crying baby

Give yourself a break–Don’t have a baby during residency

Overheard in the OR—a surgery chief resident ruefully explaining to a senior surgeon why no intern or junior resident was available to scrub in on his case.  “Everyone in our department is either pregnant or on maternity or paternity leave,” he said.

The senior surgeon just shook his head.

From my vantage point as the anesthesiologist on the other side of the drapes, I thought to myself, “Really?  What’s wrong with these people?  What would give anyone the idea that residency is a good time to have a baby?”  When I look back to what it was like to deal with pregnancy, give birth, and look after an infant, all I can say is that internship was easier.  After all, as an intern—even in the bad old days—I had some nights off.

Yet having a baby during residency is increasingly common among male and female residents alike.  For women especially, it sounds perfectly awful.  We’ve all heard the stories—pregnant residents struggling with nausea and fatigue during long nights on call, or vomiting into a trash bag in the operating room; new mothers trying to breast-pump in the hospital locker room during a half-hour lunch break.

One possible response is to argue that senior physicians should be more sympathetic to pregnant and nursing residents, and give them longer lunch breaks.  This would be in keeping with the kinder, gentler world of limited resident duty hours and mandated nap times.

But it’s equally fair to consider that residency might be a bad time to have a baby.

Even with today’s work hour limits, residency in any field involves stressful days at work, limited control over your schedule, and frequent nights on call.  It’s hard to get nutritious meals on a regular basis, even if a pregnant resident could stomach the food in her hospital cafeteria.  Nor can she get enough rest.  Anyone who’s been pregnant can recall moments of such profound fatigue that she would kill for an afternoon nap, and a resident can’t simply lie down when she feels like it.  Can this be a healthy way to go through pregnancy?

Time to study

Even if a pregnancy is easy, there are other issues.  The purpose of residency, after all, is to train a new physician in the knowledge and practice of the specialty he or she has chosen.  There is a great deal to learn.  Textbooks must be read.  Sometimes even Wikipedia can’t bail you out in time; you actually have to remember things.

It’s hard for anyone to come home after a full day of work and summon the energy to read a textbook or journal.  For a pregnant resident, it’s even more of a challenge.  For a resident with a new baby in the house, it’s tough to get any uninterrupted studying done whether you’re the mother or the father.  Sleep is inevitably in short supply for both parents, and this goes on for months unless you are lucky enough to have an angelic infant who sleeps through the night at an early age.

And though it isn’t politically correct to say so, pregnancy is notorious for a combination of fatigue and mental fog that is sometimes referred to as “pregnancy brain” or worse, “momnesia”.  (I’ve heard physicians refer to it, not jokingly, as “dementia of pregnancy”.)  Though it hasn’t reached the status of a legitimate diagnosis, it’s hard to convince many women (and their partners) that “pregnancy brain” isn’t real.

One residency director (who prefers anonymity) bluntly advises her female residents not to become pregnant at least during the first two years of residency.  “You won’t study enough,” she says, “and your board scores will suffer.”  Certainly high scores don’t always correlate with stellar performance as a physician at the bedside.  But I think we can all agree that high board scores at least demonstrate facility with the subject matter.  Given the choice, I’d just as soon have a doctor taking care of me whose scores were at the higher end of the scale.

Taking care of the patients

A residency director recalls the day when a resident came breathlessly into her office with the news that yet another resident was pregnant.  “What are you going to do?” the resident asked, meaning how could all of the surgical cases and the night calls be covered.  “No,” said the program director.  “The question is, what are all of you going to do?”  The hospital isn’t going to hire more doctors to cover for resident maternity leaves.  The burden of coverage will fall on the remaining residents in the program.

In the majority of teaching hospitals, residents are critical for providing patient care—in the clinics, on the wards, and in the operating rooms.  When the responsibility falls on fewer and fewer remaining residents, they may easily become resentful.  The solidarity and morale of the group is bound to suffer. Eventually a critical point may be reached where there aren’t enough residents to cover the service.

It would be easy to suggest that residency programs should be expanded.  With more residents on hand, maternity and paternity leaves wouldn’t be an issue.  Many people fail to realize, though, that the number of residency positions in the U.S. is capped.  In 1997, Congress imposed a limit on how many residencies the government could subsidize as part of the Balanced Budget Act.  The Senate failed to pass an amendment to the health care bill that would have created thousands of new residency positions.  Future decreases in Medicare spending threaten the funding of the residency positions that exist now.

Hospitals could be forced to hire mid-level practitioners to make up for a lack of residents:  nurse anesthetists to replace anesthesiology residents; physician assistants or nurse practitioners to replace residents in other fields.  If that happens, we can’t blame the public, the government, and hospital administrators if they reach the conclusion that people with far less training can do the work of doctors.  We could face further downgrading of the physician’s role in American health care.

What’s the hurry?

I don’t understand what the hurry is for residents to start having babies, unless they started training later in life.  If you go straight from college to medical school and residency, even if you complete a fellowship you are likely to finish your training in your early thirties.  Nationally, later childbearing is the norm for many educated women—the Pew Research Center reports that births to women ages 35 and older grew 64% between 1990 and 2008.  The likelihood of conceiving is still high for women in their early thirties, and the risk of chromosomal abnormalities is low.

