Hospital medicine pioneer John Nelson, MD, used to believe that hospitalists only made sense for large hospitals in metropolitan areas. Dr. Nelson, who serves as a practice consultant, was convinced there was no way small hospitals could afford doctors dedicated solely to inpatient practice.
Now, his phone rings several times a month with queries from small rural hospitals that are ready to commit time and money to hospitalist programs. While many of these hospitals struggle with issues ranging from affordability to community acceptance, others “from central Vermont to eastern Oregon “have found that leaping into hospital medicine can produce big payoffs in terms of better business and better care.
Exactly how many hospitalist programs are in rural areas? While only 18% of all hospital medicine groups were in rural communities in a recent survey, data showed that the number of those groups was growing fast. One in three rural groups reporting began operating only in 2004, the year before the survey was taken.
While rural hospitalist programs face considerable challenges, particularly in recruitment, a growing number of hospitals are deciding that they need to pay whatever it takes to get a program up and running.
That’s because hospitals in rural settings increasingly view hospitalists as the best way to stop the hemorrhage of specialists and admissions to big city hospitals. Even more importantly, hospitalists have become the dealmaker “or dealbreaker “when it comes to recruiting primary care physicians into rural communities.
Wanted (desperately): primary care physicians
For much of the last decade, hospitals have been turning to hospitalist groups to achieve goals like cutting down on excessive call and lowering lengths of stay. In the heartland, however, these goals take a back seat to a much more immediate concern: bringing desperately needed primary care physicians to the community.
The primary care base that serves the 49-bed Mid-Columbia Medical Center in The Dalles, Ore., is a perfect example. In recent conversations, the local general internists and family physicians have talked to third-year internal medicine residents, but not one expressed an interest in setting up shop in this desirable community in Oregon’s Columbia River. All the while, the number of traditional internists practicing in town dropped from eight to five.
"Our concern was that if we didn’t make the sudden change to a complete inpatient-outpatient split, we would not be able to provide internal medicine care in our community," says Tom Nichol, MD, who last year became a full-time hospitalist at the medical center after working as a general internist for nearly two decades.
"When we brought locum tenens and chief residents in, we had a chance to find out what residents were looking for," Dr. Nichol explains. "Not one that we talked to was looking for traditional medicine. They wanted a completely office-based or hospital-based practice, so we realized we needed to change to that model too."
Saving primary care
As a result, Dr. Nichol and the other local general internists divided themselves into outpatient and inpatient physicians. Now, he points out, "any physician who comes to this town has the option of having a 100% hospitalist or a 100% office-based position. We wanted to create recruiting opportunities for people who wouldn’t come here otherwise."
In less than a year, that strategy has begun to pay off. Mid-Columbia has now been able to recruit three hospitalists (who join Dr. Nichol and the other internist who gave up an outpatient practice), as well as two new office-only internists. All of the physicians, who are part of a hospital-owned group, are still looking for another hospitalist and several more outpatient physicians.
"Small hospitals are not talking a lot about saving money," says Dr. Nelson, who is also director of the hospitalist practice at Overlake Hospital Medical Center in Bellevue, Wash. "I think they will see that too, but their No. 1 driver is to dramatically expand the pool of candidates they are targeting." That new recruiting capability, he points out, can "save primary care" in these communities.
The virtue of starting small
Despite Mid-Columbia’s success, recruiting top-notch physicians to rural communities is turning out to be tough for many, particularly given the shortage of both hospitalists and primary care physicians.
That can be the case even when the hospital is not particularly small and the community not entirely rural. In the Rocky Mountains of Northern Idaho, for instance, Coeur d’Alene’s Kootenai Medical Center created a hospitalist program a year ago, even signing with a national hospitalist company to run it.
Since then, however, the 240-bed Kootenai has been unable to hire physicians, and the hospitalist program remains a plan, not a reality. "There just aren’t enough hospitalists to go around," explains Joseph Bujak, MD, the hospital’s vice president of medical affairs.
Kootenai has scaled back its initial plans for the program. Today, instead of trying to hire enough hospitalists upfront to provide 24/7 service, the hospital is looking for just one or two, hoping that a fledgling but up-and-running program will attract more physicians than one that exists only on paper. Hiring the right program director early in the process, says Dr. Bujak, will also have a big impact on recruitment.
Scaling back and starting small “even if the ultimate goal is 24/7 service “is common for rural hospitalist groups. Dr. Nelson says he often offers small hospitals this advice: Don’t insist on getting dedicated full-time hospitalists before you start.
"In most cases, hiring four hospitalists to cover 24/7 isn’t realistic," Dr. Nelson points out. "If you set your sights too high and you are in a small place, you are going to get frustrated."
Moreover, he notes, small hospitals may not have enough business to support a 24/7 in-house practice. A more cost-effective approach is to hire one or two hospitalists to cover days, while depending on community physicians to cover nights and weekends, and building from there.
That go-slow strategy also has the benefit of easing community concerns or opposition, he says, which can create hurdles in small communities where people have longstanding relationships with physicians and don’t want to feel abandoned when hospitalized.
Martin Christopher Johns, MD, took just such a pioneering position last May at the 25-bed Gifford Medical Center in Randolph, Vt., after finishing a med-peds residency. He opted for a rural hospitalist practice in part because he wanted to use all his skills, from general medicine and pediatrics to intensive care. (See sidebar for more information.)
Another draw: A rural practice qualified him for loan repayment assistance. And he and his family were attracted to the quality of life possible in a rural setting.
After 11 months as the medical center’s sole hospitalist, Dr. Johns and the hospital are in the process of recruiting another med-peds or family practice hospitalist and two physician assistants, one of whom has already started. And since he came on board, the hospital has realized one major goal: convincing some primary care physicians to stop telling patients to check into the big tertiary centers at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., 40 miles away, or Fletcher Allen Health Care in Burlington, Vt., 60 miles away, when they need hospital care.
