Returning to work after six weeks of maternity leave made Victoria Chase question her decision to become a doctor. The grind of the Ob-Gyn residency at the University of Vermont was brutal. “In my first two months back, I worked six out of the eight weekends,” Chase says.
Ob-Gyn is a predominantly female specialty, but Chase was one of only two women in her 12-person program with children. She had been a week overdue with her son, which caused a domino effect of scheduling conflicts. The resulting year, she says, turned out to be a nightmare. “I honestly don’t remember the first year of my son’s life. I see pictures, but I don’t remember living it. I was just not there,” she says. “At that point, if I had really known what I was getting into, I would’ve done something else.”
Chase is in a tough spot — one familiar to many mothers working in convenience stores or the corner office. But hers is also particular to the medical field, which is built around a system of education and on-the-job training that was designed for a world that no longer exists. The dilemma that Chase and others face raises serious questions about whether that system attracts, educates, and retains the best prospective doctors.
Many female physicians who choose to have children are fighting an uphill battle. The current model of medical education and training, after all, was designed exclusively for men more than a century ago. It consists of a rigid curriculum with a tight timeline for rotations, boards, and fellowships, to say nothing of the 80-hour duty weeks and, at times, punishing schedules. But is that the best way to fill the ranks of tomorrow’s clinicians? When our structure for minting new doctors imposes hardships on almost half the people going through it, is it their fault — or the system’s?
In the mid-1970s, 10 percent of medical school graduates were women. Today, it is 50 percent. And since the average age of first year residents is 30 years old, many female residents and fellows are smack dab in the middle of their prime childbearing years. As the demographics have changed, so too has the conversation around culture and work-life balance in the medical community.
For older generations of female physicians, there was only one way to make it work: Wait. Elizabeth Breen, a colorectal surgeon and assistant professor at Brigham and Women’s Hospital, says that when she was training in the 1990s, the idea of childbearing and medical training were mutually exclusive. “Everyone just waited to have their kids,” she says.
The medical community is well aware of the potential complications of advanced maternal age. Yet many female physicians report butting up against a culture that still discourages childbearing during training. Karen Law, a residency program director at Emory University School of Medicine, says many young female physicians report that male mentors explicitly discourage them from having children during any point of their training. “If we take that advice, we have eliminated 8 to 10 years of a woman’s peak childbearing age — clearly we need to change the conversation,” she says. “As much as we are thrilled that our incoming medical school classes have had anywhere between 40 to 60 percent women, we still operate in a culture that is very much male driven.”
But reforming medical education means reforming a labyrinthine system. Each program, after all, has to coordinate the logistical and administrative headaches of doctors’ schedules, patient coverage, and national board exams. Often, the next phase of training begins just a day or a week after the previous one ends, which means finding time to squeeze in a maternity leave of any length can be difficult. There are whole message boards online devoted to the tricky and meticulous family planning processes female physicians undertake. And that’s assuming there aren’t complications. As a result, many physician mothers are in a rush to return to work as soon as possible so as to not delay their training.
It’s a testament to the old adage that physicians make the worst patients. “We don’t take our own advice,” Law says of allowing for flexibility in recovery. “And we don’t structure our programs to make it easy for us to take our own advice.”
Carol Bates, the associate dean for faculty affairs at Harvard Medical School, says there’s only so much individual programs can do. While programs tend to work with and accommodate physician mothers on a case-by-case basis, the real leverage for change rests in the hands of national regulatory bodies. “Programs struggle with trying to really blow up the system entirely,” she says, “and to do that as a matter of routine.”
While nearly everyone agrees the current standards for clinical time and exposure are necessary for proper training, there is at least one effort to build in more flexibility at the national level. The American Board of Surgery, for example, has historically offered four weeks of nonclinical time during each year and allows for an additional two weeks for medical leave. A new program, however, hopes to give residents — both male and female — a lot more control and flexibility in their own lives. Called a “five in six pathway,” it extends clinical training from five to six years, but allows residents to easily take 12 months off in any way they choose.
Jo Buyske, associate executive director at ABS, says the option is unique among the national regulatory bodies, and, as a surgeon with four children of her own, she sees its creation as her top accomplishment. The program was designed for mothers but is not limited to them. “I kept hoping someone would ask me to use it to go climb Mount Everest,” says Buyske, who personally reviews all the applications, “but they never did.”
The program has been slow to catch on, but Buyske has received more than 30 applications so far this year. She’s hopeful more men and women will take advantage of it going forward, both to have both better work-life balance and to become better surgeons. “Having a healthy outside life in terms of relationships and also your personal physical and mental health is really important,” she says.
While individual programs and national institutions are beginning to offer solutions, getting a fix on the size and scope of the problem isn’t easy. The last study, done in 1993, found that 50 percent of children born to women physicians were born during residency training. Thirty percent of those women took only four weeks of maternity leave.
Jennifer Best and Shobha Stack, two doctors at the University of Washington, are working to update that data. The current generation of physician mothers, they say, is advocating for themselves more effectively than previous generations, making it increasingly difficult for the medical community to ignore the fact that medicine’s most demanding training window often coincides with childbearing. But while there are plenty of success stories of women who have made it work, they acknowledge that stories like Chase’s are all too common.
“It’s a really personal time in people’s lives that butts up against their professional life and professional goals,” Best says. “As they’re training, women may be reluctant to express some of their needs out of concern that it could impact their evaluations or future career options.”
In a recent national survey of physician mothers, conducted by Nelya Melnitchouk, a surgeon at Brigham, and Jennifer S. Davids, a surgeon at UMass Memorial, found that roughly half of those with proceduralist jobs (e.g., Ob-Gyns, surgeons) expressed regret about their chosen track. Women are still underrepresented in a number of specialties, including surgery, which is a problem. Since there’s no reason men would have better skills in these fields, the lack of representation suggests that people who might have considered that field are being discouraged from going in.
Support groups and mentorship are critical, of course. So too is the promotion of earlier generations of women to leadership posts. Currently, only 15 percent of all department chairs at teaching hospitals are women. While there has been progress in recent years, women are still largely absent from the very leadership positions that have the power to think innovatively about transforming systems of education, training, and culture at academic hospitals.
In some of the programs where women have risen in the ranks, however, there are obvious benefits to physician mothers in training. Kacey Kronenfeld, a disaster medicine fellow at Indiana University, says she chose to “broadcast” her children during her residency interviews in order to find a “family-friendly program.”
Emergency medicine is still largely male, with only 36 percent female residents. Even though Kronenfeld started as the only resident in her 21-person class at IU with children (she had a toddler and a newborn at the time), the fact that her department chair is a woman helped her have a more positive experience, she says.
Her fellowship began just two weeks after the birth of her third child, and her program director worked with her to come up with a flexible schedule. She sometimes even brought her infant son (outfitted in his own “Indianapolis EMS” onesie) to the state fair when she was running medical care or to military bases when she was doing disaster training simulations. A firefighter once told her he’d never seen someone breastfeed in so many random places.
It takes that kind of commitment and perseverance. Breen, the veteran Brigham surgeon, says she’d probably do things a bit differently. “I would have had more confidence in setting boundaries with what I would give to the job,” she says. “Part of it was self-imposed boundaries instead of saying, ‘If you want me, this is how I come.’”
A new generation of physician mothers, it seems, is starting to say just that.
Chloe K. Fox is a freelance writer and editor based in Cambridge.