Parenting in Medicine, Part 2 – A Conversation with Dr. Charlie Goldberg

Learn with us from Dr. Charlie Goldberg, an internist and leader in graduate medical education, about the impacts of parenting on career development and advancement in medicine, as well as the leave protections specifically granted to physician trainees during their residency and fellowship years.

Learning Objectives

1. Understand how family planning can differ between physicians and non-physicians.
2. Know the minimum standards for parental leave as outlined by the ACGME.
3. Discuss ways in which having children impacts career choice and trajectory. 

Credits

• Guest: Dr. Charlie Goldberg
• Co-Hosts: Dr. Pooja Jaeel, Dr. DJ Gaines
• Executive Producer: Dr. Tammy Lin
• Co-Executive Producers: Dr. Pooja Jaeel, Dr. Maggie Kozman
• Senior Producer: Dr. DJ Gaines
• Managing Producer: Joanna Jain
• Production Assistants: Clara Baek, Ann Truong
• Website/Art Design: Ann Truong
• Music: Chris Dingman https://www.chrisdingman.com

Connect with us on Instagram at @thedayshift.pod and via email at thedayshifthealthcare@gmail.com

Transcript

[00:00] Pooja Jaeel: Welcome to The DEI Shift, a podcast focusing on shifting the way we think and talk about diversity, equity, and inclusion in the medical field. I'm Dr. Pooja Jaeel, a Medicine hospitalist and Pediatric primary care doc, here with my co-host and senior producer of The DEI Shift…

[00:24] DJ Gaines: Dr. DJ Gaines, a hospitalist in San Diego. We are excited to launch this very important, relevant discussion on the many facets of parenting while in the medical field. This is a topic that is relevant for many of us. Personally, two years ago, my wife and I welcomed our son to this world. I remember being told that nothing could prepare you for the sleep deprivation. I thought my residency training would have prepared me for it, but boy was I wrong. Not to mention the continued balancing act between parenting duties and physician duties. 

[00:55] Pooja: Yep, and as for me, I'm a new mom to a one year old toddler. As a Pediatrician, I thought I had a pretty good idea of what this parenting thing would entail, but also learned that I have a lot to learn. When it was time for me to go back to work, especially the combination of sleep deprivation, breastfeeding, pumping, and then switching from doctor duties to mommy duties without any break, plus the constant mom guilt, that was all so overwhelming. And I kept thinking, how do people do this? 

[01:19] DJ: I know, and as parents in medicine, we found that we were all going through similar struggles, though it's not discussed formally in our professional lives. Over the years, there has been more data about the impacts of parenting on career development and advancement in medicine, as well as more research about the different trends of family planning between physicians and folks in other career fields. While we realize there is some overlap with physicians who are also caregivers and parenting, we will specifically be discussing parenting today. To help us with this topic, we are thrilled to introduce Dr. Charlie Goldberg. Dr. Goldberg is an internist and is currently the Associate Dean of GME and Designated Institutional Official at UCSD. He is a former Associate Program Director at the UCSD Internal Medicine Residency Program. Both Pooja and I had the fortune to learn from him during our residency training, and we can't wait to learn from him today. Welcome, Dr. Goldberg!

[02:13] Dr. Goldberg: Thanks for having me. Really pleased to be here. 

[02:16] Pooja: So we like to keep things casual here on our podcast, and we ask that you call us by our first names. And is it okay if we call you by yours? 

[02:21] Dr. Goldberg: Yes, please do. The only person who calls me Charles is my mother.

[02:28] Pooja: Go Charlie!

[02:30] DJ: Great. All right, Charlie. Thank you so much. Before we get started, we'd like to ask each of our guests on the DEI shift to share something with our listeners about themselves. This can be something like a hobby, favorite food, or a meaningful experience of yours that helps us get to know you and your background a little better and to flex our cultural humility muscles.

We call this our step in your shoes segment. So Charlie, what would you like to share with us today?

