Thursday, September 14, 2017

Consider an Away Elective. Now is Your Chance!

Image Credit: Pixabay
Author: Teresa M. Ross, MD
2011-2012 AAEM/RSA President
Originally Published: Common Sense March/April 2014

If the only medical world you’ve ever known is the infinite connecting hallways of a classic teaching hospital, you’re not alone. Medical school and residency naturally bring us to these oldies but goodies as the epicenter of our academic and clinical training.

But step away for a while – imagine a world where emergency docs come to work in jeans, know their colleagues (and their families) by name, and can’t count on off-hours, in-house consultants except medicine and pediatrics. There is an exciting world out there beyond formal department conferences and journal-quoting consultants.

In the emergency departments of rural hospitals, physicians deliver care to some of the most remote communities of our nation, and they’re pretty good at it. Your ED attendings might not be boarding your trauma transfer for eight hours, but they sure are doing their own fracture reductions, nasopharyngoscopy and complicated facial laceration repairs. And they are most likely running the entire show on a single-coverage shift with nothing but a dedicated nursing team backing them up. Whether you imagine yourself practicing rural medicine, or even community medicine, or have committed to research for life, it is an invaluable experience to learn from these opportunities.

Medical school and residency offer the perfect opportunity to travel and appreciate the spectrum of care and resource management that exists in our field. Away from your Level-1 Trauma Center and academic tertiary referral hospital, you will learn to value not only the skill sets of rural physicians but also the magnitude of work that is done with the resources of a smaller hospital.

If you’ve only ever practiced in a land-locked northern city, here is your chance to treat desert snake bites and coastal drownings. If you’ve always lived on a southern plain, here is your chance to see frostbite and altitude sickness. Additionally, you’ll manage STEMIs without a cath lab and stabilize severe trauma patients for transfer when your hospital doesn’t carry platelets for transfusion. You could be paged to the ICU for an emergent intubation. The family medicine hospitalist might call you for a curbside in-patient consult when there is no one else to discuss a new drug rash with except you.

Who are the patients of rural hospitals?

Sixteen percent of Americans live in “rural” communities (2012 U.S. Census), down from 21% in Census 2000. Compare that to 51% of Americans living in the suburbs. (Definition of “rural”: population <50,000 in non-metropolitan area.)

Two million American Indians and Native Alaskans are served by 45 hospitals of the Indian Health Service.

The average doctor-patient ratio is one primary care physician (PCP) per 1,300 Americans, versus one PCP per 1,910 rural Americans. Generalists outweigh specialists. Family medicine physicians outnumber emergency medicine physicians seven to one in rural areas (American Academy of Family Physicians).

Many rural areas are characterized by extreme poverty, high minority population and significant chronic disease.

Fifteen percent of rural Americans live in poverty, compared to 12% elsewhere.

One in five uninsured Americans lives in a rural area.

Rural Americans suffer from more obesity, hypertension, diabetes and heart failure (HHS) than the population as a whole.

In a 2011 study, rural rotations were required in six (5%) of emergency medicine residencies, elective at 92 (83%), and not available at 13 (12%). Overall, 197 (8%) residents completed a rural rotation during residency, and 160 (7%) selected their initial job in a rural area.

If you don’t have a mandatory rural rotation, how do you set one up? Talk to your medical school or residency program director. Programs often have a pre-existing arrangement with a government-sponsored program (i.e., Area Health Education Cooperatives (AHEC) for medical schools, or Federal Civil Service, National Health Service Corps, or Indian Health Service for eligible residents and graduates).

No matter where you choose to practice, use your training as an opportunity to appreciate the variety of emergency medical practice in our country – if not in the world. You will see clinical scenarios and pathologies you may never see again and will meet physicians and mentors who exist beyond the horizon of your standard academic program. They are the networks that feed into our large tertiary referral centers. We can learn a lot by going to the source and learning from them.

Coming soon: visit for detailed information on international rotations and resources. RSA is With You All The way!


1. Rural Practice, Keeping Physicians In (Position Paper). American Academy of Family Physicians, 2009. Accessed March 9, 2012. <>.

2.Chang J, Sheshamani M. More Choices. Better Coverage: Health Insurance Reform and Rural America. HHS Office of Health Reform. Accessed March 9, 2012. <>.

3. Indian Health Service. U.S. Department of Health and Human Services. Accessed March 9, 2012. <>.

4. Talley Be, Moore SA, Camargo CA, Rogers J, Ginde AA. Availability and Potential Effect of Rural Rotations in Emergency Medicine Residency Programs. Acad Emerg Med, 2011; 18:297–300

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