“It was not perfect.”
I was so happy to be pregnant with my second child. It took a while, so when it finally happened, I was not thinking about anything but the pure joy of it. That lasted for a week or so and then I started to plan.
At the time, I was finishing my fellowship training and an ideal faculty position was opening up in the hospital with which I was already affiliated. As a fellow, I was technically employed through an area health center, but I spent the majority of my time in the hospital on Labor and Delivery caring for patients and teaching resident physicians. The faculty job was perfect and I was very excited about not having to leave my “old stomping grounds.” The chair of my department even KNEW I was planning another baby and was supportive.
When I accepted my faculty job in February, I was in the spring of my second year of fellowship and in the first trimester of my pregnancy with an October due date. So, I spoke with the various people in the know about the planning of a maternity leave. I was told that I would get six weeks of paid leave, and it would start at my due date. If I needed more leave time, I would have to use my vacation time. I had not planned on more than six weeks so this was, once again, perfect.
But as the July 1st start date of my new employment got closer, it became clear that I was not actually eligible for the maternity leave employee benefit. Even though I had worked at this hospital for five years of residency and fellowship, I would not qualify for a paid maternity leave because I was not technically a hospital employee during my fellowship. I could still take six weeks of leave (I could even take more!), but they would not pay me for any of it.
But by then my husband had already moved to part-time employment so he could care for our new baby when I returned to work. We could not afford to have no income for six weeks and, in addition, to pay for our benefits. So, my only option was to take my entire annual vacation as maternity leave and to come back to work full-time in November after four weeks.
So that is what I did. It was not perfect. It was not pretty. I was tired and probably not so good at my job for a while. And most of all, I am disappointed to this day because I had been told it would be different.
A Year Off
I became pregnant during the beginning of a year off I had planned between my third and fourth years of medical school. While we hadn’t planned this in detail, in hindsight the timing worked very well for us. I was able to focus on research field work for the majority of my pregnancy and found that after the birth of my daughter the less labor-intensive aspects of research such as literature reviews and writing I could fit into my day working around nap times. This was also a nice way for me to begin to integrate the mother and future doctor sides of me.
Pregnant Resident
The majority of my residency colleagues appeared mostly indifferent to my pregnancy, which I took to mean quiet support. I was disappointed, however, when on my due date, another resident asked the group for help in covering her overnight call that weekend. Her father-in-law had died, and she needed to attend the funeral. I looked around the room dumbfounded as no one volunteered. Finally, I raised my hand and told her that I would do it, assuming I hadn’t gone into labor by then. Someone would obviously have to be backup, I said. After much hemming and hawing, they finally assigned the job to the one resident who wasn’t there. I went into labor that night.
A Healthy Family
My husband and I tried to have a baby during my last year of residency. I did get pregnant but then I miscarried one night on call in the middle of my first trimester. It wasn’t until the second year of my fellowship that my husband and I felt ready to try again. After using birth control together for more than ten years, it was ridiculously stressful and not all that romantic to try to time a pregnancy with a due date near the end of my fellowship. If we got pregnant too soon, I would have to drop out of my public health classes. If it took us too long to get pregnant, then I would have to delay looking for my first post-training job. Eventually, we had to lower the over-achiever bar a little and just be grateful that we got pregnant at all. All of a sudden fellowship and medicine became much less important to us than starting a healthy family.
Baby Boom
Our practice has several young female physicians which is wonderful. Four of them have had babies in the last 18 months, one after the other, which is also wonderful. However, as a result of this procreative surge, the entire group has been functioning in near-crisis mode with too few people to cover too many responsibilities for more than a year.
Bridging the [Baby] Gap
Our practice has several young female physicians which is wonderful. Four of them have had babies in the last 18 months, one after the other, which is also wonderful. However, as a result of this procreative surge, the entire group has been functioning in near-crisis mode with too few people to cover too many responsibilities for more than a year.
