 It's just easier to record now than at the introduction. Exactly. So I'll just give it, I'll just give it a minute or so for those of you who are joining, I'll introduce Dr. Marshall and then we'll get started at the talk, so let me give it just a minute or so. Okay, so I'm going to go ahead and introduce Dr. Marshall, welcome to the McLean Gender Equity and Ethics lecture series. We're now in the seventh out of 10 of the fall speakers, and we've really been inspired by a wonderful speaker, so we're looking forward to a great talk today. As I'll also say at the end, we're going to take a break for Thanksgiving next week, and then back starting in early December, we will have three more talks. The first two on November 30th and December the 7th will be back in person. With Dr. Cortina from University of Michigan talking about sexual harassment on November 30th, and then followed by Dr. Julie Silver on Wednesday, December 7th, that will be back in person, back in P117 with the hybrid option, and really looking forward to continuing this on with 18 more talks in 2023. So without further ado, let me introduce our speaker today. I'm looking forward to hearing from Dr. Ariela Marshall. She's a hematologist specializing in disorders of thrombosis and hemostasis in women. She's a graduate of Harvard Medical School and completed her residency in internal medicine at the University of Pennsylvania, followed by a fellowship in hematology oncology at Dana-Farber Institute at Mass General Hospital. She worked at Mayo Clinic in Rochester, Minnesota from 2015 to 2021, and recently joined the faculty at University of Pennsylvania in Philadelphia where she is director of the women's thrombosis and hemostasis program. Dr. Marshall is a medical educator with a focus on career development, leadership and mentorship, and serves as the associate program director for the benign hematology fellowship at the University of Pennsylvania. She has particular interest in gender equity in medicine and leads several research projects and advocacy initiatives to advance efforts in fertility awareness, parental health and gender equity for women in medicine nationwide. In addition to her career, Dr. Marshall also places great importance on her family, including her husband and son, and enjoys traveling, dance, and foodie culture. Looking forward to hearing from you, Dr. Marshall. Thank you so much. I'm honored to have the opportunity to speak with everyone here. Thank you for the kind of invitation. So I'll just pull up my slides. Hopefully everyone can see them okay. Let's switch to presentation mode here. Is that working for everyone? Perfect. I think we see the presentation mode, so I don't know. The presentation mode. Let me see if I can switch that out. How about that? Perfect. Great. So your CME code is right here. I'll give that a second. All right. So I wanted to spend the talk today discussing a topic of motherhood in medicine. Here are my disclosures. So in terms of objectives, we'll talk about the challenges of being a physician parent. And I do want to put out just to start that this talk is really not meant to be motherhood is hard, fatherhood is easy, nothing like that. I do think that a lot of the literature we actually have is on physician mothers. There's not a lot of literature on physician fathers. And so my message is not that all these challenges are really restricted to being a physician mother. It's just that that's what we have in the literature, and that's of course my personal experience, but it's not at all to say that physician fathers have no challenges. We'll talk about how development and all development and discuss a framework for possible interventions with a focus on what can be systemic versus focusing on the individual. So we'll start with a case. And then we'll talk about those challenges and consequences and talk about some potential solutions. So like any good medical talk, we'll start with the case presentation. So we have a 37 year old woman. She's G1 recently underwent IVF with a frozen embryo transfer male embryo with normal pre-implantation genetics greening. Antipartum course was relatively uncomplicated, just some glucose intolerance. Delivery was at 39 weeks and three days. There's a plan for induction, which led to a semi-urgent C-section for failed induction of labor and non-resuring fetal heart tracings. And then three days after delivery, she presents with three plus bilateral pitting lower extremity edema to the thigh, a blood pressure of 140 over 100 with a baseline of 90s over 60s. Initial labs show creatinine of 1.88. That's as opposed to hospital discharge from the C-section where the creatinine was normal at 0.64. And over the course of the hospital stay, you can see that for about five days, the creatinine continues to rise to 2.37, ultimately peaks and declines. Hospital discharge is on the 11th and creatinine is back down near baseline as of the 14th. There's a mild transaminitis, an acute reduction in albumin and an elevated 24-hour urine protein. So on first admission, the diagnosis of preeclampsia with severe features is made based on the creatinine. Patient was put on a magnesium drip. Hypertension is treated with nephetapine as needed, hydrolysine. And she switched to oral amlodipine for discharge. One month after discharge, the creatinine is normalized. The protein area has resolved. Amlodipine is able to come up within three months. And our new baseline blood pressure is within the normal range, although higher than that 90s over 60 is pre-pregnancy. There is persistent glucose intolerance and a diagnosis of pre-diabetes. So why did I present this case? Some of you may have realized that this is me. This is my case. This is me at delivery with my husband and my son, Ravon. This is how I looked at home the day I went back into the hospital. So not good, essentially. And happily, here's where we are now. So things turned out for the best. But this is something that is very personal for me, obviously. And I think kind of illustrates the physical consequences of what we as physician and mothers are at risk of. And we'll talk more about the psychological consequences. So I can't show those. I can't give you numbers to say this is what's happening to me psychologically as I'm going through this process. But some of the things, I was sitting in my hospital room on a magnesium drip. I don't know if anyone in the audience has ever been on a magnesium drip, but it makes you extremely loopy. But because of the way we are bred as physicians, I felt I'm spending 24 hours a day in this hospital. I don't really have much to do or much to show for it. Maybe I'll just get on my Zoom and attend these meetings that are still on my calendar. So that's what I did. I sat in my hospital room in the bed on a mag drip and was attending Zoom meetings because I felt that I should still be contributing because I had nothing else to do. We were out in Minnesota and both my husband and myself are from the East Coast. We were hundreds of miles from family support and just felt very isolated. After I went home from the hospital and was recovering a few weeks later, a big leadership opportunity came up for me. And as I talked to my mentors, one of them actually asked me, you're a new mother. Are you sure you want to take on a big leadership position right now? And then, of