Combining pregnancy with surgical training
Authors: Julie Cornish, Anne Gaunt, Diane Adamson, Sarah Mills, Pirko Schuppan, Deborah Markham
Publication date: 02 Nov 2012
Julie Cornish, Anne Gaunt, and colleagues report on the varied clinical experiences of surgical trainees during pregnancy
Over the past decade more than 50% of UK medical graduates have been women, and 54.1% of current trainees (foundation year 1 to specialist registrar) are women. Women made up 8.4% of consultant surgeons in 2008, but 27% of the core surgical trainees appointed in 2007 were women. If all these female core surgical trainees progress with their surgical training, just over a quarter of all surgical registrars could opt to take maternity leave at some point during training, and many of them will potentially work part time afterwards.
Combining starting a family with a career means that pregnancy creates special challenges for doctors in training (box 1). Our own experiences as pregnant surgical trainees were that it was difficult to find and get access to reliable advice about working during pregnancy, and our individual experiences of working during pregnancy differed widely. We conducted a survey of surgical trainees to establish their concerns about training during pregnancy.
Survey of pregnant surgical trainees
In October 2010 members of Women in Surgery (a branch of the Royal College of Surgeons of England) were invited to complete an online questionnaire about their experiences of training during pregnancy. The questionnaire was sent to over 2000 members, and only those who had been pregnant during surgical training were eligible to complete the questionnaire. A total of 187 responses were valid for analysis. Over half the respondents were still trainees (58% of the total), mostly specialty registrars (47%), and the remainder have now become consultants (42%).
First pregnancy was at 31 years (mean), with respondents having a median of two pregnancies (range 1-8). Of the women who were now consultants, 97% were pregnant as trainees, with 28% of this group also going on to experience pregnancy as consultants. The median time for starting maternity leave was at 36 weeks’ gestation, with a third of women working beyond this.
The respondents who were currently trainees were more likely than their consultant colleagues to have become pregnant during their core surgical training posts. There may be several explanations for this. For example, an increase in the number of graduate entry medical students could mean that women were older in core training than previously and more likely to start a family earlier in their career, or the reduction in working hours could have meant that trainees felt more able to work during pregnancy and as mothers. Finally, it is possible that pregnancy has become more acceptable during surgical training.
Only a small proportion of trainees (12%) found that no aspect of clinical work was more demanding during pregnancy than when they were not pregnant, but despite this nearly all trainees (94%) took little or no time off sick during their pregnancy. Many women believed that on-call night shifts were demanding during pregnancy, and daytime on-call shifts were generally perceived as less demanding. Nearly a fifth of all respondents (19%) reported having difficulties with their trainer while pregnant, and 18% had difficulty with other trainees.
Most respondents (over 90%) were physically able to operate as normal during pregnancy. Nearly one in six trainees was not allowed to operate as normal during pregnancy because of restrictions imposed on them by their trainer, local protocols, or managers.
Only one in three trainees found information from their trainers and occupational health to be useful. Most respondents did not seek information from all available sources (table). Respondents said that information about on-call commitments (70% of current trainees and 39% of consultants) and theatre safety (53% of current trainees and 37% of consultants) would be most useful.
|Source||Useful||Not useful||Didn’t ask|
|Association of Surgeons in Training||0||4||96|
|Royal College of Surgeons of England||2||12||86|
|Other hospital staff||49||18||33|
Qualitative data identified some of the concerns that current trainees and new consultants had about working when pregnant. Some were anxious about working during pregnancy (figs 1 and 2 ). This was related to a perceived change in role, concerns about what other people thought, not wanting to let other people down, and concerns about future career planning. Other respondents were more confident about working during pregnancy and suggested that trainees should put themselves first and not be afraid to ask for help.
External factors affecting respondents’ experiences of working during pregnancy included dealing with colleagues’ perceptions of pregnancy in training and trainees’ experiences with their trainers. Also, trainees wanted consistent advice to be available, particularly about on-call issues, accepting that “all experiences of pregnancy are different.”
