Rural Ethics in Healthcare: Are They Different? Should They Be?

Cheryl Clark, for HealthLeaders Media , June 10, 2009

When a rural town's long-time surgeon becomes ill and must retire, a junior partner is quickly trained to perform C-sections and his credentialing is fast tracked, writes Denise Niemira, MD, a family practitioner at the Women's and Children's Health Center in Newport, VT.

But a family physician whose patients may have complicated deliveries is worried about the lack of the surgeon's experience. He wonders if he has an ethical obligation to tell his patients and give them an option to go elsewhere.

"But he is also concerned about the fragile state of surgical and obstetrical services at the hospital" which has had trouble recruiting doctors to such a small town.

At another small rural hospital, doctors struggle with a decision on what to do with heart attack patients. Should they keep them at the hospital and administer clot busting drugs, thus maintaining the hospital's necessary cardiac volume, or sent to a tertiary facility 100 miles away for more appropriate interventional cardiology. "Underlying the discussion was the tension between the need to maintain a competent critical care unit for the community and the desire to serve the best medical interests of each individual patient," Niemira wrote.

One essay by Ann Freeman Cook and Helena Hoas, of the National Bioethics Project at the University of Montana-Missoula, highlighted some disturbing findings. In nine studies they conducted over four years, they interviewed a wide range of health professionals who worked in rural settings throughout the Western U.S.

The authors concluded that "most rural healthcare providers believe that they and their hospitals are genuinely concerned about patient safety. When asked to rate their ability to make healthcare safer, respondents . . . gave themselves high scores."

But, they wrote, "rural healthcare providers consistently demonstrate discrepancies in their abilities to recognize errors, report errors, allocate responsibility for patient safety, design interventions that increase patient safety, implement new practices and sustain change.

"Moreover, among healthcare disciplines there are vastly different perceptions as to what constitutes and error."

Physicians, they wrote, "generally viewed the errors contained in the case studies as 'practice variances,' 'suboptimal outcomes' or examples of differences in 'clinical judgment.'" And as such, they deemed an disclosure to their patients, notations in charts or filing incident reports "as unnecessary and inappropriate," Cook and Hoas wrote.

"As one respondent explained during an interview: 'We just don't talk about that (error) stuff with one another.'"

Klugman and Dalinis warn "the lack of relevant resources for the rural practitioner is troublesome."

They add, "the differences between rural and urban areas are so complex that some have called for specialized training for physicians working in rural areas."

Miles Sheehan, MD, of Loyola University of Chicago's Stritch School of Medicine in a review of the book in the May 27 issue of the Journal of the American Medical Association, wrote, "Reading the essays in this volume is like acquiring a new set of glasses. It made me better able to perceive differences in how ethics can be considered based on culture, population, geographic challenges, and personal connections."

The 224-page hardcover collection of essays is published by Johns Hopkins University Press. $50.

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