[Editor's Note: This is a guest post from a physician and a long-time reader who wishes to remain anonymous. We have no financial relationship.]
I'm a physician in an academic setting married to an artist. We had three children in three years: my first child at the end of residency, my second at the end of fellowship, and the third after being an attending for 18 months. They were all born in different cities and different hospitals/health systems with different insurance plans. My husband quit his job after our first was born partly because we were moving for my fellowship and partly to take care of our son. He has been staying home since then with our three kids under 5, which has been an amazing benefit for me and our family. We are frugal and generally follow the WCI ‘rules', [more like guidelines-ed] but have found that a female physician being the primary breadwinner and provider of health insurance has been surprisingly difficult and complicated. I wanted to give some tips to other women (and men!) who are trying to figure out the financial logistics of starting or expanding a family.
Pregnancy and childbirth are unpredictable processes, as we all know as physicians. This is irritating to people like me who would like to have a child exactly on a certain day to ensure the maximum amount of maternity leave, or who were asked not to work after 38 weeks due to difficulty possibly finding coverage but are then sitting at home losing money. I happened to have three very easy births around 39 weeks, but I fully realize how lucky I was. Anything can happen, and the more you know about the benefits in your state, hospital, and group, the better off you'll be.
# 1 The Family Medical Leave Act
The Family Medical Leave Act (FMLA) is a federal law that applies to people who have been working for at least 12 months in a business with 50 or more employees to take 12 weeks of family leave within a year of birth or adoption. All this law does is guarantee you that you will not lose your job. It is unpaid leave and does not apply to many smaller private practice groups.
# 2 Pregnancy timing
FMLA only applies to employees who have been in their positions for a year or more. This can be a huge issue for physicians, since female physicians in fellowship may only be in their positions for a year, or may get pregnant during their final year of residency, giving them less than a year at their jobs prior to having a child. In general, especially if you are supporting your family, having a child after you have been at a hospital or organization for a year is the safest way to make sure that you can actually take time off in excess of just your accrued vacation time, and possibly get some pay. Obviously, pregnancy is not always an event that can be timed with certainty, and you have to do whatever makes the most sense for your family.
Since some fellows are considered residents and others are considered attendings in terms of benefits (including leave time), this may also influence whether you can legally and financially take more than just your vacation or sick time. Crucially, it also determines whether you may be eligible for any paid parental leave, which, even at 60% pay for 8 weeks, is still a lot of money.
# 3 State benefits
Some states, notably California, New York, and New Jersey, provide some amount of paid family leave. DC, Hawaii, Rhode Island, and Washington state also have provisions for paid leave. Some others provide a little more unpaid leave. These all vary quite a bit, most are complicated, and all must be researched and applied for.
# 4 Save up vacation days
No matter what kind of benefits your employer offers, you will want to save up your vacation days if you get them. These can be used to prolong maternity leave either in a solid chunk to avoid taking an unpaid leave, or use them to make yourself functionally part-time (working three days a week for several months, for example, and using two vacation days per week). This can allow you to still receive full-time pay rather than half-time pay while still working fewer hours per week.
# 5 Save up money
You may have to be off work much longer than you expect if you have complications either before or after having your baby. If you are expecting to receive no pay if that happens, then you should have at least 3 months of an emergency fund (preferably above your usual emergency fund) if possible. You don't want to be worrying about paying your rent while you're hospitalized for pre-eclampsia.
# 6 Research electives
This applies mainly to residents and fellows, but many programs will allow you to do a research elective. I did these during both my residency and fellowship and worked on the projects several months ahead of time to help decrease the amount that I would need to do during my actual elective, which happened to be immediately after my 3 weeks of vacation ran out in each case. This allows you to get paid your full salary while having a comparatively low workload.
# 7 Health insurance
This really applies equally to men and women, but if you provide the health insurance for your family and have a pregnancy, delivery, or an infant during a gap in coverage, you should take advantage of the 60 days that COBRA gives you to elect coverage. I had my first child 8 weeks before the end of residency, and was able to get my son's vaccines and well-child check the day before my residency coverage ran out, and then had a 6 week gap until my fellowship health insurance began (they required all employees to work there for at least a month before being eligible for health insurance). My family was lucky and didn't require any medical visits or hospitalizations during that time and thus paid nothing for health insurance, but could have paid for COBRA if we had. This would have been a big financial strain, but better than paying out of pocket for time in the NICU.
