By Glenn Regehr
When I was in Prince George a while ago visiting with the faculty and staff of the Northern Medical Program, I had the pleasure of meeting with Robin Roots and chatting about the issues of developing a Physical Therapy program aimed at educating effective rural practitioners. As part of our discussion, we started exploring the issues of health professional ethics as they relate to rural settings, and in the course of this discussion she helped me to appreciate just how urban-centric our codes of ethics are in their construction.
As a result of this urban-centric construction, rural practitioners must engage in a highly sophisticated management of these seemingly “clear” ethical standards rather than simply “following them”. However, the positioning of their management of these issues is viewed as a “compromise”.
As an obvious example, the Canadian Medical Association code of ethics (2004)1, item 20, states:
20. Limit treatment of yourself or members of your immediate family to minor or emergency services and only when another physician is not readily available; there should be no fee for such treatment.
In everyday terms, I have heard this interpreted roughly as “don’t treat your family (or friends) as regular patients”. Of course, in urban settings, where there are many practitioners and many people who are not one’s friends and neighbours, this is fairly easy. In rural settings and small towns where everyone knows everyone else and there may not be another health care provider to refer a family member to, it is pretty much impossible. So rural practitioners find themselves “bending” this “rule”, and again their solutions to the dilemma are seen as compromises to ideal practice.
But I wonder whether there is not a better way of constructing this notion of professional and personal boundaries that more respectfully represents the special skills that are enacted by the rural practitioner. If, for example, the code were to speak of the need to effectively manage the potential conflicts that arise at the interface of professional and personal boundaries, then the “compromises” made by rural physicians would not be compromises at all … they would be the height of sophisticated professional conduct. Of course, urban practitioners may not need to become so sophisticated in these skills. They could, with relatively little sophistication, simply refer their family, friends and neighbours to other practitioners. But the rural practitioner would need to manage these potential role conflicts in a much more elaborate way, using enhanced skill sets with additional finesse and insight.
To reconstruct the codes of conduct and ethics from a rural perspective, then, opens the possibility of creating more sophisticated versions of each code…versions that more accurately reflect the complexities of real life practice rather than spouting an overly simplified “ideal” and leaving it to practitioners to individually struggle with their “inability to achieve this ideal”. The more sophisticated behaviours could then become an explicit part of the curriculum (perhaps even as explicit competencies that learners might eventually be entrusted to perform without oversight?) rather than ad hoc and “under the table” bits of advice and personal discovery to be enacted behind the veil. Of course, as with professionalism, the community might need to deal with a bit more ambiguity with regard to what is “right,”2 but since comfort with ambiguity seems to be a luxury of expertise (perhaps a topic for another blog), this ambiguity might force us all to become more expert in our treatment and management of these issues.
I am not, myself, sufficiently aware of rural practitioners’ day to day experiences to be able to think through all the issues of managing professional and personal boundaries in a truly sophisticated way. Nor could I hope to imagine all the other codes of conduct that have similar implications for the ways in which rural practitioners must grapple with these overly simplified versions of “ideal” practice. So I would encourage others to pick up this thread and to elaborate the sophisticated code of professional conduct as enacted with skill and finesse by rural practitioners every day. And I might encourage urban practitioners to learn these more sophisticated competencies even if they need enact them in only the most rudimentary way in their own practices.
- Canadian Medical Association Code of Ethics (Revised 2004, Reviewed without revision 2015). Accessed on December 11, 2015 at http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD04-06.pdf
- Ginsburg S, Regehr G, Mylopoulos M. From behaviours to attributions: further concerns regarding the evaluation of professionalism. Med Educ. 2009 May;43(5):414-25