The Rural Surgeon: The burden of transfer

I have been on both ends of the phone call. I began my career at a several-hundred bed community hospital in a town without a university medical center. We took all the local knife-and-gun club incidents, and whatever other surgical emergencies might arise, while receiving phone calls from nearly every point of the magnetic compass. It’s easy to recall the sagging feeling when you realize more serious work is coming in on the helicopter from Podunk, USA, and you’re not off call for another few hours. These memories linger as now I’m the one making the phone calls. When I state that I am the one, I mean the one and only; this is solo general surgery practice and I’m the only general surgeon in my county.

When I do speak with colleagues kind enough to accept our patients, I feel relieved. But the burden of transfer doesn’t travel away with the patient in the ambulance or on the airplane. There always seem to be questions or looks of concern lately, and I don’t just mean from other medical professionals. Maybe it is an Internet thing, but everyone is a critic these days. We are being watched by more than partners and employers, more than payers and agencies, more than our government bean counters. Families, allied health professionals, and even nonclinical staff all have opinions about which patients stay and which leaves our 14-bed, critical access hospital. Gods may have once walked these halls, but nowadays it’s just me!

Of course, any interested party can also criticize my decisions to keep any particular patient; why would anybody restrict their furrowed glare only to transfers? When we keep patients at the edge of our practice, or perform a procedure that is only done rarely locally, we incite more than just the volume debate on the ACS Communities. Goodness – my wife has heard about cases I have done via town chitter-chatter before I even get home!

How does one deal with being whipsawed? This phenomenon is defined in the business world as being subjected to two difficult situations or opposing pressures at the same time. If you transfer, you are criticized. The only thing that changes are the critics if you keep and care for that very same patient! For many rural colleagues, being whipsawed is on the short list of job dissatisfaction drivers; somewhere behind the heavyweight champ of being asked to be in two different places at the same time.

Transferring a patient rarely leads to the lasting criticism that keeping an ill patient locally can. Obviously keeping a patient extends the time period where others can knowingly shake their heads in disbelief. That extra time allows us to educate staff and others as to why a patient with more than simple hernia or appendicitis is being admitted to our little hospital. We can detail why this is a really good thing for everyone – including the patient!

So many of our locals are elderly, and when we keep one for serious surgical illness, so much goes into that decision besides just the patient’s age and comorbid conditions. Immediate family, friends, or existing social support all must be examined and understood. A significant number of geriatric couples are only “independent” together; send one off for surgery a hundred or more miles away and the remaining spouse suffers measurably. Sometimes there is no local family, as nuclear members live in neighboring states or even overseas. I’m always surprised when my patients have trouble even arranging rides to and from our facilities for the routine procedures we do regularly. I think to myself, what will they do when the inevitable happens?

Our geography plays a serious role for those patients who don’t drive any appreciable distances. The mountains to our east are difficult to negotiate and west, well, you’ll get wet rather quickly. Going north and south on Highway 101 can be tricky during summer and dangerous any time in bad weather. I talk to some patients about sending them to Portland and I get looks in response like I’m proposing surgical care in some exotic foreign capital. Urban anxiety, traffic, and unfamiliarity with our largest metropolis make the 300-mile journey untenable for many of our patients; and the TV show isn’t helping our cause! Even cases that define themselves from the get-go as major university referrals return afterward and ask us to assume their postoperative care. Our patients often can’t make the trip to follow-up with the experts who provided their life-saving care.

Stretching our surgical muscles is obviously important for all ACS members. In bigger facilities you can see and sometimes scrub into fascinating cases in other subspecialties, or at least participate in discussions about such in the surgery lounge. I won’t attach a photo of the desk space that serves as my lounge, dictation station, bathroom, and locker. Let’s just say it’s probably not quite the same as many Fellows are used to.

For the rural solo practitioner, a bigger case, done perhaps with a medical student or just scrub technicians, may not be done as slickly as it would be by a surgical team approaching the same at the university. If the case can be done safely though, it pays dividends. After all, it could be tonight when a major car wreck happens, or a hemodynamically unstable abdominal sepsis case presents, and we are forced to do a serious case – perhaps surgery at the edge of my comfort zone or something we don’t do with frequency. Keeping some bigger cases makes those scenarios just a bit less scary.

