Orthopedics

Feature Article 

Program Directors' Perception of Pregnancy and Parenthood in Orthopedic Surgery Residency

Chelsea Nemeth, MD; Elizabeth Roll, MD; Mary K. Mulcahey, MD

Abstract

Orthopedic surgery has one of the lowest percentages of women of all medical specialties. The purpose of this study was to determine the perception of pregnancy and parenthood during orthopedic surgery residency among program directors. An anonymous survey was distributed to all program directors who were members of the American Orthopaedic Association's Council of Orthopaedic Residency Directors. Twenty-six (53%) of 49 male program directors believed that pregnancy and parenthood negatively affected female residents' scholarly activities (P=.02), whereas 10 (83%) of 12 female program directors believed that it had no effect. Significantly more program directors believed that pregnancy and parenthood imposed a burden on fellow trainees for female residents than for male residents (77% vs 45.9%, respectively; P=.0004). This study demonstrated that orthopedic residency program directors perceive the effects of pregnancy and parenthood more negatively for female residents, especially related to scholarly activities and the burden placed on fellow residents. [Orthopedics. 2020; 43(2):e109–e113.]

Abstract

Orthopedic surgery has one of the lowest percentages of women of all medical specialties. The purpose of this study was to determine the perception of pregnancy and parenthood during orthopedic surgery residency among program directors. An anonymous survey was distributed to all program directors who were members of the American Orthopaedic Association's Council of Orthopaedic Residency Directors. Twenty-six (53%) of 49 male program directors believed that pregnancy and parenthood negatively affected female residents' scholarly activities (P=.02), whereas 10 (83%) of 12 female program directors believed that it had no effect. Significantly more program directors believed that pregnancy and parenthood imposed a burden on fellow trainees for female residents than for male residents (77% vs 45.9%, respectively; P=.0004). This study demonstrated that orthopedic residency program directors perceive the effects of pregnancy and parenthood more negatively for female residents, especially related to scholarly activities and the burden placed on fellow residents. [Orthopedics. 2020; 43(2):e109–e113.]

Although 47% of current medical students in the United States are women, they are not represented equally in all medical specialties.1 Orthopedic surgery has one of the lowest percentages of women, with only 14% of current residents being female.2 Female medical students continue to be somewhat reluctant to enter the field; this could be attributed to a variety of factors, including perceptions about residency training and clinical practice.2 A prospective cohort study of male and female students at 2 medical schools determined that female students had negative perceptions about orthopedic surgery, including male dominance in the field, a challenging lifestyle, increased physical demand, and barriers to promotion and acceptance by senior faculty.3

All surgical specialties have demanding lifestyles, which can add to the stress of pregnancy and parenthood. In 2012, Hamilton et al4 surveyed female surgeons from several surgical specialties and found that a greater percentage of female orthopedic surgeons worked more than 60 hours per week and spent more time in the operating room compared with females in other surgical specialties. This study also demonstrated that female orthopedic surgeons tended to have children at an older age than US norms and to have a pregnancy complication rate that is higher than the general US population.4

Similarly, in 2012, Turner et al5 surveyed female general surgeons regarding their experiences with pregnancy and childbirth. The authors found that there remains a largely negative attitude toward pregnancy during residency; therefore, most female surgeons wait until the conclusion of training to have children. A separate study surveying general surgery residency program directors found that 67% of programs have a formal maternity leave policy.6 Furthermore, a recent survey of program directors of accredited orthopedic surgery programs by Weiss and Teuscher7 found that 80% of programs had a formal maternity leave policy, whereas only 49% had a formal paternity leave policy.

The purpose of this study was to determine the perception of pregnancy and parenthood during orthopedic surgery residency among program directors and its effect on the performance and well-being of male and female residents. On the basis of studies from other surgical specialties,5–7 the authors hypothesized that gender biases related to pregnancy and parenthood exist in orthopedic surgery residency programs.

