What Future Surgeons Really Want: Postpartum Care Trumps Parental Leave in Program Rankings

When medical students decide where to train in surgery, the fine print of family support policies may matter more than anyone assumed. A new survey-based study published in Global Surgical Education, the journal of the Association for Surgical Education, has upended a common assumption about what aspiring surgeons value most when weighing residency programs. Rather than the headline policies that dominate institutional marketing, such as paid parental leave, female and gender-diverse medical students placed the highest value on supports for postpartum well-being, emotional and physical health, and pathways to parenthood through adoption, fostering, and surrogacy. Parental leave, long treated as the centerpiece of family-friendly reform in surgical training, ranked at the very bottom of the list.

The study, led by Alexandria L. Soto of Duke University Hospital together with colleagues at Virginia Tech Carilion School of Medicine, Jefferson Einstein Philadelphia Hospital, and the University of North Carolina School of Medicine, set out to quantify the relative influence of ten distinct domains of parental and reproductive support on residency rank list decisions. The research team hypothesized that comprehensive parental leave policies would emerge as the most influential factor. Instead, the data told a different and more nuanced story, one that suggests trainees are thinking about family building as a continuum that extends far beyond the birth itself.

To capture these preferences with statistical rigor, the researchers employed Best-Worst Scaling, a survey methodology developed by decision scientists and described in detail by Louviere, Flynn, and Marley in their foundational 2015 text. Unlike conventional Likert ratings, in which respondents tend to rate nearly everything as important, Best-Worst Scaling forces participants to make trade-offs. In this study, respondents faced fifteen forced-choice questions in which they identified both the most and the least influential factor from subsets of the ten support categories. From these repeated choices, the team calculated standardized impact scores ranging from minus 1.0 to plus 1.0, allowing each domain to be ranked by its relative pull on decision-making.

The survey was administered electronically to medical student members of the Association of Women Surgeons between March 27 and June 7, 2025. The eligible pool comprised 1,050 medical students drawn from multiple medical schools and academic centers, and 158 students completed the survey, for a response rate of 15 percent. The respondent body was 99 percent women, with 32 percent in their fourth year of medical school and a median age of 27 years, spanning an interquartile range of 25 to 29. This population is precisely the demographic that surgical residency programs most need to understand, since women remain underrepresented in surgical specialties and family-related concerns are repeatedly cited as a deterrent to entering the field.

The results were striking in their ordering. Postpartum well-being topped the rankings with an impact score of 0.56 plus or minus 0.12, followed by physical and emotional well-being at 0.45 plus or minus 0.21, and adoption, fostering, and surrogacy support at 0.38 plus or minus 0.15. Grief and loss resources, a category that rarely appears in institutional policy discussions, registered a positive impact score of 0.19 plus or minus 0.19. At the opposite end of the spectrum, pregnancy support scored minus 0.51 plus or minus 0.24, and parental leave scored minus 0.64 plus or minus 0.10, making it the least influential of all ten domains. In Best-Worst Scaling terms, these negative scores indicate that respondents systematically identified these categories as the least decisive factors when forced to choose.

The authors interpret this counterintuitive hierarchy as evidence that pregnancy-specific support and parental leave, while necessary baseline protections, do not by themselves address the broader family-related challenges that arise during surgical training. The finding may also reflect perceived gaps in how existing leave policies are executed in practice. A policy on paper is not the same as a policy that trainees trust, and prior research has documented skepticism among surgical residents about whether taking full leave carries professional penalties. If students assume that leave will be grudgingly granted or structurally disruptive, its presence on a program website may carry little persuasive weight during the application process.

That interpretation gains weight from the broader literature on pregnancy and parenthood in surgical training. Studies published in JAMA Surgery have reported high rates of infertility and pregnancy complications among female surgeons, including a 2021 analysis by Rangel and colleagues documenting the incidence of infertility and pregnancy complications in US female surgeons, and a 2023 study by Lai and colleagues linking high infertility rates among female physicians to a need for culture change. Other work by Rangel’s group associated childbearing during residency with dissatisfaction in training and career. The American College of Surgeons issued a revised statement in 2024 emphasizing the importance of workplace support for pregnancy, parental leave, and lactation for surgical trainees, and the American Board of Medical Specialties adopted a policy on parental, caregiver, and medical leave during training in 2021. Institutional frameworks, in other words, have been evolving, but the new data suggest that what applicants scrutinize is not the leave policy itself.

The prominence of adoption, fostering, and surrogacy support in the rankings also reflects a growing recognition that family building takes many forms. A 2022 study in Annals of Surgery by Atkinson and colleagues examined assisted reproduction, surrogacy, and adoption among US surgeons and highlighted how costly and logistically complex these routes to parenthood can be, particularly for trainees with limited income and unpredictable schedules. Assisted reproductive technology, abbreviated ART in the study’s abbreviations list, represents a significant financial burden, and programs that offer fertility benefits, flexible scheduling for treatments, or institutional support for adoption expenses may signal a genuinely comprehensive commitment to trainee families. The Association of Women Surgeons has itself launched comprehensive initiatives for healthy surgical families, described in JAMA Surgery publications in 2023 and 2025, indicating that professional societies are moving toward this broader framing.

Equally notable is the appearance of grief and loss resources among the positively scored categories. Miscarriage, stillbirth, and pregnancy loss are common experiences that surgical trainees have historically navigated in silence, with little institutional scaffolding. The study’s authors suggest that the need for accommodations that account for loss, recovery, and other complex circumstances has been underappreciated in policy design. For residency programs seeking to recruit competitively, the message is that a support portfolio spanning emotional health services, postpartum care coordination, and compassionate responses to pregnancy loss may resonate more strongly with applicants than a headline leave duration figure.

The study, which received no external funding and was determined exempt from formal review by the Duke University Health System Institutional Review Board under protocol Pro00117361, carries some limitations inherent to its design. The response rate of 15 percent leaves open the possibility of selection effects, since students most invested in family planning issues may have been more likely to respond, and the sample was drawn exclusively from members of a single professional society. The authors also note that data supporting the findings are available upon request. Nevertheless, the methodological approach of Best-Worst Scaling provides a disciplined way to elicit true preferences, and the consistency of the top-ranked categories, all clustered around well-being and non-traditional paths to parenthood, offers residency programs a concrete signal. As programs compete for a shrinking and increasingly diverse applicant pool, the evidence suggests that the most persuasive family support is not the policy with the largest number of weeks attached to it, but the one that accompanies trainees through the entire, unpredictable arc of building a family during the most demanding years of medical training.

Subject of Research: Family and reproductive support factors influencing surgical residency rank list decisions among female and gender-diverse medical students

Article Title: Ranking family support resources by influence on rank list decisions

Article References: Soto, A. L., Mallett, C., Prezelski, K., Cannada, L. K., & DiLalla, G. A. (2026). Ranking family support resources by influence on rank list decisions. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 140. https://doi.org/10.1007/s44186-026-00544-0

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00544-0

Keywords: surgical education, parental leave, postpartum well-being, Best-Worst Scaling, medical students, residency rank list, family planning, Association of Women Surgeons, gender equity, adoption and surrogacy, pregnancy loss, graduate medical education