Originally published March 2013
Rural physicians deliver a wide spectrum of care to the sparsely populated regions of Canada and need to be aware of specific issues that can generate medico-legal risk in their practice.
While the majority of Canadians live in urban centres, more than 31% of the Canadian population lives in rural areas — an estimated 9 million people. Communities of fewer than 10,000 people account for 22% of the rural population and are served by 10% of the physician population.1
The conditions in which Canadian rural physicians practise depends very much on remoteness or proximity to urban centres, health facilities, and staff. While some rural physicians may live within an hour or two of a major city and large health centre, others may practise in communities that are many hours away by land or air.
Some of the medico-legal implications that must be considered by rural physicians revolve around access, including delays in transfers or referrals to specialists. The availability of resources remains the most challenging aspect of rural healthcare delivery. Whether healthcare human resources, equipment, or facilities, physicians who practise in rural settings are called upon to overcome demanding realities.
Distance, travel, and resources
For many rural doctors, one of the main issues is accommodating their patient population within the constraints created by time, distance, and resources.
When time is of the essence, transferring a critically ill patient to a tertiary care centre can be challenging. Rural physicians may be concerned with the medico-legal implications of these transfers, particularly if resource limitations, distance, or inclement weather create unforeseen delays. Meeting the standard of care in such circumstances doesn't imply providing specialized care beyond a physician's knowledge and experience. The courts have stated they expect physicians to practise in the manner expected of a normal prudent practitioner of similar training and standing in similar circumstances.2 In treating any acutely ill patient, physicians practising in a rural setting should continue to provide care to the best of their ability, and initiate the transfer process. While awaiting transfer, the physician may wish to access consultation services over the telephone to obtain advice regarding concurrent treatments. All efforts in obtaining the transfer and phone consultation should be documented in the patient's medical record. The copy of relevant information from the record should be provided as part of the transfer, ensuring that the receiving centre can initiate prompt treatment. Having pre-established protocols with hospitals will contribute to the effective transfer of patients.
The use of telemedicine to deliver healthcare is seen by many as particularly suitable to address the needs of physicians and patients in rural and remote communities. When determining whether to use telemedicine in a patient's treatment, physicians should first consider the patient's condition.
Telemedicine may be appropriate in many different situations, including delivery of routine or elective procedures and examinations, as well as urgent cases. In some circumstances however, where there is an unusually high level of risk or a hands-on physical examination of the patient is more suitable, physicians should consider whether telemedicine is the best option.
Telemedicine also carries medico-legal challenges that physicians should be aware of, including licensing requirements, and the need to keep patient information private and secure. As there is no national framework for telemedicine, the licensing requirements for physicians vary for each province and territory. Physicians must therefore be familiar with the requirements of each province and territory in which they practise and their patients reside. When providing telemedicine services across provinces and territories, physicians will want to take appropriate steps to keep patients' personal health information confidential and comply with the privacy legislation applicable in each jurisdiction.
Healthcare human resources in rural settings
While human resources within the healthcare sector is a key issue, in rural settings the issue is magnified considerably. Finding someone to step into a rural practice, even for a short period of time, is difficult. Physicians in rural settings may also be called upon to work extended hours, given the limited availability of other physicians. The availability of other healthcare providers who are essential to support quality patient care can also be challenging. Management of available healthcare human resources entails proper planning, professional development, and retention strategies. Appropriate management of human resources will help reduce medico-legal risk.
These stressful conditions may give rise to a physician's personal fatigue or other health conditions. This in turn may increase the clinical risks for patients and the associated medico-legal risks for the physician. Regulatory authorities (Colleges) and courts generally expect physicians to be aware of their capacity and fitness to provide competent clinical care. The CMPA addresses the issue of physician fatigue in the article "The new realities of medical care."
For many rural physicians taking a day off or an annual vacation depends on the availability of professional back-ups or locums. Coordination and communication are key to smooth transitions, referrals, and follow-up.
When a rural physician is transferring care to a locum or other professional within the community due to a vacation or other planned absence, attention to detail is required in communicating and documenting patient care, particularly for those patients who have specific or more urgent medical needs.
Detailed information about the case, history of the patient, and most recent medical condition and observations should be included in the documentation. The record should be clear, legible, comprehensive, and include as much information for the receiving physician as possible.
Another aspect of healthcare human resources that takes on additional importance in remote and rural communities relates to professional networks and medical advancements. Rural physicians may at times feel isolated from physician colleagues and will likely need to create opportunities for professional development not only for themselves, but also for members of their staff. Attending conferences periodically or engaging in online learning activities may help to support the need to remain current. Peer-to-peer learning between rural physicians should be encouraged, as it allows colleagues in similar circumstances to learn about and better address the challenges of practice.
Physicians in rural and remote communities frequently rely on other healthcare professionals when treating patients. Nurse practitioners and registered nurses with extended training have long been an integral part of the healthcare human resources in northern Canada, often working semi-autonomously in communities that only have a visiting doctor.
Interprofessional care brings many benefits, including giving patients greater access to a range of skills and knowledge. It also, however, places greater emphasis on the need for effective, clear, and timely communication between physicians and other healthcare professionals. The CMPA article "The new reality: Expanding scopes of practice" provides details on how to achieve good communication. Physicians should also be aware of the unique liability risks associated with this model of healthcare delivery. As discussed in the CMPA publication, Collaborative care: A medical liability perspective, these risks can be mitigated when all health professionals have adequate liability protection and when the roles and expectations of each health professional are delineated.
Communication between physicians and healthcare team members
In the normal course of a week, the rural physician may attend to patients in several communities, with satellite offices set up across an expansive catchment area. Travelling to these communities, ensuring follow-up to referrals and consultations with specialists often located in urban areas, and coordinating between healthcare teams are all elements of a rural practice.
