This piece was originally published on Bill of Health, the blog of Petrie-Flom Center at Harvard Law School.

In my junior year of college, my pre-medical advisor instructed me to take time off after graduating and before applying to medical school. I was caught off guard.

At 21, it had already occurred to me that completing four years of medical school, at least three years of residency, several more years of fellowship, and a PhD, would impact my ability to start a family. I was wary of letting my training expand even further, but this worry felt so vague and distant that I feared expressing it would signal a lack of commitment to my career.

I now see that this worry was well-founded: the length of medical training unnecessarily compromises trainees’ ability to balance their careers with starting families.

In the United States, medical training has progressively lengthened. At the beginning of the 20th century, medical schools increased their standards for admission, requiring students to take premedical courses prior to matriculating, either as undergraduates or during post-baccalaureate years. Around the same time, the length of medical school increased from two to four years. In recent decades, the percentage of physicians who pursue training after residency has increased in many fields. And, like me, a growing proportion of trainees are taking time off between college and medical school, pursuing dual degrees, or taking non-degree research years, further prolonging training.

The expansion of medical training is understandable. We know far more about medicine than we did a hundred years ago, and there is correspondingly more to teach. The increased structure and regulation of medical training have made medical training safer for patients and ensured a standard of competency for physicians. Getting into medical school and residency have also become more competitive, meaning many trainees feel they must spend additional time bolstering their resumes.

However, medical training is now longer than it needs to be. Many medical students do very little during their fourth year of medical school. Residency programs also require trainees to serve for a set number of years, rather than until they have mastered the skills their fields require, inflating training times. And many medical schools and residency programs require trainees to spend time conducting research, whether or not they are interested in academic careers. While many trainees appreciate these opportunities, they should not be compulsory.

There are many arguments for shortening medical training. In other parts of the world, trainees complete six-year medical degrees, compared to the eight years required of most trainees in the U.S. (four years of college and four years of medical school). The length of medical training increases physician debt and healthcare costs. In addition, it decreases the supply of fully trained physicians, a serious problem in a country facing physician shortages. Since burnout is prevalent among trainees, shortening training could also mitigate burnout. And critically, the length of medical training makes it challenging for physicians to start families.

Because medical trainees work long hours, have physically demanding jobs, and are burdened by substantial debt, they are sometimes advised or pressured to wait until they complete their training before having children. But high rates of infertility and pregnancy complications among female physicians who defer childbearing suggest this is a treacherous path.

Starting a family during training hardly feels like a safer option. In my first year of medical school, I attended a panel of surgical subspecialty residents. I asked whether their residencies would be compatible with starting a family. The four men looked at each other before passing the microphone to the sole woman resident, who told us she could not imagine having a child during residency, as she didn’t even have time to do laundry, so instead ordered new socks each week.

In my second year of medical school, a physician spoke to us about having a child during residency. I asked how she and her husband afforded full-time child care on resident salaries. She confided that they had maxed out their credit cards and added this debt to their medical school debt to pay for daycare. There have been encouraging anecdotes, too, but these have often involved healthy parents relocating, significant financial resources, or partners with less intense careers.

Admittedly, shortening medical training would not be a magic bullet. Physicians who have completed their training and have children still face myriad challenges, and these challenges disproportionately affect women. Maternal discrimination is common, and compared to men, women physicians with children spend more than eight hours per week on parenting and domestic work and correspondingly spend seven fewer hours on their paid work. Nearly 40 percent of women physicians leave full-time practice within six years of completing residency, with most citing family as the reason why.

However, shortening medical training would enable more trainees to defer childbearing until the completion of their training. This would help in several ways. For instance, while most trainees are required to work certain rotations (e.g., night shifts), attending physicians often have more flexibility in choosing when and how much they work. In addition, attending physicians earn much more money than trainees, expanding the child care options they can afford.

In recent years, many changes have been made to support trainees with children, from expanding access to lactation rooms, to increasing parental leave, to creating more child care facilities at hospitals. But long training times remain a persistent and reduceable barrier. To address this, medical schools could only require students to take highly relevant coursework, reducing the number of applicants who would need to complete additional coursework after college. Medical schools could also increase the number of three-year medical degree pathways and make research requirements optional. Residency and fellowship programs could create more opportunities for integrated residency and fellowship training and could similarly make research time optional.
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It will be challenging to create efficient paths that provide excellent training without creating impossibly grueling schedules. But this is a challenge that must be confronted: physicians should be able to balance starting a family with pursuing their careers, and streamlining medical training will facilitate this.

Haley Sullivan, Emma Pierson, Niko Adamstein, and Sam Doernberg gave helpful feedback on this post.

