COLUMBIA — Richard Blubaugh, an emergency physician from Branson, once scared a man into quitting smoking.
"I don't care if you quit," he told his patient. "It's job security for me."
"I was kind of blunt, as emergency doctors are," he said.
But his bluntness worked. His patient quit that day.
Emergency medicine doctors are used to facing challenges and finding creative solutions. They also work long hours because emergency departments are open 24 hours a day, no matter the weather conditions or the holiday. Blubaugh plans to spend his Thanksgiving Day working rather than sharing a family meal with his wife and two young sons.
Emergency physicians now face a growing source of stress: There are too few of them, especially in rural Missouri. That means they're more likely to work in understaffed emergency rooms.
"There's probably 10 or 15 EM jobs out there for every doc that's out there," Blubaugh said. By his estimation, he receives at least two calls a day from other hospitals looking to recruit him. Residencies aren't keeping up with demand.
In response to the growing nationwide shortage, MU is launching a new residency program for emergency physicians in July 2014. The three-year residency will begin training six to eight residents in emergency medicine every year.
Marc Borenstein, an MU professor and chair of MU's Department of Emergency Medicine, will serve as director of the program. Its the sixth program he has created, revived or helped stabilize in his 25-year career in academic emergency medicine. He started laying the groundwork for the new program when he arrived at MU in October 2011 but gives credit to the more than 50 administrators, health care providers and faculty who had roles in creating it.
Residents will spend three years learning emergency medicine-specific skills, dividing their time about 60/40 between the emergency department and training outside it in technical areas including trauma, surgery, labor and delivery, and airway management in critical situations when patients are at risk to stop breathing.
But it's also important to teach less technical skills such as communication, building relationships and teamwork, Borenstein said, because people come into the emergency department under very difficult circumstances.
"They are coming in with a lot of uncertainty in a situation where they may not have picked their doctor or their hospital or their nursing staff" because of the urgency of their health condition. That means emergency medicine physicians have about one minute to build trust with their patients, in his estimation.
A newer discipline, greater need
Emergency medicine residency programs are relatively new to the medical field and began in the early 1970s. The University of Southern California launched the first EM medical school program in the country in 1974.
"If you go back 20 to 25 years ago, it was very unusual to find an emergency medicine residency program at a medical school," Borenstein said. "And very few medical schools had academic departments of emergency medicine as a faculty."
Now, the vast majority of the 141 medical schools in the country have an EM residency, Borenstein said.
Meanwhile, an increasing number of people are visiting emergency departments. According to the Centers for Disease Control and Prevention, Americans made nearly 130 million visits in 2010. That's a 34.5 percent increase from 1995.
"The workforce alone to see that many patients is substantial," Borenstein said.
Meanwhile, technological advancements have changed the way hospitals see patients. Complex medical evaluations that once took two days to complete in the hospital can now be carried out in an emergency department in eight hours. The advances are beneficial for the patient in terms of time and cost, but they also require team effort from the hospital staff and highly sophisticated skills.
At the same time, emergency departments continue to serve as a safety net for uninsured and under-insured Americans who may have no where else to go for urgent health care needs.
Demand outweighs supply
Kathleen Quinn, the program director of the Area Health Education Center at MU's School of Medicine, has been researching the physician shortage in Missouri for six years. At the moment, she said, there aren't enough residency programs for graduating medical students.
Last year, 500 U.S. medical school graduates did not match into any residency training programs because the residency programs are not keeping up with medical school expansion, Quinn said. That means 500 students who could now be training to become doctors are waiting a year until a space opens up for them. However, slots may not be available again next year, she said. That creates a backlog of students awaiting residency training.
She cites flat national funding since 1997 for graduate medical education as one cause of the problem.
The lack of expansion, in turn, is playing a role in physician shortages, which are more pronounced in rural areas, primarily because of the financial resources available there, Quinn said. Doctors are attracted to the higher-specialty salaries available in urban areas, and most graduates come out of medical school with six-figure loans. High-paying specialties based in cities are much more attractive to them than a lower-paying job in a small town, she said.
Medical school students are also less inclined to practice medicine in rural areas, she said. A recent medical study found that just 3 percent of students who matriculate to medical school say they plan to practice in small towns or rural areas upon graduation.
Physician shortages have existed in rural areas for many years, Quinn said. The Missouri Rural Health Biennial Report found that 28 percent of Missourians lacked adequate access to health care in 2010-11.
Rural populations tend to be older and more impoverished, Quinn said. Moreover, since they have to travel a long way for medical care, they are less likely to be able to access care.
According to the report, 41 of Missouri's 103 rural counties do not have a hospital, which means that emergency and specialty care are particularly hard to find.
Quinn said that 37 percent of Missourians live in rural areas, but only 18 percent of doctors practice rural medicine. Nationally, 20 percent of Americans live in rural areas, while 11 percent of physicians practice rurally.
That leaves people in need of emergency care in a tough spot.
Traveling ER doctors step in
Kevin Kane, an MU professor and faculty director of clinical curriculum at MU's School of Medicine, said a few different models have emerged to help fill the gaps. One of them is having family physicians provide emergency care if there's no emergency medicine physician on staff at the local hospital, Kane said.
Although family physicians are not trained to handle trauma, he said their training does equip them to handle many of the patients coming to the emergency department.
Some rural patients at a small local hospital will be seen by a traveling emergency medicine physician.
"In Fulton, for instance, they have an emergency medicine group that staffs that hospital," Kane said. But those doctors may also travel to Hermann, Moberly and Boonville, he said. "That's one model that seems to work."
But there's no getting around the simple fact of a dire shortage.
Borenstein and Quinn are both hopeful that some of the future emergency medicine residents will eventually decide to practice in rural Missouri.
Blubaugh is hopeful as well but also concerned.
"It’s good they're training six to eight (residents) a year," he said. "If they had twice that many, it still wouldn’t be enough."