Download - Characteristics of and Issues Faced by Rural Female Family Physicians

Characteristics of and Issues Faced by Rural Female Familv Phvsicians

Gwyn E. Barley, Ph.D., C. Brooke Reeves, B.A., Ann O‘Brien-Gonzales, Ph.D., and John M . Westfall, M.D., M.l?H.

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 pkysicians. 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 percent). 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 communities 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 indefinitely. Assumptions regarding rural physicians, especially women, must be updated to accurately assist communities in recruiting rural pkysicians and to assist medical schools and residencies in adequately preparing graduates for rural practice.

he literature suggests that female physicians are less likely to practice in rural areas. Rosenblatt, et al. (1992), in a study of which medical schools produce rural phy- T sicians, found that women were much less

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 (D’Elia and Johnson, 1980). Little has been written, however, about the is-

sues facing female physicians currently working in rural settings.

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.

Barley, Reeves, O’Brien-Gondes and Westfall 251 Summer 2001

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 D’Elia and John- son to declare in 1980 that:

. . . 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. (D’E!lia and Johnson, 1980, p. 584)

A recent study reported that of all U.S. female physicians, 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 choosing rural practice, has led to concern that the geographic disparities in physician supply could increase further (McDontald, 1993).

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 responsibilities (Brotherton, et al., 1997). The longer hours and more frequent call schedules common to rural medicine are drawbacks to many female physicians (Mc- Donald, 1993).

There is little in the literature, however, that describes women who do choose to practice in rural settings. The specilic aims of this study were to describe issues facing female family physicians currently practicing in rural communities in the United States.

Several reasoris have been proposed for the low pro-

Methods

A 37-item survey was designed to obtain demographic information about the background, community and practice of rural female physicians. Also included

in the survey was one open-ended question about the issues and problems faced by female physicians in rural 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) practicing in communities with less than 50,000 inhabitants 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 physicians 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.

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.

This article reports the descriptive analysis of respondents’ rural experience and current practice patterns 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 analysis with results derived from quantitative analysis of survey data (Miller and Crabtree, 1999).

Table 1. Demographic Characteristics of Respondents (n=587).

Table 1. Continued.

Characteristic Number Percentage

Age, years 30-39 172 40-49 304 50-59 88 60-69 18 70-80 3 Missing 2

Single 54 Marital status

Married 476 Separated 6 Divorced 30 Partner 13 Widow 5 Missing 3

Spouse’s occupation Physician 134 Other professional 156 Laborer 34 Homemaker 29 Agriculture 27 Self-employed 23 Retired 12

Other 84 Missing/no response 84

Unemployed/disabled 4

Children Yes 470 No 117

Population grew up in <999 66 1,0004,999 103 5,000-9,999 62

10,000-25,000 76 >25,000 270

Weeks of rural experience in medical school None 160 1-4 143 5-8 131 >8 146

Missing 10

Missing 7

Weeks of rural experience in residency None 225 1 4 137 5-8 108 >8 111 Missing 6

29.3 51.8 15.0 3.1 0.5 0.3

9.2 81.1

1 .0 5.1 2.2 0.9 0.5

22.8 26.6 5.8 4.9 4.6 3.9 2.0 0.7

14.3 14.3

80.1 19.9

11.2 17.5 10.6 12.9 46.0

1.8

27.3 24.4 22.3 24.9

1.1

38.3 23.3 18.4 18.9 1.1

Characteristic Number Percentage

Size of community where practice located <999 40 6.8 1,000-4,999 191 32.5 5,000-9,999 126 21.5

10,000-25,000 150 25.6 25,000-50,000 69 11.8 Missing 11 1.8

Results

Completed surveys were received from 597 of 850 practicing female family physicians surveyed (70.2 percent). Ten surveys were eliminated because the respondents were no longer in rural practice, resulting in 587 out of 840 usable surveys returned (69.9 percent).

Demographic Characteristics. Table 1 describes the demographic characteristics of the respondents, including age, marital status, spouse’s occupation, children, the population of the community where the re- spondent grew up, weeks of rural experience in medical school and residency and the size of the community where the practice is located.

