Podcast: The inconvenience of motherhood during a medical career
Transcript
Dr. Mojola Omole: Welcome to the new CMAJ podcast, I'm Dr. Mojola Omole.
Dr. Blair Bigham: I'm Dr. Blair Bigham. Long time listeners might notice a few differences to the podcast. We've got a new theme, new artwork and a new mission.
Dr. Mojola Omole: And then there's us.
Dr. Blair Bigham: Yeah, that's right. We're also new, maybe we should introduce ourselves.
Dr. Mojola Omole: So I go by the name Jola to most of my friends. During my daytime, I'm a general surgeon and a breast surgical oncologist at Scarborough Health Network.
Dr. Blair Bigham: And I'm Blair, an emergency and ICU physician from Scarborough, Ontario as well. Jola and I both went to the same journalism school and we can't wait to put our skills to work exploring the latest in Canadian medicine from coast to coast to coast.
Dr. Mojola Omole: Our goal is to delve deep into the scientific and social health advances on the cutting edge of Canadian health care. We're going to bring you real stories of patients, clinicians, and others who are impacted by our health care system.
Dr. Blair Bigham: The stakes are high, so let's get to it. Our first episode centers on parenthood and medicine, a recent article in CMAJ, The Inconvenience of Motherhood During a Medical Career, highlighted the struggles of women as they navigate both their careers and family aspirations. Here's a quick summary.
Dr. Mojola Omole: Although we've made strides in recognizing the importance of physician wellbeing, childbearing during medical training and early career still carries an unfair burden to the childbearing physicians.
Dr. Blair Bigham: The consequences of delaying childbearing has been associated with increased rates of infertility, with as many as one in four women physicians reporting a diagnosis of infertility.
Dr. Mojola Omole: Systemic factors, such as discrimination against trainees who wish to have children in training, the unbalanced ratio of trainees to workload, and a general culture in medicine that stigmatizes when we prioritize our own wellbeing, all contribute to physicians delaying childbearing.
Dr. Mojola Omole: So, in a nutshell, when young doctors delay having children until after medical school, this soon turns into after residency and then, as residency ends, it becomes after fellowship, or a few years after you've been on the job. The decision to have children keeps being pushed back, and the assumption is that their fertility will be right there waiting for them when the time is finally right. But as Dr. Sophia Park experienced, that's not always the case. Dr. Sophia Park is a medical biochemist at the Royal Columbian Hospital and a clinical associate professor at the UBC Department of Pathology and Laboratory Medicine. Sophia, how old were you when you first thought about whether you would want children or not?
Dr. Sophia Park: So, Jola, when I was a teenager, I thought that by the time I was in my mid-thirties, I would be married and have a job, and own a place, and have kids.
Dr. Mojola Omole: Eventually, you go to medical school, and did that become more upfront in your brain? Or was it still let me finish medical school and then start thinking about it?
Dr. Sophia Park: I would say that there were a few matters which came up during my medical training which would delay our eventual attempt to conceive. The first was my financial situation. I was debt free before I started medical school, but by the time I finished residency, I had about $200,000 in debt. I didn't have a safety net, so I knew I was the only one I could rely on to pay off this six figure debt. There was really nobody else in my family that could help me, so it was really important to me that I get a job right after I finish residency.
Dr. Sophia Park: Other factors which incorporated into my decision was that I was in a highly specialized field so there were very limited job opportunities. I could really only work as a medical biochemist in a bigger urban center, at medium or large size labs. And then on top of that, there were residents who had graduated in the years before me who were having some difficulty landing a full time or permanent job. Those were things that really worried me and kept me up at night as a resident. During my residency years, I really didn't think about having kids because I was just really trying to leave a good impression. I was trying to be a reliable, high performing trainee, so what I did focus on was I got an MBA during my residency. I published papers. I studied all the time. I made sure that I did well on my rotations so that I would be able to land a job when I graduate.
Dr. Mojola Omole: So in a way, it almost felt as if you needed to secure getting your job, and not putting anything to jeopardize that ability, and then have kids.
