A study in the latest issue of Plastic & Reconstructive Surgery reveals that although a rising number of women are training to become plastic surgeons, they may be experiencing a lack of support if they become pregnant.
Only about one-third of plastic surgery residency programs have a formal maternity leave policy in place. In addition, most of the policies that are in place fail to enumerate emergency call coverage, work expectations according to weeks of gestation, and breastfeeding allowances, according to the study.
The duration of leave documented in the study ranged from 4 to 12 weeks, reflecting the contradiction between the Family and Medical Leave Act (FMLA), giving a woman the legal right to 12 weeks maternity leave, and plastic surgery training requirements of 48 work weeks per year. One director stated his program’s 6-week leave policy “could cause problems,” notes a media release from the American Society of Plastic Surgeons.
According to the study’s authors, consequences of the anti-pregnancy culture could include higher pregnancy complication rates among surgery residents, especially with frequent night call and long hours in the operating room; higher age-related infertility rates at time when residents finish training in their mid-30s; unintended childlessness; heightened maternal and fetal health risks; and higher elective abortion rates.
“A number of studies illustrate these consequences for female plastic surgeons,” says Dr Heather J. Furnas, adjunct assistant professor at Stanford University Medical Center and lead author of the article, in the release.
“[these consequences include] a 57% pregnancy complication rate and a 26% elective abortion rate for female plastic surgeon trainees compared to a 41.5% complication rate and a 8.7% elective abortion rate among trainees across all other specialties. Also, unwanted childlessness rate are as high as 43% after training for female plastic surgeons, over three times the 12% childlessness rate for male plastic surgeons,” she adds.
The release notes that the reasons for not establishing a leave policy included concerns of insufficient training time, a shortened clinical experience, and a lack of residents to cover the plastic surgery service. Directors’ comments referred to pregnancy during training as “a difficult issue” because “the other residents have to work harder.” According to one director, having two or more residents pregnant at once “would have a major impact on delivery of care.”
Although only 14% of all plastic surgeons are women, 37% of current trainees are female. “The old training model, in which women were shoehorned into a mold made for men, no longer works,” Furnas states in the release.
Instead, to better support women plastic surgery trainees, the study’s authors propose a standardized leave policy with 8 weeks leave, scheduling flexibility, no make-up call, breastfeeding allowances, and 24-hour childcare; service coverage by paid clinical associates rather than by co-residents, which breeds resentment towards the pregnant resident; and a culture shift away from discouraging pregnancy to actively encouraging female trainees to have children.
Additional propositions include raising awareness of infertility risks, from college through residency; flexible residency start and completion times, with competency-based promotion; and optional research years, since required years lengthen training and raise infertility risks.
“We must support and celebrate pregnancy among female residents,” Furnas concludes in the release. “If we don’t, female plastic surgeons will continue to be a minority at a time when women are increasingly valued in the specialty.”
“Female physicians have been noted to show more concern and empathy toward their patients and to engage in a more partnership-building style compared with male doctors. In our own specialty, women patients with complaints after the physical changes of pregnancy or mastectomy may specifically seek out a female plastic surgeon. Establishing maternity support for trainees will be difficult, but the human cost of not doing so is too high,” she adds.
[Source: American Society of Plastic Surgeons]
I’d like to add a reality check to this discussion to share my perceptions that when alternatives exist, residency training (as it exists right now) may not be the best time to choose to have a child. My reservations are not just for well-being and education of the trainee, but also for the child. Every child deserves a parent that is able to actively participate in the crucial early years of development. Every child deserves a parent who is able to prioritize that child’s well-being without significant and critical distractions. I have the greatest respect for those of my colleagues who have accomplished this balance, but both residency and parenting are time intensive endeavors, and it’s likely that compromises in the quality of each will occur.
For successful implementation of the article’s suggestions, residency training would have to undergo an overhaul to transition from a specified training time to include competencies, with flexible start and finish dates. Bench-marking competencies for skills is feasible, but bench-marking competencies for problem solving is challenging. ACGME committees struggle with this concept. We can all agree that there is more to being a qualified doctor than a list of competencies, and some of that skill requires working experience. “Apprenticeship”is a vital component of residency learning and requires time and presence.
The flexibility of scheduling for pregnancy absences would also make it difficult to create a residency program where the residents are able to contribute in a dependable and meaningful way to ongoing patient care. When the presence or absence of the resident becomes irrelevant to patient care, as it must be if they could be gone for 12 weeks in the middle of a rotation, then the responsibilities for patient care will be shifted to another doctor. It’s likely that an attending would need to cover these leaves since other residents already have rotations. As the attendings assume primary responsibility for patient care in the new order of flexibility for the residents, the residents become superfluous. In the absence of these primary patient care responsibilities, the resident moves to an observer role. We have all seen this trend as an offshoot of the 80 hour work week regulations. While mentored observation is useful, true learning is often stimulated by semi-autonomous patient care.
Paternity leave would need to match maternity leave. Additional staff would need to be hired to cover residency leave. In small programs this may not be feasible.
Exposing the issues of residency pregnancy challenges and making residents aware of post residency infertility concerns are laudable goals. Opening the discussion of modifications of our residency education process to encourage and recognize the importance of family and life balance is vital. However, residents who chose to become pregnant and raise children during residency, as it currently exists, should be aware that they face significant challenges to their simultaneous success in both realms.