Precarious Employment - Life in locum limbo

Dennis Jeanes
Manager, Communications & AdvocacyCanadian Orthopaedic Association

In early 2011, Dr. Gerard March found himself in a real bind. His second fellowship, this time in sports medicine, was coming to an end. He and his wife were expecting their second child - soon. And still there was no job in sight. He'd sent out his CV to just about everywhere and everybody. He'd even had an interview, but hadn't heard anything. Fortunately, his fellowship supervisors could see that the job market had drastically changed and allowed March and a few others in the same straits to focus on finding work: "They were very kind. They understood how much pressure I was under. But I must admit the job situation took away a bit from my fellowship experience, having to focus on the job search, doing weekend locums, sometimes weekday locums, listening to the scuttlebutt from reps, staff and other residents. Who's got an opening? Who's going to retire?"


While March regrets that he couldn't have spent more time getting involved in his fellowship, giving that little bit extra, he had no choice. As soon as his fellowship duties were done for the day, he was out the door, often to get to rounds at one hospital and then fighting traffic to start a call locum at another: "It's not really how a fellowship is supposed to go."

As far as locums are concerned, March notes that in the greater Toronto area it's a bit of a free-for-all because there are so many fellows and new graduates available. And forget any notion that all the people doing the hiring are elder surgeons who would prefer not to do call but aren't ready to give up their elective resources: "That's not what's happening. I was doing locum calls for surgeons who had graduated maybe five years before me. I don't fault these people in the slightest. If I had someone saying to me, 'I need to earn money, and I need to get experience. I would love to do your call.' I'd probably find it hard to resist, too."

The root problem with being an "on-call-ogist" doing just emergency call on locum and no elective surgery, says March, is that there is no community connection, no compensation beyond fee for service. Doing locum call for a year might be bearable, but two or three years would surely prove detrimental to the soul, not to mention subspecialty skills. "The community provides us with our ability to do our electives, so we offer emergency call in return," he says. "I'm happy to do this service so that I don't have to rent my OR time. Okay, I won't put my kids to bed one night in five, but I'll cheerfully step up and fix anyone who needs to be fixed that night. But when you're on call only, you're no longer the one who receives the opportunity afforded you by the community. Somebody else does."

March was in the last week of his fellowship, when the phone call came confirming him as the successful candidate for a full-time opening in Sarnia, Ontario, where a surgeon had decided to retire. Acutely aware of his great good fortune, he feels his competitive edge may have been his fellowship skills, which were still fresh and up to date: "I have this job pretty much because of the timing. The guy who finished his fellowship the year before me may not have the same appeal because he floated for a year. Well, that's not his fault. No jobs were available."

The divide that separates the full-time surgeon from the short-term contract surgeon couldn't be more night and day - literally and figuratively. As March points out, there's no middle ground when you're on the market. You're either living the dream, or weighed down with uncertainty, often in a dark mood: "At one point, my wife and I felt we were in so much trouble and we felt lost, and then all of a sudden everything was exactly the way we wanted. Either you're in trouble or you're not. It's very tough."

It's this bi-polar existence that rankles, especially its seemingly arbitrary and opaque process for lifting successful candidates out of the darkness of call into the light of elective practice. Certainly that's the tenor of a number of remarks made on a CORA survey that went out last year to all graduates for the last five years, asking about their employment situation. Feelings ran high about how jobs aren't widely posted, if at all, and often only for a short time. One respondent reported a situation where job applicants were expected to locum as part of the hiring process, which meant passing up work elsewhere, as well as underwriting travel, accommodation and provincial licensing expenses. Also, there were complaints that postings for new openings were written specifically for a current locum's skill set and then advertised as a "competition."

Responding to a job posting that seemed to fit his qualifications to a tee, Bill Smith (not his real name) was dismayed that he didn't even qualify for an interview: "I found out that only two applicants were interviewed for the position, and other qualified but more informed applicants had not even bothered to apply." So it comes as no surprise that Smith - who is married and has children - should feel discouraged and find himself prey to self-doubt the longer he looks for work: "I have frequently asked myself, 'Am I even employable?'" Smith has even considered giving up on a surgical career and cobbling together a living from office work, medico-legal cases and surgical assisting: "I can't keep moving around like this. My kids are school age and need stability. The further I get from my fellowships, the less confident I feel that I'll be able to easily integrate into a surgical practice even if I do get hired."

Dr. James Matthew, who did locums for about two years in BC's interior before finding full-time work in Surrey, knows the feeling: "Surgeons are giving up as much call as they can. The way things are going with locums, it's really bad on so many levels. The new surgeons are being taken advantage of, but on the other hand they're also being provided with the only kind of work that's available right now. You have no choice. You have to do it." Matthew sees a serious problem in the lack of proper patient follow-up. At one hospital, where he worked, he did only call and had a cast clinic where he could do follow-up, "but the way locums work is you do call for someone, and then you never see that patient again. It's pretty well defined who is responsible for the patient, but what actually happens may be another story. I certainly had lots of people coming to my cast clinic that I hadn't really been involved with before."