The pressure of having a baby during residency will strain even the strongest relationship.  Residents of either gender may feel entitled to shift much child-care responsibility to their partners.  Women residents face the impossible task of reconciling their desire to nurture the new baby and the need to return to work.  The husbands and wives of today’s residents are likely to have careers of their own and resent the idea that the resident’s career should take precedence.

If you postpone having children until you finish residency, you can decide with less financial pressure where you want to live and what kind of practice you want.  Raising a child to the age of 18 costs well over $200,000 by current estimates, not including the cost of college.  It’s easy to slip into credit card debt on top of medical school debt if you have children before you can afford them.  Heavy financial obligations can force you into career choices you wouldn’t otherwise make.

Sermo readers opine

There’s been an interesting chain of opinions recently on the physicians’ website Sermo, responding to the post “Actual Resident Comment”.  This post concerned a resident who asked to switch a call night in the ICU when his wife needed induction of labor.  Many readers were sympathetic; others took the side of the resident who wouldn’t take the call in his place.  A radiation oncologist offered a different take:  “Residents should not be having babies, period.”

Other writers disagreed vehemently. “Physicians who want to be parents make some of the best in the world by the examples of dedication, hard work, compassion, use of intellect, etc. that they set for their children,” wrote a specialist in allergy and immunology.  “This capacity for caring for others leads us to want children of our own.”

But no one was saying that physicians should never procreate.  The point was that childbirth during residency could be a problem. An emergency medicine physician noted that she conceived at the end of her intern year despite birth control pills, and went back to work five weeks later.  “I had my second as an attending,” she wrote. “MUCH easier.” She advocates having children after residency as a first choice.

The achievement checklist

In a way, the determination and single-mindedness of physicians may help to explain why they have children during residency.  Having a baby becomes part of the achievement checklist.  Finish college—check.  Finish medical school—check.  Score residency position—check.  Find life partner—check.  A baby becomes the next item on the list, and residents often feel pressure from parents and in-laws who are anxious for grandchildren.  For the young resident who’s been a bridesmaid in her best friends’ weddings, it can be hard to see them having babies without feeling the urge to have one of her own.

I certainly understand the desire to have children.  I had my first at the age of 22, and started medical school when she was four years old.  Not once did it cross my mind to have another until I was done with my fellowship—life was busy enough.  My other children were born after I went into practice.

For today’s residents, my message is simply this:  Give yourself a break.  Take advantage of all the teaching, and look at residency as the time to learn your life’s work.  Take care of your husband or wife or partner, and cherish that relationship.  Go out for a drink with your fellow residents occasionally, and enjoy those friendships.   Take a breath; pass your boards; establish some financial security.  Don’t let yourself get burned out before you’ve really started life as a physician.  There’s time ahead to have children.

 This column was featured on the Sermo Speakers Series on March 6, 2012

 

37 COMMENTS

AK

Frankly, I’m disappointed. I’m entering medical school this year a little later in life. I’ve put a lot of thought, time and energy into this career so far, and I expect that to continue. However, as I’m older I’m faced with the prospect of having the ‘window-closing’ on fertility should I wait until my training is finished. I don’t think it’s fair for someone to demand that I either choose medicine or choose to have a family. And, no I don’t want children because I’m checking some item off my list, I want children for the same reasons many reasons want children. With all due respect, if you didn’t actually have children during your residency, how can you fully comment on all its challenges and offer a blanket statement of when women should or should not choose to have a family. Instead, you sound like someone griping because you want new trainees to go through the same kind of hazing during residency that older doctors had to endure. I understand the necessity for doctors to be trained and qualified, but stating that the only way for this to occur is for women to forgo or put off having children is offensive.

[Reply]

Dear AK,

Please take my column as it’s intended–as friendly advice from someone who entered medical school at 26 with a four-year-old, and went on to have her other children after residency. I work in a teaching institution, and have watched many residents go through pregnancy. I get the strong sense that many had no idea what they were letting themselves in for, and it’s no wonder to me that they give up on their careers early because they’ve taken on too much too soon. I certainly can comment from experience on the challenges of pregnancy, childbirth, and studying medicine. I can also comment on the actions of people running for President even though I haven’t run for President and am unlikely to do so.

This has nothing to do with “hazing”, and I have no idea what would make you think so. Residency these days is clearly easier than it used to be, but I still think it’s not a great time to have a baby. Again, my advice is to give yourself a break–don’t take on too much at one time. Neither residency nor pregnancy has to be miserable, but there’s a much better chance of that when they’re combined. You should and will do whatever you choose; no one is issuing any ultimatum or blanket statement. I wish you the best of luck in whatever your path may be, and will follow your progress with interest should you continue our correspondence.

All the best,

Karen Sibert

[Reply]

jde

The author is of course entitled to her opinion and privelege to broadcast these opinions. The issue of procreation and timing of things is purely personal.I chose not to get pregnant until the formal ie examinable component of my medical training was completed but other colleagues& friends did not. It is hard & difficult being a physician & parent but one should be able to decide when to begin the journey to parenthood on an individual basis rather than be dictated to.

