The Rewards of Rural Emergency Medicine Training for APPs
In part one of this series, we gave a history and overview of our advanced practice providers program, exploring how our clinical training model has served to empower APPs and help alleviate staffing concerns in rural facilities. (To explore further, read here.) In this blog, we will continue to advocate for the criticality of helping APPs function at the top of their license amidst the ongoing physician shortage and rural healthcare crisis. But we will also delve more deeply into the resulting rewards.
Often, APPs face systemic barriers to gaining the experience they need to truly succeed—in both emergency medicine and rural environments. However, our internship model is designed specifically to equip providers with unique opportunities for education and career advancement in both spheres. Read on to get a deeper view of how our training model leads to positive effects for the wider healthcare ecosystem, benefiting physicians, small rural hospitals, and patients most of all.
The Unique Value of APW’s Training Model
In a time when rural medicine is at a critical junction, Aligned Providers Wyoming feels it’s imperative to offer resources to communities where the nearest hospital would otherwise be 50, 100, or more miles away. For example, it is currently estimated that 46 million Americans, or 15% of the population, are living in rural areas and lacking access to care. Between 2010 and 2020, 136 rural hospitals closed, worsening the challenges in these communities. Of these, the rural population tends to skew older, with a median age in rural areas of 43, indicating a group that has more health needs. An additional concern is difficulty with transportation, which makes it hard for many to get to preventive care or specialized services—other than emergency department visits.
In a time when rural medicine is at a critical junction, Aligned Providers Wyoming feels it’s imperative to offer resources to communities where the nearest hospital would otherwise be 50, 100, or more miles away.
As we’ve discussed in a previous blog, it is vital to empower APPs because the physician shortage does not appear to be abating—for a variety of reasons. A recent Lown report noted, for example, a mismatch between medical school enrollment, residency slots, and the need for physicians in the workplace. According to the researchers, this “resulted in a lose-lose situation where perfectly competent physicians face barriers to working while simultaneously, entire regions of the country are without sufficient access to physicians.” Amongst its recommendations, the Lown report suggested not only increasing residency slots but also “increasing the number of licensed medical professionals, such as nurse practitioners and international medical graduates; reducing burnout; and incentivizing trainees to serve in medical deserts.”
As a provider-led clinical staffing group, we want to provide training that improves medical access in rural America—especially where APPs are the primary source of care. As April Kapu, DNP, APRN, ACNP-BC, FAANP, FCCM, and past president of the American Association of Nurse Practitioners (AANP) has herself expressed: “[APPs] in rural areas wear many hats.” She goes on to say, “They may be seeing primary care patients; they may be tasked with extended care rounds in nursing home facilities, which requires extensive geriatric management; or they may be in a setting that requires knowledge of trauma. So, we try to prepare them in a way that is global in that manner.”
This perspective resonates with us at APW, where we have witnessed the impacts of shutdowns on rural communities. Unfortunately, patients often end up paying the price when they have to delay care, especially if they have to delay it for a long time. From what we’ve seen, having APPs play a central role is also key for hospitals to maintain financial feasibility.
“That’s the biggest need in rural America,” says Joann Bourlier-Childress, Board Chair of Aligned Providers Wyoming and original co-founder of the training program. “Because unfortunately many small hospitals struggle to afford doctors. But they can afford APPs.”
That said, it is important to acknowledge that some members of the medical community have expressed a general concern with moving away from a fully physician-led ED. The primary concerns cited are inexperience and quality, as well as cost.
But the vast majority of emergency departments in the country, including highly respected healthcare systems like Stanford, UC Health, Mass General, and the Mayo Clinic all utilize APPs as part of their healthcare delivery teams in their emergency departments and inpatient floors. Additionally, various states (like APW’s home state of Wyoming) have actually gone on to expand APPs ability to staff EDs with a wider scope of practice.
Joann notes that there is a concern from some about the cost of tests APPs order. But to get ahead of and avoid this perception, the APP program trains interns in best practices for utilizing CT scans and other diagnostic testing. Zach Bjore, PA-C, who directs the training program, continuously asks the interns why they’re using certain tests and what outcomes they expect. According to Joann, “Part of the internship is teaching them how to be good clinicians and diagnosticians, not to always just depend on the test.” This goes back to the program’s emphasis on didactic training in order to make differential diagnoses, discussed in depth in part 1.
In our experience, when physicians and highly trained APPs work together in the ED (even remotely), patient wait times decrease, patient access to emergency and critical care services increase, and patient outcomes improve. However, as we’ve noted, it is also true that many new APP graduates come out of school with limited training in high-acuity care and critical procedural knowledge. To help them play an ever-more integral role in the success of emergency and hospital-based clinical services staffing, we prioritize mentorship.
In our experience, when physicians and highly trained APPs work together in the ED (even remotely), patient wait times decrease, patient access to emergency and critical care services increase, and patient outcomes improve.
One unique aspect of APW’s program is the degree to which interns work closely with physicians and preceptors at the key site hospital, Cheyenne Regional Medical Center. Here, they get to know physicians either in a lecture setting or hands-on in the ER. “The doctors are really invested,” says Zach Bjore, from his position overseeing the program. “They want to see the APPs continue to do well after they graduate…Because this is their future colleague.”
This type of specialized and collaborative training strikes us as still unusual in the world of APP fellowships. There are not many to begin with, and to our knowledge, few preparing APPs to function independently and with few resources in remote rural areas.
But key is the fact that “our interns can go anywhere and still be comfortable with calling one of the mentors they had during this internship,” says Joann Bourlier-Childress. On APW contract sites, there is always a physician on call. “So they’ve already made that relationship with these providers,” she says. “If our interns go work at a site for us, there will always be an on-call person for them, whether it’s inpatient or ER.”
