Rural hospitals are struggling in many areas, in part because the Critical Access Hospital (CAH) designation was created by the Centers for Medicare and Medicaid Services (CMS) to make rural hospitals band-aid stations. CAH staff is there to triage patients and send most to specialists in metropolitan hospitals. As with many CMS schemes, all the CAH designation did was kill the effectiveness of many vital, necessary, and very good rural hospitals. Almost the first service to go is obstetrics. Too risky, the management claims. The pregnant mother who must travel a hundred miles one way to deliver her baby is the one at risk here.
Loss of Obstetrics Radically Changes Hospital Environment
Once the rural hospital nurses have lost their obstetric or operating room skills, the CAH hospital is left with nurses who seldom see much because everything gets sent off to the metropolitan hub. Before long the nurses become afraid of many procedures considered standard nursing care in metropolitan areas, from care of a pic line to how to debride a gangrenous wound.
Nurses training has changed radically in the past 30 years, according to a retired nursing manager I know. Much of the practical nurses training used to be based on actual hospital experience with nursing students making rounds with an instructor. This kind of practical experience has been largely replaced with book learning. One young nurse told me she had found her nurses training mostly about how to do electronic medical records and how to—and these are her words—“lie” in the charts to cover up mistakes. Indeed, in some hospitals it’s hard for a physician to find a nurse willing to make rounds at all. The nurses are too busy writing in the electronic medical records (EMRs). The ward clerks who used to do the secretarial work for the nurses are long gone.
CAH Hospitals Become Band-Aid Stations
Working environment changes a culture, sometimes for the worse. In many CAH hospitals, at least in rural North Dakota, the working environment provides little chance to learn and grow. Sometimes, when a rural practitioner calls to request a metropolitan ER physician accept a patient, the response can be less than cordial. The distant ER physicians response might be “We can’t admit patients with abdominal pain.” Bad response, though probably looks good on a checklist somewhere. The pain isn’t the issue. The cause of the pain is. This kind of response doesn’t help the rural physician who has already looked for the many usual reasons of this kind of pain and has decided to ask the experts for help. Patients die when doctors assume there’s nothing wrong because they don’t fit narrow checklist patterns of practice. This is especially true with elderly patients.
My point is that rural hospitals serve patients with very different demographics than metropolitan hospitals, even within the same state. Indeed, rural hospitals in South Carolina are going to serve patients with very different demographics than rural hospitals in North Dakota. Like all “evidenced-based” decisions, subjects which don’t fit the pattern are tossed out of the metrics to avoid messing up the purity of the data, the meaningful use metrics, or to avoid penalties for “inappropriate” hospital admissions.
Much Exercise and Often High Levels of Pain
People in North Dakota are largely farmers and and ranchers and they work hard most of their lives. They don’t have to go to the gym to exercise. As my uncle told me at the age of 80, he had hauled hay for over 60 years and he figured that was “plenty good enough.” Furthermore, in rural North Dakota, the elderly can often live on their own and remain independent far longer than they can in cities. With little traffic on the roads, they can drive to town and get their own groceries well into their 90s if they choose. Anyone they pass on the gravel roads probably knows them and might even stop the car, open the window, and chat a bit before moving on.
Besides getting plenty of exercise, farmers and ranchers are often subjected to a lot of physical pain. They can develop a tolerance for pain which isn’t understood in metropolitan areas. They may not lose a hand to their farming equipment, but trying to keep farm machinery working often involves tools that slip and catching fingers and hands between tools and equipment. Then there’s the cattle which can kick ranchers on a fairly regular basis. And finally, farmers in North Dakota are exposed to extremes of temperature few willingly tolerate. They still have to feed their animals even if it’s 30 below outside.
Tractor accidents are frequent in farming communities. A rancher working on a fence line was knocked off his tractor. A wire under tension unexpectedly broke loose, knocked him off the tractor, and while he was unconscious, drug him many yards before the tractor stopped. When he regained consciousness, he knew he was alone, he wasn’t going to be able to find his cell phone, and knew he would die if he didn’t get help. So he crawled as best he could back up on the tractor, started it, and drove himself home, where he could find someone to drive him to the ER.
