Support for Rural Practice: Female Physicians and the Life–Career Interface

Introduction:  The need for family physicians in rural areas across the USA and Canada is a longstanding issue that has r Rural and Remote Health rrh.org.au James Cook University ISSN 1445-6354

been well documented. Since family physicians constitute the largest population of rural practitioners, the problem has been exacerbated by a sharp decline in medical students' interest in the field of family medicine and the aging of the current rural workforce. Previous research has shown that female physicians in rural areas need strong support networks to maintain a healthy work-life balance. The purpose of this study was to better understand the types of support they need and how they find it, as well as how their needs change over time. Methods: Twenty physicians from the same rurally focused family medicine residency were interviewed over a 3-month period using a semi-structured format. Physicians ranged in experience from 1 year out of residency to 25 years out of residency. Using a phenomenological approach, interviews were transcribed and then coded and analyzed by three members of the research team, one of them an experienced qualitative researcher, who met periodically to reflect on the process of coding. Emergent subthemes and themes were discussed by the multidisciplinary team.

Keywords:
female physicians, life-career interface, primary care, retention, support networks, USA.

Introduction
The need for family physicians in rural areas across the USA and Canada has been well documented . Since family physicians constitute the largest population of rural practitioners, the problem has been exacerbated by a sharp decline in medical students' interest in the field of family medicine and the aging of the current rural workforce .
The need for physicians is especially acute in the north-west, where a vast physical frontier constitutes one of the most rural segments of the USA. Alaska, Idaho, Montana, Washington and Wyoming, for example, encompass 27% of the nation's land mass and only 3.3% of its population . The practice of family medicine in these areas is very broad in scope and covers a diverse population in terms of age and health status. Physicians there must perform a wide range of procedures and be available for long hours of call.
Although women are more likely than men to go into family medicine, they are less likely to practice in rural areas . Female physicians are more likely to attend to births and women's health issues than their male colleagues , and rural areas suffer from a shortage of obstetric providers .
Recruiting, retaining and promoting the success of female physicians in rural communities are therefore crucial steps in improving rural health.
The most salient factors for recruiting and retaining female physicians can be subsumed under the category of supportthrough organizational structures and practices, networks of people, and personal coping strategies that give women a sense of control over their time and resources .
This qualitative study provides a more in-depth examination of the types of support female physicians need and how they find it, as well as how their needs change over time. The context of support used to guide this research was informed by the literature on gender differences between male and female physicians, as well as research on emotional labor, especially as it applies to the practice of medicine. The findings, which are consistent with earlier research on female physicians, provide a better understanding of the strengths and limitations of current medical training and identify information for future training that would improve women's preparation for rural family practice.

Methods
This was an exploratory descriptive study using a phenomenological approach to data gathering and analysis .
The goal was 'to capture the meaning and common features, or essences, of an experience or event' , in particular the lived experience of female physicians practicing in rural areas in the north-west region of the USA. Many themes emerged, including areas of adequacy and inadequacy in preparation for rural practice, but these are beyond the scope of the present article. Interviews were conducted between June and October 2016.
The physician-peer interview approach may lead to greater disclosure and more meaningful conversations than interviews conducted by non-physicians . In keeping with the phenomenological method of observing participants 'in context,' the primary researcher traveled to remote locations and interviewed most of the physicians in their homes and offices.
The interviewer formulated overall impressions afterwards and reflexively noted her own presuppositions, surprises and emotional reactions . All interviews were recorded to a secure electronic device. Collected data were de-identified using a master list of participant names and a unique identifying number.
After the interviews were completed, they were transcribed verbatim by the primary researcher, transported into Dedoose, a digital program for coding qualitative and mixed methods research, and initially coded by the primary researcher. A descriptive coding framework was developed around the interview topics. Among the key themes that emerged from the first coding was the necessity of support systems.
Subsequently, two other members of the research team, neither of whom were physicians, downloaded the transcripts on their laptops and recoded them intuitively. In that process, the descriptive codes related to support were divided into subcodes. All three researchers used an immersion and crystallization approach in which they immersed themselves in the transcripts by reading, rereading and note-taking; reflected individually and collectively on the data analysis; and coidentified emergent themes and subthemes . Discussions of the data and coding were held with the full research team -an interdisciplinary group of researchers in public health and the social sciences -to resolve differences in interpretation and to discuss implications.

Ethics approval
All research procedures were approved by the University of Washington Internal Review Board (#51665).

