Characteristics of and Issues Faced by Rural Female Family Physicians

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<ul><li><p>Characteristics of and Issues Faced by Rural Female Familv Phvsicians </p><p>Gwyn E. Barley, Ph.D., C. Brooke Reeves, B.A., Ann OBrien-Gonzales, Ph.D., and John M . Westfall, M.D., M.l?H. </p><p>ABSTRACT: Tke purpose of this study was to identfy characteristics of and issues faced by female family pkysicians practicing in rural areas. A 37-item survey was designed to obtain demographic information about the background, community and practice of rural female pkysi- cians. A n open-ended question regarding the issues and problems faced by female physicians in rural communities was included. Study subjects were identified from the membership of the American Academy of Family Physicians (AAFP). The questionnaire m s mailed to all 850 active female AAFP members practicing in communities with less than 50,000 inhabitants during the winter of 1999. Completed and usable surveys were received from 587 (69.9 per- cent). Tke auerage age of respondents was 45. The majority were married (81.1 percent) and kad children (80.1 percent). H a y of the m m e n had grown up in communities of 25,000 or less population. Twenty-seven percent of the respondents had no rural exposure in medical school; 39 percent had no rural exposure in residency; and 16 percent had no rural exposure in medical school or residency. The majority of respondents (62 percent) practiced in commu- nities of less than 10,000. A large majority (70 percent) of these r m w n planned to stay in the community for 10 years or more, with 58.6 percent responding that they plan to stay in- definitely. Assumptions regarding rural physicians, especially women, must be updated to ac- curately assist communities in recruiting rural pkysicians and to assist medical schools and residencies in adequately preparing graduates for rural practice. </p><p>he literature suggests that female physi- cians are less likely to practice in rural ar- eas. Rosenblatt, et al. (1992), in a study of which medical schools produce rural phy- T sicians, found that women were much less </p><p>likely to enter rural practice. In another report, a 30- year study of female physicians practicing in non- metropolitan areas, the greatest change found in distribution patterns from 1950 to 1980 was the de- crease in the number of women practicing in areas with the smallest populations (DElia and Johnson, 1980). Little has been written, however, about the is- </p><p>sues facing female physicians currently working in rural settings. </p><p>This research MS made possible through funding from the University if Colorado Health Sciences Center, Department of Family Medicine Predoc- toral Education Division Fellowship and a National Znstitutes of Health Student Fellowship. The authors would like to thank Gretchen Amend and Jcnntfer McCabe for tlEir assistance, as rwll as the female physicians who participated in this study. For further information, contact: Gwyn E . Bar- ley, University of Colorado School of Medicine, 4200 East Ninth Avenue, Box C-290, D e n w , CO 80262. </p><p>Barley, Reeves, OBrien-Gondes and Westfall 251 Summer 2001 </p></li><li><p>The need for physicians in the most rural areas of the United States is well-documented in the literature. Although one-quarter of the U.S. population resides in rural areas, only 1 in 10 physicians practice in these same locations (Rural Information Center Health Ser- vice, 1999). The 30-year downward trend in women practicing in rural communities led DElia and John- son to declare in 1980 that: </p><p>. . . in light of public investment in production of physicians and need for accessible and available physician services, the finding that women are less likely than men to enter one of the areas of need makes it important to identify the characteristics of those female .physicians who are in the less populat- ed areas. (DE!lia and Johnson, 1980, p. 584) </p><p>A recent study reported that of all U.S. female physi- cians, only 8.9 percent were in rural practices (Frank and Lutz, 1999). An increase of more than 300 percent in the number of female physicians, residents and medical students since 1970, combined with the sub- stantially lower proportion of female physicians choos- ing rural practice, has led to concern that the geo- graphic disparities in physician supply could increase further (McDontald, 1993). </p><p>portion of female physicians choosing rural practice, including seeking more flexible practice arrangements such as salaried and part-time positions to adapt their work situations to family responsibilities. Some data indicate that almost half of female physicians change career plans or behaviors because of family responsi- bilities (Brotherton, et al., 1997). The longer hours and more frequent call schedules common to rural medi- cine are drawbacks to many female physicians (Mc- Donald, 1993). </p><p>There is little in the literature, however, that de- scribes women who do choose to practice in rural set- tings. The specilic aims of this study were to describe issues facing female family physicians currently prac- ticing in rural communities in the United States. </p><p>Several reasoris have been proposed for the low