Abstract

Background: Residency Program Directors (RPDs) balance administrative, scholarly, teaching and patient care responsibilities. The 2002 Accreditation Council for Graduate Medical Education (ACGME) guidelines introduced reforms that increased administrative burdens for RPDs. However, the impact of these changes on RPDs’ families, particularly on their children’s career trajectories, is unclear. This study aimed to assess whether increased administrative responsibilities influenced the likelihood of dermatology RPDs’ children pursuing careers in healthcare.

Methods and Findings: A cross-sectional survey was distributed in May 2024 via the Association of Professors of Dermatology (APD) ListServ. Eligible participants were dermatology RPDs or associate RPDs (aPDs) with at least one child aged 18 or older. Of 134 invited participants, 130 completed the survey (97.0% response rate), with 36 meeting inclusion criteria. The survey collected demographic data and perceptions regarding parental influence. Sixteen RPDs (44.4%) had children who pursued healthcare careers (including all allied health fields), while 20 (55.6%) did not. Among RPDs who served before 2002, 5 of 6 (83.3%) had children enter healthcare, compared to 11 of 30 (36.7%) among those who served during or after 2002. Half (18/36) believed their career influenced their child’s decision; of these, 10 (55.6%) had children pursue healthcare. In contrast, only 4 of 16 (25%) who perceived no influence had children in healthcare. RPDs most frequently cited institutional or departmental demands as deterrents to careers in medicine. Limitations include a small sample size and potential response bias.

Conclusion: These findings suggest that the evolving administrative landscape of Graduate Medical Education (GME) may shape how children of dermatology residency leaders view careers in medicine. Institutional factors emerged as key influences, raising important considerations for workforce development and the long-term impact of policy reform on generational interest in academic medicine.

Keywords: Residency Program Directors; Children; Graduate Medical Education

Abbreviations

ACGME: Accreditation Council for Graduate Medical Education; aPD: Associate Program Director; GME: Graduate Medical Education; RPD: Residency Program Director

Introduction

Residency Program Directors (RPDs) are pivotal leaders in Graduate Medical Education (GME), responsible for balancing administrative, scholarly, teaching and clinical duties. As key architects of residency training, they help shape the future physician workforce. Over time, increasing administrative demands have raised concerns not only about the well-being of RPDs themselves but also about potential impacts on their families [1]. Yet, how these systemic changes affect the next generation, particularly the children of RPDs, remains underexplored.

One of the most significant systemic shifts in modern GME came with the Accreditation Council for Graduate Medical Education’s (ACGME) Outcome Project, introduced in the late 1990s and fully implemented in 2002. This reform established six core competencies foundational to U.S. medical training: patient care, medical knowledge, professionalism, practice-based learning and improvement, interpersonal communication skills and systems-based practice. To support these competencies, new assessment methods and greater programmatic oversight were introduced, significantly increasing the administrative burden for RPDs. These reforms, while aimed at improving educational quality, brought additional demands such as reporting requirements, compliance monitoring and expanded faculty development [1-3]. Existing studies document the professional challenges faced by RPDs, including burnout, administrative fatigue and job dissatisfaction 1,4-6]. However, little research has explored how these increasing demands extend beyond the professional realm to affect the families of RPDs, particularly their children. Given that medicine often runs in families, children of physician-leaders may have unique exposure to both the inspiration and strain that accompany academic medical careers. Some may be drawn to the profession by their parents’ dedication, while others may be dissuaded by visible stress and diminished work-life balance [7,8]. These dynamics raise important questions about how institutional changes in medical education may shape generational interest in the field. The purpose of this study is to examine whether the implementation of the 2002 ACGME guidelines influenced the career decisions of RPDs’ children. Through a nationally distributed survey of dermatology program directors, this study explores how increasing administrative responsibilities and evolving program leadership roles may influence how their children view careers in medicine. By addressing a previously underexplored dimension of medical education reform, this study provides insights that may inform future policy discussions on RPD workload, faculty well-being and medical career pipeline sustainability.

Methodology

Study Design and Participants

We conducted a cross-sectional survey study to examine how the experiences of dermatology RPDs and associate Program Directors (aPDs) influence their children’s career decisions. Eligible participants were dermatology RPDs and aPDs with at least one child aged 18 or older. Participants were recruited via the Association of Professors of Dermatology (APD) ListServ and the survey was disseminated in May 2025.

