I went off to Anchorage to work for three weeks and to find out what spring was like in Alaska. I had been there twice before in August and September and had seen late summer and early fall and had watched the snowline gradually move down the Chugach Mountains. Yes, break-up is over and spring will be getting going, they assured me. Well…

The last 20-30 minutes of the late afternoon flight into Anchorage were past range on range of rugged snow-covered mountains. There was still lots of snow around on the ground, including those dirty late season heaps piled along the roads and at the edges of parking lots. The woman who let me into my apartment, when I made some comment about it looked like a lot of winter was still around, said, “At least the light is back…”

As the days went by things gradually got warmer. The first nights were nearly in the teens but some of the days were getting well into the 50’s. I am still amazed how quickly the days lengthen – more than 5 min. 30 seconds each day. You can notice from day to day. I am also amazed how warm 40-50 can feel. I never would think of walking around here when it is in the 40s with my jacket unzipped. And locals would be appearing in T-shirts and shorts exposing very white legs. Last Thursday I thought I saw the first sprigs of green along the road as I drove home after work.

Then Friday, April 25th dawned. There were a few flakes of snow beginning to come down as I drove to work. It was hovering just about at freezing. They were those big, fat, sloppy flakes we are all familiar with from western Washington. And they kept falling and they kept falling and they kept falling …They stuck to the bushes and the trees and the cars and everything. The parking lot looked like a lot of overstuffed marshmallows when I went out to drive home. I’m not used to driving in snow and ice. We don’t go off to the mountains in the winter here. It was 40+ years ago we moved to California. And, in fact, I had never driven in that much snow. I was scared – even for the 3 or so miles I had to drive to get home. It still was not freezing so there was not any ice down on the road surface. Lots of slush. All seemed to be driving slower and I did get home uneventfully.

Turns out that all this snow is not at all the Anchorage-rule. It kept snowing until there was 15-16 inches in the bowl where most of the city of Anchorage is located It was the most snow ever to fall in an April day and the third most snow to fall in Anchorage in a single day ever in the nearly 100 years they have been keeping track of such things. And it was late. The snow plows had been put in the yard for the summer. They got them out and went to work. Not surprisingly my week-end plans were cancelled. I got my exercise by leaping over ankle deep and more slushy curbside puddles. The days and nights kept warming, most of the snow is now melted and I think that I saw those blades of grass again as I drove home my last afternoon...

And, so it went for another short stay working in Alaska. Thought you might be interested. I certainly find it interesting. Alaska is a different place. They say the rest of us live Outside. We do.

I am excited about my future. I will be starting as a hospitalist with Southwestern Vermont Health Care in July. Currently a 3rd year Internal Medicine Resident, and chief resident, at Stamford Hospital in Stamford, Connecticut, I started considering positions last summer. I was considering a fellowship and other hospitalist positions when I received an email from VISTA’s Search and Consulting division about an opportunity in Bennington, Vermont. The opportunity appealed to me because of its location and the drastic change of pace from Fairfield County and I am looking forward to the challenges of a rural hospital, working in an area in need of physicians, and being in a nice community to raise a family.

As for my experience with VISTA, it was so easy, I was sure we were missing something! From the beginning, I was partnered with a dedicated recruiter, Kelley Hekowczyk, who walked me through every step. Kelley helped me prepare for interviews by briefing me on what to expect so there were no surprises. I appreciated Kelley’s knowledge of the job, position, and hospital and I felt that her relationship with the hospital was almost as if she were one of their employees. Her knowledge and the fact that she kept in constant contact with me made the interview and hiring process an easy and pleasant one.

Bennington, here I come!

A lot has changed over the past three years in regards to getting physicians credentialed and ready for locum tenens assignments. Applications are longer, medical staff offices are understaffed and require more time to process applications, and the types of documents required have changed significantly.

In the past the focus was on the written word and the ability of your peers to express their ideas and opinions about their professional interaction with you in a simple reference letter. This “Letter of Reference” actually served two purposes: 1. As an introduction to a client. 2. As a professional reference to fulfill hospital by-laws.

