At 6 in the morning, Amber Patterson, M.D., was already out of bed. As a resident, she knew she had a long day ahead of her, but first things first. She woke Reid, the son she carried while in medical school, helped him dress and made him breakfast. His father, a consultant who works from home, would take care of him after that, so she dressed for work, slipping into a comfortable maternity top. This time she was pregnant with daughter Lena.
Patterson recently completed fellowship in allergy/immunology and is now working full time at Nationwide Children’s Hospital and Ohio State University in Columbus. She delivered her third child while still in fellowship at Ohio State.
Patterson admits it’s been hard to be both pregnant and a physician in training. "When you’re so driven and you work so hard, you hate to throw something else into the mix," she says. But she wouldn’t change her pregnancies for anything. "I’m glad I’ve had children while I’m still young," she says.
She’s not the only physician who feels that way.
Today’s medical training programs are wrestling with a new generation of physicians who are no longer willing to settle for the kind of medical career their father - or mother - had. These physicians want controllable schedules and a life that swings equally between career and family.
In a 2006 Survey of Physicians Under 50 conducted by the Association of American Medical Colleges and the American Medical Association, 66 percent of male physicians expressed that time for a family and personal life were important considerations when choosing a practice. For female physicians, it was was 82 percent.
And female physicians are no longer willing to wait to start their family.
Neelum Aggarwal, M.D., a Chicago neurologist and board member of the American Medical Women’s Association, says times have changed. "When I was training, most women waited until their fellowship year to start a family."
That’s not to say there were no pregnant residents before this decade. There were, says Samuel Sandowski, M.D., director of the family medicine residency program at South Nassau Communities Hospital in New York. "There have always been pregnant residents," he says.
But three factors have made pregnancy during residency more common today.
First, there are now more women in medicine. In her article, "Pregnancy during Residency: A Literature Review" for the April 2003 issue of Academic Medicine, Susan J. Finch, M.D., noted that by 2010, it was believed that 30 percent of all U.S. physicians would be women - so it only makes sense that a larger number of pregnancies during training programs would result.
Yet there’s a second factor at work, too - one that explains why women today are not waiting until training is over, or almost over, before starting families. That factor is expectations.
"When I was a resident, we wanted time for families and a personal life, too," says Sandowski, "but it was never something we thought we could get. We were doctors first, even when we weren’t on the job. Today, though, this generation sees medicine as a job that ends when the day ends."
That may be why, for the second year in a row, more U.S. medical student seniors have chosen to train in primary care areas in 2011. Family medicine, pediatrics and internal medicine are the big winners - and these specialties offer more controllable hours.
Jewel Kling, M.D., an Arizona internist, says future job flexibility was one of the reasons she decided to enter internal medicine. "I wanted an 8-to-5, Monday-through-Friday job," she says. With a son, she knew that, for her, the future would mean striking a balance between work and family.
The new "expectation" mindset may also explain why more medical students are looking at careers as employees rather than starting their own practices, says Iverson Bell, M.D., director of the psychiatry residency program at the University of Tennessee Health Science Center. Most of the residents he trains today are looking for regular salaries, he adds. "They’re going to group practice or into a community mental health setting."
"I think there is a shift in priorities for many people," says Kathleen Stirling, M.D., an emergency medicine physician who is the mother of twin boys and currently working a locum tenens job in New Zealand with her husband, Nathan Unkefer, M.D. "Family and life outside of medicine is the priority."
So, given the increase of women in training programs, new expectations of a life outside medicine, and the fact that women in medical training are generally in their prime child-bearing years, it’s no wonder that more and more resident programs are seeing an increase in pregnancies.
But a third factor has helped, too, and that’s the shorter, 80-hour workweek for residents. Kellie Flood-Shaffer, M.D., director of the obstetrics/gynecology residency program at the University of Cincinnati Academic Health Center, says the shorter workweek has helped ease a lot of the stress that comes with residency. "But that’s still a lot of hours, and you can’t diminish the workload, whether the resident is pregnant or not," she says.
It’s up to the resident to meet those hours, and if he or she misses time for whatever reason, the time must be made up. That’s why women who are pregnant during residency often become creative in planning their maternity leave.
Most hospitals do offer a maternity leave policy (the women interviewed for this article had between six and eight weeks off), and a few hospitals offer up to three weeks of paternity leave. Other facilities offer pregnant employees a short-term disability leave, and there is always the Family and Medical Leave Act, which allows employees up to 12 weeks of unpaid leave if certain requirements are met.
