Three years out of fellowship, I (Amber Charoen, MD) found myself trading a tertiary-care academic campus for a small critical access hospital in the wheat and fields of Eastern Washington. What felt at first like a professional detour has become a front-row seat to one of the most pressing challenges in American gastroenterology: delivering subspecialty care in rural “medical deserts.”
Critical access hospitals (CAHs) are often the only inpatient and emergency resource for communities separated by 35 miles or more from the next hospital, frequently across mountainous terrain or secondary roads. These facilities keep essential services alive in towns too small to support full acute-care systems — but they rarely host advanced physiologic testing.
The rural GI gap
Recent data underscore just how wide the rural GI gap has become: approximately 69.3% of U.S. counties — 2,183 out of 3,149 — have no gastroenterologist at all, leaving nearly 49.4 million people without local specialty access. Roughly 80% of these GI-empty counties are nonmetropolitan, with older populations that are at higher risk for digestive disease.
In our stretch of Eastern Washington and Eastern Oregon, patients routinely traveled three to five hours for esophageal manometry, anorectal testing, or ambulatory reflux monitoring — if they went at all. For a farmer in harvest season or an older adult on a fixed income, a “routine” academic referral can be prohibitive in both time and cost. In this context, our CAH was not just a hospital; it was the only realistic point of entry to the GI system for many patients.
From academic fellowship to critical access practice
During fellowship at a tertiary academic center, high-resolution esophageal manometry, anorectal manometry, pH impedance and wireless capsule reflux testing were embedded into daily practice. Access, interdisciplinary collaboration and subspecialty backup were assumed.
Arriving at a CAH in rural Eastern Washington, I quickly realized how rare those assumptions are outside metropolitan areas. Our hospital — small, Medicare/Medicaid-heavy, and surrounded by agricultural communities — had developed robust endoscopy but no motility lab. Patients with refractory gastroesophageal reflux disease (GERD) were escalated empirically, motility disorders were suspected but seldom confirmed, and pelvic floor dysfunction was under-recognized and undertreated.
A rural partnership: mentorship meets mission
I was able to collaborate with a mentor with significant motility experience: institutional memory and systems savvy, paired with the energy and procedural training of a recent graduate.
Together we asked: if large urban centers can run comprehensive motility labs, why can’t a critical access hospital — especially when it may be the only hospital for tens of miles in any direction?
Building a motility center in a CAH
We set out to build a full-spectrum motility center inside a CAH, not a scaled-down “lite” version of an academic lab. Our diagnostic suite now includes:
High-resolution esophageal manometry with 36-sensor solid-state catheters for achalasia and spastic disorders.
Anorectal manometry to evaluate pelvic floor dyssynergia and fecal incontinence, crucial for women’s health in a region without nearby pelvic floor centers.
24-hour pH impedance monitoring for patients with persistent symptoms despite proton pump inhibitor therapy.
Bravo wireless pH monitoring as a catheter-free option that aligns well with the outpatient, community-based realities of rural care.
This made our CAH the first facility in our multi-county region to offer all four modalities locally.
Training from zero in a rural environment
In a rural CAH, you do not recruit experienced motility nurses; you grow them. We selected motivated local nurses and built training from the ground up — catheter calibration, Chicago Classification workflows, artifact troubleshooting and patient coaching.
We implemented standardized checklists, simulation-based dry runs and recurring quality review sessions. Watching nurses who had never seen a manometry catheter become confident motility technologists reinforced an important lesson: specialized diagnostics are teachable, even in resource-constrained settings, when there is a clear plan and committed mentorship.
Integrating within the rural care ecosystem
A motility lab in a CAH must function as a regional hub, not an isolated service line. We built tight connections with:
Local general and colorectal surgeons for preoperative reflux and defecatory disorder evaluation.
Pelvic floor physical therapists for biofeedback based on objective anorectal manometry data.
Primary care clinicians and regional gastroenterologists who previously referred exclusively to distant academic centers.
For patients with refractory GERD, pre-fundoplication workups now occur close to home. For women with chronic constipation or incontinence, anorectal physiology testing and subsequent therapy no longer require a 200-mile round trip. In a region with high rates of diabetes and obesity, we are now systematically diagnosing conditions like gastroparesis and pelvic floor dyssynergia that were previously under-evaluated.
