Transcript

MIC CAVAZZINI:               Welcome to Pomegranate Health, a podcast about the culture of medicine. I’m Mic Cavazzini for the Royal Australasian College of Physicians. In the previous episode we heard from participants of a simulation workshop to help paediatricians and other health professionals return to practice after extended leave, usually to have kids. There is some evidence that doctors who take six months or more off work lose their touch a little, and certainly they experience a drop in confidence. The idea is of the workshop is to brush off the cobwebs and build a culture of mentorship to support the transition back to work.

In today’s podcast we’ll hear how having children doesn’t just mean 9 or so months of maternity leave but leads to prolonged periods of part-time work. This in turn has impacts on a woman’s visibility in the workplace and the rate of career progression. To mitigate the so-called “motherhood penalty” requires a serious look at government legislation and culture in the workplace. And partners, too, have a critical role in pushing back against societal expectations about breadwinners versus caregivers.

This discussion is important because it relates not just to the wellbeing of individual medics but also to the depth and diversity of the workforce. In a large analysis of pay records from the UK’s National Health Service it was shown that at any moment, almost 4 percent of female doctors and dentists under 50 were on maternity leave. About three quarters of UK-trained doctors have a child over their career, a comparable rate to the average population although the age at which they have their first child is typically a few years later.  

Associate Professor Kara Allen is a clinician researcher who has examined the pressures on women within her craft group, the Australian and New Zealand College of Anaesthetists. She’s been running a return to work course for critical care specialists called CRASH that’s now in its tenth year.

KARA ALLEN:      My name's Kara. I am an anaesthetist, a specialist anaesthetist at the Royal Melbourne Hospital. And I have a Clinical Associate professor appointment at the University of Melbourne. And my background is in medical education.

MIC CAVAZZINI: Go on, Jenny.

JENNY PROIMOS: Hi, I'm Jenny Proimos, I'm a paediatrician, an adolescent health physician, and I'm doing a PhD looking at how we can create system change to advance women in leadership. And specifically, I'm looking at the role of colleges and other member organizations, such as professional associations, in doing that.

MIC CAVAZZINI:               Fabulous. Kara, there’s plenty of literature on how intimidating the return to work can be after a long break. I’ve already spoken about a survey of British paediatric trainees from 2020 with the title “Predicting risk of underconfidence following maternity leave”. It was found the re-entry was easier for those who had maintained some contact with their workplace while on leave. Were there any other standout findings from your studies that have informed how you do support colleagues on breaks and returning for breaks?

KARA ALLEN:      Yeah great question. Things like things like, you know, where is the breastfeeding room? Is it a 15 minute walk from the operating theatre or the ICU? In which case, nobody's going to use it. And we know that women do stop breastfeeding when they go back to work because clinical medicine does not generally structure itself in such a way. So, there's that sort of sense of, “I just need to keep my head down and get the work done, so that people know that I'm competent, know that I can do the job”.

MIC CAVAZZINI:                               Yeah, that was something that came up, I think, in Australian surveys as well as British ones and American ones, that the lack of available time and space for breast pumping, I suppose, rather than feeding. Jenny, what are the legal requirements on workplaces around this?

JENNY PROIMOS:             Well, breastfeeding is a protected ground of discrimination according to the Fair Work Act. So, employers are legally obliged to provide support for breastfeeding for people who are returning to work. Nevertheless, it's very hard when you're in a position of such a power imbalance and you're relying on these people for your job and for your training to be able to complain about something like this. And so, some of the research that we've done shows that people tend not to report it or not to complain. So, the leadership really has to take ownership of this and say, “Right, I'm going to make this work. You know, I'm going to value these people who are returning to work and I'm going to make this work for our organization”.

MIC CAVAZZINI: I think this is a theme that's going to come up a fair bit, that these requests shouldn't be seen as inconveniences by the leadership but simple rights. And in fact, the British trainees that were surveyed, when they were asked what aspect of returning to the job trainees found most stressful, sure, some of them mentioned practical procedures or remembering protocols as discussed in the last episode. But by far the most common response, in almost half of those surveyed, was the time pressures relating to work hours and childcare drop-offs. Similarly, in an Australian qualitative survey with the title “Merging Motherhood and Medicine” one registrar said, “I can’t just pull childcare out of thin air to be able to cover somebody’s sick leave.” Kara, how easy is it for a workplace to grant returning parents more flexibility with regards to caseload? Are there some departments that are more flexible or at least more understanding than others?

KARA ALLEN:      I would have thought Obstetrics and Gynaecology—you know, that's a very feminized workforce. But I know that there are definitely challenges within that workforce in terms of creating flexible work arrangements. And it is a 24-7 specialty in a way that perhaps clinic medicine is less inclined to be working at two o'clock on a Sunday morning. But I mean, anaesthesia is a specialty that should lend itself to part-time work fairly easily and also flexible work outside the standard nine to five. But our biases against flexible work practices have held us back from being innovative in terms of operationalising a huge pool of talent that we risk not accessing because we have a very rigid structure about the way that we approach clinical work. So, I completely agree with Jenny that it's a top-down experience.

