RESSOURCES
Practice Management

Locum tenens

Having a win-win experience

Joshua Tepper, MD

The literal translation of the Latin phrase locum tenens is “place holder.” Locum tenens physicians (locums) have always had an important place in the work force, and current physician shortages make it even more critical to understand their role.

Provision of locum coverage is one of the retention strategies for helping to keep physicians in rural communities. Locum coverage is often included in benefit packages for physicians and are a component of government retention programs.

For new physicians, locum placements offer important opportunities. They experience not just a variety of clinical settings, but also life in various communities. For well established physicians, doing locums can provide opportunities to explore new ways of practice, develop (or maintain) different skills, or help out colleagues. For some it could be the beginning of a shift toward retirement.

Because both incumbent physicians and locums can benefit, patient care is at stake, and it is important that the experience be positive. Clinical practices are complicated, varied, and highly personal entities and can pose challenges for both parties. Attention to some suggestions can help ensure successful experiences for all.

For incumbent physicians

• Review in detail with your locum cost-sharing arrangements, including all areas of potential income: fee-for-service, hospital work, emergency shifts, third-party payments, unlisted services, and on-call stipends. If a standard contract is being used as part of a provincial locum program, the physician and locum should review it together.
  While you want to cover costs, locum coverage should not be seen as a profit-making opportunity. You might consult colleagues or your provincial medical association about the nature of current cost-sharing arrangements. Be fair: you might wish for time off again, and it is nice to have a locum available who already knows your practice. Also consider hidden costs for your locum, such as travel, accommodation, hospital privileges, and licensing.
• Outline clinical expectations clearly, including home and nursing home visits and prenatal and obstetric care. Give some indication of clinical volume, keeping in mind that locums typically see fewer patients because patients will wait for you to return. While you could see 40 patients in a nursing home during a morning, a locum new to the setting might be able to see only half that number. Indicate your expected frequency of visits for patients like those in chronic care.
• If you have a particular procedure or area of specialty (vasectomies, trigger point injections), see whether your locum is willing to provide that service or inform your patients that it is unavailable.
• View your locum not just as a temporary service provider, but as the next potential recruit to the community. Inform your recruitment and retention committee about the locum’s arrival. Even if this locum does not move to your community, one of his or her colleagues might. A locum can be a community’s best reference during recruitment drives.
• Provide a list of the specialists and referral centres you usually use. Also highlight anyone you would prefer your locum avoids. Give guidance for referrals to the nearest hospital, computed tomography clinic, or tertiary care centre.
• Keep the forms required for referrals, diagnostic tests, and laboratory tests in an obvious place.
• Be sure the rest of your staff do not take the same vacation time as you. Simultaneously bringing in new doctors, nurses, and secretaries can lead to the blind leading the blind.
• Anticipate problems. Leave a list of patients you most dread seeing, patients with upcoming test results likely to be bad news, patients with narcotic contracts, and patients in acutely stressful situations. Even in a busy practice, this list should be less than 15 patients long, if well prioritized.
• Inform your colleagues, patients, and other health care workers in your practice, community, emergency room, and nursing home that you plan to have a locum. Give them the dates and arrangements you have made for service provision.
• Locums are people, too. I have heard many complaints about locums as uncommitted “fly-by-night” physicians. Most locums, like most established physicians, are deeply committed to patient care and willing to work hard to help your community.

For locums

• Read the above 10 points and make sure they have been covered.
• Make only commitments you can keep. Many urban (and rural) myths, with solid fact at their core, tell of locums who canceled at the last minute for more lucrative offers elsewhere or just a change of heart. The result is a stranded doctor with $5000 in airplane tickets and a family waiting to go on vacation.
• Be financially fair. In the current market, locums can sometimes drive hard bargains. While luxury rental cars and fancy resort accommodations are nice perks (and, sadly, often part of the negotiated package these days) for hard work, consider how you will be perceived by the local community and other physicians.
• Time your locums. In fee-for-service practices, it is important to keep busy. You will almost never be as busy as the regular doctor. When a doctor promises you will see 50 patients a day, remember you might see about a third fewer. Patients will cram in right before their doctor leaves and then wait until he or she returns. Think about starting your locum a few days after the doctor leaves and book more emergency shifts and nursing home visits toward the beginning and end.
• Leave the place tidy. Try to hunt down laboratory results, finish paperwork (including insurance forms), and clarify orders at the nursing station and the pharmacy.
• Flag disasters. If a patient stormed out swearing because you refused to give the “1000 Percocets” they “always” get from the doctor (but that did not seem to be documented anywhere), leave a note. Also note patients who died, received serious diagnoses, or were upset about other issues.
• Assess your skills fairly. If you are uncomfortable intubating patients or dealing with postpartum bleeding, do not sign up for emergency rooms with no anesthetist backup or offer to take obstetric call. Always raise these concerns with local physicians; they are often willing to provide backup.
• Check out the local resources. Most practices have a range of textbooks. If you have a favorite reference text, call ahead and see if they have it. Your call will save schlepping Harrison’s. In places with large hospitals, libraries are usually accessible 24 hours daily and have some lending flexibility. If you are doing a lot of locums, you might consider accessing resources on-line; most hospitals have Internet access.
• Speak no evil. Avoid negative comments about the practice or physician you are covering. Even offhand comments can damage local patient-physician relationships. Most physicians will prefer to hear your concerns directly from you—not from their patients.
• First do no harm. Be cautious about using your short stint to change the practice patterns of the office. While you might favour one medication or procedure over another, try to curb your personal preferences and reflect the practice of the physician you are covering. Of course you should never feel obliged to practise “bad” medicine, and you have the right to refuse to continue certain practices. Most physicians will appreciate a note in the chart suggesting a different option or approach.
• Make sure your Canadian Medical Protective Association coverage matches what you are doing as a locum, including surgical assists and emergency coverage.
• When you deal with large institutions, leave yourself several weeks for arranging local hospital privileges, getting letters from the College, and completing other inevitable paperwork.

Dr Tepper is a rural locum. He can recommend the best way to pack for 1 week in one knapsack. He can be reached at joshuatepper@hotmail.com.