Chair: Dr Barbara Doty, Alaska

Members: Dr Lexia Bryant, Australia, Ms Jo Wainer, Australia, Dr Kate Dawson, Scotland [please add yourselves to this list]

To support women working in rural and remote family practice

To increase the number of female doctors working in rural and remote family practice

To ensure that female rural and remote doctors have equitable input into the development of policy and programmes affecting the rural medical workforce

1. Recruitment
1. Attracting rural women into medicine
2. Providing female medical students with rural experience
3. Female mentors
4. Teaching about gender issues for rural doctors
2. Training
1. Accessible appropriate skills training for rural practice
2. Flexible and accessible continuing medical education
3. Safe learning environment
4. Female trainers
5. Gender skills as core curriculum
6. Support and assistance for workforce re-entry
7. Training in management, leadership, negotiating skills and information technology
8. Child care arrangements for continuing medical education events
9. Training in methods of dealing with threatening, difficult and dangerous situations
3. Support
1. A place for the whole family
2. Support for the doctor while she cares for her community
3. Regular leave and female locum support
4. Female rural doctor network
5. Respect from male colleagues
6. Access to health services for self
4. Structure of rural medical practice
1. Flexible work practice
2. Embed systems of part-time and interrupted work
3. Transparent (contracted) working arrangements
4. Provision for flexible on-call arrangements
5. Maternity leave policies
6. Child care for on-call and after hours work
7. Safe working environment
5. Representation and leadership
1. Equitable representation in rural doctor professional organisations
2. Search plan to recruit women into leadership positions
3. Organisations responsible for ensuring women are included
4. Present at national and international conferences

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.

International organisations are now recognising that twenty-first century science will demand a twenty-first century work place where women and men from diverse regions of the world are fully and equally empowered to do their best for the world's future (Consultative Group on International Agricultural Research 1999).

The biggest challenge to the prevailing social order is the release of the productive and creative energy of women from the constraints of reproduction. For the first time in three thousand years women are beginning to take their proper 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 which 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, which have been developed without their input.

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 doctors, 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 are women (MWIA 2001). 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). 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).

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 a period of 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 emphasise 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. 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.

Because the current system of Western medicine has always been practiced by men, 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 different priorities and values of women.

Doctors are underrepresented in rural and impoverished areas, and in Western countries female doctors are currently even less likely to go into rural practice than their male colleagues (Strasser, Kamien, Hays & Carson 1997).

In the USA only 12% of rural family physicians/general practitioners are female (WAMI 1998), although this is nearly 43% among the most recently graduated cohort. Female generalists in the USA are consistently less likely than males to practice in rural areas. In Australia 27% of rural general practice doctors are female, although 40% of rural family physicians under the age of 35 and 60% of rural family medicine trainees are female. In the Philippines a majority of rural doctors are women. [we need data from other countries here please]

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.

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). 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.

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.

Workshops at Wonca World Rural Health conferences in Durban (1997) and Kuching (1999), and at the Wonca Conference in Dublin (1998) have tested the theory that women and men practice medicine differently, and some of the implications of that. The Wonca 4^th World Rural Health Conference in Calgary produced the Calgary Commitment to Women in Rural Family Medical Practice.

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:

• listening

• good at teamwork and relationships with nursing staff

• understanding gynaecological problems

• value taking care of children

• oriented to primary care and prevention

• greater room for diversity

• will work for less money

• allow the men to value their feminine

• value rural life as better for family life

• female patients appreciate female doctors

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).

