Providing surgical call coverage in rural areas of the U.S. and Canada is a constant struggle. With many small hospitals being covered by only one or two surgeons, issues related to lack of time for family and the inability to take time away from practice to learn new techniques leads to burnout and early retirement or an exodus to larger areas offering the opportunity for potentially better positions. The pool of rural surgeons is already at a crisis level, with many hospitals losing the capability to offer surgical services when their surgeon leaves or retires. Statistics also show that too few trainees will be available to fill these positions.
Research done by Julie Conyers, MD, MBA, FACS—a founding member of the American College of Surgeons (ACS) Advisory Council for Rural Surgery—revealed that the locum tenens market is a $21 billion business, with the companies taking 20 to 50 percent of their fees as profit and many times providing staff of variable quality. Dr. Conyers’ 2016 survey of approximately 1,000 surgeons via the ACS rural surgery listserv showed that nearly 50 percent of rural surgeons were on call every night or every other night; 20 percent had no coverage during the infrequent times they were away from their practice; and 62 percent said that locum tenens coverage would improve their quality of life, but costs to their facilities were the biggest barrier to providing locum tenens coverage. These findings were presented at the 2016 ACS Advisory Council for Rural Surgery annual meeting. Interestingly, when survey participants were asked, “In the right circumstance, would you consider working as a locum tenens surgeon?” more than 80 percent of urban and rural surgeons said they would consider work as a locum tenens surgeon. Surgeons older than age 50 were most receptive to the idea of working as a locum tenens surgeon, and more than 50 percent of that older group might consider doing full-time locum tenens work.
High-quality locum tenens surgical coverage can provide call relief for rural surgeons, especially if it can be arranged on a regular basis and by the same pool of surgeons. Rural hospitals, rural surgeons, and rural communities can benefit greatly from a well-developed locum tenens coverage arrangement. Two locum tenens systems, one in Canada and one in the U.S., are discussed in this article and may serve as templates for locoregional solutions for rural surgical call coverage.
CAGS Rural Locum Tenens Project
To help rural communities provide surgical care, the Canadian Association of General Surgeons (CAGS) has developed the Rural Locum Tenens Project. The goal of this program is to help provide locum tenens surgeons to rural areas in anticipation of creating more stable long-term surgical coverage. This program attempts to develop a team of six to eight surgeons who will provide regular locum tenens coverage to a rural community in one- to two-week time blocks.
The rural community of Thompson, Manitoba, was selected as a pilot site for the CAGS Rural Locum Tenens Project. Thompson is a community of 13,000 people and serves as the hub of northern Manitoba. At the time the project was initiated, Thompson was down to only one surgeon.
The Thompson project launched with advertisements describing the need for locum tenens surgeons on the CAGS website and in the CAGS monthly newsletter. A video also was created, which showed the area and community and highlighted the need for additional surgical coverage.
There was a brisk response of applicants for the locum tenens positions, and after more than 20 surgeons sent in their curriculum vitae, no further applications were accepted. Since the project began, two locum tenens surgeons have accepted full-time positions in Thompson. As a result of the Rural Locum Tenens Project in Thompson, the surgical care of patients of the community has improved significantly.
Several important points were learned as a result of this pilot project. At the time this project was initiated, licensure to practice surgery in Thompson required an in-person interview through the Manitoba Registrar, which created a barrier for locum tenens surgeons who were interested in the position. Subsequently, the CAGS has worked with the Manitoba Registrar to allow the interview to be conducted either by telephone or via Skype. It also became clear that the local health authority and the CAGS needed to collaborate. This partnership led to the development of a fact sheet for applicants containing important information regarding the locum tenens position and allowed for early identification of potential candidates for the positions.
Because of the success of the Rural Locum Tenens Project in Thompson, the CAGS has plans to expand this program to other remote rural areas in Canada that have had difficulty providing surgical care to the members of their communities.
A locoregional solution in rural Ohio
In the U.S., locoregional locum tenens solutions can alleviate the usual burdens of credentialing, licensure, and medical liability insurance coverage. A small independent surgical group providing services in Cambridge, OH, a town of 11,000 people in rural southeastern Ohio, has collaborated with the leadership of a small hospital in an adjoining county to provide locum tenens surgical coverage. The practice provides true general surgery services, including vascular, endocrine, and some thoracic surgery, and basic and advanced endoscopy.
