Key points are not available for this paper at this time.
The rural general surgical workforce is vital to delivering high standards of healthcare for all Australians. Maintaining rural general surgical services will require greater recruitment of female surgeons as women are increasingly represented among surgical trainees. Currently 21% of the Australian general surgery workforce are female, but only 16% of the rural general surgery workforce are female.1, 2 It is also imperative that the rural general surgical workforce reflects the gender proportions of Australian communities (51% of rural Australian adults are female) in line with the RACS Diversity and Inclusion Plan.3, 4 The characteristics of female rural general surgeons in Australia have never been studied. This study aims to characterize this group and assess factors that may affect recruitment. A 38-question online survey (Appendix 1) was distributed to female rural general surgeons across Australia identified by publicly available Health Workforce Data. Ethics approval was obtained from Monash University (MUHREC: 30642). The survey was distributed via the RACS Women in Surgery and RACS Rural newsletter, February to April, 2022. The survey explored surgeons' demographics and perspectives of working rurally. The primary work location of each surgeon was geocoded according to the Australian Statistical Geography Standard's classification of Remoteness Area: Major City (RA1), Inner Regional (RA2), Outer Regional (RA3), Remote (RA4), and Very Remote (RA5) which is consistent with rurality categorisation by RACS (Appendix 2).5 RA3, RA4 and RA5 were combined to ensure consistency across Australian States and Territories. Statistical testing was not conducted due to the small cohort of respondents. Thirty-six responses were obtained, representing 54% of female rural general surgeons across Australia. Respondent characteristics are shown in Supplementary Table 1. The majority (78%) of respondents were located in RA2 areas compared to RA3+ (22%). Respondents from the RA2 cohort were younger and attained FRACS more recently. A higher proportion of the RA2 cohort lived near extended family (14% versus 0%) and followed their partner's work rurally (20% versus 0%). Of respondents with children, the RA3+ cohort were more likely to have primary school-aged children (67%), whereas the RA2 cohort had children more evenly distributed across age groups. Compared to the RA2 cohort, a greater proportion of the RA3+ cohort had a rural primary (50% versus 25%) and secondary school (38% versus 29%) background. Both cohorts spent 36 months of accredited training time in metropolitan centres (Supplementary Table 2). Thirty-nine percent of respondents took six or more months of time off during accredited training, which was primarily for parental leave (57%) or illness (21%). Appeals and barriers to working rurally are shown in Supplementary Table 3. Overall, respondents most enjoyed working rurally due to ‘proximity to work location’ (92%), ‘lifestyle’ (78%) and ‘nature of work’ (75%). By cohort, RA2 respondents cited ‘proximity to work location’ (93%) and lifestyle’ (86%) as appealing, while RA3+ respondents favoured ‘proximity’ (88%), ‘opportunity to work in a salaried role’ (88%) and ‘job opportunities' (75%). The greatest barriers to working rurally were ‘distance from family/friends' (72%), ‘large workload due to workforce insufficiencies' (50%) and ‘large on-call volume’ (42%). These sentiments were consistent across both cohorts. This research demonstrates factors important to female rural general surgeons. Australian studies have shown that childhood rural background is an independent predictor of future work in a rural setting.6 Our research supports this, especially for those working most rurally (i.e. RA3+). This supports the selection of surgeons of rural background to increase the rural workforce. Our research has shown that flexible working conditions are required to attract and retain female rural general surgeons. Female general surgeons typically work less hours and are less likely to reach leadership roles compared with males, possibly because they are fitting in other life commitments, such as caring roles.7 General surgical training is long and typically occurs alongside major life milestones such as pregnancy and parenting, which may require time off work, particularly for maternity leave. Thirty-nine percent of our respondents took at least 6 months off during accredited training (commonly for parental leave). Furthermore, RACS flexible training candidates are more likely to be female. Therefore, rural flexible training options should be implemented, as all existing RACS flexible training locations are based in metropolitan centres.8, 9 We acknowledge that flexible working conditions may not be limited to rural work, but may be harder to achieve in rural areas and therefore deserve specific attention. Inflexible and longer hours may deter the recruitment and retention of female trainees into rural general surgical vacancies.7 Supporting the non-professional needs of female rural general surgeons is also critical. Australian research has shown that female doctors move away from smaller rural centres when they have young children and a partner in the workforce, in contrast to their male colleagues.10 The majority (86%) of respondents had partners and one-fifth of RA2 respondents reported following their partner to work rurally. Therefore, rural centres may need to consider partners' employment needs in their recruitment strategy. Moreover, childcare is traditionally perceived as a female responsibility, and this requires more support in rural areas compared to urban areas.7 It is important that rural employment opportunities match the preferences of contemporary female surgeons. For RA2 respondents, ‘lifestyle’ and ‘nature of work’ were favoured, suggesting a more personal decision for their choice of workplace. Comparatively, RA3+ respondents favoured ‘salaried role(s)’ and ‘job opportunities’, suggesting the decision to work more remotely is potentially an employment or financially security dimension. Barriers to working rurally were consistent across cohorts (distance from family and friends, large workload and on-call volume). Whilst separation from family and friends is an inevitable challenge, high workload and on-call volume represent workforce shortages that could be addressed with improved recruitment. We anticipate that having a larger pool of surgeons would enable greater flexibility and better work conditions. Jessica A. Paynter: Conceptualization; data curation; formal analysis; investigation; methodology; writing – original draft. Belinda O'Sullivan: Supervision; writing – review and editing. Kirby R. Qin: Data curation; writing – original draft. Christine Cuthbertson: Supervision; writing – review and editing. Janelle Brennan: Conceptualization; data curation; writing – review and editing. Ethical approval was obtained from Monash University Human Research Ethics Committee (MUHREC) Project Identification: 30642. Supplementary Table 1. Demographics of responding female rural general surgeons. Supplementary Table 2. Progression through education and surgical training of female rural general surgeons. Supplementary Table 3. Appeals and barriers to working rurally. Appendix 1. Survey questions. Appendix 2. Australian statistical geography standard remoteness area. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
Paynter et al. (Wed,) studied this question.