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Parental Support: Policies In Surgery Training · Behind The Knife: The Surgery Podcast

• BTK_Kanters_Shubeck === [00:00:00] Hi everyone, and welcome to another episode of Behind the Knife. I'm Kara Button, a general surgery resident and behind the Knife Surgical Education fellow. Today we're diving into a topic that has been receiving long overdue attention, and that's parental support in surgical training. Surgical trainees are accustomed to putting their personal needs aside. They manage long hours, high expectations, and have a truly deep commitment to patient care. But when trainees become parents that landscape shifts. Research shows that childbearing surgeons face higher rates of pregnancy related complications, including infertility, pregnancy loss, preterm birth, and non-elective C-sections. And the mental health impact of being a parent during surgical training can be substantial, especially when programs lack meaningful support. And if you hadn't had a chance to listen to the Behind the Knife episode from 2021. Where this topic is talked about a little bit more, I encourage you to do so and we'll link that in the show notes. Over the past decade, studies have increasingly highlighted the unique difficulties that surgeon parents [00:01:00] encounter, and while prior research has focused mostly on childbearing, parents navigating pregnancy and recovery during training. More recent studies underscore that non-child bearing parents are negatively impacted by the lack of support. So the central question becomes, how do we recruit and build a surgical workforce that is skilled, resilient, and genuinely supported in their endeavors to become parents? To explore this topic, I am honored to welcome two leaders and advocates for inclusive and comprehensive parental support policies, Dr. Ariel Cantor and Dr. Sarah Beck. Dr. Cantor is a colorectal surgeon and the associate program director of the Colorectal Surgery Fellowship at the Cleveland Clinic. She completed her general surgery residency at the University of Michigan and her colorectal surgery fellowship at the Cleveland Clinic. Dr. Beck is an assistant professor of surgery and a breast surgical oncologist at the University of Chicago. She completed her general surgery residency at the University of Michigan and her breast surgical oncology fellowship at Memorial Sloan Kettering Cancer [00:02:00] Center. Together they co-authored the University of Michigan Guidelines for Wellness of lactating surgical residents, and the important. Of parental leave and lactation support policy for surgeon parents, which has served as an inspiration and evidence to establish parental support policies at other institutions, including at my own Dr. Cantor and Dr. Schuberg. Thank you so much for being here today. Thanks so much for having us. Yeah, thank you. So I really want to start at the beginning for both of you. What inspired you to become involved in this work and how did you end up working together? I'm happy to start with that question, so thank you so much for talking about this. I think this work is not only really deeply important to me, but also the reason why Ari and I are as close and connected as we are today. Um, our origin story is that Ari and I had babies around the same time in a season of life where we weren't particularly close friends. You know, residency is really, really hard and it is one [00:03:00] of those things where I, I thought I was just kind of getting through, um, and really didn't have the connection and grounding in the program that maybe I, I, I could have gotten if I had reached out. So, you know, Ari and I both had our first children in our third slash fourth year of residency at the University of Michigan. And it's kind of a trauma bond that I think has forged our relationship in a really meaningful way. And that's because for the first time, you know, we had a very visible demonstration of shared struggles, right? It's hard to be a pregnant surgical resident. Everyone wants to talk to you about how hard it is to be a pregnant surgical resident. And so I think. We really came together in this grounding of shared hard, but also shared joy, right? Our kids are incredible. Our daughters are really strong and wonderful little women who push us to be better at our jobs. And I think both Ari and I had the pleasure of becoming more ambitious people after becoming parents, which I think is true of a lot of us. This work became frustrating though, because when we were both trying to breastfeed and ate for our babies, we were doing all these [00:04:00] professional obligations that didn't have accommodations or didn't really have clear paths for us to do that, that well without feeling like we were a bother and we were trying to take up space in the right ways, right? We were trying to contribute, we were trying to learn, we were trying to grow, and I just felt like I was groveling for time or for space to pump for my daughter. And I think the shared frustration became kind of a lightning bolt for us, where we felt that instead of complaining or instead of feeling like we were asking for something so big, why not just make a positive stand and fix it for everybody else? And so I think that's, that's kind of where it starts for me. And I think, you know, I want Ari to, to kind of give her perspective too. 'cause it's, it's funny how we had such a shared experience, but we think about this in different ways and I think that's part of the value of our partnership and relationship. And so I think it's an important thing because it's. Important to us because our kids are important to us, but most importantly for this conversation, because our work is important to us, I will echo everything that. Just mentioned, um, especially [00:05:00] the trauma bonding aspect. And I, I will add on to say that, and Dr. Beck is really the one who, who kind of came up with this entire concept of developing a policy that would promote the wellness, um, of our lactating residents. So she and I like, like she mentioned, we. Struggled to kind of find our space in a appropriate, you know, politically appropriate way, and then began to realize there's no reason why this needs to be as stigmatized or. A hush hush aspect of our own wellness and the wellness of our children. We were fortunate enough to be in a program that is really advocates for all of residents, especially as within our female residents, but we wanted to do more than that. And so Dr. Sbe mentioned she came to realize, she's like, this is more of a health concern than a woman's concern. This is not, this is a medical issue. She identified that once, you know, she and I made it work. We were able to lactate as long as our goals had been. We met our personal goals, which was really what we wanted, but this could be so much more. And so once we were [00:06:00] actually done with our own experience of lactation as a surgical resident, she said, let's, let's do something to make us better for the people who come after us. And this was, I