Tuesday, January 13, 2009

Traveling Surgeons

Dr. Wes wrote about this today. There's an article in the WSJ about the increasing attractiveness of locum tenens careers for general surgeons. As reimbursements for surgical procedures have dropped off and overhead costs have skyrocketed, it has become more and more difficult to maintain a classical private practice in general surgery, especially in the rural setting. The article outlines the travails of one Dr. Jennifer Peppers who had to shutter her practice and take out a line of credit to pay her mortgage. So now she travels to rural and small town hospitals for one or two-week contracts, knocks out emergency appendectomies and incarcerated hernias and splenectomies, doubles her salary and doesn't have anymore overhead or follow-up hassles. Sounds sweet, right?

Well not so fast. The idea of the "itinerant surgeon" is, rightfully, a career paradigm of last resort. There will always be situations where travelling surgeons will be needed; i.e the small hospitals who need to temporarily fill the void left by retiring or relocating surgeons until a new permanent surgeon is hired. But this is not what you want. You're not a professional if this is what you're doing. You're not practicing general surgery; you've become a technician.

Here's why it's a disastrous model:
1) Continuity of care is tossed out the window. You operate and let someone else take care of your complications two weeks later when you've moved on to the next village. Which is frankly embarassing. In this day and age of resident work hour reform and a creeping shift-worker mentality, the last thing we need is a model that further erodes a surgeon's professional code.

2) You're going to lose your skills. You take emergency call in Podunk, Illinois and maybe you do a few gallbladders and appendectomies but that's about it. Certainly there will be plenty of nights when nothing comes in and you sleep. And you're not going to do any complicated elective cases because you won't be around to take care of the patient afterwards.

3) It's expensive for hospitals. They're paying twice and sometimes four times as much to itinerant surgeons/anesthesiologists as they would to a fulltime community surgeon.

4) It denigrates the professionalism of physicians in general, and surgeons specifically. Physicians are a part of the community in which they serve. The moment that starts to change, the moment a patient realizes that his/her doctor is a contingent entity, beholden to financial incentives, unmoored to the community in which he serves, then we can give up for good all future notions of "doctor as healer" and the idea that physicians pursue a "noble cause".

Here's the deal:
Hospitals (especially smaller community ones) need surgeons. Surgeons need better remuneration and more support from hospitals. There has to be a way to entice surgeons permanently to smaller communities. And not just with the typical three year guaranteed salary deal that we so often see. Perhaps some sort of profit sharing arrangement between hospitals and surgeons is one way. Or longer term salary guarantees. One way or another rural and small town America is going to need the unflashy, bread and butter general surgeon. And this army of fellowship trained colorectal and bariatric and vascular specialists and plastic surgeons graduating from programs isn't going to be there to fill the void. If you want a general surgeon in your community you're going to have to pay for it....


Anonymous said...

I love Locums Work, sorta like bein a pinch hitter in the Bigs...and your points are well taken...BUT...have you BEEN to Southwestern Georgia??? Even Jimmy Carter just flys over. And how'd you like to be the one surgeon in Upper Michigan right now...

Anonymous said...

so why would hospitals pay for these traveling surgeons indefinitely but be unwilling to support a local surgeon (for less money apparently) indefinitely? are there laws against it?
what about call issues if you support a local surgeon? it's better to have a surgeon one night in 4 than no nights in 4?
how much support do you think a rural community hospital needs to provide a general surgeon to keep them? 100k a year?

Anonymous said...

I am a locum tenems surgeon like Dr. Pepper in the article. I've been to the northernmost aspects of Alaska, to the cold winters of Montana, to the bayous of Louisiana and to the desert areas of Texas. No general surgeon in the US would ever want to work permanently at these places. So as a locum tenems surgeon, I provide a service where there is a great need. Yes, continuity of care is sacrificed, but the alternative is NO CARE. I had a classical small town practice in which I was the only general surgeon for three counties and a population of about 70K. I never went on vacation, and I never had a weekend off. There would be times that I would be up three nights in a row, for emergency appendectomies and csections, etc. And I didn't make much more than Dr. Pepper in the article. That is NO LIFE for a general surgeon!