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JACC Adv
JACC Adv
JACC: Advances
2772-963X
Elsevier

S2772-963X(24)00444-7
10.1016/j.jacadv.2024.101213
101213
Viewpoint
Beyond Parental Leave
Addressing Infertility, Pregnancy, and Postpartum Complications Among Cardiologists
Koczo Agnes MD koczoa@upmc.edu
a∗
Reza Nosheen MD b
Hayes Sharonne N. MD c
Freed Benjamin H. MD d
Gulati Martha MD MS e
Merz Noel Bairey MD e
Berlacher Kathryn MD MS a
Sunthankar Kathryn MD f
Tamirisa Kamala P. MD g
a Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
b Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
c Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
d Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
e Barbara Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
f Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
g Division of Cardiology, Texas Cardiac Arrhythmia, Dallas, Texas, USA
∗ Address for correspondence: Dr Agnes Koczo, University of Pittsburgh Medical Center, Scaife Hall S630, 200 Lothrop Street, Pittsburgh, Pennsylvania 15213, USA. koczoa@upmc.edu
21 8 2024
10 2024
21 8 2024
3 10 101213© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Graphical abstract

Key words

infertility
postpartum complications
pregnancy loss
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pmcCardiologists experience a disproportionately greater risk of complications on the road to parenthood as compared to their nonphysician counterparts. For many, difficulties begin with infertility, which is experienced at a reported rate of 1 in 4 surveyed physicians.1 A recent JACC paper reported about 38% of female cardiologists also experienced pregnancy complications, a rate nearly double that of their nonphysician counterparts.2 Issues including infertility and pregnancy complications are amplified among physician trainees, as training years often parallel periods of life in which individuals and/or their partners contemplate parenthood. As such, the focus on complications around parenthood as well as the search for effective support mechanisms is paramount.

Unique to physicians, young adult life is often filled with physical, emotional, and financial strains, including long working hours, complex tasks in the hospital, interrupted sleep, extended training into the late 30s, and the specter of repayment of significant education debt. Many of these aspects of training and early career practice may underscore the disproportionate rates of complications surrounding planning for parenthood among cardiologists and cardiology-trainees.

A recent focused session on this topic at the 2024 American College of Cardiology Annual Scientific Sessions highlighted programmatic and policy changes enacted at academic centers throughout the country that addressed challenges surrounding achieving parenthood (Figure 1). We highlight approaches undertaken by national physician organizations and the authors of this paper with their respective institutions from this session and from other sources. We also outline future focus areas for change.Figure 1 Implemented Policies and Programs Toward Addressing Parenthood Complications

Policies and programs as well as future directions targeting infertility, complication support networks, and lactation. AMWA = American Women's Medical Association.

Implemented programs and policies

Infertility summit/coverage at work toolkit

National multispecialty organizations, including the American Women’s Medical Association (AMWA) have spearheaded efforts toward actionable change to address infertility.3 Their 5-part strategic approach includes:1. to increase fertility awareness starting with early education in college and continuing through medical training,

2. to target both insurance coverage and access to fertility assessment and care among all physicians,

3. to ensure support systems among physicians that can provide both emotional support and wisdom during the fertility treatment journey,

4. to focus research highlighting the economic benefits of supporting fertility treatment among the physician workforce,

5. and to enact supportive policy from state to a national level.1,3

In partnership with RESOLVE, a national infertility association, AMWA organized annual physician infertility summits spanning 2021 to 2023 to accomplish these aims. One of their most actionable items features a “Coverage at Work” toolkit. This toolkit includes documents like letter templates for physicians to advocate for infertility coverage at their organizations at multiple levels, from human resources to institutional leadership. Their toolkit also includes infertility insurance coverage facts and resources. All seminar lectures and toolkits are readily downloadable from their website.3

Infertility, pregnancy, and postpartum complications support network

One of AMWA and RESOLVE’s strategic approaches is to ensure support systems for physicians provide emotional backing and wisdom regarding reproductive life events. Responsive to this, the University of Pittsburgh has created a support network for physician and physician-trainees to provide support and information about topics from infertility through postpartum complications.

To “construct a village” of support, a committee, including multispecialty program directors, convened a leadership team who were both impacted on a personal level and/or were passionate about supporting physicians who had experienced difficulties around reproductive issues. They constructed a 10-question/5-minute survey that was inclusive, short, and anonymous. Embedded in the survey were requests for personal recommendations on resources including supportive groups, mental health professionals, physicians, doulas, and faculty peers that they had found useful. From this, a list of local resources was created. The survey also sought to obtain qualitative information with open-ended questions including “what other topics can you provide support for” and “how else can we best support you?” A total of 11 support topics were identified: infertility, high-risk pregnancy, multigestational pregnancy, miscarriage, late pregnancy loss, neonatal illness, adoption, postpartum anxiety and/or depression, unplanned childlessness, breastfeeding difficulties, and egg cryopreservation/donation.

A Department of Medicine Grand Rounds at the University of Pittsburgh was held to raise awareness of issues surrounding parenthood and to introduce the support network.4 A best practice document was developed for support members, which included crisis and suicide network emergency contacts. There was also dissemination of the network both on physician and trainee listservs, as well as engagement of outside institutions to disseminate program implementation and solicit advice for future additions.

Breastfeeding/lactation support

Updated guidance by the American Academy of Pediatrics recommends breastfeeding for up to 2 years “as mutually desired by mother and child.”5 Physicians and trainees who breastfeed can incur many challenges in achieving this recommended guidance. Prior to returning to work, one barrier includes low breastmilk supply.6 This is an aspect of breastfeeding among physicians that is sparsely covered in studies amidst growing scientific evidence that focuses on benefits of breastmilk in both maternal and infant health. This can deeply impact physicians who may be well acquainted with the benefits of breastfeeding from the scientific literature, but data on low breastmilk supply is not adequately covered.

