Flexibility in Faculty Work-Life Policies at Medical Schools in the Big Ten Conference: A Ten-Year Follow-up Study

Background: Flexible work-life policies for medical school faculty are necessary to support career progress, advancement, retention, and job satisfaction. Objective: Our objective was to perform a 10-year follow-up descriptive assessment of the availability of flexible work-life policies for faculty in medical schools in the Big Ten Conference. Design: In this descriptive study, a modified objective scoring system was used to evaluate the flexibility of faculty work-life policies at 13 medical schools in the Big Ten Conference. Policy information was obtained from institutional websites and verified with the human resources offices. Scores from the 2011 study and 2020 were compared. Results: Michigan State and Ohio State Universities offered the most flexible policies (score 17.75/22) with the University of Michigan following (score 16.75/22). The largest delta scores, indicating more flexible policies in the past decade, were at University of Michigan (6) and University of Minnesota (5.25). Policies for parental leave and part-time faculty varied widely. Most schools earned an additional point in the newly added category of “flexible scheduling and return-to-work policies.” Nearly every institution reported dedicated lactation spaces and improved childcare options. Limitations: Limitations included missing policy data and interpretation bias in reviewing the policy websites, unavailable baseline data for schools that joined the Big Ten after the 2011 study, and unavailable baseline data for the additional category of return-to-work policies. Conclusions: While progress has been made, every institution should challenge themselves to review flexibility in work-life policies for faculty. It is important to advance a healthy competition with the goal to achieve more forward-thinking policies that improve retention, recruitment, and advancement of faculty. Big Ten institutions can continue to advance their policies by providing greater ease of access to options, further expansion of parental leave and childcare support, and offering more flexible policies for part-time faculty.


Introduction
Work-life balance is defined as the way in which an individual divides time between work and activities outside of work. Work-life well-being is becoming increasingly important to both employers and employees as millennials enter the workplace. The ability to recruit and retain a highly skilled and trained workforce is directly impacted by the employment policies of an institution.
Organizational policies that support the individual employee's personal health and wellness while also allowing pursuit of a rewarding, upwardly mobile career may contribute to greater job productivity while decreasing burnout. [1][2][3][4][5] Monetary compensation, paid time off, flexible scheduling, childcare and backup childcare resources, on-site fitness facilities, healthy on-site dining options, and paid and unpaid leave policies are examples of ways, in which employers have tangibly supported work-life balance. 6 Historically, the field of medicine has embraced a ''live to work'' mentality with its associated expectation of sacrificing individual wellness in the pursuit of clinical excellence. 7 In recent years, many younger physicians have embraced a ''work to live'' mindset which has challenged leaders in academic medicine to creatively develop employment policies that promote a healthier balance between meaningful work and the physical, mental, and emotional health of individual physicians. This wide array of inclusive policies that allow for the enhancement of work-life integration is often defined as flexibility in the workplace.
While enrollment in medical school is now equal between genders, 8 addressing the gender gap in faculty recruitment, promotion, and leadership positions has been slower and more challenging. Workplace flexibility is a primary concern for female professionals who continue to bear disproportionate responsibility for domestic work. 9,10 In addition, the increasing prevalence of dual career couples among highly educated professionals along with rising expectations for fathers' involvement in childcare make work-life balance a challenge for a growing proportion of men. 11 Improving work-life policies for academic physicians may minimize turnover for both men and women while decreasing the gender gap in academic advancement.
Over the last decades, increasing numbers of women have chosen careers in academic medicine. Some research efforts have highlighted problematic issues in work-life balance while others contributed to the development of creative policies, which facilitate combining successful careers with rewarding lives outside of medicine. For example, female physicians report improved job satisfaction when they do not delay important life events such as marriage or childbearing. 12 In addition, studies by Clem et al. and Rizvi et al. have shown that career satisfaction is directly linked to flexible scheduling, supportive colleagues, and time spent with family. 13,14 Another example of work-life balance advocacy by younger physicians was the successful implementation of flexible scheduling policies for pregnant residents. 15 Both academic physicians and the universities that employ them can benefit from increased attention to work-life balance issues. When universities adopt policies that meet the needs of a younger, more diverse faculty, they are more likely to recruit, retain, and promote these talented individuals.
Universities can learn from forward-thinking employers in private industry that have successfully implemented initiatives that support both traditional and nontraditional gender roles, dual-career couples, and those who are caregivers for young children and/or aging relatives. 6 Many physicians in these groups have historically been forced to choose between career advancement and providing care to their loved ones, which has contributed to a significant gender gap in academic advancement and promotion of female faculty in medicine. 9 In 2008 and 2011, two independent studies were published that assessed employment policies affecting work-life balance for academic faculty in United States medical schools. Bristol et al. evaluated employment policies of the top 10 medical schools in the United States, while Welch et al. analyzed them among medical schools in the Big Ten Conference. 16,17 The objective of our study was to perform a 10-year follow-up descriptive assessment of the Welch et al. study of the availability of flexible work-life policies for faculty in medical schools in the Big Ten Conference.

