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Rural Hospitalists Face Myriad Challenges, Rewards

From: The Hospitalist, July 2012

In addition to the lack of specialist backup, recruiting doctors to fill hospitalist positions in rural settings can be a major challenge.

by Larry Beresford

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.

But rural hospitalists also emphasize the lifestyle benefits of calling a rural community home, such as the absence of crime, a slower pace, easy access to outdoor recreation, and the satisfying personal relationships that can develop in smaller communities.

“I like rural hospital medicine,” says Larry Labul, DO, FACOI, SFHM, a hospitalist at Franklin Memorial Hospital in Farmington, Maine, population 7,760. “I like being a big fish in a small pond, doing my own procedures, managing patients in the ICU. If I sometimes don’t know how to manage a procedure, I have a choice: Learn how to do it or send the patients somewhere else.”

Hospitalists in rural areas often become integral parts of their communities, says John Nelson, MD, MHM, medical director of the hospitalist program at Overlake Hospital in Bellevue, Wash., a Seattle suburb.

“There’s a reasonable chance you know your patients socially,” says Dr. Nelson, co-founder and past president of SHM and practice-management columnist for The Hospitalist. “I’ve been in the same place for 11 years, and if I have any connection with my patient, it’s a strange coincidence.”

Too often for urban hospitalists, he says, the next patient is just the next patient, whereas in a rural community, the odds are better than even that the doctor at least knows someone in the patient’s family. “That gives you a whole different perspective on the work.”

The Challenge: Recruitment

Despite the virtues of small towns for those who can appreciate them, rural hospitals face an uphill battle in attracting the desired complement of hospitalists to staff their programs. HM’s explosive growth means the field generally has benefited from a seller’s market, and rural communities have struggled to fill both inpatient and outpatient positions.

“Recruiting is tough in rural areas, even as some metro areas are starting to fill up with hospitalists,” Dr. Nelson says. Michael Manning, MD, a hospitalist at Murphy Medical Center in Murphy, the westernmost town in North Carolina (population 1,568), says it’s especially hard if the nearest airport is hours away. “A small hospital’s efforts to advertise just gets lost unless the candidate is actively looking for a rural setting to practice. Here we’ve got hunting and fishing. I came for the whitewater kayaking,” Dr. Manning says.

The challenge is to convince people who have never visited the area that a rural hospital is a great place to practice, says Brian Bossard, MD, FACP, FHM, director of Inpatient Physician Associates in Lincoln, Neb. “There are lots of barriers to address in order to negotiate a positive outcome. The more rural it is, the harder the job of recruiting. What more can we offer a recruit? Sometimes it’s money, a signing bonus, a benefit package. With many recruiting efforts, the spouse is part of the equation.”

Recruiting doctors to rural areas starts by leading with the hospital’s strengths, such as high-quality care, manageable workloads, or sustainable schedules, Dr. Bossard says. Recruiters also focus on the advantages of living and raising children away from the big city. International medical school graduates have long been a recruitment target of rural hospitals, but they present bureaucratic hoops that some hospitals are unwilling to jump through. (Visit the-hospitalist.org to learn why Foreign Medical Grads can bolster your HM group staffing.) Other hospitals employ recruiting staff, recruitment firms, paid advertising, and old-fashioned word of mouth—talking with anyone and everyone who might know a physician who could be interested.

Fannie Vavoulis, medical recruiter for Chatham-Kent Health Alliance in Chatham, Ontario, agrees that it can be difficult to recruit physicians to a setting like her predominantly agricultural community. But she has enjoyed recent success, in part due to the efforts of a 25-member community volunteer group of local business and health leaders who woo physician candidates. “We use the volunteers to show them around, help find opportunities for their spouses, and offering ongoing mentorship once they come here,” Vavoulis relates.

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A Little Like Home

Dr. Poudel
Dr. Poudel

Rapid City, S.D., with a population of 68,000, isn’t the most rural of settings, although Rapid City Regional Hospital (RCRH) also serves a large rural catchment area, with affiliated rural satellites. But the Black Hills are worlds away from places like Chicago or Dallas or New York City, where many future hospitalists do their residencies.

Pushpa Poudel, MD, came to 400-bed RCRH in 2010 following a residency at Wyckoff Heights Medical Center in Brooklyn, N.Y. “The people I met on my interview days were nice, but I was more attracted to the work environment and the dedication I found in the hospital here,” he says.

