Ronald F. Martin, MD, FACS, Consulting Editor
Many of you as you went through training in medical school, residency, or elsewhere may have heard the statement that people are divided into 2 groups when it comes to problem diagnosing: lumpers and splitters. I think a majority of surgeons tend more toward the “lumper” category as we frequently have to make decisions with incomplete data. As those of you who have read the forewords in the Surgical Clinics may have noticed, I tend to lump not just diagnoses of clinical processes but somewhat extend the problems we face as physicians and members of the health care industry to society at large. This foreword will be no exception to that. The topic we need to examine as we prepare to consider the issues facing rural surgery is that of reserve or perhaps the lack thereof.
As of the writing of this issue, we are finding our way through the middle of the pandemic’s transition from first wave to whatever we will agree to call the period when reopening led to and/or coincided with a resurgence of viral cases. Multiple analyses are being posited by the lay press about the similarities of disease spread of COVID-19 and our ability in the United States to respond to the disease comparing the period of mid-April 2020 with the period of early to mid-July 2020. Some of those comparisons are fairer than others. While the case number rises are reminiscent, the lethality is a bit different as are the hospitalizations, depending on where you look geographically. There may be good reasons for this difference. Perhaps we are better capable of detecting, isolating, and treating patients who are sick now than we were a few months ago. Perhaps testing is more available than it was, even if not as available as we would like. Perhaps younger people have led the charge of being the infected group as the weather warmed. Even if all those factors are at play, the factor that is likely more impactful in the difference between prevalence and lethality is reserve.
It was not that long ago, a few decades, that hospitals had physical stockpiles of supplies, had ample amounts of days-in-cash (that were intended to be used for emergency, not to prop up bond ratings), had adequate personnel in reserve to supplement staffing, and had available beds for surge capacity. These systems were less efficient than the ones we have now. With hospitals now functioning much more like other non–health care corporations, the ever-increasing demand for short-term financial performance and maximizing profit (spelled “margin” if you work for a 501c3 but treated pretty much just the same as for-profit entities treat profit), the reserves of these systems have been eroded.
Since the widespread adoption of the Internet that provided us with Amazon.com and other companies who sell via the Internet, along with their global supply chains, the idea of keeping inventory on hand when it can be ordered “just-in-time” has markedly vanished. Keeping on “expensive” full-time staff when one could use short-term temporary staffing to bolster periodic needs has been considered a cost too high. An empty hospital bed might be just as easily looked at as a poor productivity metric rather than as a strategic reserve. In short, many hospitals and health care organizations have stripped down their systems of “dead weight” in order to improve financial performance.
Hospital-based platforms and health care systems are not alone in this regard. The overwhelming majority of people in the United States act in a similar fashion. I have heard estimates that more than 95% of people in the United States would have to sell something to handle a short-term financial burden—like getting ill, for example. Many people have little to no financial reserve at home in case their job suddenly goes away.
Companies similarly rely on cheaper labor and products from the global supply chain assuming these chains will be adequately reliable—and if not, one can buy from another country who will provide cheap labor. These same companies who rely on just-in-time global supply chains frequently live and die financially based on quarterly reports. If they are publicly traded, they are forever hostage to algorithmic machine trading on the various exchanges, which magnify the effect of disruptive events in their business models.
All in all, as grim as the above may sound, it has actually worked pretty well for the past several years to few decades. It is a remarkable and remarkably connected system that allows many to benefit from the ability to transmit information and money instantly. As a result, companies can use this network to meet our collective needs. It should always work like a charm unless one thing happens—the whole system breaks at once.
Pandemics are fundamentally different from most catastrophic events in one major way. In most disasters, we try to colocate people and resources to improve our ability to cope. We increase personal contact and facilitate the movement of needed supplies. In pandemics, we try to dislocate and diffuse people as much as we can in order to prevent transmission of disease. We also disrupt travel and transport of goods. Diffusion and lack of contact by their very nature generate less efficient systems. Everyone needs to shelter in place with their stockpile to weather the problem. We can’t rely on one another for shared efficiencies. Panic buying begins along with hoarding on occasion. Disputes as to what services are essential and disruptions to workforce—either from disease or from competing burdens for family care—further decrease overall system efficiency.
