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From the Editor

How Can We Create a More Family-Friendly, Healthful Environment for Our Future Health Professionals?

Sklar, David P. MD

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doi: 10.1097/ACM.0000000000002397
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Some years ago I was working a night shift in the emergency department, with only Mary, a senior emergency medicine resident, and Tom, an off-service psychiatry intern, assisting me. Mary (name changed) was nine months pregnant and due to deliver any day. I remembered how I had first learned about her when she was an applicant to our program in the Couples Match. The internal medicine program director had approached me because he was hoping that my department would consider ranking Mary highly, which would help him recruit her fiancé, a promising future academic cardiologist. Mary had a good but not outstanding record at medical school, and our selection committee had a long and contentious discussion about moving her up on our Match list to increase the chances that she and her fiancé would Match together at our institution. Some faculty did not feel it was fair to give Mary an advantage over a single applicant; others raised concerns about previous couples at our institution. But we decided to take a chance on her, and were never disappointed with her performance. Even during her pregnancy near the end of her residency she had not required any adjustments in her schedule or other assignments. Now as we began our night shift, she joked about where our emergency delivery tray was stored, just in case, but we quickly got down to business as we noticed the grim faces of the outgoing team.

“We’re really backed up,” said the charge nurse. “This is unacceptable.”

“I’m sorry about the mess,” said George, the outgoing attending. “It’s been one crisis after another. We could never get caught up. I’m exhausted. Sorry. “

“All right,” I said. “I get the picture. Mary, how are you feeling?”

“I’m okay. I might need to take a little rest halfway through the shift if that’s possible.”

“Sure, sure,” I said. “Just let me know.” But my voice probably conveyed the anxiety I was already feeling about the state of the emergency department, and whether our team was up to the task. Mary’s dark eyes darted nervously about the room as she surveyed the cubicles and stretchers in the halls. She quickly grabbed a chart and hurried off to see patients. I didn’t see Mary for several hours as I tried to respond to the charge nurse’s requests to discharge patients and make room for those in the waiting room. There was not a moment to think about Mary. When I finally caught up to her, she was grimacing and holding her back. “Are you okay?” I asked.

“I’ll make it,” she assured me, trying to replace the contortions of her face with a forced smile. She went right into a description of the three patients she had just seen. I nodded, rushed off to confirm her findings, and then wrote a note on the chart documenting my assessment. Partway through writing my notes, something flashed through my mind. I stopped writing and decided to check on Mary again. I found her on her back on one of our patient stretchers. “I think I’m in labor,” she said. “My water broke during rounds.”

“That was three hours ago,” I said. “Why didn’t you say something?”

“We were so busy. I didn’t want to worry you. I was hoping I could get through the shift.”

“No, no. You need to go to labor and delivery now. Tom will pick up your patients.”

“I’m not going there. I’m having a home birth. I have a nurse midwife, and she will meet me at home when the shift is over. I’ve already called her. Meanwhile I would rather just stay here and work. My contractions are only every 10 minutes. I feel better now. I’m ready for another patient.”

Before I could respond the charge nurse grabbed my arm and guided me to the waiting room to see a man who had fallen out of a wheelchair. “I’ll be right back,” I shouted in Mary’s direction. An hour later after I had called neurosurgery to admit the patient for a subdural hematoma, I checked back on Mary. She was on her feet examining a man with a fever. “Mary,” I said. “At least go up to labor and delivery and have them check on you.”

“I already had one of the OB residents who was doing a consult down here check me. She said I’m only two centimeters dilated. It will probably be another five or six hours. I’m fine,” said Mary and she smiled bravely. As the night went on, I felt a crescendo of unease about Mary. Around 4 am I saw her grimace and bend over holding her stomach, and that was all I could take. I told her to go immediately to labor and delivery. One of our nurses wheeled her upstairs to the obstetrical triage area as I called the obstetrics attending. A few hours later as the shift was ending I heard the news that Mary had delivered a healthy baby boy and everyone was fine.

I am sharing this story to put a face to a problem that is too often discussed in abstractions—the challenges of combining a career in medicine with raising a family. These start with the residency selection process, accelerate during residency training, and continue during the transition to a career in academic or community practice. While there are challenges at every step along the way, the stress of pregnancy during residency is probably the most difficult. Fortunately, Mary did not have a bad outcome, but I still feel bad that I allowed her to continue to work her shift while in active labor. While Mary’s story is an extreme example of the types of conflicts facing our students and faculty, the tensions between personal health, patient needs, and professional expectations occur regularly. Even when we have supportive policies, our attitudes may not encourage their use. How can we create a more family-friendly, healthful environment for our future health professionals that can nurture their goals of a healthy family, a fulfilling personal life, and a successful medical career?

