Table 3. A summary of the major challenges to the resilience of female family doctors and possible recommended solutions at the personal, team, and systemic level
At the personal level
Unplanned transitions pose a greater threat to resilience. Control is important.I suppose it undermined my confidence as well because I felt that well ok this is something that I’d not planned and so I thought people may think I am irresponsible or whatever ...’ (P37) 1. Rehearse possible scenarios : planned life transitions, such as a career shift, getting pregnant, or retiring, are all good examples of transitions where the next step can be rehearsed. Talking to people who have already had similar experiences, exploring implications with significant others, and listening to your own fears and doubts can all be useful. Planning for the unexpected can help when unplanned life transitions arise, for example, illness or sudden loss.
Gendered expectations lead to pressure on females from multiple competing demands, influencing resilience. ‘There were some nights I was on call on labour and delivery and they would text me pictures of their homework and we would do homework over the phone, while I was watching the monitor of a patient in labour. This was not the way I wanted to be a mum to them, and this was not the way I wanted to be a doctor. I was pulled in two different directions and not doing either job well.’ (P3) 2 . Be kind to yourself and take a long - term view : decide on your priorities and make proactive choices to enable you to achieve these. Ask for help and do not put pressure on yourself to be, for example, the ‘perfect doctor’ and the ‘perfect mother’. Take time for yourself and protect your own personal interests.
Individuals need access to personal support networks to build and retain resilience. ‘So when I speak about my resilience or how I am able to adjust to make it work, I must also speak about my support, my village, my community ...’ (P3)‘So I’m lucky here that I do have a few very close friends that feel like a family to me actually so I guess where you go you kind of you know you find people I suppose that understand you ...’ (P8) 3. Ensure that you access supportive others who have relevant experience and expertise : friends, colleagues, professional support networks, mentors, and your own doctor or occupational health lead can all be useful. Doctors often need to give themselves permission to confide in others and ensure confidentiality, but the literature shows that sharing concerns and allowing emotions to surface are important for successful transitions, particularly if these are unexpected and/or traumatic. Being in a new situation can be isolating; reach out early to find local support or plan regular contacts with previous friends and colleagues via the internet.
At a team level
Isolation is a risk during some transitions, for example, those early in a career, working in more dispersed settings, or returning to work from a period of leave. ‘I was alone with my two partners who were old and close to leave so they didn’t want to make any innovation in the office and it was very difficult for me because it wasn’t what I wanted ...’ (P26) 4 . Create support structures and personnel leads as well as protocols and guidance so that everyone in a team knows how to access these when transitions occur : these may be guided by legal or personnel frameworks and may also be needed when people return to work, as this is often a period of stress and uncertainty.
Lack of formal or informal mentorship can be a barrier to resilience, as can a lack of female role models. ‘I had good examples from our senior mentors [consultants] like they were mums they raised families they raised kids and they all turned out to be good family physicians … and they’re good leaders in our national organisation and they’re such an inspiration for us younger consultants or younger practitioners ...’ (P23) 5. Offer a contact or mentor for a specific situation : mentorship in a new role or a return to work enables proactive support. Having a named person gives the message that it is acceptable and important to seek help.
Inflexible working hours, insufficient affordable childcare, and poor support for those working LTFT may lead to females leaving the workforce.‘... part of the challenge will be retaining family doctors especially female doctors if there isn’t more part time options ...’ (P8) 6. Create flexible opportunities and ensure inclusivity and skill development for all : no member of staff should be systematically excluded from training and development opportunities because they are part-time, have been off work for a period of time, female, less experienced, or hold a position perceived to be of lower importance to others.
A culture of medicine that prizes hard work and invincibility as a badge of honour (P3) exacerbates risk of burnout. ‘There are so many societal expectations, colleague expectations, training expectations, financial expectations, that push us toward working harder, seeing more patients, and ignoring our own feelings.’ (P3) 7. Create a supportive workplace ethos with a shared work ethic and regular contact with peers : ensure all staff feel valued by patients, colleagues, and the organisation. Monitor working hours and create a culture where working overtime is seen as a problem that needs to be proactively addressed.
At a systemic level
Legislative, licencing, and bureaucratic barriers can impact on females’ ability to undertake work. ‘So there was no specific programme system that a doctor is trained in family medicine you either set up your own clinic or you worked in a private hospital with somebody there’s no organised healthcare system ...’ (P39) 8. Knowledge of rights, laws, and best practice should be actively disseminated by national bodies : ministries, training schemes, employers, medical licensing agencies, insurers, and professional member organisations can all play a part in ensuring that doctors are aware of the ‘rules’ that should protect their situations. It is especially important that these are shown to be applicable to the different settings where doctors may practice; small businesses, managed care organisations, and those that are self-employed need to be included, just as issues for females or LTFT workers may need specific information. Progressive and inclusive legislation and policymaking should routinely take a gender equity lens and make explicit the ways in which different situations may legitimately need different solutions within a framework of principles and values.
Expectation of full-time working for doctors in many countries can be a barrier to retention. ‘I think the reality is that women have more family issues and especially in the Asian culture like we are expected to look after the kids and we take on that responsibility, and so should there be some kind of flexibility in the system.’ (P37) 9. Careers and workforce planning should embrace and expect flexible working : most doctors in most specialities will have periods where they need time out to be caregivers or for their own wellbeing; this is also relevant if people adopt more than one role or special interest. Professional and personal reasons for breaks in service and LTFT working should be treated equitably, and similar solutions may be found regardless of the reason. The culture and practice of medicine can be improved by career variation in a lifetime, and flexibility enhances both retention of talent and professional skills. Examples of good practice and innovative solutions should be shared at a systemic level (for example, via family medicine organisations).
Legally defined gender discrimination may be relatively rare, but experiences of gender inequity are common. ‘Unfortunately we are not winning the battle yet … the requirements for women for a woman are much stricter than for a man and of course I experienced that personally where a man was chosen before me not because he had more qualifications’ (P17) 10. Equitable career opportunities : specific outreach is appropriate to ensure people access new opportunities and the monitoring of uptake by gender, speciality, and working background is appropriate.
  • LTFT = less than full-time. P = participant.