[03:09] Dr. Goldberg: Oh, I guess a couple of things. One, I was born and raised in suburban New York -- my early passions were sports, and I was a competitive athlete through college. I played soccer and lacrosse, and if I could have been a professional soccer player, I would have, but I wasn't nearly skilled enough, but I really did enjoy it.

I went to medical school at the University of Vermont and I met my wife, Teddy, on the first day of med school, and then we embarked on a journey through training. I started out, actually, my career as a Urology resident, so I spent two years doing General Surgery. Then I began the Urology portion, and realized that the light at the end of the tunnel was not coming from a cystoscope, so I stopped. I really wasn't deriving satisfaction from that field. It's no criticism of the field of Urology or Surgery. I went back and trained in Internal Medicine. I was an intern again and went through residency, and I had a great ride ever since.

[04:06] Pooja: I appreciate you talking about switching programs so early in your training! Sometimes we go in thinking it's such a rigid path and there is no room for flexibility and going back and changing your mind or figuring out what's a better fit. Thank you for being an example of that. So to start, we just wanted to ask, maybe we can start by having you describe your role within GME and some of the trends that you've noticed as of individuals who are becoming parents while they're in training.

[04:30] Dr. Goldberg: Every large or even small academic medical center has someone in my position: the Associate Dean for Graduate Medical Education. And the term DIO, Designated Institutional Officer, is an ACGME term. So we're a large academic medical center like many; we have 98 ACGME accredited residencies and fellowship programs -- that's us. There's almost a thousand trainees in that space, and then we have another 55 programs and 70 trainees who are in the non accredited space, which are usually very small fellowships. They're stretched across the major UCSD hospitals up in La Jolla and down in Hillcrest, and then our major affiliates, which are the VA and Rady Children's Hospital. So it's a big, busy, robust place. That's 1,100 trainees, 150 programs. almost 2,000 faculty. There's a lot going on! The truth is, the majority of the programs, they're run by their own leadership groups. So in my position, my office has oversight for all of them. We help assure that they're compliant with rules and regulations, benefits, salaries,... All that comes through this office, and my personal passion is creating community across GME and vertically with our health system, with our medical school, and helping programs become the best versions of themselves in terms of providing the right education.

[06:00] Pooja: Sounds great. And as you see the trends from across different programs, are you seeing that individuals are becoming parents differently in different training programs or even as students?  

[06:10] Dr. Goldberg: I guess I could speak to… If I look at the broader arc, say 40 years, what I see is, and I think the data bears this out, is that more people in healthcare are having kids during training. A small number have them during medical school, and I remember when I was in med school, and I graduated in ‘91, there were odd folks who seemed to manage having a family and doing medical school. I think most people would just try to swim hard themselves to get through it. The number of people that I've seen, I have a footprint in the UME space as well, who come to school with partners or not and have children during med schools more than it was. And certainly in the GME space, more people are having children than they had say a decade, two decades, three decades ago. It's impressive because training hasn't gotten any easier, yet people are finding ways of managing these aspects of their lives in the middle of it, which is many joys and many challenges.

[07:09] Pooja: Why do you think that trend is? 

[07:11] Dr. Goldberg: Oh, I can hypothesize. I could tell you I am, in terms of my expertise, I'm like an N = 2 expert as a parent, you could ask my boys that, and my wife, and then I'm an observer. So please take what I say as this is not necessarily evidence based, but I think people are less interested in delaying things. I think they want their life to continue as they're going through training. They don't want to necessarily wait, and it's a reflection of lining up priorities for our trainees and not just being focused on “I've got to learn and master this craft”, which everyone does and does it well, but not to the exclusion of everything else. And whether people are also more aware of fertility challenges as people get older, that waiting… You're not necessarily guaranteed that it'll all work out. Maybe people are finding partners sooner or figuring out whatever their birthing strategy is going to be. Obviously, there are a lot of ways of having children and raising them.