Moreover, says Dr. Johns, the hospitalist presence has made it possible for specialists “including a second orthopedic surgeon “to begin offering additional services at Gifford a few days a week. Specialists weren’t always able to extend inpatient services before because no provider would be in-house to round on patients on days the specialists practice elsewhere. Patients also seem to like the idea of having another doctor involved in their care.
Dr. Johns’ arrival has also improved communications and relations between his medical center and Dartmouth-Hitchcock and Fletcher Allen. The two centers occasionally transfer a patient of theirs to Gifford to free up beds needed by sicker patients.
Before he joined the staff, Gifford’s inpatient census usually ranged from eight to 12. Now, it’s "in the 15 to 20 realm," Dr. Johns says. "Once you get a hospitalist program started, people start coming to the hospital."
Recruitment and retention
Initially, primary care physicians were reluctant initially to have him admit patients, but some now use him. While that’s good news for him and the hospital, it has made recruiting efforts for more hospitalists that much more urgent.
One challenge is that many factors that tie the hands of rural hospitals when it comes to recruitment are outside hospitalists’ control. A good example is the lack of subspecialty surgeons and the unwillingness of some physicians to accept Medicaid.
But even with subspecialty support, there are only so many physicians interested in rural practice. Hospitalists Management Group (HMG), a company based in Canton, Ohio, that has a growing roster of hospitalist practices in several states, has several practices in small hospitals. According to chief executive officer Stephen Houff, MD, however, the company has had to turn down requests to start programs in some rural settings because of their "very challenging geographies."
That’s because if recruiting is tough, retention can be even more brutal. "Increasingly, the issue that these smaller hospitals have is that they brought in two hospitalists three years ago, but now one has his green card and he’s leaving," Dr. Houff says. "The hospitalist recruiting market in 2007 is much more difficult than it was in 2004."
Creative approaches to recruiting
Still, many rural hospitals are learning "to be creative" in their recruiting drives, says Michael Metry, MD, HMG’s Southeast regional director and a hospitalist/intensivist in Zanesville, Ohio. The HMG hospitalists in Zanesville, for instance, work 16 12-hour shifts a month. Dr. Metry says that means "you don’t have to live here, but you can work here and then leave."
At Kootenai Medical Center, Dr. Bujak says the hospital is beginning to think about creative salary packages and other types of incentives to attract physicians to town. "In smaller communities," he points out, "successful recruitment often depends on finding suitable work opportunities for a hospitalist’s spouse, who is often a highly skilled professional as well."
Despite the formidable challenges involved in starting a rural hospitalist program, other hospitals are deciding that it’s time to take the plunge.
In Twin Falls, Idaho, for instance, Marlys Massey, RN, MSN, director of critical care at St. Luke’s Magic Valley Regional Medical Center, says that the hospital for the past year has been discussing how to launch a hospitalist program, which administrators believe is imperative.
While St. Luke’s hopes that a hospitalist service will help standardize care and meet national patient safety goals, Ms. Massey says, the hospital is also hearing an increasingly relentless message: With half of the local primary care doctors over age 50, all potential recruits say they will go only to communities where there are hospitalists.
Deborah Gesensway is a freelance writer who reports on U.S. health care from Toronto, Canada.
Like most rural hospitalists, Martin Christopher Johns, MD, is trying to recruit new colleagues.
But Dr. Johns, who last year became the first hospitalist to sign on at the 25-bed Gifford Medical Center in Randolph, Vt., plans to be selective. As he points out, not all hospitalists are a good match for rural practice. Physicians working as hospitalists in rural areas need to make do with less: to research issues more themselves, consult fewer subspecialists and perform a broader range of procedures.
"Sometimes you have to be more open-minded about what you can do for a patient," Dr. Johns explains. During his residency at Geisinger Medical Center in Danville, Pa., he learned that many inpatient consults that take place in larger centers happen simply because specialists are available.
"Take a patient with an infection," he says. "How long should he be on what drug? You could go and look it up, but you consult an infectious disease doc because he is there “and because the patient expects to see a subspecialist." In his new practice, "I may run something by a specialist at Dartmouth-Hitchcock or Fletcher Allen over the phone, but for the most part, I can manage."
Serving as default intensivists
That ability to do more with less is exactly what Hospitalists Management Group (HMG), a company based in Canton, Ohio, that has a growing roster of hospital medicine practices across several states, looks for when recruiting hospitalists for smaller hospitals.
"Hospitalists are really the default intensivists" in these places, explains Stephen Houff, MD, HMG’s chief executive officer. Rural hospitalists, for example, have to be comfortable managing airways and unstable patients because they may not have reliable backup.
To stay busy “and earn income “hospitalists in small facilities often do the outpatient and inpatient stress tests for local primary care physicians. They also read all the event and Holter monitors and pulmonary function tests in the hospital.
But the key to a successful hospitalist service in a small hospital is making sure the hospitalists are the go-to providers for critical care as well as for general medicine. Michael Metry, MD, HMG’s Southeast regional director and a hospitalist/intensivist at Genesis Healthcare System in Zanesville, Ohio, credits this strategy for keeping his 10-physician group busy and growing.
"The amount of RVUs generated by critical care is much higher than daily visits, so it generates a lot more money," Dr. Metry says. Critical care also brings more patients to a service, solidifies hospitalists’ leverage in a facility and staunches the exodus of patients to larger hospitals.
"We are constantly looking to increase our market share," Dr. Metry notes. "Now there is another community hospital nearby sending us all their critical care" rather than sending those patients to another hospital that doesn’t have a hospitalist program.