Although he's pretty sure his subspecialty skills helped clinch the deal in terms of landing full-time work, it was far from straightforward. Matthew remembers that the Surrey position was first advertised in late 2009, while he was still doing a foot and ankle fellowship in New Zealand. He contacted the group then, and they said, yes, they wanted someone, but they didn't have any new resources. Eventually, the job posting was taken down. In 2010, Matthew and his young family returned at first to his in-laws' home in Winnipeg and eventually went to Vernon for a 10-month locum and then to Kelowna for another 10-month contract. Meanwhile, in Surrey, construction on the Jim Pattison Outpatient Care and Surgery Centre was progressing on schedule for a May 2011 opening. Surrey's orthopaedic group re-posted the position, and Matthew contacted them again: "They had come up with a formula that allowed them to bring someone else on. We have the new Centre, so in my case it was kind of a new job that was created, except OR time remained the same for the group. Everybody agreed to take less OR time and less call."

Matthew feels that the specific need for a foot and ankle specialist likely helped narrow down the pool of applicants, but thinks his long-term locum work in BC may have also been an influencing factor, since his supervisors would have had time to form an opinion of his skills and his work ethic: "If I hadn't been successful, I don't know that there would have been a whole lot of other opportunities. I was pretty lucky, I guess, that my subspecialty matched the job opening."

Dr. Jim Jones (not his real name) worries that he may be losing his fellowship skills. Since graduation, he has done a one-year fellowship and over 18 months of locums for the same hospital, which entails call and cast clinics: "I thought it might be a great lead in to an employment opportunity. So far, no luck. I don't operate during the day. I only operate at night or on weekends. I work at times that nobody else wants to work. That's my current state of employment. I am, however, thankful for the work that I do get. It pays my loans and affords me a comfortable lifestyle. I have not been discreet about wanting a job with this group. They know I'm hoping there's a light at the end of the tunnel."

Jones isn't sure if his loyalty to one group will lead to a position, especially since his employers aren't approaching retirement. He admits that it's quite possible that he has put himself at a disadvantage compared to other new surgeons who are moving from hospital to hospital. Be that as it may, Jones' strategy has more to do with professional ethics than it has to do with currying favour: "I think patient follow-up, knowing how you've done and following your work, is extremely important. What I managed to do is get enough work that I can follow my patients. That's really important to me, so that's why I do what I do. I think one of the worst things you can do as a surgeon is offer somebody an operation, do something for them, and then never see them again. Short-term locums mean that you're not held accountable for what you've done."

For Jones, morphing into a community traumatologist, is deeply conflicting. On the one hand, apart from the occasional patient, he rarely does anything that pertains to his subspecialty: "I feel my fellowship skills are melting away. Your clinical acumen goes, and it's difficult to keep up with the literature if you're not seeing the cases." On the other hand, he doesn't find trauma boring, far from it: "We get our fair share of complex single-system injuries, and there are lots of things that I find extremely challenging. It's enjoyable. But I question the year I spent to do a fellowship. Although, I hear your skills come back."

It's estimated that there are nearly 400 exceptionally bright and dedicated men and women presently filling orthopaedic residency positions in Canada. About 70 surgeons graduate each year and are faced with either finding temporary sanctuary in a fellowship or fighting for short-term locums, all the while waiting for elder surgeons to retire or fall ill. It's a precarious existence.

"The problem is," says James Matthew, "the population is increasing and we're not. We don't have enough practising orthopaedic surgeons in BC. Wait lists are really long. I've been in practice for a year, and I have a wait list of 140 patients. I have well over a hundred referrals that I haven't seen yet."

"I don't have a job, a hometown or financial stability," says Bill Smith. "Ironically, it's been my one comfort that I am not the only 'unemployed surgeon' in Canada."

"The health region I work in," says Jim Jones, "is completely understaffed, and there have been a lot of well-written documents supporting this. Surgeons have put their blood, sweat and tears into this work to try to show that we need more orthopods. We don't have the numbers to serve the population that we have. For Canadians to have reasonable access to elective orthopaedics, I think the COA's magic number is one surgeon per 22,000 people. It's clearly not going to happen. That's what makes it so frustrating."

"What will Canadian orthopaedics look like in ten to fifteen years?" asks Gerard March. "Are we going to have an 'underclass' of angry surgeons who only did the unwanted work, or are we going to have a healthy, strong group of people who are closer together because of today's struggle? What do we want the future to look like?"

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