Guest blog from Dr. Sarah Newbury, Chief of Staff of Wilson Memorial General Hospital, Marathon, ON
Mary is a 75 year old woman for whom I have been the family physician for the past 15 years. When I received her mammogram report 10 years ago which identified a cancer in her breast, she entered an active phase of care. Following her mastectomy at the regional tertiary centre, she began her chemotherapy, almost all of which was delivered locally in our outpatient department under the guidance of the oncologist in Thunder Bay and with my local supervision. During her visits for chemotherapy her labwork was drawn by the lab tech she has known for 20 years and the chemo itself was delivered by a nurse who has been part of our hospital for 25 years. When her COPD worsened a few years ago and she had a number of admissions in the year for her poor breathing, I saw her daily in hospital as her family physician, and at her bedside nursing care was provided by familiar nurses, several of whom she has known for years. Now she is developing dementia, and while I continue to see her in the clinic regularly, it will not be long before she is admitted to the chronic care ward of our hospital where I anticipate that I, and the nursing team that she knows, will continue to care for her in that familiar setting through that phase of her life’s story.
Mary is just one example of the many, many people in small communities served by community based family physicians working in small local hospitals. These citizens of small rural communities receive their hospital care in a familiar setting from a care team that they often know well through overlapping community circles, and that they trust to provide high quality, local, continuous, comprehensive care.
In the current era, as across the system we work to try to contain costs and create a sustainable health care system, there is great focus on the hospital environment. We talk about “hospitals” as though there are varying sizes of the same institution – small hospitals simply being miniature versions of large hospitals. But small hospitals are very different than their large urban counterparts in many ways.
The large hospital delivers secondary and tertiary level care – by its nature episodic and consultative with specialization within and between institutions. Small hospitals in rural settings are, by contrast, largely extensions of the primary care relationship with predominantly generalist family physicians providing comprehensive care across the spectrum of illness and in the context of the continuous physician patient relationship. In small communities, the small hospital serves as a support for the primary care doctor-patient relationship when the care required cannot be managed in office or home setting.
The need for added layers of “navigators” and “care coordination tools” are much less important when the small hospital provides the single point of entry to the system for such things as urgent after hours care, telemedicine, in-patient, chronic, obstetrical and palliative care and is often the home of many community based services as well.
When I consider an effective system, I believe that patients want a system built on good therapeutic relationships, a system that is easy to navigate and provides high quality, timely care. Health care providers want a system that is efficient for them to work within, that values their role and that allows them to provide high quality care within their scope of practice. Administrators of the system also want an efficient system that provides high quality, coordinated care of good value.
We need to see and understand the relationships that small hospitals have to their communities differently. The small hospital extends the primary care relationship in a way that enriches and supports the potential for high quality care. In Damariscotta Maine, (population 2218) which ranked most highly on one survey of US hospital safety this year, the staff attributed their good track record to the fact that the patients that they care for are their neighbours and their friends.
The relationships that are at the heart of small communities are at the heart of the work of small hospitals, too. Our small hospitals need to be seen through a different lens than our large urban hospitals, because the work that we do and the context of the primary care relationship through which we do much of it is different, and is efficient and valuable. We need to support small communities to anchor services in and around the hospital environment, continuing to build on the relationship the hospital has to the community and the relationships that patients have to the health care providers who serve them.