Maximizing the locum experience

In other countries

It is difficult to establish the precise number of locum physicians in the United States; estimates ranged anywhere from 4%⁴ to 36%⁵ of practising physicians for 2008. While there are groups of locum physicians at the start and end of their careers, similar to the situation in Canada, a growing number of physicians in the United States are choosing to do locum placements as a career.^5,6 In the past, locums in the United States were perceived to be physicians who were not suitable for permanent practice owing to competency issues or unwillingness to commit to permanent practice.^5,7 This perception is changing, however, likely in part because of the formalization and organization of locums.

To that end, most locum placements in the United States are organized through locum placement agencies.⁸ There are dozens of for-profit placement agencies matching locum physicians to assignments in what has grown to be a billion-dollar industry.⁸ These agencies typically review curriculum vitae, check references, and confirm appropriate licensing and credentials for the locum physicians they place.⁷ The advent of such a booming for-profit industry has led to the formation of the National Association of Locum Tenens Organizations,⁸ which sets standards of practice and codes of ethics for locum agencies, physicians, and hiring organizations.⁹ To our knowledge, no comparable standards have been set out for locum physicians in Canada by any of the medical associations or licensing bodies.

Data on locum demographic characteristics in the United Kingdom are more complicated to extract, as most research groups locums together with other GPs who work part time. The National Association of Sessional GPs¹⁰ in the United Kingdom reports that 25% of GPs work as locums; 60% of those who work as locums are between the ages of 30 and 39.^11,12 Similar to the Canadian situation, locums in Scotland¹³ are often at the beginning of their careers looking to gain experience or work part time to balance family commitments, or GPs at the end of their careers who want to work without the responsibility of full-time practice.

Locums in the United Kingdom tend to be more organized than they are in Canada, with an association that advocates on their behalf to improve access to continuing medical education and to promote appropriate working conditions.¹⁰ In particular, this group lobbies for reducing “enforced underperformance.” Essentially, this requires establishing the infrastructure so that locums can safely and optimally care for patients. This includes contracts that clearly articulate locum responsibilities, ensuring access to medical equipment, allowing adequate time to assess patients, and providing a “locum pack” (a standardized folder outlining office protocols and referral processes, resources, local hospitals, and lists of specialists). Locums have more channels to access placements through industry agencies in the United Kingdom and might be placed locally or travel extensively for positions.

Obligations

There have been calls for greater regulation of locums in the United Kingdom and Europe, driven by well-publicized cases of patients who were harmed by locum physicians, including the death of a patient in 2010 and cases where locums were found to have never undertaken medical training at all.^14,15 Recommendations include a centralized system for assessing competence and standardized review of locum references, licensing, and past training.^16–18 The potential for harm compels hiring physicians to carefully consider their professional and legal obligations to patients and to locums in the hiring process.

In Canada there is very little case law concerning the responsibilities of the hiring physician regarding any issues arising from the care of patients by a locum tenens during the hiring physician’s absence. A search for cases using the word locum resulted in 2 cases that were relevant but contradictory.^19,20

With such contradictory judgments, the onus must be on the hiring physician to ensure that the locum meets the standards of care, including being in good standing with the provincial College of Physicians and Surgeons, having liability insurance, and having references that attest to his or her clinical competence. The scope of practice during the hiring physician’s absence must be made clear, including all expectations for communicating results to patients and to the hiring physician, as well as the appropriate management of those results (eg, follow-up, referrals, treatments). This would be explained in an orientation to the practice, which would include direction about record keeping, office procedures, referral sources, and use of administrative staff.

To ensure this occurs, the legal department of the Ontario Medical Association advises that the locum and hiring physician sign a formal agreement before the start of the contract (such a contract is available from HealthForceOntario²¹). This agreement should clearly state the responsibilities of each party and clarify the relationship between them, including the purpose and term of the agreement, the obligations of the hiring physician, the locum physician’s duties, and the distribution of billings. The hope would be that fulfillment of the obligations in the comprehensive agreement would ensure that each party is protected in case of litigation.

Recommendations

With these contractual obligations in mind, the following recommendations for both hiring (Box 1) and locum (Box 2) physicians are meant to facilitate office-centred care. Similar to the pragmatic considerations covered elsewhere,²² this term covers the physician’s experience of returning to a well-ordered office, the locum’s experience of integration into the office team, the administrative and interprofessional staff’s experience of feeling assisted, and patients’ experience of and satisfaction with their care. A little work up front will improve the locum experience for all involved.