I can't think of a better way to introduce the concepts, triumphs, and battles associated with rural emergency medicine practice than a candid talk with the country's most well-known rural emergency physician, Edwin Leap, MD, of Blue Ridge Emergency Physicians at Oconee Memorial Hospital in Seneca, SC. Known as the award-winning EMN columnist of Second Opinion, Dr. Leap is also an op-ed columnist for the Greenville News, the author of three books, Working Knights, Cats Don't Hike, and The Practice Test, and a prolific blogger.
How do you define rural emergency medicine practice?
I'm not sure what the definition is. It could be based on population, though I'm not sure how I feel about that. Less than 20,000 maybe? Our current volume is 38,000, and we are the only hospital in the whole county. We get patients from surrounding counties and north Georgia. Our volume was 25,000 when I got here. There's no official trauma level.
What drew you to practice in a rural setting in the first place?
Culturally, this was a lot like home. I was an Appalachian kid, a Marshall and WVU grad, a mountaineer. It was the same idioms, cultural and political beliefs, like going home, but the thermostat was set higher, and there was more sunshine. Also this was a very fair and democratic group. AAEM [the American Academy of Emergency Medicine] was just getting started, so that sensitivity to equitable contracts was going on. The guy who hired me was a Charleston man, and had the same values and attitudes. He took me aside, and said, ‘I know you are well trained, and will fit in here just fine. I'm not worried about you. I want to talk with your wife, and be sure she can be happy in this area.' The rural ED group is more family-oriented, interested in family activities. This particular location was also close to each of our family homes, with a six-hour drive to either. It was a good mix and a good fit.
In terms of the actual practice, I was tired of the trauma center setting, and wanted to move on beyond that. Even then, I realized I was going to be called on to use my skills more. You get to be more essential in an outlying area than you are in a large urban or suburban setting with all sorts of backup, with a specialist coming down to do every little thing. Here you get to do all the cool things you were hoping to do. You just have more opportunities to be essential, more opportunities to make a difference.
Did the reality live up to your expectations?
Oh, yes, no question! When I started practice here, there were internists and family docs but only one cardiologist, a few surgeons, a couple of pediatricians, and one ENT. The other specialties just weren't available. It was two nurses and me at night. We had to do all the work involved with making arrangements. Stabilize and transfer was the usual routine for complex problems. There was one afternoon when EMS transported a young man who had been stabbed in the chest. The transport time was about 20 minutes. He was pulseless the entire way. In the ED, my partner and I were working double coverage. One of our general surgeons happened to be there as well as an anesthesiologist. I did a thoracotomy, my partners placed a central line, anesthesia intubated him, and the surgeon took him to the OR. He closed the cardiac wound, and believe it or not, the kid left our hospital alive, neurologically intact, and went home.
What surprised you the most about the practice of rural emergency medicine?
The way that you could be talked down to by other physicians when you tried to transfer a patient. When I was in residency, we were taught courtesy, but the responses from docs in the two med centers we transfer to were difficult to come to terms with. We only have two major referral centers. Sometimes they got very ugly questioning our abilities as physician and accusing [us] of dumping problem patients on them. There was even a neurosurgeon who, after you paged him, always called back collect! It's all much better now with transfer lines and perhaps with more “hunger” in the referral centers for paying patients, but the old days were a drag!
What do you like most about working rural?
When you're the only game in town like we have always been, you have some major creds with the hospital. We even had the ability to define insurance coverage and other things. For years we declined to participate with Blue Cross-Blue Shield. We made some enemies, but stood our ground because their reimbursement rates were ridiculously low. When you're the only option, there's power. Is it a monopoly? Not really. I suppose anyone can always open a freestanding urgent care and compete.
More important by far, I am part of a community; I know people and they know me. When I walk down a street, I know most of the people I meet. They may say, “You took care of my Dad.” There's a great connection with people. The little kids I took care of when I first got here are now having their own little kids. So certain elements of this practice make you like a family physician whether you want to be one or not. Hospital staff all know each other; there's not a lot of turnover. A very cool thing for the hospital is to have that continuity and trust among the docs. When we need something, we can go to administration and get it because we don't make big demands. We aren't whining and complaining all the time about not having this or that. We don't have a sense of entitlement which comes from the belief, “We're here from Olympus to rescue you!” I believe that you need to invest yourself in the practice and community. When you do that, it has dividends.
