This piece was originally published on Bill of Health, the blog of Petrie-Flom Center at Harvard Law School.
In my junior year of college, my pre-medical advisor instructed me to take time off after graduating and before applying to medical school. I was caught off guard.
At 21, it had already occurred to me that completing four years of medical school, at least three years of residency, several more years of fellowship, and a PhD, would impact my ability to start a family. I was wary of letting my training expand even further, but this worry felt so vague and distant that I feared expressing it would signal a lack of commitment to my career.
I now see that this worry was well-founded: the length of medical training unnecessarily compromises trainees’ ability to balance their careers with starting families.
In the United States, medical training has progressively lengthened. At the beginning of the 20th century, medical schools increased their standards for admission, requiring students to take premedical courses prior to matriculating, either as undergraduates or during post-baccalaureate years. Around the same time, the length of medical school increased from two to four years. In recent decades, the percentage of physicians who pursue training after residency has increased in many fields. And, like me, a growing proportion of trainees are taking time off between college and medical school, pursuing dual degrees, or taking non-degree research years, further prolonging training.
The expansion of medical training is understandable. We know far more about medicine than we did a hundred years ago, and there is correspondingly more to teach. The increased structure and regulation of medical training have made medical training safer for patients and ensured a standard of competency for physicians. Getting into medical school and residency have also become more competitive, meaning many trainees feel they must spend additional time bolstering their resumes.
However, medical training is now longer than it needs to be. Many medical students do very little during their fourth year of medical school. Residency programs also require trainees to serve for a set number of years, rather than until they have mastered the skills their fields require, inflating training times. And many medical schools and residency programs require trainees to spend time conducting research, whether or not they are interested in academic careers. While many trainees appreciate these opportunities, they should not be compulsory.
There are many arguments for shortening medical training. In other parts of the world, trainees complete six-year medical degrees, compared to the eight years required of most trainees in the U.S. (four years of college and four years of medical school). The length of medical training increases physician debt and healthcare costs. In addition, it decreases the supply of fully trained physicians, a serious problem in a country facing physician shortages. Since burnout is prevalent among trainees, shortening training could also mitigate burnout. And critically, the length of medical training makes it challenging for physicians to start families.
Because medical trainees work long hours, have physically demanding jobs, and are burdened by substantial debt, they are sometimes advised or pressured to wait until they complete their training before having children. But high rates of infertility and pregnancy complications among female physicians who defer childbearing suggest this is a treacherous path.
Starting a family during training hardly feels like a safer option. In my first year of medical school, I attended a panel of surgical subspecialty residents. I asked whether their residencies would be compatible with starting a family. The four men looked at each other before passing the microphone to the sole woman resident, who told us she could not imagine having a child during residency, as she didn’t even have time to do laundry, so instead ordered new socks each week.
In my second year of medical school, a physician spoke to us about having a child during residency. I asked how she and her husband afforded full-time child care on resident salaries. She confided that they had maxed out their credit cards and added this debt to their medical school debt to pay for daycare. There have been encouraging anecdotes, too, but these have often involved healthy parents relocating, significant financial resources, or partners with less intense careers.
Admittedly, shortening medical training would not be a magic bullet. Physicians who have completed their training and have children still face myriad challenges, and these challenges disproportionately affect women. Maternal discrimination is common, and compared to men, women physicians with children spend more than eight hours per week on parenting and domestic work and correspondingly spend seven fewer hours on their paid work. Nearly 40 percent of women physicians leave full-time practice within six years of completing residency, with most citing family as the reason why.
However, shortening medical training would enable more trainees to defer childbearing until the completion of their training. This would help in several ways. For instance, while most trainees are required to work certain rotations (e.g., night shifts), attending physicians often have more flexibility in choosing when and how much they work. In addition, attending physicians earn much more money than trainees, expanding the child care options they can afford.
In recent years, many changes have been made to support trainees with children, from expanding access to lactation rooms, to increasing parental leave, to creating more child care facilities at hospitals. But long training times remain a persistent and reduceable barrier. To address this, medical schools could only require students to take highly relevant coursework, reducing the number of applicants who would need to complete additional coursework after college. Medical schools could also increase the number of three-year medical degree pathways and make research requirements optional. Residency and fellowship programs could create more opportunities for integrated residency and fellowship training and could similarly make research time optional.
It will be challenging to create efficient paths that provide excellent training without creating impossibly grueling schedules. But this is a challenge that must be confronted: physicians should be able to balance starting a family with pursuing their careers, and streamlining medical training will facilitate this.