MIC CAVAZZINI:               It is shameful that mothers are so impacted in the choices and success of their careers. A common theme across many of the studies I read was that doctors often delay their family plans to fit in with their career [and a quarter of them experience infertility]. Some have smaller families than they would otherwise choose, and some female anaesthetists that Kara and your colleagues surveyed had abandoned family plans entirely. I should note that medicine exaggerates trends that have emerged across the population already. So, for example, in 1981, only 15 percent of Australian women had a child while in their thirties, whereas now it’s about half of women. Our College, the RACP, did in 2023 introduce a flexible training policy, whereby interruptions in training for parental leave or medical leave would no longer count towards the total time limit for training completion. Jenny, you’re are a Fellow of our College. Do you know how this has this been received and is there anything more could the College do to make it easier for young parents?

JENNY PROIMOS:             In short, it's been received really well. And it's across many of the colleges that we've been talking with in our community of practice, it is seen as a bit of a it's seen as a really good exemplar of a flexible training policy. It's fair to say though, that most of the college, most if not all the colleges have flexible training policies of some kind. And the question is not so much what the college's policy says as much as how it translates into the workplace. And we in my research, my training survey, certainly a lot of trainees are saying, “it's all well and good having a College training policy, but I still can't get a part time job in my in my hospital”.

It's really interesting as a paediatrician, we've had flexible workplace, workplaces for many, many years, and just as men take time out, men take part time positions, et cetera. And yet within the same College in the adult division, it's much, much harder to find training programs, organizations that allow for part time positions. So how it translates at the workplace is very patchy and very different. And so, then it becomes a question of what power do the colleges have over the local workplaces or how can the colleges enforce their policy? And we've been exploring different mechanisms to do that. And it's different for each college to be fair. So, for example, the College of Surgeons, where there are far fewer job sharing opportunities, Fellows in that College are really keen that the College itself sets up a person within the College that actually can help trainees navigate finding part time positions, to take it away from the individual having to be the one to negotiate individually with a local workplace. There's been a lot of discussion about whether the colleges can incorporate flexible training positions into their accreditation process. And there's this huge appetite for that actually among the trainee population.

MIC CAVAZZINI:               I want to pan out now from this framing around practitioner wellbeing to the broader picture of workforce capacity. Australia’s National Health Workforce Data Set is extracted from unique AHPRA registrations but then synthesised to reveal a wide angle picture only. In 2022 there were over 115,500 medical practitioners in the Australian labour force. 44.5 percent of these were women, though when adjusted for full time equivalence, female representation was three points lower. If you look specialty by specialty, more feminized ones like paediatrics—59 percent women— tend to have a lower average of weekly work hours than those with very few women like surgery, at 15 percent. There’s also an inverse relationship between the proportion of women in the specialty and observed rates of extended leave. These trends would be very strong indeed if it wasn’t for a couple of outliers, including obstetrics and gynaecology mentioned earlier so there are also idiosyncratic differences between specialties that drive these relationships.

Back to the more granular NHS payroll data;  94 percent of female doctors without children are employed full time, but after having kids the picture changes dramatically and persistently. Immediately after maternity leave, new mothers typically return to work 3 or 4 days a week. Two years after their return, only about 40 percent are back to a full-time load and the contraction in hours persists right into the child’s first year of school. A similar finding came out of a study of large US physician records published in 2019. Even six years after completing specialty training, 23 percent of mothers were working part-time compared to under four percent of fathers.

If child-rearing has such an impact on the ability of women doctors to contribute to the workforce you’d expect some recognition of this issue at the level of government. Jenny Proimos told me that Australia’s Productivity Commission had not addressed it in any of its reports, and the National Medical Workforce Strategy up to the year 2031 only mentioned it in passing, but without putting numbers or detailed plans down. Interestingly, regulators do deal very seriously with doctors who have had a break from practice of three years or more. Both AHPRA and the Medical Council of New Zealand have a formal process which includes a return to work plan, periods of supervised practice, mentorship and workplace-based assessment through the relevant College. And remember how the COVID-19 pandemic prompted discussions about how to bring retired doctors and nurses back into the workforce to deal with surges in demand. I asked Dr Proimos whether applying such scrutiny to those taking just a year off would prompt more adequate levels of support, or instead, rolls of red-tape that could actually discourage people from coming back.

JENNY PROIMOS:             A couple of points on that. I think firstly, I'm not so sure that the regulators need to get involved in return to work for people on parental leave. And it would probably cost too much, I suspect to be prohibitive. Nevertheless, the principles behind, what the regulator expects are actually the right principles in terms of supporting somebody returning to work. So, the person who returns to work should be able—you know, if they were able to have a conversation with their workplace that says, “okay, what supports do you need?” “I need mentorship, I need whatever” or that the workplace is innovative enough to anticipate those things and offer them a series of supports around return to work. I think that would probably be a more palatable option. I think involving the regulators is probably overkill.