course, the things that are very familiar to any physician, parents in the audience, stress of finding child care. I made a decision to give up a lot of my committee roles because all of these meetings occurred at night and that's the only time as if it's any really have to spend time with your family and your child. So I made that personal choice because of that and because of the fact that I did want to spend time with my family. I did have a sharp decline in academic productivity. And that's just pretty much a given consequence if you make the type of choices I make. And so these are things that can't be encapsulated in a graph or a number, but are very real consequences. So these challenges, let's take a look at the literature and what it says. So the first challenge is even becoming a mother. I see Dr. Aurora is on the call here and we've written about this, but we know that infertility affects up to one in four female physicians. That's about double what we see in the general population. That's one in eight factors that contribute to this. Definitely time and training and delayed childbearing. Also, some of this has been attributed to the stressful nature of our jobs. The schedules often overnight shift work has been associated with infertility risk. Treatments are available, but these treatments require a significant amount of time and financial resources that are not available to everyone. And also, I would say a lot of emotional investment that is very real and very stressful and can have a big impact on us personally, but also on our career development. Leadership, so the people that are making the decisions about our clinic schedules, about our research time, and this includes female leaders. They may be unaware of how the process works. So when I was going through my fertility treatments, my chair, who is a very sweet woman, but had not been through or learned about what fertility treatment entails. When I said, I may need a little bit of time off for egg retrievals or for egg implantation. So that's okay, just let us know a couple of weeks ahead of time so we can make plans. And that's just not possible when you're going through this process. You're let know the day beforehand when you need to take a day off. It's unpredictable. There's a huge emotional toll. I remember the first transfer we had, it didn't take so essentially, this was an embryo transfer that did not lead to a pregnancy. And I'm sitting in my office crying and I'm about to go round on inpatient service. And it just feels very kind of isolating in a profession where we're expected to continue to go about our jobs as if nothing's going on otherwise. And infertility is not one size fits all. So some delay childbearing as I did during training and early career. So at that point, if you're starting fertility treatments in your mid to late 30s, it can be challenging to have even one child. And I feel very lucky that throughout all of this, we actually did have a healthy pregnancy and my son is healthy now because that doesn't work for everyone. There's a lot of complications associated with pregnancy that we'll talk about in more detail. Multiple miscarriages, late-term losses and some may need assistance with the gestational carrier. We also don't talk or have literature about male infertility in physicians. So we know that a good percentage of fertility issues in the general population are due to male factor infertility, but we don't have that literature in physician populations itself. So it's possible that rates of infertility that we quote for females as being twice as high as the general population, we don't know what that looks like in the male physician population, but maybe having a role as well. Infertility can be an issue later on as well. So some people say, oh, you had to help us pregnancy. What's the issue? It's not the case that if one pregnancy went well, a second pregnancy always will. And also not everyone has a traditional kind of defined as male, female family. So there are lots of couples or individuals that want to have children that may need fertility assistance. And we also know that pregnancy does not equal birth. We know that physicians have higher rates of elective termination in some studies compared to the general population. And this seems to be specifically in female residents. So they're three times more likely than partners of male residents to electively terminate in the highest rates are among surgeons. There's about an 11 to 12 percent rate of abortion among physicians and trainees. And those who report having abortions are more likely to have delayed childbearing for training related purposes. And those who report abortion are more likely to have a physician partner. So dual physician couples carry many challenges, including trying to decide if and when to have children. This is a graph you can see on the left looking at the fertility rate kind of declining. But what I want to point out that we don't talk about enough is if you look over on the right, pretty much that decline is happening during our peak years for career development. So medical training can go from the 20s through the early to mid 30s. Even later, if someone does training in a program that has a prolonged course, such as, you know, a surgical subspecialty or somebody starts their training later on in life. And then expected early career productivity is really hitting at that, you know, mid to late 30s, early 40s. That's when you're supposed to be pumping out all the papers, doing all the grant writing. And that's right when fertility takes that huge decline. So it's something, you know, again, that you're trying to balance the risks and benefits and not having the information early enough because we don't talk about it in medical school and residency can really do people a disadvantage. So all of that said, if somebody does become pregnant, we know that complication rates are also higher in the medical profession than among the U.S. general population. So probably about a third of physician pregnancies are associated with complications. Some studies find that there are higher rates of spontaneous abortion, hypertensive disorders of pregnancy, such as preeclampsia, intrauterine growth restrictions, small for gestational age fetuses. And we know that what we do in our schedules contributes to adverse pregnancy outcomes. So these rotating shifts, night shifts, working longer hours, all associated in the physician literature, but also in the literature in general with adverse pregnancy outcomes. And postpartum depression is something I would consider a complication of pregnancy. So there's about a 25% prevalence, but the scary statistics, I think, are that only about 40% of those who reported postpartum depression. Remember, these are people who are willing to report that they have it. So there's under-reporting bias at baseline. But of those who reported having postpartum depression, only about 40% got any type of treatment. About 75% said there is something wrong, perceived for themselves, or as perceived by society, that there's something stigmatizing about having mental health issues. And people who reported that were less likely to get treatment for postpartum depression. So this is a big potential complication of pregnancy. So take a deep breath. We're not done yet. That was kind of the complications of