The locum tenens industry, which provides organizations with temporary or supplemental physicians for anywhere from a weekend to a year, got started in the U.S. in the 1970s in response to staff shortages in rural communities. So it will come as no surprise that requests for locums increased by 20% from 2006 to 2007, with 77% of hospitals now using them at least occasionally, according to the latest survey from Staff Care, the largest temporary physician staffing company in the country.
After all, more than a quarter of U.S. physicians are 55 or older, with 10% 65 or older, and many of them want to slow down - just as the population at large is aging rapidly and will need more services. Others have had it with the paperwork, regulations, insurers, while many younger physicians simply aren't interested in 100-hour work weeks.
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Ready to step into their shoes on a temporary basis are more than 36,000 physicians who want to work as locum tenens at least some of the time, including 30% of them who practice this way exclusively. Some, ironically, are older physicians who want to work less but aren't ready to retire. Some are just finishing residencies and want to try out different practice styles and locations. And some in mid-career are looking to relieve burn-out or boredom, secure a financial safety net while they pursue other interests, or try out different areas of the country with an eye to relocating.
Wanted and Needed
For hospitals, there are other reasons besides shortages to turn to locum tenens: To fill in for staff members who are ill, on vacation or maternity leave, or attending CME courses; to staff new or vacant positions while permanent physicians are recruited; or to try out potential employees before hiring them, which 55% of organizations end up doing.
Also, many places use locum tenens as an integral part of their master staffing plans, both to allow permanent staff more of a balanced lifestyle and because it's more efficient and cost-effective than maintaining peak staffing levels and paying for lots of downtime.
According to Merritt, Hawkins & Associates' 2007 Survey of Physician Inpatient/Outpatient Revenue, the current daily rate for locums is $750-800 for family practitioners, who will generate, on average, approximately $1,433,000 a year on behalf of their affiliated hospitals, or about $4,000 a day.
Today's tough economic climate is shifting things about somewhat, says Brent Bormaster, divisional vice president at Staff Care. "We are seeing more long-term assignments, as hospitals try to bridge the gap between permanent positions, and fewer short-term ones, as some physicians opt to shut down their offices for a long weekend rather than take an expensive vacation."
The days when hospitals and their staffs looked down their noses at locum tenens physicians, seeing them not as a bargain but as merchandise that just never sold on its own merits, are gone - for the most part. On the other hand, according to the latest Staff Care survey, while only a tiny percent of hospitals and physicians do not accept locum tenens physicians, 19%-21% of administrators and staff physicians merely "tolerate" them.
It's essential, says Bormaster, that hospitals make these vital links in the chain feel wanted as well as needed. Because make no mistake, it's a two-way process and first-rate locums are much in demand; they probably have their choice of hospitals. So why should they choose yours?
"The key is to educate your staff on the specific need for locum tenens, "whether it's to keep an ICU open or a cardiology unit up and running. 'We're bringing this person in to eliminate patient migration, to keep the revenue stream open.' Because if a patient leaves a hospital for another one, they're probably not coming back."
A Successful Transition
Imaging staff at Carilion Clinic, a tertiary care, Level 1 trauma center in Roanoke, Va., are very clear on the importance of locum tenens, and go out of their way to make them feel not just needed and wanted but cherished. At the end of 2006, Carilion lost its radiology group. Among those leaving was Wayne Gandee, MD, who agreed to come back as medical director of imaging and put together an in-house department. Since then, Carilion has been able to recruit 20 of the 25 radiologists they need. But, says Gandee, they could never have done it without locum tenens.
They don't call them locum tenens, because technically they're contract workers, but they don't call them that either. They call them guest radiologists, says Gandee, because that's the respectful thing to do.
"We welcome them, embrace them, celebrate them, and treat them as we do our regular radiologists. They were critical to this transition period, and we ended up hiring two of them who liked our philosophy - it's we not me, it's yes rather than no."
Gandee says he has every guest radiologist sit in a plain film reading slot the first week "so we can assess their personal and professional behavior. Out of the 50 or 75 we've had so far, there were just three we didn't ask to come back."
The best ones, he says, "are those who are in a good practice somewhere else and who have so much vacation time that they're willing to take part of it and come work with us."
Lightening the Load
At about the same time that Carilion was losing its radiologists, Mercy Medical Center, Roseburg, Ore., lost three of its four general cardiologists over a 12-month period. As a result, Mercy had to send many patients out of the area, which was a significant burden on patients, the community, and the hospital, says Joan Peak, RN, director of medical services.
So in 2007, they retained LocumTenens.com, selected a cardiologist for a two-month period - and ended up hiring him.
