- Hierarchy, Ethics and Rural Healthcare
My medical school requires students to spend at least seven weeks, split between two blocks, in a rural family medicine [End Page 98] clinic. I spent all seven weeks in the same clinic, located in a community of fewer than 15,000 people. I quickly learned how unique, special, and undoubtedly needed rural healthcare is. But I also learned it can often be challenging, isolating, and laden with the potential for ethical missteps.
During my rotation, I learned of an obstetrician/gynecologist in the community whose practice style raised ethical questions in the minds of the hospital staff assigned to care for her expectant patients. One staff member confided in me that this doctor managed her obstetric patients in such a way that purportedly, unnecessary cesarean sections were performed on her patients in place of the more traditional, lower-risk, less expensive vaginal deliveries. When I asked for an example, the staff member remarked, “How can I pick just one?” She described situations where the patient would be admitted with orders for an immediate induction due to low amniotic fluid or uncontrolled gestational diabetes, for example, but then these indications would not be substantiated at the hospital. The amniotic fluid level was normal when the ultrasound tech checked it at the hospital. The lab reported normal blood glucose levels after the patient was admitted to the floor. And despite the order being for an immediate induction, some patients would labor for as long as 5 days, leaving an emergency c-section as their only option when they were completely and utterly physically and mentally exhausted. “The patient’s management and mode of delivery would have been completely different if this was [another doctor’s] patient,” the staff member lamented. This made me wonder—was it inexperience that contributed to the physician’s management decisions, or was it something more sinister, such as monetary gain?
The experienced staff that worked with the obstetrician/gynecologist knew that her patient management was not always appropriate, but they shied away from raising their concerns due to a fear of retaliation and a lack of “safe” reporting avenues. Not only did the doctor have clout simply because she was a physician, a scarce resource in a rural community like this one, but she also held the top ranking position on a hospital administrative committee. This was the same committee that likely would be involved in receiving and investigating such reports. As it’s oftentimes difficult to recruit and keep providers in these rural communities, decisions to report alleged misconduct tend to be balanced against the potential that a complaint may play into a provider’s decision to leave the community, increasing the patient load on already overwhelmed providers in an underserved area. Perhaps the staff members justified their decision not to report their concerns based on the simple fact that although some of her management decisions were questionable, she, in other ways, provided excellent care for her patients and was a valued member of the community. And, according to the staff member, there hadn’t been any “bad” outcomes, aside from the known, albeit unnecessary, consequences of a c-section. I wondered if this was true.
The hierarchy that exists in all of medicine is arguably more ingrained in rural healthcare than in healthcare provided in more urban areas. This is especially problematic as rural settings, by their very nature, have fewer people and fewer experiences and, therefore, potentially fewer well-trodden avenues for reporting issues or concerns that may arise. All healthcare organizations, especially those in rural areas, need to consider implementing reporting and anti-retaliation policies to support those with the moral courage to speak up. But the solution to this problem is much more complex than simply adopting and training employees on a policy. The issue—an inability to speak up when it is most needed—is unfortunately pervasive in medicine. It’s a culture issue. And the million-dollar question is, how do you change a culture? Particularly when those who engage in this culture may not see an issue with it?
Ethics courses are crucial for future physicians and health care workers...