The average age of respondents was 45 years; 81 percent were less than 50 years old, and 29.3 percent were less than 40 years old. Ages of respondents ranged from 30 to 74 years. A large majority was married (81.1 percent) and had children (80.1 percent). The number of children ranged from 1 to 11. Nearly half of the respondents (49.4 percent) were married to physicians or other professionals. Few respondents were married to men engaged in agricultural or trade work (8.8 percent), and less than 5 percent were married to men who were homemakers. Half of the women had grown up in communities with populations of 25,000 or less. Half had fewer than four weeks of exposure to rural practice in medical school, and more than half (61.6 percent) had four weeks or fewer in their residency program. 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.

Barley, Reeves, O‘Brim-Gonzales atid Westfall 253 Summer 2092

Table 2. Practice Characteristics of Respondents (n = 587).

Table 3. Response to Common Rural Practice Issues by Respondents (n = 587).

Characteristic Number Percentage Issue Number Percentage

Type of practice Private 357

HMO 15 Other 164

Community health center 49

Missing 2

No. years in practice 4 9 332 10-1 9 196 20-29 45 >30 9 Missing 5

No. of other female physicians in practice None 190 1 4 237 >5 145 Missing 15

Hours worked/week <20 15 20-39 150 40-60 286 >6O 115 Missing 21

Hours on call/week None 87 < 24 157 > 24 260 All the time 65 Missing 18

Distance (in miles) to nearest tertiary care center <30 63 31-100 375 >I00 137 Missing 12

60.8 8.3 2.6

27.9 0.3

56.6 33.4 7.7 1.5 0.9

32.4 40.4 24.7 2.6

2.6 25.6 48.7 19.6 3.6

14.8 26.7 44.3 11.1 3.1

10.7 63.9 23.3 2.0

Practice Characteristics. Table 2 describes the practice 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.

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

Local opportunities for continuing medical education Yes 467 79.6 No 107 18.2

Satisfaction with medical equipment/resources in the community

Missing 13 2.2

Yes 482 No 86 Missing 19

Satisfaction with income Yes 445 No 125 Missing 17

Use of Internet/e-mail in practice Yes 234 No 345 Missing 8

Practicing in rural setting because of loan repayment Yes 37 NO 539 Missing 11

Spouse satisfied with rural setting Yes 464 No 27

96 Not applicable or no response

Plans to stay in a rural practice setting Unknown 61

1-5 years 49 6-10 years 57

Indefinitely 344 Missing 15

11-20 years 61

82.1 14.7 3.2

75.8 21.3 2.9

39.9 58.8

1.4

6.3 91.8

1.9

79.0 4.6

16.4

10.4 8.3 9.7

10.4 58.6 2.6

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.

Responses to Common Rural Practice Issues. Table 3 describes the responses to common rural practice issues, including local opportunities for continuing

The \ournu1 of Rural Health 254 Vol. 27, No. 3

Table 4. Family and Social Issues.

Theme Quotes From Physicians

Balancing work and family

Being single and/or finding a partner or spouse

Being accepted into the community

Maternity leave and child care

They all have spouses who stay at home caring for their children, cooking, cleaning, etc. My spouse works

There is a pressure, which is subtle but real, for women to perform up-to-par with their male colleagues.

There are few opportunities to meet men of my level, comparable education or life experience, a major reason I

Married people seem to want to socialize with other couples. Married women physicians are too busy trying

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

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.

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.

every day. This makes me twice as busy and chronically tired.

Therefore, cutting back for family obligations is difficult.

intermittently consider leaving a practice I love.

to be "two" women and have no time for friendship.

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

for 14 years. Trying to work part time was a joke-when you work part time you really work full time.

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?"

medical education, satisfaction with medical equipment/resources in the community, satisfaction with income and use of Internet/e-mail in the practice. Table 3 also describes respondents practicing in rural communities because of loan repayment responsibilities, satisfaction of spouse/partner with the rural setting and plans for staying in the community.

Most women in the study (79.6 percent) reported that they had locally available continuing medical education opportunities and that they were satisfied (82.1 percent) with the availability of medical equipment and resources. A substantial number (39.9 percent) reported 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 setting. Nearly 70 percent planned to stay in the community for more than 10 years, with 58.6 percent responding that they planned to stay indefinitely.

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).

These women were compared with the other rural female physicians. Female physicians in the most rural communities reported more hours of call than the other rural female physicians did (P=O.O11). The number of other female physicians in the community was also significantly lower in these more rural communities than in the rest of the communities (P=0.038). There were no other differences in demographic variables, previous rural experience, physician satisfaction or plans to stay in a rural practice.

