Global parental leave in surgical careers: differences according to gender, geographical regions and surgical career stages

Global parental leave in surgical careers: differences according to gender, geographical regions and surgical career stages S. Au 1 , V. Bellato 2 , J. M. Carvas 3 ,C.D.Co´rdoba 4 , D. Daudu 5 , J. Dziakova 6 , K. Eltarhoni 7 , N. El Feituri 8 , A. C. H. Fung 9 , C. Fysaraki 10 , G. Gallo 11 , F. Ayca Gultekin 12 , J. L. Harbjerg 13 , F. Hatem 14 , A. Ioannidis 15 , L. Jakobsen 16 , D. Clinch 17 , H. Ø. Kristensen 13 , S. Z. Kuiper 18 , A. M. F. Kwok 19 , W. Kwok 20 , M. Millan 21 , K. M. Milto 1 ,H.J.Ng 22 , G. Pellino 23 , A. Picciariello 24 , S. Pronin 25 , G. H. van Ramshorst 26 , M. Ramser 27 , R. M. Jime´nez-Rodrı´guez 28 , J. C. Sainz Hernandez 29 , E. Samadov 30 , S. Sohrabi 31 , M. Uchiyama 32 , J. H.-S. Wang 33 , M. U. Younis 34 , S. Fleming 35 , S. Alhomoud 36 , J. Mayol 37 , G. Moeslein 38 , N. J. Smart 39 , K. Soreide 40 , C. Teh 41,42 , D. Verran 43 and Y. Maeda 44,#, * 1 NHS Education for Scotland, Edinburgh, UK 2 St Mark’s Hospital, London, UK 3 Hospital de Braganc¸a, Portugal 4 University of Lausanne, Lausanne, Switzerland 5 Faculty of Health and Medical Sciences, University of Western Australia, Australia 6 Hospital Clinico San Carlos, IDISSC, Madrid, Spain 7 Borders General Hospital, UK 8 Tripoli, Libya 9 Department of Surgery, The University of Hong Kong, Hong Kong SAR, China 10 Urology Department, Mid Yorkshire Hospitals NHS Trust, UK 11 Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy 12 General Surgery Department, Zonguldak Bulent, Ecevit University School of Medicine, Zonguldak, Turkey 13 Department of Surgery, Research Unit C119, Aarhus University Hospital, Palle Juul-Jensens, Aarhus N, Denmark 14 Glasgow Royal Infirmary, Glasgow, UK 15 Athens Medical Centre, Athens, Greece 16 UiT, The Arctic University of Norway, University Hospital of North Norway, Tromso, Norway 17 Department of General Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK 18 School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands 19 Western General Hospital, Edinburgh, UK 20 Royal Infirmary of Edinburgh, Edinburgh, UK 21 Coloproctology Unit, Department of Surgery, La Fe University Hospital, Valencia, Spain 22 Royal Alexandra Hospital, NHS Greater Glasgow and Clyde, UK 23 Department of Advanced Medical and Surgical Sciences, Universita` degli Studi della Campania ‘Luigi Vanvitelli’, Naples, Italy 24 Department of Emergency and Organ Transplantation, University ‘Aldo Moro’ of Bari, Italy 25 College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK 26 Ghent University Hospital, Ghent, Belgium 27 Department of Surgery, Solothurner Spita¨ler SoH, Bu¨ rgerspital Solothurn, Solothurn, Switzerland 28 Colorectal Unit, Hospital Universitario Virgen del Rocı´o, Sevilla, Spain 29 Instituto Nacional de Ciencias Me´dicas y Nutricio´n ‘Salvador Zubira´n’, Mexico City, Mexico 30 Surgical Department, LEYLA Medical Centre, Baku, Azerbaijan 31 NHS Lothian, Edinburgh, UK 32 Showa University School of Medicine, Tokyo, Japan 33 Australasian Students’ Surgical Association, New Zealand 34 Mediclinic City Hospital, Dubai, United Arab Emirates 35 Barts and the London School of Medicine and Dentistry, London, UK 36 King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia 37 Hospital Clinico San Carlos, Instituto de Investigacio´n Sanitaria San Carlos, Universidad Complutense, Madrid, Spain 38 Ev. Bethesda Khs Duisburg, University of Witten, Herdecke, Germany 39 Royal Devon & Exeter Hospital & University of Exeter Medical School, Exeter, UK 40 Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway 41 Department of Surgery, Makati Medical Centre, Makati, Philippines 42 Department of General Surgery, National Kidney & Transplant Institute, Quezon City, Philippines 43 Ramsey Health Care, Sydney, Australia 44 Department of Colorectal Surgery, Western General Hospital and University of Edinburgh, Edinburgh, UK #Globalmentorssurgical diversity team *Correspondence to: Western General Hospital and University of Edinburgh, Crewe Road South, Edinburgh EH4 2XU, UK (e-mail: [email protected]) This study was accepted as an abstract to the European Society of Coloproctology meeting, 2020. Received: January 14, 2021. Revised: March 24, 2021. Accepted: July 01, 2021 V CThe Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: [email protected] 2BJS, 2021, 108, 1315–1322 DOI: 10.1093/bjs/znab275 Advance Access Publication Date: 1 September 2021 Original Article Abstract Background: There is a lack of information regarding the provision of parental leave for surgical careers. This survey study aims to evaluate the experience of maternity/paternity leave and views on work–life balance globally. Methods: A 55-item online survey in 24 languages was distributed via social media as per CHERRIES guideline from February to March 2020. It explored parental leave entitlements, attitude towards leave taking, financial impact, time spent with children and compatibility of parenthood with surgical career. Results: Of the 1393 (male : female, 514 : 829) respondents from 65 countries, there were 479 medical students, 349 surgical trainees and 513 consultants. Consultants had less than the recommended duration of maternity leave (43.8 versus 29.1 per cent), no paid maternity (8.3 versus 3.2 per cent) or paternity leave (19.3 versus 11.0 