Newsletters

POSTED: March 15th, 2023
POSTED IN: 2023 Quarter 1, EM Pulse - The Official Newsletter of MOCEP,

Written by Dennis Hughes, DO, FACEP

Dr. Hughes has practiced rural EM in SW MO for over 25 years.  He currently serves on ACEP Wellness and Membership Committees as well as the MOCEP Rural EM and Membership Committees.  

Both an optimist and a pessimist can look at the same scene and provide diametrically different interpretations.  And, in most instances, the truth ultimately falls somewhere in the middle of those polarized views. Also, consider that what many have said about rural Emergency Medicine may or may not be accurate-like so many “conventional wisdoms”-it all depends.

On balance, working in the rural environment has the potential to be personally and professionally challenging and satisfying.  There is the opportunity to build and shape a cohesive team that functions in an efficient environment.  Such an opportunity is rare when one joins an academic or well-established urban emergency department.  Rather than becoming one of the “worker bees” in the large hive, one can quickly become a leader, influence processes and truly make a difference.

Many discover that once they dip their toes in the water they become immediately and irretrievably immersed.  Personal satisfaction can be quite gratifying.  It would be unrealistic to ignore the realism that there are those who are not suited to the environment and never find their level of comfort.  No, it is not for every person.  

Over 97% of Missouri land area is classified as rural.  Historically, 92% of certified emergency physicians practice in urban areas.  Clearly there is opportunity for well-trained and qualified EPs.  Overcoming inertia continues to be a stumbling block.  

Increased exposure to rural EM practice during residency training can open both the eyes and the door to those who may have not considered that as a possible career path.  Another potential avenue is the physician who grew up in a rural community returning home after education and training.  This “homecoming” could result as a nidus to establish the conduit for classmates or other professional contacts to test the waters.  Ultimately this could increase the penetrance of EPs in the rural communities.  

Bringing the right physicians to the right locations can be a bit of a hit or miss proposition (true no matter what the environment-be it urban, rural, academic, community, etc).  Various work models exist in the rural areas :  CMG staffing, fully-employed locally or as part of a health care system, locum-contracted or independent group.  Whichever arrangement prevails, what has proven to contribute to a sustaining and mutually-rewarding situation is building local relationships.  

The emergency department is the most frequent door to admissions (70% per most recent ACEP data) no matter where the hospital is located (urban versus rural).  All hospital administrators know this and value an efficient department in which the physicians provide competent and compassionate care.  Working hand in hand with the local physicians is vital to success.  If appropriate care is initiated in the ED, many patients can be kept in their local communities, which is what they desire.  Additionally, high quality comprehensive assessment and stabilizing care of those patients who require more than can be provided at the local rural site is correlated with improved outcomes.  If everyone is aware that the ED is functioning at a high level and staffed with physicians on par with those in the “downtown” emergency departments, the end result is a win for all. 

The trend for some time has been consolidation of dispirit groups of physicians as well as the continued development of large corporate entities.  Such organizations can carry large fixed costs and potentially be out of touch with local administration and influencers.  Again, building and maintaining personal relationships is a major key to continued success.  

In many cases regional or local groups may be an answer to fulfilling the shortage of EPs in the rural locations-both in Missouri and nationally.  The ability to be facile and relate to local needs and politics with short lines of communication can benefit the “boots on the ground” EP with support, mentoring and advice from a leader who has walked the walk him/her self.   Such groups are the minority, but those in current existence are thriving-particularly those involved with staffing rural locations.  

No matter what the contractual or administrative relationship in which one finds themselves, there are strategies one can use to aid in achieving success.  While many of these are applicable to any practice, some are particularly useful in a location that has not experienced what a well-trained emergency physician brings to the table.  

It is important to build your work environment.  Teach the staff and give them background on the when and why-they love it.  Especially important is getting involved with the local EMS.  Teaching and interacting with them will make one’s life a whole lot easier.  Becoming their medical director is another opportunity that many do not get in the urban setting.

A supportive network is vital.  This is especially true if you are the first of your kind in your location.  It can get awfully lonely at 3 a.m.  Know your referral centers and make contacts there before that urgency arrives.  Keep your old residency classmates on speed-dial/text.  We all know that a sounding board can be illuminating when one becomes anchored.  

What local resources exist?  Is there a homeless shelter, a substance abuse center, or a staff social worker (who are worth 10X their weight).  

And, don’t forget yourself.  Wellness is more important than ever and fortunately most new trainees are receiving many tools that didn’t get mentioned or exist in the past.  Use them.  They will keep your life full and rewarding.  ACEP continues to evolve the resources for keeping Emergency Physicians on the path. 

Yes, rural EM is fun, challenging, rewarding and evokes all that is good about Emergency Medicine.  And after a time, many may agree that MacGyver is the patron saint of the rural emergency physician.