Enemy Within Intensifying Rural Clinician Shortages?

Marcia Frellick

October 25, 2019

Interviews with primary care clinicians and clinic directors in a rural agricultural region of California revealed that harassment and institutional discrimination were factors in some clinicians deciding to change practices or leave the area, researchers reported October 23 in JAMA Network Open.

The study was small and its generalizability to other areas is unclear. Without a nonrural comparator group it is difficult to tell whether the experiences of those interviewed are connected to the rural environment or if they would have had those experiences elsewhere.

But the findings show that harassment and discrimination in rural areas can present a real health access issue, because if affected clinicians relocate, there may be no one to replace them, lead author Michelle Ko, MD, PhD, told Medscape Medical News.

For example, if discrimination results in a hospital denying privileges and it's the only hospital in the region, a physician would be forced to move.

Multiple female clinicians interviewed reported leaving a practice because of a hostile work environment, said Ko, with the Division of Health Policy and Management at University of California, Davis.

That's an issue, for instance, if what they're leaving is a community health center, Ko continued. "It's so hard to get people to come to these areas as it is."

Previous Studies Focused on Nondiverse Clinicians

Ko and coauthor Armin Dorri, BA, BS, also from UC Davis, note that previous studies nationally have not reflected the diversity common to California's agricultural areas, and instead have primarily included non-Latino white men and women and looked at different workforce issues.

"To date, no study has examined differences by race/ethnicity, sexual orientation, or gender identity," they write.

The region sampled was California's Central San Joaquin Valley. Of the 4 million residents in the eight-county area, 44.5% are uninsured or enrolled in Medicaid, 51.4% of the residents are Latino, 34.1% are non-Latino white, 6.6% are Asian American, and 4.5% are African American/black. An estimated 5.4% of residents identify as a member of a sexual and gender identity minority (SGM) group.

Of the 26 primary care clinicians and clinic directors interviewed, 16 (62%) identified as female, 12 (46%) as non-Latino white, and 3 (12%) said they were part of an SGM group.

Reports of Harassment and Hostility

The researchers found discrimination against those in SGM groups was the most severe, as some said they were denied hospital admitting privileges and were threatened with loss of license.

"Two SGM participants described overt hostility, including receiving expletive-laden notes and vandalism of their cars," the authors write.

Those who identified as female, nonwhite, and of certain sexual orientation and gender identity minorities "described burnout from bias, harassment, and hostility in their professional relationships with colleagues and health care staff," the authors report.

"Three participants reported harassing behaviors from male colleagues (including sexually inappropriate jokes and degrading comments about females) and the use of medical practice and hospital computers to view pornographic material," Ko and Dorri write.

Many of those interviewed said they felt unsupported by administrators, who denied the claims of bias, according to the authors.

Participants who reported negative experiences emphasized that they occurred with colleagues, staff, and administrators, but did not come from patients.

Ko and Dorri bring to light an important aspect that may affect further recruitment of clinicians in rural areas, writes Donald Pathman, MD, MPH, with the Cecil G. Sheps Center for Health Services Research at University of North Carolina in Chapel Hill, in an invited commentary.

He suggests pathways for widening these discussions.

"Through the annual conferences of the National Rural Health Association, National Association of Community Health Centers, National Rural Recruitment and Retention Network (3RNet), and state primary care associations, physician leaders and administrators can be made aware of the problem and its consequences, taught to recognize the issues in their own organizations, and learn of remedies," he writes.

He adds that a restorative justice model may be a strategy for approaching the problem because participants gather, acknowledge the offenses, try to repair harm, and prevent recurrences.

Ko said they did not set out to study harassment and bias, but rather to explore what primary care practice meant currently in the diverse central valley.

Interviewees quickly introduced the topics of bias and harassment, so researchers added questions to the interviews, she said.

Ko said she hopes their article inspires people to think about harassment and discrimination within the context of rural/agricultural areas as medicine works to increase healthcare access. She also hopes it sparks discussion "whether these issues need to be confronted in policy or in the culture of our profession."

JAMA Netw Open. Published online October 23, 2019. Full text, Commentary

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