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Tue Jan 13 18:29:34 GMT 2009

http://online.wsj.com/article/SB123179145452274561.html

When someone doubles over from stomach pain, the general surgeon is the one
who performs an appendectomy. Gallstones? The general surgeon removes the
gallbladder. Breast and colon tumors and hernias are also matters for the
surgeon's scalpel.
 [image: [Jennifer Peppers]]

Jennifer Peppers

Now the economic and cultural forces reshaping U.S. medicine are prompting
an exodus from this once venerable field, creating a growing market for
temporary surgeons-for-hire.

As a general surgeon in her hometown of Franklin, Tenn., Jennifer Peppers
could no longer keep her practice going after eight years in business. Faced
with rising overhead costs and declines in reimbursements, she and her
partners stopped drawing salaries last winter. To pay her home mortgage, Dr.
Peppers had to borrow from a credit line.

So the surgeons shuttered their practice, and Dr. Peppers, 42 years old, hit
the road. Her typical month might now include a weekend in Springfield,
Ore., removing ruptured spleens or repairing obstructed bowels, followed by
two weeks at a rural Kentucky or New Hampshire hospital. Though she misses
her husband, she earns double her old salary and has paid off a big chunk of
her medical-school debt. "I'd much prefer to be in my hospital in my little
town," says Dr. Peppers, who is now licensed in five states. "But I don't
see how that's possible."

The shift toward temporary assignments comes as the traditional way of
practicing general surgery is fading in many parts of the country. For
decades, general surgeons have been the backbone and economic engine of the
community hospital. While maintaining their own private practices, they
staff trauma and critical-care units and perform most common abdominal
procedures. Without them, hospitals couldn't provide many emergency-room
services. In rural areas, their backup is necessary for everything from
complicated births to inserting chest tubes.

But the increasingly grueling schedules, shrinking payments and the
temptation of more profitable surgical niches have made the field less
attractive. Over the past 25 years, the number of general surgeons per
capita has declined 25%, according to a study published in the Archives of
Surgery earlier this year. Other specialties are also seeing shortages as
their ranks grow more slowly than the overall population, but the decline in
general surgery is steeper than most. And while the number of physicians
overall isn't in decline, general surgery is one of the few fields where the
absolute number of surgeons is actually shrinking.

It's possible that the implosion of Wall Street will rekindle an interest in
medicine as a career, but future medical-school graduates could continue to
flock to specialties that pay more than general surgery. Nearly
three-quarters of surgeons-in-training already are opting for lucrative
subspecialties with more predictable hours, such as cardiovascular surgery
and neurosurgery, the American College of Surgeons says. That's left
community hospitals around the U.S. struggling to provide some of their most
basic services.

Some are turning to temporary physicians to fill the void. General surgery
is now among the fastest-growing areas of a temporary-medical-staffing
industry that's expected to double to $2.1 billion in 2009 from five years
ago, according to Locumtenens.com, a staffing agency. The company, which
takes its name from the Latin phrase meaning "to stand in another's place,"
matches hospitals with what the medical field calls *locum tenens* doctors.
Rising demand for these services, in turn, is prompting more of the
remaining general surgeons to choose a life on the road and in hotels.
  [image: [Surgeons perform open heart surgery at St. Vincent Infirmary
Medical Center in Little Rock, Ark.]]

Surgeons perform open heart surgery at St. Vincent Infirmary Medical Center
in Little Rock, Ark.
Health Blog

   - Hot Temp Jobs for
Doctors<http://blogs.wsj.com/health/2009/01/13/what-kinds-of-docs-are-in-demand-for-locum-tenens-jobs/>

Staffing agencies estimate that at least 1 in 20 of America's 17,000 general
surgeons now work on a temporary basis some or all of the time. Full-time
temporary surgeons can earn $250,000 or more a year, in some cases nearly
twice as much as in private practice. That's largely because they don't have
to pay overhead costs anymore.

Critics of the practice worry that it carries potential safety risks. A new
surgeon arriving in town may not be familiar with a hospital's staff, for
example, or with surgical patients coming in for follow-up visits. "That
continuity of care in surgical diseases is really important," says Phillip
Burns, chairman of the University of Tennessee's surgical department. As the
one who performs the surgery, "you are the best one to handle [any problems]
because you were the one inside."

Some who've switched to temporary work say patients often fare better with a
surgeon who can focus entirely on providing care instead of the
administrative hassles of a private practice. "I don't pay a penny of
overhead now and I feel better than I have in years," says Kenneth Lawson,
55. Dr. Lawson left his practice in Roseburg, Ore., in 2005 to travel as a
temporary surgeon.

While in private practice, Dr. Lawson says he would often spend five nights
in a row on call, "bleary eyed," performing emergency surgeries.
Increasingly, he says, these patients had no insurance. Hospitals typically
have the means to pursue debts from patients or write the losses off as
charity care, but doctors don't always have the manpower to collect on their
portion of the bill. "We got to the point we wouldn't waste a stamp trying
to get that money," says Dr. Lawson.

