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IMPACT survey: IMpaired fecundity in Physicians and Association with Clinical Time

Abstract Objective Studies suggest female physicians experience higher rates of infertility than the general population. The overall objective of this study was to determine the rate of impaired fecundity in a sample of female emergency physicians and compare it to the Centers for Disease Control and Prevention (CDC) National Survey of Family Growth (NSFG) data. Impaired fecundity is defined as physical difficulty in getting pregnant or carrying a pregnancy to live birth. Methods We performed a cross‐sectional survey of female emergency physicians to determine the rate of impaired fecundity. Survey questions were adapted from the NSFG to allow comparison to the general population. Statistical comparisons were made using contingency tables (with chi‐square and tau‐c assessments), 1‐sample t tests, and independent samples t tests, as appropriate. Results A total of 2072 women completed the survey with a mean (SD) current age of 38.9 (7.2) years. Data were analyzed for women of childbearing years (15–44 years old as defined by the CDC; n = 1705 [82% total responses]). The rate of impaired fecundity in emergency physicians was 24.9% as compared to the NSFG cohort (12.1%; P < 0.001). Female emergency physicians with impaired fecundity reported working 9.8 overall more clinical hours (95% CI 2.5–17) and 4.5 more night hours (95% CI 0.8–8.2) than those with normal fecundity. Conclusion Female emergency physicians have increased rates of impaired fecundity when compared with a general population cohort. Clinical workload and night shifts are greater in female emergency physicians with impaired fecundity. Research is needed to elucidate work‐related impaired fecundity risk factors.


Background
The number of women in medicine has grown significantly. A 2017 Association of American Medical Colleges (AAMC) survey of accredited medical schools revealed that over half of matriculants were women. 1 In emergency medicine women now comprise 35% of applicants to emergency medicine residency programs 2 and 28% of the active workforce. 3 Women who obtain advanced degrees have an increased risk of involuntary childlessness related to delayed childbearing. 4 In a study including all specialties, female physicians were diagnosed with infertility at a rate over twice the national average (24.1% vs 10.9%). 5 Female physicians in procedure-oriented specialties may experience a higher rate of infertility than the general population. 4−7

Importance
Rates of infertility in women practicing emergency medicine are unknown. This knowledge gap limits the ability of advisors and medical specialty boards to support female physicians planning a career in emergency medicine. Female doctors who face difficulties in the field of reproduction are potentially more likely to experience burnout. 8 Concern about pregnancy and childbearing may affect medical students' decisions on careers. Healthcare leadership needs accurate data to be able to counsel female medical students, residents, and faculty appropriately on potential infertility risks.

Goals of this investigation
This study examines the rate of impaired fecundity in a sample of female emergency physicians and compares this rate to a national database (2011-2015 Centers for Disease Control and Prevention's [CDC] National Survey of Family Growth [NSFG]). 9 Impaired fecundity is defined as physical difficulty in either getting pregnant or carrying a pregnancy to live birth. 10 We also aimed to describe some emergency medicine work-related characteristics that may affect impaired fecundity. We hypothesized that women in emergency medicine would have higher rates of impaired fecundity when compared to the general population. To our knowledge, this is the first study to evaluate impaired fecundity in emergency physicians and is the largest survey of practicing women physicians related to reproductive health.

Study design and participants
We performed a cross-sectional survey of women in emergency medicine to determine the rate of impaired fecundity and compared

The Bottom Line
In this cross-sectional survey of 1705 female emergency physicians, impaired fecundity was found in 24.9% of respondents compared to a national cohort sample (12.1%; it to the national 2011-2015 CDC NSGF database. 9  After the initial draft survey was completed, we took the following steps to provide validity evidence for the survey questions and design. First, subject matter experts in reproductive medicine reviewed the survey and provided input. Second, we pilot tested survey items for readability and clarity. Specifically, a pool (n = 10) of individuals representing the target subjects (women in emergency medicine) completed the survey and provided feedback regarding the survey prior to field implementation. Third, we conducted cognitive interviews using "think aloud" techniques to determine the extent to which the survey items represented the areas of interest of the investigators. 11,12 Finally, questions were refined and reevaluated to establish content validity of survey items (Supplemental File 1).

Survey implementation and data collection
All surveys were implemented using the University of Florida's Research Electronic Data Capture (REDCap) program. 13 We utilized electronic mailing lists from three female-oriented emergency medicine professional organizations ( A closed social media group on Facebook for emergency physicians to "share challenges and joys of emergency medicine" non-academic settings, a link was posted on a closed group social media outlet for emergency physicians (https://www.facebook.com/groups/ 132952066891217/). IRB informed consent was contained on the first page of the survey. The survey link was sent twice to each electronic mailing list to improve response rates and reduce error from nonresponse. All responses were anonymous. Participants were instructed not to complete the survey if they had done so before; however, there was no formal mechanism to prevent duplicate responses.

