Pregnancy of the Early-Career Psychiatrist

The most common time for physicians to become pregnant is near the end of training or soon after training is complete (1), which means that many early-career psychiatrists are also early-career mothers. In 1990 a total of 43 percent of residents in psychiatry were women (2). These residents are now in their early careers. It follows that as we approach the end of the decade, a substantial number of early-career psychiatrists are planning their families or expanding them. In 1990 a membership survey of the American Medical Women's Association found that the primary concern of its members was maternity (3).

Much of the literature on the psychiatrist's pregnancy is about the patient's reaction to the pregnant therapist. The most significant of these contributions were made more than a decade ago and were written largely from a psychoanalytic perspective. Workplace issues are addressed in more recent articles that focus on residency training during pregnancy. Maternity-leave policies for residents and conflicts about the increased workload for colleagues have been covered. To date, these concerns have not been addressed for the early-career psychiatrist. The purpose of this paper is to provide a single convenient resource that addresses issues that arise during a practicing psychiatrist's pregnancy.

Methods

A MEDLINE search was conducted. Literature on the pregnant physician, the pregnant therapist, and the pregnant resident was reviewed. Recommendations found in these resources were combined with the author's observations, and this paper describes common problems and practical strategies for the psychiatrist who is pregnant.

Results and discussion

The psychiatrist-mother

The potential impact of the job on the health of the pregnant physician and her baby is an understandable concern. Pregnant physicians have long been thought to be at increased risk of having an adverse outcome (4). Klebanoff and associates (5) refuted the notion that pregnant physicians are in a high-risk group. Using results from a large national questionnaire-based survey about pregnancy and work, they compared the responses of women residents to those of wives of residents. The results revealed no difference in outcomes for pregnant female physicians and for other pregnant women of similar socioeconomic status. Only physicians who worked 100 hours a week or more had an increased risk of preterm delivery. The rate of delivery of low-birth-weight infants was lower than that in the general U.S. population. The most comprehensive study to date is reassuring about the effect of work on the physical outcome of pregnancy among physicians.

A risk exists that the pregnant psychiatrist will fail to recognize emotional needs during pregnancy and may even take on more work to prove her capability. Counterdependent defenses are most likely to be manifested by those who are invested in maintaining an identity as a strong, capable, and independent woman (6).

A woman can reinforce this image of herself in several ways. For example, a physician may ignore her obstetrician's advice to reduce her work hours. She may convince herself and others that she is indispensable and may rationalize that her obstetrician is overly cautious. She may not stick to her part-time work schedule because she is too busy to leave the clinic on time. She may take telephone calls from her hospital bed when she is unexpectedly admitted for observation because of a pregnancy complication.

The superwoman fantasy is often at the root of such denial, and this fantasy is directly challenged by pregnancy. It may be the first time the physician has felt physically limited. She is confronted with being a wife and mother in addition to being a doctor (7). However, she may not feel as confident in any of these meaningful roles as she thinks she should.

Most physicians' husbands are supportive during the pregnancy (1). About half of the husbands are also physicians (8). Besides a woman's husband, her female peers with children are often good advisors. An obstetrician who frequently sees professional women—and after the birth, an understanding pediatrician—can also be helpful. It has been reported that of all physicians, women over 40 as a group are the most supportive of their pregnant colleagues (9). Sinal and colleagues (1) reported that women physicians with children seem to be as satisfied with their careers as those without children, but that those with children are less satisfied with the time they have for their husbands and for themselves.

Because more women are becoming physicians, it is likely that more medical couples will be struggling to prioritize career goals, provide child care, and divide mundane household duties. The chances that a caring couple will become a nurturing family are improved if communication is optimized, daily tasks are shared, and each respects the other's need for professional growth.

Some couples benefit from professional help in sorting out mutual career and family priorities. Nadelson and Notman (10) wrote about some of the typical problems in the woman physician's marriage when two careers must be considered. Less is known about challenges to the single or gay physician parent.

