Emergency medicine training has incorporated more rural rotations to give EM residents some exposure to rural medicine and rural life, Dr. Jameson noted. But he wondered if there could be some kind of carve-out in these mandates for very low-volume facilities, an exception to ACEP’s aspirational standard.

Could the affected professional societies come together to define and advocate for training programs to better prepare PAs and NPs for the rural ED, given the reality that many rural hospitals now employ them without direct physician involvement? “We should at least advise that they need more training and help define that training,” Dr. Jameson said. And could telemedicine from urban centers provide more short-term support for the unsupervised clinicians that are already out there?

Family Physicians Want More Respect

The laws in Indiana and Virginia state that EDs should be staffed with a licensed physician, without requiring that physician to be board certified in emergency medicine. Rural hospital advocates point out that many of the physicians now working in rural EDs are family medicine doctors—and they bring invaluable skills to those settings.

Non-emergency-medicine physicians who work in EDs, typically family practice physicians, are actually really good at it,” Dr. Parker said. “I’ve worked with them.”

Dan Doolittle, MD, was trained in family medicine, served in the Air Force, and then, 30 years ago, started practicing emergency medicine exclusively. He deliberately sought out a career in a rural setting.

Dr. Doolittle

“I came to Southern Illinois, where I could buy land and raise my kids on that property,” Dr. Doolittle said. He grew comfortable practicing rural emergency medicine and opted not to be “grandfathered” into board certification when that was offered by the American Board of Emergency Medicine (ABEM) based on hours of clinical practice.

Recruitment of residency-trained emergency physicians to critical access hospitals can be incredibly difficult, Dr. Doolittle said. Many emergency physicians did their residencies in urban programs and are reluctant to move to rural areas to work in rural hospitals. Sometimes these physicians are uncomfortable being the only doctor in the hospital, perhaps in the whole county, during their shift.

“I get that. They’re really smart and trained in trauma medicine. They enjoy the fast pace, and they typically work eight-, 10-, 12-hour shifts in busy EDs,” he said. They have built relationships with their colleagues and hospitals. A rural EM service, by contrast, might ask them to work 24- or 36-hour shifts, which includes time for sleeping, Dr. Doolittle said. “In rural emergency medicine, we sell a whole different product—with a different pace.”