Today the Letter of Reference has shed some of its responsibilities. Your locum tenens recruiter will still need it, along with your CV and any supporting documents, to assess your fit with locum tenens work. However, from a hospital credentialing point of view the letters are outdated. These days we find that medical staff offices prefer their own version of the Letter of Reference: A Reference Questionnaire or Evaluation that is specific to each facility. These are usually one to two pages and consist mainly of a handful of questions that rate your performance in a number of areas, followed by a few questions that allow your colleague can elaborate in a more general form. So far the response has been hit or miss, as it does alleviate the need to type out a letter and the forms usually only take a minute or two to complete by hand. However, it is another piece of correspondence in a physician’s busy schedule.

A good rule as you move forward as a locum tenens physician is to keep your references current. I suggest that new doctors gather up a few references prior to leaving their practice, residency or fellowship and current assignment. Basically keep a running list of their work address, phone, fax and email address. This way, you’ll give outdated references a bit of relief and improve the odd of getting the newer references to respond in a timely manner.

Another change that is just as significant as your references is the Procedure Log. Almost anyone who is going to work in a hospital setting or perform any type of procedures is going to be asked to provide a copy of their Procedure Log for the past 24 months when applying for privileges. This includes new residents and fellows. The Procedure Log is basically a running tally of specific procedures and the number of times you performed them. Most modern hospitals and clinics have these readily available and can usually print them out on request. Again, I would suggest asking for a copy of your Procedure Log before you leave your training program or current assignment. Hang on to them for at least two years. It will save you a lot of time and effort trying to track them down after you leave.

Lastly, the UPIN number and all the paperwork and headache it took to get this number are all but gone. The number still shows up on credentialing applications that have not been revised, but the focus is now on the NPI number. Instead of three months, the new NPI number application takes five to 10 minutes to complete online. You are emailed a confirmation letter with your NPI number that you will use for the rest of your career. But that’s not the end of it. Hospitals now require that confirmation letter as part of your credentialing, so please don’t delete that email. Keep a copy handy.

The good news in all of this is that when you work locum tenens assignments through VISTA, we help you make sense and keep track of all of this.

State medical license renewal applications are much simpler than initial applications and re-licensure applications. The vast majority of state medical boards now offer on-line renewal.

The process generally requires the following:

• Verifying personal data
• Answering questions regarding discipline, criminal matters and mental health conditions
• Certifying completion of mandatory CME for the prior one- or two-year registration period

CME requirements range from 12 hours per registration year in Alabama to 50 per registration year in Illinois, Maine, Washington, Massachusetts, Pennsylvania, New Hampshire, New Jersey, and North Carolina. Specific class content may be required such as risk management, palliative care, and ethics.

Additionally, a certain percentage of your CME must be designated Category I. Make sure to keep your CME certificates, because boards often conduct audits and may request proof of CME. You may also want to apply for the AMA Physician’s Recognition Award, which measures Category I CME content. This certificate is accepted as an equivalent for licensure renewal by more than 75 percent of state medical boards.

You will usually receive your renewed license certificate in 15 to 30 days after the application is submitted.

Your first step is understanding your eligibility, which varies by state, and is based on:
• Whether you are an American or international medical school graduate and, in some states whether your medical school is approved by the state. VISTA’s team will research a state medical board’s website or utilize the WHO Directory of Medical Schools or the ECFMG FAIMER Directory to determine if a school is acceptable.
• The length of post graduate training you have completed. International graduates are commonly required to complete three years of PGT; American grads may meet eligibility with one or two years of training after graduation.
• Limitations on licensure examination, e.g., some states do not accept a “state” exam—these were the norm prior to NBME, FLEX and USMLE.
• The status of your original license. Some states require that your first license remain active.
• When you took the USMLE; USMLE failure rate on each of the steps; weighted score of the exam.
• How long it’s been since you took a licensure exam along with ABMS certification. Some states invoke “The 10-year Rule,” which states that if a physician has not taken a licensure exam within 10 years of application and is NOT board certified, he or she may be required to take the SPEX Exam.

VISTA’s recruiters review all locum tenens candidates’ applications and work with our licensing specialists to determine whether these requirements will impact your ability to qualify for a new state license. This is an important step in assessing locum tenens opportunities.

Once we help you determine your eligibility, a Licensing Specialist will walk you through the steps required to apply for the license. It is important to decide if you can meet the requirements, especially if you may be required to take the SPEX or obtain ABME certification. It is also important to know up front if a state will require an on-site interview or exam.

Once you have worked through the above, you must complete and certify the application for licensure and an FCVS profile application, if required by the board. Additionally, for those states that require an associated controlled substance certificate, you must complete a separate application and meet specific requirements.

