Pregnancy Poses Multiple Challenges for Surgical Residents

Norra MacReady

March 22, 2018

The challenges facing female surgical residents who become pregnant can have a significant effect on their career satisfaction and should be addressed "to attract and retain the most talented workforce," the authors of a new study warn.

In a survey of 347 female surgeons, respondents said the biggest obstacles they encountered when pregnant during residency included inadequate maternity leave, limited access to lactation facilities, and a lack of mentorship on balancing family and career responsibilities, Erika L. Rangel, MD, and colleagues write.

Nearly one third of the respondents said they would advise female medical students to avoid a career in surgery because of these difficulties, the researchers report in an article published online March 21 in JAMA Surgery.

Doing a surgical residency while trying to start a family is like mountain climbing, the authors of an invited commentary write. For both, "factors such as health, drive, and an adequate support system are essential parts of the equation." Anticipatory planning is also critical, to ensure that whatever leave time is necessary meets the guidelines established by the Accreditation Council for Graduate Medical Education.

For the study, Rangel, from the Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, and colleagues developed the 74-question survey. They distributed it electronically to professional associations of women surgeons, as well as to social media groups of female physicians and surgeons. Eligible participants were women who had had at least one pregnancy during an Accreditation Council for Graduate Medical Education-accredited surgical residency in 2007 or later.

The 347 women who met the eligibility criteria had a mean age of 30.5 years (standard deviation, 2.7 years). Eighty-three percent of the respondents had at least one pregnancy during clinical training, although 101 (22.3%) of the 452 pregnancies reported occurred during research years.

One common theme that surfaced in the responses was a stigma against pregnant trainees or childbearing during training. Nearly three quarters (253; 72.9%) of respondents reported hearing negative comments made by faculty members or other residents. Yet, "297 women (85.6%) worked an unmodified schedule until delivery, with 289 (83.3%) and 300 (87.0%) reporting that requesting accommodations for less demanding rotations during pregnancy would have been perceived negatively by their peers and supervising faculty, respectively," the authors write.

Programs with formal maternity leave policies were reported by 121 participants (34.9%), with leave policies established by the American Board of Surgery cited by 268 respondents as a major barrier to obtaining the desired length of leave. Indeed, the authors note, 220 (63.6%) respondents felt "concerned that their work schedule or duties adversely influenced their health or the health of their unborn child."

Of respondents who answered the question on leave duration, 251 (78.4%) reported maternity leave times of 6 weeks or less.

Although 95.6% of respondents affirmed the importance of breast-feeding, 58.1% reported that they stopped nursing sooner than they would have liked, because of the challenges of balancing work responsibilities with the need to express milk. Even when lactation facilities were available, 85.2% of the participants said they felt uncomfortable asking for permission to scrub out during a case to express milk.

All in all, "135 respondents (39%) reported that their experience of pregnancy during residency made them strongly reconsider whether they wanted to continue their surgical training," the authors state. "A total of 102 respondents (29.4%) would caution a female medical student against a career in surgery because of the difficulty of balancing the profession with motherhood."

Study limitations include the method of distribution, which prevents calculation of a response rate, the authors write. Survey bias is also possible, as more dissatisfied surgeons may have been more likely to respond to the questionnaire. The authors also cautioned against making causal inferences because of the cross-sectional study design.

Nevertheless, with attrition rates in general surgery residency programs of 20% or more, program directors must do more to keep good candidates, they warn. Women make up nearly half of medical school graduates, yet general surgery programs lag behind other specialties, such as pediatrics and obstetrics and gynecology, in terms of time allowed for maternity leave.

"Open discussion among surgical leaders and educators must develop strategies for workforce shortages, improvements in the working environment, flexible leave policies, and preservation of the integrity of education for the pregnant resident and her colleagues," they conclude.

"The current situation of women surgeons in the United States demands and requires change," Kelly L. McCoy, MD, Linwah Yip, MD, and Sally E. Carty, MD, from the Division of Endocrine Surgery, University of Pittsburgh, Pennsylvania, write in an their commentary. Although it is possible to be both a surgeon and a mother, "[i]f the prospect of leaving a recital, fencing match, or tickle-fest to perform urgent surgery is enough to sway a young doctor away from a particular specialty, their gut may be guiding them in the right direction."

One of the study authors is a cofounder and equity shareholder of the company that runs the website http://www.doctella.com. The authors and the editorialists have disclosed no relevant financial relationships.

JAMA Surgery. Published online March 21, 2018. Article full text, Commentary full text

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