Infusing work-life balance in medicine: reflections from Katrina B. Mitchell, MD, IBCLC, PMH-C, FACS

— “…Breastfeeding isn’t about ‘success’ or ‘goals’ — it’s a human experience.” —
Mitchell’s son captures her on the job. Used with permission: https://www.instagram.com/p/CuN_G35Rc0h/

Katrina B. Mitchell, MD, IBCLC, PMH-C, FACS, a breast surgeon, lactation consultant, and perinatal mental health provider in Santa Barbara, Cali., went back to work at five weeks postpartum.

“Looking back…I have no idea how I did this,” she reflects.  “I know this is still far better than migrant workers on the central coast of California, who may not even have a week to recover.”

In part, Dr. Mitchell recognizes the support she received from a pediatrician; he counseled her on bed sharing during the time she was breastfeeding as a single parent in surgical training.

“This literally saved mine and my son’s physical and emotional health (as well as allowed me to exclusively breastfeed for six months and then onward for years),” Dr. Mitchell explains. “Sure, it was still terrible to have to pump milk in a bathroom by the OR and lug my pump all over the hospital, but I really believe I stayed on a postpartum high because I got to sleep and nurse my baby at night when I got home.”

She continues: “[Bedsharing] saved every possible complication we could have experienced with me being back at work operating 14 plus hours a day at that point in time…. I am forever grateful to this pediatrician…”

Dr. Mitchell captured these early experiences in a book she wrote for her son about being a surgeon mom.

In her practice today, Dr. Mitchell tells her patients who are going back to work that the ounces in a bottle during the day are not nearly as important as feeding baby at the breast when the dyad is together and feeding overnight on cue.

“Safe bedsharing is what facilitates this and results in continuation of breastfeeding far longer than separate surface bedsharing, sleep training, and feeding a pump rather than the baby,” she explains.

In particular, physicians have long struggled with “pouring from an empty cup” alongside being influenced by insidious industry tactics, mechanical culture and inadequate education. Nikki Lee and I wrote about these forces in Physicians as parents: How can one pour from an empty cup? and Physicians as breastfeeding supporters.

In New study calls for greater access, equity for breastfeeding surgeons author Hilary Brown reports on “A new vanguard of physicians… determined to make the field more hospitable to working mothers by establishing dedicated pumping spaces and allotting time for pumping without fear of retribution or punishment.”

Brown goes on, “… No one should be denied professional opportunities just for choosing to have a work-life balance. For too long, surgeons were lauded for not having families, or prioritizing their work over a personal life. To be a martyr to the field was considered the highest level of dedication. But ultimately, such devotion has proven to be a detriment. Excellent patient care, London-Bounds says, starts with self-care.”

Dr. Mitchell acknowledges that “..the surgical world is becoming more attune to this topic.”

In 2020, the Association of Women in Surgery released a position statement on supporting physicians and trainees who are breastfeeding.

In regard to lactation accommodations in the workplace though, Dr. Mitchell says she often thinks of something Kimberly Seals Allers pointed out many years ago when she said something along the lines of: “We are a pump nation — we shouldn’t be celebrating being gifted a pump from our medical insurance.  We should be demanding adequate paid maternity leave.”

“Accommodations should really be focusing on this governmental-level change,” Dr. Mitchell elucidates.  “Not only is it the right thing to do for human beings, but it reflects one of the fundamental principles of economics 101:  opportunity cost.  You lose some productivity up front by giving mom a longer maternity leave, but you exponentially recoup this cost when moms breastfeed rather than wean and have good mental and physical health when they return to work.”

In this landscape without paid leave, there can be a layer of tension that brews between colleagues.

“A  lot of the hostility towards lactation and lactating patients does stem from physician personal experience with lactation (which was unfortunately largely negative in the past, and can persist today no matter what accommodations we provide),” Dr. Mitchell begins.

“And these negative experiences are a direct result of the medical patriarchy, which provides little to no education on the breast and lactation in medical school, residency, or fellowship training.  Because of this, just like all other patients, physicians themselves are at risk for not receiving appropriate evidence-based support and education surrounding lactation and breastfeeding.”

She continues, “As we all know, the postpartum time period is one of great vulnerability, and a person’s experience with breastfeeding can play a central role in how they navigate early motherhood.”

Juxtaposing the way that we look at lactation and breast cancer care, Dr. Mitchell says that we would never tolerate breast cancer care as being reflective of personal experience, but this often happens with lactation.

“With breastfeeding, there’s the dismissive comments of ‘oh, it didn’t work for me, so it’s fine it doesn’t work for you.’  We would never say ‘that chemotherapy didn’t work for me, so it’s ok if it doesn’t work for you,’” she explains.

Clear to recognize that this is not the fault of the individual, Dr. Mitchell says it’s instead a reaction to “the fact that the patriarchy didn’t support them, either.”

And so, to influence real change, we have to start at a systems level in medical education, she says.

Training needs to include education about things like safe bedsharing, how formula feeding and breastfeeding are vastly different in terms of volume and infant behavior (e.g. the normal distraction of a breastfed infant at four months old versus a bottle fed infant taking a bottle on schedule), Dr. Mitchell explains.

“…This should be standard education for all of us.”

Physicians from less traditional backgrounds have great power to drive change too, Dr. Mitchell suggests, sharing her personal experience:  “I am the only person in my generation on one side of my family to go to college, much less medical school.  Three quarters of medical school matriculants come from the top two household-income quintiles — I was not one of them.  Since I was a teenager, I worked my way through school.  I had a liberal arts background and undergraduate degree, and I think all of this made me see things from a different perspective than other medical students and physicians.  I was also lucky that my mom pushed back against the tide of formula feeding in the late 1970s, and I was a breastfeed infant myself because of this.”

In a powerful Instagram post, a photo snapped by her seven-year-old son is captioned “I love this moment because it’s the ultimate rebellion against corporate medicine. No one can take away the power of human connection.”

The post is commentary on a simpler, more connected way of caring for patients.

“Instead of a patient having to login to the EMR or deal with a centralized scheduling call center to make an appointment, [the post] reflected the way we used to care for people in medicine and what I try to preserve as much as possible:  a patient needing help, contacting me directly on a weekend, us all going in with casual clothes and me just doing my job as a doctor,” Dr. Mitchell explains. “ No electronic medical record, no ‘15 minutes with each patient’ corporate mandates, no ‘you can’t do this or that’ by the administration.”

Ironically, Dr. Mitchell continues, she’s noticed that corporate medicine has made certain aspects of lactation accommodations better.

“The one positive aspect …is oversight and standardization and human resource departments,” she says.   “If there’s a law for accommodations, there is someone enforcing them (along with all the other not-so-helpful ‘enforcements’ like clicking through countless screens in the EMR simply to write a quick note on a patient).”

During the 2020 COVID-19 pandemic, Dr. Mitchell created the Physician Guide to Breastfeeding, a hub where she’s committed to sharing openly and advocating for improvements in broader maternal child health education. You can explore her collection here.

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