Why is maternity leave for doctors such a complete mess?

I was sitting in my car around 4 p.m. on a Friday, waiting in the parking lot to be called in for my pre-delivery Covid test. I was equally exhausted from the physical demands of my second pregnancy and the emotional labor of typing up my loose ends at work with hundreds of patients.

That’s when I received an email from an administrator at the hospital where I worked. “Oops,” the message read, “sorry I didn’t send this to you earlier.”

It contained a long list of important things I needed to complete before my parental leave to maintain my health insurance and be paid accurately during my time away. There was no way I could complete it all before I gave birth.

“Why does having a baby always feel like a hot disorganized mess?” I asked myself.

“The first thing to realize for anyone going toward a parental leave is that it is not managed,” said Daisy Dowling, an executive coach who specializes in supporting working parents. I read her book “Workparent: The Complete Guide to Succeeding on the Job, Staying True to Yourself, and Raising Happy Kids,” and now regularly recommend it as a resource to patients in my reproductive psychiatry private practice. I reached out to her to better understand why preparing for a parental leave seems so much harder than it needs to be — and why it seems particularly onerous for physicians.

“You may feel like you don’t have a playbook or a script for your own parental leave, and I can very much assure you that your organization does not, either,” Dowling said.

That was certainly my experience. I’ve been thoroughly confused by my two experiences being pregnant as a doctor. My profession attracts people who are great at making sense of the complexity of the human body and experience. We painstakingly gather evidence to develop clinical protocols and guidelines that allow us to deliver high-quality care to our patients. We don’t wing it. Where, then, are the protocols that would help us manage work while pregnant and preparing for leave?

“It’s the same for so many people in demanding professions — financial services or law or academia. There are very clear rules and those rules exist for a reason, and we internalize them. And then all of a sudden it’s just sort of this free-form thing,” said Dowling. “It’s a free-form thing that also happens to be the most emotional time of your entire life because you are welcoming a human being into your midst.”

That all makes sense — except I held my profession to a higher standard. Medical organizations are tasked with upholding the health and wellness of our communities — and doctors are, in fact, members of that community, too. Yet I’ve found that doctoring often means denying your own needs. Grit and resilience are rewarded above balance and self-care.

In medicine, we often don’t practice what we preach. The American Academy of Pediatrics, for example, advises three months of paid parental leave. According to a 2018 study published in JAMA, at 12 of the top medical schools, the average paid parental leave was 8.6 weeks, with trainees eligible for even less time off. (Hopefully this has changed in the five years since.) I feel lucky to have had 12 weeks of leave with both of my children.

I had it relatively good, thanks in no small part to the fact that I’m a psychiatrist. My colleagues, experts in the biological, psychological, and social factors that influence mental health, understood the monumental transition I was making to motherhood. My supervisors, women and parents themselves, were personally familiar with the chaos I was trying to control as I managed responsibilities at home and at work.

And my institution offered some useful benefits: As an attending physician, I even received a modest stipend that Harvard hospitals give to eligible physician mothers to help offset the costs of new-parenthood, including time taken off for doctors appointments or child care emergencies.

Physicians in other specialties or institutions don’t always get the same care or compassion. A friend from medical school who trained in OB-GYN told me horror stories of her co-residents who had to return to work shortly after delivery, still bleeding from childbirth.

So why do health care organizations make it so hard for us to be human, including becoming a parent? Is it a huge blind spot, or more cynically, are they taking advantage of the ways in which physicians have been socialized to sacrifice themselves and disincentivize physician-parenthood?

Of course, there’s no clear answer — it’s probably some complicated blend of the two. But there are maybe few reasons the broader health care profession has not made the investment in cultivating best practices around parental leave.

Until recently, medicine has been male-dominated. In 1970 women accounted for 10% of incoming medical students and in 1992, 40%. The 2017-18 school year was the first time we made up 50% of medical school matriculants. As of 2021 women make up a little over a third of the American physician workforce. While more women are entering the workforce, the impossibility of work-family balance is also driving many female early career physicians out: A study published in 2019 found that approximately 40% go part-time or leave the profession entirely.

Meanwhile, new fathers are less likely to take parental leave due to gendered stereotypes around caregiving and the negative impact time away can have on a career. With women long in the minority and men disincentivized from taking leave, parental leave policies have not been a priority in the medical profession.

Women in medicine may even face pressure to stay quiet about a pending parental leave, making it challenging to advocate for themselves and others. Dowling explains that people in historically underrepresented groups try to avoid “stacking of differences” between themselves and others. “If you are female and most of your colleagues are male, you are less likely to want to bring out your personal stuff in front of them.”