per cent) compared with trainees. Females were less likely to have children than males (36.8 versus 45.6 per cent, P¼0.010) and were more often told surgery is incompatible with parenthood (80.2 versus 59.5 per cent, P<0.001). Males spent less than 20 per cent of their salary on childcare and fewer than 30 hours/week with their children. More than half (59.2 per cent) of medical students did not believe a surgical career allowed work–life balance. Conclusion: Surgeons across the globe had inadequate parental leave. Significant gender disparity was seen in multiple aspects. Additional content An author video to accompany this article is available at: https:// oup.cloud.panopto.eu/Panopto/Pages/Sessions/List.aspx#folder ID=%22cecaf919-7e86-43a9-adc3-ad1700a2f629%22 Introduction Over recent decades, the proportion of female medical students 1–4 , doctors 5,6 and surgeons 6–9 has increased across the globe. Despite the growing female medical workforce, surgery remains the most male-dominated (88 per cent) specialty with the lowest proportion of female doctors in training (32 per cent) in the UK 6 . Medical students may be dissuaded from pursuing surgery as they perceive surgical careers to be incompatible with family life 10 and would not allow a balanced lifestyle 11 . Studies from the USA showed that childbearing has increased amongst surgical residents 12 but pregnancy during training is thought to have negative impacts on mothers’ and children’s health 13–16 , with duration of maternity leave believed to be inadequate 13 . Stigma is still common with two out of three women stating that their childbearing decision has been negatively influenced by peers and faculty 17 .Thisisechoedby60percentofUSsurgicalpro- gramme directors who believe that motherhood negatively affects a trainee’s work 18 . Until now, the predominant focus has been on maternity leave but recently the importance of paternity leave has been increasingly recognised. It has been demonstrated that fathers who take paternity leave are more involved in subsequent childcare 19 and have strengthened bonds with their children 20 . Flexible and supportive workplace policies are vital in making surgery a more family-friendly specialty to attract and retain talents. There are very limited studies on maternity/paternity leave policies for surgeons and these mainly focus on one country 13,21,22 .Onlyone study has surveyed maternity leave policy for surgeons internationally but it has not evaluated the provision of paternity leave 23 . Methods Design and content of surveys A 55-item open survey in English was created. Items were chosen by literature review and created to assess specifics of maternity/ paternity leave provision. The survey was shared among the participating members on Slack, a cloud-based collaborative platform, for refinement. Depending on their self-reported stage of training (Appendix S1), the respondents were directed to the medical student, surgical trainee or those who have completed training (abbreviated to consultants) part of the survey. The student survey, consisting of 11 specific questions, included questions on the participant’s interest in a surgical career; their views on work–life balance, part-time/flexible training and compatibility of parenthood with a surgical career; and the availability of legislation regarding maternity/paternity leave in their country (Appendix S2). Each of the surgical trainee and surgical consultant parental leave surveys consisted of the same 18 questions, but with wording adjusted to suit the different stages of career (Appendices S3 and S4). They included questions on the availability of legislation regarding maternity/paternity leave in their country; their leave entitlement; their views on covering colleagues for maternity/paternity leave; work–life balance (with ‘too much work’ defined as a score of 0–3; ‘neutral’ defined as a score of 4–6; and ‘too much family time’ defined as a score of 7–10) and compatibility of parenthood with a surgical career. Trainees who had become a parent during training or consultants who had become a parent whilst being a consultant in the last 5 years were additionally asked about workplace attitude towards their taking of maternity/paternity leave, reasons for not taking full entitlement and the ease of their maternity/paternity leave application (‘easy’ if respondent has answered that the leave policy is being used without issue or without prejudice and ‘not easy’ if respondents answered that they have been ‘frowned upon when applying’ or there is ‘much hindrance when applying’ or ‘leave policy is not available’). All trainee and consultant respondents who had children were also asked about time spent with children, childcare arrangements and financial impact of childcare. The online survey was created on www.smartsurvey.co.uk,in accordance with the Checklist for Reporting Results of internet E- survey (CHERRIES) guideline (Appendix S5). It was translated into 23 languages, including Arabic, Azerbaijani, Chinese (simplified and traditional), Czech, Danish, Dutch, Farsi, French, German, Greek, Italian, Japanese, Malay, Norwegian, Polish, Portuguese, Russian, Slovak, Spanish (European and Latino), Turkish and Urdu. The translation of each language was performed and verified by at least two native-speaking authors. The aims of the survey were explained and completion of the