PERS PE C T IV E
Rural Health Care
Rur al He alth C are
Thirty Miles at Sea Providing Consistent Care
in an Inconsistent Environment
Margot Hartmann, M.D., Ph.D., and Jason Graziadei, B.A.
S mall community hospitals
throughout the United States
are facing threats including low
volume, declining reimburse-
ments, and staffing challenges.1,2
Nantucket Cottage Hospital, a
19-bed facility and one of the
smallest hospitals in Massachu-
setts, must also navigate the com-
plexity of operating on an island
30 miles offshore, where the
year-round population of 15,000
swells to more than 60,000 dur-
ing the summer months.
There is no off-the-shelf staff-
ing model that works in the clin-
ical environment of our emer-
gency department (ED). The ED
provides care to more than 10,000
patients every year, but the ma-
jority of them present between
Memorial Day and Columbus Day.
Our ED team sees everything you
would expect at a community
hospital, plus more than our share
of tickborne illnesses (ranging
from routine to catastrophic),
whose incidence is far higher on
Nantucket than in many other
places in Massachusetts.3
The evolution of emergency
services on the island has been
dictated by the potential risk of
high-acuity, low-frequency events
for a small hospital with limited
human resources. For us, a mass
casualty incident is a van rollover
with 16 elderly victims or a car-
bon monoxide leak in an over-
crowded basement apartment.
Nantuckets location means that
medical transfers to a tertiary care
hospital on the mainland arent
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Copyright 2017 Massachusetts Medical Society. All rights reserved.
always possible. Inclement weather
or fog can prevent Boston Med-
Flight from making it to the is-
land, and in the post-9/11 world,
the Coast Guard isnt always avail-
able. The tricky equation of ap-
propriate and efficient ED staff-
ing4 is made more complex by
Nantuckets geography and sea-
sonality. So despite our low clini-
cal volume, we need emergency
physicians with high skill levels.
For the season on Nantucket,
when our population explodes and
the demands on our ED surge,
our answer for many years was
to put together a varied team of
board-certified physicians that
tended to come back year after
year with their families, but with
no guarantee on either side. We
were hiring 30 to 32 people from
Memorial Day to Columbus Day
in 2-week shifts in order to have
24/7 coverage. Though we were
certainly fortunate that a stint on
Nantucket was attractive to some
physicians and their families, we
had to house them, find ways to
accommodate them with their
dogs and their grandmothers, and
organize everything for their stay,
in addition to coordinating travel
on the ferries to and from the
island. A big part of the chal-
lenge was juggling these teams
amid the islands ongoing hous-
ing crunch.
We also had to manage physi-
cians expectations of work ver-
sus vacation discouraging the
perception that the assignment
would entail sitting on the beach
n engl j med 376;14 nejm.org April 6, 2017
The New England Journal of Medicine
thirty miles at sea
with a pager. Whereas urban and
suburban institutions may have
teams from cardiology, pulmonol-
ogy, psychiatry, and other spe-
cialties on call to support the ED,
our rotating ED team and the few
year-round island doctors were
our total resources. Some people
saw that limitation as a wonder-
ful opportunity to exercise their
problem-solving skills in a low-
resource environment, but not
everyone found it so thrilling.
So we ended up with a mix of
summer providers that we had to
reinvent every year, always under
pressure to get it right. Before
each summer, we would launch a
process involving recruiting, licens-
ing and credentialing, and man-
aging various logistic challenges.
It was not a way to create a cohe-
sive team; some visiting physi-
cians didnt have a real stake in
this place after they left.
In recruiting this team, it was
difficult to convey the types of
judgment calls that needed to be
made in a place like Nantucket to
physicians who would be here for
a very short time but were being
entrusted to provide care during
our highest-volume period. It was
anxiety-provoking to recognize
that we might not have the best
match between resources and pa-
tient needs or that a visiting doc-
tor might be on service with a
visiting nurse, neither of whom
was schooled in our particular
practice environment. These visit-
ing providers had to constantly
keep track of factors that might
PE R S PE C T IV E
be unfamiliar to them: What staff
members are on island and on
call? Is orthopedics here? Whats
the current volume? Will the
weather prevent MedFlight from
getting here?
