Originally Published: Common Sense November/December 2016
July was a whirlwind. Fresh out of medical school, I moved to the desert in California to a brand new emergency medicine residency. I was one of five interns and the only female in our inaugural class. Five weeks into the program, I felt strangely tired and nauseated every day. The positive pregnancy test confirmed my suspicion. I knew, without a doubt, that being an emergency physician was exactly what I wanted to do — a stroke in one bed, major trauma in another, appendicitis next to that patient, etc. But now I had the internal turmoil of figuring out how to balance working hard and taking advantage of all the learning opportunities presented to me with proper self-care — which really means baby care. Additionally, the anxiety of having to reveal my pregnancy to my program director, coordinator, fellow residents, and the hospital was a heavy burden. I feared this news might be detrimental to the newly minted EM program and to me as a new physician.
The number of women in the physician workforce has increased substantially over the last couple decades. According to a recent survey by the American Medical Association, approximately 48% of those enrolled in medical school are women. The average age of a graduating medical student is 28.[1-2] For those already in their 30s, the pressure to have children increases as advanced maternal age looms. And complications are a reality for pregnant physicians. According to surveys conducted in surgical specialties, high stress levels and long hours increase the risk of preterm labor, pre-eclampsia, and other obstetrical complications.[3]
The female physicians I know personally chose to have their children later in residency or after residency. The intern year is critical for building a knowledge base, gaining as much patient interaction as possible, and learning the idiosyncrasies of the hospital. According to a recent survey of female thoracic surgeons, 98% of the women in one program felt that having a child during their training would adversely affect their career. The same seems to hold for other specialties, mostly because many residents don't receive the support they need during pregnancy.[4] Some female residents feel anger or resentment from colleagues because of the extra shifts that have to be covered during their maternity leave. This increases the pressure to take less time off postpartum.[5]
According to surveys in surgical subspecialties, flexibility in resident scheduling helps alleviate the physical and emotional stress of returning to work after pregnancy. Early communication about the pregnancy with program leadership allows for scheduling through less exhausting rotations closer to the due date and helps with maternity leave, especially if the resident has a complication during or shortly after pregnancy. Clear policies and expectations regarding time off help the resident meet board eligibility requirements.[6-8]
With the exception of pediatrics and family medicine, however, well-delineated policies for maternal and paternal leave do not exist. The American Academy of Pediatrics (AAP) has the most comprehensive and straightforward set of recommendations for parental leave during residency.
“[…] All residents including interns receive the benefits consistent with the Family Medical Leave Act (FMLA) and residency programs should guarantee 6 to 8 weeks, at a minimum, of parental leave with pay after the infant’s birth or adoption. Additionally, the resident should be allowed to extend the leave time when necessary by using paid vacation time or leave without pay. […] No loss of training of training status if the leave is not more than 3 months.”[9]
The American Academy of Family Physicians (AAFP) also has well-delineated expectations regarding time off, call schedules, and co-resident coverage. Both the AAP and AAFP have clear policies that allow parental leave to include both parents as well as adoption.[9-10]
Emergency medicine has the advantage of natural flexibility, with shift scheduling that can allow for parental leave within residency. Time used for maternity leave can often be made up during residency or by extending residency by one to two months. The Policy Statement from the American College of Emergency Physicians (ACEP) upholds overall principles in regards to family leave time, encompassing both residents and attendings. The policy statement also includes using the time to care for sick family members.[11] The American Board of Emergency Medicine (ABEM) requires emergency medicine residents to complete 46 weeks of training per year in both three-year and four-year training programs. ABEM states that no more than six weeks total per academic year can be taken off for vacation, sick leave, etc. without extending the residency training.[12] It is unclear whether or not this time is fixed or flexible. Additionally, this family leave time could vary from program to program in its application. If the current policy is fixed, it may not account for postpartum complications or for family bonding time, which may call for more time in the academic year. For example, a resident could save up vacation time and subsequently do a less time-intensive rotation. Allowing flexibility to take off more time in one year due to pregnancy and less time in other years, as long as the average amount of time off for the duration of the program does not exceed six weeks per year, could help accommodate mothers without reducing total training hours.
How did I survive pregnancy during internship? By not going it alone. I gathered as much support and advice as I could, as early in pregnancy as I could. Program leadership knew exactly what was needed and gave me the flexibility I needed to attend to my growing family and to my needs as a resident. My most demanding and difficult rotations, such as trauma surgery and neurosurgery, were scheduled during my second trimester. Attending physicians and nurses in the ICU often warned me of hazardous or infectious exposures. My program coordinator advised me to save the four weeks of allotted vacation time per year. On the advice of many of those I worked with at the hospital, I took an additional four weeks to heal from a difficult delivery. I was unable to walk, stand, or sit without immense pain for six weeks after delivery. Additionally, my husband has a job that requires a two-hour commute one way, but negotiated to work from home two days a week to help with the baby. I arranged for child care from my mother and postpartum doulas, who did some nanny work overnight. They helped with the late night feeding and diaper changing. I had friends from the hospital, old med school classmates, and my church community to help me with meals and laundry.
