Rural emergency medicine means accepting live chickens in lieu of payment, living in a shack with an outhouse, and having no paved roads while being surrounded by barefoot neighbors with Chevys up on blocks in the front yard, old sofas on the porch, and a still in the backyard.
That's the picture most residency trained emergency physicians have in mind when they hear the phrase rural emergency medicine. While I think you might actually be able to find a backyard still or two in Appalachia, the rest is just myth. The best way I know to debunk myths is to go straight to the source. In the August issue, I treated you to a candid interview with the most famous rural EP I know, Edwin Leap, MD. This month I snared some quality phone time with two major figures in rural emergency medicine, Todd Crocco, MD, an associate professor and chairman of the emergency department at West Virginia University, as well as Harry “Tripp” Wingate, MD, the chair of the ACEP Rural Emergency Medicine Section. Here is their take on the most prevalent myths of rural emergency medicine.
Rural emergency medicine means earning no money. If one were to equate rural incomes to those of RVU-production-based incomes in Texas and Mississippi, there would be quite a difference, but reported incomes range from $230,000 to $300,000. In low-volume EDs, physicians can work longer hours and chalk up higher earnings while getting quality sleep at night, Dr. Wingate said of positions in rural Georgia. Dr. Crocco pointed to one rural practice in West Virginia with a $225,000 base plus benefits and incentives reaching $300,000. Rural areas also have a significantly lower cost of living that allows the dollar earned to go much further.
Rural emergency medicine means patients pay their bills with livestock. Drs. Crocco and Wingate swear they've never been paid in poultry. Both describe some unusual perks such as lovely cards, flowers, and some pretty amazing pies and goodies delivered by grateful patients in appreciation. This spotlights one very important element of rural emergency medicine: the patient appreciation quotient is far higher, which leads to the next myth.
Rural emergency medicine means high risk because these people sue for everything. In fact, according to Dr. Wingate, industry data indicate that medical malpractice rates are actually lower in rural emergency medical practices. Jonathan Glauser, MD, in a July 2008 EMN article on the etiology of malpractice, notes that work overload was a contributing factor in 23 percent of medical malpractice cases. That is not an issue one faces in rural emergency medicine with an average patient-per-hour rate of 0.5 to 1.
Rural emergency medicine means lousy hospital services, if any at all. Wipe that vision out of your head. Many rural hospitals are modern, and those that were built earlier in the past century have been totally renovated. The services they provide are based on their specialty capabilities. “Administration wants you to be successful,” Dr. Wingate reported. “Many hospitals provide free meals to their docs, comfortable call rooms with beds, Internet access, and cable TV.”
Many programs are being created to extend the reach of rural hospitals into the community, especially emergency services, but we'll get into that next month with the report on the future of rural emergency medicine.
Rural emergency medicine means no up-to-date diagnostic equipment. No ancient x-ray machines here. While many rural hospitals don't have MRI or PET scanners on premises, they have access to one reasonably nearby. “Basic equipment adequate for what we usually do is available,” said Dr. Wingate. “Since we usually don't have other expensive toys, we have to practice a low-tech/high-thought approach to medicine.”
Rural emergency medicine is boring. “Only if you find medicine boring and quality interaction with patients boring!” responded Dr. Wingate. While there is frequent downtime, especially on the night shift where you might see only four to six patients between midnight and 7 a.m., the peak times deliver a wide range of blunt trauma, penetrating trauma (pitchforks anyone?), and a whole host of adult and pediatric medicine. As Dr. Wingate puts it, “Emergency medicine practiced anywhere is always fraught with uncertainty, occasional tragedy, frequent humor, and always a sense of gratification when you get to make a difference in someone's life.” I think this particular myth is easily put to bed by reading a collection of Dr. Leap's columns; if you find those boring, then you find emergency medicine boring, no matter where you practice.
Rural emergency medicine means low volumes and no acuity so you lose your trauma skills. Dr. Crocco made a point of emphasizing the amount of acuity seen in rural EDs. “The thought that you don't see trauma in rural emergency departments is just wrong. And you have to be a very good clinician when it presents because, in most cases, it's just you and a nurse, and the ability to turf is not always achieved easily,” he said. “Rural ER docs have to be better than urban docs who have all the great specialty backup like trauma teams. In the rural ED, you're on your own.”
Dr. Wingate agreed. “Low volume is good!” he said. “Level I trauma will come into your rural ED. You will have to lead the team, and quickly assess the need for transfer to a higher level facility. Fortunately, standards and courses today address the special challenges of rural trauma such as the Rural Trauma Team Development Course. (http://bit.ly/RTTDC) Basic trauma skills like chest tube insertion, cricothyrotomy, etc., will be called upon, but there are many courses now available that allow you to refresh your skills and stay sharp.”
Just like their big-city counterparts, the growing ED work overload is an issue in rural emergency departments. The patient-per-hour-per-physician rate is rising as census numbers climb, yet the coverage numbers don't necessarily go up with them. Dr. Wingate recommended that EPs watch the independent film, “The Vanishing Oath,” created by and starring Dr. Ryan Flesher. (http://bit.ly/VanishingOath. Also read “Doctors Quietly Opting Out of Medicine” by the film's producer Nancy Pando at http://bit.ly/PandoOath.) With this in mind, rural emergency medicine is like a shining beacon with average attrition way below what ACEP considers acceptable.
Rural emergency medicine means a serious downgrade in lifestyle. Dr. Crocco said the definition of “rural” is “hazy.” It can be a matter of annual volume or location or a combination. Whichever it is, the majority of residency trained emergency physicians never even consider looking at a rural practice. According to Dr. Wingate, most rural emergency physicians do not live in the same community where they work and are not required or expected to. The wide variety of lifestyles available to rural emergency medicine start at beachcombing, extend through mountain chalets, and end at multi-acre ranches and farms.
Most rural hospitals are within a few hours of a metro area. Some experienced rural docs have their own planes and fly to work. Others work in blocks of shifts, commuting only once a week. But there are others, like Dr. Leap, who experience great joy living in the rural community in which they work. Being the big fish in the little pond can be extremely gratifying, and then there are also all those really good pies!
Next month: The future of rural emergency medicine, where it's going and how you can get involved.
Ms. Katz is the president of the Katz Company, an emergency medicine consulting firm dedicated to providing expert physician recruitment services and training emergency medicine residents in effective job searching.