MINDFUL OF MEDICINE

Thank you to everyone who shared their responses to the optional, anonymous survey. This was a needs assessment survey to gauge the current climate and conditions for medical students and trainees. The next step is a formal survey (IRB and everything) of potentially all current residents and fellows across the country, and including all specialities. It’s a big endeavor but I intend to create even bigger change. The sentinel article that showed me it could be done was by Halley et al at UCSF (https://www.bmj.com/content/363/bmj.k4926) which, along with their sub-analysis on demographic data, showed that maternal discrimination is significantly distinct from other forms of gender discrimination and is perpetuated by unique anti-maternal factors. The study is monumental however only 9.2% of their respondents are current residents, and among all respondents greater than 70% identified as white. This leaves room for further analysis which I’ll be doing formally. If you think about it, even with Halley’s study little sweeping change has occurred - that’s because institutions and medicine as a whole wont change out of the kindness of their hearts. Rather there has to be external pressure that directly threatens their financial risk and legal exposures. Which is the goal of my other project.

The results of this survey are below. Overall, all respondents were of reproductive age and mostly age 25-34. Most were current residents (62%), then medical students (30%), and fellows were the smallest group (7.58%). I found the third question to be quite illuminating and helped delineate where our needs are: lack of time, finding a clean/private space, and feeling isolated were top challenges. What i found most interstiung is that ALL respondents had suggestions for change (n=66) and only 36 women shared a positive experience. Moreover, those with positive experiences tended to be current medical students which may suggest that medical schools are probably doing a better job (used loosely) than residencies at imposing barriers on pumping/lactating mothers. It’s no secrete that residents lack basic rights as detailed by labor laws even though we are covered on paper. Women and mothers are far less protected and I suspect than when we cross the threshold from student to employee/cheap labor institutions and programs are comfortable witholding rights because they know 1. We show up and do our jobs regardless, 2. Dont’ have other options, 3. Very few of us are knowledgeable about what actions/recourse is available, and 4. Even fewer of us are in an emotional/financial place to seek out legal action.

• If you are a resident or fellow, then you are an employee and may seek out an Equal Opportunity Employment Claim (EEOC.gov). Be mindful that incidents are limited by state-determined deadlines and that your legal recourse may be limited if not filed in time. 
• Residents and fellows may also seek out the ACGME reporting feature. Complaints may be filed anonymously in some cases. 
• If you are a student, institutions often have confidential reporting. You may also consider escalating experiences to educational boards directly. 

1. Lerner, Gerda. The creation of patriarchy. New York: Oxford UP, 1986.
2. https://www.latimes.com/local/lanow/la-me-ln-usc-fellowship-accreditation-loss-20190425-story.html

Below is the orginal version of the piece shared on KevinMD.com. These are the words that came to me and needed out. Here they are without word limits.

“Why did you wait to schedule this meeting until September, why not July or August?" Candidly, I replied, "I have a family and being on nights, spending those 90 minutes with them a day is very important to me." It was then, behind closed doors, in an office where he held all of the power that he said: “You know, I don't think women with families make as good of doctors as those without.” I was shocked. Is this really happening? Surely he knew this was inappropriate, I thought. Surely he will stop there, I thought. But he continued, “I can offer you two things - a lawyer for a divorce from your husband and also to give up custody of your son.” I laughed nervously as I contemplated what felt like a dozen scenarios, all wagering the power that this man with all of his accolades and decades of institutional backing could wield against me - call him out and risk him ruining my reputation, politely leave and risk any chance at fellowship, leave and find help - someone would listen, right? I made the, albeit unsatisfactory, decision to brush past and redirect the conversation back to the project. To this day, I wish I had said more. But it was what followed that left me without recourse:


It was only my third month of residency. A freshly-minted doctor with fellowship goals, I was ready to network and build research experience. Nervously, I had smiled, but my head pounded. Is this really happening? I had heard stories like this before but I naively thought it would never happen to me. Walking to clinic that afternoon, shame crashed over my shoulders. Who do I tell? What do I do? Maybe this is just the way things are?

Normalized and silenced by leadership and systems allegedly meant to offer protection, I felt isolated. I felt like somehow I had done something wrong. I spoke to friends, to my partner, to family. Those closest to me echoed outrage and disbelief. What I would soon learn is that the disbelief was in vain: this is Medicine.

Inner turmoil followed - a cognitive dissonance where my identity as a new mother and a new doctor seemed incongruent yet required for daily function. Depression enveloped that first year of doctoring. I questioned my career in medicine daily - something I had worked toward literally my whole life. Something that, as it turns out, is not structured to support doctors who are mothers, much less offer them tangible protections particularly in training. Though it took a year, I found my voice amidst my pain and turned it into a passion: changing medical training and practice for mothers. But it did not come easy.

What kept me in medicine are the very things that were threatened: my son, my family. Above all, I am a mother. That alone negates any attempts to destroy my self-worth. Motherhood, to me, is the absolute privilege of being everything to a new person who is everything to me. It is guardianship over their early worldview in the hopes of creating a more brilliant future. The infinite, visceral love therein is all consuming and self-sustaining. It is the reason I choose to help mothers and their babies in the field of women’s health. The irony of the struggle of being a mother in a field dedicated to caring for mothers is not lost on me. And when my son asks me what I did to make space for mothers in medicine I intend to have concrete answers.

Despite the increasing proportion of women matriculating to medical school, 51% in 2018 compared to 7% in 1960, and those graduating (7% to 47% in 2018), women remain marginalized in both medical practice and in leadership 1,2. It is important to note the 4% attrition rate of women medical students and critically consider the role that stressors like being unsupported in motherhood and womanhood play. While 46% of US resident physicians are women, they only represent 38% of academic faculty and 15% of department chairs 3,4. This funnel effect leaves gaps in, and opportunities for, representation that could provide a voice in spaces of power and the access to tangibly affect change for women and mothers in medicine. When surveyed, greater than 70% of women physicians report experiencing gender discrimination 5. Prior literature has suggested that most female physicians desire children, and a more recent survey reports that 80% of female physicians who are or will become mothers have experienced a form of maternal discrimination 6.