Materials and Methods

After obtaining institutional review board approval, an anonymous, 26-question survey was distributed to 151 program directors who were members of the American Orthopaedic Association's Council of Orthopaedic Residency Directors (CORD) as of August 2016. This included all Accreditation Council for Graduate Medical Education–accredited programs, as well as 4 osteopathic programs. The survey included questions regarding the demographics of the programs, resources available to residents within their programs, as well as program directors' individual attitudes and perspectives. The questions included in the survey were based on questions asked in other studies surveying female general surgeons, but not yet asked of female orthopedic surgeons.7,8 The survey was distributed using REDCap electronic data capture tools (version 6.10.17; Vanderbilt University, 2016) in 2016. Email addresses for the program directors were collected using publicly accessible information. A follow-up email was sent 2 weeks later to encourage more participation.

The survey included questions concerning the demographics of the residency program (eg, location, size of program), the percentage of residents with children, and the demographics of the program directors (eg, sex, age, parental status). Program directors were also asked about their perceptions of the impact of pregnancy and parenthood on residents' well-being, dedication to patient care, and scholarly activities. In addition, the survey inquired about any specific facilities and related policies for residents with children (eg, childcare, breastfeeding, flexible scheduling). Each question was scored using a binary system (ie, 1=yes, 2=no) and the data were analyzed using the chi-square test.

Results

A total of 61 (40%) of 151 program directors responded to the survey, 49 (80.3%) of whom were male. Thirty-one (50.8%) of 61 program directors were between the ages of 40 and 49 years and 52 (85.2%) of 61 were from university-based institutions. Forty-one (67.2%) of 61 program directors stated that their programs had 4 to 7 residents per year. Forty-two (68.9%) of 61 program directors stated that 0% to 20% of their current orthopedic surgery residents are female, whereas 17 (27.9%) of 61 program directors stated that between 21% and 40% are female.

Residency programs varied in the types of services provided for new parents. Thirty-seven (60.7%) of 61 program directors indicated that their institution offered breastfeeding facilities, whereas 35 (57.4%) of 61 offered childcare services (Table 1). Thirty-five (57.4%) of 61 program directors responded that residents should be allowed to scrub out of a procedure to pump breast milk, whereas 26 (42.6%) responded that they should not be allowed to scrub out. Fifty-four (88.5%) of 61 program directors indicated that there is flexibility in scheduling for parents during residency training (Table 1).

Resources Available for New Parents

Table 1:

Resources Available for New Parents

Of the program directors who participated, 39 (63.9%) believed that pregnancy and parenthood had a minimal effect on female residents' work performance and 34 (55.7%) believed it had a neutral effect on female residents' well-being (Table 2). For male residents, 46 (75.4%) of 61 program directors thought parenthood had a minimal effect on work performance, whereas 43 (70.5%) of 61 believed that it had a neutral effect on well-being. Furthermore, 57 (93.4%) of 61 program directors believed that pregnancy and parenthood did not have an effect on female residents' dedication to patient care (Table 2), whereas 58 (95.1%) of 61 program directors thought that it did not have an effect on male residents' dedication to patient care. These results were similar regardless of the sex of the program director (Table 3).

Attitudes Toward Pregnancy and Parenthood for Female Residents

Table 2:

Attitudes Toward Pregnancy and Parenthood for Female Residents

Most Common Responses by Sex of Program Director

Table 3:

Most Common Responses by Sex of Program Director

Forty-seven (77%) of 61 program directors believed that pregnancy and parenthood among female residents imposed a burden on fellow residents (Table 2), whereas for male residents, only 28 (45.9%) of 61 program directors believed this to be the case (P=.0004). Forty-two (68.9%) of 61 program directors believed that pregnancy and parenthood did not have a negative effect on scholarly activities for male residents, whereas only 33 (54.1%) of 61 program directors believed that it did not have a negative effect on female residents' scholarly activities (P=.0944). Twenty-six (53%) of 49 male program directors believed that pregnancy and parenthood had a negative effect on female residents' scholarly activities, whereas 10 (83%) of 12 female program directors believed that pregnancy and parenthood had no effect on scholarly activities (P=.02; Table 4).