The struggle to balance career and family is often unanticipated. The early-career psychiatrist who has postponed pregnancy in favor of work may not be prepared for the contentment she experiences with motherhood (11). A new psychiatrist-mother expressed this contentment by saying she had not fully appreciated the sheer pleasure she would feel simply holding her baby daughter. Because of the intensity of the mother-infant bond, the psychiatrist may doubt her commitment to medicine. Having been comfortable in her identity as a physician, she now has the challenge of integrating two potentially all-consuming roles.

Fenster and associates (12) pointed out that the peak period of emotional stress is likely to occur during the first few months postpartum because of physical fatigue, the need to meet the infant's demands, and what Winnicott (13) referred to as "primary maternal preoccupation." For the psychiatrist-mother, it may be difficult to temporarily abandon her infant in favor of her patients. If she is breast-feeding, she has the additional physical reminder of her infant.

Feelings are sometimes mixed. The mother may feel guilty not only about returning to work but also about wanting to return to work. A part-time schedule for the first few weeks can ease the transition back to the workplace. Most professional mothers navigate through the pregnancy and postpartum months to find that the trade of one identity for another is ultimately replaced by an integration of both identities.

Early in one's career is a time to lay the foundation for professional achievement in academia. Those who devote the most time to their careers seem best positioned to achieve at the fastest rate. For the first time in her career, the psychiatrist-mother may be falling behind her male peers in salary and in professional recognition. The early-career psychiatrist who is at the same time building a healthy marriage and family may be akin to the tortoise who travels at a slower pace but keeps making steady progress toward the goal. One way for the psychiatrist-mother to ease her feelings of inadequacy and frustrated competitiveness is to realize that she does not have to emulate the male colleagues she admires. She can develop her own timeline to accomplish her career goals.

For the practicing physician, no professional recognition for parenting is obvious. However, pregnancy and childrearing have benefits for one's psychiatric practice. As pointed out in an editorial in the New England Journal of Medicine, a physician's experience as a mother may ultimately mean as much to her development as a physician as did her training (14). For instance, her experience of the life cycle will broaden by having a child of her own, and thus she may better understand the complexity of multigenerational issues and of parenting decisions. She may return to work with a more complete awareness of herself and of her patients.

Patient care

Patients' reactions to the psychiatrist's pregnancy vary, depending on their sensitivity to abandonment issues, the psychiatrist's stage of pregnancy, and patients' investment in the psychiatrist. Times during the psychiatrist's pregnancy that threaten abandonment are pivotal in the therapeutic relationship with vulnerable patients. Four such situations are the announcement of the therapist's pregnancy, the final appointments before maternity leave, the beginning of leave, and the return to practice.

The patient who fears separation is vulnerable on learning that the psychiatrist is pregnant, usually in the first or early second trimester. This knowledge can acutely destabilize the patient. During the final appointments, when the termination phase is under way and arrangements are being made for the psychiatrist's leave, the patient may act out in an effort to maintain the attachment. Unconscious expressions of anger may be made toward the psychiatrist, her baby, or the approaching leave.

Once the maternity leave has commenced, the patient has in reality been separated from the psychiatrist at the same time the new baby has displaced many other concerns of its mother. The patient may have an accompanying fear that the psychiatrist will never return or will never be the same. On the psychiatrist's return to work, the patient's fantasy that the psychiatrist is able to meet every need is sometimes replaced with the knowledge that she has a real life with competing interests.

Many patients react to the pregnancy in the same way that others do, with increased familiarity, friendliness, and basic human interest. For most clinicians, these reactions are pleasant. Some psychiatrists expecting their first child or some who highly value strict boundaries between patients and professionals may be uncomfortable. Most patients' responses to the pregnancy are socially appropriate, but sometimes reactions reflect anger about the pregnancy. Anger commonly stems from themes of rejection, sibling rivalry, oedipal strivings, and identification with the therapist or with the baby (15). These reactions have been well described (6,12,15,16,17). In a general practice, patients who have minimal investment in their relationship with the psychiatrist, such as those seen in a one-time consultation, are most often congratulatory.