Dr. Sophia Park: Exactly.
Dr. Mojola Omole: So, residency is over. Did you think about children at this point?
Dr. Sophia Park: I became staff when I was 32 years old, and the first three years I really focused on paying down my debt. I was also saving up for a down payment for a bigger place, because at the time we were living in about a 500 square foot, one bedroom apartment, and that was not big enough to raise a family. And I really wanted to just start living my life because I spent my whole life studying, and so I wanted to actually live. And this was also the first time that me and my partner could afford to take vacations outside of North America, so we did some traveling in Asia and Europe and then, career wise, I really was trying to establish myself. I knew that some of my classmates, they would join a group practice and within six months to a year, they would go on mat leave. But I worried that might be perceived as you not being a team player, or you haven't paid your dues, so I was thinking that I would work at least two to three years before I would go on mat leave.
Dr. Mojola Omole: Did you hear comments that were disparaging in your training? Or whispers? Or is it just more of what you perceived?
Dr. Sophia Park: I did not hear actual comments, but they were insinuated when people did go on leave, especially right after they joined a practice.
Dr. Mojola Omole: So, for you, were you concerned about, as you were getting older, what impact this could have on fertility for you?
Dr. Sophia Park: So I was, but then at the same time, I also heard a lot of people having kids in their mid to late thirties, sometimes even in their early forties. So I thought, "Oh, I should be fine." I just really thought that I would be one of those people that shouldn't have any trouble conceiving because I'm relatively healthy and I felt young.
Dr. Mojola Omole: And when you and your husband started trying, what happened?
Dr. Sophia Park: By age 35, we were ready to have kids. We tried for about a year and a half. We didn't have much success. And then we went to a fertility clinic, and I remember checking my voicemail on Valentine's Day in 2019, and getting the notification about our first clinic appointment, and I thought that would be the best Valentine's Day present if this whole experience led to a baby. We did one and a half rounds of IVF. We had to stop the first round halfway because the size of my follicles was all over the place. And then the second round resulted in the transfer of two embryos, but both did not implant. I also learned at these clinic visits that, even though I look and feel and sound very young, my eggs were actually not young, they were much older and not as good quality as those of a typical 36 year old.
Dr. Mojola Omole: And how did that make you and your partner feel?
Dr. Sophia Park: Well, I think at that point, me and my husband, we really sat down and had to make a decision about whether we will proceed with more rounds of IVF and, if so, how many? So we really thought about our experience in the last two years, and it was truly an emotional roller coaster ride. I think anybody who has gone through infertility and IVF would know that. So when my period was late, I was so excited, but then the pregnancy test would come back negative. I wouldn't trust the results, and so I would pee on the stick again the next day only to have it come back negative again. And so that was a constant up and down of emotions, which was very tiring.
Dr. Sophia Park: The IVF cycles themselves were also really emotionally draining. There were injections, appointments, ultrasounds, and you're trying to fit all that in while working full-time. I also remember seeing women in the waiting room who were pregnant, and then wondering when that will be my turn. At this point, we had also spent about $20,000 and really have nothing to show for it. So at the end, we decided to not proceed with any further IVF. I recognized that we could have, and if we did, maybe we would have a baby by now, but I was just really tired at that point. I felt like so much of my life has been a struggle and I just felt really tired. And so at that point, I just felt like I'm going to accept things as they were.
Dr. Mojola Omole: As you're telling your story, I can definitely sense the hardness of IVF and, as someone who's gone through it, I can attest to that. So if you're looking back now, do you think that if you had started younger, you would've had less difficulties in terms of being able to be pregnant?
Dr. Sophia Park: Yes, most definitely. I wish that I had known, as a medical student, about some of the statistics described in the article, that as many as one in four female physicians has infertility, because I didn't know that. And I keep on hearing stories about how women in their late thirties and even early forties were having children, so I really thought that would happen to me as well. It just didn't seem that hard when you hear so many success stories. I also wish there was increased awareness of egg freezing because right now I feel like it is still this fringe procedure, but it really isn't, and shouldn't be. So that would be my main regret because I don't have good quality eggs anymore and I can't go back in time.
