- Email: [email protected]
Impact of Procedural Training on Pregnancy Outcomes and Career Satisfaction in Female Postgraduate Medical Trainees in the United States
ORIGINAL SCIENTIFIC ARTICLE
Impact of Procedural Training on Pregnancy Outcomes and Career Satisfaction in Female Postgraduate Medical Trainees in the United States Jennifer S Davids,
MD, FACS,
Rebecca E Scully,
MD, MPH,
Nelya Melnitchouk,
MD, MSc, FACS
Compared with nonprocedural fields, procedural specialization requires longer training, less flexible schedules, and greater physical demands. The impact of these factors on pregnancy, maternity outcomes, and career satisfaction has not been well described. STUDY DESIGN: Data were gathered from 738 US postgraduate medical trainee mothers via an anonymous, IRB-approved online survey. Univariate analysis was performed using chi-square tests. A logistic regression model was used to investigate the impact of procedural training on odds of assisted reproduction use and pregnancy complications, adjusting for age at first pregnancy. RESULTS: Of the 738 respondents, 221 (30.0%) were in procedural fields. A greater percentage of procedural trainees were more than 30 years old at the time of first pregnancy (52.9% vs 43.1%; p ¼ 0.01). Controlling for maternal age, procedural trainees were significantly more likely to require assisted reproduction (odds ratio [OR] 1.28; 95% CI 1.01 to 1.61; p ¼ 0.04), and trended toward increased odds of prolonged time to conceive (OR 1.62; 95% CI 0.99 to 2.65; p ¼ 0.06). After delivery, procedural trainees also had higher adjusted odds of shorter maternity leave (OR 1.52; 95% CI 1.06 to 2.18; p ¼ 0.03) and were significantly more likely to report a desire to have chosen a less demanding specialty or job (OR 1.95; 95% CI 1.40 to 2.72; p < 0.001). CONCLUSIONS: Procedural trainees have higher rates of assisted reproduction, shorter maternity leave, and are ultimately more likely to express career dissatisfaction. These findings illustrate the need for adequate support for trainee mothers, particularly in procedural specialties. (J Am Coll Surg 2017;-:1e8. 2017 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.)
BACKGROUND:
(66.7%), and the lowest percentages in orthopaedic surgery (13.2%), neurosurgery (13.9%), and thoracic surgery (19%).2 Previous small studies suggested that most female physicians historically have chosen to delay childbearing until completion of training, particularly in male-dominated specialties.3,4 Our previous work demonstrated that, of early career physician mothers who became pregnant after completing their training, those in procedural specialties were more likely to wish they had chosen a less demanding job or specialty, compared with their nonprocedural peers.5 We also demonstrated that, regardless of specialty, women who have children while in practice experience high rates of preterm labor, cesarean section, and pregnancy-related complications compared with the general population, even when controlling for age.6 As more women are becoming physicians, more are also deciding to have children during postgraduate training.7 There is considerable variation in maternity leave policy
More women are becoming physicians in the US. Even though only 30.4% of physicians in the US are women, half of 2016 medical school matriculates are women.1 More women are entering postgraduate medical training programs, and now 41.6% of all ACGME-accredited trainees are female. Considerable variation in the percentage of women still exists between different specialty training programs, with the highest percentages in obstetrics/gynecology (81%), pediatrics (72.7%), and endocrinology Disclosure Information: Nothing to disclose. Presented at the Academic Surgical Congress 12th Annual Meeting Las Vegas, NV, February 2017. Received April 10, 2017; Revised May 25, 2017; Accepted May 25, 2017. From the Departments of Surgery, University of Massachusetts Medical School, Worcester, MA (Davids) and Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (Scully, Melnitchouk). Correspondence address: Jennifer S Davids, MD, FACS, University of Massachusetts Memorial Medical Center, 67 Belmont St, Suite 201, Worcester, MA 01605. email: [email protected]
ª 2017 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.
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http://dx.doi.org/10.1016/j.jamcollsurg.2017.05.018 ISSN 1072-7515/17
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Abbreviations and Acronyms
IUI ¼ intrauterine insemination OR ¼ odds ratio PMG ¼ Physician Moms Group
between different training programs under the American Board of Medical Specialties, and many specialties do not have a set policy.8 Accordingly, a recent survey of 66 US general surgery program directors found that one-third lacked a maternity leave policy, and 61% believed that becoming a parent negatively affects female trainees’ work and well-being.9 Further, the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial demonstrated that female mid-level residents were significantly more likely than their male peers to feel dissatisfied with their overall well-being and to perceive negative effects on duty hours on time for family.10 Moreover, multiple studies have established that women in surgical specialties have lower career satisfaction compared with their male counterparts.11-13 To date, there has not been a systematic nationwide study of the personal and professional issues relating to pregnancy, maternity leave, and career satisfaction among postgraduate medical trainees across all specialties in the US. We hypothesized that trainees in procedural specialties face greater challenges given the longer duration of training, the decreased capacity for scheduling flexibility, and increased physical demands of the job.14-17 To address these questions, we used social media to recruit a large, representative cohort of female physicians in the US who have had children during medical training.
METHODS The study protocol was reviewed by the institutional review boards of both the University of Massachusetts Medical School and Partners/Brigham and Women’s Hospital and was granted exemption. A 45-question multiple choice survey was created and posted online using a secure website (eDocument 1). The survey was formatted for compatibility on computers as well as portable devices such as tablets and smartphones. Respondents were anonymous and IP addresses were tracked to prevent duplicate entries by the same participant. Participants were recruited by posting a link to the survey on the Facebook page of the Physician Moms Group (PMG), which is a social media organization exclusively for physician mothers. Membership in PMG is free, selfselected, and voluntary, and physician status is confirmed by the organization’s administrators. The link was posted
on PMG on April 28, 2015 and the survey remained open for 4 weeks. The survey was open to all female physicians in the US; however, for the purpose of this analysis, the study cohort consisted of only those who had a child during postgraduate clinical medical training in a US program, which included internship, residency, or fellowship. The following specialties were defined as procedural: all surgical specialties, anesthesiology, gastroenterology, and obstetrics/gynecology; all other specialties were considered nonprocedural. Prolonged time to conceive was defined as more than 1 year for women less than 35 years old, and more than 6 months for women 35 years or older.18 Short maternity leave was defined as less than 6 weeks for vaginal delivery and less than 8 weeks for cesarean delivery, based on the recommendations issued by the American College of Surgeons.19 Bivariate analysis was performed using chi-square tests. For adjusted analysis, a logistic regression model was created to evaluate the impact of procedural vs nonprocedural training on pregnancy outcomes, adjusting for age at first pregnancy, based on its known impact on pregnancy outcomes20 and on bivariate testing. For survey elements regarding career satisfaction and perception of support, odds ratios are unadjusted. A 2-sided p value < 0.05 was used to determine statistical significance. All analyses were performed using STATA 14.1 software (StataCorp).
