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Life in Emergistan

Life in Emergistan

An Emergency Physician's Guide to Locums

Leap, Edwin MD

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doi: 10.1097/01.EEM.0000483169.33694.e4

    Part 1 in a Series

    Many years ago before our specialty evolved, emergency departments across the country were often covered by physicians who came to the hospital for a few shifts and then went away. An ophthalmologist might be the weekend emergency physician, or a pathologist or internist would fill in those empty shifts for extra money. Sometimes they weren't members of the community, and in many cases were poorly prepared for the situations that presented to the department.

    I recall hearing the pejorative “backpack doctors.” They came in scrubs and running shoes with books, food, and a stethoscope in their bags. They ran in and ran out. We were told this was not an optimal situation. (In fact, the bad outcomes associated with this old system helped drive the creation of our august specialty in the first place.)

    We were taught when I was in residency that proper emergency physicians took jobs with groups or hospitals and were settled and committed (despite the fact that we engaged in lots and lots of moonlighting ourselves). Emergency physicians, like their professional ancestors, should be on committees, know the staff, work with the administration, spend 20 or 30 years in the same place, then cut back or change if they wanted. It was supposed to be a job, like jobs always were.

    Times have changed, however. Now, fee-for-service groups are under enormous pressure and seem to be vanishing as large hospitals and health systems rule the day. Young physicians in particular seem drawn to the allure of benefits and academic opportunities. Employment, with its attendant benefits, has a certain appeal to many.

    The problem is that those hospitals and systems are vast, and physicians (and others) are increasingly cogs in the great wheel of the medical business. And when this happens, that dedication and devotion, from hospital to physicians, fades away.

    It's replaced with unpleasant schedules that disregard health and personal requests. It's replaced with customer service paradigms, LEAN programs, assorted consultants, coding offices, and EMRs that make physicians little more than slaves to the keyboard, tasked not only with caring for the sick and dying but with entering mountains of data and coding it correctly in real time.

    Instead of being part of a family, physicians become problems to be solved, threatened with a loss of income over Press Ganey, boarding, throughput times they cannot control, and other quality measures that leave their incentive pay just out of reach, quarter after quarter. “Sorry, guys, you were close! Maybe next time.”

    Backpack EPs Return

    Sadly, this is occurring even as emergency department volumes continue to grow while space and staffing do not. The ED is where people go when they can't find a physician, can't afford one, or have a deductible too high to do anything except come to the ED. The vital epicenter and entry point of the hospital is full of physicians who feel abused, misused, and exhausted.

    Is it any wonder that the days of the backpack physician have returned? A physician can come to work, see patients, make good money, and have only tangential connections to the drama and control of the larger organization.

    My own journey began because I needed a change of venue after 20 years in the same shop. Locums made sense for my family and me for various reasons. Since starting my travels three years ago, I've had many physicians with regular jobs come up to me and say, “So, Ed, you like locums? I've been thinking about it. Just not sure if I'm ready.” They've asked me with whom I recommend working, where to go, how to incorporate, and why I keep doing it. (It's almost like they're asking about a potential prison break.)

    After I work and talk with them, I can see that much of the drive behind the movement is simply unhappiness because physicians are treated as commodities rather than professionals. Many hospitals, because of location or unwise staffing policies in the past, are short good physicians. They have realized they have to staff the place where the patients are being seen, and it behooves them to staff that place with qualified physicians. Although locums can still be a refuge for scoundrels, the medical equivalent of the French Foreign Legion, I see that less and less. And I can tell because I'm seeing great advertised rates unimaginable in the past, even in small EDs with volumes of 10,000 per year. But many of these are only for ABEM-certified physicians.

    Only you can decide if work as a locums physician is for you. But I'll try to help you decide as we discuss more about it in the next couple of columns, with specific tips on working with hospitals and companies and living as an independent contractor, or as I like to think of it, a masterless Samurai.

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