As he entered the ER, anyone could see the skin on both cheeks had been scraped off down to the bone, on one side perilously close to his eye. While the ER doctor was calling a metropolitan hospital to arrange for a transfer to a trauma center, the nurses removed his shirt. They were shocked to see the wire had cut a deep gash across his midsection. One lung was clearly visible and they could see his heart beating among the many broken ribs. Amazingly, the patient never lost consciousness once he woke up in the field and crawled to his tractor.
When farmers or ranchers wind up in the ER, the pain scale of 1-10 can be relatively meaningless. Chances are they passed 10 long before they showed up in the ER. I doubt anyone in the ER asked this patient the ubiquitous question about how much pain he was in on a scale from 1 to 10. But I strongly suspect the meaningful use folk gave a demerit for the oversight.
North Dakota is the home of John Thompson who lost him arms in a farm accident. His parents weren’t home, so when he woke up, he made his way to his house, dialed 911 with a pencil in his teeth, and sat in the bathtub waiting for the ambulance to arrive. He didn’t want to get blood all over his mother’s new carpeting. It should be noted that John Thompson was first taken to a rural hospital to be stabilized before being sent on to a trauma center, although at that time, there were no CAH hospitals. Rural hospitals were often community owned and operated, and offered obstetrics and surgery as well as stabilization of trauma patients before their transfer to trauma centers.
My point, besides the uselessness of a lot of meaningful use data? The metropolitan perspective on patients from rural areas—and of rural hospitals— is often seriously flawed.
Treating the Elderly
In a hospital full of specialists, a 95-year old diabetic patient with poor circulation and sores on her heels will find her age a serious impediment to receiving simple, effective treatment of her feet. With poor circulation in her extremities, the specialist suggestion may be to simply amputate the leg above the knee. After all, at this age, the assumption is the woman isn’t going to live much longer anyway. No matter that she is totally oriented times three and living independently. If she refuses the amputation, it’s possible the specialists will get angry at her “non-compliance.” In this situation they may call the rural primary care physician and ask if the rural hospital can provide comfort care for the patient who it is assumed will die from the gangrenous sores on her feet.
What ever happened with “do no harm”? And what ever happened to simple, non-invasive care? Or patient choice?
Healthy, 95-year old patients should be able to refuse invasive care by specialists and not be punished for choosing a level of care the specialists aren’t willing or able to provide. This woman’s foot sores were serious, but treatable with debridement and proper wound care. But this was not offered in the metropolitan hospital. Instead, the rural hospital physician was called, not to see if wound care could be provided, but to see if the rural hospital could provide “comfort care” as she died.
Watch and Wait
Increasingly, the standard of care is becoming “watch and wait” on one test after another. In areas in which people live long and often healthy lives, this serves no purpose except to let the patients die from diseases that would have been curable if tested for and treated earlier. In our rural area, an 85-year old man may be told that his kidney cancer doesn’t need to be treated because he will die from other causes. In rural areas where people often live long lives, this is a dangerous assumption on the part of physicians. This patient may easily live long enough to die from untreated metastatic kidney cancer.
The CAH hospital designation has turned often useful, effective rural hospitals which offered vital services to their communities into what the hospitals in the early 19th century were—places where people went to die.
It’s time to stop bemoaning the death of health care in rural communities, including the closing of numerous rural hospitals. It’s time to start looking at ways to build thriving, productive relationships between the physician specialists in metropolitan areas and the many competent rural practitioners who know their patients’ histories. Part of the building of this working relationship may be as simple as specialists going to the rural hospitals regularly to see patients. Not just once or twice a month, but several times a week, as in this University of Iowa outreach program.
The city-physican/country-physician relationship needs to be one based upon respect for both the rural practitioner and his or her knowledge of the patients and their stories. Metropolitan specialists can provide specialty services patients need, but without patient stories, the specialists, even if they refer to the patients by name, really only know their patients as “the broken femur” or “the hot appy.”
The road between the rural physician and the specialist at a distant hospital requires the respectful meeting of the two, and most importantly, the transfer of patient story. That vital information from the primary care physician seeking a specialist to accept a patient won’t be found in the “evidence-based medicine,” the checklists, the standard of care, or the electronic medical records. Until physicians, rural and urban, meet on the yellow brick road of patient story, and take back the practice of medicine, our health care system will remain what CMS has wrought: constant belittling of physicians for over-testing and over-charging, much public relations noise about physician “fraud,” and denying patients care by turning the practice of medicine into evidence-based checklists.
It’s time to put patient story back into medicine.
This can only be accomplished when physicians take back the practice of medicine.