think, in so many ways this brilliant idea because we're coming at it from a, not from a self-serving standpoint, but from the standpoint of someone who's experienced a challenge and recognizes opportunities to make it better for the people behind us. So I credit her through and through for having the gall and the chutzpah to, to pull this one off. And I am honored to have been a part of the. All of this along the way and to carry it forward. Now that's very generous, but I also shout out it's true. Shout out to our program leadership who enjoys very true the meetings and I, I think uniquely this work also selfishly, is why I'm a breast surgical oncologist. You know, I was so driven to make this objectively better. Right. I think so often these concerns about health, pregnancy, lactation are kind of, not dismantled, but described as selfish, right? As like a, a one-off [00:07:00] need or a cat, or the person is maybe described in a negative light. And I found that so frustrating because these are super humans, right? Like it's quite superhuman to grow a baby. To lactate for that baby and still be a great surgical resident, right? Mm-hmm. But also, it's super human to have any other health condition and still show up to work and do the work that our residents do. And I, I, you know, I think that's really where. We never thought of it as Ari had mentioned as just something to make our lives better, but rather as this very visible, very kind of almost lightning bolt polarizing thing to talk about childbearing in residency. And it was really having a moment and I. I do wanna give credit for a lot of the empowerment that I felt was because one of my dearest mom friends is a developmental and behavioral pediatrician, who was the first person to bring me food after I had my baby. And she's on faculty at the University of Michigan. Her name is Dr. Megan Pesh. And she was a source of support and sounding board and was also kind of working on this with us. And so I think we had the perfect recipe to be empowered, but also to be very proactive. [00:08:00] Yeah. One thing that strikes me as you went through this experience is that you took your own personal experience about the challenges, created a policy, but then also have this bigger vision about what parental support means in a. Bigger sense for resident wellness. Um, and you know, Dr. Sbe, you had mentioned that parental support policies are really of a reflection of how programs actually support their residents more broadly. And we're in interview season and we have these meet and greets, and that's something that residents or. Future residents ask a lot about is how does a program support you? And I think having a parental support policy is one of those examples that we can pull from to say, Hey, this is how a program is supportive. But I'd love for you to talk about that a little bit more about kind of what this means in the overall context. I think, so I'm not a program director, just for disclosure, I'm not a program director, but I'm a resident advisor at U of C, which means I am [00:09:00] invested and engaged in how people do in this program. And so I think that's the lens through which I think about a lot of this is that, you know, I want people to see. Checkbox examples that we're willing to put our words on paper, that we're willing to support people for different phases and different challenges. This is truly just one opportunity. I think if we could make parenthood in surgery less extraordinary, that would be quite remarkable, right? I think we all look forward to living in a time or training people in a time where we are in a post guideline setting, but I think right now what guidelines often do is it gives shared common language. It gives confidence for the person who's asking for support, and it gives an expectation that we all can do a great job. Right. So people aren't walking around with a printed copy of the guideline, or certainly, I hope they don't have to, and I, but I think what it does is it says, Hey, listen, this is important to us. If it's important to you, it's not a mandate to breastfeed. It's not a [00:10:00] mandate to lactate, right? Your body, your choice. But I think what we're saying in this case is that it's okay to be a human being who has other things that make you you. And that's really what I think of when I think of lactation and parenthood for surgical trainees, at least for myself, is it was not the dominant characteristic. I did not become Sarah, the mother. Right. I was, Dr. Beck and I had some stuff going on on the side, and I think that for a lot of us, this was not central to identity. And so I think it's just another aspect. So whether you find it and replace the word, you know, parental support or lactation support, it's just meant to be an idea that our program was invested in the people around us. And I remember very vividly having that conversation with our program director, Dr. Paul Gauger is saying, Hey, look, it. It's not really gonna change how people actually pump, right? People are still gonna pump in closets and on rounds and you know, between cases in the OR and it's not gonna make everything better. But what it is gonna say is that we're supportive. That's enough. And I think that was really, really meaningful for me as a person. You know, I became a certified lactation counselor through this journey. I learned I love taking care of women. I picked my specialty for [00:11:00] goodness sake. And a lot of that was because everybody around me said, yeah, it's okay for you to care about that. We're excited about the fact that you're excited about it. So I, I think of it as really that example. So whether you replace it with ulcerative colitis, diabetes, fill in the blank condition, the idea is that we're humans too, who wanna do a really good job. And if I can, I wanna, I wanna highlight something about the intentionality behind the language that Dr. Chu's using and the language that was used in the policy. The, the initial policy itself and moving forward is that it is not a gender based policy. This is based on a lactating adult. This is based on parenthood. And I think one of the things that's really challenging, especially as two women who came forth and had, were able to bear children and lactate during our residency. This is not a woman's problem. This is a global resident issues. This is a global resident wellness decision. To become a parent or the ability to become a parent is a gift if that's what you choose. And we need to be able to facilitate that both from a resident, from a [00:12:00] male, female, and anyone who is choosing to have children stand. There's a whole other aspect about, we talk about parental leave, not maternal leave, not paternal leave. Because the idea is the minute you introduce a discrepancy between maternal and paternal leave, you're introducing a discrepancy in the. Male versus female experience. And so instead talking about parental leave, lactating resident, et cetera, this is a global wellness issue. Definitely. And I think, I think we can go from