Study design and population
This study was a descriptive assessment of faculty work-life policies at medical schools in the Big Ten Conference in 2020. We followed a standard protocol similar to that described Bristol 16,17 The findings were then compared to findings from the 2011 study to report any notable changes. 17 As of 2020, 14 institutions comprise the Big Ten Conference as designated by the National Collegiate Athletic Association (NCAA). With the exception of Northwestern, which is a private/nonsectarian university of 22,000 students, the institutions are public universities with undergraduate enrollment ranging from 25,820 to 61,170 students.
Thirteen Big Ten universities with medical schools were included in this study:

Procedure
We accessed each institution's website between July 2020 and December 2020 and searched for information on policies for medical school faculty in the following categories: parental (maternity, paternity, and adoption) leave, extension of the tenure probationary period (defined as the time for the review before tenure), part-time appointments, part-time tenure track, health benefits for part-time employees, child-care options, including on campus care as well as subsidization, and lactation policies.
In addition, in this 10-year follow-up study, we added a category for postpartum scheduling (i.e., prolonged flexible scheduling and return to work options in the postpartum and postadoption periods). Regarding part-time appointments, part-time tenure track, and part-time benefits, we used each institution's own definition of part-time when relevant.

Verification of policies
To verify the accuracy of the work-life policy information gathered from the institution's website, an email was sent to each respective institution's Human Resource (HR) office contact person(s). In the email, we described the study, attached a summary of the policy information gathered from their website, and requested a phone or video call to verify their policies. Scores were adjusted based on information provided by the HR representative. If there was no email response, we sent two follow-up emails over 8 weeks. Upon completion on data collection, two authors again reviewed each institution's website for any updated policies to ensure all scores were the most current available. For institutions that failed to respond, scores represent information from online data collection only.

Scoring and analysis
For an individual institution, each policy was scored on a scale as described in the Work-Life Policy Scoring Assessment, with higher scores indicating greater flexibility (Table 1). 16,17 Two authors applied the scoring rubric and discrepancies were resolved by a third author. This scoring system was modified from Welch et al., which was based on Bristol et al., to include one additional policy of return-to-work scheduling. Category scores ranged from 0 to 3. Higher scores in each category indicated more flexible policies.
To address the variability of family leave policies available and their utility over the course of a career, these leave policies were further evaluated as to their availability on day of hire, after 1 year of employment, after 2 years of employment, and for part-time employees. An average score was then determined for each of the family leave policy categories (maternity, paternity, and adoptive leaves) with the maximum score of three available for each category. This expanded family leave scoring system considered varying family leave options. The average score ensured that it was not weighted more than the other policies measured in the total score.
A total score was then derived and assigned as the score for all policies for each institution (ranging from 0 to 21). A total score of 0-22 was also included to reflect the additional category of return-to-work scheduling.
To report changes in faculty policies in medical schools in the Big Ten between the 2011 study 16 and 2020, a delta score was calculated by subtracting the total score in the 2011 study from the total score in 2020.

