Physicians, Pregnancy, and Parenthood: A Conversation on Work-Life Integration with Dr. Erika Rangel

Interview by Jessie Liu

HHPR Senior Editor Jessie Liu interviewed Dr. Erika Rangel, MD, a general surgeon and surgical intensivist, the Director of the Surgical Intensive Care Unit at Brigham and Women’s Faulkner Hospital, and the Associate Surgical Clerkship Director for Harvard Medical School.

Her academic interest centers on defining the challenges facing surgeons starting a family, demonstrating how these impact burnout and career dissatisfaction, and using evidence to inform policy change to better support alignment of personal and professional priorities. Her work has characterized stigma, unmitigated work schedules amidst health concerns, problematic maternity leave policies, and little postpartum support or mentorship among pregnant residents which lead to high risks of career dissatisfaction and thoughts of attrition. She has published on the elevated risks of infertility, miscarriage, and major pregnancy complications among female surgeons and described the impact of low workplace support for these adverse obstetric outcomes. Her Pregnancy Mentorship Program is now nationally disseminated in the SECOND Trial, a randomized controlled trial to improve wellness for surgical residents.

JL: I'm so excited and grateful to have you speaking with us today, Dr. Rangel! One of the reasons we've reached out to you is because of your uniquely prolific focus on and advocacy surrounding infertility, pregnancy, parenthood, and parental leave among US surgeons—what would you say sparked your interest in this particular issue?

ER: Well, to start, I’m a surgeon mother with two boys: my first son was born when I was a fourth-year surgical resident at the Brigham, and my second son was born during my first year in practice. During the process of having both, especially the first, I was struck by how challenging it was to have a child while in training. There wasn't a lot of infrastructure in place for how that would be accommodated—and I use the word “accommodation” loosely, because it makes it seem like pregnancy is something that needs to be adjusted for rather than something that should be celebrated.

Both of my kids were born prematurely, and my second son spent two months in the ICU because he was so early. During that time, it was really difficult to make the choice to stay in something that I previously loved, and I thought I was alone in that. I didn't know anybody else who had had a child during training, and it seemed abnormal. And you know, I think it could have gone any which way; I might not have finished, but I did, because I had a supportive husband and family.

However, in the years after that, when social media became more prolific, people would talk about similar experiences on social media, and I think there was kind of like a camaraderie and relief in that—a sisterhood. Over the years though, it occurred to me that nothing was actually going to change if people just talked about it behind that cyber wall. In medicine, we are trained to be so academic and data-driven, so policy changes to our training, which has deep historic roots, requires some good data to justify why it's necessary. That’s where my advocacy comes in.

JL: With the COVID-19 pandemic, there's been a renewed public focus on the well-being of healthcare workers where it hadn't been spotlighted before. In your opinion, what are some of the most pressing and under-reported issues experienced by physicians (or surgeons) today? Do you observe disparities of any kind, and do you think the COVID-19 pandemic has changed anything on this front?

ER: Right now, the number of people, women in particular, that are having children in training is really taking off. If you look at data from 20 years ago compared to now, we're almost approaching gender parity in terms of numbers of surgical trainees, but unfortunately, I don’t think the underlying culture of surgery has necessarily kept up with that growth and increased diversity. And so we’ve seen that there are certainly greater absolute numbers of people who are becoming pregnant during training, but still there's a huge gender disparity in how men and women who have children in training are perceived. Thus, we see many fewer female surgeons having children during training, compared to their male counterparts; we see the women being counseled not to have children during their clinical years of training—or, if they do have children, to consider a so-called “easier” subspecialty.

All of that contributes to this perception that pregnancy is not a welcome event, so we see women postponing pregnancy. By the time people are done with a five- to nine-year long training, they’re in their mid-thirties, and infertility and pregnancy complications become big issues. It’s just not talked about publicly, but even the women surgeons who do have children end up having fewer than they want because of fertility issues and can’t really complete the family they might have imagined.

