EXECUTIVE SUMMARY

The objective of this study was to provide a profile of locum tenens providers and their motivation for choosing this practice pattern. The research design used was a cross-sectional mailed survey questionnaire. Participants included the 1,662 physicians who accepted at least one locum tenens assignment in 2001 from one physician staffing service. They were asked to complete a 50-element questionnaire; 776 (47 percent) responded.

The average age of respondents was 53.0 years. Men represented 70.3 percent of the sample and were significantly older (56.3 years) than women providers who responded (45.3 years). One-third considered a locum tenens practice pattern permanent. Primary care locums were younger than specialists and subspecialists. Female providers were disproportionately practicing in primary care specialties (43.9 percent); 64 percent used locum income as their sole source of support and were frequently (31 percent) motivated by a need for a flexible work schedule. Male forum physicians were weighted toward the subspecialties and were motivated mostly (62 percent) by a desire to continue to practice part time. They used locum income as a secondary means of support (33 percent) or to augment pension and retirement resources (38 percent).

A physician workforce from most major specialties and subspecialties and all age groups and career stages fulfills career and economic goals by working in a short-term, temporary employment pattern. Locum tenens appeals to physician providers who desire a healthier, more controllable lifestyle.

**********

The training and distribution of physician healthcare providers have historically been unresponsive to an equitable and need-based distribution (Starr 1982). Traditional methods of allocating physician providers, staffing practices, and practice coverage--family ties, informal "cross-coverage" arrangements, inter- and intrainstitutional referral, and advertising--have often proved to be inadequate in an era of multispecialty and multisite practices. Regardless of whether the physician is a solo practitioner or a group-practice member, vacations are taken, illness occurs, continuing education is a necessity, practices grow, and providers retire. One partial solution to providing coverage for these needs is the rapidly expanding temporary physician staffing system or locum tenens (LT).

The term locum tenens is literally translated from Latin as "one holding a place." Historically, LT was used principally in British medicine to designate a substitute physician. However, as applied in the United States, it has come to mean any temporarily employed physician. In addition to serving as temporary replacements, LT physicians have also been widely used during recruiting or practice expansion. While the literature from the Commonwealth of Nations (formerly known as the British Commonwealth) has focused on the more traditional use of such physicians in family practice settings (Morgan, McKevitt, and Hudson 2000; McKevitt, Morgan, and Hudson 1999; Godwin et al. 1998; Hoyal 1998), reports in the American literature have usually addressed their use in a single specialty (Lalman et al. 1998) or as part of a physician training program (Poole et al. 1996; Larsen et al. 1999). Sporadic attention has also been paid in the lay press (Kaufman 2001), business periodicals (Thompson 2000), and regional medical publications (Rodawig 1993; Bedell 1992).

Physicians secure temporary positions by three principal methods: (1) arranging a position through their personal contacts or traditional advertising, (2) as a temporary salaried employee of a hospital or healthcare network, or (3) periodic assignments arranged by a physician staffing service. The exact size of these three networks is unknown. Currently, at least 25 placement agencies nationally are regularly engaged in LT placement (NALTO 2004).

To date, no study has been published on the general temporary physician staffing industry, nor on the motives and goals of LT physicians. The purpose of this study is to provide a descriptive analysis of who becomes an LT provider, why LT is done, and how physicians use LT income.

METHODS

A 50-item multiple-choice questionnaire was mailed to 1,662 physicians who worked at least one LT assignment from one placement agency, Salt Lake City-based CompHealth, during the period January 1, 2001 to December 31, 2001. For the purpose of this study, an LT physician provider is defined as a contingent physician contracted to provide stipulated clinical services within a specified healthcare setting for a defined period of time without obligation for permanent placement.

