Balancing specialist training and parenting is challenging, but it is increasingly common and increasingly supported. Many doctors complete specialist training while raising children. This article aims to outline practical advice, parental leave entitlements, and training considerations for doctors in specialist training in Victoria, with a focus on anaesthesia but relevant to all specialties.

Reference document

https://amavic.com.au/insights/resources/current-enterprise-agreement-for-doctors-in-training

Parenting and Specialist Training: The Big Picture

There is never a perfect time to have a child during medical training. Training programs are long, exams are stressful, and rosters are unpredictable. However, many trainees successfully navigate training and parenting with planning, support, and knowledge of their entitlements.

A key concept to understand is that you have two separate systems to manage

1. Your employment (covered by the Enterprise Agreement)
2. Your training program (e.g. ANZCA interrupted training)

These operate separately and both need to be organised early.

When Is the “Best Time” During Anaesthetic Training?

This is highly personal, but common considerations include

Introductory Training

Often the most difficult time due to

• Must be a continuous 6 month period as per ANZCA
• No control over rosters
• Learning new systems and skillset
• Limited flexibility

Many trainees find this the hardest time to have a newborn.

Basic Training

More manageable for some trainees, but must consider

• Primary exam timing
• Study demands
• Rotations

A ‘good’ time can be post primary exam as study pressure is off and you are feeling more comfortable in your registrar role.

Advanced Training / Provisional Fellowship

Often easier because

• More seniority, it can be easier to regain skills.
• Exams potentially completed
• Greater flexibility for part-time work

There is no perfect time! All stages of training have both advantages and disadvantages. But hopefully with the right planning and support you can have a child when it’s right for you. 

Your Rights: Parental Leave (Victoria Doctors in Training Agreement)

The Doctors in Training Enterprise Agreement 2022–2026 contains extensive parental leave provisions.

Key Requirement

To qualify for paid parental leave you must have

• 6 months continuous service within the public health service.

This is extremely important when planning rotations or contracts.

Types of Leave Available

1. Paid Parental Leave

Under the Enterprise Agreement:

Primary Carer

• 14 weeks paid parental leave, or
• 28 weeks at half pay

Non-Primary Carer

• 2 weeks paid parental leave

This is in addition to any Commonwealth Government Paid Parental Leave.

Paid leave can also be

• Spread over a longer period 
• Taken concurrently with government leave
• Paid in different arrangements by agreement with employer

2. Long Parental Leave (Unpaid)

• Up to 12 months unpaid parental leave
• Must be taken as one continuous period
• Can request extension to 24 months total leave

3. Short Parental Leave

• Up to 8 weeks unpaid
• Typically used by non-primary carers
• Usually taken in blocks of ≥ 2 weeks

4. Flexible Parental Leave

A newer provision:

• Up to 30 days of long parental leave can be taken flexibly within 24 months of birth.

This can be very useful for

• Settling childcare
• Exam preparation
• Transition back to work

5. Paid Parental Leave Pooling

If both parents are doctors in Victorian public hospitals, paid parental leave can be pooled between them.

This allows families to distribute leave more flexibly.

Important Administrative Requirements

You must

• Provide at least 10 weeks written notice of parental leave
• Notify 4 weeks prior confirm intended commencement date and end date 
• Provide required documentation/statutory declaration
• Apply for Interrupted Training with your specialist college if leave > 12 weeks

Failure to organise this early can cause significant training delays.

Pregnancy at Work (Anaesthesia-Specific Considerations)

Anaesthesia has some unique pregnancy challenges

• Lead gowns (pelvic/back strain)
• Radiation exposure (interventional radiology)
• Long theatre cases
• Epidural lists while heavily pregnant
• Inability to leave theatre when nauseated
• Night shifts and fatigue

Having a chat to the person in charge of rosters is pretty important to help with the complex organisation required. 

Many hospitals require a medical certificate confirming fitness to work after ~34 weeks.

Trainees often stop nights, on-call and heavy theatre lists earlier.

In any case, letting your supervisor know as early as possible is generally good practice. 

Interrupted Training (Specialist College)

For anaesthetic trainees (ANZCA)

• Leave >12 weeks requires Interrupted Training
• Maximum interrupted training is typically 104 weeks
• Training resumes on return to work

This is separate from employment leave entitlements.

Returning to Work After Parental Leave

Returning to work is often harder than expected.

