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The Cruel Paradigm of Working in Neonatology

Op-Med is a collection of original articles contributed by Doximity members.

As neonatologists, we often discuss career plans with pediatric residents considering fellowship. Increasingly, residents share that they enjoy the science and patient care in neonatal-perinatal medicine, but don’t want the “lifestyle” because “neonatologists work all the time.” Extreme schedule stories are indeed rampant — back-to-back weekends, minimal parental leave, shifts lasting more than 32 hours, q3 call, late-night charting and academic work. These stories are augmented by literature rife with evidence of physician burnout, work dissatisfaction, and poor work-life integration. Though positive staffing changes have occurred over the past decades, they have not kept pace with our evolving workforce and workload. 

As neonatologists have advanced the science, care, and survival of critically ill newborns, challenges such as patient acuity, chronicity, and complexity have soared. Parallel to this, clinical obligations such as in-house 24/7 coverage including holidays and weekends, EMR management, and third-party payer requirements have grown. Increasing professional expectations — administrative duties, business travel on weekends, mandatory education, licensure and certification requirements, quality improvement, and academic work — are piled on top of clinical responsibilities. Regardless, most neonatologists deeply enjoy their work and consider it a calling, so they have progressively absorbed these demands, prioritized professional over personal commitments, and created a “new normal” to adapt over time. If we take a step back, however, we can see that some of these practices may be abnormal and harmful for our profession and patients.

Neonatology often continues with outdated work models created when most neonatologists were men with a spouse at home full-time. Staffing models and expected work hours vary widely, including time allocated for nonclinical responsibilities critical to most hospitals’ missions and individuals’ career development. Service to national professional organizations, though highly valued for multicenter collaboration, promotion, and advancing the field, is typically unaccounted for in institutional margins and done on personal time. Though staffing frameworks are challenging to structure, they are further hindered by a lack of transparency and information sharing. Questioning existing staffing concepts or suggesting change can make one seem unprofessional or not a team player.

Shift work is an accepted reality in our round-the-clock world of intensive care medicine, but many neonatology models do not allow flexibility to accommodate changing personal and professional situations. Work hour limitations have evolved to protect trainees, but they disappear as an attending. Shifts of 30-plus hours remain, despite neonatology having the oldest hospital-based workforce of all pediatric subspecialities and the fourth oldest workforce overall, with a median age of 53 and one-third over 60 years of age. Physician fatigue and stress are real concerns in a role responsible for managing emergencies, acute critical illness, and longitudinal complex care decisions.

Staffing models have minimal reserves for inevitable needs that arise for medical, personal, and family leave. Taking allowed leave is not always culturally acceptable. The limited flexibility of intense academic tracks further restricts leave or hinders professional advancement. Despite the American Academy of Pediatrics supporting at least six months of parental leave, many pediatricians take fewer than 12 weeks, with 80% taking less than they deem adequate. A pregnant neonatologist often squeezes all her clinical time into the months surrounding her leave, rather than getting true leave, and has inadequate lactation support upon returning to work; both may worsen her and her infant’s health. Nonbirth parents, caretakers for ill family members, or those with personal health concerns are similarly susceptible to repercussions of inadequate leave. These effects ripple through our colleagues with the burden of extra clinical work at the expense of their own professional or personal time. Ultimately, the consequences of physician fatigue, stress, and distraction extend to our patients and undermine the care we work so hard to provide. It is a cruel paradigm that many fields outside of medicine have made positive change for longer paid leaves, yet the field specializing in the care of infants and families and most knowledgeable about its proven benefits trails woefully behind. 

Collectively, these issues have left neonatologists stretched thin, with burnout concerns on the rise. These challenges are most palpable at the beginning of our careers, when early-stage physicians may be building both careers and families, and disproportionately impact women, who often carry extra responsibilities at work and home. Yet these issues affect physicians of all genders and levels, including during the prime years of career development and when raising young adult children, as well as during our later years, when we should be enjoying well-earned professional flexibility without having to worry about reduced pay due to a decrease in clinical duties. The COVID-19 pandemic exacerbated these struggles into an “acute on chronic” problem. Even still, some hospital leaders remain unaware of the extensive reach of these issues — issues that would not be tolerated in high reliability organizations. 

A cultural shift in the neonatology workforce is long past due; a shift will be instrumental to increasing professional engagement and wellness. It requires awareness and advocacy for change, along with a balance among competing interests, at the patient, divisional, and hospital leadership level. Transparent information sharing across hospital-based services within and between institutions could facilitate better understanding and optimization of current staffing models and create standard definitions of clinical full-time equivalents. Neonatologists warrant stakeholder input in our staffing models. Staffing models should incorporate a margin for leave, time for lactation, and jeopardy staffing for acute needs. Though needs are difficult to predict precisely, maximally allocating service without some anticipation of additional coverage needs is unrealistic. Taking allowed, needed leave must be culturally acceptable for both women and men, without resentment, stress, and significant impact to our career advancement or our colleagues. Part-time work should be possible without negative ramifications if circumstances require it. Shifts over 24 hours should be reconsidered. Increased scheduling flexibility, including night shift allocations, is warranted to support neonatologists at various life stages. Frontline clinicians and ancillary staff should be empowered to better distribute neonatologist work load. Trainees deserve education about these issues, especially when considering specialties or employers. There needs to be more research into the potential effects of staffing on patient and physician outcomes in order to make balanced adjustments. As neonatology has adapted to increased professional needs over time, now is the time to adapt staffing models for the health of our physicians and patients. 

What strategies and changes do you believe will help improve work culture in pediatric subspecialties? Share your thoughts in the comment section.

Drs. Machut, Bishop, Miller, Cuevas Guaman, and Dammann are neonatologists passionate about improving the health of the pediatric workforce alongside their patients. They actively address workforce gender inequities with the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine Women in Neonatology Special Interest Group. They can be reached at @WomenNeo.

Illustration by Diana Connolly

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