They might look cute now, but someday they may be pregnant physicians!
# 8 You will make less money during maternity leave
You will probably not make the same amount as you usually do when you are on maternity leave, if you make anything at all. Some hospitals cover it with sick days plus short-term disability (which is generally at about 60% of salary pay), and others have a parental leave policy that is also often around 60% of pay. Many, of course, pay nothing. All these policies are generally time-limited and almost never as long as you would like them to be, and if you decide to take an extra month or more off it will most likely be unpaid.
# 9 You will make less money even before you have a baby
As a pregnant person, there is going to be less willingness to allow you to sign up for paid call coverage toward the end of your pregnancy, whether it is moonlighting or incentivized attending pay, due to the difficulty with covering these shifts if you go into labor. You may not feel like doing these anyway, but some women feel completely fine and would like the extra money to help pay for delivery and new baby costs. If this is a concern for you, you may need to take the extra calls earlier in your pregnancy to help make up for this.
# 10 You will probably make less for several months after you come back from maternity leave
In my job, 24h weekend calls are heavily incentivized, but I can't keep my milk supply up while I'm breastfeeding if I have to pump for 24h straight, so I don't do them. This seriously decreases my pay for about 6 months after going back to work.
# 11 Delivery costs
My delivery cost for my child was $75 during residency, $750 during fellowship, and $1700 as an attending. These had nothing to do with how complex my care was, and was solely dependent on what the coverage happened to be at the time. I was lucky that my coverage happened to be worst when my income was the highest, and it was really no big deal for us to cover it. A few years earlier, coming up with $1700 would have been a lot harder.
# 12 Private Practice vs Employee jobs
The WCI often extolls the virtues of private practice, many of which I agree with. And some private practice groups have employee-like benefits like paid vacation. But for those that don't, think carefully about how your pregnancy and maternity leave will affect your finances if you are in an “eat what you kill” group. A lower salary with better maternity leave and vacation may actually put you ahead financially if you have several kids. Of course, if you can make enough money in private practice and are diligent in saving, this shouldn't be a huge issue.
What do you think? How did your or your partner's pregnancy affect you financially? What “hacks” did you use to lessen the blow? Comment below!
1700 is cheap! Our first child cost us about $4,000. The second cost us around $14,000. (NICU Stays are expensive). If you are thinking of having kids and have good coverage in residency….from a purely economic standpoint my advice is have the kids then.
Thank you for your thoughtful post, very helpful information for both partners. One of the more important points is #7. Important to understand that you can wait to sign up for COBRA coverage so that you’re not out of pocket for unnecessary premiums during that 60-day gap.
If a person chooses to not sign up for COBRA, would the person be penalized for not maintaining health insurance coverage for 12 months on their taxes (whether it is an individual for whom they do not take out COBRA, or for a family)? What if a person doesn’t sign up for COBRA and then gets hospitalized in some sort of emergency before they sign up? Would it provide retroactive coverage for the first day of hospitalization?
Yes, it’s retroactive. If you don’t sign-up, I would think you would owe the penalty.
Actually, there is an exception to the ACA penalty for one gap of 2 months or less of coverage in a year. So no worries using the COBRA gap in terms of ACA penalties.
As WCI said, COBRA coverage is retroactive.
Under ObamaCare, you are allowed one gap which covers less than three months in a row without coverage each year. In other words you are exempt for two full months, but need to have coverage for at least one day of the third month. Any month in which you are covered at least one day counts as a covered month, so you could actually go almost 4 months w/o coverage and avoid the penalty.
Interesting. Thanks for pointing that out.
Just to reiterate, #7, invoke COBRA, can save you a lot of hassle and money if you are going from residency/fellowship to private practice, which can be like taking a cold shower (welcome to the real world of high deductibles). Kudos to the author and Whitecoat for this post. I think if we had read this years ago, and become aware of FMLA, we would have used the full twelve weeks on at least one of our three.
