Training as a father
Jonathan Noel, current BSoT Chair and a final-year trainee in the London North Deanery, writes about combining training with fatherhood:
“ ... My wife and I have been blessed with a son when I was an ST3, followed by a daughter during my current post as an ST6. As I near the final year of urological training, I just wanted to share a few thoughts on this journey as a surgeon-father.
"Multi-tasking” would be one word to describe the journey of training as a parent. I listened intently to many of my seniors, just before becoming a Registrar, on the “best” time to start a family while becoming a surgeon. One thing rings true from conversations with all of them: everyone has his own path, and all variations have been successful, so just do what’s right for you!
My personal view on fatherhood in surgery is that you have to be honest with yourself and your family, on splitting your time between them and work. The rest will always fall into place, commensurate with how much energy you put into each.
Paternity leave can now be split 50:50 with maternity leave, potentially allowing fathers to take up to six months of leave. I did not take advantage of this because, for me, my training momentum would have been compromised. That said, colleagues have taken extended leave, and have restarted clinical training seamlessly.
General urology offers a work/life balance that is favourable for family life. During training, on-call periods are becoming less frequent than one-in-two rotas experienced by previous generations. The nature of most emergency presentations, and efficiency in the A&E Department together with a capable SHO, mean that time at home is only minimally disrupted. Urological training should not discourage anyone from starting a family.
Uro-oncology is as popular as ever and is my area of interest ... go figure! But this sub-specialty can be demanding on family time. Long proc edures such as cystectomies, with complex reconstruction or pelvic exenteration, can take eight hours or more. The peri-operative care of these patients is relentless; they often have complex multi-disciplinary needs.
However, whether it is endourology (endoluminal or even exoluminal), andrology or functional urology, there will always be a demand on your time. I believe strongly that you have to follow your passions in your career, and find enjoyment in your job day-in and day-out. If you don’t, your mood will be negative and your family life will suffer.
Urology is a fantastic specialty. I truly believe that it encompasses so many great aspects about being a doctor, for example:
- technology (robotics, lasers, endoscopes);
- therapeutics (Botox, immunotherapy, the “ever-debated” alpha blockers and ureteric calculi);
- prosthetics (penile or testicular);
- unique patient/doctor relationships - for example, in a check flexible cystoscopy clinic, where a long-standing patient knows the theory of doing the cystoscopy better than you may as a trainee.
I hope I have encouraged a few of you to take on this specialty, especially if you had reservations with regards to family life. Your bosses have a wealth of experience to impart, as they did and continue to do for me throughout my fatherhood and training ... "
Training as a mother
Felicity Reeves, specialist trainee in the Yorks & Humber Deanery, writes about combining training with motherhood:
“ ... I completed most of my urology training as a full-time SpR, which helped to get up my learning curve but, in turn, also helped with having a break for maternity leave and being part-time.
In terms of maternity leave, it is good to plan to take a year out because you do not know how everything will be and how you will recover; it's easier to plan a year out and come back early than to try and extend an existing 6-month period. You can opt to spread your maternity pay over 12 months which is much easier for planning mortgage payments and bills; the default position is tto get full pay for eight weeks, half pay for seven months then nothing for the final three months. If you return early, you are back paid the remaining amounts.
“Keep in touch” days are advocated, where you plan to go in to work for a particular session to keep your skills up. People worry they will de-skill over 12 months and you will definitely feel a little rusty with some of your operative skills. However, in my experience, your clinical judgment and decision-making remains largely unchanged. If you take more than two years out, that gets more challenging, but it does not take long to get up to speed; you just need to re-set your expectations.
I have been less than full time (LTFT) starting from ST6. I was lucky to get supernumerary funding for 12 months, because there was no-one to share a job with when I applied for LTFT training. The process was relatively simple: discuss it with your Training Programme Director (TPD), complete the appropriate deanery forms get signed off by your TPD and mentor. I was allocated an excellent mentor in urology to aid with the process and I believe this is a requirement for all deaneries.
Out of three full days, my job plan includes on call 8-8, MDT, Admin, Study/Audit, two half-day theatre sessions and a clinic.
