The impact of interpersonal relationships on rural doctors’ clinical courage

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Walters L, Couper I, Stewart RA, Campbell DG, Konkin J. The impact of interpersonal relationships on rural doctors’ clinical courage. Rural and Remote Health 2021; 21: 6668.

Commentary Sarah Walker (PhD Candidate): Following on from previous work on the role of clinical courage in rural generalism, Professor Walters and her colleagues explore how the relationships rural doctors develop impact on their clinical courage. The concept of clinical courage can sit uncomfortably with some of us, however the six features of clinical courage described in previous work (Konkin et al. 2020) alleviate those concerns. Although clinical courage Is formed amongst uncertainty (2) in often under resourced (4) settings, clinicians are cautious not to conflate confidence with competence (3) when clearing the cognitive hurdle and deciding on a point of action (5) that is often intrinsically tied to a deep commitment of providing care to their community (1). Critical to this is their “collegial support to stand up again” (6) where rural doctors can share discourse and use their peer reflections to support their own self reflections – it is this feature that Walters seeks to explore further in this study.

The community of practice that rural doctors build with their communities, patients, peers, and local and national healthcare teams and leaders does affect their clinical courage. The social and geographical bond these rural doctors have sets them apart from other medical communities of practice and suggest that clinical courage is seen as a meaningful and encouraged characteristic in rural generalist practice. The relationships formed within their community of practice are not taken lightly, requiring time and effort to develop and maintain. For the healthcare team, only once these relationships are appropriately developed can trust be placed on each other’s skillset, becoming an issue in areas where workforce turnover is unsettling.

Despite not being a rural doctor, Walter’s work piques my interest as a rural health professional. Working as a physiotherapist in a small team, across a large geographical area, and in many clinical areas, the concept of clinical courage resonates well with me as I am sure It does for my other allied health and nursing colleagues. I am certain that furthering our understanding of these other disciplines in rural areas will help in understanding the complex and dependent relationships and skills required for rural generalist practice.

Konkin J,  Grave L, Cockburn E,  et al.   Exploration of rural physicians’ lived experience of practising outside their usual scope of practice to provide access to essential medical care (clinical courage):  an international phenomenological study.  BMJ Open 2020;10:e037705.  doi:10.1136/ bmjopen-2020-037705



Introduction:  Clinical courage occurs when rural doctors push themselves to the limits of their scope of practice to provide the medical care needed by patients in their community. This mental strength to venture, persevere and act out of concern for one’s patient, despite a lack of formally recognised expertise, becomes necessary for doctors who work in relative professional isolation. Previous research by the authors suggested that the clinical courage of rural doctors relies on the relationships around them. This article explores in more depth how relationships with others can impact on clinical courage. Methods:  At an international rural medicine conference in 2017, doctors who practised rural/remote medicine were invited to participate in the study. Twenty-seven semistructured interviews were conducted exploring experiences of clinical courage. Initial analysis of the material, using a hermeneutic phenomenological frame, sought to understand the meaning of clinical courage. In the original analysis, an emic question arose: ‘How do interpersonal relationships impact on clinical courage’. The material was re-analysed to explore this question, using Wenger’s community of practice as a theoretical framework. Results:  This study found that clinical courage was affected by the relationships rural doctors had with their communities and patients, with each other, with the local members of their healthcare team and with other colleagues and health leaders outside their immediate community of practice. Conclusion:  As a collective, rural doctors can learn, use and strengthen clinical courage and support its development in new members of the discipline. Relationships with rural communities, rural patients and urban colleagues can support the clinical courage of rural doctors. When detractors challenge the value of clinical courage, it requires individual rural doctors and their community of practice to champion rural doctors’ way of working.

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