Temp surgeons creating concerns for risk managers
General surgeons have become scarcer in hospitals across the country, many of them beaten down by diminishing payments and grueling work hours, and some lured away by specialized surgery niches that offer more money and a better lifestyle. That means hospitals are increasingly dependent on surgeons-for-hire.
The number of general surgeons per capita has declined 25% over the past 25 years, according to the American College of Surgeons in Chicago, and the trend has every sign of continuing. Almost 75% of surgeons-in-training are choosing subspecialties that are more lucrative and offer better hours than general surgery, the college says. Hospitals are left with no other choice but to rely more heavily on locum tenens surgeons who are called in as needed, often arriving within hours of the surgery and leaving just as quickly when it is done.
The shorter stays are another part of the trend that concerns risk managers. Previously, locum tenens physicians stayed longer, and the same doctor might visit on a regular basis. Now the statistics show that locum tenens surgeons are more often visiting for just a week or a few days, and then they're gone.
The concept of temporary surgeons is nothing new, and the medical community has long recognized that they can pose some risk to patient safety. But the growing dependence on surgeons-for-hire means that whatever has always existed is now growing too, says Leilani Kicklighter, RN, ARM, MBA, CPHRM, LHRM, a patient safety and risk management consultant with The Kicklighter Group in Tamarac, FL, and a past president of the American Society for Healthcare Risk Management (ASHRM) in Chicago. What once may have seemed an unfortunate but tolerable risk is now becoming more worrisome, she says.
"I think the trend is going to continue to get worse, and we will see more and more problems," she predicts. "We may be seeing the tip of the iceberg now."
The risks are easy for any risk manager to spot. For starters, the locum tenens surgeon arrives with scant knowledge about the patient and little time to study the case. And then after the surgery, the temporary surgeon leaves the patient in someone else's hands for follow-up care. The whole concept of continuity of care is thrown out the window.
But another concern for risk managers is that the locum tenens surgeon is not part of the hospital's culture and community. The surgeon does not know the staff he or she will work with in the OR, and neither is he or she familiar with the equipment to be used in surgery. That can be important in a crisis, when familiarity with the surroundings and equipment will facilitate a quick response with fewer mistakes.
Perhaps one of the most vexing problems for risk managers is that the locum tenens surgeon is not party to all of the policies and procedures, inservices, and other education that the risk manager has deemed so important for everyone else at the hospital. The traveling surgeon may be required to sign off on certain requirements, and the agency providing the surgeon may certify that he or she meets certain standards, but that is not the same as knowing that the physician has been part of your own hospital's learning process, Kicklighter says.
It can be hard enough to get physicians to comply with all your expectations even when they are local, operate at your facility regularly, and are part of the hospital's community, she points out. The risk manager faces a real challenge when the surgeon just flew in, is tired, and the patient needs surgery in a hurry.
"In the world of risk management, the first requirement is adhering to your own policies and procedures. If they don't know what you require, how can you expect them to comply?" Kicklighter says. "These aren't just a few simple rules, after all. We're talking about a whole slew of specific things that are not going to be the same from one hospital to another."
The risks posed by itinerant surgeons can be mitigated by carefully choosing the agencies and the individual surgeons, she says.
There are other risk exposures to consider also, Kicklighter says. If the hospital provides accommodations for locum tenens surgeons, such as an apartment near the facility, there can be potential general liability issues there. Similarly, local transportation for the surgeon and security if the hospital is in an unsafe area can bring liability for the hospital. Workers' compensation also is a concern.
"If they get stuck in your hospital and don't tell you about it, you aren't able to get a baseline on them or do any follow-up. But then they may come down with something, and years later you're brought in to a lawsuit," Kicklighter says.
Kicklighter also is concerned about how a risk manager could do a timely and effective investigation after an adverse event when the surgeon has left the community and has little obligation to participate. Also, she questions the ability to conduct a proper disclosure after an adverse event. If the surgeon is gone several days later, once you've investigated, is it right to disclose details to the patient without the surgeon participating in person?
Claims related to the surgery also could be problematic, Kicklighter says.
"If a claim is filed several years later, what kind of guarantee do you have that you'll be able to track this doctor down? What kind of leverage do you have to ensure the doctor will be cooperative?" she asks. "I also expect a lot of claims in which there is disagreement about whether the fault lies with the surgeon or the doctor who was left to follow up with the patient after the surgeon leaves town."
Documentation also can be an issue with locum tenens surgeons, she says. With the move toward electronic medical records (EMR), physicians must know how to use the hospital's system.
"How are we going to orient the surgeon to this particular hospital's EMR? It's one more thing to teach them when they arrive, and there's no time for it all," she says. "I'm concerned that we might see a lot of incomplete records."
Arun Ravi, a health care consultant with Frost & Sullivan, a consulting firm in New York City, says there is growing concern about whether traveling surgeons are adequately rested.
"We're always concerned about surgeons working long hours and irregular hours, then being asked to perform a complex procedure," he says. "That is a concern, even with local surgeons, and then it becomes a much bigger concern when you have someone flying in from out of town, plus you have no idea what sort of experience they have had in the previous day or two."
Ravi notes, however, that the increasing use of locum tenens surgeons is not all bad. Though it is a solution that comes with its own batch of potential problems, using locum tenens surgeons addresses the shortage of surgeons by allowing hospitals to maintain their surgical revenue. The practice also helps patients avoid traveling to distant locations for surgery.
"This seems to be a pattern of practice that has taken hold in the medical community, for better or worse, so it is up to hospitals to come up with policies and procedures that address some of the inherent risks," he says. "The most important thing right now is to understand that the use of temporary surgeons is not going to be just an aberration. It's going to be a common situation that needs the risk manager's attention."
Sources
For more information on risks posed by locum tenens surgeons, contact:
Leilani Kicklighter, RN, ARM, MBA, CPHRM, LHRM, The Kicklighter Group, Tamarac, FL. Telephone: (954) 294-8821. E-mail: [email protected].
Arun Ravi, Frost & Sullivan, New York City. Telephone: (877) 463-7678.
General surgeons have become scarcer in hospitals across the country, many of them beaten down by diminishing payments and grueling work hours, and some lured away by specialized surgery niches that offer more money and a better lifestyle. That means hospitals are increasingly dependent on surgeons-for-hire.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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