2. A Note to Facilitators
Dear Facilitator, Thank you for using Rural PREP’s materials to create an active learning experience for your site. Use this slide deck, along with the online Facilitator Lesson Plan, to facilitate the Grand Rounds event at your site. Many of the slides contain additional information in the presenter notes area, so be sure to review the presentation and the notes prior to your Grand Rounds event.

3. Session Overview
10 minutes: Go over and discuss pre-assignment answers with the full group
20 minutes: Watch a recording of Randy Longenecker’s Presentation
20 minutes: Facilitate the Team Activity
5 minutes: General Discussion and Social Charge
5 minutes: Evaluation of the Learning Materials as a group (5 minutes)
Facilitator,
Here are some time estimates to guide you as you move through each activity in this active learning session.

4. Rural PREP Grand Rounds
Good Fences
Rural PREP Grand Rounds
Presenter: Randy Longenecker, MD
Ohio University Heritage College of Osteopathic Medicine, Athens, Ohio
This presentation was originally recorded on August 23rd, 2018, in front
of several live, online sites connecting from different places across the country.
Facilitator,
Once you have gathered your teams in one place and confirmed that each person has brought with them a copy of their individual responses to the pre-assignment activities (from the web link you sent them), you can begin with this slide to introduce the active learning session.

5. Objectives After this presentation, participants will be able to:
Articulate the difference between boundary crossings and boundary violations
Describe and recognize a dual relationship
Develop a personal and professional plan for negotiating dual relationships in rural practice
Facilitator,
Please review these learning objectives with your teams. At the end of the session, we will ask you to evaluate how we our materials meet these objectives.

6. Team Readiness Quiz
Which of the following are boundary crossings and which are boundary violations? Why and how might it be different in rural practice?
Facilitator,
You are about to begin the Team Readiness Quiz. The next few slides contain the scenarios you provided to your participants for the pre-session activity. Following each scenario slide, there is a slide with an explanation of the specific type of boundary crossing, if any. We recommend you allow for a large group discussion while on each scenario slide and before moving onto the explanation slide immediately after.
The first scenario is on the next slide, and the first explanation slide is immediately after.

7. Team Readiness Quiz
A family physician calls in a script for his son’s acne medication

8. Team Readiness Quiz
A family physician calls in a script for his son’s acne medication Boundary crossing; becomes a violation in a number of ways, e.g. if it is not documented in the son’s medical record; if it were deemed by the son’s primary physician or consulting dermatologist to be inappropriate medical care, or it undermines the son’s relationship with his physician (PC or consultant) These can be mitigated by at least a documented approval from another physician. A rural physician should always have someone who is a physician for family member, even if it is a remote physician consultant.

9. Team Readiness Quiz
A female physician has a consensual sexual affair with one of her male patients

10. Team Readiness Quiz
A female physician has a consensual sexual affair with one of her male patients This is always a boundary violation, prohibited by medical boards and considered unethical by all major professional associations

11. Team Readiness Quiz
A hospital-employed physician accepts a quilt from an Amish family in payment for services rendered

12. Team Readiness Quiz
A hospital-employed physician accepts a quilt from an Amish family in payment for services rendered This is neither a crossing or violation, as long as the physician’s employer is aware and approves. It could be a violation of policy or contract as a hospital employee.

13. Team Readiness Quiz
A family physician offers their employees free well-adult exams, including a complete physical

14. Team Readiness Quiz
A family physician offers their employees free well-adult exams, including a complete physical
Clearly a boundary crossing; very easily becomes a boundary violation because of perverse financial incentives and multiple potential conflicts of interest around the employer-employee relationship and the intimacy of the doctor-patient relationship, history taking of intimate life details, and of course any intimate exams. This could potentially be insurance fraud if the employee or physician submits the service for insurance reimbursement in part or in whole. This is not a good idea and rarely, even in rural practice, are there no other alternatives. If a physician does care for employees, the relationship must be professional, including appropriate documentation and billing. Doing something for free increases the power differential between doctor and patient and increases the chances of inappropriate care and abuse of the either relationship.

15. Rural PREP Grand Rounds
Good Fences
Rural PREP Grand Rounds
Presenter: Randy Longenecker, MD
Assistant Dean Rural and Underserved Programs
Ohio University Heritage College of Osteopathic Medicine
Athens, Ohio
August 23, 2018
Launch the Presentation Now
Facilitator,
It is now time to play the presentation by Randy Longenecker. Click on the “Launch the Presentation Now” link in the slide ( to play the video, which is 18:00 minutes long.

16. Team Activity Facilitator,
Now that you’re finished playing the presentation, it is time to begin the team activity portion of the session. The next slide presents four cases. Assign each team a case (or multiple cases, depending on how many teams you have).

17. Team Activity
Choose a case, from among the cases of boundary violations that you have observed yourselves and have in mind, and outline for your practice setting how such a violation might be addressed, including any of the following:
Office policy
Reporting mechanism
Preventive program
Case remedy, including reparations
Assign each team a case (or multiple cases, depending on how many teams you have).

18. Discussion Facilitator,
Allow a member of each team to share their case and report on how they would respond to the case to the entire group. You may wish to ask questions about each case as it relates to your particular rural context.

19. Social Charge
What are you personally going to do with this information?
Facilitator,
As a group, consider how you might use this information to improve your rural practice.

20. Evaluation
Please evaluate these learning materials as a group:
Facilitator,
While you still have everyone together, please take a few minutes to provide us with some feedback so we can better serve you. Complete the following form:
You only need to submit one form for your entire group.