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Monday, November 23, 2015

MiM Mail: Making residency safer for pregnant residents

Mothers in Medicine! I am seeking your advice/expertise on the difficult subject of how to treat pregnant residents. A little background: I am a chief resident at a busy anesthesia program that takes frequent and draining 24 hour calls in the OR. Those calls are such that, most of the time, the call room is a distant fantasy. I am also a mom to an active preschooler and pregnant with #2. All was going well until after a particularly exhausting 24 hour call, when I started having frequent, regular contractions at 20 weeks. I had to take several days off work and (thankfully!) things calmed down. I'm now trying to ease myself back into the OR call rotation.

My question for all of you who have been through a resident with tough, frequent 24 hour calls or night shifts... how did your program handle pregnant residents? I've heard from friends at other programs about policies that were put in place to limit calls because so many pregnant residents were going into preterm labor. Other programs limited night shifts for the same reason. Obviously, these changes put strain on non-pregnant residents. Was there widespread resentment to enacting such restrictions?

Amazingly, I'm the first resident to be pregnant at our program in over a decade, but I know there are many women behind me hoping to do the same. I'm hoping to find some common sense changes that can be made to keep pregnant residents working, but in a safe way for mom and baby.

Thanks in advance!

11 comments:

  1. I'm an anesthesia resident in Canada (BC). Most, if not all of, the anesthesia programs in the country have moved to a 12 to 16 hour call shift system. In my program, depending on how many residents we have at a given hospital, we each do 4-7 call per 4 weeks, and at some sites we cover 12-hr day call as well. We have pre-call day time off before we work a night, so the longest I've worked on anesthesia is about 14 hours. Additionally, the guidelines for all programs in the province are that after 24 weeks, pregnant women do not have to work more than 12 hour call shifts. Most programs allow residents to stop doing overnights all together somewhere in 28-34 weeks. These are all optional, so you could work and do call until you were in labour if you wanted to. My program is very supportive and most of the senior residents are parents, so I haven't heard any ill-will towards mat leave (most take 6+ months) or being off call. That said, there is a fairly strict rule that you can't do more than 1:4 call - so the extra call burden would rarely push anyone over our maximum number. All that to say - there are ways to make it safer for mom and baby, but it usually takes a cultural and system overhaul to make it work. The 12-hour call makes a huge difference. I'm trashed at the end of a busy night, and I can't imagine doing it safely and repeatedly for 24 hours in a row.

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  2. I finished my residency at a large US program several years ago. For all pregnant residents (not just anesthesia), you were permitted to opt-out of overnight in-house call in the 3rd trimester without repercussion. All pregnant residents were also permitted to limit their duties to 12 hours of continuous work. In practice, this part (limiting to 12 hours) was not always feasible. Given that we were a big program, the increase in call burden to other residents was not much, which helped and thus resulted in essentially no resentment toward pregnant residents. Plus, when you're not taking call, you miss out on any chance to be relieved early (pre-call days!). That being said, my program also had all PGY-2 and PGY-3 residents come in at 11a for most overnight call shifts (i.e. 20 hours, not 24) and PGY-4 at 3p (i.e. 16 hour call). So, a much better starting point for everyone. It also probably helped that many of the men in my program had families of their own and tended to be a bit sympathetic toward the pregnant females when they saw us working clear up to delivery while their wives often had a different experience. Culture change takes time, best wishes to you!

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  3. I'm an OBGYN resident in Canada. I had my baby at the beginning of pgy4. Our resident contract states that pregnant residents are relieved from overnight call after 28 weeks, or sooner if recommended by a physician, without penalty. I did 't feel any resentment at all. I also found the nurses to be quite protective of me, making sure I had time to eat and bringing me fluids during busy shifts.

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  4. I'm an Emergency Medicine attending in Minnesota, but had my last of 3 children during my third year of residency. I was also the only woman in my residency class. I approached the residency administration early in my pregnancy, and was able to arrange my schedule for the year to avoid heavy call months during the third trimester (and luckily, the second). I was also allowed to avoid all overnight shifts during the third trimester. I found that there was no resentment at all from my male counterparts once they learned why I was asking for the exemptions. I did end up re-allocating those shifts to different parts of the year, so overall it was still even. Make sure you talk to your residency director and are firm in your convictions about what is healthiest for you and your baby… we in medicine are often most at fault for not following our own good advice about how to stay healthy, but it is important for all of us to remember how to take care of ourselves and one another.

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  5. I'm a mom in a surgical field. My suggestion is to discuss your work restrictions with your doctor and have her write them for you, then be sure that those who control your schedule have been made aware of the restrictions "imposed" upon you by your doctor. Tell people you are a high-risk pregnancy--as a resident, that's the truth.

    I would hesitate to turn your individual situation into "rules" for all women in your field, however, though I'm sure your heart is in the right place and you're expressing a desire to make things better for those who come after you. For me, pregnancy was neither a disability nor a disease and I felt I had to be very careful so that my male colleagues and attendings would view me as capable and allow me the learning opportunities that I needed even though I was pregnant. My field is quite physical, but there was very little I didn't or couldn't do.

