What it’s Like Being an Emergency Physician at a Rural Critical Access Hospital

By Christian Casteel, DO
PGY-2, Rush University Medical Center

The designation “Critical Access Hospital” was created after the passage of the Balanced Budget Act of 1997 and is given to rural hospitals deemed eligible by the Centers for Medicare & Medicaid Services (CMS).¹ This was a legislative response to the closure of more than 400 rural hospitals in the 1980s and early 1990s. For a hospital to get critical access status, it must meet the following criteria:

• Have 25 or fewer inpatient beds
• Be located >35 miles from another hospital (there are some exceptions to this)
• Have an annual average length of stay of 96 hours or less for acute care patients
• Have 24/7 emergency care services

As of 2022, there were 1,360 critical access hospitals in the United States. As mentioned above, every one of these hospitals must have 24/7 ED services and at least 1 MD/DO on call and available to be on site within an hour.¹

Given that patient visits to emergency departments in rural and critical access hospitals have risen 50% in the past 10 years in the United States, it is clear that emergency physicians currently are, and will continue to be, desperately needed in this setting,² especially as these communities disproportionately have less access to primary care. Though exposure to rural/critical access emergency departments during residency training is becoming more common, it is still often minimal or completely lacking.

I had a discussion with Jeremy Sturgell, MD, who has been practicing emergency medicine in the rural/critical access setting for more than a decade. The goal of this piece is to increase awareness and education regarding EM practice and lifestyle in this setting, particularly for residents considering a career in rural EM.

Dr. Casteel: Hey doc, can you give readers a little background on yourself?

Dr. Sturgell: I practice in southwest Missouri in a small critical access hospital. Our ED volume is around 7,000 visits annually. I went to medical school at the University of Missouri Columbia and then did an emergency medicine residency at the University of Illinois College of Medicine in Peoria, Ill. I grew up in our county, so immediately after graduation from residency I took the role as director at our hospital. I’ve been in that role for 12 years now. About half of that time, we were an independent critical access hospital. About five years ago, we affiliated with a larger regional system.

Dr. Casteel: Other than the larger hospital affiliation, have you seen any other major changes in the 12 years you’ve been there?

Dr. Sturgell: When I started, I was the only residency-trained, board-certified emergency physician in the group and in our county. One of my many roles as an administrator has been recruiting. I’m pleased to say that we now have a group of six residency-trained, board-certified EM physicians, which is unusual for critical access hospitals to be able to achieve.

Dr. Casteel: How did you end up in rural practice? Is it something you knew you wanted to do as a resident?

Dr. Sturgell: When I started, I imagined I would end up at a larger community medical center like the majority of EM graduates. When I was in residency, our program required us to work two shifts a month on the helicopter service during training. I had a very scary near-accident on a flight made in bad weather, so I told them I wasn’t going to fly anymore. In lieu of that, I started working two shifts a month in a rural department in central Illinois. It was a great experience and really opened my eyes to rural emergency medicine.

Dr. Casteel: How do you feel EM residency prepares or exposes trainees to rural EM practice?

Dr. Sturgell: I’ve learned over my career that we need to do all we can to get our colleagues into rural settings — especially places of leadership in these rural settings. That is where we can make the most impact. I think it should be a goal of our professional societies to at least have a residency-trained, board-certified emergency physician directing every rural emergency department in America. Many graduates leave residency without any understanding of rural emergency medicine or any appreciation that there exists a whole network of critical access hospitals in this country with a desperate need for qualified emergency medicine practitioners. I know some of our professional societies are actively looking into solutions for this issue, and I certainly think requiring rural emergency medicine rotations at the training level is a necessity. I think now more programs have seen the light and have incorporated rural rotations into their curriculum. I think this is important because there does not seem to be a lot of mentors in academic emergency medicine who practice in a rural setting.

Dr. Casteel: In your opinion, what is an advantage you find with your practice setting over a more urban setting?

Dr. Sturgell: One significant advantage I have found in practicing rural emergency medicine is the freedom you have with scheduling. This can often be an angle for recruiting. If your ED volume is low enough, you can safely do 24-hour shifts. Our full-time docs work five 24-hour shifts a month. This allows for plenty of time off that can often be arranged for extended time periods. It’s not unusual for our docs to easily get 10 days off at a time if needed for vacation. I found that this has been a very important factor in recruiting EM docs from larger tertiary centers. While I lived locally, all of my other docs on the roster lived out of town — commutes anywhere from 45 minutes to 1.5 hours. Obviously the 24-hour shifts make the longer commute more feasible.

Dr. Casteel: A common question from EM residents regarding rural EM is, “How do you stay current on EM literature/guidelines and procedural skills?” What do you recommend?

