Parenting in Orthopaedics - A Global Perspective

Sheanna T Maine, FRACS, AUSTRALIA Ciara M. Stevenson, MBBCh, BaO, FRCS(Orth), UNITED KINGDOM

ISAKOS eNewsletters   Current Perspective 2025   Not yet rated

Introduction

Wanting to be, struggling to become, and being a good parent are the day-to-day challenges of everyday lives. Add in 15 years of surgical training, competitive high-stress environments, and a societal expectation, and it’s no wonder why parenting orthopaedic surgeons feel like they are constantly plate-spinning….and burning out.

In March 2024, the ISAKOS gender and diversity task force hosted a webinar that explored the challenges faced by orthopaedic surgeons as parents. We present a narrative review of the discussion to raise awareness, stimulate discussion, and, hopefully, provide workable solutions within our global community.

Fertility and Family Planning

Orthopaedic surgery is the surgical specialty with the lowest proportion of women. Hiemstra et al. conducted a systematic review in 2022 to evaluate the challenges related to family planning, pregnancy, and parenthood¹. The authors found that female orthopaedic surgeons were twice as likely to experience pregnancy-related complications than the national average, with 67% of surgeons delaying child-bearing due to their career choice. They also noted that the mean age of a female orthopaedic surgeon at the time of their first child was more than a decade older than that in the average population. The elephant in the room is that orthopaedic surgical training does not match our fertility windows. Put simply, we are destined to fail.

If we look specifically at the female fertility timeline, the best egg quality is between the ages of 18 and 29 years, which corresponds to the time when surgeons are in medical school and internship. After the age of 30, a woman’s egg quality starts to decline just as she is about to start orthopaedic training/residency. Over the age of 35 years, egg quality reduces significantly, and the risks of chromosomal issues increase (Figure 1).

Fig. 1 Female fertility timeline.

In 2020, Kim et al. distributed a questionnaire in the United States (USA) and found that, compared with male surgeons, female surgeons had fewer biological children and were more likely to require IVF assistance². The authors also noted that, when compared with female non-surgical partners, female orthopaedic surgeons were almost a decade older at the birth of their first child, more likely to work more than 60 hours per week, and more likely to have pregnancy-related complications. These differences remained significant after controlling for age, race, and ethnicity.

Pregnancy loss is heartbreaking, and yet 42% of female surgeons in the USA have experienced it—more than double the rate in the general population. Following miscarriage, 75% of female surgeons took no time off work, and, following a still birth, 45% of surgeons took less than 1 week². Surgical training programs should consider offering bereavement support and mandated leave after pregnancy loss to reduce the burden of guilt associated with taking time off work. It’s time to change the narrative.

If I knew then what I know now, what would I do differently? This was a question asked of our more established orthopaedic surgeons during the parenting webinar. The answers were as follows: (1) be proactive about fertility, (2) don’t delay starting a family, (3) take time off during IVF cycles, (4) reduce working hours in the latter stages of pregnancy, and (5) reduce the physical demand of your practice to the extent possible during pregnancy.

Cultural change and open discussion may enable trainees to make better-informed decisions about the timing of attempts to become a parent. ISAKOS encourages established surgeons who are parents to join the conversation and to provide visibility and mentorship. We commend organisations such as the Canadian Orthopaedic Association for setting the example with a position statement addressing these fertility and family planning issues³.

Travelling Fellowships

Passing the fellowship/board exam is usually a brutal and demanding experience for trainees and their families. Once the trauma of a grueling study regimen has been rewarded with the elation of passing the exam, a fellowship can then put yet additional stress on our careers. It is common to be juggling a young family as well as the expectation of a fellowship early on in your career. If you have a working partner, your options will in part be dictated by their flexibility as well as the demands placed upon you by your family.