Our results show that generally pregnancy is well tolerated among surgical trainees and most were able to continue with training with no or some modification to their current role. However, trainees lacked clear guidance on their rights and responsibilities during pregnancy. Better sources of information are needed to allow people to make the appropriate choices for themselves and their families during pregnancy.
Box 1: Case studies
Case study 1
I was well in both of my pregnancies, a registrar during both, and worked as normal in the daytime doing a busy job and long days on call until 32 weeks the first time (my job finished then) and 36 weeks during my second pregnancy. I stopped working 24 hour on-calls from 24 and 32 weeks, respectively. I had supportive peers and bosses, and ate probably more chocolate than was good for me.
Case study 2
I was a senior house officer in my first pregnancy and worked to 38 weeks with full on-calls. My second pregnancy was during my research post, and I worked until 40 weeks and locumed until 38 weeks, which caused consternation among some consultants. During my final pregnancy, as a registrar, I worked with full on-calls until 38 weeks. My bosses were slightly puzzled by my determination to remain full time and with full on-calls, but all of them were supportive.
Case study 3
I had two pregnancies, and there was a substantial difference between them. The one constant was the support from consultants, trainees, and nursing staff. The first pregnancy went very smoothly. I had issues with fainting for the first 12 weeks but this settled.
The second pregnancy was with twins and the fainting problem persisted and became worse, and I was unable to operate for longer than an hour before crawling out of theatre. I was taken off the on-call rota from 12 weeks but helped colleagues out in the acute admissions side of on-calls. I finished at 30 weeks and had twins at 35 weeks.
Working successfully during pregnancy
Telling your employer
NHS Employers details the requirements for informing your NHS employer about taking maternity leave. You must inform your employer that you are pregnant by the 15th week before your expected week of childbirth—that is, 25/40 pregnant. You are expected to tell your employer your estimated week of childbirth and the date that you wish to begin maternity leave. You can start maternity leave from any point after you are 29 weeks pregnant. Many employers want to see a copy of your maternity certificate (MATB1 form), which you get from your midwife after 20 weeks of pregnancy.
The evidence about working during pregnancy in acute hospital specialties is limited (box 2). A cohort study from the Netherlands reported that there were no significant associations between physically demanding work or working hours in relation to babies born small for gestational age or with low birthweight, or preterm delivery, although women in physically demanding jobs who worked more than 40 hours a week had slower rates of fetal growth, which resulted in slightly smaller babies. One review of shift working during residency training in America concluded that there was an increased risk of preterm labour, premature delivery, pre-eclampsia, stillbirth, low birth weight, and placental abruption among pregnant residents. It should be noted, however, that a number of the studies used in this review pre-date current junior doctor working patterns and are unlikely to be relevant to the UK.
According to the Royal College of Physicians’ national guideline, physical and shift work in pregnancy are associated with a small level of risk for some adverse pregnancy outcomes in relation to lifting and heavy work, prolonged standing, and long working hours. The college adds, however, that studies to date have been inconclusive and that further evidence is needed. It recommends that, where possible, pregnant women should reduce very heavy physical activities and lifting; avoid standing for longer than three hours; and limit working hours to about 40 a week.
When it comes to working with imaging, current advice states that if you wear a lead gown, the effective radiation dose to the fetus is very low. It is your right to decide how much radiology you do, but in certain specialties, such as orthopaedics, your training may require that you complete a certain number of cases.
No guidance is currently available to trainees on whether or when to stop being on call before taking maternity leave. This may be because every trainee’s pregnancy and pattern of working are unique to them. The BMA guidance for on-call shifts states that, if the employee or her child would be at risk by continuing and she can do the rest of her normal job, she would not be expected to continue with on-call shifts.
Your NHS employer is obliged to arrange for you to have a risk assessment of your working conditions during pregnancy. This documentation is usually available through human resources departments.