Results
Work-life policy data were collected from their websites for all institutions with medical schools. An HR contact person was identified at each institution and asked to review each posted policy and verify accuracy. Data were verified for 5 of 13 schools (University of Illinois, Indiana University, Northwestern University, Ohio State University, and Pennsylvania State University). Other institutions referred us back to their websites without specific verification of collected scores.
Overall, more institutions possessed work-life websites in comparison to the 2011 study; however, websites were challenging to navigate, and obtaining data was time consuming. Most websites did not have a central repository of faculty policies, requiring searches of multiple web pages or online documents for each institution.
Michigan State University and Ohio State University demonstrated the most forward-thinking and complete work-life policies with a tied score of 17.75 cumulatively with the additional return-to-work category   considered. Both universities earned a score of 6.75 for family leave policies specifically and scored additional points in part-time employment policies, lactation accommodations, childcare options, and return to work scheduling ( Table 2).
In descending order after Michigan State and Ohio State Universities, the University of Michigan earned a cumulative score of 16.75, followed by the University of Minnesota (16) Table 2).
In comparison with the 2011 study, the greatest improvement was demonstrated by the University of Michigan, whose score improved from 9.75 to 15.75 with a delta score of 6 through significant improvement in parental leave policies. The University of Minnesota demonstrated the next greatest change in score from 9.75 to 15 with a delta score of 5.25 by improving leave policies, adding lactation policies, and increasing part-time benefits. The University of Wisconsin demonstrated no advancement in policies from the 2011 study to 2020 with an unchanged score of 12.25 (Table 3).
Notably, Rutgers University earned the lowest score of 5 demonstrating minimal leave policies or part-time options (Table 2).  (Table 4).
Rutgers University, the University of Wisconsin, the University of Iowa, and the University of Illinois offer minimal leave reporting only Family and Medical Leave Act (FMLA) policy or FMLA plus accrued sick leave regardless of an individual's time of employment (Table 4).  (Table 5).
In comparison to the 2011 study, only 3 of 13 universities did not offer parental leave to part-time faculty. This is improved from the 2011 study when only 4 of 10 universities offered parental leave for part-time faculty.

Part-time appointments
All institutions offered options for part-time faculty employment. This is unchanged from Welch et al.'s findings in the 2011 study.

Part-time health benefits
All institutions offered health benefits to employees with at least 50% Full-time equivalent with the exception of Indiana University who offers health benefits to employees with greater than 75% FTE and Rutgers University who does not offer benefits to part-time employees (Table 5).
Policies for part-time faculty tenure track Institutions were further examined for part-time tenure track. A score of 0 indicates this is not offered and a score of 1 indicates part-time tenure is pursuable. Seven of thirteen institutions offer tenure track for part-time faculty (University of Illinois, University of Iowa, University of Michigan, Michigan State University, University of Minnesota, Ohio State University, and University of Wisconsin) ( Table 5).

Extension of probationary period
Extension of the probationary period offers further flexibility to junior faculty on the tenure track. A score of 0 indicates an institution does not offer extension, a score of 1 indicates a 1-year extension upon request, and a score of 2 indicates automatic 1-year extension. Only three universities do not offer extension of probationary period (Penn State University,   Rutgers University, and University of Maryland). The most frequently offered option was an automatic 1-year extension ( Table 2).

Childcare options
All institutions offered childcare options. Three schools reported affiliated childcare centers only. The remaining 10 institutions offered onsite or affiliated childcare as well as financial aid or discounts. All websites provided easy to navigate options for investigating childcare (Table 2).

Lactation policy
Every institution reviewed offered dedicated lactation spaces, which improved from 70% of schools reporting lactation space in the 2011 study (Table 2).
Return-to-work scheduling policy (post-partum) Eleven of thirteen schools offer flexible scheduling options in the return-to-work or postpartum period after addition of a child. Flexible scheduling included condensed work weeks, options to work from home, and continued flexible hours to support childcare. Only the University of Iowa and Northwestern University did not offer flexible return to work scheduling options.
Noteworthy policies falling outside study purview During our investigation, we discovered noteworthy policies that were not captured in the scoring rubric. Northwestern University reported a robust wellness and work-life policy, in which new parents are provided consultation with a wellness team which provides guidance in managing the transition to parenthood, finding and establishing childcare, work-life integration, sends follow-up resources, and assists in application to public schools. Further, elder or senior care benefits are also offered to employees, similar to childcare benefits.

