WASECA -- It's easy to mistake Rhonda Wallace, in her white coat and stethoscope, for a doctor.

Many patients do, the first time they see her in the emergency room at Waseca Medical Center.

She's the one who patches their wounds, reads their X-rays and diagnoses their pneumonia. But she's always careful to correct any misconceptions.

The fact is, there are no doctors at Waseca's emergency room, at least most of the time.

Two years ago, the hospital gave up trying to find physicians for its small ER in southern Minnesota. Instead, it hired what it calls "midlevels" -- nurse practitioners and physician assistants such as Wallace -- to staff it around the clock.

"For the most part, we're it," said Wallace, a former nurse. Whether it's a cut finger or a heart attack, she said, "We do what we're required to do."

In Waseca and elsewhere, a chronic shortage of doctors is forcing rural hospitals to "be creative," as one expert put it, to keep their emergency rooms alive. In this case, the answer was to hire other medical professionals and put them on the front lines.

By law, physician assistants and nurse practitioners are allowed to do much of what doctors do -- diagnose and treat patients -- as long as they have a doctor's supervision. In Waseca, local doctors serve as backup, mostly by phone, said Michael Milbrath, the hospital's executive vice president. But they can be there in minutes if needed.

Hospital officials admit they were nervous when they made the switch in 2006. "We had no idea what the community was going to think about it," said Dr. Edward Wolske, a family doctor and medical director of the emergency room.

But since then, the emergency room has been busier than ever and patient satisfaction rates have soared, Milbrath said. Last summer, Waseca's patients gave the emergency room and its caregivers some of the highest ratings (99th percentile) among 1,500 hospitals surveyed by a national company, Press Ganey.

All at roughly half the cost of staffing the emergency room with doctors, according to hospital projections.

"I think we're on the front edge of this," said Milbrath. "I see this as one way that small rural communities can fill a medical need."

Doctors burning out

In some parts of the country, physician assistants (PAs) have long been a mainstay of rural medicine. But their numbers and influence are spreading.

In 2007, one in seven rural hospitals had only PAs or nurse practitioners staffing their emergency rooms, according to a national survey by the University of Minnesota's Rural Health Research Center. "These rural hospitals have to do this," said Ira Moscovice, director of the research center. "They have to be creative in using a variety of different approaches."

For many years, Waseca was like most rural communities, relying on local doctors to handle emergencies. But by the 1990s, that was taking a heavy personal toll, said Milbrath. Doctors were burning out seeing patients all day and covering emergencies nights and weekends. That, in turn, made it harder to recruit doctors to town.

Then Waseca got a break. In 1995, the University of Minnesota started sending newly minted doctors to the hospital as part of a residency training program in rural family practice. Suddenly, the staffing problem was solved: The young residents would run the emergency room, under the supervision of local doctors.

"It worked very well for us," said Milbrath. Until the program was moved to Mankato in 2006.

Then the hospital faced a dilemma: Go back to the way it was, or try something new.

Earaches and gunshot wounds

Mark Ross readily admits that he doesn't have the same training as a doctor. A former paramedic, he went back to school for 27 months to become a physician assistant. But, he says, "our job here is no different than any other ER."

He examines patients, orders tests, prescribes drugs and much more. If someone comes in with a heart attack or stroke, or something equally life-threatening, he calls for backup and starts treatment. The goal, in those cases, is quite clear: to stabilize the patients and transfer them out to the nearest trauma center, usually in Mankato, as fast as possible.

But most cases fall well below that threshold.

"It's not like TV, where everyone comes in here critical," Ross said. "You see the earaches and coughs and sneezes more than you see the gunshot wound to the chest."

At the same time, Ross and Wallace have plenty of help when they need it. With digital scanners, they can send a CT scan to a heart specialist in another hospital for a second opinion.

Skeptics, though, say there's a danger in replacing doctors with "midlevel" practitioners in a setting like this.

"There may be something going on here that may be a little more than meets the eye," said Dr. Robert Solomon, an emergency room physician in Ohio and spokesman for the American College of Emergency Physicians.

Without proper training, he said, it's easy to mistake something serious -- like a blood clot -- for something harmless. "The bottom line is, if you're the patient in the emergency department, you want the person that you see to have the education, the training, the expertise to manage critical problems, and also to figure out whether the symptoms that you have are anything really bad."

On that point, no one disagrees.

"We don't provide the same level of care," said Peter Lindbloom, a physician assistant who heads the emergency room at the Mille Lacs Health System.

Still, he said, "even a board-certified emergency physician can miss things."

The reality is, there simply aren't enough emergency-room doctors to go around, Lindbloom said. That's one reason that his emergency room switched to physician assistants five years ago. "The key is to know our limitations," he said, "and when we need to call in the doctors."

Moscovice, of the university's health research center, agrees. "Yes, in an ideal world, we'd love to have a well trained specialist in every situation," he said. "In this case, I think it's a good trade-off."

Maura Lerner • 612-673-7384