For being here. Um, she is, uh, someone that many of us know well. Um, and, uh, she is a, uh, trauma surgeon, acute care surgeon, critical care surgeon at Brigham Women's Hospital. Um, and, uh, she's also a mother and a wife and with Doctor, uh, other Doctor Rangel here, um, uh, they're parents. Um, and, uh, we look forward to hearing her talk about her, her research, which really has been groundbreaking in, in, um, uh, the world of surgical training and education. And I think um is uh really appropriate to all of us, um, whether we are the mothers, fathers, to be or have been, um, um, and sort of balancing, uh, our lives as busy surgeons, trainees, um, and, uh, members of family. So, um, thank you, Doctor Rango. Good morning. Um, I'd like to thank Doctor Demy and, uh, Doctor Shamburger, who I know couldn't be here, uh, for inviting me to Boston Children's to give grand rounds. Um, besides the fact that my husband Sean works here, I think it's, uh, especially, um, Uh, special experience for me to be welcomed back here cause it's almost 9 years to the day after I rotated here as a 4th-year, um, general surgery resident at the Brigham. Um, I have no disclosures other than to tell you my personal journey that began this work. Um, in 2008, I moved from California to Boston, um, as, um, With my husband who had just taken a faculty position here. And after a critical care year in 2009, I became a surgical resident at the Brigham as a PGY4 as a transfer from Stanford in California. And I was just sort of adjusting to that culture shock when I discovered that I was pregnant. So, knowing almost no faculty and very few residents, I did a little sniffing around and I found out that only one female resident before me had been pregnant during her non-research years. So, I was more than a little anxious to go to my program director and tell him the news, but his response was actually pretty positive. Great, he said. Uh, we need more female residents to have babies during training. But the reality of that was that we really had very few, we didn't have any conversation about how uh my pregnancy was gonna affect the logistics of the rotations. All I knew was that he was gonna give me all 4 weeks of my vacation time and I was gonna get 2 extra weeks of medical leave and that was gonna give me 6 weeks of maternity leave. Um, and he actually offered me a second choice, which was taking an extra year off and spreading the remaining, uh, uh, remainder of my training over an additional 12 months, but Um, I, 6 weeks seemed really short, and at the same time, I was, uh, painfully aware that I had just taken 3 years off and researched clinical fellowship, and I wasn't getting any younger, so I passed on that second option. Were there any other options? I kinda didn't really know because the ABS website suggested that there weren't any other options and I really was too scared to ask. So not wanting to create any more of a ruckus, um, I wanted to show everybody that I wasn't gonna be a burden on my co-residents, that I could be just as strong as all the other residents, um, and that I wasn't gonna be any different. So, um, With that in mind, um, I went back to work and things went pretty well until I was in my 3rd trimester and I was getting kind of slow and uncomfortable. And about 36 weeks of pregnancy, they pulled me off a relatively light MIS rotation to be the vascular surgery chief resident. And as luck would have it, I also had developed the flu, um, but I certainly wasn't gonna tell anybody because residents don't say they're sick. Um, and, you know, the caseload was really, really heavy, and I, most importantly, didn't want to be viewed as the weak link. So, at 5:30:30 in the morning, enormously pregnant and febrile, I'd go to work and I'd be on my knees, Dopplering in these ischemic feet, and then we'd go to the OR where the cases would be long and there really wouldn't be enough time to eat or drink anything. And I think I went the whole day before I realized that the baby wasn't moving. So in between cases, I went to LND. And they did an ultrasound and a bunch of tracings and said the baby wasn't doing very well and it had to be delivered. So even then, I was so worried that I hadn't found coverage for myself that I was still answering pages for the vascular surgery pager as I went back to the OR to get a C-section. So we had a baby boy that night, um, and after the fiasco of the C-section, I had just fallen asleep in my room and Seann had just gone home when the neonatologist comes running into my room and says that Ethan had developed bilateral pneumothorasis. So, um, apparently these things happen when the baby is premature enough not to have enough surfactant, um, but the chest wall is still strong enough to pull and develop these pneumothorases. So while I had been sleeping, My infant boy had gotten bilateral chest tubes and been intubated. I've been a mom for less than 12 hours and I already felt like I had failed him by prioritizing my reputation as a resident over my health and therefore his health. So, it actually went fine after that and we went home and I had just about 4 weeks left of my um maternity leave. So with no family in town and a 2 surgeon household, we had to stick to our original plan of sending this tiny little guy to a small daycare we'd found in Coolidge Corner and picked on the basis solely of the fact that they were open at 6:30 in the morning. Um, the hospital sponsored daycares all have these really long 1-year waiting lists. Um, they were really too far to walk to anyway, and, uh, most importantly, they open at 7 in the morning, which was something that was way too late for a two-surgeon family, um, for a two-surgeon household. So as you might imagine, my son was literally sick all the time at daycare. So I was determined to at least provide breast milk. But the reality of that was that you have to pump for 30 minutes every 4 hours. Um, and that was really an unrealistic feat when you imagine that you're a resident who operates all day long and the nearest lactation room is 10 floors away in a different building. So I got up at 4 in the morning. I usually skipped lunch because I needed every single free moment to pump. And even then, I got mastitis all the time because it wasn't often enough. Um, and, you know, there's really no reason that a resident can ever ask to step out of the operating room to pump, so, or step out of the operating room for any reason, much less to pump. So, in about 5 months, I gave up on nursing despite my initial determination that I was gonna provide him the antibodies that I really thought he needed. So whenever he got a cold, Shawn and I would put Tylenol or ibuprofen in his bottles and we would cross our fingers and hope that daycare wouldn't call us for a fever because certainly neither of us could take time off to go and pick