Season 3 Episode 8: Filling the Gap: Rural Medicine & the Relias Fellowship with Dr. Rick Carlton

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Rick Carlton’s the kind of physician whose career is difficult to capture in a few paragraphs, not simply because of all he’s accomplished, but because of the impact he’s made along the way. An academic and clinical career in emergency medicine for more than four decades, Dr. Carlton has spent much of his career championing rural medicine and creating pathways for physicians to learn, train, and ultimately serve in communities.

Where access to emergency medicine education has historically been limited. Long before rural medicine became a national conversation, he recognized the need and began doing the work to fill it. He served in numerous leadership roles throughout Mississippi and beyond, including helping establish and lead rural emergency medicine training programs and advocating nationally for the unique

needs of rural emergency departments and the physicians who serve them. We’re incredibly fortunate to have Dr. Carlton serve as emergency medicine fellowship director with Relias, where our fellows benefit not only from his extraordinary depth of knowledge, but from the f wisdom of someone who has spent a career investing in the future of emergency medicine. Dr. Carlton is a pioneer, an educator, a clinician, and a tireless advocate for rural health care.

But perhaps most importantly, he’s someone who saw a need and has spent his life working to meet it. We’re grateful he continues to share that experience with the next generation of physicians. And even more grateful to have him with us today on his what I cannot believe is his first podcast. And Dr. Carlton’s somebody who I’ve always looked up to as a clinician.

not only as an educator and and all of those other accolades and certainly glad to work alongside you now as a colleague and as I say happy to have you on the podcast today. Dr. Carlton, thanks for being with us. Well Joe, thanks for that introduction. I honestly had to kind of glance around the room to make sure you weren’t talking about somebody else, but there was nobody else in on the podcast. But awfully kind. I appreciate that.

Yeah, Dr. Carlton, I’ll I’ll echo what Dr. Johnzi said in the few times that I’ve gotten to interact with you. It is very evident your advocacy and your heart for education and rural medicine. So I really would love to just start kind of at the beginning, when you think back on your career and not just as a clinician leader, but also as a human being, what is your story? What has kind of brought you to where you are now? Which I know is a pretty loaded question. So answer how you’d like.

boy. You know, that’s that’s a issue that could take up way more time than this podcast allows. But I will maybe start sort of in the middle. and and maybe that’ll help help people understand. When I was a child, my family who all were from northern Mississippi moved back there from Memphis. And so I kind of grew up in a rural area. the county I was in had no hospital.

And so you kind of knew that, you know, if anything were to happen, you had to go to Memphis for significant care. Intermittently, they’ve had a hospital, but that illustrates the struggle that you have in the rural community with the not just the existence of a hospital, but proper staffing, proper equipment, proper capabilities. But honestly, as a child, you didn’t give much thought to that. but after getting through college and then medical school, and then really once I was on the faculty.

at the university in emergency medicine, which started in nineteen eighty-five, began to see, you know, the capabilities that we had there. And as we took transfers from around the state, particularly the central portion of the state, but it’s true all over, you saw the gap in sometimes it was knowledge, sometimes

The physician knew what needed to be done. They didn’t have the capability to get it done where they were. They didn’t have the equipment. They didn’t have the additional expertise required. So you began to see this disparity that over time has just gotten more and more significant. people, when they finish their training in in medicine, and that means completing residencies, perhaps completing fellowships.

tend to gravitate towards the more populous areas. And that’s true not only in Mississippi, but all over the country. And so it caused an even greater widening of the gaps that existed when I was a child. And I guess when I was, it was right after I took over the the program at the university, and this would have been in ninety one.

So the dean of the school at the time asked me to put together a program looking at agricultural health issues in Mississippi. And he did that because of my toxicology background, which we didn’t talk about and don’t need to. But there was concern, particularly from the Mississippi Delta, about pesticide use and herbicides and and a variety of chemicals and the safety of not just the human population, but animals included, but particularly humans, and that was my angle.

