Providing a lifeline for rural doctors

Tim Baker
Med J Aust 2015; 203 (7): 277. || doi: 10.5694/mja15.00768
Published online: 5 October 2015

Telemedicine programs are often designed to meet the needs of specialists rather than rural doctors

Australia has almost twice as many small rural hospital-based emergency facilities as designated emergency departments.1 They see 16% of Australia’s emergency patient presentations, or almost 1.3 million presentations each year.1 Although small rural facilities are tasked with managing mainly minor injury and illness, they also treat patients with complex and time critical problems.2 These facilities are staffed by nurses alone, or by junior doctors, general practitioners or rural generalists. Rural doctors often have specific training for rural emergency medicine, and they usually have more years of experience than junior doctors who treat most patients in urban emergency departments. What they lack is immediate access to onsite specialist advice.

Tertiary specialty units that receive patients from rural areas are often aware of this deficit. Concerned about the poor outcomes for their rural patients (although rural–urban outcome research is often confounded by hard-to-control-for factors3), some have created systems to provide a lifeline for early advice and support. A recent systematic review4 described tele-emergency programs that provide support for stroke thrombolysis, trauma management, burns care, eye conditions and several other specific problems.

Direct access to specialists with a passion to help rural doctors is incredibly valuable. Rural doctors feel more supported, and may be more likely to stay in rural practice.5 It is easier, and likely to be safer, than the usual process of speaking to a registrar at a suitable hospital, although robust evidence is lacking.4

However, telemedicine projects that are driven by specialty units create problems. When each program chooses a separate technology that is ideal for their condition of interest, rural doctors can struggle to maintain familiarity with each system. Of more concern is that advice can only be obtained if the patient is critically ill or has a condition that interests one of the specialty telemedicine programs. Advice is difficult to obtain if the patient presents with an undifferentiated illness that is probably self-limiting but in which life-threatening conditions have not been excluded. Telemedicine advice providers with limited resources have complained they are there to “consult with sick patients … Not [to deal with] every other thing”.6

But undifferentiated problems, such as dyspnoea, chest pain, abdominal pain, collapse and headache, are among the most common emergency presentations at both large and small facilities.2 No rural ambulance service has the capacity to transfer all such patients to a larger centre just to make sure that the small number of serious diagnoses are detected. These decisions can be difficult. An expert opinion in borderline cases can make a difference, sometimes avoiding unnecessary and expensive transport and keeping patients where they would rather be. It can also save lives. The South Australian Integrated Cardiology Clinical Network provides advice to rural clinicians for any patient with chest pain. As a result, within a decade, they have removed the gap between rural and urban mortality from myocardial infarction.7

The alternative approach is to create a centralised telemedicine system staffed by emergency medicine specialists.8 This replicates the practice in many regions where emergency physicians provide telephone support to surrounding small hospitals. This system has several advantages. Emergency specialists become more familiar with the small hospital environment by seeing it regularly during consultations. It provides a single access point for rural clinicians. No type of presentation should be out of their scope of practice, even if the patient has vague symptoms or is drug affected.

There is a disadvantage too. In emergency departments, emergency specialists rely on inpatient unit specialists directly reviewing some cases. Unless this is explicitly built into a centralised telemedicine system, emergency specialists must use an ad-hoc system of calling specialists or their registrars at surrounding hospitals who may have no access to the video-links and may feel that offering such advice is not part of their employment.

How do we combine a centralised system with a system of specialty units on call? A centralised telemedicine system may have to be located at an actual hospital with a full complement of speciality units resourced to help rural doctors. There is a system like this in Australia, or actually over Australia. For more than a decade, the Good Samaritan Hospital in Phoenix, Arizona, in the United States, has been providing advice for medical situations on Qantas, and many other airlines’, flights. A doctor on shift in the emergency department is called to provide advice, with all the specialist and subspecialist resources of a large tertiary hospital available for backup.9 Can we provide the same service, or something similar, for rural hospitals on the ground?

Provenance: Commissioned; externally peer reviewed.

