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Thursday Oct 29, 2020

Pregnancy Taught Me How to ‘Lean Out’

I did a first today. I started filling out disability paperwork. Don’t get excited, I fill out such forms for patients all the time. The first was filling it out for myself.

[pregnant woman with hand to face]

I had two children during medical school, when childbearing meant taking on additional loans, no leave, a stint on Medicaid and significant stress. Yet sitting down to fill out my portion of medical leave paperwork has brought its own distress, guilt and doubts. But let’s back up.

As of this writing, I am exactly 23 weeks pregnant. I have bled on and off since I was five weeks pregnant. I thought I was losing the pregnancy, so I didn’t rush to establish care. I got labs drawn, had some ultrasounds to make sure it wasn’t anything life-threatening, and continued my average 60-plus-hour work weeks, which include nights, hospitalist shifts, obstetrics shifts and clinic.

I left a COVID-19 inpatient shift because of my first significant bleed. The subsequent labs and ultrasound were reassuring, so I resumed my shift, rounded and completed sign-out. Other than the maternal-fetal-medicine doctor and my husband, no one knew I was pregnant yet. At 19 weeks, I called the doctor who had read my previous scans. I was on my way to my overnight shift, but I was bleeding again. I called at 6:45 p.m. and told him I’d work my overnight shift and stay later in the morning so we could rescan.

He gave me another plan. He’d scan me now and send me home. We did an ultrasound on L&D. There was going to be more bleeding. I had a good cry, packed up my stuff and went home. I stayed home for four days.

It finally slowed down. And now it’s paused, again, though there are still subplacental hematomas. I’ve since established care, and I’ve had multiple scans. There have been even more wrinkles that have come and gone, and still some keep coming. I have been silent and worn baggy clothes. (Scrubs are awesome!) I have laid awake many nights, tossing and turning. I have cried many nights in the wee hours when there’s nothing to distract me from fear. During the scariest days, I’ve confided in just a couple of friends I’ve wanted to talk to. My big, extrovert personality has been driven inward. And though I am not out of the woods (are we ever?), I am at a place where I can talk about it.

Outcomes of pregnancy are different in residents and those who keep resident schedules. (Cue my husband’s four-year-long argument that I should not continue to maintain a residency schedule). There are higher frequencies of preterm labor, preeclampsia and fetal growth restriction(pubmed.ncbi.nlm.nih.gov) in female residents than in spouses or partners of male residents. The average age of first pregnancy(deepblue.lib.umich.edu) is more than 30 years old in female physicians, with 24.1% of female physicians who attempt pregnancy diagnosed with infertility by 33.7 years of age (29.3% of those with diminished ovarian reserve). For reference, the CDC states that the average age of first pregnancy in the general population is 26.3, and 12% of women ages 15-44 struggle with infertility.(www.cdc.gov)

Practice Self-Care Before You Think You Need It

In a profession that values self-sacrifice over self-care, it’s easy to become overwhelmed without even realizing it’s happening.

Turn to the AAFP for help before you get to that point, because if you’re not taking care of yourself, you’re not doing your patients any favors.

Start by completing the Physician Well-being Index to assess your well-being, and then use the AAFP’s Well-being Planner to track and reach your wellness goals.

To help your colleagues achieve wellness, consider participating in the Leading Physician Well-being program, where you’ll learn how to lead change to boost well-being in your workplace ― at no charge.

Finally, know that you can always reach out for emergency help by calling 911 or contacting the National Suicide Prevention Lifeline at 800-273-8255.

When I see women struggling with fertility, pregnancy loss, complications of pregnancy, difficulty around childbirth and breastfeeding, they often feel isolated, even in a healthy relationship. I often try to explain to the partner, or other accompanying friends or family members, that there is nothing more personally painful than when our bodies cannot create, support or nourish an infant when that is what we feel we need to do.

With the ongoing bleeding, I didn’t even have the insight to stop working. It was ultimately the maternal-fetal-medicine physician who pointed out that my schedule may not be the healthiest option. Now that I have had three weeks on a reduced schedule, I already feel the pangs of guilt.

“What is your career trajectory?” I asked myself.

“What is going to happen to your career if you slow down?”

“Are you as valuable if you’re only working part time, or if you stop working?”

I know I would not tolerate these questions if they were asked of a friend. But too much first-generation upbringing, too much Catholic school, and the strong imprints from nine years of medical training make for a pathologically strong guilt complex.

My 4 a.m. research changed. I shifted from researching what outcomes are for patients with late second trimester bleeding, to what the outcomes are of women (and men) who take medical and family leave. Unfortunately, what I found just added to my worries. There is a wealth of evidence that women who take longer leaves are perceived as less hireable,(hbr.org) less dedicated to their work and less dependable. The same holds true for research that included men. Strong letters of recommendations and strong relationships with peers were equalizing forces. Not surprisingly, shorter leaves are better tolerated.

What seems to be the best tolerated (and often the hardest to access) is partial leave. Women and men who stay connected to their job with a reduced schedule seemed to have the best career outcomes and satisfaction. A potential common theme here is that “making it easier to be a working mother(pubs.aeaweb.org) may matter more than the length of leave or the payments that new parents receive while out of the labor force.”

This inherently makes the most sense to me. I am not a mom or a physician. I am both. And regardless of where I am, I am both 24 hours a day. And now I am a pregnant woman, a mom and a physician 24 hours a day.

It continues to be a mental hurdle to hold myself back from taking more shifts, from watching the COVID-19 numbers rise and know that I will not be on the front lines of the pandemic like I was in the spring. I may indeed sit something out, which is something I don’t often do.

To be clear, my colleagues, supervisors and institution have been immensely supportive. I am clearly my own hurdle. I have, predictably, found other projects to fill my time, from home, while continuing to do the clinical work that I can manage. What I know most clearly about doing this work, as a family physician, and as a mom, is that everyone has their own needs and balances. And being on the needier side for the last few weeks, and next few months, shines a light on how we as women and physicians don’t always listen to our own needs until they become blatantly obvious to others. And we need to do a little more a little earlier, to listen to ourselves and one another, to learn how to lean out, with support from our colleagues and institutions, so we can balance all aspects of our health.

MaryAnn Dakkak, M.D., M.S.P.H., practices full-scope family medicine and is a clinical assistant professor at Boston University Medical Center. She is Women’s Health Director at Manet Community Health Centers. Her views do not represent those of the organizations with which she is affiliated.

Posted at 05:30AM Oct 29, 2020 by MaryAnn Dakkak, M.D., M.S.P.H.

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