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.