Healthcare Deserts
I have recently written an article here on Substack about obstetric deserts in North Dakota, and although obstetric deserts and healthcare deserts have similarities, they’re not exactly the same. The problems with health care deserts are somewhat different and possibly not what you might expect them to be.
My first home was on a small farm in rural North Dakota. Unlike many physicians, I enjoy living in the country. The persons studying why rural areas have so much trouble attracting physicians usually blame physician wives for wanting to live in metropolitan areas (yes, I’ve heard this offered as a reason rural areas can’t attract physicians). True, there’s no concert hall, dance studio, symphony orchestra, or Walmart. But to me, I value feeling safe and having good neighbors.
Where I live, the population density is two persons per square mile. Farms usually have at least one light attached to an outbuilding which comes on at night. The light tends to keep predators away but more importantly, lights the path to the buildings after dark. At night I can see a sky full of stars and about 15 yard lights scattered across the many miles visible to me out my window.
Everybody knows that I have about 60 pet chickens and I give away the eggs, several dozen a week. The day before Thanksgiving, I got a call from a neighbor wondering if we could spare two dozen eggs. I give the eggs away, but out here people are hesitant to take something for nothing. She further said, “Can I trade you a pumpkin pie for the eggs?” I knew it was homemade. How could I refuse?
But there are problems with rural healthcare, problems which are easily repairable, but the repairs just never seem to happen.
The most difficult part of being a physician in a rural area is that we need to be a jack-of-all-trades, practicing medicine in many ways as it was done 50 years ago. Not so long ago, a medical student could do an internship for one year and immediately set up a practice. We still have some of these doctors in North Dakota. Many of them went to small communities where they did surgeries including mastectomies, cholecystectomy’s, appendectomies, hip repairs, c sections, obstetric care, deliver babies, manage of heart attacks, diabetes, cancer and all manner of illness.
At that time, there weren’t many differences between health care in rural areas and health care in urban areas. Sending the rural patients off to urban areas would have resulted in very similar care. Today many rural hospitals don’t offer surgeries, but in many ways, the practice of medicine still involves being a jack-of-all-trades. For the last two decades I have been this jack-of-all- trades doctor.
Most recently I have been in charge of five nursing homes, two hospitals, and four clinics. I was on call at least one weekend a month and one or two nights a week. So, at 73 years of age I was less inclined to want to be up all night and all day as well. And that’s one of the problems in rural healthcare. Those of us practicing in rural areas are getting older.
About 50 years ago the University of North Dakota and the North Dakota legislators decided to address the problem of medical care in rural areas. Graduating my OB/GYN residency in 1981, I became an assistant clinical professor, and later an associate clinical professor at the University of North Dakota. During most of that time I was the obstetrics director in what was called the South East AHEC or Area Health Education Center. In my capacity there, I taught the residents and students about how to do obstetrics in rural America. They learned labor and delivery and how to do a caesarean section. Unfortunately, most of these family practice residents chose practices in urban areas. Only a few went to rural areas. That program, although well-intentioned, did not increase the number of graduates choosing to practice in rural areas. The problem with rural healthcare is not so much recruitment, but rather retention. So, in the unlikely event that a young doctor tries to go to a rural area, how do we keep them?
Hospital CEOs
According to recent articles, in the last two decades hospital and clinic administrators have increased 3200 percent. How has this happened? Hospital boards have a large and sometimes thankless job. In my experience, they are often not up to the job. They are responsible for the quality of care in the hospital and overseeing the behavior of the CEO. In North Dakota, the responsibilities of hospital boards are defined by state law. I have worked in several hospitals where the flow of power is often inverted, with the CEO in charge of the board, the opposite of what is required by law.
Years ago, I met the CEO of a very nicely run nursing home. He didn’t hesitate to tell me that he could get his board to do anything he wanted them to. Therein lies the problem. There’s absolutely no downside for the under-performing hospital boards, which often don’t fully understand their role about how to run a hospital or how to hold the CEO responsible to standards of care. The state and federal governments need to design programs not only to teach the boards what they’re supposed to do, but also to make sure that the boards are actually doing what they’re supposed to be doing. Somebody should care.
In my experience, there is no board oversight. At one hospital I worked at I was Chief of Staff, but the CEO carefully kept me out of most of the largest portion of each board meeting. I suspect the CEO did this so the board members would not hear alternative approaches to the CEO’s agenda.
Most hospital boards make the mistake of looking at a CV and hiring someone based on the paper. Many people have a PhD in healthcare or a MA in business administration. That does not mean this person has the slightest idea about how to run a hospital. I have seen dozens come and go. Unfortunately, the hospital board doesn’t know how badly the hospital is being run until the hospital is 2 million dollars in debt.
Having a master’s degree in business admin doesn’t mean the CEO can actually lead. Having a healthy and constructive working environment where staff can feel safe and valued is vital to a hospital’s patient care. In my experience, I have seen more bully’s as CEOs than leaders who comprehends the value of hospital staff.
Some boards eventually recruit as a CEO someone who has worked at the hospital or clinic a long time, someone who’s a part of the community and loyal to the hospital. These people usually make the best CEO’s, not the ones who like to bully, have a fancy degree, demand a large salary, and live in a different city than their hospital.
Retaining Good Physicians
Years ago rural areas attracted and retained good physicians by taking good care of them. The story of Dr. Hordinsky and how the small town of Drake, ND, attracted and kept a remarkable physician is one any rural town should read. Unfortunately, when the story is told, the response is often “we don’t do things that way anymore.” Well, perhaps we should reconsider the way we do things in healthcare.
To retain good physicians, a hospital’s Board and CEO need to value them. In fact, I would recommend that any hospital board have at least one practicing physician as a board member.
I wrote about five reasons health care costs so much 30 years ago in Modern Medicine: What You’re Dying to Know. The five big players in the high cost of health care are still with us, only worse: CEO’s and big business medicine, health insurance, managed care, an artificially created nursing shortage, and the medical malpractice industry. All contribute to the decreasing access to health care rural or urban, but rural health care is more adversely affected because choice is missing.