Effect of Pregnancy and Parenthood on Female and Male Orthopedic Residents' Scholarly Activities

Table 4:

Effect of Pregnancy and Parenthood on Female and Male Orthopedic Residents' Scholarly Activities

Discussion

Of the 61 programs with survey respondents, 42 (68.9%) had fewer than 20% female residents in their program. Most institutions provided breastfeeding facilities, childcare services, and flexibility in scheduling for parents during residency. Of note, the survey did not specify whether these support structures were specifically aimed at orthopedic surgery residents or for the institution as a whole. Pregnancy and parenthood were thought to have a minimal effect on female residents' work performance, well-being, and patient care. Forty-seven (77%) of 61 program directors believed that pregnancy and parenthood among female residents imposed a burden on fellow residents, whereas only 28 (45.9%) program directors believed this to be the case for male residents (P=.0004). Significantly more male program directors than female program directors believed that pregnancy and parenthood negatively affected female residents' scholarly activities (P=.02).

Many studies have attempted to determine why only a small percentage of women pursue a career in orthopedic surgery and why the growth of women in the specialty has not matched that seen in other surgical specialties.2 Increased exposure during medical school and more opportunities for female mentorship may help,8 but female students continue to have negative perceptions regarding a career in orthopedics.2 Female medical students are often concerned about the impact of child-bearing on their work performance and career during residency. Several studies have demonstrated that there is no significant difference in performance between male and female orthopedic residents; however, pregnancy and parenthood were not specifically taken into account.9,10

Despite men being increasingly involved in responsibilities at home, women still bear more of the burdens of housework and childcare,11 which can exacerbate an already busy residency schedule. In the current study, most institutions provided breastfeeding facilities (60.7%), childcare facilities (57.4%), and flexible scheduling (88.5%). Although increased availability of such facilities and resources may help, it remains unclear whether they are commonly used by residents and what attitudes persist about these resources within programs. For example, more than one-third of program directors responded that they do not think women should be allowed to scrub out of a procedure to pump breast milk, raising the question of whether having policies in place is enough to support mothers during residency. Furthermore, 77% of program directors thought that pregnancy and parenthood for female residents imposed a burden on fellow residents, whereas only 45.9% of program directors believed this is the case for male residents (P=.0004).

A survey of general surgery residency program directors similarly determined that 61% believed that parenthood negatively affects female residents' work, including an increased burden on fellow residents.6 The residents who were also interviewed in this study described difficulties in managing breastfeeding and childcare during residency, as well as the worry that they would be viewed as a burden on their fellow residents.6 Further studies could elicit from program directors why specifically they believed that these residents imposed a burden on their fellow trainees and why there is a difference for male and female residents. It is also important to realize that an absence from a residency program for any reason can create a burden on fellow trainees. Therefore, it would be useful in future studies to understand why program directors thought pregnancy and parenthood were burdens and whether it was solely related to the residents' absence.

Scholarly activities, especially publication in medical journals, are often used as a measure of academic productivity and are an important component of fellowship applications.12 A study by Jagsi et al12 in 2006 compared the sex of first authors and senior authors over several years in 6 prominent medical journals. The authors found that the overall proportion of female first authors increased from 5.9% in 1970 to 29.3% in 2004; however, it remained low in certain journals (eg, Annals of Surgery: 2.3% in 1970 to 16.7% in 2004). Although these numbers may be reflective of the low number of women in surgery, it is unlikely the only contributing factor.

A similar assessment of publications in Obstetrics & Gynecology and the Journal of Pediatrics, which are primary journals for specialties with a high percentage of female physicians, demonstrated that women comprised 40.7% and 38.9% of first authors, respectively, in 2004.12 In interviews with female physicians, common factors cited for leaving academic medicine included a lack of role models, work-life balance, frustrations with research, and the institutional environment seen as biased toward male faculty.13 These studies suggest that the greater burden placed on women, including the demands related to pregnancy and parenthood, can pose a significant barrier to a career in academic medicine.

