 All right, so welcome to the spring part of our lecture series. We're back to our Wednesdays in person. And we do have a number of in person lectures coming up in the next few weeks. So I'll just remind everyone. Today I'll be introducing Dr. Anna Volerman is speaking today, followed by next week, Carl Street, who's a physician and graduate of the University of Chicago. And we'll be coming back to visit with us and then followed by Pringle Miller, who also is a graduate of the University of Chicago, also here locally and will be back with us. Followed by April 12, a panel of our local female surgeons who run the Department of Surgery women's committees just a discussion of the state of women in surgery so really excited for the upcoming events but with that I'd like to introduce Dr. Volerman who be speaking today and Dr. Volerman is an associate professor in medicine and pediatrics at the University of Chicago. She's a primary care physician for both children and adults and a health services researcher, focused on reducing inequities. Her work applies community partnered research and implementation science with the goal of reducing long standing systemic and structural factors that drive health and education disparities in communities. I'm passionate about increasing representation and diversity in the biomedical workforce. I work closely with her and she is a subcommittee chair in the Department of Medicine women's committee, and I think we'll hear about her work today with Dr. Laura and some of the work supporting women here at the University of Chicago so welcome Dr. Anna Volerman. Thanks Julie, I have to adjust the mic appropriately for height differences that might arise. So, thank you all for the opportunity to be here today, and I'm excited to have the chance to talk with everyone about gender equity and caregiving. I think to start, I want to kind of set the foundation that we are all caregivers, where we will all be in need of caregiving at some point in our lives. These are incredibly powerful words by former First Lady Carter, who indicated there are only four kinds of people in this world. Those who have been caregivers, those who are currently caregivers, those who will be caregivers and those who will need caregivers. Caregiving is universal. And so I think no matter who you are, no matter what stage you are in your life, caregiving is something that will be a part of your life if it isn't already. And I think important kind of to bring that foundation to the discussion today. So in terms of disclosures, the work that I'll share today has been funded by the National Institutes of Health and by the Walder Foundation. I think an additional disclosure that the information that I present today come both from my experiences as a faculty member for my work with other faculty, staff and trainees, but also myself as a caregiver for three young boys. And in that process, I've had support from my parents for my caregiving, and now have recently become a caregiver for my mother in the setting of my father's recent death. I will acknowledge I have been very privileged and lucky in my caregiving journey, and not everyone is. And we'll bring that to the discussion today. So to get started or what I'm hoping you'll get out of this talk is really just understanding what is caregiving and who are the caregivers. How caregiving impacts the work that we do as physicians, and why it is so important to support physician caregivers. And then also consideration about the approaches that we can use to fix not just individuals but to fix the system to support caregivers. Thank you so much for the caveats for the presentation today. I will discuss gender, and I acknowledge gender is not binary, but for the purposes of the work presented today, many of the studies have been done using gender in a, in a binary way, and I will share what has been published in that regard further data and evidence about race and ethnicity, as well as individuals who identify as LGBTQ is limited. And only what's available will be presented. So to start, what is caregiving and who are the caregivers. Sorry, I'm thrown off because the font looks completely different. So to start a caregiver, you know, if you, if you open up Google and you look up the definition for caregiver, a caregiver or caregiving is the activity or the profession of regularly looking after a child, or a person who's sick, elderly or disabled. And most commonly this caregiver is assisting with impairments that arise as a result of age or of disability or disease. Now in our minds, caregiving may bring a very different concept depending on your professional or home situation. I want to acknowledge terminology because there's quite a bit out there when we think about caregiving right as physicians, or as clinicians we often think about caregiving from the perspective of caregivers or home health aides that support our patients. As parents we might think about nannies babysitters and AIDS, and that that the terminology used for that is a formal caregiver or a paid caregiver. What we'll talk about largely today is informal caregiving, or that that is, that is the role of a parent, a grandparent, a sibling, a friend, a neighbor, a guardian. And I think also acknowledging, I will use the term either informal caregiving or family caregiver throughout the discussion just to be clear about these distinctions. So, who are the informal caregivers and it's, it's interesting because there's very, there's there's not a lot of data out there that says X amount of people have informal caregiving responsibilities in the US right. So we're very kind of stratified in our studies. And so to start kind of thinking about who are the informal caregivers for children. This varies quite a bit based on age of an individual, as well as their gender, but it's estimated that about 86% of American adults who are over the age of 45 have children, and so have caregiving responsibilities. In the US households 40% have a child in the home, whether that's a biological child a step child or an adopted child. And when we think about families who have children, at least one parent is employed in nine out of 10 families. And in about 60% of those families where there's a married couple, both parents are employed. I think also importantly to think about gender here. When we think about who's participating in the labor workforce, and this is broadly not just among physicians, about 70% of women with children participate in the labor workforce in 2021. So we've come a long way in that and we exist in a system that was largely not built for women in the workforce and so that's what we'll get to you today. Informal caregiving for the elderly, or those who have diseases or disabilities. This is actually much more quantified in the literature, because of the focus on elderly that has that have been that has been done. So informal caregivers provide up to 90% of long term care within the home for adults. And currently about one in five Americans are providing unpaid caregiving to an adult who's either elderly or has health or disability needs. 