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

BACKGROUND: 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. STUDY DESIGN: 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. RESULTS: 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. CONCLUSIONS: 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.