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Group Policy for Female Family Physicians in Rural Practice 3rd May 2002 CONTENTS
Key
objectives
These strategies have been drawn from international work carried out at previous Wonca Conferences and from research into the experience of female rural and remote family physicians.
After three thousand years women are beginning to take their place in the public arena and to contribute to the public discourse about truth and the proper order of the cosmos. The truth women experience is different from the truth that has dominated the public domain up until now (Belenky et al 1997, Gilligan 1982). The challenge facing all of us is to incorporate the knowledge and culture and experience of women into thought systems and knowledge structures, such as medicine. The maldistribution of doctors has been identified as an important equity and workforce issue in many countries (Makan, 1998, AMWAC 1998) that is being confounded by the changing sex ratio of the physician workforce, and the different way female and male doctors contribute to medicine. In the developed world there has been a radical change in the sex ratio of the students studying medicine. In the year 2000 fifty six percent of first year medical students and forty five percent of the whole student body in South Africa were women (MWIA 2001) and 47.9% of doctors in their post-intern year are female (de Villiers & de Villiers 2002). Canada, the USA, South Africa and the United Kingdom report similar trends and in Australia there is an equal number of females enrolled as first year students (Birenbaum 1995, NEJM 2000, Moodley 1999, Canadian reference from Leslie Rourke). The proportion of women among medical students in the United States has increased steadily, especially over the past decade and in 1999, forty four percent of first-year medical students were women (NEJM 2000). During the period 1983-1999, the percentage of female general practitioners in Englandand Walesincreased from 17.4% to 31.75%. The figures are similar in Scotland and Northern Ireland where approximately one third of all unrestricted principals are female (36.1% and 29.5% respectively). This trend is likely to continue as the number of female GP registrars now accounts for over 57% of all GP registrars (Royal College of General Practitioners 2002) According to the Association of American Medical Colleges, in 1999 there were 38,529 medical school applicants -- a 6.0 percent decrease overall from 1998; among those who were accepted, there were 8809 men (a 2.2 percent decrease) and 7412 women (a 3.5 percent increase). The female medical workforce is growing at a much faster rate than the male medical workforce. The increased numbers of women in the medical workforce is a global trend. This increasing female participation in the medical workforce, combined with the different work characteristics of male and female practitioners, is likely to have a substantial impact on the future supply and distribution of medical practitioners (McEwin 2001). Female medical practitioners tend to chose general practice, work part-time and practice in capital cities or major urban areas. Women also tend to leave medicine or practice at quite low activity levels for legitimate reasons for a short time during their careers (AMWAC 1998). In addition, there is now good evidence from Australia and other Western countries that while all doctors have a shared body of knowledge, core competencies and professional ethos, there are different preferred working styles that can be identified as favoured by women and men (Hojat, Gonnella & Xu 1995; Turner, Tippett, Raphael 1994). An Australian study, by Redman, Saltman, Straton, Young & Paul (1994) has found that women doctors are more influenced than men in their choice of speciality by the need for "the opportunity for holistic care" (86% of women compared with 58% of men). In general, men value psychosocial aspects of health less than women do, and tend to operate more strongly from a biomedical rather than biopsychosocial paradigm. They place less emphasis on holistic care, practice less preventive medicine, deal with one problem at a time rather than the many which patients present with, do less counselling, and prefer to carry out procedures rather than deal with mental health issues. (ref) Patients are much less likely to present to male doctors with issues of interpersonal violence or sexual assault. (Wainer 1998). These different priorities are reflected in different styles of practice (AMWAC 1998) and combine with different expectations from patients (Rogers 1996). Female medical practitioners have distinct work characteristics. Britt, Sayer, Miller et al (1999) found that by comparison with males, female general practitioners tend to have longer consultations; manage significantly higher numbers of problems per encounter; see a higher percentage of younger patients and new patients; and manage depression more often. Tolhurst (1999) found that women doctors do more counselling and work with violence and sexual assault cases. They do the mental health work of the community. A report on professional skills of rural doctors in South Africa found that female medical practitioners were statistically more likely than male doctors to perform termination of pregnancy (De Villiers & De Villiers 2002). This is important data in understanding why the presence of women as medical providers is so important to women as patients. There has been an unacknowledged convergence between "medicine" and "male-practiced medicine". It has taken the presence of women in sufficient numbers to begin to assert their own style to raise the possibility that there is a way to practice medicine that reflects the priorities and values of women.
