Dr. Rick Kulkarni founded medtigo in 2014 as an organization that was singularly focused on providing temporary staffing for hospitals, i.e., locum tenans. Dr. Kulkarni went to the University of California to obtain his medical degree and to the Harvard Affiliated Medical Residency program for training in Emergency Medicine.

In a special conversation with medtigo, Dr. Kulkarni talks about the motives and inspirations behind starting a staffing organization and how it has evolved with services and content divisions in the past few years. He also discusses some major issues revolving around the healthcare sector and what the future holds for locum tenens.

medtigo (m): First off, tell us, when did you decide to become a healthcare expert?

Dr. Rick Kulkarni (RK): That’s an interesting question, and it’s actually quite straightforward for me to answer. I really didn’t have a choice on whether to enter medicine or not. It was something that my parents had decided for me. So, from an early age, I was told that you’re going to be a doctor. I was always encouraged to seek out experiences or other activities that might help pique my interest in medicine or prepare me for a career in medicine.

I did have my moments when I was in my educational training. For example, when I was in college, I actually went in as a mathematics major. And I informed my father that I was going to be a mathematician. But he discouraged me from doing that and brought me back to the pathway that he had in mind over the course of maybe the first year, what were the next year or so after I declared my major at college, and eventually, it turned out exactly the way that my parents had hoped. And I ended up enjoying medicine.

I think it had been everybody’s hope. My parents, aunts, uncles, and many people had their hopes pinned on you becoming a cardiologist. But I guess that was my moment of rebellion. And I said, nope, I’m not going to be a cardiologist. I’m going to be an emergency medicine doctor.

At least for the second half of my career, I found it tremendously professionally satisfying as well as personally kind of reaffirming to be able to care for people at the bedside to put my hand on their shoulder to be able to tell them what was happening, whether it was good news or bad news. It’s a tremendously rewarding interaction, and it’s a privilege to be in that position. And so, at the end of the day, having had a profession in medicine for the last 20, 30 years, I’m very satisfied, and I’m very happy with the decisions that I made and the decisions that I was encouraged and required to make by the people who surrounded me as I was growing up.

(m): What challenges do you think physicians faced when you entered the industry, and how different were those challenges from today’s physicians?

(RK): Medicine, 25-30 years ago, when I finished medical school, medicine was a lot simpler than it is now. There are a lot of new technologies and new treatments that have developed over the last two to three decades. I think it’s a real challenge for medical students these days to really learn in-depth, everything there is to know about everything.

It’s not to say that medicine wasn’t complex even back then, but it was less complex, and it was in a way more traditional. If you go back to the forties and fifties, medicine was very paternalistic. There was the older man who had white hair who would wear a long white coat and would basically tell not only the patients but also the nurses and the junior doctors and anybody else who was on his team, who was almost always a man would tell his team kind of what to do and why to do it. And their orders were orders, and nobody really questioned anything. And when I was, when I finished medical school, that paternalistic model was starting to fade. And it was more about empowering individual doctors to be able to advocate for their patients and developing a physician-patient relationship where there was more information was communicated to the patient. And the patient was empowered to be able to make decisions for themselves based on being more informed. And we’re at a point where I think doctors don’t hold the same position that they did 30 years ago.

They’re part of an integrated team of providers. So, you have nurses, pharmacists, social workers, and other important members of the healthcare team that together are helping to advise a patient about the best route forward. And the patient themselves are very empowered and have choices that they can make in terms of their own care. And so, I would say that’s one of the main differences and main challenges that graduates today have compared to when I graduated, I think in the first instance. One challenge is medicine itself is much more complex.

(m): You are the founder and the President of medtigo. Tell us your motivations for starting the company and what services it provides?

(RK): Well, medtigo was started about seven or eight years ago. And it started off as an organization that was singularly focused on providing temporary staffing for hospitals, which in the United States is called a locum tenans. I started it for two reasons; in the first instance, I felt like a lot of the community hospitals that were outside of the major urban areas here in Massachusetts and New England suffered from a lack of availability of quality physicians that they could staff their departments in their hospitals with to be able to provide care to their patients. And on the flip side of it, there was this intense concentration of academic doctors and other doctors who were practicing at the top of their game in these urban areas and very little incentive for those doctors to go out to the community two-three hours away by car and to be able to provide their services. So it was kind of a mission-driven purpose, if you will. And that I wanted to try to build a model where high-quality doctors could go out and provide their expertise and their services to community hospitals and help provide excellent care to the patients served at those community hospitals.

