It's hard being a female surgery resident

I've always believed that us males have it much easier in surgery. Now, I have a little data to back that up. I've attached a survey study that many of us filled out (given during the 2008 ABSITE with a 82% response rate). It's obviously soft data, but it evaluates the effect of marriage and children on the happiness of surgical residents.

4,402 residents responded. Men were more likely to be married (58% vs. 38%) and more likely to have kids (32% vs. 12%). The rest of the stats were also quite interesting, as was the fact that "the female gender was negatively associated with looking forward to work." (OR 0.81, p=0.007) Unfortunately, being married or having children did not significantly affect the female residents' desire to work.😉

Female residents have several factors working against them: While having children during residency isn't prohibited, the co-residents often resent them for screwing up the call schedule, and it often puts them behind in their work and their life. When dating, dudes can often find strong, successful females to be intimidating, etc, which may contribute to the fact that 33% of female respondents were not in a relationship.

I'm interested to hear what other SDNers think about this study. Should training be modified to allow a better balance between family and career? Is this gender inequality inherent to surgical training, or can something be done to make surgery more friendly for females? If something can be done, should it?

Great article. Thanks for posting it.

It may be hard, but women are filling a lot of spots. Example, Baylor-Dallas, one of the best "Ol' School" programs:

http://www.baylorhealth.edu/Education/gradmeded/Residencies/GeneralSurgery/Pages/Residents.aspx

wow.

Danbo1957 said:

It may be hard, but women are filling a lot of spots. Example, Baylor-Dallas, one of the best "Ol' School" programs:

http://www.baylorhealth.edu/Education/gradmeded/Residencies/GeneralSurgery/Pages/Residents.aspx

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I'm not sure I would really put much weight into something based on responses after ABSITE. I know I didn't really put much thought into my responses. Besides, some of the differences that were statistically significant did not really seem that "clinically" significant. I certainly never felt like my satisfaction at work, or with my pay was in any way related to my gender, but more with whether or not I was having a good day. My unmarried female colleagues weren't necessarily trying to be married, so it may not be that they are unable to find a suitable mate (I never wanted to to get married, but happened to find a guy that changed my mind about it). The females may be childless by choice, not because residency is holding them back. I am not convinced there is a problem that needs to be fixed. If anything, studies like this might create a problem by making programs think that they will have happier and potentially more effective residents if they select married men with kids whose spouse is the primary caregiver. I admit I am somewhat biased by the past since I originally tried to get into a male dominated field (ortho) and feel that my gender played a role in my lack of success.

I interviewed prospective residents for the first time at my program and I have to say there was no shortage of bright, well qualified, and motivated students to select from (and I know we are not a highly sought after program). Do we need to make big changes to try to recruit more? I am all for better pay and better conditions for residents, but if we start talking about extended maternity and paternity leave it could result in need for extended training. It would be nice if that didn't mean that even more work would be dumped on the remaining residents but we all know that isn't reality at most programs. Not sure what kind of strategy could be implemented to help the single residents find a mate, but I don't think that needs to be the business of the program. I also don't know of a way that would make everyone happy to come to work every day short of daily massages (with or without happy endings) or some other incentive. Some days just suck for reasons that can't easily be fixed.

dpmd said:

I'm not sure I would really put much weight into something based on responses after ABSITE. I know I didn't really put much thought into my responses. Besides, some of the differences that were statistically significant did not really seem that "clinically" significant. I certainly never felt like my satisfaction at work, or with my pay was in any way related to my gender, but more with whether or not I was having a good day.

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One could argue that surgery's attitude toward female residents being married and having kids may cause more females with a different agenda to gravitate toward surgery. IMHO, his paper supports your assertion that females in surgery don't have marriage and kids as a priority (as evidenced by the fact that the presence/absence of this did not affect their happiness).

You comment that being more family-friendly may extend necessary training. Does this mean that the current approach is necessary to train women in 5 years?

SLUser11 said:

You comment that being more family-friendly may extend necessary training. Does this mean that the current approach is necessary to train women in 5 years?

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I'm unclear on what you're asking here? I think 5 clinical years works well overall; I think subtracting time from that baseline makes it difficult, regardless of gender. If a male resident had an illness or other life event which required an equivalent time period away from clinical duties, the same standard would apply. We have one female resident who had children (TWO) in residency and I think she is the first to do so in the history of our program - the fact that she is a bad ass resident can only help future women who find themselves in a similar situation. That being said, we are a 6-year program with built-in research time and the program was able to adjust her schedule in a way that did not affect her clinical schedule because of that. She's been able to pull it off, but I'm not sure that I could, even if I was in a position to do so. She essentially has a stay-at-home husband, which obviously helps.

LucidSplash said:

I'm unclear on what you're asking here? I think 5 clinical years works well overall; I think subtracting time from that baseline makes it difficult, regardless of gender.

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I'm asking if the structure of residency makes it extremely difficult for women to have a family. If so, is this structure appropriate?

You describe a program with 1) a required research year and 2) administrators willing to adjust schedules to make a family possible....yet only one female resident has been able to have 2 kids during residency, and she was a super-bad@$$ with the aid of a stay-at-home husband. How many other female residents will have such a favorable situation?

Should female residents wait until residency is over to start a family? The first couple years of practice are usually even busier than residency...should they wait until after that? As an alternative, should they work part-time? They've worked pretty hard for multiple years to settle into a part-time position.

On another note, when they finish residency in their early or mid-30's, will it be difficult to start a family? Aren't most available guys damaged goods at that point? Won't the stress of a ticking biological clock affect judgment?

Certainly there are exceptions, but is a female's choice to be a surgeon a huge roadblock to marriage and kids? For those female surgeons who have families, would you want your daughters to become surgeons?




This is not meant to be a misogynistic rant. It's meant to illustrate how uneven the playing field seems to me...and I'm the one with better field position.

SLUser11 said:

One could argue that surgery's attitude toward female residents being married and having kids may cause more females with a different agenda to gravitate toward surgery. IMHO, his paper supports your assertion that females in surgery don't have marriage and kids as a priority (as evidenced by the fact that the presence/absence of this did not affect their happiness).

You comment that being more family-friendly may extend necessary training. Does this mean that the current approach is necessary to train women in 5 years?