getting pregnant and having a pregnancy. So what happens after delivery? So parental leave. I'm not going to go through every single one of the studies because they all have similar results, which basically say we as physicians don't get enough parental leave. So the recommendation by the AAP is for 12 weeks of paid leave. Studies show that the average duration of paid leave for birthing mothers, and that's combining leave for physically giving birth versus also the parental leave, is around seven to eight weeks. Many institutions don't offer any paid paternity leave. So my husband, once I delivered, was on at home with an infant alone because I was back in the hospital with these complications at work doing remote meetings because he did not get any paid paternity leave. About 75% not surprisingly feel that time for parental leave is insufficient. And the scary thing is that this research has been going on for years and years and years, and we can't point to any clear changes. Similar for breastfeeding. Multiple surveys, similar results. A lot of women report that they intended to breastfeed for a certain duration, but the actual duration that they breastfed was much less than that. And not surprisingly, again, the most common reason for that was workplace related conditions and concerns. About 50% are unable to use their breastfeeding leave rights. And we know that longer exclusive breastfeeding leads to less maternal stress and longer breastfeeding duration is a longer maternity leave and low levels of maternal depression and all these other good things that we see here, but people are not either given the time specifically or the policies that exist are not actually able to be enacted. It may seem your institutional policy that you get protected time for breastfeeding, but when it comes down to it and you say, well, I need to adjust my clinic schedule, somebody says, that's going to be real tough. But we're not sure we can help you with that. And then moving on to the portion of the talk that, again, I'm most certainly not trying to say it's all the guy's fault. We have evidence and then I have a couple of slides that are more kind of a funny picture of how things go. But again, I'm really not saying this is all the fault of the guys. Most physician mothers are partnered or married, yet most report that they have the sole or primary responsibility for the domestic task. In a couple of surveys, less than 60% of physician fathers are into income families, but almost all physician mothers are. So there are two working folks at home that could theoretically be dividing up this labor, but almost all physician moms reported that they have primary care taking responsibilities. And we know from literature that that only worse than with COVID. So the way I think about it, it's not that we're living with a bunch of people who don't want to do the work. It's that we have different ways of thinking about it. You know, our mind just works in different ways. And again, this is very personal, you know, every relationship is different. But I often find myself saying, can you do this? Well, yes, I'll get to it at some point. And then just I'm going to I'm going to give up and do it myself. So a couple of funny comments on the left. You know, you can you can read that and draw your own conclusions. And then just I personally know I do have this ongoing loop of things to get done at home. And, you know, what needs to be done for school and what needs to be done for the household. And, you know, my husband is more than happy to do any of these things if I ask him. But my mind is kind of saying, well, you know, you should just know that this work needs to be done. So this is called the mental load. And well, it's not something that is reported very well in the literature. Most mothers I've talked to, whether a physician or not report that this happens to some degree in their households. So going back to where, you know, we can see the evidence to support things. So discrimination specifically against physician mothers. And this is, you know, separate, but in addition to discrimination that women physicians face, but specifically for physician mothers. There is a lack of support during pregnancy in the postpartum period. And these challenges and work life balance are not always accepted at work. And physician mothers report that what they perceive is there's disrespect or lack of involvement in decision making about their own career path once they become a mother. And so this is a survey that was thousands of physician mothers online. And you can see here that many of them report kind of that sense of disrespect are not being included in decision making, which takes away our autonomy and really contributes to a feeling of work life imbalance and dissatisfaction, which can lead to burnout. So from personal experience, you know, what was it like kind of prechild versus what is it like post child? So on your left, what is work expected of you? OK, you're going to log into that meeting, you know, maybe from Zoom, maybe in person at 7 a.m. to start your clinic and be there to at least five. That's being generous. After that, you're going to do your notes. You're going to finish some notes. You're going to finish some emails. Maybe you're going to spend a little time with your spouse. And then maybe you're going to do some academic writing, you know, later on in the evening. But if you superimpose that and what's going on in life once you have a child in the mix, that time is no longer solely your own to focus on your work, you know, school drop off, school pick up needs to happen, dinner needs to happen, bedtime needs to happen. If you're ever going to see your significant other, it might be after, you know, the kid or kids go to bed. So you can't be two places at once. And this is where some of the hard decisions need to be made. And so what about those decisions and what about these consequences? So again, a caveat, this is mostly literature related to women physicians in general. It's not necessarily specific to physicians who are mothers. However, you know, the majority of women in medicine do have children. So I'd say that it's at least, you know, pertinent. So slower career development. We know that despite starting at the same time, women physicians are less likely to receive grant funding or publish large numbers of papers, less likely to achieve high level leadership positions like dean and department chair and less likely to become full professors than men, although there are similar professional roles and achievements. And I'm sure many of you have seen this graph before, but just this kind of leaky pipeline and sharp drop off. You know, there is gender parity in medical school matriculants. But by the time you get to those senior positions, it's less than 20 percent burnout. Several studies have reported that burnout is higher among women in medicine compared to men in medicine and also poor work life integration. So work life integration, when we study it, it's usually asked with this question, my work schedule leaves me enough time for my personal life and my family life. And women physicians are much more likely to report that they do not perceive that their schedule leaves them enough time for personal and family life. There are some nuances here that I'd like to point out as well. So we