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Small city health care quality
Old 12-22-2013, 07:17 AM   #1
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Small city health care quality

Not wanting to derail the New Mexico thread. The following members made a couple great points deserving discussion:

Originally Posted by NW-Bound :
The problem with living in a small town anywhere is lack of advanced health services when one gets older. It may not be a big problem when one is in the 50s or 60s, but by the time people are in the 70s, many health issues surface. Of course, some unfortunate people need advanced healthcare quite early, way before their 70s.

Meirrlde replied:
Of course this depends on the size of the region. If you get up to 20-30k then you have reasonable options all be it no level 1 trauma center (they fly folks to San Antonio for that). If you have a big city 60-80 miles away if you need that kind of care you are close enough to get at it. (In some small towns in counties of 4k folks you have to leave town even to find an OB/GYN.


My wife and I are trying to figure where to move for ER in a few years. Neither of us like big cities but we keep seeing the 'best hospital' type studies and are questioning the quality of care in the smaller cities we prefer.

I had colon surgery at a a 'best hospital' facility in the Boston area last summer. The surgeon was great but the quality of care at the big city hospital was much worse than when I had other surgery a few years back in Pac NW suburbia smaller hospital. It felt like I was just a number and that the staff was stretched too thin. Might just be the Boston personality differences compared to the west but I guess that's a different discussion...

With the transfer of technology, flow of information and training available today, are the smaller city hospitals significantly different than the big name hospitals? Have the big research hospitals always been less personal? How much of quality health care is having the absolute top experts on your case vs. having caring, qualified people close to an area you want to live? Can you find high quality care in smaller cities or do you need to be close to the big University hospitals?
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Old 12-22-2013, 07:28 AM   #2
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Yeah, we are in a very small town where the nearest emergency facilities (also in a fairly small city of about 6,000) are about 25 miles away, and it's only a Class 4 trauma facility. And in reality, many patients going there are quickly sent off to Victoria or even to San Antonio, depending on the severity of the situation and the availability of appropriate staffing and equipment. Depending on your circumstances, you may be better off just driving an additional 25 miles to Victoria.

I would imagine it's this way in most small town hospitals. Triage what you can, and what you're not equipped to handle on your own, transfer them to the city.

As far as non-emergency considerations, even most of the general practitioners are about 25 miles away from here. And when a specialist is that close (instead of in Victoria), they are usually only there one day a week. And yet, this area is significantly overrepresented by elderly and very elderly (80+).
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Old 12-22-2013, 09:30 AM   #3
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That was one of the factors we considered when moving from the DC area. There is one hospital close by (10-15 minutes) that I think is a level 1 trauma center, and another within 30 minutes, and a third - not sure if it's a trauma center - that has a good rep for cardiac issues that is 30 minutes the other way.
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Old 12-22-2013, 10:21 AM   #4
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Originally Posted by woodguy00 View Post
I had colon surgery at a a 'best hospital' facility in the Boston area last summer. The surgeon was great but the quality of care at the big city hospital was much worse than when I had other surgery a few years back in Pac NW suburbia smaller hospital. It felt like I was just a number and that the staff was stretched too thin. Might just be the Boston personality differences compared to the west but I guess that's a different discussion...

With the transfer of technology, flow of information and training available today, are the smaller city hospitals significantly different than the big name hospitals? Have the big research hospitals always been less personal? How much of quality health care is having the absolute top experts on your case vs. having caring, qualified people close to an area you want to live? Can you find high quality care in smaller cities or do you need to be close to the big University hospitals?
I dated a Physician's Assistant who worked at the largest healthcare network in the St. Louis area. The main hospital campus is known for having the top surgeons/cancer care in the area, but she said that if she ever needed to go in for something, she'd want to go to one of their smaller hospitals they staffed rather than the main campus. Her reasoning was similar to yours, where it's more 'clinical' and teaching-based, rather than feeling like you're being attended to by the staff to help you get better.

While you are subject to receiving 'substandard care' at any facility (depending on the particular staff that is assigned to you, and their varying levels of competency and concern for their patients), as others have commented on other healthcare threads, you'd likely want to go to major medical facilities that specialize in critical/important procedures for that procedure.

