Here’s my column in this month’s EM News

Second Opinion: Emergency Medicine in the ‘Sticks’

Leap, Edwin MD

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I have most of the credentials I need to do my job. I graduated from an accredited medical school, completed an emergency medicine residency, and passed my American Board of Emergency Medicine exams. I am a board certified, residency trained emergency physician, the highest form of life in the specialty.


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I’m proud of my training and knowledge base, and I believe I have a very specific set of skills. Those skills also limit me. I don’t deliver enough babies to feel any sense of wonder and delight if I do. I wouldn’t dare to manage chronic illnesses in a family medicine office. I have no desire to provide long-term intensive care to a patient with pneumonia and sepsis. And if I had to manage chronic pain in a pain clinic…well, it’s too awful to contemplate.

I recognize that even though I limit my practice due to my training, several other types of physicians work in emergency departments. The founders of our specialty were certainly trained in other disciplines because emergency medicine had to begin somewhere and from some origin. Nowhere is the variety of physicians in emergency departments more evident than in rural America.

In many areas, like the rural South where I live, work, and enjoy pork rinds, the only doctors willing to work in some of the small emergency departments that dot the landscape are those trained in other fields, like family medicine, internal medicine, and pediatrics. What many of them do is far beyond moonlighting. They are often devoted to their facilities and communities and also to learning as much as possible about emergency medicine.

And they are needed because young, graduating emergency physicians aren’t actually going to rural areas. They go to larger teaching centers or urban hospitals. Small facilities, like the ones just off that lone exit on that long, lonely highway you travel on vacation, need physicians to take care of the sick and injured. If our bright, shiny emergency medicine specialists aren’t going to the hinterlands, who will?

It begs the question, “Are we truly concerned about rural patients?” Are we worried about their ability to survive car crashes, MIs, strokes, and poisonings? Do we want to reduce accidental deaths and intervene early in life-threatening illnesses? Or are we such regional snobs, such urban and suburban elites, that we can dismiss those areas, and say to ourselves, “Well, that’s their problem. If they want good care, they shouldn’t live in the sticks!”

The problem is, of course, that we all need the sticks. We need farmers and loggers, coalminers and truck drivers, factory workers and dairy workers. We need places to vacation and places to hunt, fish, and kayak. All we hear these days is the endless drone about the importance of green spaces and the environment. But we seem to forget that those green places, those empty spaces, those amber farms of grain and majestic purple mountains are inhabited by human beings who fall victim to the same things that afflict their city-mouse cousins. And those enlightened urbanites who venture out into the woods, fields, and rivers sometimes get sick and injured and seldom have their own helicopters waiting to whisk them off to the big city.

So if we do care, as we purport to, we should all put our heads together to help, encourage, and provide education and leadership to those who do go to rural areas or smaller urban facilities. In the process, perhaps we can bring about cooperation and strength in numbers.

Let’s face it, folks, medicine as we practice it today is a profession that has been conquered by division. Politicians, policymakers, insurers, and lawyers push us around at will because we’re usually too busy arguing over turf to lock shields and run the vermin off.

What if we could improve our political power by offering an affiliate ACEP membership to those who are not trained and board certified in emergency medicine, but are employed in rural emergency departments? This has been considered before. If accomplished, those physicians could have access to specific education and support activities not readily available through their original specialties. Not only would rural citizens benefit, we would have more allies to bring to the many fights we face day after day, year after year. More allies to the tune of possibly 12,000 physicians, which is nothing to sneeze at for a specialty as relatively small as our own.

There always has been and there always will be a running argument over alternative board certification. Who knows where that will end? I do know that I could not be certified in any specialty other than emergency medicine, while physicians trained in internal medicine, among others, can practice in emergency departments without completing another course of training. And a second residency is roughly as inviting as a three-year case of scabies.

Regardless of the turf and the future, we can at least cooperate now so that those of us trained in emergency medicine can show the value of our training to those who did not benefit from it, and share some of our expertise for the health and safety of patients in East Jebip. And maybe we can learn from them as well.

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Dr. Leap at the ACEP Scientific Assembly

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