Why Does No One Care about the Crisis in Rural Emergency Medicine?

Figure: rural EM, emergency medicine, critical access, EDs, Dr. Glaucomflecken, rural hospitals, inpatient beds, specialists, residency, American Academy of Emergency Medicine's Rural Interest Group, EPs, Midwest, South, Society for Academic Emergency Medicine, REH, WWAMI, Health Professional Shortage Areas, HPSAWill Flanary, MD, is an ophthalmologist and comedian who regularly posts humorous yet precisely on point medical videos under the handle Dr. Glaucomflecken. In one of his segments, a multitasking emergency/family medicine physician in a rural hospital greets a new medical student. Rural medicine physician: Welcome to rural medicine. What do you want to do while you're here? Medical student: I'm sorry? Doctor: Deliver a baby, fix a broken leg, admit a patient with sepsis, do a central line, mental health counseling. What do you want to do? Student: You know how to do all those things? Doctor: Yeah. The nearest tertiary care hospital is 200 miles away. Student: What if something comes up that you don't know how to do? Doctor: We're in the middle of nowhere, but we still have internet. (Watch the full video at https://tinyurl.com/7j3m7ef8.) It's a scenario that wouldn't be unfamiliar at many rural hospitals in the United States as a shrinking pool of emergency physicians is called upon to provide care for an increasing number of patients. There were 1368 critical access hospitals in the United States as of April, a federal designation created to preserve access to essential health care services in rural communities. (Rural Health Information Hub. April 25, 2024; https://tinyurl.com/ycxyha6b.) These hospitals have 25 or fewer inpatient beds, are located more than 35 miles from another hospital, maintain an average length of stay of less than 96 hours for acute patients, and provide 24/7 emergency care. Multiple barriers impede emergency care in these rural emergency departments, including staff shortages, transportation difficulties, poor administrative support, single coverage, lack of resources and specialists, poor access to care, and lack of residency training in rural environments. A 2022 study found a major scarcity of emergency medicine residents and residency training programs in rural areas of the United States, but that's no surprise with 98 percent of 6993 emergency medicine residents working in urban areas. (Ann Emerg Med. 2022;80[1]:3.) The authors also found that 92 percent of the nearly 50,000 clinically active emergency physicians in the country practiced in urban areas, with just eight percent (3927) practicing in rural communities, a decline from 10 percent in 2008. The median age for urban emergency physicians is 50, but the median age is 58 in large rural communities and 62 in smaller rural communities. “The sadness of it is, there are a lot of questions to which we really don't have good answers,” said study author Christopher Bennett, MD, an assistant professor of emergency medicine at the Stanford University School of Medicine. “Our emergency physician workforce has most certainly grown.” The number of graduates from emergency medicine residencies increased by more than 60 percent between 2008 and 2020, but that growth has been uneven, he said. “We have deserts in the predominantly rural center of the country. The older emergency physicians who are retiring in those areas are from the generations who used to stay there, while younger emergency physicians are more likely to stay in the urban or suburban areas where they have trained, since that is where most emergency medicine residencies are.” Supply and Demand Rural hospitals typically have difficulty recruiting physicians, according to Robyn Hitchcock, MD, who practices at Providence Mount Carmel Hospital in Colville, WA, a mountain town of about 5000 people in the northeast corner of the state, 20 miles from Idaho and 20 miles from the Canadian border. “The pay is usually lower. There are lots of fun outdoor things to do, but cultural opportunities tend to be limited,” said Dr. Hitchcock, who founded the American Academy of Emergency Medicine's Rural Interest Group. “The small, rural schools may not have all the advanced college prep courses that people might want for their kids,” she said. “You're farther away from all of the resources you might have been used to in your urban or suburban training program, like stores and restaurants.” Dr. Bennett and colleagues found that the supply and demand for board-certified emergency physicians varied widely by state. Sixteen states had enough board-certified EPs to staff their EDs, meeting at least 100 percent of demand, while 15 states met less than 50 percent of demand. (Acad Emerg Med. 2021;28[1]:98; https://tinyurl.com/5ca9dezt.) States with a larger rural population and those in the Midwest and South had lower densities of board-certified emergency physicians, and they also had stagnant or worsening shortages over time. The supply of emergency physicians in North Dakota, for example, represented only 24 percent of demand. “If you look at the middle of the country, straight down from the Canadian border to the north of Texas, we're seeing attrition across the board, with doctors retiring at accelerated rates,” Dr. Bennett said. “And getting people to move into many of those areas is a hard