I have been recruited as an advocate for our College, trying to influence those in our nation’s capital to reexamine the 96-hour rule as it applies to critical access hospitals. A phone call to my senior senator’s staff leads to a conference call and follow-up I remain involved with – a first in my professional career. One issue that resonated with D.C. staffers was recruiting my successor. How do we entice the young surgeon to a rural practice if all we do are lumps and bumps, appendectomies, and inguinal hernias? Regionalization of surgical care may be coming but that can’t excite our younger and future colleagues. In each of the last 2 years my third-year medical students parked here for their first rotation and got hustled into the OR to assist with emergency surgery. The enthusiasm was palpable and energizing, but one was a case that raised some eyebrows: pneumatosis intestinalis requiring two small bowel resections with anastomoses and an open abdomen in an elderly male. This fellow did great; I see him doing his grocery shopping these days. My perspective is that case enabled this year’s day 1 emergency, making the surgery safer here in rural America.

When we call to transfer a patient, please understand real thought and a piece of who we are as surgeons accompanies that patient. Transfer is very rarely a reflex action. Also, realize that not every case we keep is a weak fastball over the middle of the plate; sometimes we do real work here at the limit of our comfort zone, but we do so for myriad good reasons.

Dr. Levine is a general surgeon practicing in coastal southwestern Oregon. Despite growing up in Brooklyn and on Long Island in New York, he has been a practicing rural surgeon since 1999. Folks barely even notice the accent anymore!

I have been on both ends of the phone call. I began my career at a several-hundred bed community hospital in a town without a university medical center. We took all the local knife-and-gun club incidents, and whatever other surgical emergencies might arise, while receiving phone calls from nearly every point of the magnetic compass. It’s easy to recall the sagging feeling when you realize more serious work is coming in on the helicopter from Podunk, USA, and you’re not off call for another few hours. These memories linger as now I’m the one making the phone calls. When I state that I am the one, I mean the one and only; this is solo general surgery practice and I’m the only general surgeon in my county.

When I do speak with colleagues kind enough to accept our patients, I feel relieved. But the burden of transfer doesn’t travel away with the patient in the ambulance or on the airplane. There always seem to be questions or looks of concern lately, and I don’t just mean from other medical professionals. Maybe it is an Internet thing, but everyone is a critic these days. We are being watched by more than partners and employers, more than payers and agencies, more than our government bean counters. Families, allied health professionals, and even nonclinical staff all have opinions about which patients stay and which leaves our 14-bed, critical access hospital. Gods may have once walked these halls, but nowadays it’s just me!

Of course, any interested party can also criticize my decisions to keep any particular patient; why would anybody restrict their furrowed glare only to transfers? When we keep patients at the edge of our practice, or perform a procedure that is only done rarely locally, we incite more than just the volume debate on the ACS Communities. Goodness – my wife has heard about cases I have done via town chitter-chatter before I even get home!

How does one deal with being whipsawed? This phenomenon is defined in the business world as being subjected to two difficult situations or opposing pressures at the same time. If you transfer, you are criticized. The only thing that changes are the critics if you keep and care for that very same patient! For many rural colleagues, being whipsawed is on the short list of job dissatisfaction drivers; somewhere behind the heavyweight champ of being asked to be in two different places at the same time.

Transferring a patient rarely leads to the lasting criticism that keeping an ill patient locally can. Obviously keeping a patient extends the time period where others can knowingly shake their heads in disbelief. That extra time allows us to educate staff and others as to why a patient with more than simple hernia or appendicitis is being admitted to our little hospital. We can detail why this is a really good thing for everyone – including the patient!

So many of our locals are elderly, and when we keep one for serious surgical illness, so much goes into that decision besides just the patient’s age and comorbid conditions. Immediate family, friends, or existing social support all must be examined and understood. A significant number of geriatric couples are only “independent” together; send one off for surgery a hundred or more miles away and the remaining spouse suffers measurably. Sometimes there is no local family, as nuclear members live in neighboring states or even overseas. I’m always surprised when my patients have trouble even arranging rides to and from our facilities for the routine procedures we do regularly. I think to myself, what will they do when the inevitable happens?