MIC CAVAZZINI:               Yeah. In the UK there is a formal program known as Supported Return to Training. It’s more than just a guideline for employers, it’s described at an NHS website as a centrally funded program that includes webinars, mentoring, simulation training. I suspect that this has been taken so seriously following the tragic saga of Jack Adcock and Dr Hadiza Bawa-Garba which I described in great detail in episode 34. For those that don’t remember Jack was a 6 year old boy with special needs who died of septic shock in 2011. Paediatric registrar Dr Bawa-Garba was found guilty of gross negligence and struck off the register. She was later reinstated after it was accepted that she had been dumped with responsibility for three different units on her first day in an acute setting after 14 months of maternity leave. Her consultant had been out of town for a lecture and the electronic medical record was on the blink. Now, I don’t want to make listeners paranoid about deskilling, just to ask whether that kind of Quality and Safety framing is helpful in bringing the attention that this issue deserves.

KARA ALLEN:      Yeah, I guess like Jenny, you know, the regulator involvement or a Quality and Safety lenses is, in my mind, a very much as a Safety-1 lens of what's gone wrong and where did it go wrong? Whereas, you know, I think if we take a Safety-2 perspective of most of the time things go right, you know, these doctors are well trained and the education theory would say that these are adult learners who are going back to work and so are able in many cases to identify where their gaps are.

My research suggests it is very common that people want that informal guidance or support when they go back to work and it is variably available. So, some departments are well set up, you know, return to your in-hours work where there were plenty of people around and a collegiate work environment where cases were expected to be discussed; and then with a graded return to after-hours work once you're feeling comfortable and confident about in-hours work— and other places operate more as if individual clinicians come in and do their work and there's no collegiate contact and then they go home.

I would like to draw a distinction between people who've had time off for parental leave and for sick leave versus people who've had interactions with the regulators that have resulted in enforced time off. We know that their outcomes are not as good. And you mentioned the returning to work after retirement, the outcomes are possibly not as good there either. That's a group that we don't have a lot of data on, so recognising that the process is quite individual is part of the employer's responsibility, I think, to a certain extent. And I'm not sure if there's clear regulator or Quality and Safety stuff that you could place around that without it seeming punitive.

MIC CAVAZZINI: Yeah, and when I bring up Dr Bawa Garba, I don't mean to say, “Oh look, we should be on tiptoes around women returning after maternity”. It's more that we should understand, and they themselves will understand their limitations and we shouldn't drop them in the deep end in the first week back. So, it's more of a systems response and a buffer to help people reintegrate. Jenny, do you have anything to add to that?

JENNY PROIMOS: Yeah, Mic, one of the things that we've been doing as part of my research is we've developed a community of practice amongst the number of College partners and member organizations that we have that are part of the Advancing Women in Healthcare Leadership initiative. And that includes many of the colleges, so College of Physicians, Surgeons, Psychiatrists, Anaesthetists, O&G, General Practice is just about to join, Dermatology, the AMA is part of it. So, we have a significant number of the colleges represented.

And one of the things that we have landed upon in terms of an output is to develop a Flexibility in the Workplace toolkit. And this is some of the work that did come out of the NHS after the Bawa Garba case, actually. So, over the next six months to a year, we will have something in place that hopefully the colleges can endorse and—I wouldn't call it standards, but set out a series of strategies and a series of supports for them to support all people who are either working flexibly or returning to work after a period of leave.

MIC CAVAZZINI:               To continue on the theme of workplace capacity, there have been some pretty cynical editorials over the years suggesting that in economic rational terms, female doctors are less productive. There was even one in the New York Times, written by a woman specialist, stating baldly that part-time medics are not a good investment for the taxpayers who subsidize their training. And that women waste scarce places in residency programs at a time when the workforce can’t keep up with demand. But it seems to me that if all it would takes to retain some of these women long-term is to invest in programs like PRAM or CRASH, it’s a no brainer are far as economic ROI is concerned. That might be a Dorothy Dixer, but is there anything you want to elaborate on that?

JENNY PROIMOS: So, the research is pretty clear that investing in women in the medical workforce is actually good for three different reasons. The first is there's the social justice reason. So, three quarters of the healthcare workforce is women. And you want to be able to see women at the top who represent the community that they are a part of. The second is that women leaders actually have significantly better outcomes in a range of different fields. And some of the work that's come out of, you know, some surgeons that have been here in Australia actually, as well as with Canada, showing that better surgical outcomes and less complications post-surgery from women surgeons. But the third is McKinsey, which is a big management consulting firm, released a report looking at women in the workforce and showed that women in leadership actually provide a better return on investment in organizations. So, increased profitability, increase return to the shareholder investor, et cetera.

MIC CAVAZZINI:               Not just because they get paid less?

JENNY PROIMOS: No, the bottom line. It actually affects the bottom line. So, having women leaders is important. Now, the reason why I raise that is because what we do know is that women leave the system all the way along. What we call the leaky pipeline so, you know, if they can't get the right conditions that they need for training they will not train in a particular specialty. If they can't get the right conditions as junior consultants or as consultants that are rising to the ranks, they leave the system and either go into public or go into part time, work or leave medicine altogether and there's a small proportion of women who do that. And so, actually, to support women through that career pipeline and to get them to the leadership at the other end is actually an important thing to do to ensure that we actually get better quality and safety, better business returns, better social justice for community as well at the other end.

