AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. September 2003, Volume 5, Number 9.

Medical Education

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Pregnancy and Parenthood in Residency

Residency program directors need to establish clear guidelines and policies to accommodate pregnant residents that foster a more conducive and supportive working environment for parents.

Timothy Flynn, MD, and Lara Bonasera, MD

The theme of physician health and well-being cannot be thoroughly explored without introducing the complicated case of a resident physician who is pregnant. The issue is complicated because of the many interrelated, competing (and potentially conflicting) interests of the parties involved. These include the family and health interests of the resident and her fetus; the interests of others in the residency cohort who may have to cover for the pregnant resident and who may have ranked their own family interests secondary to their residency demands; and the interests of the program director who must balance the needs and interests of the pregnant resident with those of other residents and those of patients. Because of the annual matching program by which residents obtain their jobs and training positions, a resident's unexpected need for extended time off or for a reduced work schedule cannot be accommodated easily and may cause interruption in her training which may result in delayed completion of residency.

What policies do you think residency programs should adopt to balance these competing interests most fairly and effectively?

Commentary 1

by Timothy Flynn, MD

There is no doubt that this is a highly charged issue for all involved, but it is unfair to characterize it as a "pregnant resident" problem since that stigmatizes the individual who is most vulnerable. The days of residents being unmarried men living in the hospital are long gone and are not coming back nor should they. We should think of this in the context of the complex family issues all residents encounter. Sometimes I think faculty believe residents have no other life except to serve the program. Moreover we should not look at this situation as somehow unique because the individuals involved are residents. People in their twenties become fathers and mothers; it is what is supposed to happen. The better-run, most profitable corporations in this country have already figured out how to deal with this issue and retain productive employees, even those who have children.

The real issue is not policies but attitudes. While I agree that programs absolutely need clear policies, it is up to the educational leadership to create an environment that does not expect residents to be in reproductive limbo for the duration of training. As employers (we could argue whether residents are employees or students, but to do so would be missing the point), we have a legal and ethical responsibility to be supportive of the family needs of our residents. This is not an issue of training; it is an issue of who does the work. As program directors and faculty, we ought to be able to figure this out. Although, as the furor around the 80-hour week has so well demonstrated, it might not be easy. Yet, it is unfair to blame the residents for a system that we have created.

So the first policy is that residents have the right to pursue having children as they see fit in relation to their own situation. Ironic as it seems for those purported to be in the healing profession, faculty must give support to this notion and make it clear that the program will be supportive. Once it has been established that the program will find ways to support the resident, then it is important that clear policies be written so that everyone knows what to expect. The resident must take responsibility to notify the program administration as soon as possible about her pregnancy or that of a spouse if paternity leave is requested. This must apply to adoption as well. The program director and resident should discuss what rotations the resident should be on while pregnant and ways to accommodate the workload so as to not endanger mother or child. Although not entirely predictable, the duration of the time off should be specified. Most policies identify 6-8 weeks. There must be agreement on what type of leave will be used—vacation, sick leave, leave without pay, and whether any of this can be carry over from previous years. It is also helpful to review the resident's fringe benefits, especially if there is a chance that there might be complications for the mother or child. The resident must be notified by the progam of the effect that time away may have on his or her Board eligibility. The program should also anticipate what steps it would take if there were complications and the leave period had to be extended. All policies must be in compliance with federal law. It is helpful to consult your institutional Graduate Medical Education office to be sure policies meet the legal requirements.

Setting policies is usually the easy part. For the resident taking leave, the experience will be shaped by the reaction of the program director, faculty, and peers. Setting the expectation that parental leave is acceptable is the first step. The real determinant of how a resident's leave will impact the program and the attitude of the other residents is how the program director makes up for the loss of the resident in the schedule. This problem cannot be left to the peer residents to solve. The program director and faculty must find a solution that does not simply shift the work to the remaining residents. This may involve reassignment of mid-level providers, temporarily rearranging services, or having faculty fill in. Whatever solution is chosen, acceptance will be determined by the expectations set initially.

Timothy Flynn, MD, is a professor of surgery and the associate dean for graduate medical education at the University of Florida in Gainesville, FL.

