Published in the February 2009 issue of Today’s Hospitalist
Ask Rachal David, MD, why she’s spent the past year working locum tenens, and she explains that she’s “auditioning” hospitalist jobs in her search for a permanent position. Dr. David has done stints at hospitals in Denver and Vancouver, Wash., and she’s now focusing on hospitals in North Carolina, where she hopes to eventually settle down.
“I typically spend eight weeks at a hospital to optimize the number of places I get to see,” says Dr. David, a family medicine physician who finished her residency in 2007 and finds positions through Delta Locum Tenens, a placement agency. “I’ve seen six hospitals already, and I’ve revisited one.”
For Suzanne Fidler, MD, JD, the choice to go locum wasn’t about finding the right fit as much as fitting in a new career. Locum work led to more opportunity as she transitioned from a solo internal medicine practice in Orange County, Calif.
“I realized I could do per diem work while pursuing a law degree,” says Dr. Fidler, who has found locum opportunities through Medstaff National Medical Staffing. She recently took a job as the senior director of risk management for a hospital in Palm Springs, Calif., a position that draws on her experiences as both a lawyer and a hospitalist. She plans to fit locum work into her new schedule.
During the current recession, hospitals “which pay a premium for locum services ” may be taking a harder look at their costs. But that has yet to slow the demand for locum hospitalists. One recruiter at a firm that specializes in placing locum physicians reports that hospitals are booking his clients up to a year in advance.
As for why physicians find that a turn doing locum helps their careers, their backgrounds and motivations vary. But these doctors share attributes critical to their success as itinerant practitioners: the ability to adapt quickly to new systems, protocols and hospital cultures, and a solid grasp of their own skills and limitations.
Making the adjustment
For many physicians, the choice to work locum comes down to one thing: independence. Both Diego Gonzalez, MD, and Cristina Lecaros-Trinidad, MD, hospitalists who work locum in different parts of the country, are savoring the luxury to travel that the field “and their freedom from family obligations “provides. Dr. Gonzalez, who finished his residency in 2006, has yet to settle down, while Dr. Lecaros-Trinidad’s children have moved on to college and careers of their own. “I like seeing different parts of the country and experiencing the culture of each new city,” says Dr. Gonzalez, who works assignments in California, New Mexico and Washington, and plans to work locum for at least two more years. “I have the freedom now to do that.” Dr. Gonzalez has also found locum opportunities through Medstaff National Medical Staffing.
Dr. Lecaros-Trinidad, who gave up a solo internal medicine practice of 15 years in Princeton, W. Va., worked briefly at an outpatient facility until she discovered locum hospitalist work. She continues to turn down offers for both permanent primary care and hospitalist jobs. “I like the independence,” she says.
But that doesn’t mean adjusting to new routines isn’t difficult. For one, locums have to learn the layout of their new hospital on top of “a full patient load and new charting system,” says Dr. Fidler. Learning different computer systems is also challenging, as are various management protocols.
“Certain hospital programs have their own ICU attendings, for example,” Dr. Fidler points out. “In others, the hospitalist admits and the ICU attending co-manages. Still others require hospitalists to formally consult the ICU attending, but they are otherwise in charge.”
Local hospital culture can likewise present a steep learning curve. “You need to figure out who among the doctors wants to be called daily about patients and those for whom communications are more informal,” she says. Plus, “handoffs within hospitalist programs vary. Some hospitalists use voicemail while some use the computer, and others provide sign-outs face-to-face.”
A good match
While treatment protocols are increasingly standardized, locum physicians say they encounter significant differences in resources from one hospital to another, including the availability of specialty physicians.
Dr. David says she works mainly at small and medium-size hospitals in rural and suburban areas, because facilities in more urban areas tend to hire only internists as hospitalists.
She says she makes no assumptions about a facility’s resources, particularly in more isolated areas. She zeros in on what procedures she would be expected to do and what type of subspecialists a hospital has. “If they don’t have a subspecialist in an area,” says Dr. David, “I want to know if they have a transfer plan.”
Sometimes her comfort level doesn’t match that of her new hospital. During a recent stint, for example, she was asked to admit a patient with unstable GI bleeding, after being told no gastroenterologists were available. She refused.
