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Invited Commentary
Diversity, Equity, and Inclusion
May 18, 2022

Supporting Physicians Along the Entire Journey of Fertility and Family Building

Author Affiliations
  • 1Division of Hematology-Oncology, Department of Internal Medicine, University of Pennsylvania, Philadelphia
  • 2Department of Medicine, Stanford University, Palo Alto, California
JAMA Netw Open. 2022;5(5):e2213342. doi:10.1001/jamanetworkopen.2022.13342

Although the majority of people have children, medical culture is filled with implicit and explicit signals that family building is at odds with career development. This is a setup for physical and emotional trauma due to delayed childbearing, missed opportunities (related to constraining one’s career choices to have children, missing time with one’s family due to career obligations, or both), burnout, poor work-life integration, and regret. Family building, defined here as growing one’s family with the addition of children, is rarely formally discussed during medical training despite the fact that 1 in 4 women physicians face infertility challenges and many report that, in retrospect, they would have undertaken cryopreservation, tried to build a family earlier, or altered their specialty choice.1

In addition to the pressure to not have a family, once women physicians have children, they face maternal discrimination, delayed career progression, and the need to reduce work hours or leave medicine to accommodate family needs.2,3 This struggle between workplace and family is not unique to our profession, but the lack of support for pregnancy is particularly pronounced in medicine. Although other workplaces, such as Microsoft, Google, and Facebook, long ago adopted policies to support employees’ family building, including via cryopreservation, those in medicine all too frequently must pay back their parental leave, make up missed call, or even pay back money to their practice.4 It is embarrassing that employees of tech companies have better support for reproductive health than do physicians.

The recent study by Smith et al5 reported on structured interviews and a pilot-tested survey with female physicians exploring family-building concerns. Their participants reported inadequate education regarding fertility with a desire to improve medical education in this regard. The authors found that physicians hoping to build families face a frustrating dilemma wherein the fear of derailing one’s career to build a family forces delays in childbearing (likely one factor in the high rates of physician infertility) but the lack of support for physician parents leads to changes in career trajectory such as reduced hours or even leaving medicine all together. These 2 factors are likely part of the reason almost 40% of women in medicine transition to part-time work within their first 6 years in practice.3

As 2 physicians who have battled infertility and faced family-building challenges ourselves, we have an intimate knowledge of the hardships physicians face during this process. One of us has written publicly about the damage her career as a surgeon has done to her ability to build a family, noting the length of training, inflexibility in scheduling, and disregard for trainees’ and colleagues’ personal lives to be critical factors. Shortly thereafter, she abandoned her surgical practice to focus on building the personal life and family she always wanted. Four years later, she is still trying. The other of us attests to ongoing pressure to continue performing at the same level academically during fertility treatments and subsequent pregnancy, including scenarios such as writing a paper while hospitalized for induction of labor (tossed aside only when taken to the operating room for an urgent C-section) and taking Zoom meetings from the hospital room while on a magnesium drip to treat severe postpartum preeclampsia. Although mentorship is essential to career development in medicine, both of us have experienced mentors who gave well-intentioned but potentially damaging advice that was contrary to our family-building goals.

A system which sets physicians up for this cruel dilemma is broken, and substantial change is needed. This is not just an issue for women physicians, but an issue for all physicians who want to have children. We applaud ongoing efforts to advocate for physician parents and also strongly believe that the family-building process extends from before the addition of new members to one’s family (eg, fertility and conception), through pregnancy and lactation, as applicable, to what comes after (childcare). Therefore, we advocate for change in all 3 phases of the family-building journey: fertility awareness and infertility management, childbearing and bringing children into a family by any method, and childcare and career development support for those physicians who become parents.

As we and others have previously argued, fertility awareness should start in medical school and should involve adequate education about the risks of physician infertility and the options available for fertility preservation along with financial and clinical coverage for workup and management.6,7 In addition to financial and clinical support, we must change the culture of medical training to support trainees who wish to become parents. If trainees feel supported to build families at any time, they may feel less pressure to delay childbearing until after training is complete, which may then reduce infertility rates.

For physicians who become parents, we need adequate paid parental leave, not only for parents who give birth but for all parents involved in child-rearing. Providing leave to only one parent sets up a discriminatory standard of the one who does childcare vs the one who continues to work. In addition, those who grow their families by other means, such as adoption, legal guardianship, or the aid of gestational carriers, also deserve paid parental leave. We must also provide adequate space and protected time for lactation. Long-term support of physician parents, extending beyond the birth of a child to include childcare support and encouragement of healthy work-life boundaries is also essential. From medical school onward, we must support childcare and allow for flexibility with scheduling to accommodate differing needs. We must also implement zero-tolerance policies for parental discrimination and training for all leaders on how to create an environment in which those considering family-building feel supported.

Additionally, despite the fact that families are created in numerous different ways, too often discussions about fertility and family building focus on cisgendered women in heterosexual couples. Focusing research and policy related to fertility and family building on cisgendered heterosexual women does a disservice to everyone. Both in research and through policy, it is critical to consider the needs of single people (of any gender) and those in same-sex partnerships. Not everyone wants to have children, of course, but for those who do, we must be inclusive of the different ways this happens. For example, even when insurance policies cover fertility treatments, they often require a period of trying to conceive before providing benefits. How do 2 women, 2 men, or a single person try to conceive? We must eliminate such nonsensical policies. In addition, we need to learn more about these differing needs and challenges in order to create inclusive workplaces that allow everyone to thrive. The more we focus these efforts on 1 group, cisgendered heterosexual women, the less likely we are to make progress.

In summary, support of physician family building must involve cultural and structural change at the highest levels of institutional leadership. Only with intentional change at every level can we truly support physicians before, during, and after they expand their families. Those physicians who wish to build and nourish a family should be granted the dignity and respect to do so while also being supported in developing their careers to the fullest degree.

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Article Information

Published: May 18, 2022. doi:10.1001/jamanetworkopen.2022.13342

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Marshall AL et al. JAMA Network Open.

Corresponding Author: Arghavan Salles, MD, PhD, Department of Medicine, Stanford University, 300 Pasteur Dr, Palo Alto, CA 94305 (arghavan@alumni.stanford.edu).

Conflict of Interest Disclosures: None reported.

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