As for how COVID-19 amplified these issues, it’s increased the challenges in all the ways that you've seen in the lay press, unfortunately. Despite how far we’ve progressed, I think we still have a lot of gender norms that persist in society. In many families, the bulk of domestic duties still falls on the mom. When all of a sudden, the kids are home from school and there are a lot more domestic duties to be undertaken, we see that a lot of the women are disproportionately picking up those responsibilities, and that really drops down their academic productivity and it negatively impacts their career.

JL: Right, and so how would you say that echoes your own experience in balancing personal and professional aspirations?

ER: I try not to use the word “balance,” because I find that it frustrates people because it's sort of like the holy grail which can never be achieved. Failing to find balance doesn't mean failure overall. I prefer the term “work-life integration” instead. My kids and family are integrated into every aspect of my professional life. My husband happens to be a surgeon too at Boston Children's Hospital, so that means we integrate Disneyland trips with talks at surgical conferences and we travel together that way a lot. The kids come with me when I’m on call on the weekends, and that helps them better understand what I do and hopefully gives them an early viewpoint on what it looks like to lead a multidimensional life and how rewarding it is to dedicate your career to making others healthier.

For our family it's worked really well, but everybody has to find their own path. My husband's extremely supportive and progressive in these aspects, he’s watched this journey as my biggest cheerleader, and he is happy to partake equally in domestic duties. I’m lucky that I don't have to struggle with somebody who doesn’t play those roles, but not everyone’s that fortunate.

JL: That sounds like a really interesting model you have there! Understandably, women physicians have often been the focus of conversations around pregnancy and parenthood, but how do you think discussions explicitly about gender and physicians who are men might add to our understanding?

ER: Parenthood is not a gender issue inasmuch as we have these gender schemas that society has created around the idea. The more we prioritize the role of the non-childbearing parent, the more quickly we can change the conversation surrounding parenthood to be something that should be integrated into the professional life of every surgeon, every position. The sooner that we change the conversation to include parents of both genders, the sooner we can address burnout across medicine and promote a healthier environment where it's considered normal to have children and to want to be part of their lives. We did some work that looks at paternity leave, specifically about what the challenges are for the non-childbearing parent; they don't have it easy either, so excluding them from the challenges surrounding parental leave perpetuates this narrative that parenthood is just for women, that we just need to make accommodations for women, and that's not good.

Physician burnout is a significant topic in medicine today; we talk a lot about it in terms of the syndrome of depersonalization and emotional exhaustion, and we know that it's an epidemic among American surgeons. People who are burned out leave their careers earlier, suffer more alcohol abuse, and commit more medical errors, so for all those reasons we have to fix this issue. We know that having imbalance between your work and domestic life is a huge driver of burnout for both genders, so this conversation around parenthood and training isn’t just for women.

JL: I really appreciate how you use the gender-neutral language of childbearing versus non-childbearing parents. Considering that, how might family-building for physicians who are single, identify as members of the LGBTQ+ community, or who seek to pursue non-traditional family building options fit into this picture?

ER: A few years ago, probably in 2017, parental leave was considered a medical leave; you got two weeks off because you gave birth, which was no different than breaking your leg, and if you didn't actually give birth you didn't get that two weeks. That left out a lot of people, and it was very personal for me because I had a friend who adopted a son out of state and couldn't get any time off to go down there with his partner. There are very stringent rules around adoption and how long you have to be there to get all the paperwork done, and it was so difficult because he hadn't actually given birth to this child.

It is just an unfair way to handle things, and I think we're lucky that the American Board of Surgery has been very progressive. They recognized this issue and immediately addressed it, changing it to call it family leave. That includes trainees who become a parent without a partner and all members of the LGBT community who are adopting and doing surrogacy—all those people are entitled to the exact same benefits as if you had had that child physically.

There’s also a whole other group of parents—single parents that may have wanted to undergo cryopreservation and have a child on their own. That's something that has been much more openly discussed recently because the technology has come a long way, and so debates around fertility preservation and its coverage have become a new hot topic. Is it sending the right message? Are we giving people who pursue fertility preservation autonomy, or are we encouraging them to postpone their personal goals for the sake of their professional fulfillment? I personally think it's mainly about giving women a choice, but that is open for debate. I do think the most important thing is to use inclusive language and recognize that there are so many pathways to becoming a family that don't involve the standard, heterosexual couple and pregnancy.

