Trauma and Orthopaedic Surgery is the career choice of many female medics. Currently 5% of the consultant body are female but approximately a quarter of all new trainees at ST3 level in orthopaedics are female. The following pages aim to inform current and future trainees about the details of training in orthopaedics as a woman.
Am I physically strong enough?
Yes! An average person male or female who might occasionally go to the gym (or not) will be physically strong enough to perform most orthopaedic operations. Modern power tools such as power saws, drills and reamers mean that there is a lot less heavy work than previously for the bigger operations such as hip and knee replacements. This is still a physically demanding speciality and at the end of a whole day list of operating most of us are physically tired.
Why are there no female orthopaedic consultants?
We’re coming! There are indeed very few female orthopaedic consultants, in 2014 about 5% of UK orthopaedic consultants were female. However approximately 25% of new orthopaedic trainees are female, so it won’t be long before you start to see the change in the consultant body of your hospital. Traditionally long hours and antisocial career pathways have put women off as it was difficult to combine with having a family, however this is increasingly a thing of the past.
Is it possible to combine a surgical career with having a family?
Definitely. It’s possible to be married to a doctor, even a surgeon and have kids.
Many trainees choose to have children during their time as an orthopaedic trainee. They take a planned break for maternity leave then come back either full time or part time as they wish. People take off anywhere form 6 weeks to 1 year maternity leave. Depending upon their family situation many use a combination of family support, nursery and childminders to help with childcare after they go back to work. As a consultant it is possible to negotiate how many sessions a week you want to work to fit in around you family life.
Yes, but wouldn’t it be easier to be a GP if I want to have kids?
No, I don’t think so. Speaking to my colleagues who are female GPs and GP trainees I think they face their own challenges. Orthopaedics allows you to take maternity leave and work part time just like working as a GP. In some ways it is easier as a orthopaedic trainee as our training is longer so you have a longer period of time where you benefit from the maternity leave benefits offered by the deanery. Organising childcare can be a challenge for anyone who works, for orthopaedic surgeons our early start times and occasional late finishes for overrunning operating lists can require extra organisation.
Trainers tend to be very supportive of pregnant trainees.There is no problem with taking breaks to eat regularly or to go the toilet. Heavy lifting in theatre can be avoided and you can have a high stool on hand to sit down when required.
When is the best time to have children?
Essentially it’s always the best time!
It is possible to have children at any point in your training but some time points are easier than others. Depending on you age when you graduated from medical school you may have more or less room for manoeuvre as to when you choose to get pregnant.
During your foundation years is a tricky time. Foundation 1 year is a stressful time for anyone as there is so much to get used to. The rules during foundation mean that you are not allowed to miss more than 4 weeks of work out of any one year without risking repeating the year, so even if you combined this with your annual leave allowance would still be a relatively short amount of time for maternity leave. However, you would not be the first or last person to have a baby during their foundation programme.
During your Core trainee years most people are working very hard to accumulate the necessary exams, publications, and courses to apply for registrar jobs so it is not a the commonest time to have children, however if you could organise yourself to have everything else in order then it may well not be a bad time. If you do get pregnant and it coincides with accepting an ST run through programme then you can delay starting until up to a year after the baby is born. Additionally you will still get maternity pay even if it is a different deanery as your current deanery can extend your contract to cover your maternity leave.
Many trainees choose to delay having kids until they are on an orthopaedic training programme as that is a major hurdle to get through and before that they are usually busy studying for exams and interviews. After that you are guaranteed to be in a relatively fixed geographic region for 6 years, which gives you a bit more stability. However having children during this time does interrupt your surgical training and if you take a lot of time out it can take time to get back to your previous surgical skill and confidence levels.
Do you encounter sexism at work?
No…. well only from the patients occasionally. The NHS is a very egalitarian place and orthopaedics is no different.
What can I do about feeling faint during surgery?
Many of us will have fainted in theatre at some point particularly when we were younger. It certainly does not mean that you are not well suited to a career in surgery. Women are physiologically four times more likely to faint than men and if you are standing very still for long periods of time whilst assisting feeling light headed is certainly common. Most female trainees will tell you that their body has gradually got used to long periods of standing up over time and that they no longer have so much of a problem with it. However there are other things you can do to combat it.