The Nature of the Problem

More than 10 years ago, Jagsi et al1 addressed the challenges of pregnancy and childbirth during residency. As part of their discussion, they suggested that competent residents should not have to make up leave time taken in conjunction with the birth of a child. They also recommended on-site child care, federal reimbursement of GME that includes paid family leave, and increased part-time training options. Rangel et al,2 in a survey of female surgeons who had given birth during residency, found that 63.6% of the respondents felt that their work schedules during pregnancy adversely affected their health or that of their unborn child. Moreover, 29.5% said they would discourage female medical students from choosing a surgery career because of the difficulties of balancing pregnancy and motherhood with training.

These results are consistent with findings from a survey of surgery program directors by Sandler et al3 in which 61% felt that becoming a mother adversely affected female trainees’ work, including placing an increasing burden on fellow residents. Adesoye et al,4 in a survey of 5,782 physician mothers, found widespread perceptions of discrimination regarding pregnancy, maternity leave, or breastfeeding. Those who reported discrimination were more likely to report burnout than those that did not. Workplace changes that they suggested included more flexible weekday schedules, longer paid maternity leave, child care on-site, backup child care, and support for breast feeding.

Concerns about disparities related to gender associated with career obstacles and advancement in academic medicine were also raised in a longitudinal 17-year follow-up study by Carr et al5 reported in this issue of Academic Medicine. The authors noted that

women were only half as likely to attain senior leadership roles in academic medicine as medical school deans, associate deans, provosts, and department chairs compared to men over the course of our follow up. The gender difference in senior leadership was not modified by inclusion of any of our covariates, including academic productivity.

Previously, Carr et al6 had identified obstacles to a successful academic career for female faculty with children; these obstacles were related to less institutional support.

While I believe that the suggestions of Adesoye et al would address many of the obstacles to combining a family with a career in medicine, they may not fundamentally change how we think about the problem, particularly our attitudes about making the changes needed to implement new policies. In an effort to stimulate discussion, I describe below the problems of combining family and a career, beginning with residency selection and hiring, then resident training, and, finally, further career development and support. For each of these three phases, I offer suggestions for improvement.

Residency Selection and Hiring

The resident Match, and in particular the Couples Match for those who are in a relationship, can lead to results that create a geographic separation of family members. Alvin and Alvin,7 in a recent letter to the editor, observed that while the two of them were able to Match as a couple, some colleagues were not. “Many married and unmarried couples did not receive such good news … both individuals were in tears after Matching at institutions far from each other.” In many cases there may be a perceived difference in the qualifications of one member of a couple compared with those of the other, leading the two program directors to give the members rankings that could exclude one of them from the institution’s program. Also, interviews may not be coordinated, and communications between programs may be inconsistent.

Are there alternatives? Putnam et al8 in this issue describe a process for hiring of faculty whose spouses are also academicians that may provide some ideas for the resident Couples Match. Putnam et al recognized the risk of the process appearing to be unfair to other applicants as well as to the couple and recommended that each member of a couple, when applying for a position, undergo the standard application process. They also proposed a process of tandem hiring in which both hiring units engage in the process in synchrony, including coordinating visits, communicating with each other and both spouses, and delivering letters of offer simultaneously. A family-friendly selection system for residents might provide similar coordination of visits and communications between program directors of the Matching couple after the visit.

Residency Training

The most contentious and stressful aspect of combining a family with a career in medicine often occurs during residency, when unrelenting 80-hour workweeks create little flexibility to manage the uncertainties of a pregnancy, childbirth, and child care. I wonder whether we might be able to create more flexibility by integrating the profound personal learning and growth that occurs during a pregnancy with learning objectives for residency and thus reduce other work time. Learning theory such as Kolb’s9 theory of experiential learning would support such an approach. Kolb’s theory emphasizes the important role that experience has in stimulating learning, reflection, and abstraction. For most residents and students, particularly those who will choose such specialties as obstetrics–gynecology, pediatrics, family medicine, emergency medicine, psychiatry, and to some extent other specialties, the experience of pregnancy and childbirth would deepen their understanding of patients who seek care related to a pregnancy and newborn care. By going through a pregnancy during training, residents would likely become more knowledgeable and empathetic providers of that care. If we were to consider a resident’s pregnancy as a learning experience and incorporate reflection and abstraction to further develop understanding of the patient experience, there would undoubtedly be profound learning on both abstract and practical levels.

With a learning framework that encompasses personalized learning, I believe educators could make strong arguments with accrediting organizations and certifying organizations that nonclinical time related to a pregnancy, childbirth, and infant care could contribute toward a variety of training objectives and might be partially counted in the overall training requirements. Such an approach might allow for a more gradual return to full clinical rotations after maternity leave had run out—for example, a 40-hour clinical workweek for the first month back from maternity leave rather than 80 hours. Recent work by ten Cate et al10 has called into question the rigid time-based organization of residency and suggested replacing it with a time-variable program dependent upon achieving defined competencies. If time could be removed as the organizing principle of residency and replaced by an outcomes- and competency-based approach, there might be an opportunity to use learning theory to integrate the experience of pregnancy and childbirth into residency and remove some of the time pressures, applied by certifying boards and accreditation boards, that have limited parental leave.

