Physician Mothers and the Breastfeeding Challenge

Sarah Yahr Tucker

August 16, 2022

The responses to the survey are frustrated and angry, and they paint an unflattering picture of life as a breastfeeding physician.

"I pumped 2 years on a hospital bathroom floor."

"Any changes to schedule had to be approved by chair. There was no way he was going to approve pumping slots."

"My chief resident thought it was funny to 911 page me while I was pumping ― or knock on the door telling me to get back to work!"

"I lose quite a bit of my pay due to pumping milk because I am paid strictly on RVU [relative value unit]. I chose this for my family, but the pay disparity is pretty high."

Many of the statements came as no surprise for Snigdha Jain, MD, who conducted the survey, a national study of breastfeeding physicians that was recently published in the Journal of General Internal Medicine. Jain, who works in pulmonary/critical care and geriatrics at the Yale School of Medicine, is currently breastfeeding her second child and has ample experience with the problems breastfeeding physicians face when they return to work.

"I had the perspective of pumping at work both as an attending physician and then going back to training as a fellow," Jain says. "And that got me thinking about writing about these experiences and also advocating for other women who were in my position or are going to be in my position."

If any cohort understands the many benefits of breastfeeding children, it's doctors. Numerous organizations, including the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the World Health Organization, strongly recommend breastfeeding. They advise that infants exclusively receive breast milk until 6 months of age and that breastfeeding be continued for up to 2 years or longer.

All breastfeeding parents who return to the workplace must regularly express breastmilk to provide for their children and maintain their supply. But the widespread lack of accommodation for physician parents shown in Jain's survey and others is startling, given the support for breastfeeding in the medical field. Wouldn't it be expected that physicians would practice what they preach?

Studies have found that physician parents as a group are particularly at risk for ending breastfeeding prematurely or before they have reached their personal goals. Over 90% of physician mothers initiate breastfeeding, but by 12 months post partum, the figure drops to about 41%, according to a 2018 study from Brigham and Women's Hospital. Previous studies found rates as low as 34%. Nearly half of respondents in the 2018 study reported that they would have breastfed flonger had their jobs been more accommodating.

The Challenges: Time and Space

Federal law requires employers to provide "reasonable" break time to express breastmilk and also to provide a private space to do so that is not a bathroom. But the law only applies to employers that have more than 50 employees and allows break times to be unpaid. Some states have passed additional laws with further protections. In reality, physicians say, accessing time and space is often very challenging, especially since working hours can be unpredictable and the "private space" may be nowhere near their clinical area.

"One of the biggest challenges I encountered as a fellow was telling your attending that you needed to go pump," says Jain. "The second was finding space. And that was a theme we found in this qualitative study. Most hospitals now have lactation rooms, but [often] you don't know where they are. I would end up using a call room, which was intended for residents, so I'd always feel like this is somebody else's space, not a dedicated facility for lactation."

Many physicians report that even rooms specifically designated for lactation may lack essentials, such as a fridge for storing breast milk, a sink for cleaning breast pump parts, or a computer for continuing work-related tasks.

Gul Madison, MD, an infectious disease physician at Mercy Fitzgerald Hospital near Philadelphia, has breastfed three children and says she found that breastfeeding the third was the most difficult, owing to her work situation. At the time, she was part of a private practice and conducted rounds in seven hospitals. Time and space were hard to find.

"I had conversations with each of these hospitals to see how I could pump milk," Madison says. "Some of them looked at me like I had two heads, and some were very accommodating. One of them gave me key for a little closet and said, 'This is yours. You can use it.' One of them actually had a lactation room. It was extremely challenging, and there were many times when I ended up pumping in the hospital bathroom or in my car."

Madison also found herself working longer hours. Although she was able to take breaks, she was adding 15 minutes three times a day to her work schedule and felt she was still expected to see the same number of patients. Although her colleagues were supportive, she says the lack of a structure and the expectation that she maintain productivity were stressful with a baby and two older children at home.

"There's a disconnect," Madison believes, "in terms of what we recommend vs whether we apply that to our lives or not."

