Comparison Shopping for Rural Hospitalists

Recently a reader asked me why I left rural practice, and I took this as a sign that my recent job-hopping has made me seem like one of them fancy-pants, highfalutin' cityfolk doctors who make such a stir on TV. At one time, I too believed a country doc stayed in one town for thirty years, delivering babies and burying octogenarians, until you finally drop dead in the office one day after seeing a clinic full of patients. Modern doctors seem to move from job to job, role to role, throughout their careers, as mobile as information technology supervisors, customer service representatives and hedge-fund managers, regardless of the demographic they serve.

Because, in fact, I have not left my rural community at all, only shifted over to the larger hospital in the county (Macy's) and expanded into the next county (Extra-Rural) to work half-time at their hospital (Nordstrom). So not only am I still a rural doc, I'm now a commuting rural doc who is in a position to know the ins and outs of every hospital in our nutty little middle-of-nowhere region.

Since announcing the painful and life-transforming news about my departure from Gimbels, accompanied by my friend and colleague Smurf, I've started not one but TWO new hospitalist gigs and have a good run of shifts under my belt at each facility. Here's my initial impressions:

Macy's

• Physical plant: large-ish (three floors) and expanding, with brand-new extra-large ER/OR/ICU being built in front of the current building.
• Patients: usual rural assortment of respectable middle-class, street junkies, underinsured, desperate cases, and occasional lunatics. No celebrities or Saudi princesses.
• Services: most of what you'd expect in a "real" hospital: cardiac surgery, radiation oncology, dialysis, PET scans, etc.
• AM labs done on time?: yes, results viewable on EMR but takes forever to be filed in paper chart. EMR is not unified under one program for labs, studies, etc.
• Hospitalist staff: well-intentioned but lacking talent (except for me and Smurf, of course). Overly prone to say "yes" to surgeons and ER. Desperately understaffed. B-minus team overall.
• Consulting staff: too many and yet too few of quality. Tend to dump on hospitalists ("Consult for HTN management" ordered at 5pm after elective surgery, for example). Older members of the hospitalist staff tend to consult about every little thing ("Acute renal failure? Did you call nephrology?") which creates a dependency dynamic I was not accustomed to at Gimbels.
• ER staff: C-minus team. Married to the shift mentality, resulting in requests to admit chest pain patients on whom first troponin is still pending. Some very erratic ER management resulting in hair-pulling on my part (stay tuned for gory details in future post). In comparison, Gimbels used to have an A-minus ER team during the Golden Years, and my residency hospital never dipped below a C even on bad days.
• Political landscape: discontent and hostile, reminiscent of Medici Florence without the poison rings. A lot of yelling and posturing and talking dirt behind each others backs.
• Hospitalist per diem: 19% more on average per 12-hour shift than Gimbels, as long as I work eight shifts or more per month (i.e. bonus for meeting target schedule).
• Patient load per hospitalist: 18-22, with some memorable 28-patient days which I find appalling. 
• My emotional landscape while on the job: resentful, despairing, but grateful to be working alone at night, when most of the nastiness has crawled back into its cave to sleep.
• Professional forecast: rainy, chance of thunderstorms.

Nordstrom

• Physical plant: small, single-level hospital, a lot like Gimbels but brand-spanking new. Located 75 minutes north of my home, just over my personal limit for a daily commute. Out of town hospitalists are barracked in a pretty tacky vacation rental apartment off the main drag.
• Patients: same as Macy's, except relatively fewer respectable middle-class.
• Services: no-frills. General surgery available, orthopedics some of the time, but otherwise nothing. Stress testing is done out of town. Patients requring pacemakers need to be transferred. A truly amazing case management staff is on seven days a week to facilitate transfer, and just two weeks ago they transferred six patients out on one day shift, including two patients to separate VA hospitals, which is something just short of walking on water, imho.
• AM labs done on time?: yes, and they land on the chart the hot minute the results come out of the lab. I don't have access to them on EMR but I have never wished to because the nurses slap those babies in front of me before I have time to wonder where they are.
• Hospitalist staff: mixed but overall pretty strong (B-plus to A-minus). A lot of out of town doctors who do long stretches at a time, including some old-timers who can handle anything. Long-standing site director is excellent and believes in treating staff hospitalists very well.
• Consulting staff: Practically nonexistent except for surgeons, therefore we're all nice and matey because there's nothing to fight about.
• ER staff: haven't met them all, but the ones I have are pretty sound. ER group is managed by the same staffing agency as the hospitalists, so the incentive to play nice and get along is strong. Haven't had any really stupid admissions here yet.
• Political landscape: fairly placid, except I don't know what goes on in the back rooms. No yelling and no trash-talking so far.
• Hospitalist per diem: 8.5% more than Macy's, no minimum shift requirement, and expected patient load is much more rational.
• Patient load per hospitalist: 12-15 per day, occasionally up to 22 but this is a rare event (unlike the regular event is has become at Macy's). Staff and site director freak out if I see more than 12, whereas I freak out if I see fewer than this number.
• My emotional landscape while on the job: placid, unruffled, mildly curious to see what will happen next. Seeing fewer patients per day means I don't get stressed out when family members show up late in the afternoon or patients want things explained to them a second or third time. Feels luxurious to me.
• Professional forecast: mostly sunny and cool.

I'm still getting my head around being a full-time hospitalist and no longer in the warm, dysfunctional embrace of dear old Gimbels. I'm trying to keep an open mind about Macy's, but it is difficult because of our stormy history and some recent events on night shift which have only confirmed my worst impressions of the place. With Nordstrom, I have no history and therefore no baggage, so it is easy to slip in here and appreciate the way the place works, and what it feels like to work at a hospital where quality of patient care is not only valued but provided the resources to thrive. I only wish Nordstrom was Gimbels, or perhaps what I really wish was that Gimbels were the hospital it should be. All in all, I'd settle for Nordstrom being forty-five minutes away from home, but I'm dipping into superhuman territory here and I'd better settle for what I've got.