JL: Can you tell me a little bit about how existing attitudes and structures within medical education and the health professional/provider community have contributed to the barriers that we’ve seen? How has your own experience as Brigham and Women’s Faulkner Hospital’s Director of Surgical Critical Care and Inpatient Programs shaped your views on these issues?

ER: Traditionally, surgical (and much of medical) training was very male-dominated. The term “resident” came from the days of William Halsted, when residents actually lived in the hospital and they were discouraged from having a personal life outside of the hospital. Their single duty was to care for patients. Things have evolved, but we are very traditional and changing culture is difficult, especially when it’s as deeply rooted as this. And so, even though a lot of the policies have evolved over time, culture follows policy more slowly. Case in point, duty-hour reform occurred some fifteen years ago to reduce resident work hours, and eventually people became accepting that this was the new norm. We are just starting to build parental leave reform in 2021 and 2022, but it's my hope that the training culture will accept this over time in a similar way.

The initial barriers were that many places didn't have any formal parental leave policies and few considered postpartum needs of trainees. Even a few years ago, only about half of training programs had maternity leave policies, and fewer had paternity policies or non-childbearing parental policies in place. There was very little in the way of childcare support or recognition that somebody who had just had a child might need to breastfeed, and so just the lack of that infrastructure makes parenthood a taboo topic. Breaking down that barrier with policy change and starting open discussions gives the trainees, who are lowest on the totem pole in terms of social capital and rank in a hierarchical system, the agency to speak up.

JL: In terms of medical leadership and this lag between policies and cultural change, what do you think leaders in the field can do in the middle to facilitate that process?

ER: So much of cultural change is based on strong leadership. It's not enough just to have a policy, because it's really important for leadership to show the rest of the faculty and people around them that this is a priority, that this is important for the department’s, even the profession’s, future. We’ve been so fortunate that the leaders of 2022 have such a focus on diversity, equity, and inclusion, and I think that has gotten the conversation going and energized people to move on this issue.

JL: It’s really encouraging to see that kind of change already beginning to materialize. As we wrap up and look towards the future, generally, undergraduates aren't quite yet at the stage where we think seriously about family planning and pregnancy. Would you have any advice for pre-med students on work-life integration, or in general?

ER: One of the things we’ve been seeing is that it’s really important to have education early, so that you're introduced to the topic of infertility and what it means to wait. A lot of us have a scientific background, and knowing what the numbers are and being educated at beginning of medical school and continuing on through residency is vital. Offering professional fertility counseling very early on so that they can make evidence-based decisions for family planning is very valuable.

I also think the conversations about work-life integration need to start early. I definitely don't want to sugarcoat it—I am very blessed with an awesome family, but it takes a village to make this work and I have an entire team of people that make this life possible. And I think that the more people openly disclose that, the better we can let younger people know that it's okay that parenthood needs a village, that it doesn't make you any less of a parent or surgeon. Pursuit of perfection on your own is a setup for disappointment, and I think all of us are just doing our best professionally and as parents. Having it all means that you find happiness whatever that looks like for you. Students hoping to have a career in medicine should know that while you may not be there to make these Instagram-worthy lunches for your kid to take to school, you're showing them what it looks like to lead a very fulfilling and multi-dimensional life.

When my kid was four, I used to drive myself crazy making perfect little sandwiches and trying to go to every field trip and making sure the kids had the perfect snow outfit for winter, and I still just felt so inadequate because inevitably I would miss stuff. And then I would come to work and see the people who were staying till 10 o'clock doing big hepatobiliary cases and then feel inadequate there too. But once you take a step back, stop measuring your worth on someone else’s vision of accomplishment, and look at what you're contributing to both sides of your life, you’ll get a well-rounded picture of achievement. That is truly fulfilling.