Women in Electrophysiology

Pregnant Electrophysiologists: How to Handle This Bump

Dina M. Sparano, MD

Staff Electrophysiologist, Cleveland Clinic

Sydell and Arnold Miller Family Heart & Vascular Institute

Robert and Suzanne Tomsich Department of Cardiovascular Medicine

Cleveland, Ohio

Dina M. Sparano, MD

Staff Electrophysiologist, Cleveland Clinic

Sydell and Arnold Miller Family Heart & Vascular Institute

Robert and Suzanne Tomsich Department of Cardiovascular Medicine

Cleveland, Ohio

Focus on the Positive

Few symbols are more iconic than the plus sign of a positive pregnancy test. The first time I stood eye-to-eye with this small but mighty character was at the time I was transitioning from my general cardiology to EP fellowship. No matter how calculated or wished for, there is little news we women receive in life that is more leveling than this.

And who am I, you might ask? I am somebody’s mother. We operate in a data-driven world, so my N of 2 hardly constitutes as robust evidence, or even expert opinion for that matter. Still, the more I talk with my female colleagues, my anecdotal experiences do not deviate significantly from that of other women in our field.

Pregnancy follows a principle with which we electrophysiologists are already familiar; that is, it is an “all or nothing” concept. Once you have had the true privilege of being catapulted into the throws of pregnancy and motherhood in the workforce, you are, for all intents and purposes, an expert. In fact, you are the expert when it comes to you, your body, and your offspring. There have been many times that I have felt everything in my life is at least a little out of control. As a result, herein began the never-ending barrage of questions I ask myself about that which is unknown but inevitable. Things like, “Is it the right time to start a family?”, “How will my colleagues and superiors react to my being pregnant?”, “What is the correct radiation safety protocol for pregnant women?”, “How will I make it to all of these doctors’ appointments?”, “How will I get through the long cases or nights on call when I feel so lousy and tired?”, “Will I be able to breastfeed my baby?”, “What will I do when my kid gets a fever or the nanny calls off?”, and so on.  I am not here to answer these questions for you, but rather to share some of the details of my experiences in an effort to open a dialogue amongst us brave and few EP moms.

Prior to becoming pregnant, my experience as an EP fellow had begun to bring out certain personality traits in me that frankly I did not recognize, or like, for that matter. Always the rule follower, I climbed the ranks in subordination and always with respect. However, there was an overwhelming amount of information, skills, and advanced concepts to grasp. I was also now in a rigorous surgical subculture, and entering into a primarily male-dominated field. I became timid and insecure — I had never been like this before, and frankly, I was disgusted with myself.

However, once I became pregnant, I snapped. It dawned on me that I was a thirty-something adult who was nice, hardworking, and smart. I deserved to be where I was, and could practice and learn with humility while still exuding confidence, and I knew that I had the skills and work ethic to not only survive, but thrive. As these endless questions persisted on replay inside my head, I could now address them all with one simple answer. And though it is generally ill-advised in medicine to answer a question with a question, it was appropriate here. Without fail, this response to any uncertainties I have instantly snaps me back to my priorities: If not me, then who? It was up to me to decide — insist upon, actually — the answers to the questions I would be facing as a new working mom in a manner with which I was content. In this new light, I began to realize that embarking on this journey while pregnant was not only possible, it was empowering.

When I learned I was pregnant with my first child, my husband and I were ecstatic, but I also initially felt panic because of the possible effect it would have on my career. My husband and I were long distance with our respective fellowships, and I was one-month shy of starting my EP fellowship, so this, I was convinced, was the worst timing ever.

