How can we redefine locum tenens? [PODCAST]

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“Hiring locum tenens clinicians often proves to be more efficient, and when a position goes unfilled, health care organizations are potentially leaving millions of dollars on the table in unrealized revenues. Once in place, locum tenens clinicians can help organizations expand their service lines, provide access to specialists, relieve existing staff workload, keep the operating room running, manage throughput in the emergency department, and cover call. They are also part of a growing natural progression in health care — telemedicine. Locum tenens clinicians are being used in telehealth settings, allowing the flexibility to simply video chat with a patient for a consult or provide a second opinion to another physician.

Utilizing locum tenens clinicians ultimately benefits patient care while positively impacting the bottom line. Among the available strategies to deal with the current challenges in clinician recruitment, the locum tenens model can undoubtedly evolve into a viable and attractive long-term strategy for the provision of everyday health care access.”

Sridhar Rajamani is a pulmonary physician and member of the advisory board, LocumTenens.com.

He shares his story and discusses his KevinMD article, “How can we redefine locum tenens?”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Sridhar Rajamani. He’s a pulmonary physician, and he wrote the KevinMD article “How can we redefine locum tenens?” Sridhar, welcome to the show.

Sridhar Rajamani: Thank you, Dr. Pho.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Sridhar Rajamani: Like you said, I’m a pulmonary critical care physician. I finished my fellowship almost 20 years ago in New York, and my wife wanted to go someplace warm, so we went to southwest Arizona and started a private practice supported by the hospital. That was not my passion, though. My passion was always critical care, the ICU, and I wanted to start intensivist services. This was the infancy of all these closed ICUs, Leapfrog, and all of that stuff.

Luckily for me, the hospital was very supportive. A few years into my practice, they said, “Why don’t you guys get together and put together a practice?” And we did a 24/7 in-house intensivist practice. We grew from a 16-bed ICU to a 42-bed ICU. The hospital grew, the ICU group services grew, and we had phenomenal outcomes. We ran the program for about 15 years, until earlier this year, when we decided we were all getting older and it was getting a little difficult to run practices and do all of these things. The hospital was gracious enough to take over the practice and run the practice, as they’re doing right now.

I have to be honest: I couldn’t have run the whole program, or we couldn’t have run the whole program, if not for locum support. So over the last maybe 10 years or so, I got to know a lot of different locum companies, and we brought in a lot of different locum physicians, and we learned from them. When the hospital took over our practice, many of these locum physicians got absorbed as full-time employees or contractors. So that’s pretty much my journey, and now I do a lot more locums than I used to, and I’m having fun with it.

Kevin Pho: Let’s transition now to your KevinMD article, “How can we redefine locum tenens?” Now, for those who haven’t read the article, can you just walk my audience through it and maybe share the story of why you decided to write it?

Sridhar Rajamani: Last year, I was invited to attend a retreat of the LocumTenens.com customer advisory board. I had used physicians from the locum tenens company LocumTenens.com to staff our practice, and I also worked with them on the physician side, a first couple of assignments here and there. So I got to know them, they got to know me, and they said, “You know, you have experience on both sides of the aisle. Why don’t you come and give us your input?” So I went there, and I got to meet a lot of similar-minded physicians and some administrators as well. As I got to talking and gave my perspective as the client and the physician, they said, “Why don’t you write an article, and I’ll see how this goes?” Because locum tenens, as you know, Dr. Pho, has not always been received in a positive way, and there have been different names called. So, to put some positive, for lack of a better word, spin on the whole locums opportunity, they said, once you put together an article. And I did that. That’s what happened eventually, with the help of LocumTenens.com. We wrote this article.

The goal for this article is not to promote locums and not to promote; that’s not it. It’s basically my observations, my personal experiences, and what I think is the future for health care staffing. I’m a critical care physician. There are maybe 5,000 of us who are board-certified, and there’s not a whole lot coming out every year. So it is a difficult specialty to recruit. Hospitalist is a difficult specialty to recruit. And we cannot have the same mindset we had 20 years ago, 30 years ago, in terms of recruitment.

This is another tool in the toolbox for recruitment, and as opposed to common thinking, it is not that expensive. It’s either on par with regular recruitment, or sometimes it even comes out cheaper. So that is what I wanted to focus on: Use this. This is a tool you can have in your arsenal of how you staff and all of that stuff. We have to get creative. As you see, the article pretty much highlights all of those points and what the good things are that can come from locums. It’s not for everyone. It’s for a lot of people. So that’s pretty much how it is.

Kevin Pho: Now, what would you say are some of the biggest misconceptions about locum tenens?

Sridhar Rajamani: Bad quality. “The locum guys come, they punch and punch out, they don’t care about quality.” That’s a huge misconception, and I’m going to talk about it in just one second, why I think it’s a misconception. Two, it’s very expensive, and that again is wrong. I have recruited locums, I have used locums in my own private practice, and it is not any more expensive than a regular full-time physician.

