The health benefits of breastfeeding for both mothers and children are well established. Children who are breastfed have reduced rates of respiratory and gastrointestinal tract infections, allergies, obesity, and overall mortality, while lactating mothers benefit from reduced rates of breast and ovarian cancers as well as Type II Diabetes Mellitus.1 The American Academy of Pediatrics recommends a minimum of 6 months of exclusive breastfeeding with continued breastfeeding to 1 year or longer depending on the interest of mother and child.1 A study by Melnitchouk et al2 found that even though a larger proportion of women physicians initiate breastfeeding compared with the general population, less than one-third of practicing physicians reach their personal breastfeeding goals and only 42% reach the recommended 1-year target. Significant barriers to physicians reaching their breastfeeding goals include inadequate time for milk expression, limited flexibility in work hours, and insufficient access to private lactation spaces.2,3 For those surgeons who choose to breastfeed, additional barriers include limited availability of dedicated lactation spaces in and around an operating room as well as perceived lack of support from administrators and peers. These barriers contribute to 58% of surgical trainees failing to meet their personal breastfeeding goals3 and only 41% of surgical residents successfully continuing lactation at 6 months compared with nearly 60% in the general US population.3–5
The barriers faced by lactating physicians and surgeons are not exclusive to these groups and have been creatively addressed in industries outside of healthcare. For example, elementary school teachers have fixed work day schedules with limited break time and are often unable to leave their classrooms for milk expression. To address the issue of limited flexibility, an elementary school in Connecticut coordinated a system of float staff to be available to provide classroom coverage so that lactating teachers have the time to express milk.6 To provide accessible and appropriate private lactation spaces, the city of Los Angeles has converted a room in every fire station throughout the city to accommodate lactating employees who do not have a primary work location, such as bus drivers and police officers.6 Manufacturing organizations, including Shaw Industries, have converted unused office space to lactation spaces near the manufacturing floor. Finally, to address the barrier of leadership support, the online store BirchBox implemented and championed a company-wide policy to support lactating employees which has been embraced and well utilized by employees.7 These policies not only benefit lactating employees but also benefit the employers as well. Following implementation of a comprehensive lactation policy at Cigna, healthcare costs and lost productivity among employees both significantly decreased.8 Drawing from these nonmedical industries, solutions to improve work place support for lactating individuals can be modified and implemented for surgeons.
In the context of the growing population of women in training programs as well as surgical practice and the increased emphasis on diversity in medical training, improving lactation support for surgeons is critical to providing an inclusive environment. To address programmatic and institutional barriers to continued lactation for surgical trainees in particular, two residents at the University of Michigan (S.P.S. and A.E.K.) prepared the “University of Michigan Department of Surgery Guidelines for Lactating Surgical Residents” based on the specific challenges and experiences of prior lactating trainees under the guidance of a development and behavioral pediatrician and lactation counselor [Appendix 1, http://links.lww.com/SLA/B618]. This guideline identified the challenges faced by lactating surgical trainees, delineated responsibilities of lactating residents in the clinical setting, and identified opportunities to accommodate the time necessary to express milk during educational and clinical duties. The UM lactation support program identified and converted underutilized call rooms and offices to “priority lactation spaces” to expand access to private, nonbathroom options for lactating trainees. Finally, the document served as a show of support for lactating surgical trainees and clearly demonstrated that the wellness of postpartum residents was a priority for department leadership.
After initial review and feedback from current U of M surgical trainees, this guideline was reviewed and subsequently sponsored by the department chair and general surgery program director. The document was presented at the Graduate Medical Education Committee prior to approval by the General Surgery Program Evaluation Committee. The guideline was then presented at a faculty meeting and distributed electronically to department members including current trainees as a new health and wellness initiative for trainees. Departmental leadership demonstrated strong support of these efforts through provision of financial support for additional lactation space modification, continued dissemination of the document, and development of ongoing residency program wellness initiatives that stemmed from this initial policy.
Following dissemination of the Lactation Guideline at UM, faculty and residents were able to identify potential solutions to meet the needs of lactating trainees. For example, multiple faculty members offered to offload resident workload before starting cases to provide time for a lactating resident to express milk. Additionally, the expansion of private, nonbathroom spaces from underutilized daytime call rooms led to minimization of time away from clinical duties for lactating residents. By contributing to the normalization of this basic health need of postpartum residents through educational efforts, faculty and logistical support, the UM Department of Surgery has decreased some of the burden felt by postpartum trainees by reducing their need to ask for individual accommodations.
The implementation of this initiative was well received at UM and was additionally piloted at the University of Wisconsin (UW) to further identify opportunities and barriers to widespread implementation throughout surgical training programs as well as Departments of Surgery [Appendix 2, http://links.lww.com/SLA/B618]. The UW Department of Surgery implemented a similar structure and further expanded upon the UM initiative. UW adopted a “cross-cover” model encouraging lactating residents to have other residents assist in the operating room during noncritical portions of the case if the primary operating resident needed to express milk that has been very well received and easily implemented. While providing time to express milk addresses the major barrier most surgeons face, UW also identified the need for support of lactation specialists to address individual issues that arise. The UW Department of Surgery coordinated with lactation specialists employed by hospitals where UW surgical residents rotate to ensure availability of lactation support for faculty and trainees either in person or via phone as needed without requiring prior appointments. The administration at UW Department of Surgery has championed this initiative from the start by prominently promoting the policy to both trainees and faculty as well as highlighting it during prospective resident interviews. Finally, UW hospital leadership also has made incorporating lactation spaces in all work spaces a priority by converting unused offices to lactation rooms and including space to express milk in plans for on-going construction projects in all UW Health locations further supporting surgeons to continue lactation if desired.
As additional trainees utilize the tools and our educational efforts continue, we are actively gathering data at both the University of Michigan and University of Wisconsin on resource utilization, the impact of the program on trainee success in reaching personal breastfeeding goals, and the cultural environment for postpartum trainees and transition back to clinical residency following parental leave.
While supporting lactating surgeons presents several obstacles to surgery departments, all of these obstacles have been overcome in nonmedical industries as well as in our experiences at the University of Michigan and University of Wisconsin. These efforts are particularly important as starting in July 2020 all ACGME-accredited residency programs will be required to provide residents with “clean and private facilities for lactation that have refrigeration capabilities, with proximity appropriate for safe patient care.”9 It is essential that surgery departments meet this upcoming minimum benchmark as outlined by the ACGME, but also provide support for the health needs of lactating surgical trainees and faculty surgeons. Specifically, during the critical transition back to training for postpartum clinicians, these and similar efforts may help to curb issues of burnout, job dissatisfaction, and stress. We hope that our experiences will serve as a template to address lactation support and other health and wellness needs within departments of surgery and to serve as a starting point for other programs to champion and support the increasingly diverse surgical resident and faculty population.
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