[Reply]

Dear Jde,

Of course the decision to procreate is personal. I am simply offering some advice–from the point of view of someone who went through both medical school and residency with a child, and has watched many others over the past years. It’s tough to be pregnant, a new mother or a new father as a resident. My intent was to provide a reality check, since I think many people have no idea what they’re getting into when they have a baby. You’re free to take my advice or leave it, just as you would take or leave advice from any mentor or your mother.

Thank you for reading, and all the best–

Karen Sibert

[Reply]

A

Dr. Siebert,

You have noted in your response to the previous two comments that you don’t mean this post to sound scolding or judgmental, you mean it to sound like “friendly advice” from “any mentor or your mother.” I wanted to comment briefly on why I don’t think it comes off that way to most people, and then share my own experience with this issue.

I think part of the problem is your choice of language. For example, when you open the post with an anecdote in which you introduce the concept of women having kids in residency with the thought “What’s wrong with those people?” in the context of implying that patient care is being compromised because literally there are no junior residents available to help on the case since they’re all off having babies – it starts things off with a very judgmental tone.

Another issue is the explanations of not just why you think this is a bad idea from the perspective of the resident making the decision, but why you think it is a bad idea for, basically, all of medicine. When you give reasons for it being a bad idea that include ‘you just won’t be as good a doctor’ or that your leave “could lead to the further downgrading of the physician’s role in America’s health care”, you’re certainly moving out of the realm of “friendly advice” – you’re directly saying, with strong and direct wording, that my having a baby during residency will harm my patients and my colleagues.

Finally, I think that your comments feel very heavy-handed to read in large part because of how you frame the advice and conclusions themselves. You do not say “I think sometimes these factors and consequences are not fully appreciated by young residents when they are making these choices, and I want people to understand them.” You instead make a string of very blanket statements, implying that you are describing all or nearly all residents who have children. Even your last line – “There’s time ahead to have children” – ends on a note that rings very false to many in medicine.

I would like to contrast your points with my own experience, briefly. First, I think I am a good example of someone who the statement “there is time ahead to have children” does not apply well to. I was drawn to medicine with the plan of doing an MD/PhD in Neuroscience/Psychiatry from the start. I feel strongly that new concepts and treatments are critical in psychiatry – and I also felt, and continue to feel, that my own personal strengths and interests put me in an unusually good position to contribute to these much needed developments. But unless you start out years ahead of the game by eg skipping high school or something, there is almost no way to do a full PhD in the areas I worked in, plus medical school, plus residency, and finish in time to have 2 kids before you turn 35, even back to back (and even if you did – two kids back to back during the single most important period of time in establishing your own research program would certainly be a bad sign for your ability to actually accomplish a career in research!). So, the way your comments play out in my mind is that you’re suggesting that women should never do MD/PhDs unless they don’t want to have kids (and perhaps men who do this should only marry significantly younger women…?).

I can also add the perspective of someone who actually has had kids in both medical school and residency. And… I *strongly* recommend it. I would do it again, the same way, without hesitation. Both pregnancies were planned in advance, and in fact discussed with the relevant Dean of Students / Program Director in advance, to ensure that the timing would work as well as possible with my training (both institutions were both encouraging and extremely supportive). Both times I was able to stay home for ~3 months, before coming back to initially part time and then full time work. And in each case, I was grateful for so many things about the timing – including something that you may not be very familiar with in your very non-patient-relationship-focused-specialty, but which in psychiatry (and much of medicine!) is very important: the times I arranged to have my maternity leave were carefully chosen to avoid periods of time where I was the ongoing provider for continuity patients. Even in specialty practices, where ongoing patients are only seen every couple of months, I have seen junior attendings lose huge fractions of a slate of patients they had worked so hard to build up when a maternity leave ended up preceeded by an extra month of bedrest. In psychiatry, being unavailable for 3 months is even more difficult on a patient load. For my situation, I think my ability to provide for the patients I will see in my career was optimized by the timing of my maternity leaves.

Finally, I want to address directly the idea that you should delay having kids until you’re a junior attending because being pregnant and then having young kids make you dumb. Now, being a neuroscientist and a physician, I wouldn’t of course dismiss this possibility outright. I’ve never seen any data substantiating this, though. And I am confused as well why you would use this as an argument that women *should* go ahead and have kids when they’re first practicing independently, instead. But most importantly, I would add that in the absence of data, all I can go by is what is the most important to me: having gone through the process as a trainee, I was pregnant and nursing and caring for one then two young children as a highly supervised, constantly tested young physician. And for any other women out there reading this and worrying – all I can say is I did very well, and have no doubts about the education I received or the care I was able to provide my patients during these periods. Could I have done even better on my exams if I hadn’t been pregnant? Perhaps! Could I have done even better on my exams if I did nothing in my entire life but work and study? Perhaps! But what I do know is that I would not have gone into medicine if the choice were medicine OR family. And doing it the way I did it, I still got 99th percentiles on shelf exams while a pregnant med student, and led my residency in in-service exam score while a (junior!) pregnant resident, at a large well-known East Coast training program. So if the choice is me-while-sometimes-pregnant or the-person-who-would-have-gotten-into-med-school-if-I-hadn’t-gone, I don’t think my patients were hurt by my choosing this career path.

