August 4th, 2013 by Dr. Val Jones in Opinion, True Stories
Tags: Costs, Hospital, How To, How To Find The Best Locums Agency, Internal Medicine, Locum Tenens, Physician, Salary, Traveling Physician
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On Assignment In Idaho
It’s been a couple of months since my last post because I’ve been traveling around the United States working as a locum tenens (in Latin, “place holder” – a more elegant name than “temp”) physician. We’ve all heard of traveling nurses, but more and more physicians are also “living la vida locums,” as it were. There are actually over 100 agencies who find/provide temporary physician coverage for hospitals who need to fill gaps in their full timers’ schedules. You can find out more about these agencies at their trade organization site, the National Association of Locum Tenens Organizations (NALTO).
For those of my peers who’ve been curious about locums work, but haven’t tried it, I thought I’d provide you with some personal thoughts and insights in the form of Q&A. Please feel free to ask your own questions in the comments section and maybe we can generate a nice, interdisciplinary discussion about locums work. I’d love to hear from others who have worked locums!
Q: Why should I work as a locum tenens physician?
If you don’t mind travel and are a fairly adaptable individual (i.e. can learn new EMR systems, staff idiosyncrasies, and navigate hospital politics without excessive angst), then you can expect to make at least 33% more in salary working as a locum (with professional liability insurance, housing and travel covered included). In addition, you have no administrative or teaching responsibilities, coding/billing hassles, or staff management issues. You’re paid an hourly rate for a minimum number of hours, with overtime negotiable. You get to see different parts of the country, and can control where you go and how much you work. (E.g. Summers in Sonoma, winters in Florida… not a bad lifestyle choice.)
Q: What kind of physicians do locums work?
In my experience, there are four kinds of people who do locums work: 1) Retirees – those who have essentially retired from full time medicine and want to keep their hand in clinically without overwhelming responsibilities and work hours 2) Salary Seekers – those who want to make 33-50% more salary and don’t care where they live to do it (they work 22 days/month or more as a locums doc) 3) Dabblers – those who want to work part time because they are busy with another job or family responsibilities and 4) Problem People – those who have personality issues and/or a legal history that make it difficult to hold down a regular job.
I don’t know the relative numbers of these 4 subtypes of physicians who do locums, but I’d guess that 20% are Retirees (Rs), about 10% are Salary Seekers (SS’s), 60% are Dabblers (D’s), and 10% are Problem People (PP’s). I’m a D, and I have met Rs, SSs, and PPs on the work circuit. I’ve also spent time talking to internists and specialists who work as locums physicians so I have an idea of what others outside my specialty are up to.
Q: What’s the difference between locums agencies?
Each locums agency has its own “corporate culture” and some are more attentive to their physicians than others. For example, when you’re traveling en route to an assignment and your flight gets cancelled on a weekend, you suddenly realize how nice it is to have a responsive agency to help with travel triage. Choosing an agency is more than just finding the one that offers the best hourly wage, it’s about how they choose and negotiate with clients (hospitals), how many staff they have to help with payroll and travel, and if the recruiters themselves are patient and attentive. All of this is primarily learned by trial and error – alas. And I think it’s probably time to create a “Yelp” destination of sorts for physicians who are interested in locums work. I wish I had had one!
That being said, what I’ve learned is that agencies vary A LOT in what they offer you and that there is usually about 25% wiggle room in hourly rate negotiation, especially for highly-sought after specialties such as Internal Medicine. In one case, a client (hospital) confirmed to me that two different locums agencies presented the same candidate to them – one was charging $90/hour more for the physician, but the physician had been quoted the same hourly rate by both agencies.
One would think that there would be an advantage to being represented by the “Platinum level” locums agency because they’d negotiate higher pay rates for you, but what happens is that they negotiate high pay rates and then don’t pass it along. In the end, the only hospitals that use those companies are ones who’ve exhausted every other avenue. So if you work for a Platinum agency, you end up with an average salary working in the most difficult situations (i.e. where no one else would go and the hospital, in an act of desperation, had to pay through the nose for you.) In addition, I’ve had a Platinum agency take 3 months to pay me, whereas another agency regularly turned my time sheet into direct pay in 7 days.
So be forewarned – the biggest, shiniest agency might not be your best bet.