survey inferred consent. The items were not randomized but adaptive, with a maximum of 26 items which required answering. A survey was deemed complete when respondents arrived at 1316 | BJS, 2021, Vol. 108, No. 11 the last page and clicked the ‘Finish Survey’ button. Due to its open nature, there was no mechanism to ensure that only the target population were answering. Dissemination of the survey The survey was disseminated via social media, including Facebook and Twitter, and through emails to medical student societies, surgical societies and women’s surgical societies around the world (Appendix S6) from 22 February 2020 for 6 weeks. The survey was terminated prematurely on 28 March 2020 due to the COVID-19 pandemic. Participation in the survey was voluntary and no incentives were offered for its completion. No personally identifiable information was collected. Analysis of surveys Only complete surveys were analysed. Responses from all duplicated IP addresses were checked manually. If they were different, they would be assumed to be from different visitors with the same modem. Statistical analysis was performed using SPSS Statistics Version 26 (IBM, Chicago, Illinois, USA). Normality of data was checked by visual inspection of histograms, or by Anderson– Darling test and Shapiro–Wilk test. Non-parametric data were reported as median (i.q.r.). v 2 tests were used to compare categorical and ordinal variables, with significance level set at P<0.050. Results A total of 1894 responses were received and 1393 (73.5 per cent) of them were complete. The full extent of survey dissemination is unknown, thus a formal response rate could not be ascertained. Eighty-nine responses originated from the same IP addresses and were from 25 modems. Each of these responses with duplicated IP addresses was cross-checked and found to be different from every other response and were thus included in the analysis. Overall, the median age of the respondents was 29.5 (i.q.r. 24– 37) years, 829 (61.5 per cent) were female and 527 (39.1 per cent) had children (Table 1). The respondents were spread across 65 countries and six continents with the majority of respondents from Europe (57.9 per cent) and Asia (34.6 per cent) (Table S1). The countries with the greatest number of respondents were Turkey (180, 13.3 per cent), Switzerland (175, 13.0 per cent), Denmark (150, 11.1 per cent), Japan (112, 8.3 per cent) and the UK (87, 6.5 per cent). In terms of stage of career, 479 (34.4 per cent) of the respondents were medical students, 349 (25.1 per cent) were surgical trainees and 513 (36.8 per cent) were consultants. Fifty-two respondents (3.7 per cent) did not provide an answer as to their stage of career and were therefore excluded from subsequent analysis. Legislation for maternity/paternity leave There were 1161 (83.3 per cent) respondents who stated that legislation was in place to govern maternity/paternity leave in their country while 131 (9.4 per cent) did not know if such legislation existed. Respondents from Asian countries were statistically more likely to answer that there was no legislation in place for parental leave compared with their counterparts in European countries (P<0.001). There was a significant difference in the lack of knowledge of such legislation across career stages (18.6 per cent of students versus 5.2 per cent of trainees versus 4.7 per cent of consultants, P<0.001). Medical student survey The median age of the medical students was 22 (i.q.r. 20–24) years and 353 (73.8 per cent) were female (Table 1). A total of 326 (68.0 per cent) respondents were interested in a career in surgery. However, 397 (83.1 per cent) had never received any formal surgical career advice, and 365 (76.2 per cent) felt that work–family life balance is important/very important in choosing a career. More than half (283 (59.2 per cent)) did not believe that a surgical career allowed such a balance and 226 (47.3 per cent) believed pursuing a surgical career would negatively impact on their family planning or engaging in relationships (Table 2). Moreover, 369 (77.4 per cent) stated that they would be more likely to pursue a surgical career if there were an option of part-time/flexible training, but 361 (75.7 per cent) did not know if their desired employer provided such policies. There were no significant gender differences in these views except that female students are more likely to feel that a surgical career would impact negatively on their family planning (49.5 per cent versus 40.7 per cent, P¼0.003). Surgical trainee and consultant surveys The median ages of surgical trainees and consultants were 29 (i.q.r. 27–32) and 39 (i.q.r. 34.5–45) years respectively. Regarding gender, 59.1 per cent of trainees and 51.6 per cent of consultants were female (Table 1). Trainees were significantly less likely to have children than consultants (36.3 versus 73.5 per cent, Table 1 Demographics Overall (n51393) Students (n5479) Trainees (n5349) Consultants (n5513) Age (years)* 29.5 (13) 22 (4) 29 (5) 39 (10.5) Sex Female 829 (61.5) 353 (73.8) 205 (59.1) 263 (51.6) Male 514 (38.1) 123 (25.7) 141 (40.6) 245 (48.0) Non-binary 3 (0.2) 1 (0.2) 1 (0.3) 1 (0.2) Prefer not to say 2 (0.1) 1 (0.2) 0 (0) 1 (0.2) Marital status Single 400 (29.6) 260 (54.3) 90 (25.9) 48 (9.4) In a relationship 317 (23.5) 174 (36.3) 93 (26.7) 50 (9.8) Married 613 (45.4) 44 (9.2) 164 (47.1) 398 (77.7) Divorced 16 (1.2) 0 (0) 1 (0.3) 13 (2.5) Widowed 4 (0.3) 1 (0.2) 0 (0) 3 (0.6) Number of children† 0 819 (60.8) 458 (95.8) 221 (63.7) 135 (26.5) 1–2 434 (32.2) 18 (3.7) 112 (32.3) 299 (58.7) 3–4 86 (6.4) 2 (0.4) 14 (4.0) 68 (13.4) >4 7 (0.5) 0 (0) 0 (0) 7 (1.4) Age of having first child (years) <25 42 (3.3) 8 (1.8) 9 (2.8) 23 (4.6) 26–30 211 (16.5) 17 (3.9) 67 (20.7) 125 (25.2) 31–35 208 (16.3) 6 (1.4) 46 (14.2) 152 (30.6) 36–40 80 (6.3) 0 (0) 10 (3.1) 68 (13.7) >41 14 (1.1) 0 (0) 3 (0.9) 11 (2.2) N/A 725 (56.6) 408 (92.9) 198 (61.1) 117 (23.6) Partner’s occupation N/A 394 (29.4) 236 (50.1) 93 (27.0) 62 (12.1) Surgeon 142 (10.6) 6 (1.3) 39 (11.3) 94 (18.4) Medical but not surgeon 211 (15.8) 18 (3.8) 65 (18.8) 127 (24.9) Medical student 65 (4.9) 60 (12.7) 4 (1.2) 1 (0.2) Non-medical 482 (36.0) 148 (31.4) 138 (40.0) 191 (37.4) Homemaker 45 (3.4) 3 (0.6) 6 (1.7) 36 (7.0) Values in parentheses are percentages unless indicated otherwise; *values are median (i.q.r.). †Binary comparison between trainee and consultants, trainees were significantly less likely to have children than consultants (P<0.001). N/A, Not answered. Au et al.| 1317 P<0.001). Overall, females were significantly less likely to have children compared with males (45.6 versus 36.8 per cent with no children, P¼0.010). Work–life balance Too much work was reported by 206 (59.5 per cent) trainees and 265 (52.0 per cent) consultants. There was no significant difference between genders or continents (Europe and Asia) in the work–life balance score. Views on covering for maternity/paternity leave A majority of trainees/consultants (670 (85.2 per cent)) stated they were happy or did not mind covering for colleagues on leave. Those with children were significantly more likely to be happy/do not mind covering compared with those without (60.4 versus 39.6 per cent, P¼0.004). There was no statistical difference in the feelings regarding covering colleagues on leave in Europe versus Asia (84.3 per cent happy/don’t mind to cover in Europe versus 87.6 per cent in Asia, P¼0.194; Table S2). Maternity and paternity leave entitlement The commonest maternity leave entitlement for trainees was 7– 12 months (26.6 per cent) and partially paid (38.4 per cent), while the commonest entitlement for paternity leave was less than 1 month (44.4 per cent) and fully paid (42.1 per cent). For consultants, the commonest entitlement was 1–3 months (35.5 per cent) and partially paid (39.6 per cent) for maternity leave and less than 1 month (44.9 per cent) and fully paid (37.3 per cent) for paternity leave (Table 3). Of the 235 respondents, 155 (66.0 per cent) found maternity leave application ‘easy’ while 105 of the 215 respondents (48.8 per cent) found paternity leave application ‘easy’. Comparing European and Asian countries, there was no significant difference in the ease of maternity and paternity leave application (P¼0.071 and P¼0.199 respectively). Subgroup analysis showed that European trainees were significantly more likely to find maternity leave application ‘not easy’ compared with Asian trainees (51.5 versus 16.3 per cent, P¼0.001). There was no geographical statistical difference amongst consultant maternity leave and paternity leave of trainees/consultants. Full entitlement was not taken by 52.5 per cent (52 of 99) of trainees and 60.7 per cent (82 of 135) of consultants. The commonest reason was pressure from employer/senior/ peers followed by financial pressure. Attitude towards taking maternity/paternity leave Over 50 per cent of trainees and consultants felt that their employer, seniors and colleagues were supportive or very supportive of their taking of leave, while at least 8.1 per cent of trainees and 21 per cent of consultants felt unsupported/very unsupported (Table 4). Childcare On average, trainees and consultants who had children reported using 1.6 modes of childcare arrangement. The commonest modes of childcare arrangement were help from family and friends (98 of 481 respondents, 20.4 per cent), nursery/school (89 of 481, 18.5 per cent) and a combination of both (79 of 481, 16.4 per cent). On average, trainees and consultants who had children spent 11–20 per cent of their salary on childcare and school fees (Table 5;Fig. S1). Comparing European and Asian countries, there was no significant difference in the spending on childcare (52.5 per cent in Europe spending less than 20 per cent on childcare versus 58.5 per cent in Asia, P¼0.209). Comparing female and male, males were significantly more likely to spend less than 20 per cent of their salary on childcare (47.4 versus 64.2 per cent, P¼0.000). There was no significant difference between trainees and consultants (57.9 per cent trainees spending less than 20 per cent on childcare versus 54.8 per cent consultants, P¼0.545). Time spent with children Of those who had children, 503 (96.7 per cent) of the trainees and consultants answered questions regarding time spent with children. The mean ‘time spent with children’ was 21–30 hours (Fig. S2). Male surgeons were found to be significantly more likely to spend less than 30 hours per week with their children (73.1 versus 50.4 per cent, P<0.005). There was no significant difference in the time spent with children between Europe and Asia (60.9 per cent in Europe spent less than 30 hours per week with children versus 60.0 per cent in Asia, P¼0.855). Notably, 45 per cent or greater