Dr. Gylten
Dr. Gylten

Dr. Poudel, who is from Nepal and attended medical school in Kathmandu, says the scenic Black Hills reminded him a little of home. After interviewing at RCRH, he went back to New York and talked two Nepalese physician friends into joining him there. Today, the multinational HM group at RCRH includes six hospitalists from Nepal, as well as others from India, Egypt, Costa Rica, and the Republic of Georgia. “We now have 28 hospitalists, and in the seven years since the program started, we’ve only lost one of them,” says Kristi Gylten, MBA, the service’s director.

All of the hospitalist group’s members meet candidates when they come for interviews. “They are the biggest sellers of the program,” Gylten says, although work-life balance, recreation in the Black Hills, and the reputation of the local school system are also draws. “Often the hardest part is just getting them to come out here. Once they come to Rapid City and see the community, it surprises them.”

—Larry Beresford

The Challenge: Expanded Scope

“This is a different brand of hospital medicine, with the potential for an expanded scope of practice,” says Dr. Bossard, whose group staffs hospitalist programs in Lincoln, Neb., and two rural communities in that state. “Physicians looking at your program need to understand that. 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,” he explains.

Rural hospitalists often need to master procedures and medical specializations (including critical care) that many of their urban counterparts hand off to specialists. For conditions they can’t manage, the alternative is transferring the patient to a larger hospital, sometimes by ambulance or helicopter.

“Some physicians are uncomfortable with the level of expertise and procedural skills required to manage in this setting,” says Dr. Nelson, whose consulting firm regularly works with HM programs in rural areas. “But the hospital and the physician community are looking to the hospitalists as a resource to keep patients in the community as much as possible. If the hospitalists are too risk-averse, that may be a problem.”

Some physicians are uncomfortable with the level of expertise and procedural skills required to manage in this setting. But the hospital and the physician community are looking to the hospitalists as a resource to keep patients in the community as much as possible.

—John Nelson, MD, MHM, hospitalist program medical director, Overlake Hospital, Bellevue, Wash., co-founder and past president of SHM

Dale Vizcarra, MD, a hospitalist at 60-bed St. Mary’s Healthcare Center in Pierre, S.D., has gotten used to not having on-site access to cardiology, anesthesiology, ENT, psychiatry, or pulmonology. “So you’re kind of piloting on your own,” she explains. “That could be hard for a new graduate who’s not used to flying solo.”

Dr. Vizcarra and a hospitalist partner navigate the lack of in-house specialist support by utilizing technology—for example, eICU-monitored beds or phoning physician colleagues in Sioux Falls. “The big question is, Do people know what they don’t know? It’s possible to be too quick—or not quick enough—to pick up the phone and ask for help,” she says.

Rural hospitals also face many of the same quality expectations and looming financial disincentives as their urban counterparts, but with fewer resources to devote to them. They conduct quality and safety projects and participate in SHM’s Project BOOST and similar quality initiatives. Three rural hospitals—Mariners Hospital in Tavernier, Fla., Miles Memorial Hospital in Damariscotta, Maine, and Sebasticook Valley Hospital in Palmyra, Maine—recently were named among the Leapfrog Group’s 65 top hospitals for 2011.1

A recent study by Karen Joynt, MD, MPH, of the Harvard School of Public Health and colleagues found that rural critical-access hospitals overall had fewer clinical capabilities, worse outcomes, and higher death rates for patients with heart attack, congestive heart failure, or pneumonia than their more urban counterparts.2 But Dr. Vizcarra says hospitalists can bring higher quality of care to rural hospitals.

Dr. Sanders
Dr. Sanders

“I also think staff satisfaction is better,” she says, adding that rural hospitals can try quality approaches tailored to the unique setting. “For example, because we have a lot of diabetic patients who are often noncompliant, we established a goal to have multiple members of our hospital team—from nurses to housekeeping—receive extra training in diabetes management and share it with patients. Sometimes it’s the person who hands out the food trays who has the best chance to reach the patient with this information.”

Dr. Vizcarra has lived in Pierre for 20 years and just became a hospitalist in April 2011. She loved primary care, but she says that “being a hospitalist in a clinical setting is a blast. There’s so much you can do—so many areas where you can improve care.”