Unfortunately, smaller agencies (who may be more generous with salary rates) sometimes suffer from skeleton crew staffing and fall short of being able to triage travel disasters and manage client-related problems (e.g. the hospital said you’d see 12 patients a day but when you arrive they ask you to see 24) as needed.
When it comes to a locum agency, you want someone who’s not too big, not too small, and where you can establish a relationship with a recruiter who is responsive and smart. I cannot stress this enough. Your recruiter is your lifeline while you are on the job. Recruiters don’t just spend their time finding physicians to fill positions, they are the key point of contact between you and the hospital where you work. Their role is to lobby for you, and keep the hospital accountable for your work load and work environment. If the hospital promised that you’d only need to see X number of patients/day, then your recruiter is the one to hold them to that standard. If you are concerned about patient safety because staff members are incompetent in some way, then (believe it or not) your recruiter will convey those concerns to the hospital and get the problem solved.
So overall, your locums experience depends on the corporate culture of your agency, the size and number of travel/credentialing staff they have available 24/7, and the quality of recruiter assigned to your case.
In my next post I’ll cover the following questions:
Q: Where are the most favorable locums jobs?
Q: How can I negotiate the best salary?
Q: How do locums agencies decide how to match you with a given job opportunity?
Q: What is the licensing and credentialing process like? How do I make it easier?
June 3rd, 2013 by admin in Opinion, Quackery Exposed
Tags: Alzheimer's, Carotenoid, Dr. Oz, Dr. Oz Show, Exaggerations, False Claims, Indonesia, Malaysia, Mehmet Oz, Miracle Cure, Red Palm Oil, Snake Oil, Vitamin E, Weight Loss
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Dr. Oz is a powerful guy, blessed with a name that conjures up wizardry. He just unveils his latest “miracle,” which seems to happen on an almost daily basis, and people scamper off to the nearest the health food. Recently the great Oz anointed the oil extracted from the fruit of the palm tree that grows in Indonesia and Malaysia as a wonder product that can aid weight loss and reduce the risk of Alzheimer’s and heart disease. Introduced to this marvel by his a guest, a homeopath, Dr. Oz excitedly gushed about the beta carotene and “special form of vitamin E” found in “red palm oil.” A curious business. Tell me, does a Professor of Surgery at Columbia University with over 400 research publications under his belt really need advice on nutrition from a homeopath?
As is usually the case with Oz’s miracles, there is a seed of truth that then gets fertilized with lots of verbal manure until it grows into a tree that bears fruit dripping with unsubstantiated hype. For example, one study did show a reduction in the severity of cholesterol-induced atherosclerosis in rabbits fed high doses of red palm oil. This has little relevance for humans but magicians who pull rabbits out of hats may consider adding red palm oil to the diet of their little assistant. The red colour of the oil comes from beta-carotene, the same substance that contributes to the hue of carrots and many other fruits and vegetables. It is the body’s precursor for vitamin A, which makes it an important nutrient.
Unfortunately, in many areas of the developing world there is a shortage of both beta carotene and vitamin A in the diet leading to a high incidence of blindness, skin problems and even death. In such cases red palm oil would be useful, but of course there are numerous other ways to introduce beta-carotene into the diet including “golden rice” that has been genetically modified to provide the nutrient. Aside from remedying a vitamin A deficiency, there is not much evidence for increased intake of beta carotene outside of that contained in a balanced diet. There are suggestions that higher blood levels of beta carotene reduce the risk of breast cancer in high-risk women, but the beta-carotene levels may just be a marker for a better diet.
As far as the Alzheimer’s connection goes, Oz may have been referring to a study in which 74 seniors with mild dementia were compared with 158 healthy seniors. People with dementia had lower levels of beta-carotene and vitamin C in their blood. Again, this does not prove that the lower levels are responsible for the condition, they may just signal a diet that is poorer in fruits and vegetables. Tocotrienols, the “special form of vitamin E” Oz talked about, have shown some borderline effects in Alzheimer’s patients at doses way higher than found in red palm oil. There is no evidence for preventing the disease.
What about the claim that red palm oil causes loss of belly fat? That seems to come from a rat study in which a tocotrienol-rich fraction extracted from palm oil caused a reduction in fat deposits in the omentum, the tissue that surrounds organs. There was no evidence of abdominal fat reduction, and furthermore, the study involved putting the animals on an unnatural and unhealthy diet. But these are not the facts that the audience was treated to on the Dr. Oz Show.
