Local standards of practice should be relegated to the horse-and-buggy era where they started. They can discourage advances in medical practice and place extra burdens on physicians, especially those who practice in more than one state.


That’s the conclusion Michelle Huckaby Lewis, MD, JD, and two colleagues reach in a recent essay in the Journal of the American Medical Association (2007;297:2633-2637).

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In some states, judges and juries decide malpractice on the basis of what a reasonable clinician would do under the circumstances, they write. In the 21 states with some version of the “locality rule,” cases are decided according to the standard of care in the locality.


The result can be care at odds with national, evidence-based standards, argues Dr. Lewis, a Greenwall Fellow in the Bioethics and Health Policy division at Johns Hopkins University in Baltimore.


“If a new test or procedure has shown tremendous benefit for patients, but no one else in the locality is using it yet, then the first doctor who does is potentially putting himself at risk,” she explains. “If the test or procedure is accepted as a national standard, but no one in the locality has adopted it yet, then care becomes below the national standard.”


The locality rule is also used to disqualify expert witnesses because they are not familiar with community standards. It was devised in the 1880s to protect rural doctors who did not have the same access to education or information about medical advances as their big-city colleagues.


Modern media and CME programs have rendered that fear obsolete, Dr. Lewis maintains.

“We advocate a resource-based national standard,” she says. “Obviously accessibility to facilities and subspecialists are different across country. Rural doctors don’t have the access to testing and specialist resources that their urban colleagues do. But all physicians should be expected to be equally competent” in evidence-based medicine practices.