Island health care gets a shot in the arm

Martha's Vineyard hospitalists will be responsible for patient care on the hospital floor. — By Nelson Sigelman

Martha’s Vineyard Hospital is preparing to add three hospitalists — doctors who treat only inpatients — to the hospital staff. The program, which has seen wide acceptance in hospitals around the country, is designed to free hospital primary care doctors from the often time-consuming responsibility of admitting and discharging patients and on-call assignments, and to provide better continuity of care for inpatients.

Hospital officials expect to have the hospitalist program in place prior to the busy summer season, when primary care doctors and the emergency department face additional demands.

“The one thing we hear loud and clear from the Island community is that it’s really hard to get a doctor,” Tim Walsh, Martha’s Vineyard Hospital chief executive officer told The Times. “The hospitalist program is a significant investment, but it’s really what we have to do in order to open up the primary care practices and at the same time, provide excellent inpatient care at the hospital.”

Last Friday, Mr. Walsh, along with James Ferriter Jr., director of physician services, and Dr. Jeffrey Zack, head of emergency services, sat down with The Times to discuss the far-reaching benefits that the new physicians will provide to the hospital, to Islanders, and to overstretched primary care doctors.

Mr. Walsh estimates the hospitalist program — three physicians and two mid-level support personnel, most likely a physician’s assistant and nurse practitioner — will cost about $1,000,000 a year. Some of the costs will be offset because primary doctors will be able to see more patients, and because the hospital will treat more patients who would otherwise have been sent off Island.

At the end of the day, the program will lose money, Mr. Walsh said, but he thinks that in this case, there’s much more to consider than the bottom line. “This is going to provide for better quality of care for patients across the board,” he said. “Overall, the community is going to get more access to health care, which is what the community has been asking for. The community is going to win on this one.”

Protocol overhaul

Large city hospitals started using hospitalists in the late 1990s. Over time, hospitalists have also become increasingly important in meeting the demands of smaller, rural hospitals such as MVH, which qualify as critical access hospitals.

The 10 primary care doctors on the Martha’s Vineyard Hospital staff maintain a grueling schedule. They’re responsible for outpatient care in offices that are stretched to capacity. They diagnose and supervise care of inpatients — they order and read tests, they confer with specialists, and they have conversations, sometimes very difficult ones, with patients and their loved ones.

“It’s unusual in this day and age to do both inpatient and outpatient medicine,” Dr. Zack said.

Primary care doctors at the hospital also supervise the crucial transition from the emergency room (ER) to the hospital. They also eventually oversee the patient’s discharge from the hospital and they deal with a mountain of paperwork along the way. They’re also on 24-hour call once every other week, and in addition, every tenth weekend they also supervise inpatient care for the entire hospital.

“When you’re in a practice where you have outpatients scheduled every day and you’re on call for the inpatients, it’s a bear,” Mr. Walsh said.

Under the current system, a primary care doctor might have to admit a patient to the ER at 1 am and be at his or her outpatient office clinic early the same morning.

The addition of staff hospitalists will dramatically change this dynamic.

“The primary care doctors are all really embracing this.” said Mr. Ferriter. “They’ll be able to take care of more patients and see them more quickly. It will also make doctors at the hospital more available to speak with family members. Before, they’d have to wait until the primary care doctor had time to leave his clinic. Now the doctor will be right there.”

Dr. Zack noted that with more time for patients, staff doctors might help their patients avoid the need for hospital care. Under the new system, the hospitalist will be the de facto primary care doctor for any patient who doesn’t have one. The addition of these three doctors also means that there will now be a doctor on premises at the hospital, 24/7, 365 days a year.

“You can make a case that for every inpatient admission a primary care doctor does, they can see four to five outpatients” said Dr. Zack. “When a primary care doctor has to see a patient in the ER and get them upstairs, that can take over an hour — so now that hour gets pushed upon the rest of the patients. Nobody’s happy about it, and it creates a lot of stress for the doctors and you’re apologizing all day long.”

Positive side effects

A hospitalist can spend more time with an inpatient than a harried doctor with an angry waiting room awaiting them.

Because of their added expertise, hospitalists are expected to save some Islanders the inconvenience, expense, and rigor of going to the mainland for treatment.

“When someone gets sick, they don’t want to leave the Island,” said Dr. Zack. “Traveling is hard, getting back is difficult. Now we’re bringing in physicians that have the talent and experience to deal with sicker patients.”

Hospitalists will also facilitate a smoother transition for patients from the ER to the hospital. They will work in close concert with Dr. Zack, which is part of the reason Mr. Walsh chose him to spearhead the hiring process.

The handoff — transferring a patient from the ER to inpatient care, then from one shift to another — is a critically important procedure that’s vulnerable to error, he said.

“When you involve more people, you’re opening yourself up for more risk for something going wrong, maybe somebody forgets to tell somebody something,” said Dr. Zack. “You reduce your risk by consistency, by who’s taking care of that patient. Shrinking it down to three people significantly reduces the possibility of error.”

Dr. Zack noted that upcoming Medicare funding will depend, on some measure, on the timing and efficiency of the ER to hospital transition. “It’s in everybody’s best interest to move that process along,” he said.

The current discharge process is not efficient. Hospital patients can’t be released until the primary care doctor signs them out, which in itself can be a lengthy process. Although a morning discharge is ideal for both outgoing patients and for the hospital, a primary care physician who’s having a chaotic day may not get to the hospital until early afternoon. “Since the hospitalist will be available at 6 am, we can ensure a morning discharge, which will open beds more quickly,” said Mr. Ferriter.

“We don’t have a lot of beds, and sometimes we have a lot of sick patients, so this is important,” said Dr. Zack.

Docs to the rock

Dr. Zack said the hiring committee has been pleasantly surprised by the number and the quality of applicants for the hospitalist positions.  In addition to evaluating their medical qualifications, Dr. Zack, who arrived in 2002 and lives in Oak Bluffs with his wife and three children, also tries to evaluate their Island adaptability.

“We make sure they know the Island factor, the cost of living, the isolation, and we hand them a Real Estate Guide,” said Dr. Zack with a laugh. “There’s also certain challenges to being a doctor here, like the lack of specialists. You have to be able to think through problems yourself. You can’t call neurology or cardiology. From a medicine standpoint it’s one of the wonderful things about being here, but it’s also one of the difficult things. We’re very lucky, the hospital has a great nursing staff, people that work here genuinely care about the community and it shows. We have a brand-new hospital, great equipment, it’s not a hard sell from a job standpoint. But life is more than just your job. We want someone who’s going to be happy here.”

Dr. Zack said they are close to making offers and they hope to have the hospitalist program up and running by May 1. He also said finding the right people takes precedence. “We want to get the primary care offices open as soon as possible, but not at the expense of hiring the right people,” he said.