Published in the October 2012 issue of Today’s Hospitalist
AS COMMUTES GO, the trip that Eric Kerley, MD, PhD, makes twice a month sounds tough. Since February, the hospitalist has been making a 13-hour commute from his new home in Charleston, S.C., to Ketchikan, Alaska, where he works as many as 14 locum shifts a month.
Dr. Kerley, an internist and pediatrician, was director of a hospitalist program in eastern Tennessee for five years. While there, he started spending one week a month in Alaska working locum. The location and the locum life quickly got under his skin.
“The Alaska work was actually respite time,” Dr. Kerley says. “It was a relatively easy workload and a nocturnist position that gave me time to read. I felt like I got my head together every time I went up there.”
Dr. Kerley plans to continue his commute until he lands a full-time job in Charleston, where he says that jobs are scarce. For Stephen P. King, MD, on the other hand, its the real estate market “not the job market ” that keeps him working locum.
The hospitalist moved from eastern Washington state to El Dorado, Ark., for family reasons, but he wants to return to the Northwest. “Initially, I planned on working locum until our house sold, but it’s been over two years,” says Dr. King, who has held locum positions in both the Northwest and the Southeast.
Then there’s Philip Paustian, MD, a Panama City, Fla., hospitalist who now works locum exclusively. For 19 years, he ran a busy solo internal medicine practice, then had positions with two different hospitalist groups. When the second group lost its hospital contract in 2010, Dr. Paustian decided not to work for the program that took its place.
Today, Dr. Paustian moves among four Southeastern states and Texas, working in hospitals ranging from 60-bed rural facilities to 400-bed urban centers. He doesn’t miss either the business pressures of a fulltime practice or the group politics.
I have the pleasure of knowing that I’ll get a paycheck and won’t have to worry about making payroll,” Dr. Paustian says. “And as an independent contractor, I don’t get quite as excited about the politics because I know I’m not going to be there forever.”
Executives with locum placement firms say there’s no typical profile of hospitalists who work locum. They range from doctors just out of residency to those who want to work a few more years before retirement and “lifers” who simply enjoy the travel. One common thread, however, is that most physicians work locum for practical reasons. Some wish “or need “to bring in extra income; others are between jobs or accommodating particular family needs.
“Overall, I’d say that it’s the lifestyle and the flexibility that are most important to hospitalists who work locum,” says Robert Harrington Jr., MD, chief medical officer of Locum Leaders, a national recruitment and staffing company based in Atlanta.
“Traveling to different hospitals is good for you professionally,” says Dr. Kerley, who has also worked locum positions in Colorado and Pennsylvania. “I have gained from seeing how things are done in other places and become more flexible in my own practice.”
But hospitalists who work locum admit it’s not always a bed of roses. The near-constant travel “especially with back-to-back assignments “can be physically challenging and taxing on family life. So can credentialing hassles and the need to constantly adjust to new protocols and IT systems.
Wyoming-based hospitalist Robert Blankenship, MD, who recently worked locum exclusively for several years, now combines it with a “place-based” position. He says that shifting from one IT system to another is tough, even for the tech-savvy.
“In hospital medicine, you have to learn a different IT system almost everywhere you go,” says Dr. Blankenship, who’s worked with several different locum companies. “Even if you go to three hospitals that all use the Meditech EMR, for example, they’re likely using three different versions.”
Dr. Kerley concurs, noting that he has particularly bad memories of an assignment that started just as the hospital was switching to a new CPOE system. “That,” he recalls, “was a few days of serious pain.”
The learning curve in a new facility is a lot worse, he maintains, if the hospital doesn’t build in sufficient orientation time. Some facilities allow locum hospitalists a day or two to get oriented, while others expect doctors to hit the ground running. “That can prove very challenging,” Dr. Kerley notes.
