for same sex and adoptive parents)Provision of parental or familial support to an immediate family member with a serious medical illness
      Recruitment & retentionEnhanced economic security

      3.3 Individual

      Providing new parents with paid time off to care for a newborn or recently adopted child improves maternal health by allowing physical recovery, promotes bonding, and enhances families' economic security.
      • Van Niel M.S.
      • Bhatia R.
      • Riano N.S.
      • et al.
      The impact of paid maternity leave on the mental and physical health of mothers and children: a review of the literature and policy implications.
      As of 2019, 41% of working mothers were sole breadwinners, earning at least half of their total household income and nearly a fourth of mothers were co-breadwinners, earning about 25–49% of the household income; therefore, for many families, unpaid leave is untenable.
      • Glynn S.J.
      Breadwinning mothers continue to be the U.S. norm - Center for American Progress.
      Specific benefits of paid family leave for men (Table 3) include that fathers on paid leave tend to build closer relationships with their children; paternity leave improves male health and reduces household conflicts; and, paid paternity leave is linked to increased life satisfaction for men.
      • Huang G.
      The business case for paid leave at your company. Forbes.
      • Hedlin S.
      How paid parental leave benefits men, too. Harvard Journal of Law & Gender.
      Paid medical and caregiving leave allows workers care for themselves and loved ones when ill or injured, and reduces financial insecurity and stress during those times.
      Table 3Top benefits of paid paternity leave for men.
      Fathers on paid leave tend to build closer relationships with their children
      Paternity leave improves male health and reduces household conflicts
      Paid paternity leave is linked to increased life satisfaction for men

      4. Paid family/medical leave coverage and costs

      With the numerous benefits of paid family/medical leave established, the “risks” of coverage and cost must next be considered. Undoubtedly, both issues are more of a challenge for a small group of three radiologists compared to larger group of 30 or more radiologists. In the 2016 ACR Commission on Human Resources Workforce Survey, it was revealed that most practices (80%) made no workforce changes to cover absences due to FMLA leave.
      • Arleo E.K.
      • Parikh J.R.
      • Wolfman D.
      • Gridley D.
      • Bender C.
      • Bluth E.
      Utilization of the Family and Medical Leave Act in Radiology Practices According to the 2016 ACR Commission on Human Resources Workforce Survey.
      However, this approach – or lack thereof – fails to take into consideration the prevention of burnout in radiologists who remain on the job. While there may not be advanced notice in the case of a serious medical condition both for oneself or for an immediate family member, pregnancy and adoption generally provide several months' notice for impending leave during which coverage can be organized.
      Regardless of the scenario requiring leave, practices and departments can cover leave by bringing radiologists on site or providing coverage with remote work. Remote work has never been more ubiquitous or seamless in radiology. While teleradiology used to be limited to specific groups, it is now the rare practice or department that is not equipped for some remote work due to operational changes made due to the COVID-19 pandemic. In short, with the recent renaissance of remote radiology work, coverage for family/medical leave is arguably easier to implement than ever before.
      Furthermore, the potential savings of providing paid family/medical leave balance perceived costs (Table 4). As previously delineated in a 2020 Clinical Imaging article on paid family/medical leave, direct costs include continued pay, continued benefits and other employee-related costs, temporary staff and overtime.
      • Arleo E.K.
      Paid family/medical leave: that's great - what's next?.
      Indirect costs may include program administration. Conversely, direct savings include reduced wages if a practice has group short-term disability insurance or operates in a state with a paid leave program. Indirect savings include reduced hiring costs by retaining employees and increased productivity of employees who take sufficient leave and return ready to work. Additionally, an important cost not often considered is presenteeism, defined as “the problem of employees who are not fully functioning in the workplace because of an illness, injury or other condition.”
      • Arleo E.K.
      Paid family/medical leave: that's great - what's next?.
      Presenteeism 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, as it does in radiology.
      • Schultz A.B.
      • Chen C.-Y.
      • Edington D.W.
      The cost and impact of health conditions on presenteeism to employers.
      Thus, it is incumbent upon us in radiology to mitigate presenteeism.
      Table 4Paid family/medical leave: Potential savings outweigh costs.
      SavingsCosts
      Short term disability or state paid leave programContinued pay & benefits
      ↓ Hiring costs by retaining employeesAdministrative
      ↓ Presenteeism
      Defined as “the problem of employees who are not fully functioning in the workplace because of an illness, injury or other condition.”13
      a Defined as “the problem of employees who are not fully functioning in the workplace because of an illness, injury or other condition.”