“I told the emergency room physician the patient should be transferred, and he didn’t like the idea,” Dr. David recalls. “These situations are difficult because you’re not from the hospital, and yet you are called upon to make decisions on your first day there.”
Another major challenge: figuring out the capabilities of the nursing staff. Some places, Dr. David says, have a lot of RNs, while others let LPNs do more work on the floor.
“You need to know that clinical assessments are accurate and reliable, and whether you can trust what is being described over the phone,” she points out. “If I feel they’re not sure, I ask if they need me to come and see the patient.”
A region’s demographics also shape each assignment. In Sacramento, for example, where there is a sizeable homeless population, discharging patients can be challenging, says Dr. Gonzalez.
“How that works varies according to local government rules and resources, and who pays for it varies from state to state.”
Dr. Gonzalez makes a point of getting to know the discharge planners and case managers at the large, regional hospitals where he works. “They know where the nursing homes are and what resources are available, and they also help with insurance issues,” he explains.
A role as troubleshooter
Always being the new doc on the block has its awkward “and comical ” moments.
It can take a while, for instance, for other doctors to figure out who you are. “One doctor thought I was the dietician,” Dr. Fidler says. “He started to ask me for a nutrition consult, telling me to calculate a patient’s dietary requirements. I had to explain that I was the hospitalist “and that I was also looking for a dietary consult.”
But outsider status usually confers one distinct advantage: being shielded, for the most part, from local hospital politics. That gives locum physicians a unique opportunity to serve as troubleshooters.
During one assignment, Dr. Gonzalez received an alert that a suspicious package with white powder had been sent to a state government building. He was told to prepare for a possible influx of patients.
While it turned out that the threat wasn’t real, Dr. Gonzalez was able to recommend ways to mobilize more of the hospital’s physicians. “Based on the number of potential patients, there should be a certain number of doctors ready for admissions,” he says. “I made suggestions on how to decrease the response time in a potential disaster.”
Dr. Fidler says she has also offered advice about successful practices at other hospitals where she has worked. She describes a pneumonia order sheet she used at one setting that was particularly helpful.
“It was self-contained and efficient, and by suggesting treatment choices based on patients’ presentations, helped to reduce the sort of aggressive use of antibiotics that can lead to resistance,” Dr. Fidler says. “I was able to discuss this with physicians at other hospitals and bring it up to their chiefs.”
Physicians also say they are warmly received by new colleagues, who are grateful for the needed help.
“If you’re new,” says Dr. Gonzalez, “people tend to welcome you. Other physicians have invited me to dinner.”
And, Dr. Fidler adds, “I look forward to getting out of Orange County for a change of pace. The hassle is making sure that all of my personal business is taken care of ahead of time: that all my bills are paid, the newspaper stopped and the law office rent is in on time.”
Tracey Regan is a freelance health care writer based in Hoboken, N.J.
Thinking of working locum? Avoid these pitfalls
What should you look out for when considering locum assignments? According to hospitalists who work locum, an unwieldy caseload is the fastest route to frustration and failure.
Physicians agree that trouble starts at about 20 patients a day. “Patient load is the main red flag, and 20 to 25 patients a day, including ICU duties, is extremely shorthanded,” says Rachal David, MD, who has been working locum tenens for the past year. “If I hear it’s 20 a day, I avoid those places.”
When approaching any prospective position, Suzanne Fidler, MD, JD, an internist and a lawyer, recommends that physicians ask about hospital conditions before they sign a contract.
“Find out what sort of problems a hospital is having and why they need locum help,” she says. “If four hospitalists left abruptly, that might signal a problem.” In such a situation, she suggests that you try to speak to one or more of those hospitalists. “You should also ask if they will shift patients if one team is overloaded.”
Another must-do, particularly when working through a locum placement agency, is making sure the agency will advocate for you. “Make sure they’re on top of scheduling and travel, and that they have included your arrangements in the agreement,” Dr. Fidler says. “And make sure they’re covering your malpractice while you’re there and tail coverage after you leave.”
Diego Gonzalez, MD, who works locum jobs in California, New Mexico and Washington, recommends making calls first to see what procedures you’ll be expected to do. He also asks ahead of time about something he considers a deal-breaker: night shifts.
“I try to be flexible,” Dr. Gonzalez says, “but if a hospital requires a lot of night shifts, I won’t go there.”