1. Competence Revisited in a Rural Context Case examples for each domain

2. Domains for Rural Practice
Adaptability
Agency and Courage
Collaboration and Community Responsiveness
Comprehensiveness
Integrity
Abundance in the Face of Scarcity and Limits
Reflective practice
Resilience

3. Adaptability: Case example
After beginning practice, a rural family physician realized that no providers in the region were performing vasectomies, and most couples in the area were choosing tubal ligation for permanent sterilization. To meet this need for the community, the physician contacted a former colleague who was actively performing the procedure and co-scheduled several patients in her office for mentoring and precepting in order to relearn the technique. Once able to safely perform independently, he began to offer this contraception option within his rural community.

4. Agency and Courage: Case example
A rural physician is staffing a critical access hospital emergency room when a patient arrives who has been involved in a snow machine accident. The patient has extensive head and facial injuries which will require surgery; this will require transfer to the regional hospital. Although immediate transfer is ideal, the weather is poor enough that this will not be possible until the following morning. The rural physician stabilizes the patient, intubates to protect his airway, communicates with the regional specialists, and controls the patient’s pain until the following day when transfer is possible.

5. Collaboration and Community Responsiveness: Case example
Some residents of a rural community have become concerned the the fluoride added to the city water supply may be dangerous to ingest. They have approached the city commissioners and organized a ballot referendum to remove fluoride from the community water supply. As the physician in town, you collaborate with the local dentist and public health director to participate in several town meetings prior to the election to educate the community about the safety and purpose of fluoride.

6. Comprehensiveness: Case example
In a small isolated rural community, a single physician continues at age 60 to provide care for children and adults in the community, elderly patients in assisted living, and maternity patients. He offers office-based surgical care and hospice services, even though many urban peers his age have restricted their practice over time. In fact he continues to expand his scope when needed, e.g. to include administrative duties and public health.

7. Integrity: Case example
A few patients from your rural community have been accessing a physician several towns away for controlled substances. Although you don’t want to abandon these patients, you realize that you may be enabling this practice. You contact each of these patients and explain your limits, including that you will not continue as their physician if they are receiving medication from another primary care provider. For those that stay with your practice, you work to decrease their narcotic dependence; for those that wish to remain patients of the other physician you facilitate a transfer of records.

8. Abundance in the Face of Scarcity and Limits: Case example
A patient has just returned from a hospital stay at a tertiary care center during which he was diagnosed with Wegener’s Granulomatosis. You have no other patients with this diagnosis. Prior to his return to your community you read about the diagnosis and current treatment options. You discuss his case with the transferring physician and develop a plan for follow up care. You are prepared to monitor his renal and liver function, you understand the warning thresholds, and have arranged spirometry. You know who to contact and how to reach these teams if a problem develops.

9. Reflective practice: Case example
Recognizing the importance of mindful practice, you and your partner establish a regular time each week to meet with staff and discuss a difficult case. Since there are only two physicians and a nurse practitioner in the practice, even staff members can participate and the group is still small. Whether they possess a high school diploma or graduate degree, all members bring their multiple perspectives to the situation, and mutually problem solve. This time is often used to debrief following a tragedy in the practice or community.

10. Resilience: Case example
Following the unavoidable death of a long-term patient from your rural practice, you find yourself waking at night wondering whether you could have better predicted and/or avoided this outcome. Recognizing this may be affecting your own health, you do a few things (avoiding any HIPAA violations). You discuss the case with staff members involved in his care, giving you and your staff an opportunity to work through any lingering concerns. You allow yourself to grieve within your support network, acknowledging your own loss and role in the patient’s care. You express sympathy to family members, to help with your own closure as well as theirs.