Locum tenens

My FP buddy Jeff recently dropped a bombshell, saying he’s closing his practice to do locum tenens work. His reasons are ones that many family physicians can understand: too much overhead, not enough take-home pay. “Besides, I’m not really enjoying my practice,” he confessed. “Doing locums will allow me to choose my jobs and work when I want. I’m kind of looking forward to it.”

Jeff had made some preliminary inquiries to a few locums firms, and they were already making him offers – before they had even seen his resume. He admitted some apprehension about baby-sitting someone else’s practice and working in an unfamiliar space with unfamiliar patients, but I ventured that he could probably get work locally. “When our colleagues hear what you’re doing, your phone won’t stop ringing,” I predicted. “Just to start you out, I’d like to reserve the week of March 24.”

Several days later Jeff called to say another physician had booked him for a week, he would be taking some evening hospitalist call at our local hospital and a family physician in a nearby town wanted him to cover her three-month sabbatical, starting next month. “Whew,” I said, “I’m glad I got onto your dance card early. Pretty soon you’re going to be as hard to book as a plumber or an electrician.”

Job security

As family physicians, we have to count our blessings, the biggest of which is that we can make our living outside the politics and turmoil of hospitals. In this era of managed care, it seems hospital administrators are driving a wedge through their medical staffs, separating us into haves and have-nots – those who are on the hospital payroll and those who are not. Collegiality and fraternity, once the staples of our profession, have been replaced by rancor and adversarial relationships as physicians scramble to survive economically. We have been divided and conquered.

It wasn’t always this way. I can remember when there was solidarity among physicians, when chiefs of staff weren’t in the pockets of hospital administrators, when we could decide how to practice medicine, when taking care of hospital patients wasn’t a battle but a pleasure, and when family physicians weren’t being marginalized in the pursuit of hospital privileges but welcomed in every department. How far we all have fallen.

Where does this leave us? Actually, we’re in the enviable position of not having to be hospital-based to practice medicine. Feel sorry for pathologists, radiologists, surgeons, hospitalists and ER docs, but not for FPs. A hospitalization for us should be a treatment failure, an untoward event that needn’t happen if we ply our craft with art and skill and if our patients are compliant. In our offices, our patients are our employers. Should one of them fire us, our economic livelihood is not in jeopardy. That’s real job security.

The oracle

As part of my wellness program, I performed a prostate-specific antigen test (PSA) on Ron, a 46-year-old mill worker. The test came back at 7 ng/mL, so I repeated the PSA and asked for a free PSA as well. The report was ominous: PSA 11.6 ng/mL; free PSA 1.7 percent. I referred him to Fred, a urologist, who did a six-quadrant biopsy. The pathologist’s report said it was benign, and Fred suggested we repeat the PSA in six months.

When we retested Ron, his PSA had risen to 20 ng/mL and his free PSA had decreased to 0.2 percent. Had Fred simply missed getting it on biopsy? I ran that hypothesis by a visiting oncologist after a Friday morning conference. “Your patient has prostate cancer,” he said. “Have your urologist do a 12-quadrant biopsy. If that’s negative, bring the patient back in three months for another one.”

Ron was less than thrilled to undergo another procedure but relieved the results of the 12-quadrant biopsy were also benign. In addition, two of three subsequent PSAs were normal. Piqued as to what it all meant, I decided to get a second opinion from Bryce, a urologist I had gone to during internship when I had kidney stones. (What endeared Bryce to me was the way he addressed my fears about urinating blood. “Pee in the dark,” he suggested.) Bryce listened thoughtfully to my patient’s problem, considered it for a moment and said, “Send him to Yamaguchi at the medical center.”

“That’s it?” I asked.

“Yup, we send him all our tough cases.” he said.

“But what do those numbers mean, if not prostate cancer?”

“Damned if I know.”

Dr. Yamaguchi’s note came a month later: “On examination his prostate gland is felt to be very small and flat, without any induration. … Since the patient has had very low PSAs twice in the past, I do believe that this low PSA is his baseline and he occasionally has a falsely elevated PSA. … At this point, I do not recommend further studies.”

“So,” I thought to myself with a sigh of relief, “this is where the buck stops.”