- Eat regular small meals and certainly never miss breakfast or lunch
- Stay hydrated
- If you feel yourself getting slightly light headed do some heal raises or dance around a bit at the table to get the blood pumping back up from your legs.
- If you really feel faint step back away from the table and sit down, you will desterilise yourself but clearly that is highly preferable to fainting onto the patient’s open wound and jeopardising the sterility of the operation.
- Some people find DVT stockings or maternity compression stockings helpful.
Is it OK to work with the image intensifier during pregnancy?
As orthopaedic surgeons some of our work, particularly fracture fixation uses X-rays during the operation to aid the procedure. We routinely wear lead gowns to minimise the radiation dose to the internal organs during the procedure. During pregnancy there is a potential risk of radiation to the foetus. Radiation exposure if wearing a lead gown is less than 1 milliSievert over nine months, to put this in perspective the dose for a patient receiving an X-ray of the spine is 1.5 milliSievert.
There are ways to further reduce your radiation dose whilst pregnant;
- Tell the radiographer you are pregnant so that they can collimate or focus the X-ray beam on the area of interest.
- Use the mini c arm if possible which has a smaller radiation dose.
- Get into the good habit of taking less X-rays
- Stand further away from the C arm, 2m away dramatically reduces the dose.
- Stand behind a portable screen in theatre.
- Wear a lead skirt and top rather than a tunic for extra protection and comfort.
Hospitals usually leave it up to the surgeon’s individual preference what they want to do. In most units the other registrars and consultants can manage to accommodate you if you don’t want to do a particular case involving a lot of X-rays.
Is it OK to work with cement for joint replacements during pregnancy?
The vapours from PMMA cement are classified as irritant. The main problem they can cause is irritation to the conjunctiva or respiratory tract. Mixing using a vacuum and using a cement gun along with the laminar flow air system all help to reduce our exposure to the vapours. There is no known evidence of risk to the foetus from these fumes but the effects have not been studied. Most hospitals will leave it up to you if you want to do cases involving cement during pregnancy and most people choose to continue as normal. The alternative is step outside while the cement is used, theatre staff are generally accommodating of this.
How do I cope with nausea and vomiting during pregnancy whilst trying to operate?
Nausea is a horrible symptom even at the best of times. The standard advice for nausea during the first trimester is to eat small meals often which are quite plain e.g. crackers / toast etc to help settle the stomach. Strong smells can trigger the nausea, which may be unavoidable in theatre. Staying hydrated and well rested is also thought to reduce the severity of the nausea. In some cases it may be necessary to discuss anti-sickness medication with your doctor. If you feel really sick it can help to unscrub for a few minutes. Clearly if you are actively vomiting it is unwise to operate.
When can I stop doing night shifts?
There is no specific time during your pregnancy when you are obliged to stop working nights. However due to the tiredness that accompanies pregnancy many people choose to negotiate with their employer to stop working nights in the final stages of pregnancy. There is some evidence that working night shifts during pregnancy may increase the risk of premature labour.
How long is maternity leave?
You are eligible to take up to 52 weeks off. You will accrue annual leave during this time, which you can also take off. How much time you take off will obviously depend on your health post pregnancy, your baby and your childcare arrangements at home. Some trainees say they have found it easier to get back into the swing of work when they have had 6 months off rather than a whole year, particularly if it is a second child. You are obliged to take the first 2 weeks off post delivery.
When can I start my maternity leave?
You need to inform your training programme director in advance of your due date, it will be helpful to them for rotation planning if you can tell them when exactly you intend to go off and how long you intend to take off. Maternity leave can start from 29 weeks gestation. Most people stop working at 36 weeks, but you might want to go on until 38 weeks. If you need to take sick leave because you are unwell during you pregnancy that is not a problem however if you need to take sick leave in the last 4 weeks of pregnancy then you employer may ask you to start your maternity leave rather than take sick leave.
How does pay work during maternity leave?