did a study of practice setting and women versus men. And there are some differences between burnout and work life integration. So practice setting appears to be some of the explanatory factor for who's reporting burnout or not. But work life integration is universally worse in women physicians compared to male physicians, regardless of practice setting. And what does all this lead to? If you're burned out, if you're not satisfied with your work life balance, you're more likely to lead the workforce. So in this study, they they did find that a significantly higher percentage of women physicians are planning on leaving the workforce and are currently practicing than men physicians. And you can just see this sharp drop off over time, which is really bothersome because this is our workforce. You know, these are the people taking care of patients now and going five, 10, 20 years into the future. And it's great to say we have equal numbers of men and women in medicine based on who's in medical school. But if you complete your residency and then leave the workforce, you know, that is certainly not going to lead to gender parity. And it's going to lead to these disparities, you know, across time in our full physician workforce. So that sounds like a lot of bad news, right? So, you know, we see burnout, we see poor for work life integration, we see lack of support, we see maternal discrimination. So what can we do about all of this? So my main message is that it's not about saying, you know, let's, you know, tell our women physicians to do X, Y and Z to, you know, advocate more for themselves and to, you know, create better work life balance by yoga retreats. It's about fixing our system to make things more hospitable for physician mothers. So I actually overheard this in a GME meeting and it was somebody saying, if our other faculty, Miss Clinic, for any reason, they need to make it up. Just, you know, that's all our view targets are set up. So if a woman misses time for breastfeeding, it's only fair that she needs time, you know, she needs to make up that time, too. So how about we fix the system to allow for miss time instead? If we're saying that as a culture, as a system that we want to give women time to breastfeed, we can't be turning around on the back end and saying, yes, we want to give you the time, but if you take the time, you're going to have to come back and make it up. Like that is not a system that actually supports breastfeeding. And this is, you know, again, just an example, you could say this about maternity leave, paternity leave, you know, support for infertility treatments, any of the above. The fixes need to be systemic. They can't be individual. So I frame this in my mind as the things that are most important to me from what I've learned is the facts, flexibility, autonomy, access to childcare, time off and sponsorship and mentorship. And I'll go through each one of these. So flexibility, if you're at an academic institution, depending on your track, there's often an upper outstructure. So from the minute you hit the ground on faculty, the clock is ticking. What's your academic productivity? How many grants do you have? How many papers are you publishing each year? That disincentivizes and almost punishes spending time with children. So women are faced with this almost impossible choice of either saying, I'm going to sacrifice my time with my children so that I can progress in my career. And hopefully, you know, I'll get the grants and I'll publish the papers. And later on, I can take that time and spend it with my family. Or if somebody says it's really important to me to spend time with my family, but I might get fired, I might get kicked out of this institution. So we need to change the structure to be able to allow for flexibility. So institutions that can temporarily stop the clock or at least float down and say there are going to be periods in your career where your productivity naturally waxes and wanes. How about this year or next year? We reduce those goals, you know, you need to have half of the amount of publications that we would generally expect. Maybe it will take you longer to go up from assistant to associate professor. And that's OK. Instead of saying the average time in this institution to be promoted to X, Y and Z is this, you know, you're not on track. It's OK to say, OK, my productivity went down. But, you know, I'm going to be OK with that because it's a choice I made. And my institution allowed me the flexibility to not essentially be kicked out because I made this choice. That's kind of the longer vision of flexibility. But there are day to day things as well. So flexibility in scheduling. So meeting time if there is a meeting time that always occurs at a certain time of day that overlaps with when somebody is spending time with their children or their family or in my mind, any time that's not during the work day, that time either needs to be switched or at least it needs to be alternated. So if there's a meeting that occurs regularly on a Tuesday at 8 p.m., maybe consider alternating that between Tuesday and 8 p.m. and, you know, Tuesday at 10 a.m. or maybe rotate the day or maybe rotate the time to a couple of different options. So you don't have to say, I unfortunately can no longer participate on this committee because of the meeting time. I've had to do that many times and several times I have asked, can we just rotate the time so I can attend 50 percent of the time? Virtual participation options are so key. How many of us have attended meetings while picking our child up from daycare or, you know, right after drop off while heading into the hospital and still not there? I think it's key. And when people say we need to get back to the in person, you know, yes, there's something to be said for having that collegiality and sitting next to a colleague. But if it comes down to the choice of either not being there at all or attending virtually, I think most of us will want the virtual option. So I really think that we always need to have that hybrid option. Being somewhere, you know, whether you're remote or not, it's better than not being there at all. So autonomy, allowing us to determine how we structure our clinical time. There's no reason that everybody's clinic template has to look the same. Or even that every individual's template has to be the same on a given day of the week. We need control over our schedule and making adjustments over time. So my current institution is actually very good at this. So when I first got here, I was asked, what do you want? You know, there's a certain number of slots you have to have. But what do you want your template to look like? And I could give a start time. And based on that, you know, I could adjust, you know, how late am I going to be there? You know, which day is going to be half day, which is going to be a full day? And then, you know, we got to a point where childcare changed. I need to start my clinic later. And so I just extended my half day by a couple of hours. You know, institutions that allow that flexibility that really is a breath of fresh air because it makes us feel like we have control. And allowing us to develop our own solutions. So can you time share with colleagues and you have part time options? The institutions that say you're either, you know, 1.0 FTE or nothing, you know, that's