Ripal H. Patel, MD, MPH, relates a few of his most terrifying locum tenens horror stores and gives his advice on how to avoid the same fate.
I love horror films. It’s what drew me into film school. The Exorcist, Psycho, anything Alfred Hitchcock… oh and It — that was the end of it for me and clowns. As much as I love horror, I definitely don’t need it in my professional life. I think back to my initial days flying across the country parachuting into locum gigs, grossly unaware of what was lurking. Not killer clowns or psychopathic serial killers (oh Texas Chainsaw Massacre, sigh), but sometimes unexpected scenarios that caused an equal amount of lost sleep.
And so I shall lay down on a couch, you as my audience, and dispense my own locums nightmares. Three stand out in particular. They make me want to lie delirious moaning “the horror, the horror, the horror:”
Nightmare 1: Locums life
Gee, this is great! What was I so hesitant about? I make my own schedule, travel for work to cool places, meet new people.
I began my first assignment in the far reaches of Texas in a tiny border town called Eagle Pass. The acuity was high, staffing low, and patients immensely grateful. But as I began working there, I came to realize how under-resourced the ER was. The gravity of that hit me when I saw Janice, a morbidly obese women gasping for breath from a COPD exacerbation. She looked almost blue, and as we rushed her back, I knew I would need video assistance to perform an intubation. As I looked at my staff for the videoscope, they frowned. “We don’t have that Doc, I’m sorry.” I paused. Blinked. Looked back at my crashing patient. While whispering a prayer — and knowing there was no anesthesia back-up — I summoned every airway maneuver I could fathom to perform the procedure, and by some act of God everything went ok.
When I drove back to my hotel, I spent a lot of time thinking about locums and part of the reason I did it. I have an inherent distrust in the corporate healthcare system — in large emergency medicine staffing companies (not to be confused with locums agencies), and administration. So why in the world would I have a blind faith my ER would be fully stocked so I could perform my job flawlessly? Wishful thinking.
And so I began slowly buying more and more of my own equipment and traveling with it (and from that was born my Suitcase Manifesto). Amazingly as I have learned, there aren’t that many critical items you need to purchase to brave it in the roughest of ER waters, but having them tucked away safely with me makes shifts far more placid.
Nightmare 2: It’s not like I can’t handle the load
One of my old senior residents would love to playfully mock the interns constantly, claiming that “YOU ARE THE BOARD” (i.e. the more patients you have on the board defines your own self-worth). And so we all would strive and push to see as many patients as we can.
But when is too much too much? Most studies would claim after 6-7 patients at one time, your productivity drops precipitously, and beyond that it’s a vortex of chaos and diminishing returns. So, when I was working in El Paso with another physician, I realized the minute I walked in how insanely understaffed the ER was. Understaffing happens everywhere, and usually one would hope by the time you get there, these kinks have been worked out. If 100 patients check in, and 99 are not acute, and one is sick, the 99 have to wait if you are the only provider. And ideally, administration will support that, because one physician cannot take on 100 patients.
But, what if almost 80 of them were sick? Now drop that to more practical terms: 15 patients expected to be carried at one time, and 10 of them are critically ill. Such was the climate of the El Paso hospital I was staffing. I struggled through that shift in El Paso. My documentation was poor, physical exams less than optimal, and I was trying to avoid suffocating from how many things needed to get done — all while trying to keep some mental checklist of who was the sickest.
I still shudder from that experience — stabilizing the most critical, how upset the non-critical patients were while waiting for dispositions, and the regional director coming up to me and trying to micromanage. I always tell my residents, if something feels wrong, then it PROBABLY IS. In the middle of all the chaos, I was also asked to cover in-hospital cardiac arrests. So when the sirens went off in the hospital, I ran upstairs to the CCU to manage a CPR. One hour lost. I came back down whimpering, in dread at what awaited me and how much more I had to do before my shift ended.