there to talk about, you know, there's been a lot of progress in this space. Programs have started instituting. Parental leave policies and really using that language as having parental leave policies. And, you know, some of my co-residents have taken paternity leave, which is fantastic, and I fully support them in doing so. But you know, we, we have a ways to go. There are things that we can improve upon. And both of you have the experience from being residents and now being resident [00:13:00] educators of, you know, having an experience making a change. Working with leadership to make that change. And now having the opportunity to advise residents who might be advocating for change. So, you know, what are we getting wrong still and what opportunities do we have to improve on that? I think one of the really big areas of improvement, and this is coming as a staff, um, so I'm associate program director for a fellowship. Um, we have a very large fellowship here. It's our responsibility. So I think one of the biggest things about improvement is not to put the onus on the residents, but to put the onus on the leadership. And we, so again, to the points that were already made is by putting forth a policy, we're showing our support. It will not change how someone feels about things or it, it may not change, I should say how someone feels, but they should feel empowered and not that the responsibility falls on them to make the adjustments necessary to accomplish their health goals. So. As [00:14:00] a leader in the surgical department, as a leader in the surgical education realm, we need to come forth and say, look, this is what we, how we are going to support our residents at every stage of their life, uh, their personal and professional life. So if you have a resident coming onto, you know, someone's pregnant, you know, someone's lactating, the support for that resident should already be established before they come forth and have to come and ask for that support. And. The more that we do this from the beginning, the more it'll just become inherent to the program. So it has to be intentional in the beginning, and the goal eventually will be for it to just become the norm. But the leadership needs to take the onus because the hierarchy exists in surgery in a way that it's not going away anytime soon. And we recognize that there's a power imbalance with the resident, the junior residents to the senior residents, senior residents to the staff, et cetera. And so if you can instead turn it into a trickle down. Plan then that'll actually take care of the people who otherwise may not have a voice. I also think there are already lessons learned in this and [00:15:00] so I think, you know, the first document that I drafted was like filled with rage and stress and feminism, and I remember those first meetings and realizing that I wasn't gonna get anywhere by getting mad at people. I think this is, you know, should be a reflection of my own personal growth. And the role of kind of studying that Dr. Cantor played in the work was that, you know, coming at this from a very positive, very proactive opportunity to do a good job taking care of people is something that pretty much any physician can get on board with, right? All I do all day. Think about how I can take good care of people in front of me. And I think that the extension of that is to give people the benefit of the doubt that they wanna take care of their learners too. And so I think, you know, we're, we're talking about this from a very post successful state, but there were bumps along the road, right? Like people said, well, why should we have to care about this? Or, you know, this doesn't apply to me. Why does it matter to me? And I think that really the opportunity of this particular domain was, it was something everyone was talking about, right? Parenthood surgery is still controversial. [00:16:00] To your point, Kara is like. We're in 2025 and people still are like, oh my God, you had a baby in residency? And I'm like, yeah, she's nine now. And I think, and it's really, we came at it in this way. We started having success when we framed it as like, look at this. Like look at, we are having trouble and we think other people will too. And can you help us? And people always said yes. And I think this was a space where people were uncomfortable. Like it's uncomfortable to talk about people's breasts. It's uncomfortable to talk about breastfeeding or lactation. 'cause some people have had really crappy experiences. Talking about pregnancy and surgical training is hard because of all the challenges you've outlined, and it was not easy for us either. And I think that when we find a common space of understanding and mutual benefit of the doubt, we're more productive. And so the advice that I give people, and the advice I tell myself every time something is getting me heated is that, you know, we have to find a place where we're working from an opportunity instead of a, a complaint. Right? I think that so often, practically, if you, if you find a problem like this, if you're a person affected by this, [00:17:00] the answer is like, Hey, I know this person at University of Chicago who's suggested this. Can we try that here? You know, and, and kind of blame it on somebody else, right? The biggest problems when things break down in support for folks is when they need accommodation that other per people perceive as unfair. 'cause we're all human beings, we're all exhausted, and we all wanna get home at the end of the day. But I think if we can use these lessons learned and use lactation or parental support as just another ex. Experience that people have in surgical training or as surgical faculty that might need a little bit of support, will have better success in getting to that post world We all dream of where people are well cared for at their work, can work as hard as we want them to and as much as they want themselves to. And we can make really amazing surgical. You know, surgical faculty on the backend. And so I think a lot of this, the practical advice is to lead from the positive, give people the opportunity, give people the space to ask honest questions. The number of questions I got about breastfeeding were amazing when we were going through this process and showed me that people are not acting from a place of being unkind. They're acting from a [00:18:00] place of not understanding or not having access to that information. And so I think from a very, you know. Practical overhear way lead from a place of positivity because people are gonna rise to the occasion if you give them the opportunity to do so. And that was really the consistent lessons learned and a huge reason why I look back on my days at Michigan with so much, you know, kind of respect for that piece. The fact that I was supported to become bigger than I thought I could. And that allowed this to be central to my identity. And I think that's a lot of credit to the leadership for pushing us to lead from a positive, proactive space. I guess the one other thing I would just briefly say, and