PERSPECTIVE: Women and rural physician leadership
Sarah Newbery, MD
Rural physicians already have a wider scope of practice, higher workloads, greater difficulty accessing continuing medical education, and limited specialist consultation compared with their urban counterparts. As the demand for effective clinical governance, quality improvement, and more formal accountability increases, a commensurate increase in physician resources is needed to lead that work. The proportion of women in rural family medicine is increasing. If we take seriously the need for effective leadership in small systems, then we need to support women to have the capacity to do the work of leadership in small systems effectively.
Marathon is a community on the North Shore of Lake Superior with a population of approximately 3600. The hospital and family health team there also serve the communities of Biigtigong First Nation and Pic Mobert First Nation and offer obstetrical support to other area communities.
The back story
In 1996, my friend and colleague Rupa Patel and I came to do a site visit in Marathon, Ontario, on the North Shore of Lake Superior. We were both finishing a few months of “enhanced skills” PGY3 time in preparation for rural practice and, together with our physician partners, Eli and Mike, we were looking for a community that needed us.
At the time, there was one physician in full-time practice in Marathon and a retired general surgeon who was doing part-time general practice. Approximately 85 physicians had come and gone over the preceding 10 years, and Marathon’s health care system had become unstable. The hospital had lost its accreditation and when, during our site visit, we met the hospital board members, we were shown the stack of burlap sacks that had been prepared to cover the “blue H” hospital signs on the highway. The closure of the hospital’s ER was anticipated if the community was not successful in recruiting.
I was struck by a comment from one of the board members: “The community has never had women physicians before.... I’m not sure how long you’ll last.” He expressed happy surprise when he learned that our husbands were also family physicians: they were getting four docs, not two and, moreover, they were getting two more male physicians to whom the community was accustomed. Top
When we were joined by another two physicians, also a couple, we formed a group of seven rural generalist family physicians: four men and three women. At the time, Marathon was “designated” for five physicians only, and some thought we were foolish to “over doctor” the community.1,2 Statements like, “You won’t be busy enough” followed by “you won’t make enough money” were commonly expressed by other colleagues.
So why would we come to this small town, against others’ good counsel, given all the issues the community faced? We chose to come, in part, because the one physician in full-time practice was willing to embrace a shared leadership model and, in part, because we believed that in having “too many” doctors, we could create a sustainable local health care system for the community.
Now, 22 years later, although as expected in rural communities, clinicians have come and gone, our clinical group has maintained a “full complement” or more of physicians, except during two 3-month periods. Although I have no formal data, I have come to understand that this is an exceptionally rare thing in the context of rural medicine in Canada over the past two decades.
The current state
Our physician group demographic has shifted and is now made up of five women and two men. Ten years ago, physicians led the move locally from a physician-based clinic with a small support staff to a collaborative interprofessional family health team with a physician-led governance model. Our clinic physician group is also our highly collaborative hospital medical staff. Through our clinic and hospital settings, we meet the obligations of our “Rural and Northern Physician Group Agreement”3 to provide care for all who live within our postal code catchment for primary care, ER, and inpatient services 24/7/365. Twenty-two years ago, we led the redevelopment of a low-risk obstetric program that continues still, and we provide local chemotherapy, palliative care, and primary care-based chronic pain and addictions management. Each of these domains of care has required a commitment to clinical leadership.
Our local leadership style is both practical and collaborative. Although some of us have formal leadership roles (chief of staff, chair of board), much of our local clinical leadership is determined informally based on who on our team has the energy, capacity, and passion for particular issues. Our work together is guided by a mission, vision, and principles statement that supports decision-making and helps us maintain our focus on our local social accountability.
We are intentional about working to balance local clinical needs with the needs of our families, our professional interests, and our personal interests outside of medicine in things like coaching local teams, supporting local community initiatives, travel, and personal learning and growth.4
Although there was no LEADS framework at the time, our work here began with local social accountability and, I think, a somewhat intuitive understanding that if we could lead ourselves as individuals (Leads self) and support each other in our work (Engaging others), we could achieve local results. Ensuring that we had adequate local capacity to go beyond the clinical demands meant that we had time for reading, learning at the point of need, and intentional conversation about applying principles of collaborative leadership.
Over time, as members of our group have become more “seasoned” clinicians and our local capacity has been sustained, we have been able to explore research and have taken up formal leadership roles with the Northern Ontario School of Medicine, our regional Local Health Integration Network, and the Ontario College of Family Physicians. Together, we have been able to do this because of a focus on ensuring that our local physician resource capacity considers the needs, goals, and interests of our clinician group beyond day-to-day clinical medicine.
