Discussion Questions

Discussion Questions
Questions are arranged by section and by the themes addressed in The Reader’s selections.

  • Who We Are
  • Where We Are
  • Whom We Serve
  • Our Resources and Challenges

Thematic topics:

  • Populations
  • Provider issues
  • Patient care issues
  • Health care structure
  • Resources
  • Resiliency

Who We Are:
1. Professional boundaries are a source of consternation in rural practice. What are
professional boundaries when you work, eat, play, raise children and practice
medicine alongside your patients? How do you maintain them?
2. What are the benefits and challenges to serving as your neighbor’s physician? How
might these help or hinder the care you give to your neighbor/patient?
3. Author McRay goes a step further by becoming his grandfather’s physician.
What are the benefits and challenges of interpreting health and illness for family
What are the benefits and challenges of actually providing care for members of your
family like author McRay did?
4. What are the pros and cons of praying with patients, sharing your spirituality with
Author Farah and her patient shared their religious tradition, how do you do address
spirituality when you and your patient have different religious traditions?
When might it be inappropriate to do this?
5. Over the last twenty to thirty years, how has the organization and delivery of health
care changed? Both authors Luskin and Harman discuss the downsides, what are
the benefits?
6. Consider the number of foreign born and foreign-trained physicians who provide
care in rural America. Why has this occurred? Research J-1 visa waivers and talk
about their impact on the workforce in rural areas.
What are the benefits and challenges of this reality?
7. As a provider, if you are foreign born or different from the majority culture of the
community you serve, what are the challenges? How does author Onime manage
these challenges?
8. Authors Gibes, Niedringhaus, and Harman come from backgrounds that are foreign
to the values of the communities they serve. How do you familiarize yourself with
communities that are different from what you grew up with or what you know?

Where We Are
9. Berlin’s poems, in particular, talk about the beauty of his rural landscape and the
regenerative nature of the seasons and living close to the earth. How has rural life or
your time spent in nature been healing for you?
10. What are the values of “rural” life? How do they inform patients’ expectations?
How do they impact the care providers give?
Author Loxtercamp has much to say on this topic. Have the values of rural life
changed over the last decades or not?
11. How does rural geography affect the kind of health care delivered in rural areas?
What impact has technology had? How has that enhanced and challenged rural
health care?

Whom We Serve
12. What are the challenges of blending new cultures into a rural community that was
previously populated by one ethnic group and one religion? How might a
community act proactively?
13. How does class and economic status affect the ability of new populations to
14. As a health care provider, how can you prepare yourself to better serve patients
who are different from you? What are the ways to educate clinic /hospital staff
about the customs of patients and personnel that are different?
15. Author Ercole uncovers the values of many undocumented workers who have come
to the U.S. Are you surprised by what he learns? Why or why not?
16. In the national health insurance reform bill passed in 2010, undocumented workers
are not eligible for health insurance and must pay out of pocket for their health care.
Some states, such as Minnesota, are more generous. If the undocumented worker’s
health problem is determined to be an emergency (i.e. appendicitis), then he/she
can apply for Medicaid. Pregnant women receive coverage during pregnancy and
children born in Minnesota qualify for Medicaid.
What are the pros and cons to the national policy? To Minnesota’s policy?
How do undocumented workers contribute to the U.S. economy?
17. What are the challenges of caring for communities with “traditional” values? For
example, the Amish are selective about what mainstream medicine in the U.S. has to
offer (i.e. avoid immunizations, limited use of interventions).
What other communities in the rural U.S. have values different from mainstream
U.S. health care?
18. How does a local hospital /clinic work with a local community like the Amish? What
arrangement did authors Gibes and Kroening’s hospitals make?
19. How do we provide good medical care for communities with values different from
our own (religious, culture, distrust of medical care, etc.) while still respecting their
culture? What are the critical ingredients?
20. What are the challenges and benefits of caring for the growing elderly population?
What is particularly challenging about caring for the elderly in rural areas? (See the
work but authors Lederer, Fleg, Farris, and Kollisch)
21. What are the challenges of caring for patients with illnesses that have stigma such as
AIDS (See authors Gutterman and Jennet) and mental illness (See authors Orem,
Rosmann and Zink) in rural areas? Are there benefits?
22. How has the economy in the rural U.S. changed over the last two generations (family
farms vs. corporate agriculture, urban influences, changes in communication, etc.)?
Consider the selections by authors Gutterman, Rosmann, Perry and Brodt as you
answer this.
What has remained the same about rural areas during this same period?

Resources and Challenges
23. How does your rural community deal or not deal with innovations in medicine? Why
or why not?
24. What has been lost and what has been gained with modern technology and
communication in medicine?
25. Why is there a bias that rural clinics and hospitals are backward (see author Halaas)?

Blending different cultures in communities, new Americans, undocumented workers and
respecting values

  • Ercole, Pursuing the American Dream
  • Cohen, Welcome to Elma
  • Lederer, Lost On Call
  • Verghese, My Own Country
  • Bradley-Jennett, Mississippi Mayhem
  • Onime, When Hostility Melted

1. Choose one of these selections and write your own story or poem on a similar
2. Find a news story that illustrates a theme in one of these stories and write about it.