Commentary 2

by Lara Bonasera, MD

Here is the bottom line on residency training: it is not family-friendly. Residents work long hours, take call, and work weekends. This work schedule does not include the academic demands that accompany the job. Throw pregnancy or family into a hectic work week and the stress-meter rises. Male colleagues struggle with the juggling act of work and family, but their wives—bless them—usually pick up the slack in making family life run smoothly. Many fathers are as present in their children's lives today as mothers are—a happy and promising change. Nevertheless more is expected of mothers. And physicians who are mothers, even those with supportive spouses, have complicated choices to make, especially physician-mothers of young children.

Unless a resident's pregnancy is complicated, residency programs need do little to accommodate her. The problems of endless nausea and need for a nap are just a new state of being hormonally "souped up." Being pregnant and tired is not that different from baseline exhaustion on any given post-call day. That said, more rooms in hospitals designated for the napping needs of a parturient woman would be a small accommodation that make a big difference. If the pregnancy is complicated and a woman needs time off to deal with pre-term labor, on the other hand, she has no choice but to finish training later than expected. Bedrest or a reduced work schedule, with resultant delay in completing residency, is a small price to pay to avoid delivering a premature baby.

Despite the continued increase in the number of women in medicine, the struggle of how to balance work and family seems far from settled. Though men are now more involved in their children's lives, raising young children still seems to be chiefly a woman's concern. Ellen More, medical historian and author of Restoring the Balance: Women Physicians and the Profession of Medicine, 1850-1995, reports one male resident's view: "The prevailing attitude is that child-rearing is woman's work. If I ask to leave rounds to attend a sick child or cover for an absent babysitter, I run the risk of appearing as though I have a lackadaisical attitude or my work comes second...The first step is to try to understand that the enormous responsibility we have as parents is a shared one--not borne by the mother alone" [1]. Our profession pays lip-service to the importance of family and living a balanced life, but, in truth, it holds childrearing in low regard, as anyone knows who has taken a day off to care for a sick child. One feels as though a pound of flesh is due to atone for the inconvenience inflicted on colleagues. Nor is this devaluing of childrearing limited to the medical profession. To openly place the needs of our children and family ahead of our work demands, is to risk being a second-class citizen among our working peers. To avoid this we must either be twice as clever or twice as hard working. I have yet to meet a physician-mother who does not feel that she has made significant compromises at home or work, or both. They are proud of the work that they do, but wish for more time with their children and spouses.

Last week, to take just one example, my son had a miserable bout of diarrhea, and the daycare staff told me to keep him home until things improved. My husband was out of town, meaning that I would have miss work. When I called the OR coordinator to let her know I would not be in the next day, she was gracious and sympathetic to my plight. Still, I was sure there would be a price for this "inconvenience" to my colleagues. I had already been issued a warning, in confidence, by a different member of the practice. I was counseled that I should make different child care arrangements once I earned an attending's salary. After all, nannies are perfectly capable of managing a nasty bout of rota virus. Calling in sick, either because of myself or my child, was a definite black mark on my record. I felt demoralized, deflated, angry. I vowed in that moment that, no matter how sick I was, I would show up for work. After all, I do have student loans to pay. But when it comes to my son's or my family's needs, the decision is simple. Jobs come and go; families don't—or shouldn't. I want to be present to toast my son on his wedding day with as few regrets as possible.

To quote More again: "Unquestionably, the greatest obstacle still facing women practitioners is the need to accommodate the demands of childbearing and childrearing" [2]. How a woman balances work and family will be unique and tailored to the demands of her life. There are no easy answers here for residents or residency programs. Admitting that our lives and the lives of our colleagues are multifaceted is a start. We have to honor that raising children is a sacred task, sacred not only because children are our future, but because they are a precious part of making our lives whole.


  1. Milgrom E. Parent or resident or both: a father's dilemma. Hosp Phys. 1989;25:52. Cited in: More ES. Restoring the Balance: Women Physicians and the Profession of Medicine, 1850-1995. Cambridge, MA: Harvard University Press; 1999:251.
  2. More, 248.

Lara Bonasera, MD, is a fellow in pediatric anesthesiology at Children's Hospital in Chicago.

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