Strengthening a support network for plastic surgeons starting a family
I am one of more than 400 women training in plastic surgery residency and fellowship in the United States. The number of women entering our field now represents 38.1 percent of residents. We train during our childbearing years, and as I approached advanced maternal age (35 years), the implications of starting a family during residency became very real.
The gravity of these issues is obvious for women, but they also affect men. If a program does not have established mechanisms to ensure clinical duties are covered when a female trainee suffers obstetrical complications or is on maternity leave, other residents must take on additional responsibilities, which can create a climate of resentment and exhaustion. It's also been reported that 33.3 percent of married male plastic surgery trainees are wed to another physician, which means the medical-training environment affects the health of their spouse and children. Men need flexibility in their schedules for paternity leave and urgent family issues.
Research year seemed like the best time to have a baby, so I became pregnant in my third year of residency. I was shocked by how pregnancy affected every organ system of my body. "Morning sickness" is a complete misnomer, as the nausea and vomiting are often (as in my case) constant and unrelenting. For many women, it subsides after three months. For me, it lasted until my third trimester. I became well acquainted with the locations of bathrooms so I could make a quick break while suturing lacerations in the E.D., on rounds – or even in the O.R. The most severe form of nausea and vomiting of pregnancy is called hyperemesis gravidarum. Women with this suffer from persistent vomiting, weight loss greater than 5 percent of pre-pregnancy body weight, and ketonuria. Although rare in the general public, a survey of plastic surgery residents and Fellows demonstrated an incidence of 16.7 percent.
Another aspect of pregnancy that surprised me was the intensity of physical exhaustion. Although familiar with working long hours, staying up all night on call and operating late into the next day, the combination of long hours and stress when pregnant created a new level of fatigue that I hadn't thought possible.
In hindsight, I'm glad I didn't know then what I know now – specifically, that 55.6 percent of plastic surgery trainees have an obstetrical complication, which is nearly four times higher than the general U.S. population. Sleep deprivation and more nights on call are correlated with complications and adverse outcomes. Furthermore, working more than 60 hours per week and longer operative hours per week correlate with higher rates of pregnancy complications. Risk of preterm labor is increased in women working more than 42 hours per week or standing more than six hours daily.
Everyone in my program was incredibly supportive throughout my pregnancy, but I privately considered quitting residency because I didn't think I could physically continue. The thought of asking for a lighter rotation or day off never crossed my mind. Even if I'd had the option, I would have been ambivalent about taking it. As a woman in a male-dominated field, I feel pressure to prove women are as good or better than men at plastic surgery. Also, when would I make up the more demanding rotation? After coming back from maternity leave when I am already waking up every two hours to breastfeed a crying baby?
Our first baby was a beautiful, healthy girl. Our second baby was born 10 days after I completed residency, so I started my fellowship while on maternity leave. Before returning to clinical duties, I went to a breastfeeding and working class, where we were instructed to pump every three hours. To optimize milk let down, we were told to pump in a calm and comfortable environment, and it was recommend we look at baby pictures to increase oxytocin levels.
I have not followed any of those recommendations. Every morning I get up early to feed the baby, then pump in the car on the way to the hospital. I look at the O.R. schedule to determine the optimal cases to pump between. No matter how efficient I am with discharge and pre-op orders between cases, there simply is no way to pump every three hours. I have pumped in locker rooms, attending and nurse's offices, lactation rooms, patient exam rooms, conference rooms and call rooms.
I know that under the Fair Labor Standards Act of 2009, employers are required to provide "a place, other than a bathroom, that is shielded from view and free from intrusion from coworkers and the public, which may be used by an employee to express breast milk." All hospitals have a lactation room somewhere – just not necessarily close to the O.R. I am not comfortable asking an attending to take additional time between cases or scrub out of a case to pump, even though I know it is my right as the law requires employers to provide a "reasonable break time for an employee to express breast milk for her nursing child for one year after the child's birth each time such employee has need to express milk."
I am not alone in prioritizing being a "good resident/fellow" who keeps the flow of the O.R. and clinic smooth above the health and nutrition of my baby. Only 19.5 percent of female plastic surgery trainees breastfeed for 12 months, which is the recommended duration by the American Academy of Pediatrics. More than one third of female trainees are dissatisfied with their length of breastfeeding (35.6 percent), and satisfaction is significantly correlated with length of breastfeeding (p=0.009). Female trainees are significantly more likely to disagree with the statement "attending surgeons and resident colleagues are supportive of pumping during clinical duties" compared to males (31.3 percent vs 8.2 percent respectively, p<0.001). Less than one-third (29.4 percent) of respondents report lactation facilities in close proximity to O.R.s and only 12 percent report their program has a formal lactation policy.
My second baby was three months old when I sat for my written boards. After scheduling my test, I called the testing center to ensure they would be able to provide me with a place to pump during the seven-hour exam. I was told that there was no accommodation for breastfeeding mothers, but I could use the public bathroom that was shared with all the offices on the floor or go out to my car to pump. The accommodation support personnel informed me that there are three test centers in the country that provide a place for women to pump, and none were near me. I found this shocking and disappointing. Conversely, ABPS was very accommodating and provided me with an additional hour of break time to ensure I had adequate time to pumpand followed-up with Prometric regarding their deficiency in appropriate facilities. I was lucky to discover that one of our clinics was in the same office building from Prometric and the nurses allowed me to use one of the empty patient rooms to pump during my test. I don't think anyone knows how many medical students and physicians across the country have had to pump in a public bathroom while sitting for exams.