I mean there's a lot, there's, we hoped and we hoped and have seen, we're very happy to have seen that this was a jumping off point. This is. Barely scratching the surface of like what we started doing, what, however, many years ago, I guess. Yeah, it was eight years ago, nine years ago now. Um, barely scratches the surface of the challenges of residency ESP and especially [00:19:00] related to child rearing, childbearing and lactation. Sarah and I both have our own anecdotes, right? So every resident we know has our, has their anecdote of the challenge. And our hope is that as time progresses. Those anecdotes will be fewer and far between, or at the very least, they won't be secret anecdotes or things that we can share and actually be open and comfortable discussing. The fact is that this is a really historically male dominated specialty. We know that. We know that we are historic. We are called residents because we're supposed to even live in the hospital. The whole concept of prioritizing our wellness and childcare and all of the above is not. It's barely, it's acknowledged now, but not accepted. And so we're optimistic, especially given how welcomed we were when we came forth with this idea that, that we're at the kind of turning point across the United States. And, and as, as Sarah said, you know, we wanted to put something out there so other places can [00:20:00] turn and say, well look, they did this, so what if we just adopted? It's not coming up with a de novo idea. Right. And. Sarah mentioned, she's like, I know I, I'm a, I'm a bit of a, I play by the rules really well, and she's the one who's the fire under my butt. So I will say, if anyone's thinking about an opportunity to enact a change, whether it be wellness related or otherwise, having that balance in the people who come forth is amazing. Dr has been the light under my butt for the last 10 years and long before then. And, I just, I encourage anyone who's considering trying to implement something like this to find their yang begin to their yang, and together you can actually do about five times more than you thought you could do by yourself. So I'm grateful to have been a part of this early on and grateful to get to continue working on it in in my own realm within colorectal surgery. In this hospital system, but also acknowledge how much more there is to come. And so please, if there's anything we can ever do to help facilitate any other residents out there, any other staff, faculty, programs, [00:21:00] whatever the case may be, we are happy to be there to be your, the voice to help you out because we've got a long way to go, but at least the conversation's being had and credit to you, Dr. Button for trying to put this out there in more of a, a national and international, uh, interface. There's a lot of opportunity there. Yeah, that's incredibly generous. Ari, and I'm, before I, I don't want you to let me take credit for this, but I, I think one of the most important things about this is that when we first released our guideline and we shamelessly were waiting by our phones for someone to tell us that it had been approved so that we could send it out on social media to be represented of the era that we were in. I got emails from people, from all flavors, all states of in all different programs, right? Peds programs, internal medicine programs, other surgical disciplines, anesthesia residencies saying, Hey, we modified it and here's our version. And it was this really cool thing that I did not even think could have a space outside of surgery. So if, if one more program does a good job, if one more [00:22:00] person feels that they can ask. Clear program to do a good job. I think that that will have been enough because I never was a pregnant resident again after we did this work. Right. But I know now that there's a lot of people who have babies after me and who feel that they can just ask me about it. And yes, as Ari mentioned, everybody wants to share war stories. Right? And we can do that. We can talk about the hearts, we can talk about how everything became really complicated and challenging. But we can also talk about how we don't have to make other people go through that, right? Lessons learned. We're standing on the shoulders of some pretty giant people who went before us for many of these issues, right? The 80 hour work week I think is a good thing. But I think all of those, all of that positive progress is made when folks step up and say, man, I wish we could do something better. And so if our daughters who are fearless, fierce, and brilliant young women, my God, I'm scared of the potential that they have mm-hmm. Become surgical residents. They better not have trouble in this [00:23:00] space. Right. And I think that that's a lot of what we're working toward is how can we really rise together and how can we have just been another footnote in someone's more triumphant story? And I think that that's really what a lot of this work feels like right now is it is bigger than Ari and I, and I'm so grateful for that. And there are so many more people talking about it. And I think that we can learn so many lessons from the folks who are doing the work now that allow us to even think about it in a way that we never considered possible in the era that we were training, which wasn't that long ago. And so, so, yeah. Thank you for, for letting us talk about this. It feels a little bit like a homecoming, a little. Remember when, and I think, you know, I'm, I am grateful to this work for giving me Dr. Canters. Right, and I think we probably would not have come together in the meaningful close friendship and mutual relationship in terms of like support as attendings in terms of parents and trying to do this and, and being as dear as we are now without having to fight this common cause. And so I think it's okay to speak up. It's okay to try to make positive change. And in fact, it's a sign of leadership. And for [00:24:00] programs, I think this is how you keep great talent, right? Like these are the things that programs can do. That I can say like, listen, we're doing this great and oh my God, they really want me to stay and like talk about a huge win for a place to hire, retain, support, a person who is dedicated after they felt supported during maybe one of the hardest and or most joyful chapters of their life. What an opportunity for a surgical leader to keep great people. And so I think if we can lead from a positive lens, if we can stay from the front in that way, our trainees will benefit. And I know I would've benefited from it when I was in that seat. And I will say I did benefit, just as a side note, I did get to firsthand find out how great this policy was when my son was born in my chief years. And Dr. Sbe literally would scrub me outta cases so I could go pump. So it's, it works. It is feasible. It is doable. I do wanna ask the hard question, especially for maybe those who might be in a [00:25:00] program who isn't particularly supportive because there is this interplay between autonomy and hierarchy and training and