a very rigid, nearsighted view, you know, of somebody who has a lot to offer and could potentially be part time now, but maybe go to full time in the future. So we need to have this flexibility and reward participation in non-traditional areas if somebody chooses to do this in your non-clinical time. So by this, I'm talking about committee service and advocacy activities, you know, how many of us sit on committees and never really get anything for it. And it's our choice, you know, and it feels like this is maybe the first thing to knock off the list, you know, when you're trying to pay her down on things to make time for your family because it's unpaid and unrewarded. But if this is something you're truly passionate about, your institution should be rewarding your participation in that and making you feel like it's an important part of your job. Child care, I am probably preaching to the choir here. It's one of the biggest sources of stress for physician parents. On-site child care, I think would be amazing. It's a huge ask. I don't know a lot of institutions that offer it. Actually, my institution does offer it, but the wait list is basically two years long. So that's not going to help. So institutions, you know, I think should really make efforts to provide on-site child care. And that needs to have extended hours because not everyone works, you know, seven to five or seven to six, you know, it really needs to be, you know, kind of a six to six type of thing to accommodate, you know, schedules reasonably. Institutions can also partner with child care offices or childcare centers that are close to the hospital, you know, maybe offer an employee discount. But this is something that is really, really important and under looked at. Coverage for backup care is really important as well. So if an institution doesn't have the facilities to provide child care, at least it can say we'll cover you for up to 10 days, you know, 15 days of backup child care. Currently, my institution will basically pay throughcare.com to provide backup care if you're in a pinch. Time off, prevent a leave. It's not just a mother issue. It's not just a birth parent issue. So what happens when we say, oh, our institution is so forward thinking, we give moms 12 weeks off. Like my question is like, OK, so what do you give, you know, the non birth parent? And often the answer is nothing or maybe a week or two weeks. But what's the problem there, you know, that sets up a disparity. It sets up the expectation that the birth parent is going to be at home because of that leave taking care of the child and probably doing all that domestic work that we talked about already as well, because there's a longer period of leave. That's the person who's home. That's the person who should naturally be doing it. And if you're not giving leave for a father, for a non birth parent, you're essentially saying, well, they should be back at work. That's denying them the time to bond with their new child. And it's also putting all of that domestic expectation on the birth parent. And that really sets up that disparity for years to come. So I think it should be parental leave and it can't be exclusive to somebody who has given birth. It should be 12 weeks. It should be paid and breastfeeding. So there need to be a way to block time and facilities that are not, you know, a closet. So we actually just revamped our lactation policy at Penn. So actually, number one, we changed change the terminology from breastfeeding to lactation, because not everyone is breastfeeding. Not everyone has breasts. But lactation seemed to be the best term. But we made it much more specific. So we specified, you know, that people have to have, you know, breastfeeding space or lactation space that's within a five to seven minute walk of their clinical space, an area that's private, an area that has access to a phone and a computer, an adequate lighting and adequate, you know, heat and air conditioning. And we specified, you know, that, yes, on average, lactation will take, you know, anywhere from 15 to 30 minutes. And if you add in, you know, this amount of time to get there and from there should be a 45 minute, you know, block of time. And that should be able to happen, you know, a couple of times within a workday. And so making policies as specific as possible is very important. And then sponsorship and mentorship. So it's one of our greatest sources of strength and support. And we talk all the time about having career mentors, about having research mentors, about having clinical mentors. I think we should have motherhood or parenthood mentors and work life integration mentors as well. So my mentor, when I was going through the entire fertility process, yeah, she was in hematology, but we talked maybe one percent of the time about hematology. And most of it, she was a mentor to me because she had been through IVF and had two children that way and been through all the complications and all of the ups and downs and the heartbreak and the making things work as a physician mom and having somebody who can specifically speak to these challenges and offer suggestions and offer support instead of being the person who says, you know, are you sure you're ready for this big leadership, you know, position because you're a new mom? This is so important and support groups and hospitals for new physician moms, for moms of toddlers and also for parents in general. So it's not just, oh, mom's going to the support group. It can be support groups or parents. So all of these things are relatively, you know, low input from a systemic standpoint, but are so important to us as individuals. So in summary, I think that physician motherhood and I would say physician parenthood. And again, it's not, you know, that this is unique to physician mothers. We just don't have the literature on physician fathers. And that's a that's a big area that needs to be explored more. But there are multiple challenges. It's hard. The fixes really need to be systemic rather than focused on individuals. We need to normalize motherhood and parenthood. We need to say, no, please don't be on that Zoom meeting while you're in the hospital on a magnesium drip. We need to change the culture to embrace parenthood. I will say that, you know, at Penn where I am right now, we have a cohort of about, you know, 10 to 12 fellows a year. And we have three births in our first year fellow class over the past two to three months. So, you know, almost the over a third of our of our first year fellowship cohort is out. And our program has been nothing but supportive and we provided emotional support and gifts and, of course, clinical coverage. And I don't think any one of our fellows has felt like it's a burden. And that's how the culture should be. It should be normal to take that parental leave and not feel guilty about it and not be at work while you're on leave. And then focusing on the facts like I like I talked about. And then just personal advice for any physician parents in the room. It's really important to define your boundaries and you can make rules and you can make exceptions to the rule. But don't make it a rule to have those exceptions. So, you know, when you're talking about I said, I'm not going to do committee meetings, you know, in the evening anymore. Have I occasionally broken that rule to give a