While it may seem like a good idea to compete for the best possible fellowship available, it is also important to ensure that your family has the capacity to manage the demands that this will place upon them. It is therefore important to communicate well with your fellowship supervisors and family to ensure that you all have a good understanding of the fellowship expectations as well as time and financial commitments. Don’t be afraid to say no if the fellowship does not suit your family. It may not feel like it at the time, but your career is not entirely dependent on those one or two years of training. The career will always be there, whereas you only get that time with your children once. It is incumbent on fellowship supervisors to provide the flexibility in their roles, keeping in mind that the best orthopaedic trainees are not necessarily those without a family or those prepared to sacrifice their family for the sake of their training.

Short travelling fellowships that require a brief period of absence from home also can cause internal conflict. Clinical child psychologist Dr. Alanna Keirans provided valuable insight during the webinar to highlight the impact that parental absence can have on early child development. She introduced the concept of values and enrichment and explained that, by competing for these prestigious fellowships, we can become role models for our children and give them a sense of work ethic, ambition, and achievement. She made the point that physical distance does not mean psychological absence and that, while being away from home, parents can use technology to bridge the gap with regular contact. Techniques to include children in the travelling fellowship such as interactive maps and treasure hunts make the process an exciting adventure and changes the narrative significantly.

A valid point made by Dr. Keirans was that some parents can be at home all day with their children but not mentally present, engaged, or providing the learning opportunities that they need. A surgical parent who is happy and fulfilled will prioritise their time to be fully present with their child. This will often provide more meaningful play and connection essential to their development. Parental guilt is there to keep us in check and to make us pause, reflect, and rebalance.

Finding the Balance

The juggling act of being a parent and an orthopaedic surgeon is difficult. Previous generations may have had “stay at home” partners, but it is more common in 2024 for households to have two working parents. This is particularly difficult in a two-physician family, in which both partners have on-call commitments. Within our global community, marriages have ended and relationships have failed when an imbalance of shared care has created a disconnect between partners.

Childcare often does not open until after work starts and closes before theatre lists finish. Departmental meetings are often scheduled at children’s bedtimes, which forces orthopaedic surgeons to make difficult choices and sacrifices. A common theme during the webinar was that the surgeon will prioritise children’s bedtimes and then catch up on paperwork late into evening, often sacrificing meaningful time to catch up with their partner or friends.

Most surgeons across the globe describe finding a rhythm and holding it together until an attack of norovirus, chest infections, head colds, and flu add to the physical exhaustion of it all. The stress of not being able to send your sick child to daycare, the tension between parents as to whose job takes priority, and the guilt of not being present to care for your sick child all contribute to this exhaustion. We explored this topic with our colleagues from Hong Kong, where it is part of the culture to have “live-in” help. The “household worker” handles the cooking, cleaning, and childcare. Our orthopaedic colleagues concluded during the webinar that this arrangement allows them to prioritise the time when not at work to be fully present with their children instead of doing laundry or grocery shopping.

Prioritising self-care is essential. Often, this is an afterthought after a busy day of surgery and constant juggling, but it is vital to set aside time to exercise, meet friends, and connect with your partner. This was felt to be an essential requirement to avoid burnout and maintain relationships. Be selective on your roles and outsource household tasks. Some are lucky to have immense family support, whereas others rely heavily on childcare. Balancing work and family responsibilities is possible but requires a lot of organisation and planning. Shared calendars can be helpful, and clear communication is important.

Returning to Work After Leave

Returning to work following the birth of a child is challenging. There is no easy solution, and there will always be an element of sacrifice, be it time and connection with your child or the experience and continuity of your role as a trainee or surgeon. One of the most critical elements in returning to work is the perception of dedication and commitment to your job. The conversation around parental leave regardless of gender is critical in defining boundaries and not succumbing to the implication that someone is not committed to their job because they feel it necessary to spend time with their newborn.

Massachusetts General Hospital (MGH) and Brigham and Women’s Hospital, both affiliated with Harvard University, recently introduced the Supporting Our Physician Parents program, which serves as an example of how childbearing surgeons could be supported⁴. The structured program for postpartum junior faculty physicians and fellows facilitates return to work with coaching sessions, lactation stipends, support groups, and a program for emergency backup pump supplies. A post-implementation survey showed strong agreement that the program contributed positively to physicians’ health and well-being.