Although patients who rely heavily on the psychiatrist are often more vulnerable during her pregnancy, it is not only long-term psychotherapy patients or those with primitive personality structures who may have strong feelings about the pregnancy. Sometimes patients who have been categorized as medication clinic patients or supportive therapy patients react strongly to the news of the pregnancy. Whereas some have psychopathology that was not previously apparent, others have individual issues related to pregnancy, such as sexual trauma, infertility, or prominent dependency needs (18). The psychiatrist may inadvertently discourage patients from working through conflicts by denying that her pregnancy is of significance to them. She may deny that her patients know that she is pregnant. She may be uncomfortable with her patients' anger in an unconscious attempt to protect the baby (16) or her own joy about impending motherhood.

Alternatively, the psychiatrist may be affectively unavailable or may secretly wish the patient would leave therapy (19). For some psychiatrists, empathy wanes with physical discomfort, and they risk trivializing the patient's complaints, especially somatic preoccupations. When patients fail to acknowledge the pregnancy or are prone to act out or the psychiatrist has questions about boundary concerns, supervision with a trusted colleague is advisable. Exploring the therapist's reactions and addressing the patient's conflicts provide an opportunity to avert acting out and to make therapeutic gains.

Many psychotherapists apparently believe it is therapeutic for the patient to bring up the pregnancy first. If the therapist makes the announcement, it could reflect her need to talk about her pregnancy, which may prevent the patient from working through relevant conflicts. However, some patients feel uncomfortable bringing up their psychiatrist's pregnancy, or they may be in denial about it. Men tend to comment later and less directly about the pregnancy than women do (16).

If the patient fails to comment on the pregnancy, the psychiatrist can initiate the discussion, giving each patient two to three months for termination of the therapy (20). For sicker patients, it has been suggested that disclosing the pregnancy at the end of the first trimester gives additional time to process termination (21).

The psychiatrist may find it helpful to set a date by which all her patients are aware of her pregnancy and upcoming leave (12). The psychiatrist should consider not initiating treatment in difficult or long-term cases if an extended leave is anticipated. Patients who have significant abandonment issues, such as those with borderline personality disorder, are likely to have the most difficulty (21).

In some cases, an interim psychiatrist is needed (22,23). Other patients have minimal needs during the maternity leave, which can be met by their primary care physician or nonmedical therapist. For some, it is sufficient to have the phone number of a secretary or an office to call in case questions arise, have the name of a backup psychiatrist, or understand where to go for emergency services. In case the psychiatrist needs to leave sooner than expected, every patient needs to be clear about the plan and agree to it in advance of the scheduled absence. Before the psychiatrist begins her maternity leave, she can tell concerned patients that all is going well, if that is true. After the birth and when maternity leave is under way, patients who are anxious about the leave or who have impaired object constancy may benefit from a birth announcement that all is going as planned (24). Patients should be told when to expect the psychiatrist's return.

When the psychiatrist returns to work, patients may also have mixed reactions. Acting out can occur at this stage, but more commonly the psychiatrist is faced with baby gifts and inquiries about the infant. This culturally appropriate reaction can be confusing for the first-time mother, who has been taught to respect the boundary between doctor and patient. Besides fulfilling a cultural norm, gifts and questions about the baby may meet emotional needs of the patient. They may be a way to express affection, deny hostile or envious feelings, provide closure to the event, ensure the return of the psychiatrist, or attempt to be special to the psychiatrist. Imber (25) pointed out the patient's need to share the experience and, in some cases, to defend against a wish to steal the fetus away.

