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Family-Friendly Workplaces as a Foundation for the Future of Pediatrics

Family-Friendly Workplaces as a Foundation for the Future of Pediatrics How can we—as pediatricians and more broadly as people devoting our careers to medicine—work together to improve the interplay of personal and professional roles? As I set out to share my observations and thoughts about the importance of creating family-friendly workplaces for the future of pediatrics as a profession, let me start on a personal note, as personal is precisely the heart of the matter. In October 1978 when my husband and I were both senior residents, our first daughter was born. Just weeks later, I was back in the hospital, resuming every fourth night call. I was breastfeeding, and despite our efforts my daughter refused to take anything from a bottle. So with youthful enthusiasm and inexperience, we hatched a plan: when I was on call, my husband (juggling his own call schedule) would drive to the hospital a few times a night with my daughter so she could nurse. We did have some concerns about this scheme but had neither better ideas nor anyone whom to ask for advice. My first night back on call was simply a disaster; I could not get back to my call room to nurse my hungry daughter. Patients kept arriving to be admitted and those already hospitalized demanded attention. As I hustled about, a cadre of students anxious for teaching were left as hungry as my child. Meanwhile, holed up in my hospital call room, my husband paged me repeatedly, eventually putting the phone next to our crying infant to emphasize the point that she was hungry. By the time I got to my room, my daughter was too overwrought to nurse. Although still new at this business, my husband and I were pretty sure that this did not constitute good parenting. By the early light of day when a moment of quiet finally arrived, I was stunned with disappointment in the complete failure of my first foray into combining my roles as parent, physician, spouse, and teacher—and overwhelmed with the loneliness of the position in which I found myself. This was not how I had expected young motherhood to feel. As physicians, we spend many of our waking hours in our workplaces. But, what do we, as professionals devoted to the care of children and of necessity their families, know about family-friendly workplaces? Not much, judging from the published literature; according to PubMed, 5 articles were published on this topic in 2004 and 2005, and precious few were published before this recent “burst” of interest. This neglect and the resulting deficient understanding of the impact of parental workplace on both parents and children are a problem that I believe must change if we are to speak compellingly and with integrity about women in medicine. Indeed, as a pediatrician, professor, and department chair, I have come to view the relationship between the work environment and the families of our faculty, staff, and students as the foundation of physician professionalism, humanism, and mentoring. My views are in part owing to my awareness throughout my career of how my generation marked a fundamental shift in the demography of the workplace. In 1960, 11% of women with children younger than 18 years worked outside of the house; that number had increased to 47% in 1975 and peaked at around 72% in the late 1990s,1 declining marginally since 2000.2 Women's share of the overall workforce was 26% in 1950, 33% in 1960, and 46% in 1998 and is expected to be 48% in 2015.3 Within medicine, the number of women graduating from US medical schools has risen from 7% in 1966 to 47% in 2005.4 In the 1960s and 1970s, the arguments in favor of women entering the workplace were simple: everyone would benefit. First, women would benefit because they would be intellectually challenged and would experience the greater rewards possible through direct involvement in the working world. Second, society would benefit because women would be contributing to the economy, the workforce and talent pool would double, and differing perspectives would be brought to many domains. Finally, families would benefit because women would be happier and would contribute to the household finances. Now 3 decades later, how do these 3 arguments hold up? Turning first to the expectation that women will benefit, the evidence is mixed at the level of individual women. Women who combine roles experience less depression and greater self-esteem and life satisfaction than women who play fewer roles.5 Employed women report better mental health than women who do not work outside of their homes.6 For many women, returning to work has been felt to reduce or prevent postpartum depression.7 However, rates of depression among female physicians are twice as high as among male physicians and 4-fold as high as the general population.8 A meta-analysis reveals that physicians of either sex have higher suicide rates than the general public: for male physicians, the odds ratio for suicide was 1.41 (95% confidence interval, 1.21-1.65), whereas for female physicians, the odds ratio was 2.27 (95% confidence interval, 1.90-2.73).9 Turning to the expectation from 30 years ago that the entrance of large numbers of women into the workforce would benefit society, all may not be well. Although the numbers of women entering the workforce and professions (including medicine) are impressive, the statistics regarding their ascension in the workforce are underwhelming. Within medical schools, women are less likely to be full professors than are men. In a national survey,10 66% of men with 15 to 19 years of seniority, but only 47% of women, were professors. These deficiencies were not explained by differences in numbers of publications, hours worked, subspecialty, or minority status. A recent article11 documents that these findings extend to the