Rural Medicine

Five Tests and Treatments to Question

by
Society of Rural Physicians of Canada
Last updated: July 2022

Don’t send a patient for a specialist visit that requires several hours of transport if the visit can be done virtually or by a local physician.
1

Due to the location of many rural communities, it is very challenging for rural patients to easily access many specialist physicians who typically practice in more urban centres. Travel away from a community removes patients from their support systems, induces financial burdens and can create safety concerns for patients, especially in the winter months. Telemedicine provides a cost-effective solution to improve access to care closer to home. Thus, if the option is available, and in consultation with the patient, physicians should consider utilizing telemedicine.

Another option is to have the out-of-town specialist communicate with the local physician who can provide follow up care. Local physicians should receive explicit detailed instructions as to what issues need to be addressed, and the appropriate time frame for follow-up.

Sources:

Jong, M., Mendez, I., & Jong, R. Enhancing access to care in northern rural communities via telehealth. Int J Circumpolar Health. 2019 May;78(2), 1554174. PMID: 31066652.

Nasser, A., & Chen, N. Telehealth in rural Canada. University of Western Ontario Medical Journal. 2014. 83(1), 49–50.

Sevean, P., Dampier, S., Spadoni, M., Strickland, S., & Pilatzke, S. Patients and families experiences with video telehealth in rural/remote communities in Northern Canada. J Clin Nurs. 2009 Sep; 18(18), 2573–2579. PMID: 19694885.
Don’t send a low risk patient to a distant centre for a screening test (i.e. mammography) if the risk of injury from transportation to the centre is higher than the benefit of the test and if there are other screening options available in the local community (i.e. mobile mammography, mobile ophthalmology, fecal immunochemical test).
2

In 2018, for every billion kilometers travelled by a motor vehicle in Canada there were 4.9 fatalities and 390 total injuries (including 24.2 serious injuries). The risk of travel in rural communities is greater than urban areas. Despite rural areas accounting for only 18% of the population, 54% of fatal motor vehicle collisions in Canada occur on rural roads. The danger of rural roads has been attributed to multiple factors including greater distances to medical facilities, inclement weather, higher speed limits, animal crossings, poor lighting, and poor maintenance.

Screening is important for disease prevention. It is important to weigh the risk of transportation with the benefit of the test, patient specific risk factors and patient preferences. Arranging screening tests when the patient is already visiting the centre for another reason is efficient.

Sources:

Bell, N., Simons, R.K., Lakha, N. & Hameed, S.M. Are we failing our rural communities? Motor vehicle injury in British Columbia, Canada, 2001-2007. Injury. 2011 Jul;43(11), 1888-1891. PMID: 21839445.

Osmun, W. E., Copeland, J., & Boisvert, L. Mammography screening: how far is too far? Rural and Remote Health. 2013 Feb; 13 (1), 2149. PMID: 23406261.

Transport Canada. Rural Roads [Internet]. 2013.

Transport Canada. Canadian Motor Vehicle Traffic Collision Statistics: 2018 [Internet]. 2018.
Don’t transfer a palliative patient to a facility far from their friends and family without considering if their goals of care can be achieved locally.
3

Advanced care planning is an important part of primary care to establish individual patient’s goals of care. This is especially true for rural patients who may need to be transferred to an alternate community for care.

Studies have shown that rural patients prefer to die in their home communities. It is important to consider the patient’s goals when contemplating sending them away from the community for medical treatment at the end of life. If the patient is transferred to an alternate community, ensure an updated, written advanced directive accompanies them to the receiving community.

Sources:

Wilson DM, Fillion L, Thomas R, Justice C, Bhardwaj PP, Veillette AM. The “good” rural death: a report of an ethnographic study in Alberta, Canada. J Palliat Care. 2009;25(1):21-29. PMID: 19445339.

Government of Alberta. Advance Care Planning and Goals of Care Designations. 2018.
Don’t call in staff for an investigation (i.e. blood test, imaging, operative procedures, etc.) at off-service hours unless it is likely to change management.
4

Health personnel are valuable resources in rural communities. It is important that provider well-being is balanced with optimal patient care, especially where human resources are limited.

Sources:

Nicol, A.M., & Botterill, J. S. On-call work and health: a review. Environ Health.2004 Dec 8;3(1):15. PMID: 15588276.
Don’t transfer a patient by ambulance with skilled personnel if the patient is unlikely to require medical intervention en route.
5

Health personnel are valuable resources in rural communities. Sending a nurse or physician en route to an urban centre can leave a rural hospital without medical support for significant periods of time. Consider the evidence when deciding whether a patient needs to be accompanied during transport. Consider calling the receiving hospital to mutually agree on the need for skilled personnel during urgent or emergent transport.

Sources:

Brayman C, Hobbs B, Hill W et al. ICU Without Walls — Interprofessional High Acuity Response Teams (HARTs) improve access to higher level of care in rural and remote communities. CJRT. 2012 Nov;48(4):14-19.

Kornelsen, J., McCartney, K., Newton, L., Butt, E., & Sax, M. Rural and Remote Division of Family Practice. Rural Patient Transport and Transfer: Findings from a Realist Review. [Internet]. (2016). Applied Policy Research Unit, Centre for Rural Health Research.
How the list was created

The Society of Rural Physicians of Canada (SRPC) established its Choosing Wisely Canada top 5 recommendations through collaboration with its internal members and with medical students of the STARS program (Students and Trainees Advocating for Resource Stewardship). The list started with brainstorming overuse topics in rural medicine based on the experiences of rural practitioners across Canada. Over several months the list was refined based on feedback received from SRPC members, a peer-review process, and a review of relevant scholarly research. A preliminary list was shared at the SRPC Annual General Meeting in May 2020, from which a final list was established. Globally, this is the only known rural-focused Choosing Wisely recommendation list.

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