What the eager viewers witnessed were three visually captivating but totally irrelevant demonstrations of the purported health benefits of red palm oil. First in line was a piece of apple that had turned brown because of “oxidation.” This could be prevented with a squirt of lemon juice, Oz explained. Then came the claim that red palm oil protects our brain the same way that lemon juice protects the apple. This is absurd. Vitamin C inactivates polyphenol oxidase, the enzyme that allows oxygen to react with polyphenols in the apple resulting in the browning. The human brain, however, bears no resemblance to an apple, except perhaps for the brains of those who think it does. Yes, oxidation is a process that goes on in the human body all the time and has been linked with aging but suggesting that beta-carotene because of its antioxidant effects protects the brain like lemon juice protects the apple is inane.
Just as zany was the next demo in which two pieces of plastic half-pipe representing arteries were shown with clumps of some white guck, supposedly deposits that lead to heart disease. Oz poured a gooey liquid, representing “bad fats” down one of the tubes, highlighting that it stuck to the goo. Then he proceeded to pour red palm oil down the other pipe and lo and behold, the deposits washed away. Totally meaningless and physiological nonsense. The homeopath then explained that saturated fats behave like thick molasses cruising through the cardiovascular system, but palm oil does not, despite being high in saturated fats. While saturated fats may lead to deposits, they do not do this by “thickening” the blood. Arterial deposits are the result of some very complex biochemistry and are not caused by “sludge” in the blood. Oz even exclaimed that this demo was indicative of how red palm oil reduces cholesterol in a month by 40%, better than drugs. A search of Pubmed reveals no such study.
The final demonstration involved Dr. Oz lighting a candle and a flare, without wearing safety glasses mind you. The message seemed to be that the body burns most fats slowly, but it burns red palm oil with great efficiency, preventing weight gain. Where does this come from? Possibly some confusion about medium chain triglycerides which are somewhat faster metabolized than other fats. But these are not found in palm oil. They are found in coconut oil and palm kernel oil. Oz and his homeopath expert were as confused about this as about the rest of red palm oil info they belched out.
Aside from scientists who took issue with the misleading information, animal rights groups also attacked Oz’ exhortations about the benefits of the oil claiming that it will lead to destroying larger stretches of the jungle, home to many wild creatures including the orangutan. They maintain that when the jungle is cleared every living creature is either captured or killed and adult orangutans are often shot on sight. A tragedy. Another tragedy is that Dr. Oz could be doing so much good if he just focused on real science, as he sometimes does, instead of drooling over the latest “miracle” as presented by some pseudo expert.
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Joe Schwarcz, Ph.D., is the Director of McGill University’s Office for Science and Society and teaches a variety of courses in McGill’s Chemistry Department and in the Faculty of Medicine with emphasis on health issues, including aspects of “Alternative Medicine”. He is well known for his informative and entertaining public lectures on topics ranging from the chemistry of love to the science of aging. Using stage magic to make scientific points is one of his specialties.
May 19th, 2013 by Dr. Val Jones in Opinion
Tags: AMA, Care Quality, Differential Diagnosis, Minute Clinic, Naturopaths, Nurse Practitioners, Primary Care, Risks, What's The Harm
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Image Credit: Dan Page, Boston Globe
What is the US going to do about our current and future primary care physician shortage? Many believe that the solution is to expand the scope of nursing practice, and license non-physicians (such as naturopaths) to practice medicine. In the face of scarcity, 17 states have licensed naturopaths to provide primary care and nurse-led, in-store pharmacy clinics are gaining popularity.
Studies have shown that nurse practitioners are as capable as physicians at treating common primary care complaints such as strep throat and headache. What studies have NOT shown is that nurse practitioners recognize and diagnose less common diseases with similar symptoms. What if the strep throat were throat cancer? What if the headache were meningitis? Substituting practitioners with half the training and experience of an MD comes at a price. And that price may include missed diagnoses, delay of appropriate treatment, and life threatening consequences.
But the lure of cost savings cannot be ignored. Nurses are paid less to practice primary care, so in theory we could save untold millions each year by having patients see nurses instead of doctors. That sounds good, but now nurse practitioners are lobbying to receive the same salary as MDs for their time. After all, they’re doing the same work, right? Never mind that everyone they treat must be squeezed into a limited set of diagnosis codes – when all you have is a hammer, then everything starts looking like a nail. “Poof” goes the savings, while care quality standards are permanently reduced by forced limitations on differential diagnoses.
