Locum practice by recent family medicine graduates

ABSTRACT

OBJECTIVE

To explore the demographic characteristics of recent Alberta family medicine residency graduates choosing locum practice, as well as their reasons for choosing and leaving locum practice and the frustrations and rewards of locum placements.

DESIGN

Web-based and mailed cross-sectional survey and interviews.

SETTING

The family medicine residency training programs at the University of Calgary and the University of Alberta.

PARTICIPANTS

A total of 152 graduates who had completed family medicine training between 2001 and 2005, inclusive, and who had either done locums in the past or were doing locums at the time of the survey. Interviews were conducted with a subsample of this group (n = 10).

MAIN OUTCOME MEASURES

Duration of locum practice, reasons for choosing and leaving locum practice, and frustrations and rewards of locum practice.

RESULTS

Of the 377 graduates surveyed, 242 (64.2%) responded. Among the respondents, 155 (64.0%) had in the past practised or were at the time practising as locum physicians (complete data were available for 152 respondents). Most (71.7%) had arranged locum placements independently. The average duration of a locum placement was 9.1 months. Female and younger family physicians were more likely to practise as locum tenentes. The most common reason for doing a locum placement was as a practice exploration to increase experience or competence (46.7%). 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. Locum tenentes were frustrated with negotiating locum contracts, low patient volumes, lack of patient continuity, and working with difficult staff. Rewards of locum practice included flexibility and freedom in practice, gaining experience, and the rewards that come from seeing patients. In total, 44.6% of family medicine graduates joined practices in which they had done locum placements.

CONCLUSION

Locum practice is a common early career choice for Alberta family medicine graduates. The most common reason for doing a locum placement was to gain experience, not to delay commitment. Locum practice tends to appeal more to female and younger family physicians. Rewards of locum practice were also cited as reasons for participation. Locum tenentes tend to be frustrated with the business aspects of arranging placements and with the generally low patient volumes. Long-term recruitment efforts by community physicians should be initiated within the first week of locum engagement.

A locum service physician has been defined as a “healthcare provider who is serving as a temporary relief or substitute.”¹ Locum placement as a career choice has increased considerably worldwide during the past decade,^2–4 yet little is known about this pattern of practice. As far back as 1985, many (41%) family medicine graduates were choosing locum practice.⁵ According to the 2007 National Physician Survey, 58% of graduates intended to practise as locum tenentes in the first 2 to 3 years of practice.⁶ While the use of locum physicians is widely acknowledged as a potential strategy to recruit physicians to underserviced areas, some communities and practising doctors remain frustrated by such new graduates’ delay to commit to established practices and interpret this as the “disappearance” of new graduates into this style of practice.

The literature surrounding locum tenentes is not robust, but it can be grouped into 3 broad categories: personal anecdotes by physicians working as locum tenentes^7–11; descriptions of locum programs^12–16; and studies examining the motivations for choosing locum practice.^17–19 Locum services have often been described from a British or American perspective, and to date only one paper has characterized the Canadian locum practice experience.¹⁸ Godwin and colleagues¹⁸ identified a negative trend of committing to practices in physicians graduating after 1985.

Knowledge of who chooses to do locum placements after graduating from family medicine residency, why it is seen as an attractive career option, and the characteristics of this type of practice are of policy and planning relevance. In order to further advance our understanding in this area, we examined locum practice by recent family medicine graduates in Alberta. The objectives of the study were to describe the demographic characteristics of family medicine residency graduates who chose locum practice; to examine the extent (number and duration) of family medicine locum activities by age and sex; to ascertain reasons for choosing to do locums and for leaving locum practice; and to identify the rewards and frustrations of locum practice experienced by family medicine graduates.

METHODS

Both quantitative (survey) and qualitative (interviews) research methods were employed to explore locum practice patterns and experiences.