really adds a level of complexity. There might be junior residents in a place where they don't feel like they can speak out and ask for what they need to stay healthy, regardless of whether it's for. Their own, you know, health in a pregnancy supporting a partner who's pregnant or for other health needs, and even sometimes in really positive environments where people are supportive. Sometimes your own work ethic and your love for surgery and you know your own. You know, commitment to your co-residents who you see work really hard and you know that you're gonna be asking them to take on more work can kind of blind you to what you actually need and how to make positive change for yourself or for others in that regard. So, how do you, how do you ask for help when you really need it? I think if, if a resident is in an environment where they feel like the onus would be entirely on them to [00:26:00] fight during a pregnancy, to fight during their lactations period, they're in trouble. Those are the people we're worried about, right? Because those are the people who don't have someone to call on. The person affected should not be the only and or loudest advocate. That's a one-way ticket to isolation, to being a polarizing figure. Or to be the dreaded difficult. Right. None of us wanna do that. And I think the thing about this is where now I'm sitting from the outside is watching people do this and remembering that the same things that drew me to surgical residency drew them to surgical residency, hard work, dedication, willingness to to sacrifice for the cause. But I also know, and I am a doctor, just like all of us on this call, and probably many people are listening that my priority is making sure people are okay. So I think to that one person, you know, find your one person, I promise you, someone in your department can be a compassionate, kind ear and a sounding board. Because oftentimes the anecdotes that tell us that things go off [00:27:00] the rails are when people are perceived as complainers. No one wants to be that right to the point so much that we will self sacrifice. I think it is also incredibly important to mention in this space, no one can force accommodation, so each person, each pregnant person, each lactating person is in charge of their own body, is in charge of their own safety. So no policy should ever mandate that people cannot do their job. And so a lot of this is, I think, and I advise people all the time, take it out of yourself. Talk to your doctors, tell them what you're doing at work, and ask them if they think it is safe for you. And if they don't think it is safe for you. Get medical documentation and take it to your program. Just like any other workplace accommodation, you know, this shouldn't come from personal. Like, I think I need this. It should come from a space that I've thought about this, I've discerned with my doctors. This is something that's making me unsafe and I need this to change. And I think then your program, right? Program directors wanna help people learn how to be surgeons, right? Like give them [00:28:00] grace. They wanna do a good job. And I think let people in maybe a little sooner than you want to. I remember when I was pregnant with my daughter, I had had a really hard time getting to that point, and I was immensely fearful of people finding out. I don't know why now in retrospect, 'cause I'm a very different post baby person who is very empowered. But at the time it was really terrifying and it was the best thing in my life that Ari was also pregnant. So I could tell people, no, you're not thinking of me. You're confusing me with the other one. And so I think that I hid, I hid behind that shield because I didn't want people to take cases from me. I didn't want people to think I couldn't fulfill my duties or in any way blame my performance on my pregnancy. I hate that now in retrospect. So I think, I think we don't want to find ways for people to fail. And I get how Pollyanna, this sounds, right. I want my residents to be deeply successful and do better than me. Just like I want my kids to rise to places I've never even considered, right? And so I think in this space, find that one person who can be your sounding board, because when you're alone and you feel like you need to be [00:29:00] more alone and more alone and more alone, that's when you do things that are unhealthy. And so I'm a, you know, I'm a lactation counselor. I help a lot of people with breastfeeding challenges and milk expression challenges in the workplace. I see it all the time. People get mastitis 'cause they're not pumping or they're not stepping away and, and so I think that there are real health challenges on the line here. People can make different choices for themselves. Nobody has to breastfeed, nobody has to accept workplace accommodations for their pregnancy. But I think it is very important to kind of lead by example too, in that way. But each pregnant person does not have to trailblaze. That is too tiring when you're already exhausted. Yes. So I actually, you, you, those are the two exact things I was thinking. It's, it's two ways. One is find the other person to advocate for you. Let it be, let, don't let it sit on your shoulders. This is not a you problem, this is a global issue. Every program director took on that role to support their residents. Turn to your program director, turn to your, even your co-resident, your chief resident. There should be hopefully at least one person in your department that you feel can. [00:30:00] You can turn to, to help get that additional support. Who could be the person asking? Alternatively, take the U out of it. Turn it into a medical issue. This is not, this is a mastitis. Risk lack, lack of lactation or lack of pumping leads to mastitis. Mastitis leads to time off work to, you know, severe systemic infection, et cetera. Turn this into a medical problem. If you feel like, oh, I don't wanna be the, the needy one. You say you, you take yourself out and you say, hi, this is how often I pump. This is what I have to do. And you bring in your letter from your physician. The other thing though, and again, this is, I, I hope that staff are listening to this because this, my, my hope is that this does not fall on the resident. And I think in time, just like now, so Sarah and I we're the residents, but we're the staff now. And so now it's our opportunity to turn back and say, Hey, look, I went through this already. This is not gonna be your fight. I'm carrying this weight because we have the power and we have the, we have the power, we. We're [00:31:00] kind of invincible in this realm. Truthfully, you think about it from like a political standpoint, like no one's gonna take us down for coming forth and saying, look, my residents need equal care and access to care for themselves so that they can achieve appropriate wellness. And so as this generation continues up as the, those of us who had kids in residency, just like we turned to our staff who had kids in residency to help us, our hope is that our incoming trainees will be able