The VISTA Licensing Specialist then begins requesting primary source verification of your credentials, which always include:

• Medical Education- all schools attended
• Post Graduate Training
• Licensing Exam Scores
• All state licensure – active, inactive, and training
• Professional’s statement regarding history of malpractice experience, discipline, and mental health issues that could affect or limit his/her ability to provide competent medical care.
• ECFMG for all international graduates

These additional verifications and requirements are requested by most states and processed by the Licensing Specialist:

• AMA or AOA Profile
• Federation of State Medical Board Clearance
• NPDB
• Transcripts
• Practice experience – this varies by state in terms of how far back your work history needs to be verified.
• Liability insurance coverage
• Certified birth certificate
• Legal proof of name change, if applicable
• Fingerprinting and background checks
• CME required for licensure- FL
• Passport photos
• Referencing – many states have their own forms; others require a statement

The Licensing Specialist contacts primary sources and then follows up to assure a response to the board is completed.

Once the application and all requirements for verification and documents are received by the board, the Licensing Specialist will stay in contact with you and the board until a decision is made.

If at any time during the application, you experience an unusual negative experience, even something like a traffic ticket (yes, just for speeding) you must notify VISTA and fully disclose the circumstances to the board you are petitioning for licensure.

Tricky question. It’s tough to pin down processing time for a new state medical license because, although the requirements are the same for each applicant, a physician’s unique history and situation impact processing time.

For example, an American medical graduate with no malpractice claims or disciplinary issues, who has practiced in one location for the 10 years since completing training, will take much less time than an American medical graduate with the same length of time in practice, but who worked in five locations and had a significant malpractice settlement.

In VISTA’s experience the wait for a locums license has varied from three weeks in New Hampshire to two months in North Dakota. Temporary licenses, requested in conjunction with an application for a permanent license, can be issued in a month in Hawaii. It may take up to three months to get the same license in South Carolina. Full, permanent licensure can be processed in two months in Hawaii, but may take as long as one year in Texas.

There are also a host of variables that are essentially out of our hands—and yours. VISTA’s licensing specialists are very knowledgeable about most of these processes and calculate an expected delay into the overall time frame when discussing licenses with you. California, for example, has a 45-day waiting period once an application is at the board before any action is taken on an application. North Carolina has specific deadlines for application completion so an application can be reviewed at a scheduled board meeting. The deadline is usually six to eight weeks in advance of the meeting.

All medical boards experience heavy application volume from March through August because physicians are completing their post-graduate training programs and preparing for practice. We plan for an additional one-to- two week delay during this time.

At VISTA we help physicians apply for licenses in anticipation of locum tenens assignments, and for new permanent positions through our Physician Licensing Resources Division. One of our medical directors has had up to 19 active state medical licenses at one time, so don’t let the prospect intimidate you. Concentrate on the steps that follow, and VISTA will make the process as simple as possible.

• Keep very thorough records of practice experience dates, locations and addresses, especially when on locums assignments.
• Maintain a file of certificate and document copies. If any of these have been lost, obtain an official copy from the institution issuing the certificate.
• Be prepared to provide a detailed and thorough explanation for any or all disciplinary actions or malpractice cases.
• Do not discard court documents, even if very old, or letters from attorneys or from medical boards. Do not depend on attorneys to maintain your documents.
• Thoroughly read and understand every question asked of you on a medical application, especially those concerning malpractice, discipline, arrest/conviction history, substance abuse, and mental health. Be sure to answer correctly and provide a full explanation for each circumstance.

For more information about licensure in conjunction with a locum tenens position talk with your VISTA recruiter or scheduler. If you are interested in help obtaining a new state license independent of locum tenens work, contact our Physician Licensing Resources Division at 800-366-1884. Adventure awaits. We can get you there!

Forget travel, forget rental cars, forget apartment keys under the mat at midnight...Getting licenses in new states can actually be one of the most challenging aspects of locum tenens practice—or medical practice in general for that matter. But there is a glimmer of “standardize this process for the betterment of humankind” hope on the horizon.

A new, on-line application process called the CLAF, Common License Application Form, has been launched. Ohio was the first board in the country to implement it in 2007, followed by Kentucky and New Hampshire. The new on-line system application is linked from each board’s web site to the Federation of State Medical Boards. Physicians do need to have an FCVS Profile or apply for one to use the CLAF system.

