Integrated primary care is particularly valuable to rural communities. Behavioral health care is often in short supply, and small or close-knit communities can intensify the stigma of seeking specialty mental health in rural settings. These and other barriers result in reduced access to needed behavioral health care. Nonetheless, rural practice of integrated primary care presents unique challenges to practitioners of multiple disciplines, including issues of competence, confidentiality, and dual relationships. This article provides an illustrative vignette to describe ethical issues in the rural practice of integrated primary care. It will review discipline-specific guidance in approaching these challenges and will offer recommendations for addressing disparities in the approaches of various disciplines engaged in the practice of integrated primary care.

CONTEXT: Small towns across the United States struggle to maintain an adequate primary care workforce. PURPOSE: To examine factors contributing to physician satisfaction and retention in largely rural areas in Massachusetts, a state with rural pockets and small towns. METHODS: A survey mailed in 2004-2005 to primary care physicians, practicing in areas designated by the state as rural, queried respondents about personal and practice characteristics as well as workforce concerns. Predictors of satisfaction and likelihood of remaining in current or rural practice somewhere were assessed. FINDINGS: Of 227 eligible physicians, 160 returned their surveys (response rate, 70.5%). Approximately one third (34.0%) reported they had grown up in communities of 100,000 or larger. Factors associated with higher overall practice satisfaction included not feeling overworked (P = .043) or professionally isolated (P = .004), and being involved in their practice (P = .045) and home communities (P = .036) as well as ease of seeking additional physicians for practice and obtaining CME credits (P = .014 and P = .017, respectively). Female physicians were more likely to report an intention to remain in rural practice somewhere for the next decade (P = .034). In rating their satisfaction with various aspects of the rural practice environment, physicians reported greatest satisfaction with their practice overall (67%) and their call group size (66%). They were least satisfied with their current (30%) and likely future income (40%). In multivariate analyses, larger practice community size was positively related to the dependent variable of overall satisfaction and negatively related to likelihood of staying in current practice or in rural practice somewhere. CONCLUSIONS: Our findings reaffirm the importance of rural medical education opportunities in physician recruitment, retention, and practice satisfaction. They also indicate that in a small New England state, a major source of physicians for rural and small town communities is physicians who have been raised in urban/suburban communities and who were trained outside of the region but who were prepared to live and to practice in rural and small town communities.

CONTEXT: Hospitals in rural communities may seek to increase specialty care access by establishing clinics staffed by visiting specialists. PURPOSE: To examine the visiting specialist care delivery model in Massachusetts, including reasons specialists develop secondary rural practices and distances they travel, as well as their degree of satisfaction and intention to continue the visiting arrangement. METHODS: Visiting specialists at 11 rural hospitals were asked to complete a mailed survey. FINDINGS: Visiting specialists were almost evenly split between the medical (54%) and surgical (46%) specialties, with ophthalmology, nephrology, and obstetrics/gynecology the most common specialties reported. A higher proportion of visiting specialists than specialists statewide were male (P = .001). Supplementing their patient base and income were the most important reasons visiting specialists reported for having initiated an ancillary clinic. There was a significant negative correlation between a hospital's number of staffed beds and the total number of visiting specialists it hosted (r =-0.573, P = .032); study hospitals ranged in bed size from 15 to 129. CONCLUSIONS: The goal of matching supply of health care services with demand has been elusive. Visiting specialist clinics may represent an element of a market structure that expands access to needed services in rural areas. They should be included in any enumeration of physician availability.