Dr. Blair Bigham: Sophia, your story is, it's heartbreaking to hear. You can really hear in your voice how you wish that things have been different, kind of going back in time. And I've heard from other friends of mine in medical school, in residency, and then in staff life, that there's just never a good time to have a baby. If you go back with your experience and your perspective, when do you wish you started trying to have a child?
Dr. Sophia Park: Okay, so I wish I had a child before I went to med school.
Dr. Blair Bigham: I know it would be easier, right?
Dr. Sophia Park: Yeah, it would be. I guess my other thing is, I wish I didn't have so much med school debt, because if I didn't, then I think I would feel more comfortable taking a year of mat during residency, or I would keep on doing more IVFs.
Dr. Blair Bigham: When we talk about the cost of infertility and the cost of planning for that in terms of freezing your eggs at a young age, that would add additional burden. If you're a medical student or a resident there's always more cost involved, but then the consequence, later on, is that you may not be able to have a baby. Do you think that the medical schools, or the universities, have some sort of opportunity here to either provide coaching or counseling or support early on when it might not be on people's minds?
Dr. Sophia Park: Yes. I definitely think that. I think increasing awareness of procedures like egg freezing so that it doesn't seem like it's a taboo subject is something that we can more readily talk about. I think it would be really helpful. And I think at a national level, it would be really nice if things like IVF would be publicly funded. I know that in certain countries like Australia and Sweden and the UK, it is something that is covered by the public health care system, but that is not the case in Canada. And I think it really put women like me, who have spent many years training to achieve their career of choice, it really does put us at a disadvantage.
Dr. Blair Bigham: Do you feel like it's a taboo subject now, that people just aren't willing to talk about it during residency training because they're worried about getting a job or having their peers fret over the workload?
Dr. Sophia Park: I wouldn't say it's a taboo subject, but I feel like maybe we have a bias when we look at the statistics of infertility because we're like... Well, first of all, I think many of us don't know the statistics, but then for those that do, we think that, "Oh, I'm going to be one of those three people that do get pregnant because I know so and so who did." So I think we always tend to focus on the success stories, but then we don't hear about the stories from the individuals who have tried it and weren't successful. So I think having experiences and hearing from people like me who did try it, it didn't work, and then end up not having kids, I think is probably as important.
Dr. Mojola Omole: I find that the conversation is just not something we have. Medicine was created by men, and our training dogma is still for cis males. And so there's no real opening for it. And I do find that it's taboo in the way of people also view going through IVF as almost like a failure. I would say that I felt that way, even though, as a queer person, this was the best option, that people are a bit squeamish about it. So I often find that we don't really create an environment that we can have honest conversations with medical trainees about, listen, one in four physicians is going to have issues with fertility, so I do think that it is taboo in an odd way.
Dr. Sophia Park: Yeah, I think you raise a good point, Jola. I'm thinking about, there certain topics that we always cover with residents like your mental health, how do you set up a practice? How do you build? But maybe one of those topics should be family planning.
Dr. Mojola Omole: Yeah. I tell all of my medical students, if they're interested in surgery, I'm like, "Listen, freeze your eggs. I know it costs money, but that line of credit, this is the time that it gets the best. Don't go on certain trips and freeze your eggs because that gives you at least some insurance policy." Obviously it's not a fool proof method, but it gives you some insurance policy that later on down the road, that if things do become difficult, at least you have something to fall back on.
Dr. Blair Bigham: Jola and Sophia, you both have brought up freezing your eggs, and I've heard this from a lot of my colleagues back in medical school as well, but what does that say about our culture and the way we do business when it puts the onus on women to go and freeze their eggs in anticipation of this career that doesn't allow you to get pregnant when you want to? It just sounds like we're trying to misplace the responsibility for fixing this problem on women who are in the profession instead of on the profession itself.