talk, you know, that was an invited talk, you know, at seven to eight p.m. because you were trying to get to listeners on Pacific time as well. Yes, absolutely. But I'm not going to commit to having, you know, twice weekly meetings between seven and nine p.m. because it's just not right for me. That may not be your choice. And I respect every person's single choice. But if you make a rule for yourself, it's OK to occasionally break it. But don't, you know, find yourself breaking it all the time. Say, oh, it's so hard to give this up. I just got to do this. I just got to do that. Then you're going to look back and say, well, you know, I was just at four committee meetings for four out of five days and I didn't put my child to bed for most of the time. Trajectory changes over time. So it's not that stepwise ladder like medical school residency, fellowship, attending job anymore. You're not it's not going to be well. It's going to be, you know, four years until I'm, you know, going from instructor to assistant professor and another six years before I go from assisting to associate and another 10 years before I make full professor, you can't plan it out like that anymore. There's going to be periods of time when there's less productivity and there's going to be periods of time when there's more productivity. And it's OK to take that step back as long as the overall trajectory is still up. And I will tell you if you are burnt out and dissatisfied with your work life integration, you know, no matter how hard you're working, your trajectory is eventually going to fizzle out and it's not going to be up anymore. So it's better to take the small hits and take that time for yourself on the one year, two year and a period rather than over the next five years. Notice that your productivity has steadily gone down because you are dissatisfied with your balance. And then finding your tribe. So this this is my mentor, Dr. Walensky Spinner. She was with me through the whole process from the very start of fertility treatment. She gave me the most amazing advice. I couldn't have done it without her. Find your friends, find your mentors and sponsors, find supportive colleagues who you can confide in what's going on at work. And, you know, these are the people that are going to be with you through it all and always, always advocate for your priorities. So here's where we are now. And I would love, you know, I left a lot of time on purpose because I would love to make this a discussion. Thank you so much, Dr. Marshall, what a wonderful talk and and I think really, you know, it's very very vulnerable and honest and a lot of us have experienced many of those things. I really appreciate that. One thing that I just wanted to ask, and we'll we'll take questions in the chat if you type them, we will answer the live. And if you'd really like to say something, you can raise your hand if you can promote you. But as I have noticed, I was thinking of your example with three fellows needing maternity or maternity parental leave in the same time. And I think as our university has gotten more flexible and supportive of parental leaves, one of the things I notice is that scrambling on the back end for coverage and like kind of the burnout that causes when the people that are there are like last doing double work for a period of time. And I have just been really trying to brainstorm systemic ways, whether like at our institution or even like policies that like allow for building in flexibility, especially in training, maybe in faculty, that's a little more challenging, but like having, you know, an extra trainee so that you can manage all the leaves that need. So I was just wondering if you have heard of or having about like managing kind of being as supportive as possible, but managing all the work that happens on the back end. Yeah, it's a great question. I mean, some of that comes down to planning, right? So it's very important to have those discussions ahead of time. So we purposely, you know, ask fellows to, you know, come tell us, you know, as an open discussion, if you or your partner are expecting a child. And so we're able to have a lot of our fellows kind of be on outpatient or elective rotations here during those last couple months. So there's something did happen. It wouldn't be kind of taking away from an inpatient service or something where a fellow is essential. I think highest level would be increasing your, you know, your, your trainee numbers to have kind of a couple extra backup folks. I mean, that's a whole revision with ACGME and all this so that, you know, not to say that we can't do it, we've actually talked about the need for increasing our fellowship compliment. And not just because of this, but because there's always a COVID, you know, I think that you cannot plan for. But that's kind of the highest level. I think the next level is allowing trainees the opportunity to moonlight and get paid for coverage. So they're not feeling like, oh, you're getting pulled from a required rotation that you're going to need to go back to later, or you're not getting pulled from your research time in the lab, but you instead say, hey, you know, this is the first year fellow like what, you know, who's out. Our second year fellows or third year fellows who have done this rotation, we will pay you add a moonlight or salary to come in and cover this. And that's, you know, I think, and even if it's not, you know, the full moonlight or silly, at least some type of stipend for people to feel like, you know, they're being rewarded for, you know, giving up their time and have it seem at least semi voluntary, rather than just, oh, sorry, you know, you're coming down to lab for this, this next month to cover the liquid on service. So I think, I think that's something, but again, it really is that planning component and, you know, putting those stacking those outpatient rotations, you know, as much as possible. Great. I don't know if any of you have a question or there's somebody who raised their hand, I need to figure out how to allow them to talk or take that in the chat. Yeah, I can just reflect on the medical education side a little bit and, you know, kind of offer, you know, some some of what we're doing here. Obviously, you know, it would be great if we had redundancy on the bench with all staff and faculty and residents and, you know, what one of the concepts I think we all use is like, we staff up and we, you know, you know, we we don't go any more extra, you know, it's always like, I was just in a meeting today where it's like, do we have the, you know, the education and clinical need to increase the size of this program? And so this is always a question that's, that's coming up. But then we face burnout, right? And then we worry about the retention issues. So I some somehow we have to kind of bring those folks on the same page. And so as an institution, we did hire a chief wellness officer for faculty, and we have a lot of wellness activities going on for the students and residents. And work also going on that Julie is involved with with Dr. Oilers saying is involved with with, you know, and others addressing some of the work around lactation and, you know, and particularly for parents. We saw a lot of this in the pandemic. So on the hospital side, I think that that forced, you know, really the discussion of who