The Rhinelander Daily News - Online news and information for the Rhinelander, Wisconsin region

Chances are you’ve never heard of a locum, but your life may depend on one someday. Locum tenens, the Latin expression for ‘place holder,’ is the term used to describe stand-in clinicians in the medical field, and as a result of state and nationwide shortages of medical professionals, healthcare groups like Ministry Health Care and the Marshfield Clinic rely heavily on locums to fill out their staffs. According to a report released last week by the Wisconsin Council on Medical Education and Workforce (WCMEW), there are about 10,000 doctors in the state but at least 600 physician jobs still need filling.

“The supply of physicians will not keep up with the demand of patients as the population ages,” Dr. Carl Getto, senior vice president of medical affairs at the University of Wisconsin Hospital in Madison, told the Chicago Tribune.

As the country’s aging population continues to grow, so does the population of doctors nearing retirement, which means the physician shortage is likely to get worse before it gets better. The WCMEW report also concluded that the shortage of medical clinicians is most acutely felt in rural areas.

According to Dr. Byron Krouse, director of the Wisconsin Academy for Rural Medicine (WARM) at the UW-Madison, around 60 percent of students educated in medical schools in Wisconsin leave the state for their residency programs. To make matters worse, matriculation surveys of students entering the UW-Madison Medical School showed as recently as two years ago that only four percent of the school’s med students considered living and working in rural areas after graduation. Krouse said the number has risen to eight percent as the result of administrative efforts to familiarize students with opportunities in rural medicine, but the reality facing healthcare administrators in the Northwoods is that the demand for doctors and nurses is greater than the supply.

In the meantime, administrators count on locums to assure they can supply services in an array of specialty areas.

Why locums?

Dr. Robert Sookochoff is a family practice physician who serves as Regional Vice President of Ministry Medical Group, Northern Region, based in Rhinelander. Sookochoff said Ministry employs locums under three circumstances: First, to fill in for existing clinicians during planned absences that involve a significant period of time; Second, to fill in for clinicians who have left the organization– the national turnover rate for medical clinicians is around nine percent per year– while Ministry works to find a permanent replacement; And third, to quickly populate an emerging service area with staff until Ministry can assemble a permanent staff.

Ministry recently employed this method to populate its hospitalist program at St. Mary’s Hospital. At the moment three-quarters of the hospitalist providers at St. Mary’s are locums.

According to Sookochoff, at any one time about 20 percent of the physicians at St. Mary’s are locums, a number he said is similar at other specialty groups in the region.

“Our target percentage in a perfect world would be zero,” Sookochoff said. “We would like to have all of the services staffed with full-time providers. That would be in an ideal world. This 20 percent in my estimation is too high but I think most medical organizations would say, in the absence of a full-time clinician, this is our next best option.”

Julie Thompson, northern division administrator for the Marshfield Clinic based in Minocqua, said the shortage goes beyond physicians.

“There is a shortage of many of the people involved in providing healthcare,” Thompson said. “That includes staff in the labs, nurses, radiology technicians. We use temporary people in all of those roles when we have to.”

Thompson estimated that at any one time five percent of Marshfield’s medical professionals are locums, but she said the number is higher for physicians.

She also said northern Wisconsin provides a particular hiring challenge because of its rural environment and long winters.

“What you have to have to be successful is someone who wants to live in this part of the country,” Thompson said. “And that’s a smaller group than the group who wants to live in a mid-size city of a large urban area.”

According to Thompson, another barrier to hiring permanent staff is that lack of availability of jobs for their spouses.

“Professional people tend to be married to other professional people,” Thompson said. “And finding jobs can be challenging.”

The problem with locums

Sookochoff says locums present a variety of problems to organizations like Ministry.

The first problem is availability.

“They’re not always available because of the national shortage of clinicians,” he said. “We might have a need for a locum provider and the agency may just say they’re not available.”

The second problem posed by locums is that while they go through a rigorous screening process it is nearly impossible to ensure that they possess the technical skill set Ministry needs.

“When they come here sometimes we find out that they didn’t tell the whole story. We may find gaps in their technical skill set,” said Sookochoff.