So if you have a broken bone, you'll likely get better attention at a small town care center compared to a big(ger) city hospital. Same could be guessed for care from the staff if you're admitted before or after a procedure - possibly better attention/care from a smaller town.

However, for the actual surgery/procedure, I'd want to go to the big city for the actual work being done to me, since those who perform the procedure the most will probably have the best skills and best chance at doing it the best. While your after/recovery care and attention at a big city/institution may lack a little bit, I'd rather feel less than impressed with recovery care and attention after a very successful surgery or scope procedure, than be waited on hand and foot after a not-so-experienced surgery!
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Old 12-22-2013, 10:35 AM   #5
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I'd like to add another element to the small/larger town medical discussion.

When you retire to a new city you have to find all new Doctors. I've had the same Doc for over 10 years, I can always see her in an emergency and she knows the best Docs if I need surgery. I would lose all of this knowledge and our caring relationship if I move to another city. So, I'll stay where I'm at most of the year and spend a little time in a 2nd home in a warmer climate.

This philosophy really is paying off. I needed back surgery and I now need cataract surgery next year. The surgeons she recommended are great.....they are busy and won't take any patients without a referral from a Doc they work with. I can't believe how great the back surgery went.....it was a spinal fusion.....compared to others that have had the same surgery.

I just wanted to add this thought to the health care discussion. I'ts why my DW and I won't consider leaving the city we live in.
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Old 12-22-2013, 11:28 AM   #6
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Wow what a great topic. I'm in a small town outside a metro area. Level 2 trama center 7 miles away. Two level 1 trama centers 25 miles away.

My recent stay at the level 2 trama center, 7 miles away, not ever going there if I have a choice. I'm currently waiting patiently for the administrative staff to call me back regarding a screw up they made, that could have been very serious. If they don't, I'll be writing the CEO letters or posting on social media(someone here gave me the idea).

That said for major issues I'd rather have a broad choice, like I have here. If I lived where I grew up, lack of facilities and trained medical staff would concern me. DF was denied testing as there were only 6 beds in the county certified to do it. Few hours away they might have a bed in a few weeks.

I too, fear my Dr. of 13 years retiring. He's 7 years older than me so I know he'll retire some day. He did tell me he uses E.D.J. as his FA, so maybe not to soon.

I do agree, based on the condition, a smaller facility may be better. For more serious conditions, you may be a number.
Maybe that's ok for serious conditions, if you get the proper care.

MRG
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Old 12-22-2013, 01:39 PM   #7
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However, for the actual surgery/procedure, I'd want to go to the big city for the actual work being done to me, since those who perform the procedure the most will probably have the best skills and best chance at doing it the best. While your after/recovery care and attention at a big city/institution may lack a little bit, I'd rather feel less than impressed with recovery care and attention after a very successful surgery or scope procedure, than be waited on hand and foot after a not-so-experienced surgery!
A friend lives in Tacoma, a pretty good sized city of 200,000 in the city limits and a much larger feeder area of surrounding suburban development on the mainland and across the Tacoma Narrows Bridge . He needs heart valve surgery, and there are no docs down there who do the newer and less traumatic procedure called trans-catheter aortic vale replacement. His cardiologist does not even have referral relationships with centers up here which do this surgery.

So community hospitals have their advantages, but it may need to be a fairly large community depending on what sort of work is needed.

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Old 12-22-2013, 01:44 PM   #8
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So if you have a broken bone, you'll likely get better attention at a small town care center compared to a big(ger) city hospital. Same could be guessed for care from the staff if you're admitted before or after a procedure - possibly better attention/care from a smaller town.

