Rural Hospitalists, Part Two: Macys vs. Gimbels

I have to make a decision about my hospitalist job pretty soon. (No I'm not going into the details right now, but stay tuned.) As I consider my options, I've also been thinking about the role of hospitalists in rural communities and the role of family doctors as hospitalists. Before you can grasp what it is like to be a rural hospitalist, you need to know what the rural hospitals--and the medical community that supports them--are like

But first--a brief disclaimer: even though I'm obviously drawing on personal experiences, the hospitals I describe in the remainder of this post are actually composites of several of the small-town hospitals in which I have worked. I'm fictionalizing the hospitals to be discrete, because I have to live and work in a small community, and even though the conflicts and difficulties the hospitals I describe are largely a matter of public record, it would be a blot upon my professionalism to talk about them by name.

Without further ado, I present to you two hospitals, nicknamed Macys and Gimbels.

GIMBELS: THE LITTLE HOSPITAL WITH A BIG HEART

Gimbels is a small, single-story independent hospital. It has about 70 beds but is usually only staffed to a maximum of 30 patients. It offers all basic medical services, including maternity care. In addition to inpatient services, it has a limited number of outpatient specialty services which draw revenue to the main hospital: outpatient lab and radiology, a wound care center, outpatient physical therapy, home health and adult day health care programs. There are several suites of professional offices associated with the hospital, but not many medical or surgical specialities are represented in the suites. Currently Gimbels has the following physicians affiliated with it:

• 6 general internists, one of whom is an infectious disease specialist
• 1 otolaryngologist
• 1 OB-GYN
• 6 or 7 general surgeons, who also have offices near Macys
• 2 orthopedic surgeons
• 3 ophthalmologists, who also have offices near Macys
• 2 pulmonolgists

Because Gimbels doesn't have a lot of specialists affiliated with it, they don't do any high-paying procedures such as cardiac caths or joint replacements. Being independent, they don't have a network of hospitals to spread the burden of expenses. Consequently, Gimbels tends to be a tad behind the times when it comes to technology and equipment. One of the pulmonolgists refers to the ventilators in Gimbel's ICU as "sacks of roach shit," and one of the hospitalists once had to arrange to borrow a good ventilator from Macys for a patient who needed pressure-cycled ventilator settings. Gimbels uses a paper-based system for charting and requisitions, and they don't pay their staff particularly well so the place is run by entry-level technicians, especially in the lab where paperwork on important tests such as cardiac enzymes is often lost, much to the dismay of Gimbel's hospitalists.

Despite its many flaws, Gimbels is a great place to work because the staff are all truly kind and devoted people and the atmosphere is friendly. There are many local physicians who admit they prefer to work at Gimbels, because the people are so nice, but they are compelled to take a lot of their profitable business to Macys because of the greater material support for them there.

MACYS: A COG IN THE CORPORATE MACHINE

Macys is located about twelve miles away from Gimbels, but the differences between them span a much larger distance. Macys is four stories high and looks like a real hospital. (Gimbels, on a good day, looks like an elementary school.) It is one of five hospitals in a regional network of healthcare centers and consequently has deep pockets to fund its programs. Macys runs inpatient and outpatient physical rehabilitation programs, a dialysis center, a local SNF, a home health program, and a radiation oncology program. Their affiliated doctors occupy a number of nearby office suites and represent a wide range of medical and surgical specialties such as

• 3 cardiologists
• 3 urologists
• 3 nephrologists
• 2 gastroenterologists
• 3 heme/oncs
• 1 rheumatologist
• 1 neurosurgeon
• 6 OB-GYNs
• 2 plastic surgeons
• 1 cardiothoracic surgeon

Macys also has a huge, state-of-the-art imaging center and a brand-new Urgent Care Center that just opened. They are able to purchase up-to-date equipment and consequently they are able to keep five operating rooms and a cath lab running every weekday, doing well-reimbursed specialty procedures.

Furthermore, Macys pays their staff well, much better than Gimbels. Poor old Gimbels is known as a training ground for new nurses, who leave after a year to take a signing bonus at Macys. They certainly run a tight ship at Macys, although this occasionally requires Captain Bly to make one of his crew walk the plank. Those that survive the dunking often return to Gimbels and tell dark tales of yelling and name-calling that goes on behind Macys closed doors.

HOW DO MACYS AND GIMBELS COLLABORATE IN RURAL, CA.?

The old saying goes: "Macys never talks to Gimbels," and that about sums up how the fictionalized Macys and Gimbels get along up here in Rural.

