For all physicians, residency training and the first few years of one's professional career are times of intense professional and personal development. Pediatricians in training are expected to refine their clinical pediatric skills, solidify their fund of knowledge, and continue developing their personal style of interacting with patients and their families. Residents also need to make personal decisions about family life, while simultaneously making decisions about their future training (ie, fellowship) or practice setting after residency. Although these issues are important to both men and women in training, women who have children before or during residency must also consider the implications of pregnancy, childbirth, and maternity leave while meeting the rigorous demands of residency training. The next stage of a career in pediatrics, whether in private practice or academic medicine, part-time or full-time, requires continued révaluation and balancing of personal and professional priorities.
BALANCING WORK AND FAMILY DURING RESIDENCY
The imperative of "finding one's personal balance between family and work" is not unique to pediatrics or to women. However, women in pediatric training or early in their careers may experience this process in a unique way when compared with men in similar positions, with women in nonmedical academic positions, or with women more advanced in their pediatric careers.
A recent survey of pediatric trainees in a South African program1 found differences between the experiences and perceptions of men and women during their pediatric training. There was no significant gender difference in the hours that these trainees worked per week (men 65.7 hours; women 67.8 hours) or in their rate of passing postgraduate pediatric examinations (men 85%; women 76%). However, women reported significantly different experiences related to their status as a woman: 59% of women felt they had been disadvantaged in their training because of their gender; 28% reported "more was expected of a woman trainee"; and 22% of women had experienced what they perceived as sexual harassment during their pediatric training program. A large majority of women trainees (82%) reported that they had contemplated taking time off from clinical pediatrics in the future, mainly for childbearing purposes. From this study, it appears that there was little difference between men and women with respect to the objective outcomes of their residency (ie, experience derived from hours worked during residency or knowledge gained as reflected in postgraduate examinations). However, women reported subjective experiences suggesting that residency may be a qualitatively different experience for men and women.
The self-reported job satisfaction of women pediatric residents has been compared with that of women in nonmedical academic positions and with that of women in academic pediatrics who are at least 10 years past residency.2 The authors concluded from their sample (15 women in each of the 3 categories) that women residents, who worked significantly more hours per week, had a significantly lower level of satisfaction with their work than did women in the other two groups. The stress of their residency years was hypothesized to impact not only their work satisfaction but their entire self-concept. It is reasonable to expect that the perceptions of women pediatricians during training impact their decision making with respect to family and later career choices. The underlying factors that contribute to these perceptions are not well characterized, but family concerns were often mentioned.
Gender differences have been reported to affect a resident's decision to have children during residency. A survey of pediatricians who completed training in eight university-based residency programs found that men were significantly more likely than women to have had children during their residency years.3 Nearly two-thirds (265 of 417) of the respondents were married, although only one-third of those who were married had children during residency. Of those who were married but did not have children (n = 170), women were significantly more likely than men to believe that having a child during their residency would have had a negative influence on their careers. Women also were more likely to report that having children would have been associated with difficulty finding child care. However, among pediatricians who were married and had children during their residency, perceptions of the impact on their career of having children did not vary by gender. It is also not clear from this report whether post-residency plans (practice, fellowship) or the specific residency program significantly affects these perceptions. But for at least a portion of women pediatric residents, childbearing decisions appear to be delayed because of concerns about conflicts between motherhood and professional development.
Pregnancy during pediatric residency can be challenging for both the mother-to-be and the residency program. Infectious disease risks related to common pediatric diseases such as parvovirus or varicella are a concern for all pregnant women. In addition, long work hours may be even more difficult for pregnant women. In a survey of a small group of women residents who had been pregnant during residency (n = 35), complications were reported in 36% of the pregnancies.4 Of women who had complications of their pregnancy, 40% of complications led to time lost from residency and 35% led to hospitalization of the mother. Thirty-seven percent of the respondents in this study stated that they would prefer not to have been pregnant during residency, if given the option again.
CAREER CHOICE AFTER RESIDENCY
Pediatricians have an array of career options following residency training, ranging from part-time to full-time work in settings as diverse as private practice, managed care organizations, or hospital-based inpatient care to pursuing further academic training. Little data are currently available characterizing the differences between the family constellations of pediatricians in various practice or academic settings. However, a national survey of members of the American Academy of Pediatrics explored the differences between pediatricians working part-time versus those working full-time.5
In this sample population, the mean age of both part-time and full-time women was 40 years, whereas for men working full-time it was 46 years. Thirtyseven percent of the women had worked part-time at some point in their careers and 21% were currently working part-time. Only 70% of the full-time women were married, compared with 97% and 95% of the part-time women and full-time men, respectively. The full-time women had significantly fewer children (mean 1.27) compared with the part-time women (mean 2-34) and the full-time men (mean 2.39). Women who worked part-time in academic medicine tended to do little research or administrative work, but had more teaching responsibilities. Almost all part-time women were happy with their decisions and careers, although they acknowledged that they had made a compromise with respect to their pediatric careers. Many of the full-time pediatricians (both men and women) reported that they would like to work less.