entire field of academic science and engineering. To the extent to which the profession itself regards these milestones of rank as the hallmarks of success—and this is certainly the case—our profession implicitly reveals a persistent ambivalence about the contribution of women in academia, including academic pediatrics. Turning lastly to the belief that families would benefit by a shift of women into the workplace, a recent trend might call this assumption into question as well: despite the increases in women working outside of the home in the last 30 years, the proportion of working married women with children younger than 3 years actually declined from 61% in 1997 to 56% in 2002. The reduction was largely among women with higher education; 22% of women holding graduate or professional degrees are at home full time with their children.1 Although a woman's decision as to whether to be at home or at work is ultimately—and appropriately—a personal decision, I believe that this recent decline reflects a broader failure of the medical profession to grapple with some of the most difficult and persistent dilemmas that balancing a family and a career pose. Many of our resident physicians confront these dilemmas on a daily basis, grappling not only with the myriad responsibilities of becoming a mature physician but also the protean challenges of becoming a parent at about the same time. We cannot overstate the amount of change that these young physicians experience. After years of schooling (one of the most dependent and self-focused of activities), they suddenly become responsible not only for their livelihoods but for the lives of hundreds of children while they continue to prepare themselves for examinations. We expect them to have become teachers, generally with limited training for that role. Many have only recently become committed to a long-term partner. Add to this the new role of parent. The demands placed on young doctors by the medical profession are stunning. One of the few articles12 addressing this topic found that among 230 residents, 9% had experienced significant emotional problems. In the lives of residents, changing roles becomes a routine monthly event but little is known about role changing and the assimilation of new professional and parental roles. A thought-provoking ethnographic study13 of 39 biographies found that while young male professionals “dream” of their careers, female professionals have “split dreams” of career and family. At about age 30 years, women in this study reappraised their lives with regard to the dream on which they had focused until that time and began to refocus on the relatively ignored dream. In the case of our residents, fellows, and young faculty, a reassessment at age 30 years would occur right when the steep climb in academia or the establishment of a practice was starting. As a society and a medical profession, we have simultaneously encouraged women to enter this field and steadfastly refused to seriously alter its demands or pathways to encourage both professional and parental success. The one success we might like to point to—the 80-hour work week—was, as we know, imposed on us and was motivated by concerns for patient safety, not personal sanity. We continue to expect women and men to comply with the rules established by a profession that at one time was dominated by men who traditionally had wives who attended to all domestic matters. This model does not recognize the demands of dual careers, the reality of the “biologic clock” of mothers, or the notion of child needs. During the 1980s and 1990s, I participated in innumerable discussions regarding the stalled progress of advancing women physicians through the academic hierarchy. Although the phenomenon of female career stagnation was disheartening, equally disquieting was my sense that these discussions, typically focused exclusively on the end points of promotion, tenure, and leadership positions, actually prevented us from seeing the bigger picture. What matters most in our lives, and certainly for me, is not academic title or career aspirations. Instead, when I think about every phase of my training and career, consistently the first thoughts that flood my memory are those that reflect the interface of my role as a mother and wife with my role as a pediatrician and scientist. When I became division chief of general pediatrics, my children were in elementary school. The last patients in our ambulatory clinic were scheduled at 4:45 PM, usually allowing us to leave at about 5:30 PM. If I left no later than 5:40 PM, I could arrive at my daughters' after-school program just in time for the final “late” pickup at 6:00 PM. Typically I only had 2 clinics in the afternoon per week and so between us, my husband and I could accommodate my clinic schedule. But, he traveled a great deal; on the days he was absent, I would look anxiously at the registration line as the clock approached 4:45, hoping it would be short and that my last cases would not be complex. More nights than I would like to remember, I dashed to my car, liberally interpreting yellow lights as I raced to the after-school program. Evenings went by in a flash, filled with dinner preparation, homework, kids' activities, and chores. Then, when parental duties were complete and I lay down to sleep, my mind would wander back to the last patients I had seen in clinic. Did that dull red tympanic membrane really explain the fever with a temperature of 39.4°C? Did that child with wheezing really clear after his albuterol treatment? Some nights these worries haunted me, relieved only by a call to the child's parent just to see how things were going. The truth is that most women in professional careers cannot neatly disentangle their roles as mothers, spouses, daughters, and sisters: to imagine a distinct career path, separate from all of the other paths of our