Important supports include

• Keeping in touch days (up to 10 days)
• Breastfeeding/pumping facilities and allocated breaks
• Graduated return, staging of supervision
• Part-time work arrangements
• Re-entry to practice plans (for some colleges)

Many trainees report

• First 2 weeks very difficult
• Improves significantly after 3–4 weeks
• Easier with subsequent children

Practical Survival Tips From Trainee Parents

Common advice from parents in training

Organisation

• Multiple shared electronic calendars
• Schedule childcare pickups
• Share schedules with partner and carers
• Plan study time early

Outsource Where Possible

• Grocery delivery
• Cleaner
• Laundry
• Childcare even when not working (for study/rest)

Backup Childcare Is Essential

Sick child + on-call = major stress without backup care.

Learn to Say No

You cannot

• Do every research project
• Attend every meeting
• Volunteer for every extra list
• Be perfect at work and home simultaneously

Studying for Exams With Children

Universal rule: Children will always find you when you try to study.

Strategies

• Early morning study or study post bedtime.
• Study at work, library not registrar room!
• Use childcare days for study
• Accept slower progress
• Study groups
• Online lectures/podcasts – listen whilst driving to work, folding washing, taking your child for a walk in the pram.
• Stay at the hotel at the exam location to allow full mental focus on the exam in the days leading up. This allows good sleep/rest and any last minute study/rote learning that needs to occur e.g. drawing out blocks. This should be guilt free as optimising your exam attempt will return you to your family!

Mental Health and Support

Parenting and specialist training is stressful and burnout can happen.

Helpful supports include:

• Other trainee parents
• Supervisors of training
• GP mental health care plan
• Perinatal mental health services
• Raising Children Network raisingchildren.net.au 
• Perinatal Anxiety and Depression Australia www.panda.org.au
• Beyond Blue https://www.beyondblue.org.au/ 
• College wellbeing services

Seeking help early is important and common!

Final Advice for Trainee Parents

If there is one takeaway message

You can complete specialist training and have a family. Many people do.
But it requires planning, flexibility, support, and knowing your entitlements.

Key advice

1. Read the Enterprise Agreement
2. Plan parental leave early
3. Talk to your supervisor early/roster consultant
4. Arrange interrupted training early
5. Organise childcare early. Plan and communicate your week of work/parenting then run the game-plan to reduce day-to-day stress and mental load. 
6. Accept that some years will be survival mode
7. Build a support network
8. Be kind to yourself

Most importantly — there is no perfect time to have children during training, but there are many ways to make it work. 

A 45-year-old anaesthetist was found dead in the doctor’s room of his hospital after being on call the night before. An empty syringe was found next to him, and the toxicological analysis detected the presence of laudanosine (a metabolite of atracurium) both in the syringe and in samples collected from his body. The anaesthetist was on venlafaxine for depression. Based on the results of the autopsy, case history, and toxicology, the forensic pathologist ruled that the cause of death was an overdose of atracurium, and the manner of death was suicide [1].

The findings of this case report are not isolated, but part of a wider body of evidence suggesting that anaesthetists might be at increased risk of suicide when compared both to the general population and to doctors working in other specialties. However, data on this topic are often historical, and many studies report contradictory results. So, what does the latest evidence tell us about the incidence of suicide amongst anaesthetists and which could be the main reasons for the increased susceptibility?

Firstly, it is important to note that a recent meta-analysis has shown that physicians in general are more prone to suicide when compared to the general population, even though all-cause mortality is lower amongst medical practitioners [2]. The Standardised Mortality Rate (SMR i.e., the ratio of the mortality rate of the exposed cohort to the mortality rate of an unexposed control group) for physicians was 1.44 (95%CI 1.16, 1.72), with higher risk reported for female doctors (opposite to the general population) and for those practicing in the US [3].

According to the same meta-analysis, some specialties are at higher risk of suicide [3], and these include Anaesthesia, GP, Psychiatry and General Surgery. When interpreting these data, however, it should be noted that these analyses are prone to bias due to the different number of physicians within each specialty (with Anaesthetists usually representing the largest group of consultants in the hospital and GP being the most represented specialty of all). Furthermore, the studies included in this meta-analysis are all retrospective and based on health registries or self-report questionnaire [3], which rank very low in the hierarchy of evidence for clinical research.