Survey

A cross-sectional survey was conducted among family medicine graduates from the University of Alberta and the University of Calgary who had completed their residency programs during the years 2001 to 2005, inclusive. The survey mailings began November 1, 2006, and responses were received until May 31, 2007. A Web-based version of the survey was also available. The population surveyed included all graduates who were in the 2-year family medicine programs, as well as those who completed third-year additional skills training. The final sample included 377 graduates who were either mailed or faxed the survey.

The questionnaire was based on previous questionnaires used to survey the 1985 to 1995 and 1996 to 2000 Alberta family medicine graduates. The questionnaire addressed 6 main areas: medical education; career history (clinical and nonclinical activities, current practice, practice location); community involvement; intimidation, harassment, and discrimination; family medicine program evaluation; and demographics. This locum analysis is a subset of the larger study. The survey questions related to locum practice are outlined in Box 1.

Box 1. Survey questions related to locum practice.

What was your main reason for doing a locum? (Check only one) □ To gain experience or increase competence □ To shop for practices □ To allow lifestyle options (eg, travel, time off) □ To increase earning power □ To delay commitment to a specific practice □ To delay commitment to commence practice □ To allow for spouse’s career or education □ Other (specify): ________________________________ What was your main reason for leaving locum style of practice? (Check only one) □ Style did not fit with personal philosophy of family medicine □ Career choice of spouse or partner □ Settled into a practice □ Less need for higher income □ Exhaustion □ Other (specify): ________________________________ □ Not applicable: currently in locum practice Did you do locum(s) in addition to full-time practice at another location? □ Yes □ No Did you choose to settle in a practice in which you had done a locum? □ Yes □ No □ Not yet settled in a practice While doing locums, how long did it usually take to “understand” a practice in order to determine if it was a practice option for you? □ First day □ Within the first week □ Within the first month □ Within the first 6 months □ More than 6 months How did you arrange your locum(s)? □ Independently □ Through a locum program □ Both independently and locum program

Data were analyzed using descriptive and χ² statistics. Mean number of locum placements and locum duration were examined according to age and sex using ANOVA (analysis of variance). An α level of .05 was used to test for statistical significance.

The survey was pilot-tested by graduates who were not included in the study sample (7 graduates completed the hard-copy version, and 4 graduates completed the Web-based version).

Interviews

As part of the survey, graduates were asked if they would be willing to be contacted to take part in focus groups or interviews. Those who indicated that they would be willing and who had also done or were doing locum placements formed the sampling frame for the qualitative part of the study. Given the varied geographic locations of participants, telephone interviews were conducted between May and September of 2007. Those who agreed to be interviewed and provided written consent were included in this phase of the study.

The interview questions on locum practice addressed when the decision was made to do locum placements, the reasons for choosing and leaving locum practice, and the rewards and frustrations of locum practice (Box 2). The telephone interviews were conducted by a third-party interviewer who was not connected in any way to either of the residency programs. The interviews were audiotaped and transcribed. There were not enough graduates doing locums who agreed to be interviewed to reach the saturation necessary to carry out a thematic analysis of the data. Consequently, the researchers approached the data from a descriptive perspective. The qualitative interview findings supplemented the quantitative findings from the survey.

Box 2. Interview questions related to locum practice.

After completing the residency program, how prepared did you feel for doing locums?

At what stage in your training or career did you decide you would do locums?

Probes

• At what point during the residency program did you decide you would do locums?

• If you decided to do locums after completing the residency program, exactly when did you decide?

• What were the key reasons for choosing to do locums right after graduation?

Are you currently doing locums?

Probes

• If no, what were the key reasons for leaving locum style of practice?

• If yes, what key reasons have led you to continue in the locum style of practice?

What were the characteristics of the practices that you prefer or preferred to do locums in?

Probes

• Did you choose locum practices that excluded certain areas of family practice?

• How long did it take to understand a practice while doing a locum in order to determine if it was a practice option for you?

What rewards have you experienced in practice?