I don’t know what your intentions were in writing the above post. I feel like some of it is sensationalism – and I worry about playing into that with this long comment. But I also think that this topic is very important. And I want women who read your post to know that the issues you are describing are, many of them, narrow ones, focused on your experience, at your program, in your specialty, and aimed at women in your rough position in life and with your approximate goals. But that despite your experiences, there ARE lots of ways to make medical training – and even academic, research-track medicine – work for women. I know, because I’ve done one, and I am so very grateful that I did not let posts like the one above scare me off from trying for it back when I was making my own career decisions.

Sincerely,
A.

[Reply]

Dear Dr. A:

Thank you for reading, and for taking the time to write such a detailed reply. I am certainly glad that your choices worked well for you. I specifically steered away from personal example and anecdote because I think the bigger picture is the issue. None of the things I’ve talked about are unique to any program or specialty. Naturally, an extra-long training program has different implications for the timing of childbearing. But a choice that works well for one resident may be fine; the same choice made by thousands of residents has more impact. You may be an excellent student while pregnant; many are not.

Of course I am making judgments; that is what opinion columnists do. May I gently suggest, though, that if this piece meets your criteria for sensationalism, you may not be reading enough non-medical content. The arguments on the opposite side have been made by many writers in many places, so I see no need to cover the same ground in the interests of presenting a more “fair and balanced” view.

All the best,

Karen Sibert (with only one “e”)

[Reply]

Jenna

I could not have said this better myself and I 100% agree.

[Reply]

JH

The only thing I’ve heard throughout my medical training process is: “there is no good time to get pregnant.” Pregnancy was not something I was thinking about at age 22 after college, or at 24 when I started medical school.

[Reply]

This article is quite unbalanced. Dr. Siebert, I would have liked to hear about your experiences as a mother of a young child during medical school and residency, rather than second- and third-hand complaints about other residents’ pregnancies. “Pregnancy brain” has been debunked in a number of studies, most recently by Christensen et al. in a prospective cohort study published in the British Journal of Psychiatry. You can find it on PubMed.

Obviously, having a baby at any time is difficult and would require a great deal of family support. The problems you raise here, like strained relationships and the expense of children, are certainly not unique to medicine. Granted, the issue of coverage is quite real, especially in smaller programs. But are you seriously suggesting that people make their family choices based on the convenience of their co-workers?

[Reply]

Dear Scrivener,

Thank you so much for reading, and for your reply. I particularly like your “pen name”.

My experiences during medical school and residency were quite unremarkable. I did exactly the same things as everyone else. I do recall bringing my daughter to the hospital with me occasionally when I needed to go back in the evening to admit a patient for the next day. She would sit at the nurses’ station and get lots of attention and treats.

People who work together in close-knit, interdependent groups often make personal decisions with the best interests of the group in mind. The military is an example that comes to mind, and it has been an honorable tradition for residents as well. If this has become a silly idea, I am sorry to hear it. It strikes me that individualism is a creed is easily carried too far. “Because I want to” is a reason I expect to hear from children, not from physicians.

I look forward to hearing from you again.

All the best,

Karen Sibert (with only one “e”)

[Reply]

Your post on pregnancy during residency inspired me to write my own post about my pregnancy in 1981 at an ivy league graduate school. http://ow.ly/9w9Lq
The university was not understanding or accommodating, and as a matter of fact how they handled the situation would probably be viewed dimly if not litigiously today.
In reading the comments above from other readers, I gather that this is such a personal issue that many find it difficult to separate their feelings and desires about how to handle this from the practical and rational advice you offer. But so often, in the medical field especially, the advice and indeed the truth we hear is frequently not palatable.
Medicine can be a ruthless career, and it is one where often the student or new physician pays their dues up front so to speak by working long hours with grueling demands placed upon them. I can’t imagine what it would be like to be pregnant and post-partal during that phase of one’s career.

[Reply]

Holly

I am a third-year OB/Gyn resident, and while I haven’t yet had a baby, I’ve been thinking long and hard about it. A lot of residents in my program have children or have been pregnant during residency. Overall, I don’t think it’s a bad thing. I would argue that it’s less about the achievement checklist and more about whether you’re ready to have a baby, in the sense that you would think about whether you’re ready if you were a teacher, or lawyer, or anything else. My residency program director actually encourages us to get pregnant during residency if that’s what we want to do. (His only plea is that two of us from the same year don’t go out on leave at the same time.) The arguments are that there is NO perfect time to have a baby, and waiting isn’t necessarily the right thing to do. You get older, it might get harder to get pregnant and in the end, more expensive, if you need to pursue artificial reproductive technologies for assistance. In residency, you do have a guaranteed amount of time off with pay, whereas as a practicing attending, it might actually be harder to take time off and away from the RVUs you would otherwise be earning. In some jobs, being an attending doesn’t necessarily mean things are easier (there’s no 80-hour workweek for attendings, as many people say!), so you still might be trying to pump on a 30-minute lunch break. Not everyone goes through their medical training straight out of college (or college straight out of high school), so if you’re older when you’re pregnant, you’re putting yourself at an increased risk for more complicated pregnancies. By no means am I saying that I think getting pregnant during residency is always the right thing to do, but I don’t think it’s correct to say it’s NEVER the right thing to do, either.