I was hopeful for the gift to start a family, but as with many women who become pregnant (especially working women), we cannot help but focus at some point on all of the ways a pregnancy will impact us and those around us. In the musical Waitress, Jenna is panicking she may be pregnant, and her two girlfriends try to comfort and calm her by telling her to focus on (while she prays for) “The Negative”. For us working women, we also wonder how this will affect our careers — first the day-to-day, and eventually our overall career goals and paths. In particular, we women directly concern ourselves with how our pregnancies will affect our colleagues — I believe this is because as nurturers, we are naturally concerned about those in our spheres of influence. I wish I could advise you simply not to worry about it, but that is not realistic. There will be issues, inconveniences, and changes which all need addressing. Personally, once I got past the initial surprise, I knew it was all going to work out, I just had no idea how. In hindsight, I now realize it is perfectly normal to feel this uncertainty — pregnancy turns our lives upside down. For me, I stopped worrying about that which I could not control and did exactly as I would advise anyone when it comes to reacting to this awesome news — I call it my practical pregnancy pearl #1 — I focused on the positive. I was going to be a mom.

Get the Lead Out, and Other Practical Considerations

As electrophysiologists, particularly if we are in training and thus not exactly in command of our own schedules, sharing our news in the workplace carries its own fun layers of complexity. We inevitably become concerned with how this will affect scheduling, our ability to perform, our radiation exposure, the perception of us as dependable coworkers, and perhaps above all, our ability to “stay on top of our game”. There are the day-to-day considerations as well, such as, “What will I do when I have to vomit/pee/drink/eat in the middle of a case?” Hopefully, most of us eventually come to realize that many of these worries were excessive.

Before I was ready to share my news, I wanted to keep my secret a secret. However, the telltale sign of a pregnant electrophysiologist is the dreaded “doubling-up” of our lead aprons. As if wearing one layer of lead after hours in the lab is not difficult enough, we now have to endure wearing two sets of armor on our sore, nauseous, and exhausted bodies. While literature on radiation exposure is ample, objective data regarding fluoroscopic techniques during pregnancy are not nearly as robust. Thus, most of us let our nerves get the best of us and do not perform cases with only a single layer of lead. Again, there really is no data that support a need to worry, provided that smart and thoughtful fluoroscopy techniques are practiced. Of course, the alternative is to avoid the lab entirely, although not only is this unnecessary, but it is also not desirable for those of us that perform procedures for a living.

This brings me to my practical pregnancy pearl #2: order lead that is double-lined in the front of the skirt. The layers are thin, resulting in a far less cumbersome experience when compared to double-leading, and subsequently allows for “hiding” your pregnancy until you are ready to spill the beans.

I shared my news with my colleagues at 9 weeks gestation — earlier than I would have liked, but given that my EP fellowship was starting, this was the responsible thing to do. The reactions were overwhelmingly positive and supportive, with the exception of one “You can’t cry over spilt milk” comment, which I later realized was probably as much a reaction to my nerve-racked, almost confession-like divulgence, as it was this person’s own unfiltered feelings. Much of the anxiety I felt was nothing more than a reflection of my own fears: Would my pregnancy somehow erode my fellowship experience? Would I be seen as a less dependable colleague?

Although there was no malintent bestowed by any of my colleagues, no one can help the fact that you might simply be less present. It is easy and natural to feel a little lost in the shuffle when you are at times physically and — let’s be honest — mentally absent. At times, it felt as though I had a case of senioritis — except I was the freshman. My head was somewhere else. As a result, I busted my hump after I returned from my maternity leave, working longer hours than I needed to, completing tasks assigned to others, and studying around the clock. I hear so many women describe taking a similar approach. In all honesty, it is hard to say what is the “right” thing to do — do we let these insecurities propel us forward, or hold our heads up and refuse to succumb to them? One thing I do know — looking back, I would not have changed my seemingly imperfect timing for anything.

