EPA 6 - Overview

EPA 6:  Negotiates dual relationships with integrity and role fidelity

Brief explanation: Clinicians entering practice in rural and underserved settings will manage the multiple roles that inevitably arise in caring for patients with whom they interact in other settings across the community. Small rural and underserved communities in all settings increase the likelihood of dual roles and the physician has the professional responsibility to manage these relationships ethically.

Key Functions

Skills Progression 

Demonstrates keen awareness of the role one is in at any given moment and shows attention to appropriately fulfilling that role in a way that acknowledges but subjugates all other roles and furthers the interests of the patient and community

Demonstrates awareness of the potential risks of therapeutic relationships with patients and family who are also friends, coworkers, acquaintances;

Establishes therapeutic relationships in straightforward encounters and maintains confidentiality;

Understands potential conflicts of interest and bias that can arise when caring for patients one knows from a different context

Reflects on dual nature of their own relationships with patients in the community;

Maintains appropriate professional role during therapeutic encounters with patients/family members who are also friends, coworkers, acquaintances keeping communication and care in the appropriate venues; Establishes/maintains therapeutic relationships in challenging patient encounters and demonstrates awareness of being trusted with highly sensitive confidential information; Manages dual relationships in a small community, respecting patient confidentiality, maintaining objective clinical lens, code/role switching when necessary; Acts with integrity to appropriately maintain clinical objectivity 

Seamlessly balances access to care, trust, approachability, and confidentiality with equanimity;

Role models and mentors others in situational awareness and critical self-reflection to consistently assure patients, families, colleagues, and community that communication and disclosures will be appropriate for context;

Analyzes complex situations using ethical principles to guide action

Uses humility and gentleness to guide others in the community who may inadvertently push the clinician to mix their competing roles inappropriately

Recognizes the risks of casual communications around health care concerns with friends, coworkers, acquaintances

Respectfully redirects inappropriate communications from patients who are also friends, coworkers, acquaintances while assuring timely care;

Recuses self when conflicts of interest/bias can’t be mitigated and safely transitions care/task to appropriate team member if able

Optimizes whole-person care using appreciation of individual in context of community while gracefully keeping communication appropriate to setting

Appreciates the increased context and depth that these multiple roles bring to the provider’s understanding of their patients, their health needs, and the needs of the community

Identifies that dual roles within and across organizations can create conflicts of interest;

Respectfully communicates concerns about the system aiming for system improvements and solutions

Initiates difficult conversations with system stakeholders to improve the systems;

Works to manage and mitigate conflicts of interest created by dual roles within and across organizations

Facilitates constructive dialogue regarding systems issues among community stakeholders, acknowledging historic and structural inequities of medicine and healthcare;

Optimizes synergies and trusting relationships stemming from dual roles to improve health and maximize system functioning

Instructional Strategies

Didactics

Ethics of Role fidelity for physicians in defined communities:

Healthcare dilemmas in small communities: Hastings center report Links to an external site.

Workshops

Rural PREP toolkit on “Good Fences” https://ruralprep.org/good-fences/ Links to an external site.

Community Projects

Engage local ethics committee and community members in a dialogue and shared educational event on ethical dilemmas of small communities using these topics: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2598268 Links to an external site. 

Reflection and Coaching

Reflective writing on expected or experienced dual roles and how a professional would respond in actual situations or in response to prompts from the cases in https://journalofethics.ama-assn.org/article/overlapping-roles-rural-doctor/2011-05 Links to an external site.

Assessment Methods and Tools

Multisource feedback

Direct observations

Standardized patient/OSCE