AMA Journal of Ethics^®

In its 12-year history, Virtual Mentor has never published an issue specifically addressing rural health. As I worked on this issue, several colleagues have asked what makes the ethics of rural medicine any different from the ethical concerns encountered in urban or suburban environments. Having grown up in a rural state, these differences, though sometimes subtle, are obvious to me. Rural physicians face challenges related to their overlapping roles in the community, the emotional and academic difficulties associated with being the only physician in a sparsely populated area, and complicated interpersonal dynamics in communities where privacy is hard to come by.

In a small town, one’s physician is often a friend, coworker, or even family member; in such an environment, the range of privacy concerns spans reproductive rights, the stigma still associated with psychiatric care, and the medical treatment of friends and family. When specialists are geographically distant, physicians are often placed in the difficult position of performing procedures that may be outside of their comfort zone in order to provide optimal patient care. Frequently, rural physicians must cope with being the sole medical resource for a community, creating the potential for isolation and burnout. The first half of this issue of Virtual Mentor examines some patient-physician relationship dilemmas that are more often encountered in rural medicine than in larger, more populated regions.

There is an enormous need for rural practitioners: in February 2011, 65 percent of primary care health professional shortage areas were rural, and there are currently 55 primary care physicians per 100,000 residents in rural areas, when 95 are needed [1]. Reproductive health care is also sparse in rural environments: as of 2005, 87 percent of counties in the United States, the majority of them rural, did not have access to abortion services [2]. People residing in rural areas are also more likely to suffer from chronic health conditions and less likely to receive preventive care [3]. Decreasing interest in family practice disproportionately affects rural communities, which means the inequities between rural and urban health will continue to grow unless we take steps to ameliorate the situation. It follows that there is an ethical obligation to provide medical care to the underserved.

Awareness of these issues is growing. The 2010 Patient Protection and Affordable Care Act and other federal legislation fund initiatives to recruit physicians to rural areas and decrease geographical inequities. Medical schools across the nation are investing resources in programs that train and encourage medical students to practice in rural areas upon graduation. The second half of this issue of Virtual Mentor discusses a number of policy initiatives currently being undertaken on national and state levels, as well as new strategies in medical education, to increase physician workforce.

Throughout this issue, we have tried to offer geographically varied perspectives on the ethical concerns we feel are most pertinent to physicians practicing in rural environments. These are important concerns that need to be borne in mind not only by physicians and patients, but also by policymakers and legislators. While most rural practitioners are already aware of these issues from their own experiences, this is an excellent opportunity to gain fresh perspectives on old dilemmas and incorporate ethical decision making into clinical practice.