When to have children is an age-old question that’s complicated for women physicians because of the length and rigor of our professional training. Unfortunately, there’s no tried and true single answer that works for everyone. Please keep in mind I am writing from my own perspective and experience; others may feel differently.
The Variables That Affect Timing Of Pregnancy for doctors
I will list these in the order of importance.
- Profession and income of the partner.
- Specialty of the physician in the couple (e.g. family medicine versus neurosurgery)
- Support system near home.
Physician Partner’s profession and income matters
When having children in the context of a two-person long-term relationship, the most obvious question is whether one of these two people will become a stay-at-home parent or reduce their hours. I find that the question of the partner has two facets: (1) What does the partner do, i.e. what is their profession? (2) What is the partner’s income? What is the opportunity cost to the family if they step away for a few months or years? And how does that income stack against the cost of childcare?
One of my co-residents had two children. His wife was a teacher before pregnancy and so after the first baby was born, she became a stay-at-home parent until the younger child could start a part-time preschool solution. With regards to feasibility, I do not know the particulars of her situation but I can imagine that she weighed her options for future career success and decided to stay home. If I had to guess, I think the financial concerns ruled the day.
Let’s break it down.
In 2019-2020, the salary for a beginning elementary school teacher in a California school with medium attendance was $51,450.[1]
Teacher’s Salary, Less Childcare
After taxes and childcare, the take-home pay works out to a little better than minimum wage in California. And remember, the infant will also require childcare when she’s home, too, and this becomes a second shift for both parents. Then there are the other areas of household management that must be done by someone. These include grocery shopping, planning meals, strategizing finances, scheduling dentist appointments, keeping up with old friends. All in all, at this level of income, it may be worthwhile for this partner to stay at home to improve the family’s quality of life.
On the other hand, when I became pregnant with our first child, my husband and I were both residents, and one of us stepping away from medicine for years was not an option. In the end, I spent the first year of my older son’s life doing research; I was not quite a stay-at-home parent, but I was home far more often than I might have been as a medical resident. We had a much leaner budget than we enjoyed during our brief dual-income-no-kids (DINK!) year as newlyweds. And then the next year, I went back to residency, but my husband was an attending physician. His take-home pay was much higher than minimum wage. I’ll write out the math, using real numbers from an old paystub of his.
Attending Physician Salary, less childcare
And at the same time, I was also working. Now I actually put half of my gross income into pre-tax vehicles like 403b, 457 which were available to me. Therefore my take-home pay was substantially lower than what you’ll see here. But for a California medical resident who must pay for at least 40 hours of childcare, the effective wage is lower than a teacher’s. The numbers were are taken from an actual pay stub of mine from November 2019, when I was a fourth-year resident or PGY-4. In reality, a medical resident often has more expensive childcare than the average employee because of the nights and weekends we work in the hospital. In my family’s case, we had night time and a weekend nanny on call.
Medical Resident Salary, assuming 60 hour work week, less the cost of childcare:
That’s far below California’s minimum wage of $15/hour and will be less than Florida’s minimum wage (which is set to be $11/hour any minute now). However I do not think most young doctors would choose to forego the value of their medical degrees and the ability to practice by leaving medicine at this stage. In other words, for most of us, residency is not optional.
As you see, the reason I could well afford to have children during residency was because I had a high-income earner for a spouse. In the case of a median income earner, life becomes hectic and I think the decision more nuanced.
Of note, I have been discussing the cost of childcare purely from a cashflow perspective. A thoughtful approach would also consider the opportunity cost of these funds which might have been used to reduce student debt or invest. I think that is the topic of another article.
Just as important as the income and occupation of the partner is the specialty choice of the physician(s) in the couple.
Specialty choice of physician matters when having children
Absolutely, women can go into any field of medicine.
However, it is undeniable that resident and attending lifestyle can be specialty dependent. I remember arriving to the hospital at 6:30am, a full two hours AFTER the neurosurgery intern. He was often still working when we left, too.
The longer hours can be challenging from the childcare standpoint as well. For the families using daycare, many don’t open for business before 6:30am, and only on weekdays. For the hospital medicine and surgery physicians, this is inadequate coverage for childcare. In cases such as this, the burden of childcare drop-off can fall to the other family member. Or a second solution, such as a babysitter or nanny, has to be recruited.
It’s a situation that feels impossible when you fall into it – how does one pay for 80 hours of childcare? I will tell you it is not impossible. It’s very challenging, but achievable.
Less anecdotally, it has been documented that burnout is more prevalent in certain specialties including urology, ophthalmology, and emergency medicine compared to internal medicine.[2] It has also been reported, in a study of over 700 trainees from Mayo Clinic, that partnered or married people and parents have stronger perceived social support and are less likely to experience burnout.[3]
In short- women can and should pursue the medical career they most desire; however, it’s undeniable that some specialties may require more hours on the job. Medical students already consider lifestyle among other factors such as income and prestige when choosing their specialties.[4]. This data is from a self-reported survey of attending physicians representing 41 specialties; at least 20 respondents in each.
Adjusted mean differences in annual work hours compared to family medicine
Medical students are already looking at this data to make decisions about future career.
Length of training is a separate matter to the question of work hours per specialty. Many specialties will require longer training. This is relevant because during training there is little career flexibility, lower pay, and longer hours compared to after training. There is no part-time option for residency.