to turn to us as well. But if the policy's already in place, that takes one other barrier outta the way. I also think a lot of people just don't know, like Right. And, and so mm-hmm. Maybe you're the first person to have a baby in your residency program. Right? Like, that's real for a lot of people. Right. And, and that's, mm-hmm. So maybe you're the first one. Maybe you have to be a trailblazer. I'm really sorry. It sucks. It's very lonely and hard to be a trailblazer, but I think what, what often is the problem is that people just don't know what it takes. Right. Pumping doesn't take that long. Right. Think how many things we do in a day as a resident, or we did in a day as a resident that wasted 20 minutes. Right. Just, just like think of it and think how [00:32:00] long room turnovers are and they, you know, and so I think the problem is, is that it's often perceived as a huge ask both by the asker and the person being asked, but probably it's not a huge deal, right? We make accommodations for our residents to be in mandatory teaching. We go without our residents for a couple of hours. Sometimes they let the attendings do things on their own. Right? And I think that that just shows you that we're capable too. And so it's really, I've never felt as an attending. Certainly that it's a big deal, I guess. Yeah, I'm a safe space. I want everyone to feel like they can take care of their basic health functions, right? But nobody tells you're attending when you're going to the bathroom. No one tells you're attending when you're sneaking a snack. Like we don't need to check out a hall pass like we did in elementary school. And so I think really if we act from a place that people are responsible, grownups who are trying to take care of our patients to the best of our ability, and that we're all the dedicated people, we sat around and making our rank lists, prioritizing and, and cherishing. Those people are still true today, and I think that they are often made the better for a parenthood experience. And so if we invest in [00:33:00] them when they need us a little bit more, I promise you they'll be even better on the backend, right? Because they will have gone through something that is probably uniquely transformative for them, whether it's this or any other health challenge, right? And I think that that's really. You're investing in the short term to get a great resident in the long term. That's really how I think of it, is like, yeah, I can be nice and accommodate you. 'cause then guess what? I'm gonna have an awesome resident who's calling me in the middle of the night, managing my patients, taking care of them, doing the hard work so that I can be home now as an attending. What a privilege. And if they're just asking me for 20 minutes, man, and if I have a problem with that, that's something I need to really think long and hard about. And I think that culture change. It's something that is already real, right? And I, you know, I, I had a baby in my first year on faculty at the University of Chicago. They were so great about it. It's a huge reason why I stay, right? Because I felt well supported. And I think that that has been a palpable experience for me is that if we can do a good job in this way, we're gonna have people who are even more dedicated, who are [00:34:00] even more loyal. Who are even greater afterward, whether it's this or any other kind of health challenge that comes their way during residency. So I think it is, it's a, it's an opportunity and it, I know we sound really corny now, and it wasn't always easy and it's not gonna be easy for the people who do this. Having a child is never easy, but I think really, you know. It shouldn't be, you shouldn't be waiting to live your life for surgical residency. I really believe that, right? Having my kid during residency is a huge reason why I finished. She's a huge reason why I have the goals and ambitions that I do, and I think that. I, I just, I would've been so, it would've been such a missed opportunity for me if it didn't become a positive. And I'm so grateful that childbearing and residency for me is a strength and was a triumph as opposed to one of the hardest things of my life. So, I, I don't know. I think we can be corny now, and I think we can be positive and I think we can be optimistic. And I'm happy to be the fun aunt to anybody who needs me to be. And really, I think it's, it's, we're moving forward in a direction as fast as [00:35:00] we possibly can to do things better, even outside this domain. It's gonna take time though. I think it's really special to be a resident and watching the culture shift change from the time that I was in medical school. To see people like really fight for what they need to now have people looking a little more proactively to say, gee, we might want to think about making a policy about this that is inclusive of all things that is inclusive of infertility for parental leave, for childbearing and non childbearing parents, for lactation, for, you know, any. Postpartum leave that a resident might leave or any leave after any child is, you know, born or comes into a family in any way. And I think that's really special to now say that this isn't just about childbearing, this is about the. Everybody being able to have the opportunity to be a surgeon and have a family, and that's [00:36:00] something that is really inspiring as as a trainee, when I have third year medical students who come to me and say, I'm nervous about doing surgery because I love it, but. I'm worried about what it means to have kids, and I think that conversation probably looks a little bit differently for me than it did for the two of you, um, when you were medical students and trainees as well. So I just wanna say thank you for being part of this change. You know. And I told Dr. Beck this off the record, but I actually saw her her article in the New York Times when I was a medical student. And that actually had a huge impact on me. That's wonderful. And I think being able to talk about these things in a positive way is really, really important because it means that the people who come behind us have the opportunity to have a really positive experience. That's incredibly gracious and so meaningful and makes it all worth it. But I just wanna also be honest behind that article was so much fear, right? I gave a pretty scorched earth [00:37:00] honest portrayal of having babies in surgical residency to that reporter, and I was painted in a really positive light. And I think that that was such a gift because they could have taken the morsels that made me sound negative, and so it changed my life, right? That experience, this whole experience changed my life. But the seed of it was my child, right? My daughter changed my life. All of the rest of this is the wraparound spillover effect. And so I think if nothing else, the more important goal in my life was to become a parent. That's unique to me. Nobody else has to do that if they don't want to. But the second one was to become a surgeon. And so I think that you're absolutely