Update December 2020: Check out our articles on the 6 Benefits and Challenges of Working in a Rural ED and Pros and Cons of Working in a Rural ICU

One ED doctor, George Belkowski, MD, shares his experience shifting from family medicine clinical training to emergency department clinical work.

What was your route from family medicine to the ED?

I was interested in emergency medicine from the time I was in medical school, but I wanted to do rural medicine because I wanted to live in Michigan’s Upper Peninsula when I got done with school. But back then–the early ’90s–people told me if I wanted to do ED in a rural area, I’d be better off doing family medicine due to the type of practice a rural hospital’s ED would require. So basically, I never really thought I’d do family medicine. I thought I might do a little of it, but my goal was always to do emergency medicine in a rural area.

How did you learn the ropes?

I did my family practice residency in Marquette [in Michigan’s Upper Peninsula]. In my second year of residency, I could get a Wisconsin license and start moonlighting. I would work a 72-hour weekend in a small ED there–kind of scary because, as a second-year resident, you just don’t know what you don’t know. In my third year, I could get a Michigan license, so I was able to moonlight in an ED just up the road. The rules have changed a lot since then. After my third year of residency, two full-time jobs opened in the ED where I was moonlighting. Both were 24-hour shifts. I worked there 10 years before I [became an affiliated partner with] Emergency Consultants.

Was FM to EM a huge learning curve?

You certainly can’t do a family medicine residency and walk into a high-volume ED. Those guys that do emergency medicine residencies are no doubt way better trained than I was coming out of residency, but again, they’re usually going to start working in bigger centers with higher volumes. They also will have more resources to call upon. If you want to work in a rural hospital ED, your resources to gain experience will be your specialty colleagues in the community. A colleague of mine I work with now, who worked at a Level I trauma center in Mississippi for 20 years before moving back to the Upper Peninsula, once told me that rural emergency medicine was a totally different EM specialty to him. I agree with him. Family practice and general medicine folks have a lot of skills that are well suited to working in rural EDs.

How did you prepare to practice emergency medicine?

What I did was take a few electives during my residency: anesthesia to learn how to intubate, ED rotations in a bigger center to get experience there, peds stuff, trauma courses–that kind of thing. I also worked in an ED that saw about 25 patients in 24 hours, which is a low-volume ED. If you don’t have EM experience, that’s the way to do it, because when there are fewer patients at once, you can take your time, research things, and lean on consultants to gain experience.

What if, post-residency, a family medicine physician decides he or she wants to pursue emergency medicine?

I know at my hospital, we’ve allowed people who want to do emergency medicine, but don’t have EM experience, to come in and work as a midlevel in the ED. You’re not going to get paid as much as you would working as a physician, but you can see patients, get ED experience, and still get paid without having to work alone. You also could check out the American Board of Physician Specialties. For someone who doesn’t qualify to take the ABEM, it offers a path to obtain a base of EM knowledge through board certification. It is rigorous and worthwhile. Or, as an FM physician, you could go to a small-volume ED that gets about one patient an hour. You’re much slower, but you’ll be able to get by and gain experience.

You don’t think an FM-trained physician would feel like a fish out of water even in a low-volume ED?

Say you’ve worked five years doing family medicine and want to switch over. You’ve also got four years of med school and three years of FM residency. That training overlaps a lot with emergency medicine, so you’re only missing a certain percentage as far as I’m concerned. And I think you can learn that percentage if you’re assertive and motivated. Again, moonlight in a midlevel position somewhere or consider doing a yearlong fellowship in emergency medicine. You’d have to be highly motivated, but you definitely have options.

What do you enjoy most about practicing emergency medicine?

There are a lot of perks. For one, it’s shift work–on/off. I don’t carry a beeper. I don’t work all day and then take calls. I don’t have to work on a productivity basis like some of my friends do–I just get paid by the hour, which I like. I earn a lot more than my family practice colleagues. Here in Escanaba, we’re the only hospital for a 60-mile radius. Often I’m the only physician in the hospital. It was scary when I first started doing it–you never know what’s going to walk through the door–but whatever does, you get a chance to take care of it. I think a lot of my hands-on and procedural skills are better because of that.

What typically walks through the door of a small rural ED?

Sick elderly people–pneumonia, sepsis, or people who can’t live at home anymore for no specific reason other than they’re frail and old. Lots of pediatrics. Plus you’ve got the sick community kids with chronic conditions whom you get to know really well. We’ve got to take care of them too. Lots of trauma. Let’s say you get a snowy day, which we have a lot of up here. This year, four patients in one day came in who stuck a hand down their snowblower chute. Lots of motor vehicle trauma as we sit along the US-2 [highway] corridor. Table saw accidents too–nobody up here has a safety guard on their table saw, but everybody has a table saw. We provide a lot of non-emergent care as well. It’s not trauma after trauma. People often get upset with all the non-emergent care we provide. I tell them, don’t think of it as an “emergency department” all the time. It’s the only place in town you can see a doctor 24 hours a day and get your concerns addressed with no concern to us whether you can pay or not. I think that’s pretty worthwhile.