As Dr. Eli Orrantia stated in his 2005 article, “Making a priority of keeping a balance in our lives has provided the creative energy to continue investing in our profession.”4
Rural physician resources, female physicians, and leadership
Small systems require effective leadership for all of the same reasons that large health care systems do. One of the current significant challenges in small systems is that, as the demand for things like effective clinical governance, quality improvement, and more formal accountability increases, there has not generally been a commensurate increase in physician resources to lead that work.
In Northern Ontario, work has just begun to examine the need to match physician resource planning to demands beyond the more traditional clinical workload. Matching physician resources to community and health system needs, changing community demographics, and the needs of physicians is complicated and dynamic. It includes consideration of the challenges of historic maldistribution, increasing numbers of women in family medicine, and the workload of rural generalists.
We know that, while 18% of Canadians live in rural and remote communities, only 8% of Canada’s physicians work in those communities5; almost all are family physicians. And we know that the proportion of women in medicine is increasing. In fact, between 1986 and 2009, the proportion of female physicians overall increased from 18%6 to 40%.7 In parallel, the proportion of family physicians who are female in 2015 was cited to have increased to 43.2%.8
There appears to be a difference in the way that rural and urban family physicians work and in the hours that they devote to clinical work overall. A 2010 study by the Canadian Collaborative Centre for Physician Resources9 noted that rural family physicians reported working more hours in direct patient care and on call than did their urban counterparts. In addition, rural physicians have a significantly wider scope of practice than urban counterparts and need to maintain competence in different clinical areas (ER, obstetrics, palliative care) despite having higher workloads, having greater difficulty accessing continuing medical education, and having no professional backup and limited specialist consultation.10
In Northwestern Ontario, as the proportion of female physicians in rural practice has increased, so too has their proportion in some leadership roles. As one example, in Northwestern Ontario, there has been a shift from having no female hospital chiefs of staff in 1996, to six out of 14 in 2018.
The challenge of limited human resources in rural settings not only affects the ability of rural physicians to meet local clinical needs, but also increases the difficulty they have in obtaining access to leadership education, mentorship, and support and in participating meaningfully in leadership roles in the organizations that shape rural health care in domains of education, policy, and health care delivery.
If we are going to succeed in improving equitable access to high-quality care for rural Canadians, then rural physicians need to be able to participate meaningfully at these broader policy tables as well. That success will depend on having adequate local physician resources, understanding the particular working patterns of rural women physicians, and enhancing access to leadership education and mentorship. Top
Required support for effectiveness
The little research on rural leadership that exists comes mainly from the nursing profession or other international jurisdictions. Hana and Rudebeck11 looked at rural clinician leadership in northern Norway, and their results resonate with me and colleagues with whom I have explored the thinking. These researchers note that the important work of leadership in rural settings is typically done “off the side of the desk” without the ability to create committed time for the key functions of leadership: setting a vision, guiding activities, and building relationships.
Rural health care teams often do not have the luxury of selecting local physicians for their leadership skills.11 There is rarely a list of candidates for rural physician vacancies. Small community health care system stability, then, sometimes rests on the serendipity of leadership interests of the clinicians they are able to recruit and whether the community can recruit to full complement, so that those with leadership interests can create the time to exercise their leadership skills. Given the desperate shortage of clinicians in many rural communities, the adage that “beggars can’t be choosers” is one that often informs the recruitment approach and can create significant challenges for rural communities that need good local leadership.
Contrary to the situation in rural environments, when clinicians enter academic domains or urban hospital departments, some do so with an interest in leadership and with a desire to pursue advancement in leadership. Hana and Rudebeck11 found that the motivation for leadership is not the same in rural areas and settings. In our case, as in many rural areas I have seen, those in rural leadership roles are seen to “have drawn the short straw,” to have been the one “to have blinked first” or simply “it must have been their turn.” Leadership does not have the same cachet as it does in other settings and is not often seen as an achievement but rather as a burden to be borne for a while until another colleague’s turn comes around.
Yet, effective local leadership with support for skills acquisition, time to devote to local system development and evolution, and time to sustain collegial relationships and mentor new clinicians to practise may be a key part of what is needed to create sustainable, robust rural clinical groups that can meet the needs of the whole of the rural or remote community.
The proportion of women in family medicine is increasing. Anecdotally, the proportion of women in rural family medicine is also increasing. If we take seriously the need for effective leadership in small systems, then we need to support women to have the capacity to do the work of leadership in small systems effectively.