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As lucidsplash said, I think the current approach for training either gender requires a minimum number of weeks of training. Missing several months of training because you have a child, a sick relative, or a personal illness may be ok if you still receive the required weeks of training, but I don't think it can be considered helpful to your training. There is so much in residency that is learned by participating, that anything that decreases that has to be taken in to account. Clearly I am not advocating a system where you never leave the hospital, and I don't think the current work hours restrictions mean we need to extend the length of residency, but I don't see how a 20 hr workweek would be sufficient (one way to be family friendly, or even dating friendly for the single people would be to make it a part time gig-then even with study time there is plenty of time to do life stuff). I am not sure even a 40 hr week would be enough in a 5 year program.

We also have a resident who had two kids during residency (she is a fourth year, so I guess I can't rule out the possibility she will have another). We are a small 5 yr program. The first kid was planned and things worked out ok since she was able to work up to the day she planned to start maternity leave. Other people had to cover the month she was off, but it wasn't that bad. This kid wasn't planned and she ended up starting maternity leave early and had to have a c-section which extended her leave. The coverage has been trickier since we have people on away rotations leaving things even shorter, and since she was supposed to have been on general surgery we have been short a resident for some cases (I would have been doing some stuff without a resident if we didn't have someone willing to violate work hours to do the case). Even if we had some midlevel help for coverage and floor work to free residents to operate, this particular resident will have missed one month during third year and possibly two months during fourth year (unless she gets permission from her doctor to come back early), on top of vacation and other time off. She is already at risk for needing to extend her training per ABS rules.

SLUser11 said:

Certainly there are exceptions, but is a female's choice to be a surgeon a huge roadblock to marriage and kids?

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Yes.

SLUser11 said:

For those female surgeons who have families, would you want your daughters to become surgeons?

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Nope. Nor my sons.

SLUser11 said:

...illustrate how uneven the playing field seems to me...

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Gender playing fields are uneven many professions due to the work required: airline pilot, ship captain, bricklayer, plumber, etc. As I posted years-ago, every woman surgeon is valuable, for the work that she does and the difficulties she overcomes...

Hey all, I've been largely absent from this forum for the last two years, but just so happened to come back today to find this thread front-n-center.

I'm female. I'm married. And, towards the end of my PGY-2 year, I had a son.

Most women will spout meaningless BS, frankly, on the work-life balance. They'll say "you can make it work, you just have to be really organized" or "it's easy to have a baby in residency, you just have to prioritize" without really getting not the nitty-gritty. Well, here's the nitty-gritty: having a baby in residency, as a woman, is really really f*****g hard and you shouldn't do it.

I had a dream pregnancy. Was on call on my due date. Worked all the way up to 41weeks. The only accommodations I requested were not being assigned to endovascular cases due to the fluoro, which was fine. I had my son, had a 28-day maternity leave (sacrificing all vacation and flex time for the whole year in order to meet the RRC's 48 wks of active clinical duty requirement. Remember, trainees in other fields can actually take their FMLA for longer leaves, or arrange 'research electives,' but we can't, not if you want full credit for the year). Then I came back to transplant, with its erratic q2 40- hr calls and long procedures. When you're holding a liver retractor for 8 hours, how amenable do you think the attending is to you scrubbing out to go pump for 30 minutes at a time, q3 hours? I had a month-old baby whom I wasn't seeing, or nursing, for 2 days at a time. I was contributing absolutely nothing to his care, nothing. It is impossible for female trainees in other fields to understand how much more radically different the demands of surgery residency are on motherhood.

The other thing to keep in mind is once a child enters the picture, you examine your own working life in a new light. You have to find someone else to provide competent, reliable care for that child literally every single minute you're out of the house. What nanny-- or nannies, because you'll need at least two-- will arrive at 4:30AM when you leave, be content to stay till nine when you said you'll be home at seven because a patient had a complication, work overnights, weekends, holidays, covering 30+ hours at a time? At least 95% of the burden will fall on other people, be it your partner, family members, or commercial help. To make up for this, you also, out of inclination and biology, will be "on" from the moment you step foot in the door at night till you leave in the AM. Words really cannot express how completely exhausted you'll feel, being q1 for months on end, with absolutely no post call day to make it up. The worst, hardest month you ever experienced in residency is absolutely no comparison.

Finally, as prosaic at it sounds, you suddently do have competing demands which genuinely compromise your ability to be a good resident. I will say that unabashedly, if no one else does: being a woman and having a baby makes you a worse resident. The exhaustion honestly compromises your ability to think, speak, read and analyze clinical situations. I felt I was functioning completely on autopilot. I do not think any patient was harmed, but I cannot be sure. Then there are the time constraints: you are nursing your baby at 4 AM, since you need to be out the door at 445. The time comes and he hasn't finished. You can't make him drink faster. Do you leave him unsatisfied, or show up to work 10 min late? Or, you're signing out in the evening and you get a page that a patient is near to coding. Any decent resident would go look in on their own patient and manage the situation. But your daycare is closing-- staff is going home-- in 30 min. Your first duty is to your own child, isn't it? You have to go get him, no questions asked, else-- seriously-- he goes into protective custody via CPS overnight, as do all unclaimed children. Again prosaic concerns, nothing exciting, but you must make a million such small choices which will result in suboptimal residency performance and suboptimal mothering.

Ours is a system that runs on a permanent skeleton crew, with absolutely no slack or redundancy built-in. It is impossible to overstate the differences between having a baby as a surgical resident versus being in pediatrics, medicine, psychiatry, pathology, FM, EM, etc.

Marriage is completely different. Marriage involves almost no time or personal sacrifice when it comes to residency. Butif anyone is contemplating a planned pregnancy in Surgical residency, I would advise them not to do it. At least as an attending you have some control over your own day, schedule and normal workplace protections like FMLA. Otherwise, simply understand that you will be entirely dependent on other people to raise the baby.

SLUser11 said:

Certainly there are exceptions, but is a female's choice to be a surgeon a huge roadblock to marriage and kids? For those female surgeons who have families, would you want your daughters to become surgeons?


This is not meant to be a misogynistic rant. It's meant to illustrate how uneven the playing field seems to me...and I'm the one with better field position.

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I don't see how it is any more of a roadblock to marriage and kids than any other high powered career that takes a great deal of initial investment in order to become successful. I don't really see how it is any harder for a female resident to date than it is for a male resident (I mean logistically, not getting into the issue of desirability, which I don't think would be changed by any adjustments to the structure of residency-even with a bunch of free time a confident/intelligent/focused woman who wants a traditionally male career will have a more limited pool of potential mates). The only reason there is such a roadblock to kids is because typically speaking the woman will have to carry the thing for 9 months even if she has the most supportive partner who will then be the main caregiver. One way around this would be to adopt or use a surrogate. This would allow women to participate in the child's life in whatever way they choose, just like a man can. The issue is I don't think that society approves of absentee mothers or people with functional wombs not using them. Unless that changes, there is always going to be a bit of an uneven playing field.