The Financial Cost

A few months after returning from maternity leave with her second child, Rebecca Shatsky, MD, received a troubling email from her hospital administration. She was seeing fewer patients, and this was a problem. Shatsky, who is a medical oncologist specializing in breast cancer at the University of California San Diego Health, does not have a fixed salary. A large percentage of her income is determined by RVUs, a common compensation model based on the number of patient visits or procedures a physician performs. To produce enough breast milk for her infant son, Shatsky had to block at least two time slots at her clinic per day. She realized how much her financial situation would suffer as a result.

"My administration wasn't very happy, because I wasn't as productive as I previously was because I was pumping," Shatsky explains. "And while they didn't come right out and say, 'Please stop pumping,' they would give me monthly reminders that my productivity wasn't as good as it used to be. It was really stressful."

Shatsky took her concerns to Twitter, posting, "I am an academic physician getting penalized for breastfeeding my infant son." Her tweet received nearly a thousand likes, but she also got angry messages from men protesting that they shouldn't have to pick up the bill for her decision to breastfeed or suggesting that she simply quit medicine and stay home.

Ann Kellams, MD, is a pediatrician at the University of Virginia Health and also serves as president of the Academy of Breastfeeding Medicine, a global organization for physicians aimed at promoting, protecting, and supporting breastfeeding. The group has published more than 30 clinical protocols related to breastfeeding, including one for creating a breastfeeding-friendly office. Kellams sees accommodation for lactating doctors as an "investment" that all institutions should be making in their employees. The result, Kellams believes, will be more loyalty and greater retention.

"I think that as a whole, the profession is starting to wake up and realize that we need to be taking care of ourselves," Kellams says. "And the investment in young families, making accommodations for them, being flexible with scheduling, and supporting maternity leave, paternity leave, and childcare are going to be what helps us get there."

Solutions That Work

At a time when nearly half of graduating medical students are women, the need to find solutions for breastfeeding physicians is especially urgent. Some institutions have taken a receptive approach, encouraging their trainees and faculty to voice concerns so that problems can be addressed.

Hannah Hughes, MD, an assistant professor and associate medical director with the University of Cincinnati emergency medicine department, has a 6-month-old baby and has received strong support for breastfeeding from her colleagues. Hughes uses a recent innovation in breast milk expression: wearable breast pumps. She says they have been a "game changer."

As an emergency department physician, it is often impossible for Hughes to leave the department. Unlike traditional breast pumps that are bulky and must be plugged in, cordless wearable pumps fit directly into a bra. Although she prefers to pump privately ― there is a separate lactation room inside the emergency department ― it is possible for Hughes to walk around and see patients. She even rushed to a bedside and performed an intubation in the middle of a pumping session.

"It's been a huge win for trying to maintain our breastfeeding culture," Hughes says. "That case actually spurred us to have a conversation as a department. And now my department funds wearable breast pumps for any of our providers, our residents, PAs, NPs, and attendings who come back from leave, if they want them."

However, wearable pumps don't work for everyone, and so Hughes' hospital has gone further, creating a formal lactation committee to share best practices across specialties and encouraging specific departments to write their own lactation policies. These can dictate shift schedules, allowing employees to take breaks, and also return-to-work protocols after maternity leave.

Other institutions are beginning to address the pay disparity by adjusting the RVU model. Acknowledging that pumping breast milk results in decreased productivity, the University of California San Francisco Health recently began providing RVU credits that apply to the breaks needed for lactation. The program allows physicians to schedule a 30-minute break for each half-day clinic session for up to 1 year following childbirth. Those breaks are reimbursed with a set amount of RVUs, and in addition, RVU targets are reduced.

Elsewhere, individual groups of physician parents are pushing for changes. Madison has been involved with designating a lactation room at her hospital. At the University of Texas Southwestern Medical Center, where Jain began her fellowship training, she formed a committee and scheduled meetings with the administration. The institution has two hospital sites. At one, Jain says they were able to procure a lactation room, laptop computers, and a fridge. Despite multiple discussions, no changes materialized at the other site.

Still, Jain feels that the burden on physician parents to organize their own breastfeeding support is too great. For people already stretched in many directions, she says it's unfair that they should be expected to make changes happen on their own time.

"Returning to work is so stressful post maternity," Jain says. "To have experiences like this where your work environment is really adding stress is just unacceptable.... It's kind of like creating restrooms. They just need to be there. You should not have to go and build one yourself."

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