I did avoid the lab during the earlier phase of my first pregnancy, though I was never instructed or advised to do so. I asked my obstetrician, pediatrician, my own department, and radiation safety, and no one had any direction to offer. During my second pregnancy, I was already an EP attending, so I did not avoid the lab at any time. This was not out of a more lackadaisical approach to my second pregnancy, but now that I was in charge of the radiation exposure and had increased savvy about navigating my procedures with minimal fluoroscopy, I simply felt much more comfortable this time around. Radiation safety is paramount, and it takes on a whole new meaning when you are pregnant. Enduring long cases, particularly with respect to prolonged standing, as well as ensuring adequate sleep, hydration, and nutrition are all big concerns in our field. Also, as physicians, we treat the sick, and sometimes this involves potential exposure to blood-borne and airborne pathogens. Pregnancy calls for a heightened awareness, beyond which already demands extreme caution. So my practical pregnancy pearl #3 is: no one is going to tell you how to do you. You have to decide, unapologetically, what works and what does not, for you and baby. And stick to it.

Unapologetically is the hard part, right? We do not practice medicine in a vacuum. These choices do affect others around us, and it is practically impossible to not feel like you are inconveniencing everyone around you at some point or another. Most of us are not used to, nor are we comfortable with, all the seemingly unbalanced favors that come our way ranging from voluntary coverage, unquestioned excusals, and, if we are really lucky, the plate someone thoughtfully fixed for us while we were scrubbed so we did not miss a meal. So the best advice I could give here is to accept that upping the ante on respect and reverence for pregnant women is our societal norm and generally the rule as opposed to the exception.

Once you are comfortable sharing the news of your pregnancy, familiarize yourself with your employer’s maternity leave policy. It may be helpful to ask other female colleagues, but I would strongly advise against relying solely on this. There are different policy manuals for different levels of employees, and the plan may have changed since someone else had her experience. Though you can never really be sure when your maternity leave will start, prepare as much as you can and swap out of any call responsibility that is set to transpire while you anticipate being on leave. I suggest that you try to reciprocate before baby when at all possible. It is tempting to avoid any extra responsibility, particularly those that involve nights and weekends when you are pregnant, but you will sincerely thank yourself later.

Upon your return to work, your chief concern will be your childcare situation. There is no failsafe here that covers 100 percent of everything. Trust that others around you — at least those that are reasonable — know that you are doing everything you can to create the most nurturing and safest environment for your child while respecting your job and that of those around you. I once heard someone say, “Those that get it do not need an apology, and those that do not, never will.” The best advice I can give here, obvious as it may seem, is twofold. First, do create backup plans. Talk to other moms about nanny share options (even if just in the event of an emergency), learn about drop-in policies for daycare, and try to have two or three babysitters on standby. But life happens, as they say, and when your seemingly infallible childcare arrangements — and all of your backup plans — go sideways, you are a mom first. This may seem obvious, but you would be surprised how unnatural it feels during a conundrum to put something ahead of work. We wear two hats that are always on — “mom” and “doctor” — but when these roles collide, the question of “What do I do?” is best answered once again, in my humble opinion, by the question, “If not me, then who?”.

How to Deal with the Baby Elephant in the Room

The challenges we face as EP moms go far beyond childbirth. Everyone seems to forget that after the pregnancy comes a human being for which you are the number one. Again: if not you, then who?

Now, it’s not everyone’s job, or problem for that matter, to be constantly aware of what physical, emotional, or mental challenges that new (or even veteran) motherhood may bring to us. Understandably, hospitals have policies that are ultimately designed to protect pregnancy rites. As a result, most people are super cautious about bestowing fair, or sometimes even preferential treatment, upon pregnant women. As a result, no one blinks when you leave early for yet another doctor’s appointment, or your co-fellow takes on the 10-hour VT ablation on the patient with hepatitis C so you do not have to, and so on. I will never forget when I scrubbed a subcutaneous ICD with one of my attendings during fellowship. It was customary for us to push the device pocket up against the rib cage during defibrillation testing. But when the time came and my attending gestured for me, I asked, “Will the shock harm the fetus?” I knew it was a silly question and offered to proceed, but he stated matter-of-factly, “No, you said fetus. So you can’t do it.” We all laughed, but I understood and appreciated the mentality and pressure he must have felt to make sure my experience as a pregnant fellow was pristine. I truly believed as well that he genuinely cared for my well-being.