lives, is merely a convenient fiction. For me, back when I was in the thick of juggling work with raising young children rather than thinking about climbing the academic or administrative hierarchy, the conflict between my family role and my pediatrician role caused me the greatest concern. Interestingly, although I have had several wonderful mentors throughout my career, this parent-professional role conflict was never a topic we discussed privately. Then again, when my daughters were born, any conversation we might have had would have been based solely on opinion because at that time, the scientific literature regarding the effects of day care or nonmaternal infant care on child development was meager. This is no longer the case. During the past 3 decades, several longitudinal studies have raised concerns regarding impaired social and cognitive development in children exposed to nonmaternal care, particularly when it begins in the first year of life. Although other studies have not found such deleterious effects and a few have noted benefits, the now complex and at times admittedly contradictory literature is frankly disconcerting. For instance, the 1986 National Longitudinal Survey of Youth14 followed up 1872 children from birth to age 7 or 8 years. The Peabody Picture Vocabulary Test demonstrated a negative effect on children aged 4 years who had received nonmaternal care. The negative effect was limited to boys in higher socioeconomic brackets and was not found for girls, those with a lower family income, or children of mothers who returned to work after the first year of life. This later finding was subsequently replicated15 in the National Institute of Child Health and Human Development–funded Study of Early Child Care, which has followed up more than 1000 children since 1991. The investigators found that maternal employment by age 9 months was associated with lower School Readiness scale scores at age 36 months. Effects were more pronounced if the mothers had worked for more than 30 hours per week, among male children, among married women, and if the women were not sensitive. The negative effects persisted even after controlling for child care quality.15 At age 54 months, the more time children had spent in nonmaternal care, the more externalizing problems and conflicts with adults they manifested in kindergarten as reported by parents, caregivers, and teachers.16 Regarding social interactions, another analysis of the National Institute of Child Health and Human Development cohort found mixed results: blinded observations of children at age 36 months in play settings revealed that those with day care experience exhibited more positive, skilled peer interactions; they were rated by their teachers, however, as having more negative interactions.17 In a summary of findings from the National Institute of Child Health and Human Development study, the investigators concluded that the mother's sensitivity, responsiveness, and overall psychological adjustment predicted infant-mother attachment security at age 15 months. Low-quality care arrangements, spending more than 10 hours per week in child care, and frequent changes in child care increased the risk when combined with low maternal sensitivity.18 Although the findings from the literature are disheartening, perhaps even more disturbing is that we have not as a profession taken them to heart. We have not developed career paths that tolerate or encourage our young pediatricians to take a year off or at least substantially reduce work hours during their child's infancy. We have not invested in experiments in child care to determine which types of child care (if any) might be equal to or surpass maternal care. Examining some of the strategies that physicians use for maintaining a balance between work and home might provide insight into what needs to be done to render the workplace more family friendly. In a survey of more than 800 academic physicians in departments of medicine throughout the country, respondents were asked to provide coping strategies used to balance career and personal life.19 From the 77% of respondents providing at least 1 coping strategy, 1117 strategies were offered in 4 general categories: (1) changing structural aspects of their lives; (2) relying on social support; (3) increasing efficiency; and (4) limiting personal expectations. Among changing structural aspects of personal and professional life, hiring help was the most common (77%), 54% reported limiting social obligations such as entertaining, and 14% reported limiting professional commitments such as committee work. Social support was infrequently cited, but more than half of the respondents reported activities to increase efficiency.19 Personally, I was very fond of efficiency strategies, adopting several such as getting up an hour ahead of the family, not to do chores but to write. Another strategy I embraced was making sandwiches on Sunday afternoons for both of my daughters' school lunches for the whole week. I was rather self-satisfied with the effect of this strategy on reducing before-school chaos. Not a sandwich eater myself, I was shocked to learn from my children years later that these sandwiches had become more than just unappetizing after Tuesday or Wednesday and completely inedible by Friday. More to the point, although I do recommend the early morning wake-up and counsel against Sunday sandwich assembly, the strategies for improving work-life balance need to extend beyond the individual efforts of physicians and instead reach into the physician workplace and its organizational culture. To wit, a survey sent to the 309 women of the medical faculty at Stanford University found that the highest perceived needs were a flexible work environment without negative consequences for women with young children, a 3-month sabbatical from clinical and administrative duties during childrearing