"He was a perfect fit for the organization," says Peak. "He was very willing to take feedback and ideas, and the patients love him. The hospital has been able to improve services and the bottom line because we're not losing so many patients; he helped stabilize treatment in the heart center and alleviated stress on staff and physicians."
Last August, Mercy decided to start its own hospitalist program; by this August, they will have six of the specialists on board. In the meantime, says Peak, "as we've built the program and recruited for it, we've used several locum physicians." And again, they hired one.
Peak doesn't use locums for vacation or CME coverage, only when she has an open position and preferably for a full week. Like Gandee, she uses agencies but prefers contracting directly with local physicians who have their own practices and will pick up weekend or night shifts for Mercy.
"There are major advantages to using local doctors. For one thing, I save some $60/hour in agency fees. For another, local doctors are a known entity; we know their skill set, they have relationships with other physicians in the community, and there's just a higher level of trust."
When they do use agencies, says Peak, "we ask for the same physicians to come back the next time we have a need. Not only have they gone through orientation already, but it cuts down on credentialing time."
Physician Involvement
Every time Carilion brings in a new physician, Gandee explains, they're looking at about four months of credentialing.
"If we hire a person in June, we probably won't see him or her until the first of November. That's because we don't rely on any external credentialing process, even if it's Joint Commission approved and accredited. We do our own primary source verification, going back to medical school, and we don't take copies from the physicians or from the agencies that employ them."
Every organization has to credential locums for themselves, but other places may be more willing to accept information provided by agencies. Which is why some hospitals may prefer not to hire independent locums.
"It can be a problem if there's just one credentialer at a hospital and that person is swamped with recredentialing the medical staff," says general surgeon Ken Cohn, MD, MBA, FACS, himself an independent locum.
If a hospital works with agencies all or part of the time, says Peak, it should make sure its credentialing department has a good relationship with the agencies' departments. "It's a very important relationship and will definitely expedite the process."
Either way, all three emphasize the importance of having physicians pore over CVs and, whenever possible, call physician references. "Physicians will speak more openly with a physician than with an administrator or recruiter, says Cohn.
"And it's easier for them to use the snowball technique, reaching out beyond the person who's listed. If someone's a surgeon and they've given other surgeons as references, I'd ask to talk with the anesthesiologist who worked with the person in the OR: 'Did they have good technical skills, good judgment, were they a good leader, were they open to opinions from others?'"
Cohn also recommends calling the last place the candidate worked - even if it's not listed as a reference - and Googling the person. "If they've been fired on short notice, someone will have written about it."
Medical staff leaders often get involved in the final decision, says Bormaster. "Sometimes the ultimate decision maker is the medical director, or a colleague the locum will be working with; it may even be the physician they're going to replace, who will say 'I'm fine with Dr. X coming in to cover my patients.'
"If this is the case, you want the rest of the staff to be aware of that involvement and endorsement."
Hit the Ground Running
Between a locum being hired and starting work is a critical step for the hospital in making his or her stay successful: orientation. As Gandee puts it, "you don't ask your guest radiologists to come in, put them in a corner in a dark room, say 'go at it,' and walk away."
At Carilion, the first half day is spent getting oriented to the hospital and its equipment, including the PACS system and the voice recognition dictating system. The second morning is given over to orientation to the system's electronic medical record.
Mercy Medical Center starts its orientation the day before a locum's first shift, so that person can hit the ground running. They call it Day One Orientation and it takes about two hours.
"We give them their badge, go through our confidentiality agreements and the basic rules and regulations of the hospital" says Peak. "We show them where to park, where the physician lounge and sleep rooms are. And then they work with IT to learn our computer systems. On their first day, we have them work with one of our experienced physicians, who will shadow them, walk them through, introduce patients, and answer any questions.
Going in the day before is something Staff Care encourages, says Bormaster. They also encourage all their clients and physicians to do as much as they can over the phone beforehand, especially in terms of physician-to-physician conversations.
"Often, it's possible for locums and the physicians they're replacing to map out the time in advance -- the types of patients the locum will be seeing, whether there will be new consultations or only follow-up care. The more specific the better."
In other words, start off as you mean to continue, and treat locum tenens physicians with the same consideration you give to staff physicians. You don't have to throw a farewell party when they leave (although some hospitals do), but you should always keep in mind that that person filling in may become a part of your staff at some point, or if not, may spread the word that your hospital is a great place to work - or not.
In any event, they are doing your organization a favor, so do yourselves one, and make them welcome.
Publication Date: Monday, August 24, 2009