is going to come to work when the schools closed, right? So that's when we saw the opening for all these conversations to occur. And then now what we're seeing, which I just wanted to get your take on is, you know, I mean, I have small kids, you have small kids, right? The pandemic is still going, right? I mean, my son had RSV, and, you know, I, you know, one of them might get COVID again now with the Omicron, or you know, the new Omicron variants. And so but then like, everything is back to normal, but we don't have the emergencies anymore, the childcare funds and all of this. And so I think that's something that we're seeing a lot of is people in duress, because the understanding and sort of the, you know, oh, you can be on Zoom and don't worry, etc. Like all of that grace is going away, which really is concerning me. And so I'd be curious what you're seeing and sort of what we can do to maintain that. Yeah, no, it's so tough, because everyone feels like, oh, everything is back to normal. But it's not. Thankfully, I feel like in terms of childcare, I am seeing a little bit less of like the frequent closures of daycare centers and a little bit more availability of people for backup childcare. But I think that's why it's just so important that hospitals offer, you know, if not on site childcare, at least, you know, the coverage for backup childcare, because it's an ongoing problem. It's just, you know, it's not something that, oh, for the past two years, we dealt with it and everything's fine now. It's just going to be, you know, an ongoing problem. And that also does lead to the idea of flexibility, right? It shouldn't be, you know, a shock. It's always a shock in medicine when somebody calls out, you know, when they're sick, and our culture really needs to change. And I actually think that, you know, leaders do have some of the burden for this to set, you know, set the tone. You know, I want to see a department chair say, geez, you know, like, I just can't come in today, because, you know, I'm sick or I got COVID or, you know, my actually, my division chief the other day, and we were talking about, you know, presentation, somebody was doing a heme conference, and he said, you know, I'm sorry, I'm just not going to be able to be there. I'm dropping my son off at the train station. And it's a very small thing that role modeling that, especially as a male is so important. And that actually, I see there's a comment in the Q&A about kind of balancing the needs of fathers. And I think that is so important for male leaders to actually be setting the tone there that they have responsibilities outside of work, because that's good for everyone. It's good for male trainees to feel like they're not the only ones who are saying, you know, I want to be present for my children. I think that, you know, male need to bond with their children just like, just like females do. So it's so important that leadership set that right tone, you know, there have been number of men in my department who said, gee, I'm sorry, I can't attend because of and then X, Y or Z child care, you know, I'm dropping my son off, my daughter has a school play. And I really appreciate when people do that, because that does the dual work of saying, yes, men have responsibilities outside you. And it makes women feel less like, Oh, here's another woman, you know, saying she has a child care responsibility, it makes it feel like it's just equal for everyone. So I really think that again, this is a systemic that needs there needs to be leadership training for all leaders, but especially for male leaders about setting that tone appropriately, you know, within the people that you're leading and kind of normalizing being a parent. Dr. Marshall, I would totally disagree that when I was seen here is that there's more and more of a culture of both men and women taking paternal leave. And then that culture sends the message that it is not just the woman's job to take care of the children, that it is all of our jobs to take care of our children. But it's definitely a culture change that happens. Like at first, women are getting like, two to four weeks, then they get six, then they got 12. Now both men and women and anyone who, you know, can get the full leave. And then it becomes, you know, it is the family's responsibility. So I love that you're talking about that. And I think you were, you were answering Dr. Rogers, stolen Rogers question. And then if you see this other one is that's anonymous, the sense is that the bottom line for institutions as financials, any data showing that allowing for the interventions you described for position mothers does not affect revenue. And that's a tricky one. I know. Yeah, I do not know of any data because I think that's just such a hard thing to show. You can't randomize people into, well, you get some leave and you don't get some leave. And let's see, you know, what happens to RV. And a lot of this is also, you know, personal, right? It's not that there's a cost to the institution necessarily, because, you know, most institutions set our view targets. And then if somebody doesn't meet them, you know, the institution can theoretically cut their pay. So I think it would be hard to actually show the data that giving people leave is hurting the institution from the bottom line financially. I think, you know, the more important question is if we give people leave without consequences, if we allow for people to have true, you know, protected time for parental leave and for lactation, and don't cut their pay and don't adjust, you know, don't feel the need to, you know, have them still meet the same RVU target. That's, you know, that's what would be the more helpful study, but I don't know of any literature showing that. Yeah, and then I'll just read a few other things that are coming in. A lot of them are like, thank you, I feel seen. And that also not only during this part of period, but also just like continual things that happen over a faculty's life. And some of them are more acceptable. And I think the point is that like, you know, having a child is acceptable, but there are other things that still feel a little unacceptable to take time off for and how to like allow for all of the things that happened during a physician's life to support them is challenging. Yeah, absolutely. So we talk a lot about, you know, pregnancy and birth, but you know, there's years and years and years that happens after that. And I do think, you know, I'm reading the comment here as well. And I really think it is that just setting the right tone, you know, first within each individual's division and then, you know, at the institution level as a whole of leaders saying, you know, why aren't there people that, you know, go up and start a big talk, you know, for the whole institution by saying, hey, sorry, I'm a little late. I was dropping my kid off, you know, at school or sorry, I had to reschedule, but something came up fairly was, I think there's a lot of, you know, hesitation to actually admit that we have lives outside of the hospital. And that somebody has to start doing it. And I think that if a couple people, you know, I've noticed that once, you know, our chief said, oh, I can't make this meeting because I'm dropping my kid, then a lot of us felt a little bit more comfortable just saying, oh, I'm not going to be able