Although it is reasonable to consider the meaning of these gestures, it is also reasonable to allow patients to acknowledge the event (12). A range of appropriate responses exists, depending on the degree of privacy the psychiatrist believes is therapeutic for the patient and comfortable for her to maintain. It can be helpful to think ahead of time about possible answers to likely questions. For example, in handling requests to see baby pictures, some physicians choose to openly display family pictures, and others elect not to make pictures available in the workplace. A few patients require a great deal of care in working through the leave, some make satisfactory connections to other care providers, and many tolerate the absence well.

Relationships with colleagues

The relationships of pregnant physicians with their practicing colleagues have received little attention. Colleagues' feelings will most likely vary depending on the practice setting. In a small private practice, the burden of missed time due to pregnancy can seriously affect the care of patients and the workload of the health care professionals who remain. The less established psychiatrist may not have developed alliances with colleagues that can ease the transition into her leave.

This situation may bear some similarity to conflicts among resident groups in response to a pregnancy (9,26,27). These conflicts have primarily revolved around the increased workload placed on other residents during maternity leaves. Resentments have included the perception that pregnant colleagues receive special treatment, get time off, are less invested in medicine, and are selfish for not postponing pregnancy until a more convenient time (28). Greater indignation has been reported among male residents than among nonpregnant female residents, who tend to expect that pregnancies will occur (29).

Academic departments are not insulated from colleagues' concerns about pregnancy. A 1992 report about physician pregnancy summarizes the results of a questionnaire that was mailed to residents and faculty at a midwestern medical school (29). It found that although residents' responses were seriously split along gender lines, faculty members' replies were split on any one item. More male faculty than female faculty believed that women of childbearing age are a risk to the optimal functioning of a department.

An early paper by Nadelson and her colleagues (6) about the pregnant therapist mentioned the potential strain that pregnancy can cause in professional relationships. They suggested that both men and women sometimes envy their pregnant colleague, feel angry about having to assume extra work, and become oversolicitous as a defense against these feelings. Male colleagues may defend against sexual or maternal feelings through compliments on physical appearance. Two decades after these authors addressed the issue of relationships with colleagues, the issue is still pertinent for the pregnant psychiatrist. Although it can be helpful to recognize that unconscious motivations affect male and female interactions at work, it is equally important to appreciate the effects of practical issues on relationships with coworkers. The most important factor is probably the ability of the department to support maternity leaves and flexible schedules with some comfort.

The pregnant physician can take steps to help ease workplace tensions. She should notify colleagues of her pregnancy as early as possible to allow ample time for rescheduling and for coverage to be arranged. It is appropriate for her to be openly appreciative of those who help to cover during her absence (28). In some medical settings, staff are unaccustomed to working with a pregnant colleague. Both the pregnant physician and other staff may be naive about workplace protocol.

For example, in one instance a highly valued physician was the first pregnant woman to work in a certain clinical program. She was offended when she found that her schedule of patients ended a full month before her anticipated leave. She was unsure whether colleagues were overprotective or were sending a message that they could no longer depend on her. In another example, a secretary had scheduled a pregnant physician to see patients well past her due date. Although unconscious motivations may have contributed to these awkward situations, a psychiatrist may avoid such problems if she makes clear and early communications about her work plans.

Benedek (30) addressed the effects of a psychiatrist's pregnancy on paraprofessional staff when she described the impact of her pregnancy in the milieu of a residential treatment unit. She observed that feelings of staff members are similar to those of patients. They may feel joy, protectiveness, separation anxiety, denial of the pregnancy, or overinterpretation of the pregnancy's influence. She recommended that the psychiatrist share her personal plans gradually and obtain the team's advice in making treatment decisions that cover the upcoming absence. Inpatient units and partial hospital programs that have a stable staff may be similarly affected, although the effect on staff and patients in briefer, less intensive programs may not be as pronounced.

