I once told my husband on a whim, while we were hanging up our seemingly endless pile of laundry after returning from an overseas trip, that I do not think I want kids. Immune to my random rants, he calmly asked how I had come to that conclusion. Lamenting, I told him: if I could barely keep on top of laundry for two people, how would I ever manage laundry for a family? After all, we had previously talked about wanting two kids. Amused, he replied, "Laundry is not an excuse not to have kids."
Amid Singapore's falling total fertility rate, I too find myself wondering what it would take for me to start a family. As a resident, I find myself thinking about juggling the demands of residency and the responsibility of nurturing the healthy growth and future of a little being. We are expected to learn, perform, take on increasing responsibilities, do well for examinations and progressively become the specialists we aspire to be. Similarly, we also want to do well in our postings, successfully complete training and excel in our chosen fields.
I have enormous admiration for my peers who have embarked on parenthood during residency, particularly the women who have navigated pregnancy, miscarriage, maternity leave and the postpartum period while continuing to meet the demands of their training. Sometimes I look at them and wonder: how did they do it? At other times, perhaps more uncomfortably, I wonder: would I be able to do the same?
Other questions have also crossed my mind. Would taking maternity leave cause me to be perceived as being less invested or capable in my training and career? Would I fall behind my peers as they continue their training while I am away? Would I be seen as someone who is less willing to make the sacrifices needed to succeed? Would I be letting my team down by being absent from work to manage the demands of childbearing or child rearing?
Residency training shapes our parenthood choices
I am glad to know that I am not alone in having these concerns.
An unpublished survey was conducted by a group of National University Health System (NUHS) resident leaders, surveying residents across 17 NUHS residency programmes. The survey found that 70% of respondents (n=86) felt that residency training had delayed their decision to have children, while 70% cited career progression concerns in parenthood decisions. Of residents who were parents (n=36), 80% had concerns about the impact of parenthood on their careers.
Other findings also stuck with me. Surveyed residents reported significant concerns about the demands and inflexibility of training: 84% cited lack of scheduling flexibility and long working hours, 80% cited night duties and examination commitments, and 62% reported difficulty using parental leave.
I am fortunate that being in the National Preventive Medicine Residency Programme, I am allowed considerably more flexibility in leave requests than in the clinical training environments. I know that if I need to attend a medical appointment, I can generally do so without feeling that I am leaving my team short-handed in the wards. Should I need to plan for maternity leave, I do not have to worry about returning to find that months away have affected my clinical acumen or procedural skills. We also do not do calls, which means I do not have to imagine combining pregnancy or caring for a young child with the physical exhaustion of being post-call.
Like any other residency, our training in public health is not without its stresses and demands, but I really appreciate the greater capacity that our work allows in accommodating the realities of personal life. I am well aware that that capacity is much harder for my clinical counterparts to find.
And yet, as a senior resident, in some ways I feel more pressure than ever to make the most of these final years of training. I think back to my registrars and residency seniors who had children during residency – some even twice – and wonder how they navigated this especially demanding phase of training alongside pregnancy and parenthood. I also wonder how these stresses might have affected their pregnancies.
Uncertainties of pregnancy
I know of residents who have experienced miscarriage, sometimes more than once. Among the surveyed female residents who had been pregnant, 18% had experienced miscarriages, 23% faced intrauterine growth restriction and 9% had preterm deliveries. I cannot imagine how difficult it must be to face such pregnancy complications while navigating residency training, as well as the impact on their mental health and marriage. I am also not confident if I would be resilient enough to put myself through it.
Even if I overcome the question of whether I can juggle parenthood with residency, there is another uncertainty: would I be physiologically able to conceive? In the resident survey, 23% reported difficulty conceiving, which was defined as taking more than six months to conceive. Of those residents who had children or were trying to conceive, 4.4% had undergone fertility treatment.
I have seen friends and family go through cycle after cycle of fertility treatments, facing disappointment after disappointment, each time having their hopes raised and then having to cope with the loss. It made me realise how much of parenthood is ultimately beyond our control. Being able to conceive, carry a pregnancy and bring a healthy child into the world is indeed a blessing in itself.
Making space for parenthood in residency
I have been told that having children is not a logical decision. Parenthood comes with financial costs, health risks, career implications and an enormous amount of uncertainty. Wiser friends told me: have a child only if you really want one. I agree.
I do not yet know if or when I will become a mother. I do not know whether it will be straightforward nor do I know the amount of heartbreak I will have to endure. And I certainly have not figured out how I will manage the never-ending pile of laundry that comes with having children in the household. But I do know that parenthood will always involve sacrifice. I just hope that the way we structure training does not make that sacrifice harder than it needs to be.
Living as a DINK (dual income, no kids), some may question whether I have the moral authority to talk about the challenges of parenthood at all. I do not claim to know what parenthood in residency is like. But I hope I have fairly echoed the sentiments of a generation of younger doctors who are ready or of the age to start families, while also trying to reconcile that desire with the demands of a profession they have worked so hard to enter and hope to excel in.
These challenges are not unique to our generation or even our profession. Many of our seniors have had their own difficult experiences: missing their child's birth because they were called back to do an emergency surgery, or missing milestones as their children quietly grew up while they spent long hours at work treating patients. But I believe our profession has come a long way in recognising the importance of our medical workforce's wellbeing. Perhaps we could also ask ourselves how the medical fraternity can go one step further and better support our junior doctors through parenthood during training.
The answer is not to make residency easier or to lower the standards we expect of our residents. But perhaps it is to ask how the same rigour of training can be arranged differently, in ways that allow our doctors to develop into excellent specialists while also having the space to build the families they hope for. And perhaps those who have been on this path before have the best insights and are in the best position to help make that change.
Acknowledgements
I would like to thank Group 3 of the NUHS Residency Leadership Development Programme (Cohort 10) for being the inspiration for this commentary and for allowing me to share the findings from their survey.