Not Your Typical Conference
When I negotiated the details of my maternity leaves for two of my children, I was working full-time as an academic physician. As such, I had clinical care as well as my academic responsibilities to consider. Both maternity leaves were ten weeks long: six weeks of paid maternity leave as an employee benefit, three of my four weeks of annual vacation, and one week of professional conference time. During each leave, I took the new baby with me to the conference.
With my second child, I had a wonderful experience at a career development conference near the end of my maternity leave. My son was nine weeks old, I was starting to feel a little more human and a little less sleep-deprived than when he was first born, and my dear aunt that I do not get to see nearly enough was able to get a free airline ticket using frequent flier miles and come spend the week with me and my new son in a place she had always wanted to visit. The travel there and back was quite smooth. My aunt and I flew from different cities and met up in the Cincinnati airport. We then flew together with the baby on the second flight. On the way home, we reversed the process. She stayed in the hotel room with us at no extra cost. For that trip, my husband and older child stayed home.
While I was in conference sessions, my aunt would go for long walks with the baby. He came and nursed quietly at a few of the larger sessions and attended all of the networking sessions snuggled in his Bjorn. Being on maternity leave meant that I had a little more distance from the day-to-day aspects of my job than some of the other conference attendees. I actually felt freer to think about my career objectively than my colleagues who had pried themselves away from their clinical practices and teaching, research, and administrative responsibilities for a few days to attend the meeting. I was able to do important work but also be with my newborn son. I came home refreshed and renewed from spending quality time with both my peers and my family.
With my third child, I negotiated to attend a medical education conference during my maternity leave hoping to extend my paid leave by a week and to recreate the same positive experience I had had with my son. Unfortunately, the timing was not as good since this conference turned out to be just two weeks after my daughter was born. Also, the meeting was held in a smaller city that was not easy to get to except by car. Finally, I was scheduled to give a presentation at the conference with two medical students so I was expected to be coherent and mentoring this time which, for me, takes somewhat more energy than just networking and being reflective.
Since my daughter was so young and I had a presentation to give, I did not want to go to the conference alone with her. I wanted to have someone there to help me care for the baby when I was working. But no one outside of my immediate family (parents, siblings, aunts, friends, etc.) was free to come with me. So I brought my entire family including a tired husband and a two- and a five-year old still reeling from the shock of a new baby sister. To get there, instead of flying and driving, we took a six-hour train trip thinking it would be fun for the older kids (it was not) followed by renting a car and driving the last hour and a half. The train was crowded and dirty and the kids were not allowed to move around. When we got off the train, the car rental company in the train station had lost our reservation and did not actually have a car the size that we needed. In the end, we rented a car from another company.
Eventually we got to the conference hotel where the five of us holed up in our room with take out food from the hotel restaurant and cable TV which is normally forbidden at home. I would breastfeed the baby and then when she was napping, I ventured out for brief periods to network and mentor and then returned to help my husband care for three young children in a small hotel room.
Knowing that our family would probably not survive the reverse of the same trip to get home, my husband spent a good deal of the conference on the phone with Amtrak to get vouchers for the return trip that we were not going to take. He also convinced the car rental company to let us keep the car we had rented at the train station and just drive it all the way home.
In the end, my husband packed the car during my presentation. We left the hotel less than one hour after my talk was over and drove the rental car directly home to our house, 341 miles and 12 hours away.
Who’s the Patient Here?
With one of my children, I had a due date in October. The clinic administration did not want to schedule routine visits for me in case I went out before my due date. As a result, during the last month of my pregnancy, I saw eight to ten sick people every time I was in clinic right at the start of the cough and cold season in primary care. Even with rigorous hand washing, it should not surprise anyone that I got sick with bronchitis a few days before I went into labor. I coughed my way through labor which was incredibly uncomfortable lying down with an epidural. Then I kept coughing for the first two weeks after my son was born until eventually my doctor saw ME instead of my son when I went in for his regular check up. Fortunately, the antibiotics she prescribed me were compatible with breastfeeding. As a direct result of our clinic’s pre-maternity leave scheduling policy which inadvertently exposed me to multiple respiratory infections just when I needed to be at my most healthy, I was unusually sick for several weeks.
