Rural Hospitalists Face Myriad Challenges, Rewards

Michael McMahon, MD, one of two hospitalists at Carilion Giles Community Hospital (CGCH), a 25-bed critical-access hospital in Pearisburg, Va., started practicing HM two years ago after spending three decades as a family physician in the town of 2,761. Although he feels a strong connection with his close-knit community, Dr. McMahon faces the overriding challenge many rural hospitalists encounter daily: lack of immediate, on-site access to essential medical specialty resources.

“In a setting like this, it’s just me and the emergency department doctor. There are no specialists,” Dr. McMahon says. “Our nearest general surgeon is responsive but lives 30 miles away. So I have to wear a lot of hats.”

The biggest question Dr. McMahon deals with regularly is whether patients can be taken care of in-house or need to be transferred to a larger hospital, such as Carilion Roanoke Memorial Hospital, a 700-bed CGCH affiliate that is 60 miles away.

“Some decisions are obvious, and others are gray areas,” he explains. “We don’t do dialysis here. If it’s serious trauma, they go. If it’s a [myocardial infarction] needing acute cardiac intervention, they go.”

But some patients don’t want to go and would rather rely on what Dr. McMahon can achieve with his practice-honed diagnostic skills. He also uses relationships developed over the years with cardiologists, nephrologists, neurologists, and others in Roanoke—about 60 miles away—for telephone consultations on tough cases.

“This job requires much more clinical judgment than you would need in other settings where you can lean on other people or on the medical technology,” Dr. McMahon explains. “I have a good feel for where my own line is and for what this facility can handle.”

Dr. McMahon is part of a growing rural HM movement. According to a recent survey by the American Hospital Association, the number of rural hospitals with HM coverage is growing. One in 6 hospitals with fewer than 25 beds had HM programs in 2009, double the penetration of six years before. For hospitals with 25 to 49 beds, nearly 1 in 3 had a hospitalist presence in 2009—twice the number as in 2003.

Every hospital medicine program has its own identity and culture, but rural programs definitely have a culture of greater independence and autonomy. It’s a different breed of physician—a different culture and different standards of what hospitalists do and don’t do.

—Brian Bossard, MD, FACP, FHM, director, Inpatient Physician Associates, Lincoln, Neb.

In addition to the lack of specialist backup, recruiting doctors to fill hospitalist positions in rural settings can be a major challenge. Other issues include staffing and scheduling, providing on-call and off-hours backup, and the economic stressors on small hospitals that constrain their ability to offer competitive compensation.

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