For example, some of Gimbel's doctors have said that Macys has pursued a policy of poaching all the procedural specialists to work at their own store--er, hospital. However,the procedural specialists will tell you that Macys has invested extra money into their specialty, and that's why they won't come over to Gimbels if they can help it. One of the nephrologists has actually resigned her privileges at Gimbels so she CAN'T consult over there.

If you're reading between the lines, you may have already surmised that the rift between Macys and Gimbels has a parallel rift in the medical community of Rural County, California. The truth of the matter is, practically nobody gets along with anybody else. One of the nephrologists is in practice with a partner and the third nephrologist is solo, and the solo guy doesn't really speak to the duo. The large orthopedic practice affiliated with Macys has nothing to do with the two solo orthopedists affiliated with Gimbels. The large group has two semi-retired surgeons who take call at Macys only; there is no nighttime orthopedic coverage at Gimbels because the two guys there won't take call. Plain out flat won't do it.

It's all quite absurd, really.

WHAT ALL THIS MEANS FOR RURAL'S HOSPITALIST PROGRAMS

Obviously, with two such different hospitals, a single hospitalist model will not work for both facilities. Macys needs a larger program, a bigger staff, and a pretty sophisticated bunch of physicians to help pull all the the different services together. Gimbels needs fewer physicians but those physicians need to be extremely good at making dysfunctional systems work to best advantage. They also have to be good diplomats in order to get the high-maintenance consultants to see Gimbels' patients.

Why not create a large hospitalist group to serve both Macys AND Gimbels? This would be a terrific idea except that the local culture of mutual animosity between the two facilities won't permit it to succeed. The CEOs of Macys and Gimbels appear to be working against the interests of the other department store--er, hospital. For example, Macys likes to insert noncompete clauses into their physician's contracts that would potentially expose a physician to breach of contract if they made a separate agreement to provide services at Gimbels. This animosity makes it almost impossible to create a single group that provides an equal commitment to both hospitals. Of course, the big hospitalist staffing agencies can provide services to both facilities, because they have huge legal staffs and don't belong to the local medical community and are therefore not subject to its petty politicking. However, as I'll discuss in a later post, these staffing agencies are an expensive business and not a viable solution for a rural community's needs.

In the next post in this mini-series, I'll describe three rural hospitalist programs currently providing inpatient care to the people of Rural.

Comments

[Theresa]

That's a terrible picture you describe. I figured if it was happening here, it must be happening in small towns everywhere.

Here in Rural, people are supportive of the hospitals. The *staff* of Gimbels is pretty upset with some of the financial decisions they've made recently, and this is causing a huge decline in morale.

[CancerDoc]

Here, in Smalltown America, we had a similar situation with two hospitals in a town of under 30,000 with catchment area of 60-70,000. I don't know the make up of specialists, etc. practicing at each hospital, but they were eating each other alive. About 4 1/2 years ago, both hospitals were bought by the same for profit group which didn't invest in the infrastructure.

In the four years that I have worked here, there has been an erosion of the hospital staff. Several primary care doctors left the community, several internists refused to admit to the hospital, and we lost GI, neurology, radiology and a couple of urologists. The remaining primary care doctors are trying to get out of the hospital -- unassigned call is killing them with the number of uninsured patients that they have to take on. It is a horrible situation, as those with means flock to the Big City, while the poor (who can not afford the gas) and uninsured continue to use the Smalltown Hospital. Unfortunately, because Smalltown Hospital is old and falling apart, it gets a lot of undeserved criticism. Much of what patients complain about is no better in the Big City hospitals (I worked there for 18 months), but I think people are swayed by the high gloss floors.

Do I think there is a health care crisis? Yes. Right now, the hospital is hiring hospitalists - but the way that they have defined their coverage makes me wonder if the program will survive. In our community, the crisis is one of lack of insurance, lack of confidence in the local hospital because it is old and falling apart (everyone loves their docs, they seem to hate the hospital). The community doesn't have the funds to build a new hospital. Because those with insurance tend to transfer to the Big City....it is a never ending cycle.

[anonymous]

welcome to small town living!
enjoy reading your blog, and keep the faith.
best of luck with any decisions you face in the future.
regards
another small town doc

[Theresa]

I don't know--I'll republish the feed this weekend and see if it happens again. Thanks for alerting me.

[flo]

hey ... any idea why the links from your rss feed appear to be broken? Somehow in the link structure the month gets put wrong (6 where it should be 7) so the link won't work. Not that big a deal of course, but still ...