him up. The workers um got used to the fact that we were usually the Ethan was the first to arrive and the last to leave. Um, and Sean and I, even then, we had a more than a few near misses when both he and I were stuck in the operating room and the daycare was closing, so we would pay the daycare workers under the table to stay a little bit longer in that darkened daycare to sit with him past closing, and that was something that weighed really, really heavily on my already guilty conscience for feeling like I was an absentee mother. One day, Sean was actually slated to give Gren rounds here, and as luck would have it, of course, the daycare worker chose that day to oversleep. So at 6:40 in the morning, he comes pulling into the Brigham Circle and frantically hands me this baby with a poopy diaper, and he's like, I gotta go. And so I take the baby and I finish trauma rounds holding this crying baby in my arms, and then run and I have to give M&M with poop on my white coat. And all the while, my co-residents are sort of passing the baby around the back of the conference room. And I can hear a few snickers from people saying, who would bring a baby here to a conference? And so I felt like I was really failing as a mother and failing as a resident. And those were the two jobs that were the most important to me just a few years ago. And I had a pretty good sense that um postpartum depression probably played a role in my struggle, but there was really no time to seek treatment. And after a few months of this, I felt pretty empty and I had lost my love of the operating room and of the profession. I once prided myself on being an efficient, tough resident, the kind where the training superseded everything else. And here I was having trouble with surgical life, which to me equated to the idea that I probably really shouldn't be there anymore. I really wanted someone to talk to, but I didn't see anybody who was out there balancing being a mom and a surgeon, and at, at least there was really no one that outwardly did so. Um, so 6 times I stood in the hallway of my program director's office planning to quit. So the salvation of my career is sitting right there. Um, he would often meet me in between cases in the lactation rooms, having already bought a sandwich, and he'd feed me and wipe away tears and talk me off the proverbial program director's ledge and keep reminding me how I had once loved surgery. Um, and, you know, thank God I stayed. So today, I, I love what I do. I have this great mix of academics and critical care, um, and general surgery and teaching. Um, but that experience that I share with you is indelible in my mind, and I later learned that there were countless other women around the country who shared similar journeys and similar struggles. Were we all just weak residents who couldn't handle the stress? Was the profession better off without us, with people who could dedicate their entire soul to the hospital and this profession without the burden of babies and family? I didn't really think so, but I thought there needed to be a collective voice. Something to quantify and fuel change. And so with that in mind, I wanted to share what I've learned with you. So in case my personal story doesn't convince you, I'm gonna share some dry facts with you. Um, half of medical students are now women, but females are still underrepresented in surgery, making up about 40% of general surgery residents and 18%. Of faculty in the United States. And uh the data says that medical students, female medical students are less likely to pursue a career in general surgery. They make up just 3% of all general surgery applicants over the past 4 years. They're represented by the red bars here. Family and lifestyle really um uh drive medical student specialty selection. And um there's actually a lot of articles that describe the impact of family and lifestyle and on the decision to pursue a career in surgery. Doctor Tarpley's group at Vanderbilt looked at nearly 1000 medical students, about half of whom were women, and they were asked to complete this sentence. I would be more interested in a surgical field if, and there was a big gender discrepancy in the way they answered or they finished that sentence. So, 84% of women versus 50% of men agreed that they would be more interested in surgery if a 6-week parental leave were more accepted. And 75% of women versus 46% of men said they'd be more interested in surgery if on-site childcare were provided at their hospital of employment. Similarly, um, another group looked, uh, through the Association of Surgical Education looked at 1300 medical students. Again, half of them were women. Um, and they were asked about how their attitudes toward, uh, asked about their attitudes towards sur uh surgeons and how that impacted their desire to go into surgery. Women more than men were discouraged from a surgical career by their decision to have a family, and similarly, women much more than men were deterred by this perception that surgeons don't lead well-balanced lives. So Pat Newman is the founder of the Association of Women Surgeons and the past president of the American College of Surgeons. She wrote the commentary to that paper, and she said the strong influence that students placed on do not lead well-balanced lives and decision to have a family and their perception of unhappiness speak clearly to their assessment of our lifestyle and their values. We can address issues such as parental leave, childcare, and reduced work hours, which would improve lifestyle. So sage words, but much easier to say than to actually do. So let's talk about the current status of integrating motherhood and surgical training. What do we know about pregnancy and surgical training? It turns out we don't actually know that much. There's just a smattering of single institution studies, most of them with 6 to 9 women who've been pregnant during their training. And one study says that the women who had pregnancies actually did pretty well on their residency. They scored similarly on their sites before and after their pregnancy. Um, and if you look at proportions, a greater proportion of them matched into their fellowship of choice versus the people who hadn't been pregnant. But there are a lot of problems including women who worked all the way until they delivered and pregnancy complications and short maternity leaves. Um, some people talked about how they had trouble breastfeeding for how long they wanted to and talked about the stigma related to pregnancy and didn't really understand all the institutional parental leave policies. So despite lacking a lot of data about the experience, we know that it's now more common for women to have children during training than it was in the past. A survey was done in 2008 of 2000 women in the American College of Surgeons, and they showed that more