The conversation on potentially elevated suicide rates in anaesthesia started way before the results of this meta-analysis. The first few studies on this topic were published in the ‘60s and ‘70s and reported inconclusive and contradictory results [4], [5]. The latest review addressing suicide rates specifically in Anaesthesia was published in 2021 and reported findings from 54 studies conducted after 1990 [6]. Seven studies included epidemiological data, three of which showed an increase age adjusted SMR for female anaesthesiologists but not for their male counterpart. The more recent papers included in this analysis, with data from Finland and the Netherlands, reported the proportions of anaesthetists’ deaths that were due to suicide, which ranged from 7.2% to 17%, and were noted to be higher than the proportions historically observed in the general population (which is around 2–4%) [7], [8], [9]. The largest study included in this meta-analysis comes from the US, and it analysed the causes of death of more than 40 000 anaesthetists between 1979 and 1995. The main findings are a Rate Ratio (RR) for suicide of 1.45 (95% CI 1.07-1.97, P = 0.016) when comparing anaesthetists to internists, and an even higher RR of drug-related suicide (RR 2.21,95% CI 1.33-3.66, P=0.002). As observed in the general population, suicide rates were shown to increase over time after graduation from medical school [10].

Heavy workload, unpredictable hours, having to deal with life-or-death situations, and ease of access to potentially lethal medications are the most common reasons presented to explain increase suicide rates among doctors in general [3]. Furthermore, certain personality traits common amongst physician (such as conscientiousness, commitment, and perfectionism) may contribute to this phenomenon [11], [12]. Data from the studies presented so far suggest that ease of access to potentially lethal medications might represent the main cause of the particularly elevated risk of suicide among anaesthetists. Plunkett et al. reviewed five studies with data coming from Germany, the UK, Australia, Japan, and China, which found a correlation between mode of death and specialty [6]. In particular, the Odds Ratio (OR) for overdose with an anaesthetic drug for anaesthetists was 21.30 (95%CI 6.47–72.77) when compared to doctors of other specialties [13]. The Japanese study reported that 80% of suicides amongst Japanese anaesthetists occur by poisoning, whereas this modality accounts for only 5% of suicides in the general population [14]. These results are in keeping with those included in the study by Alexander et al., which reported a RR of 2.21 for drug-related suicide among anaesthesiologists, and another study which demonstrated that half of all suicide deaths in Anaesthesia results from anaesthetic agents [13]. Furthermore, twelve case reports of suicide or suicidal attempts of fourteen Anaesthesia providers were included in the study by Dutheil et al., all of which involved IV injection of drugs commonly (and even exclusively) used in Anaesthesia. The drugs most commonly featured in these case reports are neuromuscular blocking agents and drugs used for induction, with another study reporting data from autopsies performed in Germany, Austria and Switzerland that confirmed a central role of propofol in suspected suicide cases amongst personnel working in Anaesthesia [15]. Lastly, the study by Hawton et al. added barbiturates, opioids, and the combination of paracetamol with dextropropoxyphene to the list of drugs most used for suicidal purposes.

In summary, the latest evidence supports the hypothesis that anaesthetists might be at increased risk of suicide, even though most of the studies on this topic were conducted decades ago and suffer from many methodological limitations. What seems to emerge more clearly from the data, though, is that the main reason underpinning the excess of suicides seems to be ease of access to potentially lethal medications, which are routinely used in Anaesthesia.

On a more hopeful note, over the last few years there has been a marked increase in resources available to tackle mental health issues, and the UK Association of Anaesthetists produced a guidance specifically aimed at anaesthesia departments and health care workers regarding suicide prevention and how to deal with the death of a colleague [16]. The main recommendations included in this document are:

• improving the recording and reporting of suicide as a cause of death amongst doctors,

• identifying an individual in each anaesthetic department with a lead role in supporting the mental health of the staff,

• providing ongoing education within departments and organisations about suicide,

• early involvement of specialist medical input (GP, psychiatry, occupational health) where appropriate,

• the creation of a ”safety plan” for high-risk individuals and a plan for staff-related crisis (including suicide) [16].

Where available, these recommendations are based on evidence, but for the most part they are the result of expert opinion and current “best” practice [16]. The presence of guidelines from such a respected organisation is for sure a good starting point to raise awareness on the issue of suicide amongst anaesthetists, but more studies will need to be conducted in the next few years to understand the impact of these recommendations on suicide rates and modalities amongst anaesthesia professionals.

References:

[1] M. A. Martinez, S. Ballesteros, and E. Almarza, ‘Anesthesiologist Suicide with Atracurium’, J. Anal. Toxicol., vol. 30, no. 2, pp. 120–124, Mar. 2006, doi: 10.1093/jat/30.2.120.

