Starting a Family

A NextGen Women in Medicine Article

For many women, medical training spans most of their reproductive years. With women making up 50% of the medical school applicant pool and 42% of residents and fellows, more women than ever before must face making lifestyle decisions. (1) Somewhere between tending patients, absorbing vast amounts of medical information, and responding to a host of obligations and stresses placed on physicians and medical students, many must also find time to start their own families while beating the ticking biological clock. As policies regarding maternity leave become more supportive of women who choose to have children while in training or in practice, female doctors and medical students are also finding more ways to reorganize their time and plan for their personal priorities.

The Challenge

The vast majority of the challenges that confront female doctors intent on starting families during medical training relates to the demanding nature of the medical profession. Medical students and residents could potentially risk their health and the health of their babies by starting a family during the physically demanding period of training. A retrospective survey of recent graduates with a large specialty cross-section showed elevated risks of pregnancy complications, such as placental abruption, low birth weight, still-births, pre-term labor, premature births, and preeclampsia, a condition characterized by high blood pressure, headaches, vision changes and can endanger both the mother and the child. The same group of risks is also associated with women in physically strenuous jobs. (2)

And while most hospitals are reluctant to set a work hour limit or even make recommendations regarding the size of appropriate workloads for pregnant residents, few obstetricians would hesitate to discourage their pregnant patients from working beyond 80 to 100 hours per week. (3) Especially during residency, when physicians-in-training must face taxing factors such as frequent and irregular calls, long hours, emotional strain, and fatigue, starting a family could prove particularly stressful. Some residents, whether due to feelings of guilt or pressure from co-workers, sometimes overcompensate and often work until the delivery date, and take minimal maternity leave, with some taking off virtually no time. (4)

Apart from the demanding nature of the job, other health threats relate to pregnancy among medical students, residents and physicians include environmental risks associated with medical setting, such as exposure to radiation, infectious diseases, certain toxins, and chemical agents. (5)

Policy on Parental Leave

The cap on the number of work hours for residents has lowered, alleviating some of the time-strain that has long been associated with residency. However, most doctors still suggest that residency is one of the most difficult periods to start having children. Dr. Margulies points out that during residency, when doctors must spend long shifts at the hospital, it would be very difficult "to be even more sleep deprived and spend so many nights away from home."

According to its 2005 guidelines, the American Medical Association (AMA) recommends that "medical schools, residency training programs, medical specialty boards, and the Accreditation Council for Graduate Medical Education to incorporate written leave policies, including parental leave, family leave, and medical leave." (6) Furthermore, the AMA suggests that physicians who are unable to work because of pregnancy, childbirth, and other related medical conditions should be entitled to such leave and other benefits on the same basis as other physicians who are temporarily unable to work for other medical reasons. (7)

Like the AMA, the Association of Women Surgeons also recommends departments to not expect women to to compensate for time missed by working longer hours before the delivery or to make up the missed work after delivery so that they would have accomplished the same amount of work as their non-pregnant colleagues. They suggest that one "would not expect a resident to make up [work] after marrying, breaking an ankle on a planned ski trip, presenting a paper at an academic meeting, or taking sick leave for elective or emergency medical care." (8)

Following the recommendations of the Association of Women Surgeons, departments such as the Department of Surgery at the University of Pittsburgh School of Medicine offer many policy points such as the allowance of four weeks of maternity leave in addition to two weeks of accrued vacation time, then ask that the residents "plan to come back to work full time." (9)

Policies regarding maternal and paternal leave, however, remain highly variable across institutions and even among departments within each institution. The situation becomes more confusing when residencies based in universities are affiliated with privately managed hospitals, an increasingly common situation as private hospitals buy county facilities often associated with public universities. In these instances, policies regarding maternal leave may be established by the private hospitals instead of the university. (10)

While some residents feel that most faculty leadership encourage women to avoid starting family during residency and to give plenty of notice before having children. (11) In general, institutions' policies on women physicians and residents becoming mothers are becoming more open and supportive.

Coping strategies

When it comes to coping with pregnancy while pursuing a medical career, finding ways to address the time shortage problem is imperative. "There is very little downtime when you have small children and a busy medical practice," said Dr. Margulies. And while women of all career fields grapple with this problem, the field of medicine poses one of the most challenging and inflexible schedules, forcing many women doctors to develop a variety of coping methods.

Dr. Leonor Fernandez, a physician in internal medicine who started her family five years out of residency, has developed "tricks" to balance her life. She finds that by working 80% of the time, she may enjoy time with her family and find time and activities for herself such as taking a dance class when her children have gone to sleep or joining a monthly book club.

For the female medical student who has decided to start a new family, how positive her experience is often depends on the supportiveness of her colleagues. Since residents often work in groups, support provided by other team members sometimes determines how easy the transition is for the pregnant member. (12) Members of the more female-dominated specialty programs such as OB/GYN and pediatrics may see more of their colleagues taking parental leave: 14% female obstetrics and gynecology residents and 38% of pediatric residents reported having at least one pregnancy during residency. (13)

Surveys have shown that other residents sometimes harbor negative feelings toward the pregnant resident, particularly due to the anticipation of workloads. (14) Dr. Margulies, who started her family after entering a practice, believes that her good relationship with the other physicians at her practice helped her obtain a more flexible schedule that is supportive of raising children.