women um who graduated over the past 10 years have been pregnant during training compared to their counterparts in years past. So, even though there's that shift, the current support of pregnant residents by training programs is really variable. This is a survey of US General Surgery program directors in surgery that was just published about 1.5 or 2 years ago. And they showed inconsistent maternity leave policies, just about 50% reporting lactation facilities and much, many fewer providing any sort of childcare support. Um, their responses also showed that implicit bias may still exist at the surgical education leadership level, with almost 50% of program directors saying that the best time to have a child during training is during your research years, and over 60% saying that becoming a parent negatively affects a female trainee's work. And a third, saying that pregnancy places an increased burden on, on the woman's fellow residents. And program directors perceive children's children as decreasing a female trainee's well-being more often than men, to the tune of 32% versus 9%. So these studies suggest that bias probably does exist and there are probably some issues, but should we really care if women wanna have children during residency, or is it really just enough to focus on the OR experience and the training? So one rationale is that we have plenty of women going into surgery. I just told you that there's 40% of residents being women. So if you believe the pipeline theory, it would seem natural that eventually it's gonna even out and we're gonna have a lot more female faculty, right? Um, I'm gonna, that's actually the wrong mindset, and let me tell you why. So, attrition in general surgery is still problematic, with some studies suggesting that women are at higher risk than men, 25% versus 15%, uh, leaving the profession. And as I showed you, medical students are deterred by this perception that we don't lead well-balanced lives and we don't have enough time for, for family. So our pipeline is in fact not as robust as it needs to be, given that half of our pool of talent comes from women. Both of these issues directly affect the US surgical workforce in an era where recruiting general surgeons is becoming increasingly difficult. With more women choosing to have children during training and the, uh, um, the impact of childbearing and motherhood on attrition and recruitment needs to be better understood. So with that in mind, we wanted to characterize the national experience and perception of women who have been pregnant during their surgical training and to describe the challenges, the potential impact on training. And to identify the areas with the greatest potential for improvement. So we devised a 74 question survey and we sent it to all surgeons who had more than one child during an ACGME accredited, accredited US General Surgery training program over the past 10 years. And that was distributed through all active members of the Association of Women Surgeons, the Association of Program Directors in Surgery, in which program directors were asked to collaborate with us by sending the survey to current and past female trainees and through social media platforms like Facebook and Twitter. And we use these Two, Facebook, uh, groups, the Physician Moms Group and the surgeon Moms group. Um, some of you may be familiar with these groups, but for those of you who don't know, these are Facebook, closed Facebook groups where membership is by invitation of another physician or surgeon only, and the membership consists of all mothers. Um, uh, the membership's very robust. There's over 70,000 in PMG worldwide and over 1100 in SMG worldwide. So, um, we collected information about level of training during pregnancy and residency program information, and we really focused our questions on the six themes of working while pregnant, maternity leave policies, breast breastfeeding and lactation, childcare, mentorship, and career satisfaction. And despite running focus groups to develop the survey, we were cognizant that structured forced choice questionnaires probably wouldn't capture a deep understanding of a complex social experience like this. We also didn't really want to just focus only on the negative experiences. So we included an opportunity at the end of the survey for open ended questions that asked, what's the main change that would have made your pregnancy during surgical residency more manageable? And are there any other issues regarding your experience of pregnancy during training that you want to discuss? And this paved the way later for qualitative content analysis to establish common themes, both positive and negative. So, we ended up having almost 350 women with 450 pregnancies over the past 10 years who answered our survey. And um this graph shows the timing of their pregnancies during their training with the majority of them having at least one child during their clinical or non-research years. I'm gonna spend the next several slides sharing resident perceptions on each of the six themes that I talked about beginning with working while pregnant. And I'm also gonna show you several slides with this format. So let me just take you, uh, spend a moment to tell you how it works. So the survey questions are on the left, and the percent of people who disagreed with the statement are represented by the blue bars, and the percent who agreed with the statement represented by the red bars. So most residents worked an unmodified schedule until they gave birth, and yet 3-quarter of them agreed with the statement, I worried my work schedule compromised my health during pregnancy or the health of my baby. Most, or 85%, said that they were worried that they would be perceived negatively by their colleagues or faculty or cause resentment if they asked for a lighter schedule during any time during their pregnancy. And 60% said that they felt that there was a negative stigma associated with being a pregnant resident. So even though residents expressed concern about the impact of rigorous rotations on maternal and fetal health, many were reluctant to ask for accommodations. Fear of appearing weak was an important theme identified in uh qualitative analysis. I'm sorry. Um, this respondent said she didn't wish to appear weak and therefore she would never ask to leave a case to pump in the middle and she operated until the day of her induction. Fear of such stigma impacted how often res uh respondents spoke up about their health concerns, but we found that many actually wished for work modifications during the late stages of their pregnancy due to health concerns. This respondent described um This respondent described feeling overworked because she was required to pay back her call for maternity leave, and she believed that was related to her premature contractions and she felt like her health