Brent Bormaster, vice president of the locum firm Staff Care in Dallas, agrees that adequate onboarding is essential to a successful assignment. He tries to ensure that the hospitals where he places hospitalists allow a reasonable onboarding period “and that the variables of each assignment are fully communicated so everyone knows what to expect. “If they don’t,” he says, “the experience can be disappointing for both parties.”
Of course, if the assignment lasts less than a week, there won’t be much time to adjust. As a result, hospitalists considering locum must be flexible.
“I once worked at three hospitals in five weeks,” Dr. Kerley recalls. “It was hard to keep straight who does what in terms of nomenclature, protocols, patient diets and running IVs.” Hospitalists who plan to work locum, he adds, “can’t be set in their ways. That definitely doesn’t work in this type of practice.”
The issue of credentialing
Texas hospitalist Krishna Kumar, MD, who has worked locum off and on for many years and exclusively since 2008, says she takes the IT adjustment in stride. (Starting this month, she’s taking a permanent position.) She began working locum early in her career to afford her daughter’s boarding school.
For Dr. Kumar, one big challenge is dealing with credentialing hassles. She maintains credentials at multiple hospitals so she’ll have assignment options, but that means managing a lot of paper.
“Keep in mind that it’s pretty easy to get rid of a locum because there’s no real commitment on either side,” Dr. Kumar says. “It’s challenging sometimes to keep up with the paperwork. But the other way to look at it is that there are jobs galore if you do good work and have an impeccable record.”
Dr. Kerley decided to limit the number of facilities where he works so he’s not saddled with paperwork.
“With the challenges in credentialing now, you don’t want to have 25 hospitals under your belt,” he says. “That could make things very difficult if you’re moving around.”
David Schumann, vice president of ECHO Locum Tenens in Grapevine, Texas, an affiliate of Sound Physicians in Tacoma, Wash., that was launched in late 2011, cites the “chronic credentialing” process as a chief hassle for locum physicians and staffing companies.
“The credentialing never eases,” Mr. Schumann says. “We always have to credential out 60 to 90 days in advance, whether we have a need now or six months from now. And some doctors back out during the credentialing process because they get tired of waiting. It’s a vicious cycle.”
Dr. Kumar points to another frequent challenge: navigating care in facilities with little specialist or subspecialist backup. She advises hospitalists evaluating locum opportunities to thoroughly look at backup in advance, especially at small or midsize hospitals.
Her last locum position (at East Texas Medical Center in Tyler, Texas) had “lots of backup “full neurology, neurosurgery, cardiology, nephrology, wound care,” she says. “That makes a huge difference. I know, because I’ve worked in places where it was just the opposite.”
Although the demand for locum doctors across the board has declined with the mass movement toward hospital employment, hospitalists haven’t felt the pinch. Hospitalist locum demand remains steady, especially in regions where it’s tough to recruit full-timers.
Staff Care alone filled more than 15,000 hospitalist days in 2011, up 10% from 2010, Mr. Bormaster notes. And despite its recent arrival on the scene, ECHO Locum Tenens is filling a growing number of shifts each month “without yet having to tap into the corps of moonlighters that Sound Physicians maintains.
According to ECHO’s Mr. Schumann, the past year has seen a number of smaller locum startups looking for a piece of the vibrant hospitalist sector. At the same time, hospitalist management companies have been starting their own locum divisions to better match the needs of individual hospitalist teams and their hospital partners.
They’re finding a receptive audience. The 2011 Today’s Hospitalist Compensation & Career Survey found that 10% of all U.S. hospitalists had at least dabbled in locum work in the past year. The survey also found that 82% of hospitalists who worked locum had full-time jobs.
But while locum opportunities are plentiful, Dr. Harrington from Locum Leaders notes that many hospitals are requiring more of their physicians. In particular, a growing number of hospitals are asking for hospitalists with critical care experience, in part because of the intensivist shortage.
“Rural and small community hospitals need hospitalists who can help get patients through their first three or four days in the ICU,” Dr. Harrington explains. “For patient satisfaction and customer service reasons, they want to avoid transferring them out. There’s a financial incentive to try to keep those patients.”
