Nearly 40 percent of pregnant surgery residents consider dropping out. Many wonder: Why can’t the system accommodate motherhood?
As a health care professional, Dr. Erika Rangel is trained to know when things are going wrong. That alarm went off one day in her fourth year of surgical residency. Her son, just 3 months old, had developed a fever. She couldn’t be late for her operating shift, but his day care wouldn’t accept him if he was sick. So she did what desperate mothers do and got inventive: She slipped liquid Tylenol into his bottle, in the hopes of lowering his temperature, and dropped him off.
Later that day, she stood in surgery with her eyes continually checking the clock, willing the operation to finish in time for pickup. She prayed that the day care wouldn’t realize he was feverish. Had they noticed that his milk had turned medicine pink?
“I felt like I wasn’t being a great mom or partner or resident,” said Dr. Rangel, 42, now an assistant professor of surgery at Harvard Medical School. “Something had to give. I thought about quitting a lot.”
When Dr. Rangel was in medical school, she searched diligently for a specialty that she liked as much as surgery. Her friends cautioned her that if she became a surgeon, she would never have a personal life. She wouldn’t have time for children, they warned — and what man would want a spouse who was constantly in the operating room?
“It became a tug of war between choosing a lifestyle profession versus something I truly loved with all my heart,” Dr. Rangel said. “I chose surgery in spite of all the warnings, and I’ve spent my whole life navigating that balance.”
Even as American medical schools have reached gender parity, certain specialties remain stubbornly male, particularly surgery. Women comprise only 23 percent of practicing surgeons. A recent survey conducted at Harvard Medical School found that the majority of students pursuing surgical careers reported verbal discouragement, and 72 percent of female students perceived it as gender-based; they wouldn’t be able to balance their careers and their maternal responsibilities, they were told. The warnings aren’t unfounded. Surgical residency, which lasts upward of seven years, requires 80-hour workweeks, with little flexibility to accommodate personal or family responsibilities.
The training starts, for most, in their mid-20s and continues into their early 30s — prime childbearing years. Parental leave varies across residency programs, although many residents take six weeks (four allotted for vacation and two for sick leave). When the residents return to the hospital, the 12-hour shifts make child care, breastfeeding and even sleep a challenge.
A 2018 study in the Journal of the American Medical Association surveyed women who were pregnant during surgical residency and found that 39 percent considered dropping out and nearly 30 percent would advise female medical students to pursue a different career. The attrition rate for female surgical residents is 25 percent, 10 percentage points more than their male counterparts.
By 2032, the country will lack as many as 23,000 surgeons, according to a report prepared for the Association of American Medical Colleges. Some medical administrators say the shortfall provides an opportunity to recruit more women to the field. But in surgery, the obstacles to gender parity are formidable.
Gifty Kwakye, 38, an assistant professor of surgery at the University of Michigan, was told by her medical school classmates that she was too “nice” for surgery. She never questioned her own drive to operate, but she did worry that it would be difficult to balance her work with dreams of being a mother. She hoped to start a family during the research phase of her training, when she had more control over her schedule, but things didn’t go as planned. Overcoming medical problems, she became pregnant three months before she was scheduled to return to clinical residency.
Transitioning from maternity leave back to clinical work felt like having “cotton wool stuck in your brain,” Dr. Kwakye said. She woke up every two hours at night to feed her baby. She was so dazed that she covered her home in sticky-note reminders: Bring the pump to work, the nipple protectors, the ice packs to keep the milk cold.
Worst was the guilt she felt spending 12-hour shifts away from her child. When Dr. Kwakye squeezed in a pickup at day care to relieve her husband, she watched her daughter run to the teacher and call her “Mommy.” That prompted a day care administrator to ask Dr. Kwakye whether she was on the list of adults approved for pickup, and the doctor had to explain that she was indeed the mother.
“The kid didn’t want to go to me, and I was like ‘O.K., I deserved that, that was fair, you have no idea who I am,’” Dr. Kwakye said. “But what that does to a mother is painful. I had a moment when I was like, ‘I can’t do this anymore; I’m failing as a resident and I’m failing as a mom.’”
One morning she sat in her car crying because she didn’t want to leave her baby. She wondered if she should have heeded the warnings not to pursue surgery. She told herself, “Maybe they saw something you didn’t see and you’re not tough enough.”