For cardiologists and trainees able and willing to breastfeed, additional barriers to recommended breastfeeding durations become apparent once returning to work. A prior survey by the American College of Cardiology noted that around 68% of cardiologists reported barriers to breastfeeding at work. Some of these barriers included trouble finding space to pump, time constraints for pumping, and trouble with low breastmilk supply.6 The Mayo Clinic conducted a trainee-specific single center survey and found that half of trainees (including cardiology trainees) reported breastfeeding cessation prior to 6 months.7 Several authors have undertaken approaches to address these barriers. At least one institution arranged for the location of lactation rooms, including portable/temporary units, close to procedural and operating room suites to accommodate physicians who have the greatest time constraints for pumping.

One academic medical center, the University of Pennsylvania, instituted a university-wide faculty lactation policy. This policy outlined a reduction in outpatient clinical effort equivalent to up to 30 minutes for every 4 clinical hours for up to 12 months after the birth of a child. It also mandated target relative value units to be prorated for leave as per allotted by the Family and Medical Leave Act. Further, it calls for equity on incentive opportunities otherwise available to faculty based on this prorated relative value units adjustment. Their strategic approach has been published for adaptation at other institutions.8

As noted, challenges around breastfeeding can impact trainees even more than practicing cardiologists. To help mitigate resource challenges, Vanderbilt University Medical Center obtained funding for at-work wearable breast pumps to be shared among physicians and physician trainees. In addition, a best practice document was created for resident trainees. This includes a stepwise approach to securing time for pumping during rotations. Support documents include letter templates to send for upcoming rotations to supervisors and established communication lines between the resident-parent and leadership advocates within medicine.

Focus areas for change

Improving insurance coverage for infertility treatment and cryopreservation

As noted, data suggest around 25% of birthing-capable physicians reported infertility diagnoses.1 This exceeds the reported national 13% rate of infertility.9 Investigations and treatment for infertility are often a time-consuming and expensive process. Physicians will often undergo numerous fertility specialist visits, lab work and imaging, followed by pharmacologic and invasive therapeutic interventions toward achieving a successful pregnancy. Prior surveys have noted costs from around $1,100 for fertility medications and exceeding $60,000 until pregnancy via in vitro fertilization was successfully achieved.10

These costs are typically unaffordable under trainee salaries and for young clinicians. A recent study collected information on insurance coverage for physicians among several top academic institutions throughout the country. They found many institutions do not provide enough coverage for even one cycle of in vitro fertilization, while many individuals require 3 or more cycles for successful egg retreival.10 For those looking to preserve fertility via egg, embryo, or sperm cryopreservation, an even smaller percentage of academic medical institutions offered specific insurance coverage for cryopreservation.10

Rethinking bereavement leave

The United States is one of the few countries for which there are no policies to ensure paid parental leave. Time off for up to 12 weeks following the birth of a child, including adoption, or for the care of one’s own medical condition is detailed under the Family and Medical Leave Act. However, there may be financial difficulties that result from this unpaid policy, which may compound if a trainee must extend their training time.

One solution may include expansion of these policies to include initiatives like flexible work hours. Bereavement policies exist among many training programs and hospital employers to offer time and support for physicians and their families following the loss of a partner or close family member. Pregnancy loss is not consistently included in these policies. While some physicians feel being at work with their colleagues may be helpful, they should be afforded flexibility and protected time if they prefer privacy. The current structure at most fellowships and health care institutions is such that you are either at work or not. This inflexibility can serve to create more stress for physicians who may only need short time periods off intermittently to attend therapy, support groups, or physician appointments. A progressive structure of paid time-off for bereavement in the setting of pregnancy loss should be offered by training programs and healthcare systems.

Directed counseling services

The emotional bereavement process following reproductive difficulties can be complex. As mentioned, the stigmatization of experiences including infertility and miscarriage can further complicate individual coping and support networks. Many hospitals and associated trainee programs have established confidential referral services. These include therapists and psychiatrists as well as peer-to-peer physician support.

Both trainee institutions and hospital systems should ensure their resources adequately cover support for these topics for both physicians and physician-trainees. Support resources and networks should be readily accessible and available to their trainees. Trainees and practicing cardiologists should also be provided resources to help navigate the legal requirements of institutions and hospitals for pregnancy and parental leave, such as The Center for Work Life Law (www.worklifelaw.org).2

Conclusions

For cardiologists who choose to pursue parenthood, the road can be physically taxing, emotionally difficult, and financially burdensome. Cardiologists and cardiology-trainees must be provided with support, flexibility, and counseling resources to change a culture of silent coping with infertility, pregnancy, and postpartum complications toward a destigmatized, caring community at work. Those in leadership positions, specifically training program leadership, division leadership, and hospital administration, must create progressive parenthood policies and build robust support structures so that physicians and physician-trainees who encounter parenthood complications have the tools, financial/insurance coverage, and community network to overcome these hardships.

Funding support and author disclosures

Dr Reza is supported by the 10.13039/100000050 National Heart, Lung, and Blood Institute of the 10.13039/100000002 National Institutes of Health under Award Number K23HL166961 . The content is solely the responsibility of the author and does not necessarily represent the official views of the National Institutes of Health. Dr Merz serves as a director, holds stock in iRhythm, and receives consulting fees from SHL Telemedicine. Dr Gulati serves as an advisory board member to Medtronic and Esperion. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
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