Solving the Rural Hospital Equation

July 6, 2020

Sitting next to her husband’s bed in the small rural hospital emergency room, Mrs. Hill had a worried look on her face. Outside, the winter evening was fast approaching as the darkness grew. I had just introduced myself to this lovely senior couple as the attending physician. Mr. Hill held his wife’s hand tenderly. “I’ll be fine dear,” he said, speaking softly. I tried to reassure Mrs. Hill by explaining the treatment of her husband’s congestive heart failure and what to expect. “But doctor, you don’t understand, you are new here. I know he will get better… he always does after a few days in the hospital,” she said, with a weariness that only comes from experience. “However, you will send him to the city hospital from this emergency room—just like all the other times and I dread driving hours through mountain roads to visit with him at the city hospital, especially now that the days are so short.”

Mrs. Hill was right. I was new; it was just my second day working at this rural hospital. Truth is, it was my second day at any rural hospital ever. It was also my last shift for the week since I was hired to fill in when the local community physicians needed a break. She was also right that Mr. Hill was often seen in the emergency room and then transferred to the nearest metropolitan hospital.

Unfortunately, the reason for these transfers had nothing to do with the hospital’s ability to admit Mr. Hill or the competence of the physicians or the hospital staff. The hospital had all the needed technology – tests could be done and the results delivered to me much faster than I was accustomed. The medical community was caring, compassionate and experienced. However, there was just one problem: There were not enough physicians to take care of all the patients.
It broke down to simple numbers and hours in a day. The few physicians who lived in the community ran busy clinics, took night calls for their private practices and did emergency room and hospital calls on top of that. In this dizzying swirl of activity, it was almost impossible to pause everything to visit and examine an unexpected patient in the hospital. The physicians had families but the strain on the family-life was simply unimaginable. The only way to make sure that the patients who needed hospital admission could receive care was to transfer them to another hospital in a bigger community to try to make a dent in the workload.

Over the years a few physicians in this community had retired while others relocated to larger cities. All the while the community population was getting older with a predictable increase in age-related illnesses. This made for a very bad situation where a well-equipped hospital with expert caring staff was withering and the community members needed to travel hours to receive hospital care.

This scenario has been repeated thousands of times all over rural United States. About 20 percent of the US population is considered rural, which is almost 60 million people. But this 20 percent is served by only nine percent of the US physician workforce. That is like trying to build a river dam with a tennis net—it doesn’t work. The demand and supply are completely out of balance. It is a crisis, not only medically but one that also has social and emotional ramifications on the affected family members of both physicians and patients.

During one of my next shifts, the hospital administrator spoke with me. It wasn’t particularly busy. In a hospital designed for 42 beds, we had approximately four patients. Together we sat in the physicians’ lounge and began to discuss our individual healthcare experiences. He knew from my resume that I had served as a medical director in the past. We began talking about the effect of having a dedicated physician team for the hospitalized patients (these physicians are known as “Hospitalists”). The challenge was how to recruit and retain physicians to move to and work in a rural community. In my mind the situation was unusual and when presented with unusual problems, people will come up with unusual solutions.
The unusual solution was seemingly simple. As far as I knew no one had tried it. Since we could not get physicians to move into the community permanently, the next best thing was to ask them to stay in the community for about seven to ten days straight and then travel back home. It would take about three physicians to work a month’s worth of shifts.

This was in mid 2000s. That first experiment did really well; in fact, some of the physicians that collaborated on the first iteration of the model are still working at that same hospital. We went very quickly from having about five patients a day to close to twenty consistent in-patients at the hospital. Staff was no longer being sent home just because the number of patients dropped below expectations, as was the case previously. Now the problem was quite the opposite! Somedays we couldn’t get enough staff to care for the increased number of patients!

The community physicians were happy as they were given the choice to treat their own patients when admitted or they could defer to us, the hospitalists. The hospitalists were able to enjoy a rewarding professional and predictable family life. This also meant the community physicians didn’t have to worry about hospital call and cancelled weekend plans. Perhaps most importantly, patients did not have to be transferred to a larger community hospital to receive hospital care unless absolutely necessary.

As a very pleasant consequence, it also brought together a few dedicated people with different skill sets that have worked very hard over a decade and half to create “Rural Physicians Group.” This incredible group of people has made an outsized impact on the daily lives and well-being of both patients and the medical community with an out-of-the-box, yet practical approach. Rural Physicians Group now serves rural communities across the United States in both hospitalist and surgicalist capacities.

-S. Pannu, M.D.
CEO/Founder Rural Physicians Group
(Names changed to protect privacy)

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