The ACEP Rural Emergency Care Task Force (RTF) Summary states that despite a more than 25% increase in the total number of emergency physicians since 2008, there has been a decrease in the number of physicians practicing in rural ED’s, particularly at very low volume ED’s. This has created a challenge for rural hospitals to find providers to staff their ED’s, as they need to have emergency departments open 24/7.
The evidence is clear from survey data collected by the ACEP RTF that most rural hospitals across the country do not require the adequate training and onboarding education needed to practice safely and competently prior to allowing physicians, PAs, and NPs to get credentialed to work in their ED’s. Lack of availability of qualified clinicians and financial constraints have made it difficult for rural hospitals to fill the emergency provider gap. This issue has been largely overlooked up until the past few years, because the focus of improving care in emergency medicine has been in urban areas rather than the rural, where the emergency department volumes are much smaller. It’s important to note though that despite their comparatively small size, rural emergency departments “represent 53% of all hospitals in the US and 24% of total ED patient volume” (Camargo, Jr. et al., 2020). That same report provides a comprehensive analysis of data about rural emergency departments, their financial vulnerability and risk of closure, and reveals a disconcerting trend: rural EDs often turn to PAs and NPs to provide emergency care, with little or no physician supervision.
Some physicians, PAs, and NPs have taken it upon themselves to get extensive post-graduate training in emergency medicine, and have performed very well in the rural environment. Many, though, have migrated to emergency medicine without any formal training. There is currently no minimum standard of training to work in EDs. Working solo in rural EDs without formal training in emergency medicine is reckless and dangerous. Non-EM trained physicians, PAs, and NPs can clearly practice safely and effectively in emergency medicine, but need a robust onboarding educational program to get them launched.
Happily, while it can be daunting to think of the enormity of the preparation required to practice emergency medicine, the ACEP Rural Emergency Care Task Force Summary provides a plan to help better prepare non-EM trained physicians, PAs, and NPs to work more confidently and competently in rural ED’s. This task force recommends a 5 step process:
1. Foundational Training
2. Airway Training
3. Simulation Training
4. Work in a high volume ED with EM trained/boarded physicians
5. Telemedicine support/oversight
The first step is robust foundational training. One of the key resources listed in the summary for this purpose is Emergency Medical Core Training (EMCT), the most robust and comprehensive online emergency educational program.
EMCT offers emergency training to clinicians looking to practice in emergency and urgent care medicine. It consists of 14 online modules (10 systems-based and 4 specialty) which the student can complete at any time, and even in conjunction with an orientation period. Each module defines its specific objectives, then goes right into three consistent sections of Anatomy & Physiology, Pathophysiology & Treatment, and Work-up, Diagnosis, and Management. The latter section is all about scenario-based learning, so students have an opportunity to practice responding to realistic scenarios that they will encounter in their work. EMCT prides itself on bringing subscribers to the bedside, often with video of actual patient encounters. Users will receive instruction on the numerous procedures performed by emergency providers, and all of the procedures are demonstrated via video on emergency patients, not manikins.
This training is not meant to replace board-certification or a formal EM residency. The simple truth is that many rural EDs across the country are staffed with non-EM trained physicians, PAs, and NPs rather than board-certified emergency physicians. Access to emergency medicine-specific education can help physicians, PAs, and NPs who lack that formal training feel more confident and prepared to take care of their patients. The ultimate goal is to ensure that emergency care providers all have a strong foundational base of knowledge so no matter the facility, whether it’s an urban ED seeing 100,000 patients per year or a rural ED seeing 1,500 patients per year, every single patient receives adequate and efficient emergency care. This is all about patient safety and emergency provider confidence in the practice of emergency medicine.