The topic of what rural docs should or should not be doing - what services rural patients should be able to have close to home and which they should be referred for - has no current "right" answer. It depends as much on personality as any evidence-based policy. Keith MacLellan
Keith continues:
The issue is only indirectly related to whether we should be attaching the reality of the abysmally underserviced state of health care most rural populations endure to the current problem of access to urban care for rural patients. I still hold that, when beefing about the latter we should always mention the former.
But Ray brings up the notion that we rural doctors should stick to what we do best - uncomplicated MI's, geriatrics, palliative care, basic medical problems, uncomplicated obstetrics, psycho-social problems and the like - basic medical services at a cost savings to the government.
He has a good point, as always. Perhaps very realistic too. However, what happens when the uncomplicated MI goes into heart block? Or the CHF patient needs intubation for a few days? Or the routine delivery goes bad? Well, they are transferred, unless a specialist is available. This may or may not be good for the patient, depending on the geography and the weather, to name only two factors. It also raises the issue of whether we should be treating such cases at all if we can't handle most of the complications.
Is this up to good standards of care? Ideally, should an MI patient be cared for in a rural hospital that is not comfortable with central lines?
In many circles, the feeling is that our training system should be turning out many more specialists - internists, general surgeons and psychiatrists, etc - sending them to rural areas to handle "secondary" and "tertiary" care. I have no trouble with this concept (although it isn't very realistic), but I do have trouble with generalist rural doctors being restricted to "primary" care. I would argue instead for an expansion of the GP/FP capabilities in rural areas, including ventures into "higher" levels of care.
Really what happens (I like to think) is that rural doctors operate on a fluctuating level, almost hourly, between primary, secondary, and (occasionally) tertiary care. Ideally they do this in teams, however informal. Personally, I have thought that the best way to learn a limited specialty skill set is to find find what is boring, every day, bread and butter within one specialty and learn that - split thickness skin grafts in plastic surgery, for example. Of course, there are other, more formal ways to acquire specific skills.
A visit to any tertiary care ICU will show that the majority of their patients are only moderately ill, that what once was "complicated" care 30 years ago is now routine ICU stuff now, usually left to the first year resident. Ventilating a patient with pulmonary edema overnight, for example. Putting in a temporary transvenous pacemaker. An arterial line for the hypertensive crisis. These are the type of cases we could be handling (cost-effectively) in rural areas, if only we did not blanch at the prospect because there is no conceptual support for the idea in our medical and licensing system. I don't see how else rural populations are going to get the care they deserve.
I am not suggesting we do liver transplants in rural areas, but we should be careful what we label as "tertiary", nor should we buy into any rigid categories of what we should or shouldn't do. And we should be generally trying to offer more specialized services closer to home - I agree with the politicians on that one.
Keith MacLellan kmaclell@CA.INTER.NET