60% of these individuals are women, typically mothers daughters and sisters of the individual. And these numbers will likely continue to increase because of the aging population we have in our country. And it's estimated that that the economic value of this unpaid caregiving that's provided is over $500 million billion dollars per year. I want to take for a minute and lump these two together so the informal caregivers of children and the informal caregivers of elderly. Kind of you lump together and this is often referred to the sandwich generation, this most often affects individuals who are in their 30s or 40s. And they're individuals responsible for bringing up children, as well as caring for aging adults. It's estimated that nearly a quarter of all adults fall into this category, and over half of American adults in their 40s doom. These individuals often face higher burdens, because of these, these, the needs that exists within the home as well as the emotional and financial aspects that come with this care. This picture will hopefully in this image reminds me often that caregiving is not just something that affects individuals when they have children, but it really again affects us all throughout our lifespan and throughout our career span, when we think about physicians. So, to talk to really think about focusing this conversation on physicians. There's actually limited information about how many physicians are caregivers. There's actually limited information about how many that was done really focused on physician mothers, right so already physicians, providing care to their patients and mothers providing care to a child. And 16% of those 16% of those individuals were also carrying somebody with a significant health condition. You can see nearly half of those were parents. And, but in many cases there was other relatives even friends and children. And individuals were older. And I think that you know the term often used for this group is actually individuals who are triple caregivers, really caring for patients within the health system, children, and elderly or ill individuals. So, with some, some insights on what is caregiving and who are the caregivers. Let's talk a little bit about the impact of caregiving. So, some may say, like, well, caregiving that happens in the home. And how does that really relate to what happens here within our institutions or in other clinics or academic institutions. The reality is it's impossible to celebrate separate work at home. And so it's important to think about what's the effect of individuals. I'm going to pull out the study first to start a conversation that was done back in the 1990s that we're talking 30 years ago. And this was one of the early studies that was done to quantify the effects of having children within the home. There was a survey done of Ontario based physicians who were certified in family medicine. And here participants reported their work hours. And also reported the amount of hours spent on unpaid work within the home or domestic work as they, as they term. I think for baseline kind of characteristics, approximately three fourths of these individuals were married and have had children in the home. And women who were in this group were more likely to have a spouse who worked full time rather than men. So when we take a look at this table, what I'd like to do is first start with kind of breaking it down for you. So first they delineate what has the time been spent on, and then they provide the number of individuals that they have data for, but then the mean hours. And that's really where I want you to focus is the mean hours for women versus the mean hours. I'm sorry, versus women in an average week. And so to start, if you start by looking at the professional activities and the time spent on professional activities you can see men with children at home and without children at home spent about the same amount of time on professional activities. In contrast, if you look at women, women who spend women who have children spend significantly less time on professional activities than their counterparts without children. Moving on to the household piece. You can see that not surprisingly both men and women who have children at home spend more time on household responsibilities than those who don't have children. Although you can see that that number significantly larger for women than it is for men or that increases significantly larger. And then the child care piece. Men who have children at home spend about 11 hours per week with for childcare, as compared to zero hours for those who have no children at home. In comparison, women who had children at home spent 40 hours a week, the equivalent of a full time job on childcare at home. And so, you know, not only significant differences in numbers but really eye popping differences in those numbers. So when you when you combine both professional and responsibilities within the home. You can see some, you know, some significant things are some important points for those who have no children at home. The hours spent in total are pretty similar between men and women. However, for individuals who have children at home women spend 22 more hours per week on all professional domestic related activities than men. So some people would say that was done 30 years ago what happens today, or what is, is it still relevant today. And so this is data from a study that was done in around 2010, and it focused specifically on early career physician researchers and also looked at the time spent on both professional work and domestic work. And in general they found out of about 1000 respondents who are all academic physicians. There was a mean age of about 40 90% were married and 80% plus had children. They found that, again, women were more likely than men to have spouses or domestic partners who were employed full time. And then women. So this is looking specifically at individuals who were married or partnered and had children had children women spent eight and a half more hours per week on domestic activities. And that included after adjusting for other factors such as work hours spousal employment and other considerations within the home structure. In addition, I think importantly the study looked at a subgroup analysis of individuals who had spouses or partners that both worked full time, and in that subgroup. When there were situations where the usual childcare arrangement was disrupted, women were significantly more likely to take time off as compared to men in that setting. You know, I, I think pretty significant data both many years ago and in the early studies and also today, or more recently that suggests that women take on the disproportionate amount of responsibilities within the home, and have a total number of hours that are significantly greater and so take on kind of the burden of those domestic responsibilities in the setting of caregiving for children. I think thinking, you know, about this work family conflict that occurs, you know, these responsibilities create conflict, a