A locum service physician is a healthcare provider who serves as a temporary substitute for doctors who are vacationing, sick, attending conferences, or on leave for other reasons. In the United States, which first started using locum tenens in the 1970s, demand for these temporary physicians has quietly exploded over the past 15 years – and the number of U.S. physicians working as locum tenens has risen steadily from an estimated 26,000 physicians in 2002 to 48,000 physicians in 2016, or approximately 5% of the physician workforce (1). Although locum tenens as a career choice has increased considerably worldwide during the past decade, there are a few unanswered questions regarding the pattern of practice. Knowledge of who chooses to take on locum placements after graduating from residency, and the characteristics of locum work are of policy and planning relevance (2).
In 2010, Myhre et al. surveyed 377 recent family medicine residency graduates in Alberta, Canada to explore their reasons for opting into locum practice (2). Of the 377 graduates surveyed, 242 (64.2%) responded. Among the respondents, 155 (64.0%) had in the past practiced or were at the time practicing as locum physicians. The average duration of a locum placement was 9.1 months. Their findings also revealed that, proportionately, female and younger physicians were more likely to practice as locum tenens, and that the decision to do locum placements tends to be made during the second year of residency training. Additionally, financial benefits do not appear to play a large role in the motivation for becoming a locum tenens. The findings of both the survey and the interviews consistently identified the opportunity to gain (clinical and business) experience and flexibility (46.7%) as the main reasons for recent family medicine graduates choosing to do locum placements. Finally, the primary reason for leaving locum practice was to settle into permanent practice (52.1%); interview data revealed that this reflected a desire for stability, a desire for continuity with patients, personal life changes, financial considerations, and the end of a perceived need for exploration (2).
Given that locum placements tend to be seen as more temporary and are often used as a way for younger physicians to gain experience, there has been concern over whether these physicians provide lower quality care compared to permanent staff. Particularly in the UK, which relies heavily upon locum physicians, concerns about their quality of care have grown as demand for temporary physician coverage has outstripped the supply of qualified locum candidates, leading, at times, to locum tenens being hired to cover medical specialties they’re not trained in (3). While surveys of administrators at U.S. hospitals indicate that they are generally satisfied with the quality of locum tenens’ work, little empirical data exists on the quality and costs of care delivered by locum tenens physicians.
In 2017, Blumenthal et al. attempted to address this knowledge gap by evaluating the quality and costs of inpatient care delivered by substitute physicians to Medicare beneficiaries hospitalized with a general medical condition (e.g., pneumonia, heart failure, shortness of breath) between 2009 and 2014. They found that patients treated by locum tenens and non-locum tenens physicians had similar 30-day mortality rates (8.8% for locum tenens’ patients versus 8.7% for non-locum tenens’ patients). Thirty day readmission rates were 22.8% for patients treated by locum tenens physicians, and 23.8% for patients treated by non-locum tenens physicians, a small, yet statistically significant difference (3). They also discovered that, on average, patients treated by locum tenens physicians cost $124 more than patients treated by non-locum tenens physicians ($1836 vs. $1712) and spent an additional 0.4 days in the hospital (mean length of stay was 5.6 days for locum tenens’ patients and 5.2 days for non-locum tenens’ patients). Both of these findings were also statistically significant, but were not large in practical terms. While they were unable to evaluate exactly why patients treated by locum tenens had higher costs of care and longer lengths of stay, one potential explanation is that because locum tenens aren’t as familiar with the work environment, they’re not as efficient. It takes time to learn how to operate efficiently in a new clinical delivery system, and higher costs of care and longer lengths of stay for locum tenens’ patients could reflect this learning curve (3).
With the demand for temporary physicians expected to keep growing in the United States and abroad, it will become more important to learn about why physicians choose to work as locum tenens, what their training and qualifications are, and how hospitals and clinics onboard, evaluate, and manage them. It must be noted that the previously mentioned studies only looked at two specialities (family medicine and internal medicine). Additional research would be needed to find out if the practice patterns of other temporary physicians are consistent with these observations.Currently, there are no national guidelines on “best practices” for hiring, training, and integrating locum tenens. Developing these could help hospitals and clinics better identify, onboard, and manage highly qualified locum tenens.
References
- Gianas, M. (2018, August 15). The impact of locum tenens. Retrieved from https://www.physicianspractice.com/article/impact-locum-tenens.
- Myhre, D. L., Konkin, J., Woloschuk, W., Szafran, O., Hansen, C., & Crutcher, R. (2010). Locum practice by recent family medicine graduates. Canadian family physician Medecin de famille canadien, 56(5), e183–e190.
- Blumenthal, D., Olenski, A., Tsugawa, Y., Jena, A. (2017). Association Between Treatment by Locum Tenens Internal Medicine Physicians and 30-Day Mortality Among Hospitalized Medicare Beneficiaries. JAMA, 318(21), 2119–2129. doi:https://doi.org/10.1001/jama.2017.17925