Probe

• What are the unexpected advantages or benefits of doing locums?

What frustrations have you experienced in practice?

Probe

• What are the unexpected drawbacks or disadvantages of doing locums?

How does the remuneration in practice compare with what you expected?

If currently doing locums, how long do you plan to continue doing locums?

If not currently doing locums, do you plan to return to a locum style of practice?

This study was approved by the Health Research Ethics Board (Health Panel) of the University of Alberta and the Conjoint Health Research Ethics Board of the University of Calgary.

RESULTS

Survey results

Of the 377 graduates who completed family medicine training between 2001 and 2005, 242 (64.2%) responded to the survey. Of the respondents, 155 (64.0%) had either done locum placements previously or were doing locum placements at the time of the survey. Complete demographic (sex, age) and locum (number and duration of locums) data were available for 152 (62.8%) respondents. The age and sex distributions of the 152 respondents are noted in Table 1. Proportionately, a significantly greater percentage of female (73.2%) than male (53.6%) physicians did locum placements (P < .002).

Table 1.

Characteristics of locum physicians: N = 152.

DEMOGRAPHIC CHARACTERISTICS	N (%)
Sex
• Male	59 (38.8)
• Female	93 (61.2)
Age group
• Younger (< 35 y)	96 (63.2)
• Older (≥ 35 y)	56 (36.8)

The 152 family medicine graduates reported a total of 243 separate locum placements. The mean (SD) number of locum placements was 1.6 (0.9) and the mean (SD) duration of each was 9.1 (10.5) months. The average (SD) total amount of locum time reported by the 152 physicians was 14.5 (13.9) months. Physicians who practised as locum tenentes were less likely (P < .01) to do third-year additional skills training (15.2%) compared with those who did not (32.5%).

The age range of the 152 respondents who did locum placements was 28 to 49 years, with a mean (SD) age of 34.6 (4.5) years. There was no significant difference in age between female (mean age 35.1 years) and male respondents (mean age 33.9 years). Age was classified into younger (< 35 years) and older (≥ 35 years) categories. A greater proportion of younger physicians (73.3%) compared with older physicians (53.3%) did locum placements (P < .002). These results cannot be explained by sex differences, as the proportion of male and female respondents in the younger age group was similar. A 2-factor ANOVA (sex by age) was performed, with number of locums and duration (in months) of locum placement as dependent variables. This analysis permitted the examination of not only the main effects, but also the possibility of a simultaneous interaction effect. Results revealed no significant interaction or main effects. There was no significant difference in the mean (SD) number of locums done by male (1.5 [1.0]) and female (1.6 [0.8]) or younger (1.7 [0.9]) and older (1.4 [0.9]) respondents. There was also no significant difference in the mean (SD) duration of locum time for male (12.0 [10.5]) and female (16.0 [15.6]) or younger (14.1 [13.2]) and older (14.0 [15.2]) physicians.

Most (71.7%) respondents arranged locums without access to locum service providers, and nearly half (48.7%) indicated that they could tell within the first week whether their locum placements were suitable practice options for them. One-quarter (24.3%) of the locum respondents indicated that they did locums in addition to full-time practice. Among those who joined practices after doing locum placements, 44.6% joined practices where they had done placements.

Interview findings

A total of 10 survey respondents agreed to be interviewed. Participants noted that, while the actual timing of the decision to do locum placements varied, it tended to be made toward the middle or end of residency training.

Seventy-one (46.7%) of the 152 survey respondents indicated that the main reason for choosing locum practice was to increase experience or competence (Table 2). Secondary reasons included allowing for lifestyle options and delaying commitment to a specific practice. The interview findings were consistent with the survey findings. Three reasons for doing locum placements emerged from the interviews: flexibility, exploration of practice (location, business aspects, networking), and gaining clinical experience.

Table 2.

Main reason for doing a locum: N = 152.

