By Grace K DeHoff, MS III
Many women in medicine struggle with when the optimal time to have children is during their medical training. Medical school is rigorous with limited time off available in the first two years with only a little more flexibility available in the last two years. For women who are not in a position to have children in medical school, the next option is during postgraduate training. Residency in any medical field is known to be difficult with long hours, large workload, steep learning curve, and limited time off. Some of these factors can be mitigated when programs have a large number of residents in each class allowing for the work load to be dispersed more evenly. The programs that accept larger groups of residents each year are better equipped to help arrange call schedules around maternity leave or unexpected sick days. Some surgical residencies only have one to two residents in each class, making workload a larger burden for the remaining residents during a woman’s maternity leave.
Policies for time off
The American College of Surgeons Women in Surgery committee released an updated statement on parental leave in February 2016. This association is dedicated to “improving the quality care of the surgical patient by setting high standards for education and practice”. The ACS has a Division of Advocacy and Health Policy which actively interacts with federal and state policymakers on issues that impact the surgical profession, including but not limited to payment reform, work hours, safety and liability and parental leave. This most recent statement on parental leave was directed at furthering support of entering parenthood as a surgical resident for both men and women. For women specifically, the policy stated that:
“Surgery should be supportive of healthy pregnancy outcomes, and should not impose punitive repercussions on those surgeons who choose to have children”
The full statement can be read here. The new policy has statements that include a maternity leave of at least 6 weeks, being relieved of call during their leave without being required to make it up, and breastfeeding accommodations including reasonable break time and sanitary conditions to express breast milk in, all without prejudice.
A quick search of various surgical residency policies shows many have maternity leave and family leave policies, but most programs still handle a pregnancy on a case by case basis. The biggest concern for any program is determining who will handle the caseload while a resident is out on paternity/maternity leave. Therefore, programs often prefer to know about a pregnancy and anticipated due date as soon as possible to optimize scheduling around your absence.
Pregnancy During Surgery
For surgeons in particular, there are a host of circumstances encountered during residency that make pregnancy even more challenging. Many surgeries in all specialties use fluoroscopy which includes the use of x-ray during the surgery. Typically, all staff in the room during these procedures will use a lead apron and thyroid cover to shield against the radiation, but in pregnancy there is always a worry about radiation exposure, especially if it occurs on a daily basis. Many surgeons elect to get scrubbed out of the room during the use of fluoro, or try to limit the cases they did where it was required. Other risks occur when surgeries include intraoperative chemotherapy or radiation treatments.
Occupational physical activity that surgeons are typically exposed to include long work hours, shift work, lifting, standing and physical work load. A 2015 retrospective cohort study examined the obstetrical complication rate for medical and surgical residents and found that complication rates significantly increased when surgeons worked more than 6 call shifts per month (P<0.001) or worked more than 8 hours in the operating room per week (P<0.001). Complications included higher rates of miscarriage, hypertension in pregnancy, placental abruption and intrauterine growth restriction. Surgeons should work closely with their OB-GYN during their pregnancy to determine what work restrictions will be most beneficial during their peripartum period.
Non-Structural Workplace Challenges
The many benefits of breastfeeding for the newborn infant are well-documented and the American Academy of Pediatrics recommends that all infants be “exclusive breastfeeding for the first year” of life. For surgeon mothers, this can be especially challenging . Pumping facilities in the hospital are now more often available as there are mothers of every job category that also use these resources. For surgeons, finding a location to pump is not the only challenge. Attempting to pump on a regular schedule can be disrupted by unpredictable schedules, late night calls, and long surgeries. On clinic days many women are able to schedule an empty appointment time that they can pump during and many surgeon mothers are very successful in their pursuit of providing breastmilk for their babies as long as they can. Under the Affordable Care Act, section 4207, the Fair Labor Standards Act now states that an employer is required to “provide reasonable time for an employee to express breast milk for her nursing child for one year after the child’s birth each time such an employee has need to express milk”. Despite the regulations in place to allow mothers this time, many surgeons struggle to find the time to express milk with such a rigorous and unpredictable career.
In residency sometimes the resentment at the increased workload comes from both male and female colleagues who have additional responsibilities in the absence of another resident. However, many women have found a majority of their colleagues are largely supportive of their pregnancy and maternity leave. There are signs of progress to hear that surgical residency programs have become more supportive of their residents’ pregnancies. Many surgeons who have had children during residency have had positive experiences, but structural changes and policy support are necessary to protect residents choosing to have children.
In general, between the ACS and the ACGME regulations on parental leave, surgeons who decide to become mothers have increasing protections in their endeavors to start a family during residency. The difficulty persists in finding the right balance. Unlike with other careers, when we are not at work, the work does not necessarily stop. Someone else must pick up the work load, or our patients suffer. For women employed in fields other than medicine, 6 weeks is not considered sufficient to recover from pregnancy and labor and to begin the life of motherhood. For many surgeons though, 6 weeks is regarded as a fair compromise between having enough time to feel established in motherhood and getting back to practicing medicine before feeling as if they have missed too much time away from the practice of medicine and surgery. The balance is delicate; the fact that even a remote balance exists is regarded as a success in the context of a surgical residency. Practicing medicine, especially surgery,is a skill that takes devoted practice and it is difficult to obtain mastery in this skill without appropriate training and ongoing practice.
Grace DeHoff is a third year osteopathic medical student at Pacific Northwest University and is interested in pursuing a career in Neurosurgery. She is a Denver, CO native but currently lives in Boise, ID with her husband and one-year-old son. She is the Diversity Chair with the National Medical Student Committee for the Association of Women Surgeons. In her free time, she enjoys running and has completed several half marathons and relay races.
Our blog is a forum for our members to speak, and as such, statements made here represent the opinions of the author and are not necessarily the opinion of the Association of Women Surgeons.