[08:14] DJ: That's really interesting, Charlie. We've seen some studies specifically comparing physicians and non physicians that shows that physicians tend to delay childbearing with a median age of 32 years versus 27 years in non-physician populations. I know you said you're not necessarily an expert in this particular field, but we'd love to hear your thoughts. Why do you think there's a difference in the physician versus non-physician population? 

[08:38] Dr. Goldberg: I think a lot of it is that when people look at the career medicine, they tend to wall off sections of it, like here's my medical school thing, and now I'm in my residency thing, and now I'm in my fellowship thing, and it might be easier to just keep it compartmentalized and just say “I'm just going to focus on that area”. And when I get to the other side, that is when I'm going to have the time, space, resources, etc. to have a family. I think a lot of people come with that notion. Again, you guys have both been through residency training programs. It's rigorous, even with work hours, awareness, etc. It's a tough time. It's tiring. It's rewarding, but there's a lot to do and a lot to master, and I think maybe in our heads it can be easier to just think of the delayed gratification or delayed planning and say, “I'll just get to that phase later on”, and I think people look at their peers, and frequently, you're doing similar things.

Most people in any residency program are not having children. The trends are higher for sure, but I'm just saying if you look at the totality of the residents in your program, most are not having kids at that moment. And so when you look to peers and look for clues and cues as to what should I do? How do I manage this?How are others managing it? There's probably a preponderance of folks who are waiting. We live in our very immersive world, like we know healthcare, and then we don't tend to look too much over the wall and say, “What are other people doing?” Because their lives are completely different from ours. I think those are probably the things that influence it. And the modeling that is probably demonstrated by faculty, just indirectly, if people get to know their faculty -- they're older, certainly, and When they did it, they probably were even more likely to have started families if they have families after training. It's the braver few that are moving it and shifting it sooner, but the majority probably are stuck in this mindset. Not stuck, but have adopted the mindset of delaying and when things settle down to do it. 

[10:51] DJ: There's a lot of stuff that you said that really resonates with me, especially the concept of walling off sections of our life, which I feel like is so common during medical training. I had the same kind of thought: I have to do my medical school, and I have to do my intern, and I have to do my residency, and I have to think about parenting, and so I walled it off intentionally. And then we always talk about delayed gratification in the medical field. It's something that we're just used to because it's such a rigorous and long training, so I really like the way you framed that. Also that we're indirectly demonstrating this because I can think of my colleagues and like how a lot of them are expecting or just recently had a baby, and so that's such an interesting concept.  

[11:33] Pooja: Yeah, I think the mentioned things are settling down. I think there's a sense of control versus “things are out of your control”, so much during training, especially during residency, even starting with location of where you're going to be let alone your schedule and finances. Everything's just so up in the air that feels like after training, things are more in your hands. And there's a little bit more predictability and stability, not just for yourself as a parent, but something you can offer your children, too. We touched on this a little bit, and you were saying that over the last couple of decades, there have been more folks who are having more kids and families in training. So I just wonder from that ACGME perspective, are there protections that are provided or any standards that are dictated for our trainees to have some time?

[12:16] Dr. Goldberg: Yeah, so the ACGME in 2022 came out with a regulation rule that programs had to provide at least six weeks of paid parental leave, and then an extra week for other leave as needed. And before that, it hadn't been defined. So I think that was a positive step. I will say the ACGME, they set the floor. It doesn't mean programs can't do more, right? You can opt to say that's great, but we want eight weeks. We want 10 weeks. We want 12 weeks. So when the ACGME does that, they're very particular about saying, “Okay, minimum is this, but please, if you feel this is important in your world, you can do more.” So there's a lot of flexibility. I will say there are rules around having spaces for lactation and pumping. Some institutions have on-site daycare. There are various ways of making a place not just, “in words” friendly for having families during training or even working, but actually, putting the nickel down and paying for extra things that will facilitate engagement of faculty, trainees, or students who are at wherever, somewhere along the arc of family-forming.

