Wanted: Small-town hospitalists

Hospitalists can bring some relief to short-staffed rural areas by taking over inpatient care. But as more rural communities consider implementing hospitalist programs, they find themselves faced with the same recruitment challenge that helped create the problem: a rural venue.

North Valley Hospital, a 25-bed critical access hospital in Whitefish, Mont. (pop. 7,500), was facing a crisis in 2006. A doctor shortage had hit the area hard. Overworked local internists, doing double-duty as hospitalists, were threatening to leave town if they didn't get coverage.

That's when Betty Kuffel, FACP, an internist who had years ago gone from private practice to full-time, scheduled ED service, decided to take action. She and three other internists began offering weekend inpatient coverage to community physicians. Within a year, they were providing 24/7 hospitalist care.

“It became so popular, all but one physician group asked us to cover all hospital admissions, and even that group wanted weekend coverage,” Dr. Kuffel said. The program, in full gear since March 2007, has three full-time and three part-time hospitalists on call 24/7. Each hospitalist has one week on duty (with one free night mid-week) and three weeks off.

Creating a viable hospitalist program to support overburdened local physicians in private practice is one way rural communities are responding to a nationwide physician shortage. A 2002 report from the American Academy of Family Physicians noted that rural communities have 70% fewer physicians per 100,000 persons than major metropolitan areas.

Hospitalists can bring some relief to short-staffed rural areas by taking over inpatient care. But as more rural communities consider implementing hospitalist programs, they find themselves faced with the same recruitment challenge that helped create the problem: a rural venue. Physicians, administrators and consultants involved with rural hospitalist programs say that flexibility and local involvement are key to keeping a program going and attracting new talent.

Making it work

“We couldn't really afford a hospitalist program, but we couldn't afford not to,” said Craig Aasved, North Valley's CEO. “It has a lot of internal value. It reduces length of stay, helps with physician recruitment and retention, provides consistency for our nursing staff and allows private practitioners to be more productive in their practices.”

The hospital is handling the financial concerns by shifting costs from one program to another, an approach that seems to be working, said Mr. Aasved. “After nine months, the program isn't costing us as much as we initially thought.”

North Valley also saved by Dr. Kuffel to coordinate the program instead of working with a consulting/recruiting company to design and manage it. Hospitalists are hired on an individual contractual basis, and the hospital doesn't provide them with benefits, except for malpractice insurance. “This is a huge financial benefit to the hospital,” Dr. Kuffel said.

Like North Valley, Wayne Memorial Hospital started its hospitalist program in response to a hue and cry from overworked physicians. Located in Honesdale, Pa., the hospital has 98 beds and serves a population of about 100,000 in Wayne and Pike counties—two of the fastest-growing counties in the state. As the population grew, it became increasingly difficult for physicians to meet patient needs.

“Patients were waiting one to two months for an office appointment, practices were closing their doors to new patients and physicians were leaving the area,” said James Hockenbury, director of ancillary services at Wayne Memorial. “The emergency room became inundated with patients using it as a primary provider rather than solely for emergency care.”


Louis O’Boyle, FACP, director of the hospitalist program at Wayne Memorial Hospital in Honesdale, Pa., talks with a patient.

Faced with threats of abandonment from harried physicians, David Hoff, Wayne Memorial's CEO, called for the creation of a hospitalist program. Louis O’Boyle, FACP, a local internist, happily took the lead.

“After talking with my three partners, we calculated that if one partner went to the hospital full-time, and the others were in the office full-time, it would be the equivalent of adding another one-half partner,” said Dr. O’Boyle.

In January 2007, the hospital contracted with INCARE, L.L.C., a hospitalist recruiting and management company headquartered in Bloomsburg, Pa., to provide hospitalist coverage at Wayne Memorial. Dr. O’Boyle was hired by INCARE to serve as director of the program. He and four other hospitalists employed by INCARE now handle about 75% of inpatients. Flexibility is a key component: Three hospitalists work Monday through Friday, and two hospitalists round on weekends in rotation. On-call for evening hours is rotated. Primary care physicians can fully participate or sign out to the hospitalist on an intermittent basis. But once admitted by a hospitalist, patients will be followed by him or her through discharge to ensure continuity of care.

