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Why Having a Baby Pushes Women Out of Medicine

It can be prohibitively hard to have kids when you’re a surgical resident.

Erin O’Brien tried to get pregnant at a more convenient time. Granted, when you’re a surgeon-in-training, there’s never a great time to have a baby—but O’Brien, then an ear, nose and throat resident at the University of Iowa Hospitals and Clinics, was aiming for a three-month window during a research stint, her only respite from 80-hour work weeks and hours-long operating-room stretches.

Life, as is its wont, didn’t work out that way. After two miscarriages, she gave birth in 2007, halfway through her last year of residency.

Like many medical residents, O’Brien forwent maternity leave, against the advice of her doctor. She’d already been accepted to a fellowship with a strict start date; she couldn’t extend her training any further. Instead, she used up all her days off, sent her newborn to day care, and returned to work, often ducking into a shower stall mid-surgery to pump breast milk.

The intensive, years-long training process required to become a doctor, known as residency, certainly wasn’t designed with parenthood in mind, with its unforgiving hours and a rigorous calendar that dominates the decade in which most parents start families.

It’s particularly long and grueling for residents in specialties such as surgery—so much so that women surgeons who got pregnant as residents are warning other women away, a recent survey found. And there’s little indication the process will become much friendlier to new parents, even as industries outside medicine beef up parental-leave benefits to woo top talent. There’s no shortage of med-school grads competing for a scant few residency spots.

An aspiring doctor is already in at least her mid-20s by the time she finishes medical school. Her residency will last an additional three to seven years, depending on the specialty she chooses—pediatrics, three, and surgery, at least five. Optional further specialization requires a fellowship that tacks on another year or two. By the time O’Brien had finished her seven years of training—her five-year ENT residency plus two more research years—and given birth to her daughter, she was 33 and headed off to a sinus surgery fellowship.

The difficulty of having kids during residency appears to be discouraging women from becoming surgeons, researchers at Brigham and Women's Hospital in Boston recently found in a survey of 347 active surgeons who had been pregnant during their residencies in the last decade. Just under half the surgeons surveyed said they considered quitting their residencies during pregnancy. About a third said they wouldn’t recommend that women in medical school become surgeons.

These days, men and women are going to medical school in equal numbers. Once they’re doctors, however, women are still earning less than men, in part because they more often go into lower-paying specialties, such as pediatrics and family medicine, with shorter residencies that tend to be more flexible. (Surgeons can be paid twice what family doctors get.)

Forty-four percent of the country’s medical residents last year were women. But whereas females made up two-thirds of pediatric residents, they consisted of only 36 percent of surgical residents—and just 14 percent in the particularly lucrative subspecialty of orthopedic surgery.

“There is still this gender gap in our field, and we have a low proportion of female surgical faculty in the U.S.,” said Erika Rangel, a trauma surgeon at Brigham and Women’s and an author of the study. (A 2014 report found (PDF) that women make up only 22 percent of full-time faculty and only 1 percent of department chairs.) “There is a perception that the field isn’t compatible with the desire to have a family.”

That, she said, has contributed to an attrition problem among women surgical residents. A study last year found that 25 percent of women surgical residents drop out of their programs, compared to 15 percent of men. The most commonly reported cause for both: the “uncontrollable lifestyle.” Surgical residents who left most often switched to family-friendlier specialties with more predictable schedules, such as anesthesia and family medicine, the study found.

At the Icahn School of Medicine at Mount Sinai in New York, which has the nation’s largest medical residency program, women who have children during surgery training typically take off six weeks or fewer, said Michael Leitman, the dean for graduate medical education. “Most residents deal with it. Do they find it adequate? Is it really good for families? No, it’s not good for families,” he said.

The surgical field has evolved somewhat. As recently as 25 years ago, it was still “extraordinary and rare” for women to have children during surgical residencies, said Jo Buyske, the executive director of the American Board of Surgery, which certifies surgeons. When she trained at Massachusetts General Hospital in the late 1980s and early ‘90s, “there weren’t that many women residents, and the vast majority did not have children during residency,” she said. Danielle Walsh, a surgery professor at East Carolina University’s Brody School of Medicine in Greenville, North Carolina, echoed the sentiment: “People just knew that training was too tough to have kids then, and you’re just going to have to delay it until you’re done.”

"For many years, there was an expectation that surgical residents, essentially all men, would not be married,” Buyske wrote in a 2005 article in the journal Archives of Surgery. Even after women entered the field, “the idea of a pregnant surgeon or surgical resident was shocking, although male surgeons and residents commonly had children,” she wrote. Buyske, who had children after she’d finished training, said that even her own attitude on having children during residency has evolved: “Twenty years ago, I would have said it’s just not a good idea.”

Residency program directors, medical organizations and doctors across the profession recognize there’s still a problem. Back in 2009, in an effort to provide greater flexibility, the board Buyske heads began letting residents take an additional year to complete their general surgery training—but the number of residents who do so each year is in the "low double digits,” Buyske said. They must also get requests approved by their individual programs, which itself can be a challenge, especially at smaller institutions.  And while surgical residents can now combine four weeks of vacation with a two-week medical leave to get six weeks off after childbirth, the American Congress of Obstetricians and Gynecologists—which recommends (PDF) at least six weeks of paid parental leave for all workers—says residency programs should find ways to let residents take more time without killing their shot at getting board-certified.

But it’s not a simple thing to change.

Medical training runs on a strict schedule. As graduates progress from medical school to residencies to fellowships, most institutions count on new classes starting July 1. And since all surgical residents must get 48 weeks of clinical training per year, taking a few months off to have a baby can scramble a resident’s timeline or disqualify her from taking her boards, which are only given once a year. It can also complicate matters for the other residents in her program and for hospital staffing, since surgical programs in particular tend to have just a handful of residents at a time. “There’s no slack built into the system,” said Buyske.

Compare that with the pediatrics program at the University of California-San Francisco, one of the most flexible medical residencies in the country. Its residents can take up to six months off for any reason, including maternity leave. The program pays for six weeks of maternity leave on top of the standard paid vacation; the rest of the time off is unpaid. (Elsewhere, most residents use vacation days as maternity leave.) “It’s been very helpful for a lot of women in our training programs,” said Dan West, the program’s director. “San Francisco is expensive. It’s hard to be without income.” West, however, admits that the pediatrics department, which admits around 28 residents per year, can absorb more flexibility than surgery can.

But even in such a relatively forgiving environment, residents who want to squeeze additional leave into their training schedule are left with less-than-ideal options. Elizabeth Spiegel found out she was pregnant during the first week of her pediatrics residency at UCSF in 2015. To take a three-month leave, she squeezed 12 months of training into nine months, which meant skipping a fellowship. “I feel like I missed out on some of the subspecialty knowledge that I could’ve gained,” she said. She could’ve opted into UCSF’s six-month flex program, but she wanted to get her already-grueling residency over with. “I didn’t want to keep prolonging this period of time that is extremely intense.”

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