Issues Facing Female Family Physicians. Responses to the open-ended question regarding issues for women in rural practice were grouped into two major themes-those related to family and social issues (Ta- ble 4) and those related to professional issues (Table 5 ) . Respondents cited professional issues such as the need for advanced training, work overload and/or setting limits, being accepted into the community, devel- oping a consulting network, feminization of practice profile, lack of female colleagues, differing patient expectations, the "old boy network" and staying medi- cally current. Respondents related family and social-

Barley, Ream, OBrien-Gonzales and Westfall 255 Summer 2001

Table 5. Professional Issues.

Theme Quotes From Physicians

Feminization of practice

Lack of female colleagues

Differing patient expectations

The “old boy network”

Many women want to see me; I had to close my practice after 1 year (9-month waiting list for Pap

Excess popularity because I am female. Very strong predominance of women in my practice (80 percent).

Women are needed in rural practice. When I came to town women who hadn’t had Pap smears in years

smears at that time!)

High demand from community for teaching, education or women‘s health issues.

turned up for exams. I think I am a positive force for women‘s health care in my community. I also do more deliveries than any other single physician does.

women to talk to about problems combining family and career. have no peers who have children and face similar life issues and are physician/mother/spouse. do think that being female makes me more ”approachable,” and consequently I do more “medicine” outside of the clinic than my husband does.

don’t look like Marcus Welby (or Doc Smith who just died), so it is harder for some people to respect my opinion.

was directed to the wives’ meeting at my first medical society meeting. The society’s president didn’t make that mistake again.

When I first arrived I was the only woman physician, and there were no other role models, no other

My partners go fishing or snowmobiling or hunting on their day off. I clean house and do laundry. The “old boy network’ was alive and well when I started. I had some trouble getting privileges to do C-

sections because of them.

Noti, This table includes responses to the open-ended question, “What are some of the Issues/problems you have experienced as physician in a rural community?”

female

specific issues including privacy, being single and/or finding a partner or spouse, balancing work and family, maternity leave, child care and job opportunities for partner or spouse. Thirty-nine percent of respondents reported that they believe these issues are unique to female physicians. However, some of these issues may be common to male physicians and to female physicians practicing in urban settings.

Discussion

Most studies of women practicing medicine in rural settings have reported on small samples in limited geographic areas (Crandall, et al., 1990; D’Elia & John- son, 1980; Moore-West, et al., 1982). The current study reports findings for 70 percent of the female members of AAFP practicing in communities of fewer than 50,000 people. The majority of respondents in this study were in communities with populations of fewer than 10,000 and were practicing in a community more than 30 miles from a tertiary care center, supporting the belief that these truly represent rural physicians.

Few differences were identified between women practicing in the most isolated communities and women practicing in larger rural communities. The increased number of hours of call experienced by these female physicians may be because there are fewer physicians with whom to share call.

As previous studies have demonstrated, most of the female physicians surveyed were married to other physicians or professionals. This finding is in contrast to findings in another study that found that two- thirds of female spouses of male physicians were not employed outside the home, and only 13 percent were employed full time (Ogle, et al., 1986). A larger study, done in 1990 using 1980 U.S. Census data, found that most male physicians (64.3 percent) had spouses who were not in the labor force, despite most being college educated. It also showed that most married female physicians had spouses who were also pursuing professional careers (Uhlenberg and Cooney, 1990).

ical school and residency has been predicated on the belief that “the increased length of post medical school time required to complete specialty training

The need for exposure to rural settings during med-

256 Vol. 77, NO. 3

means that practice location decisions were influenced by more than a decade of post high school professional socialization that usually occurs in urban or subur- ban settings” (Crandall, et al., 1990). The present study found that more than half of rural female physicians (52.29 percent) grew up in towns with fewer than 25,000 people and that more than half (51.7 percent) had four weeks or fewer of their education in rural settings. Many women commented on the impact of student or resident rural educational experiences on their decision to pursue rural practice. However, even female physicians with no rural history or educational exposure entered rural practice. Further examination of the issues surrounding women’s decisions to practice in rural communities may help shed light on why both male and female physicians choose rural practice. Experience indicates that communities and physician recruiters target residents who either grew up in rural communities or had significant rural experience in medical school or residency. These findings suggest that recruiters should also target women with little or no experience in rural medicine. In addition, anecdotal wisdom has held that many rural physicians were short-timers paying back a loan obligation, but only 6.3 percent of the women responded that they were practicing in a rural setting because of a loan obligation.

of issues facing female providers in rural communities: those related to family and social issues and those related to professional issues. Rural female family physicians may face a combination of issues relating to rural practice and to being female physicians. Like female physicians practicing in urban areas, they face issues of pregnancy and maternity leave and of seeing mostly female patients. Like their rural partners, they face the issues of small-town practice, primarily too much call and too little vacation. Although this study had no comparison group of urban female physicians or rural male physicians, this combination of issues may be unique to rural female physicians.