Joe, you’ll probably appreciate this. I asked him for about a month to study the issue. And then I went back and told him, yes, I would do it, but I could only do it in collaboration with the land grant universities in the state, which meant Mississippi State University and Alcorn. he was less than thrilled, but when I made my case, he agreed with me and and we started working on that. And we just called it the Mississippi Agri-Micine Program.

and I worked on that until I left the university in Jackson, and then handed it off. And frankly, I think state kind of picked up the ball and has managed it more since that time, fortunately. But you know, you realize at least that taught me the interplay that goes on, especially in the rural communities, between physicians and now, of course, at that time we didn’t have PAs or nurse practitioners, but any kind of a provider. And

extension services and a variety of others that played a role. People in in the city don’t think about extension, but they’re you know, i the whole process was very eye opening. I I knew about some of the gaps in healthcare, but going to farms, watching how they did things, listening to farmers and people involved in production talk about what their issues were and everything was very eye opening. And

you know, just further strengthen my interest in and concern for and try to come up help come up with ways to improve, which is actually what the dean was asking me to do in the first place, to improve health care for the people in rural areas. Now what I c ultimately came up with, I don’t know that he necessarily would have signed off on, but because he his primary interest obviously was

with the university as it should have been. you know, doing everything he could to develop the university. And, you know, that’s that’s an integral part of what needs to be there. But there’s also a large component outside the Metro Jackson area that needs some attention as well. And so that’s where I decided I had to make my focus. Kind of a long-winded answer to a relatively simple question, but that’s kind of

how I ended up, I guess where I am. I I think you know, I’m hearing from that, obviously your background where you where you came from, the state that we’re we’re from drives that that that rural aspect of your career and your focus that you’ve been in. I’m interested to know I think it’s always interesting to to understand how we get into the specialty that we’re in.

What what drove you into emergency medicine of all the the specialties? How did you wind up there? I know for for me, going through selecting things, I I I I was a tech in the ED and the nurses I was working with when I was in college, I was a tech in the ED and the nurses all said, you know, you’re gonna come back and work in the emergency department here and it it was a

Corinth, and I told those nurses, I said, there’s two things that I know for sure. I don’t know what I’m gonna do as a doctor when I when I get out of medical school, but there’s two things I know for sure. One is I’m not gonna be an emergency medicine physician, and two, I’m never gonna work here. And of course, my first job was as an emergency medicine physician at that that hospital. So I I I was not good at predicting what medicine would lead me into, but I’m interested to know.

How did you get led into emergency medicine? Great question. And and what you said illustrates one of Rick’s dictums. Never say never and never say always. Because you just never know what’s gonna happen. Actually, in medical school, I like every single rotation I rotated through, but I also get bored easily. And I I was concerned that I would.

I just need more to challenge me than just a single specialty or subspecialty. And the thing that I really like about emergency medicine is I have no idea what I’m gonna see next. I have no idea, even if it’s I know the complaint, I have no idea of what it still might be. Yeah, I mean, you know, a classic example, you know, is chest pain. It could be cardiac, it could be lung, it could be chest wall, it could be GI. You know, and so you have to be able to think in all of those

capacities, whereas if you train in GI, you’re only thinking GI. And that’s a bit of an exaggeration, but you know, we are trained to think more broadly. And what I tell our family medicine colleagues is we are truly the only two generalist specialties. We treat people from all ages of life with all types of problems. And that’s what appeals to me most especially about emergency medicine. The acuity side of things is fun.

But sometimes the less acute stuff is is just as interesting and rewarding when you come up with a solution for a patient. So it’s it like I said, it’s it it’s partly the interest and in everything, and yet the knowing that I I would be eventually I would get bored silly if I were just practicing in one narrow little field.

Yeah, Dr. Carlton, you talk about loving the challenge of emergency medicine. And certainly we can can see probably, I imagine, how that’s evolved over time in your career. and you spend a lot of time with with new, relatively new clinicians and training. I’m curious from your perspective, what do you think is the biggest challenge that clinicians face today? boy, there there are several, and and you know, let’s break that into two.