really wasn't a priority to the residency. And then another described being on call every other day during her third trimester, she developed pregnancy complications and delivered prematurely. Stigma related to pregnancy and being a mother manifested in the term of negative, uh, I'm sorry, manifested in the form of negative comments or implicit bias. One respondent felt that she was perceived differently after she became a mom, like somehow she wasn't as committed or she was more distracted. Attendings would question her availability or her career choices. Several commented, well, you're a mom now. At, uh, she felt that there was a strong perception among women in surgery that being pregnant is looked down upon by other surgeons. Another respondent commented on the stigma she felt from her co-residents who said, who she said acted like she was going on vacation during her maternity leave. She felt like her absence was a burden to them because of the lack of redundancy in the resident workforce. Next, we evaluated maternity leave policies. Just a third of residents reported that their program had a formal maternity leave policy. This graph shows the number of weeks maternity leave residents were given with the most common duration being 6 weeks, and 78% of residents getting 6 weeks or less. 72% of residents felt that the length of their maternity leave was not sufficient. And the majority thought that they took less maternity leave than they would have liked because of the American Board of Surgery leave policies. So I wanna give you some perspective and I have the ABS leave policy here. It states that it requires 144 weeks of training during your 1st 3 years of residency and 96 weeks during your last 2 years of residency, and that leaves 12 weeks in your PGY 1 through 3 years for vacation, and 8 weeks during your PGY 4 and 5 years for vacation or non-clinical time. If you have a documented medical condition, 2 additional weeks are allowed off without affecting your graduation, and that includes pregnancy. So most women are taking their 4 weeks of vacation time, adding it to the 2 weeks of medical leave and that's how they come up with their 6 weeks. Um, so like I previously showed you, comments about maternity leave support generally fall into these two categories. The first were people whose program lacked any type of leave policy, and they talked about the stress that caused. And the second group, um, were people who felt like the American Board of Surgery were responsible for limiting the duration of maternity leave. So this resident points out that the presence of clear maternity leave policies would normalize pregnancy and motherhood, and it would help to remove the negative connotation currently associated with pregnancy. Many discussed the reasons they felt like the 6-week leave was inadequate. This resident used all her vacation time and all of her medical leave to get the 6 weeks, um, and the exhaustion and stress of such a short period off combined with postpartum depression really, uh, compromised her growth as a surgical chief resident. Comments showed very limited understanding of the ABS leave policies. This resident says that her program told her she could have as much time as she wanted, but it was the ABS rules that forced her to come back after 6 weeks. The second respondent describes the lack of clarity in the board's policies. She wasn't sure if leave could be extended by just a few more weeks or would you have to take an entire extra year off. So we'll come back to this in a little bit because in reality, there are a lot of other options. So next, we evaluated resident perceptions on breastfeeding and lactation support. Breastfeeding was important to almost all residents with 90% of residents breastfeeding for some duration um of time at least, but over half stopping earlier than they wanted to due to the challenges balancing work duties with time to express milk. Designated lactation facilities were available for 63% of respondents, but access was hindered by the inadequate number and location of facilities for half the women. Leaving an operation to pump milk was considered difficult. Um, these questions showed that a minority of women, just about 15%, agreed that they were comfortable asking attendings to leave a case to pump. Similarly, few were of the opinion that their attendings would not mind if they asked to scrub out to leave a case to pump. And 2/3 of women favored the establishment of case coverage policies by fellow residents to allow time to express milk. These written responses underscore the importance of residents being able to breastfeed or to provide milk for their newborn infant, um, given the, uh, long hours they spent away, and they described dismay over the inadequate facilities. One described, um, one described using closets, toilet stalls, and showers, and she ended up having to stop pumping earlier than she wanted to. Requests for improvements in lactation facilities were straightforward and based on the desire to improve work efficiency. For example, the second quote here, requests computers in the room to get work done more efficiently. And other common requests were rooms with proximity to the operating room and practical amenities like a refrigerator for storing milk. So the fourth theme of the survey focused on childcare support. Childcare support was defined as a preferential or discounted uh enrollment in a daycare, a backup childcare center, or a monetary stipend to assist with childcare costs, and that was available for just 18% of residents represented in red here. But only 3% represented by that little purple bar had daycare accommodations that were compatible with the surgical residents' work hours. Over three-quarters of women felt like they would have been able to focus on their duties and education more if they had more childcare support by their institution or program. And comments described difficulty that residents had in finding childcare that accommodated a certain schedule and the prohibitive expense of a nanny. Early mornings and late evenings really limited their options, and long waiting lists precluded the uses of these daycares anyway. And the 5th theme of the survey focused on mentorship. Just a third of respondents were satisfied with the mentorship they got during their residency on integrating a motherhood with a surgical career. Women wanted guidance on accessing resources and balancing family needs without sacrificing their training, and several were discouraged by the paucity of female role models that showed the balance between being a mother and being a surgeon. But those that did have support from female faculty emphasize the value that those relationships provided. This person describes how helpful it was to have a surgeon mom on faculty who provided her advice on rotation schedules, being a