pro- </p><p>Methods </p><p>A 37-item survey was designed to obtain demo- graphic information about the background, community and practice of rural female physicians. Also included </p><p>in the survey was one open-ended question about the issues and problems faced by female physicians in ru- ral communities. The questionnaire, accompanied by a personal letter and a self-addressed stamped envelope, was mailed to all 850 active female members of the American Academy of Family Physicians (AAFP) prac- ticing in communities with less than 50,000 inhabi- tants during the winter of 1999, as identified by AAFP Membership Services. The 50,000 population cutoff was chosen in an attempt to be inclusive of all people who consider themselves to be in a rural setting. Defi- nitions of rural vary greatly among publications and organizations, including the AAFP. Therefore, to better characterize the rural nature of their practice, subjects were asked to describe their practice site in terms of population of the community, number of other physi- cians in the community and distance from the closest tertiary care center. The questionnaire was piloted on physicians and researchers in a department of family medicine. </p><p>Surveys were numbered to allow identification of survey respondents and nonrespondents. A second copy of the survey was mailed to nonrespondents ap- proximately four weeks later. The study protocol was reviewed and approved by the University of Colora- do Health Sciences Center Institutional Review Board. </p><p>This article reports the descriptive analysis of re- spondents rural experience and current practice pat- terns and a qualitative analysis of their issues. Com- parisons were made between women practicing in the most rural and isolated communities (less than 10,000 population and more than 100 miles from the closest tertiary care center) and the other women. The quantitative analysis was done using SPSS 8.0 for Windows (SPSS, Chicago, Ill.). Analysis of the open-ended question What are some of the issues/ problems you have experienced as a female physician in a rural community? was accomplished in two phases using the AtlasTI software program (Scientific Software Development, Berlin, Germany). The first phase consisted of coding raw data from surveys as collected without imposing a priori coding schemes. Codes consisted of tags or labels to assign units of meaning to portions of text transcripts. Initial codes were descriptive, meant to assist the analysts in grouping like data. The final phase consisted of trian- gulating themes developed from the qualitative anal- ysis with results derived from quantitative analysis of survey data (Miller and Crabtree, 1999). </p></li><li><p>Table 1. Demographic Characteristics of Respondents (n=587). </p><p>Table 1. Continued. </p><p>Characteristic Number Percentage </p><p>Age, years 30-39 172 40-49 304 50-59 88 60-69 18 70-80 3 Missing 2 </p><p>Single 54 Marital status </p><p>Married 476 Separated 6 Divorced 30 Partner 13 Widow 5 Missing 3 </p><p>Spouses occupation Physician 134 Other professional 156 Laborer 34 Homemaker 29 Agriculture 27 Self-employed 23 Retired 12 </p><p>Other 84 Missing/no response 84 </p><p>Unemployed/disabled 4 </p><p>Children Yes 470 No 117 </p><p>Population grew up in 25,000 270 </p><p>Weeks of rural experience in medical school None 160 1-4 143 5-8 131 &gt;8 146 </p><p>Missing 10 </p><p>Missing 7 </p><p>Weeks of rural experience in residency None 225 1 4 137 5-8 108 &gt;8 111 Missing 6 </p><p>29.3 51.8 15.0 3.1 0.5 0.3 </p><p>9.2 81.1 </p><p>1 .0 5.1 2.2 0.9 0.5 </p><p>22.8 26.6 5.8 4.9 4.6 3.9 2.0 0.7 </p><p>14.3 14.3 </p><p>80.1 19.9 </p><p>11.2 17.5 10.6 12.9 46.0 </p><p>1.8 </p><p>27.3 24.4 22.3 24.9 </p><p>1.1 </p><p>38.3 23.3 18.4 18.9 1.1 </p><p>Characteristic Number Percentage </p><p>Size of community where practice located </p></li><li><p>Table 2. Practice Characteristics of Respondents (n = 587). </p><p>Table 3. Response to Common Rural Practice Issues by Respondents (n = 587). </p><p>Characteristic Number Percentage Issue Number Percentage </p><p>Type of practice Private 357 </p><p>HMO 15 Other 164 </p><p>Community health center 49 </p><p>Missing 2 </p><p>No. years in practice 4 9 332 10-1 9 196 20-29 45 &gt;30 9 Missing 5 </p><p>No. of other female physicians in practice None 190 1 4 237 &gt;5 145 Missing 15 </p><p>Hours worked/week 6O 115 Missing 21 </p><p>Hours on call/week None 87 &lt; 24 157 &gt; 24 260 All the time 65 Missing 18 </p><p>Distance (in miles) to nearest tertiary care center I00 137 Missing 12 </p><p>60.8 8.3 2.6 </p><p>27.9 0.3 </p><p>56.6 33.4 7.7 1.5 0.9 </p><p>32.4 40.4 24.7 2.6 </p><p>2.6 25.6 48.7 19.6 3.6 </p><p>14.8 26.7 44.3 11.1 3.1 </p><p>10.7 63.9 23.3 2.0 </p><p>Practice Characteristics. Table 2 describes the prac- tice characteristics of the respondents, including the type of practice, the number of years in practice, the number of other female physicians in practice in the community, the hours worked per week and on call per week and the distance to the nearest tertiary care center. </p><p>The majority of respondents (62 percent) practiced in communities of less than 10,000. Nearly 90 percent reported that the closest tertiary care center was more than 30 miles away, and 23 percent reported that the </p><p>Local