kind of that that balance between work and family. And for some that does mean transitioning away from working full time or leaving the field all together. And so this is a study that focused on early career physicians across all specialties so they actually enrolled individuals, during their current year at the University of Michigan, and then followed them for several years after training. And they hear this, these results focus specifically simply on whether they were individuals worked full time or not in the current years after completing in the years after completing residency training. So on this table here you can see the number of years that have passed since they finished training so at one year. As far out as six years, and you know the respondents here what about 50% female, the median age was 35, and the median years post residency training was 3.2 years. Overall, women were more likely to report that they were no longer working full time, starting as early as one year after completing training and growing exponentially with each year. So you can see here, even at the first year out of training women were two times more likely to report that they were no longer working full time. At six years out they were 27 more times more likely to report that they were no longer working full time. In fact, at the six year mark, three quarters of women reported that they either had already reduced work hours or considering reducing work hours. So this gap that emerges really early in a person's career is, you know, is, is impactful and that it really sets the foundation individuals who leave. It becomes increasingly hard to come back as you're, as, as you're gone for any period of time but particularly as you've gone for longer, because of there was requirements for regaining your, both your certification, but also your privileges. There's, there's a requirement for explanations for time away from practice, and then also sometimes even shadowing or supervised practice when you return. And so that retention piece within the workforce becomes really important, but also this type of these types of differences early in a career really set the foundation for differences that arise over time. So, beyond, you know, beyond just the number of hours and an overall remaining in the workforce, it's important to think about what are the impacts of caregiving on individuals who do stay in the workforce and this study focused on physician mothers, and compared physician mothers who had additional responsibilities versus versus those who did not. So, looking here. This is, this is a survey that was done. And so this is all respondents and that breaks down to individuals who were simply physician mothers, and then individuals who were physician mothers with other caretaking responsibilities right so also so likely in the sandwich generation caring for a neighbor or caring for a neighbor others. So you can see even for physician mothers alone without additional care taking responsibilities. There were significant impacts both in terms of behavioral health, such as, you know, a third were likely to have a mood or anxiety disorder, or even have risky behaviors such as drinking or substance abuse. These numbers, particularly from the standpoint of depression and anxiety were even higher for those who had additional responsibilities. And then beyond the behavioral health, thinking about impacts on an individual's career. Nearly one in 10 individuals had career dissatisfaction and large proportions, 40% of individuals physician mothers reported currently being burnt out and this was a survey that was done well before the coven 19 pandemic. You know, and we're not been linked with many negative effects, both in terms of patient outcomes, academic productivity, and also impacts on children and their development. And so really, kind of foundational in terms of the, the other effects that can occur. There are many other outcomes that haven't been specifically described in the literature. Oftentimes because they are invisible, they're hidden. Many individuals sit with these or experience them. You know, in the rush of the day to day. Or oftentimes there's challenges with linking physician workforce data with patient outcomes data and so have kind of precluded that piece of it. I think importantly, you know, when we think about these impacts, there's both short term impacts and long term impacts and we're at a, we're at a point where we've reached equity in terms of the, who's entering medical school and who's graduating from medical school, and yet the data very clearly shows that women do not advance and academic medicine, and not because they're not talented, not because they're not capable of it. But because there's multiple barriers along the way, and the disproportionate caregiving responsibilities are one piece of that. You know, and those responsibilities perpetuate the gender gap and then equities and promotion and advancement and leadership and ultimately in compensation. And so I want to, I want to briefly touch base on coven. I think to step back for a moment outside of the physician workforce. The pandemic overall resulted in an increase of informal caregiving, I think not surprising to any of us. 51% of new informal caregivers reported that it was a result directly of the pandemic. There could have been done in this area show significant burdens as a result in terms of mental health from stress and worry, fear of infection, but also brought on by the pandemic and isolation a lack of respite care or other avenues to support child care or elder care or care for elderly. And the caregiving also increased during the pandemic. There was a longitudinal study that was done part of that continuation of that interns health study that I mentioned earlier that looked at two time points. August of 2018 before the pandemic in August of 2020 during the pandemic. And this graph here shows kind of the work family experience that occurred as a result of the pandemic. I surveyed 215 physician parents about half of whom were female with a mean age of 40. And they found that women were more likely to be responsible for child care and schooling. They were more likely to be responsible for household tasks. They were more likely to work primarily from home, reduce their work hours, have greater work family conflict and experience depressive symptoms and anxiety. So, I think, importantly, from the perspective of of thinking about dual employed households, those individuals who were physicians working full time, and also had a full time physician partner. There were greater gender differences in the household responsibilities and childcare overall. And so again, signs that even in environments where there's two physicians in a household together that the women physicians face the disproportionate effects. I think another interesting results of this finding that isn't depicted here is that they actually before the pandemic there was no difference in depressive symptoms among men and women. And as a result of the pandemic in August 2020, they