The third issue Sookochoff sees with locums is the discontinuity they can introduce into the culture of the organization. He described Ministry as a values-based organization, focused on service, justice, vision and presence in the community.

“There may be an issue with their emotional state, their communication skills, or simply that they don’t fit our expectations,” said Sookochoff.

The fourth, and perhaps most apparent problem, is cost. Locums cost up to three times are much as a permanent clinician. With the price of health care already becoming prohibitive, Sookochoff said the cost of maintaining locum doctors is passed on to the communities in which they serve.

“It’s also a problem for the community because ultimately the costs are transferred to the community,” he said.

The long-term solution

Sookochoff is not one to list problems without offering solutions. Ministry has undertaken two initiatives to stem its dependence on hiring locums. The first is to maintain a primary care float pool, essentially a pool of physicians and nurses already in the Ministry system to operate as internal locums when the need arises. Sookochoff said that program is still in its nascent stages, having been initiated only six months ago, but it promises to lower costs if Ministry can cover short-term absences with permanent doctors.

Ministry has also undertaken a more aggressive long-term solution. Beacause locums are essentially a creation of the shortage of clinicians, particularly in specialty areas like pulmonary and critical care and dermatology, Ministry is hoping to find new ways to populate their permanent pool in those specialty areas.

“In some of these very hard to recruit specialties we’re identifying high functioning physicians and sponsoring them to go back to school and train for these specialties,” said Sookochoff.

The organization would invest in the further education of its doctors and hold the doctors, in turn, to a contract of service that would require them to work two years at Ministry for every one year of schooling paid for by the organization.

Sookochoff said Ministry is also examining the possibility of offering loan forgiveness for promising medical students in their service areas.

“We’re very excited about this because people who understand the area and have family and ties in the community, who know what makes it special, they’re much more likely to stay over the long-term,” Sookochoff said.

Loan forgiveness is something Krouse believes must be a part of the equation if the shortage of primary care providers is to be solved over the long run. The average debt loan for medical students in $132,000, a fact which leads many of them to pursue lucrative specialties to the exclusion of less profitable but very necessary areas of care.

“How do you not look at your professional choice in terms of your earning potential?” Krouse said.

He said that while a multi-factorial solution to the problem is necessary, loan forgiveness programs are a way of luring students to areas they may end up liking.

Another way to attract doctors to rural areas is to familiarize them with the rural environment during their schooling. Working in partnership with WARM, the Marshfield Clinic in Marshfield is one of three regional placement centers in the state to host WARM students in their third and fourth years. The students have the chance to familiarize themselves with rural medicine by practicing at rural placements in Rice Lake.

“If you bring people into rural sites, it gets them embedded,” Thompson said. “We think that will be a good recruitment strategy in the future.”

WARM now has ten students finishing their medical schooling at rural placements arranged through partnerships with Marshfield, Aurora Bay Care in Green Bay and Gunnerson Lutheran in La Crosse. The number will increase to 50 third and fourth year students by 2010, and Thompson said North Minocqua may by that time serve as a placement site.

But WARM’s efforts are a long-term solution to a problem with an immediate and fast-growing impact. Krouse said the medical field is taking a hard look at ways to turnout better doctors quicker, but the increasing complexity of medicine is an obstacle.

“The reality is medicine is not becoming less complex,” said Krouse. “The question is how to reduce the time and still produce the same quality of doctors.”

Sookochoff said that while locums are perhaps not the result of an ideal set-up, they are a necessary means to guaranteeing service to patients.

“You can’t look at locums without looking at the whole picture,” Sookochoff said. “There are issues but nevertheless its a valuable service.”

Meet the locums

Holly Anderson is a provider recruiter for Ministry. It’s her job to fill both permanent and temporary staff positions for the group so she is perhaps more familiar than anyone else with the locum system.

According to Anderson, locums are hired through staffing agencies, and she prefers those like Weatherby Locums, a Fort Lauderdale-based company that belongs to the National Association of Locum Tenens Organization (NALTO).

“It really depends on the specialty, but most of the time the companies are nationwide, providing services from California to New York and everywhere in between,” Anderson said. “We try to use companies that are members of NALTO, because that organization has an established set of standards for service. The other important characteristic of NALTO is that they try to make sure the organizations are focused on the patients.”