The medical workplace

The public has come to expect that women physicians will be available, but the medical workplace has been slow to adapt to the presence of childbearing and childrearing women (31). The manner in which reproductive women are integrated into the workplace is not a problem unique to women physicians but parallels that of other working women in the U.S. In 1978 a step forward was taken for working women when the Pregnancy Discrimination Act was appended to the Civil Rights Act. It bans workplace discrimination against pregnant women and forbids employers to ask prospective employees about their childbearing intentions (32). The Family Leave Act was passed in 1993, mandating employers of more than 50 people to hold an employee's job for three months during a period of family need.

Although the 1990s have been called the family-friendly decade, no consensus exists about workplace policies for pregnant women. The U.S. lags behind other industrialized countries, such as Canada, where 20 weeks of paid maternity leave is available for all workers, including medical residents and practicing physicians (14). Only 37 percent of U.S. companies offer paid parental leave (33).

Medical residents fare better than most working women in terms of leave. However, surveys conducted in the first half of this decade estimated that 15 percent to 25 percent of training programs did not have written maternity leave policies (34,35). Psychiatric residencies have been among the best in providing leave guidelines (35). Several authors have pointed out that institutional maternity leave policies for residents are highly variable nationally (34,36,37). According to some women, this problem continues.

The American College of Physicians (ACP) has recommended that a parent be the primary caregiver for at least the first four months after delivery and that leave begin two weeks before delivery (38). The lack of consistent leave policies is one factor that prevents pregnant physicians from complying with the ACP recommendations. Some have expressed the concern that if these and other allowances are made for pregnant physicians, additional costs to employers could result (35). However, a workplace that is progressive in promoting benefits for parents can make a great difference for women who combine medicine and motherhood. One study found that residents tend to mute their happiness about being pregnant when they are not in a supportive culture (39).

The woman who is choosing a practice may want to consider recommended guidelines for the resident workplace. The American Medical Association (AMA) ad hoc committee on women physicians suggests that residents analyze several characteristics of leave policies when selecting a residency program (40). The same factors can be important in a practice setting: duration of leave both before and after delivery, paid or unpaid leave, continuation of insurance benefits, whether vacation and sick leave can be accrued from year to year or used in advance, leave for adoptions and paternity, and whether schedule accommodations are allowed (40). Other favorable characteristics are an adequate number of women physicians, their equitable status in the department, and the availability of potential mentors. Flexible hours, part-time work or job sharing, on-site child care services, including emergency and sick child care, and breast-feeding conveniences are accommodations that may come to mean a great deal to the new psychiatrist-mother and her infant.

A 1997 survey of the best 100 companies for working mothers included only four health care companies or hospitals (41). The list included companies with large workforces as well as those with relatively few employees. Companies were ranked on pay, advancement opportunities, on-site and backup child care, opportunities for work flexibility, and paid maternity leave. The medical profession has taken stands in support of the mother and child. However, the business side of medicine does not appear to be taking the lead in making policies that are consistent with the recommendations endorsed by AMA, ACP, and training programs in various subspecialties.

Conclusions

Psychiatry is one of the medical specialties often considered an advocate for children, family relationships, and strengthening the maternal-infant bond. Psychiatry residencies are among the best in providing maternity leave benefits, and the specialty is predicted to continue its successful recruitment of women physicians. With this solid foundation, psychiatrists are well positioned to endorse workplace accommodations for parents.

However, basic information about the types of accommodations available for women psychiatrists practicing in a variety of settings is lacking. Little is known about the numbers of women who happily balance career and family or about those who could do so with some workplace modifications. Such data should be gathered to improve understanding of the needs of this growing segment of the professional workforce. To fully integrate women psychiatrists, it will be necessary for the profession to accept both of their meaningful careers—medicine and motherhood.

Dr. Tinsley is a consultant in the department of psychiatry and psychology at the Mayo Clinic and Mayo Foundation, 200 First Street, S.W., Rochester, Minnesota 55905 (e-mail, [email protected]). She is also assistant professor of psychiatry at the Mayo Medical School in Rochester.