"It was the best of times; it was the worst of times."
That quote, from Charles Dickens' historical novel "A Tale of Two Cities," is perhaps the perfect way to describe what it's like to work in a rural ICU.
Dr. David Grace, Senior Vice President and Group Medical Officer, SCP Health, agrees.
"A hospitalist working in a rural intensive care unit will see the best of times and worst of times," he said in an interview. "Intensivists are not really a role in rural ICUs, so hospitalists are usually the ones providing critical care. It's important that they know how to cope with the worst and make the most out of the best."
The Best of Times
Dr. Grace pointed out that a hospitalist working in rural medicine has the opportunity to single-handedly save the life of a critically ill patient, often with little or no support.
"In so much of our careers, we're part of a much larger team," he said. "But in rural ICUs, you may be a team of one. There may be no other physician in or near the hospital, aside from the ER doctor, which means you're likely delivering 100 percent of the critical care services yourself. In urban ICUs, you're only delivering 10 to 15 percent yourself."
Doing all the work to repair failing organ systems and seeing the patient through to discharge can be one of the most rewarding aspects of healthcare, Dr. Grace notes.
"You feel the difference you made in someone living or dying," he said. "In an urban setting, when you're one of ten doctors on the case, that feeling gets diluted."
The Worst of Times
Doctors in rural hospitals aren't always able to manage patients back to health, of course.
"When a patient's condition starts to deteriorate beyond your capabilities and help is hours or days away, you do what you can, knowing it may not always be enough," Dr. Grace said.
That's also not the only "worst" scenario — the time it takes to handle critical situations is another.
"If a patient gets worse or a situation escalates, it takes a much larger portion of your day because you don’t have other physicians to rely on," Dr. Grace said. "Your remaining workload is still all on you, so it can be a lot more overwhelming, and you have to be ok with that disruption."
Also, the skill set of nurses and ancillary staff is typically less developed and experienced in a rural environment, which can present an added challenge when confronted with a highly traumatic circumstance. The reason, according to Dr. Grace: “Rural staff don't see this as much, so are less adept at treating such patients.”
An additional challenge is the physical and emotional energy it takes to practice in a rural environment.
"You’re often the only person standing between the patient and death," Dr. Grace said, "and that can take a toll."
Making the ‘Worst’ Better
There are several steps that providers in rural critical care settings can take to prevent worst-case scenarios or turn a crisis around. Those include:
Building Relationships with Fellow Staff
"Those who work in rural hospitals may be more willing to step outside their comfort zones since they are all each other has," Dr. Grace said. "It’s important to have good working relationships everywhere, but it is imperative in rural environments to be able to work with and rely on the few people you have around."
He emphasized that of all the relationships a rural hospitalist should build, the one with the emergency room doctor is paramount.
"The ER doctor has many skills that hospitalists don't," he said. "If you need to insert a chest tube, for example, few hospitalists know how to do that, but ER doctors can."
Use of Telemedicine
Telemedicine, already a clinical staple in rural settings, brings specialists to the bedside virtually, providing much-needed assistance to patients requiring specialty care outside the hospitalist's capabilities.
Leveraging PAs and NPs
Nurse practitioners and physician assistants working alongside doctors can save a facility as much as 40 percent in provider costs versus a program staffed by physicians alone, making them a vital part of the continuum of care for rural hospitals that can afford additional staff.
Skills Needed to Make it the ‘Best’
Dr. Grace offered the following advice to doctors working in rural critical care:
- Be a strong clinician and focus on building and maintaining a great set of skills, particularly in key areas such as respiratory patients on ventilators, patients with severe sepsis, severe pneumonia, or chronic heart failure.
- Know the most common illnesses or issues you are going to see and prepare to deal with them well, even in stressful situations or with fewer resources.
- Concentrate on what you can do rather than the limitations that working in a rural ICU brings. You don’t want your admission rate to decrease because you’re negatively assuming that you can’t help with limited resources.
Best (and Worst) Time to Work in Rural Medicine
Dr. Grace said two scenarios represent doctors with strong clinical expertise that make them ideally suited to rural medicine: those coming right out of residency and those with extensive experience working in urban hospitals.
"Right after residency, the hospitalist is up to date on all specialties, and their knowledge level is high across a wide spectrum of illnesses, diseases, and issues," he said. " Also, after practicing in an urban environment for several years, a hospitalist has seen many different scenarios and witnessed how specialists handle situations."
Conversely, he said that doctors who come out of residency and work in smaller, more limited hospital settings for many years aren't well-suited to a rural ICU.
"You don’t see as wide a variety of patients, nor do you have the exposure to as many specialists to learn from," he said. "You don’t have that deep knowledge base (from residency) or deep experience (from urban/large hospital)."
Benefits of Working in a Rural ICU
There are a number of benefits associated with working in rural settings. Apart from the clinical rewards that Dr. Grace talked about, two, in particular, come to mind:
1. Better Standard of Living
Doctors may make more money in a large hospital, but the cost of living in an urban area can also be much higher contrasted by the lower cost of living in rural areas. Also, many states offer financial incentives to physicians willing to work in rural areas, including loan forgiveness and repayment.
2. Better Reputation
Doctors can impact the hospital’s community reputation and patient satisfaction in a rural setting more significantly than in a more populated area. The doctor becomes a familiar face and valued member of the community, trusted and appreciated by the patients he or she serves.
Working in a rural ICU presents an entirely different set of responsibilities, opportunities, and challenges for physicians than an urban ICU.
Hospitalists providing critical care are guaranteed to experience the best and worst. But, as Dr. Grace said, the key to success comes down to knowing now how to cope with the worst and make the most out of the best.
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