Are rural doctors held to big city standards?
Q: I'm a primary care physician in a rural area that doesn't have nearly enough specialists or the latest equipment and technology. It seems unfair to hold rural physicians to the ivory-tower protocols and expectations that might apply to urban doctors, who have specialists and MRIs on every corner. Is there a national standard of care?
A: A generation ago, physicians were held accountable to the standard of care of doctors practicing in their own community. Now, with the wide dissemination of medical information and growth of national specialty programs, the "locality rule" has largely given way to what a "reasonable" physician in the same specialty would do in a similar circumstance, regardless of where the care was provided. Thus an internist in rural Kansas may be expected to meet the same basic standard of care as a colleague in Boston. A plaintiff may call an expert witness from anywhere in the country to testify about whether the standard was met.
Even so, most juries will take into account the fact that specialized facilities, tests, procedures, and physicians aren't always available in remote areas. It's simply unreasonable to expect a small rural hospital to offer the same services and sophisticated level of care as a major medical center in a large city. Doctors are required to use their best judgment with the resources available to them, however.
Jurors often forgive honest mistakes and support a local physician who can document that he did his best with the available resources. It's up to your defense attorney and witnesses to present a more reasonable standard, and to point out that day-to-day medicine practiced by physicians in your community isn't the same as that in academic settings.
You can help yourself in this situation, though. Even if the patient won't travel to see a specialist, you might consult with one yourself, just to get a better handle on the clinical situation. Many malpractice cases could be avoided by the judicious use of consultants.
If telemedicine is available, consider sending X-rays, lab results, photos, or even live videos of the examination to the expert specialist. Legal issues regarding licensure, privileges, and reimbursement are still being ironed out, but telemedicine is spreading widely in rural areas, and the federal government has funded many projects to study possibilities for the future.
Right now, the standard of care pretty much entails an in-person examination, but that's shifting as the technology expands and improves. Teleconferencing long-distance with subspecialists may become the standard of the near future. Before long, a plaintiff's attorney may even demand, "Doctor, why did you treat this condition yourself instead of videoconferencing the examination with a known expert?"
Your best asset is the familiar doctrine of informed consent. Be candid with patients about the limitations in your community. Offer them the option of traveling to a larger medical center. Inform them about the use of telemedicine. Outline the risks and benefits of these options, including the time and expense required as well as treatment issues. Document your discussions, as this will be your strongest defense if something goes wrong.
Lee Johnson. Malpractice Consult. Medical Economics 2001;12:101.