Breastfeeding and documentation shouldn't be either-or for residents, U of Washington dean says

Almost half of physician moms stopped breastfeeding sooner than they planned because their jobs were not supportive enough, according to a study published in JAMA Internal Medicine and featured by Reuters.

In fact, many residency programs — even those already offering private space for lactation — could serve to review the quality of their facilities and policies related to pregnancy and motherhood. The findings may be surprising.

That was the case for Jennifer Best, MD, the associate dean for graduate medical education at the University of Washington School of Medicine in Seattle. An internal needs assessment of lactation facilities produced responses Dr. Best found "heartbreaking."

"I'm a mom of two boys who are grown now, but I had my first in training and I took a healthy amount of leave with my second one, so this is obviously of personal interest," she said.

Dr. Best and her assistant conducted an internal needs assessment to gauge how satisfied residents were with UW's lactation facilities and find areas of improvement ahead of required updates from the Accreditation Council for Graduate Medical Education. Beginning July 1, ACGME will require hospitals hosting residency programs to have clean, private lactation rooms, located close to patient care areas and equipped with refrigeration.

UW has roughly 1,400 residents and fellows, and Dr. Best estimates 91 female residents have taken parental leave since 2014. Fifty-three residents completed the survey.

She tweeted one open-text response from a resident that stuck with her: "I have considered either reducing how much I pump or stopping altogether if it interferes with getting my documentation done." It got more than 50 replies and nearly 100 retweets on Twitter.

Becker's caught up with Dr. Best to discuss the findings from the needs assessment, why medical education culture has silenced these issues until now and what hospitals can do to address them. 

Editor's note: Responses have been edited lightly for length and clarity.

Question: Were you surprised by the response you got from the internal needs assessment and on Twitter?

Dr. Jennifer Best: That particular quote I just found so heartbreaking because the idea that you would have to choose between your own life and health, and the life and health of your child, and documentation just seems almost like … they're not even apples and oranges. They're such different things, that one would even inform the other, I just thought, this is just so far beyond what makes sense. 

As I started looking through the internal data, I found most of our lactation rooms are not equipped with computers, and in some cases not even with a phone or Wi-Fi. Really, people do have to make that choice of taking time away from their clinical work and leaving on time. A lot of people responded if there was only some way to multitask while pumping, that they would feel more at liberty to use their time because they could document and pump hands-free, for example.

I think the assessment opened a fountain of opportunity to explore these decisions that can be really personal and quite painful. There is this culture of silence around pregnancy, parenthood and lactation. As progressive as we like to think we are, even now with 50 percent of matriculants in medical school being women, it's still not something people feel like they can discuss openly. I think Twitter gives people that opportunity.

Q: Why do you think there is a culture of silence around pregnancy in the medical field?

JB: It's interesting. I've been involved in a research team looking at what has been written about parenthood in graduate medical education, and I think broadly there is a perception among training program directors that residents who are parents don't do quite as good a job — despite evidence that suggests women who've had children perform just as well on board exams; they match just as well into fellowships; they perform as well on standardized tests. It's really perception and not reality. Residency and fellowship can be such a heads-down experience, where often there is that motive of "I just really need to survive," and any additional convenience or rule-bending that an individual might require as a result of being a breastfeeding mother probably just doesn't seem worth the trade-off.

There's already a very robust body of literature that exists just around gender bias, without children in the mix. Women are sometimes struggling to prove themselves in an environment where they don't always feel perfectly welcome.

Q: Have you gotten any other feedback from your assessment from residents about what would help them most?

JB: The things we heard pretty loud and clear: There's obviously the need for large cultural change — that this is something that should be normalized and discussed. There's been talk that there should be resident peer mentoring programs. How neat it would be if they'd had another physician resident, a fellow mother, to talk to and share information.

Another very large theme was having time built into your day to pump without having to ask for it or sneak it. It's one thing for people to tell you, you can pump, and it's another thing entirely for them to actually block time for you to pump. There's sometimes this sense that people are pumping and trying to get out of work. Anybody who has pumped would tell you it's actually just doing extra work.

The proximity and equipping of lactation facilities to allow for concurrent work — that was also a theme. We have lactation rooms, but the top three places people said they used were a call room, a faculty or staff office, and the third most common location was people's cars.

Q: Why are they not using lactation rooms?

JB: The lactation rooms are not close enough to patient care areas; the codes might not be available; they are shared with nurses or other staff members. There isn't reliable access, so people are doing a lot of workarounds. Just the cognitive load of having to add that to learning clinical medicine is pretty astonishing, actually. These are people who are very bright and really having to solve this problem on the fly, when we should be arguing that this isn't a "problem to be solved," it's just a normal part of life. Your peak child-bearing time is during training, usually.

Q: As a physician and a mother yourself, is there anything you think is commonly misunderstood among hospital employers about breastfeeding for residents?

JB: One of the things I have heard people say is: "Oh well, they let me go once a day," but if you've ever tried to feed a child or pump, that's probably not realistic. That can lead to plugged ducts and discomfort and mastitis. That may be OK for somebody, but just the idea that, "Oh you already did that once, do you really have to do that again?" — that is a barrier.

The other thing I think is really important is that it would really help if residents didn't need to figure this out all on their own. Administration could do some proactive outreach to the physician who needs lactation accommodations. It's not as if this has never happened before. It would go a long way to have ready-made materials that are clear, and have somebody at the institution who knows where the locations are and does an assessment of the quality of those rooms, really thinks critically about whether they are in places that are going to be used by people who are in the middle of their busy clinical day. This is often owned purely on the physician side, but this could be owned by the health system.

Q: Is there anything else you think is important to mention?

JB: We have done some work around maternity leave and residency and have been able to show that people who had longer leaves were able to maintain breastfeeding longer. This is a much larger issue that has a lot of overlay and a lot of stakeholders — employers and specialty boards, ACGME, and the training program. Empowering people to take longer leaves does allow them to be more successful. Whatever we can do to embrace pregnancy and lactation as a normal part of life, versus treat as a problem to be solved, we are going to go a long way. That's slow work.


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