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Locum Tenens:An Alternative Mode of Practice

Ethan Ruben, MD, FAAP Section on Administration and Practice Management Member

Are you ready to start practice but are unsure of the kind of practice or where? Are you in between positions or not quite ready to retire, but want an alternative to your current practice or location? Then consider becoming a locum tenens. Locum tenens is a Latin term that refers to the use of a substitute physician to replace physicians who must be absent from their practice because of vacation, continuing education, or illness. Most physicians are contract employees of the physician with whom they are working. In this situation, you will be an independent practitioner and paid by the hour, day, or week. A contract worker will have no payroll deductions for taxes, Social Security, and Medicare, and no retirement and medical benefits.

I sought locum tenens positions after closing an urban private practice and moving to rural Alabama. As it would have taken several years to build a new private practice, I took my first locum tenens position as a pediatrician at an Army hospital for 5 months. Since that time, I have worked in 5 states, including 2 placements with the Indian Health Service. Some of the benefits for my wife and me included the adventure of working in new areas with people of different cultures—the Navajo Nation in Arizona and the Choctaw Nation in Oklahoma. I was freed of the expense and responsibility of managing a private office while receiving an adequate income without having to see a very large number of children each day. Typical case loads in my positions were 20 to 30 patients per day.
 
Some positions require computer skills and knowledge of electronic medical records. However, the software is not uniform, so there may be a significant learning curve. Certification in Basic Life Support, Pediatric Advanced Life Support, and the Neonatal Resuscitation Program may be required. Some placements require you to be responsible for the actions of an advanced practice nurse. If you are to be covered by the client’s own liability insurance, there should be a “collaborative practice” agreement in the policy.
 
Advantages of locum tenens employment vary according to the stage of your career. If you are just completing training, you may be able to evaluate a practice before signing a contract for permanent or long-term employment. You may not have decided yet where you would like to live and work. A temporary position will not tie you to a long-term contract. For the physician considering semiretirement, there is the ability to choose his or her own schedule and location, and let the practice be responsible for employees and billing.
 
If the position is federal, including the Department of Defense or Indian Health Service, you will need a license in only one state. Non-governmental opportunities require a medical license for the specific state. Therefore, licensure in several states provides for additional practice opportunities. Your agency will be of considerable help in completing and expediting a licensure application, and may pay for it if you have already committed to the position. Your Drug Enforcement Administration certificate is valid for any state or territory, but you will need a separate controlled substance state certificate for any other position. Medical liability (malpractice) insurance is almost always provided by your agency. It may be an occurrence policy or a claims-made policy with an extended reporting endorsement (tail). In some situations, the client will cover you with its own policy. Be sure to keep documentation of coverage. United States government positions are covered under the Federal Torts Claims Act, in which the “defendant” is actually the US Government, which will appoint its own attorney for (your) defense.
 
How may you find a reputable agency? Many of the agencies also recruit for permanent positons. Begin with the National Association of Locum Tenens Organizations (http://www.nalto.org/). Its official publication, LocumLife, is free and available on the Internet at http://locumlife.modernmedicine.com/. The American Academy of Pediatrics also posts locum tenens positions at PedJobs. The National Association of Locum Tenens Organizations represents its member agencies and not necessarily the needs of its providers. Read announcements and classified advertisements in state medical publications and national journals such as Pediatrics and the New England Journal of Medicine. You also may wish to place your own classified ad in the state medical publications where you hold active licenses. “Googling” locum tenens and the location may provide positions and agencies servicing a specific area. There are dozens of reputable agencies, but get references for the agency and for prospective clients, especially if this will be a long-term placement. The same will be required of you, and most agencies will credential you using processes similar to that of hospitals and managed care organizations. Review any contracts carefully and, if there are questions and concerns, legal assistance should be sought.
 
There are disadvantages and even some hazards in accepting locum tenens. There are rules that are unique in working with these agencies, especially with government clients. Protect your professional reputation and your own ethical and moral principles. You can be terminated for just cause or, for that matter, if the client is not satisfied with you for any reason. If you are not a formal employee of a practice or agency, you are self-employed and must keep proper records of all income and deductable expenses and pay estimated taxes as necessary. Communicate only with your employing agency. This is especially important should you encounter a significant problem with the client. Do not terminate your position without proper notice.
 
Government positions require strict adherence to their own rules and standards. You may have unusually limited drug formularies, delay or outright refusal to approve consultations, or lack of continuity of care. Match your skills, experience, and emotions with the job. Document all of your actions to protect yourself from untrue charges, termination for cause, or loss of hospital privileges. Be careful in prescribing narcotics and other controlled drugs. Some patients will test the will of a new doctor in town and may be receiving prescriptions for more narcotics by their own physician than you would choose to provide. A careful history and physical, combined with a check with local pharmacies, may disclose narcotic prescriptions from several physicians at the same time.
 
Specific sources of information about locum tenens and the provider’s needs and point of view may be difficult to find in the pediatric literature, though there is one article in Pediatrics that may be of some interest:
 
Poole SR, et al. Pediatric locum tenens provided by an academic center. Pediatrics. 1996;98:403-409. Available at: http://pediatrics.aappublications.org/cgi/reprint/98/3/403.pdf. Accessed June 26, 2009
 
Additional information:
 

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