However, the other barrier to increased flexibility for resident work schedules has been the need by hospitals for the clinical services provided by residents. While there may be some educational benefits from an 80-hour workweek, the physical and mental costs may outweigh the benefits. High-quality training has been demonstrated in many European countries with a 48-hour workweek.11 Unfortunately, while 80 hours remains the standard for graduate medical education workweeks, and as long as hospitals are dependent upon residents for clinical service, the ability to craft a family-friendly educational environment will be limited. A decoupling of clinical experience needed for the development of expertise and clinical experience to address hospital service needs would provide the opportunity for creative redesign of the clinical learning environment. Even without such a radical redesign, steps suggested by those surveyed by Adesoye et al,4 such as more flexible scheduling and child care on-site, could provide substantial improvements in creating a family-friendly resident educational environment.

Further Career Development and Support

After residency and fellowship, those academic medicine faculty attempting to combine a health professions career and family must face not only the usual academic challenges—such as pressures to publish scholarly works, competition for grants, and assuming leadership roles—but also the ongoing challenges of raising children and maintaining a strong relationship with a partner. There may also be caregiving responsibilities for family members that interfere with professional duties. In this issue, Hartmann et al12 describe the difficulties of caregiving on early-career faculty. Twenty-three percent of the respondents in the authors’ study had a child or adult in the household who was hospitalized in the previous year, and such stressful events caused 70% to consider leaving academics. Levine et al13 interviewed early-career women physicians who left academic medicine and found that the lack of role models for combining career and family responsibilities, frustrations with research (funding difficulties, poor mentorship, competition), issues of work–life balance, and an insufficiently supportive institutional environment were key factors in a decision to leave academic medicine. One respondent explained:

I was very stressed out; it was too much to do. My boss was very nice and fairly supportive of having flexible hours but he kept pushing me to do more and more and more. I needed to publish this; I needed to do this grant; I needed to have this clinic and see these patients. There are only so many hours in the day…. My husband and I were both working after our child went to sleep…. I’d stay up to 2 or 3 in the morning.

Levine et al suggest the promotion of family-friendly policies and flexible work options to help women remain in academic careers and become role models for others. Fassiotto et al14 have described a program at one institution that can mitigate some of the work–life and work–work conflicts for faculty to help meet career and life goals through coaching, and a time banking system that can provide needed family support for such activities as shopping and house cleaning.

Family-Friendly Environments for All

While the descriptions of the current challenges to combining a medical career and raising a family can be discouraging, there are signs of a shift in attitude. Cedfeldt et al15 have described a time-off policy to provide time and support for residents’ health needs through scheduling time off. This is an example of a proactive step to change the environment. But they also found that even when provision for time off was available through institutional policy, residents did not take advantage of the time off because of concerns about the effects of leaving on other residents. This finding makes clear that we must all take responsibility to first encourage culture change so that when we then make a policy change, our colleagues understand it and feel empowered to use it. Shauman et al16 found similar resistance to the use of family-friendly policies among faculty at one institution due to cultural pressures and attitudes such as the following:

I support family-friendly policies, but the university has to provide support so that others are not burdened by the family leave of others. In my recent experience, family leave of a colleague means that everyone else remaining is required to work harder.

Thus it appears that implementation of family-friendly policies will need to be accompanied by culture change, communication, and additional resources to prevent burdening others. Shauman et al also describe concerns about unfairness among faculty who, therefore, would not anticipate using the policy.

Dyrbye et al17 have increased our awareness of high burnout rates of students, residents, and early-career physicians, and Yaghmour et al18 have increased our awareness of deaths of residents from possibly preventable causes. Their work has helped foster a recognition of the deleterious effects of stressful work environments on health professionals and those training to be health professionals. Yaghmour et al state that

efforts to enhance physician well-being must begin during the medical education years, and strategic interventions to initiate habits of self-care and improve use of mental and physical health care should target residents and faculty.

Unfortunately, the medical and psychological needs of medical trainees have not thus far received adequate attention or support. Creation of family-friendly policies could improve the learning and work environment for all health professionals through providing increased flexibility and support. As our educational programs move away from time-based curricula to competency-based time-variable programs, the resistance to curricular change from accrediting and certifying organizations will likely be reduced, providing the opportunity to redesign our training and work environments. Now is the time to demonstrate that we are serious about wellness for our trainees and new faculty by investing in the creation and support of family-friendly learning and work environments and by increasing institutional resources to develop a work culture that best meets the diverse needs of all.


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