REASONS	N (%)
To gain experience and increase competence	71 (46.7)
To allow lifestyle options (eg, travel, time off)	29 (19.1)
To delay commitment to a specific practice	19 (12.5)
To shop for practices	11 (7.2)
To increase earning power	6 (3.9)
Other	10 (6.6)
No response	6 (3.9)

Graduates said they chose the locum style of practice for the flexibility that it afforded (ie, flexibility of time, flexibility to accommodate family and lifestyle, and flexibility to change practice whenever one desires because there is no commitment to a particular practice).

[Y]ou can set your own hours …. You’re not tied down to a clinic ... and tied to an overhead that you have to pay … if you want to take time away from the practice.

[I]t’s a lot less hassles; you don’t worry about the business … [you] mostly just concentrate on your practice.

[T]hen I had my daughter; it worked out well that being a locum has given me more flexibility. And I’m actually a permanent part-time locum … I just work 2 days a week.

Moreover, locum practice allowed for exploration of practice types and business styles, and offered opportunities for networking:

I wanted to see how other family doctors ran their practices before I decided to set up my own.

[I became a locum tenens] for 2 main reasons: [first] because I had no idea how to run a practice and [second] because it gave me a more detailed exposure to how people individually are doing it.

Gaining experience, especially in areas graduates did not feel confident in, was identified as a third reason for choosing locums:

I intended to go into full-time or part-time family practice. You know with my own office and then the other days I’ll just work everywhere to gain experience … [in areas I do not feel] quite confident in.

While the survey findings revealed that the primary reason for leaving a locum (52.1%) was to settle into permanent practice (Table 3), interview findings provided more in-depth insight into the reasons for leaving locum practice. Five areas were described as reasons for leaving locum practice: desire for stability, end of the need to explore practice options, desire for continuity with patients, personal life stage, and financial reasons.

I would settle down into one location so that my life were more predictable.

I found a practice that suited ... how I wanted to build my practice; so then I had an opportunity to join the practice so I just did.

Table 3.

Main reason for leaving locum style of practice: N = 117.^*

REASONS	N (%)
Settled into a practice	61 (52.1)
Style did not fit with personal philosophy of family medicine	18 (15.4)
Career choice of spouse or partner	9 (7.7)
Exhaustion	5 (4.3)
Other	12 (10.3)
No response	12 (10.3)

^*35 respondents were still in locum practice at the time of the survey.

Data available only from the interviews revealed that graduates experienced frustrations in locum practice in 4 areas: exploration of practice style, flexibility, continuity, and expectations or ability to cope with the reality of practice. In terms of the business side of locum practice, respondents conveyed the following challenges:

It’s just frustrating to have to negotiate your terms every month.

Setting up contracts and things can be frustrating, and some of the physicians can be not understanding or angry about things that you have in your contract.

From a practice perspective, low patient volume was expressed as a concern for some locum tenentes.

[S]ometimes because you’re the locum ... patients don’t want to come see you, and so you’re not terribly busy and you may have driven, you know, a distance to go do this locum and then find out that you’ve got 5 patients and, you know, you twiddle your thumbs and wait for your time.

[I]f you do a short locum, you don’t get the same volume of patients. If their doctor is only leaving for 2 weeks, some patients will just wait for them to come back.

Locum tenentes also expressed frustration over the lack of patient continuity in locum practice:

[It is frustrating] not being able to follow up … you start all these tests rolling and then you never necessarily know how they end up. So you don’t get to follow people longitudinally, which has its pros, but it also has its cons ’cause you don’t get to learn from, you know, what happens.

Being accepted by the practice and working with difficult staff was also an issue.

I found that sometimes ... [as far as the staff were concerned] you’d be kind of the last … on the list if you needed something done—[for example] if you need an urgent ultrasound, you know, if they were doing something for somebody else. So I guess sometimes respect in the office sometimes can be—from the staff—can be a problem.

