I use hyperbole to make a point, but the frequency of such confluences of events in the lives of academic physician parents may help to explain the findings that Carr and coworkers report in this issue [1]. A growing body of research demonstrates that women ascend the ranks of academic medicine more slowly, to lower levels, and with smaller paychecks than their male colleagues [2-4]. Carr and coworkers explored the possible reasons for these discrepancies and found slower career progress and less professional satisfaction for women with children than for men with children or faculty without children. Like much good research, this study generates more questions than it answers.

Are the problems greater for academic medical mothers than for those in other professions? All working parents perform a precarious juggling act, yet academic medicine's work ethic separates it from other demanding professions. People get sick without regard for business hours, weekends, and holidays. Businesses close on holidays; hospitals do not. Unrealistic as it may be, patients want their physicians available 24 hours a day, 7 days a week, and 365 days a year. Even though "on call" pressures diminish greatly after training, the sense endures that we must run whenever patients, students, or research projects beckon. We feel guilty and worry that our colleagues will disparage us (and they sometimes do) when we cannot.

Are things any better for academic doctor dads? At first glance it seems so-the fathers in the study by Carr and colleagues advanced in academia "despite" their children. Unfortunately, the investigators collected no data on the study participants' spouses. Had they done so, they might have found that academic physician dads married to academic physician moms were less academically productive than those with wives who have less demanding careers or, better yet, wives who do not work outside of the home. Juggling family responsibilities is a fact of life in dual-physician families [5, 6], and the juggling probably impedes both careers. Further, academic physician fathers probably raise more eyebrows than the mothers do when they must forgo professional activities for family ones. In medicine's legendary "days of the giants," a giant rarely left work early to pick up a sick child at day care.

Why should medical schools pay attention to the needs of women faculty? Women comprise an increasing proportion of the physician workforce [7] and may actually take academic positions more frequently than their male colleagues [8]. Women are more likely than men to work in areas of need, such as primary care; to care for underserved populations [8, 9]; and to deliver appropriate preventive care [10]. They are apt to view health and illness from a broad biopsychosocial, rather than a narrower biomedical, perspective [11]. Women also spend more time on the essential, though often neglected, duty of academic medicine-teaching [1]. Academic centers need female clinicians to attract the many patients who prefer female physicians, and an increasing number of established investigators are women. Female faculty play an important role in the fulfillment of academia's mission. Finally, as more male physicians have spouses who work, issues that have previously affected only academic physician mothers are rapidly becoming issues for all faculty parents, regardless of sex.

Is there a solution? While some envision monumental changes in societal attitudes toward women and family as the solution, most academic faculty parents look for more mundane solutions. As Carr suggests, academic physician parents would welcome efforts to keep meetings comfortably within the confines of a normal workday. They would also welcome more explicit attention on the part of academia to such issues as parental leave and child care. Few female physicians take more than 6 weeks off after the birth of a child [12], yet data suggest that longer leaves optimize the mother-infant bond [13]. Most are reluctant to take more time off because doing so will burden colleagues. When academic physicians become new fathers, they commonly take off little more than the time it takes to coach the delivery. The structure of many departments is such that having even a single person out, whether because of new motherhood or illness or even the death of a family member, wreaks havoc. Mothers, fathers, and others would benefit if academic medicine built some flexibility, through more faculty or fewer expectations, into its departments.

Nothing creates greater angst for parents than finding nurturing child care for the times when they cannot be with their children. Academic physician parents would appreciate institutional support in helping to ensure that such care is available. Unfortunately, many academic institutions do not have close affiliations with child care establishments. Such affiliations or the maintenance of a current clearing-house of child care programs in the area would be an important benefit that institutions could offer faculty. Academic centers with high-quality on-site child care programs might even hold a competitive edge in attracting young faculty. Institutions should create child care programs that, unlike conventional child care situations, would give their faculty the flexibility to work early, late, and on weekends and holidays, when necessary. Academic medical centers might even consider developing innovative day care programs for children with minor acute illnesses that preclude their usual school or child care routines.

It is unreasonable to expect that faculty who take substantial breaks in their careers to raise children will advance as rapidly as their peers who do not. However, on most academic tracks, slowing down for any reason can lead to derailment. Faculty who opt for part-time work, job sharing, or extended family leaves might welcome different options for academic advancement, albeit at a slower rate, as alternatives to leaving academia altogether. Some institutions provide such options but offer scant evidence that they truly condone them, and faculty may avoid them for fear of risking their academic longevity.

Like previous investigations, this most recent study of women in academic medicine did not specifically inquire whether women physicians were, on balance, content with their choice to combine career and family. Working mothers commonly lament about a feeling of mediocre performance at both home and work but would be loath to give up either set of responsibilities. Most do not blame their institutions for these circumstances but see them as expected tradeoffs for their own life choices. Many women choose positions that will afford them the flexibility they need to attend to their families. However, few choose to have lower salaries or less administrative support than their male colleagues with similar professional responsibilities, and institutions must recognize and rectify such inequalities. At least one institution has demonstrated the preliminary success of a multifaceted intervention to foster women faculty and remove unjust sex-based inequalities [14].

I am relieved if, rather than sex bias, the reason why more women are not breaking through the glass ceiling of academic medicine is because their children are hanging on the tails of their white coats. Most of us are happy to have them there, and academic medicine offers a level of professional fulfillment, financial stability, and geographic flexibility that is well worth the juggle. The experience of parenting probably nourishes our performance as teachers, scientists, and clinicians. Nonetheless, it is distressing that Carr and colleagues' 1998 study suggests, as did one published in 1968 [15], an inverse relation between child rearing and academic success. Academic medical centers must develop ways to support their faculty's efforts to combine two of the noblest pursuits-doctoring and parenting.