Amanda Brower

"I was a bit burned-out from medicine," says Yeaton, who has completed more than 100 assignments in 14 years. "Locum work gives me the light at the end of the tunnel, so I don't get burned-out." 

Yeaton's career has taken him to some of the most remote locations in the world and, domestically, to a few slightly less glamorous assignments-from prison and military work to Indian Health Service gigs. 

"The common theme across the board is, working as locum tenens offers physicians the freedom and flexibility so they can choose where, when, and how they want to work," Heffernan says. "There is no typical locum tenens physician," though most share a love of travel and curiosity about other cultures. 

Heffernan helps physicians seeking assignments, as well as practices in need of their services-and both are increasingly in demand.  

Today's physician shortage has helped make locum tenens a $1.9 billion industry, with more than 100 recruiting firms across the country, according to the National Association of Locum Tenens Organizations. The group estimates there are 43,000 locum tenens physicians in America, up from 26,750 in 2001. Of those, 30 percent practice exclusively as locums and 41.5 percent are in primary care.  

According to Heffernan, these figures likely will continue to spike as more physicians retire.  

Locums are in greatest demand in rural areas and other places underserved by full-time physicians; one staffing firm, Locum Tenens Healthcare, reports that 60 percent of its business is in rural America. Hospitals, too, use locums across a variety of specialties. 

Locum life appeals to young physicians because it affords them an opportunity to try out different types of practices and regions before making long-term career choices. Retired physicians extend their careers by taking on locum tenens positions that allow them to work free of the responsibilities of private practice. Staff Care, a physician hiring firm, reports that 92 percent of locums previously held permanent positions-most for more than 20 years.  

Women make up a growing percentage of locums, largely because it offers those who are raising families the chance to strike a balance between work and home life. For this reason, female locums are more likely to seek assignments close to home and mostly on a part-time basis. It offers a good way for those who have been out of medicine for a while to dip their toes back into the water.  

				Hiring locum tenens can be expensive, but many practices are willing to pay to maintain their patient bases (see sidebar, above).			

"If you have a physician that is going to be out for any length of time, you run the risk of losing revenue if you don't have another physician available to see those patients," Heffernan says. 

Articles

Freedom from the stress of private practice is a common reason physicians hit the road as locum tenens.

Locum work can offer relief to weary private-practice docs

National Cancer Institute Specialized Program of Research Excellence (SPORE) in Prostate Cancer

Department of Defense Prostate Cancer Research Program Clinical Consortium Award (this award supports the Prostate Cancer Clinical Trials Consortium, coordinated by MSKCC)

Prostate Cancer Foundation Challenge Award for development of targeted therapies for men with advanced prostate cancer

Number of referrals to Sidney Kimmel Center for Prostate and Urologic Cancer

Annual new visits for prostate conditions (2008) – 3,309

Likelihood of recommending physician – 95.4%

Likelihood of recommending facility – 96.1%

Follow-up care programs (secondary prevention, patient compliance)

Care provided for patients at a follow-up clinic who have undergone surgery for early stage prostate and renal cell cancers. The clinic offers comprehensive services, including a history and physical, screening for recurrence, surveillance for other cancers, education on long-term effects of treatment, and healthy living recommendations. In 2008, the follow-up clinic provided care to over 1,200 urology cancer survivors.

Quality improvement initiatives under way and systems in place to prevent errors

Electronic Adult Treatment Order: Implemented at the center in September 2008. The clinician order entry system for chemotherapy administration provides numerous safety checks throughout the prescribing and drug preparation process.

Patient Portal: In April 2008 the center implemented a private, personalized online medical chart through which patients can securely access information about their care. It provides patients with e-mail to their primary physician’s office, access to appointment and billing information, the ability to update their contact information, and more.

Evidence of incorporating research and clinical care

Annual visits to the center’s Experimental Therapeutics Center (2008) – 2,792

ETC staffing: 1 clinical research nurse, 2 patient care technicians

More than half of all men with prostate cancer participate in clinical trials

Research developed through the SPORE and the Prostate Cancer Clinical Trials Consortium is regularly integrated into clinical care.

Participation in national therapeutic initiatives (e.g., the National Cancer Consortium)

Funded by the Prostate Cancer Foundation and the Department of Defense, the Prostate Cancer Clinical Trials Consortium is composed of 13 institutions and coordinated by MSKCC. As of the end of 2008, 60 of the 78 study proposals submitted to the consortium have been approved. Between October 2005 and December 2008, 1,386 patients were entered into consortium phase 1 and 2 trials

Awards and distinctions that make Sloan-Kettering's Sidney Kimmel Center for Prostate and Urologic Cancers a Center of Excellence.