Baby Decoy
With our second child, I worked until I went into labor at term. I was out for ten weeks, did not move during my leave, and went back to the same job. The first time my husband and I took our new baby into the office during business hours so I could pick up some paperwork, we actually made a game plan in the elevator outside the department. He moved the baby to his left arm, put me on his right side, and we entered the office baby first. As predicted, our son instantly attracted the attention of most if not all of the people in the office. I was then able to sneak around the right side of the ogling, cooing crowd and get to my own office unencumbered. The baby decoy allowed me to retrieve the papers that I needed in a very efficient manner, socialize on the way back out, and leave without lingering.
Reset, Replace
After realizing that it would be hard to get any work done during maternity leave on a workday with everyone around, the next time I needed to go to the office, I set aside a few hours on a Saturday morning to come in and go through my mail and check my email. I had gotten a babysitter for my older child. I was very tired and not thinking all that clearly but I thought that I could at least weed out some of the junk and keep on top of my work (different from actually doing it). But once at the office, I could not log on to my computer. I tried several passwords and different tricks, all to no avail. I ended up leaving having spent two hours at work but not having gotten anything done. I found out the following week that my chair had temporarily given my office and my computer to one of my colleagues and changed all the settings to be hers which was why I could not log in to my own computer.
Diaper Demonstration
During my maternity leave, I got someone to cover all of my teaching responsibilities while I was out. Everything but one session on maternal-child health that was scheduled for the last week of my leave. I tried four different people but no one was available. So eventually I decided to just bring the baby with me for show and tell and to teach the maternal-child health workshop myself. Ultimately that plan turned out to be less work that finding someone else to teach it.
During the two-hour workshop with twelve medical students, my ten-week-old daughter had a massive poop. Based on the noise and the vibrations, I knew I couldn’t stall on changing her, even though I was mid-sentence. So I promptly put her on a blanket on the floor and changed her diaper. Then I made each student examine her dirty diaper up close for color, consistency, and odor. Although these yet-to-be parents were clearly grossed out, some of the students were still talking about what they learned from that diaper as they prepared to graduate from medical school two years later.
Case of the Missing Clerk
At around six weeks after the baby was born, I went to my own post-partum visit as a patient. Coincidentally, my own primary care physician’s office serves as one of the clerkship sites for the clerkship that I direct. In passing, I asked my doctor where her medical student was since I knew that she had a student assigned to her site during that rotation. Not only had the student not shown up that day but it turns out that she had actually missed several days of her clerkship. Thus my own personal post-partum visit resulted in “busting” a delinquent clerkship student. While initially kind of funny, it actually turned out to be a lot of work for me tracking her down and coming up with a remediation plan while I was on leave. Ultimately, she was required to repeat some of the course during the spring of her fourth year of medical school. In retrospect, I wish that I had delegated that particular administrative task.
Not So Smooth, After All
My third child was born in October. My plans for maternity leave were this: eight weeks as a paid employee benefit, three weeks of vacation, and a conference for a total of twelve weeks of paid maternity leave without interruption of either salary or benefits. My leave went smoothly and I returned to work after the holidays.
In early January, after being out of the country for a few weeks, my husband went to withdraw money from an ATM and was quite surprised to find that we were more than $8000.00 overdrawn and that as a result, we had accrued several hundred dollars in late fees. It turns out that due to an administrative error in my department, my direct deposit paychecks had been stopped after the initial eight weeks of my maternity leave employee benefit and that I had not been paid for a month.