#13 Retain a good lawyer
A friend notified her job that she was pregnant. The group posted an ad for her job 2 weeks later. A week after giving birth they notified her that her contract would not be renewed. Getting pregnant is risky.
I can relate. I’m also a female professional sole breadwinner. Years ago, I was fired 3 weeks after returning from maternity leave. And I’m a lawyer! The firm had a history of firing women associates who had children (I was at least the third that happened to, but, the firm had a history of firing many of their associates, pregnant or no, so it would have been relatively hard to prove that the firing was related to pregnancy/motherhood). Unfortunately, this type of thing is actually quite common in law. I was able to start working at another law firm right away. This forum is likely not the place to debate this, but essentially, the world is VERY stacked against women professionals who wish to have children. I believe the medical profession might be better than most, but in a more business-related profession you are really taking your chances to start a family.
The more I hear stories like this the more I like being self-employed.
My take on it now is that for women are trying to move into male-dominated professions, it is difficult for the “work model” to change to accommodate them. It seems to me that traditionally female-dominated professions are more forgiving of people moving in and out of the workforce. On the other hand, for a lawyer, once they make the move to stay home for a few years, it is very rare for them to be going back, at least not in a high-level type position. They’ll have to compete with the next class of up and comers graduating from law school, who are younger and don’t have a demonstrated history of putting their job second. We all know there are too many lawyers! This may be true of doc’s as well: I don’t know of too many female doctors who were out of the workforce for a few years after their kids were born, they all seem to continue working. On the other hand, I have a few women friends who are nurses, and after a substantial period of time out of the workforce, it seems that it was relatively straightforward for them to get back in. I guess the moral of the story, and related to the title of this post, is that one of the financial considerations of pregnancy should perhaps include consideration of the impact on one’s chosen career and what steps need to be taken to ensure a return to that career. Assume that it will be difficult. And I can’t really blame the working world for this. It’s a headache and difficult for small business owners to deal with this issue.
If eligible fund your HSA! Additionally realize you will hit your out of pocket maximum, so take advantage of any other services you may need throughout the year.
Short term disability could also be a consideration. We bought a contract with AFLAC after our first child but before we were pregnant with second. You need to plan ahead when buying this policy, since there is a lag in the coverage for pregnancy (I think 6-months, which means that AFLAC got 15-months of premium before the birth). We came out ahead and then cancelled the policy (I guess this is a form of free riding).
My wife was also able to talk her practice into offering paid leave after the first child. So, if you work for a moderately large practice that doesn’t have paid maternity leave, don’t be afraid to ask (it can reduce employee turn-over).
Husbands who take FMLA may consider working part-time (I worked Monday-Wednesday-Friday, home on Tuesday Thursday) so that health insurance, short-term disability, long-term disability etc can still be deducted from a paycheck. Otherwise, you need to mail a check to your employer.
Finally, don’t forget to take a vacation with the kid(s) before maternity leave ends. We arranged a vacation with extended family to the Outer Banks – which provided mom with some beauty before heading back to work. Flying with a nearly 3-month old isn’t too bad and you will rarely have another opportunity to take more than 5-consecutive days off when you go back to work.
I was pregnant when interviewing for residency and wanted a few months at home with the little guy, so I was able to find a program (actually several programs) that were willing to let me start residency October 1 instead of July 1. Of course this meant that I had to make up three extra months at the end of residency, but it was worth it, I would not have traded those five months at home with baby for anything. Fortunately, in Family Medicine, the programs I was looking at were used to residents with families and were willing to let me stay home for a bit before starting. I am sure there are specialties in which this would not be allowed. For Baby#2, I had told them when I took my first job that another baby would eventually be on the way and I wanted four months of maternity leave. They were uncomfortable writing “maternity leave” into my contract so they called it “leave for medical purposes” or something vague like that and guaranteed my four months in writing years before Baby#2 arrived. With first baby, we lived on next to nothing and even had to use credit cards a few times to make ends meet. With second baby, I picked up extra hours early in the pregnancy and built up a cushion in our bank account to live off of while I was not working. I worked until one week before my due date and she arrived four days after her due date. I also was able to collect state disability/maternity leave payments for a certain number of weeks (six, I recall?), much less than a salary but it all helped!
