I was recently at a meeting where some very influential physicians were discussing a question that I’ve been thinking about for a while: how do we find medical staff for rural emergency rooms and hospitals? It’s a tough question, because, increasingly, it seems that young physicians are trained to work in urban hospitals. Those are also the places these young doctors prefer to practice. Big hospitals and teaching centers in the city. Modern medicine is highly technical and remarkable specialized, so many young docs are very uncomfortable when they have to practice far from ‘the mother ship’ (the term we use to jokingly refer to large referral centers with every specialty under the sun).
This discussion of the medical work force is complicated, but it’s clear that for the foreseeable future, rural hospitals will struggle to get physicians. It’s bad enough that we frequently lack the specialty back up of larger urban centers (just try to find a neurologist or cardiologist outside a large urban area), but we don’t even have all of the advanced technologies that are common elsewhere. You won’t get a coronary stent placed in a small county hospital, for example. Getting highly specialized, cutting-edge care often requires patients be transferred over long distances to larger facilities.
It’s an interesting phenomenon; people in urban areas would be shocked and outraged if their hospitals suddenly had to transfer all of their complicated patients to another location. And yet, Americans accept this as axiomatic in rural areas.
So let me suggest that rural America lead the way in creative alternatives to care, and in the process offer our young people some fantastic new career options.
One thing that’s being employed in some areas today is the ‘community paramedic.’ More than a provider of emergency care, the community paramedic is a professional with extra training who goes to patients’ homes. The community paramedic manages other routine medical issues as well. They can provide some basic primary care and health education and help sicker patients stay out of the hospital by engaging in good health behaviors and by following their hospital discharge instructions if they were recently inpatients.
As hospitals struggle with patients coming back over and over to be admitted for preventable problems (something for which Medicare punishes hospitals), the community paramedic can be a valuable member of the care team. Becoming a community paramedic would require that one undergo training as an EMT, then as a paramedic (which now requires a two year associates degree). Then there will be some additional training. It appears that the extra training would involve a little over 300 hours of classroom and clinical exposure for one to qualify as a community paramedic.
Next there are what we in medicine call ‘mid-level providers.’ These come generally in two varieties: the nurse practitioner (NP) and the physician’s assistant (PA).
A nurse practitioner has a four-year nursing degree, followed by a masters (and increasingly doctoral) degree as a nurse practitioner.
A physician assistant gets a four-year degree, takes specific prerequisites, then goes to PA school for two years, culminating in a master’s degree.
Members of both groups do many of the same things as physicians, particularly in primary care fields. Some work alongside specialist physicians as well. Many a night I have tried to reach on on-call cardiologist or surgeon, only to speak to their personal NP or PA (who often has a more pleasant personality in the wee hours of the night).
In many rural areas, the NP or PA may be the only available care provider. Some models suggest that this would work well if supplemented by telemedicine supervision; the doctor on the other end, who could be hundreds of miles away, connects via video-conferencing technology to offer insight and guidance on the complex, difficult situation.
I’m a huge advocate for physicians going to rural areas to practice. But current trends suggest this is happening less. So in order to get the best care, we need to be flexible and creative.
Many young men and women in rural areas are deeply connected to their homes and regions, and want to go back after school and make life better for their families and neighbors. They also know that medical school is long and costly and that they want to get on with life and have families instead of continuing training for over a decade.
So tell the kids (and the adults contemplating a new career) to consider the fields I’ve listed above. People in rural America are just as sick (and sometimes sicker) than those in urban locales. They deserve good care. And they’ll get it from well-trained community paramedics, nurse practitioners and physician assistants.
And phooey on the doctors who won’t work there! They don’t know what they’re missing.
Edwin Leap, M.D., is medical director of the emergency department in a small North Georgia hospital. He lives in a log home in a remote part of Upstate South Carolina. Originally from West Virginia, Dr. Leap is married and has four children. Follow him on Twitter @edwinleap.