[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.]

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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!