Consider future child care options when planning a pregnancy (if you can), after med school we moved to a state where we had no family and this made things a bit more challenging. I was able to find a home day care to put him in for the first year and he actually spent nights at that home when both husband and I were on call in the hospital overnight. After internship year he started at a traditional day care center, but I remember having trouble finding one that opened early enough for a 7 a.m. drop off so I could get to the hospital at 7:30 a.m. and also a late enough pick up time for those days when I got stuck in the clinic. Also, child care is expensive! Fully half of one of our salaries during residency went toward paying for day care.
I chose erratic work hours after residency so I could have some weekdays at home with both kids, I worked evenings and weekend days so I could be home on some weekdays until the first one hit Kindergarten age, then went back to full time until the second one came along, then worked the same part time schedule until the second one hit Kindergarten. When you look at my Social Security annual earnings statement, you can see when my kids were born because there is an enormous drop in salary in the few years thereafter! In retrospect, may not have been the best financial decision, because it enormously effected my ability to pay down student loan debt/save for retirement, but it was right for me at the time so I can’t regret it. They’re only small once!
Reminds of a “side job” my wife took shortly after she started staying home with our eldest when I was a PGY2 or 3. One of my co-residents had a baby. His wife was an ICU nurse at the time so they occasionally had a time when neither could be with the baby but they were evenings, nights, weekends, holidays etc. So my wife watched the child for pay. Win-win. Just finding someone who can watch a child if you work weird hours can be very tricky.
How do you guys manage a kid or two during residency and fellowship? I hardly could keep my head out of water with all the work, calls and studying for exams.
How can one come home and study when there are kids to take care of…
Something that come up related to this post is that certain boards are strict about months of certain experience during residency and sometimes people have to complete additional time to qualify for boards if they have >1 child during residency and/or there are complications with a pregnancy. I just wanted to put this out there as another thing to consider because I have heard of this being an issue.
Great post! I had one baby during residency. I showed up to my first job 15 weeks pregnant with #2. My job was actually really great about it – I’m a hospital employee, and we purposely saved our sign-on bonus to use for maternity leave. I took 12 weeks with the second baby – 6 weeks disability (came to <2/3 pay) and 6 weeks unpaid. It was rough just trying to keep up. The third baby I was the sole bread winner (and it was only 13 months after the second baby) so my maternity leave was only 8 weeks. This will be my first year working all 12 months on attending salary and we're just now catching up. I had a similar experience with the residency baby being a lot cheaper (despite NICU stay and longer hospitalization for me) which shows a trend toward much better health care plans for residents than for attendings and I agree that this might be the best time to have a baby (don't tell program directors!)
We just assume that every time we hire a female doc or APC that she will have 1-2 babies in the next 5 years. Maybe it’s because we’re in Utah, but that assumption is probably right 90% of the time.
My residency baby was $10. Not quite the $0 of the two we had in the military, but way better than the $5K the 4th one cost.
Great post! I had my first child in med school (end of 3rd year) and spent the whole pregnancy fighting with administration to allow me to take a year off after I had him. I figured if classmates could take a year to “find themselves” and bartend, surely I could stay at home and take care of my son. This was very important to me and I was honestly willing to quit med school if they were going to make me go back after 4-6 weeks. Luckily, it all worked out and my alma mater now has a policy in place that allows any med student in good standing to take a full year off after having a child. While that year was incredibly difficult, I am so thankful to have had that time. 8 years later, I’ll be having my second child in October as an attending. I’m an outpatient doc so I’m trying to balance my needs, with the baby’s, with my patients. I’d love to take another year off, but I love my job and don’t want to abandon my patients. So I’ll do the 3 months of maternity leave (employee at at academic medical institution,6 weeks is paid, the other 6 weeks will be paid via sick/vacation time) and then I’m scaling back from 0.75FTE to 0.25FTE for a year or so. Then I’ll scale back to 0.75FTE over another 1-2 years. I guess I’m technically the “breadwinner”, but because I only work part time, I only make about 40% more than my husband. We’ve got all debt outside of mortgage paid off and we specifically picked a house that we could afford even if I wasn’t working so we’re financially set to make this transition work. That’s one of the benefits of following the WCI guidelines-it allows you to pick your work schedule based on what works for you, not based on what bills you owe.
