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Academic Medicine:
doi: 10.1097/ACM.0b013e31828a0ca6
Letters to the Editor

More About Managing Professional Boundaries in Rural Environments

Watts, Lisa MEd; Parker, Lisa MMed, MA

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Research officer, Rural Clinical School, University of New South Wales, Sydney, New South Wales, Australia; l.watts@unsw.edu.au.

Lecturer, School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia.

To the Editor: Brooks and colleagues’ study1 raises the important issue of how and where medical students learn best about professional boundaries and more generally about clinical ethics. We agree with the authors that more attention needs to be paid to the impact of diverse clinical settings on students’ professional development and ethical capabilities. This recommendation is particularly relevant in Australia, where increasing numbers of medical students are undertaking extended clinical placements in rural and remote areas.

We were interested in the authors’ findings that doctors developed individualized approaches to the management of professional boundaries, something we have also observed in our study-in-progress on training rural clinicians to be ethics facilitators. We suggest that medical schools can and should foster such individual growth and maturity in their students by expanding generic teaching activities to include opportunities for students to express and justify their own views and values in a supportive peer environment.2 This would include encouraging students to explicitly discuss the ethical dimensions of clinical cases during their rural placements. Such an arrangement would allow students to have a range of case discussions about professionalism and ethics, including cases involving boundary issues, confidentiality, and dual roles.3 These discussions would not be exclusive to the rural context but could involve consideration of different management strategies required when working in a small interconnected community. At our school, we have tried this approach in a series of rural clinical ethics ward rounds; students have been positive about this learning method and particularly valued the opportunity to learn from each other through peer feedback and listening to the experiences, opinions, and management strategies of their fellow students.

We encourage medical schools to make room for relatively less structured teaching time within their curricula to allow for student-driven case discussions around the challenging topics that arise from rural placements. These opportunities may usefully build upon the formal teaching program, particularly in the realm of professionalism.

Lisa Watts, MEd

Research officer, Rural Clinical School, University of New South Wales, Sydney, New South Wales, Australia; l.watts@unsw.edu.au.

Lisa Parker, MMed, MA

Lecturer, School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia.

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References

1. Brooks KD, Eley DS, Pratt R, Zink T. Management of professional boundaries in rural practice. Acad Med. 2012;87:1091–1095

2. Fryer-Edwards K, Wilkins MD, Baernstein A, Braddock CH 3rd. Bringing ethics education to the clinical years: Ward ethics sessions at the University of Washington. Acad Med. 2006;81:626–631

3. Parker L, Watts L, Scicluna H. Clinical ethics ward rounds: Building on the core curriculum. J Med Ethics. 2012;38:501–505

© 2013 Association of American Medical Colleges

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