One note of advice that has surfaced recurrently is that the size of the program plays a role in how well the pregnancy will be received—it is usually best to work in large programs with enough colleagues and available personal support.

Dr. Margulies, who works with seven other physicians, also mentions that working with a larger group of practitioners also has proven to be very helpful, as her patients become well-aware that their needs will be addressed by the other doctors on the days when she does not work. She believes that by having so many women in medicine, not only have regulations and policies changed, patient's expectations have also been altered. "My patients know that I have young children [that] there are times that I am not available."

Sometime, restructuring certain systems of operation in the practice also helps physicians save time. Dr. Margulies indicates that during after hours, some primary care physicians have turned to caring for patients over the telephone to address most issues and concerns. This ensures that only patients that require direct observation and evaluation arrive at the hospital. Furthermore, many hospitals have greatly increased the efficiency of patient admission, lowering the number of physicians and support staff needed on a given night.

Of course, support from spouses and extended family members also helps alleviate the burden on pregnant doctors and new mothers. Dr. Judy Ann Bigby, the Director of the Office for Women, Family and Community Programs at Brigham and Women's Hospital and the Director of the Harvard Medical School Center of Excellence in Women's Health, highlights the importance of both parents making strong commitments to maintaining a family. The mother of two children, one of which was born during residency, she believes that "the biggest challenge women face in having children is that many partners don't equally share the parenting. This is of course a choice that couples make together." Dr. Bigby coordinates her schedule with that of her spouse, who also happens to be a doctor. They share equally in household responsibilities and "both attend every play, dance recital, sports event, teacher conference, birthday party" and other events "non-negotiable in terms of priorities." Additionally, Dr. Fernandez gives this advice to female doctors: "Try to make some time for your partner and yourself apart from your children," noting that female physicians have to pay attention to another aspect in the "family" side of the work-family balance.

For those who choose to dedicate their lives to treating the sick and improving the health of others, finding time to do fulfill one's desires–"to be a good physician, be a person who is physically active, intellectually alive, emotionally whole"–may be challenging. However, Dr. Fernandez mentions that one would feel greater fulfillment in "seek[ing] projects and activities that interest you and in which you find meaning; and conversely, look for meaning in that which you do."

All in all, young women aspiring to be in the field of medicine would fare well in making lifestyle and career choices by "figuring out what you want and asking for it," advises Dr. Margulies. "Stand firm on issues that are really important to you... There may never be a 'perfect' time to have a child. You may need to make a decision and go for it." 

Serene Chen is a writer for the Next Generation and a member of the Harvard College Class of 2008.

  1. AAMC, Women in Academic Medicine Statistics, 2005. Accessed February 18, 2006. <www.aamc.org /members/wim/ statistics/ stats05/start.htm> (Text)
  2. van Dis, J. JAMA 2004; 291(5):636 (Text)
  3. Finch, SJ. Pregnancy during Residency: A Literature Review. Acad. Med. 2003;78;418-428 (Text)
  4. Finch, SJ. Pregnancy during Residency: A Literature Review. Acad. Med. 2003;78;418-428 (Text)
  5. Carty, SE., et al. Maternity policy and practice during surgery residency: How we do it. Surgery. 2002; 132(4):682-688 (Text)
  6. AMA Policy H-420.961. Accessed February 18, 2006. <www.ama-assn. org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/H-420.961.HTM&&s_t=& st_p=&nth=1&prev_pol= policyfiles/HnE/H-415.999.HTM&nxt_pol=policyfiles/HnE/H-420.959.HTM&> (Text)
  7. AMA Policy H-420.961. Accessed February 18, 2006. <www.ama-assn. org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/H-420.961.HTM&&s_t=& st_p=&nth=1&prev_pol= policyfiles/HnE/H-415.999.HTM&nxt_pol=policyfiles/HnE/H-420.959.HTM&> (Text)
  8. Carty, SE., et al. Maternity policy and practice during surgery residency: How we do it. Surgery. 2002; 132(4):682-688 (Text)
  9. Carty, SE., et al. Maternity policy and practice during surgery residency: How we do it. Surgery. 2002; 132(4):682-688 (Text)
  10. Lewin, MR. Pregnancy, Parenthood, and Family Leave During Residency. Ann Emerg Med. 2003; 41:568-573 (Text)
  11. Carty, SE., et al. Maternity policy and practice during surgery residency: How we do it. Surgery. 2002; 132(4):682-688 (Text)
  12. Carty, SE., et al. Maternity policy and practice during surgery residency: How we do it. Surgery. 2002; 132(4):682-688 (Text)
  13. Gabbe, SG., et al. Duty hours and pregnancy outcome among residents in obstetics and gynecology. Obstet Gynecol. 2003; 102:948-951 (Text)
  14. Finch, SJ. Pregnancy during Residency: A Literature Review. Acad. Med. 2003;78;418-428 (Text)

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