sounding board, and just an overall source of support. And lastly, we evaluated career satisfaction. So, the challenges these women faced may have a significant impact on our surgical workforce, with over 40% of respondents saying that their experience of pregnancy during residency made them strongly reconsider whether they wanted to stay in surgery. Over 25% of women said that they, given the chance to choose again, they would have preferred that they had chosen a career more accommodating of surgery and family. Than, um, I'm sorry, pregnancy and family than surgery. And 30% of residents said that if a female medical student came to them for advice, they would caution her against going into surgery specifically because of the difficulty balancing a surgical career with motherhood. So, over 50% of residents expressed agreement with some form of professional dissatisfaction here. And we asked ourselves why? So there's a lot of issues here and some are easily fixed and some not so easily, and we wanted to know what are the structural and cultural factors within residency that would make the biggest impact so we could focus our efforts there. So we use multivariate analysis to look at which risk factors were most associated with career dissatisfaction. We found that lack of a formal maternity leave policy at a program and the perception of stigma against being pregnant were independent risk factors. But I thought most interesting was that women who had, were at greatest risk of professional dissatisfaction were the ones who had changed fellowship plans because they perceived difficult uh difficulty balancing their original subspecialty choice with motherhood. So that concept takes a second to wrap your mind around, right? Essentially, this is what these women are thinking. So they go into residency and they have a passion for a particular subspecialty, or they develop one during their residency. And then they have a baby, and after the baby, they think, gee, I don't think that subspecialty is gonna work with my family, and it's not gonna let me um really be a mom. It's not really doable with that kind of a career. So, for those women, this is what they're looking at. Do I make a fellowship change, not because of academic or clinical interests, but because the alternative is to quit or to go into something that I don't think is gonna work with my family. So some women end up giving up their fellowship choice, 16% to be exact. And this 16% were the most likely to respond with uh professional dissatisfaction. So, this is kind of a busy chart, but let me just orient you. The X axis shows um the original pre-pregnancy fellowship training plans listed by the survey respondents, and the Y axis or the height of the bar, um, shows the percent of residents who changed their fellowship plans after having a baby because they think that that preferred subspecialty doesn't accommodate motherhood. So residents who originally intended to train in surgical oncology and pediatric surgery were most likely to change their fellowship plans. 58% of people who originally wanted to go into surgeon um changed and went into something else. And 38% of people originally wanting to do pediatric surgery changed and went into something else. So then we looked at the career path of people who changed fellowship plans after pregnancy. So, what happened to those 16%? What did they ultimately do? So the postgraduate training plans are listed here with frequency and descending order, and for some reason, my PowerPoint isn't compatible with this form here, but it shows that the most common choice was for residents to forego fellowship training altogether. That's 30% of people ended up, uh, just going into general surgery. And the second most, um, common choice was the second bar, um, with 29% going into breast. And this might help you make sense of what I think is going on. So, I just told you that most residents who alter their subspecialty training plans after pregnancy forgo fellowship training altogether. And discontent from that decision may stem from this commonly held belief among surgical residents that subspecialty training is important. Um, this comes from the NERS survey or NES study, which is a huge study of over 4000 categorical general surgery residents. They surveyed people taking the Adsite in 2008, and over 80% of categorical residents answered this question. Um, the majority think that you have to sub-specialize to improve your future lifestyle, compensation, and marketability for jobs. So why is it that women feel like they shouldn't maybe have to give up their fellowship that they want? Don't male residents with children experience those same pressures? So to help you take a, a deeper look at that question, I'm gonna show you some sociologic data on surgeons that shows that women surgeons are a little bit different and they have um different pressures and spend more time fulfilling parenting obligations. So, UC Davis reviewed the child rearing practices of surgeons who had trained at their program. And they, like a bunch of other studies, found that men and women spend equal amounts of time at work, about 65 hours a week. And yet women spend twice as many hours a week on parenting. Looking at the residents with kids, the most common form of childcare was a stay at home spouse, but the majority of, um, those were residents, I'm sorry, the majority of residents with children were men. And so that model doesn't work for a lot of women because the data shows that most partner women have working counterparts, and half of married female surgeons are married to another physician. So, as a result, women are more likely to have family obligations impact their career choices. Bigger studies like um this one from the American College of Surgeons looked, look at how work-home conflicts are resolved. Um, it showed that women surgeons have a much higher chance of having such conflicts over the past 3 weeks, and women with kids were at especially higher risk. And the practical implications of these conflicts were that women are less likely than men to rely on their spouse to care for a child out of school at home sick. They were more likely to feel like child rearing had slowed their career advancement, and that sort of work-life imbalance can be really tough. It causes burnout and depression. And regardless of your personal opinions on how trainees deal with these classic gender schemas, I bring up those issues to you because the pressures of caring for a new child as a female trainee can be overwhelming without it, um, adequate program support. And these pressures cause women to make these undesirable choices when they perceive this fork in the road. Sacrificing career prospects and the intellectual rewards of a preferred subspecialty to reconcile domestic duties may reduce enthusiasm to continue training, and