RESULTS Demographics Membership in PMG at the time the study was posted was 14,518. A total of 2,363 subjects completed the survey, which represented 16.3% of the total group membership. Of those responding, 738 indicated that they were in internship, residency, or fellowship during their most recent pregnancy and therefore were eligible for inclusion in the analysis. Respondents were from every state except Idaho, Wyoming, and Alaska (Fig. 1A). Of the 738 individuals included the current analysis, 221 (30.0%) were in procedural fields (Fig. 1B). There was no significant difference between procedural and nonprocedural trainees with respect to race, marital status, or the percent with a spouse who worked full-time (Table 1). Overall, 96.9% of respondents were married, and more than half had spouses who were employed full-time. Nonprocedural trainees were more likely than procedural trainees to be married to a physician (30.5% vs 22.5%; p ¼ 0.03), yet procedural trainees were more likely than nonprocedural trainees to be married to a surgeon (9.6% vs 5.3%; p ¼ 0.03). Maternal age and use of reproductive assistance In univariate analysis, a significantly higher proportion of trainees in procedural fields were more than 30 years old
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Figure 1. Geographic and specialty distribution of respondents. (A) Distribution of respondents by state reported as proportion of respondents. (B) Distribution of residents by specialty. Derm, dermatology; EM, emergency medicine; GI, gastroenterology; Neuro, neurology; Path, pathology; Psych, psychiatry; Rads, radiology.
at the time of first pregnancy (52.7% vs 43.1%; p ¼ 0.02). A higher proportion of women in procedural fields required assisted reproduction to become pregnant (18.6% vs 10.1%; p ¼ 0.001). Of the subset who used assisted reproduction, there was no difference between proceduralists and nonproceduralists in the rate of in vitro fertilization or other modalities such as Clomid (Sanofi US) or intrauterine insemination (p ¼ 0.50). In adjusted analysis, controlling for age at first pregnancy, procedural trainees trended toward being more likely to have prolonged time to conceive, although this did not meet statistical significance (odds ratio [OR] 1.62; 95% CI 0.99 to 2.65; p ¼ 0.06). Procedural trainees were significantly more likely to require assisted reproduction (Clomid, intrauterine insemination, in vitro fertilization) than nonprocedural trainees (OR 1.28; 95% CI 1.01 to 1.61; p ¼ 0.04). Pregnancy outcomes and missed work There was no significant difference in the percentage of procedural vs nonprocedural trainees with respect to missed work due to pregnancy-related issues (25.9% vs 24.8%; p ¼ 0.74). Specifically, there was no difference between proceduralists and nonproceduralists in the rate of missed work due to preeclampsia, hyperemesis gravidarum, preterm labor, or neonatal ICU admission, although nonproceduralists were significantly more likely to miss work due to bedrest (12.6% vs 4.9%; p ¼ 0.003). There were significant differences between procedural and nonprocedural trainees with respect to who arranged coverage for missed work. Proceduralists were significantly more likely than nonproceduralists to have relied
on themselves or their co-residents to arrange coverage rather than their chief resident or department chair/chief (55.4% vs 32.8%; p ¼ 0.004). Delivery and maternity leave The overall rate of cesarean delivery was 28.4%, with no difference between proceduralists and nonproceduralists (27.6% vs 28.7%; p ¼ 0.75). After delivery, a higher proportion of procedural trainees had a short maternity leave of less than 6 weeks after vaginal delivery and less than 8 weeks after cesarean section compared with women in nonprocedural fields (30.5% vs 22.1%; p ¼ 0.017). Adjusting for age at first pregnancy, there was no difference in the likelihood of cesarean delivery (OR 0.89; 95% CI 0.62 to 1.28; p ¼ 0.54) or missed work due to preterm labor (OR 1.34; 95% CI 0.8 to 2.27; p ¼ 0.27). In this model, trainees in procedural fields were less likely than those in nonprocedural fields to miss work due to bedrest (OR 0.36; 95% CI 0.18 to 0.72; p ¼ 0.004), and were also more likely to have shorter maternity leaves (OR 1.52; 95% CI 1.06 to 2.18; p ¼ 0.024; Fig. 2). Support from colleagues, specialty choice, and career satisfaction Respondent opinions regarding support, specialty choice, and career satisfaction were analyzed (Fig. 3). There was no difference in perception of support from both male and female colleagues both during and after pregnancy for women in procedural and nonprocedural training programs (Fig. 3). Individuals who became pregnant during procedural training were significantly less likely to report that their decision of specialty was influenced by
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Table 1.
Demographics and Patient Characteristics
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Variable
Current age, y 25e30 31e35 36e40 41e45 Race White Black Hispanic Asian Married Yes No Current spouse/partner’s profession Full-time professional Physician Surgeon Full-time parent Age at first pregnancy, y <25 25e30 31e35 36e40 41e45 Time to first pregnancy 0e6 months 7e12 months 1e2 years >2 years Reproductive assistance during most recent pregnancy Yes No Reproductive assistance type Consult only Clomid IUI IVF Surgery C-section during last pregnancy Yes No Cause of missed work during most recent pregnancy Bedrest Pre-eclampsia Hyperemesis gravidarum Preterm labor
Nonprocedural (n ¼ 517) n %
Procedural (n ¼ 221) n
%
p Value
0.60 73 317 106 21
14.1 64.3 20.5 4.1
27 146 42 6
12.2 66.1 19.0 2.7
357 20 14 95
69.1 3.9 2.7 18.4
162 8 6 28
73.3 3.6 2.7 12.7
502 15
97.1 2.9
213 8
96.4 3.6
261 156 27 44
51.0 30.5 5.3 8.6
117 49 21 21
53.7 22.5 9.6 9.6
9 282 205 18 0
1.8 54.9 39.9 3.5 0.0
4 100 110 5 2
1.8 45.5 49.6 2.3 1.0
379 72 27 20
76.1 14.5 5.4 4.0
152 29 19 13
71.4 13.6 8.9 6.1
52 464
10.1 89.9
41 179
18.6 81.4
17 22 10 18 2
24.6 31.9 14.5 26.1 2.9
6 16 11 13 1
12.8 34.0 23.4 27.7 2.1
148 367
28.7 71.3
59 155
27.6 72.4
61 23 23 46
12.6 4.7 4.7 9.5
10 14 11 25
4.9 6.9 5.4 12.3
0.39
0.61
0.08
0.02
0.19
0.001
0.50
0.75
0.003 0.25 0.71 0.27 (Continued)
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Continued
Variable
NICU admission Other Person who arranged coverage if missed work Chief or department chair Chief resident Co-residents You Length of maternity leave after most recent pregnancy, weeks None <2 2e4 4e6 7e8 9e12 13e16 >16
Nonprocedural (n ¼ 517) n %
Procedural (n ¼ 221) n
%
p Value
20 33
4.1 6.7
7 14
3.5 6.6
0.68 0.98 0.03
15 46 12 28
14.9 45.5 11.9 27.7
4 12 11 20
8.5 25.5 23.4 42.6
4 2 52 138 121 159 30 11
0.8 0.4 10.1 26.7 23.4 30.8 5.8 2.1
2 3 24 103 42 36 5 5
0.9 1.4 10.9 46.6 19.0 16.4 2.3 2.3
<0.001
IUI, intrauterine insemination; IVF, in vitro fertilization; NICU, neonatal intensive care unit.
pregnancy or children (OR 0.24; 95% CI 0.17 to 0.34; p < 0.001) and were more likely to report a desire to have chosen a different specialty or job (OR 1.95; 95% CI 1.40 to 2.72; p < 0.001).
DISCUSSION In this work, we found that, compared with their nonprocedural colleagues, female trainees in procedural specialties are more likely to require assisted reproduction, controlling for maternal age. Proceduralists also are more likely to have a short maternity leave and need to rely on themselves and their peers to arrange coverage for missed work. There was no difference between groups
in the rate of cesarean section or missed work due to pregnancy complications. Although proceduralists were less likely to have chosen their field based on pregnancy or children, they were more likely than nonproceduralists to express desire to have chosen a less demanding specialty or job. Our results are consistent with smaller previous studies of medical trainees by other investigators. A recent survey of residents in all training programs in a single institution demonstrated that attitudes toward pregnancy during residency generally improved from 2008 to 2015, although surgical residents still had lower perceptions of support compared with residents in other specialties.21 They also determined that departments with female leadership were
Figure 2. Adjusted odds of time to conception, reproductive assistance use, pregnancy complications, and maternity leave length. *p < 0.05; odds ratio (OR) <1 indicates greater odds among women in nonprocedural specialties, OR >1 indicates greater odds among women in procedural specialties; adjusted for age at first pregnancy.