CCE Prostate Cancer: Sloan-Kettering -- Selection criteria

 “Today we cannot cure a man with metastatic prostate cancer,” says Peter T. Scardino, FACS chairman of the Department of Surgery at Memorial Sloan-Kettering Cancer Center (MSKCC).

That will change in the next 10 years for most men, Scardino believes. The MSKCC Sidney Kimmel Center for Prostate and Urologic Cancers is striving to make that happen through aggressive efforts in prevention, detection, diagnosis, research and treatment.

There are limited options for the prevention of prostate cancer. Lack of genetic testing to indicate a patient’s risk of developing the disease makes it even more difficult to determine.

“We just don’t know enough about the genetic risk factors for prostate cancer to be really able to give people credible information, other than from their family history,” Scardino says. “In the prostate cancer world the most profound thing that has happened in prevention is a study done by the National Cancer Institute (NCI) that looked at Finasteride for the chemotherapy prevention of prostate cancer and that study was a huge success.”

MSKCC is doing studies to identify men at increased risk of developing prostate cancer who might benefit from chemoprevention. Recent trial results indicate that prophylactic use of these agents is not linked to the development of more aggressive tumors, as was shown in a previous study.

“That is the most important thing that is going on in the prevention of prostate cancer today,” Scardino says.

Hans Lilja, MD, PhD, a clinical laboratory physician at MSKCC, holds patents for his development of free prostate-specific antigen assays. “Free PSA is now a standard test worldwide in determining who should have a biopsy if they have prostate cancer,” Scardino points out.

In addition, MSKCC researchers are studying how a single PSA test can predict younger men’s risk for prostate cancer. A study published by researchers at MSKCC and Lund University in Sweden found a PSA test taken before the age of 50 can be used to predict who will get advanced prostate cancer in men up to 25 years later. As a result, for men in their 30s and 40s, it might be possible to use the PSA test as a predictive tool to determine their lifetime risk of developing prostate cancer, Scardino explains.

“We have been extremely interested in understanding the powerful predictive nature of PSA levels, and I think this will lead to eventually profound changes in the way we recommend men use PSA testing,” he says.

MSKCC employs a “watchful waiting” approach for those diagnosed with prostate cancers that are not life threatening and do not need immediate treatment. For these patients, MRI and repeat biopsy are regularly used to monitor disease progression and confirm that treatment is not needed

MRI and repeat biopsy should be more widely used,” Scardino says.

The biggest strength of the prostate cancer program is its depth, which allows patients to find comprehensive treatment regardless of the stage of their disease, Scardino says.

“When a patient comes to us, what we can do is offer them one-stop shopping to be able to look at all of the different choices in prostate cancer treatment,” he says.

MSKCC pioneered the use of high-dose intensity-modulated 3-dimensional conformal radiation therapy (IMRT) and helped develop brachytherapy. MSKCC also played an integral role in the development of a prostate cancer nomogram to predict how serious a prostate cancer is and the chances that it might recur after treatment.

Each of the urologic surgeons at MSKCC specializes in only one type of surgical technique for the treatment of prostate cancer and performs that technique exclusively-open, robotic or laparoscopic. “That is a big strength and unique feature of the program,” Scardino stresses.

 by Andrew Vickers, PhD, associate attending research methodologist at MSKCC

 prostate cancer patients treated by highly experienced surgeons are much more likely to be cancer-free five years after surgery than patients treated by surgeons with less experience.

Patients with advanced prostate cancer will be treated by medical oncologists who are among the world’s leaders in developing new treatments. The world’s largest prostate cancer clinical trial consortium is centered at MSKCC. Led by Howard Scher, MD, chief of Genitourinary Medical Oncology, the consortium of 11 cancer centers is investigating new treatments for advanced prostate cancer.

Patient care is backed by groundbreaking research.

The NIH in 2001 awarded MSKCC a grant to establish an ongoing Specialized Program of Research Excellence. The program’s primary goal is to translate population-based clinical investigations and basic research findings into clinical trials of both early and late prostate cancer and eventually reduce the incidence, morbidity from and mortality of prostate cancer.

Another major effort is to further characterize the pathways involved in prostate cancer initiation, progression, and metastasis through molecular analyses of transgenic murine models and well-characterized cohorts of prostate cancer patients at all clinical stages of the disease.

MSKCC also is working on a comprehensive genomic analysis of a series of 200 tumors to characterize all the genetic alterations using a variety of high-throughput technologies. About 80 percent of the research is complete and the data are expected to be published this year. Scardino explains that the research will, “at a deeper level than ever, determine what are the genetic changes that are really driving prostate cancer.”