Several years ago, the Cambridge group was approached by a small community hospital 30 miles away in Coshocton to help provide surgical services. The hospital’s two staff surgeons were both in the process of slowing down and retiring. The Cambridge group had four surgeons, which allowed the group to help the neighboring facility. The arrangement began with all members applying for full staff privileges at the outlying facility and then arranging their schedules so that someone from the group could provide call coverage for one or two days a week and one or two weekends per month. The two older surgeons on staff at Coshocton provided the rest of the call coverage.
This was all done through a direct relationship and arrangement between the Cambridge surgical group and the Coshocton hospital administration with no locum tenens company involved. The involvement of the Cambridge group as full surgical staff members facilitated the recruitment of two younger surgeons to replace the outgoing older surgeons without any interruption in surgical coverage for the facility during the transition. The involvement of the well-established and respected Cambridge surgical group in the region increased the volume of surgical and endoscopic procedures performed in the Coshocton facility. Their presence made it possible for the two new surgeons to cover the facility and still have time off for family and travel for continuing medical education (CME). Since all surgeons involved practiced in Ohio, credentialing and licensing of the Cambridge surgeons was simple for both parties. The Cambridge surgeons were covered by their own liability policies because they were all credentialed as full-time staff at Coshocton, and the locum tenens services were considered work performed at a satellite office.
Collaboration with the local surgical group to provide locum tenens surgical services greatly benefited both the Coshocton hospital and the local facility in Cambridge. Because of the direct relationship between the group and the outlying facility, the Coshocton hospital could better afford the coverage without paying the exorbitant fees locum tenens companies charge. The hospital could also offer a fair daily stipend for the locum tenens work and allow the Cambridge surgeons to bill for their services, which they have done through their home office. This additional income makes this arrangement financially beneficial for the Cambridge surgeons.
Lastly, involvement in the outlying hospital and community resulted in many referrals to the Cambridge hospital for advanced laparoscopic and endoscopic cases. Other specialists in Cambridge, including oncologists, cardiologists, and pulmonologists, benefited from increased referrals from the outlying community as well. This locoregional system of providing surgical call coverage has been a definite win-win situation for the surgeons and hospitals of both communities.
Small facilities with solo or two-person surgical groups that are struggling to provide full-time surgical services can benefit from direct relationships with surgeons from neighboring facilities in their state or region. If locum tenens coverage can be arranged directly between hospital administrators and surgeons, without going through locum tenens companies, costs can be controlled, surgeons providing the locum tenens coverage can be more fairly compensated, and the local surgeons can have more time off for family and CME opportunities, resulting in less chance of burnout. If a small core of regional surgeons can be attracted and given full staff privileges, then it bypasses the constant struggle to credential new locum tenens surgeons. If the facility only deals with board-certified Fellows of the ACS, then it also guarantees that care is provided by qualified surgeons, something not experienced in many cases when locum tenens is provided by a large company.
A similar approach to such a locoregional system of locum tenens surgical coverage might possibly be facilitated by state chapters of the ACS or by the largest health systems in the state, which probably are already affiliated in some way with most of the small rural hospitals in the region. Another mechanism to help connect small hospitals in need of locum tenens help might be an Internet-based site that matches rural hospitals with locum tenens surgeons and surgeons interested in doing locum tenens work. By promoting this system on a regional level, the sometimes difficult issue of obtaining the proper state medical license could be minimized.
Conclusion
The 60 million rural Americans, and even larger populations of rural Canadians, face a real problem with access to surgical services because of impending shortages of surgeons in these areas and a maldistribution of newly trained surgeons into surgical specialties in mostly urban areas. Rural surgeons bear a significant call burden that restricts their time away for family activities and educational opportunities. Innovative locoregional locum tenens solutions that provide quality locum tenens surgical coverage for rural communities at a reasonable cost can significantly improve the situations of rural surgeons, their hospitals, and their communities.