actually showed that women were more likely to be depressed or have depressive symptoms than than men. And so, again, just thinking about that those significant tolls and significant burdens and the impacts of them. There's been growing research into the effects of the COVID pandemic on women. There was a report from the National Academies of Sciences, Engineering and Medicine that that focused on what the impact of COVID-19 would be on the careers of women in academic medicine. And here they surveyed women faculty back in 2020, about six months into the pandemic and found that, you know, nearly a third, nearly 75% of women faculty with children reported negative effects. And that 90% of the women were handling the majority of school and childcare related demands. And I think notably only 9% of these individuals shared that they shared these demands equally with their spouse. And at that time only 3% had helped from a sitter, a nanny or a tutor. I do want to highlight silver linings of the pandemic because it helps me stay positive about the last few years and so 13% of women faculty did mention positive effects of the pandemic on family life like more time together. And I do want to highlight ease in managing work family demands, and even things like not having to get dressed for work. So, I do want to share for a minute here, a survey that we did here at the University of Chicago with funding from the BSD pilot awards that focused on early career investigators. We focus specifically on early career researchers because they're really at a key time in their training and in their careers. And they're also really important to the scientific advancement that's going to happen in our nation right there the folks that are going to bring new ideas and new skills. However, these early career years often overlap with prime family responsibilities both family building child rearing, and there's important considerations that lead to vulnerability and attrition. We did a cross sectional study in 2021 that evaluated both the professional and the personal effects of the pandemic on early career researchers. This was a survey that was sent out to all K awardees nationally. We had about 1500 faculty reply to the survey. And as you can see here. Over half 58% had caretaking responsibilities for children and one in 10 reported caretaking responsibilities for their parents during this time. We asked about the personal effects of the pandemic on early career investigators and found that women disproportionately reported negative effects related to caretaking and mental health. This is very much consistent with the prior literature that I've shared. But you can see here that women were more likely to report negative effects in terms of personal mental health supports within the home childcare responsibilities and elder care responsibilities from a professional impact standpoint. Women also disproportionately reported negative effects on a variety of career measures related to productivity and to output. So women were significantly more likely to meant more likely than meant to report that their overall research productivity was negatively affected. The research productivity for the K award was negatively affected, which is critical for getting the next step of funding, as well as significant differences in terms of manuscripts. Interestingly, we also collected data about grants submitted and grants received, and there was no difference between women and men and that was thought largely to be as a result of where the where the, the participants are in their level of training and that they're really not focused on getting that next large big grant as a whole group of K awardees while some might be that that's not. The entire group. Interestingly and not depicted here we also asked about negative effects from the cancellation of conferences. And that is one area where men were more likely to report negative effects as compared to women. And I think largely because of the networking that occurs at those conferences, and potentially, you know the participation of individuals and conferences before the pandemic. So this survey also had a set of open ended questions and I think some of these are really interesting to highlight, because I think the words of our participants are even more powerful than the words that I can use to capture them. Many recurring themes arose around personal well being and family balancing that with research and its effects on working work advancement or professional advancement. Many pointed out the childcare was a huge challenge that the lack of access to safe and reliable childcare that was associated with remote learning quarantines and even changes in the family routine. And also described challenges with visiting and caring for aging and vulnerable parents. The quotes here highlight that early career researchers had to balance just an overwhelming amount of demands in both their emerging careers and their personal lives, and that these impacts were deeply tied we really can't just fix one or the other. There are multiple interrelated effects. You know, and given the strain of the pandemic, it shows that early career researchers really are a group that need additional support. And it's really important to make sure that we can continue the scientific advancement in our country and ensure that their success. How exactly can we support physician caregivers right we've talked about who they are. We've talked about the inequities there. We've talked about how cove is just made a worse. And so what exactly can we do and before we say what we can do I want to talk about the imperative to do. Physicians and and all individuals must take care of themselves so that they can take care of others right and if our expectation in the in healthcare is for physicians to take care of patients. We as individuals and those institutions must take care of those individuals who are taking care of our patients if we want to meet. You know that aim of healthcare. There's an imperative to act because these disparities persist, and they will worsen. If we don't, you know, frankly, though, the data currently suggest they'll take about 50 years to reach equity. And, and, you know, that that was potentially worsened in the setting of the pandemic. I think if you're driven economically. I think there's also a financial imperative to act, both in terms of the retention of women in the workforce and the cost of replacing individuals. But I think also an imperative for for from the financial perspective of individuals medical school graduates finish training with about $250,000 in debt. And so there's a there's an incredible burden on individuals. And if we're not supporting them and remaining in the workforce and they leave the workforce they're still facing that debt that debt doesn't magically go away. So let's dive first into what currently exists to support physicians who are caregivers and I think when when this question comes up, most people are like oh yeah there's there's leave there's parental leave right like that's kind of