      5. Radiology family-friendly policies: recent and next steps

      The 2020 decision by the American Board of Radiology (ABR) to transition examinations to a virtual environment in response to the COVID-19 pandemic
      June 22: ABR moving to remote exams. American Board of Radiology.
      was a family-friendly policy change and inspired many to advocate for additional family and workforce friendly policies. At the May 2021 ACR annual meeting, the ACR voted to adopt amended Resolution 48, which supports 12 weeks of (unspecified paid or unpaid) family/medical leave during residency without extension of training.
      • Wang S.S.
      • Patel A.
      • Everett C.J.
      • Guerrero-Calderon J.
      • Ali K.
      New Heights for family and medical leave policy for radiology and radiation oncology trainees.
      Subsequently, by July 1, 2021, the ABR released its updated residency leave policy, such that “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.”
      American Board of Radiology Residency Leave Policy.
      The ABR's leave policy means residents can take up to 16 weeks family/medical leave if needed in addition to four weeks of vacation per year during residency without extension of training.
      The ABR residency leave policy is focused on training requirements (i.e., eligibility for board certification and possible extension of training) and thus appropriately does not comment about whether the leave itself is paid versus unpaid. However, the updated Accreditation Council for Graduate Medical Education (ACGME) institutional requirements effective July 1, 2022 requires 6 weeks paid family/medical leave for all trainees in accredited programs regardless of program length, starting on the first day of the program, and with a separate week of paid vacation in the same year.
      Accreditation Council for Graduate Medical Education. Institutional Requirements: ACGME-approved focused revision: September 26, 2021; effective July 1, 2022.
      Additionally, in October 2018, the Society of Chairs of Academic Radiology Departments (SCARD) voiced support for 12 weeks of paid parental leave for faculty in academic radiology departments. This support was articulated in a letter to the editor stating that, “SCARD members support the AAWR and pledge to strive for departmental, institutional, and organizational change that provides 12 weeks of paid parental leave for eligible (as defined by the FMLA) faculty members of all genders.”
      • Canon C.L.
      • Enzmann D.R.
      • Grist T.M.
      • et al.
      Society of Chairs of Academic Radiology Departments statement of support for paid parental leave.
      The next logical step would be support by our specialty and its major organizations, including the ACR, for academic departments, private practices and training programs to strive to provide paid family/medical leave. An ACR resolution on paid family/medical leave would be consistent with the ACR's stated commitment to, “the radiologist's well-being as an integral part of high quality and safe patient care and the health of our members,”
      Statement of support: National Academy of Medicine Collaborative on Clinician Well-Being and Resilience. American College of Radiology.
      and “to actively promote inclusion at all levels of training, practice, and leadership.”
      Excellence Through Diversity and Inclusion. American College of Radiology.
      The operative word “strive” is important to reflect the complexity of implementing a leave policy across different practice types and settings.

      6. Conclusion

      In medicine, we talk about risks, benefits and alternatives; with respect to paid family/medical leave, the benefits outweigh the risks and the alternative (the status quo) is discordant with the ACR's commitment to the well-being of radiologists throughout their professional career. Paid family/medical leave supports those who experience a serious medical condition themselves (or have family members who do) and those who experience pregnancy and childbirth or adoption. These conditions apply to essentially all radiologists at some point in their career. While there is a cost to paid family/medical leave, these costs can be mitigated with short-term disability, state programs, as well as careful organizational planning. The business case for paid family/medical leave is compelling, with research showing improved retention, recruitment, productivity and morale. These outcomes are important to all practices and are critical to the future of radiology as a whole. Support for paid leave at the ACR level would help normalize family/medical leave and establish radiology as a leader among medical specialties.

      Declaration of competing interest

      1st author is Editor-in-Chief of Clinical Imaging.

      Acknowledgments

      None.

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