However, for the actual surgery/procedure, I'd want to go to the big city for the actual work being done to me, since those who perform the procedure the most will probably have the best skills and best chance at doing it the best.
This is how most folks here and in the last small town I lived in did it. They might go to the small town ER to get pain relief or to get some treatment started, but then prepare to transfer to a big city hospital for subsequent surgical procedures.
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Old 12-22-2013, 03:08 PM   #9
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This is how most folks here and in the last small town I lived in did it. They might go to the small town ER to get pain relief or to get some treatment started, but then prepare to transfer to a big city hospital for subsequent surgical procedures.
I suspect it somewhat depends also on the demographics of the area. If a large population of elderly are there then the local practitioners are up on things like heart attacks and the like. If the local hospital does not feel up to something they will transfer the patient to San Antonio (this happened to my mother in 2003, all be it the care at the hospital in San Antonio with respect to discharge was terrible). (Local nursing homes would also not take an admit from an San Antonio physician).
Now sooner or later choice will be restricted by insurance saying we will pay $x for a procedure, and here is where you can get it for that price, some plans will even pay travel expenses and hotel for a companion while away. (This relates to a factor of 3 difference in pricing between hospitals).
On the topic in question it should be noted that the University of New Mexico in Albuquerque has a medical school. If one looks at a 90 mile radius you get Grants, Santa Fe, Moriarty, and Soccoro.
Here it should be noted that serious accident trauma cases get flown to San Antonio, but other types of emergencies are handled locally.
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Old 12-22-2013, 03:48 PM   #10
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I too, fear my Dr. of 13 years retiring. He's 7 years older than me so I know he'll retire some day. He did tell me he uses E.D.J. as his FA, so maybe not to soon.
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To me that is a hazard of a smaller town with fewer doctors, you get 'stuck' with the same doctor for years. I've seen relatives of mine who loved their doctors and stuck with them until the bitter end. But for the rest of the family, it appeared that their eventual death was hastened by sticking with the same 'quacks'. It is worth it to see other doctors now and then, but that is difficult in small towns.
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Old 12-22-2013, 07:45 PM   #11
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I suspect it somewhat depends also on the demographics of the area. If a large population of elderly are there then the local practitioners are up on things like heart attacks and the like. If the local hospital does not feel up to something they will transfer the patient to San Antonio (this happened to my mother in 2003, all be it the care at the hospital in San Antonio with respect to discharge was terrible). (Local nursing homes would also not take an admit from an San Antonio physician).
Now sooner or later choice will be restricted by insurance saying we will pay $x for a procedure, and here is where you can get it for that price, some plans will even pay travel expenses and hotel for a companion while away. (This relates to a factor of 3 difference in pricing between hospitals).
On the topic in question it should be noted that the University of New Mexico in Albuquerque has a medical school. If one looks at a 90 mile radius you get Grants, Santa Fe, Moriarty, and Soccoro.
Here it should be noted that serious accident trauma cases get flown to San Antonio, but other types of emergencies are handled locally.
Your point on being in an area with extensive retiree populations may be key. Being in a stagnant area without a lot of retirees sounds like a recipe for bad care.

I still wonder if the quality spread in practioners from area with 50,000 population to the hospitals in big cities is really all that big. Maybe the issue is being in a town of 2000 or 5000 in the middle of nowhere. Thinking about growing up in the midwest, people with major cases ended up at the U of I hospital in Iowa City or at the Mayo Clinic. My parents when elderly were treated (competently I believe) for bypass, cancer treatment, etc in Dubuque a city of 60K if I remember correctly. Certainly not a retirement destination but an aging population.
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Old 12-22-2013, 08:09 PM   #12
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Your point on being in an area with extensive retiree populations may be key. Being in a stagnant area without a lot of retirees sounds like a recipe for bad care.

I still wonder if the quality spread in practioners from area with 50,000 population to the hospitals in big cities is really all that big. Maybe the issue is being in a town of 2000 or 5000 in the middle of nowhere. Thinking about growing up in the midwest, people with major cases ended up at the U of I hospital in Iowa City or at the Mayo Clinic. My parents when elderly were treated (competently I believe) for bypass, cancer treatment, etc in Dubuque a city of 60K if I remember correctly. Certainly not a retirement destination but an aging population.
You captured my point exactly above some level health care reaches a reasonable level in the local area. I suspect its somewhere in the 30k plus population level. Now west of where I live you have a stretch of 250 miles where you have to travel for almost all medical. (These areas still meet the old definition of frontier from 150 years ago). The next county west for example has 4000 people if you look for OB/GYN's as a speciality you find you have to go 40 miles to find one (to my town or east).
So I agree the distinction is between areas of 30k population and areas of 4k population. (Note that this is much less of a problem east of the Mississippi).
In the case of New Mexico along I-40 and US 84 That would be Clovis and ABQ with no town inbetween, for example.
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Old 12-22-2013, 08:31 PM   #13
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My parents when elderly were treated (competently I believe) for bypass, cancer treatment, etc in Dubuque a city of 60K if I remember correctly. Certainly not a retirement destination but an aging population.
I have to say, that if I had a life threatening cancer or heart issue I would probably seek some medical consultation outside Dubuque (or New Orleans, for that matter).
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Old 12-22-2013, 09:52 PM   #14
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This thread reminds me that I have the best of both worlds. I live in a wonderful small town, BUT there are two top-notch university medical centers within a 20 minute drive. Several years ago I had a serious surgery at one of them. My surgeon was a real cold fish (she had zero personal skills). I researched her background before the surgery, to determine her credentials, and the only other thing I wanted to know from her was how many of these operations she had successfully performed in her career. I cared how she handled a scalpel, not if she was going to hold my hand. During my recovery her residents and fellows did lots of handholding and had great bedside manners, so I really lucked out all the way around.
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Old 12-23-2013, 11:39 AM   #15
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I too, fear my Dr. of 13 years retiring. He's 7 years older than me so I know he'll retire some day. He did tell me he uses E.D.J. as his FA, so maybe not to soon.