In the USA are consistently less likely than males to practice in rural areas (Doescher, Ellsbury & Hart 2000). In Australia nder the age of 35 and 60% of rural family medicine trainees are female. In the Philippines a majority of rural doctors are women. Data from other countries may compliment this evidence. Several Australian and Canadian papers (Rourke 1996, Wainer 1998, Carson 1998, Thompson 1997) have analysed the evidence for an emerging cultural change within the rural medical workforce and Tolhurst (1997) has drawn out some of the tensions experienced by female rural doctors as they find ways to mesh their family and professional responsibilities. The work choices of women are generally modified by the priority they place upon the development and maintenance of personal and family relationships and the requirement to balance family responsibilities with their clinical work ( Strasser, Kamien, Hays & Carson 1997). An emerging finding from Canadian research suggests that once women are recuited to rural practice, they tend to stay and the average working week for a female doctor is 48 hours per week (ref from Mary). Female practitioners tend to be the main family carers (Wainer 2001). Hence many young women favour practice styles that have more flexible working environments and generally little or no requirement for irregular working hours and on call (McEwin 2001). Rural medicine is the point in the profession where the changes stemming from the presence of women will be felt first and most fully. Rural medicine is almost the only branch of the profession with a shortage of applicants. It needs more recruits than apply for positions, which provides room for negotiations to reshape practice. There is a parallel between the dialogue within rural medicine and between women and medicine. Both groups (rural and women) are saying they do medicine their own way. Their way converges with the prevailing medical culture in core skills and knowledge, and differs in context and priorities.
At the workshop in Durban doctors were asked to consider how to work with the strengths of women in rural practice. Participants first had to consider what those strengths might be, and they agreed that the strengths of female doctors are:
Durban workshop participants put forward recommendations that were refined by a small working group, submitted to the Recommendations Committee, and presented to the whole Conference. All but the first of these recommendations are included in the Wonca Policy on Rural Practice and Rural Health (1999).
Recommendations that women be involved in the planning and presentation of Wonca Rural Health conferences, and that women's health, and gender issues for the rural workforce, form part of the programme content for rural conferences, have been implemented at the Kuching (1999), Calgary (2000) and Melbourne (2002) Wonca Rural Health Conferences. Doctors attending the workshop conducted in Dublin in 1998 ( Wainer, Bryant & Strasser 1998) agreed that women and men practice medicine differently. Women know this and men tend to contest it. Table 1: Women and men practice medicine differently
Table 2: Interactive style of women and men
A workshop on designing female friendly rural medical practice was held at the Wonca 3rd World Rural Health Conference in Kuching. Emerging issues from that conference included
More work needs to be done to bring forward these issues into a policy framework and to integrate the international work on a gender perspective in medicine and the human rights context of women's health. The Wonca 4th World Conference on Rural Health held in Calgary in 2000 included a plenary address about Women as Rural Doctors and developed the Calgary Commitment to Women in Rural Family Medical Practice. Strategies
Strategies
The system would begin by recruiting rural students into medicine and providing them with exposure to rural medicine. It would continue with the provision of post-graduate training in rural hospitals and practice and include training in the skills rural doctors need. Professional support would be provided by continuing medical education that was accessible to women in terms of cost, travel, child care and hours. It has been suggested that some events be held during working hours to minimise disruption to families. Additional topics for continuing medical education identified by women include non-threatening training in emergency management, with child care provided; reskilling programmes for women wanting to move from part-time to full time-work or to return to work after taking a break for parenting; and negotiation and management skills. Strategies
The Australian Medical Association recommends that local community support and incentives be provided for rural doctors, their spouses and families and that this include: education for prospective rural medical practitioners about the community; opportunities for short term tenures which may be facilitated by the Commonwealth Government purchase of the house and practice, and subsequently maintained by the local community. (Australian Medical Association Position Statements: Rural and Remote Health (July 2001). Women have identified professional and female peer support and networking as important ways to continue professional development and reduce isolation, supported by a mentoring scheme for female trainees and new recruits to rural practice Women want to be valued for what they do. It is a recurrent theme in the research (Tolhurst 1997, McEwin 2001, Wainer 2001) that women find themselves regarded as 'not proper doctors' because their style of practice in some ways does not mimic that of men. Women want a cultural change so that when they bring a different style to rural practice it is valued and rewarded by their colleagues, practice staff and the system, reflecting the value placed on their practice by their patients. Strategies
In Australia the Royal Australian College of General Practitioners Rural Faculty is developing a resource kit for local government and communities to assit them understand and respect the family needs of rural doctors, with an initial focus on women.