The recommendations are:

1. That women be involved in all representative bodies and involved when decisions are being made.
2. Ensure that doctors in rural areas reflect an appropriate skills and gender mix to meet the needs of their communities
3. Support be provided for female rural doctors in practising in ways which reflect their multiple roles of doctor, wife and mother including developing strategies to empower women and men in rural medicine to set their own limits to practice. This may include, but not be limited to, flexible working hours and discontinuous training.
4. That practice patterns preferred by women be adequately remunerated and acknowledged in fee structures.
5. The establishment of spouse and family networks such as the Rural Medical Family Network, education regarding rural doctor/family relationships and professional boundaries
6. The education be provided to communities on the needs of rural doctor and their families
7. That employment opportunities be provided for doctors’ spouses
8. That suitable education opportunities be provided for doctors’ children or funding to facilitate education of the doctors family and to visit family members undertaking secondary or tertiary education
9. That there be funding to permit travel by the doctor and family for recreation and other forms of leave
10. That financial assistance with accommodation be provided for the doctor and family
11. That future international conferences on rural health be structured to ensure the participation of as wide a spectrum of rural doctors as possible, with particular regard to involving women health workers.
12. That future WONCA regional meetings and world congresses contain a strong rural component.
13. That particular attention be paid to the involvement of women in the planning, organisation and programs of conferences. A substantial amount of time should be included in conference programs to discuss gender-related issues, including but not restricted to consideration of personal, family and professional relationships for male and female physicians, and that this include presentation of issues at plenary sessions.
14. That issues in women’s health be highlighted in the clinical sessions at future rural conferences.
15. That child care and programs for children of delegates be provided at all rural health meetings and conferences.
16. That WONCA develop a policy to ensure equitable representation of women doctors on all decision-making bodies.

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.

At a preliminary workshop held in Sydney in 1998 the interactive style of female and male doctors was noted. This showed the following:

The doctors concluded that men need to be more flexible and women need to set limits, and that medical students and young doctors should be taught about this.

A workshop on designing female friendly rural medical practice was held at the Wonca 3^rd World Rural Health Conference in Kuching. Emerging issues from that conference included

• Sustainable practice supportive of women
• Funding that recognises the way women work
• Valuing the feminine style of practice
• Women friendly models of technology
• Gender issues in rural health research
• Gender specific and sensitive indicators of well being
• The health effects of the subordinated status of women
• Bodily integrity for women as a human right
• Women’s sexual health as a priority rural health issue

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 4^th 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. This reads as follows:

The Women in Rural Practice (WIRP) group of the Working Party on Rural Health was established as an outcome of this Commitment and its Chairperson is a member of the Working Party. The development of the Policy on Women in Rural Family Medical Practice is part of the mandate for the working group.

Drawing on this previous work at Wonca rural health conferences and research on the experience of female rural family physicians, the following strategies are put forward to meet the needs of female doctors, and the need of rural communities for women to contribute to their medical care.

Thinking at a systems level female doctors in Australia have identified the strategy of increasing the number of medical students from a rural background, linking female medical students with female rural doctors, providing undergraduate and postgraduate education and training in rural areas, and ensuring there was a career path in rural practice (Wainer 2001, McEwin 2001, White & Fergusson 2001). Australian universities and medical colleges are already putting these strategies into place through the encouragement of rural students to apply for medicine, positively selecting rural origin students into the medical course and helping them maintain their links with rural communities through the activities of rural clubs and mentor schemes that offer all first year students a rural doctor as a mentor through their course. These universities are also increasing the amount of education students undertake in rural settings and in some instances providing a substantial portion of clinical training in rural hospitals and general practice.

1. Attract rural women into medicine through work with rural late primary schools, secondary schools and universities to promote application and acceptance of rural-origin students into medical and health careers
2. Provide female medical students with rural experience
3. Provide female medical students and post-graduate trainees with female rural doctors as mentors
4. Teach about gender differences in professional life and clinical practice as core curriculum in medical undergraduate and post-graduate education.

Australian female rural doctors have recommended that training be available part-time, that female trainees be matched with female mentors, and that training include adequate skill development in areas important to rural practice including emergency, anaesthetic, surgical and obstetric skills (Wainer 2001, White & Fergusson 2001, McEwin 2001). The women are clear about the need for a systematic and comprehensive system of professional development and support tailored to provide them with the skills, professional relationships and confidence to provide the care communities asked of them.