Interviewees described the rewards of locum practice as being similar to the reasons for choosing to do locum placements: flexibility, exploration of practice style, gaining clinical experience, financial benefits, and achievement and enjoyment of the professional role.

It’s also good when you’re a new doctor to learn who the good specialists are in town, and you can ask … who they normally refer to and that kind of thing. It helps you to get to know the community.

The rewards just come from your patients … expressions of their appreciation and the fact that sometimes you feel like you actually did make a difference.

One graduate summarized the locum experience in the following way: “I thought I learned a lot. I earned a lot of money, and I met a lot of people.”

DISCUSSION

This is the first study to define a subset of the locum pattern of practice by family physicians in Alberta. A key strength of the study is the use of both quantitative and qualitative research methodologies.

The study findings substantiate previously noted sex differences in locum practice³ (ie, females chose locum practice at a much higher rate than their male colleagues do). Irrespective of sex, family physicians who did locum placements averaged slightly more than a year in this style of practice.

Our findings also revealed that, proportionately, more younger physicians tend to choose to practise as locum tenentes and that the decision to do locum placements tends to be made during the second year of residency training. During training, efforts to recruit residents into locum practice should focus on younger residents. Older residents appear to be more amenable to recruitment into permanent practice at the same stage of their training. Although proportionately more physicians in the younger age group chose locum practice, interestingly, among the group of physicians that did locum placements there were no statistical differences in the mean number of locums done or the duration of locum time according to sex or age. This suggests that efforts aimed at recruiting locum physicians into permanent practice should be broadly based and not preferentially targeted to either age group. All efforts targeted at recruiting second-year residents into permanent practice should include a willingness to mentor and nurture these new graduates as they establish their own practices.

Most (71.7%) family medicine graduates arranged their own locum placements, independent of placement services. Only 12 respondents exclusively used locum services, indicating that overall there seems to be poor use of locum service providers in Alberta by family medicine graduates seeking locum placements. On the other hand, many practices do use these programs to secure locum physicians. This suggests a definite disconnect between those seeking locum physicians and recent graduates who are contemplating locum practice. Strategies to align the efforts of both groups would appear to be sensible.

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 as the main reasons for recent family medicine graduates choosing to do locum placements. The questionnaire design was such that it was not possible to distinguish between gaining experience and gaining confidence; however, there is some indication from interview data that gaining confidence through locum practice should be explored further. It might be inferred that some graduates who did not do locum placements might have satisfied their need for more experience through formal additional skills training, but specific inquiry into this area is necessary.

After just over a year, family physicians in this study predominantly left locum practice in order to establish conventional practices. Therefore, while these graduates are delaying their commitment to settle into practice, they are not necessarily “disappearing” into permanent locum practice. The reasons for initially choosing locum placements and the reasons for leaving appear to be opposites of the same domain: while the flexibility that locum practice can provide is initially attractive, after some time the desire or need for stability appears to take priority.

Although locum placements remain a valuable practice recruitment strategy for communities, our data reveal that the window of opportunity is narrow. Regardless of locum duration, about half of the respondents decided within the first week of the locum whether or not that practice was a potential permanent location. This narrow window of career-shaping opportunity is a reality that communities and practices should address in their planning, policies, and practices. It would appear that recruitment efforts should be concentrated in the first week of locum placements, as our findings indicate that locum physicians tend to make early judgments about practice suitability.

Family physicians early in conventional, full-time practice might also do locum placements. One-quarter of the respondents indicated that they performed locums in addition to full-time practice. While the reasons for this “dual track” practice activity are not clear, our interview data suggest that, for some, dual tracking might allow physicians to increase income while waiting for their own practices to fill. Dual track practices are a professional practice option that could be promoted. They are one seemingly underexplored option for physician recruitment or service provision in underserviced communities. Further scholarly exploration of this is warranted.