the default answer and so that's among the most common structures we have so to start what is parental leave look like across health systems and academic medical centers across the country. And I will say just to summarize, there's a lot of variation. So there's been two great studies done in the past five years that focused on leave policies for faculty that looked at top ranked schools across our country. I will share that these are. This is the data for medical schools and ranks by US News or World Report I will not get into that whole discussion right now. And I will just share that this is the case for faculty and that the leave policies for trainees for staff are often significantly lower or worse and with more variation than they are for faculty. So I think, first to site here, this study that looked at these at the 90 medical top top 90 medical schools as ranked by in our country. In terms of, you know, most policies break this down by parental status and so a quarter of institutions had no paid leave at all they indicated that individuals could use their vacation time their sick time or the short term disability time. The remainder provided some paid leave, and about 15% provided full pay for at least 12 weeks which is the case here at University of Chicago, the median duration of paid leave was four weeks. For non birth parents, over 40% had no paid leave. And you can see the breakdown about 40% had one to 11 weeks. 12% had 12 weeks or more, which is currently the case at University of Chicago. Similarly for adoptive parents 40% of institutions had no paid leave and similar rates had less than 12 weeks and about one, one and nine had 12 weeks of paid leave. And then for foster care 31% of the policies didn't even mention foster care. And the majority had no paid leave, while a small proportion allowed 12 weeks of leave. Notably, you know, there are national guidelines for recommendations for for leave that are put out both by the American Academy of Pediatrics and the American College of Obstetrics and gynecology, the talk about the benefits of paid leave both for the child and for the parents and parents. And so these these as a whole are significantly lower than those recommendations and we know significantly lower than many countries internationally. I will also add that that this on paper is what is cited as the policy and I think it's important to recognize that the implementation of policies can often differ from what's actually put on paper. So I'll tell you a story of a colleague who was a dual physician couple who happened to work at the same institution, and they were essentially told by their institution that they could not take leave at the same exact time. Even at the time of the birth of the child that the leaves could not overlap in any way. And so I think it's important to recognize that while something might exist on paper. It's really impractical for not to have both parents, if they are, if there are two parents at a birth and so I think really important to think not just what's on paper but also what's implemented by different individuals both leadership administrative support human resources and beyond. Thinking beyond, you know, family leave at an institutional level, and parental leave specific thinking beyond parental leave, I think thinking about family and medical leaves. And nationally there's guidance from the family and medical leave act locally leaves very significantly by state by county and by city. You can see here this map from the Kaiser Family Foundation that shows, you know how few states actually have paid family and medical leave enacted. And how one state has simply paid medical leave enacted. And there's quite a bit of variation in terms of what actually individuals can use and I think often limited information available without digging quite a bit into finding that information. Also recognizing, you know, it's sometimes it's not simply, you know, a longer leave but it's it's sick leave. It's either for sick days or for a small number of days. And you can see here there are a few more states that have paid sick leave laws, and that there's also some cities and counties including in Chicago, here with with such laws. And to consider that some of these sick leave laws are acknowledged only the individual versus sometimes they acknowledge additional children or elderly individuals that the individual might be caring for. So going beyond leaves I want to talk about a few topics. Because, you know, the reality is clearly caregiving doesn't just exist in chunks of time, but that it's really something that that is there 24 seven, you know, for throughout much of a lifespan. So first to talk about lactation studies show that about a third of physicians meet their personal breastfeeding goals, and half would have breastfed longer if they were able to, or if it was possible. There are many workforce and workplace challenges cited including inaccurate time in flexibility with schedules and insufficient space. And these peripartum concerns are often opportunities for supporting and retaining and recruiting women faculty. I want to highlight some of the policies at University of Chicago, you know that while exist and meet national laws, you know are quite vague. This this policy is very similar to policies that exist across many institutions. And so making a really challenging to implement. You can also see here, you know various kind of maps and resources that exist, including Mama Vapods that support, you know, lactation. But also important to think about how large of a campus we have and where are the spaces for it and then also how is it enabled throughout the day, everything from during rounds during surgical cases. During busy clinics, you know how is it made possible. I think, in addition to that, even just recognizing things like lactation support services, while seemingly not profitable are incredibly important from an institutional standpoint, and currently here at University of Chicago don't exist in an outpatient process. And so, there are ongoing efforts between the women's committees in the departments of surgery medicine and pediatrics, working with the fact to really advocate for demonstrated support for women who are laxating, both in terms of the resources necessary, but as well as modification of duties and appropriate, appropriate adjustments in productivity and compensation as a result. So let's first, let's next talk about childcare. There are nationally very few places, very few academic institutions or health systems have childcare present on campus, University of Chicago is unique in that about 10 years ago they invested into childcare centers that I know my kids have been lucky to benefit from and I know many of our faculty here have been. The broadest investment is incredible I think it's important to acknowledge that daycare centers are necessary and not sufficient. Some individuals choose in home childcare, and the workforce for paid caregiving, often tends to be focused on women and it's important to think about what support is being