NARRATION:      The “leaky pipeline” that Jenny Proimos refers to is easy to see.  Despite filling more than half of places in Australian med schools, women represent 45 percent of all medical practitioners and just 36 percent of specialists. Female representation among chief medical officers is similar but only 30 percent of school deans are women. Interestingly, alongside an analysis of NHS records published in 2014 it was stated that, “When working full-time, female and male doctors progress at the same speed …. to consultant posts.” That’s to say, that time spent out of the workplace is the biggest determinant of career progress. Remember, how I said that even after coming back from maternity leave, it took more than six years for women doctors to return to a full time load of work, on average.

Typically, these doctors are in their early thirties when they have their first kid. As noted by the authors of the US study I cited earlier, “The emergence of this gap [in hours] so early in physicians’ careers may contribute to later gender inequities in compensation and promotion and suggests the importance of expanding social and institutional support for work-family balance.” If we look at the pay gap, one study from 2016 showed that female GPs in Australia earned 24 per cent less than men and for specialists the disadvantage was around 17 percent. Similarly, in the UK, the average pay gap between male and female doctors was reported to be 18 percent. The authors of this BMJ paper, again, suggested that most of that pay gap was down to women taking more leave, engaging in more part time work and consequently building up the experience for job promotion more slowly. Controlling for these factors, they said, revealed a “true” gender pay gap of 5.6 percent among consultants.

I guess the air quotes the authors place around the word true indicate that the penalty faced by taking time out is no less gendered. I think of female participation in the workforce as being affected by push and pull factors. The push factors are the cultural expectations about gender roles that affect the dynamics within a couple. And the pull factors are the policies that would allow mothers and their partners to spend equal amounts of time at home, thereby both taking on a share of that career penalty. I asked Dr Proimos to elaborate on those impacts on career advancement .

JENNY PROIMOS:             Yeah, so one of the one of the things we do see, and what the research shows, is that men are more likely to do things that that increase their visibility. For example, they will take on committees, they will take on roles in the colleges, for example, they will do sort other things that they look upon as career enhancing opportunities.

And what we also know is that there's still in medicine quite a lot of shoulder tapping. So, the people who are around more are more likely to be shoulder tapped more for positions of promotion or to take on a particular project that might be seen as a prestigious thing to do or go on to a committee that's a prestigious thing to do. So, for women who are part-time, they might not be there, they might not be as visible and are not available there to be shoulder-tapped. And for a woman who perhaps is—or a man who's working part-time in order to balance their family responsibilities—they may not have the time to actually take on those committees in the same way and do those same things.

I've done a survey recently of the training experience across all colleges, and some of the qualitative comments that came back were really well, (a) disappointing but (b) quite shocking sometimes. Some of that “decisions are made on the golf course” thing still actually exists, even though we'd like to think that it doesn't. I suspect it doesn't exist as much as it used to, however, there is still a sense of that, you know, increased visibility, you know, you are top of mind and you are more likely to be offered positions.

MIC CAVAZZINI: It’s not the golf course anymore, it's the CrossFit Gym.

JENNY PROIMOS:             Yeah, possibly. The cycling! The cycling on the weekend.

MIC CAVAZZINI: That's right! And again, the authors of that BMJ paper say that once that time off component is controlled for, there is an extant pay gap of only 5.6 percent. And this is something that they don’t put data to, but they speculate that this is because female doctors focus more time on running services than those extra curricula roles that pad out the CV. Perhaps even in the absence of children to care for women have a different style of working, a different focus of their work. And perhaps we can add to that pile the trope that men have more confidence to apply for new and challenging roles or negotiate for a better salary. Kara what do you think about these explanations? Do women doctors just need to “lean in” as Sheryl Sandberg might put it? A grimace from Jenny.

KARA ALLEN:      I liked the person that said that leaning in really helped Sheryl Sandberg, but I'm not sure that it helped the standard female at Facebook or improved their lot in life very much. So, it's much easier to lean in if you're already in a position of power in an organization. And I think that's where, you know, women in leadership have this kind of dual responsibility to a certain extent to bring up other women behind them or with them that, perhaps, men don't experience in quite the same way.

In terms of what does “leaning in” look like, well some of it is about, are we valuing what women are doing? So, if women are taking longer in clinic because they're addressing some biopsychosocial aspects of care that are not otherwise addressed by their fellow clinicians, then isn't that something that's considered as valuable as being a member of the hospital's Quality and Safety Commission? And I ask that as a rhetorical question, because I know the answer is no.

MIC CAVAZZINI:               And that's a very repeatable result, that consults with women doctors are longer, not because they're wasting time because they're digging into the deeper stuff.

