Locum Tenens has long been considered a means of assisting rural physicians and their patients. The literature has long noted that rural physicians rank the ability to get away from practice as a high priority. Rural physicians do work longer hours and see more patients. Also there are still rural physicians that have solo or small group practices. These locations sometimes have no options for coverage. Concerned physicians at these locations feel an obligation to provide medical coverage.
My concerns regarding locums involve mainly the impact on the rural physician work force in states and in local situations. These are based on observations as well as a few articles in the literature. I have also been a rural locum tenens doctor from time to time.
One article by Kronhaus in NC noted that locum tenens doctors were often not accessed by patients, especially when a known physician was available in town. Patients would rather crowd in with a known entity instead of an unknown. If the locums is known in town (past grad, regular locums, nearby physician) this may not be as much of a problem. In a more isolated area, the use might decrease some, but the need would still continue, depending on how long the regular doctor was gone. If a town has a regular turnover of residents (mining or other non-agriculture base), then locums may look enough like regular physicians not to matter.
At the state level there have been several examples of locums programs. These have often involving AHECs or Family Medicine departments. Some residencies have been involved in locums through moonlighting. In the past some have been able to cover liability costs as part of the residency liability package. States could probably negotiate this for medical education but doubt they have attempted this.
North Carolina attempted some locums programs, but had difficulty recruiting and retaining suitable physicians. This is not hard to believe as the life of a locums is more difficult for those with families or ties to a community. Locums can be a transitional situation for many physicians, but this is not a reliable labor supply.
Some Family Medicine departments and residencies are writing locums obligations as part of faculty contracts. The intent of some of these is to act as backup in case sources of coverage fail (residents, fellows, a few hired locums). In some states there has been a feeling that FP and medical school faculty are not busy and have time to provide care in distant locations. In Nebraska a survey of faculty indicated some interest in a few, but no takers when a program was proposed at the state level. Our chair monitored the program carefully to be sure that the department did not get obligated in some private sessions. For those who think that department faculty have some time so spare, this may work out. I don’t know many of these, nor do I know many without the family and personal obligations that would prevent locums participation. Also those with a need for more income tend to choose other jobs other than faculty work.
In other instances such as Alaska, the intent of the residency was to have a regular exchange of faculty out to relieve practitioners and graduates of the program so that faculty stayed sharper and relevant and practitioners got a break. The program is too new to evaluate yet.
Another problem is that many urban situations pay more for locums. This is based on the higher volume that can be generated in urgent care locations. This has driven up the cost of locums for all locations.
To me one of the real problems with locums in rural areas is that the main folks attracted to locums is existing rural doctors. The grass always looks greener and it is tempting to get rid of overhead and community obligations and call to have more control over hours and patient obligations. There is also the potential to get paid more but this depends on the contract. Locums often does not include benefits and does not allow certain expenses to be included. This is like moving from Tennessee to Nebraska with a pay raise but realizing that the change in state taxes and state retirement policies results in less take home pay.
I have seen locums programs destroy primary care in rural communities. In Tennessee one hospital worked for years to reopen and attract family physicians. Just when a critical mass began working together, the hospital offered an hourly contract to one of the doctors. Soon they had most of the doctors on contract and the primary care base was gone. Patients no longer could access the clinic, they could only use the ER.
In Nebraska we have small towns with 3 or 4 physicians residing in town, but 1 or 2 commute out of the town to do locums. They used to do primary care continuity practices in town but have given these up. If you multiple this effect over a state or nation you can see why I am concerned regarding the establishment of and incentives for locums programs. At stake is continuity of care, retention of market share for rural communities, and the survival of rural hospitals.
Another development has been paying local physicians to be on call. I believe this was picked up from Canada and transplanted. We have one location with a stable hospital that pays physicians on weekends. I have seen rates from $25 to $50 and sometimes the doctor can bill for patients on top of this rate. On the positive side this is one way that hospitals can encourage local care, familiarity with local providers, and shared call. Physicians in such arrangements must be punctual for care, often staying in house for busier locations. This is also one of the few legal ways that hospitals can support physicians, IRS restrictions being rather sticky in this area. In such situations when a physician leaves, at least there is some monetary increase when the call load increases. Out of this increase, some locums can be bought by physicians until another regular can be hired.
Obviously my bias is toward local programs and control rather than dependence on outside entities such as the state or hospital networks or the feds.
I do not think locums is always a problem:
Locums care over weekends by known physicians can be very helpful in shortage situations. The difference between being on call every 3rd weekend vs ever 4th is remarkable. Most newer graduates will not go to or stay in communities with more frequent call. Of course the call load often is determined by community factors such as whether the doctors come in to see patients when they are not on call. Communities where doctors work together and have trained patients to accept the doctors on call are likely to be much better at recruitment and retention.
Residents are ideal vehicles for locums coverage. They get to evaluate the community and rural practice. Low volume locations are a good way for residents to build confidence. Obviously they need some backup assistance until their experience grows.
For a Different Perspective in a Study, Seet Locum Tenens and Relief Models in New Mexico and North Carolina http://hsc.unm.edu/locum/article2.html
Locum Tenens – Pro and Con, An Outline
From the perspective of the practitioner
Cost
Utilization by patients
Depends on size, relationships, length of absence, and competition
From the perspective of the state or other potential sponsor
Desire to respond to cries for help from rural doctors
Desire to respond to surveys and political pressure from rural people, docs, med assoc.
Drawbacks, state is not willing to pay
May try to obligate state agency such as medical school or fp dept
From the perspective of those who might be willing to provide a service
FP Department or Residency Program
Avoid obligations that will make faculty life miserable
Don’t make promises that you cannot keep
Be sure residents or faculty doing locums have liability cover
Fellows can do some coverage (Maine program in past)
Hospital networks
Can be helpful, can negotiate for better costs,
Could provide coverage from within network
From persptective of FP Residents
Good experience
Make sure about backup
Added pay, make sure to withhold taxes to prevent nasty surprises
yes, it is expensive, but even more important, it is very difficult to replace the skill set at any price. Trauma, ortho, ICU/CCU skills and basic ob (much less high risk ob and c/sections) are often part of rural practice and finding a locums that can do it all is next to impossible in my previous remote rural practice experience. I am now on the faculty of Oregon Health Sciences University. I am working on the early stages of a locums program for the rural physicians of my state, trying to address these issues and would love to hear from anyone who has had any success in addressing the scope of practice issues I mentioned above.
Lisa Grill Dodson, MD
Director of Rural Programs
Department of Family Medicine
Oregon Health Sciences University
(503) 494-3986
dodsonli@ohsu.edu