Now, coming back to the quality piece. When you bring in a locum physician, you’re credentialing them exactly like you do anybody else. But the advantage with these guys is that they come from different experiences and backgrounds, and they bring that experience with them. They’ve seen different protocols and different guidelines, and they bring all of that to your practice, and they support your practice doing that. If anything, it elevates your care. It gives you more diverse clinical experience, if you may. So, in my personal experience, in the way we have practiced in our intensivist group, they have actually improved, and we have learned a lot. We have brought in new procedures and new services because of these guys. So quality, that’s a big, big misconception. That is not true.

On the financial aspect, yes, if you look at the initial dollars and cents, it looks like it may be expensive. But in the long run, if you have a steady locum crew of locum people coming to you and working with you, your overheads are pretty much the same. You pay them an hourly or a daily per diem, or whatever it is, but you’re not worried about your disability, your life insurance, your malpractice. All of that stuff is baked into the equation here. When you run the balance sheet at the end of the year, it’s almost similar to a full-time employee.

The one advantage you have with locums is that if you don’t think it’s the right fit, if you don’t think that’s the right person for your organization’s culture, you can always give a 30-day notice, and that person walks out. It’s a clean split, and everybody is happy. But it’s very hard to do that when you have a full-time employed physician or provider. Then you have to worry about tail insurance. You have to worry about how you separate or sever yourself. If you sever yourself from an employment contract, it can get a little tricky sometimes. So there are advantages to this whole locum opportunity.

Kevin Pho: Now, in general, can you tell me about the pool of physicians that you could draw from in locum tenens? In other words, what kind of doctors normally apply to become locum tenens physicians?

Sridhar Rajamani: Initially, it used to be hospital-based practices: hospitalists, anesthesiologists, emergency room physicians, ICU doctors. Now, when I go visit other places, I see neurologists and cardiologists. I even know a cardiac surgeon who did locum work. Infectious disease has become that, because these are specialties that are now not easily available for recruitment.

The other thing that you see is that most of these locum opportunities used to be in very rural, remote areas. That is the past. Now even big cities and big suburban areas are requiring locums, just because there are not enough people coming out of fellowship or training or residency training at this time. So even though hospitalists and hospital-based practices are still the largest number of locum physicians, there are the other physicians, outpatient care, for example, offices, pulmonologists. I’m a pulmonologist, and more and more these days I hear people calling me, saying, “Would you like to cover eight hours of office work? Because we don’t have a pulmonologist in our outpatient. We have 250,000 people in this town, and there’s not a pulmonologist in town, and we’d like to start up an office practice to take care of asthma and COPD and decrease readmissions.” So there is opportunity for that as well.

Kevin Pho: Now, if I’m a medical institution looking for a locums physician, as you know, there are so many different companies available out there. On the other side, as a physician myself, I get emails all the time from different locum companies. Now, what separates one company from another?

Sridhar Rajamani: There used to be maybe five large companies in the past, but now we have probably 500 of those. Even physicians who are very entrepreneurial have started their own locum companies. At the end of the day, it doesn’t matter who anybody works with; it’s the service you get from them, and that personalized service. Physicians want to have less hassle. That’s the reason why some physicians choose locum opportunities: to have less hassle. Somebody takes care of your logistics, and if you’re in a difficult situation, you call them, they figure out what’s going on, and they help you with maybe travel, maybe other things.

They also listen to what you want. That’s important in a company. When a company picks up and says, “Hey, Doc, I have a position here. Do you want to go?” Instantly. They call and say, “Hey, I’m available. If you’re available to do locums, I’d like to hear more about your story and see what you want to offer, and then let’s see if I can find a good fit for you.”

Kevin Pho: Now, if I’m a physician and I’m thinking of transitioning into locums, what are some of the things that I should look for when evaluating a potential locums opportunity?

Sridhar Rajamani: Do you like traveling? Would you be comfortable staying away from family for periods of time? Would you be willing to take care of your own retirement planning, your own taxes? The taxes get a little complicated when you work in three or four different states; with each one, you have to file taxes in different states. It’s a little more complex. Would you be comfortable buying your own health care insurance? Do you like flexibility? Do you want to work holidays? So there are a lot of different spokes to this wheel, and at the end of the day, it’s what is it that you want, and where is your comfort zone?

One thing I have to say, that I have seen across the board when I talk to other locum physicians, and I have had this experience too, is when you come out of your comfort zone. You were happy in XYZ hospital or in a practice, and good or bad, you kind of got used to that practice. Now you go from that practice, and you’re dislocated into a different place where the culture is different, the people are different, and sometimes the practices are different. You’re completely out of your element, out of your comfort zone. Are you going to be OK making the transition? You will be comfortable eventually, but for the first few days, a few weeks, maybe you won’t be. Is that something you are comfortable with? Is that something you are going to be able to work through? So those are the things I would suggest looking at.

Kevin Pho: We’re talking to Sridhar Rajamani. He’s a pulmonary physician, and he wrote the KevinMD article “How can we redefine locum tenens?” Sridhar, are there any red flags that physicians should look out for when it comes to evaluating the various locum tenens companies? You mentioned customer service; of course, that’s important. But what are some of the other red flags that should serve as warning signs?