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. There was a suggestion that some events be held during working hours to minimise disruption to families. Additional topics for continuing medical education identified by the women included 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.

1. Accessible appropriate skills training for rural practice, provided locally
2. Flexible and accessible continuing medical education
3. Safe learning environment
4. Female trainers
5. Gender skills as core curriculum
6. Support and assistance for workforce re-entry
7. Training in management, leadership, negotiating skills and information technology
8. Child care arrangements for continuing medical education events
9. Training in methods of dealing with threatening, difficult and dangerous situations

1. Ready access to re-training
2. Training in management, leadership and information technology

Gender sensitive curriculum includes teaching about the importance of research that reflects the way women experience health and illness, and the disaggregation of data by sex. Gender –specific data is data with indicators appropriate to one sex. A gender –sensitive approach recognises different treatment for women and men in the same situation, and Gender-disaggregated research and treatment recognises that the same treatment may have different outcomes in men and women. Both sex -the biologic aspects of being female or male - and gender – the cultural roles and meanings ascribed to each sex - are determinants of health. Medical education, research and practice have all suffered from a lack of attention to gender and a limited awareness of the effects of the sex-role stereotypes prevalent in our society.

Australian research on the changes needed to attract women to rural medicine has found one of the most important is the need to provide work for the partners of female doctors if they are to be attracted to and retained in, rural practice (Wainer 2001). The women were clear that most doctors come with families, and communities and practices that want to attract them would do well to act on the understanding that there must be a place for everyone in the family if they are to move to a new location. This means a job for their partner, and child care and schooling for their children. Single women have different needs, related to isolation and friendship and the awkwardness some rural communities have with single professional women.

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, as well as by their patients.

1. A place for the whole family
2. Support for the doctor while she cares for her community
3. Regular leave and female locum support
4. Respect from male colleagues
5. Female rural doctor network
6. Access to health services for self

The continuing societal expectation that women take primary responsibility for families has a substantial impact on the way women experience and contribute to their profession of medicine. This is highlighted in those areas of practice, such as rural medicine, that require substantial on call work and are resistant to quarantining personal time.

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. 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 Participation in the Medical Workforce)

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) (from A Life, not a wife).

The Australian Medical Association recommends support for female rural doctors to practice in ways which 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).

Australian research (Wainer 2001) has identified that the change that most women felt was important was to be paid properly for what they do. 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.

1. Flexible work practice
2. Adequate payment for the more time-consuming clinical interactions initiated by the patients of female rural doctors
3. Embed systems of part-time and interrupted work into practice structures
4. Transparent (contracted) working arrangements
5. Provision for flexible on-call arrangements
6. Maternity leave policies
7. Child care for on-call and after hours work
8. Safe working environment

All over the world people are drawing attention to the loss to medicine arising from the under-representation of women in decision-making and other positions. The World Health Assembly passed a resolution in 1997 (WHA50.16) "Recognising the additional value that a balance of male and female staff can bring to the work of the Organization: [and] Calls for the target for representation of women in the professional categories to be increased to 50% in WHO".

1. Equitable representation in rural doctor professional organisations
2. Search plan to recruit women into leadership positions
3. Organisations to be responsible for ensuring women are included
4. Present at national and international conferences

Women, and many men, want to be rural doctors and to have compassionate and rewarding family and personal lives as well. To have time and energy for laughter and fun and joy. They love having babies and they love being parents. They are demanding that rural medicine be restructured to allow them to serve their communities while expressing their full humanity, and in so doing are giving men permission to require that too.

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 the competitive and hierarchical nature of other areas of medicine as one of the main attractors to general practice. 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.