Two components because the new physicians are trying to learn to think like an emergency physician. Because for the most part, medical school is not taught the way we have to think. And once you’re out of training, there are different issues that you face. I spent some time with the fellows this week talking about system one and system two thinking. System one is more gestalt, where and and you’re not always right with your gestalt.

with your just gut feeling about what’s going on with the patient. but most of the time you are. And some people are better at that than than others. I’ve been fairly fortunate, but some some people it’s just almost an inherent skill they have, but you have to understand it’s not a hundred percent. Some people can’t live without uncertainty and they lean more towards system two type of thinking where they have to have all the facts before they make a decision.

And I, you know, we can give examples of of specialties and subspecialties like that. Probably infectious disease would be one of the better ones where they want every single test that you can possibly get before they give a final recommendation. They may give you some preliminary, but very system two sort of thought processes. And we don’t, you know, all we typically go in a patient’s room, we have incomplete data, and we don’t have the ability to get a complete set of data to make

the decision, sometimes it needs to be made. We love it when we can and we do we do the best that we can and we’ve got some pretty good guidelines now that kind of help with with much of what we do. but I think that’s one of the biggest challenges for people when they first finish medical school and and start a residency or fellowship is just learning how to think like an emergency physician because it’s different for an emergency physician, as I said.

than it is, say, for an internist or a pathologist or these other disciplines. I think for people that are out in practice, dealing with the medical bureaucracy these days is quite a challenge. You know, fortunately, you know, I I sympathize with my colleagues who are every day lamenting the difficulty they have getting prior authorizations done, how much time that takes, how unnecessary much of it is.

but dealing with insurance companies and that sort of thing. You know, one of the nice things about what we do is we don’t have to, you know, it we are required by law to see the patient and and evaluate them and stabilize them if need be. And we don’t give a thought to what their insurance status might be. And it makes we don’t even know. We’re blinded and we do what we know we need to do for that patient regardless. And insurance companies don’t get in the way. So there’s that.

You know, and then you have the just the bureaucracy inherent in any hospital system. and it you know, it can start with the electronic medical record, which by and large I think is a good thing. I think it got rolled out too early before enough quality control and integration had been done. But I think largely it’s a good thing, and eventually I think it will get there. but it is it’s it’s better. It’s just not there yet.

But I think EMR and the bureaucracy for the people out in practice are the two biggest challenges. Yeah, I was I was just listening to a business podcast on the epic story. and it went through a lot of that the design, a lot of the design of the EMR as we know it today is meaningful use that’s designed by by Congress really, so that it it it makes.

the the EMR can prove that the EMR the hospital is doing what it’s supposed to do to get the payment or not get the penalty that it so that it r when it received the money that it did to pay for the EMR, it doesn’t have to, you know, give that money back to to Congress. So, you know, everything Congress does works very smoothly and doesn’t have any unnecessary steps in it. We all know that.

But that was that was sort of their their point there, that this was not something that was designed by a nerd, so to speak, that it reduces unnecessary burden or or or makes, you know, friction in the process. It’s it’s designed by bureaucrats that don’t think that way, that actually think opposite typically in what they do. And so that is a lot of kind of that that challenge that

molasses feeling that we have there when we’re trying to do something very smoothly, but we have 56 clicks to deal with a patient, or some some it was some number like that that they were talking about that the EMR puts in there. It’s very interesting tracing it back to when those got ubiquitously put into our environment. But I, you know, I think that there is a little bit as you start to see the cosmos

databases that are coming out where you’re starting to finally find, okay, there’s something positive here. We’re in where you’ve got a mu you know, this broad perspective here of where we’ve been and where we’re going. You you you’ve seen a lot. What what gives you hope? What gives you energy? What’s the what’s the light at the end of the tunnel that you’re seeing for medicine that keeps you?

