Boston, MA-- Surgeons take pride in the intensive training they endure, spending between five and nine years after medical school dedicated to gaining the skillsets needed to provide the best possible care for their patients. For female surgeons who wish to have children, this means that they either start a family during training, or wait until the end of the lengthy training period often when they are in their mid- to late-30s. Women constitute more than half of today's medical school graduates, yet they remain underrepresented in general surgery, making up 40 percent of residents and only 18 percent of faculty members in the United States. This gender discrepancy has been attributed to lack of female role models, gender discrimination, as well as pregnancy and child care concerns, which significantly impact general surgery residency program recruitment and attrition rates. To better characterize their experiences and target interventions, investigators at the Center for Surgery and Public Health at Brigham and Women's Hospital conducted a national survey of 347 general surgery residents who had at least one pregnancy during residency. Their research reveals significant cultural challenges and infrastructure shortcomings that led 39 percent of respondents to seriously consider leaving residency and 30 percent to report they would advise a female medical student against pursuing a career in surgery. The findings are published this week in JAMA Surgery.
Social media played a critical role in the study, providing platforms for female surgeons to discuss their experiences during pregnancy and the challenges they faced.
"Overall, women were very excited to have this issue studied formally. There have been publications reporting a growing number of female surgeons having children during residency, but this is the first national study to look at the actual perspectives of general surgery residents who were pregnant," said Erika Rangel, MD, MS, lead study author and a surgeon and researcher in the division of trauma, burn and surgical critical care at BWH. A 74-question survey was electronically distributed to active members of the Association of Women Surgeons (AWS), members of the Association of Program Directors in Surgery listserv, and targeted groups on the social media platforms on Facebook and Twitter, including the Physician Moms Group and Surgeon Moms Group, which posted membership numbers of 67,156 and 960 respectively at the time of survey distribution.
Researchers used a cognitive testing approach to develop the survey, and, after several rounds of cognitive feedback, the final survey instrument was developed and piloted with a small group of female surgeons at the AWS. The survey collected demographic and residency program information that assessed perceptions on working while pregnant, maternity leave policies, breastfeeding and lactation, childcare and motherhood, job satisfaction, perceptions of stigma, attitudes of colleagues, and satisfaction with training program support.
The results of the survey reveal a lingering negative stigma surrounding pregnancy, with 75 percent of respondents having witnessed faculty members or other residents making negative comments about pregnant trainees or childbearing during training. Sixty percent of participants reported that there was a negative stigma associated with being pregnant as a surgical resident, and just over half perceived pressure to plan pregnancies during nonclinical time. The majority (86 percent) of women worked an unmodified schedule until delivery, with similar numbers reporting that requesting accommodations for less demanding rotations during pregnancy would have been perceived negatively by their peers and supervising faculty. Two-thirds were concerned their work schedule or duties adversely affected their health or the health of their unborn child. Inadequate workplace infrastructure, including lactation support and child care options, also posed challenges for participants in addition to a lack of mentorship on balancing career with pregnancy and motherhood.
"Over half of medical school graduates are women," said Rangel. "If we want to educate and retain the best surgeons, we need to create a better training experience for women who wish to start families during their training."
Only a third of respondents reported the existence of a formal surgical program maternity leave policy at their programs, and a majority cited the American Board of Surgery (ABS) Leave Policy as a major barrier to obtaining the desired length of leave. However, according to Rangel, said, "There is a misconception that the ABS is an obstacle to getting longer maternity leave. In general, about 78 percent of women were getting six weeks or less of maternity leave, and about 72 percent thought this wasn't enough time. Most people thought it was because ABS didn't allow more time. However, the goal of the Board is to ensure the adequate training of surgeons to be prepared to take care of patients, and they offer several leave options to make this feasible for everyone, even with longer maternity leave."
Since the results of the survey were first presented, the ABS has clarified its leave policy on its website, and the Association of Program Directors in Surgery will be meeting in May this year to discuss how to improve the training experience for pregnant residents. "There are a lot of low-hanging fruit - smaller modifications that can be made to make the overall training experience much better for this group of women. If you don't have a maternity policy, make one. It can reduce the stigma of having to ask for help," said Rangel.
At BWH, the Department of Surgery is actively working to create an equitable work environment for its surgical trainees. Douglas Smink, MD, surgical residency program director and coauthor on the manuscript has organized discussions on gender issues and disparities within residency for trainees, facilitated by female faculty. "At BWH, we have accommodated a variety of maternity leave requests for our surgical residents, considering their various needs. Each maternity leave is managed on a case by case basis, depending on what the resident's wishes are," said Smink. "We are also putting together support documents including information on lactation support, childcare assistance, and examples of various maternity leave options so that residents are well-informed," said Rangel. "Additionally, we have a group of female faculty who meet routinely in a social setting with the resident mothers to provide mentorship and support as well.
"There is no good reason why the goals of training in surgery, and starting a family should feel mutually exclusive. Understanding what that experience has been like for recent trainees is a next step in the continuous improvement of surgical training. Developing effective, progressive employment practices for our surgical residents will help us to recruit, to retain and to deliver the most prepared surgeons to society," said Gerard Doherty, MD, chair of the Department of Surgery and Surgeon-in-Chief at BWH,
Next, Rangel is set to publish a qualitative analysis of the survey, facilitating better targeting of potential interventions by general surgery programs directors.
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Paper cited: Rangel, et al. "Pregnancy and Motherhood During Surgical Training" JAMA Surgery. DOI: 10.1001/jamasurg.2018.0153.
The Center for Surgery and Public Health (CSPH) at Brigham and Women's Hospital was established in 2005 as a joint program of Harvard Medical School and the Harvard T. H. Chan School of Public Health. Its mission is to advance the science of surgical care delivery by studying effectiveness, quality, equity, and value at the population level, and developing surgeon-scientists committed to excellence in these areas. CSPH works with a diverse set of collaborators, including academic institutions, non-profit and for-profit organizations nationally and internationally, in order to eliminate disparities and foster patient-centered care through policy and practice.
Brigham and Women's Hospital (BWH) is a 793-bed nonprofit teaching affiliate of Harvard Medical School and a founding member of Partners HealthCare. BWH has more than 4.2 million annual patient visits and nearly 46,000 inpatient stays, is the largest birthing center in Massachusetts and employs nearly 16,000 people. The Brigham's medical preeminence dates back to 1832, and today that rich history in clinical care is coupled with its national leadership in patient care, quality improvement and patient safety initiatives, and its dedication to research, innovation, community engagement and educating and training the next generation of health care professionals. Through investigation and discovery conducted at its Brigham Research Institute (BRI), BWH is an international leader in basic, clinical and translational research on human diseases, more than 1,000 physician-investigators and renowned biomedical scientists and faculty supported by nearly $600 million in funding. For the last 25 years, BWH ranked second in research funding from the National Institutes of Health (NIH) among independent hospitals. BWH continually pushes the boundaries of medicine, including building on its legacy in transplantation by performing a partial face transplant in 2009 and the nation's first full face transplant in 2011. BWH is also home to major landmark epidemiologic population studies, including the Nurses' and Physicians' Health Studies and the Women's Health Initiative as well as the TIMI Study Group, one of the premier cardiovascular clinical trials groups. For more information, resources and to follow us on social media, please visit BWH's online newsroom.
Journal
JAMA Surgery