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The big and small of it
One hospital size is indeed better... so is the other
By Michael Sergeant, MD
Those of us who have spent a decade or more (some of us much more) in medicine have lived through geometric changes in the way our art is practiced. This has meant watching and often participating in repeated versions of “new.” Specifically, we have all been adapting to a relatively new movement whose protagonist is called a hospitalist—first with wonder, then with trepidation, possibly then with active resistance and (for most of us) ultimately acceptance. This is not unlike Elisabeth Kübler-Ross's stages of grief. What is different, for at least many of us, is yet another stage: excited embracing, with reservations.
That last stage is admittedly a bit schizophrenic in nature, and much of the published work regarding the hospitalist movement reflects just that. There is nothing really new in the recognition that our way of caring for our sickest patients has so rapidly changed or in the observation that there are many pitfalls inherent in that. Still, as has been said myriad times already, the hospitalist train, with its benefits and dangers, has left the station and is not expected back. A huge literature has erupted over the last few years dedicated to this train. What seems to attract less attention is how varied our new specialty is, how remarkably different it is to practice in a small, rural hospital than in its urban big brother.
Photo courtesy of Dr. Sergeant.
Many of the differences between the medicine practiced in these most disparate of worlds are obvious, but having recently migrated back and forth between a 55-bed rural hospital and some 300- to 600-bed urban ones, I have found much of what is good and much of what is problematic in hospital medicine manifests quite differently in these respective environments. It does so in ways both expected and surprising.
Unique to the geographically isolated small hospital is the need for the hospitalist to function effectively not only on the med-surg unit, but in the ICU and probably at least sometimes in the emergency department. Perhaps throw in some long-term care and maybe even the nursery in some settings. Further, much of this work (even in the ICU) likely happens with minimal, if any, direct support from subspecialists. In this environment, we typically have no cardiology, neurology, nephrology, vascular surgery and so on. The irony is that often the very well-trained, experienced urban hospitalist may well not be comfortable or even qualified to fill the shoes of his or her rural counterpart.
There are many negative aspects of this reality. Recruiting, already challenging due to lack of amenities in the rural environment, can be very difficult. A hospitalist who might find the rural life romantic may find the lack of backup too uncomfortable. Even if a hospitalist is willing and capable of managing a patient in renal failure, on pressors and on a ventilator, the idea of doing so at 3:00 a.m. when she still has to work the following day is just not very attractive. Compare that to a job at an urban center, where this same hospitalist can work a 12-hour shift, perhaps have the intellectual stimulation of caring for this same critically ill patient, but be able to do so with an intensivist, a pulmonologist and a nephrologist on board for backup, and further, know that at the end of the shift she can sign out and go home. Rural hospital work can be both lonely and scary. In addition to all this, the rural hospital may not be able to attract the same quality of nonphysician personnel or have the same level of ancillary services. Many lab tests whose results are quickly available in a large hospital may be sendouts in the small one. MRI, nuclear medicine, echocardiography and many other tests may only be available on a limited basis, if at all.
In contrast, in the large urban hospital, the hospitalist has so much at his fingertips that it can feel like anything the patient needs, he can provide.
So given all this, why do I continue to spend much of my professional life in this remote, scary and challenging environment, often working long hours with frequent periods of sleep deprivation? Well, as with so much in life, hospital size and location cut both ways.
A sense of personal impact is possible in the small hospital environment but remarkably elusive in the dynamic, impersonal expanse of a major medical center. What I have found most poignant is that as the number of doctors on a team goes up and the number of specialist consultants increases, the communication among them often goes down. This is, of course, a generalization and at first it seems counterintuitive; shouldn't there be more opportunities for discourse as the number of potential interactions increases? Well, my observation is that this potential is frequently not realized.
In a small group with one to three doctors on at a time and a census on the service of less than 30 or so, I have found it possible for us to fairly consistently meet at checkout and go over all, or most, of the patients together. The majority of patients are quickly reviewed, but a few of the more challenging ones are gone over in detail, and all on the team have a chance to share ideas and learn from one another, even if the discussion is about a patient we will not have primary responsibility for. We all learn, and we all share ideas.
As a small group, we tend to get to know one another well, and as the geography of a small hospital is limited, we are in frequent proximity to one another on rounds and thus we get more chances to talk about approaches to the care of our patients. We also develop a sense of community and will help one another if the load becomes unbalanced among us. Also, with the dearth of specialists, we truly are managing patients instead of, as is sometimes true in the large medical center, managing consultants. This is a joyful way to practice medicine.