The current study had several limitations. First, the response rate of 40% indicates that the population surveyed may not be representative of the total population of orthopedic residency program directors. Furthermore, because this study only surveyed program directors and did not include other faculty and residents, it is not necessarily representative of the entire field's perception of pregnancy and parenthood during orthopedic residency.

Second, 19.7% of the program directors who responded to the survey were female, which, compared with other surveys of orthopedic residency program directors14 and statistics of women in leadership positions,1 is much higher than one would expect, suggesting that female program directors are more represented in this study than in the total population.

Third, given that women comprised less than 20% of the residents for 68.9% of the programs that responded, it is likely that the program directors' observations are based on the experience of a small number of pregnant residents. Program directors may have only worked with a few or no pregnant residents, and those who had issues with a pregnant resident may have been more likely to respond.

Fourth, many of the survey questions were subjective and could be susceptible to variable interpretation, especially those that asked respondents to differentiate between “positive,” “negative,” or “minimal” effect. Furthermore, the authors did not ask program directors to provide specific examples in their responses, which could be included in a future study.

Finally, this study is subjected to the response bias that can occur in self-reported surveys, even though the respondents were assured total anonymity. Future studies should consider surveying female orthopedic surgery residents to compare their perceptions of pregnancy and parenthood to those of the program directors. Future studies should also continue to explore what other factors contribute to fewer female medical students pursuing orthopedics.

Conclusion

This study demonstrated that although orthopedic surgery program directors did not indicate that pregnancy and parenthood have a more negative effect on female residents' work performance, well-being, and dedication to patient care, they did perceive the effects of pregnancy and parenthood more negatively for females concerning scholarly activities and the burden placed on fellow residents. To reduce the perceived burden on the program and encourage more accepting attitudes toward pregnancy and parenthood during training, program directors can better work with residents to devise more accommodating schedules that are less disruptive to the program and to the resident's education.

References

  1. Association of American Medical Colleges. The state of women in academic medicine: the pipeline and pathways to leadership, 2013–2014. www.aamc.org/members/gwims/statistics. Accessed November 15, 2016.
  2. O'Connor MI. Medical school experiences shape women students' interest in orthopaedic surgery. Clin Orthop Relat Res. 2016;474(9):1967–1972. https://doi.org/10.1007/s11999-016-4830-3 PMID: doi:10.1007/s11999-016-4830-3 [CrossRef]27084717
  3. Baldwin K, Namdari S, Bowers A, Keenan MA, Levin LS, Ahn J. Factors affecting interest in orthopedics among female medical students: a prospective analysis. Orthopedics. 2011;34(12):e919–e932. https://doi.org/10.3928/01477447-20111021-17 PMID:22146211
  4. Hamilton AR, Tyson MD, Braga JA, Lerner LB. Childbearing and pregnancy characteristics of female orthopaedic surgeons. J Bone Joint Surg Am. 2012;94(11):e77, 1–9. https://doi.org/10.2106/JBJS.K.00707 PMID: doi:10.2106/JBJS.K.00707 [CrossRef]22637217
  5. Turner PL, Lumpkins K, Gabre J, Lin MJ, Liu X, Terrin M. Pregnancy among women surgeons: trends over time. Arch Surg. 2012;147(5):474–479. https://doi.org/10.1001/archsurg.2011.1693 PMID: doi:10.1001/archsurg.2011.1693 [CrossRef]22351877
  6. Sandler BJ, Tackett JJ, Longo WE, Yoo PS. Pregnancy and parenthood among surgery residents: results of the first nationwide survey of general surgery residency program directors. J Am Coll Surg. 2016;222(6):1090–1096. https://doi.org/10.1016/j.jamcollsurg.2015.12.004 PMID: doi:10.1016/j.jamcollsurg.2015.12.004 [CrossRef]26776357
  7. Weiss J, Teuscher D. What provisions do orthopaedic programs make for maternity, paternity, and adoption leave?Clin Orthop Relat Res.2016;474(9):1945–1949. https://doi.org/10.1007/s1199]-016-4828-x PMID: doi:10.1007/s11999-016-4828-x [CrossRef]27075331
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  9. McKinley SK, Petrusa ER, Fiedeldey-Van Dijk C, et al. Are there gender differences in the emotional intelligence of resident physicians?J Surg Educ. 2014;71(6):e33–e40. https://doi.org/10.1016/j.jsurg.2014.05.003 PMID: doi:10.1016/j.jsurg.2014.05.003 [CrossRef]25012606
  10. Pico K, Gioe TJ, Vanheest A, Tatman PJ. Do men outperform women during orthopaedic residency training?Clin Orthop Relat Res.2010;468(7):1804–1808. https://doi.org/10.1007/s11999-010-1318-4 PMID: doi:10.1007/s11999-010-1318-4 [CrossRef]20333491
  11. Parker K, Wang W. Modern Parenthood: Roles of Moms and Dads Converge as They Balance Work and Family. Washington, DC: Pew Research Center; 2011.
  12. Jagsi R, Guancial EA, Worobey CC, et al. The “gender gap” in authorship of academic medical literature: a 35-year perspective. N Engl J Med. 2006;355(3):281–287. https://doi.org/10.1056/NEJMsa053910 PMID: doi:10.1056/NEJMsa053910 [CrossRef]16855268
  13. Levine RB, Lin F, Kern DE, Wright SM, Carrese J. Stories from early-career women physicians who have left academic medicine: a qualitative study at a single institution. Acad Med. 2011;86(6):752–758. https://doi.org/10.1097/ACM.0b013e318217e83b PMID: doi:10.1097/ACM.0b013e318217e83b [CrossRef]21512363
  14. Nguyen L, Amin NH, Vail TP, Pietrobon R, Shah A. Editorial: a paucity of women among residents, faculty, and chairpersons in orthopaedic surgery. Clin Orthop Relat Res. 2010;468(7):1746–1748. https://doi.org/10.1007/s11999-009-1125-y PMID: doi:10.1007/s11999-009-1125-y [CrossRef]