Many medical journals will publish ~1,000-word opinion pieces written by medical students. There is a lot of luck involved in getting these published, but here are tips others have given me, as well as lessons I have learned on how to do this:

1. Presubmission inquiries are helpful. Many journals allow (or require) you to email them a short blurb about your piece before you formally submit it. It’s good to use this option when it’s available, especially if you haven’t written a draft yet. You’ll usually hear back quickly and may save yourself and the editors time (and the headache of formatting citations).
2. Collaborate with people you like and respect. I have been assigned some amazing mentors and stumbled across some brilliant collaborators (it was helpful to be born into the same family as two of them). But I have also signed onto some projects with people I didn’t work well with, and none of these wound up getting published. For me, figuring out who to work with is mostly about compatibility, and this means identifying my own strengths and weaknesses (e.g., my writing is dry, so it’s good for me to work with people who have beautiful prose). Some ways I’ve tried to determine whether I’d work well with someone are: collaborating with them on a low-stakes/non-academic project, talking with other people they’ve worked with, meeting to assess vibes/communication style, reading other things they’ve written, and asking them for feedback on my writing. One litmus test is: if we got some reviews back on this piece, would I trust my co-author(s) to revise and resubmit this without my input? (I’m not saying I’d ever do this, but it’s good to know your collaborators well enough to make this assessment and to have this level of confidence in them.)   
3. Be candid with people at the outset. During early brainstorming sessions about a piece, it’s useful to a) discuss how much time everyone can commit and over what time period b) outline the basic arguments for the piece (and make sure everyone roughly agrees) and c) clarify authorship order and roles. This is particularly important if you’re working with people you’re close to because you do not want to let work disputes harm your relationships. One litmus test for figuring out who should be first author is: who wrote the first draft of the piece? Having said this, sometimes circumstances change, and it becomes necessary to rethink authorship order. Authorship is definitely not worth burning relationships over. People are way more likely to work with you again if you were generous with them (about authorship, time, feedback, etc.) and if they're good collaborators, they will remember and pay it forward. Plus, it’s easy to overestimate how much work you have done.
4. Get feedback on your ideas before you spend time writing them. These conversations can also be useful for figuring out how to frame an issue (e.g., what aspects of it are people interested in and what parts are they confused by?). Another way to get feedback on an idea is to tweet about it, although this presents some theoretical risk of getting scooped. On occasions I’ve done this, it’s helped me figure out whether people cared about an issue and agreed with the take.
5. Get feedback before you submit your piece. This is pretty obvious. But one less obvious way it’s been useful: sometimes someone will tell you you’re aiming too low or too high. Last year, I sent a piece that wasn't very good to some friends, and one of them gently pointed out some major problems with it, and so I ended up turning it into a blog. On the other hand, I sent a blog post draft to a few friends who were like “you should publish this,” and after some serious revisions, I did.
6. Shoot your shot. If people you respect have given you good feedback on an idea or a piece, it’s worth aiming high, especially with a presubmission inquiry. After all, there are a lot of journals and some of them publish a lot of short pieces.  
7. Writing on time-sensitive issues is risky. I have had mixed success writing about things that are time-sensitive (petition to rename these pieces "deciduous"). On the one hand, lots of journals will want to publish a piece about a hot issue, and there are probably good, novel takes that haven’t been written yet. On the other hand, if you miss the window of opportunity, you may not be able to publish your piece at all. (RIP our article about whether medical students should be considered health care workers for the purposes of vaccine triage: it got reviewed, but by the time we got the R, most medical students had been vaccinated.) If you’re writing on a time-sensitive issue, submit a presubmission inquiry, consider sending the piece somewhere it won't be peer reviewed, and think about collaborating with someone who can help it move through review quickly. In other words…
8. Consider finding someone senior to work with. I have only co-authored opinion pieces with friends/sisters. You may not need someone senior on your piece, especially if you’re writing about something you know a lot about (e.g., something specific to the medical student experience). I have never felt that my work wasn't taken seriously just because I was a medical student, and it can also be really fun to work with your friends. But having someone senior involved may often lead to a better product and increase your odds of getting it published. Senior people may have connections with editors and may be able to advocate for your piece more effectively.
9. Have a backup plan. Have a short list of journals +/- a blog in mind before you start writing, and write with their word counts in mind. It is time-consuming to undertake major revisions (e.g., cut your piece in half) after each rejection.
10. Write takes you’re excited about and think are true and important. I have only ever regretted getting pulled into projects I wasn’t excited about. Revising a piece for the 7th time is hard enough, even when you care about the issue. An added benefit is that even if you have a hard time getting your piece published, you’ll have read and thought a lot about an issue you care about.

Medical trainees will change the culture of medicine for the better (as generations of prior trainees have done for us), and we can accelerate this change by sharing our opinions.