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SURGICAL PERSPECTIVES

The Baby and the Board

A Step Toward Normalizing Childbearing During Surgical Training

Letica-Kriegel, Allison S. MD; Griggs, Cornelia L. MD

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doi: 10.1097/SLA.0000000000005073
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I gently placed my 9-day-old son in his bassinet and kissed him goodbye. It was 4 o’clock in the morning as my husband and I sped toward the emergency room while my parents took over the remainder of the newborn night shift. We didn’t know what was making me so sick and we were both scared – an unusual scenario for 2 surgical trainees. It turns out that I was septic as a result of severe cellulitis at my cesarean incision and luckily I recovered quickly after inpatient hospitalization for antibiotics. I had supportive family nearby and my husband was able to take a brief leave to help with the baby. I am still recovering from the sequela of my postdelivery complications and feel lucky to be working from home during my 2 years of research time. But I cannot help thinking that this experience would have truly broken me if I had to return to full-time clinical residency a few short days or weeks later, as so many surgical trainees routinely do.

My coauthor's first pregnancy was complicated by hydrops fetalis, the direct result of a parvovirus infection she contracted unknowingly while covering a shift at a nearby children's hospital. A surgical critical care fellow at the time, she would dart postcall from intensive care unit shifts to have repeated fetal echocardiograms before returning home for fitful bursts of rest, constantly preoccupied with the guilt that she had subjected her unborn child to a dangerous viral infection contracted at the hospital. These stories of pregnancy and postpartum complications are not uncommon among our colleagues. In fact, pregnancy complications occur in almost one third of childbearing surgeons.1 Much attention was paid to Dr. Eugene Kim's recent presidential address at the Academic Surgical Congress, where he recounted a harrowing story of a junior attending at his institution who suffered a hemorrhagic stroke while pregnant with twins conceived after multiple expensive rounds of in vitro fertilization. As more and more of these stories are shared in the national spotlight, it is time to question how we treat our childbearing surgical trainees and what it says about our profession.

Surgical trainees are allowed just two weeks of parental leave by the American Board of Surgery (ABS).2 This is insufficient. For comparison, our trainee colleagues in both Anesthesia and Obstetrics and Gynecology are allowed 8 weeks of parental leave, separate from vacation.3,4 Many surgical trainees find ways to patch together a 6-week leave by using all of their allotted vacation time (4 weeks) for the entire academic year. But current ABS policies, which have been recently adapted with the goal of more flexibility, still preclude any leave longer than 6 weeks without having to borrow vacation time from other clinical years or extend one's training time beyond planned graduation. This policy leaves no room for extended leave in the setting of child illness, postpartum complications, or difficult transitions from parental leave to full-time clinical duties. Extending surgical training to accommodate a longer parental leave complicates timely advancement to subspecialty fellowships and jobs. In other words, even with the slightly more flexible ABS policies, surgical trainees who bear children during residency still face a treacherously short leave policy that can predispose many mothers and families to unnecessarily difficult and, in some cases, traumatic transitions back to the workplace.

For decades, childbearing surgical trainees have suffered in silence, operated through miscarriages, delayed childbearing, and timed their pregnancies to coincide with easier schedules during their nonclinical professional development years if at all possible. They have struggled with delays in their academic productivity when they are able to take longer parental leaves. In allowing this, we have created an environment that sets up childbearing surgical trainees for failure. Remarkably, we know dozens of surgeon mothers who navigated this path with apparent success. But if you ask them in privacy, many will tell you that it was immensely challenging and almost impossible. We can no longer afford to revere and glorify the toughness that got those mothers through training and beyond. It does not have to be this hard for future surgeons.

There is now convincing evidence that nearly every facet of pregnancy might be adversely impacted by being a surgeon. Studies have demonstrated that women surgeons are older at the time of first pregnancy than the general population, as well as more likely to use assisted reproductive technology.5 Women surgeons report an overall higher complication rate during pregnancy as well as preterm delivery than that of the general population.1 Supporting data suggests that working rotating shifts, night shifts, or longer hours can place a pregnant woman at higher risk of adverse outcomes.6 Women surgeons take a shorter maternity leave and breastfeed for fewer months on average than their nonsurgeon counterparts.1 Finally, several studies by Rangel et al have shown that childbearing surgical residents regard their maternity leave to be inadequate, wish that they could breastfeed for longer and perceive stigma related to pregnancy at work.7,8 These factors lead to decreased professional satisfaction for the childbearing surgical resident.9 We challenge our profession to do better, to be more innovative, and to find workable solutions to protect childbearing surgical trainees.

