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.
Hot Temp Jobs for Doctors 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.
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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