One of the realities facing trauma and acute care surgery programs across the country is the need for intermittent staffing assistance from qualified professionals. Locum tenens, Latin for “placeholder”, is one of the typical staffing models utilized so as to satisfy this shortfall. In fact, the shortfall is predicted to increase in the future. Specifically, more patients are entering the market and more are expected to continue looking for acute care services throughout the United States. The increasing patient demand is not the only impetus making centers require short term surgical staffing. General surgeons are retiring out of rural markets and finishing trainees are not keen to replace them. This leaves large rural areas with opportunities for trauma and emergency surgeons to participate in a flexible staffing model. Locum tenens surgery has often been the vehicle used to satisfy the demand for trauma and acute care surgeons in addition to other surgical sub-specialties. It is now more important than ever for us to focus on how best to train, certify, and deploy surgeons for short term staffing.
So, we are faced with a situation where the future seems to indicate a continued need for short term staffing models including locum tenens surgery. The question, then, is not whether we will continue to use locum surgeons but rather how we can best use locum surgeons. My feeling, owing to a previous role as a rural Trauma and Acute Care Surgery Section Chief, is that we can more effectively utilize locum tenens-type models. We truly can improve our use of locum tenens and per diem models.
In order to provide the best care for our patients, let’s consider some characteristics of short term staffing with respect to its classic shortfalls. First, it is challenging for locum tenens-type surgeons to sign their charts and complete medical records in a timely fashion for the institution. This inability to complete medical records in a timely fashion results, often, in medicolegal liability for the practitioners on site and the locum tenens practitioner who has left the area. Compliance with medical staff bylaws is usually lacking and often hospitals have to look the other way for the locum tenens staff involved. So, one shortfall of the locum tenens model is that many excellent locum tenens providers have “day jobs” and are not available to sign paperwork despite their best intentions. The paperwork and compliance burden, however, is the not the only challenge.
Other issues include quality of care. I have found that many locum tenens and per diem staff are excellent, skilled practitioners. However, some are not. My feeling is that there is a wide distribution of skill sets among locum tenens and per diem providers. It is not that locum tenens is ‘bad’ or ‘good’. Rather, it is the fact that locum tenens providers are very variable in what they can achieve in your system. Add the talent factor to other issues such as organizational fit, lack of familiarity with local politics, and an unfamiliarity with the system in which they are practicing and we have a setup, obviously, for poor quality.
How can we best ameliorate some of these challenges for locum tenens surgeons and the systems in which they practice? One suggestion I have is that we encourage a locum tenens certification. Think about this: locum tenens / per diem staffing has a specialized body of knowledge and special constraints. The specialized body of knowledge concerns how to enter an unfamiliar system quickly, ascertain what is necessary to make the system run effectively and how to provide excellent care despite the overall amount of friction inherent in entering a new system. It involves staying calm when the hospital does not have credentials, a parking card, or an ID ready for the arrival of the practitioner. It involves interfacing with locum tenens and short term staffing companies which often have surgeons at a disadvantage with respect to how much surgeons should be compensated and other factors involved.
Interesting “classic” locums scenarios include: you (the locums surgeon) may believe it is safe, and standard, to start chemoprophylaxis such as heparin or lovenox for patients with traumatic brain injuries that demonstrate no change on head CT after 48 hours–but the local neurosurgeons do not. Do you (A) throw a fit in the ICU and degrade the level of care at the institution (B) point to the latest guideline from EAST or a similar, respected trauma body and chuckle to yourself about how uneducated the “locals” are? (C) find the trauma program’s practice management guideline and do whatever it says (D) order a surveillance ultrasound? Issues like these, fraught with balances between local politics, personal beliefs, and keeping the peace while delivering effective patient care abound in the lives of locums practitioners. In such acute, high risk situations, doesn’t it just make sense to educate and certify surgeons in the role of locums practitioner? Wouldn’t certification guarantee a more reliable approach, with less variance, to these complex issues?
There are other considerations too, such as reputational issues for locum tenens. I am aware of many instances where the local surgeons feels that it is acceptable to sacrifice the reputation of the locum tenens surgeon in order to preserve the relationship with other physicians who are on staff full time. This unique set of circumstances makes for pressures and requirements for short term staffing and locum providers. Given the multiple constraints, high stakes quality issues, and increasing need for short term staffing doesn’t it make sense to have a credentialing body or a body of knowledge specialized for locum tenens surgeons? Doesn’t it make sense to have a professional group that is dedicated to the surgeons who practice an often very challenging craft?
Other important, less patient-oriented endpoints include factors such as independent contractor taxation levels along with other perils and pitfalls that practitioners do not fully appreciate until they have functioned within the locum tenens model. Most new graduates do not understand the business of medicine, and even fewer understand the special business issues with respect to locum tenens practice.
To this end, innovative staffing companies such as Emergency Surgical Staffing, LLC (often called ESS) have evolved as potential disruptors which a focus on issues inherent in typical locums models such as variability, inability to participate in process improvement, and challenges in completing paperwork on time. Teams like ESS have arisen to specifically address each of those issues and improve upon the current challenges in short term staffing. Information is available at EmergencySurgicalStaffing.com.
At the end of the day, locum tenens surgery will become more and more useful in addition to per diem and other staffing models so as to satisfy the surgeon shortfall–especially in rural areas. Owing to the specialized nature of what needs to be achieved by locums surgeons, it is more and more important that the specialized body of knowledge they require becomes codified and that surgeons who practice in locums venues are either certified themselves or have some special education both to protect themselves and their patients. Locum tenens practice and per diem practice are very different than routine surgical practice and should be treated as such. Rather than having a young surgeons find out the hard way about reputational issues, patient care challenges, and taxation issues it is a workable solution to evolve a locum tenens system which allows us to more effectively use the staffing medium as it becomes more and more in demand.
Disclosure: David Kashmer, author of this post, is Associate Director of Emergency Surgical Staffing LLC and highlights it here as an example of a company that seeks competitive advantage by leveraging disruptive innovations pointed at challenges in the current locums model.
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