SLUser11 said:

I'm asking if the structure of residency makes it extremely difficult for women to have a family. If so, is this structure appropriate?

You describe a program with 1) a required research year and 2) administrators willing to adjust schedules to make a family possible....yet only one female resident has been able to have 2 kids during residency, and she was a super-bad@$$ with the aid of a stay-at-home husband. How many other female residents will have such a favorable situation?

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Our research year is unique in that it is broken up over PGY 2-4; residents have 4-months of research in each of these years. Thus our chiefs are PGY-6. Our research is entirely clinical, rather than laboratory-based. IMHO, this makes it somewhat easier to have multiple children in residency.

Only one female resident at my program has tried - I don't think it's appropriate to extrapolate that to "able." I brought up the fact that she was badass because I think that helped open the minds of the powers that be about the concept of pregnant surgery residents in our program; I think most did not expect her to continue, let alone flourish. The fact that she did so with her first pregnancy had two effects: 1) No one had that much anxiety about the situation when she had her 2nd child and 2) The path will be easier for any future residents who wish to do the same. She's shown that one CAN be a mother AND a great surgery resident. It is possible - the actual performance thereafter is up to the individual resident.

I think it is difficult to do, and the need for maternity leave as well as pregnancy-related complications does make it different for women with regard to the initial physical investment required for biologic reproduction. But who asks male residents if they have a "favorable" situation when bringing up the topic of having kids? Is that even an appropriate question?

SLUser11 said:

Should female residents wait until residency is over to start a family? The first couple years of practice are usually even busier than residency...should they wait until after that? As an alternative, should they work part-time? They've worked pretty hard for multiple years to settle into a part-time position.

On another note, when they finish residency in their early or mid-30's, will it be difficult to start a family? Aren't most available guys damaged goods at that point? Won't the stress of a ticking biological clock affect judgment?

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Well, my personal experience has been that age does good things for most men, and they only start to be acceptable to my dating standards in their 30s. 🙄 Biology certainly plays a role but I'm not sure how the question of one's judgment in the men in their personal life is the concern of the residency program. This oblique characterization of women over the age of 30 without children as somehow desperate or prone to poor judgment in their personal lives does come off as a bit misogynistic, though I have read enough of your posts to believe that was not your express intent.

SLUser11 said:

Certainly there are exceptions, but is a female's choice to be a surgeon a huge roadblock to marriage and kids? For those female surgeons who have families, would you want your daughters to become surgeons?

This is not meant to be a misogynistic rant. It's meant to illustrate how uneven the playing field seems to me...and I'm the one with better field position.

Click to expand...

The decision to pursue surgery is no more or less an impediment to marriage than other individual choices and pursuits a woman makes. In my area at least, it is more difficult to meet desirable men who are interested in dating someone with my kind of job or education level. But... I'm not really interested in dating men who aren't interested in dating women with my kind of job or education level. I also tend to to have the possession of a Bachelor's degree as one of my baseline requirements for considering someone as a prospect, so it's not like the situation is unequal in terms of prejudice.

I don't have a daughter, but I am 31 and I do have a sister who is 15. Do I want her to be a surgeon? I want her to do what makes her happy, overall, without the ridiculous assumption that one can truly "have it all." I think many women of my generation were implicitly told that they could: high-powered job/demanding career and a husband with the same, perfectly kept house without outside assistance, giving dinner parties in pearls, marathon runner/masters level tennis player/etc, 2.5 kids, make every soccer practice/class play/deliver homemade cupcakes/etc. This is insane and has led to a number of fantastic women feeling like they are letting themselves and their families down because they can't do everything. Men don't "do everything" and I'm not sure why the implicit message was different for girls, except that I was born on the heels of the sexual revolution and women were (and are) still trying to balance traditional gender-based societal expectations with modern "feminist" gender-based expectations.

Women are, on the whole, horrible to other women. True feminism should be the freedom to make decisions based on the priorities you set for yourself (or you and your partner set together, if you have one) without constant public and private judgment from non-involved parties. I don't think there's a "War on Women" so much so as a "War Among Women," comparing who's made more or less sacrifice by going to work or staying home or some combination thereof.

The history of my family colors my perspective on this subject. My great-grandmother was born in 1898 and was a graduate of Women's Medical College in Philadelphia; her professors had to sneak in to teach them because otherwise they were ostracized by the medical community at large, for the offense of teaching women. She wanted to be an obstetric surgeon but went into family practice because she was told that women did not go into surgery. She married a fellow physician, but gave up practice when she had her first child. My aunt graduated from medical school in the early 1970s. There were 10 women in her class, due to quotas. She wanted to go into ortho, but was told that it was not a woman's specialty. She went into radiology; her co-residents referred to each other as "Dr." or their last names but they referred to my aunt by her first name or as "The Girl." She was required to tape a sign on the door of her callroom that said "Girl Sleeping In Here." She continued to work after my cousins were born, despite some criticism. She now regularly speaks to sub-specialty surgeons at their conferences on her area of expertise.

My medical school class was 2/3 women and I'm a general surgery resident and no one treats me differently because of my gender (except that one or two of my male attendings seem to be a little skittish that they will somehow inadvertently offend me). 4 of the 12 or so who went into surgery were women. So far, all of us are sticking it out. I see the progress of women in surgery (and having children as a resident) as part of the progress of women overall in the last 100 years. I do think that the idea of trying to balance the demands of a surgical residency and the physical act of gestation and then recovering from childbirth is something that needs to be taken into account; I think the flexibility in the clinical schedule at my program does this well. The biggest hurdles are simply the doubts in the minds of administrators (which are overcome with time and experience with women having children in residency) and women who are unclear on their own priorities or, inappropriately, have guilt over what those priorities are because of some unrealistic notion of what it really means to be a strong and accomplished woman. The world has changed a lot since the 19th Amendment was ratified, but I think we're doing just fine.

LucidSplash said:

This oblique characterization of women over the age of 30 without children as somehow desperate or prone to poor judgment in their personal lives does come off as a bit misogynistic, though I have read enough of your posts to believe that was not your express intent.