The realities of a CAH-based motility program
Launching and sustaining a motility center in a CAH is distinct from doing so in a high-volume urban hospital. It requires:
Volume modeling for a low-density, geographically dispersed population.
Scheduling strategies that maximize use of limited equipment.
Financial planning tuned to cost-based Medicare reimbursement and payer mixes typical of rural hospitals.
Ongoing education campaigns for clinicians who may have had minimal exposure to motility indications in training.
Community trust-building in towns where the local CAH often serves as the only accessible point of care.
The payoff is tangible. One local farmer, who had lost 30 pounds due to progressive dysphagia, was diagnosed with Type II achalasia through our CAH-based motility lab and underwent timely intervention. Instead of a months-long delay waiting for an urban referral, he was back to work within weeks.
Implications for GI societies and rural policy
The current distribution of gastroenterologists — leaving about 69% of U.S. counties without a single GI specialist — means that rural and CAH-based models must be part of any serious strategy to address access and equity in digestive health. GI societies are uniquely positioned to:
Develop practical toolkits for establishing motility services in CAHs and other rural hospitals.
Promote shared or remote interpretation models to support low-volume centers.
Encourage industry partners to design cost-conscious platforms and service contracts tailored to rural settings.
Facilitate mentorship pairings between academic motility experts and early-career rural gastroenterologists.
Our experience shows that when physician leadership, senior mentorship, administrative partnership and regional collaboration align, a critical access hospital can host an academically rigorous motility program.
A rural model worth replicating
Innovation in GI does not belong exclusively to large academic centers or metropolitan markets. It can, and should, emerge from critical access hospitals, farming communities and small towns where the need is greatest and alternatives are few.
If a CAH in rural Eastern Washington can establish high-resolution esophageal manometry, anorectal manometry, pH impedance testing and Bravo monitoring, other rural hospitals can too. As we refine our protocols, training materials, workflows and business models, our hope is to share them widely with colleagues who practice far from city centers but close to the heart of the rural access crisis.
Rural America deserves subspecialty-level digestive care — and critical access hospitals may be the most powerful, yet underutilized, platform to deliver it.
Amber Charoen, MD, is a gastroenterologist at Prosser Memorial Hospital in Prosser, Wash., and a clinical assistant professor at Washington State University's Elson S. Floyd College of Medicine in Spokane.
W. Michael McDonnell, MD, AGAF, is a gastroenterologist at Prosser Memorial Hospital and a clinical professor of medicine at the University of Washington School of Medicine in Seattle.
References
Centers for Medicare & Medicaid Services. Critical Access Hospitals. Available at: https://www.cms.gov/medicare/health-safety-standards/certification-compliance/critical-access-hospitals. Accessed February 25, 2026.
Rural Health Information Hub. Critical Access Hospitals (CAHs). Available at: https://www.ruralhealthinfo.org/topics/critical-access-hospitals. Accessed February 25, 2026.
Azalea Health. What Is a Critical Access Hospital and Why They Matter. Published January 29, 2026. Available at: https://www.azaleahealth.com/blog/what-is-a-critical-access-hospital/. Accessed February 25, 2026.
Shah ND, et al. More Than Two-Thirds of US Counties Do Not Have a Gastroenterologist. Gastroenterology Advisor. Published February 23, 2025. Available at: https://www.gastroenterologyadvisor.com/news/more-than-two-thirds-of-us-counties-do-not-have-a-gastroenterologist/. Accessed February 25, 2026.
Gastrobroadcast. Almost 50 Million Americans Live in Counties Without a Local Gastroenterologist. Published February 11, 2025. Available at: https://gastrobroadcast.com/2025/02/12/50-million-americans-live-in-counties-without-gastroenterologists/. Accessed February 25, 2026.
Thomson K. Study: Nearly 7 in 10 U.S. Counties Have No Gastroenterologists. The Washington Post. Published February 17, 2025. Available at: https://www.washingtonpost.com/wellness/2025/02/17/gastroenterologist-rural-counties-digestion/. Accessed February 25, 2026.