When a critical access hospital in northeast Iowa loses its only emergency physician on a Friday night, the math gets simple in a hurry. Either someone covers the shift, or the nearest functioning emergency department is forty-five minutes down a two-lane highway.
That math has become the operating logic of rural American healthcare. Between 2005 and May 2025, nearly 200 rural hospitals either closed outright or stopped providing inpatient care, and roughly one in three of the country’s remaining rural facilities is now classified as financially vulnerable to closure, according to the Chartis Center for Rural Health. For the physicians who keep these emergency departments open, the work has shifted from steady employment at one hospital to a kind of rotating coverage model that almost no medical school curriculum prepared anyone to deliver.
Dr. Danny Lewis, a board-certified family medicine physician and locum tenens emergency physician based out of Waterloo, Iowa, has spent the better part of a decade inside that model. He is currently credentialed at seven facilities across Iowa and Minnesota, from Humboldt County Memorial Hospital and Crawford County Memorial in Denison to St. Joseph’s Health in Park Rapids and LifeCare Medical Center in Roseau. Most of these are critical access hospitals, the federal designation for small rural facilities of 25 beds or fewer that serve as the entire emergency, inpatient, and often primary care infrastructure for their communities.
“Critical access doesn’t mean low acuity,” Lewis said. “It means the next nearest ER is an hour away.”
The closures that don’t make headlines
The headline statistic on rural hospital closures, repeated in policy briefings and congressional hearings, is that 182 rural hospitals have closed or converted to outpatient-only models since 2010. The number that gets less attention is what happens at the facilities still standing.
Forty-six percent of rural hospitals are operating on negative margins, according to Chartis. The Center for Healthcare Quality and Payment Reform classifies roughly 300 of them as being at immediate risk of closure. In ten states, more than half of all rural hospitals are at risk. For the facilities that survive, financial pressure translates directly into staffing pressure, which translates into the locum tenens phenomenon Lewis represents.
Lewis works through five staffing agencies simultaneously: Highland Medical Staffing, Wapiti Medical Staffing, Community Physicians Care, ApolloMD, and KPG Healthcare. The schedule is built shift by shift, hospital by hospital. In a given month, he may run codes at one facility, manage a hospitalist census at another, and cover an ICU at a third.
“You learn the EMR systems the way other people learn airports,” he said.
Why family medicine training matters in the ER
Lewis is part of a small but growing subset of rural emergency providers who came up through family medicine residency rather than emergency medicine. He completed residency at the Northeast Iowa Family Medicine Education Foundation in Waterloo, where he served as Academic Chief Resident and received the program’s Resident Teacher of the Year award in 2019. His training included more than 3,000 hours of inpatient experience, much of it on a service that managed an open ICU and an average daily census of 22.5 patients.
That background matters for a structural reason. The American Association of Medical Colleges projects a shortage of 48,000 family medicine physicians by 2034, and emergency medicine itself reached a 97.9 percent residency fill rate in 2025, leaving little slack in either pipeline. For critical access hospitals that need a single provider who can run a code, admit the patient afterward, and follow them through discharge, a dual-trained family physician is often the only realistic hire.
“In a critical access setting, the ER doctor and the hospitalist are frequently the same person on the same shift,” Lewis said. “You can’t hand the patient off. There’s no one to hand them off to.”
That continuity has clinical consequences that don’t show up in staffing models. The patient who presents to a rural ED with chest pain in the morning may be the same patient Lewis is rounding on in the inpatient unit by afternoon, and the same patient he is discharging with a follow-up plan three days later. Care fragmentation, the central complaint of urban emergency medicine, is structurally absent.
The procedural breadth the job actually requires
The procedural scope of rural emergency medicine is wider than most outside the specialty assume. On a given shift, Lewis may perform airway management ranging from BiPAP and CPAP to full intubation with initial ventilator settings, manage a code, run a primary wound repair, place a chest tube, conduct conscious sedation for an orthopedic reduction, perform a lumbar puncture, drain an abscess, or handle a gynecologic emergency, including IUD complications.