Sridhar Rajamani: Some companies are very pushy. They would call you at all hours of the day and night. I’m sure you’ve seen that; you probably get those calls too. I would caution against those. The reason is that each company is structured differently. Some of these companies have a bonus built in for a client advisor or whatever, or some of them are salaried. And it’s very easy for physicians to pick up the red flags, saying, “Are they being too pushy? Are they just trying to get me a job so that they can get to a certain quota or a certain bottom line, or are they actually truly trying to help me out here?” And sometimes you have to be careful if they’re misrepresenting some opportunities.

When people call me, I always ask, “Can I speak with somebody on the other side, who works at that place?” If they say, “I have an ICU job there,” I say, “Can I speak with the medical director there, or can I speak to some other physicians that are working there, or maybe even the ICU manager?” just to get an idea of what this is all about. You may want to do that in the beginning with any company. But once you know who your client advisor is, once you have a rapport with a certain locum company and you know that they’re representing you, truly representing you, then you get a little more comfortable working with them, and you may say, “You know what, you’re giving me this, I’ll take it, no problem.”

But in the initial stages, I suggest not just talking to your client, but talking to the clinical people on the other side. Maybe you have to walk on excess. Maybe there’s what you’d call a landmine that you don’t know about, and that is the reason for actually bringing in locums. There is a practice, and the hospital may be firing a practice for political reasons, and they want to fill that position. You may be walking into a very difficult situation. So unless you make that phone call, you wouldn’t know what to expect. Initially, I suggest having the phone call with the clinical people on the ground and then deciding what you want to do.

Kevin Pho: Now, we’re speaking in the week before Thanksgiving, and as you know, the pandemic is flaring in pretty much the whole country. How has COVID-19 affected the locum tenens industry?

Sridhar Rajamani: I don’t think the pandemic could have been countered, or at least met the way it was met, without locums’ involvement. There is absolutely no way that could have happened. People came out of retirement when locums made those calls and said, “Can you help out?” And they came out of retirement to help out.

What COVID has done is unmask the friability in our health care delivery system. I’m not talking about Washington, and I’m not talking about state laws or anything. I’m talking about every hospital and every practice: how unprepared we are in staffing and in being dynamic about our staffing through the ebb and flow. But it should come as no surprise to us how resourceful the medical field is. The front lines have pretty much been taken over by the locums. As I read in a survey, about 80 percent of physicians that went to New York during the peak of the pandemic were actually coming from another state. Their state of residence was not New York, and about 60 percent of them didn’t even have New York licenses. Without locums, I don’t think the problem could have been taken care of, and it still continues to be an issue.

Now that brings me to the other issue: what COVID has done particularly to the locums industry. Places like New Jersey, Texas, and California, they’re all difficult states to license, not because they don’t want to bring in physicians. It’s just the bureaucracy, the paperwork, and the red tape that is involved. But they quickly changed their bureaucracy, they quickly changed the red tape, and they opened up temporary licenses to face the pandemic. I hope this leads to a much more open conversation about working across state lines and getting licensed without too much of a hassle. I think that there is conversation happening at all levels, and I’m hoping and I’m optimistic that happens.

Telehealth: COVID has opened up telehealth, and there should be wider adoption. It should be increased and encouraged. With telehealth, I know state people still don’t go see their primary physicians, don’t go see their oncologists or whatever, but telehealth has opened up, and I hope it becomes permanent, with a little wider scope. So that’s what I think locums and COVID have done.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Sridhar Rajamani: You don’t have to go with the traditional job options that were on the market many, many years ago. In my case, 20 years ago, when I graduated, there were only three different options: open your own store; join a private practice, have a couple of years of sweat equity, and then buy into a partnership; or join a hospital. Now you have another option. You can have a real-life interview, a real-life test drive, if you may. After you graduate, you could do a couple of years of locums, try, see what you like, see which place you like, and decide where you want to go in a permanent job. That is an option.

I would also say the same thing to the administrators. This is another tool in your toolbox, like I’ve said, and it should not be trivialized. It should be looked at more positively. You get to test a physician. You get to see a physician in action. When I say physician, it’s clinicians these days: Nurse practitioners, PAs, all of them do that. So it’s providers, clinicians. You can see how a clinician is in their element. And then, instead of a one-day interview, come in and have a real estate tour and walk. This is a real-life interview. You can do that, and you could have a happier provider in your practice.

The bottom line is, if you enjoy flexibility, if you like career independence and making your own schedule, this could be a solid career choice, or even a part-time choice if you want to augment your current income. Hospitalists, intensivists, they have all gone to the seven on, seven off kind of deal. You have some time on your hands, and you could do some locums to augment your income, pay off those big loans you come up with, or pay off that house, the mortgage on the house, those kinds of things. So, another option to look at. That’s my take-home message.

Kevin Pho: Well, thank you so much for sharing your time and insight, and thanks again for being on the show.

Sridhar Rajamani: Thank you so much, Dr. Pho.

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