Despite recent advances made in medicine, gender-based disparities persist.1-3 In particular, women with children have barriers to career advancement and show evidence of slower career advancement.1,2 Multiple challenges for working women experiencing motherhood have been described. In academic medicine in the United States, women have limited access to paid parental leave.4-6 For women who choose to breastfeed, there is limited time, space, and support available for breastfeeding.7 Furthermore, sleep deprivation in the postpartum period significantly impacts the ability to function at work.8
Hospital medicine is a unique specialty as it comprises 47% women, 80% of whom are aged less than 40 years, suggesting that a large portion are women of childbearing age.9 The field poses known challenges to this population, including shift work, atypical schedules, and unpredictable hours. We conducted a descriptive qualitative study to improve our understanding of the experience of female academic hospitalists who have experienced pregnancy, parental leave, and the return to work as faculty. Our goal was to both explore the challenges to undergoing this experience and discover solutions to support female academic hospitalists.
We conducted a qualitative descriptive study of female hospitalists recruited from academic institutions represented in Society of Hospital Medicine (SHM) committees. Interviews were conducted between November 2017 and February 2018. Participants completed an informed consent and a demographic survey prior to the interview. Each interview lasted approximately 30 minutes; discussions were recorded on digital records and transcribed verbatim. This protocol was reviewed and granted exemption by the Institutional Review Board at the University of Colorado.
We recruited participants from a selection of hospital medicine groups nationally, chosen from SHM committee representation. A purposeful snowball approach was used to identify hospitalists from representative programs and seek their recommendation for hospitalists from other targeted programs. Ten hospitalists were approached by e-mail to determine their interest in participation, and all of them agreed to participate. Each participant experienced new parenthood within the last seven years.
We constructed our interview to represent the following timeline associated with having children as it pertains to a hospitalist position: pregnancy, parental leave, and the return to work. The interview guide was structured to invoke the positive aspects, challenges, and solutions within each domain (Appendix 1).
Codes were inductively developed from the interview data by a team of three board-certified internal medicine physicians (E.G., A.M., and C.J.), one of whom had prior training and experience with qualitative interviews and analysis (C.J.). Among the coders, two (E.G. and A.M.) conducted the semistructured interviews. Code disparities were reconciled by team consensus, where the primary coder facilitated the discussions. Themes were developed inductively from the codes, and the analysis was completed using a team-based iterative approach that was facilitated using ATLAS.ti.10 Thematic saturation was achieved. This study was approved by the Colorado Multiple Institutional Review Board.
The demographics and the characteristics of the hospital medicine group are shown in Table 1. Although we asked questions about both the positive and challenging aspects of the experience of parenthood, the interviews tended to focus more on the challenges faced and on areas for optimization.
Paid Parental leave
Most of the participants described inadequate paid parental leave, with minimal transparency in the processes for ensuring time off following the birth of their child, resulting in “haggling” with bosses, human resources, and the administrative staff. Rarely was a formal parental leave policy in place. Once a parental leave plan was established, several women reported the financial burden associated with a leave that was partially, or fully, unpaid.
“All of my leave was unpaid. .. managed to finagle short-term disability into paying for it… the system was otherwise set up to screw me financially.”
For the three women who did experience sufficient paid parental leave, they recognized the financial and emotional benefit and suggested that further optimization would include a prebirth schedule to account for the physical challenges and potential complications.
All of the women described significant physical challenges when working during pregnancy, resulting in limited bandwidth for additional academic activities outside of direct clinical care responsibilities.
“Exhaustion that hits you in your pregnancy and then you have to round. I used to lie on the floor of my office, take a little nap, wake up, write some notes, go home, take another nap, wake up, write some more notes.”
Upon return to work, women reported additional physical challenges related to sleep deprivation, impacting their productivity with academic work and emotional well-being.
“I came back from maternity leave and I was sleep-deprived and exhausted, I didn’t have the energy. All of these great projects that I had started or dreamed of … dwindled and died on the vine.”
Solutions suggested by the participants included creation of a flexible schedule with a ramp-up and ramp-down period around the birth.
The majority of participants in this study encountered several challenges associated with a shared goal of breastfeeding according to evidence-based guidelines.11 Designated pumping areas were often inconveniently located and not conducive to multitasking.