As noted above, physician assistants are of course able to practice independently in Wyoming. But it is our practice at APW to have our APPs have an on-call physician they can contact, as well as a medical director who conducts chart reviews.
The best part? This type of training, rather than causing friction with doctors, helps them do their job too. “We’ve had an amazing response from the physicians,” says Bourlier-Childress. “Because these APPs are prepared. Part of their training is how to consult with physicians and do quick patient presentations. Doctors like it because they can have input as to how they want that intern to present their case. This makes for a better working relationship. The interns learn more efficient ways of getting the patient accepted in a transfer of care from a rural site to a bigger hospital.”
A Solution for New APP Graduates
For interns like Lexi Kivari, the APP training program has been a game changer. Originally from Pennsylvania, she knew that she wanted to live out in Wyoming to enjoy the scenery and be near extended family.
Lexi started speaking with APW about working as a physician assistant following her graduation and passing of boards. “After hearing about the Rural EM Internship that they offer, I couldn’t wait to get started,” she says. “I love everything about being a PA-C, but being in a rural setting makes it really special and interesting.” She enjoys being able to hold a significant amount of autonomy and responsibility, in addition to caring for a close-knit community in such a beautiful part of the world.
“Seeing a variety of cases has been invaluable to the start of my career,” Lexi shares. But what does she appreciate the most? “The opportunity for innovation,” she says. “Rural healthcare providers often need to be creative in delivering care due to limited resources and access to specialists, which in turn can provide opportunities for finding unique solutions to healthcare challenges.”
“Rural healthcare providers often need to be creative in delivering care due to limited resources and access to specialists, which in turn can provide opportunities for finding unique solutions to healthcare challenges.” -Lexi Kivari, APW EM Intern
The fact that this has been Lexi’s experience speaks to the resourcefulness that APW’s emergency medicine training program has developed in its interns. The first intern from 2017, for example, has become an in-demand independent provider and continued on with APW. “In fact, her family moved recently but she wanted to stay connected with us at APW,” says Joann. “With her training, she’s able to work in all of our remotest of remote sites.”
This type of confidence is especially valuable given the fact that in the wider world of APPs, it can be quite challenging to get hired by an emergency department as a new graduate. It’s the age-old challenge of needing experience to get experience. For this reason, if an APP does get hired by an ED, they may be placed in a position where they are vetting cases that are lower-acuity and in some ways more suited for an urgent care.
Because of this, Zach Bjore explains, many new APPs might technically have “ED” experience but be more familiar with a lower-acuity environment. This puts both them and patients in a challenging position if they then go on to a rural critical access hospital. Because small hospitals may be struggling with staffing, a new graduate might have a better chance of getting hired. But the provider may also encounter the high-risk (albeit low frequency) procedures we previously described.
Ensuring a Positive Future for Emergency Medicine APPs
“A lot of people question whether they need this type of emergency medicine internship,” explains Joann. But to echo her earlier sentiment, “You can get out of your element so fast. It happened to me. I took a job in rural Nebraska right after I graduated. It was a rural critical access hospital, and a lot of times I would be working independently with only back-up supervision by phone.
She pauses. “It was a horrible feeling to be there and not know what kind of case would walk in the door. And whether you’d know how to take care of it.”
Luckily, Joann had the benefit of working with a highly experienced nurse in her 60s who had “seen everything in the world. She walked me through stuff that I had no idea about,” Joann says. “She taught me how to treat things in a better way.”
Joann’s experience goes to show much young physician assistants and nurse practitioners– even when naturally resourceful, capable, and strong leaders– can always benefit from specialized guidance and skill development.
It is for exactly this reason that Joann, Zach, the Cheyenne Regional Medical Center physicians, and the group of preceptors at APW are so passionate about helping a new generation of providers feel as confident as possible in treating patients in critical access hospitals around the Mountain West—no matter the scenario. According to Joann, “We want to set them up for success in all cases, so that they enjoy positive outcomes and a long career… Our interns have seen a lot of bizarre stuff,” she reports. “But they’ve managed it because they always have the support.”
“We want to set them up for success in all cases, so that they enjoy positive outcomes and a long career.” – Joann Bourlier-Childress, APW Board Chair and co-founder of Rural EM Internship
As an emergency and hospitalist medicine staffing group, we at Aligned Providers Wyoming are excited for the program to continue to evolve, as the emergency medicine landscape evolves with it. Given the success of our graduates, who have gotten positive feedback from the leaders and staff of our partnering hospitals, we are looking forward to recruiting and training additional classes of students.
The hope is that they too will go on to share this specialized emergency medicine & rural healthcare knowledge with future APPs, as Joann’s mentor shared with her. In fact, it’s already happening—a number of the intern graduates are now preceptors to newer interns.
“The goal is for us to help providers be better than we are,” Joann says. “The better we make them, the more successful that we (as an organization and as providers) will be. We want them to make us look like we have learning to do.”
Ideally, it will one day not be so unusual for APPs to be able to access dual-specialty programs like APW’s, where providers can train in both rural and emergency medicine. Summing her thoughts on why APW’s program is so important, Joann says: “Because it is just critical–the need in rural America– for APPs to be stellar.”
About Aligned Providers Wyoming
At Aligned Providers Wyoming, we are dedicated to transforming healthcare delivery through a patient-centric approach that prioritizes compassion, excellence, and innovation. Our mission is to revolutionize the healthcare industry by fostering a culture of empathy and commitment, ensuring that every patient receives the highest standard of care.