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Figure 3. Respondent opinions regarding support and specialty choice. **p < 0.001; odds ratio (OR) <1 indicates odds of agreement with the statement are higher among women in nonprocedural specialties, OR >1 indicates odds of agreement with the statement are higher among women in procedural specialties.
perceived to be more supportive. A 2010 survey of 243 female urologists demonstrated that short maternity leave, which was twice as common with trainees, correlated with decreased career satisfaction.22 A 2012 survey of 223 female surgeons from multiple different specialties found a significantly higher rate of pregnancy complications compared with the general population, and also that maternity leave of trainees was shorter than that of those in practice, with a median duration of 4 vs 7 weeks.23 Similar results were found in a survey from 2015 of 238 medical and surgical residents, demonstrating that having greater than 6 overnight calls per month or having longer hours in the operating room correlated with a higher rate of adverse obstetric outcomes, and that the overall complication rate for pregnant residents was significantly greater than pregnant age-matched nonmedical controls.24 Lastly, these pervasive issues are not limited to the US; they are also present in Canada and other countries with similar training structure.25-28 By contrast, literature from training programs in nonprocedural specialties demonstrates more evidence of established maternity leave policies and flexible schedules. For example, the majority of pediatrics residencies were found to have maternity leave policies in place, which has been strongly recommended by the American Academy of Pediatrics29; however, one-third of pediatrics trainees were unaware of these policies.30 A 2011 survey of family medicine program directors and residents from 457 different training programs found that 75% of women who had a child during training planned to extend the duration of their residency, which reflects the increased flexibility in nonprocedural training programs, where there may be more backup from trainee colleagues
and less concern about interfering with timing of fellowships.31 The challenges we identified in this study of trainees mirror our earlier study of physician mothers who gave birth while in practice, suggesting that there may be truth in the adage, “There is no best time to have a child” for female physicians. In our previous study of a cohort of 1,541 female physicians who had a child while in practice, of whom 393 (25.5%) were in a procedural field, we previously demonstrated that proceduralists were slightly older and were less likely to have a maternity leave of at least 8 weeks (53.6% vs 72.1%).6 Adjusting for maternal age, there was also no difference in time to conceive, missed work due to pregnancy, or cesarean section rate.5 Notably, overall rates of cesarean section and preterm labor for both the trainees and practicing physicians exceeded the national average, even when controlling for maternal age.32 Compared with attending proceduralists, trainee proceduralists in this study expressed similar views on choice of specialty and overall career satisfaction. The only major difference between the trainee and attending experience was the reported use of assisted reproduction, which was the same across specialties for practicing physicians; in the trainee population, proceduralists were more likely to report its use. One possible explanation is that between rotation schedules, requirements for graduation, and board examinations, trainees felt greater pressure to conceive under specific time constraints, and therefore were more likely to use assisted reproduction. Our findings in trainees may, in part, underlie the rising rates of physician burnout and attrition27,33,34 and may set the stage for the under-representation of female
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physicians in academic medicine and in leadership roles, particularly in procedural fields.28 Although the pressure to achieve success in both career and family life is not strictly a gender issue, trainee mothers face specific challenges with respect to carrying a child, recovering physically from labor and delivery, and breastfeeding. Overall, more than half of trainee mothers responded that their spouses work full-time; however, proceduralists were nearly twice as likely as nonproceduralists to have a surgeon spouse, which undoubtedly contributes to the complexity of childcare arrangements. These additional pressures may partly explain the higher rate of career dissatisfaction among procedural trainees, as seen in our data. The current workplace environment for women in medicine remains challenging and demands attention from the medical community as a whole in order to actively improve the culture. For example, affordable childcare that remains open for extended hours may be a good starting point to begin to improve working conditions for trainee parents, and therefore may relieve some of the tension between work and home demands. Also, many of the issues raised in this and in previous work appear to stem largely from the inflexibility of scheduling, particularly within procedural fields. Moving to a more competency-based training and assessment model could potentially allow for greater flexibility with maternity leave and also may decrease the sense of pressure for trainees to conceive and deliver on a specific schedule. A limitation of our approach of using Facebook for subject recruitment is that it is impossible to determine a true response rate, as we are unable to quantify how many PMG members viewed the link to the study. Recruitment using the Facebook Physician Moms Group may have introduced bias itself because it is possible that the experiences and opinions of the group members are not representative of all US physician trainee mothers. It is also important to note that 90% of women who were current trainees during the time of the survey reported being within an academic setting, which potentially affects the generalizability of these findings to community, private, or rural training environments. Despite this possibility, our study cohort does represent a very broad geographic distribution, and our breakdown by specialty is very similar to the most recent Association of American Medical Colleges data.35 Due to the retrospective nature of our survey, recall bias could have also influenced self-reported answers. Last, although we did demonstrate that there was a higher rate of prolonged time to conception and assisted reproduction use among procedural trainees, even after adjusting for age, we captured only successful pregnancies, and did not design the study to investigate the incidence of infertility in
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this population. Infertility among medical trainees remains an important related issue and is an area worthy of investigation in future studies.
CONCLUSIONS Compared with nonprocedural trainees, procedural trainees have higher rates of assisted reproduction, shorter maternity leave, and are ultimately more likely to express a desire to have chosen a less demanding job or specialty. Taken together, these findings indicate that there are significant stressors for women who have children during their postgraduate medical training. Our data suggest that these stressors may be even more intensified for those in procedural specialties, and therefore could potentially negatively affect overall career satisfaction. The importance of adequate support for female trainees around pregnancy and maternity cannot be understated, particularly for those in procedural specialties. Establishment of fair leave policies that incorporate adequate flexibility may allow for improved well-being for women who have children during their training. Author Contributions Study conception and design: Davids, Scully, Melnitchouk Acquisition of data: Davids, Melnitchouk Analysis and interpretation of data: Davids, Scully, Melnitchouk Drafting of manuscript: Davids, Scully, Melnitchouk Critical revision: Davids, Scully, Melnitchouk REFERENCES 1. US Medical School Applications and Matriculants by School, State of Legal Residence, and Sex, 2016-2017. AAMC.org. Available at: https://www.aamc.org/download/321442/data/ factstablea1.pdf. Accessed March 28, 2017. 2. 2012 Physician Specialty Data Book: Center for Workforce Studies. Available at: https://www.aamc.org/download/ 313228/data/2012physicianspecialtydatabook.pdf. Accessed March 30, 2017. 3. Pham DT, Stephens EH, Antonoff MB, et al. Birth trends and factors affecting childbearing among thoracic surgeons. Ann Thorac Surg 2014;98:890e895. 4. Willett LL, Wellons MF, Hartig JR, et al. Do women residents delay childbearing due to perceived career threats? Acad Med 2010;85:640e646. 5. Scully R, Melnitchouk N, Davids JS. Fertility and pregnancy outcomes in female physicians in procedural specialties: a large national survey. J Am Coll Surg 2016;223:S109. 6. Scully RE, Davids JS, Melnitchouk N. Impact of procedural specialty on maternity leave and career satisfaction among female physicians. Ann Surg 2017 Mar 7 [Epub ahead of print]. 7. Smith C, Galante JM, Pierce JL, Scherer LA. The surgical residency baby boom: changing patterns of childbearing during residency over a 30-year span. J Grad Med Educ 2013;5:625e629.