in here that keeps you both working, both training, both telling people. I I’m I’m always I I I I want to shake our colleagues when they when they tell people, hey, don’t come into this career. It’s terrible. It’s awful. You know, it’s the golden age was 20 years ago, you know, go go into investment banking. You’re not that guy. You’re you’re the guy who’s who’s who’s encouraged. What is the thing that

you tell these people that encourages them, that gives you hope to give them hope. Sure. several thoughts on what you just said and asked. one is I want to go back first to what you were talking about, some of the, you know, we complained about the EMR. there was the the first chair of ophthalmology at University Medical Center in Jackson was a grand old man named Sam Johnson. And Sam and I got to be friends and I was talking with him one day and he told me

And this was before the EMR, he said medicine started changing with World War Two. And you know, I think, okay, here comes how war has influenced trauma care again type of story. But what he said was so many physicians got pressed into service during World War Two that the ones that were left behind could no longer take care of p the patient responsibilities that they had and run the hospitals, which is the way it had largely been done before that time.

And he said that’s when the business world began to move into hospitals and and medical care in general. And he was lamenting this, and this would have been early 90s, so 30 years, three five years ago or something. But he he was he had that perspective that I don’t we’ve seen it evolve some, but that’s where he placed the

root of the the lot a lot of the problem that we’re dealing with. I think one thing is has, you know, and and we have to have business involved in what we do. There’s no way around it. Medicine has gotten far too complicated. We can’t go out and buy every single piece of equipment and hire every specialist and subspecialist that we would like and every single hospital in the in the country. So business has to play a role. but I I think they

shoulder too much of the load at this point. But I think there’s beginning to be enough recognition that we need to moderate a little bit. You know, so much in life is is a pendulum swinging back and forth. And I think the pendulum regarding the business model has swung about as far as it can go. And I’m thinking, based on discussions I’ve heard more at the national level, that it’s gonna that it’s starting to move back towards the middle, which is, you know, like

Socrates and Confucius said that the the virtue of the mean, you know, getting back to the middle, I think would be would be ideal. I think it won’t happen in my lifetime, but it would be nice if it did. You know, some people are just chronically upbeat. Some people are chronically almost depressed. I’m one of those people that am more upbeat by far. I I love what I do.

I’d tell people I couldn’t imagine doing anything else. I’ve had to do it all over again. I’d do it exactly. I might make some little minor changes, but I would do exactly the same thing I’m doing right now. Might have gotten to some things a little bit faster because hindsight’s 2020. But I I would do the exact same thing. I I still think medicine’s a great career. It you know, it’s a long road and and yet it’s it’s so incredibly rewarding. And I get as much satisfaction

out of taking somebody straight out of medical school or now where I am, straight out of a residency and watching them mature in in in emergency medicine through the course of the fellowship. I’ll tell you, I had a grand experience last night, and I told her so. Dr. Mashiana, who I understand was interviewed on the last podcast, I signed out to it shift change last night. And the first patient that we did together was a

a case that I was seeing with one of our new fellows. And I had to tell her, I said, You don’t know how happy this makes me to see this. But I I really mean that. And it, you know, i if that’s your perspective, I mean, I I can walk out today. I don’t have to work. You know, it’s just I enjoy it. And when it quits being fun, I I will quit. But so far it hadn’t quit being fun.

I love that. you know, I think Dr. Carlton about how many people you have influenced in your career. And, you know, even just speaking to Dr. Machiana last week and in conversations with several of our fellows, I know that that’s just the the tipping point of how many people you’ve influenced. I know we’ve got emergency physicians on staff at r relius hospitals all over that were mentored and led by you, which I think is really incredibly

remarkable for you and it speaks to your career. I’m curious because I imagine that there’s a lot of people we could ask this question and they probably would answer you. But I want to know your answer. to who do you think has kind of influenced you the most in your career, whether that’s personal or professional. is there has there been a person that’s kind of given you that guiding light? great question. Not a single person, but I will mention at least three.

that come to immediate mind. The the guy who moved to Jackson to start the emergency medicine residency, I helped him write the application. He wrote the vast majority, but he was an incredible mentor to me, Dr. Bob Jordan. He’s retired now, living in Rockport, Maine, but just an awesome teacher and and clinician. And

Yeah, you know, I I I can’t say enough good things about him. I still talk with him several times a year. S in fact, we were texting last week. But just a great guy. And he’s the one he’s the one that not only got me on track as a as an educator as far as lecturing and and and just all aspects of teaching, both in the classroom and in the department, but also getting involved in professional organizations to try to advance the cause.