Dr. Mojola Omole: Yeah. I think as Sophia, as also being someone who's BIPOC and female, is that oftentimes the solutions to issues about diversity, about gender, it's always, it's up to us, to find a workaround, right? It's always a workaround. There's no actual like systemic change, so I agree with you. And I think, as women and non-binary, we've just kind of said, "Okay, no one's going to take care of me, so what am I going to do to make things work out for myself?"
Dr. Blair Bigham: It sort of parallels the discussions over burnout and how resiliency was brought up as a solution to burnout, which really was just about getting people to be able to handle the system instead of changing the system itself.
Dr. Mojola Omole: Sophia's like, yep.
Dr. Sophia Park: Yeah.
Dr. Blair Bigham: It's just, we're really good at preserving medical culture and just telling the people who exist in that culture to figure out a workaround. And in this case it seems like freezing your eggs is a workaround to the bigger problem, which is that people can't get pregnant when they want to because medical training just isn't built around that, because it's so patriarchal and built on that cis male perspective that medicine comes from. As a residency director, Sophia, working within your university's postgraduate medical education system or within the Provincial Association, do you know of any initiatives, or places that are really looking at making a more fundamental shift to how we fund and recruit residency spots so that this doesn't become an individual's responsibility to fix?
Dr. Sophia Park: I'm not aware of any programs, but I also think that if we want to solve this issue meaningfully, it can't be a grassroots effort. It's something that we need to change nationally. It's a conversation we need to have at the national leadership tables.
Dr. Mojola Omole: And I do feel that you, showing so much grace and vulnerability to come onto our podcast, is the beginning of having that national conversation, and hopefully we can help to move things forward for medical trainees in the country.
Dr. Blair Bigham: And I think we've only just scratched the surface. We haven't even talked about the challenges of pumping milk while working as a busy physician. We haven't talked about the challenges of childcare. We haven't talked about some of the other issues around maternity and paternity leave. And so this topic just really, we're just scratching the surface here, and I'm so grateful that you came and told us your story, Sophia.
Dr. Sophia Park: Yeah. I really enjoyed the invitation and the conversation, so thanks for having me.
Dr. Blair Bigham: Sophia's story gives us an intimate look inside the findings of the paper, The Inconvenience of Motherhood During a Medical Career. Dr. Andrea Simpson is lead author of that paper. Andrea, what's your reaction to Sophia's story?
Dr. Andrea Simpson: It was very hard to listen to. I was impressed that she had the courage to share her story, and it felt all too familiar, to me as an obstetrician gynecologist, for other physicians that I've encountered in practice, who delayed childbearing, also thought that their fertility would not be overly affected, knew the numbers, but also, as Sophia talked about, felt that they might be the exception to the rule and still have no trouble getting pregnant, and then ultimately had great difficulty. So yeah, I think her story really summarizes everything that we've been seeing, and is a really hard look at what the culture of medicine might result in, like the high cost to women physicians.
Dr. Blair Bigham: When a resident is not able to get pregnant, I guess they end up in an obstetrician's office trying to sort out their challenges with infertility. How does Sophia's story compare to some of the obstacles that you've seen in your own practice or in your research?
Dr. Andrea Simpson: I think that one of the things that a lot of trainees do not realize, at least this is the case in Ontario, is that they do have drug benefits to cover fertility treatments during residency, whereas a lot of practicing physicians do not have such good drug benefit plans. So I think this is another area of regret, where physicians may have planned things differently had they known what was available to them in residency.
Dr. Blair Bigham: Sophia talked a lot about wishing she had frozen her eggs, and mentioned it as sort of a solution for women in medicine. Do you agree with that? Do you think that's the solution?
Dr. Andrea Simpson: I don't think it's the only solution. I noticed there were two comments that were made during her interview. So the first one was the option of egg freezing, and then the second was when you asked her about when she wished she had pursued fertility, she said before medical school. And I think that these two things still speak to the culture being generally unwelcoming of mothers, and that it is still very challenging to know what the best time is. And the times that she identified were either before training, or after, using frozen eggs. So I don't think that this is the solution, I think it's a solution. If it's all we have, it should be offered and it should be widely available. One of the other factors that I think we often forget is that, because of the rigorous training we go through, not everybody has a partner at the optimal age for fertility, so this might also be a great option for people who don't have a partner.
