Locum tenens surgery: An opportunity to improve access to quality surgical care

The practice of using locum tenens physicians to cover an absence or a temporary clinical need spans multiple medical specialties—from dentistry, to primary care providers (PCPs), to surgeons. Locum tenens is a Latin phrase that means “to take the place of.” In modern parlance, the term refers to a health care provider working in a hospital, group practice, or clinic temporarily for a span of a few weeks to a couple of months. Today, locum tenens physicians are most commonly sought to cover for PCPs in rural practices, but surgical locum tenens coverage also is in great demand.

Locum tenens history

The practice of using locum tenens physicians has been around since the late 1970s. The first locum tenens physicians were placed into rural Utah practices where physicians had to leave their practices temporarily to receive Continuing Medical Education (CME) training. The Health Systems Research Institute (HSRI)—a not-for-profit organization formed by the University of Utah, the Intermountain Regional Medical Program, and the Robert Wood Johnson Foundation—was created to help rural communities attract and retain physicians. The HSRI offered a program called ROPE (Rural Outreach Physician Education) in an effort to bring physicians to the University of Utah for clinical updates and CME. Because of the limited number of health care providers in smaller rural towns, individual physicians often had difficulty finding coverage for their practices locally, so HSRI also helped provide temporary physician (locum tenens) coverage.

Nearly 40 years after this early Utah experience, locum tenens physicians have become an essential part of the health care workforce, with both private contractors and health care staffing companies focused on offering temporary service coverage across the U.S. At present, more than 40,000 physicians work as locum tenens providers.¹

Accurate statistics regarding overall use of locum tenens physicians are difficult to accumulate, although larger agencies have conducted studies on the practice. The 2017 Survey of Temporary Physician Staffing Trends published by Staff Care, a health care staffing firm specializing in matching temporary physicians, found that 94 percent of the 206 hospital, medical group, and other health care facility respondents used temporary physicians in 2016, up from 91 percent in 2014 and 74 percent in 2012.2 In 2016, 10.8 percent of these physicians were surgeons.

Why surgeons pursue locum tenens opportunities

A 2016 survey conducted by the locum tenens agency CompHealth found that one in five physicians has worked as a locum tenens health care provider. The survey also revealed that physicians, on the whole, have a positive (55 percent) or neutral (42 percent) impression of locum tenens work. Survey participants noted a long list of reasons why physicians choose locum tenens positions, including supplementing core income, working an interim position while searching for a full-time position, or as a transition between full-time positions. Other factors include work schedule control; personal life transitions, including impending retirement; and the opportunity to expand experience through new cases or to work within a practice before signing a long-term contract. Some physicians find locum tenens positions attractive because they can see other parts of the country or world, including rural or underserved areas. Other survey participants found it stimulating to work in new environments, and noted that this type of work helped prevent monotony or burnout while reducing administrative burdens and providing more time for clinical care.³ For many surgeons, the opportunity to take time out of a busy or suboptimal practice to reflect and prioritize can be a welcome respite.

Need for an expanded surgical workforce

The growing need for general surgeons in the clinical workforce seems evident. From a population standpoint, the number of people older than age 65 is rising and expected to increase by up to 45 percent within the next 10 years. The complexity of medical issues in older patients also is increasing. Based on these projections, the Association of American Medical Colleges (AAMC) in 2016 estimated that 112,000 additional physicians of all types will be needed to maintain service levels. Given the static supply of surgeons completing training, the U.S. likely will have a shortage of roughly 25,200−33,200 general surgeons and surgical specialists by 2025.⁴ As an example of increasing specialty surgeon demand, E. Christopher Ellison, MD, FACS, chief, division of general surgery, and the Robert M. Zollinger Professor, Ohio State University, Columbus, at the 2017 Central Surgical Association meeting predicted that 9,000 new general surgeons will be required by 2035 to provide surgical cancer care.

In addition to a growing deficit in the number of trained surgeons, maldistribution of the surgical workforce relative to surgical care needs reduces access to surgical care. Between 2006 and 2011 (the last years studied by the AAMC), 155 rural counties and 38 urban counties experienced a drop in general surgery coverage, a trend illustrated in maps published online by the ACS Health Policy Research Institute. Another 898 counties, 29 percent of the total counties in 48 states, do not have a general surgeon.^5,6 The increasing number of rural and urban counties that are losing general surgeons or report having no general surgeons is a worrisome trend.⁷

Attracting and maintaining general surgeons within the workforce is critical. A stable and well-supported surgical locum tenens community seems to be one important option to engage surgeons who might otherwise temporarily or permanently leave the workforce. Hospitals and private practices, especially those in rural areas, recognize that locum tenens physicians are one important option that provides coverage for their surgeons for paid time off, illness, family/parental leave, or for vacation or other absences from the office.