“It’s two chairs that are behind a curtain in a women’s locker room in the basement of the hospital, that are tiny and gross. No computers, so I felt like I was wasting time.”
One hospitalist described carving out time for pumping in her office while multitasking with clinical work.
“I would get to work, set up, and pump while chart reviewing. Then I would go and see people… and come back to my office and pump and write a few notes. And go out and see more patients, and then pump and write a few more notes. And then pump, and then go home. I was like a cow.”
Women highlighted the barriers that could be optimized such as creating time in the clinical schedule for pumping, a physical space to breastfeed or pump, and accessible milk storage facilities.
When asked about the impact of parental leave on career opportunities, a few of the women described a phenomenon of no longer being asked to participate or being left out of prior projects.
“People didn’t want to offer you things or give you things because they realize you’re having this transition in your life. Not out of animosity, but out of courtesy that they don’t want to fill up your place even more. Her plate is full; we are not going to ask her to do anything extra.”
However, two women specifically reported a supportive environment without a loss of opportunities, often referenced as a boss who “saved” projects for their return.
One participant used the term “microaggressions,” to describe passive aggressions encountered by their colleagues or leadership.
“(A colleague) was diagnosed with pre-eclampsia, and very urgently had to deliver and couldn’t cover a week of shifts…She was asked initially to find her own coverage…Not treating (pregnancy) similar to other serious illnesses is what I would term a microaggression.”
Yet, women in our study also reported positive responses from colleagues and the importance of support networks of physician mothers (Table 2).
Empathy in Patient Care
Finally, the experience of motherhood impacted all of the women as physicians, described as increased empathy, patience, and understanding of difficult family situations.
“I’m just more sensitive to people’s lives outside the hospital, so, you know, when it’s difficult for a family member to get there because they have three other kids they are taking care of or, somebody that says they are leaving AMA, but it’s because they have a sick kid at home. I just have a better context for that.”
Gender disparities persist in both internal medicine and hospital medicine.1 Providers in this descriptive qualitative study suggested that the following factors contribute: lack of paid parental leave and the associated financial penalties, loss of career opportunities, the physical challenges associated with pregnancy, decreasing productivity, and the amount of time and effort involved in breastfeeding. However, the participants also shared valuable ideas for future solutions to relieve the challenges imposed on working physician mothers (Table 2).
Breaking the Glass Ceiling
Participants noted the importance of a paid leave policy that encompasses not only maternity leave but also a flexible scheduling period before and after the leave to account for the challenges of pregnancy and new motherhood. Paid parental leave is rare in academic settings, but studies from other industries show that when women take paid leave, they are more likely to remain in the workforce 9-12 months afterward, work more weekly hours, and feel more loyal to their organization.12,13 In the rare instance when negotiations around leave violate local policy or the law, women should be encouraged to seek guidance from their human resources department.
Me Too: Building Solidarity
Women in our study reported the value of a supportive workplace in easing their transition into motherhood. Specifically, they noted that a supportive boss who protected their career opportunities prevented momentum loss in their career trajectory. Access to mutual supports such as the Physicians Mom Group, a well-established Facebook group comprising more than 70,000 women, was referenced as a meaningful way to share joys and tribulations related to balancing a career as a physician and motherhood. Growth of similar support systems within institutions will further support this experience.
Time’s Up: The Promotion Clock
Women in our study described a prolonged period of diminished productivity related to having children, coinciding with a set time to promotion in academics. Flexible promotion schedules may impact women’s ability to successfully undergo promotion.
The aim of this study was to represent a shared set of experiences of female academic hospitalists who participated; therefore, the results may not be generalizable beyond this group. Due to the use of a purposeful snowball approach, there was a potential for selection bias. Future research may include comparing the experience of women at institutions that offer paid leave versus those that do not and the impact on retention, promotion, and well-being.
Women in hospital medicine encounter several challenges to having children, but they are also motivated to provide solutions. Efforts to improve the institutional and cultural landscape to better support women physicians with children are critical to prevent attrition of women and ensure equitable academic promotion and achievement of leadership positions.
The authors have no conflicts of interest to report.
Each author was involved in the creation of the study protocol, data collection and analysis, and creation of the manuscript.