provided in that regard because it can be incredibly challenging to find and retain long term childcare, particularly in the setting of long and unpredictable hours that physicians have, including weekends. And also beyond the day to day care. It's important to consider school days off sick days, and even caregiver leaves. Because oftentimes these are expected and unpredictable. I recently was talking to a neighbor of mine and just set us simply how are you. And he responded to me, we're built on sand and I kind of looks at him like what do you mean. I'm referring to an ongoing challenge that they had with the childcare arrangement they had a nanny. They had one of their kids and daycare right and I will acknowledge lots of privilege. But really depending on what foundation you have and what happens, it can really just simply take a gust of wind, or a large tide to blow away kind of the foundation. He and his spouse were both employed full time, including one of them as a physician, and they had two young children and their nanny was facing a family illness. And in that setting, their typical childcare arrangement was abruptly, you know, pulled out from under them. And they were scrapping together backup childcare and recognizing that could get pulled out in any moment. And so even with a lot of privilege and in hand. They had a bit of uncertainty about childcare. Here you can see a text thread among myself and other colleagues, where, you know, it's, it was one of these times where somebody had something pulled out from under them their, their child was sick and there was, you know, kind of a mad dash of like, who can support you guys handle this and what can I do and in this case there was actually a medical student who was willing to babysit as many of our medical students have in the past. You know, and, but then there was went on to this discussion about how do you balance childcare and these abrupt situations and how, you know, how individuals kind of mark, you know, you're the backup person in this case you're the backup person in this case and I will tell you from that person that joked we play rock paper scissors in our house. You know, because sometimes that's what it feels like honestly. You know, and we've had many of these even just last week the GI bug hit our house and it was like 1230 there's a kid puking in the bathroom and we are looking each other like, who's got the schedule, you know that that can accommodate staying home with them tomorrow. And I think to acknowledge, you know, that's the reality that plays out in many homes, you know, and we've got a GI bug. We've got strap going around right now like all of these childhood illnesses that are seemingly minor have still really significant effects on their care on the caregivers of these children, but also significant on the workforce and the ability to deliver medical care as intended and even economically. We talked about the effects of caregiving on mental health and I want to take a minute to acknowledge that there's wide variation in the mental health services that are available across institutions. Many institutions have employee assistance programs. Often these are very site specific and differ quite a bit. And in addition, these employee assistance programs can sometimes support childcare and elder care needs or help identify needs but those can also differ very much based on what's happening locally related to the childcare and elder care workforce. I think it's also important to acknowledge that sometimes these services are available institution within institutions but not well advertised or only available to certain groups, or certain ranks of individuals and so thinking about how are we supporting individuals across the lifespan recognizing that individuals at all stages will be caregivers. And so beyond kind of the leaves, you know, in academic institutions a key part of what's expected and what's necessary for promotion and advancement is even things like conference participation and training to network to present. And these things are important and at the same time often require individuals to be away from home, which can be nearly impossible for individuals who have childcare and elder care responsibilities. Professional organizations have come together and actually put together recommendations in terms of what conferences can do. So providing things like childcare, accommodating families and making it possible for families or family members to attend the conference, sharing resources within the local environment where the where the conference is being held, and also helping establish social networks between individuals to think about how to pull together care. Here's an example at a professional organizational level institutions can also provide similar support for dependent care and here at University of Chicago. There is a professional development travel grant that used to only be offered to assistant professors and now has been broadly offered to individuals at all levels that provide support of up to $1000 for childcare or elder care responsibilities in the setting of a faculty member attending a conference and so really a great tool. It's not commonly present across institutions, but a really important way that institutions can support care. And then I, you know, kind of thinking beyond just the individual conference piece. There are, you know, some really unique programs that have come about in the last 10 years. So, Doris Duke, the Doris Duke charitable foundation led some work to create a fund to retain clinical scientists, and their goal was focused specifically on early career researchers, and to support those who were facing family caregiving responsibilities and help support productivity during that time. This fund is is met was meant by the foundation to serve as a small amount of funds for the researcher to use to support not their childcare or their elder care, but support the advancement of the research. I'm thinking about supporting additional effort of the individual so that they have of the faculty members so that they can more broadly do their, you know, commit more time to their research during those vulnerable times, or to fund what they call extra hands. So a coordinator a data analyst a writer, a research assistant that can help do some of the recruitment the data collection the pipetting the animal management etc. But can be really challenging particularly on a day when a child is sick or at if that data collection has to occur in the evenings and things like that. The outcomes to date have shown that pretty small investments by an institution can have a really large return of investment for them. So the doors to foundation in a second iteration of the program actually came together, recognizing the impact of the pandemic on early career researchers came together with multiple other foundations, including the Walter foundation to fund a coven 19 fund to retain scientists and we here at the University of Chicago, we're fortunate to receive one of these grants for the secured program with Dr Olapati