Survey Instrument

The survey instrument (available as Supplemental Material 1) was developed based on a comprehensive literature review and adapted from a previously validated national survey evaluating reasons for internal medicine RPD resignation [9]. The original framework was modified to assess dermatology-specific leadership experiences and perceptions of children’s career influences. In the survey, “pursuing healthcare” was defined broadly to include all allied health fields, not exclusively medical careers. The final instrument included seven domains to assess participant demographics, program characteristics, work-life balance, professional stressors and perceived parental influence on children’s career decisions [9]. The survey incorporated multiple-choice questions, Likert-scale items and optional open-text responses to allow for qualitative elaboration. Eligibility was confirmed at the beginning of the survey and participants provided electronic informed consent prior to participation.

Data Collection and Management

Survey responses were collected using Qualtrics, a HIPAA-compliant online platform. All data were stored on a secure, monitored OneDrive server at the University of North Carolina with weekly audits to ensure data integrity.

Statistical Analysis

We conducted all analyses using Microsoft Excel and RStudio (version 2024.12.0+467), utilizing the tidyverse, ggplot2 and Table1 packages. Descriptive statistics were used to summarize participant characteristics and survey responses. For categorical variables, we applied chi-square and Fisher’s exact tests; for continuous variables, we used the Kruskal-Wallis test. Statistical significance was defined as p<0.05. Given the sample size and exploratory nature of the analysis, we did not calculate confidence intervals or conduct multivariate modeling.

Ethical Approval

The study was deemed exempt by the Institutional Review Board at the University of North Carolina (IRB-24-1410) on July 31, 2024. All procedures adhered to ethical guidelines to ensure confidentiality and participant rights.

Results

Participant Characteristics Of 134 total dermatology program directors, 130 completed the survey (97.0% completion rate). Among these, 36 (27.7%) met eligibility criteria, having served as RPDs or aPDs with at least one child aged 18 or older. Of the 36, six (16.7%) served before the 2002 ACGME guidelines and 30 (83.3%) served during or after their implementation. Sixteen RPDs (44.4%) had children who pursued healthcare, while 20 (55.6%) did not (Table 1). Younger RPDs (ages 40-50) more often had children who did not pursue healthcare (6 of 7, 85.7%) (Fig. 1). Most RPDs whose children did not pursue healthcare (19 of 20, 95.0%) served after 2002. In contrast, those who served before 2002 were more likely to report children entering healthcare (5 of 6, 83.3%) compared to those serving after 2002 (11 of 30, 36.7%) (Fig. 1). Perceived Career Influence RPDs varied in their perceptions of whether their career experience influenced their child’s decision to pursue healthcare, with 16 (44.4%) reporting no influence and 18 (50.0%) perceiving their experience as influential (Table 2). Among the 18 who believed their experience was influential, 10 (55.5%) had children who pursued healthcare, while 8 (44.4%) did not. Conversely, among the 16 who reported no influence, only 4 (25.0%) had children who pursued healthcare, while 12 (75.0%) did not (Fig. 1). Reported Reasons for Influence Thirteen RPDs identified specific factors they believed shaped their children’s career views. The most common were institutional or departmental factors (7 of 13, 53.8%). Of the 16 children who pursued healthcare, 4 (25.0%) had parents who cited these as encouraging, while 3 parents cited them but had children who did not pursue healthcare, instead viewing these factors as discouraging. Only one RPD cited work-life balance and none cited ACGME regulations or resident factors (Table 2). Parents who cited the nature of the work itself – such as administrative burden or scope of responsibilities – were more likely to have children who pursued healthcare (2 of 3, 66.7%) compared to those citing institutional/departmental factors (4 of 7, 57.1%) (Fig. 1).

Figure 1: Impact of Residency Program Directors’ (RPDs) Career Contexts on Children’s Pursuit of Healthcare Careers. (A): Career choices of children (healthcare: n=16, non-healthcare: n=20) by RPD age. Younger RPDs (40-50 years) more often had children not pursuing healthcare (85.7%); (B): Association between timing of RPD service and children’s career paths. RPDs serving during/after 2002 more often had children who did not pursue healthcare (19 of 30, 63.3%), while those serving before 2002 more often had children enter healthcare (5 of 6, 83.3%); (C): Perceived parental influence on children’s career decisions. Among RPDs who perceived their careers as influential (n = 18), 10 (55.5%) had children who entered healthcare, compared to 4 of 16 (25.0%) among those who reported no influence; (D): Reported reasons for influence. Parents citing the nature of the work as influential were more likely to have children enter healthcare (2 of 3, 66.7%) compared to those citing Institutional/Departmental factors (4 of 7, 57.1%).