A better solution would be to find ways to extend physician reach and expertise with telemedicine platforms, longer patient visit times, and by reducing their non-clinical practice burden. Nurses and ancillary providers are valued members of the clinical team who are dearly loved by patients and doctors alike, but they simply do not have enough training to be ruling out tens of thousands of rare diseases and conditions. This is why we need physicians at the helm of the clinical team – to make sure that patients are on the right treatment pathway.
Some nurses cry “prejudice” when physicians suggest that MDs provide better primary care. But we all know that knowledge and experience are a critical asset when lives are at stake. As the research results begin to roll in regarding better patient outcomes under the care of physicians versus nurse practitioners, common sense tells us that outsourcing primary care to the less qualified will have undesirable consequences for some. And if you choose to get your primary care from a naturopath or nurse, you’ d better hope that headache isn’t anything serious. Because a little savings now could cost you your life.
May 6th, 2013 by Dr. Val Jones in Health Tips, Opinion, True Stories
Tags: Best Case Scenario, Body Impedance, Clothing Fit, Diet, Eight Week Plan, Extreme Weight Loss, fat loss, Female, Is It Worth It, Middle-aged, Percent Body Fat, Strength Training, Wedding Diet, Weight Training
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Dr. Val "After" Photo #1
I just completed 8 weeks of what I’d call “extreme dieting and exercise.” I don’t mean dangerous starvation and constant exercise, I mean the hardest “medically safe” amount of diet and exercise possible. It involved about 3 hours of exercise per day (6 days/wk), along with a calorie-restricted diet of 1500 calories/day (no refined carbs, only healthy fats, relatively high protein). My exercise consisted of heavy weight lifting, kettle bell sets, kickboxing, and sprints on the bike, summit trainer, and on an outdoor track, with long walks each afternoon. Trust me when I say – I pushed myself to the very limits of what my body could handle without becoming sick or injured. I did this with the help of my dear friend and trainer Meredith Deckert.
Why on earth would I do something so extreme? Well, first of all, I wanted the “right to bare arms” on my wedding day. I just woke up and realized I was getting married in 8 weeks and that I’d have photos of the event memorialized for my future kids and grand kids… so the “bat wings” had to go (you know what I’m talking about, ladies), and the time till “lift off” was pretty short – hence the need for maximum effort.
Secondly, I was scientifically curious to know what a “best case scenario,” two month, physique optimization strategy might produce. I knew I wouldn’t cheat on the diet or fall off the exercise wagon, so at least I could be sure that results were based upon strict adherence. Self-reports of diet and exercise regimens are notoriously inaccurate, so this doubting Thomas had to see for herself! (Of course n=1 in this experiment and won’t correlate exactly with others’ experiences due to differences in starting fitness, body fat, age, genetics and gender).
And Thirdly, I wanted to experience (first hand) what is possible so that I could empathize with my patients who were trying to lose weight, and provide personal anecdotes of encouragement. Since America’s biggest health challenge (pun intended) is obesity, I feel obliged to do my part to model lean living. Otherwise, what right do I have to teach others what to do? (Note that heavier physicians are less likely to educate overweight patients about weight loss).
So what did I learn? Each of these probably merits its own blog post, so I’ll summarize briefly and dig into the details with you soon…
1. Calorie math doesn’t necessarily work with the bathroom scale. We’ve all heard that a pound of fat equals 3,500 calories, so that if you decrease your calorie intake (or increase your calorie burn) by that much, you WILL lose a pound on the scale. That has not been my experience (I lost an average of only 30% of what the scale should have shown based on the math). I have some theories as to why that might be (which I’ll share later), but suffice it to say that if you are “doing everything right” and the scale is not rewarding you – take heart!
2. Weight training improves how you look MUCH more effectively than cardio. Before my extreme diet, I was running 1/2 marathons and spending hours on the spin bike. I was in excellent cardiovascular shape, but I had a relatively high percent body fat (about 30%) and I was certainly not getting “skinny” from all the running. I was actually losing muscle and looking softer and more “out of shape.” Dialing down the cardio and increasing the weight training had a rapid, visible impact on how athletic I looked.