Being a mother/wife is full time job. Being a physician full time job. Pick one a do it right.
[I disagree and think your comments are sexist. Remainder of comment removed as it consists primarily of an ad hominem attack.]
I don’t know. I think we all have time for two full-time jobs. If being a father/husband is a full-time job, then I’ve got three.
By this defination a physician should not have kids.. Hmmmm
It is disheartening as a woman doctor to read comments like yours. I am not sure why I am entertaining a trolling comment, but I will…
One of the great things about WCI is that the site helps families evaluate whether two parents working makes financial sense and then the family can also evaluate how it fits with their own personal values. I am a doctor married to a doctor, so when we have children we will both continue to work because it fits with our value system. We both find professional joy from the work.
I am assuming by your comment that you are a doctor married to a stay at home mom. So let me ask you, if your wife died while your children were small would you quit your job to parent them? Or would you hire out the help?
First kid as military staff doc, 6 weeks maternity leave no paternity leave, worst thing was I’d saved up 4 weeks other leave to ride out the full 10 weeks from birth to PCS to Germany at home with baby but the department refused, saying it’d harm patient continuity ?!?!? They’d lost an intern 2 years earlier to PPD so probably they meant ensuring I didn’t get used to staying at home by demanding I get back to work at 6 weeks. Even worse- and probably illegal- they asked I come in to work call on maternity leave while most of them were at the residency retreat (which my husband was attending, so also no parent at night with newborn!) and the doctor requesting it said “it isn’t as if you’re actually sick!” In summary I suffered from a bunch of male docs whose wives’ maternity leave was permanent, and who clearly have no concept of the purpose of maternity leave.
Which might be why- aside from moving twice that year for husband’s military schooling- I was on sabbatical from 6th month pregnancy until baby 10 months old for second child. And even part of why I ETSed the Army.
Another caveat for military moms: the Army was fully ready to send me and my husband to our new assignment in Germany, but the 4 month old baby was not allowed to travel with us except we demanded a work around (baby had to be sponsored by someone already there who basicly promised the baby could live in their house- of course it stayed in our temporary quarters with us!). Might be a good idea for one soldier to go and get housing before Mom (usually) travels over with the rest of the kids, but a nonstarter for me as a breastfeeding mom and not pleasant for anyone to find out about a few days prior to travelling if both parents are going overseas.
Following WCI ideas we came up with before reading his fine website, we had started banking most of one of our salaries when both working, in preparation for one of us staying home with the kids when we could or when we had to (like when he was stationed in UK and it took me a year to get permission to work there). So that financial cushion let us not worry about money during the maternity leaves and husband’s military move related work gaps for me.
This is a timely post about pregnancy and the financial consideration along with it. I think it is a great piece, definitely something to really think about for all individuals considering becoming parents.
I am a female physician running own solo practice, working anywhere between part time to 3/4 full time, I completely agree with everything the writer wrote. I was a young employed attending when I had my kid, and due to changes in life (husband wanted to continue climbing his career ladder in a different way), we relocated immediately after my kid’s birth to somewhere with no family or friends. I was on COBRA for about 2 months before kid was born (we both quit our positions for the move), but luckily for us, we lived below our means and were able to save up a cushion. So even with the new addition, no help, relocation and change in partner’s career trajectory (which also initially meant a decrease in his income too), we were able to live off our savings for a good 18 months (how long I stayed at home with kiddo until I went back to work at super part time status and before we saw a profit from my partner’s new ventures). We are not kids of resources where our parents financially assist us, but we have student loans only and our own life expenses, so we were able to make it work. I regret not one iota of taking the time off and I think the time off allowed me to be the kind of mother I imagined and expected of myself.