The hospital employee handbook will generally have information about maternity and paternity leave policies. But, Patterson says, like other residents in her situation, she didn’t know what the policies were when she became pregnant. "Once I found out what they were, it relieved a lot of stress," she says.
The problem, says Flood-Shaffer, is that the hospital handbook is passed out at orientation and is generally not read. As a result, many female residents learn about maternity leave from their program directors, or even from each other.
Kelly Willman, M.D., for example, was one of the first residents in her general surgery program to become pregnant. "I didn’t know what the maternity leave policy was, so I asked other residents in other programs who I knew had been pregnant," she says.
"There isn’t a lot of talk at orientation about policies," agrees Patterson. "You’re handed an HR brochure, but nothing is said about pregnancy and maternity leave."
That’s why Flood-Shaffer says she now makes a point to explain the facility’s maternity leave policy to residents. "There are more residents in the program who are becoming pregnant, and I know they aren’t going to read the handbook, so we make a point to tell them what the policy is during orientation," she says. She also makes it clear during the discussion that they’ll need to make up any time missed.
As word gets out about the need to make up missed training time, a number of female residents find creative ways to cobble together maternity leave, sick time, holidays and vacations to take off as much as eight weeks without needing to make up lost time. Some have planned their pregnancies so the birth will fall during vacations; some will use sick leave in addition to maternity leave.
Willman, who is a critical care fellow at Louisiana State University Health Sciences Center, says she saved her vacation time for two years. "I knew I wanted to start a family during my last year of residency, and I wanted extra time post-baby," she says.
Not everyone is concerned about graduating with the rest of their class. Gina Ramirez, M.D., a pediatrician who works at the Cleveland Clinic, was pregnant in her last year of residency, and although she had six weeks of maternity leave, she decided to take eight weeks off after her baby was born. "I made up the time after others in my class graduated," she says. "It didn’t bother me. I wanted more time with my baby, and I could graduate any time."
While women are busy planning their maternity leaves, male residents are just happy if they see their facility offers a paternity leave. "They’re not always offered, but they are becoming more prevalent," says Todd Hostetler, M.D., a Columbus, Ohio, allergist who was able to take a three-week leave when his wife delivered their daughter.
And there are ways to make paternity absences more palatable to supervisors and colleagues. One option, says Hostetler, is to split up paternity leave as a friend recently did. "He took off one week when his wife delivered and two weeks when she returned to work," says Hostetler. Since the wife returned to work six weeks after delivery, it meant the baby could stay home with a parent for another two weeks.
Though paternity leave may be more common than in the past, not all new fathers take advantage of it. To some extent, it depends on the specialty you’re in. Family-friendly specialties like pediatrics and family medicine are more likely to be supportive of men on paternity leave than specialties like surgery or psychiatry, says Hostetler.
"I had one resident who took a three-week paternity leave, and it became an issue for the other residents who had to cover for him," confirms Bell. "They were angry about it."
Definitely, support by colleagues and program directors can play a role in whether the pregnancy experience is positive or negative - and while that’s true for males, it’s especially true for females.
After all, it’s not easy being pregnant and a working physician.
"Residency hours may have been reduced, but you are still working a rigorous schedule and that can mean 36 hours on your feet," says Ramirez. That can be tough when, like many pregnancies, water is retained and feet and legs start to swell.
"I remember suturing being the hardest thing," says Stirling, who was pregnant with twins. "I could never get in a comfortable position, and my back would just ache."
Other complaints include typical pregnancy discomfort, fatigue and morning sickness.
"There was one time I had to scrub out of surgery, go throw up and scrub back in," says Willman.
Then there’s the safety issue. After all, health-care environments are fraught with hazards for pregnant women. X-rays, needle sticks, exposure to chemicals and infectious diseases are all part of workplace hazards physicians face every day - but for women carrying a child, the dangers seem even more frightening. Yet the risks can be overlooked by pregnant residents.
"I wasn’t nervous at all about working in that environment," says Heidi Arbona, M.D., an OB/Gyn who delivered her daughter while she was a third-year resident. "I don’t know that I thought about it."
Willman expressed a similar disassociation. "I would double-up on lead aprons," says Willman. "But then I would go into wards with patients infected with influenza and rubella and treat them. I don’t know what I was thinking. Today, I might ask a junior or mid-level resident to go in and care for them."