Box 2: Getting the most out of your training while pregnant
Be organised (you will need to be even more organised when you return to work as a mother)
Let people know in advance of antenatal appointments
Make sure you eat and drink regularly
Be realistic about what you take on and what you want to achieve
Don’t be afraid to ask for advice or help
Without giving support and guidance it is possible that the NHS may lose current or future consultants as a result of bad experiences during pregnancy, despite its having invested time and resources in their training. Prospective data need to be gathered on the number of women becoming pregnant during medical training and the effects on their future careers. With there being increasing numbers of women medical graduates, these issues will grow in significance in the future. We also suggest that a peer mentoring programme may be helpful, so that trainees can access informal sources of information and advice. Our advice for pregnant trainees, along with that offered by our survey respondents, would be to do what is best for you and your baby.
NHS Employers. Maternity issues for doctors in training. December 2010. www.nhsemployers.org/Aboutus/Publications/Pages/MaternityIssuesForDoctorsInTraining.aspx
BMA. Working parents—maternity rights. http://bma.org.uk/practical-support-at-work/working-parents
Royal College of Physicians. Physical and shift work during pregnancy—a national guideline. November 2009. www.rcplondon.ac.uk/resources/physical-and-shift-work-pregnancy-guideline
Health and Safety Executive. Working safely with ionising radiation: guidance for expectant and breastfeeding mothers. www.hse.gov.uk/pubns/indg334.pdf
Medical Women’s Federation. Maternity. www.medicalwomensfederation.org.uk/new/maternity.html
McGoldrick C, McCann K, Black C. The productive pregnant surgical trainee. BMJ Careers, 18 August 2010. www.careers.bmj.com/careers/advice/view-article.html?id=20001324
Competing interests: None declared.
- NHS Information Centre. NHS hospital and community medical and dental staff: England 1997-2007. NHS IC, 2008.
- General Medical Council. National training survey 2012: key findings. Jul 2012. www.gmc-uk.org/National_training_survey_2012_key_findings_report.pdf_49280407.pdf.
- Elston MA. Women and medicine: the future. Royal College of Physicians, 2009. http://old.rcplondon.ac.uk/professional-Issues/workforce/Workforce-issues/Pages/Women-in-medicine.aspx.
- Van Dis J. Residency training and pregnancy JAMA 2004;291:636.
- NHS Employers. Maternity issues for doctors in training. Dec 2010. www.nhsemployers.org/Aboutus/Publications/Pages/MaternityIssuesForDoctorsInTraining.aspx.
- Finch SJ. Pregnancy during residency; a literature review. Acad Med 2003;78:418-28.
- Pope C, Mays N (eds). Qualitative research for healthcare. Blackwell Publishing, 2006.
- NHS Plus, Royal College of Physicians, Faculty of Occupational Medicine. Physical and shift work in pregnancy: occupational aspects of management. A national guideline. RCP, 2009. www.rcplondon.ac.uk/resources/physical-and-shift-work-pregnancy-guideline.
- BMA. Working parents—maternity rights. http://bma.org.uk/practical-support-at-work/working-parents.
Julie Cornish specialist registrar, general surgery
University Hospital of Wales, Cardiff, UK
Anne Gaunt specialist registrar, general surgery Warwick Medical School, Coventry, UK
Diane Adamson specialist registrar, general surgery Wrexham Maelor Hospital, Wrexham, UK
Sarah Mills specialist registrar, general surgery St Mary’s Hospital, London, UK
Pirko Schuppan registrar, plastic surgery Staedtisches Klinikum Braunschweig, Braunschweig, Germany
Deborah Markham associate clinical professor in medical educationhonorary consultant surgeon Warwick Medical School, Coventry, UK
Correspondence to: Anne Gaunt email@example.com
- There are currently no responses to this article
- Add rapid response
- NHS SHETLAND SPECIALTY TRAINEE LOCUM APPOINTMENT FOR SERVICE GENERAL SURGERY Reference: D31/BMJ
- SALARIED GP ROTHSCHILD HOUSE SURGERY, TRING, HERTFORDSHIRE We are a GMS practice seeking a permanent Salaried GP to join our friendly team.
- Greenbank Road Surgery, Liverpool Salaried GP Enthusiastic and motivated GP
- WALNUT TREE HEALTH CENTRE FULL TIME GP PARTNERSHIP
- River Place Group Practice, Islington N1 We are looking for two highly motivated and enthusiastic GPs to enhance our team