Our geography plays a serious role for those patients who don’t drive any appreciable distances. The mountains to our east are difficult to negotiate and west, well, you’ll get wet rather quickly. Going north and south on Highway 101 can be tricky during summer and dangerous any time in bad weather. I talk to some patients about sending them to Portland and I get looks in response like I’m proposing surgical care in some exotic foreign capital. Urban anxiety, traffic, and unfamiliarity with our largest metropolis make the 300-mile journey untenable for many of our patients; and the TV show isn’t helping our cause! Even cases that define themselves from the get-go as major university referrals return afterward and ask us to assume their postoperative care. Our patients often can’t make the trip to follow-up with the experts who provided their life-saving care.

Stretching our surgical muscles is obviously important for all ACS members. In bigger facilities you can see and sometimes scrub into fascinating cases in other subspecialties, or at least participate in discussions about such in the surgery lounge. I won’t attach a photo of the desk space that serves as my lounge, dictation station, bathroom, and locker. Let’s just say it’s probably not quite the same as many Fellows are used to.

For the rural solo practitioner, a bigger case, done perhaps with a medical student or just scrub technicians, may not be done as slickly as it would be by a surgical team approaching the same at the university. If the case can be done safely though, it pays dividends. After all, it could be tonight when a major car wreck happens, or a hemodynamically unstable abdominal sepsis case presents, and we are forced to do a serious case – perhaps surgery at the edge of my comfort zone or something we don’t do with frequency. Keeping some bigger cases makes those scenarios just a bit less scary.

I have been recruited as an advocate for our College, trying to influence those in our nation’s capital to reexamine the 96-hour rule as it applies to critical access hospitals. A phone call to my senior senator’s staff leads to a conference call and follow-up I remain involved with – a first in my professional career. One issue that resonated with D.C. staffers was recruiting my successor. How do we entice the young surgeon to a rural practice if all we do are lumps and bumps, appendectomies, and inguinal hernias? Regionalization of surgical care may be coming but that can’t excite our younger and future colleagues. In each of the last 2 years my third-year medical students parked here for their first rotation and got hustled into the OR to assist with emergency surgery. The enthusiasm was palpable and energizing, but one was a case that raised some eyebrows: pneumatosis intestinalis requiring two small bowel resections with anastomoses and an open abdomen in an elderly male. This fellow did great; I see him doing his grocery shopping these days. My perspective is that case enabled this year’s day 1 emergency, making the surgery safer here in rural America.

When we call to transfer a patient, please understand real thought and a piece of who we are as surgeons accompanies that patient. Transfer is very rarely a reflex action. Also, realize that not every case we keep is a weak fastball over the middle of the plate; sometimes we do real work here at the limit of our comfort zone, but we do so for myriad good reasons.

Dr. Levine is a general surgeon practicing in coastal southwestern Oregon. Despite growing up in Brooklyn and on Long Island in New York, he has been a practicing rural surgeon since 1999. Folks barely even notice the accent anymore!

I have been on both ends of the phone call. I began my career at a several-hundred bed community hospital in a town without a university medical center. We took all the local knife-and-gun club incidents, and whatever other surgical emergencies might arise, while receiving phone calls from nearly every point of the magnetic compass. It’s easy to recall the sagging feeling when you realize more serious work is coming in on the helicopter from Podunk, USA, and you’re not off call for another few hours. These memories linger as now I’m the one making the phone calls. When I state that I am the one, I mean the one and only; this is solo general surgery practice and I’m the only general surgeon in my county.

When I do speak with colleagues kind enough to accept our patients, I feel relieved. But the burden of transfer doesn’t travel away with the patient in the ambulance or on the airplane. There always seem to be questions or looks of concern lately, and I don’t just mean from other medical professionals. Maybe it is an Internet thing, but everyone is a critic these days. We are being watched by more than partners and employers, more than payers and agencies, more than our government bean counters. Families, allied health professionals, and even nonclinical staff all have opinions about which patients stay and which leaves our 14-bed, critical access hospital. Gods may have once walked these halls, but nowadays it’s just me!

Of course, any interested party can also criticize my decisions to keep any particular patient; why would anybody restrict their furrowed glare only to transfers? When we keep patients at the edge of our practice, or perform a procedure that is only done rarely locally, we incite more than just the volume debate on the ACS Communities. Goodness – my wife has heard about cases I have done via town chitter-chatter before I even get home!