that's the take-home point here. And this is where role models of the same gender and subspecialty are essential to challenge those negative stereotypes, to encourage those residents who are struggling, and to show that the field that they want to go into is compatible with a positive lifestyle. So wow, this is pretty depressing, right? We saw challenges with health concerns during pregnancy due to unmitigated work schedule. Still a lot of stigma against pregnancy in 2018, short maternity leaves of six weeks or less, difficulty. Scrubbing out of the OR to pump. A lot of programs who just don't have a maternity leave policy instill a paucity of mentorship on work-life integration. And all that, all of that put together means that a significant proportion of women having children in surgery are unhappy with the surgical profession, enough to consider leaving it or to tell the next generation of surgeons not to do it. So what are we gonna do about it? So when I first put this data out there, I was expecting all sorts of backlash from the skeptics, and, um, sure enough, um, there were some interesting opinions from the peanut gallery, and the Boston Globe ran this article the next day, and the commentary was amusing and opinionated, and I just put it up for some chuckles here. Um, this guy who calls himself Gandalf says, sorry, pal, the surgeon scheduled tonight had to go home and read to her children. If you make it till the morning, we can schedule you then. Um, the next guy says, let's just change the laws of the universe so that these women can have their cake and eat it too. And the third person says, and on the road trucking is not conducive to young mothers either. Some jobs have core requirements that make them not a good fit for everybody. So, I don't want you to think that the public thinks of women surgeons wanting children this way. In reality, um, most of the feedback that we got was overwhelmingly positive. This AAS blog, um, in response to the article was written by Doctor Andre Wall, who's a transplant surgeon at Baylor and the mom of a residency born baby, sharing her experience with a lot of the same struggles identified in this study. And she said in her conclusion, just because I managed to make it work, I don't believe it should remain a struggle. I've had countless emails from current residents who are excited that we're now talking about a topic that we never even discussed 10 years ago. I'm here giving a grand rounds about it. Um, and we're talking about it at, um, APDS, New England Surgical Society, the Pacific Coast Surgical Society, the American College of Surgeons, to name a few. And that discussion, that amplification is one of the greatest things that we can do to change surgical culture is bringing it to the forefront of the discussion. And this was the first big step. So, negative perceptions and misunderstandings of the board's intentions on maternity leave caught the eye of Doctor Bisky at the American Board of Surgery. So, uh, we reviewed this in a panel discussion, um, including Doctor Bisky and myself at the Association of Program Directors in Surgery, uh, at the annual meeting in the spring. And the ABS completely revamped their leave policies, and this is online now. To show all of the options and ways that they can support maternity leave. It explicitly now outlines the following. So first, the ability to save up your vacation time during your 1st 3 years or your last 2 years to create a longer leave. Two, the option of taking your written board exams after you finish your PGY 4 requirements, just in case you're worried that extending your training might impact your ability to be eligible for your board exam. Third is the option known as 5 and 6, meaning that you can spread your 5 clinical years of training over 6 years any way you see fit. And last, an option that many didn't know about, which is to extend the length of your training by any number of weeks or months beyond the standard June graduation, equivalent to the length of extra maternity leave that you want off. So that would mean that you would graduate off cycle and it's something that the ACGME RRC would have to approve. But it's also um something that the ACGME surgical Accreditation has told me that they have never once denied. So this is about having a conversation with your program director and finding creative ways for him or her to carry an extra chief resident through the summer months, through the summer months or however long that you want to extend. And with fellowship training now beginning on August 1st, that automatically gives an extra 4 or 5 weeks, um, that we didn't have before without impacting your postgraduate training plans. And this is gonna be an important step going forward for women who, uh, want more options when it comes to leave. It really challenges programs to find novel ways to accommodate these off-cycle, um, residents who want to train, and that's really something that we're gonna tackle next, um, in subsequent studies. So the ABS has done something really important to help with maternity leave. But what else can we do to help out with the challenges? And I think there's a lot that we can learn from successful examples of positive outliers. I was really fascinated by this article on Patagonia. Um, the CEO is this woman named Rose Marcario, and she was previously the CFO at a spin-off of Apple called, um, General Magic. And she realized that the focus was never on how to support mothers who just had a baby, or men who wanted to spend more time with their kids at home. Um, it was always on managing this problem of pregnancy and its outcome, which is the demanding child, right? And parental leave policies weren't enough to fix this leaky pipeline of women who are leaving before they reached senior management level. So she created this utopia of on-site childcare, where teachers train in early education, um, run the daycare, and kids take field trips all the time. They have this garden where the employees can go and pick vegetables with their kids during their lunch break, and Um, you know, the kids are bussed to and from school, back and forth to the company headquarters. Um, and school aid, um, business trips are accommodated, uh, by allowing a partner or a nanny to come with the employee, all expenses paid, and maternity leave is 16 weeks off, fully paid. So the result is that 100% of women who've had kids at Patagonia over the past 5 years come back to work. And to give you perspective, the national average is 69%, and 50% of Patagonia's senior leadership are women. Helping employees to find balance is business logic. People who love their jobs, they don't want to shirk their duties to spend time with their kids. Making work and raising your family a zero-sum game chases great employees away. Fortune 100 companies like the Home