In contrast, my experience working in and providing consultation for larger hospitals has been that hospitalists generally work increasingly autonomously as their numbers increase. This is easily understandable. If one has a team of 15 or 20 or more doctors and a patient census well over 100, there is no reasonable way to all get together with any frequency, and absolutely no way to review all those patients individually. Further, the logistics of scheduling scores of hospitalists results in schedules that tend to have a certain degree of randomness and are not intended to promote interaction. Added to this is the problem of night coverage. In a very small hospital, it is the same team that often, by various kinds of arrangement, covers both day and night shifts. It is not financially viable to support a nocturnist who may only admit two to five patients a night. This means that whoever is there at night needs to know something about their team member's patients, and there is yet another opportunity for the exchange of ideas.
In the large hospital, we have the nocturnist. Or two or three of them. This hospitalist, as we all know, has three roles: admissions during shift hours, cross-cover calls from nurses, and emergent care of an already admitted patient who goes south (no geographical prejudice intended). How many nocturnists are on any given night depends, of course, on the size of the hospital. There is also variation in the number of daytime hospitalists any one nocturnist is covering for. It is this last ratio that is pertinent here: My observation is that in the large hospital setting it is not unusual for a single nocturnist to provide coverage for as many as eight or more daytime doctors with anywhere from eight to 25 patients each. Simple arithmetic: This person may be cross-covering well over 100 patients. There is no way for that nocturnist to get meaningful checkout or to know all the patients she is covering. Usually she relies on a list, perhaps a few starred patients that the day doctor thought might be at risk of a problem overnight. The chances for mismanagement, or at least wasteful management, are pretty profound. (How many nocturnists does it take to order an unnecessary test?) This is usually not a reflection on the quality of the physician; it is a problem inherent in this system.
Back at the small hospital, in addition to generally being able to have a pretty good sense of whom we are caring for (patients as people), each of us on a team can positively contribute to change in an immediately palpable way. If one has an idea to improve our admitting order set, or the way we check out, or our protocol for alcohol withdrawal, we don't have to confront the inertia of a massive system. A few of us can talk, and we can set something in motion almost immediately. Of course, offsetting this benefit of a small team is the crisis that can be generated if one of us goes down (illness, family emergency, even a delayed flight). We don't have the depth that a large team has. If one of 10 physicians goes down, the others pick up a patient or two and don't feel much. If one of two goes down, the sky is falling.
There are many more ways in which these two worlds are far from one another, but what I've said thus far at least provides a sketch of planetary separation. One problem is the inhabitants of these planets tend not to have much understanding of what life is like on the other. Yet, they have much to learn from each other, and they need each other as well. The large referral center needs smaller hospitals as referral sources, and smaller hospitals obviously need major centers for specialty advice and sometimes to provide specialty (not higher-level, mind you) care.
Further, the problems each planet experiences impacts the other. It is not unusual for a rural hospitalist to have a patient whose illness(es) and needs exceed what the rural hospital can offer (fear can enter the picture here). Yet the urban hospital may not have beds, or the urban hospitalist who feels forced to accept this critically ill patient may already be trying to manage twenty or more patients and his personal capacity is exceeded. Neither doctor is in a good situation. And neither really understands what it feels like in the other's shoes (scrubs?).
So how can those of us on these contrasting planets learn something from the other to improve life? First, I believe we need to recognize that we share the problems of understaffing, dangerously high workloads (at times) and an emphasis on profit that pushes us to these levels. Along with this, I think too few of us have significant first-hand experience as hospitalists in both of these worlds. I have become a better doctor by learning the workings of both. There may be ways to give doctors from one planet transport to and experience on the other. Second, we need to borrow more from each other: There is already rapid growth in specialist access for rural physicians in areas like telemedicine, university physician access lines, and so on. What there is less of is any programmatic way to help doctors in these different kinds of hospitals understand the lives of their counterparts in such divergent environments. Further, more large hospitalist programs would do well to borrow some of the small hospitals' advantages. Their large teams might be divided into small pods that actually can meet and discuss and know all the patients. One person on this smaller team could, on a rotating basis, be available by phone to help a nocturnist with ideas for difficult cross-cover issues, and so on.
There are many ways to decrease the sense of separation. It takes creative thinking, mutual compassion and a remembrance that we are all physicians. We have all dedicated ourselves to the new, clearly diverse but still single specialty of hospital medicine. We would do well to pay attention to and respectfully learn from one another.
Michael Sergeant, MD, is the director of hospital medicine at Gila Regional Medical Center in Silver City, N.M.
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From the April 16, 2014 edition
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