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That was certainly not my intent, although I am guilty of purposefully introducing controversial topics to make SDN more interesting and thoughtful.

If anything, I was implying that a level-headed, single 36 year old surgeon would not be desperate, but may feel frustrated by the necessary timeline for kids and family going forward.

BlondeDocteur, it's nice to hear from you. Look around the recent threads, as I think you came up recently re: UW. I hope the baby boy is doing well.



To give my perspective, I had 2 children during training (1 in residency and 1 in fellowship), and my wife stayed home after the first one was born. Being an absentee father is definitely not fun, either, but I think my situation was much more reasonable than women trying to do the same thing.

I too had a child during residency...midway through my fourth year. I wasn't exactly planning to have a child during residency, but life happened and it worked out. BlondeDocteur brings up many of the realities of having a child during residency, though my experience was not quite as dire as hers for perhaps a couple of reasons. First, I was more senior when I delivered, which made it a little bit easier. The schedule was a little more controllable as a chief, though the hours were long. There is so much pressure on women to breast feed, and it was very challenging to maintain this in the face of a crazy busy service and long cases. Though people were very supportive overall, I didn't feel as though I could ever bring up the demands I felt as a mother on the job. I really didn't want to show any weakness or suggest that I had lost my edge as a surgeon after having a child, so I didn't discuss it at all unless someone else brought it up. And I never, ever, ever complained about how tired I was. No one forced me to have this child, none of my co-residents wanted extra work because I had made the decision to procreate. So in that way, it was very lonely. The other thing that worked in my favor was that my husband was able to be primary parent during my last 18 months of training. He met the nanny at both ends (we had the financial means to have a nanny which was extremely helpful) and we were able to have the nanny work a normal schedule; he (also a physician) was able to work his call schedule around mine, and also was willing to do it for that short amount of time.

If you think about it broadly, none of the guys who have kids in residency are able to be primary parent. It's really that surgical residency does not mix with being the responsible parent, but our society is so used to the women in the relationship shouldering those responsibilities that no one has ever batted an eye. Now that more women are in surgery, it's more visible. Also, speaking in broad stereotypes, there are fewer men who are interested in marrying female surgeons who are also interested in being a stay-at-home dad or really have their careers take a backseat to their wives.

I think the new ABS rules that you can essentially do five years of training over 6 years for a variety of reasons is a positive development, and I think one thing programs can do to support women who are procreating is to think creatively about staffing so that maternity leave can be used by the women and then they can graduate late.

The shame is that once you get done with residency, general surgery is an awesome career to be a woman and a mom in these days (IMHO, as a person who just had a second kid my third year of attendinghood). There are all sorts of jobs with all sorts of schedules, pay is good, and the work is very rewarding. My "full time" schedule is four days a week plus call, I'm currently back three mornings a week plus call, and I love my job. As a rural general surgeon I take a lot of call, but most of it is home call and I can hang out with my kids. I could go on.

As I was finishing training, I would drive to work most mornings, dog tired and considering quitting most days (even with a few months left in training). Sticking it out was the best decision I made.

SLUser11 said:

..would you want your daughters to become surgeons?

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I have a 5 year old daughter and like any impressionable child she wants to be a surgeon. Of course I just chuckle and let her play with my stethoscope. BTW, she also wants to be a ballerina/school teacher/race care driver. But if she ever wanted to be a surgeon and had a child during residency I'd gladly help out even if it meant scaling back my practice or taking leave.

BlondeDocteur said:

I'm female. I'm married. And, towards the end of my PGY-2 year, I had a son.

Most women will spout meaningless BS, frankly, on the work-life balance. They'll say "you can make it work, you just have to be really organized" or "it's easy to have a baby in residency, you just have to prioritize" without really getting not the nitty-gritty. Well, here's the nitty-gritty: having a baby in residency, as a woman, is really really f*****g hard and you shouldn't do it.

I had a dream pregnancy. Was on call on my due date. Worked all the way up to 41weeks. The only accommodations I requested were not being assigned to endovascular cases due to the fluoro, which was fine. I had my son, had a 28-day maternity leave (sacrificing all vacation and flex time for the whole year in order to meet the RRC's 48 wks of active clinical duty requirement. Remember, trainees in other fields can actually take their FMLA for longer leaves, or arrange 'research electives,' but we can't, not if you want full credit for the year). Then I came back to transplant, with its erratic q2 40- hr calls and long procedures. When you're holding a liver retractor for 8 hours, how amenable do you think the attending is to you scrubbing out to go pump for 30 minutes at a time, q3 hours? I had a month-old baby whom I wasn't seeing, or nursing, for 2 days at a time. I was contributing absolutely nothing to his care, nothing. It is impossible for female trainees in other fields to understand how much more radically different the demands of surgery residency are on motherhood.

The other thing to keep in mind is once a child enters the picture, you examine your own working life in a new light. You have to find someone else to provide competent, reliable care for that child literally every single minute you're out of the house. What nanny-- or nannies, because you'll need at least two-- will arrive at 4:30AM when you leave, be content to stay till nine when you said you'll be home at seven because a patient had a complication, work overnights, weekends, holidays, covering 30+ hours at a time? At least 95% of the burden will fall on other people, be it your partner, family members, or commercial help. To make up for this, you also, out of inclination and biology, will be "on" from the moment you step foot in the door at night till you leave in the AM. Words really cannot express how completely exhausted you'll feel, being q1 for months on end, with absolutely no post call day to make it up. The worst, hardest month you ever experienced in residency is absolutely no comparison.

Finally, as prosaic at it sounds, you suddently do have competing demands which genuinely compromise your ability to be a good resident. I will say that unabashedly, if no one else does: being a woman and having a baby makes you a worse resident. The exhaustion honestly compromises your ability to think, speak, read and analyze clinical situations. I felt I was functioning completely on autopilot. I do not think any patient was harmed, but I cannot be sure. Then there are the time constraints: you are nursing your baby at 4 AM, since you need to be out the door at 445. The time comes and he hasn't finished. You can't make him drink faster. Do you leave him unsatisfied, or show up to work 10 min late? Or, you're signing out in the evening and you get a page that a patient is near to coding. Any decent resident would go look in on their own patient and manage the situation. But your daycare is closing-- staff is going home-- in 30 min. Your first duty is to your own child, isn't it? You have to go get him, no questions asked, else-- seriously-- he goes into protective custody via CPS overnight, as do all unclaimed children. Again prosaic concerns, nothing exciting, but you must make a million such small choices which will result in suboptimal residency performance and suboptimal mothering.

