Letter to the Editor

Editor: I think what Eric Blazar, MD, really means when he says we probably don't need more emergency physicians is that we probably don't need any more emergency physicians like him. (“Emergency Medicine Doesn't Need More Residencies,” EMN 2019;41[2]:6; http://bit.ly/2ViAA1y.) I mean this facetiously, of course. What I mean is he might be right that we don't need more EM residency graduates flooding the urban markets where they trained. But we sure need them in the rural areas. I went to med school and residency in metropolitan areas, but the minute I graduated, I was headed to practice in a rural region. Why? Because that's the kind of area where I was raised, and it's where I like to live. Perhaps Dr. Blazar is right that we don't need another resident from Manhattan staying on in the city to compete for the few hot jobs there and that will drive down the market. But in the region where I live, very few of our hospitals have EM-trained physicians. Some of them are staffed only by NPs and PAs with no physician on site. Maybe he would be fine being treated for a cardiac arrest by a new grad NP with no physician oversight, but I'd rather not. The problematic issue in his editorial is the assumption that it's fine for rural areas not to have qualified physicians. Rural people's lives are not worth less than those of urban people. We are not a bunch of ignorant hicks who should take whatever we can get. Yes, we in the boonies have been coping with shortages of emergency physicians (and all doctors really), but the answer isn't to say that this is a permanent problem; it's to try to fix it. Dr. Blazar's dismissive attitude that primary care physicians and nonphysician providers should be doing the EM care in rural areas is not right. These are the hospitals where you don't have specialist backup or quick transfers to major tertiary centers. These are the places where you want the most qualified doctors. Because we don't have a standardized pathway for family medicine doctors to train in EM after residency, unlike Canada, the most standardized way to have high-quality emergency care is to have board-certified EPs. How do you get them to rural areas? Diversity is a hot topic in medicine, but one area rarely discussed is diversity of background (not just race and gender). Most of the physicians working at my rural hospital grew up in rural areas. It's what they know, what they like, and the cost of living can't be beat. Because of the rural shortages of physicians in all specialties, medical schools should prioritize candidates from rural areas because they are the ones most likely to be comfortable moving there to practice. Requiring EM residencies to have a rural rotation is another potential solution because many physicians do become attracted to rural areas after experiencing the environment in person. We should also be supporting loan-forgiveness programs for physicians who move to rural areas. Dr. Blazar noted that training more EPs might result in “banishing [physicians]... to work in rural settings far from the urban cores.” It's really not so tragic out here. But we do struggle with physician shortages, so the way to improve the rural health crisis isn't to cut off the pipeline. It's to redirect it to the areas where shortages continue to exist. Viktoria Koskenoja, MD Marquette, MI

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