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Tuesday Jul 12, 2016

Support, Flexibility at Home, Work Vital to Success in Rural Practice

I have been reflecting on this blog for several days now, waiting for a rare down moment to write about what being a rural female physician means to me. Tonight, as I finally have some time, I realize that the unique challenges of rural practice make life unpredictable and possibly difficult for other physicians to relate to.

My husband (and practice partner) had rounds this Sunday morning at the hospital, so he dropped my daughter and me off at church and headed to work. At church, I received a phone call telling me that I also was needed at the hospital for one of my obstetric patients. I let my daughter's Sunday school teacher know I would be leaving but that my husband would be back to pick her up.  

DMW Photography
My husband, Michael Oller, M.D., and I enjoy rural practice in Stockton, Kan., where we live with our daughter, Lyla, and mastiffs Mitch and Mosi.

My husband came back to church to get me, dropped me at the hospital, finished his own work and returned to church to pick up our daughter. A favor from a friend later and we each had a car at the hospital so my husband could take our daughter home while I stayed to deliver a baby.  

It might sound crazy, but these are situations we frequently encounter. With supportive partners at home and at work, as well as support from friends and our community, however, they always work out. I sit here tonight having helped bring a beautiful baby into the world but also having had to give up a large part of my Sunday. I consider it a worthwhile trade.

The impetus for this blog was a study published in the May/June issue of Annals of Family Medicine(www.annfammed.org) that sought to "understand the personal and professional strategies that enable women in rural family medicine to balance work and personal demands and achieve long-term career satisfaction." The study was based on a survey of 25 rural female physicians in 13 states.

The authors identified three things study participants considered imperative for successful rural medicine careers: 

  • supportive relationships with spouses and partners, parents, or other members of the community;
  • reduced or flexible work hours; and 
  • maintenance of clear boundaries between their work and personal lives.

The United States has a severe shortage of rural physicians, including a dearth of female and minority physicians. The lack of female physicians limits access to care for female patients who would prefer a female clinician. Rural female physicians are more likely to attend births(www.ncbi.nlm.nih.gov) than our male peers, which is an important part of practice in many rural areas with a shortage of obstetric care. 

Many rural physicians choose this path because it allows them to maintain a broad scope of practice. However, this broad scope often also leads to long and unpredictable hours that vary greatly from week to week. (Today's delivery was the third this week for me, leading to longer hours than usual). Creating the support system necessary to meet patients' needs while also supporting our families takes great effort.

What attracts women to rural practice? The majority of the physicians surveyed had rural life experience. However, there are others, like me, who turned their attention to rural practice after experiencing it in a rotation. I graduated from the University of Kansas Medical School, where a rural rotation is required, and I continue to firmly believe that such experiences matter greatly in the choice of future practice. 

We must continue to model for medical students what is great about our specialty, and those of us who practice in a rural setting need to be willing to precept students. It is a rare month when my partners or I don't have a medical student in our practice, and often more than one of us have students at the same time. I am proof that having a female rural medicine preceptor can take a practice setting that had never even been on your radar and make it your career. (That preceptor is now one of my practice partners.) 

There are many challenges of rural practice. As the Annals study points out, rural physicians have fewer community resources, work more hours and care for more patients compared with their urban peers. This produces added stress and, at times, feelings of isolation. In the study, physicians with young children and those new to rural practice described feeling the stress of maintaining balance most acutely. The guilt of leaving family to care for patients and, conversely, spending time with family at the expense of time in your practice, are frequent sources of stress. 

Those with good work flexibility reported highest satisfaction. For many in the study, this meant reduced work hours, especially when their children were young. 

Supportive relationships are also key. Several of the women in the study reported male partners maintaining primary responsibility for managing the household and caring for children. Many had situations similar to mine -- married to physicians in the same practice. In all of those two-physician partnerships, one or both partners worked part time.

Work partners are also important -- other physicians who are willing to help out when family obligations and emergencies arise. We are expecting twins in the fall, and although I don't know exactly what our work schedules will look like when they come, I know that owning our own practice gives us the flexibility we need.

I received an email from my practice partners this evening saying they have devised a back-up call schedule that covers the weeks leading up to the twins' due date. This is the kind of cooperation that makes rural practice, with all of its additional stresses and challenges, sustainable.

Clear boundaries were identified as key for satisfaction. Limiting work and protecting personal time were seen as essential for personal well-being. Work partners often played an important role in this. In my experience, setting expectations for patients can be hard but is extremely important in rural environments; examples include respecting physicians' days off and time with family (i.e., not approaching them with medical questions in a public place).

Corresponding author Julie Phillips, M.D., M.P.H., told AAFP News that rural physicians in the study showed "a really strong sense of devotion to their patients and commitment to their communities." Although it was clear that most physicians in the study loved their work, there were also those looking to change practice because they felt their current situation was unsustainable.

The authors of the study concluded that female physicians considering rural practice may be more satisfied if they seek flexible employment opportunities, choose communities where support is available and build support networks as they select practice settings.

Practicing self-care and setting boundaries are also important skills. These are skills, however, that we are not often taught. Perhaps they could be covered more in medical training, especially in residency. Female physicians entering rural practice need the support of those who have gone before them. These relationships can be fostered through state and national academies, rural interest groups (such as online forums offered by the AAFP), and preceptors encountered during training. 

Women need opportunities in residency training to rotate with rural female physicians. Those of us who live this practice style need to be available to serve as mentors and sounding boards. Female rural physicians are more likely than their male counterparts to plan on long-term rural careers, so let's continue to evaluate and work toward making more rural female physicians a reality.

Beth Oller, M.D., practices full-scope family medicine with her husband, Michael Oller, M.D., in Stockton, Kan.

Posted at 04:28PM Jul 12, 2016 by Beth Oller, M.D.

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