Results
The team analyzed 20 transcribed interviews, which were an average of about 5300 words in length. Participant demographic characteristics are shown in assistants and residents.
Given the long hours and the multiple and varied responsibilities of rural family medicine, physicians discussed the types of support they relied on to manage their work and personal lives. Major sub-themes included the necessity of family and social support systems, self-care practices, systemic support in the practice environment, and access to professional mentors and continued education.
Family support systems were crucial, starting with the spouse.
Besides strong support at home, extended family, friends and paid caregivers were also important. Self-care practices, such as limiting or avoiding time spent charting at home, turning off electronic devices, exercising, pursing hobbies and, for one physician, daily prayer, were crucial. At work, systemic support was necessary to assure flexible hours, including the ability to limit or avoid on-call hours and to change the scope of practice.
Access to other physicians and medical staff and time for continuing education also helped practitioners remain engaged and avoid burnout. It's hard to escape that in a small town, so you really have to disappear when you leave.'

Support from medical partners and practices
Rural physicians also need supportive work partners and a practice system that advocates on their behalf. The physicians in this study described what they would look for if they were again looking to select a rural practice location. They described the importance of researching the area and the medical practice itself. Besides the town and its proximity to family and other support networks, it is also critical to consider the gender and age of the other physicians, the group dynamics of the medical practice, the sufficiency of support staff, and the level of administrative support available. In offering a final piece of advice, one physician (participant 9) recommended finding 'a really good group to practice with' , which she explained in terms of her own experience working in two small towns just 110 km (70 miles) apart. One town had a solo practitioner and two small groups of physicians that were all 'stabbing each other in the back' . The second town had two groups of family physicians that shared a far more collegial atmosphere, and this is where she chose to practice.
A good nurse and other staff are important and sometimes hard to find in rural areas. 'They tell you that you can hire your own nurse when you come in, but there is a shortage and a lot of turnover,' said one physician (participant 19). She noted that, because two of her partners had not had a nurse in 3 years, she felt lucky to have one, although she did not think they related to one another very well, which was a continual source of stress for her.
Administrative support is not only necessary for effective contract negotiations, adequate maternity leave and flexible work hours, but also for much-needed emotional support. One The married physicians described their career-life balance in a variety of ways, ranging from 'happy' and 'satisfied' to 'not good' and 'not satisfied.' Those who were satisfied said that it had taken a while to get to there. Those who were moderately or somewhat satisfied said that it 'depends on the day' . Those who were dissatisfied usually were in a practice situation over which they had little control, were working too many hours, and were feeling unappreciated and under-compensated. physicians talk more overall and discuss more psychosocial information than do patients of male physicians. They also provide more biomedical information, perhaps because female physicians' questioning and partnership building encourages disclosure. These differences are clearly reflected in charting practices, as female physicians record proportionately more diagnoses of a psychosocial nature than do their male colleagues, which creates the need for more documentation .
It is not just the number of hours worked but also the emotion involved that sometimes makes the life-career interface difficult.
As one physician (participant 2) in this study noted, 'The harder the days are, even if they're not as long, you're left a little short with your family at the end of the day. Sometimes I feel bad because I need to come home and just take some time to myself, but I don't want to be away from them. But I'm also not really in a good place, so that kind of balance is hard …' .
This physician is talking about emotional labor, the process of managing feelings in accordance with requirements and expectations for interactions on the job and at home .
Research indicates that certain types of emotional labor, such as 'surface acting' or 'faking it' , in interactions with patients negatively correlate with job satisfaction . However, when caregiver and patient share a reciprocal, caring relationship and genuinely express those feelings, as is the case with many of the physicians in this study, work feels less emotionally demanding and more satisfying and meaningful for the caregiver . Another physician (participant 15) relishes 'those emotional connections' with patients, even though they are sometimes difficult. 'This week in particular has been really tough with two

Conclusion
Residencies training for rural practice must acknowledge the need for support systems and teach how to build and sustain them. Female physicians will better understand the relevance of support networks when they understand the costs and benefits of emotional labor. Support networks mitigate the effects of emotional labor and help build resilience, a learned trait that is strongly associated with family physicians' overall happiness and wellbeing .
Building support starts with negotiating a contract that allows for a healthy life-career interface, including a workable family leave policy and flexibility. Negotiating a contract not only involves knowledge of alternative ways of practicing rural medicine, but also self-knowledge and the confidence to ask for what one wants and needs.
Limitations of this study include a geographically restricted sample that was too small to reach saturation and a lack of diversity in terms of race and ethnicity. It is descriptive in nature and does not provide quantitative data to support qualitative findings, although results are confirmed by previous research on rural physicians. Also, the study reports exclusively on physicians who are still practicing. A study of graduates from residency programs who have left rural practice would provide useful information about the situations that cannot be successfully negotiated and the intractable barriers to a successful life-career interface.