Ours is a system that runs on a permanent skeleton crew, with absolutely no slack or redundancy built-in. It is impossible to overstate the differences between having a baby as a surgical resident versus being in pediatrics, medicine, psychiatry, pathology, FM, EM, etc.

Marriage is completely different. Marriage involves almost no time or personal sacrifice when it comes to residency. Butif anyone is contemplating a planned pregnancy in Surgical residency, I would advise them not to do it. At least as an attending you have some control over your own day, schedule and normal workplace protections like FMLA. Otherwise, simply understand that you will be entirely dependent on other people to raise the baby.

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Hell, my wife who doesn't even really work just had a baby and I feel like it made me a worse resident.

Could not even imagine if I actually had to take care of the little bugger.

It seems like men get a free pass to be poor, absentee parents while women are expected to do it all.

MsKrispyKreme said:

It seems like men get a free pass to be poor, absentee parents while women are expected to do it all.

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I think it's more complicated than that. First, there's the biologic imperative -- unless you want to go the surrogate or adoption route -- that a woman needs to be pregnant for a family to have children It's just a fact that residency/early attending career overlaps with prime reproductive time for women; it's not a conspiracy.

Secondly, my question is -- who expects women to do it all? Often times, I think it's women themselves who feel that internal pressure, and its not necessarily external messages. I think it comes down to the fact that raising children and being a surgeon are both incredibly time consuming (but ultimately rewarding) endeavors, and that those two activities take up more than 169 hours in a week, so naturally a female surgical resident "can't do it all." Traditional division of labor between the sexes did allow both jobs to be accomplished by families. As women become more prevalent in surgery, individual families are going to have to divide the labor differently. And if women aren't okay with that fact, they essentially need to decide which job they are going to do.

blue2000 said:

I think it's more complicated than that. First, there's the biologic imperative -- unless you want to go the surrogate or adoption route -- that a woman needs to be pregnant for a family to have children It's just a fact that residency/early attending career overlaps with prime reproductive time for women; it's not a conspiracy.

Secondly, my question is -- who expects women to do it all? Often times, I think it's women themselves who feel that internal pressure, and its not necessarily external messages. I think it comes down to the fact that raising children and being a surgeon are both incredibly time consuming (but ultimately rewarding) endeavors, and that those two activities take up more than 169 hours in a week, so naturally a female surgical resident "can't do it all." Traditional division of labor between the sexes did allow both jobs to be accomplished by families. As women become more prevalent in surgery, individual families are going to have to divide the labor differently. And if women aren't okay with that fact, they essentially need to decide which job they are going to do.

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I think I'm gonna become a sugar mama to some muscle-bound EMT who'd be willing to be a stay-at-home-dad.

MsKrispyKreme said:

It seems like men get a free pass to be poor, absentee parents while women are expected to do it all.

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None of the fathers in my program are "poor absentee parents." I readily acknowledge that it has been easier to be a father and a surgical resident than it must be to be a mother and a surgical resident, but that doesn't mean I walk in the door, put on my smoking jacket, sit down in front of the TV and wait for my wife to bring me dinner and care for the little ones.

BlondeDocteur said:

Hey all, I've been largely absent from this forum for the last two years, but just so happened to come back today to find this thread front-n-center.

I'm female. I'm married. And, towards the end of my PGY-2 year, I had a son.

Most women will spout meaningless BS, frankly, on the work-life balance. They'll say "you can make it work, you just have to be really organized" or "it's easy to have a baby in residency, you just have to prioritize" without really getting not the nitty-gritty. Well, here's the nitty-gritty: having a baby in residency, as a woman, is really really f*****g hard and you shouldn't do it.

I had a dream pregnancy. Was on call on my due date. Worked all the way up to 41weeks. The only accommodations I requested were not being assigned to endovascular cases due to the fluoro, which was fine. I had my son, had a 28-day maternity leave (sacrificing all vacation and flex time for the whole year in order to meet the RRC's 48 wks of active clinical duty requirement. Remember, trainees in other fields can actually take their FMLA for longer leaves, or arrange 'research electives,' but we can't, not if you want full credit for the year). Then I came back to transplant, with its erratic q2 40- hr calls and long procedures. When you're holding a liver retractor for 8 hours, how amenable do you think the attending is to you scrubbing out to go pump for 30 minutes at a time, q3 hours? I had a month-old baby whom I wasn't seeing, or nursing, for 2 days at a time. I was contributing absolutely nothing to his care, nothing. It is impossible for female trainees in other fields to understand how much more radically different the demands of surgery residency are on motherhood.

The other thing to keep in mind is once a child enters the picture, you examine your own working life in a new light. You have to find someone else to provide competent, reliable care for that child literally every single minute you're out of the house. What nanny-- or nannies, because you'll need at least two-- will arrive at 4:30AM when you leave, be content to stay till nine when you said you'll be home at seven because a patient had a complication, work overnights, weekends, holidays, covering 30+ hours at a time? At least 95% of the burden will fall on other people, be it your partner, family members, or commercial help. To make up for this, you also, out of inclination and biology, will be "on" from the moment you step foot in the door at night till you leave in the AM. Words really cannot express how completely exhausted you'll feel, being q1 for months on end, with absolutely no post call day to make it up. The worst, hardest month you ever experienced in residency is absolutely no comparison.

Finally, as prosaic at it sounds, you suddently do have competing demands which genuinely compromise your ability to be a good resident. I will say that unabashedly, if no one else does: being a woman and having a baby makes you a worse resident. The exhaustion honestly compromises your ability to think, speak, read and analyze clinical situations. I felt I was functioning completely on autopilot. I do not think any patient was harmed, but I cannot be sure. Then there are the time constraints: you are nursing your baby at 4 AM, since you need to be out the door at 445. The time comes and he hasn't finished. You can't make him drink faster. Do you leave him unsatisfied, or show up to work 10 min late? Or, you're signing out in the evening and you get a page that a patient is near to coding. Any decent resident would go look in on their own patient and manage the situation. But your daycare is closing-- staff is going home-- in 30 min. Your first duty is to your own child, isn't it? You have to go get him, no questions asked, else-- seriously-- he goes into protective custody via CPS overnight, as do all unclaimed children. Again prosaic concerns, nothing exciting, but you must make a million such small choices which will result in suboptimal residency performance and suboptimal mothering.