We must recognize not only the evolving practice patterns of women, but also the need to include committed leadership time when we think about the number of physicians we should plan for in rural and remote settings. We need to take steps to negotiate for working conditions that allow for the capacity to take on valuable leadership roles.12 We need to support all leaders in rural settings, men and women alike, with the tangibles of mentorship and education. Top
There is an opportunity to continue to build on the good work that has begun in some medical schools in developing leadership curriculum. Even if that early exposure is only to give medical students the language of leadership, an understanding of the importance of Leading self and Engaging others, and the importance of effective leadership in all settings, including small rural ones, we will have offered our graduates a head start as they enter into practice.
The CSPL white paper “Accepting our responsibility: a blueprint for physician leadership in transforming Canada’s health care system”12 makes several important calls to action to individuals, organizations, and associations. Although perhaps it is implicit in the recommended national-level actions, explicit attention must be paid to how we support rural clinicians to participate in leadership, not only locally in their small rural system, but also in representative roles across the health care system, so that we can be assured that health care policies and initiatives in medical education consider what success will be for rural and remote health care communities.
Robust rural clinical groups can be creative in their approaches to service and health care delivery and can be innovators on the margin of the system, nimbly undertaking small tests of change, and quickly responding to evolving local needs in a way that can serve communities remarkably well. Well supported, collaborative leadership in rural and remote environments can be deeply satisfying.
The stability of rural clinical groups, their ability to evolve positively and to advocate for the needs of rural communities beyond their own municipal boundaries will require greater attention both to supporting rural clinical leadership and to generous physician resource planning to support the women who will increasingly make up the rural physician work force. The health outcomes of rural and remote citizens in this country depend on it. Top
When our group of six clinicians joined the one remaining family physician in Marathon, the community had never had women physicians. There had been no female hospital CEO, there were no women practising in the adjacent communities. I am grateful for the women at a distance who took the time to mentor and encourage me, and I am grateful for both my male and female colleagues locally who created space for me to stretch into leadership roles. Truly, we are better together, and rural communities need us to continue to be better for them.
1.O’Reilly M. A Marathon session: a town’s MDs develop a philosophy to call their own CMAJ 1998;158:1516-7
2.O’Reilly M. Medical recruitment in rural Canada: Marathon breaks the cycle. CMAJ 1997;156(11):1593-6.
3.Rural and northern physician group agreement. Toronto: Ontario Medical Association; 2006 and 2008. Available: https://tinyurl.com/y9r9hva4
4.Orrantia E. Marathon works: how to thrive in rural practice. Can Fam Physician 2005;51(9):1217-21. Available: https://tinyurl.com/ycflczdg
5.Bosco C, Oandasan I. Review of family medicine within rural and remote Canada: education, practice, and policy. Background paper. Mississauga, Ont.: College of Family Physicians of Canada, 2016. Available: https://tinyurl.com/yd2sytnb
6.Pitblado JR, Pong RW. Geographic distribution of physicians in Canada. Table 3.4. Ottawa: Health Canada; 1999. Available: http://documents.cranhr.ca/pdf/distrib/GEOREPORT.pdf
7.Summary report: physicians in Canada, 2015. Ottawa: Canadian Institute for Health Information; 2016. Available: https://tinyurl.com/y8eattd4
8.Number and percent distribution of physicians by specialty and sex, Canada 2015. Ottawa: Canadian Medical Association, 2015. Available: https://tinyurl.com/yao5qceg
9.A profile of rural family physician practices. Ottawa: Canadian Collaborative Centre for Physician Resources; 2012. Available:
10.Malko AV, Huckfeldt V. Physician shortage in Canada: a review of contributing factors. Global J Health Sci 2017;9(9):68-80.
11.Hana J, Rudebeck CE. Leadership in rural medicine: the organization on thin ice? Scand J Prim Health Care 2011;29(2):122-8. Available:
12.Van Aerde J, Dickson G. Accepting our responsibility: a blueprint for physician leadership in transforming Canada’s health care system. Ottawa: Canadian Society of Physician Leaders, 2017. Available: https://tinyurl.com/ybpjzou8
Sarah Newbery, MD, is a rural generalist family physician who has been in practice in the community of Marathon, Ontario for 22 years, fulfilling roles as clinician, medical educator, chief of staff, and, from this remote setting, engaging in leadership in other areas of the health care system. Top
This article has been peer reviewed.