sell. We are getting ready to repeat some of our previous studies, and I'm honestly scared of what we are going to find.” Because 98 percent of U.S. emergency medicine residencies are located in urban areas and the majority of physicians tend to practice within 100 miles of where they trained, one potential approach to increase the rural emergency medicine workforce would be to expand training opportunities in rural locations. (Ann Emerg Med. 2022;80[1]:3.) “Rural emergency medicine is an extremely rewarding and challenging career choice, but you won't know if it's for you if you're not exposed to it,” Dr. Bennett said. Much of the discussion in a panel on the future of the emergency medicine workforce at the Society for Academic Emergency Medicine annual meeting on May 15 focused on reimbursement issues and funding to secure more residency slots in rural locations. “We have to find ways to make it feasible for more rural EDs to host more residents and for their primary institution to send them there,” he said. “If residents rotate at nonaffiliated rural sites, their programs are faced with questions on how to fund these rotations and the financial impact such support may have. We need to think about differences in structures; how can we design institutional policies that allow emergency physicians to spend time in these rural EDs, getting practical experience in those environments with a structure that allows them to safely learn?” REH Designation But more residency opportunities in rural areas, while needed, won't necessarily solve the problem, as one analysis found. (EMN. 2023;45[7]:1; https://tinyurl.com/3mcdbeb8.) One primary characteristic of unfilled programs in the initial round of the 2023 emergency medicine residency match? They were rural. A total of 18.6 percent of the 129 programs that went unfilled in the first round were rural while only 1.3 percent of the 152 programs that were filled in the first round were. Individual states and the federal government have created incentives to induce physicians in all specialties, including EM, to practice in rural areas. “I grew up in rural Idaho, where the medical school at the University of Idaho is run through the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) program, part of the University of Washington School of Medicine,” said Sara Schaefer, MD, a health care administration fellow at the Center for Healthcare Outcomes and Policy at the University of Michigan and a resident in the Department of Surgery whose research focuses on provider shortages. “Each year, every student pays $2000 into a fund that is distributed by the state as loan repayment for people who choose to practice in rural Idaho.” The federal government has also funded programs since the mid-1960s aimed at luring physicians to underserved Health Professional Shortage Areas (HPSAs) through increased reimbursement and loan repayment and forgiveness. But a 2023 study found that neither physician density nor resident mortality changed significantly after a county was designated as a HPSA. (Health Aff. 2023;42[11]:1507.) The Biden-Harris administration also created a new Medicaid provider type to rescue rural hospitals on the verge of closure. The Rural Emergency Hospital (REH) designation allows those hospitals to continue to provide emergency and outpatient care in their communities. Hospitals that adopt the categorization will close their inpatient units and provide outpatient and emergency services exclusively. Each rural emergency hospital in exchange receives additional monthly facility payments (totaling more than $3.2 million in 2023), as well as a five percent increase in payments for certain outpatient services. So far, the designation has been adopted by about 25 hospitals, Dr. Schaefer said. “Each state has to approve the designation, and it has to be created at the state level; so far, about 16 states have done that. In Michigan, we have had one hospital convert to an REH; it was going to close due to financial difficulties, and the state helped keep it alive until it could get the designation.” How the REH designation will affect emergency care remains an open question. “There are potential downsides, especially because these hospitals no longer have inpatient care, meaning that they will have to transfer patients,” Dr. Schaefer said. “This policy may work very well for a rural hospital that is reasonably close to another hospital, where it is right-sizing for the community, but it may not work well in rural Idaho with a hospital that's 200 miles from the next closest hospital. The solution is not one size fits all.” No -ologists Available Dr. Hitchcock said any effort to address the emergency physician shortage in rural areas must grapple with the much broader health care workforce shortages in these areas. “A major issue is staffing of regional hospitals and access to this higher level of care,” she said. “The first four to six hours of care, that's our level of expertise in emergency medicine. “After that, the assumption is that the patient's care will be upstairs in the hospital, in the ICU, with an advanced specialty practitioner. That's why my specialty exists, so that people in all walks of life can have access to initial stabilization and resuscitation and then be appropriately transferred to a higher level of care.” But that kind