With general surgeons in increasingly short supply, more hospitals will have to bring in temporary surgeons to help fill the demand for emergency and routine surgical services. The number of general surgeons per capita has decreased more than 25% over the past 25 years, with the diminished availability affecting not only rural communities, but urban areas, too. As it becomes more common for locum tenens to pass through the operating room, hospitalists increasingly will be caring for their patients.
“There's definitely going to be a shortage when you consider baby boomers are just hitting their retirement years and demand for services goes up with age,” said Dana Christian Lynge, MD, associate professor of surgery at the University of Washington, Seattle, who co-authored a study on workforce trends published last April in the Archives of Surgery. The study found that the supply of general surgeons in the U.S. fell from 7.68 per 100,000 population in 1981 to 5.69 per 100,000 in 2005.
Conversely, the locum tenens industry has nearly doubled in size during the past five years—from $1.1 billion in revenue in 2004 to a projected $2 billion this year, according to Billie Wickstrom, a spokesperson for LocumTenens.com, a staffing agency based in suburban Atlanta. The company said that requests for temporary surgeons are among its fastest-growing demands and cited statistics estimating that on any given day in the U.S. more than 1,300 general surgeons are on temporary assignment.
Hospitalists who work with temporary surgeons said the arrangements can be both challenging and beneficial. A visiting surgeon must be able to integrate into the workings of the regular medical and nursing staff, and that isn't always easy.
“Every institution has its own culture and it can be really challenging to work with someone who may have a particularly different approach,” said Jennifer McKay, ACP Member, co-director of the hospitalist program at Avera McKennan Hospital & University Medical Center in Sioux Falls, S.D. On the plus side, temporary surgeons can provide much-needed weekend coverage for emergencies and fill in for staff surgeons who need a break, or when someone leaves and a replacement has yet to be found.
Muhammad Faisal, ACP Member, a hospitalist at Horizon Medical Center in Dickson, Tenn., said the addition of locum tenens into the surgical rotation at his hospital has enhanced care. The hospital has two full-time surgeons and two temps who come in one week each month, an arrangement that allows the regular surgeons to concentrate on their outpatient practice during the week they're not on service.
“When they [the temps] are here, they are in the hospital all the time because they don't see patients in the office,” Dr. Faisal said. “As long as they are in the hospital, they are readily accessible.”
Dr. Faisal said he thought it helped that the same two surgeons return month after month. “It's key to have the same people who we know and trust their work,” he said. “They come here all the time so they get to know the physicians, they get to know the staff, and things run a little smoother.”
But he said there also are potential downsides to using stand-in surgeons. “Continuity of care can suffer, especially when different people are utilized,” Dr. Faisal said. Also, “Not all surgeons are created equal, meaning some may not do procedures that others may be comfortable with. Some locums don't do endoscopies and pacemaker insertions while our full-time surgeons do.”
Who gets the handoff?
Paul Collicott, MD, director of the member services division of the American College of Surgeons, said locum tenens must adhere to the same professional standards as full-time surgeons do. That means, among other things, that they must hand off cases to another surgeon.
“Care of surgical patients should be directed by a surgeon,” Dr. Collicott said. “At the time the surgeon departs, postoperative care is therefore provided by an individual with surgical knowledge and training.”
Paul Radway, MD, who became a traveling general surgeon two-and-a-half years ago after giving up his private practice in Pueblo, Colo., couldn't recall a time when a hospital had to track him down for information on a patient he'd operated on.
“I consider it unethical to operate on patients and leave and pass them off to someone who is not a surgeon,” said Dr. Radway, who operates frequently at Sterling Regional Medical Center in Sterling, Colo. Still, he also depends on nonsurgical staff wherever he goes. “You need to understand that every situation is a little bit different and keep your ears and eyes open so you know who you can trust and how you can fit in, with the good of the patient being the main objective,” Dr. Radway said.
Even with a surgeon-to-surgeon handoff, hospitalists might sometimes find themselves in the middle of a changing care plan. Dr. Faisal said that when a patient is admitted under the surgical service, “the hospitalists don't have to be middlemen as surgeons will sign off to each other. It sometimes can get to be a problem if a patient was admitted to the hospitalists and a surgeon was consulted. Once that surgeon goes off, the incoming surgeon may not always be on the same plan.”
Jennifer Peppers, MD, a locum tenens surgeon who regularly does stints at Horizon Medical Center in Tennessee, said “it's like a marriage made in heaven” when she is assigned to a hospital with a hospitalist program. Since neither she nor the hospitalists have to worry about seeing office patients, “we're in the hospital all the time and can bounce ideas off each other,” she said.
Eileen Glover, vice president for the surgery division of Staff Care, a physician placement service in Irving, Texas, said she prefers placing surgeons at facilities where there are hospitalists because it helps provide a better bridge from the departing surgeon to the new surgeon, who will become responsible for the patient's care.
“When we choose to take a search we need to be sure there's a seamless plan in place,” Ms. Glover said. “A hospitalist is typically accustomed to transitioning a patient's care from one physician to another.”
David Kapaska, DO, chief medical officer for Avera McKennan in Sioux Falls, said his hospital uses temporary surgeons to provide weekend emergency coverage and from time to time to fill in while recruiting is going on. He makes a point of orienting visiting doctors to the hospital's culture and staff. It helps when the temps get to know the hospitalists, he added, because “they can be their advocate and their support person.”
Dr. Peppers said she tries to establish good communication with staff doctors by doing such things as picking up the phone and calling a physician directly, rather than simply writing orders for a consult. In turn, she said, visiting surgeons such as herself appreciate it when staff doctors take the time to ask them about their background. She said she is always reachable by cell phone to consult about a patient after leaving an assignment.
Dr. McKay, the Avera McKennan hospitalist, said that temporary surgeons need to understand the values of the patients they're dealing with. In her community, for instance, people tend to believe that “survival into a nursing home is not survival; it's their worst nightmare,” and thus don't necessarily have the attitude that life should be saved at all costs.
“We have a big belief in the autonomy of the patient,” Dr. McKay said, something both regular and temporary staff need to respect. “We try to keep the line of communication open so we can all come to a common point to take care of the patient.”