The American Journal of Bioethics 2.3 (2002) 61-63
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In Country Doctor, Ben Dlin presents his account "of what it took to become a doctor and what doctoring is all about" (vii), which contributes to the increasingly popular genre of memoirs about becoming or practicing as a physician (e.g., Berger 1995; Kaufman 1993). Many bioethics and medical humanities scholars recognize the value of narrative accounts for portraying patient and physician experiences with health and illness within a cultural and historical context. Dlin's explicit intention is to tell his grandchildren about his life growing up in rural Canada in the 1940s and 1950s. Most of the book focuses on Dlin's second year of residency in the rural town of Eckert, Alberta, where Dlin and his mentor, Dr. Frank Cossack, treated a population of 10,000 scattered over 2,500 square miles of farm, bush, and foothills. Although not written for an academic audience, Dlin offers valuable lessons to medical students, healthcare professionals, and bioethicists about rural value systems woven into physicians' professional ethics. The rural context of healthcare presents a different perspective on some medical and ethical issues than does the urban setting. Since Dlin discussed these issues through narrative, I draw upon the social science and medical literatures to provide a cultural context of key rural practice issues, including the doctor-patient relationship, poverty, and access to care. To understand their relevance to ethics, it is essential to first gain an appreciation for what rural practice was like and highlight features remaining today.
Dlin tells his readers that training in rural practice "is the best place to learn the profession," because it requires a humanistic perspective of medicine (x). Rural medicine is humanistic because it relies on multiple approaches to address a broad range of patient conditions: medical, psychosocial, and surgical. Many medical problems resulted from occupational hazards: farmers got broken bones from being kicked by a horse or from heavy equipment falling on them. Minor surgery was required for lacerations. An interesting observation is that 75% of patients suffered emotional distress with symptoms of anxiety. Dlin lightly attributes this distress to interpersonal dynamics compounded by the tenuous farming lifestyle:
worry about money and how to manage without it was a constant for those who lived off the land. So much depended on the unpredictability of nature. One hailstorm or an early frost could wipe out a crop within minutes. (132)
Other research similarly shows how rural families elsewhere face a host of psychosocial issues (which become somatized) because of the farming schedule (Stein 1982). Having grown up in a rural setting, Dlin was sensitive to rural patients' concerns and shared the rural value system, but his medical training had not prepared him sufficiently for treating certain rural medical problems. Thus, Dlin stressed the importance of gaining additional training in psychiatry and surgery for country practice. Given this broad approach to healthcare, Dlin "urge[s] every new medical graduate to go out into some isolated area and work as I did. . . to experience what medicine is really about," because doing so "gives the specialist a broader perspective so that he or she is less likely to try to fit the patient into the narrow field of his or her specialty" (248).
A fundamental component of this holistic approach to care was the involvement of the family in caring for the patient, regardless of whether the patient was a person, pet, or farm animal. For instance, a cot would be placed in the patient's room for a family member to sleep on. Other rural populations—for example, in Kentucky and Oklahoma—similarly value family involvement in care given [End Page 61] their strong sense of family (whereas mainstream culture has a strong sense of community) and prefer not to depend on people outside the family (e.g., institutions) for care (Hansen and Resick 1990; Stein 1982).
Concerning the fortitude required to practice country medicine, Dlin's voice left an indelible trace...