Critical Care Plus: Networks More Important as Rural Emergency Rooms Close

Groups propose rural rotation for ER residencies

By Julie Crawshaw, Critical Care Plus Editor

Good ED/ICU networks are becoming more important as more rural hospitals close due to lack of funding, says Janet Williams, MD, FACEP, director of the Center for Rural Emergency Medicine and Professor of Emergency Medicine at West Virginia University in Morgantown. Williams notes that the role of a rural hospital is increasingly to assess, stabilize and package the patient for transfer to a tertiary care center, which may be 200 miles or more distant.

"It’s very interesting that most of the practice models and research and training used in emergency medicine have been based on an urban environment," Williams says. "But rural hospitals basically have a different focus for patient care when it comes to critical illness."

Williams is part of a group within the American College of Emergency Physicians (ACEP) that wants to encourage residency-trained physicians to choose practices in rural areas. One means of doing this is for academic medical centers to reach out to rural hospitals and provide either clinical consultation or access to information and treatment guidelines.

"Right now there aren’t many partnerships between academic centers and rural hospitals," she notes. Other organizations involved in this effort include the Society for Academic Emergency Medicine, the American Board of Emergency Medicine, the American Hospital Association, the Office of Rural Health Policy, the American Association of Family Practice and the Emergency Medicine Review Committee.

Different Needs in Different Areas

Williams says that there’s always been an assumption that what works in a city will work in a rural area. Rural areas, however, have far more severe agricultural traumatic injuries with frequently delayed discovery. "If you crash your car in the middle of a rural area, you may not be discovered for hours," Williams observes. "In an urban setting an ambulance is there within a few minutes. Delayed transport is another problem as it takes longer to get people to where they need to go on rural roads, which frequently cover treacherous terrain and can become impassable in bad weather. Plus, mortality and morbidity is higher in rural areas for the same type of disease process when compared to urban. Residents of rural areas often wait longer to seek medical attention. They may present several hours into a heart attack versus an urban area where the patient receives thrombolytic drugs much more quickly."

One way to get more physicians to settle in rural areas is to have at least part of their training take place there, Williams says. "We’re looking at different options. There could be a distance education component, with students attending lectures at a major university through video conferencing. But getting sufficient experience calls for doing both urban and rural medicine."

ED residents, she says, need to train for at least two years in urban areas to see enough patients to learn what they need to know. Some studies show that physicians choose their practice location based on where they did their training. "I think the reason is that all the training centers are in urban areas—nothing currently entices physicians to go to rural areas where salaries are lower, hours are longer, and the typical rural physician does a lot more multi-tasking," Williams says.

Rural Physicians Have to Do it All

J. Robert Parkey, MD, practices at Clay County Memorial Hospital in Henrietta, Texas, a town of 3,000 people and three physicians in a county of about 10,000 people spread out over 1,600 square miles. It’s a very rural county with agrarian economy, says Parkey, who practices primary care as well as emergency medicine. Last year’s leap in malpractice insurance rates caused him to stop practicing obstetrics, and Parkey delivered his last baby in January.

The biggest hurdle Parkey sees to getting more ED docs to spend time in rural areas is that ED residency programs require seeing a certain volume of patients in an educational facility, which immediately disqualifies most rural hospitals. He’d like the body governing residency requirements to agree that urban ED residents can do at least some rotations in a rural facility with a lower patient volume.

"Most of us in rural medicine would disagree that fewer patients mean the educational experience is inadequate," Parkey says. "In fact, I would even argue that possibly the opposite is true—if you don’t have to see 10 patients per hour, you have more time for teaching. That’s my opinion as someone out in the trenches, but it’s certainly not held by the folks who set the rules for residency programs."

Parkey says that ACEP has looked hard at ways for recruiting and retaining physicians to small communities. "Our colleagues in family practice have done a tremendous amount of research in this area and have found that the most successful placements of residents into small communities are physicians who are from a small community themselves," Parkey says. "It’s really a recruitment issue—identifying those medical students who come from small communities and appreciate them. Those are the guys and gals who are most likely to stay there and not bail."

Retention’s also a big issue, according to Parkey. Government programs are still available for "Northern Exposure" type payback placements, but many people don’t remain rural once their payback time is up.

Economics Require At Least 10,000 ED Visits Per Year

Studies done by ACEP’s Rural Workforce task force have shown that it takes an emergency department volume of around 10,000 visits per year to support a full-time staff that practices only emergency medicine. In contrast, Parkey’s hospital sees about 3,000 emergency room patients a year. "If I had to rely on emergency room volume to live, I’d starve to death. I have to practice primary care as well, as a matter of survival," he says.

Parkey says that one of the more interesting ideas put forth is using some type of combination program in which a resident goes through a family practice/emergency medicine program, puts in a few extra years and comes out able to be boarded in both specialties. "You’d get the best of both worlds—a boarded emergency medicine physician and someone who’s trained more in the preventive, basic OB/GYN, pediatrics, minor surgery and ambulatory medicine that an emergency medicine residency doesn’t prepare somebody for," Parkey notes.

However, success depends in large part on how long a combined residency would take. An emergency residency, Parkey observes, is usually three and sometimes four years. A combined residency could well require at least a five-year program. This could make convincing residents to stay out of the marketplace for the additional time a hard sell, especially given that there isn’t as much money to be made in a rural practice as there is in a more populated community.

"The cost of living is quite a bit lower," Parkey says. "Economically, it’s a wash, but a lot of people don’t see that. They only see what their net income will be."

Parkey adds that the residency models in use now clearly won’t solve the problem. "We need to look at an entirely new training paradigm if we’re going to develop folks who can be both comfortable and capable while practicing in communities too small to support a full time emergency room physician," he says. "I don’t have personal knowledge of how the medium-sized communities are faring in recruitment and retention, but I understand from talking with folks who work in them that they’re having some of these problems, too."

For more information contact Janet Williams, MD, at (304) 288-8297 or Robert Parkey, MD, at (940) 538-5421.