Rural Research

A recent article in the British Medical Journal, by Perry, et al., presented evidence that a CT scan within 6 hours of symptom onset yields 100% sensitivity in the diagnosis of subarachnoid hemorrhage (SAH), when read by a trained radiologist. The results suggest that in this setting the need for lumbar puncture (LP) is greatly diminished. If this data is trusted, and physicians use the CT scan as the Gold Standard, then an invasive procedure may be avoided. Currently, when a CT scan doesn’t highlight any blood, physicians are likely to order an LP to be certain that SAH is safe to rule out.
Citation: BMJ 2011; 343:d4277

However, this study is concerned with the utility of CT, not making LP obsolete. In 2008 I detoured from a cross country move, to drive through a small Kentucky town, after a sign for a hospital drew me off the road. Banners hung across the hospital’s entrance to celebrate its recent implementation of a smoke-free campus. I wonder whether the benefits of CT or smoking cessation was the first to affect the practice of those physicians.

Even without the evidence demonstrated in the Perry study, hospitals in the Texas Medical Center have long been using CT to aid the diagnosis of SAH. This study justifies ordering a CT scan to identify subarachnoid bleed when there is a suspicion of SAH. While its data is not game changing along Fannin Street, it does reinforce CT scans’ legitimacy as a covered diagnostic test, even by the stingiest of health insurer.

As the indicated uses for CT broaden, perhaps rural hospitals are more likely to purchase the advanced equipment. However, in the near term, it’s critical that research begin to focus on the way medicine is practiced in these rural areas. To do so requires dedicated NIH grants stipulating funds be spent in a rural setting.
Conducting research in this manner would inform us of the methods rural physicians use to make a diagnosis when using a less technologically advanced toolbox. Likely, we’d learn something from their practice, or maybe we’d remember things our profession has largely forgotten. But more importantly, we’d face a reality that medicine must be practiced differently by people living in rural areas.

Today’s rhetoric favors preventative medicine and seems to delight in our failure to prevent disease. Politicians introduce the topic as if they originated the idea of prevention, and admonish physicians for not participating in their unnamed solution. The natural reaction is to parry, "Society as a whole fails to take the responsibilities necessary to prevent disease; this is not the fault of physicians." Rather than join in meaningless debate, the physician profession must lead improvement. One action is the research of Primary Care methods, with aims to determine how to better prevent disease.

Today, it’s not uncommon that complicated patients in rural, East Texas be transported to Houston for higher level care. A tenet of Quality Improvement is that transportation is waste. While the patient is moved, the standard of care is temporarily lowered. Currently, the vast majority of research is conducted at tertiary care referral centers. Broadening our focus of research to include rural areas, in addition to tertiary care centers, would bolster the quality of care provided in the rural setting. Where academic researchers travel, medical residents and fellows follow, in search of training. As the government begins taxing Graduate Medical Education programs, the already meager resident salaries will thin further. A number of medical school graduates are likely to appreciate the opportunity to train in a location where their salary offers a higher standard of living.

Several factors may converge to favor the development of rural medical care. By studying the patient populations in the primary setting we’d learn more about prevention.