Locum tenens isn't a bargain for hospitals or a health-care system that is
already the world's costliest and accounts for nearly 17% of the U.S.
economy, according to federal government data.

A temporary surgeon who comes in to perform scheduled procedures and
emergency operations can cost a hospital about $1,500 a day -- between $650
and $900 for the physician and about the same for the staffing agency,
according to Staff Care, a temporary-medical-placement firm. That's in
addition to travel and lodging expenses. In traditional practice, hospitals
don't pay surgeons directly: They give them "privileges" to use their
operating rooms in exchange for sharing in emergency-call duty.
 [image: [under the knife]]

Yet, without the ability to perform surgeries, "we lose the business," says
Karen Hendren, chief operating officer of Stillwater Medical Center in
Oklahoma. The hospital plans to hire temporary surgeons this spring, when
one of its three local general surgeons leaves. Ms. Hendren is bracing for a
hit to the bottom line. In 2007, it cost the hospital $1.2 million to cover
the departure of a few anesthesiologists by hiring temporary replacements,
contributing to a $4 million drop in operating income.

Hiring temporary doctors adds "a lot of cost to the health-care system, and
it's almost certainly going to get worse," says Richard Reynolds, president
of MidMichigan Health, which operates four hospitals in the heart of the
state. He estimates it costs the company twice as much to hire a temporary
doctor than a permanent one. MidMichigan tries to pass on some of these
costs in contract negotiations with insurers, says Mr. Reynolds, but it
doesn't always succeed.

Steven Bengelsdorf, a 41-year-old doctor from Nashville, formed his own
group of temporary surgeons to contract directly with hospitals so they
avoid the extra cost of a staffing agency. Spending days or a week at a time
away from his wife and three children is tough, Dr. Bengelsdorf says, but,
"when I'm home, I'm home. I can participate in their lives and take them to
birthday parties." If he were in traditional practice working 12- to 14-hour
days, he adds, "I wouldn't get to see my kids."

The American College of Surgeons has long condemned the practice of
"itinerant surgery," where doctors operate on patients and leave follow-up
care to a family physician. But it has refrained from issuing guidelines on
locum tenens. Paul Collicott, a director of the ACS, says it's "a necessary
part of surgical practice today," given the overall shortage in the field.
He says it's the responsibility of each temporary surgeon to make sure
patients are handed off to another surgeon for postoperative care. The ACS
also advises doctors who primarily work in urban hospitals, where the work
is more specialized, not to do stints in small, rural hospitals, where they
typically need to be jacks-of-all-trades.

In 2007, Marlene Tymchuk of Reedsport, Ore., learned she needed a large pool
of blood called a hematoma removed from her groin. The hospital in her small
coastal town was staffed by a temporary surgeon; the nearest hospital with a
full-time surgeon was 45 minutes away. "I talked it over with my family,"
she says, debating whether it would be smarter to go to the bigger hospital
and have consistent care.

She decided to stay in Reedsport, in the hospital she knew well and near her
family doctor. Though she saw another surgeon for her follow-up care, she
says it felt better to be close to home.

Temporary surgeons used to be mostly older physicians who wanted a lighter
workload, or those fresh out of training, still deciding where to put down
roots. But today, more are midcareer people like Dr. Peppers, who had
originally mapped out a more traditional path. Born in the same Franklin
hospital she later operated in, she knew by age 10 she wanted to be a
surgeon. She told her future husband -- a childhood friend -- she wanted to
marry him so she could take his name and be "Dr. Peppers."

After medical school, residency and a fellowship in laparoscopic surgery,
she came back to her hometown to practice in 2000, saddled with $250,000 in
debt. Paying it back turned out to be harder than she thought.

While Dr. Peppers was in training during the 1990s, the federal Medicare
program was cutting back what it pays surgeons for many common procedures.
For instance, in 2008, Medicare paid a general surgeon $562 for an
appendectomy, compared with $580 in 1997. For a complex hemorrhoid removal,
a general surgeon got $390 in 2008, compared with $574 in 1997. Private
insurers followed suit.

Meanwhile, higher-priced procedures increasingly fell under the purview of
more specialized fields. And, reflecting a steady rise in the number of
uninsured and underinsured Americans, more of the patients whom surgeons
would operate on in the emergency room had limited means to pay for
treatment.

By 2007, Dr. Peppers says, she was making roughly $135,000 annually and her
practice was struggling to pay its overhead and malpractice insurance. Since
shuttering her practice last spring and becoming a full-time
surgeon-for-hire, Dr. Peppers says she's earned enough money to whittle her
medical-school debt to below $100,000. For the first time, she adds, she can
focus exclusively on surgery and patients. "When I had a practice, it was
like running a small business," she says. "It's like a huge weight has been
lifted."

Dr. Peppers says she is careful to take assignments where she knows the
surgeon she'll be handing cases off to and often follows up with a phone
call. "I'm very conscientious about telling the patient, 'I'm here until 7
o'clock Monday morning. If there are any problems, after that you need to
talk to Dr. so-and-so,'" she says. "I put a lot of responsibility onto
patients."

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