I found out about this situation when I came back to my office to pump breast milk after seeing patients all morning in a sleep-deprived haze. As soon as my chair and the hospital were made aware of the problem, the hospital paid me my owed salary that very same day. My husband spent the better part of a day at the bank with the baby sorting everything out. Fortunately, a kind and competent bank employee was able to make all the penalties disappear because the hospital seemed quite reluctant to pay any late fees for us.
Unfortunately, because the salary money was eventually paid in January of a different calendar year, my salary in the year of my maternity leave was 11/12 of my annual salary and my salary in the year after my maternity leave was 13/12 of my annual salary. As a result, my dependent care account and my retirement account did not fill to maximum capacity for the year the baby was born. That money was not recoverable in any way. Believe me when I say that we tried. Later that spring, my disability insurance application was negatively affected by the lower salary in the year of the baby.
Just as the dust was starting to settle on the maternity leave salary fiasco, I was then informed by the state department of health that my leave disqualified me for a year from applying for thousands of dollars of loan repayment. One of the eligibility requirements for the federal program in which I was participating is that applicants have no outstanding service commitments. But since my current service payback was extended by the eight-week length of my maternity leave, I had not paid back my current contract by the time the new contract started. It was important not to interrupt my participation in the program since renewals of existing programs get preference over new applications. The state program denied my lengthy petition for an exception, citing federal regulations. I was not accepted back into the program as a new applicant the following year.
Eventually, a year later, that lump sum in January of the previous year bumped us into a different tax bracket. So eighteen months after the baby was born, my husband and I paid additional taxes. In spite of meticulous advanced planning, my maternity leave had significant unforeseen financial implications and costs that we have never recouped.
Convincing Ourselves?
I’m amazed by how my colleagues consistently misinterpret the literature and recommendations on breastfeeding. Recently, I argued with a newly pregnant physician colleague of mine about the American Academy of Pediatrics’ recommendation to breastfeed for at least twelve months. She wouldn’t believe me until I found the statement on the Centers for Disease Control and Prevention website! Do we tell ourselves these things to assuage the guilt, or are we less concerned about the merits of breastfeeding than we are about the merits of beta blockers?
Sacred and Scared
My breastfeeding relationship with my son was incredibly important to me. I never realized how much more it would be than just the preferred way to feed my child. In honesty, I am a little scared for my next child. My son was born during my research years of residency, and I had plenty of opportunity to pump and was on call for only one week each year. I try to imagine maintaining a milk supply when I have long surgical cases and busy overnight calls after a short maternity leave. It’s been enough to make me postpone having a second child. Will I be gutsy enough to tell my attendings, “I know we are doing a critical anastamosis here, but I have to pump”? Will I trust my junior residents enough to run a trauma alert for the ten minutes it takes me to finish up a pumping session and put the milk away? I’m concerned, especially when the general culture is that breastfeeding is nice but easily sacrificed for the more important job of being a surgeon.
A Busty Interview
When my first child was two months old, I went to a job interview wearing a beautiful light purple silk suit. Since I was very afraid of leaking milk onto my suit which would have made some pretty obvious stains, I put THREE sets of disposable nursing pads into each side of my bra. Fortunately I did not leak through but it was very disconcerting to have such a large chest that day.
Multipumping
It’s amazing all the things you can do while you are pumping! You can’t provide direct patient care but you can do almost everything else that doctors do including talk on the phone, update medical records, answer email, and write papers and grants.
Once I was taking sign out about a new hospital patient from one of my Emergency Room physician colleagues over the phone from my office while pumping. The mother-doctor signing out to me was in the middle of the patient’s past medical history when she interrupted herself and said, “Are you pumping?” She had recognized the muffled sound of my electric pump in the background.
Harder Than It Looks
I got this card when my daughter was born that had a cartoon of a woman on the cover holding her infant in the football position while breastfeeding. She was looking cross-eyed at the infant as if to say “What am I doing?”
