Rural Emergency Medicine: Stigma & Stereotypes
I practice in the rural, northwest corner of South Carolina, also known as “The Upstate.” It is a place of expansive lakes, white-water rivers and the mist covered foothills of the Blue Ridge Mountains. The area includes thousands of acres of Sumter National Forest. The natural beauty is breathtaking. Sumter National Forest and our various parks are laced with hiking trails, which are lined with unique plants and trees, some found nowhere else. Fish and game abound. In fact, our wooded hospital grounds support a flock of at least 30 wild turkey. And last deer season, the only deer I saw were the three does grazing at the end of the ED driveway one night, spotlighted by two of our paramedics.
We have a lot of wonderful things here, things that are gifts of the rural life. We have good people, the salt of the earth types who care about personal morality and Southern courtesy. People who bring you a glass of sweet tea when your car breaks down. We live with a low crime rate, and minimal illicit drug use compared with more populated areas. It is a good place to raise children. It’s also a cool place to practice, where a busy summer shift can bring an acute MI, a near drowning (from inner-tubing on Class IV white water while drunk), a pit viper bite, a bull goring and many other pathologies, more or less interesting.
But, as physicians in a rural area, we pay a price. Because we have to endure a certain stigma. The stigma is this: if you practice in a small, rural hospital, you must be less than competent. Because if you were competent, you’d practice in a large, urban teaching/trauma center. I frequently face this when I speak to the out of state parents of local university students. You can tell that they are hesitant. Many are from the urban northeast, and they exude a discomfort with any physician willing to put out a shingle in a place so far off the beaten path. They want to know about the hospital, the consultants, my training, etc., And of course, this is fine. I understand that anyone might want to know the credentials of the person caring for their sick or injured child. But, as emergency physicians, I think we should try to dispel this unfortunate stereotype among patients. And the best place to start is to dispel it among our colleagues.
I read some time ago of the difficulty rural areas have in recruiting residency trained emergency physicians. I’m not surprised. Our training, mostly in large urban centers, tends to focus us on that type of medicine. We see trauma care as effective only when provided by trauma teams. We feel that cardiac care must be supported by immediate angioplasty and, if needed, cardiac surgery capabilities. We love to hear the thump-thump of those helicopter blades. Our hearts thrill at the thought of thoracotomies for penetrating trauma. We sometimes even buy the line that children have to be cared for in children’s hospitals. We like to see herds of residents and students descend to the department to evaluate admissions in the early morning hours. It’s shiny and exciting, and it’s very hard to resist.
I must admit, I was a victim of the myth myself at first. When I first came to Oconee Memorial Hospital seven years ago, I was happy about the job. But somewhere deep inside I felt that I had taken the low road. I felt that, if I were “a real doctor”, I’d have gone to a trauma center, in a large city. And no wonder. I moved to a town of 5000 persons. I became the fifth doctor in our group, seeing some 27,000 patients per year in a 10 bed ED, in a 120 bed hospital. We had one cardiologist, but no cath lab. We had no neurologist, pulmonologist, neurosurgeon, toxicologist, trauma team or pediatric subspecialties. We had nine ICU and four telemetry beds. Although our group, our department and our hospital staff have grown dramatically since the time I arrived, it was and still is a far cry from Methodist Hospital of Indiana where I trained. Thankfully, the staff at Methodist prepared me well for the adventure of rural emergency medicine.
Here’s why. In my rural department, in this relatively isolated area, my partners and I have to practice a very autonomous form of emergency medicine. We don’t have residents to help with the volume and we don’t have a trauma team. There is no helicopter service taking our patients to the regional trauma referral center; it’s at least 40 minutes away by ground. We still lack many of the support specialties I listed above. Most nights we are the only physicians in the hospital at all. We have to manage the difficult airway, obtain the emergent vascular access, make the transfer arrangements and all the rest. Like physicians at many rural centers, we sort of do it all. Of course, this is not really different from many emergency physicians in urban areas, but the difference is, we don’t have options. We are relatively alone.
But my point is not self adulation. My point is that, all across the country, emergency physicians at small hospitals provide excellent, state of the art care for patients that are just as sick as the ones in large centers. But they do so with less help, less resources, and in many ways more pressure than their friends and classmates in teaching centers. The view from the large centers sometimes gets skewed because only the sickest patients are transferred to them. So it sometimes looks like the smaller facilities do a bad job. Actually, most of them give excellent care. But patients deteriorate and patients die in hospitals of every size. It happens at Oconee Memorial and it happens at Methodist.
I believe that our specialty should encourage graduating residents to go to rural areas. I’d like to see residents taught that they can contribute to the specialty as certainly in a remote area as they would in any large city in America. There is enormous need, and there are great rewards in making a rural area safer and healthier. There is tremendous satisfaction in being appreciated by patients who might have done poorly if not for modern emergency care. When my family and I drive home to West Virginia, through rural Appalachia, I often wonder who is staffing the departments nearby, should we become intimate with a coal truck. I always hope it is someone well trained for the job.
Rural areas require that physicians sacrifice certain big city amenities, both professionally and socially. But the payoff is worth it. And if anyone reading this is considering rural emergency medicine, I encourage them to make a difference and go to the country. They won’t regret it; I certainly don’t.
Some of the best ER doctors I ever knew practiced in rural areas. They didn’t have the luxury of having high tech bells and whistles of modern technology to make a diagnosis. They listened to their patients and drew upon the many years in the medical profession to guide them in the face of life threatening emergencies. I hold them in highest regard.
MJ
“Like physicians at many rural centers, we sort of do it all. Of course, this is not really different from many emergency physicians in urban areas, but the difference is, we don’t have options. We are relatively alone.”
What about the nurses? I’m not sure how it is in your area, but in the busy New York City ED where I work, the RNs are a vital part of the team. We obtain that “difficult IV access,” arrange for intra or inter-facility transfer and are making split-second decisions when faced with unexpected responses to treatment or disease.