Flexibility Stigma and the Double Bind of Family Formation in Medical and Surgical Residency.

Abstract

Persistent burnout, attrition, and mistreatment among pregnant and parenting medical trainees suggest structural deficiencies in training environments. Flexibility stigma-bias against individuals using work-life accommodations within cultures defined by constant availability-may limit the effectiveness of existing policies. Six-month ethnographic study across two internal medicine and two general surgery residency programs at two academic teaching hospitals. Data were collected through site observations, focus groups, and semi-structured interviews examining program culture, work-life challenges, and accommodation use. Participants included 28 residents who were pregnant or parents of an infant ≤1 year of age, 23 residents without infants, and 13 program leaders. Flexibility stigma was pervasive across sites, where use of accommodations-particularly for parenting-was perceived as signaling reduced commitment to ideal resident norms of self-sacrifice and constant availability. Anticipated reputational harm led many trainees to forgo accommodations despite consequences for pregnancy health, parenting, relationships, and self-care. Trainees described "double binds" between professional expectations and essential personal goals, including becoming a parent, meeting perceived parenting standards, maintaining healthy pregnancies, sustaining relationships, and preserving basic well-being. Program-level factors, including staffing models, scheduling practices, policy communication, community culture, and leadership behavior, variably intensified or mitigated these pressures. Flexibility stigma functions as a structural barrier that limits accommodation uptake and exacerbates competing demands on pregnant and parenting residents. Addressing both cultural norms and program design is necessary to improve trainee well-being, support family formation, and advance equity in surgical and medical training.