[Reply]

Dear Holly,

Thank you so much for reading, and for your thoughtful reply. I specifically cited starting medical training later in life as one of the obvious reasons why one might wish to have a baby during residency, so I agree completely with your point there. And I don’t pretend to dictate to any competent adult when to procreate or not; nowhere did I use the word “NEVER”. I simply pointed out reasons why I think pregnancy during residency poses peculiar difficulties for the resident, spouse, and fellow residents. While you can hire a qualified substitute teacher to cover a maternity leave, and there are perhaps too many lawyers anyway, residents are essential in teaching hospitals.

You are correct in that it may be hard to take time off at the attending level, particularly in private practice. I fear that private practices in many fields are backing off from hiring young women for exactly that reason: why bother with women, if you can hire a competent man? No maternity leaves to worry about. Though you might argue correctly that it’s illegal to discriminate in that way, it’s hard to track or prove. Academic departments and large HMOs, however, are more accommodating in terms of paid maternity leave, and of course the pay is at attending level. You might even have a private office in which you can put your feet up when you need a break, or breast-pump in private if you wish.

May I gently suggest that what many residency program directors say in front of their female residents, and what they say behind closed doors to colleagues, may be very different. Don’t be naive enough to think that everyone believes the party line at the attending level, regardless of how closely they keep their cards to the vest.

I wish you all good fortune in your future career. I will follow your progress with interest, and look forward to hearing from you again.

All the best,

Karen Sibert

[Reply]

Sharp beam

Hot discussion.

As much as strongly vouch for the decision to have children to be personal, it is true that many young women are not sure what they are getting into, when they decide to have babies during a tough residency.

Those who were able to do it are still doing it – reading and commenting on the web, while their babies are being looked after, or have grown etc.

Then there are those, who are trying their best to be that great mom and the best resident and an excellent care provider for their patients, but are somehow not fortunate enough to make it work (I specifically use the word fortunate because that is the difference between life circumstances that work and those that don’t).

Perhaps the sensational effect was intended here, but I resonate with the authors view – albeit it does sound reprimanding.

Kids are precious and hard work, so is a career in medicine – after all, you wouldn’t be knee deep in loan if this career was not that important for you.

The point, beyond the “fur ruffling” tone in the article is that it is tough to balance work and family during training years – physically, intellectually and emotionally. Fortune is a chance – not a norm, therefore not dependable.

Not everyone is married to the supporting spouse, not everyone will have quiet peaceful babies, not everyone will feel energized after putting the baby to sleep….

[Reply]

Dear Sharp beam,

Thank you for writing. You certainly have my sympathy if things are as they sound–not going smoothly. The good news is that children do grow up and become more self-sufficient, so don’t lose heart. One day at a time. Don’t give up on medicine.

All the best,

Karen Sibert

[Reply]

Gentle readers,

I’m always interested to read comments, and I’ve replied to nearly everyone who posted comments on my website.

Sometimes I wonder how many of the people who commented actually read the article to the end. But no matter!

To those of you who’ve had children during residency, and are happy with your decision, I send congratulations. To those who’ve done it, and had a very rough time, I send my sympathy. It might have been a service had someone warned you sooner that not every spouse is supportive, not every pregnancy easy, and not every baby a cooing bundle of joy.

My basic message is still the same: There may be no perfect time to have a baby, but there are better times and worse times. Adolescence might be at the very top of my list for the worst time, but residency would be a close second. Medical school is an easier choice; you can take a semester or a year off without much difficulty.

Your fellow residents will cover for pregnant residents because they must, not necessarily because they’re glad to do it. Faculty members may seem supportive because they’ll run afoul of the thought police on the Residency Review Committee if they say what they really think. But behind closed doors, they may be telling a different story. Don’t be surprised if their letters of recommendation are damning with faint praise, while they convey their real opinions in telephone calls.

If women want real opportunities to lead and influence medicine, we need to step up to the plate, not demand special privileges. That involves giving careful thought to the timing of pregnancies. Different jobs may be right for you at different times of your career. A large HMO may be the right choice for the pregnancy years; a more demanding and lucrative private practice might be a better fit later on. But don’t give up on medicine, and don’t have a baby before you’re really ready.

Maybe in the future, technology will allow us to freeze our 20-year-old eggs and time pregnancies whenever it suits us. That would be lovely. But for now, my advice stands: Give yourself a break. Don’t have a baby during residency unless you truly see no other option.

All the best,

Karen Sibert

[Reply]

CK

I’d like to comment on your comment, specifically this paragraph:

“Your fellow residents will cover for pregnant residents because they must, not necessarily because they’re glad to do it. Faculty members may seem supportive because they’ll run afoul of the thought police on the Residency Review Committee if they say what they really think. But behind closed doors, they may be telling a different story. Don’t be surprised if their letters of recommendation are damning with faint praise, while they convey their real opinions in telephone calls. ”

Perhaps these comments are true in the field of anesthesia, or perhaps they are a reflection on your individual experience in residency leadership; but I wanted to add a contrasting viewpoint.