A perceived barrier to longer parental leave during training is that we will make compromises in clinical competency if we grant childbearing surgeons longer leaves. We argue that childbearing during residency does not need to result in less competent graduating surgeons. We learned during the COVID-19 pandemic that there can be more flexibility in training programs to graduate proficient surgeons with less than the mandated 48 weeks per year. We should view this as an example that we may allow more time for family planning and parental leave without harming the educational experience of the surgical resident. To date, there have been no studies demonstrating that more weeks in the hospital equates to higher competency. Overarching plans from the Accreditation Council for Graduate Medical Education to focus on competency-based metric education for graduation will help to ease the burden and concern over longer parental leaves.10 As we increase the efficiency and value of resident training, we can also create more flexible, safe, and humane parental leave policies.

Until we move toward a competency-based metric education system in surgical training, there are several avenues that may be explored to increase flexibility for both childbearing and nonchildbearing surgical trainees without compromising clinical competency. The ABS may allow program directors to petition for limited exemptions for qualified residents that have taken additional weeks away from clinical duties, much like the Deficits in Required Training Time policy implemented by the American Board of Internal Medicine.11 Elective blocks, which some programs have implemented in an era of earlier sub-specialization, could be used as parental leave at the discretion of the resident and program director. Each program may designate fundamental rotations as “core rotations” that must be completed regardless of leave time, thereby ensuring competency and increasing equity amongst all residents. Finally, advanced practice providers may step in to bridge gaps that are caused by extended parental leave, especially in the setting of nonoperative rotations and for smaller programs with limited redundancy in resident workforce. Protecting childbearing surgical trainees must not and should not come at the cost of overburdening nonchildbearing residents. Although there will certainly be challenges to creating workable solutions within each program, these challenges are not insurmountable.

It is time to change the policies within our profession to support and normalize childbearing during surgical training. We must first fully acknowledge that our specialty has changed its complexion, with women now representing close to half of our trainees. We must also no longer ignore that childbearing surgical trainees face a limited window of biological fertility that often makes it infeasible to delay family planning until after training. Therefore, we propose the creation of a task force between the Accreditation Council for Graduate Medical Education, ABS, and surgical training programs to create policies that adapt with our generation and provide surgical trainees with the flexibility to succeed both personally and professionally. In this work, we should move toward 8 weeks of paid parental leave separate from vacation for childbearing surgical residents and the flexibility of our program requirements to adapt to the unplanned complication throughout the spectrum of childbearing. In tandem, we must continue to redefine what it looks like to be a surgeon in 2021 and release the vestige of a time past. We should view a woman who operates through contractions as a warning tale and not a story of heroism. History is watching us.

REFERENCES

1. Hamilton AR, Tyson MD, Braga JA, et al. Childbearing and pregnancy characteristics of female orthopaedic surgeons. J Bone Joint Surg Am 2012; 94 (11):e77.
2. American Board of Surgery Leave Policy. October 2019. Available at: https://www.absurgery.org/default.jsp?policygsleave. Accessed February 16, 2021.
3. American Board of Anesthesiology Leave Policy. July 1, 2019. Available at: https://theaba.org/pdfs/Absence_Training_Policy.pdf. Accessed February 16, 2021.
4. American Board of Obstetrics and Gynecology Residency Leave Policy. February 11, 2020. Available at: https://www.abog.org/about-abog/policies/residency-leave-policy. Accessed February 22, 2021.
5. Phillips EA, Nimeh T, Braga J, et al. Does a surgical career affect a woman's childbearing and fertility? a report on pregnancy and fertility trends among female surgeons. J Am Coll Surg 2014; 219 (5):944–950.
6. Cai C, Vandermeer B, Khurana R, et al. The impact of occupational shift work and working hours during pregnancy on health outcomes: a systematic review and meta-analysis. Am J Obstet Gynecol 2019; 221 (6):563–576.
7. Rangel EL, Smink DS, Castillo-Angeles M, et al. Pregnancy and motherhood during surgical training. JAMA Surg 2018; 153 (7):644–652.
8. Rangel EL, Castillo-Angeles M, Changala M, et al. Perspectives of pregnancy and motherhood among general surgery residents: a qualitative analysis. Am J Surg 2018; 216 (4):754–759.
9. Rangel EL, Lyu H, Haider AH, et al. Factors associated with residency and career dissatisfaction in childbearing surgical residents. JAMA Surg 2018; 153 (11):1004–1011.
10. The Accreditation Council for Graduate Medical Education Surgery Milestones. January 2019. Available at: http://www.acgme.org/Portals/0/PDFs/Milestones/SurgeryMilestones.pdf. Accessed March 12, 2021.
11. American Board of Internal Policies & Procedures for Certification. March 2021. Available at: https://www.abim.org/Media/splbmcpe/policies-and-procedures.pdf. Accessed June 5, 2021.
Keywords:

childbearing; parental leave; surgical trainees

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