of transfer is often not available in rural hospitals. Staffing at Providence Mount Carmel is primarily via family practice physicians, hospitalists, and emergency physicians, she said. “We have an orthopedic surgeon on call an average of one week a month, a general surgeon on call half the time, and a nurse anesthetist on call to help with lines and airways,” Dr. Hitchcock said. “Our tiny four-bed ICU is also run by family physicians and hospitalists. We don't have any -ologists—no cardiologists, neurologists, urologists, gastroenterologists.” The only hospitals of any size with that kind of staffing within 100 miles are within the Providence system and the Multicare system, which serve Spokane and the Spokane Valley. “They have four biggish hospitals, but only two of them have cath labs. When you talk with doctors with resources, they have no idea what it's like to be without them,” said Dr. Hitchcock. “If I have a patient with a GI bleed and liver failure, traditionally the massive transfusion protocol would include red cells, FFP, platelets, and cryoprecipitate, but here the only blood products we have are red cells and platelets, so we do not have a full spectrum MTP. “So, I've got to get that patient out of here. Then the transferring institution asks, ‘Why can't your GI guy handle this case?’ We don't have one! We have a family doctor who does uncomplicated scopes for cancer scanning one day a week. He doesn't have the advanced procedural skills and training to cauterize active bleeding or sclerose bleeding esophageal varices. If you're a resident in a big academic center and someone comes into your ED with a heart attack, you pick up the phone and call cardiology. Here, we may have to manage these people for three days.” And the situation has recently gone from bad to worse with a change in consult protocols, she said. “The Washington transfer center will no longer put us through to most consultants if they don't have a hospital bed available. Over a dozen hospitals feed into Providence Sacred Heart [Medical Center] in Spokane, and there were dozens of us calling them every day. It was burning through the attendings, so they stopped putting us through to the consultants. Now, not only am I boarding people with liver failure, bowel obstructions, and the ‘wrong’ kind of heart attack for several days—things beyond my scope and training to manage—now I can't even talk with consultants to ensure I'm giving the best care I can.” These problems are further exacerbated by the nationwide nursing shortage. She said they went from a bad shortage to crisis when hospitals closed wards all over the country because they had no nurses to staff them, Dr. Hitchcock said. “COVID was the straw that broke the camel's back here. Now there aren't enough staff, so we try to get travel nurses, but that turns out to be robbing Peter to pay Paul because the floor nurses rightly ask why a travel nurse is getting paid twice what they are getting to do the same job. Everybody's breaking budgets and shutting down wards and floors trying to keep staff.” Dr. Hitchcock said the solution to the rural emergency workforce crisis is multifaceted. “First, we need awareness,” she said. “A health care crisis isn't your crisis until it is. We need to get the word out in larger communities about how desperate the situation is all over the country.” Second, she said, is the need for more nurses. “We cannot practice without nurses—bedside nurses, not administrative nurses. We need them at the big hospitals so they can open fully and start taking our patients, but we also need them in rural areas.” Dr. Hitchcock said she would like to see the expansion of programs like the Nurse Corps Scholarship Program (https://tinyurl.com/mr28zr5y), which covers tuition and fees plus gives a monthly stipend to nurses who agree to practice for at least two years in a critical shortage facility serving an HPSA. “Additionally, in areas like mine, where we have lost our access to consultants, we need some kind of central clearinghouse at the federal or state level where emergency physicians can reach out to consultants in real time and get support for our patients under a structure that protects them from liability in the case of bad outcomes,” she said. Dr. Hitchcock urged health care systems to pay more attention to employee retention by demonstrating that they genuinely value them. “They pay lip service to it on paper, ‘Our employees mean everything to us,’” Dr. Hitchcock said. “But when I ended up needing a heart cath from stress last fall, and I called my boss to say that I was in pain, short of breath, and scared, the first question was, ‘Well, can you work?’ I said, ‘I need to be here less, it's killing me,’ and the response was, ‘We're short-staffed, and you have a contract.’ “I'm a really good doctor, and I take very good care of my patients, but nothing has been done to make my environment a positive place. In addition to trying to recruit more clinicians, we need to keep the doctors and nurses we already have.” MS. SHAW is a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work at www.writergina.com. Follow her on X @writergina. Read her past articles at http://tinyurl.com/EMN-Shaw. Share this article on X and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected].

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