Currently, phase 1 and 2 trials are being conducted on an androgen-receptor antagonist in patients with hormone-refractory prostate cancer. In preclinical models, the research demonstrated that this agent significantly inhibited the growth of otherwise refractory human prostate tumors.

MSKCC is studying immunotherapy and its potential clinical applications as well. The effort is headed by James Allison, PhD, chairman of the Immunology Program at the Sloan-Kettering Institute.

He is investigating the use of a monoclonal antibody to stimulate the immune system in men with prostate cancer, says Scardino. Allison discovered several key molecules in T cell activation, including cytotoxic T lymphocyte-associated antigen-4 (CTLA-4). The function of CTLA-4 was discovered in Allison’s laboratory and he and his colleagues identified a monoclonal antibody to block it.

He hypothesized that by blocking CTLA-4, it might greatly enhance antitumor T cell responses. He made antibodies to block CTLA-4’s signal so that the T cells could do their work unrestrained.

His hypothesis was demonstrated to be correct and anti-CTLA-4 proved to boost the immune system’s ability to fight cancer. The first in a new class of biologic agents, anti-CTLA-4, is being tested in several clinical trials as a stand-alone treatment and also in combination with vaccines and more traditional chemotherapy drugs.

Based on this research, an antibody that binds to CTLA-4 is in phase 1 and 2 trials for patients with metastatic hormone-refractory prostate cancer.

MSKCC also developed the first knockout mouse model for prostate cancer. The mouse model has varying amounts of the phosphatase and tensin homolog PTEN gene, which is a critical gene in many cases of advanced cancer, Scardino says.

Researchers discovered that the loss of one or more PTEN tumor suppressor genes is found in 70 percent of prostate cancer patients at the time of diagnosis. Studies suggest that the less PTEN function that a cancer retains, the more aggressive it is.

“Animal models for prostate cancer-using them to both understand how cancers develop and metastasize, and how various targeted therapies might stop the development of prostate cancer-has been a major area of interest,” Scardino says.

"Today we cannot cure a man with metastatic prostate cancer," says Peter T. Scardino, FACS chairman of the Department of Surgery at Memorial Sloan-Kettering Cancer Center. That will change in the next 10 years for most men, Scardino believes.

CCE Prostate Cancer: Sloan-Kettering

Cedars-Sinai Medical Center
Los Angeles, California

            Uterine and endometrial procedures            682

            Ovarian and fallopian tube procedures         267     

            Cervical and endocervical procedures         52

            Vulva procedures                                               36

Number of ob/gyn cancer research protocols

            Number of new patient visits                                   1,166

            Number of returning patient visits                           6,372

Human Tissue/Tumor Bank and Relational Database

WCRI participates in education related to most gynecologic cancers including extensive education efforts pertaining to ovarian cancer, use of the human papillomavirus vaccine as a means of cancer prevention, and advocacy of patient participation cancer care.

Evidence of Incorporating Research and Clinical Care

WCRI’s work is based on translational research/medicine – quickly and safely bringing research from bedside to bench and back to bedside, allowing extensive study of all cancer with the goal of discovering breakthroughs that will lead to cancer cures and prevention.

The Gilda Radner Hereditary Cancer Detection Program is one of the largest and most comprehensive programs of its type in the country.

Participation in national therapeutic initiatives

            Department of Defense

            Society of Gynecologic Oncologists

            Gynecologic Cancer Foundation

            Ovarian Cancer Research Fund

            Dr. Karlan is the Board of Governors’ Chair in Gynecologic Oncology

            Dr. Karlan received the Early Detection Professorship from the American Cancer Society

            Dr. Karlan received the Gynecologic Cancer Foundation Margaret Greenfield/Carmel Cohen Prize for Excellence in Ovarian Cancer Research

            Dr. Karlan was awarded the Dwyer Award for Excellence from UCLA

            Dr. Karlan received the James Nolan Award from Western Association of Gynecologic Oncologists

            Dr. Karlan was a scholar at Harvard Physician Leadership in Academic Medicine

            Dr. Karlan is cited as one of 

            NIH/DOD Funding – 40 percent

            Foundations – 35 percent

            Pharmaceutical – 25 percent

Awards and distinctions that make the Cedar-Sinai's Women's Cancer Research Institute a Center of Excellence.

Author | Amanda Brower

Articles

Locum work can offer relief to weary private-practice docs

CCE Prostate Cancer: Sloan-Kettering -- Selection criteria

CCE Prostate Cancer: Sloan-Kettering

CCE Gynecologic Oncology: Cedars-Sinai -- Selection criteria