Resources Available for New Parents

ResourceYesNo
Facilities for breastfeeding60.7%39.3%
Childcare57.4%42.6%
Flexible scheduling88.5%11.5%

Attitudes Toward Pregnancy and Parenthood for Female Residents

ParameterValue
Increased burden imposed on other residents
  Yes77.0%
  No23.0%
Effect on female work performance
  Positive3.3%
  Negative32.8%
  Minimal effect63.9%
Effect on female well-being
  Increases significantly3.3%
  Increases somewhat18.0%
  Neutral55.7%
  Decreases somewhat21.3%
  Decreases significantly1.7%
Affects female's patient care
  Yes6.6%
  No93.4%

Most Common Responses by Sex of Program Director

Sex of Program DirectorMost Common Response

Effect on Female Work PerformanceEffect on Male Work PerformanceEffect on Female Well-beingEffect on Male Well-beingEffect on Female Patient CareEffect on Male Patient Care
MaleMinimal (65%)Minimal (78%)Neutral (55%)Neutral (71%)No (91%)No (94%)
FemaleMinimal (58%)Minimal (67%)Neutral (58%)Neutral (67%)No (100%)No (100%)

Effect of Pregnancy and Parenthood on Female and Male Orthopedic Residents' Scholarly Activities

Parameter/Sex of Program DirectorYesNo
Does pregnancy and parenthood have an effect on female residents' scholarly activities?
  Male53%47%
  Female17%83%
Does pregnancy and parenthood have an effect on male residents' scholarly activities?
  Male35%65%
  Female17%83%
Authors

The authors are from Drexel University College of Medicine (CN, ER), Philadelphia, Pennsylvania; and the Department of Orthopaedic Surgery (MKM), Tulane University School of Medicine, New Orleans, Louisiana.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Mary K. Mulcahey, MD, Department of Orthopaedic Surgery, Tulane University School of Medicine, 1430 Tulane Ave, New Orleans, LA 70112 ( mary.mulcahey.md@gmail.com).

Received: September 04, 2018
Accepted: January 14, 2019
Posted Online: December 16, 2019

10.3928/01477447-20191212-02

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