Interview with Dr. Heather Kovich, MD, Chief of Staff at Northern Navajo Medical Center in Shiprock, New Mexico, on the challenges facing patients and physicians in rural areas of the United States.
Small community hospitals throughout the United States are facing threats including low volume, declining reimbursements, and staffing challenges.1,2 Nantucket Cottage Hospital, a 19-bed facility and one of the smallest hospitals in Massachusetts, must also navigate the complexity of operating on an island 30 miles offshore, where the year-round population of 15,000 swells to more than 60,000 during the summer months.
There is no off-the-shelf staffing model that works in the clinical environment of our emergency department (ED). The ED provides care to more than 10,000 patients every year, but the majority of them present between Memorial Day and Columbus Day. Our ED team sees everything you would expect at a community hospital, plus more than our share of tickborne illnesses (ranging from routine to catastrophic), whose incidence is far higher on Nantucket than in many other places in Massachusetts.3
The evolution of emergency services on the island has been dictated by the potential risk of high-acuity, low-frequency events for a small hospital with limited human resources. For us, a mass casualty incident is a van rollover with 16 elderly victims or a carbon monoxide leak in an overcrowded basement apartment. Nantucket’s location means that medical transfers to a tertiary care hospital on the mainland aren’t always possible. Inclement weather or fog can prevent Boston MedFlight from making it to the island, and in the post-9/11 world, the Coast Guard isn’t always available. The tricky equation of appropriate and efficient ED staffing4 is made more complex by Nantucket’s geography and seasonality. So despite our low clinical volume, we need emergency physicians with high skill levels.
For “the season” on Nantucket, when our population explodes and the demands on our ED surge, our answer for many years was to put together a varied team of board-certified physicians that tended to come back year after year with their families, but with no guarantee on either side. We were hiring 30 to 32 people from Memorial Day to Columbus Day in 2-week shifts in order to have 24/7 coverage. Though we were certainly fortunate that a stint on Nantucket was attractive to some physicians and their families, we had to house them, find ways to accommodate them with their dogs and their grandmothers, and organize everything for their stay, in addition to coordinating travel on the ferries to and from the island. A big part of the challenge was juggling these teams amid the island’s ongoing housing crunch.
We also had to manage physicians’ expectations of work versus vacation — discouraging the perception that the assignment would entail sitting on the beach with a pager. Whereas urban and suburban institutions may have teams from cardiology, pulmonology, psychiatry, and other specialties on call to support the ED, our rotating ED team and the few year-round island doctors were our total resources. Some people saw that limitation as a wonderful opportunity to exercise their problem-solving skills in a low-resource environment, but not everyone found it so thrilling.
So we ended up with a mix of summer providers that we had to reinvent every year, always under pressure to get it right. Before each summer, we would launch a process involving recruiting, licensing and credentialing, and managing various logistic challenges. It was not a way to create a cohesive team; some visiting physicians didn’t have a real stake in this place after they left.
In recruiting this team, it was difficult to convey the types of judgment calls that needed to be made in a place like Nantucket to physicians who would be here for a very short time but were being entrusted to provide care during our highest-volume period. It was anxiety-provoking to recognize that we might not have the best match between resources and patient needs or that a visiting doctor might be on service with a visiting nurse, neither of whom was schooled in our particular practice environment. These visiting providers had to constantly keep track of factors that might be unfamiliar to them: What staff members are on island and on call? Is orthopedics here? What’s the current volume? Will the weather prevent MedFlight from getting here?
Assembling the summer ED team became increasingly difficult. The usual cadre was aging, and some clinicians chose not to return. Seeing that the model that had evolved wasn’t serving us and couldn’t be sustained, we began to think about an alternative. Our chief medical officer identified an emergency staffing group — MEP Health, now called U.S. Acute Care Solutions — that, far from being daunted by a new problem, was intrigued by Nantucket and its unusual circumstances. Aiming to balance delivery of high-quality medicine — an ever-evolving goal — with continuity provided by a core team that understands the puzzle we face, we negotiated a trial agreement. MEP Health became the employer of the existing year-round providers, including physicians and physician assistants, as well as some longtime summer team members, and supplemented them with rotating clinicians from its higher-volume hospitals. It took on responsibility for scheduling, peer review, and quality metrics, while building awareness of Nantucket-specific aspects of clinical judgment, so that we no longer have to constantly reorient personnel. This model forces a careful comparison between the cost of subcontracting ED staffing and the cost of directly hiring six or more ED physician and PAs, even if we could recruit them to the island and figure out how to enable them to buy into the housing market. Most of all, it takes advantage of the continuity and stability of our year-round ED base, while allowing us to stay current as medicine evolves.
Now we don’t have to worry about filling our schedule for next summer or about depending on a locum agency for physicians whose quality we have no way of judging in advance. Instead, we can focus on becoming fluent in the type of medicine that best serves our island.
From Nantucket Cottage Hospital, Nantucket, MA.
1. O’Donnell J, Unger L. Rural hospitals in critical condition. USA Today. November 2014 (http://www.usatoday.com/story/news/nation/2014/11/12/rural-hospital-closings-federal-reimbursement-medicaid-aca/18532471/).
2. Wishner J, Solleveld P, Rudowitz R, Paradise J, Antonisse L. A look at rural hospital closures and implications for access to care: three case studies. Kaiser Family Foundation, 2016 (http://kff.org/report-section/a-look-at-rural-hospital-closures-and-implications-for-access-to-care-three-case-studies-issue-brief/).
3. Massachusetts Department of Public Health. Lyme disease surveillance in Massachusetts, 2014 (http://www.mass.gov/eohhs/docs/dph/cdc/lyme/lyme-disease-surveillance-2014.pdf).
4. Collins M. Staffing an ED appropriately and efficiently. American College of Emergency Physicians, 2009 (https://www.acep.org/clinical—practice-management/staffing-an-ed-appropriately-and-efficiently/).
This Perspective article originally appeared in The New England Journal of Medicine.