Goin' to the country: challenges for women's health care in rural Canada.

Ihave been a female physician in “rural” general practice for 24 years. My husband is a rural doctor, as was my father. I have seen rural medicine before and after medicare, in the east and in the west, by sea and by mountains, in depressed and in prosperous areas, and in communities supported by fishing, farming and forestry. As the first female physician in 2 communities and, for most of the time I’ve worked, the only female physician, I have witnessed much of what constitutes “women’s health” in rural practice. Yet I have become more and more discouraged as the realities of rural practice are ignored by government, professional medical bodies, universities and even the field of women’s health itself. Of the one-third of Canadians who live in a rural setting, half are women. Rural Canadians produce 40% of the gross national product but receive only 10% of services in health and education. In one Ontario study 30% of the population but only 11% of the physicians were rural. This is grossly unfair: apparently, it is acceptable for rural Canadians to receive third-world medicine while they subsidize first-world standards for urban areas. Twenty years ago the gap in health care between urban and rural Canada began to widen; in the last 10 years it has become vast. Although some of the incentive programs, on-call compensation and acknowledgment of the special and extensive skills needed by a rural physician have started to make an impression in eastern Canada, the problems of recruitment and retention are worsening in the west. The reduced level of service previously provided is diminishing. This situation is exacerbated by the fact that the larger numbers of women now graduating from medicine have shunned rural practice, so that the undersupply of women in rural practice is greater than that of men. Much of the current discussion about recruitment and retention of rural physicians focuses on a sustainable lifestyle, but the definition of “sustainable” must change significantly if women physicians are to consider rural practice. My initiation into rural practice was a patient load of 2000, over 100 obstetrics cases per year, a 100-hour work week and an on-call schedule of 1 in 4 or 1 in 6. This was heavy enough to force many women out of rural practice and makes rural practice a hard sell to female medical students. The positive aspects of rural practice — doing “real” front-line medicine, making a difference, and experiencing the welcome and appreciation of rural women — are eroded if the load is too heavy. The positive aspects of rural living — of clean and beautiful surroundings, outdoor recreation, less traffic and noise, closer contact with your community and friends, and more independence in your life and work — can only be enjoyed if you have time and energy. Merely surviving is not a sustainable lifestyle. There have been discussions recently about call responsibilities representing a second job in rural medicine on top of a doctor’s primary job — his or her practice — but this situation is intensified for a woman physician, for whom call comes third, after home and family life and her practice. For a rural woman, to “prefer” a female physician means travelling some distance to get medical care. Rural women are a practical lot and are grateful if they can get any medical care. For them, there is little use in preferring a female doctor if it means money and time they can ill afford on a trip to the city. In my experience, the urban woman who has moved to a rural area wants and will seek the Editorial