Dr. Blair Bigham: What's driving this unfriendly culture? In your paper, you use the term pervasive maternal discrimination. What is driving that? Is it just historical? Is it something special about medicine? Because there's other careers where you work a lot, and you're expected to be in the office late, what is it about medicine that's different?
Dr. Andrea Simpson: A lot of it is historical. We definitely made good progress in raising these issues. And in some specialties, such as OB/GYN, we talk a lot more about this with our trainees, and there are more mentors, more people who have done it before them, so it makes it more accepting. But I can't say that's true for all specialties. I think a lot of it is the historical context. It's a profession that historically excluded women, and although we have made progress, I think we still have a long way to go.
Dr. Andrea Simpson: As I talked about in the paper, there have been some really great system level changes, such as the provision of call policies for residents who are pregnant so that they aren't working overnight right until the end, the provision of parental leave for residents, there are some parental leave benefits available for practicing physicians as well. So these are all positive changes, but what is left is still that systemic maternal discrimination, mothers being excluded from opportunities, sometimes some more implicit or explicit statements about how productivity is going to suffer when a woman has a child. So these are things that I still think we need to address and that we still can improve upon.
Dr. Blair Bigham: This idea of the lost productivity and the impact on the rest of the resident group, or when you're an attending, on the rest of your practice group, what are some solutions to that? It seems like we almost intentionally set ourselves up to fail if we want to be supportive of mothers.
Dr. Andrea Simpson: Yeah. These are real issues that we encounter in practice. When you have a group of four people and one person goes on leave that does affect the other three people. And medicine, currently, we just don't have a lot of slack in the system, there's no wiggle room. So I talk about parental leave as one situation in which someone might need to take time off, but there's a lot of other situations, having to take care of an ill parent, having to take leave for mental health concerns. And these are things that, there just really isn't a lot of wiggle room in the system to accommodate. I think that we need to really take a look at this and how, I guess it becomes more of a political question, as to how we can increase residency positions, how we can increase call group sizes to accommodate time away.
Dr. Blair Bigham: And it's not just mothers. What has your research found about fathers who want to take time off in medicine to help raise their children? Or trans parents who come up with challenges when trying to take time away to parent?
Dr. Andrea Simpson: Great question. What I focused on mostly so far in my research has been women physicians just because of data availability. So we looked at reproductive patterns and could only identify physician profession in women. For the trans population, for men, right now I'm undertaking a study where we're talking to medical students about their understanding of age related fertility decline and how this actually has impacted on specialty choice. And in reviewing the literature, there's actually very, very little literature out there on the trans population on men. And I think again, that reflects that we always think of this as a women's issue, but it's not. And if we can increase awareness, it'll ultimately benefit everybody and also promote allyship for people who choose not to have children in understanding why some people might need to take time away.
Dr. Blair Bigham: Your group of obstetricians in Toronto trains a lot of residents. How have you tried to build that culture of allyship? And what other supports have you been able to implement for your own residents who hope to have children?
Dr. Andrea Simpson: Yeah, so I think that our residency program here is an excellent example of a program that accommodates people who need to take parental leave. We've had a lot of male residents in our program take parental leave as well. So for some people who take leave and are planning to go on and do additional training, sometimes some of the leave can actually be for up to three months so it doesn't extend training pathways that much more. We are fortunate that we do have a little bit of a bigger program, we have about 10 to 12 residents in every year, so that does allow a little bit more scheduling flexibility compared to a program that, say has, three residents or four residents. And I think we're also very supportive of other ventures, so if somebody wants to step out for a few years, complete graduate work or a global health opportunity or something like that, that also has been accommodated.
Dr. Blair Bigham: Fantastic. I just, I look at your title again, of this paper, The Inconvenience of Motherhood During a Medical Career, and wonder if you could have shaken it up a bit and said, The Inconvenience of a Medical Career on Motherhood. Because it really does sound like there are things we can do, it doesn't need to be this way.