Overall NHS maternity pay is excellent. You need to notify your employer in good time of your intention to take maternity leave, this should be as soon as you are comfortable to do so e.g. after the 12 or 20 week scan. The latest you can inform them is 15 weeks before you are due i.e. in the 24th week. You will need to notify the maternity advisor in HR at the deanery, your own consultant, the person in charge of organising the rota in your hospital and your programme director.
The system for calculating maternity pay is somewhat complex, however the end result is essentially 16 weeks full pay, 8 weeks half pay and then statutory maternity pay (approx. £600) up until the 9 month mark, then the last 3 months are unpaid.
These links explain the complexities of maternity and parental leave in more detail:
Paternity / Partner Leave
The biological father, adoptive parent or partner of the child’s mother (male or female) may take ‘maternity support (paternity) leave’ for 2 weeks within the first 8 weeks after birth or adoptive placement.
Shared parental leave which commenced in 2015 essentially allows the child’s parents to divide 50 out of a total of 52 weeks maternity leave between themselves. The blocks of leave may also be split up.
Making the most of maternity leave.
Enjoy your baby and eat lots of cake! However if you do want to work then a good time is when they are either breastfeeding or asleep. If is very handy to have a tablet while breastfeeding as you will have plenty of time on your hands to do some reading.
Depending on the temperament of your baby and how much they let you sleep, some trainees feel able to get back to doing some work whilst they are on maternity leave after a couple of months. Trainees have used the time to revise for masters exams, finish research projects, revise for the FRCS. However there is no pressure to work while you are on maternity leave and you may well be too busy and exhausted.
It is worth checking with your deanery as you may be eligible for study leave and funding for courses etc during your maternity leave.
Will having a C section make it more difficult to return to work?
No! We don’t think so. Most people will take at least 3 months maternity leave, most take a year so it really should not be an issue. At 6 weeks you are able to start heavy lifting and exercising again then at 3-4 months your core strength and stability should return to normal but of course everyone is different.
Can I still breastfeed when I go back to work?
Yes, this is a nice way to reconnect with your baby when you get back from work. Depending on their age you may want to express milk for them to take to nursery and feed them morning and night while at work and anytime when you are off with them. Your supply should be fully established on your return to work so you should have no problems feeding them more or less and you should not become engorged.
What are the options for working part time?
As a trainee the minimum you can work is 60%, which sessions or days of the week you work will be up to you to negotiate with your trainer depending upon both your respective timetables. The advantage of less than full time training is that if you are off you cannot be allocated any additional unexpected sessions. Generally your day off will be when your consultant has no commitments. The day off needs to be the same every week if your child goes to nursery as they will have fixed days. With travel time and late finishes it is often easier to work one whole day instead of two half days.
As a consultant it is also possible to negotiate your contract around your life so that you work less sessions, or cluster your sessions on certain days. Some hospitals have evening clinics and theatre lists which mean that you can have a day off instead.
What do I do if my child is sick?
If your child is sick and there are no other options for childcare then you can take compassionate leave to care for them. Additionally your consultant could accommodate you if you had to leave early to pick them up due to sickness. There is also the capacity to take up to 18 weeks of parental leave per child up until their 18th birthday to care for them, this leave is usually unpaid.
Debbie Lees, 43yrs, ST7 Trauma and Orthopaedic Surgery.
I grew up in South Africa: my mum was an accountant and ceramic artist and my dad a veterinary microbiologist, so I spent most of my holidays tramping around the bush tracking animals, or pouring agar plates for sampling. My younger brother had severe cerebral palsy following a very premature traumatic birth, requiring multiple surgeries, including femoral and pelvic osteotomies and revisions as I was growing up. I spent a huge amount of time on the paediatric orthopaedic wards with him or helping to care for him at home and I was fascinated by it all. From an early age I was sold on the idea of medicine as a career.