I am in my 8th year as faculty in a family medicine residency and am the mother of two children (born after my residency). I trained pre-work hour rules and share your feeling that certainly during my residency having a child was unthinkable, at least to me.

However, I have not experienced the resentment and hidden criticism that you describe towards pregnant residents in training. I have personally re-worked call schedules, written many letters of recommendation, ordered rank lists, and advised countless residents and students and would never dream of calling into question the work ethic or competency of residents who choose to become mothers.

Certainly for some people the combination of pregnancy, motherhood and residency is untenable and their evaluations and recommendations should reflect this. But just as there are star performers and struggling performers in the non-pregnant pool of trainees, so there are women who are able to meet this challenge and should be praised for their exceptional abilities – serving as mother while not compromising patient care or their own education.

I hope to point out to your readers that not all training programs share the type of culture that you describe.

I believe that as the next generation of women physicians become leaders in our respective fields, the culture of medicine will grow to demonstrate a greater respect for each individual’s ability to assess his or her own values, capacity and priorities. We should hold fast to standards of excellence, integrity and commitment to patient care but cease to be prescriptive in how trainees achieve and maintain these standards in balance with their personal life.

[Reply]

Dear Dr. CK,

Thank you so much for taking the time to write. I’m so glad to hear your point of view, and the honest assessment that some–but not everyone–can cope well with the combination of pregnancy, motherhood, and residency. I fear that so often it’s assumed that everything will go swimmingly, and of course it doesn’t always.

There’s no question that programs such as family practice, pediatrics, and dermatology, which have greater than 50% female residents today, have evolved to be more “pregnancy friendly” out of sheer necessity. Unfortunately, though, training programs which involve more operating room and intensive care unit time–and more night call as a consequence–have a much greater level of difficulty in accommodating absences for whatever reason. This is not a reflection simply of “culture”, but of reality. Again, I make the point that if we could expand these residency programs without limit, then maternity or paternity leaves would be less of a problem, but we can’t do that. Often, residents don’t seem to appreciate that fact, and then they are shocked if their actions meet with disapproval or resentment, particularly from their peers. No one has ever said to them directly that “Because I want to” may not be enough of a reason. It may be better to hear it from someone like me first, so that it’s not a surprise.

As long as the financing of residency programs is so dependent on Medicare funding, it will be hard to change the fundamental nature of this problem no matter how much the culture of medicine might change. In the meantime, it’s well for us to understand the nature of the problem rather than just to decry its existence. Medicare funding is not available for significant expansion of residency positions. Residents in teaching hospitals still have patient care responsibilities that won’t go away. Is it fair for residents especially in smaller programs to do as they please in terms of having children without regard for the well-being of the other residents? Or to expect faculty members to assume more of the clinical load when they’ve already put in their own time as residents and fellows?

Thank you again for contributing to the discussion, and I look forward to hearing from you again.

All the best,

Karen Sibert

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What I think is your take-home message: that residency is difficult, having a baby is even more difficult, and if you can avoid combining the two, why not– is important to hear. Physicians are just like everyone else- they have no idea what it’s like to have a baby before they actually have their first child. However, there are two points which I think undermine your main message.

First, although many women have families after the age of 35, medical education itself informs trainees that this is a sub-optimal choice– it only takes one of those graphs with the exponential growth curve of genetic disorder incidence, or repeatedly marking down Advanced Maternal Age on charts during your Ob/GYn rotation to send this message home. The median age at matriculation for female medical students is 23, and the 75th percentile is 25. Therefore, at least half of women entering medicine will be 28+ years old at a mininum when they graduate, and 25% will be 29+, with many looking at potentially finishing training around or past the age of 35. (Particularly if they also continue the current trend to NOT pursue careers in primary care.) Combine this demographic shift with a risk-averse population (physicians) who have been well indoctrinated on the statistics regarding potential complications with delayed childbearing, and consequently…it will start to be more common for both men and women to contemplate having children in residency. Yes, certainly, everyone could wait, but I suspect the proportion who feel that maybe they should not– is not trivial.

Second, it seems to be overly simplified to suggest that residency programs are incapable of change because they are held hostage to Congressional funding decisions. There are other, not necessarily palatable, options– for example, 1) the number of residency slots funded by Medicare may be fixed, but the distribution is not. The ACGME could choose to accredit fewer programs, and with a consolidation of spots, there would be more residents per program (and yes, smaller hospitals/programs could be the big losers). 2) Programs can also choose fund their own trainees–the 6% growth in positions despite the cap instituted in 1997 is attributed to self-funding by teaching hospitals. 3)The types of accommodations made, hiring nurse practitioners, shifting work responsibilities to attending physicians (whether or not they are successful or desirable), to comply with work-hours regulations, could be expanded. 4)Alternative tracks in residency- for example, offering all residents an option for extended leave, but those who take it are required to provide extended service. It all comes down to a matter of choices– if teaching hospitals have made the calculation that they are still better off having medical trainees, be it for their mission and/or bottom line, then someone will have to grapple with staffing issues like maternity/paternity leave, and so on. Placing the responsibility solely with the trainees is a bit disingenuous and also may be a futile effort against the larger demographic trends.