Mr. Schumann reports that hospitals are also getting pickier about locums’ general skill sets and technology credentials. “Some sites are actually requiring that locum hospitalists do procedures, mostly ventilator management, code response and intubations,” he says. “This hasn’t been the case in the past.”
The welcome mat
How welcome do locum hospitalists feel in unfamiliar “and perhaps brief “assignments? Most of the time, the hospital and the medical staff are happy to have a hospitalist on site, says Dr. Paustian. “I have always found people cordial and glad that I am there,” he notes.
Dr. King agrees, but he is quick to say that working locum means proving yourself in each new environment. “When you’re a locum, it’s important to be cautious about the medicine you practice and make sure you’ve been keeping up,” he says. “If you do that, in a week or so they’ll trust you.”
Until then, he notes, you’re an unknown entity, and coworkers may not have the same comfort level with you that they would with someone they work with full time. He recalls a recent experience in which a nurse was clearly worried about a small amount of blood in a patient’s urine. While he didn’t think it was a problem, he recalls, “I took her concern seriously and ensured that she was comfortable with my explanation.”
Dr. Blankenship also says he’s been well-received overall. But he senses that “locum-type doctors are not as highly regarded because they’re temporary; they’re not making the commitment to the hospital,” he points out. “Often, people don’t take the time to get to know you because you’re there and then gone.”
Bonnie Darves is a freelance health care writer based in Seattle.
Choosing the right assignment
WHAT ARE THE KEY ISSUES hospitalists need to consider before taking on a locum assignment? Here are some suggestions from hospitalists who are locum veterans.
Philip Paustian, MD, a hospitalist from Panama City, Fla., who works locum exclusively, says that physicians need to figure out what type of assignment best suits their individual practice style. He steers clear of jobs where he’s the only hospitalist on deck.
“I prefer hospitals that have more than one hospitalist on in any 24-hour period,” Dr. Paustian explains. “You’ll get more sleep in a program that’s a bit bigger.”
Robert Blankenship, MD, a Wyoming hospitalist who now combines locum work with a “place-based” position, agrees. He warns that some hospitals want physicians to work 24-hour shifts. “You can find the three- or four-day assignment, usually in rural areas, but they’re often 24-hour shifts,” he notes. “Those can be brutal.” Dr. Blankenship adds that he avoids those assignments unless the facility can ensure a manageable average caseload and a decent call room.
But hospitalists like Eric Kerley, MD, PhD, like the smaller programs found in rural areas. Dr. Kerley commutes from his home in South Carolina to work locums in Alaska.
“I don’t think I’d volunteer to go into a pressure-cooker environment where I am seeing 25 patients a day and my pager is going off 100 times a day,” he says. In his view, 80 to 100 beds is the ideal hospital size.
“What I like is that the consultants can actually sit down and talk with you about a patient in a very constructive way,” says Dr. Kerley, “as opposed to larger hospitals where you might be working with consultants over the phone.”
Before taking an assignment, Stephen P. King, MD, a locum hospitalist in El Dorado, Ark., looks for a “manageable” census ” which he considers to be between 11 and 15 patients “and assignments that last one or two weeks.
“If the hospitalists have 18 to 20 patient contacts a day, I am not likely to take the assignment,” Dr. King says. “I look at pay last, but I tend to avoid assignments that pay poorly.” The rates he sees are between $1,200 and $1,500 a day.
There’s good news about pay for hospitalists who like to work locum. “From what we’re seeing, pay rates are edging up,” says Robert Harrington Jr., MD, chief medical officer of Locum Leaders, a national recruitment and staffing company based in Atlanta.
“The general range is $100 to $150 an hour,” Dr. Harrington explains, “but we are seeing some physicians holding out and demanding another $10 to $20 an hour for certain assignments. We can place someone in Atlanta for $100 an hour because you can’t swing a stethoscope here without hitting a hospitalist. But we may have to pay $140 an hour in rural Tennessee.”