eMJA: Tolhurst et al, Women in rural general practice: conflict and compromise

Editorial

Women in rural general practice: conflict and compromise

The difficulties of practising in the country and of being a woman compound each other

MJA 2000; 173: 119-120

Although women now make up almost 50% of Australian medical graduates,¹ they are under-represented in the rural medical workforce. In 1998, only 19% of female general practitioners (GPs) worked in rural areas, compared with 23% of male GPs, while 27% of Australia's population lived in these areas.²

Recruitment and retention of women in rural general practice is increasingly important. In rural areas, GPs provide a large proportion of medical services but are in short supply. More women than men are now entering general practice -- 57% of GP registrars who enrolled in the training program of the Royal Australian College of General Practitioners (RACGP) this year were women.³ If rural communities are to have equitable access to health services, then more women must be attracted to and retained in rural practice.

In addition, there is evidence that female GPs practise in a style that differs from that of male GPs: they treat different conditions, provide longer consultations and perform fewer procedures.⁴ The smaller number of female doctors in the rural medical workforce limits the access of rural populations to female practitioners; this is of particular concern to young women in rural areas.⁵

Until recently, research on factors that affect recruitment and retention of rural GPs has not focused on possible sex differences,^6-10 and little has been published on this topic in peer-reviewed journals. In 1997, we undertook a pilot study of factors that affect recruitment and retention of female GPs in rural practice, particularly their social support needs.¹¹ This study involved six focus groups of six to 10 women GPs, followed by a postal survey of 155 female GPs in rural Western Australia and New South Wales. The survey questionnaire was returned by 117; the concerns they identified are shown in the Box.

In addition, a number of other reports on this topic have been funded or commissioned by the Federal Government.^1,12-14 Recently, the National Rural General Practice Study (NRGPS) identified sex differences in priorities and levels of satisfaction about quality-of-life issues, such as practice and social environments.¹² Rural doctors usually work longer hours than urban doctors and provide more after-hours services.¹³ While both sexes are affected, the impact is compounded for female GPs because of their home and family commitments -- female medical practitioners commonly assume the main responsibility for childrearing and the home, whether or not they have full-time careers.¹⁴ Role conflict is thus likely to be a greater problem for female than male rural doctors, although it would also be a problem for male doctors who assume the main responsibility for childrearing and the home.

Responsibilities for care of children, as well as remoteness, also limit female rural GPs' attendance at continuing medical education events.¹¹ Involvement in after-hours work contributes to their concerns about personal safety.¹³ Our 1998 study of violence against rural GPs, which included a postal survey of 314 rural GPs (including 91 women), found that female rural GPs are more apprehensive about the possibility of violence during the course of their work than their male counterparts.¹⁵

Our 1997 pilot study also found that the small number of female professionals, particularly doctors, in rural areas compounded the problem of social isolation for female rural GPs.¹¹ Although social isolation may also be a problem for some male rural GPs (eg, solo practitioners), the NRGPS identified "more peer support" as a higher priority for female than male rural GPs.¹²

Female and male doctors are also attracted to different aspects of rural practice.^11,12,14,16 For example, female rural doctors rate the opportunity to carry out inpatient care and access to hospital as less important than male doctors.¹² A study in Victoria found that women made up 30% of doctors in towns without hospitals, but only 7% in towns with hospitals.¹⁶

We asked our focus groups for strategies to address the problems they had raised. Suggestions included:

More flexible childcare services and financial subsidies for childcare;
Childcare for continuing medical education programs;
Support and email chat groups for female rural doctors;
Discussion of gender issues in medical practice during undergraduate and postgraduate training;
Involvement of Divisions of General Practice in improving the availability of health services for rural doctors;
Adequate workplace security at a local and regional level, especially for after-hours services;
Suitable continuing medical education programs for female rural doctors that reflect their practice content; and
Retraining for rural female doctors returning to the workforce.

A number of groups, including Monash University and the University of Newcastle, the NSW Rural Doctors Network, the RACGP and the Australian College of Rural and Remote Medicine, are already developing ways to better support female doctors in rural areas, including some of the suggestions from our pilot study. These include the development of curricula on gender issues in undergraduate medical programs and support groups for female rural GPs. The General Practice Partnership Advisory Council (which advises the Commonwealth Department of Health and Aged Care) is currently acting on recommendations of the 1998 General Practice Strategy Review to increase recruitment and retention of women in rural general practice.¹⁷

The recent numbers of women entering the rural training stream of the RACGP training program are encouraging (47% of entrants in 1999³). However, to attract and retain more women in rural practice, it needs to be structured to reflect the ways in which women practise medicine. This may involve more flexible models of practice, which accommodate the doctor's home and family commitments, and in which the type of work performed by many female doctors is valued and given practical support.

Helen M Tolhurst
Senior Lecturer in Rural General Practice

Jane M Talbot
Senior Lecturer in Rural General Practice
Faculty of Medicine and Health Sciences,
University of Newcastle Newcastle, NSW

Louise L T Baker
Program Manager for Education and Workforce NSW
Central West Division of General Practice, Cowra, NSW

Australian Medical Workforce Advisory Committee and Australian Institute of Health and Welfare. Female participation in the Australian medical workforce. Sydney: AMWAC, 1996: 7.
Data supplied by the Australian Institute of Health and Welfare.
Unpublished data from the Royal Australian College of General Practitioners.
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Kamien M. Report of the ministerial inquiry into the recruitment and retention of country doctors in Western Australia. Claremont, WA: University of Western Australia Department of Community Practice, 1987.
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