KARA ALLEN:      Yeah, which might be why a recent study of female anaesthetists that indicated that there were some physiological advantages to patients in having a female anaesthesia provider. That might be because the woman has, potentially spent a little bit more time understanding who that person is. We don't know, there's not that evidence, but we do know that women, as you say, work differently and I think, to a certain extent, that's not valued. We had a volunteer survey that we distributed to a thousand Australia and New Zealand College of Anaesthetist Fellows and then obviously people self-select to fill in the survey. But of the groups that filled in the survey, women only worked on average four hours fewer per week than men. And there was a disproportionate pay gap that existed between women and men. And there were also some subtler things in terms of access to advanced clinical lists, non-clinical opportunities and private work restrictions for women that were seen as external factors. So, they weren't related to the woman's skill set or their level of training or their enthusiasm or their childcare responsibilities or anything else. They were things that were sort of externally imposed that affected their career pathways.

MIC CAVAZZINI:               I don't want to overuse the word punitive, but you're not a top team player so you don't get rewarded with these…

KARA ALLEN:      And I guess is it conceivable that women who are working part-time may bring more to a department that you wouldn't otherwise get by having a smaller number of full-timers. So, the departments that can leverage off that trade-off, I think, are the richer for it valuing that diversity of perspective and of work practice that brings lots of different ideas to the table, lots of different voices, and doesn't restrict leadership opportunities to only people who are working, you know, one FTE.

MIC CAVAZZINI: Now the thesis I want to pursue with this is that the “motherhood penalty” will only diminish if someone else takes up some of the parenting and home-making responsibilities. And there’s only so much of that which you’d want to outsource to nannies and cleaners. And I think there’s only so much that the government can pick up the tab, really, a lot of this is cultural. Classically mothers in Australia and New Zealand would be entitled to around six months of Commonwealth support at minimum wage and the other partner just a couple of weeks. But nowadays, both parents are entitled to split the payments for a primary carer.

And on top of this nationwide policy, each employer will have their own additional entitlements. Across New Zealand and the various Australian jurisdictions, 14 weeks leave paid at normal salary is the typical package not just to mothers, but anyone taking primary responsibility of the child. But the question is, how many co-parents are taking up these additional entitlements to stay home with an infant. I couldn’t find any data from Australia or New Zealand, but Japan and the UK appear to have very similar policies to us. An audit of Japanese health workforce data showed that just 0.05 percent of male physicians took up these leave policies compared to 4.5 percent of women. That’s a 90-fold difference. Kara, would you expect to find the same spread here?

KARA ALLEN:      Yeah, I mean, our data is relatively old. So, New South Wales has brought in a much more progressive parental leave policy since we last did our interrogation for trainees. But we know in training, 92 percent of the trainees that take parental leave identify as female. So, I think those numbers would be similar.

MIC CAVAZZINI:               Yeah, one of the organizers of the PRAM workshop told me that she didn't know a single male colleague who had taken the extended parental leave, even though it's been supported by New South Wales Health Policy since 2022.

JENNY PROIMOS:             Mic, can I just say, one of the things about medicine and health in particular, I think is that it falls behind some of the work that's happening in corporate Australia. And so, I think in corporate Australia, it is becoming much more socially acceptable for men to take parental leave. So, I guess, over a career, I've noticed that some of the stuff that comes into corporates will hit medicine 5 or 10 years later. And I have high hopes for the millennials and the Gen Z generations, because I do think that they take some of this a lot more seriously and are not willing to just sit back and accept the status quo quite in the same way that we did, or certainly that I did.

MIC CAVAZZINI:               Yeah. Now, there’s a survey of 360 self-selected male medics in the UK, from which three percent had taken additional parental leave in 2011 which is more encouraging than the figures we heard earlier. But the researchers wanted to investigate reasons for not taking it and a number of reasons were equally prominent among respondents; low rates of awareness compounded by very poor communication of these policies form employers; implications for disruption to training and anticipated resistance from employers; and also financial stress and an assumption that the mother would be primary carer for some time. Kara, what was the attitude of the anaesthetists you and your colleagues surveyed for a recent paper? And spoiler alert, the title of the paper is “Still a boys’ club”

KARA ALLEN:      Yeah. We definitely found that for some men, having that same kind of leave process affected them in the same way as women. So that is, taking a good chunk of parental leave and then coming back into the workforce part-time, they perceived that they were disadvantaged by that in terms of career progression. And so, I agree that until we see men wrestling with some of the balance of having a life outside of work and having a fulfilling career, that change will be that little bit slower. And I guess I'm reminded of that Ginger Rogers quote about Fred Astaire where “everybody thinks that Fred Astaire is such a great dancer, but nobody's commented that everything he does I do backwards and in heels”.

MIC CAVAZZINI: One of your co-authors, Dr Claire Stewart, showed in a recent publication that male anaesthetists aren’t convinced there even is a gender gap in career trajectory. Surgery is also famously considered a boys’ club. Female surgeons are less likely to have kids than those in other specialties, but of course, the same association is not found for male surgeons. They’re not discouraged from having families by the pressure of the workplace whether it’s explicit or not. Still on policy, Sweden has a policy where the primary carer only receives their full parental leave package if their partner takes leave as well. So that’s quite a “behavioural nudge” and one high profile academic in this field, Professor Michelle Budig at UMass Amherst, has argued that the availability of non-transferable leave for men and publicly-funded childcare would go a long way to addressing the balance. Jenny do you know how effective such policy levers can be and whether they'd ever get implemented here?