Financial constraints as result of massive medical bills for my brother meant that I couldn’t afford study medicine despite being accepted on each application and I ended up starting an undergraduate degree in basic sciences and statistics, followed by a 7-year full time postgraduate degree to be a chiropractor. As part of my degree I needed to have some basic life support skills and I enjoyed this so much, I went on to do my ATLS, which meant I was qualified to work as a paramedic on the helicopters in South Africa. During my degree I worked as a helicopter and rapid response paramedic, scuba diving instructor and commercial offshore diamond and salvage diver to pay my university fees. I then studied sports medicine for a year in the USA whilst competing as a member of the South African International Karate Team before coming to the UK in1998. I initially worked in London and surrounding areas before I came to the Northeast. I had met my husband whilst working in Norwich and he was already living in the Northeast with his own business. I started up my own successful chiropractic businesses with my husband which was all going very well until I decided to throw a spanner in the works and again apply to study medicine a the University of Newcastle-upon-Tyne, now in my very late 20s. Fortunately this time I had the means to finance my studies. During my years as a medical student I continued to work with my own business as a chiropractor, and in 4th year I sold the business and paid off the rest of my tuition fees as well as a big chunk of my mortgage.
After significant persuasion (frank blackmail actually) from my husband we had our first child in 2003 in my second year of university. Due to complications after pregnancy I needed to take a year off from university. I managed to time my second birth perfectly to coincide with the Christmas holidays of 4th year so that I could come back to student selected component modules which meant that it was easier to negotiate caring for a newborn baby around my responsibilities as a student. I remember the head of the medical school having to sit down as I discussed my plans with him. I think it came as a bit of a surprise judging from his face and the absolute silence after I had explained the situation.
Pre-planning was crucial during this time. I approached all my supervisors in advance to explain the situation and check that they could allow me to work flexibly during that time. I had chosen rotations in interventional radiology and nuclear medicine, vascular surgery and neurosurgery – none of them with a reputation for easy schedules or a love of the warm and fuzzy side of life. Because of the pre-planning, during those rotations I was able to work nights and do research work from home to fit around childcare and I completed a number of projects. I had my third child in the January of F2, and at that time there was no scope for flexible blocks of leave during the foundation programme. I did not want to have to repeat the year so I took 2 weeks of sick leave, 4 weeks of annual leave and then came back to work. I have continued to work full time throughout my training. Childcare has been extremely complicated and at times heart breaking. When they were younger, my children went to nursery part time, now they are in school and are looked after by their dad a lot of the time.
In some ways having my children before starting my registrar training has made things easier as it has allowed me to have an uninterrupted span of surgical training without periods of time off for maternity leave. However at the moment I am studying for the FRCS exam and at the weekends when many of my colleagues are able to study fairly uninterrupted, I am busy ferrying my kids around to different sports matches, birthday parties and friends houses! A lot of my revision and work is done very late at night once my kids are in bed; I have had to train myself to cope with less sleep, often only 4 hours. Fatigue has been the hardest thing to cope with during my training. I would say it is certainly possible to combine a career in surgery with having kids but at many points you will feel the effects. Perhaps you won’t be able to devote as much time to your studies as you might wish or perhaps you will resent missing out on time with your children, and the bone-weary fatigue is a given. It is hard going to work to care for other children when your own are at home missing their mum.
I plan to be a consultant spinal surgeon, I would love to work here in the UK, but the current contract changes mean that this may not be possible. I have made so many sacrifices (my kids, my relationships with friends and family- not to forget my husband, my personal interests and hobbies and even my health) to get here that I feel I would be cheating myself and everyone who has supported me along the way if I did not finish this journey.
Sarah Johnson-Lynn, 35, ST7 Trauma and Orthopaedic Surgery
From as early as I can remember I have wanted to be a doctor. For a while I toyed with the idea of being a pure science researcher, but once I had seen what a surgeon’s job entailed, I was hooked. I loved musculoskeletal anatomy and the idea of fixing people with my hands. I come from the northeast and I am the first person in my family to go to university straight out of school. Looking back it seems somewhat unlikely that I would have ended up as a surgeon but I was always got good grades at school and I genuinely didn’t know what else I would have done.
I studied medicine straight from school at Newcastle University and stayed on to work in the North East afterwards. I have a keen interest in research and hope to make this part of my job as a consultant. My first research project was with a shoulder surgeon here during an intercalated degree year and I later went back and did one of my student selected modules in year 4 of medical school with the same supervisor. After graduation I did various small clinical research projects and got an a run-through academic training number. I completed my first ST3 post and then took 3 years out of programme research to do a PhD in cellular medicine, funded for salary and lab expenses by Arthritis Research UK. This gave me an enormous amount experience of different lab techniques and successfully applying for research funding. During my PhD I began a distance learning masters degree with the University of Bath in Sports and Exercise Medicine. All the essay writing for my masters degree paid off when it came to the write-up phase of my Phd.