right, Kara, but I think it really is incredibly meaningful. It's like I had great people in my corner. And I didn't even know what was possible. Right. And I, and I think you don't have to have mentors that have checked every box that you wanna check, right? You know, some of the greatest mentors in my life have no overlap with the choices I've made with my demographic information. And it was the people who were most [00:38:00] invested in me just fulfilling my goals. And I know we say it a lot, but this one thing is just a canary in a coal mine, right? This one thing is a way that we can really test. How we take care of people. And so I was scared when I was in an article called The Surgeon is a Mom, right? I was terrified because I, somebody told me no one was gonna offer me a job, but thank God they did. Right? And I found a place that valued that aspect of myself. And I think that that's an important piece of this Kara now, is that there are many more places now that see this work as a strength, as a value add, and as a unique opportunity to demonstrate leadership. Right. Having kids in residency is a leadership experience. It's, and, and I think, and lessons learned from that have made me a better doctor, have made me a better person, have made me a better partner to my husband, you know? And so I think all of that is, it's just. It means so much to me, and I think that the fact that that still lives on, I have, I have it in my office, right? I, I, my mom framed that article and I have it in my office here, [00:39:00] and I remember being a little bit nervous to put it on the wall, but then I, I also, you know, all of this makes me nervous to talk about it, right? Is, is we're still a little bit worried. And as much as I'm done, right, I'm on the other side. I have two beautiful kids. I have a faculty position, and I, I'm okay. I still think we get nervous and that means there's work to be done, even though I'm still nervous talking about it. And so I'm sure you know we're gonna say things in this podcast that other people won't agree with, and that's okay. Right? This is a space where we wanna have positive, proactive conversation and learn. And if there's a way we can do it better or smarter for somebody to come behind us, by all means edit the document, right? Make it better than it was before. Like tell us, teach us. That was the best of what we could come up with at a time where we were really. You know, taking a shot in the dark. So I think I, I wanna watch this work become bigger. I want people like you, Kara, and anybody listening who's feeling like they have something to, to join or to say as like a, an extra piece of it to do that. Because I think it's really, this work [00:40:00] only becomes great when it's a source of community, when it is a source of connection and where people don't feel left out, isolated, or like they're the only one facing this challenge. We all did. So that means that we can lean on each other and, and grow from, from that beautiful relationship. And that's a lot of what motherhood is, right? It's a lot of like, what the hell am I doing? But I think that's a lot of what surgical residency is. There are a lot of overlaps here, and I think a lot of residency is, I don't know what I'm doing and I need help. And, and learning to admit that humbly is a part of the experience that we want our residents to have. This is just another exercise in that. And Dr. Caners, I, I just wanna kind of swing this back to you for a moment. Now, you, you are in a leadership position with the program. You're an associate program director, and how has this work really shaped the way that you approach trainee support and education as a whole? [00:41:00] Well, to go to. Go back to what I said earlier is that it's my responsibility to my trainees, the, the onus on making sure the appropriate accommodations are met. Whether it be for lactation, for parental leave, for insulin access, right? Like whatever the case is, you can, it's my responsibility. They are, they are my people. So I. Do my very best to anticipate. Now, that's not always feasible. Quite literally, before we were doing this, someone was like, oh, hey, I don't have a place to pump. I was like, oh my goodness, I need to find you a spot. So like you have I working on the lactation list and things like that. But the point is that I make myself available to. All of them, residents included. So I'm, I'm not as involved in the general surgery residency program as I am in a colorectal fellowship, but the point is, I make myself available to all of them as an advocate. I tell them, let me carry the load. You come to me. I will never judge, I will never question and let me be the voice that goes forth and says, this is what we need. This is how we need to make this better. Because [00:42:00] that way you don't have to worry about that hierarchy and you can come from a safe place. The other important thing I really try to do is it's never my decision that a resident take a parental leave. It's never my decision that they, that they. Lactate, whatever the case is. But I wanna make sure that they know I support them in whatever decision they make. So any one of our, our male residents who is taking a parental leave after the birth of their child, I try to encourage, and again, cannot force, but I try to encourage, I say, there's no circumstance under which you need to come back this quickly. There is nothing that you are gonna do in those next two to four weeks that is gonna be. Is gonna have a negative impact on your future by not coming to work. But there is an opportunity for you to be home with your child in the first couple weeks of life. That will ultimately probably carry more weight for you in the long run. Again, this is a decision between you and your partner and whatever the case may be, but please know that we support you. And so I try to lead from that standpoint and try to also just make sure I, uh. Educate my partners. You know, it's [00:43:00] Dr. Sbe and I ran into the same problem. We were residents. This question a a a staff was like, my wife's gonna kill me, but I don't remember how often you need a pump and how long it takes. And that, and that individual had multiple children. And so just now, similarly, my chair came in and he was like. So our, our partner who's coming back, when does she need to pump? I was like, I'll take care of it. We'll block her time. We'll make sure things are fine. So the idea is that like, I wanna help educate so it doesn't have to fall on the, on the shoulders of the person who's trying to experience this big new life change as it is. And again, I encourage, Dr. Beck does this. Every single day in her role and, and we, as we move up in the ranks of life, like we're able to do this more and more for the people behind us. I'm just fortunate enough to be in a leadership role and within the education system that makes it a little bit easier for me. So I ask them to come and give me their problems and I can work on it from whatever aspect I've got, whatever tools I've got in front of