I laughed out loud. I felt the same way. At the time, I had bright red painful nipples on both sides, and every time my daughter latched I would mumble (or yelp) expletives until my milk let down about thirty seconds into the feeding session. Thirty seconds is a long time. Try it–count out thirty seconds. Now swear for thirty seconds straight. Whew! How do you feel? I wondered whether my baby’s first words would be unrepeatable ones. Eventually, that got better. And then I introduced my breasts to the ‘mechanical feeder’ about one week before I was to return to work. Number one, this was not early enough–I should have pumped LONG before this. Number two, I did not know how to really work the machine, or how to time the baby’s feeds relative to pumping. So I got in this nasty cycle of pumping at exactly the wrong time. My kid would be starving and my breasts would be empty.
When I did return to work, the ‘mechanical feeder’ and I became better friends, but my milk supply was not up to par. I had to supplement with formula starting at five months, and by eight months postpartum, despite pumping every four hours at work, I was down to four ounces a day of pumped milk. It was very depressing for me. My baby is now six years old and healthy as a horse, but breastfeeding did not play out according to my plan.
When my second child was born, I was thrilled that I had experience. I pumped at the right times. I built a supply. But by five months postpartum, I was utilizing mostly frozen milk. I am still bewildered as to where I went wrong. There is a ‘sick-in-the-head’ part of me that wants another child JUST SO I CAN LEARN TO BREASTFEED.
You Still Can’t Count On It
My mother breastfed all six of her children, back in the days when “no one breastfed.” She was told that she wasn’t allowed to have the baby (me) in her room at night because it would wake the other mothers. So she and her sutured perineum sat on a wooden stool near the nurse’s station every night of the week that she was in the hospital after I was born.
Times change. I encourage and teach all of my patients about the benefits and joys of breastfeeding. I have been to countless seminars and lectures about supporting lactation. This is one of the most certain facts about becoming a mother: I will breastfeed and I can’t wait.
My son is a delight. He seems to latch on with just a tiny bit of turned in lower lip. The nurses all thought we were doing great. First visit at one week – slightly below birth weight. Okay. Next visit at two weeks – just at birth weight. Sore nipples, but otherwise I tell the nurse practitioner we are doing great. He doesn’t really cry much, though he nurses for a good solid hour every time. She suggests that we supplement, but I bargain for one more week.
After fenugreek three times a day, four or more mugs of herbal teas, two visits with the lactation consultants, pumping after every feeding (even in the middle of the night) and wearing that horrible thing around my neck with the formula tube taped to my nipple (a Supplemental Nursing System or an SNS), we establish that I can produce about fifty percent of what my son needs to grow. The rest he gets as formula.
I go back to work with a schedule that allows me to pump for twenty minutes three times a day. I come home with a total of only four ounces of breast milk for the next day. But I continue this routine as long as there is any milk. Seven months. Friends tell me about pumping at work and having bottles overflow if they don’t pay attention. It doesn’t make me feel better.
How could my body let me down? How could the most certain part of this whole adventure turn out wrong? How could I be so upset and consumed with this problem when I should be happy and grateful for a healthy child? And he seems to be a happy and healthy child, even without my milk.
No one told me that if you are committed to breastfeeding and have good support that you still can’t count on it. It went better the second time around. But as before, we still had to supplement. But I got up to about seventy-five percent of daily needs, so I patted myself on the back for improving.
More than five years later, it still eats me up. I am still as passionate an advocate for my patients and my residents, but I also tell them that it can not be taken for granted, like most good things in this world.
Security Concerns?
When my exclusively breastfeeding daughter was eight weeks old, I had to take the clinical skills portion of Step 2. The nine-hour test had a single 45-minute lunch break. My physician and I both petitioned for increased break time to pump, but the powers-that-be refused, saying that I could pump at lunch in the bathroom. I asked them to allow my parents to bring my daughter to the testing center so that she could nurse just prior to the exam and again at lunch, but they refused, saying that she would be a “security breach!” Ultimately, I took the test on the original testing date and pumped in the bathroom at lunch.