Women physicians do delay childbearing. The average age of first time pregnancy is higher among women physicians by four years compared to the national average.[6]
It’s true that having a baby is a huge distraction to an otherwise ordered life. Sleep and study patterns will never be the same. The cost is enormous. Delaying childcare until after residency seems a good choice for nearly all medical residents.
Except that nearly a quarter of female physicians are diagnosed with infertility.[6]
In addition to the cost and the disruption, it has been described before that women physicians perceive obstacles including workplace stigma, lack of institutional support, and insufficient maternal leave. In 2019, most women in surgical residencies reported taking less than six weeks for maternity leave.[7] More than half of them stopped breastfeeding earlier than they wanted to.
But effective July 1, 2022, ACGME has amended the national policy for parental leave requiring programs to extend at least six weeks of paid leave at least once per training to trainees.[8]
This is a huge step forward. I remember adding together all my vacation days to create a partially-paid leave. The trouble was, then I didn’t have vacation days for the remaining year. To create protected, paid caregiver leave for medical residents was long overdue. The impact on length of training remains less clear.
The bottom line is this: life is long. One day we will be past our years of childbearing and childrearing. Will we be glad of our specialty choice then?
Support system near place of work for doctors
I want to clarify that it’s not impossible to have children and live far away from your extended family. My father completed his residency in three countries in the days before work-hour restrictions. During the last two residencies, my mother stayed home with us; otherwise, we had no family for thousands of miles.
I too completed residency thousands of miles away from my parents and my husband’s parents. We had two children during my training. It was possible for us for two reasons: (1) we built a strong support system of friends and (2) we had the income to support the help we needed.
There are numerous, individual iterations of this story. In other words, I don’t think young doctors should rule out pregnancy and childbearing during training solely on the matter of having family nearby.
when to have children: The bottom line
Medical training is challenging but it is finite. The trouble for many women physicians is the time period of training coincides with peak childbearing years. The decision to start childbearing during training or postpone is individual; no one’s situation is altogether equivalent.
The time spent reading, networking, and learning with mentors during training cannot be replaced; there will be some natural disruption of this when becoming a parent. However, even most OB-GYN residents underestimate the impact of age on fertility.[9)
Everything is easier as an attending, except getting pregnant. Attending physicians have more money, more time, and more flexibility. We can move at will to be nearer to family. But attending physicians are older and with age comes reduced fertility.
It’s an extremely individual decision – but let it be a decision. Don’t let time make the choice for you.
Thanks for reading.
References
[1] Average Salaries and Expenditures, California Department of Education, 2019-2020 https://www.cde.ca.gov/fg/fr/sa/cefavgsalaries.asp
[2] Dyrbye LN, Burke SE, Hardeman RR, et al. Association of Clinical Specialty With Symptoms of Burnout and Career Choice Regret Among US Resident Physicians. JAMA. 2018;320(11):1114–1130. https://jamanetwork.com/journals/jama/fullarticle/2702870?resultClick=1
[3] Leep Hunderfund, Andrea N. MD, MHPE1; West, Colin P. MD, PhD2; Rackley, Sandra J. MD, MAEdHD3; Dozois, Eric J. MD4; Moeschler, Susan M. MD5; Vaa Stelling, Brianna E. MD6; Winters, Richard C. MD7; Satele, Daniel V.8; Dyrbye, Liselotte N. MD, MHPE9. Social Support, Social Isolation, and Burnout: Cross-Sectional Study of U.S. Residents Exploring Associations With Individual, Interpersonal, Program, and Work-Related Factors. Academic Medicine: August 2022 – Volume 97 – Issue 8 – p 1184-1194. https://journals.lww.com/academicmedicine/Fulltext/2022/08000/Social_Support,_Social_Isolation,_and_Burnout_.46.aspx
[4] Dorsey ER, Jarjoura D, Rutecki GW. Influence of Controllable Lifestyle on Recent Trends in Specialty Choice by US Medical Students. JAMA. 2003;290(9):1173–1178.
https://jamanetwork.com/journals/jama/article-abstract/197211
[5] Leigh JP, Tancredi D, Jerant A, Kravitz RL. Annual Work Hours Across Physician Specialties. Arch Intern Med. 2011;171(13):1211–1213. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1105820
[6] Stentz NC, Griffith KA, Perkins E, Jones RD, Jagsi R. Fertility and Childbearing Among American Female Physicians. J Womens Health (Larchmt). 2016 Oct;25(10):1059-1065. doi: 10.1089/jwh.2015.5638. Epub 2016 Jun 27. PMID: 27347614.
https://pubmed.ncbi.nlm.nih.gov/27347614/
[7] Rangel EL et al. 2018; 153(7):644-652. Jama Surg. Pregnancy and motherhood during surgical training.
https://pubmed.ncbi.nlm.nih.gov/29562068/
[8] ACGME Institutional Requirements. ACGME-approved focused revision: September 26, 2021; effective July 1, 2022.
[9] Schwartz KM, Martin CE, Hipp HS, Kawwass JF. Pregnancy and Fertility Concerns: A Survey of United States Obstetrics and Gynecology Residents. Matern Child Health J. 2021 Jan;25(1):172-179.
