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You would expect that, given a physician shortage, my goal of getting back into obstetrics would be supported and even welcomed.
By Daniel Laury, M.D.
You would expect that, given a physician shortage, my goal of getting back into obstetrics would be supported and even welcomed. The Association of American Medical Colleges expects that the US will have over 91,000 too few physicians by 2020. I graduated medical school in 1988, completed an OBG residency in 1992 and went right into private practice. By 2002, I stopped delivering babies, focusing on gynecology, women’s primary care, esthetics, teaching, writing and research.
It became increasingly clear that the private practice model has been disappearing over time. Our reimbursement is going down, our costs are up, we are underrepresented in negotiations, etc. The AMA found that since 1983, physicians in private practice have decreased from 40.5% of the total to about 18.5% in 2012. I was tired of the constant competition; in the US, the average number of OBs is one for every 13,021 persons. However, in my locale it was closer to 1 in 4,375. I was not looking forward to buying and getting trained on $50,000 of EMR. The administrative burden of OSHA, CLIA, ACA, HIPAA and other acronyms was unsupportable. Taking time off in private practice is also costly; income stops when I am not working but expenses continue including rent, staffing costs, malpractice premiums… Patients can be unhappy when you take time off, expecting that their private doctor is always available to them.
Mark Twain’s comment, “Twenty years from now you will be more disappointed by the things that you didn’t do than by the ones you did do” rang true for me. I looked at my options, many that may be familiar to you, including administrative work, insurance opportunities, working for the military, writing full time, academics, giving talks and going into another field altogether. Ultimately, I decided that locums tenens work with be the best fit. I talked to various providers and overall, they seemed happier, more mobile and worked when they wanted to.
Somewhat less than 10% of physicians are doing locums, however, this number continues to increase. I did some looking around and found that doing gynecology alone would not be financially feasible; there simply were not enough jobs available. Obstetrics was the only way to go. Generally, the locums companies wanted to see about 25 cesarean sections and 50 vaginal deliveries documented over a one to two year time period to hire you. Naively, I decided to just start delivering babies again. After all, I kept up on my reading, maintaining board certification and assisting with my patients’ cesarean sections.
My local hospital seemed supportive if I had a physician-mentor and liability coverage. Having stopped OB for 10 years, my insurance cost was by now significantly lower however it would increase dramatically if I restarted obstetrics. More importantly, my tail coverage cost would also increase substantially. I would need more staff, different call coverage, more in-office equipment… It also didn’t feel right that I would restart OB with my patients with the intent to turn around and have to stop care as soon as I had the requisite numbers required by the locums companies. Clearly, this was not viable so then I looked at helping out in other countries as a volunteer. I had connections in France and Haiti and this would obviate the need for insurance, would be helpful for whatever community I served and would be a great experience for me. Even though our medical health care system is ranked number 37 in the world, the US based locums companies refused to count foreign deliveries.
It became increasingly clear that I needed to work through some program to get my numbers up. Living in Oregon, I began querying (read pestering) Oregon Health and Sciences University literally for years trying to get into their OBGYN reentry program. If I could do perhaps a week at a time, my private practice might survive my training. Though never a large program (perhaps four physicians were offered admission), I was never accepted. My understanding was that the main issue was maintaining their current residents’ experience which would be diluted by our involvement.
I called on Colorado’s Center for Personalized Education for Physicians (CPEP). Their program is more geared towards physicians who have “had peer review dispute, or have been referred to us by a licensure board, hospital, defense attorney or other organization”, which didn’t apply to me. In addition, they don’t actually have a hands-on obstetrical program set up; I would have to find a mentor/proctor, get my own insurance, etc. bringing me back to my initial dilemma.
I had many nice talks with Drexel University College of Medicine’s Nielufar Varjavand, M.D. about their program. She was always passionate about helping physicians back to practice. She also had a hands-on Obstetrical program. Unfortunately, the locums companies disallowed simulators to count towards experience.
One physician who I called had an interesting experience. He also wanted to get back into obstetrics and was hearing the same depressing litany; however, he ultimately found a hospital that was willing to bring him on board, requiring a staff mentor after a minimal simulated experience. He admitted to me that this was a rare though fortuitous opportunity but worked out well for him. It would, however, not work for me as the plan was to do only locums.
More research found me in discussion with Cedar Sinai’s Leo Gordon, M.D. Always friendly and helpful, he gave me great advice however his one to four month program would require a California licensure; an expensive, time consuming process that I declined initiating. They have helped approximately 14 candidates over the last seven years.
I called on my own residency program, hoping that I might rely on some paternal (maternal?) succor. Once again, the specter of residents’ loss of experience was an issue. We didn’t have resident hour limits (back when I walked barefoot uphill both ways to work in the snow); however, I was seeing that this was now limiting experiences for the newer graduates.
Cold calling various other residency programs generally got me no response. There just didn’t seem to have that many options available. I read about how we need more active physicians. Many groups called upon the previously practicing physicians to reenter the workforce however no clear pathway guidelines were available. I knew that my experience could be put to good use but I couldn’t find a way to reinstate myself. Physicians leave practice for various reasons including family care, illness, disenchantment, sabbaticals… It seems that if they are back within a year generally there is minimal to no difficulty reentering the workforce. However, each state has their individual rules which vary tremendously. For example, in the AMA physician reentry summation research, they note that it can range from one to 10 years. Clearly, we all want only competent physicians working; however, the lack of consistency suggests that the impact of length of time away from clinical practice is not known.
I finally had to face the reality that I would need to shut down my practice to do this additional training. Even if I tried to do two weeks per month, it simply wouldn’t be supportable. I applied to the KSTAR-JPS program in Texas and was placed on their waiting list. I learned that I had to first undergo a KSTAR (Knowledge, Skills, Training, Assessment and Research ) two-day assessment administered through Texas A&M Health Science Center. I didn’t feel that I needed this very expensive evaluation since I was not under probation, being investigated, etc. However, it is required to be accepted in the training phase of the program.
A few months later, there was an opening and I spent about $15,000 to be evaluated. Shortly thereafter, I was informed that a three month re-entry program would be recommended. After a hectic few months, shutting down 20 years of private practice, I left for the John Peter Smith Hospital in Fort Worth, Texas. Working in my medical practice had distanced me from the academic environment and it was good to be doing the reading, conferencing and testing. The new breed of physician residents were awesome in their ability to multitask; texting, inputting, talking, caring…all at the same time. Three months after completing their regimented program, I had my first locums job, which has actually been quite pleasant and rewarding.
The moral of this story is to maintain privileges. It is worth repeating this piece of advice: “Do not relinquish them”. Unless you are sure that you will never need them again, seriously consider future ramifications. It is far easier to maintain than to reinstate privileges. It is also ridiculously expensive; the training alone was close to $30,000 not counting travel, food and lodging. Closing a successful practice was painful; emotionally and financially. Not knowing the future generated anxiety. Looking back, I would have probably taken a few locums jobs in obstetrics, even as I was practicing private practice gynecology only. Those few deliveries would have saved tremendous amount of resources. Learn from my peripatetic journey rather than be destined to repeat it.
Dr. Daniel Laury is an obstetrician-gynecologist in Hermiston, OR. He can be reached at firstname.lastname@example.org