JENNY PROIMOS:             So, in Australia, the intention is there that leave is available to both to both parents. However, culturally, clearly, we're still, a way behind that. But I suspect that it's not until we see both sides, or all genders taking up that, that leave, that we will see the benefits of it, and it will become part of the standard practice and the standard expectation.

MIC CAVAZZINI: This is good point in the conversation to recognise that the pressures discussed are obviously not restricted to heterosexual women or even to people that identify as women or mothers. No one on the spectrum of gender or sexuality should feel excluded from this discussion, and I’m sure you’ll be able to take from it whatever lessons are relevant to you. One obvious question that comes to mind is whether same-sex relationships are more egalitarian in the balance between work and parenting. I’ve only skimmed the qualitative literature on this, and certainly there is evidence there’s a more even distribution of unpaid labour around the house apparently thanks to better recognition and communication of those responsibilities. But there’s a simple analysis of census data by the Australian Institute of Family Studies that’s also quite revealing in regards to career compromises.

All parenting couples employed in all professions were allotted to three main cohorts. Both parents working full time; one parent working full time while the other works part time or not at all, and cohort three; one or both parents working part time or not at all. The size of these cohorts was very similar between opposite sex and same sex couples. In about half of couples only one parent worked full time, and the other two cohorts each made up about a quarter of couples. If you take a magnifying glass to the data, you can see a little more parity within same sex couples. In same sex female relationships there was a slightly higher proportion of couples where both mothers were working reduced hours; 26 percent compared to 20 percent for opposite sex couples. So, maybe same-sex mothers are a bit more likely to share out the earning and career sacrifices evenly.

For same sex male couples there was a higher proportion where both partners were working full time, 33 percent versus 24 percent for opposite sex couples. Here, you might infer that the role parity was achieved thanks to more reliance on daycare or other childminders. These differences aside, for me the main take home message is that in families with same-sex parents just as much as opposite sex ones, there seems to be a prevailing role distinction between the breadwinner and the primary carer, in about half of relationships.

Thinking of my own parenting journey, I wonder if there’s a bit of a feedback loop that reinforces who should take on those roles. Three and a half years in, it’s my partner who works part time and looks after our daughter when she’s not in daycare. We’d never had an explicit conversation about this but I guess it just “sorta-made sense” that I should stay working full time because I was bringing in more income than she was.

I suspect that the binary nature of this choice is compounded by the modern nuclear family, where we wait til our thirties to have just one or two kids. In times of old, and still in some societies today, there would be more aunts and uncles and younger grandparents to distribute the child-minding, allowing both parents to go back to earning an income which would in turn support the extended family. I asked Jenny Proimos what she thought of my feedback loop theory and whether that should be less prominent in couples where female physicians could well be earning as much or more than their partner.

JENNY PROIMOS:             Mic, I think in times past, yes, it was probably just, you know, assumed that that's what would be the case. Yes, probably the one who is remunerated highest is probably the one that's going to work full time. But for those who are on equivalent sort of pays, there might be more conversation about who does what when. I certainly do see amongst our junior trainees the more junior medical, medical staff and junior consultants, a lot more active conversation about that. And so yes, that's anecdotal. I can't think of any evidence. I can't think of any research around this that I've read, but certainly with this next generation of young doctors, I am seeing more people taking it little bit more—less sort of assumed and more, “Let's plan this, what's this going to look like for us”? And for some, Who does what when.

MIC CAVAZZINI: Now, we've touched on this, but I want to dig in a little bit deeper to see how strong the gender tropes are and the gender biases. You know, there's that perverse and well replicated finding that while women’s careers suffer for having kids, for men there is a so-called “fatherhood bonus”. Particularly in higher income professions, fathers end to get paid more than their childless peers without even taking time off to raise them. So, patriarchy for the win! Perhaps they’re deemed as more reliable and honest to goodness because they’ve got a family. Kara, can you contrast that with the way that women with families are viewed?

KARA ALLEN:      Yeah, one interesting finding that we had was that the motherhood penalty, and I'm using quotes around that, actually affected women who didn't have children. So even, you know, being in a workplace and being a woman of childbearing age, there was this kind of, “you know, we're watching you to make sure that you don't take maternity leave. Do you really want to take on that big project? Do you really want to start that PhD? Because, you know, even if you're not partnered, even if you haven't expressed an interest in having a family, you're a woman, so at any time you might go off and do this thing that then affects your productivity, affects your ability to contribute to the workplace”.

Whereas if you have the children, but they're being taken care of, by another caregiver, then that's fine for men, that's not a problem. For women, it's a lot more complex. And you know, the Annabelle Crabb thing of you're expected to work as if you don't have a family and expected to look after your family as if you don't have a job. You know, that tension is a daily cognitive load for women that I just, I don't see it in quite the same way coming through the literature for men. And again, there are individual examples that disprove the rule there, but we know that that is a feature of our workplaces.