Ours is a system that runs on a permanent skeleton crew, with absolutely no slack or redundancy built-in. It is impossible to overstate the differences between having a baby as a surgical resident versus being in pediatrics, medicine, psychiatry, pathology, FM, EM, etc.

Marriage is completely different. Marriage involves almost no time or personal sacrifice when it comes to residency. Butif anyone is contemplating a planned pregnancy in Surgical residency, I would advise them not to do it. At least as an attending you have some control over your own day, schedule and normal workplace protections like FMLA. Otherwise, simply understand that you will be entirely dependent on other people to raise the baby.

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Great post. Thank you. 🙂

LucidSplash said:

Our research year is unique in that it is broken up over PGY 2-4; residents have 4-months of research in each of these years. Thus our chiefs are PGY-6. Our research is entirely clinical, rather than laboratory-based. IMHO, this makes it somewhat easier to have multiple children in residency.

Only one female resident at my program has tried - I don't think it's appropriate to extrapolate that to "able." I brought up the fact that she was badass because I think that helped open the minds of the powers that be about the concept of pregnant surgery residents in our program; I think most did not expect her to continue, let alone flourish. The fact that she did so with her first pregnancy had two effects: 1) No one had that much anxiety about the situation when she had her 2nd child and 2) The path will be easier for any future residents who wish to do the same. She's shown that one CAN be a mother AND a great surgery resident. It is possible - the actual performance thereafter is up to the individual resident.

I think it is difficult to do, and the need for maternity leave as well as pregnancy-related complications does make it different for women with regard to the initial physical investment required for biologic reproduction. But who asks male residents if they have a "favorable" situation when bringing up the topic of having kids? Is that even an appropriate question?

Well, my personal experience has been that age does good things for most men, and they only start to be acceptable to my dating standards in their 30s. 🙄 Biology certainly plays a role but I'm not sure how the question of one's judgment in the men in their personal life is the concern of the residency program. This oblique characterization of women over the age of 30 without children as somehow desperate or prone to poor judgment in their personal lives does come off as a bit misogynistic, though I have read enough of your posts to believe that was not your express intent.

The decision to pursue surgery is no more or less an impediment to marriage than other individual choices and pursuits a woman makes. In my area at least, it is more difficult to meet desirable men who are interested in dating someone with my kind of job or education level. But... I'm not really interested in dating men who aren't interested in dating women with my kind of job or education level. I also tend to to have the possession of a Bachelor's degree as one of my baseline requirements for considering someone as a prospect, so it's not like the situation is unequal in terms of prejudice.

I don't have a daughter, but I am 31 and I do have a sister who is 15. Do I want her to be a surgeon? I want her to do what makes her happy, overall, without the ridiculous assumption that one can truly "have it all." I think many women of my generation were implicitly told that they could: high-powered job/demanding career and a husband with the same, perfectly kept house without outside assistance, giving dinner parties in pearls, marathon runner/masters level tennis player/etc, 2.5 kids, make every soccer practice/class play/deliver homemade cupcakes/etc. This is insane and has led to a number of fantastic women feeling like they are letting themselves and their families down because they can't do everything. Men don't "do everything" and I'm not sure why the implicit message was different for girls, except that I was born on the heels of the sexual revolution and women were (and are) still trying to balance traditional gender-based societal expectations with modern "feminist" gender-based expectations.

Women are, on the whole, horrible to other women. True feminism should be the freedom to make decisions based on the priorities you set for yourself (or you and your partner set together, if you have one) without constant public and private judgment from non-involved parties. I don't think there's a "War on Women" so much so as a "War Among Women," comparing who's made more or less sacrifice by going to work or staying home or some combination thereof.

The history of my family colors my perspective on this subject. My great-grandmother was born in 1898 and was a graduate of Women's Medical College in Philadelphia; her professors had to sneak in to teach them because otherwise they were ostracized by the medical community at large, for the offense of teaching women. She wanted to be an obstetric surgeon but went into family practice because she was told that women did not go into surgery. She married a fellow physician, but gave up practice when she had her first child. My aunt graduated from medical school in the early 1970s. There were 10 women in her class, due to quotas. She wanted to go into ortho, but was told that it was not a woman's specialty. She went into radiology; her co-residents referred to each other as "Dr." or their last names but they referred to my aunt by her first name or as "The Girl." She was required to tape a sign on the door of her callroom that said "Girl Sleeping In Here." She continued to work after my cousins were born, despite some criticism. She now regularly speaks to sub-specialty surgeons at their conferences on her area of expertise.

My medical school class was 2/3 women and I'm a general surgery resident and no one treats me differently because of my gender (except that one or two of my male attendings seem to be a little skittish that they will somehow inadvertently offend me). 4 of the 12 or so who went into surgery were women. So far, all of us are sticking it out. I see the progress of women in surgery (and having children as a resident) as part of the progress of women overall in the last 100 years. I do think that the idea of trying to balance the demands of a surgical residency and the physical act of gestation and then recovering from childbirth is something that needs to be taken into account; I think the flexibility in the clinical schedule at my program does this well. The biggest hurdles are simply the doubts in the minds of administrators (which are overcome with time and experience with women having children in residency) and women who are unclear on their own priorities or, inappropriately, have guilt over what those priorities are because of some unrealistic notion of what it really means to be a strong and accomplished woman. The world has changed a lot since the 19th Amendment was ratified, but I think we're doing just fine.

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Beautiful. Thank you. 🙂

balaguru said:

I have a 5 year old daughter and like any impressionable child she wants to be a surgeon. Of course I just chuckle and let her play with my stethoscope. BTW, she also wants to be a ballerina/school teacher/race care driver. But if she ever wanted to be a surgeon and had a child during residency I'd gladly help out even if it meant scaling back my practice or taking leave.

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🙂 That's what my Mom does. 🙂

This was a good thread. Since it was bumped, I thought I'd give an update.

I still stand by everything I posted in this thread previously. Now nearly 4 years later, 3 more of my female colleagues have had children (one of them twice). Last year, one of our chiefs delivered a couple of months into her chief year. While I don't think there's anyone that thinks that was exactly ideal, we made it work. She had to start taking chief call a couple months early so that she didn't run afoul of the ACGME requirements for chief year and need to extend her training. There are several women behind me that are newly married and I wouldn't be surprised if they decided to have children during residency. The old guard has pretty much accepted it as the new normal.