(Sources: AAMC, ACGME, COGME)

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A

I agree with the above comment.

I would add an illustration: my residency program is relatively large, and a significant chunk of each class has babies somewhere in their late-R2 through R3 years; they generally take 2-4mo of leave, and often they cut to part time after this. But, it’s a constant flow – so, yes, I drop out of the call cycle for a little while and then am at a lower rate in it (if I’m 50% time, I take 50% of the call shifts I otherwise would). But, of course, anyone who takes time off / cuts to part time makes up this time by extending their residency – so while my call burden is lower, someone else is still here doing their extra part-time year offsetting it. And then I in turn took that roll for someone else a couple of years later. This description sounds convoluted, but actually, it’s a lovely system.

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[...] time, one of which appeared in this blog. She recently posted on her blog a piece titled “Give yourself a break – Don’t have a baby during residency”, which has also created quite a stir. This posting as been the subject of many blogger’s recent [...]

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Ann

I did not have my baby in my OB/GYN residency, but took a large portion of the pain of covering 6 maternity leaves in my class, including losing my research elective time. Never had fair payback or much appreciation. My personal life was strained, I was exhausted – to the point of causing significant bitterness which I still feel 7 years later.

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Dear Biogirl:

I’ve heard the same comment from many others. The entitlement that many women seem to feel is remarkable–they do as they wish, and others have to cope as best they can with little thanks. I hope all is well these days.

All the best, and thanks for writing–

KS

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Selfish Resident Mom

I am disappointed I even stumbled upon this ridiculously naive piece.
Two years ago I had a baby while working 100+/week as a surgical intern in a small program. I was 35 at the time. I took my leave as my vacation time and even delivered two weeks late- thus using up 2 of those weeks waiting. I had an Emergency C-section and delivered a healthy baby. I extended my leave by two weeks into a radiology elective so no coverage was required. Within 6 weeks I was back to work with a newborn at home and working 100+ hours again. Not once have I called in because of my child or required my colleagues cover me. I spend my free time with my family not going out to parties or bars. As opposed to the suggestions in the blog, my husband and I are closer because of the challenges.

The bottom line is that life does not exist separately from residency. You have to live while in residency. Your life doesn’t suddenly start after you finish residency– it’s happening NOW. This is IT. You’re not guaranteed to live a day past your first day as an attending. If you need a reminder that life can be short, take a stroll through the trauma bays or the oncology floor.

Why don’t we all stop being so judgmental of each other and start practicing the compassion and empathy we’re supposed to have as doctors. How can we honestly treat patients with respect and compassion if we can’t even treat our colleagues with it?

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Dear Resident Mom,

Clearly your situation is different if you were an intern at 35, and had no children before. That has to be a very hard path to follow. I would be interested to know what you did before deciding to go to medical school, but no one, least of all I, would presume to judge your decision. I had one child before medical school, was an intern at 30, and had my other children later. With the benefit of that perspective, my piece simply suggests that for many young women there might be a time better than residency to have babies. I meant what I said, and haven’t altered my opinion that it is hard to have babies and hard to be a resident–perhaps better to stagger than to try to combine. That’s all.

Best of luck with your future endeavors–

Karen Sibert

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K

Dear Dr. Sibert,

As an attorney married to a resident, I’m constantly amazed by academic medicine’s apparent disregard for applicable federal law when the topic of pregnant residents comes up. These federal laws include the Family and Medical Leave Act and the Pregnancy Disability Act. (And, no, ACGME doesn’t preempt Uncle Sam…)

Your paragraph insinuating (see your 3/9 post) that senior physicians may, on phone calls and behind closed doors, undermine pregnant residents’ careers is consistent with this trend. Actions that block members of a protected class (i.e. pregnant women) from, for instance, access to a prestigous fellowship constitutes employment discrimination.

It is disheartening that physicians treat each other so poorly. Why in the world would residents take one for the team, as you suggest, and delay so intimate as their family planning when, in the picture you paint, senior physicians display so little loyalty in return?

Best,
K

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K.

I can speak only for myself, as the wife of a surgical resident that has had to sacrifice the little time we have together as a couple, sleep, studying time, his research elective, and vacation to cover for fellow residents on maternity leave. It has been a painful and frustrating process that leaves him and many others bitter about the circumstances. He is in a program with only three residents per class, and the loss of one even for a few weeks is devastating. We have considered starting our own family, but have been forced to put it off because of the grueling schedule and the fact that he is not guaranteed adequate time off after the baby would come to help me recover (unlike if he were a woman). So we are postponing starting our own family, yet he has to cover for those that are not making the same decisions. To each their own, but there needs to be some recourse for putting such a strain on your fellow residents. I understand that if you are older then there is little choice, but there are those that are sacrificing starting a family because it would put other residents out and there is only so much they can do before they breakdown.