Some people choose to work full-time as a parent; it is definitely down to personal choice and defining what works in your particular situation. Personally, I found full-time work with young children very unsatisfying, I felt guilty and I only saw my children at weekends when I was not on call. Since working a 60% contract, I have a much better balance and it is easier to enjoy work and family time.
The key element is having support you can rely on, whether that is paid or from within your family, depending on locality. Having a nanny or relative that can come to your house for early morning starts is so helpful. Nurseries usually open at 07:00hr and close at 18:00hr, so you will still need extra help at either end of the day. An au pair is cheaper but would, of course, be expected to live in your home, so, again, that depends on your circumstances.
Working less than full-time means being more organised with your time, making sure you are ahead preparing your theatre lists and reviewing results, and keeping abreast of your administration. It also means being very clear about what you need for CCT and where your gaps are. It is not that easy just to come in on your usual day off, because child care needs pre-arranging and is costly, so job plans need to be carefully aligned with your specific training needs right from the start. Full days are much better than half-days; it can be difficult to leave a half-day on time.
When you have extra human beings to look after, your evenings are the main time available for you to deal with exam revision, write papers etc. Evenings, therefore, become your windows of opportunity.
I have found huge benefit in splitting my days, so that I do two days in a row, followed by a day with the children, then another day on. This has meant that, for me personally, everyone has got the best out of me. When the children are ill and sleep is minimal, I can manage with this pattern and have never had to take time off as a result. There is an argument for doing your days in a row for more continuity. If you communicate well with your colleagues it is possible for this to not be an issue at all, because clear handovers and follow-up form an important part of your training.
There will never be a “good time” in surgical training to have a family, so you should put aside any concerns over when to plan. The right time is the time that is right for you as a couple - then you will make it work ... "
Training whilst pregnant
Susan Hall, specialist trainee in East Midlands Deanery, has provided the following information about the hazards which face a pregnant urology trainee:
“... Females now make up more than 50% of trainees in our region and given more than 60% of medical students are female this is likely to continue (1).
There is a significant lack of evidence or guidance for urologists during pregnancy. Our work exposes us to radiation, teratogenic/cytotoxic drugs, iodine, infections and long working hours. As a result of lack of advice, women may avoid procedures during pregnancy, potentially affecting their training and the work life of colleagues.
The most common discussion around pregnancy and working as a Urologist is that of exposure to radiation. Advice from multiple sources is that ,once the pregnancy is declared, the exposure to radiation should not exceed 1mSv (milisievert) for the remainder of the pregnancy (in addition to background radiation of 1mSv) (2). Hellawell at al showed that with an average caseload of 50 fluoroscopic procedures the surgeons would be exposed to 0.6mSv/year to the lower leg (uncovered by lead), this is within the threshold of 1mSv for a pregnant surgeon (3). A few smaller studies have looked at the radiation exposure to the foetus under a lead gown, all of which failed to show exposure levels greater than the 1mSv limit (4). In fact, a recent article showed higher radiation doses in the home environment that during a screening list, although this study included just one pregnant urologist (5). Finally, a review of 534 pregnant radiologists, most of whom continued to practice during pregnancy, showed no difference in foetal outcomes from the general population (6).
The evidence, therefore, shows us that we don’t necessarily need to avoid screening lists during pregnancy. However, the data are limited and the pregnant mother still has a right to make this choice. Lead gowns need to cover the sides of the uterus fully and, in reality, a heavy lead gown may be difficult to wear during the final stages of pregnancy. A one-piece apron style gown may be easier than a “skirt and top” style for these women. Lightweight aprons that do not contain lead, where available, are ideal.
There is clear advice to suggest that pregnant women should avoid contact with crushed 5-alpha-reductase inhibitors (N.B. this is rarely crushed in today’s practice) because this can cause abnormal development of the male genitalia in foetuses (7).
Iodine hand scrub has been shown to cause a rise in urine iodine secretion and an alteration in thyroid hormones. It is thought ithat this may be absorbed into the foetal thyroid, so chlorhexidine hand scrub should be used where possible (8,9).
There is also clear evidence that a safe level of exposure to Mitomycin C and other cytotoxic drugs cannot be determined, so pregnant trainees should not use these and should ask other colleagues to take over in these cases (10).
