Association for Academic Surgery (AAS)

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Next #AASChat: Pregnancy Among Surgeons

Join your colleagues for our next AAS Tweetchat, Wednesday, December 15th beginning at 9:00pm Eastern – Drs. Erika Rangel and Rebecca Scully will co-moderate a discussion based on Dr. Rangel’s recent blog article:

Having it All and “Leaning in”: Infertility, Pregnancy, and Obstetric Complications in US Surgeons

I became pregnant during my fourth year of surgery residency.  There were no overtly negative comments, but reactions to the news were generally of shock, followed by murmured congratulations, followed by incredulity.  How were we going to swing childcare as a dual-surgeon couple without family close by?  Wasn’t I worried about doing long cases?  Surely I was going to choose a more “family-friendly” subspecialty!  Well-intentioned questions and curiosity to see how I would pull off this unusual feat fueled my latent self-doubt that this had been a wise decision.  I hated the idea that I would be a burden to my co-residents, so I worked twice as hard to prove myself, even when sometimes I didn’t feel well.  In my 36th week, I went into labor in the operating room while covering a vascular surgery case with a bad URI and a fever.  The L&D nurse admonished me for allowing myself to get so dehydrated and snatched my pager away, not understanding the sin of leaving the consult service uncovered.  My premature son had a rapid response soon after birth for pneumothoraces requiring bilateral chest tubes and intubation.  Upon my return 6 weeks later, a group of senior surgery residents started a collection with a bet as to whether I would ask to scrub out of a long case staffed by an older male surgeon or if I would instead leak through my sterile gown.  The stigma I felt, of being an inadequate new mother and a delinquent surgery resident, was both real and self-imposed.  Nearly 12 years later, I ask myself these questions:  Why is martyrdom in our profession praised as strength?  Why do we glorify unhealthy behaviors that perpetuate unsustainable ideals?

As it turns out, my story was not unique.  As social media expanded in the years after Ethan’s birth, many surgeons shared stories far worse than mine.  Although cathartic, I knew change wouldn’t happen through private venting sessions.  I wanted other colleagues to understand what the problems were and how they could affect us as a profession.  I must be clear that I do not think parenthood is a gendered experience.  The nonchildbearing parent of today is typically actively involved in his/her child’s upbringing, making issues of parental leave and work-family integration important for all surgeons.  However, the physical demands of our profession often clash with the physical demands of pregnancy and demand special attention.

In 2017, we sought to characterize the experience of surgical residents who had been pregnant during training.  Nearly 350 female surgeons painted a picture of working unmodified work hours until birth, of worry that these schedules would harm the unborn baby (but keeping quiet due to fear of stigma), of inadequate maternity leave of 6 weeks or less.  After childbirth, the challenges continued.  Nearly half could not meet their breastfeeding goals, largely due to inadequate lactation facilities and being unable to leave cases to pump. Few had childcare support or mentorship in navigating their dueling personal and professional priorities.  These issues culminated in career dissatisfaction for many, with nearly 40% strongly considering leaving residency and 30% reporting they would discourage a female medical student from pursuing surgery due to work-life incompatibility.  The potential workforce impact of these struggles had people listening.  One of my male colleagues mused, “the women I knew who had kids in residency were the strongest of all of us. I would never imagine they had struggled”.

And yet being the “strongest” surgeon does not impart any protection against nature or medical complications.  In 2019, one of our colleagues had a hemorrhagic stroke while 34 weeks pregnant.  She had done all the right things as the “strong” surgical partner.  She had waited till training was over, quietly underwent IVF, and kept up with her busy surgical practice throughout her twin pregnancy without complaint.  She underwent surgery, her twins were delivered early, and thankfully everyone survived.  But the surgical community was reeling. What could have been done differently to prevent this tragedy?

In 2020, we surveyed surgeons across the US to understand their experiences with infertility and pregnancy complications.  What we found validated our concerns.  Female surgeons were more likely to delay childbearing due to training and were more likely to use assisted reproductive technology.  Most women seeking assisted reproduction took less than 3 days off to complete treatments, despite needing an average of 4 cycles of invasive treatments to achieve a pregnancy.  Nearly half of female surgeons had a pregnancy complication, with a 1.7x greater odds compared to non-surgeon partners of male surgeons.  As in our resident study, it was common for pregnant surgeons to push the boundaries of healthy work schedules, often due to perceived stigma or lack of support from the workplace for clinical duty reduction.  Those operating 12 or more hours a week were at highest risk for complications, yet very few reduced their workload during pregnancy and over half continued working over 60 hours a week.  42% of surgeons had suffered a miscarriage, a rate more than double the population norm, but 75% took no days off work to recover or grieve.  These struggles came at a cost, with higher rates of burnout and lower wellbeing scores among those with infertility and major pregnancy complications.  Dr. Eugene Kim presented these findings during his Presidential Address to the AAS in February 2021 as a call to action for our profession to better support our colleagues starting families.

Improving our profession means we must fight the status quo.  We cannot perpetuate unhealthy norms by commending practices like breaking one’s water in the operating room or taking 6 overnight calls the month before delivery. Taking time from work should not be considered indulgent, but must be an expectation among surgeons who espouse the importance of appropriate recovery time for our own patients.  Policies that provide support for a brief period during pregnancy is a small investment that provides a return of 25-30 more years of a surgeon that will serve the community and will model a career with work-life balance to recruit the next generation.

Questions to be discussed on the December 15 Tweetchat:

  1. Have you personally felt pressured to work beyond what you thought was healthy during your pregnancy? Did you say something to your program/work leadership or your colleagues? If not, why not?
  2. In your experience in your institution, what do you think is a practical solution to create redundancy in the workforce such that work adjustments for pregnancy do not compromise patient care?
  3. Should surgeons who take work reductions during pregnancy be reimbursed equally?  Does it matter if these reductions are obstetrician-mandated vs self-requested?  
  4. Do you believe your work duties were related to adverse maternal or fetal outcomes?
  5. Many women postpone having children until after training, which can contribute to increased risk of infertility. What do you see as the most important things our profession can do to support these struggles?
  6. Should training programs cover oocyte preservation?
Erika Rangel, MD

Erika Rangel, MD

I am a general surgeon and surgical intensivist at Brigham and Women's Hospital where I serve as the Director of the SICU at Brigham and Women’s Faulkner Hospital, and the Associate Surgical Clerkship Director for Harvard Medical School. My academic interest centers on defining the challenges facing surgeons starting a family, demonstrating how these impact burnout and career dissatisfaction, and using peer-reviewed evidence to inform policy change to better support alignment of personal and professional priorities for surgeon parents.