MIC CAVAZZINI: And that was certainly captured in the qualitative study from the US in the BMJ. One physician told interviewers; “I am tired of feeling like I am a bad mom when I am being a great doctor...and like a bad doctor when I am putting my children first.” And another said. “When my husband and I were applying to residency at the same time he was lauded for having a family, I was always asked if I thought I could handle residency and being a wife and mother.” And that's not just in the US, in another Australian paper I read an EM registrar who was told not to bother applying for a training position while pregnant. And one of the women I spoke to at the PRAM workshop had been asked in several job interviews “Is there anything that will stop you commencing this job?” She was forced to reveal she would have to delay the start date by three months to wean her child, and felt she was denied a fair evaluation as a result. Jenny, such discrimination would be illegal, but virtually impossible to prove. Again, is the law a strong enough level for culture change?

JENNY PROIMOS:             The Anti-Discrimination Act in Australia is very clear that discrimination discrimination, bullying, harassment must not occur. Now the legislation has changed recently. So last year, the Australian government implemented the Respect at Work legislation. And what this says is that organisations have a positive duty to ensure a workplace that is free from bullying, discrimination and harassment. And what that means is that hospitals don't just have to adequately deal with bullying, discrimination, harassment, what they actually have to do is prevent it. And even the colleges, in fact, fall under this legislation and have responsibility and this positive duty to ensure that their trainees are not being harassed or discriminated against in their workplaces. So, I think the Respect at Work legislation is a potential game changer.

Now the other part of the research that I've done in my PhD is showing that trainees when they feel they're being discriminated against are less less likely to report it in their workplace. They might report it to their supervisor and their supervisor might do something about it in the college if there's significant numbers of people who are coming up with the same issue. But it often does not translate into something that becomes an issue within their organization or their hospital organization. So, there's kind of a disconnect of governance there a little bit between the workplace and the responsibility of the Chief Medical Officer and the executives in that particular organization to do something about that discrimination when it relates to training in particular.

MIC CAVAZZINI:               I was surprised at how candid one of the anaesthetists surveyed by Kara and colleagues was. He said that, “young female staff start families as soon as [they] get their Public Staff job where they then take maximum mat leave. Is it really the taxpayers' responsibility to pay for their kids? If I was a manager I would be cautious about employing someone who is likely to have an extra 12–18 months off over the first 3–5 years.” And that kind of thing has been reported from half of program directors in the US.

KARA ALLEN:      Yeah, I was delighted that that came out of that survey because, this is what I love about qualitative research, right? Because this was anonymous, so people felt comfortable saying what they really thought. And I'm very confident that that person was expressing a concern that they thought was completely reasonable and valid and, in fact, is held by so many people that after the publication of that paper, many, many people have come up to me and said, “I'm pretty sure I know who said that”. And they can't all be right because they are all across Australia and Aotearoa. So, I don't know exactly who said it, but that perception is so pervasive and so efficient at cutting down women who particularly who are coming back after parental leave and whose confidence is low to have somebody bring into that space an attitude of, “you don't deserve to be here. You've taken up a spot that some more deserving person could have had because they wouldn't have taken parental leave and you're just leeching off the taxpayer”.

Like what an extraordinary and short-sighted perspective, particularly when we know that the investment to actually get people back up to speed in the workplace in terms of competence and in terms of confidence in that return to work period is such a short investment. It's in the order of days or weeks. It's not months. And that attitude is so damaging to that process that in fact I think, the attrition from that individual workplace is likely to be much higher than it should be. It's just so incredibly damaging and I'm so pleased that it came out and we could report it.

MIC CAVAZZINI: That it was captured.

KARA ALLEN:      Yeah exactly.

MIC CAVAZZINI:               And, in the large survey I mentioned in the BMJ, many physicians, women, relayed snide comments they'd heard about maternity leave being like a vacation or, as you say, were later penalised in their rostering and pay. While that was in the US, a friend of mine here in Sydney, not working in medicine, was told by a female boss, “how great for you, now you can go to the beach every day when you're on maternity leave”. We probably don't need to expand on that any further.

KARA ALLEN: Mic, what I'm hearing is that there is a sense of there needs to be a seismic shift in the way that medicine views clinicians. Which is, not that we are automatons that show up and do a 60 hour a week and then go home and do clinical research on top of it, but that we're human beings interacting with other human beings. And I feel strongly that in the right in the exponential increase in AI and technology-assisted practice of medicine, that our humanity is really the thing that we continually bring to the clinical workspace. And our willingness to sideline that and to ignore the implications of having a life outside of work and having challenging interactions and, big feelings about the clinical space means that we devalue that human side of medicine.

And I feel obviously quite strongly that that's not a gendered thing. We've attributed that to women, but I know plenty of men who bring that humanity to their clinical space, but it's not valued regardless of what gender practises it. And in some places it might actually be worse for men who are willing to talk about how they felt after a challenging clinical interaction or a death on the table or whatever else. And I think that is really where we need, as a craft group, as a group of practice to focus on. What do we bring that AI can never replace? That for me is one of the reasons why I do what I do because I want people to feel like they can be humans at work and that they can have a life outside of work and that is achievable.