Ajit K. Sachdeva, MD, FACS, FRCSC, Director, ACS Division of Education, has recognized the role that locum tenens surgeons play in disseminating different perspectives and skills to practices where they provide coverage. Given workforce limitations in general and specialty surgery, locum tenens practice should be viewed as an acceptable and essential component of surgical care.⁸

Challenges faced by locum tenens surgeons and host sites

A locum tenens position offers a number of potential advantages: financial (potential to earn full-time salary working part-time hours with hourly pay for overtime), less administrative burdens, an opportunity to travel, support for career/employment transitions, and employment flexibility. However, the limitations of a temporary practice can be significant: lack of continuity with patients and unfamiliarity with local practice, clinic, and hospital operations; limited support and back-up; and potentially having to work with an unfamiliar electronic health record. Long-term career goals can be undermined with too many short-term positions. Other deterrents for these temporary roles: the locum tenens surgeon may be viewed as an outsider and miss opportunities to be mentored and offered valuable career-advancing opportunities. They also may be assigned a higher proportion of high-risk patients.

Locum tenens agencies can have variable and sometimes challenging relationships with their contracted physicians. Agencies vary in terms of their awareness of contracted physicians’ knowledge base and skill set, level of accountability, and credentialing. Some agencies are physician-led, whereas others follow a more traditional, for-profit staffing business model. Staffing association standards focus primarily on business practices and clients, not physician capabilities, conduct, or support.⁹

From the standpoint of the host site, the transient and inconsistent nature of locum tenens coverage may adversely affect quality initiatives. Locum tenens surgeons may find it difficult to contribute meaningfully to quality and outcome metrics. Anecdotes abound regarding negative outcomes that are, at least in part, attributed to the surgeon, agency, or site failing to fully vet each other or to provide clear, upfront delineation of duties. Examples include:

• Adult specialty surgeons called upon to care for pediatric trauma patients
• Scheduling index or complex procedures without necessary short- or long-term follow-up
• Lack of full-time specialty surgeons with all coverage supplied by rotating locum tenens with limited individual opportunity for ongoing quality programs or long-term patient follow-up
• Patient/site abandonment when complications arise
• Negative patient outcomes attributed to poor surgical judgment
• Failure to comply with institutional policies and procedures

Our patients believe that every physician they encounter at an institution will be capable, credentialed, professional, and operating within their legal and technical scope of practice. They assume that a locum tenens physician is providing substantially the same care as the physician they are replacing. A study published in 2017 noted no increased mortality among Medicare patients treated by locum tenens internists in 2009−2014, but did show a significant increase in mean hospital length of stay and overall Part B spending.¹⁰

ACS policy guidelines for locum tenens surgeons

The ACS Board of Governors Surgical Care Delivery Workgroup and the Advisory Council for Rural Surgery have coauthored an ACS policy Statement on Maintaining Surgical Access with a Locum Tenens Surgeon that includes guidelines and standards for the appointment and assessment of locum tenens surgeons. This statement was approved by the Board of Regents at the ACS Clinical Congress 2017 meeting.11 This statement is aimed at protecting the interests of both the locum tenens surgeon and the host practice/institution. Although the guidelines suggested in this statement do not replace existing regulatory and hospital credentialing processes or state licensure requirements, they do provide a framework for facilitating ongoing high-quality surgical care by a locum tenens surgeon.

According to the ACS statement, the locum tenens surgeon must have the appropriate state medical licensure and be certified, in the exam process, and/or no more than six years out from satisfactory completion of Accreditation Council for Graduate Medical Education-accredited training to practice in the surgical specialty or subspecialty for which he or she is being hired. Locum tenens surgeons must be in good standing with their accreditation boards and should participate in required ongoing Maintenance of Certification. It is essential that locum tenens surgeons also satisfy the credentialing process mandated by the host practice and hospital, including background checks for previous criminal activity. The surgeon applying for these positions must be transparent regarding any pending or ongoing investigation into his or her standard of care.

To ensure an appropriate level of expertise, each locum tenens surgeon should maintain a log of his or her surgical experience and a list of references for review by the host practice/institution. The ACS Surgeon Specific Registry (SSR) is an online option that satisfies this type of documentation. This tool also can generate site-specific reports detailing an individual surgeon’s activity. To ensure that continuity of patient care is maintained, the surgeon must commit to provide adequate handoffs of all patient care activities resulting from his or her tenure on the service to host practice surgeon(s), not to another locum tenens surgeon. This recommendation is important to avoid the stigma of “itinerant surgery.” A standardized agreed-upon format for information exchange should be developed, preferably in person, with adequate overlap of coverage to handle emergencies. The Agency for Healthcare Research and Quality Team Strategies and Tools to Enhance Performance and Patient Safety (also known as TeamSTEPPS) algorithm offers excellent guidance in developing such professional communication.12

The host practice group must develop an established procedure for patient handoffs, transition of postoperative care, and long-term follow-up of patients seen and managed by the locum tenens surgeon. If available, an advanced practice provider associated with the host practice can provide support and assist the locum tenens surgeon in onboarding and practice management while also helping to provide continuity of care for long-term patients. The hospital and host practice should offer other necessary tools for successful entry into the locum tenens position, including but not limited to the following:

