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Coming Back to Work Is Part of Parental Leave, Too

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Stopped at a light on my first day back to work after maternity leave, I instinctively placed my hand on my abdomen, searching for a reassuring kick. She’s not with me, I realized, sweeping away tears. After just five and a half weeks of maternity leave, I returned to work “soft and broken,” a close friend later recounted. Expecting to resume my former rhythm, I instead found myself struggling even to walk through clinic with a still-unhealed labial tear. I tried to listen to patients but instead fixated on whether my daughter had enough breast milk. When my mother texted me a picture of my daughter, I instantly lactated through my shirt. “Back already?” several sympathetic colleagues inquired. “Yes,” I would nod reticently, thinking I might never be “back.”

The birth of my daughter was the most physically and emotionally disruptive event of my life. I felt failed by a system suggesting that just six weeks was sufficient to return to a new normal. And I felt like a failure as both a physician and a mother — ready to leave a love of medicine cultivated over a decade for the love of my daughter, manifested in an instant.

One year ago, the American Board of Medical Specialties (ABMS) created a policy mandating that programs longer than two years allow at least six weeks of time for parental, caregiver, or medical leave without exhausting all of one’s allotted leave or extending training. The policy was a welcome and critical response to a growing call for a more supportive environment for trainee parents — one which I myself rejoiced at hearing after publicly struggling with my own return to work postpartum. The urgency of having more supportive policies for trainee parents has only become more evident during COVID-19. Prior to the pandemic, 40% of women physicians in the U.S. scaled back their medical practice or left the profession within six years after residency. This figure is likely only to grow, given an increase of 2.5 million women who left work during the pandemic, with a third citing childcare as their reason for leaving. Though the ABMS policy is an important step for ensuring a more appropriate parental leave duration, the American Academy of Pediatrics (AAP) — overseeing a specialty that is 75% women and recommending guidance for the development of healthy children and families — has both the opportunity and the incentive to create policies that are at the forefront of supporting trainee parents.

A prerequisite for ensuring parental trainee wellness upon return to work is having appropriate parental leave in the first place. The AAP officially supports 12 weeks of paid parental leave for the general population, which should be extended to pediatric trainees. Several programs have taken the initiative: the University of Michigan recently enacted a policy where faculty and staff can take up to 12 weeks of paid parental leave without extending training by combining six weeks of paid childbirth leave for recovery with six weeks of parental leave designated for bonding. Adapting 12 weeks as a universal benchmark gives trainees time to bond with their infants, develop adequate milk supply, and physically and mentally heal before they return to work. In a survey of 845 pediatric residents across 13 programs, 67% reported being dissatisfied with their leave length. Furthermore, trainees with more than eight weeks of parental leave were less likely to report postpartum depression or burnout and were more likely to report satisfaction with parenthood, support from program directors and colleagues, and longer breastfeeding.

In addition to having a more appropriate parental leave duration, training programs in pediatrics should offer pathways for a phased return to work. Many pediatric programs have a “new parent elective,” in which parent trainees complete reflective and didactic exercises from home. Institutions could also leverage telemedicine opportunities for new parents as the next phase of return to work. Giving postpartum trainees telehealth days could also help maximize opportunities to feed at the breast, which facilitates bonding through increased skin to skin contact.

Even as pediatric residents learn to encourage and support breastfeeding, 37% of medical trainees stopped prior to their desired goal. And while the ACGME policy on breastfeeding and lactation delineates provisions for breast milk storage, facilities to express milk, and protected time for pumping, it does not specify the actual time needed for pumping.

Having clearer guidelines around the time needed to express milk would normalize expectations around the temporal needs of breastfeeding trainees with return to work. The American Academy of Family Physicians and the AAP recently outlined recommendations for trainees who are breastfeeding, including the need to express milk every two to three hours for 20-30 minutes to maintain lactogenesis while reducing the risk of engorgement and mastitis. There are feasible ways to allow for protected time without compromising clinical operations or clinician staffing. On an inpatient service, breastfeeding trainees could peel off rounds to pump after presenting their patients consecutively. In the outpatient setting, breastfeeding or pumping times could be blocked on the schedule. In my own experience, I used these planned breaks to either pump or even run out to the parking lot quickly to feed my daughter if a caregiver could bring her close to my clinic.

The ABMS guidelines have helped to establish a minimum standard for how institutions can support trainees in the earliest days of new parenthood. But the AAP can lobby for policies which truly embrace trainee parents when they return.

I have been fortunate to know that culture. When my clinical performance suffered after I returned, my program director met with me and disclosed her own challenges as a trainee parent. We created a plan to reduce my patient volume temporarily while focusing on key clinical domains. She ensured I had blocked times to pump on my outpatient schedule, gave me an unscheduled half day a week to attend therapy, and offered tips on how she balanced her role as a parent and program director. She fundamentally understood that my ability to be a good clinician was contingent on my ability to be a parent. She also understood that parenthood is both work and an identity — that I could not just “leave” my motherhood at home.

In an ideal world, being a physician and mother would not involve making one identity invisible for another. On-site daycares, emergency childcare for sick children, and a policy for 12 weeks paid maternity leave should be standard and not exceptional.

As one of the few industrialized nations that does not guarantee paid parental leave, the U.S. fails to recognize parenthood as work. But as part of a specialty that profoundly understands the intersection between parental wellness and childhood development, the AAP has both the onus and opportunity to take the lead.

And, as a mother of a young daughter, I am hopeful.

What are your thoughts on the current parental leave recommendations for medical trainees? Share in the comments.

Megana Dwarakanath is a third year adolescent medicine fellow in Pittsburgh where she lives with her husband, Rahul, their young daughter, Meera, and their dog, Milo. When she is not spending time with friends and family, she likes to run, swim, and bike as well as read for as long as she can in one go. Dr. Dwarakanath is a 2022–2023 Doximity Op-Med Fellow.

Image by Mary Long / Shutterstock

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