[13:30] Pooja: And just as a follow up, my question is, for programs that do choose to offer a little bit more than the six weeks, have you seen issues that come up with trainees not being able to sit for their board exams, for example, if they're taking longer? And I guess, how does that impact graduation and time later?

[13:47] Dr. Goldberg: Yeah, these are impactful. There's been like the “great white whale” of doing competency- based graduation, like you should not be in internal medicine. Well, you're a pediatrician and in internal medicine, DJ and I are just internists. There’s this notion of “it's three years to be trained”, and people have said why three years? Maybe some people get it in two and a half years, maybe some get it in three and a half years; it should be when you're competent. I mentioned this because it's really hard to set up a program around competence. How do you cycle through a lot of people and make a schedule when they are coming and going at different times? And that challenge exists also when you have people taking variable leaves for say, family formation. Every board is different, and the boards are aware that they really should be as thoughtful as possible deciding what is the core that you really have to accomplish in order to be ready for graduation. Is it a certain number of months for procedural fields? It could be a certain number of cases. How can they set things up so that you're not in some way giving the appearance of punishing people for taking more time out, but assuring also that they get their right training. And it's a dynamic balance.

That's all I can say from the board level. Each one is different. I think programs that are larger sized, like medicine or pediatrics, where there's a little bit more wiggle room in the training where, in terms of months of elective time, months inpatient and outpatient, it's a little bit easier for them to engage and provide for these unique training situations that happen when someone is taking leave. And they have more wiggle room and flexibility. I find it's much more challenging for the smaller programs or the highly procedurally oriented programs. There's less flexibility.  So I have definitely seen program directors embrace this and really work with their trainees on a one to one basis to say, “what can we do? Can you tell us this early so that we can plan accordingly?” And the programs that do it well create a very positive dynamic and environment where people want to say, “This is what I'm planning on doing. How do I make this work for me? And make it also work in total for the grander scheme of the program's needs?”

[16:14] DJ: And it's interesting, I haven't really thought about that. It makes sense that from a logistical standpoint, especially for a small six-person program, it would be very difficult. So when, a lot, but at the same time, you don't want to discourage them from delaying parenting. So I can see the difficulty there.

[16:30] Dr. Goldberg: It is. I think it's just a lot of honest dialogues that have to happen; if you can create an environment where your trainees are upfront about it, whatever they're planning, and that the program director has to be willing to be accepting of this and say, “Okay, it can't just be viewed as ‘Oh, gosh, you're creating such a challenge for my program’, it's ‘You're going to go through some joyful event, right? It's a great thing to have kids and we want to promote that. And if it's a challenge, we'll just have to figure it out. How do we cover?’” There are always ways. There are always ways, the group has to be willing and the leadership group has to be willing to embrace it. Some really do a wonderful job of it, and it's just a spectrum phenomenon. 

[17:13] Pooja: Can you give us some more specific examples of programs that you've said have done a good job of this or if there's any specific initiatives or ways that they've tackled this, just for examples for other programs who are listening to this program?

[17:35] Dr. Goldberg: I won't name programs, but I will say the elements that they do is they create an environment where people are willing to have a dialogue. The program director will put that out front and say, “At some point, some of you may opt to create a family while you're here in training. We recognize that's important. We want to embrace it and we want to support it. The best way of doing it is engaging with us to share your plans.” And then, if people are willing to do that, then they can look ahead and say, “Okay this is what it would look like. This is how we can make this happen. If you take this amount of time, our board will require x number of extra months. If you take off more than this amount of time…” And so people can be aware of the baseline, right? They can know the facts. Again the board, these days they're much more user friendly. They're not trying to be punitive. They're just trying to say, “Look, we do have to  keep our eye on the prize of what does it take to train you in this domain and to maintain that you get the right amount of experience? And if it requires extra time, so be it.”

