Rural Medicine: Training Together

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

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Thomas B. -

Great topic! I am a family medicine trained physician working in the ED and inpatient units of a rural critical access hospital in New Mexico. In general, I think the problems highlighted in this "talk" are even worse here in the US. Most rural EDs are staffed by family physicians or GPs from the older generation and there are very few opportunities to receive any formal training in emergency medicine. The 2+1 track does not exist in the US, rather you finish your 3 years in family med and then just start working in rural EDs if you want to without any additional training. There are a few 1 year EM fellowships that lead to accreditation through the American Board of Physician Specialists (ABPS), rather than the American Board of Emergency Medicine (ABEM), but this does not provide any additional employment opportunities (you still can only work in rural EDs where you could have worked without it) and involves taking a significant pay cut to be a fellow for a year. For many, this option does not make sense. Further, it does not address the issue that once out of fellowship, you will likely lose many of the skills you learned since they are used infrequently at best. Being able to have some sort of exchange whereby you rotate at a more urban center on a regular basis would allow you to retain skills more easily and in the long run would likely benefit patient care. As mentioned on this episode, it would also likely benefit many urban ED physicians to rotate at rural centers. Anectdotally, I know many EM trained physicians who say they would not be comfortable providing solo coverage of a rural ED due to the absence of specialist support services. As a family physician, I don't have much influence over academic EM programs, but those of you who are involved with them could certainly help push for such work exchange or work sharing programs.

Vanessa C. -

Thanks so much for taking the time to write in. I couldn’t agree more with your points! Thanks again for listening

Michael M. -

Great talk Vanessa. I'm a newly practicing FM physician in a 1 year EM fellowship. I cannot agree more with your points. What I've seen in my limited career in medicine is that each specialty is in such silos and each aggressively defends those areas in which they feel belong to them. Where I trained IR was taking over some procedures from GI and the two groups were in an all out war. I understand the struggle EM had to go through to be accepted and accredited as a separate specialty, however, the reality of practice in the US (and it sounds in Canada as well) is that many of the low resource facilities are manned by non-EM residency trained physicians.
Sadly, I don't think we will ever see an exchange/rotation program offered an any regular basis. Likely for same reasons that I will never be able to work with EM residents or at a level 1 trauma center. I agree that it would only serve to boost camaraderie, teamwork , and ultimately the patient if such program existed.
It's funny earlier in this same episode, with the talk about social psychology concepts, they spoke about being biased against patients and how that has a real impact on patient care. I think the same bias could be said for when physicians at both low resource and tertiary care center judge off hand the competence and capabilities of the other.

Vanessa C. -

I definitely agree Michael that we need to work hard to improve the relationships with our tertiary care colleagues. This will only help the process of transferring and sharing care of our patients, as well as improving the overall care of the patients.

I am not sure if it is possible in your system but I know that some of my rural and remote colleauges will spend one to two weeks a year working with anesthesia or other specialities in bigger centers. They work under supervision of a specialist and it seems to benefit everyone. Even our trauma team leader at the tertiary care centre has offered for us to come and shadow them on ER trauma shifts. It is all very informal, and is not paid, but very much appreciated.

Thanks for listening, and for sending in your comments.


Bruce H. -

> First, greetings from the most remote hospital in the lower 48. That
> seems like a minor claim when hearing of the tales from the far north
> of Canada.
> I too am a Family Physician working rural ED--17 years as solo, private practice FM in Aurora, CO, then doing "everything" is a small town in Montana and past 12 years doing only ED in Salmon, ID.
> I had a patient a couple weeks ago who rolled his pickup into the
> river, landing upside down and being at night wasn't able to get help,
> stayed in his sleeping bag over night on the river bank.
> Our evaluation showed, per the radiologist, an unstable C6 fracture
> with concern for a vertebral artery injury. Sure enough, the CT Angio
> showed a dissection. I had called a referral center (Level II Trauma Center) before the
> angiogram and the ED doc there wanted to have neurosurgery "weigh in" on
> what to do. I hadn't heard anything from the referral center by the time I had the angio report
> so spoke with a vascular surgeon who suggested that the dissection is
> just treated with aspirin but that I needed to wait for the
> neurosurgery response as to transfer or not. After waiting 56 minutes,
> the transfer center let me know that I should transfer the patient
> because the neurosurgeon "doesn't want to deal with this on the
> phone."
> All I could think of was Vanessa Cardy's piece on working
> together.."the more we get together...the happier we will be." When
> the radiologist calls to say there is badness on the CT, I take it
> seriously even if it isn't so serious to the specialist. But I'm 150
> miles away from definitive help.
> Guess that was a bit lengthy and "ranty."
> Bruce Hayward, D.O.

Vanessa C. -

Thanks so much for writing in, for sharing the story and for listening! And thanks for all of your work! Vanessa

Gerold K. -

Dear Vanessa! A somewhat late thank for your great talk. I am currently working in a rural hospital in New Zealand, otherwise, I do work part-time in a rural hospital in Sweden. I think many colleagues in large centers do not understand how much energy gets drained from my soul when I have to explain why I need to transfer a patient for A to B. Energy I would rather invest in other patients or my family when coming home. I even see a lack of simple kindness in the discussion on the phone. It makes life so much easier if you have a discussion in a kind manner. Jessica, one of the best ED docs I know and work with, told me that you have always 2 patients at the same time: the actual person you treat and your department. The department that you know, with the resources, the individuals that work right now, the weather conditions and so on. I believe that all the aspects that are not purely medically related, not part of any guideline or study are often forgotten by our colleagues working in the large centers.

Vanessa C. -

So true Gerold! I couldn't agree more. One of the great pleasures that I have working where I do now is that although sometimes we have to do a little bit of begging, in general most tertiary care docs are good at realizing that we are calling because we need to. When I worked in a different small town, that was closer to a big centre, I would literally sometimes spend hours on the phone looking for a bed, and begging consultants to help me. Exhausting for sure.

Thanks for all of your work and thanks for listening!


Carp27 -

Vanessa: Thank you for focusing some attention on rural emergency medicine! As an urban academician, I have the utmost respect for our colleagues around the world providing life-saving emergency care in rural settings. The utmost respect. I was somewhat surprised that your segment did not mention either the Journal of Rural Emergency Medicine ( nor the ACEP Rural Emergency Medicine Section ( JREM was born from the ACEP Rural EM Section but had to be put on hiatus due to lack of support from ACEP or Annals EM (which opposed the journal for a variety of reasons). Without a consistent voice on journal editorial boards, the stories, innovations, challenges, and opportunities of rural EM will remain largely unknown. I encourage EM:RAP listeners practicing in or interested in rural settings to check out JREM. Perhaps EM:RAP will do a segment on the JREM journal someday? Keep up the strong work Team EM:RAP!

Vanessa C. -

Thanks for the message and for the reminders about JREM and ACEP's rural ER section. I also encourage people to check out the Society of Rural Physicians of Canada, with the journal and the annual conference they organize (Rural and Remote Medicine).

Thanks again for writing in and for listening.


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