years, and departmental mentoring for the academic career.20 A growing sense of need, unmet and often unarticulated, among female pediatricians and pediatric faculty led the Federation of Pediatric Organizations to assemble a task force to formally assess the status of women in pediatrics and to recommend changes. The report of this task force opens with a paragraph underscoring the importance of family balance in the lives of pediatricians to the profession as a whole: “The commitment of pediatrics to the health and well-being of children and youth should encompass the families of those who choose to pursue careers in pediatrics.”21 Without doubt, though, there remain significant consequences to our rigid hierarchy of training and, for those who wish to remain in academia, of academic promotion. As pediatricians, we should take the lead in thoughtfully reconstructing our training programs and work environments to enable optimization of the lives of children, including the children of pediatricians. New experiments in child care arrangements, training schedules, and board certification are necessary. In the end, if we want for our profession a cadre of pediatricians who embrace multiple deeply held commitments in both their work life and their personal life, then we need to help them navigate the journey of their career by offering more than just advice: we need to change the criteria of the journey itself, resetting the pace, reformatting its structure, and reinvigorating its overarching sense of purpose. Correspondence: Dr Stanton, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, 3901 Beaubien Blvd, Suite 1K40, Detroit, MI 48201 (bstanton@dmc.org). Financial Disclosure: None reported. Previous Presentation: This Commentary is based on a talk given for the symposium Creating Institutional Change for Work/Life Balance in Pediatric Careers; October 11, 2006; Department of Pediatrics, University of Washington, Seattle. References 1. Wallis C The case for staying home. Time Magazine. March22 2004;50- 59Google Scholar 2. Hotchkiss JL Changes in behavioral and characteristic determination of female labor force participation, 1975-2005. Econ Rev 2006;1- 20Google Scholar 3. Fullerton HN Jr Labor force participation: 75 years of change, 1950-98 and 1998-2025. Mon Labor Rev 1999;1223- 12Google Scholar 4. Association of American Medical Colleges,Women in US academic medicine, 2004-2005.http://www.aamc.org/members/wim/statistics/stats05/wimstats2005.pdfAccessed October 3, 2006 5. Crosby FJ Juggling: The Unexpected Advantages of Balancing Career and Home for Women and Their Families. New York NY Free Press1991; 6. Noor NM Work and family roles in relation to women's well-being: a longitudinal study. Br J Soc Psychol 1995;3487- 106PubMedGoogle ScholarCrossref 7. Miller S Questioning, resisting, acquiescing, balancing: new mothers' career reentry strategies. Health Care Women Int 1996;17109- 131PubMedGoogle ScholarCrossref 8. Bowman MAAllen DI Stress and Woman Physicians. New York, NY Springer-Verlag1990; 9. Schernhammer ESColditz GA Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry 2004;1612295- 2302PubMedGoogle ScholarCrossref 10. Ash ASCarr PLGoldstein RFriedman RH Compensation and advancement of women in academic medicine: is there equity? Ann Intern Med 2004;141205- 212PubMedGoogle ScholarCrossref 11. Committee on Maximizing the Potential of Women in Academic Science and Engineering; National Academy of Sciences; National Academy of Engineering; Institute of Medicine, Beyond Bias and Barriers: Fulfilling the Potential of Women in Academic Science and Engineering. Washington, DC National Academies Press2006; 12. Reamy BVHarmon JH Residents in trouble: an in-depth assessment of the 25-year experience of a single family medicine residency. Fam Med 2006;38252- 257PubMedGoogle Scholar 13. Sullivan SE Is there a time for everything? attitudes related to women's sequencing of career and family. Career Dev Q 1992;40234- 243PubMedGoogle ScholarCrossref 14. Desai SChase-Lansdale PLMichael RT Mother or market? effect of maternal employment on the intellectual ability of 4-year-old children. Demography 1989;26545- 561PubMedGoogle ScholarCrossref 15. Brooks-Gunn JHan WJWaldfogel JNational Institute of Child Health and Human Development, Maternal employment and child cognitive outcomes in the first three years of life: the NICHD Study of Early Child Care. Child Dev 2002;731052- 1072PubMedGoogle ScholarCrossref 16. NICHD Early Child Care Research Network, Does amount of time spent in child care predict socioemotional adjustment during the transition to kindergarten? Child Dev 2003;74976- 1005PubMedGoogle ScholarCrossref 17. NICHD Early Child Care Research Network, Child care and children's peer interaction at 24 and 36 months: the NICHD study of early child care. Child Dev 2001;721478- 1500PubMedGoogle ScholarCrossref 18. NICHD Early Child Care Research Network, Early child care and self-control, compliance, and problem behavior at twenty-four and thirty-six months. Child Dev 1998;691145- 1170PubMedGoogle ScholarCrossref 19. Levinson WKaufman KTolle SW Women in academic medicine: strategies for balancing career and personal life. J Am Med Womens Assoc 1992;4725- 28PubMedGoogle Scholar 20. McGuire LKBergen MRPolan ML Career advancement for women faculty in a US school of medicine. Acad Med 2004;79319- 325PubMedGoogle ScholarCrossref 21. Federation of Pediatric Organizations,Report of the Task Force on Women in Pediatrics.http://www.fopo.orgAccessed September 15, 2006 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Pediatrics & Adolescent Medicine American Medical Association

Family-Friendly Workplaces as a Foundation for the Future of Pediatrics

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Publisher
American Medical Association
Copyright
Copyright © 2007 American Medical Association. All Rights Reserved.