Still, she knew she had to do the work, and as the first woman in her surgery program to be pregnant, Willman says she knew she had to be tough. "I had to be the go-getter female who showed that pregnancy wasn’t going to be an issue. I would stay late until all the work was done, I’d work through fatigue and morning sickness." And if it meant working in a unit with infectious patients, then that’s what she did.
"Women who are pregnant in training often work harder than their colleagues because they feel a level of guilt," says Aggarwal. "They try to make up for what’s perceived as any weakness."
Moms-to-be aren’t the only ones facing problems, of course. "There are issues that come up for the pregnant resident, but at the same time, there are also issues that come up for the employer and for colleagues when a resident is pregnant," says Flood-Shaffer.
For example, scheduling can become an issue. That’s why she suggests that residents who are pregnant let their supervisor know as soon as possible.
And some do. Patterson says she told both her director and colleagues right away when she learned she was pregnant. "I wanted to make some adjustments to my schedule, so I knew the earlier I told everyone, the better," she says.
But most of the women interviewed here waited until after the first trimester to share their news.
"I was nervous about telling my director," says Arbona. Two other women in the program were also pregnant, so she wasn’t sure what reception her news might receive. "I waited 12 weeks before I said anything about my pregnancy," she says.
Flood-Shaffer says she prefers learning about pregnancy at six or eight weeks. "I’m likely to put a resident on clinic rotation near the end of her pregnancy because the absence will be easier to handle if the resident goes into labor."
Ramirez, however, says she planned her ward month at the beginning of the year so she would have little interruption with patients.
If you think pregnancy presents scheduling, safety and other concerns for the training physician, it’s nothing compared to the difficulties of combining work and motherhood, say the women interviewed for this article. Finding a time and location to express breast milk, caring for a baby with middle-of-the-night feedings, and unexplained bouts of crying can add up to a lot of stress for the working physician.
That may explain why new mothers are tempted to return to work on a part-time basis.
"I thought about part-time work," says Patterson. "I even considered starting my own practice." But she discarded both ideas as impractical. After working hard to be a physician, she wanted to establish herself as one full time. And starting a practice was too expensive and risky.
"A lot of women with families seek employment because they don’t want the pressure of running a small business," says Aggarwal.
DeAnn Chiazzese, a recruiter with Vista Staffing Solutions of Salt Lake City, says more women are also turning to hospitalist programs. "They’ll work two weeks then have two weeks off," she says.
Others, like Willman and Stirling, choose to work locum tenens post-natal.
"My first year out of residency, I knew I wanted to focus on my baby," says Willman, so she chose to work temporary positions nearby. She learned, however, that working locum can be a double-edged sword for new physicians. "You have the potential to be the only surgeon on call, so you need to feel confident in your abilities to handle the work," she says. Willman says the recruiting staff and her temporary employers were supportive of her family situation.
But not all employers are happy about hiring new mothers - or pregnant women, for that matter. Aggarwal says she informally asked a group of young physicians recently whether employers asked them about family planning. "It was a 70 to 30 split, women to men," she says. "The men were surprised that women are still being asked about their plans to start a family or if they plan to increase the size of their family. The women just shrugged and said, ’Of course we’re asked.’ These questions are still going on in the workplace," Aggarwal says.
Naturally, if you’re interviewing for a new job, don’t immediately ask about maternity leave or make it the focus of your discussion, says Terri-Lynne Smiles, JD, an attorney with the law firm Collis, Smiles & Collis. "That may send up an alarm to the employer. But do make it a part of the discussion. Ask if they have existing policy or have thought about a maternity leave policy. Most large practices or employers will have dealt with this before and have a policy in place. If it’s a small practice and they don’t have a maternity leave policy, you may want to have a conversation about it."
Both sides, she says, have a responsibility to discuss the issue.
"During any contract negotiation, of course, you want to protect yourself and your compensation," says Smiles. But you should also look at it from the employer’s perspective, she adds. The pregnancy and maternity leave will cost the employer money, so there has to be compromise. "The best way to look at any contract is with both perspectives in mind," she says.
That doesn’t mean, though, that employers can discriminate against women who are pregnant or thinking of becoming pregnant soon.