The differences between male and female clinicians with respect to total hours worked is almost entirely due to the greater proportion of females who chose to work part-time. In 1994, 46.8% of Australian female clinicians worked part time compared with 15.3% of males. Part-time is defined by the Australian Medical Workforce Advisory Committee as being less than forty hours per week. This figure varies within medical specialities, and is an average of the hours worked by doctors in each speciality. The proportion of females working part time was highest in the 30 and early 40 year age groups coinciding with the time when there are extra family commitments. Generally, however, women who leave the workforce return over time. This highlights the need for suitable retraining opportunities to enhance skills as well as access to childcare, if required. Satisfactory arrangements in the workplace are needed to allow women (as well as some younger male clinicians) to re-enter the workforce. (AMWAC 1998, Incitti 2002) Recent research by Moodley, Barnes and de Villiers highlighted the scarcity of women in practice partnerships and the lack of provision of maternity leave for female family physicians in South Africa. In addition, women and men have different patterns of relationships with their careers and family life, and this will influence the way they practice medicine. Women have cyclical and interrupted careers which reflect their other productive roles as members of the community and their families, and particularly as parents. Women and men in medicine have parallel work experiences until the women have babies, at which point the women have to find other ways to work (Carr et al, 1998, Quadrio 1991, Quadrio 2001). The Australian Medical Association recommends support for female rural doctors to practice in ways that reflect their multiple roles, including the acceptance of flexible working hours and training courses. (Australian Medical Association Position Statements: Rural and Remote Health (July 2001). Women are seeking an increase in the flexibility of rural practice, supported by access to part-time work. They want flexible practice arrangements especially when the children are young, including flexible working hours and on call rosters, and the possibility of job sharing. They also want less commitment to after hours work, especially while their children are young (White & Fergusson 2001, Tolhurst 1997, Wainer 2001, McEwin 2001). Research has identified that the change that most women felt was important was to be paid properly for what they do (Wainer 2001). This could be through increased fees in recognition of the increased level of responsibility of rural practice, increased fees for the longer, more complex consultations women are often required to provide, a pap smear incentive programme, payment for being on call to offset the costs of child care, financial support to cover the costs of child care and travel when attending continuing education events, and tax deductibility of child care. Strategies
a.Ensure equitable
representation of women in rural doctor professional organisations
There are many areas of medicine where women do not experience a sense of being highly valued, and rural medicine should not be one of them. A welcoming and embracing response from colleagues and professional organisations and communities would be very attractive to women, who have identified avoidance of the competitive and hierarchical nature of other areas of medicine as one of the main attractions of family medicine. Women are hungry for the experience of being valued colleagues and members of their profession. The first branch of medicine to do that, rather than grudgingly make small incremental changes, will attract women with all that they have to offer. It makes sense for rural practice and rural communities to take the lead in this, and in some ways it has. Written by: Jo Wainer, Senior Lecturer, Monash University School of Rural Health
Chair: Dr Barbara Doty, Alaska Members of the Working Group who have provided comment and support: Dr Lexia Bryant, Australia; Ms Jo Wainer, Australia; Dr Kate Dawson, Scotland; Dr Marietjie de Villiers, South Africa; Dr Helen Tolhurst, Australia; Dr Jane Greacen, Australia; Dr Zorayda Leopando, Philipines, DrBerta Nunes, Portugal; Dr Mary Johnston, Canada; Dr Elma de Vries, South Africa; Dr Leslie Rourke, Canada, Dr Kathleen Ellesbury, USA; Dr Sarah Strasser, Australia. Additional support for the document has come from Dr Emily Bray, USA; Dr Joe Richardson, USA; Dr Cathy Scrimshaw, Canada; Dr Debra Phillips, USA; Dr Deb Pohlman, USA; Dr Jane Farmer, UK; Dr Jennet Hermison, USA; Dr Jill Konkin, Canada; Dr Maggie Watt, USA; Dr Madelyn Pollock, USA; Dr Maureen Topps, Canada; Dr Patty Vann, Canada; Dr Rebecca Bingham, USA; Dr Carol Rowntree, Canada; Dr Roxanne Farenwald, USA; Dr Georgina Moore, Australia; Dr Philippa Binns, Australia; Dr Jane Birks, Australia; Dr Ursula Russell; Dr Caroline Knight, Canada; Dr Rachelle Nyenhus, Canada; Dr Manisha Fernando, Australia. Medical student contribution and support from: Ms Tess Goodwin, Australia; Ms Yvette Vella, Australia; Ms Melissa Jackson, Australia; Ms Sam Maisey, Australia; Ms Mary-Anne Grieve, Australia; Ms Kim Yaw, Australia; Ms Felicity Hawkins, Australia; Ms Nicole Hall, Australia; Ms Emma Rosenthal, Australia; Ms Joanne Moore, Australia; Ms Camille Michener, Australia; Ms Aileen Underhill, Australia; Ms Elizabeth Stalewski, Australia; Additional student contribution from Ms Kellie Seymour, pharmacy student, Australia
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