ACS Fosters Workplace Support for Surgeons Building Careers and Families

Compared with the general US population, female surgeons are three times more likely to report fertility challenges and six times more likely to use assisted reproductive technology (ART).¹

In a recent survey of 859 surgeons, 25% of female surgeons required ART to become pregnant, and 42% reported a prior pregnancy loss—rates that are 2–3 times higher than the national average.² Overall, female surgeons in that study were almost twice as likely to have a major pregnancy complication compared with female nonsurgeon partners (48.3% versus 27.2%).²

One of the primary reasons for these adverse outcomes may be the choice by many female physicians to delay childbearing until after medical training, which for most surgeons is not until at least age 30. This reality is corroborated by a survey of more than 4,500 physicians from 2022 that demonstrated the median age of first birth for women surgeons was 32 years compared with 23 years in the general population.³ Unfortunately, it is well established that advanced maternal age is an independent risk factor for infertility, major pregnancy complications, and congenital anomalies, with risk increasing significantly after the age of 35 (see Figure 1).

In addition to age-associated risks, female surgeons encounter numerous other obstacles to a healthy pregnancy. Rotating and night shifts, as well as working more than 40 hours per week, are associated with adverse pregnancy outcomes.^4,5 A recent systematic review and meta-analysis of these factors identified a 10% increase in the rate of preterm delivery for women working more than 55.5 hours per week,⁵ and another large survey of female physicians demonstrated a 1% increase in major pregnancy complications with each additional hour worked per week.³

Additionally, surgeons are routinely exposed to known occupational reproductive hazards such as radiation, bloodborne pathogens, surgical smoke, and toxic chemicals that likely have unmeasurable effects on pregnancy outcomes.⁶

A lack of standardized policies and institutional support contributes to surgeons waiting to have children and/or feeling uncomfortable asking for accommodations during pregnancy. Inadequate parental leave, financial strain, and concerns about burdening colleagues further compound the hurdles surgeons face in building their families. These challenges are experienced most acutely by trainees who may not feel empowered to self-advocate for workplace support. It is paramount that surgical culture evolves to better support our colleagues so that we can mitigate the risks of adverse pregnancy outcomes and reduce the obstacles to building a family for future surgeons.

Figure 1. Infertility and Pregnancy Complications in Surgeons

As leaders in the surgical community, the ACS established the Board of Governors (BoG) Infertility & Pregnancy Complications Task Force (ACS BoG IPC Task Force) to study the gaps in workplace support for pregnancy, parental leave, and lactation for surgical trainees and practicing surgeons.

The ACS BoG IPC Task Force focused on the importance of workplace support for infertility, pregnancy, parental leave, and lactation for surgical trainees and practicing surgeons. The group was charged with providing guidance to surgical training programs and departments with the goal of promoting the well-being of surgeons, and thus created two resources, described in this article: Statement on the Importance of Workplace Support for Pregnancy, Parental Leave, and Lactation for Surgical Trainees and the separate Statement for Practicing Surgeons, both of which were approved by the Board of Regents during its February 2024 meeting. The statements subsequently were endorsed by the American Board of Surgery (ABS), American Board of Colon and Rectal Surgery, American Board of Neurological Surgery, American Board of Oral and Maxillofacial Surgery, American Board of Plastic Surgery, American Board of Thoracic Surgery, and Society of Gynecologic Surgeons.

The ACS statements provide frameworks for trainees and practicing surgeons who are planning families and include support for ART and/or prenatal medical care, clinical duty adjustments during the third trimester, parental leave of appropriate paid duration, and lactation support. Additionally, the list of resources for family planning was developed as a compilation of valuable external references on these topics (see Table 1). Additional resources are in development to aid surgeons and surgical trainees as conversations on these topics arise, especially with their respective department/division chairs, program directors, and other institutional leaders.

Summary of Existing Society and Board Policies

As the household structure in the US evolves and more women are in the workplace, the need for comprehensive legislation for paid parental leave becomes increasingly apparent. Despite changing societal norms and the wealth of data highlighting the benefits of paid parental leave, such legislation remains conspicuously lacking. Paid parental leave, particularly when extending beyond recovery from childbirth, is associated with improved family bonding, decreased postpartum depression, longer breastfeeding duration, retention of women in the workforce, increased employee morale, and gender pay equity.⁷

However, the US remains the only developed country lacking a paid parental leave program, leaving families without job protections, health insurance benefits, and wages. While the Family and Medical Leave Act provides up to 12 weeks unpaid leave for eligible employees (see Table 1A), currently 16 states also have adopted paid leave policies, although many still require a combination of short-term disability, paid time off, sick leave and/or vacation. There is no federal law ensuring comprehensive accommodation for pregnant and postpartum workers. The Americans with Disabilities Act only recently expanded to include temporary impairments such as those related to pregnancy.

