For physicians with a penchant for the nomadic life or an innate desire to explore new areas – or those who want to preserve time for other, possibly non-medicine pursuits – locum tenens can be an attractive practice option. And although locums is more prevalent in the primary care and internal medicine subspecialties than in the surgical fields, short-term neurosurgery positions are available in most areas of the country where trauma centers or large hospitals operate.

Typically, neurosurgeons who practice as locum tenens are either pursuing the option as a transition to retirement or as a means of earning additional income – provided they have the practice flexibility to move around several weeks a year. But it’s also increasingly finding favor among neurosurgeons and other physicians who want a more flexible practice life than neurosurgery generally allows.

Some neurosurgeons are willing to trade lower compensation for the ability to work when and where they want, while pursuing other work, such as consulting for device companies. Others simply want ot be able to preserve large chunks of time annually for personal pursuits such as volunteer work. And in some cases, neurosurgeons chose locums because they are simply tired of the hassle factor and expense of running a private practice.

To obtain a snapshot of the locum tenens marketplace and the factors that shape it, Neurosurgery Market Watch tapped longtime locums recruiter, Aaron Risen, president of The Surgeon’s Link, a locum tenens specialty services firm based in Louisville, KY., and St. Augustine, Fla. Mr. Risen recently provided a perspective on the upsides and downsides of the practice option.

Q: How has the marketplace for neurosurgery locum tenens changed in recent years, and why?

A: Until 2007, the market was very strong – neurosurgeons who were willing to take locums assignments could pretty much work anywhere they wanted and at whatever rate, within reason, they asked. But when the economic downturn occurred, the market tightened, as the rate at which neurosurgeons were retiring slowed. What we saw was that some surgeons who were recently retired wanted to come back in to the practice.

Although that trend has leveled out, and the neurosurgery locums opportunities are fairly plentiful now, it’s not quite the seller’s market it once was and the compensations has tightened accordingly, in most cases.

Q: What should neurosurgeons who’ve not worked as locum tenens before understand about the practice option?

A: The main thing to keep in mind is that pretty much 99% of the opportunities center on trauma call, because that’s where hospitals – or practices – need the extra help. Although there are some locums positions in which surgeons will also see patients in a clinic, or provide post-op follow-up care for other surgeons, most of the need is for trauma coverage. And as with the case mix at any trauma center or large hospital, there will be patients who go to surgery and those who don’t – who primarily need to be evaluated and stabilized, and taken care of while they’re still in the hospital. In general, surgeons on trauma call can expect the mix will be roughly 50/50 spine vs. intracranial.

This doesn’t mean, however, that a neurosurgeon who takes locums assignments won’t have any opportunities for elective procedures. Some neurosurgeons on long-term assignments – that’s three months, in this type of practice – or who regularly go to the same hospital for seven to 10 days of every month, may get regular referrals for non-emergent procedures, once the medical staff and other neurosurgeons come to know their work.

Q: How are locum tenens neurosurgeons compensated, and what should they take into account when discussing the financial terms of an assignment?

A: The way the compensation is structured varies somewhat from one hiring entity to another, but the most common arrangement is a stipend or per-diem payment for call duty, in the range of about $1,000 to $2,000 a day (for 24-hour call) on the top end of the spectrum, plus an hourly component. For example, the physician might earn $2,000 per full-day shift, to include up to two hours of work. Any additional work performed over the two hours/day is paid as additional compensation, at an agreed-upon hourly rate.

The hiring entity, hospital or locums recruiting agency generally pays for the malpractice coverage.

There are typically tow basic arrangements regarding billing: either the hospital pays the surgeon a flat rate and retains the right to bill and collect on the neurosurgeon’s services, or the surgeon handles his/her own billing but receives a lower per diem rate. As most physicians interested in locums work don’t want to handle the billing – with trauma call, a certain percentage of cases may be uninsured or “un-billable” in any event – few chose to handle the paperwork themselves.

There are many variations in compensation arrangements, but the basic earnings range in the market now is between $16,000 and $21,000 a week. Basically, locums income will be lower than what surgeons would earn working full-time in a private or academic practice.

Q: What are the main upsides and downsides of locums practice in neurosurgery, and what can surgeons do to avoid pitfalls?

A: The primary upsides are the practice flexibility and the ability to shed all of the cumbersome details of a practice – management, overhead and labor costs, and paying for their own malpractice coverage. For neurosurgeons who aren’t sure where they want to land, locums is also a good way to try out different regions and hospital settings.

The pitfalls are mostly assignment specific in nature. The neurosurgeon may end up in a situation in which the work load was not fully specified and might be unreasonable – such as having to cover two hospitals without a clear plan for how backup will be handled if there’s a trauma case at both places at once, for instance, or having too many back-to-back call shifts in a very busy medical center. In another potentially untenable example situation, if a single neurosurgeon is being brought in to cover for more than one other neurosurgeon in the community, the duties may be unmanageable.

Clinical support, particularly inadequate support in the area of post-procedure follow-up care and other needed specialist consultants or on-site services, is another potential issue.

To avoid both of the above, surgeons should ask for a clear picture of the work to be performed, and for details on the patterns in emergency department volume and trauma cases at the facility. For example, they should ask how many cases are there annually, and of the number what percentage, roughly, require neurosurgical intervention. It’s also important to find out how many other neurosurgeons practice in the hospital or area on a regular basis, and their roles, should the locums surgeon need or wish to interact with those surgeons.

In short, the neurosurgeon needs to know that the work load is manageable and the necessary resources available, especially in the area of patient follow-up after the assignment ends, to ensure patient safety and reduce the neurosurgeon’s malpractice risk.

The point is that even when neurosurgeons are working as locums, the basic liability and license-standing issues, such as ensuring patients aren’t “abandoned” or improperly followed, persist and “follow” the surgeon.

In addition, neurosurgeons may occasionally run into situations in which the hospital or practice wants a particular type of case handled in a way the incoming neurosurgeon would not chose to do the case. It’s difficult to tease out this sort of information ahead of time, but the locums surgeon should be prepared to deal with such practice-difference discussions from time to time.

On a minor note, some surgeons who decide to practice as locums may have concerns about how they’ll be received by the medical staff and other community neurosurgeons. For the most part, this isn’t a problem, especially when the additional services are sorely needed. But surgeons should nonetheless expect that they might have to demonstrate their skills and capabilities, to reassure their colleagues.

Finally, neurosurgeons who are interested in practicing as locums should ensure that the agency or entity they work with has sufficient experience in placing physicians in their specialty. After all, placing a neurosurgeon in a workable assignment is very different than bringing in a primary care physician to cover for a family medicine physician in a group practice who is going on vacation.

During the recent economic downturn, many startups came into the locum tenens recruiting field presumably because of the low barriers to entry. So it’s important ask how many neurosurgeons the agency has placed, and to get a sense of the range of those placements. It’s also advisable to ask for references from other neurosurgeons who have worked with the firm.