In some remote communities, regional electronic networks have been set up to facilitate the exchange of patient information, allowing rural physicians and their team members to examine diagnostic imaging studies transmitted electronically. In other cases, medical records have been digitized to facilitate transfer between satellite offices.3
Anticipating the information that members of the healthcare team may require is paramount to proper coordination, timely intervention, and follow-up related to patient care. Practising in a rural setting, given the distance, patient caseload, and need for referrals or transfers, places additional emphasis and value on clear documentation. Poor communication can lead to disruptions in continuity of care, delayed diagnoses, and unnecessary testing — not to mention frustrated patients.
Many rural practices depend on locums to replace physicians when they take holidays. Familiarizing locum physicians with systems and providing briefing notes and face-to-face updates if possible on particular cases, including any anticipated problems and how to generally manage these, will help smooth the flow of information and the transition.
Here are a couple of points to consider:
Clear and detailed documentation in the medical record on the diagnosis, test results, and the treatment plan will enable consulting physicians, the healthcare team, or locums to follow through more precisely or to adjust treatment should there be a need.
Regardless of the experience or type of practice, communication between all providers should be clear, comprehensive, and timely. Using structured communication techniques to reaffirm key messages and confirm comprehension is a good idea. For additional strategies see the CMPA article "Improving communication between physicians".
Referrals and transfers
When a rural physician decides to refer a patient to a specialist or to transfer a patient to a hospital, the facility is likely to be located at some distance. Transportation might occur by ground or air ambulance, and the family physician may not have had the opportunity to become familiar with processes at that particular urban hospital or medical facility. Whether referrals, transfers, or handovers of care, such conditions demand attention to detail. As well, given the issue of travel and distance, detailing why and when a decision has been made by the physician to transfer a patient to another facility or to a consultant for further diagnostic tests or treatment should be well documented in the medical record.
At times it is not possible for a rural physician to promptly transfer a patient to a tertiary facility due to varying conditions, be it weather, resources, etc. In these circumstances, appropriate temporary measures should be determined by the referring and receiving physicians until the conditions are remedied. In some jurisdictions, protocols have been established which facilitate the timely transfer of patients.
Here are a few points to keep in mind when a transfer or referral is being made:
Medical orders should be written in a clear and legible manner and progress notes or other suitable medical history should be available on the record or should be updated to accurately reflect a patient's condition.
Referring physicians should be aware of the core elements of a good referral including information about the problem, the clinical question to be answered, patient details, and the results of relevant investigations and treatments already provided.
Using templates for referral letters and consultation reports may enhance communication and efficiency particularly when time and distance are factors.
Referring physicians should communicate to the receiving physician's office staff any urgency or particular time frame required for a scheduled appointment. With this information, staff can determine if the timing is cause for significant concern. Should the clinical condition of the patient necessitate an earlier appointment, the physician should attempt to negotiate an earlier appointment. If this is not possible, referring the patient elsewhere should be considered.
Physicians should inform patients who are waiting for a scheduled appointment about the signs or symptoms for which the patient should immediately seek further medical care.
Communicate to the consulting physician any significant changes in the condition of the patient.
If a lack of beds is preventing a transfer or referral, the referring physician should provide sufficient clinical information so the receiving physician can form a professional opinion and give appropriate direction.
Boundary issues in rural practice
In rural and remote practices, doctors may find themselves in situations that urban physicians would not normally need to consider or confront. This occurs particularly when it is necessary to separate personal and family relationships from professional practice.
Physicians working in rural communities need to be aware and to reflect on their approach to setting boundaries in their practice. If there are other physicians in the community, the boundaries are likely easier to set since another doctor is available. If the doctor is the only one in the community, boundaries may be more difficult to establish. Colleges have written guidelines on appropriate boundaries. Physicians will want to consult and see what requirements are in place in their jurisdiction.
Below are a few strategies and points to consider in dealing with boundary issues in rural and remote practice:
Physicians have a duty to provide equal access and care to all patients. Professionalism is key to the doctor-patient relationship and so rural physicians need to place additional emphasis on maintaining confidentiality, objectivity, and avoiding assumptions when caring for patients.
Separating professional work from personal or social events is important. For example, during social events, if a physician is asked questions regarding medical conditions or medical opinion,the physician should state politely, but clearly, that an appointment during office hours would be more appropriate.
Physicians should check with their respective Colleges and familiarize themselves with the code of ethics and how to apply requirements while practising in rural and remote communities.
Living and practising medicine in a rural community can present unique challenges for physicians. At the same time, recent surveys show that the opportunity to practise a full skill set, along with the rural lifestyle, are among the most favoured reasons for physicians to work in a rural area.4 Reflecting on the differences between urban and rural practice can be a good way of anticipating situations and building workable and professional strategies that help reduce medico-legal risk.
The CMPA website houses a number of articles that deal more generally with issues such as communications, privacy and confidentiality, and new and online technologies, among others. As well, members should not hesitate to call the CMPA for advice or guidance on medico-legal risks associated with rural and remote practice.
Society of Rural Physicians of Canada website home page, www.srpc.ca. Retrieved June 25 2012 from: http://www.srpc.ca/index.html
This issue is discussed in greater detail in the article "Limited healthcare resources: The difficult balancing act."
Canadian HealthcareNetwork.ca, "EMR success story: Sustainable rural care built from the ground up," January 2012. Retrieved on January 22 2013 from: http://blog.canadianemr.ca/canadianemr/2012/02/building-an-emr-from-scratch-a-saskatchewan-success-story.html
Chauban, T., Jong, M., Buske, L., "Recruitment trumps retention: results of the 2008/09 CMA Rural Practice Survey,' Canadian Journal of Rural Medicine (2010) Vol. 15, no.3 p.101