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Life in Emergistan

Rural America, Already Feeling Marginalized, Needs Real Solutions, Not Just Telemedicine

Leap, Edwin MD

doi: 10.1097/01.EEM.0000586456.91073.0f
Life in Emergistan



Our specialty discusses rural ED staffing a lot, and it really comes down to whether rural emergency departments need or should have residency-trained, board-certified emergency physicians.

I am quite invested in this discussion as an ABEM-certified physician who spent his career in smaller rural and semi-rural hospitals. The question often comes down to money. Smaller rural hospitals do not pay the same as large urban teaching hospitals and trauma centers. This is undeniable. Small hospitals simply can't afford higher salaries because their patients have lower incomes and volumes.

A physician, particularly a young one in enormous debt, is not inclined to go to a place where his salary will be significantly lower. Understood. But often lost in the discussion is cost of living, which is definitely lower in rural and small-town America.

Loan repayment and forgiveness programs, however, need to be increased so that highly skilled physicians can afford to work wherever they want without worrying about endless debt.

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Skills Don't Fade

Critics also assert that physicians will lose their skills working in rural EDs. A physician in small-town USA will rarely do a thoracotomy or cricothyrotomy, and she will never put someone on ECMO or use a REOBA catheter, but standard skills are used with regularity. I intubate and place lines, resuscitate and reduce, suture and drain abscesses all the time.

More to the point, my skills at discerning dangerous pathology and identifying cardiac rhythms and worrisome ECG findings, developed through medical school and honed in residency, have not faded. In fact, rural America is full of bizarre, life-threatening injuries and pathologies that rarely leave the physician bored.

Some suggest that the answer is to do what family medicine physicians do—offer fellowships and other courses such as the Comprehensive Advanced Life Support course to improve the skills of those in remote locations. This is a strategy I support. I have worked with a physician who was family medicine-trained and went on to an emergency medicine fellowship, and I would trust him with my life or the lives of my loved ones any day.

This is probably where we will land because the likelihood of EM-boarded physicians going to rural areas is not high. I have long asserted, however, that semi-retired physicians or those with many years in the specialty and looking for a change, should consider going to rural America to practice. This can be done as locum tenens or full-time staff. The slower pace and great appreciation by the hospital and community can extend a career significantly. The presence of these physicians takes advantage of skills and knowledge accrued over decades.

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Stigmatized and Marginalized

I do not believe the answer is to place nurse practitioners or physician assistants alone in remote hospitals, even with telemedicine backup. This certainly happens, and I have no doubt it will increase, in no small part because of financial concerns. But it has been my experience, with rare exception, that rural sites do not need someone with less training or experience but someone with more. The limited resources and backup and the difficulty of transporting to higher levels of care would put too much pressure on staff who, though highly skilled, are not the right professionals for the location.

This is made more difficult and pressing because large hospital systems tend to buy up smaller hospitals in remote areas and then deplete them of resources and staff. Those EDs in essence become freestanding emergency departments. Even worse, the “flagship” hospitals for these EDs frequently have no beds or weather precludes transport of the sickest patients. Not only that, the families of those transported to large hospitals often can't afford to make the two-hour trip to visit them.

Maybe we need a rural health corps, like the U.S. Public Health Service, to offer national scholarships for service in remote locales. We certainly need more residency rotations in these places. Indeed, senior residents with telemedicine backup could add tremendously to remote hospitals and do it safely. They might even learn that they like these places. Residencies could rotate faculty in and out of hospitals that their systems adopt to provide life-saving care to people with limited access.

Rural America already feels stigmatized and marginalized. Something as ubiquitous as high-speed internet, often a necessity for high school students to do their work, is as rare as hen's teeth outside suburban America.

For us to constantly suggest strategies for rural health that urban physicians wouldn't want for their own families is to confirm the suspicions of so many in rural America that they just don't matter as much.

The provision of high-quality care to rural Americans is a complex problem, but we owe those citizens the same passion for excellence that we offer to those in our cities, unless, indeed, it is all just flyover country.

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Dr. Leappractices emergency medicine in rural South Carolina, is a member of the board of directors for the South Carolina College of Emergency Physicians and an op-ed columnist for the Greenville News. He is also the author of four books, Life in Emergistan, available, and Working Knights, Cats Don't Hike, and The Practice Test, all available, and of a blog, Follow him on Twitter @edwinleap, and read his past columns at

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