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IS MEDICAL MALPRACTICE, LIKE POLITICS, ALL LOCAL?
Part 1 - How locality considerations came about.
In our nation’s earlier history, the disparity in skills between urban and rural physicians was considerably greater than it is today. Before the 20th century, full-service hospitals were nearly always in large cities. Physicians in rural areas had limited office facilities and often had to go to the patient’s residence. Living conditions were not always good, and access to clean water, sound nutrition, and general hygiene was spotty.
Questions arose about how standards of care should be determined under such circumstances. The operating assumption was that it would be unfair to hold a physician who worked in a community somewhere in rural America to the same standard as that held by a physician practicing in a large urban community in the proximity of major teaching centers. To so insist might discourage medical practitioners from populating rural areas, thus depriving a large slice of the population of medical care.
At this time in our history, there was a huge range of education and training available to members of the medical profession. In some areas, physicians were highly trained, continuously learning and applying the most modern and progressive medical theories and practices. In others, they were quite isolated – cut off due to a lack of communication and transportation. These country doctors had only those medical texts that they brought with them and the experience of those who came before them.
It did not seem appropriate for both types of physicians to be held to the same medical standards when the rural doctor could not hope to achieve a similar depth of education and training. Consequently, the legal standard known as “the locality rule” came into being. By the late 1800’s, courts had begun to recognize that the degree of skill and knowledge of physicians varied widely from community to community. One of the early applications of this realization came in 1886 in a court ruling that a physician’s medical standards of care ought to be measured against others in the area where the physician practiced.
IS MEDICAL MALPRACTICE, LIKE POLITICS, ALL LOCAL?
Part 2 - Why they no longer apply.
Until the late 1960’s, there was general acceptance of the locality rule as the only fair way to even the playing field for determining applicability of medical standards of care. The first schism came about 1970, when medical specialists began asserting themselves as having specialized training, thereby maintaining knowledge of the most current scientific advancements. Since the locality rule came about to protect general practitioners who did not have access to the latest medical knowledge and training, the theory did not support those specialists who, by definition, were claiming to have advanced training and skill. As a result, in a majority of jurisdictions, specialists were no longer able to claim the benefits of the locality rule. Instead, they were required on a national level to meet the standard of knowledge and training of other specialists. Thus began the beginning of the end for the locality rule.
During the 1970’s, jurisdictions began modifying the locality rule. First, of course, specialists began to be held to higher standards. After all, if they were going to hold themselves out to the public as having specialized skill and training, they should be held accountable on a national level for having that enhanced skill and training. At first, the courts hesitated, fearing that this would discourage specialists from locating in rural areas. In those jurisdictions, compromise was reached by expanding the definition of the “locality” used to measure standards, sometimes encompassing entire states. Over time, many courts abandoned the locality and statewide rule for both general practitioners and specialists. Soon thereafter, the courts followed with similar findings for all physicians.
The availability of mass communication and mass transit meant that rural physicians, or those outside urban areas, were no longer disadvantaged through isolation. Satellite and fiber optic communication as well as cable-supported communication has made continuing education available without the need for travel. Therefore, by the 1980’s, the original rationale for the locality rule had vanished and once again the courts began to rely on a general standard of care based on the practitioner’s area of expertise. Today, all medical practitioners in most jurisdictions are required to demonstrate the same reasonable degree of care, skill, knowledge, and training that would be expected of other members of that specialty at a national level.
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