I have no recollection of my husband and me deciding to have our first baby over 30 years ago, the year after I graduated medical school, when I was an intern and he a resident. We had not discussed timing the delivery with our preassigned vacations, futile as that effort might have been, or if we could afford childcare on our meager incomes. Near the end of my internship, on a rare Sunday afternoon when we both happened to be home, I looked at a calendar and counted 80 days since my last period. I went to the drugstore, bought a home pregnancy test and peed on the plastic wand. Then, like a crazed vampire slayer, I waved the dark-blue cross back and forth in front of my husband’s initially confused and then smiling face.

It wasn’t unusual for me to arrive at Johns Hopkins Hospital, where I was interning, on a Monday morning, work without stopping until Tuesday evening and report again for work early on Wednesday. Some months were even more punishing: 24 hours on, 24 hours off, week after week. The obscene fatigue that this schedule produced made me euphoric at times, depressed, irritable and nauseated at others, but always obsessed with sleep. I would stop at the grocery store on my way home from the hospital and glare at the cashier, resentful that she could go home to her own bed at night. I envied dogs I saw in the street because they could lie down when they chose. There’s no evidence that severe sleep deprivation made me a better doctor, but I could not have survived my entire residency if I had not believed it would.

Attempting to stay energized when I was on call, I hit the vending machines for infusions of sugar—Snickers or stale Little Debbie cakes—on my way to the laboratory, blood bank or emergency room. I often chose the route that led through the surgical clinic, dark and deserted at night, in an unrenovated part of the hospital with linoleum flooring from the 1960s that reminded me of my father’s old medical office in Brooklyn. Framed black-and-white head shots of past members of the surgical staff, nearly all men, going back to the 1920s mesmerized me. So, too, did the reproductions of oil portraits of Sir William Osler, one of the founding physicians of Johns Hopkins, and his disciples, and his disciples’ disciples that hung on the walls of the wards. Sometimes, I paused by one of these portraits and listed, in my mind, the string of medical “begats” that ran from Dr. Osler through his trainees and successors to me. I never once paused to consider that my professional ancestry included few women.

Once I learned I was pregnant, I started taking prenatal vitamins and complied with all the recommended obstetrical visits, blood tests and ultrasounds. Still, I drifted through my last two trimesters in a kind of oblivion. I first felt my baby move early one morning as I stole a few minutes of rest on an empty patient bed in the coronary care unit. Strange as it sounds, being pregnant as a resident made me feel more macho.

My swagger had a price. I spent the last six weeks of my pregnancy confined at home with preeclampsia, my dangerously high blood pressure no doubt caused by long work hours. After months of wanting nothing more than sleep, I was forbidden to leave my bed. At 40 weeks, a monitor detected fetal distress, and I had an emergency Cesarean section, delivering a healthy 5-and-a-half-pound girl.

Another female resident tacked my daughter’s newborn photo onto the bulletin board in the room where we residents entered notes in patient charts and stole naps on a ratty couch.

Today, as a primary care physician and a faculty member of Harvard Medical School, I ask myself why I was so unquestioning of a system that was hostile to women and certainly to mothers. So complete was my denial that when I recently looked at a photograph of my residency class, I was surprised to see that barely a quarter of its members were women. I’d have guessed closer to 40 or 50 percent.

Medical training had been designed in the 19th century as a residency, which excluded women almost by definition: Male trainees were required to live together in the hospital and, in many programs, not even permitted to marry during residency until well into the 20th century.

The fact that my residency program had no formal maternity leave policy, that it never occurred to my superiors—or to me—that I put my and my unborn baby’s lives in danger rather than risk jeopardizing my good standing by asking for a lighter schedule, speaks to how inimical this system was to women.

I wish I could say that things are different today, that medical training and healthy pregnancy are no longer incompatible, as they were when I became pregnant at age 30 in the late 1980s. But this isn’t true. Two recent studies raised concerns about the reproductive health of female physicians in the United States: One revealed that one-quarter of all female medical doctors experience infertility (double the national average) and the other found that half of female surgeons have had a major pregnancy complication, with 42 percent suffering miscarriages (also twice the national average). A series of conversations I’ve had recently with female medical trainees both corroborated and explained these statistics. Young female physicians told me that they’re deferring pregnancy—thus incurring greater risk of infertility—because they worry about jeopardizing careers or pregnancies by conceiving during residency. Several said that requests for accommodation in grueling work schedules during pregnancy would be seen as asking for special treatment, not being a team player.

Still other physicians expressed fear that, even with an uneventful pregnancy and ample maternity leave, it might not be possible to juggle a medical career and parenting. This fear is validated by a 2014 study reporting that female physicians spend on average 8.5 hours more per week on childcare and other domestic responsibilities compared with their male partners. This discrepancy in nonprofessional responsibilities is, in large part, responsible for the 25 percent pay gap that persists between women and men in medicine (a gap that’s expanded recently due to the childcare crisis caused by the Covid-19 pandemic).

Why, when women now out-number men in medical schools, is it still so difficult for doctors of childbearing age to bear—and raise—children? A key reason is that even though more women than ever before are entering medicine, as in other professions, we’re stuck on the lower rungs. We’re more likely than our male counterparts to linger for years as instructors, assistant professors and junior attendings and we’re far less likely to achieve positions of power and influence: department chairs, medical school deans, editors-in-chief of major medical journals. We’ll never achieve gender equity in medicine until more women hold these positions, and until more men recognize that their efforts to include women at the top will benefit both male and female physicians.

Part of the difficult work is the dismantling of a deeply rooted and, in some ways, admirable medical culture in which caring for patients has long meant neglecting ourselves. Women can lead the way in shifting this narrative—if we have the chance to lead. True, there are more women today in leadership roles than when I was a resident, women whose portraits hang on the walls of hospital corridors. But they are not enough to effect meaningful change for the young female physicians who gaze up at them as they work through the night.

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Dr. Suzanne Koven is a primary care physician and an associate professor of medicine at Harvard Medical School. Dr. Koven, who has an MFA, is also the inaugural writer-in-residence at Massachusetts General Hospital in Boston. Her writing has appeared in The New England Journal of Medicine, The Boston Globe, The Lancet and other publications. This essay was adapted from her book Letter to a Young Female Physician: Notes from a Medical Life.