The trends in healthcare throughout the country over the last 50 years have always been fascinating to me. Not many people know, but in my undergraduate days I took up a Minor in Health Care an Social Issues spending hours digesting and trying to understand some of the administrative and political side of the world I hoped to wander into someday. The concept of insurance and it’s foundation to where we are now is complicated and unfortunately when approaching the future, a majority seem to focus on the moment we’re in versus understand how we got there – a post for another day. Outside of these changes in the field of medicine, the actual duties and infrastructure of care, from quality to access, has transformed considerably. As a Pediatrician, and even greater as a locum tenens provider, I have watched the country run into more and more problems with retention of providers in smaller areas in a landscape where the roles we hold are constantly morphing due to external pressures we’re not always able to control, and internal ones we don’t want to. My jobs, after all, as a locum tenens provider, exist because there is a gap. I am able to work, because someone somewhere is having a problem finding someone else. An awkward truth that I’m not afraid to discuss: Locum jobs exist because noone else wants or is able to do them.

Pediatrics is by definition a field of continuity. Traditionally in small communities years ago, there was the General Practitioner (GP) most akin to what we now know as Family Medicine Providers. With time, the explosion of medical knowledge and conveyance of information, longer life expectancies in a growing population with recognition that Humans health needs change throughout a lifetime, and more complicated sicker nuanced situations, Family Medicine sprouted into more specific fields which has brought us to where we are today – Internal Medicine for Adults, Obstetrics and Gynecology for women/females and their care, Pediatrics for Childrens, etc. Pediatricians “back in the day” were what many consider now as “full scope.” These doctors would see a new baby at the hospital after it was born, follow-up with them in clinic, and if they were admitted back to the hospital as they got older, come in after hours to see them. Some, even to this day, still will do home visits. As one can imagine, work hours become endless, life becomes sacrificed, and burnout becomes common; so, overtime a split started to occur between the world outside of the hospital and the world inside the hospital. Thus sprouted the concept of a Hospitalist – a doctor that works ONLY in the Hospital. Something, that is almost impossible to always afford or sustain in the smallest rural parts of the country.

In smaller communities, because of the aforementioned workload, a problem that more and more areas in the country are facing is that those “old-time” providers are difficult or impossible to replace. The concept of doing full scope medicine in rural communities is less and less attractive to new or young providers and thus, when the old retire, a gap forms. There comes the need for not only locum tenens providers, but also those that hold J-1 Visas – a program that allows non-US citizens to remain in the country after US residency/fellowship training with the stipulation to work in shortage areas where recruitment of a permanent position has been unsuccessful.

Maine. New Mexico. North Dakota. North Carolina. Texas. California. Missouri. Wisconsin. These are just a few of the states where I have seen these gaps form and where I will swoop in to help or that will garner the commitment of a J-1 Visa. However, the word “commitment” in either case comes generally with an end date and leaves these communities still fragmented. Just as they get to know a new provider, the new provider leaves having completed their contract. It is heartbreaking, but I have heard from multiple patients, families and workers throughout the country, the words, “We miss how it used to be when Dr. X was here” or “So, are you permanent, we really need a new Pediatrician” lamenting the end of an era when the small town doctor retired years ago and no-one could fill his/her spot.

Early on in my locum tenens pursuit, I was recruited in desperation to a job in the middle of the New Mexican desert as a full scope Pediatrician. Unemployed and also desperate, I said yes. At around 6 months of working, more opportunities had arisen and looking out for my own well-being and interest in returning to fellowship down the line, I left. There are many days when I wonder how my tiny patients are doing. The babies that I followed for months as they grew up, the child I correctly diagnosed and sent emergently to a tertiary care center for evaluation of Infantile Spasms and the community I left behind after getting to know the people and the place. But, my life was not meant to root itself down in that small town, despite how much I care about it.

Things are not what they used to be and the world is always constantly evolving, but the most important question which is sometimes never asked is the most obvious: “How do we evolve with it?”

Image Credit: https://www.forbes.com/sites/markkantrowitz/2021/01/01/permanent-changes-due-to-the-pandemic/