As health care providers, surgeons are painfully aware of the ways in which their professional commitments can harm their own health and their family’s. Alex Moore, a surgical resident at Brigham and Women’s Hospital, said that spending long days away from her 6-month-old baby was especially upsetting because she has studied the medical importance of mother-child bonding. Returning to the operating room after a 10-week leave felt “like your soul is getting ripped out,” she said.
A surgeon’s schedule isn’t just psychologically taxing, it also takes a physical toll. A resident spends most of the day on her feet. She may go eight to 12 hours without eating, or even drinking water. As one surgical resident put it, health often comes down to “Do as I say, not as I do” for doctors in training. Dr. Rangel, who had two babies, both born prematurely, wondered whether she was to blame for neglecting her health while pregnant.
“There’s a piece of you that knows better, that bad things can happen in pregnancy no matter what,” Dr. Rangel said. “But there’s another part of you that knows you didn’t prioritize your health during pregnancy. You wanted to look, to your other residents, like you’re strong.”
Dr. Kwakye grappled with a similar question: “When I was having difficulties getting pregnant, my husband was like, ‘Is this because of your residency?’ Because you’re working so hard and not taking care of yourself?’”
A recent paper in Surgical Neurology International cited estimates that, at the current pace of change, it could take nearly 120 years to achieve gender parity in surgery. But as female representation has grown in hospitals, physicians are calling for institutional changes to support residents who are balancing the responsibilities of surgery and motherhood.
Dr. Sarah Shubeck, a general surgery chief resident at the University of Michigan, had a child three years ago. Since then, she has successfully lobbied her department of surgery to convert call rooms (resting spaces for staff) into lactation spaces, and to implement a policy allowing residents to step out of operations intermittently to pump milk. She hopes to end the stigma around breastfeeding by discussing subjects like mastitis and engorgement with her male colleagues, although it sometimes makes them squirm.
Dr. Shubeck recalled that in medical school, someone told her he had “never met a happy female surgeon.” Now when she is approached by younger female surgeons, she assures them that she is fighting for institutional changes that will ease their career paths. She is part of a network of Michigan “doctor moms” who share resources and encouragement.
“It’s like a secret society that we’re all a part of,” Dr. Shubeck said. “We’re troubleshooting in the call room and helping when someone’s babysitter falls through.” For decades, she said, women in surgery kept their heads down and felt lucky just to have a spot in the operating room. Now they are asking for support for their own well-being.
Parental leave policies in surgical residency programs present another area for reform. Dr. Rangel said that, for years, the American Board of Surgery’s policies were confusing to residents and some of their program directors. In 2018, the board revamped its parental leave website to be more transparent and explicitly communicate more options for pregnant residents, such as allowing residents to graduate off-cycle and to roll vacation weeks over from one year to the next. The policy language has also been changed to include fathers.
But Dr. Rangel said parental leave reform is only one solution in the larger cocktail needed to heal a broken system. “It’s everything from the brief maternity leave to the stigma surrounding being a pregnant resident,” she said. “There are microaggressions from faculty and co-residents who feel it is a burden to have you be pregnant. There are few lactation facilities, there’s a paucity of child care support.”
John Fromson, vice chairman for community psychiatry at Brigham and Women’s Hospital, said a dearth of child care options remained a widespread problem. Some hospitals have tried to set up on-site day care facilities, but these are expensive to maintain and end up being unaffordable for the residents. The average resident earns $57,200 annually, a fraction of what their higher-ups at the hospital make.
Most residents end up relying on a combination of partners, parents and networks of friends. Dr. Moore said her husband, a lawyer, handles the morning drop-offs and evening pickups from day care. Several women interviewed said their parents retired early or moved closer to help with child care.
Making the operating room more accessible is not just an equity issue — it is also good for patients. Parent-doctors can bring an important sensibility to their work. Danielle Cameron, a chief resident in general surgery at Massachusetts General Hospital, said she had worried that motherhood might take away her “edge” or even her focus. Instead, she said, having a child has made her more empathetic and attuned to patient needs.
During a recent operation, Dr. Cameron jokingly described herself as “tough” to a male attending physician. “He responded, ‘I know you’re tough because you’re a surgeon mom,’” Dr. Cameron said. “It gave me a sense of pride because they know how much we have to balance every day.”
On Thanksgiving, Dr. Cameron took her family to the hospital to share leftovers with the residents on call. Her family has made sacrifices along the way, she said, but she hopes that her daughter has gained her grit and sense of duty. Recently Dr. Cameron passed her daughter’s room and saw her operating on her stuffed animals: She wants to be just like her mother.