I will say health systems have been good about improvising, because when someone saves extra time, it costs more money. Because you have to have more trainees at any one moment. Systems accept that. That has been another marker And that, that has been another marker of a good, healthy ecosystem around family planning. Sometimes for programs that have particularly long arcs of training, trainees decide to do it during research years, things when they have a little bit more control. So I think it's creating the space to have honest dialogue and then sharing the facts about what is allowed and what will be required, how much extra time if it's needed, etc. so people aren't in the dark and they're not afraid. 

[19:21] Pooja: Yeah, I think building that culture is so important. I think it's not just the trainee and the program leadership and isolation; in some ways,we are so tied to our co-residents, and when one person does need to take some time away, everybody else's schedule tends to change too. I think hopefully building that type of culture will make it more of an understanding with the other co-residents. But have you seen programs that have been more successful in trying to find coverage and making it so that it’s more challenging for the other co-residents?

[19:52] Dr. Goldberg: Again, it's program by program. I think the notion that it should not be seen when someone leaves is punitive to others. We feel very guilty, right? Where we have a job, we want to do our job, we don't want others to be  inconvenienced by our choices, yet that shouldn't be the perspective. So whether it requires having an APP, brought into the mix to provide coverage, an NP or PA, it depends where your wiggle room might be. It depends on what your resources are, so you can be strategic about it and you don't want to punish anyone by pulling them in from other rotations. Sometimes maybe a trainee isn't required to be on a team. So it all depends on the size of the program and what your options are in managing the workflows and assuring that great patient care continues to happen and that you can manage when someone ducks out. I mean look, illness happens, right? It happens to faculty, it happens to trainees, and we have to have a space that has redundancy. The programs that create that or can pull in those resources, it goes better. Redundancy, of course, means money, so resources and having the right resources and being able to allocate those resources. That's a big piece of the puzzle. That's an important consideration, those that have more of those resources can manage these situations better. 

[21:18] DJ: Thank you. I love that. That's a great response. All right, switching gears away from the training environment -- there was this interesting 2020 article published in JAMA that surveyed physician faculties’ perceptions of parenting challenges and career progression. We will reference the article in our show notes. Overall, the physicians surveyed in the study felt that physicians who have children, especially female physicians, fall behind in the promotion process. So we want to ask you, Charlie, as parents in medicine move along in their careers, are we seeing a difference in career advancement between physicians who are parents versus those who are non-parents?

[21:52] Dr. Goldberg: I read the article that you referenced. Anecdotally, I'm sure that it makes sense to me that there are losses that happen when people have to duck out of the academic environment. I think it's unfortunate we're a bit of an inflexible system that way, just in general. From what I understand, there are a number of other countries, Scandinavia, etc., where this has been done better. And I think, unfortunately, it is likely some part of the cost of doing business in this country. I can't quote to you numbers that say it's changing, but I feel it's improving and that people recognize that having kids is part of life, and that it requires time. That burden, even with the most enlightened pairs, falls more to the mother, it seems, that's my impression. There are discussions then about how to allow that to happen and not have academic trajectories impaired, have salary trajectories impaired. I feel that’s an honest dialogue that's happening. There's certainly more awareness about it. Have we actually made gains in it? Have the curves become closer for a male and a female who have started at the same time, but one who had children and one who didn't? Are they closer and more parallel and not having these lags? That I don't know. And I wouldn't be surprised if the lags still exist, and there's probably a lot of work that has yet to be done.

[23:31] Pooja: If I can ask, I know you are in a two-physician household raising kids. Is this something that you've seen personally in your life or your wife's career? And how that has impacted you?