of respondents from Denmark, Japan, Turkey and the UK had spent 30 hours or more with their children per week. Guilt feeling for not spending enough time with children Guilt for not spending enough time with their children was reported by 95.6 per cent of trainees and consultants. There was no significant difference between Europe and Asia (94.5 per cent of Europeans versus 95.5 per cent of Asians ever felt guilty, P¼0.632). Compatibility of surgical career with parenthood A majority of respondents in all categories had been told or heard that a surgical career is not compatible with parenthood (85.4 per cent of the medical students, 80.9 per cent of trainees and 82.0 Table 2 Medical students’ views on work–family life balance Importance of work– family life balance in career choice nView on whether surgical career allows a good work–family life balance nView on whether a surgical career will have impact on family planning/engaging in relationships n Not very important 8 (1.7) Very poor balance 101 (21.1) Very negative impact 68 (14.3) Not important 16 (3.3) Poor balance 182 (38.1) Negative impact 158 (33.1) Neutral 90 (18.8) Neutral 153 (32.0) Neutral 186 (39.0) Important 176 (36.7) Good balance 36 (7.5) Positive impact 53 (11.1) Very important 189 (39.5) Excellent balance 6 (1.3) Very positive impact 12 (2.5) Values in parentheses are percentages. 1318 | BJS, 2021, Vol. 108, No. 11 per cent of consultants). There was no significant difference across the different career stages and between Europe and Asia (80.9 versus 83.9 per cent, P¼0.178). Females were more likely than males to have been told that surgery is not compatible with parenthood (80.2 versus 59.5 per cent, P<0.001). Among trainees and consultants, the commonest sources of such comments were from seniors (21.3 and 27.3 per cent respectively) and colleagues (20.3 and 24.1 per cent respectively). Discussion This study compared the experience of maternity/paternity leave and parenthood across continents, and between genders for individuals pursuing surgical careers. The most recent review conducted by UNICEF on 41 high- and middle-income countries revealed that only the USA did not provide for statutory paid maternity/paternity leave 24 .The International Labour Organization (ILO) recommends at least 14 weeks of maternity leave at a rate of at least two-thirds of previous earnings. It also calls for the development of adequate paid paternity leave without recommending a standard 25 . Adequate paid parental leave is important as it is associated with lower infant mortality, health benefits of the mother and higher female earnings and employment 26–28 . There had been a recent trend in enhancing parental leave policies across other sectors. In the UK there is a push towards 6 months of full pay for maternity pay and aligning standalone paternity leave and pay with maternity leave 29 . Data collected on 107 major US law firms showed that 80 (74.8 per cent) provided at least 14 weeks of paid primary caregiver leave and 97 (90.7 per cent) provided paid secondary caregiver leave to their lawyers 30 . Parental leave and pay for surgeons should be aligned with those for other industries. Similar to previous studies 16,31,32 , this study demonstrated that female surgeons were significantly less likely to have children than male surgeons. The possible reasons for this might include demands of training as well as infertility 31 as surgical training coincides with female reproductive years. Another potential reason is that females might have been discouraged to have children as this study revealed as they were more likely to have been told that surgery is incompatible with parenthood, which is echoed by findings of previous studies 18,33–35 . This, in turn, might have been caused by societal pressure and expectation that women bear greater child-caring responsibilities 34 . Such gender difference in child-caring responsibilities was highlighted in this study, which found that males were significantly more likely to spend a smaller proportion of their salary on childcare and spend less time with their children. Overall, trainees were found to be significantly less likely to have children than consultants. Although not directly addressed in the study, potential reasons include trainees being younger and thus less likely to have started a family, difficulty in getting coverage 36 and time-off 37,38 , fear of interruption of training 39 , inadequate departmental support 38 and peer pressure 40 . This study showed that over 80 per cent of respondents have heard/been told that parenthood was incompatible with a surgical career, suggesting that stigma towards having a family could still be prevalent in a surgical workplace. It also demonstrated that those with children were significantly more likely to be happy or not to mind covering for colleagues on parental leave. This was perhaps because those with children had shared similar experiences and were more likely to be understanding. Although over 85 per cent of respondents were happy or did not mind covering, a significant proportion of respondents still felt unsupported for taking leave. This might be because of deficiency in other crucial factors in the surgical workplace such as clear and concise leave policies, adequate workplace risk assessment during pregnancy, opportunities to keep in touch with the workplace during