Rural Medical Practice Managing Risks | Defence Update

Australia’s population and health services resources are both concentrated in the larger and essentially coastal urban population centres. Rural General Practitioners (GPs) are central to the delivery of health services outside of the urban centres – many operate as the only GPs within their regional community. According to the Rural Health Workforce Australia’s Medical Practice in Rural and Remote Australia 2012 report, as of November 2012:

• a total of approximately 7,400 GPs worked in rural and remote Australia – of which approximately 40% worked in NSW and Victoria (largely in inner regional areas)
• approximately 2,500 GPs worked in outer regional to very remote areas – this being the norm for the larger, less populated states of Western Australia, Queensland and South Australia as well as the Northern Territory.

The number of regional and remote practitioners has steadily increased in recent years. GPs have been attracted to rural practice by the opportunity to offer communities “complete care” and practise a ”full skill set” whilst enjoying a rural lifestyle. However, it is clear that not all GPs within rural and remote areas enjoy a more favourable work-life balance.

Rural medical practice is clearly and unavoidably different from urban practice. Accordingly, the types of medico-legal issues that arise and the risk management strategies to manage them are also somewhat different.

Professional isolation

The obvious challenge for rural and remote GPs is that of professional isolation. Rural communities often lack or are located long distances from hospital services, diagnostic and imaging services, specialist services, mental health services and allied health professionals. The treatment risks posed by this reality are magnified by the fact that in many such communities, the GP is the first point of contact for many people in need of health care, regardless of whether he or she is the most appropriate health professional to consult. Accordingly, due to the practical difficulties and inconvenience for patients to access specialists and more appropriate health services, rural doctors may commonly find themselves providing care outside their usual experience and competency without optimal supports and safeguards for their patients. In particular, rural GPs have fewer opportunities to obtain peer consultation and multidisciplinary perspectives for complex assessments.

However, notwithstanding these limitations and challenges, the legal standard of care applies, namely that which can reasonably be expected of a person professing that skill. Inexperience is no defence for an action of medical negligence. For the same reasons, the standard expected of a rural practitioner is the same as his or her urban counterpart.¹

Tips

Although rural GPs have the opportunity to provide “complete care”, they must remain conscious of the limits of their competency and be vigilant in balancing the interests of the patient, particularly regarding the need for hospital, specialist and diagnostic services. The quality of such assessments can be improved by:

• developing networks of clinical support and consultation
• use of electronic communication and telehealth – opportunities for specialist consultation have improved for rural doctors
• continuing professional development.

Maintaining connections with colleagues in the region and throughout the country via meetings and electronic communication is worthwhile in staving off professional isolation and preventing significant departures from standards of care.

Complex patient profiles

GPs in rural and remote areas experience a greater diversity in patient presentations. Rural and remote patients generally do not seek medical help as vigilantly as urban patients and many, due to age, life habits (e.g. higher smoking and alcohol consumption levels) and less education are in poorer overall health. Further, rural GPs are likely to be called upon to manage more instances of emergency treatment, obstetrics and other procedures without referral. Accordingly, the care provided in rural and remote areas is complex.

Tips

Dealing adequately with complex presentations includes:

• having appropriate knowledge and skills – which requires increasing and maintaining knowledge and skills through continuing professional development; keeping up-to-date with new developments; and ensuring one’s practice reflects current standards
• recognising the need for hospital, specialist and diagnostic services to identify and address the treatment needs of the patient
• managing referral and patient transfer requirements with care, and maintaining appropriate information and record-keeping levels to allow specialist and secondary services to efficiently address the patient’s needs with the benefit of the rural GP’s treatment history.

Maintaining professional boundaries

Establishing and maintaining professional boundaries is also a challenging aspect of rural practice, particularly in circumstances where the option of transferring the patient to another GP is not readily available. In small communities there is more potential for community members and practitioners to blur their professional and social interactions, e.g. patients see the practitioner as their friend or may seek informal consultations in social settings. Section 8 of the Medical Board of Australia’s Good Medical Practice: A Code of Conduct for Doctors states that “doctors must display a standard of behaviour that warrants the trust and respect of the community” and that:

“Good medical practice involves:

8.2.1 Maintaining professional boundaries.

8.2.2 Never using your professional position to establish or pursue a sexual, exploitative or other inappropriate relationship with anybody under your care. This includes those close to the patient…”

Tips

GPs need to consciously reflect upon the need to establish and maintain appropriate boundaries in their practice, both within and particularly outside of their surgeries, by:

• communicating with patients in a manner not likely to confuse professional, social and personal boundaries
• limiting the provision of medical advice and treatment to the formal setting of the surgery.

Vulnerability to mental health risks

Rural GPs face particular challenges that can contribute to or exacerbate depression and anxiety. Many face long working hours and on-call responsibilities coupled with significant workforce shortages. The lack of health service resources and backup for the practitioner and the general sense of professional isolation can be significant and constant sources of stress. Not surprisingly, rural practitioners are at risk of occupational “burnout”.

Tips

Rural GPs must be conscious of their own state of physical and mental health and its impact on their professional competence, and should:

• recognise unrealistic professional and personal expectations, particularly in a rural setting where it may be natural or romantic to be seen, and want to be seen, as a “one-stop shop” for all health matters
• have and maintain their own treating general practitioner
• recognise the signs of depression within themselves and seek professional assistance as appropriate – see information below on beyondblue, MDA National’s Charity of Choice.

Enore Panetta is a director at Panetta McGrath Lawyers, Perth.

1. Geissman v O’Keefe (unreported, NSWSC, Simpson J, 25/11/1994) at [51]. White B, McDonald F and Willmott L. Health Law in Australia. Thomson Reuters, Sydney, 2010; 228

As part of our Corporate Social Responsibility Program, MDA National is a proud supporter of Australian Charity, beyondblue. Visit beyondblue.org.au for useful information and resources for medical professionals dealing with depression and anxiety.