The paucity of parental leave policies nationally and statewide is not due to a lack of data demonstrating its benefit. Paid parental leave that provides additional time for bonding beyond recovery from childbirth has been linked to improved vaccination rates, better family connection, retention of women in the workforce, and equalized gender pay.⁷

Many surgical societies have issued statements supporting surgeons and trainees choosing to build their families (see Table 1A). These statements support more flexibility and autonomy for surgeons and surgical trainees in making life decisions regarding family and parental leave. The organizations emphasize that a surgical career should not preclude an individual’s choice to be a parent, and the decision to have children should be free from criticism. There should be unanimous support for healthy pregnancy and outcomes without fear of repercussions or bias toward those surgeons who choose to have children.

Broad support for the following exists: paid parental leave of at least 6 weeks without extending training, inclusive of birthing and nonbirthing parents, as well as parents through fostering, adoption, or surrogacy; extensions to leave according to institutional and individual policies, which should not be a factor in career progression or promotion; and adjustments in duty hours and responsibilities after 30 weeks gestation, lactation support for breastfeeding surgeons, including hygienic lactation space and flexible breaks to express milk without bias or penalty.

The ABS has acknowledged the need to take time away from training for certain significant life events, including a new child or other personal matters such as the care of a seriously ill family member.⁸ The ABS requires 48 weeks of clinical activity for each year of residency with the remaining 4 nonclinical weeks used for vacation, conferences, and interviews. However, there is flexibility to allow the 48 weeks to be averaged over the first 3 years and the last 2. There also are options to extend the final year of training or to complete 5 years of training over a 6-year period if prior approval is obtained. In addition, the Accreditation Council for Graduate Medical Education (ACGME) now requires sponsoring institutions to have policies that include a minimum of 6 paid weeks off for medical, parental, and caregiver leave.⁹

1A. Family and Parental Leave

Parental Leave Policies

Statements by National Organizations

Examples of Institutional Parental Leave Policies

1B. Breastfeeding

Statements by National Organizations

1C. Fertility Preservation

Statements by National Organizations

1D. Infertility/Assisted Reproductive Technology

General Information

Insurance Coverage Resources

Summary of State and Territory Infertility Laws

Table 1. Resources for Family Planning

Unique Challenges for Surgical Trainees around Family Planning

Surgical training is long and arduous, with unique challenges for surgeons choosing to start a family. Surgical trainees routinely work rigid schedules with long hours (more than 40-hour weeks and up to 24-hour calls), night work, and potential exposure to occupational reproductive hazards.⁶ Since workload and patient care are shared among colleagues in a training program, there is a sense of team responsibility and fear of overburdening colleagues with undue work. Additionally, trainees are more likely to fear negative repercussions due to the hierarchical structures and power differentials inherent to surgical training.

Given these concerns, many trainees delay childbearing altogether during residency and fellowship. It can be difficult to obtain time off to pursue ART or attend obstetrical appointments. During pregnancy, trainees often do not feel empowered to ask for clinical duty adjustments due to fear of negative repercussions and guilt about burdening colleagues despite evidence demonstrating associations of increased obstetric complications and preterm birth with long working hours and night work.^3-5

After delivery, trainees face challenges receiving appropriate parental leave. Despite recent increases in the duration of family leave offered by the ABS and the requirement for at least 6 weeks of paid leave by the ACGME, trainees often are hesitant to extend their time off due to the desire to complete their training program on time.

Returning to work presents additional challenges, including limited access to appropriate time and space for lactation/breastfeeding and difficulty finding affordable childcare. Long work hours and the need to make up missed call further compounds time demands and stress for trainees in the postpartum period, with potentially adverse effects on maternal mental health and well-being. Postpartum depression is relatively common, and timely, confidential, and accessible support is essential.

Although there is widespread support from surgical societies, there often is a lack of individualized support at institutional and program levels with wide variation in family leave. Few policies detail any support beyond parental leave. Some institutions, such as the Massachusetts General Hospital General Surgery Residency Program, have instituted comprehensive parental support policies, addressing accommodations for preconception and family planning, pregnancy loss, pregnancy, and postpartum period, lactation and childcare resources, and access to mentors. These exemplary programs serve as models for other surgical residencies and fellowships (see Table 1A and 1B).

Fertility Preservation and Egg Freezing

Oocyte and/or embryo cryopreservation was initially used to preserve future fertility in patients undergoing gonadotoxic treatments. Since 2012—when in vitro fertilization (IVF) and pregnancy rates with cryopreserved oocytes were shown to compare favorably with those with fresh oocytes—this technology has been increasingly used by women to augment future fertility or to delay childbearing. Given the choice to delay pregnancy until after the completion of training and knowing the risks associated with advanced maternal age, many young surgeons now opt to pursue oocyte or embryo cryopreservation to safeguard their future fertility options.