But the other reason that I started this company was that I, myself, and observing other physicians, found myself undervalued at the hospitals where I was working. This isn’t necessarily a problem in some specialties where a specific doctor’s personality or persona is important. For example, if somebody has a brain tumor, they want to go to Dr. Brain at the best hospital in the world to get that brain tor taken care of. On the other hand, if they have a laceration or a cut on their hand, they’re going to go to the nearest emergency department, and they’re going to get the next emergency medicine doctor that is available to suture their cut. They’re not going to look for Dr. Kulkarni to come in.

For that specific business activity, we now have relationships with about a hundred different doctors and six different specialties contracts at about 20 different hospitals all across New England. We’ve diversified in the staffing division, which is one of three divisions in our organization to also do permanent placements. Basically, head hunters go in and place doctors, and the other two divisions are services and content. We provide professional services like assistance with licensing and compliance with continuing medical education requirements as part of the services division. And then, as part of the content division, we have a very active and robust effort to create original content with a dedicated news team with user-generated content blogs referenced content certificate courses, where we have over 300,000 registered users from all across the world, registering over a thousand new registrants a day. We have about 35 people working with us on staff, many now in India, which has been a tremendous success for us in terms of hiring some high-quality people who are authentic and industrious and have expertise in their field, making tremendous contributions. This is not something that we even imagined was possible a year ago when we started exploring the possibility of working in India. We have this great team now in India that’s complimenting the work the US team is doing. It’s a true honor and a privilege to be a leader for this organization. And I see it as a fiduciary duty to provide the best leadership that I can to everybody who’s giving their time. So, it’s great. It’s been a great journey for me over these last eight years.

(m): Sometimes, getting a license is frustrating, especially when you apply to different states. Tell us about your experience with getting your license as you have worked in different states.

(RK): It was something that I always knew was frustrating at a personal level because I had applied for state licenses myself. It’s a pretty complicated and somewhat arbitrary process when dealing with these medical boards. So whether they’re going to approve something or not, whether you’re going to this meeting or not, whether they’re going to tell you a month from now that something is missing and your whole application is held for two months as a result of that.

I had personal experience with the frustrations that go along with applying for a state license and the bureaucracy associated with applying for a state license here in the United States for doctors. But my visibility into that dysfunctional process and my exposure to be broad-scale with which doctors were experiencing that frustration really, was made visible to me as we applied and helped our own doctors during the first five or six years of our company’s existence get their state licenses to be able to work with us at the different sites that we had at the different states that we were working at. And so, in a very organic way, the company realized that this was an opportunity to provide additional value to the healthcare professional, specifically the doctor, as well as the physician assistant and nurse practitioner community here in the United States; we found that some companies were offering professional assistance with licensed with, with obtaining licenses, state licenses.

(m): For the past few years, locum tenens have become very popular. Many physicians have now started working as locs full-time. How do you see this change, and do you think it can really solve the issue of lack of doctors at healthcare facilities?

(RK): No, I don’t think so. I’m seeing some macro trends occurring in terms of healthcare staffing in the United States. And I suspect that some of these trends may also be driving forces in other countries, including India. We’re seeing people move more to a gig type of economy where they’re more comfortable not having a regular job or rather practicing in their chosen field more informally with several employers or with several organizations. And I think you’re seeing that play out for doctors as well. So, doctors are more comfortable working as locums physicians than they might’ve been in the past. But you’re also seeing a change in the type of provider who can provide the care that in the past was exclusively the domain of doctors. So here in the United States, you’ve had an explosion in the growth of professions, such as physician assistants and nurse practitioners. These advanced practice practitioners are not quite doctors, but they can really do 80, 90% of what a doctor can. And in my own career, over the last 25 years, I’ve seen physician assistants and nurse practitioners, for example, make tremendous progress in terms of establishing themselves as legitimate providers of care in many different venues in the hospital, be it in the operating room or on the floor or in the clinic or in the emergency department. And if I might add, do a very good job of it’s not uncommon these days to find an emergency department where half of the providers who might be working at any given time might be PAs (physician assistants). And you may have two PAs and two doctors working together, or three PAs and one doctor working together. And it’s only the complex cases or the cases that are not so straightforward or are high risk that goes to the doctors and the majority of cases that are more straightforward or require some sort of treatment or diagnostic decision‑making that is clearer, like go to the physician assistant. And I personally feel that this is a good use of resources. It was overkill to have doctors who had gone through 12 years of training, 16 years of training to be suturing lacerations; for example, you didn’t need that. A PA could do that. And a doctor who has that amount of training and fund of knowledge and expertise maybe should be a more valued resource being used for specific cases that require a different level of care and a higher level of complexity.