The Challenge: Schedules

For a hospital to offer 24/7 hospitalist coverage on site, it generally requires at least three, if not four, full-time physicians dividing up days, nights, and weekends, allowing for vacations, sick days, and training time. Even so, a group of three or four hospitalists providing round-the-clock coverage is more likely to encounter some burnout than those programs that work seven-on/seven-off schedules. If the hospital is not able to afford four FTEs of salary—or to find physicians to fill those FTEs—it might decide that it doesn’t need hospitalists on site at night, Dr. Nelson says.

Alternatives include having the hospitalists take call from home, letting ED physicians do after-hours admits, or mobilizing community PCPs to divide up some of the coverage and call responsibility. Locums physicians are popular at rural hospitals, but they come at the expense of the personal relations and community integration that are counted among rural hospital medicine’s assets. Another approach, tried in some small hospitals where the caseload is insufficient to keep both a hospitalist and emergency doctor busy, is to combine the positions of ED doctor and hospitalist, then find physicians with the skills to fill both roles.

Increasingly, an alternative to supplementing hospitalists on the ground is telemedicine, which brings specialist expertise to rural hospitals long distance via telephone lines and video equipment. This concept may be more familiar in eICUs, but Atlanta-based Eagle Hospital Physicians also offers the services of hospitalists and neurologists via telemedicine links, says Richard Sanders, MPH, FACHE, the company’s director of telemedicine services. Specialists from Eagle’s pool of physicians serving hospitals across the Southeast work from wherever they have access to a telephone and Internet service.

“In order to address the issues rural hospitals and hospitalists face, we have to be innovative in our approach. Our hospital partners struggle with having patient volumes that require more hospitalists than they can recruit for, a problem exacerbated by the need for taking call at night, which can scare off some candidates,” Sanders says.

The peak time for telemedicine for the hospital that can manage partial on-site hospitalist coverage is the night shift—“typically the least productive time for hospitalists, with unpredictable volumes,” he says, “although you still need access to someone who can respond quickly.” Eagle also uses physician extenders as key members of its team and a video-equipped RP-7 robot that can move around the hospital as directed by the remote physician.

The Challenge: Extinction

Dr. McMahon, a Virginia native who practiced in the military after attending Medical College of Virginia, was recruited in 1980 by two residency colleagues who had secured jobs in Pearisburg, a small town in the western part of the state. “I’ve been here ever since,” he says. “I live and work with these people. I’m intimately involved in this community. I attend a lot of funerals. I’m the football team’s doctor, and I teach at the college of nursing.”

Dr. McMahon says that close-knit communities, such as Pearisburg, offer a different kind of medical care; he also says that kind of care is in danger of extinction. And he says something important will be lost if that happens.

Primary-care physicians (PCPs) help supplement the after-hours coverage provided by CGCH’s two staff hospitalists. “This is a community hospital, and we all work together,” Dr. McMahon says. “I know the family practice and internal medicine physicians and they know me.” But he also fears that this level of commitment may not continue much longer.

“We’re all aging in this community, and in another three to five years, the physicians are going to start to retire,” he says. “ … We’re a dying breed from the school of hard knocks and experience, and we’re being phased out in favor of technology-savvy younger doctors, for whom basic diagnostic skills are downplayed.

“There used to be more of a sense of camaraderie in medicine,” he notes. “Back in the day, when I first started here, we considered medicine a calling and not a job.”

For Dr. Vizcarra, the HM model of inpatient care represents a sea change in the connections between physicians and their patients.

“Now, in many small towns, you don’t see your doctor anymore when you’re in the hospital,” she says, adding disconnects can be magnified in small towns. “I try to compensate by providing patients with caring, compassionate, common-sense medicine when they are in the hospital. Usually, after the first day, it’s not an issue.”

Larry Beresford is a freelance writer in Oakland, Calif.

References

  1. The Leapfrog Group announces annual top hospitals list. The Leapfrog Group website. Available at: http://www.leapfroggroup.org/news/leapfrog_news/4810593. Accessed March 31, 2012.
  2. Joynt KE, Harris Y, Orav EJ, Jha AK. Quality of care and patient outcomes in critical access rural hospitals. JAMA. 2011;306(1):45-52.

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