At first, some community physicians and patients were skeptical of the program, although a core group of community doctors signed up on day one, Dr. O’Boyle said. The hospitalists worked hard to win acceptance, speaking to community organizations, such as the Lions Club and Rotary Club, and at senior centers. Fliers were mailed, and hospitalists met with physicians at their offices, leaving literature for patients. “And having Dr. O’Boyle, a local practitioner, heading the program gave us instant credibility,” Mr. Hockenbury said.

Mary Rutan Hospital in Bellefontaine, Ohio, also has a hospitalist program formed through evolution and kept viable through a flexible model.

“About five years ago, an internal medicine group in town began to divvy up responsibilities—two of the four physicians saw patients in the hospital, the others saw patients in the office and nursing home,” said Randall Longenecker, MD, assistant dean for rural medical education at Ohio State University College of Medicine and Public Health. The 60-bed hospital soon bought the practice and retained the physicians as hospitalists.

“There's a certain fluidity [and] flexibility to the program,” Dr. Longenecker said. “While some primary care physicians turned their inpatient practice over to the hospitalists, others did not. And we have a whole spectrum in between.”

Because it's part of an integrated rural training track residency offered by Ohio State University College of Medicine, Mary Rutan has family medicine residents also provide inpatient coverage at night. Also, the Ohio State University rural program at Mary Rutan offers one-month rotations for medical students. “Most students coming through medical schools and residencies have little exposure to rural life. Less than 5% of students come into medical school explicitly interested in rural practice,” Dr. Longenecker said. “This rotation gives them a wonderful hands-on experience, as there's less competition for patients and clinical opportunities for learning. Giving them a taste [of a rural hospital] gives us a better chance of recruiting them.”

Size matters

“The unique challenge to a rural hospital is the numbers thing,” said Dr. Longenecker. “Running a hospitalist program needs a critical number of patients to make it financially viable.”

“We have 51 hospitals of all types across North Dakota, 31 of which are critical access hospitals,” said Mary Amundson, an assistant professor in the Center for Rural Health at the University of North Dakota School of Medicine and Health Sciences in Grand Forks. “And in rural North Dakota you're looking at very small hospitals—25 or so beds. They're unlikely to recruit a hospitalist.”

In rural Kansas, hospitalist groups are a new phenomenon to some of the larger facilities, “but some hospitals are too small,” said Joyce Tibbals, assistant director for rural health education and services at the University of Kansas Medical Center in Kansas City. “Kansas has 84 critical access hospitals [with no more than 25 beds], where it's not cost-effective to have a hospitalist.”

But exceptions prove the rule. North Valley Hospital met the challenge in Whitefish, and Littleton Regional Hospital, a critical access hospital with 25 beds that serves about 35,000 in Littleton, N.H., plans to start a hospitalist program soon.

“We'd like to recruit someone with experience to design a program,” said Warren West, Littleton's CEO, who hopes Littleton's modern hospital and vacation-like locale at the top of the White Mountains will help attract applicants.

“[A hospitalist program] will allow us to offer a higher level of coordinated care among our specialists, primary care physicians, nursing staff and the community,” he said, “all working in concert for the benefit of the patient.”

Sheila Dyan is a freelance writer in Cherry Hill, N.J.

Selling greener pastures

Location is often the most important piece of the recruitment puzzle, experts say. A small, quiet setting can be viewed as an asset or a liability, depending on a physician's tastes and needs.

Recruitment efforts for North Valley Hospital in Whitefish, Mont., focus on its resort-like location in the biggest ski area in the state. “It's a beautiful, low-crime area, with excellent schools,” said Betty Kuffel, FACP, who leads the hospitalist program. “And the biggest traffic hazard we have is deer.”

But the lack of big-city trappings is precisely what keeps some physicians away.

Geisinger Medical Center, in Danville, Pa., has an easy time selling its award-winning tertiary care level 1 trauma center with 437 beds, 350 physicians and 18 hospitalists to potential employees. The Danville campus, one of three hospitals in the Geisinger Health System, runs fellowship programs and an internal medicine residency from which many physicians are recruited. But it also has to convince physicians to live in a town of about 8,000 people that's more than two hours away from a major city.