I enjoy the mix of pathology most of the time, but we are also seeing a lot of chest pain due to a couple of factors: an aging population and the fact that we successfully educated people to pay attention and come into the hospital whenever they experience chest pain. There is a lot of smoking down here, and maybe we overeducated them on the chest pain thing, which can be annoying after 12 normal cardiac workups in a shift.
What do you like least?
The attitude that we are like a county hospital. Patients know that as emergency physicians we have to see and take anything and everything. As such, they think we are probably subsidized, so they don't have to pay the bill. That's the attitude of patients. It's an evolution, isn't it? Patients have this huge sense of entitlement and a general perception that in the ER, since you have to be seen by law, they don't have to pay. That makes it hard for a group to make a living. I understand why we have EMTALA laws, but the abuses are a pain in the wallet. It really is a financial hardship. We only collect about 25 percent of billing. It is really difficult considering that we pay our own insurance, our own retirement, and our own employees.
Oh, cell phone coverage can be a problem. We can put a man on the moon, but for one mile of scenic highway 11, I can't get a signal! What's up with that?
What's the biggest hurdle or problem facing rural EDs today?
The perception of young physicians regarding financial and earning levels in rural America. Young docs think, “If I go to the city, I'll make this amount. If I go to the country, I'll make less.” That might be so to a certain extent, but they will also spend a whole lot less. You'll have a much bigger home, more land, lower grocery bills … just less things you have to spend money on. The use of what you earn is much more effective.
I also think there is a kind of ruralism in the world today. It's ironic. Young college-educated folks are all about nature and the environment, but they are taught that the people who live in those places are not up to par. Frankly, academia and the entertainment industry often dismiss rural folks as de facto morons. The opposite is quite true. A brilliant engineer or physicist can speak as if he walked off the set of “Hee Haw.” Young physicians need to lose that cultural stereotype. They're taught to be deathly afraid of inappropriate judgments and stereotypes except for this one. Trust me, coming from West Virginia, I've heard all the jokes.
What ideas do you have for solving these issues?
The cost of medical education is out of control, so if you want to have that kind of debt, find a place to practice where you make good money but don't have to spend as much. Rural hospitals are going to have to start offering loan repayment or scholarships, either of which is a great lure for grads.
Why should a graduating resident consider looking at a rural practice?
The young docs these days are losing the value of continuity with all their moving around chasing the dollar. You lose track of the reason you went into emergency medicine in the first place: to intervene in the crisis of human beings in physical peril. And they should consider the value of getting along with other professionals and having a sense of belonging.
Coming to work in a more rural community takes them out of the madness. Rural communities really are safer to live in compared with even suburban ones and especially compared with cities. Kids still go out to play. In my community, we see very little penetrating trauma. Every home has firearms, but they're not killing people with them. It's a different kind of mindset and value system. Rarely does anything bad happen here, which speaks to the common cultural and moral underpinnings of the community.
Some EPs think of rural practices as a place they can go when they are going to semi-retire. How do you feel about that concept?
I think it's a valid concept. These guys are seasoned, tired of the rat race, and could also mentor younger docs as well as do the job in a small-volume ED. It's a good thing.
What personal and professional qualities make for a great rural EP?
Commitment to community and longevity in a group are big ones. You should care about and for the people you work with; look out for each other. You have to like driving down a rural road at night and keeping an eye out for deer. You should want the enjoyment of relating to people — the farmers and factory workers who will be your clientele in an area like this. You need to care about them and know that they need you to be there. Understand that. You should want to talk with them and get to understand their world. Also, just wanting to be able to spend more time with your own family, especially if your hobbies involve nature and the outdoors.
If you need Vegas style excitement and gambling, rural is not the place for you. If you are high energy and usually highly charged, it's not for you.
Why not be the guy who starts a group? Most rural hospitals would love for you to come in and start a group. Be proactive and pull it together. Set it up in a way you would want it. Many physicians are losing the idea of ownership in favor of employment. But while ownership has its burdens, there are distinct advantages in terms of your own control and freedom to practice as you see fit.
This interview will conclude in the November and December issues. Look for Ms. Katz's annual review of the job market for emergency physicians in September and October.