ISSN
1072-4710
DOI
10.1001/archpedi.161.5.511
pmid
17485630
Publisher site
See Article on Publisher Site

Abstract

How can we—as pediatricians and more broadly as people devoting our careers to medicine—work together to improve the interplay of personal and professional roles? As I set out to share my observations and thoughts about the importance of creating family-friendly workplaces for the future of pediatrics as a profession, let me start on a personal note, as personal is precisely the heart of the matter. In October 1978 when my husband and I were both senior residents, our first daughter was born. Just weeks later, I was back in the hospital, resuming every fourth night call. I was breastfeeding, and despite our efforts my daughter refused to take anything from a bottle. So with youthful enthusiasm and inexperience, we hatched a plan: when I was on call, my husband (juggling his own call schedule) would drive to the hospital a few times a night with my daughter so she could nurse. We did have some concerns about this scheme but had neither better ideas nor anyone whom to ask for advice. My first night back on call was simply a disaster; I could not get back to my call room to nurse my hungry daughter. Patients kept arriving to be admitted and those already hospitalized demanded attention. As I hustled about, a cadre of students anxious for teaching were left as hungry as my child. Meanwhile, holed up in my hospital call room, my husband paged me repeatedly, eventually putting the phone next to our crying infant to emphasize the point that she was hungry. By the time I got to my room, my daughter was too overwrought to nurse. Although still new at this business, my husband and I were pretty sure that this did not constitute good parenting. By the early light of day when a moment of quiet finally arrived, I was stunned with disappointment in the complete failure of my first foray into combining my roles as parent, physician, spouse, and teacher—and overwhelmed with the loneliness of the position in which I found myself. This was not how I had expected young motherhood to feel. As physicians, we spend many of our waking hours in our workplaces. But, what do we, as professionals devoted to the care of children and of necessity their families, know about family-friendly workplaces? Not much, judging from the published literature; according to PubMed, 5 articles were published on this topic in 2004 and 2005, and precious few were published before this recent “burst” of interest. This neglect and the resulting deficient understanding of the impact of parental workplace on both parents and children are a problem that I believe must change if we are to speak compellingly and with integrity about women in medicine. Indeed, as a pediatrician, professor, and department chair, I have come to view the relationship between the work environment and the families of our faculty, staff, and students as the foundation of physician professionalism, humanism, and mentoring. My views are in part owing to my awareness throughout my career of how my generation marked a fundamental shift in the demography of the workplace. In 1960, 11% of women with children younger than 18 years worked outside of the house; that number had increased to 47% in 1975 and peaked at around 72% in the late 1990s,1 declining marginally since 2000.2 Women's share of the overall workforce was 26% in 1950, 33% in 1960, and 46% in 1998 and is expected to be 48% in 2015.3 Within medicine, the number of women graduating from US medical schools has risen from 7% in 1966 to 47% in 2005.4 In the 1960s and 1970s, the arguments in favor of women entering the workplace were simple: everyone would benefit. First, women would benefit because they would be intellectually challenged and would experience the greater rewards possible through direct involvement in the working world. Second, society would benefit because women would be contributing to the economy, the workforce and talent pool would double, and differing perspectives would be brought to many domains. Finally, families would benefit because women would be happier and would contribute to the household finances. Now 3 decades later, how do these 3 arguments hold up? Turning first to the expectation that women will benefit, the evidence is mixed at the level of individual women. Women who combine roles experience less depression and greater self-esteem and life satisfaction than women who play fewer roles.5 Employed women report better mental health than women who do not work outside of their homes.6 For many women, returning to work has been felt to reduce or prevent postpartum depression.7 However, rates of depression among female physicians are twice as high as among male physicians and 4-fold as high as the general population.8 A meta-analysis reveals that physicians of either sex have higher suicide rates than the general public: for male physicians, the odds ratio for suicide was 1.41 (95% confidence interval, 1.21-1.65), whereas for female physicians, the odds ratio was 2.27 (95% confidence interval, 1.90-2.73).9 Turning to the expectation from 30 years ago that the entrance of large numbers of women into the workforce would benefit society, all may not be well. Although the numbers of women entering the workforce and professions (including medicine) are impressive, the statistics regarding their ascension in the workforce are underwhelming. Within medical schools, women are less likely to be full professors than are men. In a national survey,10 66% of men with 15 to 19 years of seniority, but only 47% of women, were professors. These deficiencies were not explained by differences in numbers of publications, hours worked, subspecialty, or minority status. A recent article11 documents that these findings extend to the entire field of