“Our recruitment challenge is like that of other small towns,” said John B. Bulger, FACP, director of inpatient services. “We lack services like malls, entertainment, shopping and transportation. We have no symphony. It's an hour to a minor-league sports team and the closest regional airport.”

Although rural hospitals can and do offer recruits financial incentives, such as higher salary, sign-on bonuses and school loan forgiveness, rural medicine isn't just about the money. The most important thing, experts say, is finding a physician who's looking for the benefits a rural life can offer.

For Dr. Kuffel, one of those benefits is the possibility of a unique work schedule. At North Valley, hospitalists are on duty for eight days in a row, 24 hours a day, except for a free night midweek. “This works because about half the time we can be at home handling occasional problems via cell phone,” Dr. Kuffel said. “The ED physicians help greatly by trying to defer as much as possible until morning, but sometimes we go in at night. Sometimes we get hammered, and then always someone else is available to cover for a night. The lower volume makes it possible to have a full-time schedule but still have three weeks off a month.”

Lifestyle is also one of the draws for Geisinger's Dr. Bulger. “My travel time to work and back is four minutes round trip, which affords me more time with family,” he said. “It's important for hospitalists to look at it all. The lifestyle you can afford yourself in a rural area has large advantages.”

“More than any other aspect, we truly seek a physician who wants to be in Montana,” said Kate Bogue, physician recruiter for Great Falls Clinic in Great Falls, Mont. “We've actually run ads in Field and Stream to target the right fit for our opportunity and community.”

Being a hospitalist in a rural hospital that's outside an academic setting, with reduced or no access to specialists, can also be viewed as a drawback or as an opportunity for those seeking greater control and intellectual challenge.

“In a rural setting, you don't have specialty backup, so the onus is much more on hospitalists, who need to be thorough, complete and sharp. They have to be well-trained and independent. There's just as much pathology in a rural community as in a populated area,” said Louis O’Boyle, FACP, director of the hospitalist program at 98-bed Wayne Memorial Hospital in Honesdale, Pa. “You get it all. It's never boring.”

“Working in a rural setting, a hospitalist is part of a community, and can make a difference day in and day out,” added James Hockenbury, director of ancillary services at Wayne Memorial. “It doesn't get any better than that.”

The recruiters' perspective

Recruiters who spoke to ACP Hospitalist had specific advice for rural hospitals trying to recruit hospitalist talent.

Choose wisely. “Rural hospitals should bring in someone who understands rural medicine,” said Alan Himmelstein, president of Hospitalist Care Consultants, headquartered in Dallas. In a small, rural hospital, the hospitalist will be “the top dog,” he said. “They have to be willing to be independent and sure of themselves, because they won't have [specialty] back-up close at hand.”

Be flexible. “You can't have an all-or-nothing rule,” said Mehdi Nikparvar, MD, medical director at INCARE, L.L.C., a hospitalist recruiting and management company headquartered in Bloomsburg, Pa. It's better, he said, to let local physicians feel their way with the service at first. “Some physicians will use the hospitalist for vacations, holidays or weekends, but eventually they use us more and more.”

Think globally. “Be prepared to take international medical graduates,” said Mark Dotson, senior director of recruitment for Cogent Healthcare, headquartered in Brentwood, Tenn. “They are essential to not only rural markets, but all markets right now with the high hospitalist demand.”

“In our program, 25% to 30% of our hospitalists are foreign medical graduates,” Mr. Himmelstein said. The proportion is similar at Geisinger Medical Center in Danville, Pa., according to John B. Bulger, FACP, director of inpatient services.

Sell your setting. Mr. Dotson cites quality of life as the biggest benefit of practicing medicine in a rural community, including more affordable housing and less congestion.

Offer incentives. Financial incentives at INCARE include sign-on bonuses and a partnership/ownership plan. Cogent also offers sign-on bonuses, which tend to be higher in more remote locations. Other possible incentives include salary advances and medical school loan forgiveness.