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EAT

Does anyone in this forum actually think that having a child in practice is any easier? As a surgeon and female, I regret not having my children in residency when vacation leave was paid and time off after call was guaranteed due to work hour restrictions. Neither of those things exist post graduation. And in practice, you get to figure out how to cover your overhead expenses while you’re not generating billings on your leave. Furthermore, I am appalled and offended that anyone would feel comfortable, in a public forum no less, articulating how their own lives are inconvenienced by another person’s private CHOICE to expand their family. Grow up. It’s life, it’s messy and if you allow your fellow residents, attending or peers into your bedroom when you are making decisions that affect your family, it won’t end after graduation.

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robyn

You should have children if you want them. Just keep in mind, no one is going to look after you in the medical field.
I had a child my second year of surgical residency. I never missed one day of work, never missed one case because of nausea. I was back after 4 weeks off sp C-section.
Being a mother is the best job i have. I wouldnt trade it for the world. If someone made or asked me to choose work over my kid?
Well, I would happily give them my pager and walk away.
Have kids, its awesome.
The US medical field cant afford to lose MDs. Its an underpaid under appreciated job which asks people to sacrifice their young adulthood.
We dont owe the medical profession our entire lives.

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Brittany

You must see how the way your life played out prevents you from understanding a pregnant resident’s point of view. You BEGAN medical school already having started the incredible journey of parenthood. You had already “checked having a baby off your list”. So whether you wanted more children or not, you have to see that future infertility was not as big a concern for you because at least you had the opportunity to parent one child. Can you see that pushing having a baby further and further into the 30s could be a bigger concern for those who have not yet started their families? You end your article with, “Don’t let yourself get burned out before you’ve really started life as a physician. There’s time ahead to have children.” The truth is, biologically, the time ahead we have to become parents is finite – much, much more finite than the time we’ll have to be a physician.

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Lisa

Hmm…I got all honors during second year and a 248 on Step 1 despite being pregnant. I wonder how my “pregnancy brain” impacted my performance?

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Natalie

Full disclosure: I am a veterinarian in a path residency, so my existence is a little different. However, I have felt both ways about this. It is no surprise that when I was younger, unmarried, and childless, I saw no reason for veterinary students, interns, or residents to start families during this demanding time in their career. Then I found myself graduating at 34 and facing postponing pregnancy until I finished my residency at 38…and that would be our first child. Suggesting women have children in their early thirties is easy, but any physician on this reply list knows the gloom and doom statistics that are presented to women who are conceiving at 35 and older, regardless of whether more women are choosing to do so. I had this internal dialogue: Is my residency important enough to raise my future children’s risk of Down’s Syndrome and other disorders by postponing pregnancy? No. I am going to guess no parent would answer differently and they shouldn’t. Also, I have endometriosis and we didn’t know if I would have fertility issues. Fortunately, that was not the case and I had our son during my second year. One week after my c-section, I was back in my 7 a.m. graduate class. (Veterinary residents typically complete an MS or PhD during their residency, so add that to the fun.) Six weeks later I was back on the schedule. I made sure nobody had to accommodate me and it is unfortunate that women feel the additional stress of not wanting to ask anyone for support. Many times I was working longer hours than my colleagues, and I didn’t complain. In veterinary medicine, the gender distribution has shifted in the last ten to twenty years and at this point in time, eighty percent or greater of graduates are women. In response to this, people have had to change their thinking. More women’s restrooms have been added to veterinary school teaching hospitals and buildings. Separate lactation rooms have been created. These changes serve everyone well and create an improved clinical culture. I don’t pretend to know how it is on the human medicine side, but it sounds like it may be time to recognize that helping women fulfill their various roles, rather than resenting them or providing condescending advice, is more constructive for the entire team. I like to believe that veterinary medicine has become increasingly motivated and proactive in this area and sets a good example.

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I’m curious to find out what blog platform you happen to be using?
I’m having some minor security issues with my latest site and
I would like to find something more safe. Do you have any solutions?

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WordPress. It seems to do a reasonable job of weeding out junk messages, and I have had no problems with it.

Best,

Karen Sibert

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Jessica

For some it is not that simple. My husband and I had to do IVF to get pregnant. Given that I won’t be finished with residency until the age of 34, my REI physician advised against waiting that long. So we will be welcoming our first child into the world in the middle of my intern year. Some may think I’m crazy for doing so, but we didn’t want to risk the possibility of not ever having children. It is a known fact that after the age of 30 the success rate of IVF declines. Without having a crystal ball to tell me if my ovarian function would still be adequate to do IVF at 34 years old, my husband and I chose to pursue getting pregnant just before the start of residency.

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Hello sir,
Thank you for your nice posting.My husband and I had to do IVF to get pregnant. Given that I won’t be finished with residency until the age of 34, my REI physician advised against waiting that long. So we will be welcoming our first child into the world in the middle of my intern year.
Thanks……..

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Hello sir,
Thank you for your nice posting.It is a known fact that after the age of 30 the success rate of IVF declines. Without having a crystal ball to tell me if my ovarian function would still be adequate to do IVF at 34 years old, my husband and I chose to pursue getting pregnant just before the start of residency.
Thanks…..

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