The authors concluded that many women, particularly those with children, choose part-time work to combine career and family duties. These choices may lead to different career paths for women pediatricians who choose careers in academic pediatrics. Other factors affecting women's reports of happiness with their combination of career and family, such as their spouses occupation and involvement with child care, availability of* additional family supports, and flexibility of one's department with respect to part-time employment, have not been well studied
However, it is clear that family responsibilities may affect the career choice and work lives of both men and women in pediatrics. One study, analyzing the reports of 1,782 married pediatricians included in a national survey, found that approximately one-fourth of pediatricians are in a dual-physician marriage. Logistic and multiple regression models confirmed that marriage to another physician and the presence of children affected career decisions of female pediatricians. However, male pediatricians in dual-physician marriages worked significantly fewer hours per week than other married male pediatricians.6
Fellows and junior faculty need to identify role models and a mentor as they formulate and embark on a career path. For women entering academic pediatrics, female role models and mentors are highly desirable but not always easy to find. Although the number of women in pediatric training programs and junior faculty positions continues to rise, few women have achieved the more senior ranks of full professor or department chair.
For women who elect to enter academic pediatric positions, significant gender differences have been found in the rate of academic advancement. A 1992 cross-sectional survey of salaried physicians in 126 academic pediatric departments found that significantly fewer women than men achieved the rank of associate professor or higher.7 For both men and women, measures of success (including salary or academic rank) were related to higher productivity (more publications and grants), more hours worked, and more institutional support of research. Women in lower ranking positions spent significantly more time teaching and providing patient care, suggesting that they had less time available for conducting research, writing for publication, or applying for grants.
The multiple demands of academic pediatric faculty life, including clinical care, research, and teaching responsibilities, which need to be balanced with family responsibilities, have been reported to lead to a significant prevalence of self-reported indicators of stress. A survey of pediatric faculty members at 26 medical school-based pediatric programs8 found that 46% of respondents reported "high" or "very high" levels of usual stress, 64% of respondents reported they were stressed beyond a "comfortable" level at least "frequently," 47% had considered moving to a different medical school, and another 43% had considered leaving academia. Sources of stress included pressures to do research, family needs, and lack of personal time. Assistant or associate professors, faculty on the tenure track, and women reported feeling "overstressed" more often. Stress was reported to be diminished if respondents felt valued by their chairperson or by other faculty.
In an attempt to address the current challenges facing academic pediatricians, alternative approaches to academic advancement have been suggested. Some have argued that greater flexibility is necessary when considering what constitutes "academic success."9 Clinicians, teachers, clinical investigators, and basic scientists need to be evaluated for promotion in comparison with each other, rather than all being judged based on uniform criteria. These authors suggest increasing the amount of funding targeted to support education and using it to support faculty who primarily work in these areas. The authors conclude that promotion expectations for women, who traditionally are more involved in teaching, will need to be more flexible and adjusted in concert with family responsibilities and demands.
In summary, many women entering the field of pediatrics today have concerns about balancing their personal and professional goals throughout residency and the early years of their career. As women become increasingly predominant in the pediatric workforce, it will be important that training programs and mentors of young women faculty consider the factors outside of the workplace impacting the development of their trainees and staff. Maternity policies, access to flexible child care of high quality, and options for job sharing are three areas of potential improvement for most residency programs and pediatric departments. Ultimately, consideration of both the personal and the professional trajectories of young women in pediatrics can be expected to lead to both enhanced faculty development and women faculty who are able to feel they are successful as both pediatricians and parents.
1. Saloojee H, Rothberg AD. Ii registrarship a different experience for women? South African Medical Journal. 1996;86:253-257.
2. Yogev S, Harris S. Women physicians during residency years: workload, work satisfaction, and self-concept. Sx Sd Med. 1983;17:837-841.
3. Wilson MD, Carpenter RO, Radius SM, Oiki FA. Attitudes and factors affecting the decisions of men and women pediatrics residents toward having children during their residencies. Acad Mel 1991;66:770-772.
4- Klerman JL, Weiss JC, Dabrow SM. Pregnancy during pediatric residency: attitudes and complications. American Journal of Diseases m Children. 1990;144:767-769.
5. Fritz NE, Lantos JA. Pediatricians practice choices: differences between part-time and full-time practice. Pediatrics. 1991;88:764-769.
6. Brotherton SE, LeBailly SA. The effect of family on the work lives of married physicians: what if the spouse is a physician, too? Journal of die American Medical Women's Association. 1993:48:175-181.
7. Kaplan SH, Sullivan LM, Dukes KA, Phillips CF, Kelch RP, Schaller JG. Sex differences in academic advancement: results of a national study of pediatricians. N Engl J Med. 1996-335:1282-1289.
8. Barton LL, Friedman AD, Locke Q. Stress in pediatric faculty: results of a national survey. Arch Ped Adoksc Med. 1995;149:751-757.
9. Lovejoy FH Jr, Ledley FO, Nathan DG. Academic careers: choice and activity of graduates of a pediatric residency program, 1974-1986. Trans Am CIm CSmatoi Ajjoc. 1992;104:180-197.