Fly-in Doctors Not Long-Term Solution, Doctors Feel

Thunder Bay Post, 20 April 2001

Imagine going to the doctor for an ongoing problem, and seeing a different face every visit.

This is the situation facing thousands of people in Thunder Bay. Some experts are calling for changes to keep care from suffering.

The chronic doctor shortage has led to hospitals and clinics using temporary fill-in doctors called “locums”. The term is short for, “locum tenens”, Latin for “to hold the place of” or “a held position”.

Locums fill in for others who are on vacation or on professional development training. With not enough specialists of all kinds, and little prospect of more being trained quickly, the system is growing dependent on these medical free agents.

Doctor Robert Kudlak is a locum in Thunder Bay Regional Hospital’s emergency department. He’s one of a pool of about 30 E.R. doctors who in some cases fly up to Thunder Bay, do several shifts, then fly home again until their next work period.

Kudlak, though, lives in the region, and does E.R. work to keep his hand in

the specialty. He says there are lots of opportunities to work here in different areas because the doctor shortage is so widespread. Many younger locums, however, use the experience to travel around, “trying to get a taste of working in different parts of the province”.

This sets up a situation where communities and hospitals compete for locums, offering more than just the basic compensation package. Travel, hotel, and car rental bills are picked up by Ontario’s Health Ministry, on top of either $900 a day or OHIP billings.

Richer hospitals in larger communities can offer “top-up” money over and above the basic package. That makes it difficult for smaller, poorer hospitals to compete.

Everyone in the system agrees concedes that locums can provide first-rate care, but there are concerns about the long-term impact of relying on fly-in doctors.

Another area in which TBRH relies heavily on locums is psychiatry. The hospital has eighteen psychiatrists on its roster for fill-in work on the psych ward.

Doctor Adrian Hynes is a Thunder Bay psychiatrist who’s helping develop a payment plan designed to recruit more doctors in his specialty. While supportive of locums as a short-term solution, he calls a situation where a patient sees one doctor for a particular problem, and a different doctor for follow-up a week or

two later, far from ideal.

“(Locums are) one of the best inventions that have ever happened to people who live in isolated areas, but they are only a short-term solution, not a one- or two-year solution”, he says.

The co-ordinator of medical affairs for Thunder Bay Regional, Patricia Lee, agrees in an ideal world, patients would be better served by continuous coverage by full-time doctors.

Still, she says the alternative to locum doctors would be longer waits, more on-call work for doctors living here, or more patients flown out of town for services not available here.

The system also leads to some tension between the locums, who work their shift and fly home until the next one, and resident doctors who have to be available for off-hours work over and above their regular practice. That off-hours work is an even bigger problem for specialists.

Kudlak says he has not encountered tension but he says the environments for the two types of doctoring are very different.

“When you’re on (as a locum), you’re really on, and when you’re off, you’re off. Family doctors… may not be running as fast, but it’s more like a marathon than a sprint.”

Lee agrees, saying “it’s very difficult for some of our physicians who work very hard to see locums coming in and potentially making more than them on a given day.”

Hynes is even more blunt. “One cannot be committed to a place that one flies into and flies out of without living there”, he says.

The funding environment in Ontario is driving all institutions to examine all their spending under a microscope. In spite of this, estimates of overall locum costs seem broad and vague.

The Ministry of Health pays, so hospitals say they only keep track of how much they “top up” basic compensation. The competitive environment makes hospitals hesitant to reveal how much they’re spending, in case other institutions use the information to outbid them.

In an e-mail reply to a reporter's question, Ministry spokesperson Dan Strasbourg says the MOH doesn't track “locum investments” by city or region. His estimate for last year for the Thunder Bay area – about 500 locum days funded at about $1,000 a day, meaning a total of about $500,000.

Health insiders suggest this is a very conservative figure.

Chief of psychiatry at TBRH, Doctor Lois Hutchinson, estimates the hospital spends between $600,000 and $700,000 a year on locum psychiatrists alone. This is for 18 doctors in the pool of 143 locum doctors available to the hospital.

The consensus of health care officials around Thunder Bay is that locum coverage costs between $3,000,000 and $5,000,000 a year.

Hynes says he’s not surprised at everyone’s reluctance to discuss numbers in detail.

“If I was in the position of spending a lot of money on a second-rate service, I wouldn’t necessarily want everyone to know that very clearly”, he says.

Everyone agrees the answer is more doctors moving to Thunder Bay to practise full-time. One of the big incentives will have to be money. Some say dollars could be diverted from locum funding into payment and compensation plans that encourage recruitment and retention.

“If the government is willing to spend this kind of money,” Hynes says, “it would be appropriate to use that money to attract and retain physicians rather than to provide what I’m characterizing as a second-rate service.”