Acknowledging rural context, local and generalist care

We thank Orkin and Kelly for their letter about the stated rural context in our recent Decisions piece.1

One concern they expressed is that our piece focuses too heavily on “taking a history, ordering a battery of tests and referring to specialized services.” We submit that this is the primary purpose of the case study, in line with CMAJ’s expectations for its Decisions articles, which asks authors to describe “key issues that should be addressed in the first appointment [and] may include examination, investigation, treatment, harm reduction, follow-up, or referrals.”2

Related to this, is the other concern Orkin and Kelly expressed — that the guidance does not sufficiently account for limitations of rural primary care practice. The primary purpose of this case study was to review clinical decision-making rather than provide a broad review of care disparities that may exist between rural and urban settings. Understanding that, we can also disclose that this fictional encounter was originally written with a suburban setting in a major metropolitan area in mind. The change to a rural setting occurred in response to suggestions made during the review process.

We agree that care is highly contextual and thank Orkin and Kelly for the kind reminder. In this instance, a seemingly simple change (literally altering a single word) resulted in presenting a case in a vastly different locale with challenges to the feasibility and appropriateness of proposed guidance. Ironically, while we were preparing this Decisions case, our supporting research uncovered substantial disparities in access to harm reduction services between urban and rural settings. As already mentioned, our ability to address these in detail was limited by format and space restrictions. However, we agree that differential access to various support services would impact the nature of care provided in different settings.

Further work from Orkin and Kelly would be welcome, with perhaps a specific focus on management challenges around crack cocaine use in rural settings. We again acknowledge that the original context underpinning our Decisions piece was a nonrural setting.