MIC CAVAZZINI:               Yeah, on that idea of work-life balance, I think that's really the direction we want to be going in. Northern European countries are famous for their gender equality, but I remember reading about a Dutch office where at 6pm every day, the desks retracted into the ceiling. You know that colleagues won’t be getting ahead of you while you go and pick up the kids. So that might not be so easy in medicine but yeah, they probably realize that staff with a healthy work-life balance are more productive and yes, maybe dads who have good relationship with their kids are healthier humans.

KARA ALLEN:      Anecdotally, one thing that our survey found was this deep regret amongst anaesthetists in their 50s and 60s who had outsourced family life to their partner and now reflected that they'd missed out. And, in fact, one of them, a man in his 40s said that, you know, “we need to define success as not just work-related, but a combination of a rich life outside of work”, whether that is because you have children or not, as well as career satisfaction. And the career satisfaction can be achieved in a lot fewer hours than we currently expect people to have to work to achieve it. And I just thought that was just such a fantastic highlight of this tension that women wrestle with that I think men do as well, but it's certainly not socially acceptable really to wrestle with at all in medicine.

MIC CAVAZZINI: Yeah and maybe let's end on maybe a more personal note. Do you have any words of wisdom from your own careers? I don't know if you have families yourselves, what you'd like to pass on to any Trainees listening, what worked or what to avoid.

KARA ALLEN: I've got three daughters, so this is both professionally interesting and personally challenging for me. And I would say that my life outside of work is my real life and that is the most important thing to me. And it makes me so sad to think about my colleagues not having families or putting off having families and then needing a lot more time and energy to go into that because the work environment was so antagonistic to it because it's a source of joy for me to have my daughters. The thing that I would say is that I do think that things are changing and that some organizations are doing better than others. And when you get your letters and you can make your choice, then you vote with your feet and you go someplace that values you and that recognizes how you can contribute to the workforce and isn't locked into, “you must work full time and have a PhD in clinical research to be able to contribute”—which there's nothing wrong with those things, but that's not the only thing that we need in healthcare. We do need the PhDs in clinical research. We do need the people who are working full time, but there are other opportunities to contribute. And once you have the opportunity to make choices about where you spend your time, then that is an opportunity to vote in numbers to support the organisations that are doing the good work.

MIC CAVAZZINI: I've got male friends who have chosen specialties that were more nine to five because they did want to spend more time with their families. So, I think medicine is—perhaps not during your training years but—medicine does allow a lot of choice in the type of role and career and balance that you'd like. What about you, Jenny?

JENNY PROIMOS:             I had a pretty non-traditional medical career, actually. I've done lots of different things. And part of the reason for that is because I had a husband who travelled with his work 40 weeks a year. So effectively I was a single mother for a significant portion of time while my children were very young. And I come from a non Anglo-Saxon background. And for me, the concept of “it takes a village to raise a child”, I lived it. You know, so I outsourced where I could, families, sisters, brothers, everyone got involved in looking after our children when they were younger. And I have to say, my children—I have a son and a daughter who are now young adults—I think are the better for it, actually. They understand that they didn't rely just on us for everything. And the one thing that I came away from it at the other end now, with two fabulous young adults as children, is that guilt is a really wasted emotion. You know, your children, as long as you remain connected, as long as you have quality and are present in the times that you do have together they will come to the party too. You will raise resilient young people. And so don't waste your time worrying about the guilt. Waste your time worrying about what good things you're do with your children.

And I totally agree with Kara that, I do think you have power. You know, we as doctors do really have power in the health industry compared to some of the other workforces that we work with every day. And we have and we are very well trained and we have the ability to use that for our benefit. So, work out what's important to you, work out what your values are and where your true north lies and follow that.

MIC CAVAZZINI:               Many thanks to Dr Jenny Proimos and Associate Professor Kara Allen for being so generous with their thoughts and their time. This was just an exploratory conversation and not intended to represent any formal views of the Royal Australasian College of Physicians. If you’re interested in digging further into the topic there’s a reading list at the website and the episode transcript is packed with even more links to the academic literature. Just go to racp.edu.au/podcast and click on this episode. A good starting place is the Advancing Women in Healthcare Leadership initiative that Dr Proimos is involved with. At the website womeninhealthleadership.org. you can find information about workshop and conferences and research papers like her 2024 article titled “The role of medical colleges and member organisations in advancing women in health care leadership”.

I really want to thank the women and men of the Pomegranate editorial group for reviewing early drafts of this story. They are a diverse bunch of physicians who volunteer time outside their practice to contribute to this educational resource. You’ll find their names at our website as well as a mailing list you can subscribe to hear when each new episode is published. I want to hear from you too, so please send your feedback to the email address podcast@racp.edu.au. This podcast was produced on the lands of the Gadigal clans of the Yura nation. I pay respect to the mothers who guided them for 400 generations or more. I’m Mic Cavazzini. Thanks for listening.