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.”
—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.
“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.”