I returned to work as a ST3 for 6 months before taking maternity leave to have my daughter who is now 3. I had thought about starting a family during my time out in research. I knew of many women who had successfully combined caring for a newborn with writing up their PhD however I also knew a couple of women who were not well during their pregnancy and ended up struggling to finish their research. This is not something you will know in advance and I felt that I should not risk my only chance at a fully funded PhD. In retrospect, the time I chose to start a family was pretty much perfect for me. I was still very early on in my training having only just started ST4 which means that now I have come back I have a big chunk of time to get my surgical skills up to speed before I become a consultant.
I was relatively well during pregnancy. I chose not to be involved in cases where I had to stand next to the patient whilst using X-ray but I did do cases involving cement. I had a planned elective caesarian section followed by 6 months maternity leave which was about right for me. By that time she was weaned and happily started in nursery. I think my core stability and fitness probably returned to normal by about 4 months. By that time the period of extreme sleep deprivation was over and I was able to think and feel more human again. After the first couple of months of my maternity leave I was even able to put the finishing touches to my PhD thesis and revise for the clinical exam for my masters.
I returned to work full time straight away as I felt I had delayed my training long enough already for my PhD. I am lucky enough to have my mum to look after my daughter a couple of days a week and she also goes to nursery. Fortunately my husband is not a medic so works much more predictable hours which makes pick up from nursery much easier.
I am currently studying for the FRCS and my future career plans are to be a consultant in the NHS in foot and ankle surgery with significant academic commitments.
Advice for Future Female Orthopaedic Surgeons
- Just do it! If you enjoy orthopaedics then give it a go. Overall I don’t think it is more difficult for women or people with families than other specialties.
- Don’t be put off by the lack of female orthopaedic consultants, things are changing and there are loads of us coming. There are plenty of great mentors out there who won’t treat you any differently to the guys.
- Develop a thick skin, particularly as a first year registrar. Don’t take criticism personally and don’t let a personality conflict put you off the specialty or make you question yourself.
- Pregnancy and maternity leave can definitely be done as a surgeon. Although it is of course possible at any stage, timing it well for your own career does help (if possible!). Many of us choose to do it soon after getting a training number as before then, it can feel like you can’t step off the treadmill of getting your CV ready for ST3 interviews.
- Don’t let your desire for having kids determine your career choices. You are going to spend a huge amount of time at work so it may as well be something you love.
- Accept that you are going to spend a lot of money on childcare.
- Discuss what your choice of career will mean with your partner – if they are not a surgeon they are unlikely to have any idea of the amount of extra work we put in. Be honest about your absenteeism – particular around exam times etc!
Advice for Academics
- If you are already at registrar level when you go off to do your PhD then you can better supplement your PhD salary by doing orthopaedic registrar locums at the same time.
- Under the current pay arrangements, if you maintain an NHS contract while you are out in research you will continue to accrue salary increment until you rejoin the scheme. This may well change under the new trainee contract depending on whether your out of programme time is considered to ‘benefit the NHS’.
- Although you can never know how many publications you will get form a PhD you can try to maximise your experience to different lab techniques which will stand you in good stead for future projects.
- Don’t start a project unless you think it has a realistic prospect of getting published or presented.
- Finish and write up the projects you start, don’t let your hard work go to waste!