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8. Garza RM, Weston JS, Furnas HJ. Pregnancy and the plastic surgery resident. Plast Reconstr Surg 2017;139: 245e252. 9. Yoo PS, Tackett JJ, Maxfield MW, et al. Personal and professional well-being of surgical residents in New England. J Am Coll Surg 2017;224:1015e1019. 10. Ban KA, Cohen ME, Ko CY, et al. Evaluation of the ProPublica Surgeon Scorecard “adjusted complication rate” measure specifications. Ann Surg 2016;264:566e574. 11. Marti KC, Lanzon J, Edwards SP, Inglehart MR. Career and professional satisfaction of oral and maxillofacial surgery residents, academic surgeons, and private practitioners: does gender matter? J Dent Educ 2017;81:75e86. 12. Dyrbye LN, Shanafelt TD, Balch CM, et al. Relationship between work-home conflicts and burnout among American surgeons: a comparison by sex. Arch Surg 2011;146: 211e217. 13. Gifford E, Galante J, Kaji AH, et al. Factors associated with general surgery residents’ desire to leave residency programs. JAMA Surg 2014;149:948e956. 14. Wong K, Grundfast KM, Levi JR. Assessing work-related musculoskeletal symptoms among otolaryngology residents. Am J Otolaryngol 2017;38:213e217. 15. Cavanagh J, Brake M, Kearns D, Hong P. Work environment discomfort and injury: an ergonomic survey study of the American Society of Pediatric Otolaryngology members. Am J Otolaryngol 2012;33:441e446. 16. Ahmed N, Devitt KS, Keshet I, et al. A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes. Ann Surg 2014;259:1041e1053. 17. Tsafrir Z, Korianski J, Almog B, et al. Effects of fatigue on residents’ performance in laparoscopy. J Am Coll Surg 2015;221: 564e570.e3. 18. Definitions of infertility and recurrent pregnancy loss: a committee opinion. Fertil Steril 2013;99:63. 19. Statement on the importance of parental leave. Bull Am Coll Surg 2016;101:35e36. 20. Berkowitz GS, Skovron ML, Lapinski RH, Berkowitz RL. Delayed childbearing and the outcome of pregnancy. N Engl J Med 1990;322:659e664. 21. Mundschenk M-B, Krauss EM, Poppler LH, et al. Resident perceptions on pregnancy during training: 2008 to 2015. Am J Surg 2016;212:649e659.
22. Lerner LB, Baltrushes RJ, Stolzmann KL, Garshick E. Satisfaction of women urologists with maternity leave and childbirth timing. J Urol 2010;183:282e286. 23. Hamilton AR, Tyson MD, Braga JA, Lerner LB. Childbearing and pregnancy characteristics of female orthopaedic surgeons. J Bone Joint Surg Am 2012;94:e77ee79. 24. Behbehani S, Tulandi T. Obstetrical complications in pregnant medical and surgical residents. J Obstet Gynaecol Can 2015;37:25e31. 25. Merchant SJ, Hameed SM, Melck AL. Pregnancy among residents enrolled in general surgery: a nationwide survey of attitudes and experiences. Am J Surg 2013;206:605e610. 26. Merchant S, Hameed M, Melck A. Pregnancy among residents enrolled in general surgery (PREGS): a survey of residents in a single Canadian training program. Can J Surg 2011;54:375e380. 27. Keegan RJ, Saw R, De Loyde KJ, Young CJ. Attitudes and risk of withdrawal in general surgical registrars. N Z Med J 2015; 128:61e68. 28. Seemann NM, Webster F, Holden HA, et al. Women in academic surgery: why is the playing field still not level? Am J Surg 2016;211:343e349. 29. Parental leave for residents and pediatric training programs: Section on Medical Students, Residents, and Fellowship Trainees and Committee on Early Childhood. Pediatrics 2013;131:387e390. 30. Dixit A, Feldman-Winter L, Szucs KA. Parental leave policies and pediatric trainees in the United States. J Hum Lact 2015; 31:434e439. 31. Hutchinson AM, Anderson NS, Gochnour GL, Stewart C. Pregnancy and childbirth during family medicine residency training. Fam Med 2011;43:160e165. 32. National Vital Statistics Reports, Volume 66, Number 1, January 5, 2017. December 2016:1e70. Available at: https://www.cdc.gov/nchs/data/nvsr/nvsr66/nvsr66_01_tables. pdf. Accessed June 23, 2017. 33. Dimou FM, Eckelbarger D, Riall TS. Surgeon burnout: a systematic review. J Am Coll Surg 2016;222:1230e1239. 34. Bergen PC, Turnage RH, Carrico CJ. Gender-related attrition in a general surgery training program. J Surg Res 1998;77: 59e62. 35. Distribution of residents by specialty, 2003 compared to 2013. AAMC. Available at: https://www.aamc.org/download/ 411784/data/2014_table2.pdf. Accessed June 23, 2017.
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eDocument 1. SURVEY QUESTIONS If you work in clinical medicine, which specialty do you currently practice the majority of the time? Drop-down menu (Anesthesiology, Allergy and Immunology, Cardiology, Dermatology, Emergency Medicine, Endocrinology, Family Medicine, Gastroenterology, Genetics, Geriatrics, Hematology/Oncology, Infectious Disease, Internal Medicine, Minimally Invasive Surgery, Nephrology, Neurology, Neurosurgery, Obstetrics/ Gynecology, Ophthalmology, Orthopedic Surgery, Otolaryngology, Pediatrics-General Practice, PediatricsSubspecialties, Pathology, Psychiatry, Pulmonary/Critical Care, Radiology, Rheumatology, Surgery-Breast, Surgery-Cardiothoracic, Surgery-Colorectal, SurgeryEndocrine, Surgery-General, Surgery-Minimally Invasive, Surgery-Pediatric, Surgery-Plastic, Surgery-Surgical Oncology, Surgery-Trauma/Critical Care, SurgeryVascular, Urology) What best describes your current position? (attending, fellow, resident/intern, medical student, industry, academic research-only, not currently working, other: please indicate [optional] ) If you are currently practicing clinical medicine, what best describes your practice? (academic, private, community, rural, locum tenens, N/A) What state are you currently working in? (Drop-down menu list of states; also included: I am not working in the US; I am not currently working) How old are you? (<25, 25e30, 31e35, 36e40, 41e45, 46e50, >50 years old) What is your relationship status? (married, domestic partnership, single, divorced, separated, widowed) Which best describes your spouse currently? (surgeon, physician, other full-time professional, employed parttime (20 or fewer hours per week), student, stay-athome dad, disabled, other [write-in optional]) How many children do you have? (1, 2, 3, 4, 5, >6, currently pregnant with first child) What was your age when your first child was born or adopted? (<25, 25e30, 31e35, 36e40, 41e45, 46e50, >50 years) During your last pregnancy/adoption were you a: (attending, fellow, resident/intern, medical student, industry, academic-research only, not working, other [write in optional])? How old is your youngest child? (currently pregnant with first child, <6 mo, 6moe12 mo, 1e2 years, 3e5 years, 6e10 years, 11e15 years, 16 or older) How long did you try before becoming pregnant with your first baby? (0e6 months, 7e12 months, 1e2 years, >2 years, unsure, N/A)
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Did you use assisted reproductive medicine during any of your pregnancies? (no, consultation only, Clomid or equivalent, intrauterine insemination, in vitro fertilization, surgery, N/A) Did you miss any work on due to any of these conditions? Check all that apply. a. b. c. d. e. f.
Did not miss any work due to these conditions Preterm labor Bedrest Hyperemesis gravidarum Pre-ecclampsia Unable to perform my job functions (eg, operating, prolonged standing, long hours) g. Baby in the ICU h. N/A i. Other [write-in optional] Who was primarily responsible for arranging coverage during that time? (you, chief or chairman, practice manager, partners, chief resident, co-residents, N/A, other) During your most recent pregnancy did you have a c-section? (yes, no, N/A) If you took time off (“maternity leave”) after the birth or adoption of your youngest child, how long was this time? Drop-down menu a. <2 weeks b. 2 weeks c. 3 weeks d. 4 weeks e. 5 weeks f. 6 weeks g. 7 weeks h. 8 weeks i. 9 weeks j. 10 weeks k. 11 weeks l. 12 weeks m. 13 weeks n. 14 weeks o. 15 weeks p. 4 months q. 5 months r. 6 months s. >6 months t. I did not take any time off u. N/A Which best describes you? Check all that apply. (White, Hispanic, Black or African-American, Asian, Native American or Alaska Native, Pacific Islander) For each statement choose one (strongly agree, agree somewhat, disagree somewhat, strongly disagree, N/A):
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a. My MALE colleagues were understanding of my needs during pregnancy. b. My MALE colleagues were understanding of my needs when I returned to work after maternity leave. c. My FEMALE colleagues were understanding of my needs during pregnancy. d. My FEMALE colleagues were understanding of my needs when I returned to work after maternity leave.
J Am Coll Surg
e. My decision of which specialty to train in was influenced by pregnancy and child-care considerations. f. My decision of which job to take was influenced by pregnancy and child-care considerations. g. I wish I had chosen a specialty that was less demanding. h. My significant other is supportive of my career choice.
