The Locality Rule
Are small-town physicians held to the same standard of care as their urban counterparts?
In the past, the answer to this inquiry could well have been “No” because of the “locality rule”. The rule refers to the idea that the standard of care expected of medical practitioners may be adjusted according to the location of their practice.
The rule arose in the late nineteenth century as a way for courts to deal with the wide disparities in competence and credentials which characterized medical practice in North America. At the time a graduate of a private for-profit medical school, at which the curriculum might be just one year, would be unlikely to compete successfully for patients with alumni of prestigious universities like McGill or Johns Hopkins. These lesser practitioners migrated to “country practices” where the quality of their care was acknowledged to be inferior to that of their urban colleagues, quite separate from any issue of access to medical resources. Yet without these individuals medical care would have been entirely absent in rural and remote localities. Accordingly, courts held that in malpractice litigation such physicians could only be held to a standard of care articulated by their true peers, that is, by practitioners familiar with practice in a very similar rural environment.
Over time medical education became standardized, graduates all wrote the same licensing exams, and resources like text books, clinical guidelines, and peer-reviewed journals could be accessed online from anywhere. The rationale for discounting the standard of care in rural areas disappeared. But though the locality rule had become largely moribund in Canada, no appellate court had specifically addressed the validity of locality the rule until very recently.
The issue arose in Dumesnil v Dr Jacob, 2024 MBCA 4 (CanLII). Ms Dumesnil sustained a badly fractured ankle in a motor vehicle accident. Dr. Jacobs, a general surgeon practicing in a small community in southern Manitoba, pieced the bone back together but the patient had a decade of pain and activity limitation. Eventually an orthopedic surgeon who specialized in lower extremity trauma re-operated to remove some bone and place tendons in their correct alignment.
Having at last discovered the cause of her persistent pain Ms Dumesnil initiated a malpractice action against Dr. Jacobs. She lost at trial and the case proceeded to the Manitoba Court of Appeal where she was successful. The Court found that the trial judge had wrongly relied on the locality rule to impose a lower standard of care on Dr. Jacob as a “rural” or “community-base” practitioner in comparison to a similarly qualified physician practicing in a large urban setting. This was held to be an error in law.
Already an Ontario court, in Gumbley v. Vasiliou, 2024 ONSC 4858 (CanLII), has favourably cited this judgment and it may well represent the final slaying of the locality rule in Canada. Indeed, in future the mantra of “Location, Location, Location,” will still be chanted by real estate agents or baseball pitchers but definitely not lawyers. To return to the original question, yes, small-town physicians are held to the same standard of care as their urban counterparts.
Want to read more? See:
Sam Shortt. “The Locality Rule in Canadian Medical Malpractice Litigation: Abandon or Reformulate?” 2020 39 (3) The Advocates’ Journal 29-31.