Depot, Netflix, Google, YouTube, they're all believers in this. They all have similar setups. And the Wall Street Journal says that one of the key reasons for this change is to attract and keep more talented women. So you say, well, that's great for tech and Silicon Valley companies because they have huge profit margins, but it's really not possible in healthcare or the medical field, right? Um, this great model of on-site childcare comes from the Mayo Clinic, where work-life balance is emphasized by provision of a free on-site sick childcare center staffed by nurses and an NP. It's operated at full capacity every day for nearly 20 years. And they described it all the way back in 1999, and even then, the operational cost was offset by the number of sick days off that the employees didn't have to take. For programs with space constraints like the Medical University of South Carolina, stipends have been offered to help residents defray the cost of childcare for the 1st 6 months of an infant's life. So, childcare is really expensive and improving its delivery is really a complex issue. But I'm gonna show you there's actually a ton of low-hanging fruit as well, um, that really makes a difference. And let me start with improving lactation support. The University of Michigan has really set the standard for wellness of postpartum residents in this regard. Recently, formally a Adopting a published policy. And basically, the policy sets expectations for postpartum residents and asks that they communicate their needs clearly to the program director and the faculty in turn um support the residents' lactation needs. And it sets parameters for pumping during cases, clinics, and conferences, um, with cross-coverage during OR cases. And most importantly, it emphasizes support by the Department of Surgery. And I think messages like this go a long way for boosting resident morale. This Michigan surgery resident tweeted, so proud to be a Michigan resident today. My general surgery residency program just formally adopted guidelines for wellness of lactating surgical residents. I think it's a pretty great day for women surgeons and for equity. Who's next? So, it turns out we are. So, following in those footsteps and with enthusiastic support of our department leadership, we created The Brigham and Women's Department of Surgery guidelines for wellness of lactating surgical residents, um, in May. And we also, after years of requests, we were able to get a lactation room by our operating room which has all of the items requested in our qualitative analysis. And that really seems like a small thing, but in an old hospital where space is a hotter commodity than Amazon stocks, um, this was a really big win for us. Um, initial feedback for this lactation room has been overwhelmingly enthusiastic and positive. Mentorship for residents having children is another pretty easy fix. So women mentors may be better aligned to give experience-based advice on balancing childbearing and career, but the scarcity of women in senior faculty position requires novel approaches to make sure that trainees have access to role models, and residents should know that multiple mentors of both genders might be necessary to address different facets of one's career. Structured mentoring. Programs and um planned faculty resident social interactions are effective in reducing burnout, encouraging pursuit of that particular fellowship, and most importantly, in increasing faculty approachability when that resident is facing a personal strain. And this is how easy it is. Um, these are pictures from, um, a, uh, surgeon moms group that we put together at the Brigham. I put it together with another faculty member and we just have some of the Uh, resident surgeon moms over to the house for brunch with their kids. Um, and it's just a place to kind of bounce ideas off one another and to vent and, uh, talk about periods of stress. And another photo from a, uh, resident journal club that we had our house, at our house. I think, um, having time out of the hospital really builds a sense of community and camaraderie. And it's so important when you're going through a tough time in your life. We really feel like the informal time together makes us more approachable when residents are going through, um, a tough time and they're struggling and they need an impartial ear. And how about the things that you can do? So for all the trainees in the room, and this is my soapbox for a second, um, I can't overemphasize how important it is to outsource. Time is your biggest commodity, and anything that buys it is worth it. Invest in great childcare services, a cleaning service, have your laundry and dry cleaning picked up and delivered. Get your food delivered or your meals prepped for you. Keep all your family plans and uh schedules in one. In place and make sure you have time for yourself and for your partner. Include time to exercise and take care of yourself. Renegotiate your family responsibilities and don't try to do everything on your own. And most importantly, find work partners who value family time and cover each other generously for family events. What goes around comes around. I recently came across this advice from another surgeon mom, and it resonated with me in terms of the personal strain that I think many of you are familiar with, but it's always helpful to remind each other to forgive yourself. No one is perfect. The balance you find is the right one. Don't compare yourself with other moms or other dads for that matter. Child care and household duties are not only your responsibility because you're a woman. They can be shared with your partner, your village, or great people you hire to fill your needs. 7 years into practice, my family is very much integrated into my professional life. My husband's sitting here in the audience and we're figuring it out together. Having children during training is a challenge, but it's not an insurmountable one. I encourage all the young surgeons in the audience to prioritize your family as this is a really long career. Advocate for what you need as a working parent. Align your mentors and have faith in your personal and professional networks and communities. Together, we're changing the conversation and we're redefining what a surgeon looks like today. Thanks. Mm I'll take questions. Uh, Erica, thank you very much for, uh, incredibly, uh, timely talk. Uh, as a preamble, uh, two of my classmates are female pediatric surgeons, and, uh, I graduated from medical school about 40 years ago. And, uh, they've had remarkably successful careers and their mothers. Uh, but it occurred to me as I watched their careers evolve that it At no stage has been easy. And uh I was wondering if, uh, in addition to your groundbreaking work, then uh residency, whether there is any kind of follow-up of how uh female surgeons' careers evolve and how