Oocyte cryopreservation results in pregnancy and live birth rates similar to those using fresh oocytes and is supported by the American Society for Reproductive Medicine pregnancy as a means to enhance women’s reproductive autonomy (see Table 1C and 1D). These recommendations caution against viewing this procedure as a guarantee of future fertility, as there are insufficient data regarding long-term and age-related outcomes.

Similar to IVF and other forms of ART, oocyte cryopreservation and storage are rarely covered by insurance and can cost more than $20,000. Since the procedure is mostly pursued by surgeons who are still in training, the out-of-pocket cost can represent an insurmountable financial burden. Some institutions and companies may offer discounts to trainees but the out-of-pocket cost usually is still substantial. While coverage should ultimately be provided by insurance companies for fertility-related procedures, this change is unlikely to occur anytime soon. As such, additional support from institutions, departments, and other external sources may be needed to fill the gap so that oocyte or embryo cryopreservation remains an option for surgeons who would otherwise be unable to afford it.

Special Considerations for Adoption and Surrogacy

For many reasons, an individual may choose to build their family through adoption or surrogacy. Single parents, same-sex couples, and those who have undergone unsuccessful fertility treatments are more likely to choose these options. Among survey respondents who used adoption or surrogacy, almost 20% were in same-sex relationships, and another 22% pursued these options after undergoing unsuccessful attempts at ART.²

Like ART, adoption and surrogacy can be costly. In the same study, 60% of surgeons who used adoption or surrogacy reported spending more than $40,000.² Since these processes are also generally not covered by insurance, most of the cost must be paid out of pocket.

Surgeons who pursue adoption or surrogacy represent less than 5% of those who desire parenthood. Given that few surgeons expand their family through these methods, it is not surprising that these individuals often lack time for parental leave.² Because these pathways to building a family are less common and may be overlooked, it is critical that policies explicitly address and include these options.

Figure 2. Best Practices Guidelines for Family Planning and Childbearing

Updated ACS Statements and Resources

The ACS is dedicated to “improving the care of the surgical patient and safeguarding standards of care in an optimal and ethical practice environment,” as outlined in the organization’s mission statement. However, the current work environment has not been optimal for surgeons who have suffered from increased rates of infertility, pregnancy complications, and lack of resources and support for family planning.

The ACS is committed to addressing these concerns. To that end, the BoG IPC Task Force includes surgeons in academia and private practice at varying career levels and roles to ensure diverse viewpoints were considered when developing the new statements and resources (see Table 2, online version of the article only). Specifically, the revised statements outline best practices for parental support in training programs and for surgeon employers (see Figure 2), and the list of resources for family planning provides useful information for expectant surgeons‚ and surgical residents (see Table 1).

Adoption of these recommendations alleviates the burden on trainees or junior-level surgeons from having to self-advocate in a traditionally hierarchical profession. These policies should be extended to all parents, regardless of approaches to childbearing, adoption, or surrogacy.

The ACS BoG IPC Task Force supports the message that surgical trainees and surgeons seeking to start a family should feel empowered to request support or accommodations from their training program or employer, and they should not face barriers related to inadequate time and resources or challenges resulting from a lack of understanding or cooperation. Seamless integration of pregnancy and family planning into surgical training and surgical practice is necessary for the continued well-being and overall support of the surgeon.

In the last few decades, there has been a concerted effort to better understand the challenges faced by surgical trainees and practicing surgeons as they navigate the journey of building a family—from infertility struggles to pregnancy complications to returning to work postpartum.

Not only do the statistics related to these experiences mandate action, but the lack of clear and consistent policies aimed at supporting the needs of the modern surgical family suggests that there is a pressing need for change. Without ongoing dialogue and dynamic policy creation and assessment, the challenges faced by surgeons will persist, resulting in burnout and other adverse outcomes when surgeons are faced with pregnancy-related discrimination.¹⁰

Starting from training and extending throughout professional practice, the implementation of formalized policies and supportive infrastructure are crucial to promoting a culture of support for childbearing, in which aspiring and current parents can advocate for their needs without fear of repercussions or workplace discrimination.

The ACS BoG IPC Task Force represents a pivotal national initiative to formally address current data regarding infertility and pregnancy complications in the surgical workforce, supports educational resources to mitigate risk factors for obstetric complications in surgeons, and advocates for financial and workplace support for parenthood planning.

Table 2: ACS BoG IPC Taskforce

Dr. Tiffany Sinclair is a general and endocrine surgeon at Kaiser Permanente Panorama City Medical Center in Los Angeles, CA, and a faculty member at the Kaiser Permanente Bernard J. Tyson School of Medicine in Pasadena, CA. She is completing her second term as the Resident and Associate Society Liaison to the ACS Women in Surgery Committee and serves as Chair of the Personal Empowerment Subcommittee.

References

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