When a surgeon asked Sharona Ben-Haim during a 2008 interview for a neurosurgery residency program whether she planned to have children, she responded the only way she felt she could: a resounding no.
“I was very much trying to hide being a woman, just trying to fit in,” said Ben-Haim, who now directs the surgical epilepsy program at the University of California, San Diego.
Ben-Haim and other researchers studying the experiences of surgeons and surgical residents who are pregnant or considering pregnancy have found a bleak picture. One survey of neurosurgeons and neurosurgery residents found only 35% worked at institutions with formal maternity leave policies, a problem that experts say extends to other specialties.
The result, research suggests, is a string of downstream effects. That survey and others suggest women in surgery are more likely to delay pregnancy during their training, face a pregnancy loss due to miscarriage or stillbirth, suffer major complications like preeclampsia tied to long and strenuous work hours, and often experience harassment and discrimination from colleagues.
But there are signs of progress. The American Board of Medical Specialties — which represents boards that confer certification in several surgical fields — last year changed its recommendations to suggest certifying boards should accommodate residents who take parental leaves.
For neurosurgeons, becoming board certified requires completing 125 operations during an 18-month period after completing residency — a time when many neurosurgeons might choose to have a child. Ben-Haim and other neurosurgeons had urged the American Board of Neurological Surgery to revise its rules; the organization has since said that the period for completing operations could be extended for surgeons who have reduced their schedules for family reasons. “It’s like an extra year on the tenure clock,” Ben-Haim said.
And the American Board of Surgery, which certifies general surgeons, in 2021 recommended that general surgery residency programs provide four weeks of parental leave at two points during residency, double the time it previously recommended.
The move came in response to a widely shared editorial by Allison Letica-Kriegel, a general surgery resident who experienced a dangerous infection less than two weeks after giving birth. She and her family benefitted from a paid leave program for employees at the New York hospital where she was on a research rotation — but as she wrote, that is rarely the case for her peers in surgical training.
“I cannot help thinking that this experience would have truly broken me if I had to return to full-time clinical residency a few short days or weeks later, as so many surgical trainees routinely do,” she wrote.
The national organization that oversees residency training programs in all medical and surgical fields, the Accreditation Council of Graduate Medical Education, will also require all residency programs to offer paid parental leave for six weeks starting in July 2022. Experts say family leaves are critical for all surgeons, but are especially important for residents, who are paid far less and have little control over their time once they return to work.
“Trainees have a really hard time coming back, because they have limited resources for child care, so they’re already struggling, and they come back to an 80-hour work week,” said Erika Rangel, a general surgeon at Brigham and Women’s Faulkner Hospital in Boston and a leader in research on surgeons and maternity.
Despite the progress, though, surgeons and residents say there is still an urgent need to address the realities of both working while pregnant and returning to practice after giving birth. Michaela Bamdad, a surgery resident at University of Michigan, said she knows of no health care systems that have policies limiting the number of standing hours for staffers who are pregnant, even though some types of surgeries can stretch more than 10 hours. At Michigan, pregnant trainees in their third trimester are not placed on shifts longer than 12 hours and don’t take overnight calls. Bamdad helped craft guidelines for her department allowing pregnant surgery residents to leave the operating room to eat, drink or rest “during non-critical portions of the case,” and enabling residents to attend prenatal visits.
Several universities also provide time and lactation spaces for surgeons and surgical residents who are breastfeeding and need to pump. Since 2020, the ACGME has required residency programs to provide lactation spaces that are clean, private, and near patient care areas.
Still, some surgeons and residents continue to grapple with discrimination and harassment within their workplaces during and after pregnancy.
Mecker Möller, a cancer surgeon at the University of Miami, said she’s worried that such harassment will be harmful not only to surgeons, but to the trainees they teach. She said she once comforted a pregnant resident after a male senior surgeon remarked — in the presence of medical students — that he told his daughter “not to be so dumb” as to get pregnant during residency. “This is just one of many microaggressions that happen out there,” said Möller.
A 2017 survey of mothers who are surgeons or doctors who conduct procedures found they paid a financial price during and after maternity leave due to the monthslong process of building back up referrals, in addition to unpaid leave, missed bonus opportunities, and other issues.
“It’s sort of a double whammy: you didn’t get paid for the time you were gone, and now you’re back, but you’ve lost your referrals,” said Rangel.
That was the case for a surgeon who became pregnant with twins. The surgeon, who asked to remain anonymous out of concern for professional retaliation, said that patient referrals to her practice had declined during her leave, and administrators told her she would lose operating room time if she didn’t increase her surgeries. “That was an incredibly stressful time because here I am, under the gun, trying to stay busy, expecting that they’re gonna take it away from me,” she said. She ultimately left the hospital and now practices — but no longer teaches residents — in another state.
Surgery’s culture shift towards protecting the health and wellbeing of women surgeons who become mothers, and guarding their careers, is coming more slowly than experts would like. But Rangel pointed to one positive sign of change: Many national meetings of surgeons are now discussing maternity as part of their programming. “So there may be surgical leaders who are still unfamiliar with the topic,” said Rangel, “but I don’t think that’s going to be long lasting.”