As an obgyn and fellow working mom, I see many patients or working moms trying to be everything to their kid(s) and trying to give it all to their career. Sometimes, it works out well but a lot of times, it doesn’t. It is also disheartening to see the amount of burn out these moms/ working professional experience when they are trying to be both. Of course, the fancy stuff and keeping up with the Joneses don’t help. I personally feel like, at times nowadays, even kids are a commodity in some households – they don’t really want them, but the social norm is to have 2-3, or a boy and a girl and therefore, keep having they must. But that’s a completely separate issue regarding children and its financial considerations, likely best address at another time/ post.
I do disagree with an above comment about just picking one (either be a mom or be a physician), as that is just not realistic, nor consistent with the ideals of this great country. Tho, I think that every individual should be realistic about his/her ability to juggle it all. Being a parent is hard, kids don’t come with manuals and there are a lot of unexpected cost or time commitment, either good or bad. I think its important that as adults, one should have realistic expectation about having kids, be it just one or twenty and be accepting of the short comings associated with it. Also, I think it important for young working professionals to be accepting of the fact that their career will have to adjust to their child bearing decision. We must commit to our children and they deserve our due diligence in raising them until they are able to fence for themselves. To me that might mean that in my late 20s-early 40s, I don’t reach “the pinnacle” of my career or make whatever goal income JUST YET. I don’t think that’s being lazy or settling professionally, but just being able to understand my limits right now and not automatically expecting others to help me.
I always say to myself and anyone asking: who knows, once my kid is independent and can do without my current degree of hands on involvement, I might go back to full time work with a vengeance and make up for lost time. Higher powers willing and hoping to hit FI at a reasonable age, I look forward to contributing to society for a long time, not because I have to, but because I have many personal goals that I am spreading out to accomplish over my lifetime.
I want to live good productive life, up to the end.
Thanks for tolerating this long comment.
I am also an Ob/gyn. It is hard if not impossible to have it all. I married late in life and decided against having a child As a solo parent in my 30s. I have seen a few people over the years who pulled off single parenthood but I decided I could not do it. I see a lot of frazzled female docs and lawyers. I think having a child, how many, and work arrangements are very personalized. There is not a one size fits all solution. As medicine has evolved into larger group practices with more women these decisions will become easier but not easy. Many female obs that I know are back at work in 3-4 weeks. My college roommate was trying cases within one week of delivery. Is this good for the kids? I guess time will answer that one.
My wife and I had 2 kids during residency, and one once I became an attending. We were co-breadwinners during residency as she was making almost the same as I did working as a PRN NICU nurse. An additional issue we ran into at the time was trying to get life insurance for my wife once she was pregnant. Some insurance companies flat out refused to issue a policy and the one’s that were willing to entertain issuing a policy offered crazy rates. My wife at the time was 27, totally healthy (other than the growth in her uterus) and we were getting quotes for a 20y 1Mil term policy for $2000/y. (my premium for a 30y 1 Mil policy costs me $750/y) Most companies told us to call back after she delivered. I recognize that the most apparent life threatening event facing an otherwise healthy 20-some yo women is death from pregnancy, but I couldn’t believe the risk warranted such a significant increase in premium over the life of the policy. I told her it might be cheaper for her to start smoking while sky diving after delivering and we could reapply.
Anyway, just something to think about for the single mothers or primary breadwinners out there.
My wife who is a pediatrician had 4 children all as an attending. 6 weeks for the first but increased it to 6 months by the final one. This was over a span of 5.5 years and she had the first at 38 as we were the usual late starters. We were lucky to have a wonderful nanny who was not live in. My wife has managed to stay engaged in teaching and administrative roles at the university but has likely been less busy as a clinician than she would have been if she had not had any children or not had the luxury of a spouse in a busy practice in a relatively high paying specialty. As time went by and it was clear that money wasn’t really an issue it was possible for her to chose the roles she liked and spend more time as a mom. The same was true for me in terms of time and being able to be decent dad.