Assembling the summer ED
team became increasingly diffi-
cult. The usual cadre was aging,
and some clinicians chose not to
return. Seeing that the model
that had evolved wasnt serving
us and couldnt be sustained, we
began to think about an alterna-
tive. Our chief medical officer
identified an emergency staffing
group MEP Health, now called
U.S. Acute Care Solutions
that, far from being daunted by a
new problem, was intrigued by
Nantucket and its unusual cir-
cumstances. Aiming to balance
delivery of high-quality medicine
an ever-evolving goal with
continuity provided by a core
team that understands the puz-
zle we face, we negotiated a trial
agreement. MEP Health became
the employer of the existing year-
Rural Health Care
Rur al He alth C are
And How Long Will You Be Staying, Doctor?
Heather Kovich, M.D.
Have I told you that Im
converting my garage into
a workout room? my friend asks.
We are roaming the compound,
our eyes fixed on the enormous,
changing sky, oblivious to the
tumbleweeds and empty plastic
bottles skittering across our path.
Im hiring one of the mainte-
nance guys to put down laminate
floors. Theyre even installing a
window.
The sun, down behind the
The New England Journal of Medicine
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Copyright 2017 Massachusetts Medical Society. All rights reserved.
round providers, including physi-
cians and physician assistants, as
well as some longtime summer
team members, and supplement-
ed them with rotating clinicians
from its higher-volume hospitals.
It took on responsibility for sched-
uling, peer review, and quality
metrics, while building awareness
of Nantucket-specific aspects of
clinical judgment, so that we no
longer have to constantly reorient
personnel. This model forces a
careful comparison between the
cost of subcontracting ED staff-
ing and the cost of directly hir-
ing six or more ED physician and
PAs, even if we could recruit
them to the island and figure out
how to enable them to buy into
the housing market. Most of all,
it takes advantage of the continu-
ity and stability of our year-round
ED base, while allowing us to
stay current as medicine evolves.
Now we dont have to worry
about filling our schedule for
next summer or about depending
on a locum agency for physicians
Carrizo Mountains, streaks the
sky in a saffron finale. Our dogs
chase a curious prairie dog back
into its den.
My mind turns over the impli-
cations of my friends home-reno-
vation project, and I am filled
with happy relief. We circle the
hospital and return to our street.
I cant voice my feeling shed
be disappointed that Id doubted
her commitment. Instead, I say,
Thats a lot of money to put into
n engl j med 376;14 nejm.org April 6, 2017
thirty miles at sea
whose quality we have no way of
judging in advance. Instead, we
can focus on becoming fluent in
the type of medicine that best
serves our island.
Disclosure forms provided by the authors
are available at NEJM.org.
From Nantucket Cottage Hospital, Nan-
tucket, MA.
1. ODonnell J, Unger L. Rural hospitals in
critical condition. USA Today. November 2014
(http://www.usatoday.com/story/news/nation/
2014/11/12/r ural-hospital-closings-federal
-reimbursement-medicaid-aca/18532471/).
2. Wishner J, Solleveld P, Rudowitz R, Para-
dise J, Antonisse L. A look at rural hospital
closures and implications for access to care:
three case studies. Kaiser Family Founda-
tion, 2016 (http://kff.org/report-section/a-look
-at-rural-hospital-closures-and-implications
-for-access-to-care-three-case-studies-issue
-brief/).
3. Massachusetts Department of Public
Health. Lyme disease surveillance in Massa-
chusetts, 2014 (http://www.mass.gov/eohhs/
docs/dph/cdc/lyme/lyme-disease-surveillance
-2014.pdf).
4. Collins M. Staffing an ED appropriately
and efficiently. American College of Emer-
gency Physicians, 2009 (https://w ww.acep.org/
clinical---practice-management/staffing-an-ed
-appropriately-and-efficiently/).
DOI: 10.1056/NEJMp1701449
Copyright 2017 Massachusetts Medical Society.
Rural Health Care
the hospitals house, but it sounds
awesome. I cant wait to see it.
This tension defines our lives
as rural primary care physicians.
Our patients put it the most
bluntly: And how long will you
be staying, doctor?
Over the past decade, efforts to
increase access to health care in
the United States have focused
on insurance coverage. Meanwhile,
a shortage of physicians is still
the limiting factor in rural com-
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