academic science and engineering. To the extent to which the profession itself regards these milestones of rank as the hallmarks of success—and this is certainly the case—our profession implicitly reveals a persistent ambivalence about the contribution of women in academia, including academic pediatrics. Turning lastly to the belief that families would benefit by a shift of women into the workplace, a recent trend might call this assumption into question as well: despite the increases in women working outside of the home in the last 30 years, the proportion of working married women with children younger than 3 years actually declined from 61% in 1997 to 56% in 2002. The reduction was largely among women with higher education; 22% of women holding graduate or professional degrees are at home full time with their children.1 Although a woman's decision as to whether to be at home or at work is ultimately—and appropriately—a personal decision, I believe that this recent decline reflects a broader failure of the medical profession to grapple with some of the most difficult and persistent dilemmas that balancing a family and a career pose. Many of our resident physicians confront these dilemmas on a daily basis, grappling not only with the myriad responsibilities of becoming a mature physician but also the protean challenges of becoming a parent at about the same time. We cannot overstate the amount of change that these young physicians experience. After years of schooling (one of the most dependent and self-focused of activities), they suddenly become responsible not only for their livelihoods but for the lives of hundreds of children while they continue to prepare themselves for examinations. We expect them to have become teachers, generally with limited training for that role. Many have only recently become committed to a long-term partner. Add to this the new role of parent. The demands placed on young doctors by the medical profession are stunning. One of the few articles12 addressing this topic found that among 230 residents, 9% had experienced significant emotional problems. In the lives of residents, changing roles becomes a routine monthly event but little is known about role changing and the assimilation of new professional and parental roles. A thought-provoking ethnographic study13 of 39 biographies found that while young male professionals “dream” of their careers, female professionals have “split dreams” of career and family. At about age 30 years, women in this study reappraised their lives with regard to the dream on which they had focused until that time and began to refocus on the relatively ignored dream. In the case of our residents, fellows, and young faculty, a reassessment at age 30 years would occur right when the steep climb in academia or the establishment of a practice was starting. As a society and a medical profession, we have simultaneously encouraged women to enter this field and steadfastly refused to seriously alter its demands or pathways to encourage both professional and parental success. The one success we might like to point to—the 80-hour work week—was, as we know, imposed on us and was motivated by concerns for patient safety, not personal sanity. We continue to expect women and men to comply with the rules established by a profession that at one time was dominated by men who traditionally had wives who attended to all domestic matters. This model does not recognize the demands of dual careers, the reality of the “biologic clock” of mothers, or the notion of child needs. During the 1980s and 1990s, I participated in innumerable discussions regarding the stalled progress of advancing women physicians through the academic hierarchy. Although the phenomenon of female career stagnation was disheartening, equally disquieting was my sense that these discussions, typically focused exclusively on the end points of promotion, tenure, and leadership positions, actually prevented us from seeing the bigger picture. What matters most in our lives, and certainly for me, is not academic title or career aspirations. Instead, when I think about every phase of my training and career, consistently the first thoughts that flood my memory are those that reflect the interface of my role as a mother and wife with my role as a pediatrician and scientist. When I became division chief of general pediatrics, my children were in elementary school. The last patients in our ambulatory clinic were scheduled at 4:45 PM, usually allowing us to leave at about 5:30 PM. If I left no later than 5:40 PM, I could arrive at my daughters' after-school program just in time for the final “late” pickup at 6:00 PM. Typically I only had 2 clinics in the afternoon per week and so between us, my husband and I could accommodate my clinic schedule. But, he traveled a great deal; on the days he was absent, I would look anxiously at the registration line as the clock approached 4:45, hoping it would be short and that my last cases would not be complex. More nights than I would like to remember, I dashed to my car, liberally interpreting yellow lights as I raced to the after-school program. Evenings went by in a flash, filled with dinner preparation, homework, kids' activities, and chores. Then, when parental duties were complete and I lay down to sleep, my mind would wander back to the last patients I had seen in clinic. Did that dull red tympanic membrane really explain the fever with a temperature of 39.4°C? Did that child with wheezing really clear after his albuterol treatment? Some nights these worries haunted me, relieved only by a call to the child's parent just to see how things were going. The truth is that most women in professional careers cannot neatly disentangle their roles as mothers, spouses, daughters, and sisters: to imagine a distinct career