leave, opportunities for phased/supported return, availability of lactation rooms at work and encouragement of staff to take full leave entitlement. In addition, this survey showed that over 95 per cent of respondents felt guilty for not spending enough time with their children. This could be improved by more family-friendly policies in the workplace, not limited to enhanced parental leave packages but addressing all aspects of parenthood, such as adequately staffed rotas to allow staff to go home on time or take time off, improving, advertising and normalizing flexible or parttime work and training options for all genders, or on-site roundthe-clock nurseries to help staff with childcare. Such policies require enormous political and administrative will and resources to implement. However, they will allow work to fit around family life and improve workforce satisfaction and productivity, and ultimately benefit all healthcare professionals working in the entire healthcare organization. The majority of medical students felt that work–family life balance is important in choosing a career, as shown in previous studies 10,11,13,41,42 , and they did not believe that a surgical career allowed such balance. This feeling was echoed by a rather uniform experience from a majority of trainees and consultants that responded ‘having too much work’. The students also Table 3 Global maternity and paternity leave entitlement Trainees(n¼349) Consultants(n¼513) Maternity leave Duration <1 month 17 (4.8) 24 (4.7) 1–3 months 81 (22.9) 182 (35.5) 4–6 months 76 (21.5) 144 (28.1) 7–12 months 94 (26.6) 45 (8.8) 1–2 years 10 (2.8) 24 (4.7) >2 years 2 (0.6) 13 (2.5) Don’t know 69 (19.5) 62 (12.1) No entitlement 5 (1.4) 18 (3.5) Pay Fully paid 118 (33.8) 184 (37.4) Partially paid 134 (38.4) 195 (39.6) No pay 7 (2.0) 26 (5.3) Don’t know 86 (24.6) 72 (14.6) No entitlement 4 (1.1) 15 (3.0) Paternity leave Duration <1 month 154 (44.4) 227 (44.9) 1–3 months 42 (12.1) 59 (11.7) 4–6 months 17 (4.9) 11 (2.2) 7–12 months 10 (2.9) 15 (3.0) 1–2 years 2 (0.6) 11 (2.2) >2 years 1 (0.3) 2 (0.4) Don’t know 90 (25.9) 95 (18.8) No entitlement 31 (8.9) 86 (17.0) Pay Fully paid 142 (42.1) 182 (37.3) Partially paid 50 (14.8) 108 (22.1) No pay 10 (3.0) 27 (5.5) Don’t know 108 (32.0) 104 (21.3) No entitlement 27 (8.0) 67 (13.7) Values in parentheses are percentages. Au et al.| 1319 stated that they would be more likely to pursue surgery if parttime or flexible training were an option. However, this study revealed that most of them never had any formal surgical career advice and did not know if a flexible training policy were available in their desired workplace. Therefore, implementation of flexible and family-friendly workplace policies and providing more career advice are crucial to retaining and attracting talents to surgery. One of the advantages of conducting this study through the internet was the wide dissemination of the survey, enabling it to reach an audience that would not be otherwise available through traditional channels. However, the trade-off was that there was no control over the denominator and therefore the response rate could not be calculated 43 . This study was also limited by the lower-than-expected number of respondents as it was cut short due to COVID-19. This led to the need to combine several answer categories to perform binary comparisons. It also meant that some geographical regions had insufficient number of respondents for meaningful statistical analysis and that statistical comparison could only be performed between Europe and Asia, the two regions with the greatest number of respondents. In addition, there were several potential sources of selection bias. For example, there was a clear geographical difference in response. A considerable proportion of responses from Turkey, Switzerland, Japan and Denmark, though invaluable as publications from these countries were relatively scarce, together with the low participation from USA and Canada would have combined to skew results. Moreover, there may also be selection bias within the students, as those who are more interested in surgery are likely to have responded to this survey. There were also more female respondents (61.5 per cent) than males overall, while the proportion of the female surgeons from the five countries with the most respondents was only around 7.6–32 per cent 6,7,9,44,45 . Although in the questions where there was a statistically significant gender difference in the response, the female to male respondent ratio is around 50 : 50 (with female percentage ranging from 50.1 to 54.8 per cent), this was still a relative underrepresentation of men compared with the actual population structure of surgeons. Such a higher proportion of female respondents might be because females had stronger interest in this topic. This potentially introduced bias into the survey with men being under-represented. In an era of increasing awareness of the benefits of gender diversity in the medical workforce, pregnancy-related gender and parenting inequality are still prevalent. This study revealed that a considerable proportion of surgeons had inadequate maternity/ paternity leave. Gender disparity is also found to be more Table 5 Childcare arrangement and financial burden Percentage of salary spent on childcare Trainees (n¼349) Consultants (n5513) 013 (10.2) 17 (4.5) 1–5 9 (7.1) 36 (9.6) 6–10 23 (18.1) 65 (17.3) 11–20 28 (22.0) 86 (22.9) 21–30 23 (18.1) 76 (20.3) 31–50 22 (17.3) 55 (14.7) >50 9 (7.1) 40 (10.7) Table 4 Attitude towards maternity/paternity leave Attitude Trainees (n¼349) Attitude Consultants (n5513) From deanery From employer Very unsupportive 5 (4.5) Very unsupportive 19 (11.5) Unsupportive 5 (4.5) Unsupportive 17 (10.3) Neutral 15 (13.6) Neutral 31 (18.8) Supportive 19 (17.3) Supportive 30 (18.2) Very supportive 41 (37.3) Very supportive 49 (29.7) Don’t know 21 (19.1) Don’t know 13 (7.9) N/A 4 (3.6) N/A 6 (3.6) From employer From consultant colleagues Very unsupportive 5 (4.5) Very unsupportive 17 (10.2) Unsupportive 9 (8.2) Unsupportive 18 (10.8) Neutral 18 (16.4) Neutral 30 (18.0) Supportive 26 (23.6) Supportive 31 (18.6) Very supportive 42 (38.2) Very supportive 56 (33.5) Don’t know 7 (6.4) Don’t know 11 (6.6) N/A 3 (2.7) N/A 4 (2.4) From seniors From juniors Very unsupportive 7 (6.4) Very unsupportive 9 (5.4) Unsupportive 7 (6.4) Unsupportive 12 (7.3) Neutral 21 (19.1) Neutral 21 (12.7) Supportive 32 (29.1) Supportive 31 (18.8) Very supportive 36 (32.7) Very supportive 63 (38.2) Don’t know 6 (5.5) Don’t know 19 (11.5) N/A 1 (0.9) N/A 10 (6.1) From fellow trainees Very unsupportive 5 (4.5) Unsupportive 4 (3.6) Neutral 16 (14.5) Supportive 23 (20.9) Very supportive 49 (44.5) Don’t know 11 (10) N/A 2 (1.8) Values in parentheses are percentages. N/A, Not answered. 1320 | BJS, 2021, Vol. 108, No. 11 important than geographical or career stage differences in the experience of parental leave and parenthood. Acknowledgements S.A., A.K., W.K., and Y.M. had full access to all the data in the study and take responsibility for the integrity of the data and accuracy of the data analysis. Concept and design: S.A., Y.M., D.V., J.M., G.M., S.F., N.J.S., K.S. Translation of surveys: S.A., V.B., J.M.C., C.D.C., J.D., K.E., N.E.F., A.C.H.F., C.F., G.G., F.A.C., J.L.H., F.H., A.I., L.J., D.C., H.Ø.K., S.Z.K., M.M., K.M.M., H.J.N., G.P., A.P., S.P., G.H.v.R., M.R., R.M.J.-H., J.C.S.H., E.S., S.S., M.U., M.U.Y. Acquisition, analysis or interpretation of data: all authors. Drafting of manuscript: S.A., Y.M. Critical revision of manuscript for important intellectual content: S.A., Y.M., D.V., J.M., G.M., S.F., C.T., G.H.v.R., S.Z.K., M.R., R.M.J.- H., M.M., H.Ø.K., G.P. Statistical analysis: S.A., A.M.F.K., W.K. Supervision: Y.M., D.V., J.M., G.M. Deidentified data will be available on request from the corresponding author via Google Doc. Supplementary material Supplementary material is available at BJS online. Disclosure. All of the authors have no conflict of interests with regards to this collaborative project. References 1. Burton K, Wong I. A force to contend with: the gender gap closes in Canadian medical schools. CMAJ 2004;170:1385–1386. 2. Barzansky B, Etzel S. Medical schools in the United States, 2006– 2007. JAMA 2007;298:1071–1077. 3. Tan T. More women studying medicine after lifting of quota. The Straits Times (Singapore). 2017. https://www.straitstimes.com/sin gapore/more-women-studying-medicine-after-lifting-of-quota (accessed 10 January 2021). 4. McKinstry B. Are there too many female medical graduates? Yes. BMJ 2008;336:748. 5. The Organisation for Economic Co-operation and Development. Women Make Up Most of the Health Sector Workers but They Are Under-Represented in High-Skilled Jobs. 2017. https://www. oecd.org/gender/data/women-make-up-most-of-the-health-sec tor-workers-but-they-are-under-represented-in-high-skilled-jobs. htm::text~As%20of%202015%2C%20just%20under,this%20pro portion%20is%20over%2070%25 (accessed 10 January 2021). 6. General Medical Council. The State of Medical Education and Practice in the UK 2017. 2017. https://www.gmc-uk.org/static/ documents/content/SoMEP-2017-final-full.pdf (accessed 10 January 2021). 7. Kobayashi AK. Women in thoracic surgery: Asian perspective. J Thorac Dis 2021;13:456–459. 8. Aziz HA, DuCoin C, Welsh DJ, Paramo JC, Andreone P, Butsch DW et al. 2018 ACS Governors survey: gender inequality and harassment remain a challenge in surgery. Bull Am Coll Surg 2019. https://bulletin.facs.org/2019/09/2018-acs-governors-survey-gen der-inequality-and-harassment-remain-a-challenge-in-surgery/ #::text¼The%20survey%20revealed%20that%2082.5,within% 20the%20field%20of%20surgery (accessed 11 January 2021). 9. Aspalter M, Linni K, Metzger P, Ho¨lzenbein T. Female choice for surgical specialties: development in Germany, Austria and Switzerland over the past decade. Eur Surg 2014;46:234–238. 10. Park J, Minor S, Taylor RA, Vikis E, Poenaru D. Why are women deterred from general surgery training? Am J Surg 2005;190:141–146. 11. Cochran A, Melby S, Neumayer LA. An internet-based survey of factors influencing medical student selection of a general surgery career. Am J Surg 2005;189:742–746. 12. Smith C, Galante JM, Pierce JL, Scherer LA. The surgical residency baby boom: changing patterns of childbearing during residency over a 30-year span. J Grad Med Educ 2013;5:625–629. 13. Rangel EL, Smink DS, Castillo-Angeles M, Kwakye G, Changala M, Haider AH et al. Pregnancy and motherhood during surgical training. JAMA Surg 2018;153:644–652. 14. Pham DT, Stephens EH, Antonoff MB, Colson YL, Dildy GA, Gaur Pet al. Birth trends and factors affecting childbearing among thoracic surgeons. Ann Thorac Surg 2014;98:890–895. 15. Anderson M, Goldman RH. Occupational reproductive hazards for female surgeons in the operating room. JAMA Surg 2020;155: 243–249. 