Sharon Scott, Consultant Trauma & Orthopaedic Surgeon, Aintree
Perhaps it started with Quincy… even though all his patients were dead I loved that programme as a child, so from an early age I knew I wanted to be a doctor. I worked my way through senior school and got into Newcastle Medical School. From my early experiences of surgery I was interested in pursuing Plastic Surgery as a career. However once I actually tried it as a junior doctor in Liverpool I realised I didn’t enjoy it at all. Next up was trauma and orthopaedics and once that screwdriver was in my hand, I was completely sold. Passing the MRCS exam a little earlier than my peers allowed me to quickly move onto the orthopaedic registrar training programme in Mersey. By this time I was already married and I got pregnant a couple of years into my registrar training. Back then things were a bit different and I was the first person on the rotation to get pregnant during training. I was worried about upsetting the apple cart with the deanery so I tried to time my maternity leave within a whole 6 month job placement. This meant I went off a bit early when I was only 6 months pregnant and came back full-time when my child was 3 months old. In retrospect this was a bit too early to go back for me and I did things differently for my subsequent children.
I had my second child 2 years later, still as a registrar. This time I worked up until 37 weeks of pregnancy and went back when my child was 4.5 months old, which worked out much better for me in some ways but it was difficult to go back halfway through a job and settle in again. After about 20 weeks pregnancy I didn’t do on-calls anymore, more because my colleagues were worried about me than because I was bothered. I carried on doing cases with X-ray but I spent a bit of time learning how the C arm machine worked so that I could make sure I stood in the right place to minimise the amount of radiation I received, this meant standing behind the source and at a distance. Obviously I was wearing a lead skirt and tabard which gives 3 layers of lead over the pelvis. It also made me think more carefully about each X-ray I took and whether it was really necessary.
I came back full time and carried on with work, juggling home-life with two children and revision for the FRCS exam. Towards the end of my training I became interested in frames and limb reconstruction. I then went on fellowship to Nottingham to do major trauma with Prof Moran and realised that this was where my passion lied. Returning to the Mersey region after fellowship I finished by registrar training in 2005. At this time I separated from my first husband and got my first consultant job at Leighton Hospital in Crewe. Initially this was as a locum post in trauma and elective hip surgery which was later made permanent.
I was still very interested in major trauma and I was aware that the network of major trauma centres was starting to roll out across the country. I realised that these centres would be centred around hospitals with a neurosurgery service and for our region that meant Aintree Hospital was the most likely candidate. Aintree was looking for another trauma surgeon so I started to talk with the department about how I could work with them to develop their trauma service as a new consultant. By the time I attended for my interview I was 6 months pregnant with my third child, after getting married to one of my orthopaedic colleagues. Not only this but my baby was due the day after my appointment was due to start so I started my job on maternity leave which they covered with a locum consultant for 5 months. On my return I began negotiations with my colleagues in allied trauma specialities to develop our hospital into a major trauma centre. Over the years that followed we had a lot of hard work and complex negotiations to secure Aintree as the single MTC for the Mersey Region, accepting complex and life threatening injuries from all hospitals in the region. As we know from the national MTC data on patient survival and disability following serious trauma, this single centre approach can only be considered a good thing for patients. We opened our doors as an MTC when I was on maternity leave for my 4th child…
Initially my job at Aintree was a mixture of elective hip surgery and major trauma but more recently my clinical practice has gone over to pure major trauma. I am a specialist in Pelvis and Acetabular surgery which obviously means I spend a lot of my time fixing complex pelvic fractures. I have also trained myself (with some help from my cardiothoracic colleagues) to fix rib fractures for patients with flail chests. I love waking up in the morning and not knowing what operations and problems will be waiting for me at the hospital. In terms of my other responsibilities I was initially the Trauma Lead for Aintree but later I have taken on the role of Clinical Director for the Aintree Major Trauma Service. Last year I was highly commended in the Clinical Leadership awards run by the Health Service Journal for my work in the development of Aintree as an MTC.
I have always known I wanted children and I have ended up with 4. We live less than a mile from school so the oldest 2 can get themselves there and back. Our youngest is in a nursery which opens 7:30 – 6pm, these timings have meant I have always had to be open with my colleagues about my responsibilities to my children. We have managed without a nanny although I have certainly spent a lot on childcare over the years. Having children does change your perspective on work stress although sometimes it is a relief to go back to work for a rest!
My advice to trainees would be:
- You work to live, not the other way round.
- There is no good time to have children so it is always a good time! Don’t leave it too late to have children if that is what you want.
- Be interested, be passionate, enjoy what you do, take the opportunities you get to obtain the best experience you can during your training.