How does one deal with being whipsawed? This phenomenon is defined in the business world as being subjected to two difficult situations or opposing pressures at the same time. If you transfer, you are criticized. The only thing that changes are the critics if you keep and care for that very same patient! For many rural colleagues, being whipsawed is on the short list of job dissatisfaction drivers; somewhere behind the heavyweight champ of being asked to be in two different places at the same time.

Transferring a patient rarely leads to the lasting criticism that keeping an ill patient locally can. Obviously keeping a patient extends the time period where others can knowingly shake their heads in disbelief. That extra time allows us to educate staff and others as to why a patient with more than simple hernia or appendicitis is being admitted to our little hospital. We can detail why this is a really good thing for everyone – including the patient!

So many of our locals are elderly, and when we keep one for serious surgical illness, so much goes into that decision besides just the patient’s age and comorbid conditions. Immediate family, friends, or existing social support all must be examined and understood. A significant number of geriatric couples are only “independent” together; send one off for surgery a hundred or more miles away and the remaining spouse suffers measurably. Sometimes there is no local family, as nuclear members live in neighboring states or even overseas. I’m always surprised when my patients have trouble even arranging rides to and from our facilities for the routine procedures we do regularly. I think to myself, what will they do when the inevitable happens?

Our geography plays a serious role for those patients who don’t drive any appreciable distances. The mountains to our east are difficult to negotiate and west, well, you’ll get wet rather quickly. Going north and south on Highway 101 can be tricky during summer and dangerous any time in bad weather. I talk to some patients about sending them to Portland and I get looks in response like I’m proposing surgical care in some exotic foreign capital. Urban anxiety, traffic, and unfamiliarity with our largest metropolis make the 300-mile journey untenable for many of our patients; and the TV show isn’t helping our cause! Even cases that define themselves from the get-go as major university referrals return afterward and ask us to assume their postoperative care. Our patients often can’t make the trip to follow-up with the experts who provided their life-saving care.

Stretching our surgical muscles is obviously important for all ACS members. In bigger facilities you can see and sometimes scrub into fascinating cases in other subspecialties, or at least participate in discussions about such in the surgery lounge. I won’t attach a photo of the desk space that serves as my lounge, dictation station, bathroom, and locker. Let’s just say it’s probably not quite the same as many Fellows are used to.

For the rural solo practitioner, a bigger case, done perhaps with a medical student or just scrub technicians, may not be done as slickly as it would be by a surgical team approaching the same at the university. If the case can be done safely though, it pays dividends. After all, it could be tonight when a major car wreck happens, or a hemodynamically unstable abdominal sepsis case presents, and we are forced to do a serious case – perhaps surgery at the edge of my comfort zone or something we don’t do with frequency. Keeping some bigger cases makes those scenarios just a bit less scary.

I have been recruited as an advocate for our College, trying to influence those in our nation’s capital to reexamine the 96-hour rule as it applies to critical access hospitals. A phone call to my senior senator’s staff leads to a conference call and follow-up I remain involved with – a first in my professional career. One issue that resonated with D.C. staffers was recruiting my successor. How do we entice the young surgeon to a rural practice if all we do are lumps and bumps, appendectomies, and inguinal hernias? Regionalization of surgical care may be coming but that can’t excite our younger and future colleagues. In each of the last 2 years my third-year medical students parked here for their first rotation and got hustled into the OR to assist with emergency surgery. The enthusiasm was palpable and energizing, but one was a case that raised some eyebrows: pneumatosis intestinalis requiring two small bowel resections with anastomoses and an open abdomen in an elderly male. This fellow did great; I see him doing his grocery shopping these days. My perspective is that case enabled this year’s day 1 emergency, making the surgery safer here in rural America.

When we call to transfer a patient, please understand real thought and a piece of who we are as surgeons accompanies that patient. Transfer is very rarely a reflex action. Also, realize that not every case we keep is a weak fastball over the middle of the plate; sometimes we do real work here at the limit of our comfort zone, but we do so for myriad good reasons.

Dr. Levine is a general surgeon practicing in coastal southwestern Oregon. Despite growing up in Brooklyn and on Long Island in New York, he has been a practicing rural surgeon since 1999. Folks barely even notice the accent anymore!