I’ve felt this pressure, too. When I reported the incident with the last-minute checklist being dropped into my lap to my clinical supervisor, she asked me if she should address it with hospital leadership. I declined. I didn’t want to call too much attention to my time away or seem ungrateful.

The desire to avoid the perception of being needy can drive doctors to navigate their parental leaves in isolation and undermines the culture change we desire.

As a physician-trainee negotiating parental leave, I wondered: When would my leave start? What would happen if I went into labor early? How was my on-call responsibility managed? Given problems with understaffing, who would take care of my patients while I was gone? Would my leave impact my ability to graduate on time or my eligibility to apply for a fellowship training program? Would I still be fully paid during my time away? How would I be impacted by Massachusetts’ new Paid Family and Medical Leave program? How would I transition back to work? What time would I be allocated for lactation and pumping? Physicians out of training often need to manage more complex issues around compensation, like figuring out how their productivity is measured in light of the time away.

For working professionals who know parental leave is on the horizon, Dowling recommends consulting with three to five others who have walked in your shoes, which may require meeting with people in other departments or even work in other hospitals.

As a resident I did consult with other trainees who had been recently pregnant. They were helpful in sharing the challenges they faced when organizing a parental leave in addition to useful tricks for my transition back to work, like how to set up clandestine pumping sessions to avoid being hassled by the clinic administrators for taking up rooms reserved for billable patient care hours.

What struck me, however, was that we were pregnant at different times during our four-year training programs. The considerations for a third-year resident were different than first, second, and fourth years. I’d hoped to lean on some institutional knowledge to help me fill the gaps.

And there were so many gaps. I sat down with my resident union representative to figure out what I was entitled to. The rep flipped through a thick binder of policies, looking for the pages that applied to me. He read out some passages of policy jargon, but when I asked him what that meant, practically speaking, he didn’t know.

“Policy is not enough,” says Sarah Olin, an executive and leadership coach who also specializes in helping working professionals transition to being working parents. Many organizations have policies around leave, but Olin says the most important questions revolve around how we place real people at the center of those policies.

The human element is often a missing piece of the parental leave puzzle. A friend of mine in an internal medicine training program told me about going to her chief residents about arranging coverage for the six-week intensive care unit rotation she would miss as a result of her leave. No formal plan was put in place, so every day for six weeks, the back-up resident on sick-call was required to fill in. It was not only a burden to her co-residents who had to cancel their own patients to bridge the gap in staffing, but also bad for ICU patients who did not benefit from any continuity of care. It left my friend burdened with the guilt of it all.

All of these challenges apply to physicians who need to take time off work for other reasons, too. A friend still in training recently lost his father and struggled to find peer-coverage that would allow him to travel home and attend the funeral. The whole situation left a bad taste in his mouth.

Recognizing the reality that hospital systems are often understaffed leaving the people working for these organizations feeling overwhelmed and under-supported, Olin and her company LUMO are currently exploring how hospital systems can do a better job caring for the people who care for their patients. The company is helping organizations examine the institutional culture and practices that systematically undermine the success of working parents. Empathy, she says, is at the root of this work. “Health care workers are already at high risk for burnout,” Olin said, “if their leaders don’t have training and empathy or how to manage in a multigenerational workforce or how to have hard conversations, then their rate of losing people just increases.”

Botched negotiation around these types of leave can have expensive consequences for employers, says Olin. According to the Center for American Progress, it can cost more than 200% of an employee’s salary to replace them if they leave. The working professional and working parent transition is a pivotal moment because “people are deciding their loyalty, their longevity at this organization. There’s a lot of decisions being made at that moment,” said Olin.

I gave birth to my second child on a Sunday. The next day, while recovering in the hospital with my baby in the NICU, I called HR to begin working through the action items contained in the admin email. As it turned out, I didn’t have much to do: I had already completed many of them and others were unnecessary or referenced outdated policies. I was grateful to return my focus and attention to my baby.

The stressful saga continued however, later in my leave. I had to make multiple calls to HR later to sort out delays in payment and missing funds in my paycheck. (They were eventually paid in arrears.) I was also in the first crop of parents in Massachusetts eligible for the state’s Paid Family Medical Leave, and despite paying into this benefit for a few years, no one at the hospital or the state could figure out the logistics of how it applied to me during my leave. I ended up not benefiting from this program at all.

My hope is that my profession takes the needs of working parents more seriously. It’s unacceptable for health care professionals to suffer at the hands of a system riddled with failures and gaps. It’s time we develop and receive the gold standard of care we give to our patients. Protocols for parental leave are a must.