Anderson said locums come in three different types. Some are doctors who are just out of their residency programs who use locum placements in lieu of internships to find out where they would like to settle down permanently. Others are doctors who have reached a career midpoint.

“Maybe they want a lifestyle change. Maybe they are a little nomadic and want to work in a place for a few months,” Anderson said.

And then there are doctors whose careers are winding down for whom a locum placements provides a good opportunity to earn additional income before retirement.

“The only group that’s not looking for a permanent placement is the group close to retirement,” Anderson said. “The other groups are always keeping their options open.”

Anderson said that the national shortage of medical clinicians has made hunting for locums difficult, even for agencies who offer the service.

“There’s just such a physician shortage nationwide in several specialties,” Anderson said. “I think it’s hit not only those of us who recruit permanently but also the locum companies too.”

Dr. Carlos Tan, M.D., F.A.C.S, is a vascular and general surgeon who has been working as a locum at St. Mary’s Hospital in Rhinelander. Tan fits in to the second group Anderson described. He has his own private practice in Milwaukee, but after he split with his business partner, he looked for a locum placement as an added source of revenue. Dr. Tan works for three weeks at a time at St. Mary’s, then returns to Milwaukee for two weeks to be with his wife and maintain his practice.

“I was looking for a way to generate some income,” Tan said. “I applied to several companies and eventually they placed me here.”

Tan said he went through an extensive review process with the locum agency and then again with St. Mary’s before he was given a placement. He was surprised at the quality of the facilities and clinicians in Rhinelander.

“It was fairly easy to fit in,” he said. “The main this is that I was surprised that this area had such a nice hospital. The people there are very good.”

Tan said he enjoys working as a locum at St. Mary’s and would not rule out taking a full-time position.

“There’s always the possibility,” he said. “The attraction of working as a locum is that you might be able to look at the hospital and the area and they might be an attractive place.”

This is Tan’s first time working as a locum. He said the biggest challenge is being alone in a new place.

“The hard part is that you’re kind of lonely,” Tan said. “When you go back to the hotel you’re on your own. I don’t hang out with anybody, I just work hard and workout at the YMCA four of five times a week. I’m so glad that the YMCA here is really nice.”

Tan said when he first accepted the position, the hospital was looking to hire a permanent surgeon.

“When I first started out I think they were looking for someone permanent but they had already gotten someone to fill that place,” said Tan. “They still need to fill some rotations.”

Tan will work at St. Mary’s through December, take a month off, and then return for another placement in February.”

Dr. William Wright, D.O., a family medicine physician, is an example of a clinician who used a locum placement as a pathway to a full-time position at St. Mary’s Hospital.

“I was in a small town and I ended up being the third doctor in a one-doc town,” said Wright. “This was a good way to see a new hospital and a new area. You do a test-drive before you buy a car and this is similar. I ended up working in Eagle River and then Ministry said, ‘We think you’re a good fit.’”

Wright worked locum placements with Ministry in Woodruff, Crandon, and Eagle River before taking a permanent position in Rhinelander. Wright said there is no typical path for locums.

“I’m not sure there’s a typical way for anything,” Wright said. “It’s a wide variety of people in the locums business. I know there are doctors that all only do locums placements, because it allows them to go where they want. But I was looking for something long-term.”

Wright said he and his wife were attracted to the outdoor lifestyle in Rhinelander.

“I enjoy the outdoors. My wife and I have a tandem bicycle and we ride the trails,” Wright said. “We really enjoy it here and Ministry is a great place to work and Rhinelander is just a great fit for us.”

For Anderson, who works every day trying to fill Ministry’s need for permanent and temporary physicians, the struggle to find more permanent doctors in hard-to-find specialties will continue as long as the national shortage of physicians persist. Her top priority, she said, is to make sure her patients have access to a full menu of services.

“I’m in 100 percent agreement that the goal is no locums in the system but because of the shortage, that’s just not possible right now,” Anderson said. “My focus is that our patients are provided the services they need. I have relatives int he area served by Ministry hospitals and my motivation is to make sure they have the best care available.”

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