The idea of living in idyllic surroundings, with clean air and water, a temperate climate year round, and affordable housing was immediately appealing. Commercial fishing, the Georgia Pacific lumber mill, and the 48 bed Mendocino Coast District Hospital (MCDH) were the three major employers in 1989 in this Northern California coastal community of Fort Bragg. The hospital attracted patients from a population of about 18,000 from Westport to Elk and the inland areas between them. There was a growing senior population as retirees left the metropolis for the advantages of small town living.

In 1989, oncology patients had to travel 90 minutes along steep and winding roads to Ukiah or another hour along 101 south to Santa Rosa. These were the days before the 5 HT3 receptor antagonists for nausea prophylaxis. As a result, many patients chose to forgo treatment.

In 1989 there were only six surgical specialists: two orthopedic surgeons, two gynecologists who at that time also delivered babies, one ophthalmologist and one general surgeon. There were a number of internists and family physicians and one neurologist. There were also a fair number of nurse practitioners and nurse midwives who did primary care and home deliveries. Most of the primary care doctors had entered practice right out of training. I had the advantage of 13 years of oncology practice in the San Jose area before coming here.

Ninety percent of cancers could be treated here. Acute leukemia and malignancies requiring bone marrow or stem cell transplants would have to go elsewhere.

As for education, the Internet provided access to current treatments. Opinions from experts were an email or telephone call away. CME could be obtained through office or home study.

With the advent of the hospitalist work days were shorter, vacation planning was easier, and there were more weekends at home. Finding out that your patients would get excellent medical care with the hospitalist, reduced feelings of abandonment on both sides.

Differences have had more to do with the lack of specialists and the political environment in this rural community. In 1989 few physicians in Mendocino County participated in the Medicare program. There were also no managed care contracts. That rapidly changed as the local hospital negotiated contracts with major players like the Blues. Increasing numbers of medical staff members have also become dependent on the hospital for at least some of their income. In urban areas physicians remain in control by expanding their numbers in groups.

In rural areas political power often resides with hospital affiliation. However, if the hospital suffers financially because of inadequate payment from insurance contracts, so too do the doctors affected by those contracts. In addition, loss of the autonomy and authority of the medical staff through physician financial arrangements with the hospital, threatens the ability of physicians to advocate for their patients.

In 2004, Governor Schwarzenneger signed SB 1325 giving hospital medical staffs authority in matters of patient care. That authority could be compromised by financial conflicts of interest as in the case of physicians on the hospital payroll. Another area of conflict could arise from changes in medical staff and hospital bylaws such as the introduction of the disruptive physician clause. Though intended to weed out bad doctors, it has also given the hospital and its medical staff a way to get rid of physicians who represent financial liability for the hospital.

At one time, the ER wasn’t doing blood cultures on febrile patients sick enough to be admitted to the hospital as a cost control measure. Since the ER is the point of entry for sick patients, this could pose a problem for the oncologist taking care of sick febrile neutropenic patients. With the advent of cytokines and effective oral antibiotic prophylaxis, many complications of chemotherapy have been averted and the need for hospitalization greatly reduced. Also, patients can now be treated in the outpatient setting with infusion pumps obviating the need for hospitalization for continuous infusion chemotherapy. Solutions have come through working around the problem rather than by trying to enforce a change in perception.

Today, problems administering chemotherapy in the office have more to do with the cost of chemotherapy and reimbursement issues. At one time, membership in a specialty organization such as ANCO (Association of Northern California Oncologists) allowed purchase of drugs at competitive prices through a consortium of oncologists. Now, in most cases, only those who purchase drugs in bulk from distributors or directly from Big Pharma are getting competitive discounts. This leaves the solo practitioner or small group at a disadvantage. However, things may change if CAP (competitive acquisition program) becomes a reality. The chain pharmacies are big enough to take on the financial risks of these costly drugs. Physicians may have the option of charging for their services without having to be repositories for expensive chemotherapy.

I predicted an influx of physicians from the cities to the rural communities as doctors sought a better way of life for themselves. Seventeen years later this is happening. The community should continue to benefit from the knowledge and skills these new doctors bring with them.
Submitted by: Anne M. Smith, M.D. crabdoc@mcn.org

— By Anne M. Smith, M.D.

Posted on June 1, 2006 06:00 AM