In fact, last year I walked into an OR just in time to hear one of our most "old-school" attendings in conversation with chief who was scrubbed in with him "So do you need to go pump now or can I leave and go check on something else for a bit?" While I can guarantee you that is a phrase he never expected to utter to a resident even 5 years ago, it is a new day.

LucidSplash said:

This was a good thread. Since it was bumped, I thought I'd give an update.

I still stand by everything I posted in this thread previously. Now nearly 4 years later, 3 more of my female colleagues have had children (one of them twice). Last year, one of our chiefs delivered a couple of months into her chief year. While I don't think there's anyone that thinks that was exactly ideal, we made it work. She had to start taking chief call a couple months early so that she didn't run afoul of the ACGME requirements for chief year and need to extend her training. There are several women behind me that are newly married and I wouldn't be surprised if they decided to have children during residency. The old guard has pretty much accepted it as the new normal.

In fact, last year I walked into an OR just in time to hear one of our most "old-school" attendings in conversation with chief who was scrubbed in with him "So do you need to go pump now or can I leave and go check on something else for a bit?" While I can guarantee you that is a phrase he never expected to utter to a resident even 5 years ago, it is a new day.

Click to expand...

Ill give an update too. I'm BlondeDocteur's lil bro. I'm a PGY 5 and more the typical - 31, straight thru, 4/class BUSY community program no research. Had a kid November. Would be flat out impossible for a female junior to do it without wrecking the system. Some bigger, more 'redunant' programs (academic) with plenty of class/service flexibility, it's possible. I sort of hint at it during interviews, not as a selection criteria, just so that applicants know what they're up against. As a dude, its hard even with a supportive wife..come in from call or a long OR day and get handed the baby. Holding a large textbook or doing Q banks for ABSITE is tough (it is January afterall) and I provide zero physical needs for baby - I'm really just an intern changing dressings and providing pain/nausea control and the true PCA, the pacifier..what were we talking about again?

BD has since departed...this forum. She unfortunately was the statistic (nontrad female) but ultimately surgery wasn't for her (wanted to 'think' more). After her child was born in March 2013, she went into the lab for a few years, had another child and basically decided she didn't want to be a mid/late 30's junior resident with toddlers and switched to Pathology. Which she finds much more intellectually, professionally and personally fulfilling. So there you have it. Begrudgingly she totally could have done surgery and probably would've been better/more successful than me to boot. But I have a Y chromosome.

Long and short: Possible in the right program. Really hard. Better in lab years. Not envious to those who do it.

Just to give a little contrast to that, we had our first during my chief year (I'm a male) and our second during fellowship, my wife works full time, and while it was certainly a life change and not anything I recommend lightly to anyone, it was still completely doable. I trained in sort of a benign academic program, 4/yr, but it didnt impact my work hours in any way. I'll admit I was a little beyond studying for absite, but I still logged 450 cases chief year, still studied for and passed boards, and still did an extremely busy, malignant, kick you in the ass fellowship. That being said, the male side of it is definitely easier than the female, but honestly it mostly just cut into our TV time, or our sitting down and enjoying a relaxing dinner time, or our night out at the movies time. Maybe I was a slacker as a resident, maybe I'm a super genius (100% guarantee neither of those are accurate) but you have a lot more time in your life than you think you do and if you need to find spare hours you can find them. I guess maybe my main advantage is that I dont really sleep much at a baseline? Like 4 hrs a night is my usual. So if you expect to sleep 8 hrs, keep up on Westworld, go out with your friends, and spend 2 hrs a night studying for ABSITE, sure, you cant do it. But if you are an adult and capable of making sacrifices, there are ways to do it such that none of those sacrifices relate to your surgical training.

LucidSplash said:

This was a good thread. Since it was bumped, I thought I'd give an update.

I still stand by everything I posted in this thread previously. Now nearly 4 years later, 3 more of my female colleagues have had children (one of them twice). Last year, one of our chiefs delivered a couple of months into her chief year. While I don't think there's anyone that thinks that was exactly ideal, we made it work. She had to start taking chief call a couple months early so that she didn't run afoul of the ACGME requirements for chief year and need to extend her training. There are several women behind me that are newly married and I wouldn't be surprised if they decided to have children during residency. The old guard has pretty much accepted it as the new normal.

In fact, last year I walked into an OR just in time to hear one of our most "old-school" attendings in conversation with chief who was scrubbed in with him "So do you need to go pump now or can I leave and go check on something else for a bit?" While I can guarantee you that is a phrase he never expected to utter to a resident even 5 years ago, it is a new day.

Click to expand...

Thank you, @LucidSplash, for a great update. It's great to hear that women could balance successfully the OR and the family life.

🙂 🙂 🙂 Hope to get married soon and have kids. Okay, maybe, one child during residency. My Mom is nearby though and, God willing, she would help.

With regard to hearing that surgery is not for women, I have heard it too many times.

We have family friends, a husband and wife, both "old-school" surgeons. The husband is a general surgeon, the wife is a neurosurgeon. She was all for my decision, he was totally against it with one "strong" argument that "surgery is not for women." Hmm... He has been married all his long life to a neurosurgeon. Go figure. 🙂

While I was going through medical school and the Match, it was interesting to watch them, on several occasions, go into heated discussions about my future as if I were not at the same dinner table together with ten other people. As of today, the husband gave up on changing my mind and, although, he "growls" occasionally, he is gradually turning into a wonderful mentor. Except now, they are in a different state.

Actually, my father, also a surgeon, was totally against surgery too. He is very very slowly coming to terms with the idea.

Mr Cookie Pants said:

Ill give an update too. I'm BlondeDocteur's lil bro. I'm a PGY 5 and more the typical - 31, straight thru, 4/class BUSY community program no research. Had a kid November. Would be flat out impossible for a female junior to do it without wrecking the system. Some bigger, more 'redunant' programs (academic) with plenty of class/service flexibility, it's possible. I sort of hint at it during interviews, not as a selection criteria, just so that applicants know what they're up against. As a dude, its hard even with a supportive wife..come in from call or a long OR day and get handed the baby. Holding a large textbook or doing Q banks for ABSITE is tough (it is January afterall) and I provide zero physical needs for baby - I'm really just an intern changing dressings and providing pain/nausea control and the true PCA, the pacifier..what were we talking about again?