In an urban tertiary center, those procedures are distributed across emergency medicine, critical care, orthopedics, OB-GYN, and surgery. In a critical access hospital at two in the morning, they are distributed across one physician.
Research published in the American Heart Association’s Circulation journal in 2024 confirmed that rural hospital closures are directly associated with increased county-level mortality from ischemic heart disease. The clinical reality behind that finding is what Lewis describes in operational terms. For a STEMI patient in rural Iowa, the difference between a functioning emergency department twelve minutes away and the next closest facility seventy-two minutes away is often the difference between a survivable event and a fatal one.
“The procedures aren’t optional, and they aren’t transferable to the next shift,” Lewis said.
The teaching pipeline problem
Before Lewis transitioned fully into locum work, he served as Assistant Program Director at the Northeast Iowa Family Medicine Education Foundation and as Chief of Staff and Assistant Medical Director at MercyOne New Hampton. Teaching was a substantial part of the role, and the experience left him with a specific view on why the rural physician pipeline keeps narrowing.
The problem is not that medical students don’t know rural hospitals exist. The problem is that the experience they get during training rarely resembles the work itself. Most residency programs are based at academic medical centers, where the consult lists are long, and the procedural rooms are staffed around the clock. A resident who completes three years of training in that environment and then takes a job at a 17-bed critical access hospital is, functionally, learning a different specialty in their first six months on the job.
Research from the National Rural Health Association has documented that physicians who train in rural settings are significantly more likely to practice in them. The implication, Lewis argued, is that the staffing crisis is at least partly a curriculum problem, not just a payment problem.
What locum work actually solves, and what it doesn’t
The locum tenens model has expanded from a temporary staffing patch into something closer to permanent infrastructure. Eighty-five percent of hospitals now use locum tenens physicians annually, and in rural settings, the model is often the only mechanism keeping 24/7 emergency coverage in place. Lewis’s seven-hospital credentialing footprint is unusual but not exceptional. Physicians in his cohort routinely maintain active credentials at five or more facilities.
The model has limits. Locum coverage is expensive relative to permanent staffing, and for hospitals already operating on negative margins, the rates can deepen the financial pressure that created the staffing gap to begin with. It also doesn’t build the long-term physician-community relationships that drive preventive care, panel management, and the kind of slow trust that makes rural medicine work.
Lewis began managing his own outpatient panel at MercyOne New Hampton in 2020, specifically because he wanted that side of the practice back. He continued doing so until the position concluded in late 2024.
“The locum model keeps the lights on,” he said. “It doesn’t replace what’s lost when a hospital closes.”
The pattern the rural workforce is now adapting to
What the rural emergency landscape now resembles is a system being held in place by a relatively small number of physicians willing to operate across multiple facilities, multiple state lines, multiple EMR systems, and multiple credentialing processes. Lewis maintains permanent licenses in Iowa and Minnesota, current certifications in ACLS, ATLS, PALS, NRP, and BLS, and DEA registrations in both states. The administrative overhead of maintaining that footprint is significant. The clinical breadth required to use it is greater still.
The question the next decade of rural healthcare will answer is whether this model is a bridge to something more stable or the new equilibrium. The Rural Emergency Hospital designation, created under the Consolidated Appropriations Act of 2021 and effective since January 2023, has so far drawn 40 conversions, with another 77 facilities identified by Chartis as prime candidates. Each conversion preserves emergency capacity at the cost of inpatient care, which shifts the staffing model further toward the ED-centric, dual-trained provider profile that family physicians like Lewis already fit.
The implication is that the workforce now staffing rural emergency medicine, the physicians who learned to function across seven hospitals and four EMR systems out of necessity, may turn out to be the workforce the next generation of rural facilities are designed around. The closure crisis hasn’t been solved. The model of practice it produced has simply become the structure.