[2] S. P. Swanson, L. J. Roberts, and M. D. Chapman, ‘Are Anaesthetists Prone to Suicide? A Review of Rates and Risk Factors’, Anaesth. Intensive Care, vol. 31, no. 4, pp. 434–445, Aug. 2003, doi: 10.1177/0310057X0303100413.

[3] F. Dutheil et al., ‘Suicide among physicians and health-care workers: A systematic review and meta-analysis’, PLOS ONE, vol. 14, no. 12, p. e0226361, Dec. 2019, doi: 10.1371/journal.pone.0226361.

[4] H. A. Neil, J. G. Fairer, M. P. Coleman, A. Thurston, and M. P. Vessey, ‘Mortality among male anaesthetists in the United Kingdom, 1957-83.’, BMJ, vol. 295, no. 6594, pp. 360–362, Aug. 1987, doi: 10.1136/bmj.295.6594.360.

[5] D. L. Bruce, K. A. Eide, N. J. Smith, F. Seltzer, and M. H. M. Dykes, ‘A Prospective Survey of Anesthesiologist Mortality, 1967–1971’, Anesthesiology, vol. 41, no. 1, pp. 71–74, Jul. 1974, doi: 10.1097/00000542-197407000-00017.

[6] E. Plunkett, A. Costello, S. M. Yentis, and K. Hawton, ‘Suicide in anaesthetists: a systematic review’, Anaesthesia, vol. 76, no. 10, pp. 1392–1403, Oct. 2021, doi: 10.1111/anae.15514.

[7] P. Ohtonen and S. Alahuhta, ‘Mortality among Finnish anesthesiologists from 1984-2000: Mortality among Finnish anesthesiologists’, Acta Anaesthesiol. Scand., vol. 46, no. 10, pp. 1196–1199, Nov. 2002, doi: 10.1034/j.1399-6576.2002.461004.x.

[8] P. Ohtonen and S. Alahuhta, ‘Mortality rates for Finnish anaesthesiologists and paediatricians are lower than those for the general population’, Acta Anaesthesiol. Scand., vol. 61, no. 8, pp. 880–884, Sep. 2017, doi: 10.1111/aas.12936.

[9] M. Liem, L. Liem, E. P. A. van Dongen, I. C. Carels, M. van Egmond, and A. J. F. M. Kerkhof, ‘Suicide Mortality, Suicidal Ideation and Psychological Problems inDutch Anaesthesiologists’, Suicide Mortal. Suicidal Ideation Psychol. Probl. InDutch Anaesthesiol., vol. 6, no. Suicidology Online 2015, [Online]. Available: https://hdl.handle.net/1887/46948

[10] B. H. Alexander, H. Checkoway, S. I. Nagahama, and K. B. Domino, ‘Cause-specific Mortality Risks of Anesthesiologists’, Anesthesiology, vol. 93, no. 4, pp. 922–930, Oct. 2000, doi: 10.1097/00000542-200010000-00008.

[11] B. Bressler, ‘Suicide and drug abuse in the medical community’, Suicide Life. Threat. Behav., vol. 6, no. 3, pp. 169–178, 1976.

[12] G. D. Carr, ‘Physician suicide–a problem for our time’, J. Miss. State Med. Assoc., vol. 49, no. 10, pp. 308–312, Oct. 2008.

[13] K. Hawton, ‘Doctors who kill themselves: a study of the methods used for suicide’, QJM, vol. 93, no. 6, pp. 351–357, Jun. 2000, doi: 10.1093/qjmed/93.6.351.

[14] W. Hikiji and T. Fukunaga, ‘Suicide of physicians in the special wards of Tokyo Metropolitan area’, J. Forensic Leg. Med., vol. 22, pp. 37–40, Feb. 2014, doi: 10.1016/j.jflm.2013.12.022.

[15] C. Maier, J. Iwunna, M. Tsokos, and F. Mußhoff, ‘Todesfälle durch Propofolmissbrauch: Befragung in rechtsmedizinischen Instituten in Deutschland, Österreich und der Schweiz’, Anaesthesist, vol. 66, no. 2, pp. 109–114, Feb. 2017, doi: 10.1007/s00101-016-0260-6.

[16] Shinde, S., Yentis, S. M., Asanati, K., Coetzee, R. H., Cole‐King, A., Gerada, C., … & Rowland, A. (2020). Guidelines on suicide amongst anaesthetists 2019. Anaesthesia, 75(1), 96-108.