we can be more helpful in, uh, allowing them to be the very best surgeons they can be. I think there is a lot of data talking about uh struggles that women have with career advancement and this feeling that, um, having children and this childrearing will slow your career advancement. A lot of that data comes from the college, um. Um, and I, I think there's more to the glass ceiling than just the children. I think there are probably some gender biases that are rooted sort of in these gender schemas that we have. Um, we talk so much about the glass ceiling, but I also think that it's the sticky floor, these challenges with getting up off the junior faculty level that are related to, you know, women being selected less for leadership positions, being given more, uh, tasks that don't really, um, help towards. Career advancement, sort of leading that committee or something that's, and I think that's where having um mentors and sponsors, more importantly in early faculty development is really important to steer you away from those pitfalls that aren't gonna advance your surgical career. But yeah, I think there's a lot of data and a lot, a lot more work that needs to be done in that. Erica, that was incredibly moving. I, I, uh, I think back like Tom does. I was an intern in 1986 and my main mentor was a chief resident who was a mom, and I think how incredibly difficult it must have been for, for Pat. Uh, her daughter is now a social worker here in Boston who I've had the opportunity to have some, some, uh, paths crossed with. Um, I think about how many years have passed between her as a True, you know, hen's tooth, right? And How far we still have to go, um. I'm a 2, part of a two, physician, um, couple, not surgeon, and I remember all the things that you're talking about. I remember spending Significantly more on very redundant childcare than my wife made as a faculty member, not even as a trainee, uh, and like you say, you just have to, you have to invest in the things that, that buy you the time, uh, eventually the, the fortunately, in our careers, the, the money comes back. Um, but I look at, um, we're sitting in a pediatric institution that if, if any, if any place should value parenthood, motherhood, children, uh, and, um, I remember when we applied for childcare, there was 300 people on the list. Uh, and we got a call for a part-time spot when our first was starting kindergarten. It was a little late. Uh, and, uh, I can tell you that today at the at our childcare, there's a waiting list of 300 people, the Boston Children's Childcare. Um, but I'm proud to say that we just doubled the size of the childcare. We just cut the ribbon, uh, on a childcare center that's twice as big. The physicians organization paid. Several $100,000 for the capital outlay to, to do that and to guarantee half the spots for trainees or young faculty members. Um, And I argued to keep the old one and have the new one, and people thought I was crazy, and when the waiting list didn't go down, now in the boardroom, we're talking about how, how shameful it is that we don't have this. So, um, uh, hey, I wanna thank you for, for making, for standing out and making such a, a public stance and using data. Uh, to, to make the point and be willing to, to stand out, and I would hope that, um, other parts of this hospital, a children's hospital will invite you and I'm gonna ask them to invite you to, to speak on this work to try and drive us as an institution. Because for the Brigham to be having pump rooms in the OR and us not, is not OK. So, if you'd be willing to do that. I think, um, having leadership like yourself to make those changes is so important. It shows that you're prioritizing the needs of those women and that that impact really comes from the top. Um, and I will say the only person during my entire time postpartum that ever offered me to step out of the operating room to pump was Doctor Shamburger. Uh, Erica, great talk, and I, I apologize because um we've all come up through the system and we all have stories, the men and women in this room who have completed their training of being abused or working crazy hours on call, no one should be on call every other night, that's inhumane. Um, and we've allowed the system to continue. There, there's no reason for training to be structured the way it is. It's a choice that we make every year. And I, I'm embarrassed that as a faculty member, I haven't pushed to change something that I've known was wrong ever since I completed it 25 years ago. And I think, you know, I want to emphasize this isn't about having women who are having children do any less training. I think everybody agrees that there's a certain number of cases that you have to do, weeks that you have to put in to be a safe surgeon at the end. Um, but it's about sort of restructuring that period, that very brief amount of time. Women need support during maybe 6 to 9 months to have children, and that is gonna give you 30 years of a great surgeon to serve American society. And if we can't support those women for that 6 to 9 months, we're the ones who are really gonna lose out the, the, the American public who need that surgical workforce is gonna be the ones who miss out. First And I remember, I remember distinctly when she told us about it, and uh, Universally, us as her co-residents were very supportive and offered to do whatever we could to help her. Um, I think partially cause there is this very much in the trenches sort of, uh, camaraderie. Um, I also remember thinking that my interview schedule for pediatric surgery was probably more disruptive to my co-residents than her pregnancy was. I wonder if the perceptions that um that you highlighted, um, that these women felt about um putting extra strain on their co-residents, does that actually bear out, or do you have any data about what the residents, the co-residents actually experience, um, in terms of whether that is true or not? So, we're actually, it's interesting that you ask, so, uh, we're looking at that nexus to ask what the uh entire group, the entire cohort, what their perception is of the women who are actually leaving. Some of this may be sort of a self-inflicted thing. I think several. You know, there are countless on the, on the qualitative analysis, there's countless little negative comments about, you know, surgical chairs who are saying, oh, I should have put birth control in your coffee, things like that, that probably contribute to the negative stigma. No one would say, I wish you had flunked your ab site so you didn't take your, you didn't, weren't able to, to go for your pediatric surgery interview. So some of it's sort of this implicit bias and these little negative comments and little digs. I think some of it is self-inflicted, um, but we are looking at that data coming up.
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