and Dr Aurora, and have been able to fund 10 junior faculty researchers to date to provide, most often, you know, extra which is the case that it really has been nationally. Is that about 90% of these funds are used for extra hands so each of these individuals receives, depending on how long they're funded for about $30 to $50,000 to use for over one to two years to support additional staff, or their time to move their research forward. In the process of working with these individuals. We've been, we've had the chance to chat with them about what have you know their experience has been their barriers to challenges what they would like to see, which has been really insightful in terms of thinking about right there's these supports in place and, and how do these supports play out and how have you been impacted. And there's been some, you know, these are just a few of kind of the powerful messages that have been shared. And some other insights I will pull into my recommendations kind of coming forward. No highlighting both the benefits of the pandemic and that they've seen but also challenges that they've encountered in their own environments or with the support that's available. So fixing the system. You know, I think there's, there's quite a few what I've what I've highlighted for you is a variety of, you know, supports that do exist. And then the question becomes like, well that's great isn't that enough. And the reality is it's not. It's not systemic, and they often lack full implementation. I think at the same time caregiving continues to be stigmatized and so there are many opportunities to improve the system. I think we need to recognize that the system was not designed for a workforce that had a significant percentage of individuals who provide caregiving, and that you know we really need to move beyond what has been done in the past people to stop being caregivers. And hopefully over time people there will be more equity in caregiving, but we really need to remove the stigma that exists with with it. There is individuals and groups have shared ideas have had to create more family and caregiver friendly workplaces. I'm going to kind of leverage some of these suggestions and add my recommendations, really using the sociological model to think about it. So how do we fix the system and how do we create that solid foundation that people can stand on so that the wind and the tide doesn't blow them away. So I want to start first at the institutional level in our workplaces. One of the main, you know reasons that that women leave academics. You know, comes from the perception that institutions are not supportive of caregiving of maintaining a family. Promoting that caregiving friendly workforces and workplace is important. I think traditionally institutions have used the one size fits all system. This, you know works here this will work here. We really need to move beyond that because each organization and even each department has different needs for their faculty and their staff which influences experiences. And then using that to both develop adopt and implement policy is important, but we can't stop there we need to evaluate what is that policy doing assess its benefits, but also it's unintended consequences, and then use that information to refine the policy. For example, at Harvard, at one point they enacted a policy that indicated that fathers can take the same amount of leave as mothers after the birth of a child. What's really good to happen that over that time is that it essentially became a leave where faculty members male faculty members wrote books, and so it was essentially perceived to be like, this is when you go and you write a book. Right and so we've created a culture and where there is there's an institutional policy that says you get a you know you get 12 weeks leave. But even within that policy we've created a culture where within a smaller group, there is an expectation that you're using that time away from teaching a class or away from clinical work to be academically productive right and so recognizing these unintended consequences happen and we need to understand those and refine those refine the policies that exist. It's also important to create transparency and clear processes individuals should know about how to do something when to do something what's expected of them, because that can really ease the work the time that's required for something and also streamline the processes that are required. Data suggests that work control is closely linked to career satisfaction and so enabling flexibility can help support that control within the workforce that control within the work environment so everything from the starter and times of a clinic, or enabling opportunities for telehealth or the use of telehealth can be really helpful, even things like, you know, creating more than one time of a meeting. So that individuals can, you know, if you want to create a meeting that has to have, you know, at 7am, make sure that that meeting is also available at 4pm, so that individuals can attend when it's it's convenient for them and acknowledging that 7am is probably not a time when many caregivers can attend. What's also important in an institutional level is that we really need to leave like the medieval times in terms of considerations about, you know, promotion, tenure timelines, and even expectations for call and RV use. It's unreasonable to expect people to squeeze their call into a smaller amount of time or to just add on an additional clinic visit. So, we really should be thinking about how do we adjust the call expectations are there are view expectations for leave and lactation to ensure equity in terms of the service load and really demonstrating a longer investment. I think also, you know, we have very traditional promotion and tenure timelines, but it is a faculty member any less talented if it takes them nine years to do something rather than eight or 10 years to do something rather than eight. And I think that's a tougher reflection because I think that is a larger point for discussion. Thinking beyond our institution it's important that we think about communities and in this case, both local communities, thinking about building robust childcare and older care programs and workforces in the communities, because that can really elevate everybody right it can elevate our staff our trainees and our physicians. We're thinking about creating clear linkages to services that are available. And if we know that, you know, family caregivers often go forth and need to find financial advisors or need to develop wills and living trusts. You know, having those types of resources readily available, having resources available beyond mental health supports within our employee assistance program. And those services can be more readily accessed by individuals, particularly those who are, you know, whose, whose time is limited and whose needs are high. I think also thinking beyond our local community and professional organizations and even, you know, National Institutes of Health, National NSF the