This study has several limitations. It reports only on rural female family physicians who were members of the American Academy of Family Physicians and does not include internists, obstetricians, pediatricians and non-AAFP members. As a result, these results may not be generalizable. Also, some of the issues raised may not be unique to rural female physicians. Un- doubtedly, many physicians face issues such as work- load, balancing family and work and local continuing education opportunities. However, this is one of the few studies to ask rural female family physicians to

Female physicians in this study identified two types

describe the issues they face as female physicians in rural communities. Although not necessarily unique, knowing these issues could help communities seeking to recruit female family physicians.

To attract increased numbers of female physicians to rural practice, pertinent practice and personal issues must be identified and addressed (Ellsbury, et al., 2000). For instance, 68 percent of the respondents in this study reported that another female physician worked in their communities. This suggests that women may seek communities where other female physicians or clinicians are working. Likewise, rural communities seeking to attract female physicians may want to consider recruiting two female physicians. The finding that one in six female physicians had no rural experience in their training may prompt recruiters and rural communities to broaden their search for physicians to those lacking rural experiences.

Assumptions regarding rural physicians, especially women, must be updated to accurately assist communities in recruiting rural physicians and to assist medical schools and residencies in adequately preparing graduates for rural practice. Further research on rural physicians, both men and women, and the issues they face may further help rural communities to recruit and retain family physicians.

References

Brotherton, S, Tang, S, & OConnor, K. (1997). Trends in practice characteristics: Analyses of 19 periodic surveys (1987-1992) of fellows of the American Academy of Pediatrics. Pediatvics, 100, 8-18.

Crandall, LA, Dwyer, JW, & Duncan, PR. (1990). Recruitment and retention of rural physicians: Issues for the 1990s. Joirrnnl of Rir- n i l Henltlr, 6(1), 19-38.

politan area. ]oirrrtal .f Medical Edircation, 55(7), 584.

and the rural family physician gender gap. Famil!/ Mcdicine, 32(5), 331.

Frank, E, & Lutz, L. (1999). Characteristics of women US. family physicians. Archizxs of Faniily Medicine, 8(4), 313-318.

McDonald, L. (1993). Women physicians: Are they taking over? Colo- rado Mediciiv, 90, 298-300.

Miller, WL, & Crabtree, BE (1999). Clinical research: A multimethod typology and qualitative roadmap. In Crabtree, BF, & Miller, WL (Eds.), D o i q qirolifnti7~ resenvcli (2nd ed., pp. 3-30). Thou- sand Oaks, CA: Sage.

Moore-West, M, Lucero, S, Christy, J, & Kaufman, A. (1982). A descriptive study of women physicians in rural practice. ]orrrrinl of tli~’ Anzericari Medical Woni~rk Associntion, 37(10), 267-270.

D’Elia, G, & Johnson, I . (1980). Women physicians in a non-metro-

Ellsbury, KE, Doescher, MI‘, & Hart, G. (2000). US medical schools

Barlq , Remies, O’Brien-Gonzales mid Wesfnll 257

Ogle, KS, Henry, RC, Durda, K, & Zivick, JD. (1986). Gender-specific Rural Information Center Health Service. (1999). Facts about the rural population of the United States (1998, August) [On-line]. Available: http: / /www.nal.usda.gov/ric/richs/stats.htm

Family and career comparisons. Social Science and Medicine, 30(3), 376.

differences in family practice graduates. journal of Family Prac- tice, 23(4), 358.

Rosenblatt, RA, Whitcomb, ME, Cullen, TJ, Lishner, DM, & Hart, LG. (1992). Which medical schools produce rural physicians? Iournal of the American Medical Association, 268(12), 1159-1165.

Uhlenberg, P, & Cooney, TM. (1990). Male and female physicians:

258 Vol. 27, No. 3

Download - Characteristics of and Issues Faced by Rural Female Family Physicians

Top Related