    I sympathize with you--there is an extra burden for pregnant women for sure--but not all women will have the same experience during pregnancy. I feel far more threatened by being perceived as less capable, willing or able to perform my job and I would therefore not be in favor of blanket rules limiting call shifts or duty hours.

    Put your feet up whenever you can, drink a lot of water, eat and discuss your individual limitations with your doctor. Preterm labor is scary and is a real risk for residents especially those with heavy call responsibilities. Nothing is more important than the health of your baby!

    As a side note, I find that being a mother is much more difficult than being pregnant was--figuring out who I can trust with my baby during all the work hours required of me has been unbelievably challenging. I'm also saddened by the loss of closeness that I feel now that my daughter turns to her other caretakers for comfort over me when she's hurt or upset, etc. I am not the mother I want to be! She is my top priority, but my work demands to be put first. I'm held hostage by a tradition of training that will not let me take a step back. My choices are very black and white, either commit to surgery and neglect my daughter or give up any possibility of being a surgeon, forever. It's unbearable.

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  6. I wish I could offer advice, but the truth is my small anesthesia residency program didn't offer any modifications for pregnant residents unless there was a doctor's note (6 of us were pregnant at the same time too). We took call (24 h and night shift), pushed our obese patients around, and worked in fluoro rooms. I was fortunate to have an uneventful pregnancy until 39 weeks when I went on bedrest for blood pressure, but I took full responsibilities until then...I'm surprised 24 hour cardiac call culminating with all-night BOLT at 37 weeks didn't send me into labor...maybe that's what caused my hypertension.
    I'm pregnant again now as an attending and it is much easier than the first time around (I can put my feet up AND my last call is at 33 weeks!). I did enjoy reading the above suggestions, especially the Canadian system. Another thing I would look into is considerations for breastfeeding residents. I had to stop breastfeeding early because of the lack of time I was given for pumping, both during the day and on call. Good luck!

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  7. Having had my second child in fellowship after two miscarriages in residency the discussions above trigger a lot of thoughts in me. I welcome the work hour regulations in residency in the US now as I feel it affected my health and fertility and there is no other way to arrange call to get healthy to get pregnant. I ended up taking a break year and then getting pregnant. The pregnancies went well. I took 5.5 wks for my first maternity leave and there was pressure to return fast including from myself to continue to gain skills in my first Yr of GI fellowship! My second delivery I returned after 7 weeks to a light rotation for 1.5 months so although I would have liked longer I don't regret it. The maternity leave rules need to change plain and simple. Multiple countries have systems that allow training to continue and you can't have it all and not extend your training and take more leave, but the option needs to exist before a cultural change can occur !

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  8. This post and all of the replies makes me so sad. How it's possible that there aren't more regulations in this matter is beyond me. I took a 24 hour call the night before I went to the hospital to have my baby. I honestly think that's atrocious and nobody in my program thought twice about it (in fact, I had more my last month to make up for the time I would be missing in the future.) It really has to change and it sounds like Canada, just across the border, has things much more figured out.

    Why people like Vellai are discouraging you from taking a more proactive stance is a mystery. She says, "I would hesitate to turn your individual situation into "rules" for all women in your field, however, though I'm sure your heart is in the right place and you're expressing a desire to make things better for those who come after you." But individual situations are what have to bring about rules, and I've seen more pregnant residents suffer than not from being overworked. Maybe she didn't suffer, but many, many people do and when they do there is nobody to stand up for them besides themselves. It's a sad situation. And don't get me started on maternity leave policies! We need change, and we need it now. Seriously.

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  9. I am an Internal Medicine Resident and had my son halfway during my 2nd year. I was lucky enough to have a chief resident who had recently had her first child, and she took it upon herself to go through my schedule and simply take out all rotations that involved 24-28hr calls after 20 weeks... I am in a fairly large program with several hospital sites, about 1/2 of which have q4 28hr call shifts. Unfortunately the residents pregnant this year did not have this benefit, and she is essentially toughing it out now.

    I think the notable thing about all of this is that we are all very tough women who want to work hard, and most of us (not all) are having our first child during residency- I know I didn't know what I needed to ask for! If it weren't for the guidance of my chief resident I would have had a much harder time. Guidelines for programs would be helpful for everyone- even if we have supportive programs, we wont know what to expect.

    I also want to mention that now that I have a 1 year old, the 28 hours shifts are harder than ever- not sure if anyone else has this experience. Baby boy does ok with separation the morning, but once it starts getting late and he realizes mom isn't coming home he is a basket case for my husband.... He has actually brought him to the hospital on more than one occasion so that he can nurse and hopefully doze off on the car ride home! What I'm trying to say is, in my mind, 24 hr shifts have to go. Myself and the other parents (male and female) have been pushing our program to switch entirely over to a night float system. It's just more humane!

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    Replies
    1. Totally agree! They have to go for everyone and especially for pregnant women. We do our residencies in our prime years and we deserve to have safe pregnancies!

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    2. I will be joining as intern and plan to hv baby by mid of 2nd yr. any rotations that you found difficult to deal with. I have micu/ night float , medical floor , ER rotations around after the planned conceiving time i.e by the end of intern yr. should I reschedule anything?

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