3. Your leaner self may not look the way you think it will. When I first began my weight loss journey, I imagined that I would slowly melt away all the excess fat to reveal a lovely ballerina inside. What I found was that after the fat was gone, I wasn’t a ballerina at all. I looked a lot more like a wrestler! People really have different genetically determined body types – and no amount of diet and exercise will make us look like someone else. We’ll just look like our best selves, which is ok! Don’t fall into the trap of thinking that success only looks like a Sports Illustrated swimsuit model. After all, Olympic athletes all have very different bodies, and are at the top of their respective games! (This fun, height and weight database shows how you compare to recent Olympians.)
4. Clothing size is the most helpful measure of success. After 2 months of intense diet and exercise the scale only changed by about 6 lbs. The body impedance analyzer told a little different story (the InBody 520 estimated that I had lost about 10 lbs of fat and gained 5 lbs of muscle with an overall percent body fat loss of about 4%.) But the truth is, that nothing measured my success as well as clothing. I dropped nearly two dress sizes and had to buy a new wedding dress a week before the event! So if your scale isn’t showing you love, what are your jeans saying? Listen to them.
Conclusion: In my experience, the best a slightly overweight, middle aged woman can do (safely) in 8 weeks is lose 10 lbs of pure fat and gain 5 lbs of muscle. It is extremely difficult to achieve that much, and I would highly recommend doing it over a longer period of time. Is the pain worth the effort? Here are my “before” and “after” photos. What do you think?
Before: (151 lbs)
After (145 lbs):
May 2nd, 2013 by Dr. Val Jones in Health Tips, Opinion, Research
Tags: Compliance, Influence, Internal Medicine, International Journal Of Obesity, Obese, Overweight, Patient Compliance, Physicians, Primary Care, Stigma, Survey, Weight Bias, Weight Loss, Yale
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A recent, 358-person survey conducted by researchers at Yale University (and published in the International Journal of Obesity) suggested that patients may be less likely to follow the medical advice of overweight and obese physicians. Survey respondents were 57% female, 70% Caucasian, 51% had BMIs in the normal or underweight category (31% overweight and 17% obese), and were an average age of 37 years old.
Respondents rated overweight and obese physicians as less credible than normal weight doctors, and stated that they would be less likely to follow advice (including guidance about diet, exercise, smoking cessation, preventive health screenings, and medication compliance) from such physicians. Although credibility and trust scores differed between the hypothetical overweight and obese providers and normal weight colleagues, the respondents predicted less of a difference between them in terms of empathy and bedside manner. Respondents said they’d be more likely to switch physicians based on their weight alone. There was no less bias against overweight and obese physicians found in respondents who were themselves overweight or obese.
The study authors note that this survey is the first of its kind – assessing potential weight bias against physicians by patients of different weights. Previous studies (by Puhl, Heuer, and others) have documented weight bias against patients by physicians.
While the study has some significant limitations (such as the respondents being disproportionately Caucasian, thin, and female), I think it raises some interesting questions about weight bias and physicians’ ability to influence patients to adopt healthier lifestyles.
Considering the expansion of pay-for-performance measures (where physicians receive higher compensation from Medicare/Medicaid when their patients achieve certain health goals -such as improved blood sugar levels), being overweight or obese could reduce practice profit margins. If patients are less likely to follow advice from overweight or obese doctors, then it stands to reason that patients’ health outcomes could suffer along with the doctors’ income.
I’m certainly not suggesting that CMS monitor physician waist circumferences in an attempt to improve patient compliance with healthy lifestyle choices (Oh no, did I just give the bureaucrats a new regulatory idea?), but rather that physicians redouble their efforts to practice what they preach as part of a commitment to being good clinicians.
Some will say that the problem here is not expanding provider waistlines, but bias against the overweight and obese. While I agree that weight has little to do with intellectual competence, it does have to do with disease risk. Normalizing and destigmatizing unhealthiness is not the way to solve the weight bias problem. We know instinctively that carrying around a lot of extra pounds is damaging to our health. It’s important to show grace and kindness to one another as we join together on the same health journey – a struggle to make good lifestyle choices in a challenging environment that tempts us to eat poorly and cease exercising.
To doctors I say, let’s fight the good fight and model healthy behaviors to our patients. To patients I say, show grace to your doctors who carry extra pounds – don’t assume that they are less competent or knowledgeable because of a weight problem. And to thin, female, 30-something, Caucasian survey respondents I say – Wait till you hit menopause before you judge people who are overweight! 😉