me. It's so much easier as the staff, as the program lead, like it is so much [00:44:00] easier to carry that weight. Also having gone through it myself, it, it helps a lot 'cause I've got that perspective. Um, but I think just making this okay and making this a norm, that's the first and most important thing I can do for any of my trainees. It does not, they do, they should not feel like a trailblazer. I do not want them to feel like a trail trailblazer. I want this to feel like another day at work or another thing that just they have to do. It's not a fight for them. I think also just to kind of build on that Ari, one of the things that I took from that is a lot of everybody's nervous going into these conversations, right? If you email random attending surgeon number 27, we need to talk about my pumping schedule. You don't know what their experience with that is. You don't know that they don't know how long it takes and you know, having to go have this what feels and is perceived as a very intimate conversation with someone you don't wanna have intimate conversations with. Everybody's nervous, right? So I think guidelines, like we proposed and you know, kind of open forum for q and a that we held at Michigan were really meant to [00:45:00] take the tension out of that moment. Right. I am happy to talk about people's breasts all day. Right. I am. This is welcome to my domain. That's not true for everybody else. And so I think oftentimes when we, when we think about like the role of a guideline or an example guideline that someone can bring to their program, it's really just meant to cut the tension a little bit. Mm-hmm. So that it doesn't have to be, this is what I need, this is my body, this is my decision. Like it doesn't have to be so. Strong, right? It can just be neutral. And I think neutrality is the gift, right? It is like having it not be controversial, having it not be so exceptional. Right. And having it not be so nerve wracking is such an important thing. Right. And I think, you know, as we continue to march forward here at Chicago and at lots of other places around the country. What comes next? Well, how do we think about compensation? Like how do we think about RVU productivity? How do we think about these topics that felt inaccessible in the context of these?[00:46:00] Time away leaves work reductions for lactation and pregnancy. But by having a positive and grounded foundation, it allows us to have the next level conversation that maybe is arguably even more important for the institution to think about. Like, how do we pay for this time? How do we think about, you know, what people are doing? And. And filling the hours of their day. And so I think really a lot of this is language. And so that example that Dr. Cantor just gave is basically serving as an interpreter, right? Is like two people have a problem and they're struggling to communicate about it, or maybe they don't know how to communicate about it. Every place can have an interpreter that says, Hey, listen, it's not a big deal. Don't make it weird. Right? It's like when you tell your parents like, don't make this weird, I'm bringing a friend over. Right. And I think that that's a big part of it is a lot of the time my job is just to be like, stop making this a weird mm-hmm. This person's doing a great job. Stop being weird. And so I think that's, I don't want the takeaway on this podcast to be that Sarah Beck thinks everyone needs to [00:47:00] stop being weird. But more just, that's a. And more just to say like, stop making everything such a big deal, right? Everyone's gonna have challenges in the course of their residency. It's a long, very formative time in our lives. People might have family members who are ill, people might have unavoidable conflicts or emergencies. People might have babies, people might have illness. Things are gonna happen. We can't make that seem so hard or so detrimental to their training because it is five to seven to many, many, many years of these people's lives. That is an awful degree of stress and tension to feel when things happen that affect people. We know this, right? We take care of people on their worst days every day. I'm gonna go do that right after this, but I think. We just have to give people grace, that everyone wants to do their job well, that we picked these people for a reason, that we're investing in them so that they can take care of our mothers, our sisters, our our children, when they're forged into these great general surgeons. But [00:48:00] there are gonna be bumps along the road, and if they are scared and stressed to talk about those bumps, it's gonna become exponentially worse. And so I think this is just one class. One class of those bumps. And so this is an opportunity to do something really, really well. And if you don't know how to talk about it, say that. Be like, listen, I'm sorry. I don't know how to talk about this. I think really it's just allow people space to feel uncomfortable, acknowledge that discomfort, and then come to a place of understanding as best as you possibly can, and then build the common language. And that's a lesson that can be applied to anything, not just lactation. The point, I'll echo one more time, is just you don't need to do this alone. You form your tribe. Your tribe doesn't have to be in your institution, doesn't have to be in your department, doesn't have to be any of that. But we exist. Please come find us because we're happy to fight that fight for you if you don't feel empowered to do it yourself. We're fortunate enough to be in roles of, again, leadership roles [00:49:00] and we are excited and love. This kind of thing. So if you are ever reaching that point where you're like, I don't know what else to do, turn to one of us, turn to someone that you've heard speak, send that rogue email, because the fact is, we're excited to talk about these things. Um, don't feel alone. Don't fight this alone. Let us help you. It's getting better. It's not there because that person who's trying to fight alone and gets the support, will turn around and take care of the person behind them. This is a community based effort. It is getting better. It will continue to get better, and I just can't wait to see what happens in the future. I just wanna say thank you so much to both of you. Your honesty and willingness to talk about this and your advocacy to make this better for the surgeons who come behind you and move this conversation forward in a meaningful way is, is really special. And I really hope for our trainees listening that this conversation makes you feel seen and supported regardless of what struggles you've been through and reminds you that.[00:50:00] As Dr. Kandra said, you're not alone in this fight, and for the programs and for program directors listening, I really hope that this sparks some thoughtful reflection about how you can better support the surgeon parents in your communities and gives you some ideas for tools that you can use to improve your policies moving forward. Thank you so much to both of you. Thank you. Thank you.