Dr. Mojola Omole: The one question I had for you is that this was not the first time that you've written about this subject. Was there a case or an experience that got you interested in looking at parenthood in physicians?
Dr. Andrea Simpson: Yeah, that's a good question. There's been a lot of stories of seeing trainees coming through who felt that they'd always delayed childbearing for their career and had come to a point, similar to Sophia's story, where it was too late, or they were having challenges, so I think those stories really did drive a lot of this research. Speaking from my own experience, I have two children, I had one during my clinical fellowship training, and then another in my first year in practice. And I would have to say as an obstetrician gynecologist, my experience has been overwhelmingly supportive, but there still were instances of maternal discrimination where I did get that sense that people weren't sure how successful I was going to be in academics with a child.
Dr. Andrea Simpson: I was fortunate to have good mentors in this area, and I got the sense that the people who had come before me and didn't have such great mentorship, it was a much different story for them. So I think that I was very fortunate to have this mentorship. I hope that this is something that I can pass along to the people that I train. But addressing the maternal discrimination, the pervasiveness of it, is quite different.
Dr. Andrea Simpson: I remember coming back to work, and I had a route between the operating room and the designated pumping room, for in between cases, so I had just enough time to get from the OR, to the room, pump, back in time for the second case. And I thought, this is so great that I have a place to go to do this, and these have been great things that have been incorporated and made available to physicians, but we still have a ways to go. And I'm hoping with the work that I'm doing now, that we can start to address really the culture, like thinking about how we can accommodate physicians to have children whenever they want to. And I think that's the biggest message that I'd like to impart, that I don't think egg freezing is the only answer. I don't think delaying medical school to have children is the only answer. I think that physicians should be able to have children whenever they want to, and should be supported in doing so.
Dr. Blair Bigham: I think we'll wrap it up there. That was awesome. Thank you so much for making time to chat with us.
Dr. Mojola Omole: Thank you.
Dr. Andrea Simpson: Thank you. I appreciate the opportunity.
Dr. Blair Bigham: Jola, can we come up with three things that program directors and Provinces could do tomorrow to start moving the needle on this problem?
Dr. Mojola Omole: I would say that the first one is talking about it, and that could include having didactic lectures from the beginning of medical training on family planning and what that looks like, for trainees to know that there's a chance, that they have a one in four chance of infertility. And even that we haven't even talked about male infertility, which also contributes to the reasons why people seek assisted reproduction.
Dr. Blair Bigham: I would say the second one would be advocating that the Provinces ensure that we're not too tightly scheduled with residency spots. Residents are human beings, we need more residency spots to allow residents to also be humans, and that may include taking a mat leave or a pat leave.
Dr. Mojola Omole: And I think, finally, is to talk openly about the gender based discrimination that is against motherhood. Oftentimes we hate to use words with isms on it, but we have to be very clear that microaggressive comments such as, "Where are you most likely to find this attending? More likely at the Costco line versus in the operating room." Or, "Oh, you're taking mat leave again?" Those comments have to be called out as what they are, which is gender based discrimination.
Dr. Blair Bigham: And this conversation today has certainly helped me tune my ears to those microaggressions and sort of off the cuff comments that we need to stand up against because it's not right for people to feel like being a parent is somehow making you a lesser physician.
Dr. Blair Bigham: That's it for this episode of the CMAJ podcast. Let us know what you think. Leave us a rating or review in Apple podcast, Spotify, or wherever you get your podcast.
Dr. Mojola Omole: Also, please share this episode. Rating, reviewing and sharing episodes is the best way to make this podcast easier for others to discover, so we really do appreciate it.
Dr. Blair Bigham: It'll also help our podcast create change, so please do share widely. This episode was produced by Prodcraft Productions. I'm Blair Bigham.
Dr. Mojola Omole: I'm Mojola Omole, and we'll be back in exactly two weeks. Thanks for listening. Until then, be well.