BD has since departed...this forum. She unfortunately was the statistic (nontrad female) but ultimately surgery wasn't for her (wanted to 'think' more). After her child was born in March 2013, she went into the lab for a few years, had another child and basically decided she didn't want to be a mid/late 30's junior resident with toddlers and switched to Pathology. Which she finds much more intellectually, professionally and personally fulfilling. So there you have it. Begrudgingly she totally could have done surgery and probably would've been better/more successful than me to boot. But I have a Y chromosome.

Long and short: Possible in the right program. Really hard. Better in lab years. Not envious to those who do it.

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Thank you, @Mr Cookie Pants, for the update about your sister. Glad to hear that @BlondeDocteur is happy and doing great. Her posts have always been great.

Best regards to you, your sister and the family.

🙂

vhawk said:

I guess maybe my main advantage is that I dont really sleep much at a baseline? Like 4 hrs a night is my usual. So if you expect to sleep 8 hrs, keep up on Westworld, go out with your friends, and spend 2 hrs a night studying for ABSITE, sure, you cant do it. But if you are an adult and capable of making sacrifices, there are ways to do it such that none of those sacrifices relate to your surgical training.

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I wouldn't call 4 hours of sleep a night on average something doable for the common man (or woman). Damn, surgeons gonna surgeon.

THIS. This is EVERYTHING. Thank you for this introspective, witty, and thought provoking post. You could be the women in medicine/surgery counterpart to Anne-Mary Slaughter's women in public service. This could be an excerpt from "Why Women Still Can't Have it All...In Medicine and Surgery." I hope you don't think this too forward, but if you're not already doing this, you should really consider writing for wider public consumption, a la Karen Sibert, an anesthesiologist who blogs and has written for publications like the NYT, WSJ etc. 🙂

LucidSplash said:

Our research year is unique in that it is broken up over PGY 2-4; residents have 4-months of research in each of these years. Thus our chiefs are PGY-6. Our research is entirely clinical, rather than laboratory-based. IMHO, this makes it somewhat easier to have multiple children in residency.

Only one female resident at my program has tried - I don't think it's appropriate to extrapolate that to "able." I brought up the fact that she was badass because I think that helped open the minds of the powers that be about the concept of pregnant surgery residents in our program; I think most did not expect her to continue, let alone flourish. The fact that she did so with her first pregnancy had two effects: 1) No one had that much anxiety about the situation when she had her 2nd child and 2) The path will be easier for any future residents who wish to do the same. She's shown that one CAN be a mother AND a great surgery resident. It is possible - the actual performance thereafter is up to the individual resident.

I think it is difficult to do, and the need for maternity leave as well as pregnancy-related complications does make it different for women with regard to the initial physical investment required for biologic reproduction. But who asks male residents if they have a "favorable" situation when bringing up the topic of having kids? Is that even an appropriate question?



Well, my personal experience has been that age does good things for most men, and they only start to be acceptable to my dating standards in their 30s. 🙄 Biology certainly plays a role but I'm not sure how the question of one's judgment in the men in their personal life is the concern of the residency program. This oblique characterization of women over the age of 30 without children as somehow desperate or prone to poor judgment in their personal lives does come off as a bit misogynistic, though I have read enough of your posts to believe that was not your express intent.



The decision to pursue surgery is no more or less an impediment to marriage than other individual choices and pursuits a woman makes. In my area at least, it is more difficult to meet desirable men who are interested in dating someone with my kind of job or education level. But... I'm not really interested in dating men who aren't interested in dating women with my kind of job or education level. I also tend to to have the possession of a Bachelor's degree as one of my baseline requirements for considering someone as a prospect, so it's not like the situation is unequal in terms of prejudice.

I don't have a daughter, but I am 31 and I do have a sister who is 15. Do I want her to be a surgeon? I want her to do what makes her happy, overall, without the ridiculous assumption that one can truly "have it all." I think many women of my generation were implicitly told that they could: high-powered job/demanding career and a husband with the same, perfectly kept house without outside assistance, giving dinner parties in pearls, marathon runner/masters level tennis player/etc, 2.5 kids, make every soccer practice/class play/deliver homemade cupcakes/etc. This is insane and has led to a number of fantastic women feeling like they are letting themselves and their families down because they can't do everything. Men don't "do everything" and I'm not sure why the implicit message was different for girls, except that I was born on the heels of the sexual revolution and women were (and are) still trying to balance traditional gender-based societal expectations with modern "feminist" gender-based expectations.

Women are, on the whole, horrible to other women. True feminism should be the freedom to make decisions based on the priorities you set for yourself (or you and your partner set together, if you have one) without constant public and private judgment from non-involved parties. I don't think there's a "War on Women" so much so as a "War Among Women," comparing who's made more or less sacrifice by going to work or staying home or some combination thereof.

The history of my family colors my perspective on this subject. My great-grandmother was born in 1898 and was a graduate of Women's Medical College in Philadelphia; her professors had to sneak in to teach them because otherwise they were ostracized by the medical community at large, for the offense of teaching women. She wanted to be an obstetric surgeon but went into family practice because she was told that women did not go into surgery. She married a fellow physician, but gave up practice when she had her first child. My aunt graduated from medical school in the early 1970s. There were 10 women in her class, due to quotas. She wanted to go into ortho, but was told that it was not a woman's specialty. She went into radiology; her co-residents referred to each other as "Dr." or their last names but they referred to my aunt by her first name or as "The Girl." She was required to tape a sign on the door of her callroom that said "Girl Sleeping In Here." She continued to work after my cousins were born, despite some criticism. She now regularly speaks to sub-specialty surgeons at their conferences on her area of expertise.

My medical school class was 2/3 women and I'm a general surgery resident and no one treats me differently because of my gender (except that one or two of my male attendings seem to be a little skittish that they will somehow inadvertently offend me). 4 of the 12 or so who went into surgery were women. So far, all of us are sticking it out. I see the progress of women in surgery (and having children as a resident) as part of the progress of women overall in the last 100 years. I do think that the idea of trying to balance the demands of a surgical residency and the physical act of gestation and then recovering from childbirth is something that needs to be taken into account; I think the flexibility in the clinical schedule at my program does this well. The biggest hurdles are simply the doubts in the minds of administrators (which are overcome with time and experience with women having children in residency) and women who are unclear on their own priorities or, inappropriately, have guilt over what those priorities are because of some unrealistic notion of what it really means to be a strong and accomplished woman. The world has changed a lot since the 19th Amendment was ratified, but I think we're doing just fine.

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