Impact of Procedural Training on Pregnancy Outcomes and Career Satisfaction in Female Postgraduate Medical Trainees in the United States Jennifer S Davids,
MD, FACS,
Rebecca E Scully,
MD, MPH,
Nelya Melnitchouk,
MD, MSc, FACS
Compared with nonprocedural fields, procedural specialization requires longer training, less flexible schedules, and greater physical demands. The impact of these factors on pregnancy, maternity outcomes, and career satisfaction has not been well described. STUDY DESIGN: Data were gathered from 738 US postgraduate medical trainee mothers via an anonymous, IRB-approved online survey. Univariate analysis was performed using chi-square tests. A logistic regression model was used to investigate the impact of procedural training on odds of assisted reproduction use and pregnancy complications, adjusting for age at first pregnancy. RESULTS: Of the 738 respondents, 221 (30.0%) were in procedural fields. A greater percentage of procedural trainees were more than 30 years old at the time of first pregnancy (52.9% vs 43.1%; p ¼ 0.01). Controlling for maternal age, procedural trainees were significantly more likely to require assisted reproduction (odds ratio [OR] 1.28; 95% CI 1.01 to 1.61; p ¼ 0.04), and trended toward increased odds of prolonged time to conceive (OR 1.62; 95% CI 0.99 to 2.65; p ¼ 0.06). After delivery, procedural trainees also had higher adjusted odds of shorter maternity leave (OR 1.52; 95% CI 1.06 to 2.18; p ¼ 0.03) and were significantly more likely to report a desire to have chosen a less demanding specialty or job (OR 1.95; 95% CI 1.40 to 2.72; p < 0.001). CONCLUSIONS: Procedural trainees have higher rates of assisted reproduction, shorter maternity leave, and are ultimately more likely to express career dissatisfaction. These findings illustrate the need for adequate support for trainee mothers, particularly in procedural specialties. (J Am Coll Surg 2017;-:1e8. 2017 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.)
BACKGROUND:
(66.7%), and the lowest percentages in orthopaedic surgery (13.2%), neurosurgery (13.9%), and thoracic surgery (19%).2 Previous small studies suggested that most female physicians historically have chosen to delay childbearing until completion of training, particularly in male-dominated specialties.3,4 Our previous work demonstrated that, of early career physician mothers who became pregnant after completing their training, those in procedural specialties were more likely to wish they had chosen a less demanding job or specialty, compared with their nonprocedural peers.5 We also demonstrated that, regardless of specialty, women who have children while in practice experience high rates of preterm labor, cesarean section, and pregnancy-related complications compared with the general population, even when controlling for age.6 As more women are becoming physicians, more are also deciding to have children during postgraduate training.7 There is considerable variation in maternity leave policy
More women are becoming physicians in the US. Even though only 30.4% of physicians in the US are women, half of 2016 medical school matriculates are women.1 More women are entering postgraduate medical training programs, and now 41.6% of all ACGME-accredited trainees are female. Considerable variation in the percentage of women still exists between different specialty training programs, with the highest percentages in obstetrics/gynecology (81%), pediatrics (72.7%), and endocrinology Disclosure Information: Nothing to disclose. Presented at the Academic Surgical Congress 12th Annual Meeting Las Vegas, NV, February 2017. Received April 10, 2017; Revised May 25, 2017; Accepted May 25, 2017. From the Departments of Surgery, University of Massachusetts Medical School, Worcester, MA (Davids) and Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (Scully, Melnitchouk). Correspondence address: Jennifer S Davids, MD, FACS, University of Massachusetts Memorial Medical Center, 67 Belmont St, Suite 201, Worcester, MA 01605. email: [email protected]
ª 2017 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.
1
http://dx.doi.org/10.1016/j.jamcollsurg.2017.05.018 ISSN 1072-7515/17
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Abbreviations and Acronyms
IUI ¼ intrauterine insemination OR ¼ odds ratio PMG ¼ Physician Moms Group
between different training programs under the American Board of Medical Specialties, and many specialties do not have a set policy.8 Accordingly, a recent survey of 66 US general surgery program directors found that one-third lacked a maternity leave policy, and 61% believed that becoming a parent negatively affects female trainees’ work and well-being.9 Further, the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial demonstrated that female mid-level residents were significantly more likely than their male peers to feel dissatisfied with their overall well-being and to perceive negative effects on duty hours on time for family.10 Moreover, multiple studies have established that women in surgical specialties have lower career satisfaction compared with their male counterparts.11-13 To date, there has not been a systematic nationwide study of the personal and professional issues relating to pregnancy, maternity leave, and career satisfaction among postgraduate medical trainees across all specialties in the US. We hypothesized that trainees in procedural specialties face greater challenges given the longer duration of training, the decreased capacity for scheduling flexibility, and increased physical demands of the job.14-17 To address these questions, we used social media to recruit a large, representative cohort of female physicians in the US who have had children during medical training.
METHODS The study protocol was reviewed by the institutional review boards of both the University of Massachusetts Medical School and Partners/Brigham and Women’s Hospital and was granted exemption. A 45-question multiple choice survey was created and posted online using a secure website (eDocument 1). The survey was formatted for compatibility on computers as well as portable devices such as tablets and smartphones. Respondents were anonymous and IP addresses were tracked to prevent duplicate entries by the same participant. Participants were recruited by posting a link to the survey on the Facebook page of the Physician Moms Group (PMG), which is a social media organization exclusively for physician mothers. Membership in PMG is free, selfselected, and voluntary, and physician status is confirmed by the organization’s administrators. The link was posted
on PMG on April 28, 2015 and the survey remained open for 4 weeks. The survey was open to all female physicians in the US; however, for the purpose of this analysis, the study cohort consisted of only those who had a child during postgraduate clinical medical training in a US program, which included internship, residency, or fellowship. The following specialties were defined as procedural: all surgical specialties, anesthesiology, gastroenterology, and obstetrics/gynecology; all other specialties were considered nonprocedural. Prolonged time to conceive was defined as more than 1 year for women less than 35 years old, and more than 6 months for women 35 years or older.18 Short maternity leave was defined as less than 6 weeks for vaginal delivery and less than 8 weeks for cesarean delivery, based on the recommendations issued by the American College of Surgeons.19 Bivariate analysis was performed using chi-square tests. For adjusted analysis, a logistic regression model was created to evaluate the impact of procedural vs nonprocedural training on pregnancy outcomes, adjusting for age at first pregnancy, based on its known impact on pregnancy outcomes20 and on bivariate testing. For survey elements regarding career satisfaction and perception of support, odds ratios are unadjusted. A 2-sided p value < 0.05 was used to determine statistical significance. All analyses were performed using STATA 14.1 software (StataCorp).
RESULTS Demographics Membership in PMG at the time the study was posted was 14,518. A total of 2,363 subjects completed the survey, which represented 16.3% of the total group membership. Of those responding, 738 indicated that they were in internship, residency, or fellowship during their most recent pregnancy and therefore were eligible for inclusion in the analysis. Respondents were from every state except Idaho, Wyoming, and Alaska (Fig. 1A). Of the 738 individuals included the current analysis, 221 (30.0%) were in procedural fields (Fig. 1B). There was no significant difference between procedural and nonprocedural trainees with respect to race, marital status, or the percent with a spouse who worked full-time (Table 1). Overall, 96.9% of respondents were married, and more than half had spouses who were employed full-time. Nonprocedural trainees were more likely than procedural trainees to be married to a physician (30.5% vs 22.5%; p ¼ 0.03), yet procedural trainees were more likely than nonprocedural trainees to be married to a surgeon (9.6% vs 5.3%; p ¼ 0.03). Maternal age and use of reproductive assistance In univariate analysis, a significantly higher proportion of trainees in procedural fields were more than 30 years old
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Figure 1. Geographic and specialty distribution of respondents. (A) Distribution of respondents by state reported as proportion of respondents. (B) Distribution of residents by specialty. Derm, dermatology; EM, emergency medicine; GI, gastroenterology; Neuro, neurology; Path, pathology; Psych, psychiatry; Rads, radiology.
at the time of first pregnancy (52.7% vs 43.1%; p ¼ 0.02). A higher proportion of women in procedural fields required assisted reproduction to become pregnant (18.6% vs 10.1%; p ¼ 0.001). Of the subset who used assisted reproduction, there was no difference between proceduralists and nonproceduralists in the rate of in vitro fertilization or other modalities such as Clomid (Sanofi US) or intrauterine insemination (p ¼ 0.50). In adjusted analysis, controlling for age at first pregnancy, procedural trainees trended toward being more likely to have prolonged time to conceive, although this did not meet statistical significance (odds ratio [OR] 1.62; 95% CI 0.99 to 2.65; p ¼ 0.06). Procedural trainees were significantly more likely to require assisted reproduction (Clomid, intrauterine insemination, in vitro fertilization) than nonprocedural trainees (OR 1.28; 95% CI 1.01 to 1.61; p ¼ 0.04). Pregnancy outcomes and missed work There was no significant difference in the percentage of procedural vs nonprocedural trainees with respect to missed work due to pregnancy-related issues (25.9% vs 24.8%; p ¼ 0.74). Specifically, there was no difference between proceduralists and nonproceduralists in the rate of missed work due to preeclampsia, hyperemesis gravidarum, preterm labor, or neonatal ICU admission, although nonproceduralists were significantly more likely to miss work due to bedrest (12.6% vs 4.9%; p ¼ 0.003). There were significant differences between procedural and nonprocedural trainees with respect to who arranged coverage for missed work. Proceduralists were significantly more likely than nonproceduralists to have relied
on themselves or their co-residents to arrange coverage rather than their chief resident or department chair/chief (55.4% vs 32.8%; p ¼ 0.004). Delivery and maternity leave The overall rate of cesarean delivery was 28.4%, with no difference between proceduralists and nonproceduralists (27.6% vs 28.7%; p ¼ 0.75). After delivery, a higher proportion of procedural trainees had a short maternity leave of less than 6 weeks after vaginal delivery and less than 8 weeks after cesarean section compared with women in nonprocedural fields (30.5% vs 22.1%; p ¼ 0.017). Adjusting for age at first pregnancy, there was no difference in the likelihood of cesarean delivery (OR 0.89; 95% CI 0.62 to 1.28; p ¼ 0.54) or missed work due to preterm labor (OR 1.34; 95% CI 0.8 to 2.27; p ¼ 0.27). In this model, trainees in procedural fields were less likely than those in nonprocedural fields to miss work due to bedrest (OR 0.36; 95% CI 0.18 to 0.72; p ¼ 0.004), and were also more likely to have shorter maternity leaves (OR 1.52; 95% CI 1.06 to 2.18; p ¼ 0.024; Fig. 2). Support from colleagues, specialty choice, and career satisfaction Respondent opinions regarding support, specialty choice, and career satisfaction were analyzed (Fig. 3). There was no difference in perception of support from both male and female colleagues both during and after pregnancy for women in procedural and nonprocedural training programs (Fig. 3). Individuals who became pregnant during procedural training were significantly less likely to report that their decision of specialty was influenced by
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Table 1.
Demographics and Patient Characteristics
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Variable
Current age, y 25e30 31e35 36e40 41e45 Race White Black Hispanic Asian Married Yes No Current spouse/partner’s profession Full-time professional Physician Surgeon Full-time parent Age at first pregnancy, y <25 25e30 31e35 36e40 41e45 Time to first pregnancy 0e6 months 7e12 months 1e2 years >2 years Reproductive assistance during most recent pregnancy Yes No Reproductive assistance type Consult only Clomid IUI IVF Surgery C-section during last pregnancy Yes No Cause of missed work during most recent pregnancy Bedrest Pre-eclampsia Hyperemesis gravidarum Preterm labor
Nonprocedural (n ¼ 517) n %
Procedural (n ¼ 221) n
%
p Value
0.60 73 317 106 21
14.1 64.3 20.5 4.1
27 146 42 6
12.2 66.1 19.0 2.7
357 20 14 95
69.1 3.9 2.7 18.4
162 8 6 28
73.3 3.6 2.7 12.7
502 15
97.1 2.9
213 8
96.4 3.6
261 156 27 44
51.0 30.5 5.3 8.6
117 49 21 21
53.7 22.5 9.6 9.6
9 282 205 18 0
1.8 54.9 39.9 3.5 0.0
4 100 110 5 2
1.8 45.5 49.6 2.3 1.0
379 72 27 20
76.1 14.5 5.4 4.0
152 29 19 13
71.4 13.6 8.9 6.1
52 464
10.1 89.9
41 179
18.6 81.4
17 22 10 18 2
24.6 31.9 14.5 26.1 2.9
6 16 11 13 1
12.8 34.0 23.4 27.7 2.1
148 367
28.7 71.3
59 155
27.6 72.4
61 23 23 46
12.6 4.7 4.7 9.5
10 14 11 25
4.9 6.9 5.4 12.3
0.39
0.61
0.08
0.02
0.19
0.001
0.50
0.75
0.003 0.25 0.71 0.27 (Continued)
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Continued
Variable
NICU admission Other Person who arranged coverage if missed work Chief or department chair Chief resident Co-residents You Length of maternity leave after most recent pregnancy, weeks None <2 2e4 4e6 7e8 9e12 13e16 >16
Nonprocedural (n ¼ 517) n %
Procedural (n ¼ 221) n
%
p Value
20 33
4.1 6.7
7 14
3.5 6.6
0.68 0.98 0.03
15 46 12 28
14.9 45.5 11.9 27.7
4 12 11 20
8.5 25.5 23.4 42.6
4 2 52 138 121 159 30 11
0.8 0.4 10.1 26.7 23.4 30.8 5.8 2.1
2 3 24 103 42 36 5 5
0.9 1.4 10.9 46.6 19.0 16.4 2.3 2.3
<0.001
IUI, intrauterine insemination; IVF, in vitro fertilization; NICU, neonatal intensive care unit.
pregnancy or children (OR 0.24; 95% CI 0.17 to 0.34; p < 0.001) and were more likely to report a desire to have chosen a different specialty or job (OR 1.95; 95% CI 1.40 to 2.72; p < 0.001).
DISCUSSION In this work, we found that, compared with their nonprocedural colleagues, female trainees in procedural specialties are more likely to require assisted reproduction, controlling for maternal age. Proceduralists also are more likely to have a short maternity leave and need to rely on themselves and their peers to arrange coverage for missed work. There was no difference between groups
in the rate of cesarean section or missed work due to pregnancy complications. Although proceduralists were less likely to have chosen their field based on pregnancy or children, they were more likely than nonproceduralists to express desire to have chosen a less demanding specialty or job. Our results are consistent with smaller previous studies of medical trainees by other investigators. A recent survey of residents in all training programs in a single institution demonstrated that attitudes toward pregnancy during residency generally improved from 2008 to 2015, although surgical residents still had lower perceptions of support compared with residents in other specialties.21 They also determined that departments with female leadership were
Figure 2. Adjusted odds of time to conception, reproductive assistance use, pregnancy complications, and maternity leave length. *p < 0.05; odds ratio (OR) <1 indicates greater odds among women in nonprocedural specialties, OR >1 indicates greater odds among women in procedural specialties; adjusted for age at first pregnancy.
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Figure 3. Respondent opinions regarding support and specialty choice. **p < 0.001; odds ratio (OR) <1 indicates odds of agreement with the statement are higher among women in nonprocedural specialties, OR >1 indicates odds of agreement with the statement are higher among women in procedural specialties.
perceived to be more supportive. A 2010 survey of 243 female urologists demonstrated that short maternity leave, which was twice as common with trainees, correlated with decreased career satisfaction.22 A 2012 survey of 223 female surgeons from multiple different specialties found a significantly higher rate of pregnancy complications compared with the general population, and also that maternity leave of trainees was shorter than that of those in practice, with a median duration of 4 vs 7 weeks.23 Similar results were found in a survey from 2015 of 238 medical and surgical residents, demonstrating that having greater than 6 overnight calls per month or having longer hours in the operating room correlated with a higher rate of adverse obstetric outcomes, and that the overall complication rate for pregnant residents was significantly greater than pregnant age-matched nonmedical controls.24 Lastly, these pervasive issues are not limited to the US; they are also present in Canada and other countries with similar training structure.25-28 By contrast, literature from training programs in nonprocedural specialties demonstrates more evidence of established maternity leave policies and flexible schedules. For example, the majority of pediatrics residencies were found to have maternity leave policies in place, which has been strongly recommended by the American Academy of Pediatrics29; however, one-third of pediatrics trainees were unaware of these policies.30 A 2011 survey of family medicine program directors and residents from 457 different training programs found that 75% of women who had a child during training planned to extend the duration of their residency, which reflects the increased flexibility in nonprocedural training programs, where there may be more backup from trainee colleagues
and less concern about interfering with timing of fellowships.31 The challenges we identified in this study of trainees mirror our earlier study of physician mothers who gave birth while in practice, suggesting that there may be truth in the adage, “There is no best time to have a child” for female physicians. In our previous study of a cohort of 1,541 female physicians who had a child while in practice, of whom 393 (25.5%) were in a procedural field, we previously demonstrated that proceduralists were slightly older and were less likely to have a maternity leave of at least 8 weeks (53.6% vs 72.1%).6 Adjusting for maternal age, there was also no difference in time to conceive, missed work due to pregnancy, or cesarean section rate.5 Notably, overall rates of cesarean section and preterm labor for both the trainees and practicing physicians exceeded the national average, even when controlling for maternal age.32 Compared with attending proceduralists, trainee proceduralists in this study expressed similar views on choice of specialty and overall career satisfaction. The only major difference between the trainee and attending experience was the reported use of assisted reproduction, which was the same across specialties for practicing physicians; in the trainee population, proceduralists were more likely to report its use. One possible explanation is that between rotation schedules, requirements for graduation, and board examinations, trainees felt greater pressure to conceive under specific time constraints, and therefore were more likely to use assisted reproduction. Our findings in trainees may, in part, underlie the rising rates of physician burnout and attrition27,33,34 and may set the stage for the under-representation of female
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physicians in academic medicine and in leadership roles, particularly in procedural fields.28 Although the pressure to achieve success in both career and family life is not strictly a gender issue, trainee mothers face specific challenges with respect to carrying a child, recovering physically from labor and delivery, and breastfeeding. Overall, more than half of trainee mothers responded that their spouses work full-time; however, proceduralists were nearly twice as likely as nonproceduralists to have a surgeon spouse, which undoubtedly contributes to the complexity of childcare arrangements. These additional pressures may partly explain the higher rate of career dissatisfaction among procedural trainees, as seen in our data. The current workplace environment for women in medicine remains challenging and demands attention from the medical community as a whole in order to actively improve the culture. For example, affordable childcare that remains open for extended hours may be a good starting point to begin to improve working conditions for trainee parents, and therefore may relieve some of the tension between work and home demands. Also, many of the issues raised in this and in previous work appear to stem largely from the inflexibility of scheduling, particularly within procedural fields. Moving to a more competency-based training and assessment model could potentially allow for greater flexibility with maternity leave and also may decrease the sense of pressure for trainees to conceive and deliver on a specific schedule. A limitation of our approach of using Facebook for subject recruitment is that it is impossible to determine a true response rate, as we are unable to quantify how many PMG members viewed the link to the study. Recruitment using the Facebook Physician Moms Group may have introduced bias itself because it is possible that the experiences and opinions of the group members are not representative of all US physician trainee mothers. It is also important to note that 90% of women who were current trainees during the time of the survey reported being within an academic setting, which potentially affects the generalizability of these findings to community, private, or rural training environments. Despite this possibility, our study cohort does represent a very broad geographic distribution, and our breakdown by specialty is very similar to the most recent Association of American Medical Colleges data.35 Due to the retrospective nature of our survey, recall bias could have also influenced self-reported answers. Last, although we did demonstrate that there was a higher rate of prolonged time to conception and assisted reproduction use among procedural trainees, even after adjusting for age, we captured only successful pregnancies, and did not design the study to investigate the incidence of infertility in
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this population. Infertility among medical trainees remains an important related issue and is an area worthy of investigation in future studies.
CONCLUSIONS Compared with nonprocedural trainees, procedural trainees have higher rates of assisted reproduction, shorter maternity leave, and are ultimately more likely to express a desire to have chosen a less demanding job or specialty. Taken together, these findings indicate that there are significant stressors for women who have children during their postgraduate medical training. Our data suggest that these stressors may be even more intensified for those in procedural specialties, and therefore could potentially negatively affect overall career satisfaction. The importance of adequate support for female trainees around pregnancy and maternity cannot be understated, particularly for those in procedural specialties. Establishment of fair leave policies that incorporate adequate flexibility may allow for improved well-being for women who have children during their training. Author Contributions Study conception and design: Davids, Scully, Melnitchouk Acquisition of data: Davids, Melnitchouk Analysis and interpretation of data: Davids, Scully, Melnitchouk Drafting of manuscript: Davids, Scully, Melnitchouk Critical revision: Davids, Scully, Melnitchouk REFERENCES 1. US Medical School Applications and Matriculants by School, State of Legal Residence, and Sex, 2016-2017. AAMC.org. Available at: https://www.aamc.org/download/321442/data/ factstablea1.pdf. Accessed March 28, 2017. 2. 2012 Physician Specialty Data Book: Center for Workforce Studies. Available at: https://www.aamc.org/download/ 313228/data/2012physicianspecialtydatabook.pdf. Accessed March 30, 2017. 3. Pham DT, Stephens EH, Antonoff MB, et al. Birth trends and factors affecting childbearing among thoracic surgeons. Ann Thorac Surg 2014;98:890e895. 4. Willett LL, Wellons MF, Hartig JR, et al. Do women residents delay childbearing due to perceived career threats? Acad Med 2010;85:640e646. 5. Scully R, Melnitchouk N, Davids JS. Fertility and pregnancy outcomes in female physicians in procedural specialties: a large national survey. J Am Coll Surg 2016;223:S109. 6. Scully RE, Davids JS, Melnitchouk N. Impact of procedural specialty on maternity leave and career satisfaction among female physicians. Ann Surg 2017 Mar 7 [Epub ahead of print]. 7. Smith C, Galante JM, Pierce JL, Scherer LA. The surgical residency baby boom: changing patterns of childbearing during residency over a 30-year span. J Grad Med Educ 2013;5:625e629.
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8. Garza RM, Weston JS, Furnas HJ. Pregnancy and the plastic surgery resident. Plast Reconstr Surg 2017;139: 245e252. 9. Yoo PS, Tackett JJ, Maxfield MW, et al. Personal and professional well-being of surgical residents in New England. J Am Coll Surg 2017;224:1015e1019. 10. Ban KA, Cohen ME, Ko CY, et al. Evaluation of the ProPublica Surgeon Scorecard “adjusted complication rate” measure specifications. Ann Surg 2016;264:566e574. 11. Marti KC, Lanzon J, Edwards SP, Inglehart MR. Career and professional satisfaction of oral and maxillofacial surgery residents, academic surgeons, and private practitioners: does gender matter? J Dent Educ 2017;81:75e86. 12. Dyrbye LN, Shanafelt TD, Balch CM, et al. Relationship between work-home conflicts and burnout among American surgeons: a comparison by sex. Arch Surg 2011;146: 211e217. 13. Gifford E, Galante J, Kaji AH, et al. Factors associated with general surgery residents’ desire to leave residency programs. JAMA Surg 2014;149:948e956. 14. Wong K, Grundfast KM, Levi JR. Assessing work-related musculoskeletal symptoms among otolaryngology residents. Am J Otolaryngol 2017;38:213e217. 15. Cavanagh J, Brake M, Kearns D, Hong P. Work environment discomfort and injury: an ergonomic survey study of the American Society of Pediatric Otolaryngology members. Am J Otolaryngol 2012;33:441e446. 16. Ahmed N, Devitt KS, Keshet I, et al. A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes. Ann Surg 2014;259:1041e1053. 17. Tsafrir Z, Korianski J, Almog B, et al. Effects of fatigue on residents’ performance in laparoscopy. J Am Coll Surg 2015;221: 564e570.e3. 18. Definitions of infertility and recurrent pregnancy loss: a committee opinion. Fertil Steril 2013;99:63. 19. Statement on the importance of parental leave. Bull Am Coll Surg 2016;101:35e36. 20. Berkowitz GS, Skovron ML, Lapinski RH, Berkowitz RL. Delayed childbearing and the outcome of pregnancy. N Engl J Med 1990;322:659e664. 21. Mundschenk M-B, Krauss EM, Poppler LH, et al. Resident perceptions on pregnancy during training: 2008 to 2015. Am J Surg 2016;212:649e659.
22. Lerner LB, Baltrushes RJ, Stolzmann KL, Garshick E. Satisfaction of women urologists with maternity leave and childbirth timing. J Urol 2010;183:282e286. 23. Hamilton AR, Tyson MD, Braga JA, Lerner LB. Childbearing and pregnancy characteristics of female orthopaedic surgeons. J Bone Joint Surg Am 2012;94:e77ee79. 24. Behbehani S, Tulandi T. Obstetrical complications in pregnant medical and surgical residents. J Obstet Gynaecol Can 2015;37:25e31. 25. Merchant SJ, Hameed SM, Melck AL. Pregnancy among residents enrolled in general surgery: a nationwide survey of attitudes and experiences. Am J Surg 2013;206:605e610. 26. Merchant S, Hameed M, Melck A. Pregnancy among residents enrolled in general surgery (PREGS): a survey of residents in a single Canadian training program. Can J Surg 2011;54:375e380. 27. Keegan RJ, Saw R, De Loyde KJ, Young CJ. Attitudes and risk of withdrawal in general surgical registrars. N Z Med J 2015; 128:61e68. 28. Seemann NM, Webster F, Holden HA, et al. Women in academic surgery: why is the playing field still not level? Am J Surg 2016;211:343e349. 29. Parental leave for residents and pediatric training programs: Section on Medical Students, Residents, and Fellowship Trainees and Committee on Early Childhood. Pediatrics 2013;131:387e390. 30. Dixit A, Feldman-Winter L, Szucs KA. Parental leave policies and pediatric trainees in the United States. J Hum Lact 2015; 31:434e439. 31. Hutchinson AM, Anderson NS, Gochnour GL, Stewart C. Pregnancy and childbirth during family medicine residency training. Fam Med 2011;43:160e165. 32. National Vital Statistics Reports, Volume 66, Number 1, January 5, 2017. December 2016:1e70. Available at: https://www.cdc.gov/nchs/data/nvsr/nvsr66/nvsr66_01_tables. pdf. Accessed June 23, 2017. 33. Dimou FM, Eckelbarger D, Riall TS. Surgeon burnout: a systematic review. J Am Coll Surg 2016;222:1230e1239. 34. Bergen PC, Turnage RH, Carrico CJ. Gender-related attrition in a general surgery training program. J Surg Res 1998;77: 59e62. 35. Distribution of residents by specialty, 2003 compared to 2013. AAMC. Available at: https://www.aamc.org/download/ 411784/data/2014_table2.pdf. Accessed June 23, 2017.
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eDocument 1. SURVEY QUESTIONS If you work in clinical medicine, which specialty do you currently practice the majority of the time? Drop-down menu (Anesthesiology, Allergy and Immunology, Cardiology, Dermatology, Emergency Medicine, Endocrinology, Family Medicine, Gastroenterology, Genetics, Geriatrics, Hematology/Oncology, Infectious Disease, Internal Medicine, Minimally Invasive Surgery, Nephrology, Neurology, Neurosurgery, Obstetrics/ Gynecology, Ophthalmology, Orthopedic Surgery, Otolaryngology, Pediatrics-General Practice, PediatricsSubspecialties, Pathology, Psychiatry, Pulmonary/Critical Care, Radiology, Rheumatology, Surgery-Breast, Surgery-Cardiothoracic, Surgery-Colorectal, SurgeryEndocrine, Surgery-General, Surgery-Minimally Invasive, Surgery-Pediatric, Surgery-Plastic, Surgery-Surgical Oncology, Surgery-Trauma/Critical Care, SurgeryVascular, Urology) What best describes your current position? (attending, fellow, resident/intern, medical student, industry, academic research-only, not currently working, other: please indicate [optional] ) If you are currently practicing clinical medicine, what best describes your practice? (academic, private, community, rural, locum tenens, N/A) What state are you currently working in? (Drop-down menu list of states; also included: I am not working in the US; I am not currently working) How old are you? (<25, 25e30, 31e35, 36e40, 41e45, 46e50, >50 years old) What is your relationship status? (married, domestic partnership, single, divorced, separated, widowed) Which best describes your spouse currently? (surgeon, physician, other full-time professional, employed parttime (20 or fewer hours per week), student, stay-athome dad, disabled, other [write-in optional]) How many children do you have? (1, 2, 3, 4, 5, >6, currently pregnant with first child) What was your age when your first child was born or adopted? (<25, 25e30, 31e35, 36e40, 41e45, 46e50, >50 years) During your last pregnancy/adoption were you a: (attending, fellow, resident/intern, medical student, industry, academic-research only, not working, other [write in optional])? How old is your youngest child? (currently pregnant with first child, <6 mo, 6moe12 mo, 1e2 years, 3e5 years, 6e10 years, 11e15 years, 16 or older) How long did you try before becoming pregnant with your first baby? (0e6 months, 7e12 months, 1e2 years, >2 years, unsure, N/A)
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Pregnancy and Maternity in Trainees
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Did you use assisted reproductive medicine during any of your pregnancies? (no, consultation only, Clomid or equivalent, intrauterine insemination, in vitro fertilization, surgery, N/A) Did you miss any work on due to any of these conditions? Check all that apply. a. b. c. d. e. f.
Did not miss any work due to these conditions Preterm labor Bedrest Hyperemesis gravidarum Pre-ecclampsia Unable to perform my job functions (eg, operating, prolonged standing, long hours) g. Baby in the ICU h. N/A i. Other [write-in optional] Who was primarily responsible for arranging coverage during that time? (you, chief or chairman, practice manager, partners, chief resident, co-residents, N/A, other) During your most recent pregnancy did you have a c-section? (yes, no, N/A) If you took time off (“maternity leave”) after the birth or adoption of your youngest child, how long was this time? Drop-down menu a. <2 weeks b. 2 weeks c. 3 weeks d. 4 weeks e. 5 weeks f. 6 weeks g. 7 weeks h. 8 weeks i. 9 weeks j. 10 weeks k. 11 weeks l. 12 weeks m. 13 weeks n. 14 weeks o. 15 weeks p. 4 months q. 5 months r. 6 months s. >6 months t. I did not take any time off u. N/A Which best describes you? Check all that apply. (White, Hispanic, Black or African-American, Asian, Native American or Alaska Native, Pacific Islander) For each statement choose one (strongly agree, agree somewhat, disagree somewhat, strongly disagree, N/A):
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Pregnancy and Maternity in Trainees
a. My MALE colleagues were understanding of my needs during pregnancy. b. My MALE colleagues were understanding of my needs when I returned to work after maternity leave. c. My FEMALE colleagues were understanding of my needs during pregnancy. d. My FEMALE colleagues were understanding of my needs when I returned to work after maternity leave.
J Am Coll Surg
e. My decision of which specialty to train in was influenced by pregnancy and child-care considerations. f. My decision of which job to take was influenced by pregnancy and child-care considerations. g. I wish I had chosen a specialty that was less demanding. h. My significant other is supportive of my career choice.