  • Tim Baker

  • Deakin University, Warrnambool, VIC


Competing interests:

No relevant disclosures.

  • 1. Australian Institute of Health and Welfare. Australian Hospital Statistics 2011-12. Health services series no. 50. Cat. no. HSE 134. Canberra: AIHW, 2013.
  • 2. Baker T, Dawson SL. Small rural emergency services still manage acutely unwell patients: a cross-sectional study. Emerg Med Australas 2014; 26: 131-138.
  • 3. James PA, Li P, Ward MM. Myocardial infarction mortality in rural and urban hospitals: rethinking measures of quality of care. Ann Fam Med 2007; 5: 105-111.
  • 4. Ward MM, Jaana M, Natafgi N. Systematic review of telemedicine applications in emergency rooms. Int J Med Inform 2015; 84: 601-616.
  • 5. Potter AJ, Mueller KJ, Mackinney AC, Ward MM. Effect of tele-emergency services on recruitment and retention of US rural physicians. Rural Remote Health 2014; 14: 2787.
  • 6. Westbrook JI, Coiera EW, Brear M et al. Impact of an ultrabroadband emergency department telemedicine system on the care of acutely ill patients and clinicians’ work. Med J Aust 2008; 188: 704-708.
  • 7. Tideman PA, Tirimacco R, Senior DP et al. Impact of a regionalised clinical cardiac support network on mortality among rural patients with myocardial infarction. Med J Aust 2014; 200: 157-160.
  • 8. Herrington G, Zardins Y, Hamilton A. A pilot trial of emergency telemedicine in regional Western Australia. J Telemed Telecare 2013; 19: 430-433.
  • 9. Goodwin T. In-flight medical emergencies: an overview. BMJ 2000; 321: 1338-1341.


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access_time 10:15, 6 October 2015
Tim Leeuwenburg

Thanks to Dr Baker for considering the plight of the rural clinician. With respect however, an experienced rural clinician is extremely comfortable with undifferentiated illness - specifically in the rural context. I doubt that a 'doc-in-the-box' FACEM would add value to an experienced rural doctor...their role may be useful for isolated clinics with remote area nurses or inexperienced locums.

Many of the difficulties in decision-making around such undifferentiated patients relate more to paucity of available investigations - in the bush, 24 hr turnaround for blood is typical...and the nearest CT scanner may be hundreds of kilometres or several hours flight away...

I see more benefit in dedicated systems such as iCCNet referenced (the integrated 24/7 cardiology advice line in SA) and indeed wish we had similar for radiology (mindful that most rural docs take their own films) or for dermatology, psychiatry, obstetrics - in short, access to in-patient specialist services, not access to a FACEM per se.

Competing Interests: No relevant disclosures

Dr Tim Leeuwenburg
Kangaroo Island Medical Clinic

access_time 06:27, 20 October 2015
Timothy Baker

It would be wonderful for rural Australia if every small rural hospital had an experienced rural generalist but, as Dr Leeuwenburg points out, there are many rural emergency facilities also staffed by nurse practitioners, bush nurses, junior doctors, and general practitioners without generalist training.

I agree that both rural generalists and emergency specialists value advice from other specialists and subspecialists. They are very useful when patient conditions fall within the subspecialty box. The problem is that patient problems do not always fall within subspecialty boxes. The cardiologist may be less willing to help if the patient with chest pain is also intoxicated and wanting to leave. Who will provide a sounding board when the patient has nothing much to find on examination but you just have the sense that something else is going on? 

I think few emergency specialists are ‘extremely comfortable’ with undifferentiated illness although we see it many times each day. We know how hard it is. We have seen other people make mistakes and we have made them ourselves. We are often in the position where we have to give an opinion whether we want to or not. That is why ‘undifferentiated illness’ is the real specialty of emergency specialists. A rural generalist may want to contact an emergency physician because they are two experts with overlapping but slightly different areas of expertise who want to work out the best way to help a patient with an undifferentiated, complex, and possibly life-threatening condition.

Competing Interests: No relevant disclosures

Dr Timothy Baker
South West Healthcare, Warrnambool, Victoria

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