Literature

Can J Rural Med 1996; 1 (2): 80-81

To survive in the US context, many rural hospitals must be able to attract patients. According to this study, many such hospitals are "financially strained, and in danger of closing." One apparent factor is the tendency of some rural residents to bypass their local facility and seek care in larger urban medical centres.

The authors surveyed the residents of two communities in rural Minnesota to assess the reasons why they might choose to do this, in spite of longer travel distances. They found that patients had the perception that "bigger is better, and that smaller, rural medical facilities are unable to keep up with technology."

Although rural residents felt that the primary care provided in rural areas was "more compassionate and accessible" than in urban areas, they also felt that "rural physicians are less qualified."

The perception, noted by Rieber and associates (see preceding item), that rural medical facilities are less technologically advanced may be modified over time by the widespread introduction of telemedicine projects such as the one described by Caldwell and coworkers. They report on a project in which the University of Nebraska Medical Center provided a rural hospital with advanced cardiology services. These services consisted of the long-distance transmission of cardiac diagnostic tests, as well as the remote monitoring of in-patients.

Cardiac ultrasound images were transmitted for interpretation, as were 12-lead and ambulatory electrocardiograms. The system had the ability to send both digital and analogue data, as well as static images and 30 fps video. The authors note that in addition to increasing the availability of these services to rural general practitioners, this system "has significantly reduced the time and cost to transmit vital cardiac diagnostic information, thus improving the quality of care received by rural patients."

The organization of health services in Norway includes general practitioner hospitals (GPHs), which provide an intermediate level of care and from which patients are either referred to higher-level hospitals or sent home after treatment. This organization is similar to the relationship between rural community hospitals and urban secondary and tertiary level hospitals in Canada.

The study assessed the role played by GPHs and found that over the 8 weeks of the study, 60% of patients were admitted, treated and discharged from these units (mean length of stay 6.8 days). Nineteen percent were transferred to a higher-level hospital (mean length of stay 3.6 days) and 9% were transferred to GPHs from other hospitals and stayed a mean of 22.3 days. In the judgement of the investigators, 61% of those discharged from GPHs would have required admission to a higher-level hospital, and it was therefore concluded that "the GPHs have a . . . buffer function by preventing patients with acute symptoms from being unnecessarily admitted to [higher-level] hospitals."

The role of these hospitals in providing services in "long-term follow-up care" for patients transferred to them for convalescence following treatment at a general hospital was also noted.

In response to the persistence of shortages in the supply of physicians to rural and underserviced areas of the United States, the authors attempt to define a set of educational needs that, if satisfied, might produce a physician more suited to, and more comfortable in, rural practice.

The study was carried out by surveying 1096 family physicians who had entered rural practice within the last 3 years. The response rate was 57%. The physicians were asked about the "appropriateness and adequacy of their educational process in preparing them for rural practice."

The authors were able to define a group of items that these recent graduates felt had been inadequately addressed in training programs. These included "counselling, pediatrics, obstetrics and gynecology, geriatrics, surgery and trauma, medical specialties, surgical specialties, community medicine and management, and a mixed factor that included rehabilitation, behavior sciences, learning disabilities (in children), chronic childhood problems, and human growth."

The authors conclude that it is possible to define the educational needs of rural practitioners; that these needs are not being met by standard family practice curricula; and that "if preparation for rural practice is improved, rural communities might be more successful in recruiting and retaining well-trained family physicians."