Rural ERs are increasingly run without doctors, experts say
There was no doctor on-site when a patient arrived in early June at the emergency room in the small hospital at the intersection of two dirt roads in this town of 400 residents.
Dahl Memorial’s three-bed emergency department — a two-hour drive from the closest hospital with more advanced services — instead depends on physician assistants and nurse practitioners.
Physician assistant Carla Dowdy realized the patient needed treatment beyond what the ER could provide, even if it had had a doctor. So, she made a call for a medical plane to fly the patient to treatment at Montana’s most advanced hospital. Dowdy also called out medications and doses needed to stabilize the patient as a paramedic and nurses administered the drugs, inserted IV lines, and measured vital signs.
Emergency medicine researchers and providers believe ERs, especially in rural areas, increasingly operate with few or no physiciansamid a nationwide shortage of doctors.
A recent study found that in 2022, at least 7.4% of emergency departments across the U.S. did not have an attending physician on-site 24/7. Like Dahl Memorial, more than 90% were in low-volume or critical access hospitals — a federal designation for small, rural hospitals.
The results come from the 82% of hospitals that responded to a survey sent to all emergency departments in the country, except those operated by the federal government. The study is the first of its kind so there isn’t proof that such staffing arrangements are increasing, said Carlos Camargo, the lead author and a professor of emergency medicine at Harvard Medical School. But Camargo and other experts suspect ERs running without doctors present are becoming more common.
Placing ERs in the hands of nondoctors isn’t without controversy. Some doctors and their professional associations say physicians’ extensive training leads to better care, and that some hospitals are just trying to save money by not employing them.The American Medical Association, open to all medical students and physicians, and the American College of Emergency Physicians both support state and federal laws or regulations that would require ERs to staff a doctor around the clock. Indiana, Virginia, and South Carolina recently passed such legislation.
Rural ERs may see fewer patients, but they still treat serious cases, said Alison Haddock, president of ACEP.
“It’s important that folks in those areas have equal access to high-quality emergency care to the greatest extent possible,” Haddock said.
Other healthcare providers and organizations say advanced-practice providers with the right experience and support are capable of overseeing ERs. And they say mandating that a physician be on-site could drive some rural hospitals to close because they can’t afford or recruit enough — or any — doctors.
“In an environment, especially a rural environment, if you have an experienced PA who knows what they know, and knows the boundaries of their knowledge and when to involve consultants, it works well,” said Paul Amiott, a board member of the Society of Emergency Medicine PAs.
“I’m not practicing independently,” despite working 12-hour night shifts without physicians on-site at critical access hospitals in three states, he said.Amiott said he calls specialists for consultation often and about once a month asks the physician covering the day shift at his hospital to come help him with more challenging cases such as emergency childbirth and complicated trauma. Amiott said this isn’t unique to PAs — ER doctors seek similar consultations and backup.
The proportion of ERs without an attending physician always on-site varies wildly by state. The 2022 survey found that 15 states — including substantially rural ones, such as New Mexico, Nevada, and West Virginia — had no such emergency departments.
But in the Dakotas, more than half of emergency departments were running without 24/7 attending physician staffing. In Montana it was 46%, the third-highest rate.
None of those three states have a program to train physicians as ER specialists. Neither does Wyoming or Idaho.
But Sanford Health, which bills itself as “the largest rural health system in the United States,” is launching an emergency medicine residency in the region. The Sioux Falls, South Dakota-based program is intended to boost the ranks of rural emergency doctors in those states, the residency director said in a news release.
Leon Adelman is an emergency medicine physician in Gillette, Wyoming, which, at around 33,800 residents, is the largest city in the state’s northeast. Working in such a rural area has given him nuanced views on whether states should require 24/7 on-site physician coverage in ERs.