So I think these are some of the macro trends occurring here in terms of physician staffing and where the workforce needs of healthcare are kind of going in. I think doctors are more willing to work locums just because everybody is more comfortable now in working this gig economy. I think healthcare extenders such as physician assistants and nurse practitioners are making great inroads in offering high-quality medical care for the vast percentage of presentations that may be present to a healthcare organization or a clinic.  I think there are artificial caps that are in place right now in terms of the number of training slots that are available for doctors, for example, to go into medical school or even to residency, that are putting additional strains and burdens on the need that the general population has for healthcare providers several kinds of macro trends that are playing themselves out. But I do think that the future of staffing and the needs of staffing will continue to be there because in the United States, anyway, the population continues to expand and continues to age. And it’s an established fact that as the general population ages, the utilization of medical resources increases, and because of all these technological and clinical advancements are being made in medicine, the delivery of medicine is becoming more complex, more time-intensive, and more options are available that maybe were not available 20 years ago.

(m): In the pandemic, we saw that our healthcare system was overwhelmed, and there was too much pressure and workload on doctors and nurses. Do you think locums can solve this problem?

(RK): Very hard to say. The pandemic actually caused significant disruption in the locs industry instead of encouraging growth. The reason was that there was tremendous variability in terms of demand for healthcare services by the general population depending on which phase of the pandemic we were in; for example, when the pandemic first hit, people were very anxious about going to the hospital at all because they thought that they were going to get COVID‑19 if they stepped foot in a hospital environment. And so, for example, emergency department, patient volumes fell off a cliff dropped like 30, 40, 50% sometimes even as much as 80% sometimes, but then people got sick. And so the patient census and the volumes of the hospitals went back up because there were so many people suffering from COVID, and the physician, the corresponding position needs of hospitals went way up again. And so we saw this kind of a rollercoaster, the seesawing of demand for physician services and a complete lack of demand for physician services playing out every couple of months. And the locums’ industry was just not able to keep up with these big changes that were happening so frequently. And what happened for organizations like ours is that we saw a decline in business, a significant decline in business of maybe 50% or more from where we were at our highs in 2019 to even where we are now. And the reason was that a lot of the doctors working with us for locum shifts and getting those shifts on a regular basis definitely couldn’t rely on getting those shifts predictably or reliably.

(m): Do you think there are any loopholes or are there any particular areas where our healthcare system needs to improve? And what are your suggestions on it?

(RK): With regard to staffing specifically, I do think that hospitals have a built-in dysfunction in terms of their staffing levels. It’s very expensive for a hospital to hire a new doctor. It’s a big capital expense to go out and hire a new doctor. And what hospitals tend to do is, by design, they under hire for their need. So, if they need a certain level, they may hire up to 90% of that level. So, by design, many hospitals understaff their physician services by 10-15%. And they make up for that by asking their physicians to either work extra when there is a need or turn to locum services, which are very expensive for them. So, I think this is a necessary evil if you look at it from a hospital’s perspective because, again, the last thing they want is an expensive resource that’s just sitting there doing nothing. And not able to work their contracted number of hours because these hours are just not there. And they still have to pay that person’s salary, but they’re not getting any benefit from them. And so, I think that is an inherent dysfunction and inefficiency in the healthcare system with regard to high-paid physician staffing services. I don’t actually see at this point anyway for hospitals to easily get around that.

 (m): What tips would you give to those who aspire to be a physician and work in a dynamic environment?

(RK): I actually didn’t believe this myself when I went into medicine. Again, as we discussed, this decision was largely made for me, but medicine truly is a calling. One thing that I would say to any medical student or resident is even if you don’t feel it at the time of the training that it’s a privilege and a calling to be in medicine, you should know that as you become older, as you mature, as you develop relationships with real people in real patients, this is going to be a tremendously rewarding career for you on a personal level, as well as a professional level. And the advice that I would have for them is to allow themselves to feel that connection. Don’t be a technician in medicine, be a human, allow yourself to feel what the patient is feeling. Allow yourself to share a moment with a nurse who may be upset that a patient may have had a bad outcome, allow yourself to sit down on a chair next to a patient instead of standing over them and look them in the eye and ask them, how are they doing, allow yourself to hold the hand of a family member who’s just lost somebody in their emergency department. And even if the words don’t really have much meaning at the time, allow yourself to say some kind words to that. And over time, even if you feel when you’re in the throes of your education and your training, that things are overwhelming and you’re just completely stressed out, and you’re overstretched. You’re just trying to survive by learning everything you can; somewhere down the road, your career’s going to come back to you. You’re going to feel a tremendous level of personal and professional satisfaction that I believe is unique and very special to these types of professions where you have the opportunity to help people at an individual level and society at a humanity level.

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