Dr. Sturgell: I make an enormous effort to stay current. Part of this is because we obviously are a single covered shop, and I don’t have a partner to bounce things off of in real time. With my time off, I also moonlight at other facilities. During those commutes, I listen to the products from EM:RAP. If I have some downtime between patients on shift, I usually am able to watch a few lectures from Virtual ACEP. In terms of procedures, I usually make it a point to go to a difficult airway course every seven years or so, but otherwise I feel like I get more than enough procedures. Airway skills and vascular access probably are the most critical skills to maintain. You can usually find a conference or skills lab somewhere if needed as well. Our larger health system has a program that would allow me to travel to the tertiary center in order to get procedural numbers if I felt it was necessary. They would even allow me to go and get deliveries if I so desired. I think that is a big benefit of having affiliated with a larger system. So the point being is that if you’re practicing in a rural setting and begin to feel like your procedural skills are “rusting” a little, it’s not hard at all to find ways to address this.

Dr. Casteel: In your opinion, what are some of the biggest challenges with practicing EM rurally that you would want new grads to know about?

Dr. Sturgell: Clinically the biggest challenges, especially for those new to rural settings, are that some of the decisions you need to make and factors you need to take into account are often unfamiliar to a new graduate or even a seasoned practitioner who has practiced in a larger tertiary center. You have to have an advanced understanding of EMS, EMTALA, and your own hospital’s capabilities as well as the capabilities of your region in order to get the critically sick and injured to the correct receiving facility. Transfers can be very frustrating and stressful. There were times during the pandemic where we could not find a receiving facility for our most critically sick and injured patients, and you had to sit on them and do the best you could until they could get definitive treatment. And there is no one to directly help you manage these patients typically. Taking care of the sick and injured is still very rewarding, but it quickly becomes frightening and stressful if you can’t get the patient to the proper destination.

It takes a lot of courage to practice in a rural setting and, in some ways, you have to be always at your best because at most places, you have no physical backup. It’s a much more hands-on job in a rural setting, in my experience. For example, I used to occasionally moonlight in a large Level I trauma center. I did much less direct patient care on the very sick trauma patients who arrived in that setting than I do when we receive trauma at our rural facility. In many rural settings, it is just one or two nurses. You are not going to be able to run a resuscitation from the back of the room. You have to be directly involved, and oftentimes you need to be very facile with procedures that we would traditionally assign to nursing staff.

Dr. Casteel: What about challenges from an administrative standpoint in the rural setting?

Dr. Sturgell: Administratively, the challenges are always recruiting. So, as I’ve mentioned, my role administratively has always been one of chief recruiter and someone who is able to sell this job and lifestyle to other EM docs. Another administrative challenge is always being chronically resource-deprived and being asked to do much with little. We have been blessed that our facility has recently affiliated with a larger medical center — which has helped immensely — but I know many smaller facilities in the country have not been so lucky. Many operate on razor-thin margins, so there may not be capital to pursue board-certified emergency medicine docs or purchase needed equipment for the department. Even at our hospital, I’ve had to obtain some of our equipment through outside sources through grant writing.

Dr. Casteel: When you have a tough case, how do you typically go about getting specialist input or help?

Dr. Sturgell: You really have access by phone to almost all specialists based on your regional hospitals. Every small rural hospital has to have pre-existing transfer arrangements within whatever region it abides. So this shouldn’t scare anyone away from practicing in a rural setting. You can always get a phone consult, even from a hospital outside of your system if necessary, based on these agreements and based on EMTALA.

Dr. Casteel: What is the most rewarding thing about where you practice?

Dr. Sturgell: The most rewarding aspect is having the opportunity to practice in the rural county where I grew up. There isn’t a single shift that goes by when I don’t know most of the patients I see or their families. Furthermore, I am always running into patients I’ve treated out in the community, and I’m not afraid to give out my personal phone number liberally. And these are good things. What is very memorable and humbling is when you see a patient or their family in the community, and they tell you how grateful they are for the care you gave them or for saving their life or the lives of their loved ones. Also, when the patient asks you if you have your own private practice because they would like you to be their doctor. I think this is one of the highest compliments we can receive as emergency physicians. I feel like they hold me to a higher standard of practice and behavior and make me aware that I always need to strive to be at my best. I feel a deep sense of obligation to the community in which I practice, and that is a wonderful thing that protects against the cynicism that can develop in our field.

Dr. Casteel: What is something you’ve learned or experienced while working in the rural setting that you didn’t know or expect going in, that you’d want to tell residents with an interest in rural medicine?

Dr. Sturgell: I think I didn’t realize how fulfilling rural emergency medicine would be. I really struggled coming out of residency with the thought that I was taking a “step down” by not going to a larger tertiary center. I had those same biases I spoke about, so it was nice to find that the reality was the exact opposite. What I would tell any resident interested in practicing rural emergency medicine is that rural America is a great place to raise a family and a great place to practice medicine. Your skills and training are critically needed in these settings and will be highly valued by your hospital and your communities. The work-life balance can’t be beat. The cost of living can’t be beat. If you lean in and engage, you will be more important to your hospital, medical staff, and community than you would working in a larger environment.

References

1. Rural Health Information Hub
2. Greenwood-Ericksen MB, Kocher K. Trends in emergency department use by rural and urban populations in the United States.  JAMA Netw Open. 2019;2(4):e191919.