As other licensing boards implement use of this system, physicians will be able complete one application using the CLAF. The common information that all boards require is integrated into the form used by the state board, leaving only state specific data requirements to complete.

This process will save physicians the tedium and time of entering the same information on different applications every time they apply for a license in a new state. I can’t imagine anyone appreciating this more than a seasoned locum tenens physician, or the agency supporting said physician.

Kudos to the Buckeye, Bluegrass, and Granite states for taking this leap into the information age.

The bush pilot gunned the engine of the DeHaviland Beaver float plane as it glided across the bay. We gently lifted off from Ketchikan, Alaska, on the final leg of a journey taking me to a five-week locum tenens job in Klawock, Alaska. During the 45-minute flight, I surveyed the stunning scenery of the vast Southeast Alaska wilderness, which spread out in all directions.

Klawock is located on the Prince of Wales Island, which is the third largest island in the US. The island is accessible only via float plane or a once daily three-hour ferry ride from Ketchikan. During the winter months there are many days when the float planes can’t fly due to weather. The island gets 120” of rain yearly, and it has rained nearly every day. The temperature however, is in the low 40s, and we haven’t had any snow yet.

After my first few days of work at the Alisha Roberts Medical Clinic, I discovered that the pace of life in Alaska is much slower than I had anticipated. My wife Lynn came for a visit during my third week. She enjoyed the slower pace which gave her time to reflect after her father’s recent death.

On Saturday, we travelled 30 miles on gravel roads to the village of Kasaan to see the totem park. We hiked through the rainy woods to the park where we encountered more than a dozen antique totem poles, and an old clan house. It was a marvelous experience!

The next day, we went hiking on Cemetery Island. Southeast Alaska is a rain forest so the forest is very damp, and everything is covered with lichen and moss. Along the trail we encountered several large trees that had been toppled. I was struck by the lack of deep roots, which is due to the abundant rainfall, making it unnecessary for the trees to sink deeper roots. The huge uprooted trunks were lying at crazy angles with their flat roots ripped from the earth. It was so striking that I took several pictures of the trees.

During the ensuing week, the sight of those fallen trees kept coming back to me. They could be used as a metaphor of human life. When I was born, my only “root” was the umbilical cord. Then during my childhood and early life my parents and wonderful grandmother Amanda helped me to form some first tentative roots. Then teachers, neighbors, pastors, Sunday school teachers, and other numerous mentors helped those roots to multiply, and sink deeper. These roots gave me a strong foundation to begin medical school where other positive influences continued to strengthen them.

After medical school and internship, my roots continued to be nourished by my lovely wife Lynn, practice partners, colleagues, and other friends and family. Now unlike those toppled trees in the forest, I feel “firmly rooted”, and hopefully I can withstand almost any wind of adversity. Our deep roots make us truly blessed.

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Note: Stuart Embury, MD, has been writing columns for the Cornhusker Family Physician for nearly 20 years. To read more of his work, visit www.nebrafp.org/online/ne/home/publications.html. This article is scheduled to appear in the Spring 2008 issue.

The following is one of the funniest email exchanges we have had with a physician working locum tenens with us.

Hi Melanie,

I have kind of an odd request. Do you remember when you sent me the recertification packet? Well it came with a bright green pen that had VISTA's logo on it. I wanted to let you know it was the best pen I've ever used. It fit just right in my hand and I think it actually made my handwriting neater. Sadly, it just ran out of ink. I almost cried. Now every pen I use is just uncomfortable and a pathetic substitute for my dearly departed VISTA pen. My handwriting has also suffered greatly. Is there any way you could find it in your heart to send a few more pens my way? I would greatly appreciate it. The nurses would too, so they can read my orders better, which would benefit the patient too. And in a roundabout way, even VISTA would benefit (better handwriting = fewer medical errors =happier patients = less chance of malpractice lawsuits = lower premiums). You can also think of it as an advertising investment because I'll be sure to sing VISTA's praises to all my colleagues while I'm using it. It'll be a WIN-WIN situation! Let me know if you can help me out. Thanks!
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Hi James,

I am still laughing my head off! With a request like this, how can I say no? The pens are on their way!

Have a great weekend!

Melanie
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Melanie! Oh glorious day! I received the package today and it made me sooooo happy. Woo hoo! Now I have my beloved pen back AND I got a new t-shirt and hat to boot! Thank you thank you thank you! Here's a picture of me with all my new goodies. Enjoy!

James

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