The rewards of locum practice appear to be similar to the reasons for choosing locum practice: gaining experience and flexibility. Frustrations specific to locum practice seem to be related to negotiating contracts, low patient volumes, and difficult staff interactions. Family physicians seeking locum tenentes can alleviate some of these frustrations by making locum physicians feel welcome in their practices and encouraging patients and staff to book appointments with the locum tenentes to keep them busy.

Limitations

The survey has limitations, including those traditionally associated with cross-sectional survey methodologies. These limitations were addressed to some degree by data from the interview findings. Although the study questionnaire did not provide definitions for each of the locum variables and each respondent could have interpreted the factors differently, the interview findings did provide a more in-depth assessment of the reasons for choosing and leaving locum practice. For example, interview data made a distinction between gaining clinical experience and exploring the business aspects of practice as reasons to do locum placements. Similarly, while the survey did not inquire about physician confidence as a distinct entity from physician competence, gaining confidence did emerge from the interview data as a reason for choosing locum practice. The interviews were limited by the small number of participants; therefore, the full range of responses might not have emerged and some themes might not have been identified. Moreover, primarily female respondents agreed to take part in the interviews; thus, male locum tenentes’ perspectives might not be accurately reflected in the interview data. Additionally, the dual track physicians might actually have been referring to weekend locum placements and not to the longer type of locum practice, which was the focus of this study. The study is limited to relatively new family medicine graduates and does not account for family physicians who choose locum practice later on in their careers.

This study is a first step in describing locum activities in Alberta. Much remains to be learned, and future research should replicate our study in other jurisdictions or programs in Canada and other countries; examine dual track practice; explore the topic of gaining confidence versus gaining clinical competence through locum placements; assess the use of locum placement services; and identify factors affecting decision making in the first week of the locum placement.

Conclusion

Locum practice is a common early career choice for Alberta family medicine graduates. The locum style of practice tends to appeal more to women than to men and more to younger physicians. The decision to do locum placements tends to be made during the second year of training. While the desire to gain experience and flexibility are reasons for doing locums, a desire for stability and the end of exploration of practice styles are reasons for leaving locum practice. Locum physicians tend to make early judgments about practice suitability, which suggests that practice recruitment efforts by the community should be solidly conceptualized and immediately implemented. The study findings are relevant to organizations and individuals who are working toward increasing family medicine capacity in Canada.

EDITOR’S KEY POINTS

• Locum placement has become an increasingly common career choice worldwide during the past decade. This study used a survey and interviews to explore locum practice patterns and experiences among recent family medicine graduates.

• In this study, proportionately more younger physicians tended to choose to practise as locum tenentes. The decision to do locum placements tended to be made during the second year of residency training.

• Most family medicine graduates arranged their own locum placements without assistance from placement services.

• Financial considerations do not appear to play a large role in the motivation for working as a locum tenens. Both the survey findings and interviews consistently identified gaining (clinical and business) experience and flexibility as the main reasons for recent family medicine graduates choosing to do locum placements.

POINTS DE REPÈRE DU RÉDACTEUR

• Au cours de la dernière décennie, la suppléance est devenue un choix de carrière de plus en plus fréquent à travers le monde. Dans cette étude, on a utilisé une enquête et des entrevues pour examiner la façon dont les médecins de famille récemment diplômés font de la suppléance ainsi que leur expérience de cette pratique.

• Cette étude indique qu’un nombre proportionnellement plus élevé de jeunes médecins ont tendance à opter pour la suppléance. Cela était le plus souvent décidé durant le deuxième année de résidence.

• La plupart des diplômés de médecine familiale ont déterminé eux-mêmes leur lieu de suppléance, sans recourir aux services de placement.

• Les considérations financières ne semblent pas être un facteur de motivation important pour choisir la suppléance. Les données de l’enquête et des entrevues indiquaient généralement que les principales raisons pour lesquelles les médecins de famille récemment diplômés choisissaient de faire de la suppléance étaient la flexibilité et l’acquisition d’expérience (clinique et des affaires).