Judy Galeano, who handles employee discrimination cases for the law firm Mowery, Youell & Galeano, says nothing prohibits an employer from asking about family. "But it should be in a get-to-know you kind of way," she says. Once the conversation turns to your future plans regarding family, it’s beginning to cross a line. "You’re not required to disclose information about whether or not you want to have children or are planning to have children," she says. If the questions become too personal, how you respond can be important. You can choose to be confrontational, but that may burn bridges you don’t want to burn. "It’s better to say something like, ’I’m not sure. Right now, I’m just trying to find a job,’" says Galeano.
A woman who feels as though she has been discriminated against can file a civil claim with her state’s Civil Rights Commission or with the Equal Employment Opportunity Commission. But the cases are difficult to win, says Galeano. "You have to prove failure to hire, and that can be difficult, especially if the employer hired another woman instead of you."
Many pregnant women will wait until after they’ve delivered to look for work, says Aggarwal.
"If there’s an upside for the employer interviewing a pregnant applicant," says Smiles, "It’s that they already know what the situation is and can plan for it."
But the best planning - for employer and employee - occurs during contract negotiations.
"I’m seeing more interest in contracts that include a maternity-leave policy," says Smiles. "I don’t know if that’s because there are more physicians now who need the policy or for some other reason. In my years of practice, though, I have had only one physician ask about paternity leave arrangements. That seems to be more common in other professions."
Anything, however, can be negotiated in a contract.
"If you’re planning a family, you might ask, ’What will my on-call schedule be?’" says Smiles.
Even negotiating less pay for a trade in time off may be worth it - especially when the baby isn’t sleeping through the night yet.
And if you decide you’d like to work part time after delivery, then a new contract will have to be negotiated. "If you work in a small practice," says Smiles, "it’s best to sit down and talk about the new arrangement. If it’s a large practice or employer, again, they’re more likely to have seen this before and have a policy in place. However, you can always walk into the HR office of any large practice or employer with your own proposal, one you’ve worked on ahead of time with your attorney," says Smiles.
The good news, says Craig Deao, research and development leader for the health care consulting firm the Studer Group, is that employers are becoming more sensitive to the needs of female physicians and their need for work-life balance.
"Our company did some informal research by asking men at a business conference what kind of preparation it took for them to attend," says Deao. It wasn’t much. Ask a woman with children what she did to prepare before she left, and the list seems endless.
That’s why the company decided to conduct a formal study to determine what women want from employers. "More than 80 percent of those working in health care today are female," says Deao. "And their needs are different from men. If employers want to attract women to their workplace, they need to know what to offer them."
The research found that women want supportive supervisors, ones who understand what it’s like to juggle the needs of an infant with those of a patient. The survey also found that women also want professional development opportunities and concierge services.
"Concierge services are becoming more popular, though it depends on the economy," says Deao.
Though it’s encouraging that the workplace (and medical training) is catching up with young physicians who have decided not to wait to start their families, the bottom line is that physicians are making it work, regardless.
It helps to have a good support system at home, of course - not only a supportive spouse, but also family members who can help with babysitting and errands when needed. A well-run and trusted day care is also important (especially if it’s nearby), and support from colleagues and employers both pre- and post-baby.
"Yes, you have to make some sacrifices," says Ramirez. "But you also have to realize pregnancy is a temporary thing. If you wait for the right time to have a baby, you may never have one."
The best advice for making it all work may come from Stirling: "I take each day as it comes," she says. "I’m trying to raise happy, healthy and polite little boys as well as continue to be a good doctor. And I also make a little time for just my husband and me."
Terri-Lynne Smiles, JD, says these items may be something new mothers and mothers-to-be will want to consider negotiating into their employment contracts before signing on the dotted line:
• Maternity leave (length of time allowed)
• On-call hours
• Lactation schedule
• Part-time possibilities (temporary or full-time) post-baby
Looking for a family-friendly place to work? Check out these resources.
• Becker’s Hospital Review’s 100 Best Places to Work in Healthcare (beckersasc.com/100-best-places-to-work-2010.html)
• Modern Healthcare’s Best Places to Work in Healthcare (modernhealthcare.com/article/20100907/INFO/100909978)
The Family and Medical Leave Act allows eligible employees up to 12 weeks of unpaid leave annually - if the workplace employs 50 or more employees. Leave may be taken for:
• Birth of a child
• Adoption or foster care placement
• To care for a spouse or child with serious medical conditions
• If the employee has serious medical conditions
Karen Edwards is a frequent contributor to PracticeLink Magazine.