Rural Emergency Medicine Should be an Aspiration, Not a Back Up Plan

There are many TV medical dramas that make healthcare professionals crazy because they’re not even close to depicting what really goes on in a hospital. Most of us, however, can’t get enough of “The Pitt.” As an anesthesiologist and leader of one of New England’s largest healthcare providers, I find the series to be the most accurate depiction of what goes on in an emergency department (ED), whether in New Hampshire or Vermont — or Pittsburgh, where “The Pitt” is set — that I’ve ever seen.

One of my favorite characters is Dr. Dennis Whitaker, a first-year resident who grew up on a Nebraska farm. Whitaker grows in confidence and competence as a doctor, without losing his “Midwestern nice” persona amid the chaos of an inner-city ED.

In one scene, we see Whitaker treat a gravely ill renal failure patient rushed to the ED by his teenage son, arriving in the nick of time. Whitaker learns the family lives an hour and a half away in rural Pennsylvania, and because the family’s local hospital had closed, the boy had no choice but to make the long drive to the city to save his dad. This reaffirms Whitaker’s desire to return to Nebraska, where he can help families like his patient’s and his own.

“Are you still thinking rural emergency medicine when you’re done here?” an intern asks Whitaker.

“Not thinking,” Whitaker replies. “Doing.”

To me, this representation of a talented young doctor aspiring to practice rural medicine was powerful. That recognition can be hard to come by. Young doctors who love the challenge and rush of emergency medicine often gravitate toward cities, but I’d argue more residents should explore practicing in remote areas if they’re looking for an adrenaline-charged career to keep them on their toes.

I say this from the vantage point of the health system that I lead, Dartmouth Health, which is the most rural academic medical system in the U.S. Headquartered in New Hampshire’s Upper Valley, we’re the state’s only academic system and home to its only Level 1 trauma center, children’s hospital, and National Cancer Institute-designated Comprehensive Cancer Center. We’re also New Hampshire’s dominant care provider overall. With our Ivy League academic partner, Dartmouth’s Geisel School of Medicine, we’re training medical students, residents, and fellows, and conducting research that’s transforming medicine and improving patient outcomes worldwide.

That said, you won’t see our flagship 1.9 million square foot, 525 inpatient-bed Dartmouth Hitchcock Medical Center campus from the adjacent state highway because it’s surrounded by dense forest.

Just 2 hours northwest of Boston’s world-renowned hospitals, it feels worlds away. While the backdrops couldn’t be more different, I’ve held leadership roles up and down the Eastern Seaboard, and I’d put the top-notch care, medical innovation, and first-class clinicians at our health system up against any system based in a major city.

To put it another way: We don’t play small, and rural medicine is not for the faint of heart.

While many of us jokingly describe this region as “old and cold,” there remains a deeper misconception about what “rural” means, particularly in urban America. At one end of the stereotype spectrum, rural communities are sometimes viewed as less sophisticated, less educated, and more backward than their urban counterparts. And some in rural America view city-dwellers as elitist, lazy, and out of touch.

Both stereotypes miss the mark.

While I respect the strengths and complexities of urban communities, I want us to recognize the unique grit, intelligence, innovation, and sophistication that define rural America — including world-class medicine delivered in rural counties every day.

Many rural health systems are the first line of defense for critically ill and injured patients in their regions. And the role of each of those systems that are still standing has become increasingly critical in recent decades: according to The Commonwealth Fund, since 2005, nearly 200 rural hospitals have closed completely or partially, and over 400 — more than 20% of rural hospitals — are at risk of closure.

Without a community hospital nearby, people in rural communities across America are traveling hours for care — an inconvenience at best and dangerous at worst (like we saw in that scene in “The Pitt”).

Rural trauma hospitals often must be prepared to (and frequently do) take on extremely complex and urgent cases requiring highly specialized care. Adding to the challenge of rural care is the difficulty of transporting patients through winding back roads and mountain ranges. Our region’s stunning but unforgiving terrain influences the kinds of patients we see — devastating ski accidents, stranded hikers — and it shapes our responsibility for training residents to care for such injuries.

It takes grit to do what we do. Grit to remain confident and in control when a severely injured patient is literally dropped from the sky by an air ambulance, when every second counts. Grit to treat practical, no-nonsense rural folks. Grit to advocate every day for our patients.

Rural health systems might not have bustling nightlife, abundant public transportation, and other urban comforts, but I can assure you any healthcare professional seeking a busy and exciting caseload will find no shortage in rural healthcare. And the hardworking, kind people in rural America deserve the same talented providers and high-quality care as anyone else.

It’s my hope that reframing the reality of practicing rural medicine — as well as using innovation to change how and where care is delivered, and empowering healthcare workers as advocates of their patients and communities — can help solve one of the most critical, unmet healthcare needs of our nation, by better serving the 82 million people living in rural America.