The questionnaire was reviewed and approved by the Ohio State University Institutional Review Board (Protocol Number 02E0160). The questionnaire was mailed on May 1, 2002, and all forms returned by June 29, 2002 were included in the study. Participation was voluntary, and questionnaires were returned anonymously. The questionnaire covered the following three principal areas:

1. Basic and medical-career demographic variables: age, gender, marital status, medical specialty, board certification, and time in practice

2. Placement, economic, and professional variables: length of time performing LT services, frequency and duration of LT assignments, number of LT placement agencies used, frequency of use of nonagency employment, importance of income derived from LT assignments as a means of support, and plans for future LT placement

3. Experience and level of satisfaction with the unique demands of LT work: housing, remuneration, transportation, licensure, hospital privileging, and working conditions

The first two areas are the focus of this analysis. For analysis purposes, the respondents' practice specialties were divided into primary care, specialty care, and subspecialty care categories. These categories were developed based primarily on duration of training and narrowness of practice scope. The primary care specialties studied were family practice, pediatrics, and internal medicine. The specialty group included emergency medicine, radiology, general surgery, dermatology, obstetrics and gynecology, psychiatry, pathology, urology, anesthesiology, and neurology. The subspecialty category included all of the internal medicine subspecialties (e.g., cardiology, gastroenterology), radiation oncology, neonatology, and orthopedic and cardiovascular surgery.

In addition, physicians were grouped into career stages based on the number of years they had been in practice. Early-career physicians had completed training within the previous three years. Middle-career physicians had completed training more than three years earlier but were neither retired nor semiretired. Mature career physicians considered themselves semiretired or retired when they began accepting LT assignments.

In terms of the response rate to the present survey, 776 (46.7 percent) of the 1,662 surveys were returned in the time specified. Women were significantly more likely to return the survey than men (53.1 percent versus 44.3 percent, chi sq=10.09, df=l, p<.01). In terms of age, older providers (>54 years) were significantly more likely to respond than younger ones (<55 years) (38.8 percent versus 59.7 percent, chi sq=68.0, df=l, p<.001). The level of specialty training also affected the response rate, with primary care providers being more likely to respond than subspecialty providers (50.1 percent versus 40.9 percent, chi sq=7.31, df=2, p<.05). In general, the bias of the respondents was toward older physicians, female providers, and primary care providers. Overall, the LT staffing industry is basically proprietary and highly competitive (Maniscalco 2003), making it difficult, therefore, to determine the exact sampling frame for this study. However, as most LT placements occur through national agencies (Maniscalco 2003) and CompHealth is the primary LT placement agency in the United States and lists the availability of physician providers from almost all medical specialties, we assume that our sample is representative of temporary staffing services in general but not necessarily representative of smaller, specialized agencies. All analyses were completed using SPSS 12.0.

RESULTS

Demographic Findings

The survey was mailed to 1,662 physicians, and 776 (46.7 percent) returned the questionnaire. The mean age of the respondents was 53.0 years, and the age range was 28 to 83 years. Men represented 70.3 percent (544) of the sample and averaged 56.3 years of age. Men were significantly older than women, who comprised 29.7 percent (230) of the sample and averaged 45.3 years of age (t=10.91, df=770, p<.001). On average, physicians in this sample had been practicing 22.6 years, and men, as might be expected, had been practicing significantly longer than women (26.4 versus 13.6 years; t=11.48, df=766, p<.001).

Seventy percent (545) of subjects were married or in a long-term relationship, 20.4 percent (158) were unmarried, and 8.9 percent (69) were either widowed or divorced. Because LT assignments may require travel out of town, subjects were asked whether they had dependents. Of the total sample, 27.6 percent (213) reported having either a dependent child(ren) or parent(s) in the home; men were significantly more likely to have dependents (29.7 percent [161] versus 22.7 percent [52]; chi sq=3.94, df=1, p<.05). These findings were primarily the result of the relatively young age of the female respondents, because controlling for age by using a median-age split demonstrated that among older providers (>54 years), both men and women were equally likely to report dependents (16.4 percent versus 16.7 percent for men and women respectively; p

The distribution of physicians by specialty across selected demographic and professional variables is shown in Table 1. Primary care LT physicians comprised 26.9 percent (209) of the sample, specialists comprised 53.2 percent (413), and subspecialists comprised 19.8 percent (154). Primary care physicians were significantly younger (44.6 years; p=.001) than either specialists or subspecialists (55.9 years and 56.9 years, respectively). As can be seen in Table 1, women were significantly (chi sq=57.05, df=2, p<.001) more likely to be primary care providers than men and were less likely to be subspecialists. Controlling for age, younger (<54 years) female LT providers were predominantly and significantly (p=.001) in primary care in contrast to their male counterparts (52.7 percent versus 31.4 percent). