Childbirth is one of the most natural and human function there is, and yet for many in residency training, pregnancy, childbirth and lactation are still very challenging. Over 50% of medical school matriculants are women and yet many specialties including anesthesiology still struggle with supporting their residents during this critical period. This article focuses on the plight of surgical trainees as they work to build their families, and as anesthesiologist who work with surgeons it is helpful to appreciate what our colleagues may be going through. In addition prior studies show that those in procedural specialties including anesthesiology experience many of the same issues that the authors found in this study.1 The increasing number of women in medicine and women’s committees allow for increased sharing of the realization that disparities and mistreatment remain, leading to delays in starting families, infertility challenges, stress and mental health struggles, obstetric complications, prolonged leaves, scheduling challenges, and attrition.
Original article
Li RD, Janczewski LM, Eng JS, Foote DC, Wu C, Lohnson JK, Easter SR, Kim, E, Buyske J, Hu, YY, Rangel EL. Pregnancy and Parenthood Among US Surgical Residents. JAMA Surgery. Published online July 17, 2024. doi:10.1001/jamasurg.2024.2399. Epub ahead of print. PMID: 39018050; PMCID: PMC11255977.
Invited Commentary
Anderson JE, Farmer DL. Cracks in the Glass Ceiling-Except for Pregnant Surgery Residents. JAMA Surg. 2024 Jul 17. doi: 10.1001/jamasurg.2024.2404. Epub ahead of print. PMID: 39018066.
The article by Li et al2, on pregnancy and parenthood in US surgery residents is not the first to discuss that starting a family during surgical training is a mighty challenge. This article is unique in that it examines the experiences of 5,692 general surgery residents from 325 US programs via a multiple-choice survey with a high response rate (81.2%) taken at the end of the American Board of Surgery In-Training Exam (ABSITE). With general surgery representing the largest procedural specialty,3 this study is generalizable and positioned to reinforce what we already know, teach us some of the subtleties of those challenges and, most importantly, call us all to action for culture change in all medical specialties.
The study primarily utilized previously validated questions or published instruments whereby residents self-reported race and ethnicity, gender/gender identity and sexual orientation, relationship status and parental status. All residents were asked two questions related to support for family planning: 1) If they delayed or plan to delay starting a family due to residency training; 2) If the workload of residents without children is unfairly increased when co-residents become parents.
To elicit information about pregnancy/parenthood-based mistreatment, expectant residents were asked: 1) If they were advised against having children; 2) If they experienced negative reactions to pregnancy or childcare needs; 3) If they were encouraged to choose an “easier” specialty; 4) If they experienced discrimination because of their pregnancy or childcare needs. Mistreatment was defined as an affirmative response to any of the measures.
Obstetric and postpartum experiences were explored with questions surrounding the use of assistive reproductive technology and work schedule adjustments with pregnancy. The participants were asked about obstetric complications including miscarriage, preeclampsia, placental abruption, fetal growth restriction or other complications requiring hospitalization and postpartum depression, as well as neonatal complications. Additionally, duration of parental leave, work schedule adjustments upon return to work and whether faculty identified with them more after they became parents were reported. Well-being questions explored feelings of burnout, thoughts of attrition and suicidality.
Nine hundred fifty-seven residents (16.8%) reported at least one pregnancy during surgical training. Male residents reported a pregnancy in their female partner at more than twice the rate of female residents reporting their own pregnancy (22.3% vs 10.2%; P<0.001). Those pregnancies were most likely to occur during PGY-4 and 5 years, in residents who were married or in a relationship, non-Hispanic white or at a university-affiliated program. More female than male residents reported waiting to start families (46.8% vs 32.7%; P<0.001). No gender differences were reported in the unfair increase in workload among childless residents.
Female residents reported more pregnancy/parenthood mistreatment (58.1% vs 30.5%; P<0.001), being advised against having children during residency (25.7% vs 2.9%, P<0.001), experiencing negative reactions from their coworkers or program (20.7% vs 4.6%, P<0.001), being encouraged to consider an “easier” specialty (40.1% vs 23.7%, P<0.001), and discrimination related to pregnancy or childcare status (24.2% vs 3.1%, P<0.001).
Both genders endorsed similar rates for use of reproductive assistive technologies, work schedule adjustments being made and neonatal complications. The lack of any type of additional work schedule adjustment for female residents despite the obviously increased physical toll of the pregnancy and delivery is noteworthy.
Female residents experienced more obstetric complications and postpartum depression than those reported for the partners of the male residents, although those results were not statistically significant.
The prevalence of burnout and suicidality were similar between male and female residents; however, thoughts of attrition were associated with being female even after adjustment for other factors such as program characteristics and resident mistreatment.
The authors acknowledge some limitations of the study including recall bias, cross-sectional study design limiting causality conclusions, program-level covariates, lack of reporting of male resident partners’ occupations leading to possible “double counting,” underpowering, and exclusion of characterization of those with primary infertility or adoption.
The results of this survey demonstrate that gender disparities remain, even in this more modern era where women made up 56.6% of medical school applicants, 55.4% of matriculants, and 54.6% of total medical school enrollment in 2023-24.3 Women have held these majorities for the last five years and 48% of surgical residents are women.4 Yet women are still delaying starting their families to avoid doing so during training and experiencing the physical and emotional fallout that it can bring. With delay, there is an increased risk for future infertility, the need for assistive technologies and the potential for failure to conceive. Mistreatment is more common for females, and many endorse the existence of the “motherhood penalty” whereby parenthood alters career advancement.4,5
We’ve been talking about all of this for years and while things have certainly improved, difficulties remain. Burnout and suicide in FEMALE physicians are at an all-time high, and while the reasons are multifactorial and complicated, the “motherhood” penalty may be one of those contributing factors.
If we assume some or all of these finding also apply to pediatric anesthesiology, then in the current situation where there are increasing workforce challenges ranging from dwindling pediatric anesthesia fellowship applicants, increased desire for part time or per diem work, to the early retirement of experienced physicians, we must do what we can to make our lives in this work as reasonable as possible. Otherwise, it will be difficult to attract and maintain a robust and diverse workforce. As Drs. Anderson and Farmer stated in their invited commentary6 on this article, “It is unrealistic to expect residents to spend up to 10 years of their childbearing years in training and not consider family planning.” We must find ways to be creative whereby we support those seeking to build their families while also being mindful to not overburden those who are not in the same stage or mindset in their lives.
We can do better, and we owe it to our colleagues and ourselves to try to do so.
References
1. Scully RE, Stagg AR, Melnitchouk N, Davids JS. Pregnancy outcomes in female physicians in procedural versus non-procedural specialties. American journal of surgery 2017;214(4):599-603. (In eng). DOI: 10.1016/j.amjsurg.2017.06.016.
2. Li RD, Janczewski LM, Eng JS, et al. Pregnancy and Parenthood Among US Surgical Residents. JAMA surgery 2024 (In eng). DOI: 10.1001/jamasurg.2024.2399.
3. Association of American Medical Colleges. Report on Residents: Executive Summary. November 2022 2022. (https://www.aamc.org/media/63486/download?attachment).
4. Brotherton SE, Etzel SI. Graduate Medical Education, 2022-2023. Jama 2023;330(10):988-1011. (In eng). DOI: 10.1001/jama.2023.15520.
5. Sandler BJ, Tackett JJ, Longo WE, Yoo PS. Pregnancy and Parenthood among Surgery Residents: Results of the First Nationwide Survey of General Surgery Residency Program Directors. J Am Coll Surg 2016;222(6):1090-6. (In eng). DOI: 10.1016/j.jamcollsurg.2015.12.004.
6. Anderson JE, Farmer DL. Cracks in the Glass Ceiling-Except for Pregnant Surgery Residents. JAMA surgery 2024 (In eng). DOI: 10.1001/jamasurg.2024.2404.