After I got home defeated and passed out on the couch, I woke up with my head spinning. What had I done? And why did I do it? As I dreaded getting ready for work, the phone rang. The regional director, who had been pushing me to engage in the worst forms of medicine to “move the meat,” was on the line. He began raising his voice, asking me why I left my shift for one hour the day before. I paused, appalled anyone would think — in the midst of what I could only call warfare in the ER — I’d just leave. After he finished berating me, I paused, told him politely I was covering a cardiac arrest in the CCU. I finished by saying, since he was off that day, he could cover my last shift of that run, as I would not be coming in. I hung up the phone and went back to sleep. And boy did I sleep well. I had worked too hard for my MD, expended too many years of my life on exams and training, to be put in such an unsafe work environment. No nightmares that night.
Nightmare 3: Standing firm
This one isn’t so much a nightmare. It’s an affirmation of why I do locums.
Going regularly to Central Texas to cover a hospital on the military base was a joy. I loved taking care of soldiers, both pre- and post-deployment. The surrounding areas outside of the town were replete with underserved communities that had challenging pathologies to manage. Everything was hunky dory: great scribes, wonderful colleagues, and a great nursing staff. Plus only a few hours drive from my home in Houston.
Of course, with the acuity of patients, I often would get stuck late at the hospital caring for them. No problem: they covered overtime. Until one morning, I checked my paycheck and realized none of my overtime hours had been compensated.
I scratched my head. In what world, in what universe, does a position NOT cover overtime? Most jobs pay time and a half. And yet, we as physicians, so caring and compassionate, allow ourselves to get walked over and allow this corporate malfeasance. And so I spoke to my agent, who spoke to the director, who advised me that a new staffing company was taking over the hospital, and unlike the previous group, was not covering overtime hours anymore. I sighed but stood firm. No problem, I told him. Unfortunately, as a 1099, I would be unable to work my shifts designated until this was rectified. The joy of being an independent contractor.
Boy did that set off the alarm. Now I’m getting frantic phone calls from directors and administration. I stood my ground. How dare you pull the rug out, and just expect I stay hours after my shift taking care of critical patients because you are understaffed, then not compensate me for this?
In the end, once the medical director got wind, we brokered a compromise that — as we were working that week together anyway — he would “monitor” my hours and if necessary make the case to the new staffing company to allow my compensation. So I went.
Then, 15 minutes before my first shift ends, a woman comes in with a skull fracture actively hemorrhaging, and I’m the only physician around, so I spend another hour after my shift stabilizing her. With everyone in the trauma room scrubbed in, patient hemorrhaging, blood transfusions going, and myself and my nurse carefully closing her scalp, the medical director walks in, nods, then walks out. On a normal job, you clock out and go home. But our job isn’t normal is it? But we have to stand our ground and ensure our compassion and devotion is not rendered against us.
Freedom from fear
These were some of the worst — not as bad as you think but still disconcerting. But a locums model gives you that freedom to not go back to places, to not be bound to entities which may or may not have your best interest at heart.
I want to emphasize the vast majority of my experiences have been immensely positive, with wonderful relationships formed with colleagues and staff, and patients jubilant with gratitude at my assistance. “Wow doc, you flew from Houston to here to help us, thank you so much,” is the norm.
How to avoid locum tenens horror scenarios
First off, carry your own equipment. Not like an ER supply room, just the essentials — like a videoscope, portable airway equipment, maybe a tourniquet or two — each time something feels lacking (most recently I bought small ring tourniquets for bleeding digits, cheap in cost, professional payoff immense).
Next, I’ve written a about this often, but have a checklist, both of what you want to KNOW about the hospital, and before you start, a run-through — like a pilot — of what you need to know before your shift (who is on call, scribes, access to radiology software, covering codes, etc.).
Silly as it sounds, be prepared for the worst (I NEVER expect a cafeteria to be open, and if it is, I expect the food will cause me violent gastroenteritis, so I bring/cook all my meals).
And most importantly, speak to other doctors and directors. If someone or something feels shady or off, it probably IS! And if all that isn’t enough, do a shadow shift before you start. Once again, any red flags that arise, make sure there is a way to address them.
I want to emphasize most of my locum tenens horror experiences were when I was aligned with large, corporate, private-equity-owned staffing companies assisting in their “ambassadors” programs. Regretfully, their focus on patient care is in serious odds with their goals of profit maximization. Most of my assignments — both through my company or with locums agencies — usually run smoothly.
I still love horror: but on screen only, please. Not in my professional life.