But when the pregnancy is over, it seems that some people have a much harder time empathizing with the trials and tribulations of motherhood than they do with the “delicate state” of pregnancy. The eye-rolling and “I trust this won’t happen again” comments that follow events such as your baby’s fever and subsequent mandatory early departure from daycare, or excusing oneself to use your breast pump, or tardiness because the nanny called off sick, are a stark contrast to the prenatal days filled with “Of course!”, “Can I get you some water?”, or “Why don’t you go get some rest?” Frankly, I do not know where the balance should be, but this definitely still seems off center.

Becoming pregnant on the brink of EP fellowship taught me a valuable life lesson that, much like earning an actual salary, I came to later in life compared to my non-medicine peers. I likely would have learned the lesson even later in life, had pregnancy not brought me to this party for which I was already unfashionably late. I am an independent-thinking, capable-of-making-her-own-decisions adult who should never apologize for looking out for number one or her children (practical pregnancy pearl #4). Like most of us, my adolescence and young adulthood had been entirely in the context of education and training. I functioned on a daily basis as a subordinate — I did not know anything else. It should be said that I have a deep respect for the hierarchy of medicine, but I never realized how much this had shaped my mentality with regards to my approach to life in general.

Learning this lesson very quickly helped to squash my concerns about feeling guilty for keeping a prenatal appointment, or asking to be excused so I could scrub out and grab a bite to eat or some water. And once I became a mother, this translated to a very matter-of-fact approach to things such as childcare fallouts or the fever that prevents your child from returning to daycare for 24 hours. I am my daughters’ number one, and they, above all, are my responsibility. My confidence grew as I extrapolated this philosophy to other areas in life. I was — and still am — never too proud to be corrected or taught, but now, the difference was I had this able-mindedness to make and defend decisions, and when necessary, confront others, in medicine and elsewhere in my life. I am someone’s mother, and that, for me, started a whole new ballgame. And motherhood has allowed me to evolve as a physician — these are not mutually exclusive roles that need to be in constant opposition. It is the mom in me who holds my patient's hand until they are fully asleep before the procedure, or who takes a few minutes at the end of a visit to ensure my patient knows how to work her smartphone to track her heart rate.

When I shared the news of my pregnancy with a dear friend and mentor, he said to me with the best intentions, “The hardest part of being a working mother is that you often feel you can never give 100% at either home or work, so instead you feel like you are failing everywhere.” It is ironic to me that we can feel so lost at times despite having so many defining roles. Many days that is true, although I have come to understand that these feelings of inadequacy are fueled by the greatness for which we strive and the overachieving to which we have become accustomed. At the end of the day, I always remember the first thing that our pediatrician told us on the day our first daughter was born: “All they need is food, love, and shelter.” It is the best parenting advice I have ever received. These words comfort me when I have not seen my kids awake for days, and remind me of what is truly important in life.

Now I see this as painstakingly obvious. But for whatever reason, until this point in my life, it was not. This revelation would recur throughout my fellowship, my career, and my life. I am forever indebted to my daughter for this life lesson learned during my first pregnancy. While I was carrying her, she was carrying me. When she was four months old, I said to my father, “She’s already bigger than me.” He looked up at me from across the table with tears in his eyes, and I knew that he knew that I “got it”.

Being a “doctor mom” often makes women feel like we are good at neither, when in fact, it makes us better at both. I think that is the key — putting our children before us is the best way to look out for ourselves as well. Starting with pregnancy, my daughters have become my beacon. Not only did they not hold me back, they are what got me through and pushed me to succeed even more than I would have otherwise. I turn to both of my daughters for strength and empowerment — they inspire me to live by the example I want them to follow. After all, if not me, then who? 

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