He was passionate about that and and did a did a great job and and was a a great motivator along those lines. The other was a guy that when I joined the faculty at university was family medicine trained. and it was a guy named Dr. Dr. Mike Foos, he’s from Yazoo City, and he he had been a farmer and like large farm and decided he wanted to go to medical school. And he did. That man

was the calmest individual I’ve ever met. And, you know, I I realized as I watched him what an incredible skill that is for an emergency physician. You know, he nothing rattled this man. And it didn’t matter how in your face or obnoxious some patient or family member was being he could he could just stand there and and deal with it. And I thought,

I want to be like him. So I I I’ve I I haven’t gotten to where he is yet. And I probably never will. But he has done a gr did a great job in helping me see how you really need to conduct yourself professionally. and then you know, I I’ll have to mention my wife, even though you don’t think about that in a professional way, she’s had a major influence on me professionally, because there’s no way I could have done what I do without her in the background.

Helping or taking care of the kids sometimes when I’m off at meetings or doing this or that. and of course, if I y’all haven’t had that much contact with her, but she is who I bounce ideas off of. Sometimes she’ll go, I wouldn’t do that. I wouldn’t say that. And it’s kind of the same thing, like when I’m getting ready to walk out the door and she goes, You’re gonna wear that. And I I know, okay, I gotta go back and change clothes. so you know, for because she didn’t want me looking badly in front of a

audience or something. So you know, I would say probably those three have been the big biggest influence professionally and to some extent personally, especially my wife, but secondly I would say probably Mike Fus and just the way he teaches I just try to mirror him in calmness, which may be hard to believe when you hear how I talk. This has been a wonderful conversation. one more question just to to kind of sum things up here. Dr. Carlton, you’ve already

surprised me with that one fact about this being your first podcast along the way. But what is is something people would be surprised to know about you? We we try to get this, you know, humanity side of things here in the question. So, you know, we’ve we’ve had people tell us about they they love the smell of their cut lawn so they they go out and do that or that give us their their

Chocolate chip cookie recipe or something like that. So, so what’s what’s something that would surprise folks about Rick Carleton? All right. If you’re ready for the shocker, I’ve pretty much been a musician all my life. My oldest son was a professional musician for like 12 years. Well, in medical school, it was tempting to say, hey, let’s just go to Nashville and and get out of this mess. but I I play multiple instruments, piano, guitar, my best.

instrument is a five string banjo, both three finger style and claw hammer, the older style, which relates to roots music, both country and blues, and kinda both. That’s awesome. It sounds like we need to have a fellowship party and have the main event, the entertainment. we might get up for it. That’s awesome. well Dr. Carl, it has been so wonderful having you today. I know I speak for

Oliver Lyas, when I say we are just so appreciative of your knowledge, your wisdom, ultimately your care and advocacy for rural emergency medicine and the fellowship program. you make us better. And we’re really just appreciative of you as a clinician and ultimately as the musician that you are. And certainly have a lot to thank for your wife for always bouncing ideas off of and being an influence for you as well.

Well, thanks. And I I can’t tell you how thankful I am to be involved in this fellowship. And and and one final thing sort of related to that that we didn’t really touch on, you know, we are still doing a poor job, even though we were training more emergency medicine physicians than ever in residency. They are largely not going to the to the rural areas and to most areas in the state of Mississippi. And so I think the fellowship that we have with Relias.

is a great way, not only for Mississippi, but for other states to fill that gap. and because it may eventually happen, but I doubt it. And if it does, it will never be of the magnitude that we need. And so I think I think this fellowship plays a critical role. I’d love to see it expanded and love to see it developed in other other communities. Thank you for being a big, big important piece of that. and and thank you for spending your morning with us.

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