[23:41] Dr. Goldberg: This story… I know, cause I can tell you my own story, and that I'm expert in! So as I mentioned, my wife and I, we met on the first day of med school. We've had careers I think are successful. My wife is a pediatrician and mine has been in internal medicine. A key thing for us is just you have to have, for me, having a great partner makes all the difference. There are a lot of discussions that happen all the time about who's doing what, when. What are your priorities today? What are your priorities this morning, this afternoon, this week? How do we make that happen and have academic fulfillment and family fulfillment? So we made it up and figured it out as we went, having kids. We did it at 37 and 39. We're three months apart in age. On the one hand, we were set in jobs, so we had more resources, so that was helpful. We were able to hire a nanny who came into our house, so we wouldn’t have to drop kids off at daycare. That was super helpful. On the flip side, we don't have any family out here, so we're just winging it ourselves. For the early part when the kids were young, both of us were part time, so for me it never more than 6/8 initially, and my wife was probably 2/3 time, sometimes half time, and we would cover different aspects, whatever day she was off, I was working, my day off, she was working, and that gave us flexibility.

Also, I felt like this time in life was only going to happen once, and I wanted to be able to take our kids to school and walk them there and be home, not every day, but at least a day, and there's a cost that came with it. But, if you weren't paying me to be there on Thursday, then I can do whatever I want and I want that freedom. Again, having a two-income household, two-physician income household, allowed us to have that luxury. My wife's an only child, and both her parents died when we were in med school. My family is all back in New York. You look longingly sometimes at other colleagues whose parents essentially move in or move to town or they have that pair of hands whenever, and it's probably good and bad that comes with that, but you can mix and match it. As we've moved through our careers, I've done multiple things both as a clinician and as an educator. I sometimes take on some positions because I have space and I've turned down other things. And that's probably been impactful in my own academic progression because I just didn't feel like I wanted to be on the hook every day of the week. I wanted to be in a space where I had time away and to do that I had to say no. 

[25:35] DJ: Charlie, I just want to say thank you so much for joining us today. I'm really excited to have you on the show and thank you for all the amazing words of wisdom you’ve given us. We want to give you the opportunity to leave one final piece of advice for our audience.

[26:40] Dr. Goldberg: One thing I want to say is take ownership for where you're heading. That there are options and ways of addressing your particular arc through training and in life, and you can help shape and make decisions that will allow it to go more likely in the fashion that you would like. It's not going to be perfect. You don't get to choose everything. You do have a role in shaping what's going to happen and as much as you can recognize that dialogue with the right people who are in leadership positions if you're in training and beyond, and make choices that align with your values and where you want to be. You don't want to end up 5, 10, 15 years down the road, particularly in healthcare, where everyone who's doing this is smart, capable, etc., where there are choices and say things like, “How did I get here? Why am I doing this? I'm not happy. I didn't accomplish what I wanted to.” Part of that is identifying what is critical for you. What are those three, five things that are most important? And then having a path that will not, it's not usually linear, you don't usually go in a straight line, but in a wavy-ish line, at least in the right direction. If it's not heading there, take a time out to stop and think why. And then the other thing is if you have a partner, if you're raising kids with someone, just find a great partner. That you can work with and where your goals are aligned and you can enjoy being with one another. Having kids is fabulous. 

[28:17] Pooja: Thank you so much for your time today and for sharing so much great wisdom and information about parenting and medicine in general and for giving us a lot of mentoring ourselves as we're doing this show. So that's all the time we have today. We'd love to invite our listeners to join the discussion online and share your stories and experiences with us. You can send us your experiences over email at theDEIshift@gmail.com or on Instagram and X with the handle @thedeishift. We'll also have a transcript of this conversation along with show notes that include the resources discussed today. Thanks again to our guest Charlie for joining us and to our listeners for tuning into this conversation. Don't forget to claim your CME and MOC at ACP Online. Thanks and see you next time.

Disclaimer: The DEI Shift podcast and its guests provide general information and entertainment, but not medical advice. Before making any changes to your medical treatment or execution of your treatment plan, please consult with your doctor or personal medical team. Reference to any specific product or entity does not constitute an endorsement or recommendation by The DEI Shift. The views expressed by guests are their own, and their appearance on the podcast does not imply an endorsement of them or any entity they represent. Views and opinions expressed by The DEI Shift team are those of each individual, and do not necessarily reflect the views or opinions of The DEI Shift team and its guests, employers, sponsors, or organizations we are affiliated with.