• A comprehensive orientation to the facility
• Introductions to OR/inpatient/office staff; clarification of the availability and training of surgical first assistants
• OR preference list management
• Shadowing of practice partners and proctoring as needed
• Adequate training in, and 24/7 access to, assistance for the hospital electronic medical record, emergency department, radiology, and laboratory systems

The hospital and host practice should coordinate coverage of all expenses related to locum tenens physician credentialing, contracting, and compensation. If self-insuring, the hospital and host practice should provide adequate occurrence liability coverage with a defined period of “tail coverage.” The hospital and host practice should provide the locum tenens surgeon and agency with a fair evaluation of his or her performance and have a mechanism for due process review if the surgeon feels that the evaluation is unjust. A mechanism also should be developed for the surgeon to have the ability, without retribution, to provide an honest critique of their experience to the host institution and practice. This review will enhance system improvement efforts, especially for the next locum tenens surgeon recruited to that practice.

The agency representing the locum tenens surgeon is responsible for managing and coordinating the locum tenens surgeon’s employment. In delivering a temporary professional replacement that is often mission-critical, it is imperative that the surgeons they represent meet training, experience, and professional affiliation criteria (for example, membership in the ACS) necessary to offer high-quality surgical care. Individual performance, available practice, and institutional practitioner quality measures, as well as measures of both patient and practice satisfaction, should be maintained by the agency for a defined period and subject to periodic review by the locum tenens surgeon. Individual surgeon performance, quality, and satisfaction measures maintained and disclosed to hiring institutions by the agency should be spelled out in contract language between the agency and the locum tenens surgeon, and securely stored and protected as privileged information. These performance metrics should be fairly representative of his or her practice, transparent and readily accessible to the individual locum tenens surgeon for comment, personal performance assessment, and performance improvement.

In addition to the locum tenens best practices information and research outlined in this article, we believe that with development of the ACS policy statement addressing temporary physician staff members, the College assumes a leadership role in defining standards for successful engagement of a locum tenens surgeon.

References

1. Grabl L. The history of locum tenens in healthcare. Physicians Practice. December 13, 2017. Available at: www.physicianspractice.com/cme/history-locum-tenens-healthcare. Accessed September 10, 2018.
2. Staff Care. 2017 Survey of Temporary Physician Staffing Trends. Available at: www.staffcare.com/uploadedFiles/2017-survey-temporary-physician-staffing-trends.pdf. Accessed September 10, 2018.
3. Byington M. 13 reasons why physicians work locum tenens. Physicians Practice. October 12, 2016. Available at: www.physicianspractice.com/blog/13-reasons-why-physicians-work-locum-tenens/page/0/2. Accessed September 10, 2018.
4. Dill MJ. The state of the physician workforce. Association of American Medical Colleges. November 13, 2016. Available at: www.aamc.org/download/473344/data/annualaddressofthephysicianworkforce.pdf. Accessed September 10, 2018.
5. Frangou C. A crisis in coverage: ‘Maldistribution’ of general surgeons across United States leaves many counties with little to no coverage. January 20, 2017. Available at: www.generalsurgerynews.com/In-the-News/Article/01-17/A-Crisis-in-Coverage/39059. Accessed September 10, 2018.
6. American College of Surgeons Health Policy Research Institute. Exploring change in supply of total surgeons. Available at: www.acshpri.org/documents/TotSurgChngMaps06-11.pdf. Accessed September 19, 2018.
7. Uribe-Leitz T, Esquivel MM, Garland NY, Staudenmayer KL, Spain DA, Weiser TG. Surgical deserts in California: An analysis of access to surgical care. J Surg Res. 2018;223;102-108.
8. Loe WA, Guzzetta PC, Lessin MS, Nakayama DK. Proposed standards for use of locum tenens coverage in pediatric surgery practices. J Pediatr Surg. 2013;48(3):700-701.
9. National Association of Locum Tenens Organizations Standards of Practice and Procedures. NALTO statement on guidelines for professional conduct. Available at: www.natho.org/pdfs/Old/StandardsofPracticeAndProcedures_rev2003%5B1%5D.pdf. Accessed September 10, 2018.
10. Blumenthal DM, Olenski AR, Tsugawa Y, Jena AB. Association between treatment by locum tenens internal medicine physicians and 30-day mortality among hospitalized Medicare beneficiaries. JAMA. 2017;318(21):2119-2129.
11. American College of Surgeons. Statement on Maintaining Surgical Access with a Locum Tenens Surgeon. Available at: facs.org/about-acs/statements/105-locum-tenens. Accessed September 27, 2018.
12. U.S. Department of Health & Human Services. Agency for Healthcare Research and Quality. TeamSTEPPS: Team strategies & tools to enhance performance & patient safety. Available at: www.ahrq.gov/teamstepps/index.html. Accessed September 10, 2018.