Doctorless Emergency Rooms in Rural Montana
Ekaraka, Mont. – In early June, patients arriving at the emergency room of a small hospital in Ekaraka, which has a population of about 400, found no doctors present.
Dahl Memorial Hospital’s 3-Bed Emergency Division is situated a two-hour drive from more advanced medical services, relying instead on a physician’s assistant and a nurse practitioner. Karadaudi, a physician assistant, recognized that even with a doctor, patients required care that the ER couldn’t provide. She called in medical planes for transport to one of Montana’s more sophisticated hospitals, while also coordinating medication needed to stabilize patients and guiding nurses through the administration process.
Emergency medical specialists are now aiming to fill the gap left by doctors, especially in rural regions, in light of the national physician shortage. A recent study indicated that, in 2022, about 7.4% of emergency departments across the U.S. operated without a physician at all hours. Like Dahl Memorial, over 90% of those departments are classified as low-volume or critical access hospitals.
These findings stem from responses received from 82% of the surveyed hospitals, excluding federal facilities. Carlos Camargo, a researcher from Harvard Medical School, stated that this study is unprecedented, and while there’s no definitive evidence that doctor-less staffing is increasing, he and other experts suspect it might be happening more frequently.
Utilizing non-physicians in emergency rooms sparks debate. Some medical professionals argue that only extensive training can ensure optimal care, while others believe that hospitals may be cutting costs by reducing staffing levels.
Both the American Medical Association and the American College of Emergency Physicians (ACEP) advocate for legislation that mandates having doctors on-site 24/7. Recently, states like Indiana, Virginia, and South Carolina have adopted such laws.
Despite fewer patients in rural areas, the cases they handle can still be severe, according to ACEP President Alison Haddock. She emphasized the importance of providing residents in these regions with access to high-quality emergency care.
Some healthcare providers argue that experienced practitioners can effectively manage ERs, but maintain that having a physician on-site is crucial. They warn that the inability to recruit doctors may lead to hospital closures.
“In rural areas, if you have competent PAs who are aware of their limitations and know when to consult specialists,” said Paul Amiot, a board member of the Emergency Medical Society. He noted that, although he works shifts without a doctor present, he often consults with experts and relies on the support of physicians for complex cases.
Data shows variations in the availability of doctors across different states. A 2022 survey noted that 15 states, especially those with substantial rural areas, lack sufficient emergency departments. Notably, Montana ranks third highest for departments running without consistent physician staffing.
Sanford Health, recognized as the largest rural health system in the U.S., is attempting to address the shortage through an emergency medical residency program aimed at increasing the number of emergency physicians in rural locations.
Leon Adelman, an emergency physician in Gillette, Wyoming, reflected on the complexities of enforcing 24/7 doctor presence in ERs, emphasizing a careful approach based on local conditions. He noted that some states may require alternative regulations to avoid financial motives for cutting physician staff.
Adelman believes that instead of just enforcing doctor staffing, states should regulate hospitals to ensure they are not compromising care standards for cost-saving reasons. This came up in discussions regarding Vermont’s health system issues.
Concerns have arisen about unsupervised practices by nurse practitioners (NPs) in emergency settings, with incidents of misdiagnosis being highlighted. The Society of Emergency Medicine PAS has emphasized the qualifications necessary for PAs to practice in rural emergency environments.
While some voices within the medical community advocate for staff experience requirements, Haddock from ACEP insists on the need for well-supported care structures in rural hospitals, opposing any moves that might lead to closures.
Dahl Memorial Hospital employs rigorous monitoring and maintains strong operational standards, according to Dowdy, who has transitioned from a large urban emergency room to Ekaraka. The staff are able to consult with doctors remotely, utilizing technology to enhance care. However, Dowdy acknowledged that the limited patient flow results in infrequent experience, necessitating regular training simulations to sharpen skills.
Despite a 30-year absence of doctors at Dahl Memorial, CEO Dahl Messer Smith indicated an openness to hiring doctors willing to reside in the area. He appreciates the continuity and community connection offered by advanced practice providers compared to frequently changing physician staff in other rural hospitals.
Local residents expressed satisfaction with the care they receive from Dowdy and her team. One patient, Ben Brusky, mentioned how the facility was vital for many lives, stemming from his own experience after an injury on his family ranch.