16. Rogers AC, Wren SM, McNamara DA. Gender and specialty influences on personal and professional life among trainees. Ann Surg 2019;269:383–387. 17. Turner P, Lumpkins K, Gabre J, Lin M, Liu X, Terrin M. Pregnancy among women surgeons: trends over time. Arch Surg 2012;147: 474–479. 18. Sandler B, Tackett J, Longo W, Yoo P. Pregnancy and parenthood amongst surgery residents: results of the first nationwide survey of general surgery residency program directors. J Am Coll Surg 2016;222:1090–1096. 19. Huerta MC, Adema W, Baxter J, Han WJ, Lausten M, Lee R et al. Fathers’ leave and fathers’ involvement: evidence from four OECD countries. Eur J Soc Secur 2014;16:308–346. 20. Evertsson M, Boye K, Erman J. Fathers on call? A study on the sharing of care work between parents in Sweden. Dem Res 2018; 39:33–60. 21. Altieri MS, Salles A, Bevilacqua LA, Brunt M, Mellinger JD, Gooch JC et al. Perceptions of surgery residents about parental leave during training. JAMA Surg 2019;154:952–958. 22. Gaines T, Harkhani N, Chen H, Malik RD. Current policies and practising surgeon perspectives on parental leave. Am J Surg 2019;218:772–779. 23. Walsh DS, Gantt NL, Irish W, Sanfey HA, Stein SL. Policies and practice regarding pregnancy and maternity leave: an international survey. Am J Surg 2019;218:798–802. 24. Chzhen Y, Gromada A, Rees G. Are the World’s Richest Countries Family Friendly? Policy in the OECD and EU. Florence: UNICEF Office of Research, 2019. 25. Addati L, Cassirer N, Gilchrist K. Maternity and Paternity at Work: Law and Practice across the World. Geneva: SUI: International Labour Organisaton, 2014. 26. Ruhm CJ. The Economic Consequences of Parental Leave Mandates: Lessons from Europe. Cambridge, MA: National Bureau of Economic Research, 1996. 27. Johansson EA. The Effect of Own and Spousal Parental Leave on Earnings. Uppsala: IFAU – Institute for Labour Market Policy Evaluation, 2010. 28. Amin M, Islam A, Sakhonchik A. Does Paternity Leave Matter for Female Employment in Developing Economies? Washington, DC: World Bank Group, 2016. 29. Aon plc. UK Benefits and Trends Survey 2020.2020. https://www. aon.com/unitedkingdom/employee-benefits/resources/bene fits-and-trends/default.jsp (accessed 10 January 2021). Au et al.| 1321 30. Chambers Associate. Work/Life and Benefits. 2021. www.cham bers-associate.com/law-firms/worklife-and-benefits (accessed 10 January 2021). 31. Furnas H, Li AY, Garza R, Johnson D, Anureet B, Kalliainen L et al. An analysis of differences in the number of children for female and male plastic surgeons. Plast Reconstr Surg 2019;143:315–326. 32. Sangji NF, Fuentes E, Donelan K, Cropano C, King D. Gender disparity in trauma surgery: compensation, practice patterns, personal life, and wellness. J Surg Res 2020;250:179–187. 33. Lambert TW, Smith F, Goldacre MJ. Combining parenthood with a medical career: questionnaire survey of the UK medical graduates of 2002 covering some influences and experiences. BMJ Open 2017;7:e016822. 34. de Costa J, Chen-Xu J, Bentounsi Z, Verboort D. Women in surgery: challenges and opportunities. IJS Global Health 2018;1:e02. 35. Sanfey HA, Saalwachter-Schulman AR, Nyhof-Young JM, Eidelson B, Mann BD. Influences on medical student career choice: gender or generation. Arch Surg 2006;141:1086–1094. 36. Vassallo P, Jeremiah J, Forman L, Dubois L, Simmons DL, Chretien K et al. Parental leave in graduate medical education: recommendations for reform. Am J Med 2019;132:385–389. 37. Juengst SB, Royston A, Huang I, Wright B. Family leave and return-to-work experiences of physician mothers. JAMA Netw Open 2019;2:e1913054. 38. Mohan H, Ali O, Gokani V, McGoldrick C, Smitham P, Fitzgerald JEF et al. Surgical trainees’ experience of pregnancy, maternity and paternity leave: a cross-sectional study. Postgrad Med J 2019;95: 552–557. 39. Willett LL, Wellons MF, Hartig JR, Roenigk L, Panda M, Dearinger AT et al. Do women residents delay childbearing due to perceived career threats? Acad Med 2010;85:640–646. 40. Gupta M, Reichl A, Diaz-Aguilar LD, Duddleston PJ, Ullman JS, Muraszko KM et al. Pregnancy and parental leave among neurosurgeons and neurosurgical trainees. J Neurosurg 2020;134: 1325–1333. 41. Cronin C, Lucas M, McCarthy A, Boland F, Varadarajan R, Premnath N et al. Are we reaping what we sow? Gender diversity in surgery: a survey of medical students. Postgrad Med J 2019;95: 119–124. 42. Douglas P, Rzeszut A, Merz NB, Duvernoy CS, Lewis SJ, Walsh MN et al.; American College of Cardiology Task Force on Diversity and Inclusion and American College of Cardiology Women in Cardiology Council. Career preferences and perceptions of cardiology among US internal medicine trainees: factors influencing cardiology career choice. JAMA Cardiol 2018;3:682–691. 43. Braithwaite D, Emery J, de Lusignan S, Sutton S. Using the internet to conduct surveys of health professionals: a valid alternative? Fam Pract 2003;20:545–551. 44. Kaderli R, Guller U, Muff B, Stefenelli U, Businger A. Women in surgery: a survey in Switzerland. Arch Surg 2010;145: 1119–1121. 45. Nielsen TTT. A ˚rlige tal for antal udstedte speciallæge- og specialtandlægeanerkendelser fordelt pa˚specialerfora˚rene 2000- 2016. 2017. https://www.sst.dk/-/media/Udgivelser/2019/L%C3% A6geprognose-2018-2040.ashx?la¼da&hash¼B64A451ED51D2CF DD09976F3CD49DB045BCA0451. 1322 | BJS, 2021, Vol. 108, No. 11