All of these things mentioned above happened to hospital systems just as they did to other industries and to households, though, in addition, hospitals were expected to make ready for an unprecedented and unpredictable need for medical care secondary to a single disease process. In other words, hospitals had to spend a lot of money to prepare for a disease that may or not come their way in a hypercompetitive sellers’ market for supplies. All while halting the activity that brought in revenue in the first place. This last consideration is what brings us back to the concept of rural hospitals. Rural hospitals struggle to maintain resource capability for their constituent populations all the time. The main pressure relief valve is to transfer a patient who needs greater resources to a facility with greater capability. When those higher-echelon levels of care either lose capability (beds or staffing) or lose their ability to purchase supplies, the whole system begins to crumble. When every facility has to fend for itself, the rural hospitals are frequently the least financially capable of handling the burden—even if help from other agencies is imminent.
Over the years, larger hospital organizations, for various reasons, did not maintain their reserves of people, beds, or supplies. In my opinion, perhaps many of them felt that it was the responsibility of others to be prepared for such a calamity. In the case of one or a few hospitals suddenly being taxed by demand, the option to transfer patients or borrow supplies always seemed to be there. Or perhaps, it was felt that the government should be able to provide the required missing elements at low cost or no cost in unexpected situations. I can’t say I disagree with the concepts. One description of a government is that it is an insurance company with an army. I’ll grant that description is woefully incomplete, but there is some truth to it. The federal government, in the United States anyway, represents the last line of the collective “we the people.” If the collective resources of all of us can’t solve a problem, then there is truly big trouble.
A funny thing happened on the way to the National Strategic Stockpiles. We found out upon arrival that our strategic reserves were small fractions of what we believed them to be. We then turned to manufacturing and found out that our ability to “just-in-time” order was profoundly constrained, and our ability to “just-in-time” produce goods was crippled as well. The rest of the world found themselves in similar positions. In short, we had no reserve.
For rural hospitals to survive, they either need to achieve enough “critical mass” of their own to weather storms such as these or they need to be integrated into larger systems with such capacities. Both strategies are challenging when you compare the current structures for critical access hospitals and the differing structures for prospective payment system hospitals. It gets worse when you take into account for-profit and not-for-profit entities. Even if we were to amalgamate these rural care sites with larger organizations in some way, that would not assure that we would be better positioned in the future for unexpected demand in the future. After all, neither the large systems nor the state or federal governments were remotely prepared for this latest challenge. To be fair, nobody was prepared.
We could be prepared. I am not sure that we will, but we could be. We could understand the challenges to deliver health care to austere or low-population-density environments. We could understand how to best develop and maintain strategic supplies of equipment, medicines, and personnel. We could develop state and regional agreements with the federal government for sharing the burdens and providing for rapid distribution of scarce supplies. We could find a way to support higher levels of strategic preparedness for the larger or higher-capability health care centers to stop them from going broke if they tried to do so. We could revisit the nature of medicine as a business in the United States to assure that we have a system that is capable of delivering on its many promises. We could.
As with so many things, if you want to make progress, you have to understand the challenge. In this issue of the Surgical Clinics, Dr Tyler Hughes and his colleagues have prepared an excellent collection of reviews that will help any reader to better understand the capabilities and the challenges that rural hospitals have. I am deeply indebted to Dr Hughes for his efforts. He is valued colleague and a cherished friend of mine as well as of the entire surgical community.
At the Surgical Clinics, we have maintained a philosophy that we wish to deliver content in context. We wish to have breadth and depth in our writings and provide our readership with a product that will not just answer some immediate question but also provide the material to delve deeper into the mastery of the topic. We wish to provide the ability for people to find answers—or at least direction—to questions they haven’t thought to ask yet. I encourage the reader to consume these articles, but don’t stop there. Find a way to understand how you and your organization fit into the overall scheme. Understand what you may need and what you may contribute. Take an honest inventory.
As a nation, we collectively got caught somewhat flat-footed by SARS-CoV-2 (COVID-19). We are most likely better situated to handle the rise—at least for now—in July compared to where we were in March and April of 2020. Some of that is by extreme concerted effort, and some is by luck. A big part is that we were able to make some general improvements in reserve capability (at an enormous financial cost). However, we are a long way from addressing the original concerns we had that led to our extreme lack of reserve to respond initially. Our only real countermeasure in the earlier months of 2020 was to shut down society as we understood it in an attempt to give hospitals a chance to catch up. We transferred to lack of reserve problem of hospitals to the country at large, which was not unreasonable at that time. Some people had the reserves to handle the consequences of that strategy; some did not. Lives have been inexorably altered. We as a health care system need to find a way to be better prepared to handle all-cause hazards that our communities may require. If not because it is the right thing for us to do, then because we need viable communities as much as they need us. In fact, we are one and the same thing. Good luck and stay well. Thanks for all that you do.