opportunities for continuing medical education Yes 467 79.6 No 107 18.2 </p><p>Satisfaction with medical equipment/resources in the community </p><p>Missing 13 2.2 </p><p>Yes 482 No 86 Missing 19 </p><p>Satisfaction with income Yes 445 No 125 Missing 17 </p><p>Use of Internet/e-mail in practice Yes 234 No 345 Missing 8 </p><p>Practicing in rural setting because of loan repayment Yes 37 NO 539 Missing 11 </p><p>Spouse satisfied with rural setting Yes 464 No 27 </p><p>96 Not applicable or no response </p><p>Plans to stay in a rural practice setting Unknown 61 </p><p>1-5 years 49 6-10 years 57 </p><p>Indefinitely 344 Missing 15 </p><p>11-20 years 61 </p><p>82.1 14.7 3.2 </p><p>75.8 21.3 2.9 </p><p>39.9 58.8 </p><p>1.4 </p><p>6.3 91.8 </p><p>1.9 </p><p>79.0 4.6 </p><p>16.4 </p><p>10.4 8.3 9.7 </p><p>10.4 58.6 2.6 </p><p>closest tertiary care center was more than 100 miles away. Almost 74 percent reported that they live where they practice. Only 10 percent of respondents reported being on call "all of the time"-a fear frequently cited by students and residents considering rural practice. Sixty-eight percent of the respondents reported that there was another female physician practicing in their community, whereas 32 percent reported that they were the only female physician in their community. </p><p>Responses to Common Rural Practice Issues. Table 3 describes the responses to common rural practice is- sues, including local opportunities for continuing </p><p>The \ournu1 of Rural Health 254 Vol. 27, No. 3 </p></li><li><p>Table 4. Family and Social Issues. </p><p>Theme Quotes From Physicians </p><p>Balancing work and family </p><p>Being single and/or finding a partner or spouse </p><p>Being accepted into the community </p><p>Maternity leave and child care </p><p>They all have spouses who stay at home caring for their children, cooking, cleaning, etc. My spouse works </p><p>There is a pressure, which is subtle but real, for women to perform up-to-par with their male colleagues. </p><p>There are few opportunities to meet men of my level, comparable education or life experience, a major reason I </p><p>Married people seem to want to socialize with other couples. Married women physicians are too busy trying </p><p>There are few interesting single men in a small town. As a single female physician in a small town, I am somewhat an oddity to people. They don't know whether </p><p>to drop by and visit, like they would with other male neighbors, or give me space because I work such long hours and am home for precious little time. It's been a mixed experience. I have joined the local Lions Club and enjoy that, with the community service projects and twice-a-month dinners with speakers on community topics. It's been a good way to meet new people. </p><p>Patients often call me "hon," "sweetie," "little gal," or other inappropriate or unprofessional names. Patients feel comfortable calling female physicians by their first names although male physicians are called "Doctor so-and-so." Many think I am a nurse even though I correct them frequently and repeatedly. </p><p>every day. This makes me twice as busy and chronically tired. </p><p>Therefore, cutting back for family obligations is difficult. </p><p>intermittently consider leaving a practice I love. </p><p>to be "two" women and have no time for friendship. </p><p>There is a general intolerance of my working part time and not taking call so that I can raise my children. It was difficult being on call with children and when pregnant in the private practice setting where I practiced </p><p>for 14 years. Trying to work part time was a joke-when you work part time you really work full time. </p><p>Note: This table includes responses to the open-ended question, "What are some of the issues/problems you have experienced as a female physician in a rural community?" </p><p>medical education, satisfaction with medical equip- ment/resources in the community, satisfaction with in- come and use of Internet/e-mail in the practice. Table 3 also describes respondents practicing in rural com- munities because of loan repayment responsibilities, satisfaction of spouse/partner with the rural setting and plans for staying in the community. </p><p>Most women in the study (79.6 percent) reported that they had locally available continuing medical edu- cation opportunities and that they were satisfied (82.1 percent) with the availability of medical equipment and resources. A substantial number (39.9 percent) re- ported that the Internet and e-mail were beginning to become useful practice management tools for them. A large majority (79 percent) of the women reported that their spouses were satisfied with living in a rural set- ting. Nearly 70 percent planned to stay in the commu- nity for more than 10 years, with 58.6 percent re- sponding that they planned to stay indefinitely. </p><p>Of the 587 surveys returned, 111 (19 percent) were classified as being from women practicing in isolated rural communities (less than 25,000 people and more than 100 miles from the closest tertiary care center). </p><p>These women were compared with the other rural fe- male physicians. Female physicians in the most rural communities reported more hours of ca...</p></li></ul>

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