The bottom line: I got help early and I understood my limitations. I allowed people to help me. It was not easy to admit that I needed the extra time or the extra help. I felt vulnerable and anxious about how the baby and residency would turn out. The support and flexibility demonstrated by my residency program and the hospital were crucial to my success as a resident physician and a new mother. Knowing I had all this support, flexibility, and help allowed me to become confident as both a new mother and as a new emergency medicine resident.
Special thanks to: Dr. Leila Khaezani, Dr. Michelle Mouri, Dr. Joel Stillings, Dr. Randy Culbertson, Dr. Jeff Baker, Dora Miller, and the nurses and my fellow residents at Desert Regional Medical Center.
References
1. Association of American Medical Colleges. 2014 Applicant and Enrollment Data Charts. https://www.aamc.org/download/411642/data/10282014.pdf
2. Association of American Medical Colleges. Table A-6: Age of Applicants to U.S. Medical Schools at Anticipated Matriculation by Sex and Race/Ethnicity, 2013-2014 through 2015-2016. https://www.aamc.org/download/321468/data/factstablea6.pdf
3. Hamilton, A. et al. Childbearing and Pregnancy Characteristics of Female Orthopaedic Surgeons. J Bone Joint Surg Am, 94; 11, e77.
4. Pham, D. T., et al. Birth trends and factors affecting childbearing among thoracic surgeons. Annals of Thoracic Surgery, 2014; 98(3), 890–895.
5. Merchant SJ, Hameed SM, Melck AL. Pregnancy among residents enrolled in general surgery: a nationwide survey of attitudes and experiences. American Journal of Surgery. 2013 Oct; 206(4):605-10. Epub 2012 Nov 30
6. Finch, SJ. Pregnancy during residency: a literature review. Academic Medicine, 2003; 78(4), 418–28.
7. Davis, J., et al. Maternity leave: existing policies in obstetrics and gynecology residency programs. Obstetrics and Gynecology, 2001; 98(6), 1093–1098.
8. Lewin, Matthew R. Pregnancy, Parenthood, and Family Leave during Residency. Annals of Emergency Medicine 2003; 41: 568-573
9. American Academy of Pediatrics. “Policy Statement: Parental Leave for Residents and Pediatric Training Programs Guidelines Section on Medical Students, Residents, and Fellowship Trainees and Committee on Early Childhood. Pediatrics 2013; 131;387
10. American Academy of Family Physicians. “Parental Leave During Residency Training” http://www.aafp.org/about/policies/all/parental-leave.html
11. American College of Emergency Physicians. Family Leave of Absence. https://www.acep.org/Clinical---Practice-Management/Family-Leave-of-Absence/
12. American Board of Emergency Medicine. Policy on Emergency Medicine Residency Training Requirements. February 2015. https://www.abem.org/public/docs/default-source/policies/policy-on-emergency-medicineresidency-training-requirements.pdf?sfvrsn=10
13. Association of American Medical Colleges. 2014 Applicant and Enrollment Data Charts. https://www.aamc.org/download/411642/data/10282014.pdf
14. Association of American Medical Colleges. Table A-6: Age of Applicants to U.S. Medical Schools at Anticipated Matriculation by Sex and Race/Ethnicity, 2013-2014 through 2015-2016. https://www.aamc.org/download/321468/data/factstablea6.pdf
15. Hamilton, A. et al. Childbearing and Pregnancy Characteristics of Female Orthopaedic Surgeons. J Bone Joint Surg Am, 94; 11, e77.
16. Pham, D. T., et al. Birth trends and factors affecting childbearing among thoracic surgeons. Annals of Thoracic Surgery, 2014; 98(3), 890–895.
17. Merchant SJ, Hameed SM, Melck AL. Pregnancy among residents enrolled in general surgery: a nationwide survey of attitudes and experiences. American Journal of Surgery. 2013 Oct; 206(4):605-10. Epub 2012 Nov 30
18. Finch, SJ. Pregnancy during residency: a literature review. Academic Medicine, 2003; 78(4), 418–28.
19. Davis, J., et al. Maternity leave: existing policies in obstetrics and gynecology residency programs. Obstetrics and Gynecology, 2001; 98(6), 1093–1098.
20. Lewin, Matthew R. Pregnancy, Parenthood, and Family Leave during Residency. Annals of Emergency Medicine 2003; 41: 568-573
21. American Academy of Pediatrics. “Policy Statement: Parental Leave for Residents and Pediatric Training Programs Guidelines Section on Medical Students, Residents, and Fellowship Trainees and Committee on Early Childhood. Pediatrics 2013; 131;387
22. American Academy of Family Physicians. “Parental Leave During Residency Training” http://www.aafp.org/about/policies/all/parental-leave.html
23. American College of Emergency Physicians. Family Leave of Absence. https://www.acep.org/Clinical---Practice-Management/Family-Leave-of-Absence/
24. American Board of Emergency Medicine. Policy on Emergency Medicine Residency Training Requirements. February 2015. https://www.abem.org/public/docs/default-source/policies/policy-on-emergency-medicineresidency-training-requirements.pdf?sfvrsn=10
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