Provider Issues: Negotiating professional boundaries and mandatory reporting obligations.
Negotiating professional boundaries:

  • Farah, LIFEprayerDEATH
  • Kullinat, Boundaries
  • Bibey, Inside the Mind of a Modern Country Doc
  • Zink, Thank God for my Ass
  • Onime, Synopsis—Who We Are

1. Author Farah explores the faith-life she shares with her patient. How can this
deepen a physician’s ability to work with a patient? What are the potential
2. Author Kullinat explores the dual relationships in her rural setting and how her
medical school courses discouraged such blurring of professional and friendship
boundaries. Discuss the nature of the boundaries between health professionals and
patients that might occur in rural settings? What are the problems? What are the
3. If you live in a rural community or have spent time in a rural community what has
worked or not worked for you? As a health professional, how have you maintained
boundaries? As a non-health professional what have you wanted from the health
professionals in your community?
4. Author Onime discusses the multiple layers of his relationship with his patient Ms.
Emalee. Dual relationships are discouraged, but this may not be possible or
acceptable in rural communities. How does a health professional manage
boundaries where he/she lives and works?

Mandatory reporting

  • Orem, I am the Handmaiden of the Lord
  • Zink, Everyone Did Their Part, But …

1. What are a health professional’s obligations related to patients like Dot and Mr.
2. How can the adult and child protection systems help and harm patients like Dot and
Mr. Gaines? Why?
3. How does a provider manage the relatives and friends of a patient for whom they
had to make a mandatory report? How might this be the same or different in a rural
community compared with an urban community?

Patient Care Issues: End of life, Evidence Based Medicine
End of life

  • Kollish, Good Will
  • McRay, Three Days Changed My Grandfather’s Life
  • Robotic Docs
  • Vainio, Mashkikiwinini: Thanking Sylvester for His Unconditional Smile
  • Zink, Everyone Did Their Part, But …

1. How did the final days of life and the deaths of Mr. Gaines and author McRay’s
grandfather differ? Why?
2. What can health professionals do to help patients negotiate their final days or plan
their deaths? How has this changed over the last few decades? How might end of
life care differ in rural and urban areas? What are the challenges in the rural setting?
What are the benefits?
3. What challenges does today’s technology-oriented society pose regarding end of life

Evidence Based Medicine

  • Westfall, Blue Highways
  • Loxtercamp, A Vow of Connectedness

1. For health care professionals or students: As a health care professional or student—
What are the questions patients ask for which you do not have evidence based
answers? Author Westfall gives some, can you think of others?
2. What are examples of past advice that with further research we later learned were
(For Example: scoliosis screening in schools, carotid endarterectomy surgery,
benefits of hormone replacement therapy) Can you think of others?
3. For patients: As a patient what are some of the questions you have had that your
physician has been unable to answer?
4. What suggestions does author Loxtercamp have for blending the science (evidence)
and art of medicine?
5. How do personal relationships and continuity, knowing patients over time make a
difference in patient care? (See Authors Bibey, Zink-Ass, Perry-Call)

Health Care Structure: Legislative and insurance changes that have altered the way hospitals and offices are structured and changed the way care is paid for and provided.

  • Bibey, Inside the Mind of a Modern Country Doc
  • Luskin, Mom and Pop Doc Shop
  • Frerks, The Dressing Change and More

1. Federal legislation has introduced a variety of programs and regulations to try to
improve care. How have these helped and how have these hindered care in rural
areas? What are the positives and the negatives of each of these?
• CLIA—Clinical Laboratory Improvement Amendments, “laboratory quality”
• HIPAA– Health Insurance Portability and Accountability Act, “patient privacy”
• EMTALA–Emergency Medical Treatment and Active Labor Act, “the anti-dumping
2. How have insurance and government programs’ efforts to limit health care costs and
abuse by providers affected health care delivery and private practice?
3. Examine the current regulations regarding when Medicare pays for a hospitalization
and when it does not.
4. Why have more providers joined larger health systems? What are the benefits and
drawbacks to large health care organizations?

Resources: Services in communities necessary for providing comprehensive care for patients
Mental Health

  • Orem, I am the Handmaiden of the Lord
  • Rosmann, Cattleman
  • Zink, Asking the Right Question

1. What are the Mental Health resources in your area? Are there access challenges for
patients with insurance, patients with government insurance (Medicare/Medicaid),
and/or patients without insurance?
2. If you are urban, which rural areas use your services? If you are rural, where are
your mental health and substance abuse services located for inpatient and
outpatient care? Where do patients without insurance get mental health or
substance abuse services?


  • Carter, A Night in the Life of a Rural Emergency Care Team: The Value of the
  • Comprehensive Advanced Life Support Program
  • Halaas, Local Medical Doctors: State of the Art Healers
  • Robotic Doc

1. Why might innovation be easier in rural communities?
2. What makes it more difficult in rural communities?


  • Berlin, Spring and All Revisited
  • Fleg, Sisters
  • Rosmann, Cattleman

1. What factors in rural life that might contribute to resiliency in rural communities?
2. What factors of modern day life may act as barriers to resiliency in rural
3. What supports did Kent put in place in order to face the sale of his cattle?
(Rosmann, Cattleman) When you or a loved one/friend have faced a difficult time,
what supports did you put in place?

For additional resiliency reflection see: Gerrard, et al. What Doesn’t Kill You Makes You Stronger:
Determinants of Stress Resiliency in Rural People of Saskatchewan, Canada. Journal of
Rural Health. 2004; 20(1): 59-66.

Discussion Questions CDR PDF