Regarding infections, pregnant woman who are non-immune to chicken pox should avoid contact with patients with shingles (they occasionally present to urologists as loin pain) because, although infection in the mother can be severe, the risk to the baby is low. Hepatitis B infection carries a high transmission rate to the foetus, so pregnant surgeons should ask colleagues to deal with Hep-B positive patients. Other infections to be avoided are hepatitis-A, HIV, parvovirus, cytomegalovirus, toxoplasmosis and listeria (11). Good hand hygiene will protect from many infections, along with up-to-date immunisations, and the use of personal protective equipment for certain cases.
Having said this, the greatest risk to mother and baby as a pregnant urologist is probably the workload, long hours and stress. The Health and Safety executive states that the employer should make steps to reduce these risks. In practice, the pregnant urologist needs to have frank and honest discussions with her supervisor and manager, as early as possible, in order to alter workload and environment if she feels she needs this. There is no legal requirement to tell your employer that you are pregnant, but they cannot be expected to help make changes if they are unaware ... "
- 2015 FINAL Workforce Report Master _vs2_.pdf [Internet]. [cited 2017 Feb 11]. Available from: http://www.baus.org.uk/_userfiles/pages/files/About/Governance/2015%20FINAL%20Workforce%20Report%20Master%20_vs2_.pdf
- 2009_pregnancy_and_work_in_diagnostic_imaging_departments_2nd_edition.pdf [Internet]. [cited 2017 Feb 11]. Available from: http://www.hullrad.org.uk/DocumentMirror/health&safety/RCR/2009_pregnancy_and_work_in_diagnostic_imaging_departments_2nd_edition.pdf
- Hellawell GO, Mutch SJ, Thevendran G, Wells E, Morgan RJ. Radiation exposure and the urologist: what are the risks? J Urol. 2005 Sep;174(3):948–52; discussion 952.
- Chandra V, Dorsey C, Reed AB, Shaw P, Banghart D, Zhou W. Monitoring of fetal radiation exposure during pregnancy. J Vasc Surg. 2013 Sep;58(3):710–4.
- Birnie AM, Keoghane SR. Radiation exposure to a pregnant urological surgeon – what is safe? BJU Int. 2015 May;115(5):683–5.
- Ghatan CE, Fassiotto M, Jacobsen JP, Sze DY, Kothary N. Occupational Radiation Exposure during Pregnancy: A Survey of Attitudes and Practices among Interventional Radiologists. J Vasc Interv Radiol JVIR. 2016 Jul;27(7):1013-1020.e3.
- Hirshburg JM, Kelsey PA, Therrien CA, Gavino AC, Reichenberg JS. Adverse Effects and Safety of 5-alpha Reductase Inhibitors (Finasteride, Dutasteride): A Systematic Review. J Clin Aesthetic Dermatol. 2016 Jul;9(7):56–62.
- Committee JF, editor. British National Formulary (BNF) 68. 68th Revised edition edition. Pharmaceutical Press; 2014. 1168 p.
- Velasco I, Naranjo S, López-Pedrera C, Garriga MJ, García-Fuentes E, Soriguer F. Use of povidone-iodine during the first trimester of pregnancy: a correct practice? BJOG Int J Obstet Gynaecol. 2009 Feb;116(3):452–5.
- New and expectant mothers
who work New and expectant mothers
who work New and expectant mothers
who work New and expectant mothers who work: A brief guide to your health and safety - indg373.pdf [Internet]. [cited 2017 Mar 20]. Available from: http://www.hse.gov.uk/pubns/indg373.pdf
- Avoiding infections in pregnancy [Internet]. [cited 2017 Feb 11]. Available from: http://www.uptodate.com/contents/avoiding-infections-in-pregnancy-beyond-the-basics
Summary of recommendations
- Inform your manager, in writing, as early as possible in your pregnancy;
- There are no current data to show that a urologist receives more than the recommended radiation exposure for a pregnant person;
- You may, however, wish to avoid X-ray exposure; this decision is a personal one;
- Ask for a lighter, non-lead gown;
- Avoid contact with mitomycin C, 5-alpha-reductase inhibitors, and iodine hand scrub;
- Ensure you adopt good hand hygiene;
- Avoid high infection risk cases, especially Hepatitis B positive patients.