National Science Foundation. And how those groups can facilitate participation and attendance and in person meetings. And, and funding that can support that that challenging time that individuals can experience with caregiving. And then also I would say at the national level, the policies and the laws that we adopted the national and the state level. We also have direct influences on our experiences, day to day. And so we need to promote more equity both within the healthcare and in the workforce but also societally. We can leverage our position as institutions and as physicians to recognize those broader implications of caregivers, and can advocate both for informal caregivers and paid caregivers. It's important to recognize that this this work doesn't just occur in one place but really must occur across all the levels. And that there's much that we know from our clinical and our research settings. So using concepts like user centered design, you know what would an individual who has a child. How can we set up a system that's designed to support them as opposed to, you know, here's what I think they might need. Also using concepts from quality improvement to iteratively continue to improve the aspects available and then implementation science to think about not just policies but the unintended effects of policies. I think it's important that you know we not just do things and pat ourselves on the back but we continue to elevate the work that's done. So to wrap up I hope you walk away with understanding that informal or family caregiving is common. I think even having grace for those around you asking them about it supporting them in it is an important part of what we can each as individuals do every day. Family caregiving has largely negative effects on both physical and mental health as well as career outcomes and hence the imperative for systems needed to treat family caregiving as a norm rather than an exception. Action at various levels can help support physicians who are caregivers and it's important for us not to just be idle and not just to be satisfied with what already exists but to really continue to elevate that to support equity in the physician workforce. Thank you. I have a number of excellent questions in the chat and we'll probably answer those then stop and ask the ethics fellows to come forward so I'm one of some that need to lay tear upon who's done work in this area and it's just also on our back are and basically highlighting that the community has been pretty supportive of the lactation culture and the fact is continue to advocate for that. So even if she was talking also responding to your letter of the law versus like the culture and working on both of those things. My next question is from Arlene Ruiz Deloringa and she in dermatology and if you enjoy part of your caregiving role and know for example that there is a short time where your kids are young. When your partners are still alive how can it be reconciled with the timing and road for advancement and promotion, where a slower path, where a slower path may be acceptable. That's a great question I think it gets back to this piece that we have these very like archaic promotion and tenure timelines you must, you must have done this and we have to stop the clock. You know and I think most of us don't walk around feeling that there's a ticking clock, although you know sometimes that is inspired in us. But we don't want to feel that because we want to be able to enjoy the time with our children or with our parents or things like that. And so I do think it really falls on, you know, at kind of the highest levels for universities and academic institutions to think about how have they set up promotion and tenure timelines. And what does that mean for someone who it takes a different pathway because again is is four years versus six years versus eight years versus 10 years. Really a big difference if they've accomplished the metrics. You know, I've, I've heard individuals tell me they don't want to go part time because they won't get promoted and, you know, etc. And so I think these decisions that are made about what what the requirements are for promotion and what the number minimum number of years are or minimum number of years, or you're out. I think can be really limiting for those of us who may want to enjoy that time and return to a more full time schedule down the road. And then Dr Miller asked basically other other countries that we could model after and that we should really adopt their policies. So I start with that could be another hour long talk. I think there's a lot of work internationally that you know better accounts for it. I think a large part and I think the part that's probably best known is just parental leave policies. You know there's many countries that are that allow six months or even a year of really, you know, there's no RVU requirement or productivity or things like that. You know, and so I think there's many, there's many things beyond that and the nitty gradient and I will acknowledge right like our system is not an international system. And so we do have to think about how is it practical, or how it can be adopted but I think even thinking about national policies that can even start to align with some of those things can be a step in the right direction. Yeah, I just really wanted to chime in to say, as a academic grandmother for Anna, because I'm the academic mother for me. This was one of the best things that happened during the pandemic to apply for a Doris Duke clinical scientist award, and for the women who are in this room. And for those who are outside. I think we have to be the change in the system. Right, because otherwise the system is not going to change. And since we're doing this in women's women's month. Since gender equity is really important for global health for health and wellness of society. I really want to say a big shout out for Anna, because it was really a tough time. And I also know that Francis Collins NIH, every funder is trying to make sure that we have gender equity in our health system, especially in academic health because we need more women leaders not less of them. So whether you talk about gender equity racial equity, what you just said is, is really important, we have to change the systems to support women in the workforce because that's the reality. And as we were thinking about encouraging men to be better partners to women, we also said we will fund men, as long as they are providing caregiving and they are caregivers. So I really appreciated your definition of caregiving because we have to be in this together in solidarity together. And thank you for organizing this and there's a lot of work we have to do, but we're going to stay in this institution to fix it, because we can't let the future women who are coming to America school down. So thank you, Anna. All right, so with that we will stop the recording and then ask our fellows to come down to the front and have the informal discussion with Dr. Rollerman. And then thanks to everybody else who came and participated.