The 2020 Rural Emergency Care Task Force, convened by the American College of Emergency Physicians (ACEP) Board of Directors, began work in June 2020 and published a report in October.
The 24 page summary can be accessed here. The goal of this series of two articles will be to further distill and explain the findings from the perspective of a practice – ACUTE CARE, INC. – specializing in and experienced with Rural Emergency Medicine. The report includes input from two ACEP Sections – Workforce Development and Rural – to which ACUTE CARE, INC. belongs.
The Task Force addressed assigned objectives using published methods and provided key recommendations.
In this article, the first of two planned on the topic, focused on the first three of five objectives, we draw directly from the report as a means to summarize and discuss the recommendations and how they affect the practice of Emergency Medicine in rural America.
1. Objective: Review the data from the ongoing workforce study. Review the data regarding recent closure of rural hospitals. Provide an assessment and recommendations on the current and projected workforce.
Comment: I had seen some of the preliminary data that became the report Dr. Camargo contributed to this section of the report. The measure of “EP density” is used, and it’s noted that Board Certified Emergency Physicians continue to be underrepresented in rural areas. The data regarding rural hospital closures is well known and oft-reported.
a. Develop a recommended knowledge and experience base for non-EM board certified physicians who are working in rural areas. This should not be confused as a substitute for board certification. Require a period of mentorship with an EM board certified physician via telemedicine.b. Develop a recommended knowledge and experience base for PAs and NPs who are working in rural areas. Require a period of mentorship with an EM board certified physician via telemedicine.c. Work with the American Hospital Association and other specialty organizations to provide support for rural hospitals and practitioners.
Assessment and Recommendations for Rural Workforce
Based on the best available evidence, current understaffing of rural EDs by EPs is likely to worsen in the years ahead. Restricting analyses to only those EPs with EM training or EM board certification provides an even worse situation – and forecast.
Evidence also indicates that more rural EDs are closing than opening. While the numbers are small – relative to the total of 1,899 rural EDs open in 2018 – the trends are concerning.
Taken together, we encourage ACEP to better support the EPs now working in rural EDs – regardless of their EM training or EM board-certification status – and to work with rural hospitals to develop strategies to avoid further ED closures. Ongoing support of the Critical Access Hospital Program should be an important part of any ACEP strategy to maintain and potentially improve access to rural emergency care
2. Objective: Review the outcomes of residency training programs with specific rural emphasis and make recommendations on ways to increase the number of board-certified EPs practicing in rural areas.
Comment: We have participated in discussions regarding rural rotations for EM residents, and understand the value assigned to this experience. Whether the exposure to the rural environment as part of clinical learning influences a resident physician to choose placement in such a setting is not addressed.
a. Meet with RC-EM to discuss rural ED rotations and current barriers to these experiences.b. Collaborate with CORD and EMRA to increase the options for rural ED rotations.c. Highlight rural EM through ACEP Now articles.
Comment: The report does not address a current and pressing concern that EP supply was already exceeding demand before the pandemic, and has been exacerbated by the pandemic. If we have too many residencies and too many graduating residents for the job market these physicians in training anticipated, they may need to adjust their expectations for where they will practice, and reconsider rural areas.
Comment. This is in keeping with my observation as well, though ACUTE CARE, INC. is continually evaluating and trailing education activities that address the need for critical skills maintenance. The fact that simulation and skills lab training was not addressed is a puzzlement, as these modalities are increasingly available in regional centers and accessible to rural practitioners.
a. The Board of Directors should discuss the role of ACEP in driving improved quality of care in rural hospitals.b. Create a document that outlines the recommended on-boarding for PAs and NPs in settings without EM board certified EPs, which would include specific knowledge and skills competency, as well as recommendations for supervision by EM board certified EPs.c. Create a policy that advocates that hospitals without EM board certified physician coverage should have telemedicine availability for consultation.