to do this or, oh, hey, everyone, I'm on the Zoom, but, you know, I'm going to turn my camera off because I'm walking my kid back from daycare. And so I think that it really needs to come from the top and it does need to be a continuous message rather than, hey, like, you know, here's your 12 weeks, you know, of parental leave. Welcome back and now everything's back to normal. Yeah. And then we had one from one of our chief residents. Amazing talk. Thank you. Do you have recommendations for finding mentorship, especially as trainees? It's the most important word of mouth. I think that picture of you and your mentor was inspirational and many of us have had those or been those for each other. But, you know, how did you find it and what recommendations you have for trainees for finding this? Yeah, absolutely. So that's actually, you know, I think the value of having kind of small discussions within residencies or, you know, within, say, training programs or, you know, all the fellows in an institution and having, you know, a few faculty come and talk about their experiences because those faculty may be people, you know, that can reach out and be mentors or obviously one faculty member can't be a mentor to 54 residents, but they may know others because a lot of us, I think, you know, I started talking to my colleagues when I was going through the fertility process and found out that many of them had actually been through the process as well and nobody's going out there broadcasting. But once we started talking about it, I said, oh, you know, there's actually a resident who, you know, is going through this process as well. Would you feel comfortable talking with them? And so a lot of it is that word of mouth. But again, we have to start somewhere. So here at Penn, we're trying to do a lot of kind of small group discussions either for the medicine residency or the men-peeds residency. There is one for the focus, which is the women in medicine group with and a panelist talking about their experiences. And those are kind of the, you know, the high-level mentors that can then suggest, you know, colleagues that they may know as well. Yeah, we're trying to do a few of those here. I think that you need to do it regularly because there's turnover. Exactly. And again, you know, not everyone can attend that, you know, six to seven p.m., you know, so let's do it at different times. Let's do it at different days of the week. You know, let's be as open as possible to flexibility. Yeah. So another physician asked, what about these changes leading to the improvement in terms of physician retention? This could reduce the cost of recruitment of new physicians. Yeah, absolutely. Again, we don't have that data. But certainly, and I think a lot of that is because policies are only just beginning to change now. So we don't have that five-year, ten-year data of what did, you know, improving parental leave? What did changing to virtual and giving people, you know, the option to attend remotely? What did that do to their career development? You know, what did that do to, you know, their willingness to stay at an institution to stay full-time versus drop to part-time? We don't have that long-term data, but I think that would be powerful data, both kind of from the, you know, individual level, but also from the kind of the institutional and financial repercussions and all of this. Yeah, there's so many things coming in. Bethany, I don't know if you're reading to them too anything you want to highlight. Yeah, no, they are coming in a lot. I was noticing, you know, just some of the comments are about, you know, saving your sick days and the presenteeism and it's a recipe for burnout. There's a lot about burnout and retention and work-life integration. And so I think, you know, Dr. Marshall, you've definitely touched a chord with people. A few questions here. How do you feel about the national legislation of paid 12-week parental leave rather than institutional changes? I'm wondering what you think about that. Yeah, you know, I think it's important to be aware of this. I think that institutions are not necessarily going to make changes just based on, you know, a national policy. So I think that, you know, each institution does still have to make their own decisions. But I think that by saying, you know, hey, this is the standard. You know, why does our institution not meet that? Or what can our institution do to meet this standard? You know, is definitely important. And it depends, you know, again, not to paint, you know, an overly, you know, simplistic picture, but who are the people making these decisions? It's often people who didn't have to deal with these issues. It's people who didn't breastfeed or didn't go through a pregnancy. And so, you know, knowing your audience, I think is really important. I mean, I'm just going to wrap up with this last one. Yeah, I'm going to take the prerogative to ask the last question. Yeah. You put the onus on leaders, and I sort of feel as a leader, I definitely am like, I'm getting my kid. And, you know, I have to go off of Zoom video. And so I did want to share, though, that that feels sometimes very challenging being the only one in a room full of leaders who don't have that, you know, senior leaders who don't have that. And so what can we do to, you know, really have senior leaders walk that walk, you know? And so I'm just curious what your thoughts are there. Yeah. So when I say leaders, I'm definitely thinking more in the frame of, you know, somebody who's leading a training program or a department or a division, when it gets to, like, the most senior levels of leadership, often people, you know, if they have children, they're grown. And so it becomes, it becomes very difficult. First of all, I think sometimes they're just not aware, you know, of these issues. The culture of met, again, senior level leaders are often people who are, you know, in their 60s, 70s. And so the culture of medicine was very different then. It's the same discussion we see with the culture now of, you know, why are residents complaining about being on call overnight? In my day, we were there. You know, it's the same idea that people don't want to kind of let go of the paradigms that they, you know, trained and grew up in. So some of, I don't think it's possible to change the thought process, but at least if we can change the behaviors, I think it's important to, you know, to have that leadership training and say, this is what's important now. This is what our institution is valuing now. You know, please be aware of these things. We can't change what people think about it. We can't change if people think it's a silly, you know, idea or not. But at least, you know, we can make everyone aware. Well, thank you so much, Dr. Marshall, for a great talk and a great discussion at the end. I'll just remind everybody we're off next week. Next Wednesday, we did a board Thanksgiving and then we'll be back on November 30th. Dr. Cortina from University of Michigan talking about sexual harassment. She'll be in person back in P117 with also a Zoom option. And then the week after that, on December 7th, Dr. Julie Silver will be coming also in person in P117 with the Zoom option. So really appreciate Dr. Marshall's talk today and all the conversation and look forward to seeing you in two weeks. Thank you so much.