path, separate from all of the other paths of our lives, is merely a convenient fiction. For me, back when I was in the thick of juggling work with raising young children rather than thinking about climbing the academic or administrative hierarchy, the conflict between my family role and my pediatrician role caused me the greatest concern. Interestingly, although I have had several wonderful mentors throughout my career, this parent-professional role conflict was never a topic we discussed privately. Then again, when my daughters were born, any conversation we might have had would have been based solely on opinion because at that time, the scientific literature regarding the effects of day care or nonmaternal infant care on child development was meager. This is no longer the case. During the past 3 decades, several longitudinal studies have raised concerns regarding impaired social and cognitive development in children exposed to nonmaternal care, particularly when it begins in the first year of life. Although other studies have not found such deleterious effects and a few have noted benefits, the now complex and at times admittedly contradictory literature is frankly disconcerting. For instance, the 1986 National Longitudinal Survey of Youth14 followed up 1872 children from birth to age 7 or 8 years. The Peabody Picture Vocabulary Test demonstrated a negative effect on children aged 4 years who had received nonmaternal care. The negative effect was limited to boys in higher socioeconomic brackets and was not found for girls, those with a lower family income, or children of mothers who returned to work after the first year of life. This later finding was subsequently replicated15 in the National Institute of Child Health and Human Development–funded Study of Early Child Care, which has followed up more than 1000 children since 1991. The investigators found that maternal employment by age 9 months was associated with lower School Readiness scale scores at age 36 months. Effects were more pronounced if the mothers had worked for more than 30 hours per week, among male children, among married women, and if the women were not sensitive. The negative effects persisted even after controlling for child care quality.15 At age 54 months, the more time children had spent in nonmaternal care, the more externalizing problems and conflicts with adults they manifested in kindergarten as reported by parents, caregivers, and teachers.16 Regarding social interactions, another analysis of the National Institute of Child Health and Human Development cohort found mixed results: blinded observations of children at age 36 months in play settings revealed that those with day care experience exhibited more positive, skilled peer interactions; they were rated by their teachers, however, as having more negative interactions.17 In a summary of findings from the National Institute of Child Health and Human Development study, the investigators concluded that the mother's sensitivity, responsiveness, and overall psychological adjustment predicted infant-mother attachment security at age 15 months. Low-quality care arrangements, spending more than 10 hours per week in child care, and frequent changes in child care increased the risk when combined with low maternal sensitivity.18 Although the findings from the literature are disheartening, perhaps even more disturbing is that we have not as a profession taken them to heart. We have not developed career paths that tolerate or encourage our young pediatricians to take a year off or at least substantially reduce work hours during their child's infancy. We have not invested in experiments in child care to determine which types of child care (if any) might be equal to or surpass maternal care. Examining some of the strategies that physicians use for maintaining a balance between work and home might provide insight into what needs to be done to render the workplace more family friendly. In a survey of more than 800 academic physicians in departments of medicine throughout the country, respondents were asked to provide coping strategies used to balance career and personal life.19 From the 77% of respondents providing at least 1 coping strategy, 1117 strategies were offered in 4 general categories: (1) changing structural aspects of their lives; (2) relying on social support; (3) increasing efficiency; and (4) limiting personal expectations. Among changing structural aspects of personal and professional life, hiring help was the most common (77%), 54% reported limiting social obligations such as entertaining, and 14% reported limiting professional commitments such as committee work. Social support was infrequently cited, but more than half of the respondents reported activities to increase efficiency.19 Personally, I was very fond of efficiency strategies, adopting several such as getting up an hour ahead of the family, not to do chores but to write. Another strategy I embraced was making sandwiches on Sunday afternoons for both of my daughters' school lunches for the whole week. I was rather self-satisfied with the effect of this strategy on reducing before-school chaos. Not a sandwich eater myself, I was shocked to learn from my children years later that these sandwiches had become more than just unappetizing after Tuesday or Wednesday and completely inedible by Friday. More to the point, although I do recommend the early morning wake-up and counsel against Sunday sandwich assembly, the strategies for improving work-life balance need to extend beyond the individual efforts of physicians and instead reach into the physician workplace and its organizational culture. To wit, a survey sent to the 309 women of the medical faculty at Stanford University found that the highest perceived needs were a flexible work environment without