In 1965, the proportion of medical school graduates who were women was 7%.¹ Today, for the first time in history, women constitute the majority of medical students in the U.S.² Yet, despite the ongoing focus on physician wellness, specifically trainees, there is growing evidence that women in medicine struggle with balancing the grueling demands of their career and caring for their family. A recent article in JAMA Surgery leading to a New York Times editorial revealed frightening statistics regarding female surgeons and pregnancy. Indeed, 42% experienced a pregnancy loss and 75% took no time off following a miscarriage or a stillbirth.³ There is no doubt that the culture of our profession is a contributor. We need to find solutions promptly as we are putting the physical and psychological health of our physicians and trainees at risk.

It is no surprise that women physicians often delay personal life decisions because of career plans. The ideal age for women to become pregnant often falls during training and many will decide against pursuing a specific residency or fellowship because of prolonged work hours, inadequate compensation for childcare, or the fear of a lack of support from their specialty or career disadvantage.⁴

Sadly, 80% of physicians who did decide to have children reported "maternal discrimination" in the workplace, according to a BMJ article published in December 2018.² This can be experienced in a variety of ways and is certainly underrecognized in medical education. For example, the quality of a trainee is often measured by the quality, but also quantity of work accomplished in one day. Residents and fellows who arrive early, leave late, and who spend more time than the 70+ hours to complete their usual tasks within the hospital are often praised for their dedication. I know this to be true because although I was never the smartest or the most efficient trainee, I worked the most hours and I was commended for this on many occasions. Unfortunately, this became impossible when needing to breastfeed my baby in the morning and drop her off at daycare by 7 a.m.

We need to be rid of the shackles of the hierarchy in medicine and focus on teamwork so that hours can become flexible and more conducive to work-life balance. I have had superb mentors who have split the day-to-day tasks with me so that we can both go home to our children at a reasonable hour. With the support of my colleagues and mentors, I finally felt like I could do it all. These are the small wins and should be celebrated and encouraged.

Another example of maternal discrimination is related to extra-curricular work required to become a competitive applicant when pursuing certain residency and fellowship positions. This is particularly relevant in cardiology, where research and publications are critical to a successful application. How can we expect a trainee who already works 70+ hours per week to undertake research and other career pursuits after hours when caring for children or when pregnant? Evidently, women either decide to wait to have children, putting them at risk for health complications or infertility or simply feel limited in their career pursuits. Later in one's career, promotions and leadership positions become unattainable. Let's ask ourselves, isn't our highly demanding clinical work enough?

A change in the culture in medicine starts with the support of pregnant trainees. Our fellowship is currently working to develop a parental leave and lactation guide to support trainees who are considering embarking on family planning during the cardiology fellowship. This guide includes clear instructions on the amount of time off allowed by ACGME, education on radiation safety, and support for those wishing to breastfeed after returning to work. If we cannot fully support our trainees in following our own guidelines, it is hard to believe that we will make any progress. This guide also allows for flexibility in cardiology fellowships regarding rotations, a return-to-work schedule, and support during pregnancy. It recognizes that each women's experience during pregnancy and after birth is highly unique and requires a flexible approach to support each trainee to ease the transition back to work, regardless at what stage in their family planning or training this occurs. The U.S. is one of seven countries in the world without national paid maternity leave,⁵ therefore it is up to our medical leaders to step up and provide advocacy for their trainees with the knowledge that making work flexible to accommodate family demands is not only acceptable but should be encouraged. Trainee education will not suffer. We will be successful. We will be happier. We will perform better and we will be more balanced individuals.

Several countries have already implemented parental leave policies in medicine. The Professional Association of Residents of Ontario (PARO) in Canada has a policy stating that any trainee can have up to 17 weeks of pregnancy leave and up to 35 weeks of parental leave (37 weeks if no pregnancy leave is taken).⁶ Although this amount of leave highlights a much larger issue in the U.S., this is a benchmark to strive toward in the future. As we continue to reshape medical education with aspirations to change our work culture to accommodate the needs of women and young families, I ask myself the following questions:

• What is the purpose of such delineated hierarchy in medical education? Does it improve our most important goal, achieving and maintaining high-quality patient-centered care?
• Can we improve teamwork between attendings and trainees?
• Can we work less hours, more efficiently?

Being a parent-physician should be seen as an asset. True acceptance requires a bold change in culture and mindset, which will likely meet resistance. However, if we work together, our advocacy will go a long way toward supporting male and female physicians to make family a priority.

References

1. AAMC. Table 1: Medical students, selected years, 1965-2013. 2014. https://www.aamc.org/media/8661/download (accessed 2021 October 17)
2. Halley MC, Rustagi AS, Torres JS, Linos E, Plaut V, Mangurian C et al. Physician mothers' experience of workplace discrimination: a qualitative analysis. BMJ 2018 363 k4926 DOI: 10.1136/BMJ.k4926
3. Rangel EL, Castillo-Angeles M, Easter SR, et al. Incidence of Infertility and Pregnancy Complications in US Female Surgeons. JAMA Surg. 2021;156(10):905–915. doi:10.1001/jamasurg.2021.3301
4. Simpson AN, Cusimano MC, Baxter NN. The inconvenience of motherhood during a medical career. CMAJ 2021 193 (37) E1465-E1466; DOI: 10.1503/cmaj.211255
5. https://www.nytimes.com/2021/10/25/upshot/paid-leave-democrats.html
6. Pregnancy and parental leave. Toronto: Professional Association of Residents of Ontario (PARO). https://myparo.ca/your-contract/#pregnancy-and-parental-leave (accessed 2021 October 17).