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To me that is a hazard of a smaller town with fewer doctors, you get 'stuck' with the same doctor for years. I've seen relatives of mine who loved their doctors and stuck with them until the bitter end. But for the rest of the family, it appeared that their eventual death was hastened by sticking with the same 'quacks'. It is worth it to see other doctors now and then, but that is difficult in small towns.
Great point, I'm rural but close to a major metro area with (I had to check into this), 3 Level 1 trauma centers and 3 Level 2 trauma centers in the metro area, 1 is a large teaching hospital. So I too have the best of both worlds.

But to the point of my Dr. he's only 62 so I know he'll be around for a few more years. I know he'll refer me to someone when he calls it quits. But my real question is how do you know if you're Dr. is "good"?

I have a few sniff tests I use, but past those and online information how does one know. In my case it's pretty easy, in 2000 my last Dr. was an idiot, he and his staff were responsible for my diagnosis being delayed(4 weeks). They withheld pain medications, for fear of addiction; really this was for my own good! Never mind if they talked to me they would have learned plans I had made to deal with this incredible pain. Thankfully before the plan was deployed, they finally referred me to a pain management specialist, who had no issue with prescribing proper meds and then a pair of cervical epidurals.

In 2010 I had a reoccurrence with my new Dr. and totally different experience. Yes I still was in pain, but it was managed, yes I did hours of PT. I did pass on the epidurals. My diagnosis was done the first time correctly, not having to wait for a month.

So if you have access to good healthcare, how do you know your getting what you need?

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Old 12-24-2013, 03:04 AM   #16
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We live in a county adjacent to Houston. We live in an acreage subdivision sort of in the middle of nowhere. However, we are within 20 to 25 minutes from a regional hospital and within 45 minutes from two other major hospitals (these would be preferred). One of my criteria for any house we bought was that it be within 30 minutes of at least one hospital.

DH's parents lived about 60 miles from Houston in a smallish town. He was not happy when his dad had cancer and just was treated at the local small hospital when MD Anderson was an hour or so away. But, his parents were sort of the view that one doctor/one hospital was like another... Of course, nowadays MD Anderson has a number of satellite locations, one of which is about 40 minutes from where I live.

So, I think we are OK in general for health care where we live for now anyway. However, I do worry a bit about 20 years or so from now. Right now, DH and I are in good health and fully able to drive anywhere we want to go. But 20 years from now DH will be in his mid-80s and I'll be almost 80. I'm not sure that at that time we could regularly drive to appointments 45 minutes away. Of course, I don't know what the situation will be later on so I figure I'll worry about that later.
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Old 12-25-2013, 01:07 PM   #17
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I found an interesting website providing ratings by specialty for facilities throughout the US CareChex | Hospital Quality Ratings

I was surprised that many smaller hospitals made the 'check+' ratings. Maybe quality care is spread wide. I am concerned though when I looked at MA hospitals for cancer treatment. Dana Farber at Brigham and Women Hospital and the Boston General Hospital are ranked in the top five nationwide in other studies I've seen. BGH didn't make the top five in MA according to these rankings. Doesn't make a lot of sense.
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