negative consequences for women with young children, a 3-month sabbatical from clinical and administrative duties during childrearing years, and departmental mentoring for the academic career.20 A growing sense of need, unmet and often unarticulated, among female pediatricians and pediatric faculty led the Federation of Pediatric Organizations to assemble a task force to formally assess the status of women in pediatrics and to recommend changes. The report of this task force opens with a paragraph underscoring the importance of family balance in the lives of pediatricians to the profession as a whole: “The commitment of pediatrics to the health and well-being of children and youth should encompass the families of those who choose to pursue careers in pediatrics.”21 Without doubt, though, there remain significant consequences to our rigid hierarchy of training and, for those who wish to remain in academia, of academic promotion. As pediatricians, we should take the lead in thoughtfully reconstructing our training programs and work environments to enable optimization of the lives of children, including the children of pediatricians. New experiments in child care arrangements, training schedules, and board certification are necessary. In the end, if we want for our profession a cadre of pediatricians who embrace multiple deeply held commitments in both their work life and their personal life, then we need to help them navigate the journey of their career by offering more than just advice: we need to change the criteria of the journey itself, resetting the pace, reformatting its structure, and reinvigorating its overarching sense of purpose. Correspondence: Dr Stanton, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, 3901 Beaubien Blvd, Suite 1K40, Detroit, MI 48201 (bstanton@dmc.org). Financial Disclosure: None reported. Previous Presentation: This Commentary is based on a talk given for the symposium Creating Institutional Change for Work/Life Balance in Pediatric Careers; October 11, 2006; Department of Pediatrics, University of Washington, Seattle. References 1. Wallis C The case for staying home. Time Magazine. March22 2004;50- 59Google Scholar 2. Hotchkiss JL Changes in behavioral and characteristic determination of female labor force participation, 1975-2005. Econ Rev 2006;1- 20Google Scholar 3. Fullerton HN Jr Labor force participation: 75 years of change, 1950-98 and 1998-2025. Mon Labor Rev 1999;1223- 12Google Scholar 4. Association of American Medical Colleges,Women in US academic medicine, 2004-2005.http://www.aamc.org/members/wim/statistics/stats05/wimstats2005.pdfAccessed October 3, 2006 5. Crosby FJ Juggling: The Unexpected Advantages of Balancing Career and Home for Women and Their Families. New York NY Free Press1991; 6. Noor NM Work and family roles in relation to women's well-being: a longitudinal study. Br J Soc Psychol 1995;3487- 106PubMedGoogle ScholarCrossref 7. Miller S Questioning, resisting, acquiescing, balancing: new mothers' career reentry strategies. Health Care Women Int 1996;17109- 131PubMedGoogle ScholarCrossref 8. Bowman MAAllen DI Stress and Woman Physicians. New York, NY Springer-Verlag1990; 9. Schernhammer ESColditz GA Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry 2004;1612295- 2302PubMedGoogle ScholarCrossref 10. Ash ASCarr PLGoldstein RFriedman RH Compensation and advancement of women in academic medicine: is there equity? Ann Intern Med 2004;141205- 212PubMedGoogle ScholarCrossref 11. Committee on Maximizing the Potential of Women in Academic Science and Engineering; National Academy of Sciences; National Academy of Engineering; Institute of Medicine, Beyond Bias and Barriers: Fulfilling the Potential of Women in Academic Science and Engineering. Washington, DC National Academies Press2006; 12. Reamy BVHarmon JH Residents in trouble: an in-depth assessment of the 25-year experience of a single family medicine residency. Fam Med 2006;38252- 257PubMedGoogle Scholar 13. Sullivan SE Is there a time for everything? attitudes related to women's sequencing of career and family. Career Dev Q 1992;40234- 243PubMedGoogle ScholarCrossref 14. Desai SChase-Lansdale PLMichael RT Mother or market? effect of maternal employment on the intellectual ability of 4-year-old children. Demography 1989;26545- 561PubMedGoogle ScholarCrossref 15. Brooks-Gunn JHan WJWaldfogel JNational Institute of Child Health and Human Development, Maternal employment and child cognitive outcomes in the first three years of life: the NICHD Study of Early Child Care. Child Dev 2002;731052- 1072PubMedGoogle ScholarCrossref 16. NICHD Early Child Care Research Network, Does amount of time spent in child care predict socioemotional adjustment during the transition to kindergarten? Child Dev 2003;74976- 1005PubMedGoogle ScholarCrossref 17. NICHD Early Child Care Research Network, Child care and children's peer interaction at 24 and 36 months: the NICHD study of early child care. Child Dev 2001;721478- 1500PubMedGoogle ScholarCrossref 18. NICHD Early Child Care Research Network, Early child care and self-control, compliance, and problem behavior at twenty-four and thirty-six months. Child Dev 1998;691145- 1170PubMedGoogle ScholarCrossref 19. Levinson WKaufman KTolle SW Women in academic medicine: strategies for balancing career and personal life. J Am Med Womens Assoc 1992;4725- 28PubMedGoogle Scholar 20. McGuire LKBergen MRPolan ML Career advancement for women faculty in a US school of medicine. Acad Med 2004;79319- 325PubMedGoogle ScholarCrossref 21. Federation of Pediatric Organizations,Report of the Task Force on Women in Pediatrics.http://www.fopo.orgAccessed September 15, 2006

Journal

Archives of Pediatrics & Adolescent Medicine – American Medical Association

Published: May 1, 2007

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