Many female surgeons fear that they will lose surgical skills after an extended period of leave following childbirth. While this is not necessarily justified, it does impact confidence. Some facilities offer the ability to return to work in a staged manner, being facilitated by mentors or while assisting. This does seem to provide an opportunity to recover both technical and judgment skills, as well as integrating back into the workforce, while also developing the multitasking and logistical skills required to care for a small child while working.

Norway has some of the world’s most progressive legislation when it comes to parental leave. Paternity leave matches maternity leave and removes some of the perceived gender bias around caring for children⁵. With each parent able to take one paid year off work, it promotes gender equality and helps to distribute the burden of care across both parents. Women can return to work and men are able to connect and engage with their children (Figure 2).

Fig. 2 Maternal and paternal parental leave in Norway.

Global organisations such as ISAKOS have a responsibility to their members to promote excellence in orthopaedic care. This is now being recognised to include the well-being of care-givers. Previous generations have been steadfast and resolute in the promotion of orthopaedics above all else; however, this has frequently come at the expense of themselves and their families. Moving forward, conversations about the challenges that we all face as surgeons and parents can only serve to improve our mutual understanding of those issues. We can work as a global community to draw on solutions that in turn will benefit ourselves and our patients.

Conclusion

Parenting in orthopaedics is challenging. Not everyone wishes to or is afforded the opportunity to become a parent, but, if you do, surround yourself with good friends and family who can help. Invest in high-quality childcare and outsource what household duties you can afford to. Value quality time and be present with your children, but don’t forget to aim for the stars and give them a parent to be proud of.

References

1. Morrison L, Abbott A, Mack z, Schneider P, Hiemstra L. What are the Challenges Related to Family Planning, Pregnancy and Parenthood Faced by Women in Orthopaedic Surgery? A Systematic Review. Clin Orthop Relat Res 2023:1;481(7):1307-1318
2. Rangel E, Castillo-Angeles M, Easter S, Atkinson R, Gosain A, Hu Y, Cooper Z, Dey T, Kim E. Incidence of Infertility and Pregnancy Complications in US female Surgeons. JAMA: 2021;156(10):905-915
3. Supporting Pregnancy and Parental Responsibility in the Orthopaedic Profession and Throughout Orthopaedic Training – A position statement from the Canadian Orthopaedic Association. June 2024
4. Li JH, Hanley LE, Powe CE. Supporting our physician parents: a pilot program for parental wellness at the Massachusetts General Hospital. J Clin Transl Sci 2023;7: e238
5. Au S, Bellato V, Carvas JM, Córdoba CD, Daudu D, Dziakova J, Eltarhoni K, El Feituri N, Fung ACH, Fysaraki C, Gallo G, Gultekin FA, Harbjerg JL, Hatem F, Ioannidis A, Jakobsen L, Clinch D, Kristensen HØ, Kuiper SZ, Kwok AMF, Kwok W, Millan M, Milto KM, Ng HJ, Pellino G, Picciariello A, Pronin S, van Ramshorst GH, Ramser M, Jiménez-Rodríguez RM, Sainz Hernandez JC, Samadov E, Sohrabi S, Uchiyama M, Wang JH, Younis MU, Fleming S, Alhomoud S, Mayol J, Moeslein G, Smart NJ, Soreide K, Teh C, Verran D, Maeda Y. Global parental leave in surgical careers: differences according to gender, geographical regions and surgical career stages. Br J Surg. 2021 Nov 11;108(11):1315-1322. doi: 10.1093/bjs/znab275. PMID: 34467970.

Please note: ISAKOS Newsletter Current Perspectives are not peer-reviewed articles. For peer-reviewed articles, please visit the Journal of ISAKOS at jisakos.com.