Balancing family and career is difficult for men and women in all occupations. There are unique challenges faced by plastic surgery trainees. As a plastic surgery community, we should endeavor to support men and women who have children.
Thoughts from young plastic surgeons on starting a family during training...
I am a second year, independent plastic surgery resident and I am 35 weeks pregnant with my second child. I had my first child when I was a PGY-4 general surgery resident. That pregnancy was complicated by intrauterine growth restriction, but thankfully my daughter was born without issues and has grown well since birth. I told myself this pregnancy would be different: I wasn't on call as often; I would be able to eat and drink between cases; my rotations were lower stress.
It was different. I had round-the-clock "morning sickness" through my entire pregnancy. I wasn't able to eat much. I developed severe back pain two weeks ago, making it difficult to walk – much less operate all day. The baby was discovered to have an anomaly that required frequent ultrasounds and appointments. While the tests have ruled out catastrophic issues with the baby, we still do not know if the baby will require any medical interventions after birth.
Due to maternity leave policies at my hospital and training requirements, I have to use all of my vacation time until I graduate in June 2020. Thankfully though, my program faculty continue to explore other options to allow me enough time to recover and care for my baby after birth.
– Melissa Mastroianni, MD
From a male perspective, the major impediment toward taking paternity leave is a wish not to inconvenience other residents/Fellows. There is no question that taking paternity leave affects colleagues and their workload since they have to cover for you while you are away. I was unambiguous that I was making the right choice for my family, but at the cost of adding more work to my already over-worked colleagues.
My other hesitation with taking a longer paternity leave is the ACGME-mandated policy of 48 weeks worked per clinical year (averaged over residency). Even though I could technically take longer than four weeks for paternity (and would like to), this time would need to be made up in other years.
Our country has failed to prioritize and support reasonable policies for parental leave. It's ridiculous to think that four-to-six weeks is enough time for a newborn, who is awake, feeding and in need of diaper changes every two hours.
I benefited from being in a forward-thinking general surgery program that actually had an explicit written policy, and provided me with six weeks of leave for my first child. They gave me an action plan to make up time so that I would not violate the 48-week rule.
It was surprising when I arrived at my plastic surgery fellowship and found that there was no explicit written policy, and no one seemed to know what to do about paternity leave for my second child. I had to print the University policy and the ACGME policy and then draft my own paternity leave to be approved by my directors. Although my directors and supervisors were very understanding, the lack of an explicit policy is a not-so-subtle way of discouraging parental leave.
– Brodie Parent, MD
As we often hear, there is no "good" time for a female physician to get pregnant and have a child. I met and married my husband prior to medical school. While I was working toward my MD, my husband obtained his MBA and started working toward building his career. The first few years of my plastic surgery residency were akin to drinking from a fire hose. In addition to learning how to care for patients and developing surgical acumen, we were also adapting to a new city. I became pregnant and had my first son in 2016, while I was in my 4th year of residency.
In my program, we are allowed four weeks of vacation per year in accordance with ACGME and ABPS guidelines. That meant if I took no vacations for a year, I could have four weeks maternity leave. I worked up until the day I went into labor so that I could spend those weeks recovering from childbirth and caring for my newborn.
As supportive as my program is, I was working 12-14 hours most days, with most of the night spent awake with a 1-month-old infant. I didn't anticipate that he could not tolerate infant formula and depended on breast milk for his sole source of nutrition. While most of the hospitals provide accommodations for breastfeeding mothers to pump at work, I didn't think that those designated spaces would be at least 10-15 minutes away from the O.R. By the time you walk there and set up your supplies, it's about 30 minutes and your next case is about to roll back to the O.R.
In order to maintain breast milk supply, most guidelines suggest pumping about every two-to-three hours for at least 10-15 minutes. I didn't think about the bouts of clogged ducts or mastitis if you don't pump at regular intervals. Moreover, I didn't anticipate how mentally and emotionally taxing it would be to not be able to take any time to be with my son for the following six months of his life.
If I could do it all over again, I would still choose my current residency program, and I would also choose to have a child in residency. Maybe I would have taken three weeks for maternity leave, and save the remaining week for baby bonding time.
To the professional woman who are wondering when is the right time to have a child, the answer is when you say it is. As a profession, we have come a long way, but there is so much work to do to catch up with the civilized world with regard to provisions for childbearing. Until then, the struggles continue, but it is a choice and a decision that is well worth it.
– Kerry-Ann Stewart, MD
Having a baby during residency is like starting a concurrent residency. My wife and I had our first child during my internship while my wife was a second-year pediatric ICU resident. I remember routinely dropping the baby off at the babysitter at 4 a.m. so that I could do rounds at 4:30. My wife would pick the baby up on her way back from work. At six months, we moved our daughter to a daycare center affiliated with the hospital.
It was one of the most expensive things for residents in training, but as this daycare had residents and doctors, they understood our lifestyle and were more understanding if we ran late. One benefit of having daycare next to the hospital was that between cases, I could go see my daughter, which was probably the most stress-free time of the day. My wife graduated from the pediatric residency and took a year out before starting a fellowship in neurology as we were expecting a second baby. Thankfully we are now done with our residencies and fellowships, and things are infinitely better in terms of time management and financial stability. If we had to do this all over again, we would've done it in a heartbeat – except maybe started even earlier.
– Jignesh Unadkat, MD