Discussion
Our study found that overall, Big Ten Universities have updated and expanded work-life policies for their employed physicians in the past decade.   Flexible work-life policies improve physician wellness, reduce burnout and increase physician retention and promotion at academic institutions. [18][19][20] There are multiple tangible examples of improved work-life policies that promote equity, wellness, and advancement for faculty at these medical schools. Expanding family leave to include maternity, paternity, and adoption leave supports more equitable sharing of parental responsibilities and more diverse family structures.
Part-time benefits and tenure pathways for part-time faculty are now more readily available, allowing physicians the opportunity to continue to advance their careers while spending time on activities outside of work. In addition, childcare options and flexible returnto-work scheduling ensure that key years of productivity are not lost due to childbearing, child-rearing, or other significant life events and accommodations are available for those who choose this path. Part-time options can help increase workforce diversity in other ways, such as allowing physicians to work in multiple settings while still advancing their careers in academic medicine.
Another area of improvement includes modernized lactation policies to support breastfeeding faculty members, which have resulted from an explosion of breastfeeding advocacy in the workplace and in social media. 21 The medical field has made great strides in this area and should lead the way in supporting this healthy practice for both mothers and their infants.
Improved flexible work-life policies are vital to support both early career physicians and female physicians. In a comparative study evaluating burnout differences among American surgeons, authors found that a greater proportion of early career physicians were women and that women experience more work-home conflicts than their male counterparts. Female surgeons were more likely to believe that child-rearing had slowed their career, to have experienced a conflict with their spouse's/partner's career, and to have experienced a work-home conflict in the past 3 weeks. Women also reported significantly higher rates of burnout and depressive symptoms. 22 Flexible work policies can help to reduce these stressors.
Return-to-work scheduling alternatives or options after the addition of a child (e.g., postpartum or adoption) is another example of flexible policies to support faculty work-life choices. This is a relatively new phenomenon in the past decade. Universities that have adopted these policies recognize that the challenges of new parenthood do not disappear when parental leave ends. Return-to-work flexibility may improve infantparent bonding, duration of breastfeeding, and parent mental health. 23,24 It must be noted that our study was conducted during the worldwide coronavirus disease 2019 (COVID- 19) pandemic. Across the country, workplaces had to reexamine their employment policies to offer more flexible work-from-home options, part-time options, and childcare options. This necessitated a review of current policies and an update that may not have occurred otherwise. Regardless of the pandemic, Big Ten institutions should be commended for offering these forward-thinking policies.
Despite advances in many of the above areas, few of the institutions that we studied expanded support for childcare during the past 10 years. We found that a common option for physician parents was a token partnership with a local center. Academic physicians require childcare that is accessible, flexible, and preferably onsite or close to campus, which can accommodate physicians' erratic and sometimes unpredictable work hours. 25 Some institutions have responded to this need by offering financial support or discounted pricing for dependent care. Childcare is a significant stressor for academic physicians with young children and is a vital area for increased attention and future growth. 26 Finally, our study focused solely on the existence of work-life policies at Big Ten institutions and not their implementation nor if they were accessible, affordable, or adequate. We did not study how frequently faculty members accessed the opportunities supported by these flexible work options. Others have found that academic faculty often underutilize existing policies due to absence of information, misinformation, unsupportive supervisors, or inflexible workplace cultures. To ensure that updated policies are deployed, the literature suggests that Big Ten department leaders should educate and encourage their academic physicians to utilize existing flexible work options. 11 Furthermore, institutions with a clear, easily accessible website and human resource contact may also intentionally promote their supportive policies. This may result in more successful recruitment of talented faculty as well as retention of currently employed academic physicians.
Future studies should continue to investigate innovative categories of flexible work-life policies as well as examine their accessibility and use by faculty members. Limitations Potential limitations included missing policy data and interpretation bias in reviewing the policy websites.
Most schools studied provided no centralized resource for policies. Institutions may have had policies that were available by employee-access only. Our search strategy may have not found policies that used different terminology. Baseline data were unavailable for three schools that joined the Big Ten after the 2011 study. In addition, we added a new policy category: return-to-work or postpartum preferential scheduling policies. We surmise no such category existed before the 2011 study as very few or no such policies existed.
The return-to-work policy analysis/accuracy may be limited in that many clinicians experience ''local'' processes that may not be a formal policy. Clinical responsibilities (return to work) are often determined at the division or department or clinic level based on coverage needs.
We recognize the need to reexamine the existence of new categories over time. A limitation of the scoring rubric is the way in which the scores are weighted. Certain audiences may ascribe more value to family leave policy than part-time policies, for example. Future studies may choose to emphasize specific policy categories over others.
Finally, conducting this study during the COVID-19 pandemic may have influenced office staff's ability to answer our requests for confirmation and clarification of policies due to absence from their physical office space.

Conclusions
While progress has been made, every institution should challenge itself to review flexibility in work-life policies for faculty. The improvement and expansion of worklife policies must be intentional. Those institutions that scored lower in our study may consider focusing their attention to this area to better support one of their most vital assets-the highly skilled and trained physician leaders of the clinical and academic medical workforce. Specifically, Big Ten institutions can continue to advance their flexible work-life policies by providing increased access to childcare options, further expansion of parental leave (including available leave from the first day of hire), and offering more flexible options for part-time faculty.
Moreover, this scoring tool could be used across all institutions for faculty members to evaluate their own institutional policies and use these metrics to inform best practices. Healthy competition with the goal to achieve more forward-thinking policies can improve retention, recruitment, and advancement of all faculty, leading to a more productive workplace, increased diversity and inclusion, and improved overall academic physician wellness.

Disclaimer
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.