Outcomes
The primary outcome was impaired fecundity defined as physical difficulty in either getting pregnant or carrying a pregnancy to live birth. 10 We used impaired fecundity as our primary outcome because it is more inclusive than the formal definition for infertility, which excludes women with multiple miscarriages preventing them from having a child. Our determination of impaired fecundity included difficulty in getting pregnant or miscarriage of first pregnancy. Secondary outcomes selected a priori included clinical and non-clinical hours worked and night shift hours worked. Survey items contained questions related to (1) reproductive health, (2) use of assisted reproductive technology, and (3) perceptions of work, family, and children.

Analysis
According to the AAMC there were 11,658 active female emergency physicians in 2017-given a 99% confidence level and a 5% margin of error, the required representative sample would be 630. 3

Characteristics of study subjects
A total of 2067 female emergency physicians completed the survey with a mean (SD) current age of 38.9 (7)

Main results
The rate of impaired fecundity in female emergency physicians was 24 We evaluated work schedule risk factors that are thought to affect reproductive health. 15 We found differences in work-related characteristics between in female emergency physicians with and without impaired fecundity (

LIMITATIONS
Our study has several limitations. Our sampling methodology and inability to determine a true response rate introduces nonresponse bias. We identified participants through their membership in femaleoriented professional organizations and one social media outlet specific to emergency physicians. The social media-based distribution of the survey was necessary to address issues of generalizability and help recruit non-academic physician subjects. However, it prohibited the ability to provide a true response rate. The anonymous nature of the survey also makes it possible that 1 individual could respond to the survey more than once. The investigators included warnings in emails to prevent this, but there is no definitive way to prevent multiple submissions from a single participant. We acknowledge the possibility of selection bias, as women with impaired fecundity could be more motivated to complete the survey, thus resulting in an inflated rate of impaired fecundity and presenting an additional limitation to the study.
Survey items require recall of past events, which could introduce recall bias into responses. It is somewhat unlikely that physicians would misremember birth dates or use of assisted reproductive technology; however, poor recall could impact memory of dates related to prolonged unprotected sex without pregnancy as well as work schedule details at the time of impaired fecundity. Our approach is consistent with the methodology used in the NSFG survey, which also relies on participants' recall, but recall bias remains a potential threat to validity of results.
We limited our assessment of impaired fecundity to first pregnancy.
This was done because related questions for each pregnancy lengthened the survey considerably and we were concerned that feasibility would be an issue. However, we realize that this could result in underrepresentation of impaired fecundity among participants and thus presents a limitation to the study.

DISCUSSION
This survey is the first national cross-sectional survey of reproductive health and impaired fecundity that targets female emergency physicians. Our study compared female emergency physicians with a national cohort of women surveyed through the NSFG. We found a higher rate of impaired fecundity when comparing female emergency physicians and the general population. This is similar to what has been reported in other research 5 and provides additional evidence supporting the conclusion that impaired fecundity is a potential health issue for female physicians.
To determine if the higher rate of impaired fecundity in emergency physicians was because of delayed childbirth, we performed a subanalysis of respondents based on age categories used in the NSFG analyses. We found no difference in impaired fecundity when comparing 25-29 and 30-34 year-olds with similar cohorts in the general population.
However, analysis of age groups 35-39 and 40-44 demonstrate significant increases in impaired fecundity when compared with similar age cohorts in the NSFG general population. This suggests a risk of delaying childbirth for female emergency physicians that is above and beyond baseline risks associated with advanced age and reproductive capacity.
Additionally, we propose that the occupational factor(s) responsible for these findings are possibly (1)  This study has several notable strengths. First, it represents the largest study evaluating infertility in physicians and the first to study emergency physicians. Second, this study uses the NSFG to provide a cohort for comparison. CDC data are weighted to represent the general population and thus provide the largest, most comprehensive dataset on fertility and childbearing in the United States. Finally, the sample size is large enough to allow us to begin evaluating work-related factors that can potentially affect fertility and childbearing. Although our assessment of these issues was not exhaustive, it provides a starting point for a future, large-scale study aimed at evaluating workrelated factors and infertility across both sexes.
Considering the current national focus on wellness and female physician retention, our study addresses an important issue in emergency medicine and medicine in general. Although this survey is a strong start, future research is necessary to identify the nature and magnitude of threats to reproductive health for both emergency medicine practitioners of both sexes. Overstating the effects of emergency medicine practice on reproductive health could have a significant negative impact on gender equality. Thus, it is critical that this issue be rigorously studied in collaboration with experts in occupational health, reproductive health, and gender studies. Policy should focus on providing all practitioners with accurate information and work environments that employ methods to minimize risk to reproductive health.