ACRRM Prospectus Australian College of Rural and Remote Medicine, Kelvin Grove, Queensland 1997

Australian Medical Association Publishing Company (2001), Sydney

Australian Medical Workforce Advisory Committee (AMWAC) Influences on Participation in the Australian Medical Workforce Sydney: AMWAC, 1998. Report 1998.4

Belenky M, Clinchy B, Golderberger N, Tarule J (1997) Women’s Ways of Knowing Basic Books, Harper Collins New York

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Britt H, Sayer G, Miller G, Charles J, Scahill S, Horn F, Bhasale A, McGeechan K (1999) Bettering the evaluation and care of health. General Practice activity in Australia 1998-9, Australian Institute of Health and Welfare, Canberra, Australia

Consultative Group on International Agricultural Research 1999

de Villiers PJT, de Villiers MR, Family Medicine and Primary Care in South Africa Medical Education 1999;33:716-721

Gilligan C (1982) In a Different Voice Harvard University Press, London

Hojat M., Gonnella J & Xu G. Gender comparisons of young physicians' perceptions of their medical education, professional life, and practice: A follow-up study of Jefferson Medical College graduates. Academic Medicine, 1995; 70(4):305-12

Makan, B. Distribution of Health Personnel, South African Health Review Health Services Trust www.hst.org.za/sahr/98/chap7.htm 1998

McEwin K and Levitt L Wanted: New Rural Workforce Strategies for Female Doctors: Findings from a Survey of Women in Rural Medicine Mascot: NSW Rural Doctors Network, 2001

Medical Womens International Alliance update October, http://members.aol.com/mwia/index.htm Dortmund, Germany 2001.

Moodley K, Barnes JM, de Villiers PJT. Constraints Facing the Female Medical Practitioner in Private Family Practice in the Western Cape South African Medical Journal, February 1999, Vol. 89 No. 2, 165-169

Redman S, Saltman D, Straton J, Young B and Paul C. Determinants of career choice among women and men medical students and intern. Medical Education, 1994; 28(5): 361-371.

Rogers S (1995) Women in the Medical Workforce: The Changing Gender Profile and its Implications A discussion paper prepared by the State Financing Branch, Commonwealth Department of Human Services and Health, Canberra, Australia

Rourke LL, Rourke J, Brown JB. Women family physicians in rural medicine: Can the grass be greener in the country? Canadian Family Physician, 1996; 42: 1063-7, 1077-82.

Strasser R, Kamien M, Hays R, Carson D. National Rural General Practice Study Traralgon: Monash University School of Rural Health, 1997.

The New England Journal of Medicine (2000), Editorial Women in Academic Medicine: New Insights, Same Sad News. February 10, Vol. 342, No. 6

Tolhurst H, Bell P, Baker L, Talbot J, Cleasby L Educational and Support Needs of Female Rural General Practitioners Bathurst: School of Nursing and Health Administration, Charles Sturt University, 1997.

Tolhurst H, Bell P, Baker L, Talbot J, Cleasby L. Educational and support needs of female rural general practitioners. Bathurst, NSW: School of Nursing and Health Administration, Charles Sturt University; 1997.

Turner J, Tippett V, Raphael B. (1994) Women in medicine - socialisation, stereotypes and self-perceptions. Australian and New Zealand Journal of Psychiatry, 1994; 28(1): 129-35.

Wainer J. Female Rural Doctors in Victoria: It’s where we live Melbourne: Rural Workforce Agency Victoria, 2001.

Wainer J. Rural Women’s Health Australian Journal of Primary Health Interchange, Vol 4(3) 1998 Special Issues: Women’s Health, LaTrobe University

Wainer J, Bryant L, Strasser S (1998) Women in General Practice: a workshop WONCA 1998 People and their family doctors – Partners in care: Abstracts, Dublin, Ireland:209

White C & Fergusson S. Female medical practitioners in rural and remote Queensland: An analysis of findings, issues and trends Kelvin Grove, Queensland: Queensland Rural Medical Support Agency, 2001.

Wonca (1999) Rural Practice and Rural Health Chater (ed) Monash University School of Rural Health, Traralgon, Australia

Drafted by

Jo Wainer

Senior Lecturer

Monash University School of Rural Health

Email jo.wainer@med.monash.edu.au

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