The Scariest Medical Job in America
This column is written from current experience as a hospital trustee and an earlier incarnation as a community doc. Based on that experience I believe the scariest medical job in America is in the emergency room of the small rural hospital in the middle of the night.
It’s just you, the nurse and the town cop, one or more patients, and when it hits the fan, if you’re lucky, a couple ambulance personnel. You have no medical backup. You may get the most complex case, except the word “case” implies something circumscribed and controlled. It may be up to you to convert a dreadful, deadly car crash with survivors and the mud and the blood and the beer, into “cases” and do it concurrently like spinning multiple plates. You can call for help but it will be at least half an hour getting there. Worst of all, you only know what you’re doing, kind of.
I could do other vignettes such as the dopey five month old with fever, though you don’t see kids in your day practice, let alone do spinal taps, but let’s get to the system problems.
One of the greatest advances over my 40-plus years in medicine has been the appearance of the specialty of emergency medicine. You just can’t beat knowing what to do, and, the order in which to do them, when things get quietly frantic. Every mature country doc who takes care of kids remembers the kid who died because doc didn’t start a “cut down” intravenous line the minute he walked into the room.
But Peterson and his colleagues, writing in the Journal of Rural Health (“Nonemergency Medicine-Trained Physician Coverage in Rural Emergency Departments,” Spring 2008), found that the likelihood that Medicare emergency patients would be seen by an emergency medicine specialist decreased fivefold as rurality increased. That can mean that either local docs are rotating coverage in the emergency room, or contract docs without formal training are being hired just to cover the ER. I have the impression that the arrangement whereby local docs rotate coverage, the rural standard in the past, is more common in the West but has largely disappeared in the East.
My own experience as a trustee is that lots of rural hospitals are having to cover their ERs with contract docs. The trained emergency medicine specialists are very good. The contract docs doing emergency medicine without formal training are an assorted lot, some outstanding, some not: old warriors, returned missionaries, semi-retired family docs off to see the world. Some are young docs, internists or family physicians, looking for their calling. Some tried being hospitalists for fixed hour jobs and didn’t find the responsibility they wanted. Perhaps a few were terminated under negotiated “don’t tell” arrangements.
Some troubled docs, in my experience, have been accused of not seeing the patients but “cribbing” the nurses’ histories and exams, of temper tantrums in the stress of the emergency room, and of inability to perform essential maneuvers. Trustees and management haven’t distinguished themselves either. When they have come across a problem doc, their focus, in some cases, appears to have been on protecting their institution from liability rather than protecting the public.
To come back to the opening point, we have small, isolated rural facilities, at risk of receiving really scary cases in the middle of the night, having to staff their emergency rooms with docs they don’t know, in the most dangerous situations in modern medicine.
What can we do?
First, directors of family medicine residency programs with a record of placing graduates in rural practice should push emergency rotations. There has been some tendency to steer family medicine residents away from such training for fear of losing them. I apologize if this issue has been addressed and I’ve missed it.
Second, family medicine specialty organizations should offer continuing education programs in pediatric emergency care for rural family physicians and invite rural internist colleagues. Edward Lews and Lyle Fagan surveying rural Oregon docs (“Emergency Department Coverage by Primary Care Physicians in a Rural Practice-Based Research Network,” Journal of Rural Health, Spring 2009) found pediatric emergencies their area of greatest perceived need.
Third, the only courses required to practice emergency medicine are in trauma, cardiac and pediatric life support. Each is an intense one- or two-day course certified by the American Red Cross. If someone proposes to make their living as a contract ER doc we should consider requiring a substantial, say, two-month, course in a teaching emergency room where their ability to cope under pressure, as well as medical skills, can be evaluated. I would NOT impose that requirement on docs covering the ER in their home community. The local part-time coverage docs won't do it—they would love to escape the ER coverage rotation. The other local docs and nurses generally know their colleagues' competency outside their specialty and under pressure. And no doc in active practice can close their practice and leave town for two months of training. Medical staffs need to acknowledge just what a dangerous, albeit onerous responsibility, ER coverage is, and relieve those who perform poorly: Should docs be charged to reward the other docs who have to cover more often?
Fourth, a group representing the whole community, including the medical staff, hospital management, patient advocates, trustees and emergency room users, should consider whether the emergency room needs to remain open. Would an after-hours clinic suffice? Would an upgraded ambulance capability help? This is a very complex question. Every interest sector will approach the answer differently.
Fifth, a well-designed telemedicine link could back up the isolated ER. There’s always someone in the urban ER to help.
If you have answers maybe we can circulate them. Please send your comments to me at the email below.
Wayne Myers, a pediatrician, founded the University of Kentucky Center for Rural Health and served as its director. He also served as director of the Office of Rural Health Policy in the Department of Health and Human Services’ Health Resources and Services Administration. He is a past president of the National Rural Health Association.
Opinions expressed in this column are those of the author and do not necessarily reflect the views of the Rural Assistance Center.
Dr. Myers welcomes your feedback. Comments and questions can be sent to him at myers@raconline.org.