Maternal discrimination is a form of gender discrimination that is rooted in patriarchal fragility and perpetuated by the perceived threat of fertility and/or an established identity as a mother. In a qualitative study by Halley et al at UCSF, the persistent, frequent and blatant discrimination faced by physician mothers is described unlike ever before and highlights the unique aspects of medical training and culture that contribute to maternal discrimination 7. Some excerpts are below:

Participate 166 shares: As a resident pumping for my 3 month old child (after coming back to work 4 weeks postpartum) I was told by my associate program director that my ‘personal life was interfering with my ability to perform my work responsibilities’ because of taking breaks to pump every 4-6 hours. Despite the fact that I was pumping in a public work space surrounded by attendings, residents, medical students, and occasionally consultants from other services so as not to miss any important clinical work or decisions rather than pump in private.”

Participant 13: “As a pregnant 3rd year med student, a male attending on my first rotation told me I had to decide if I was going to be a good mother or a good doctor, that I couldn’t be both.”

Of the 947 study respondents, 75% were white women, with only 8.4% Latina, and 6.3% Black women. The further compounded experience of women physicians of color who are mothers remains to be amplified. The work in elevating mothers in medicine and advocating for our protection must be intersectional.

Medicine and its culture can be characterized by great expectations and responsibility, flanked by dehumanization that serves to empower toxic hierarchical norms. Maternal discrimination is a reflection of these ills and is exacerbated by a sentiment that women, particularly mothers, do not have a place in, and do not add value to, medicine; that their responsibilities and identity as mothers are actually a detriment.

I rebuke this sentiment. Matresence, the identity shift into motherhood, is physiological, physical and spiritual. It is hard work; for some, the hardest and most beautiful work we will ever do. Transitioning into the role of Doctor is also transformative and it is familiar territory to the mother. Our ability to mother enhances our ability to doctor because it expands our humanity: to remain empathetic, multitask, and find harmony in a multivariate life.

Finding my own space in medicine has been arduous. The voice of a trainee is contractually silenced - we do not have full labor rights, we are bound by institutional policy, and even further chained by unspoken interpersonal rules that, if broken, threaten to derail our entire careers. If I could walk beside my past self on her way to clinic that afternoon, shame heavy on her heart, I would tell her: you feel powerless but you are not, you feel bound but these boundaries are simply constructs; and yes, this is Medicine - it is the way things are. But most importantly, it is wrong.

To institutions, departments, residency programs, and medical schools: you are accountable and bear the weight of responsibility. First, you must recognize maternal discrimination as a real problem. A problem that is insidious and sustained by the very structure of medicine as a whole.
Then, understand that it is perpetuated as much by the harasser as it is by normalization, complacency, and institutional protections for perpetrators. Above all, this requires accepting that the reproductive choices of women in medicine do not disqualify our intelligence and that we are unequivocally valuable to the field. Therein lies the real challenge. Therein lies the work.

Medicine has the power to save itself, and its recognition of physician mothers as humans and doctors worthy of respect and protection is pivotal. Centering the voices of those who are marginalized only ever uplifts the system as a whole. When their voices are heard and their conditions improved, the whole collectively benefits. Medicine is not an exception.

To my fellow mothers in medicine: I am sorry for everything you go through, and that our profession is so unforgivingly unkind. I encourage you to unapologetically be yourself and take up as much of your own space as possible. Realize that your presence alone makes those who are woven into the dominant frame of medicine very uncomfortable. They see no space for you, yet here you are. Find power in that, and if you ever find yourself with an opportunity to advocate for another mother be intentional and brave. Do not be discouraged by the work it takes to find your voice for when you do, you will find freedom you never thought possible. Understand that you may be silenced by proper channels in your efforts for justice, but also remember to trust patterns - not apologies or excuses. There will be times when sharing and centering your experience will feel like screaming into a void, or times where you give up parts of yourself or your story for the sake of making them palatable to the majority. In these times remember that you are worthy. I see you. I hear you. I am you.

1. AAMC Table B-4: Total U.S. Medical School Graduates by Race/Ethnicity and Sex, 2013-2014 through 2017-2018
2. Medical Education in the United States, 1960-1987 https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.7.2.144
3. AAMC. The state of women in academic medicine: the pipeline and pathways to leadership, 2015-2016. 2016. www.aamc.org/ members/gwims/statistics/
4. Guille C, Frank E, Zhao Z, et al. Work-family conflict and the sex difference in depression among training physicians. JAMA Intern Med 2017;177:1766-72. doi:10.1001/jamainternmed.2017.5138. 
5. Jagsi R, Griffith KA, Jones R, Perumalswami CR, Ubel P, Stewart A. Sexual harassment and discrimination experiences of academic medical faculty. JAMA 2016;315:2120-1. doi:10.1001/ jama.2016.2188 
6. Stentz NC, Griffith KA, Perkins E, Jones RD, Jagsi R. Fertility and childbearing among American female physicians. J Womens Health (Larchmt) 2016;25:1059-65. doi:10.1089/jwh.2015.5638 
7. Halley Meghan C, Rustagi Alison S, Torres Jeanette S, Linos Elizabeth, Plaut Victoria, Mangurian Christina et al. Physician mothers’ experience of workplace discrimination: a qualitative analysis BMJ 2018; 363 :k4926 https://www.bmj.com/content/bmj/363/bmj.k4926.full.pdf