An excerpt from the letter that my own physician wrote on my behalf to the USMLE: “I am writing to express my disappointment with the present status of USMLE testing accommodations for breastfeeding trainees. I have recently been unsuccessful in obtaining adequate accommodations for a fourth-year medical student patient of mine for the Step 2 Clinical Skills Exam. Her prenatal course and delivery were extremely complicated. She is exclusively breastfeeding. She must take the exam to graduate from medical school this month and begin her residency this July. At the time of her exam, her infant daughter will be eight weeks old. Given that the test is 9 hours long with only 45 minutes of break time, she and I have both requested accommodations on numerous occasions to prevent negative health consequences for either herself or her infant.
In my original letter, I requested accommodations given that she is exclusively breastfeeding a very young child. My second letter, addressed directly to her assigned disability officer, contained specific medical recommendations. As a result, she was assigned “comfort measures” status meaning permission to bring her breast pump into the examination area to be used in a non-private bathroom stall with no extra time allotted. I then spoke with a USMLE representative who informed me that breastfeeding was not technically a disability and so did not qualify her for accommodations under the Americans with Disabilities Act. He also explained that bringing the baby to the mother at any time during the testing day would be impossible due to security concerns. She was granted disability status for pregnancy-related complications and given a new testing date in late August of 2006 which would preclude her graduation from medical school, and she lost her comfort measures altogether.”
Embarrassing Other Students
I made friends with another medical student-student mother over pumping in our hospital. She told me that after being denied extra time to pump during her USMLE Step 1 exam, she ended up pumping in the break room during lunch. I decided against petitioning for extra time. Since I spend most days pumping and eating, I thought I would be able to do the same during my board exam. When I got to the examination site, I asked the secretary if I could pump in the break room as my friend had done. I was told that this would require special written permission from the National Board of Medical Examiners. I then explained to her that since the women’s restroom had no electrical outlets, I’d have to pump in the waiting room or the hallway where we were allowed to take our breaks. I was told that this would be impossible due to “fire codes” and the presence of “security cameras” and that it might “embarrass other students.” I was told to either reschedule my exam or call the National Board whose number was out of service. After more than an hour of negotiations, I was granted permission to pump in the break room.
Not the Best Day for a Chainsaw
A physician-mother always realizes what she is up against when Daddy goes out of town. With daycare closing when I was still on call, I had planned to have the daycare teacher walk my son over to the hospital. His presence would overlap only a few minutes with my trauma call. Of course, in those 10 minutes, we managed to get a trauma alert — not just any trauma alert, but a chainsaw to the neck! My son sensed my anxiety and clung to me, refusing to stay in the SICU with a colleague. So, in my clinic day high heels, carrying my one-year-old, I led a parade of residents and medical students down to the Emergency Department. One medical student generously sat at the desk outside the trauma bay with my son and a pile of stickers pilfered from the pediatric Emergency Room while I ran the trauma. Luckily, the patient was stable and the operation was happily given over to the ENT surgeons. An hour and a half later than we anticipated, my son and I left the hospital.
Mr. Mom
During my residency, my husband has had to become much more active in child care than many other dads we know. He fixes hair for ballet class, stays home with sick kids, and checks in with their teachers when he picks the kids up from school. As much as I miss being able to do these things myself, I am glad to know that daddies can take care of kids just as well as mommies can.
That’s Where Mommy Lives
My son is intimately familiar with the hospital where I work. His in-home provider is a block away. He has visited numerous times, which have included meals from the cafeteria, naps in the call room, and visits to the children’s ward to see the pet rabbit. Still, it is hard to maintain the quality of relationship that I want most with him. He broke my heart one day when he matter-of-factly told my husband, “That’s the hospital. That’s where Mommy lives.”
Mama, M.D. 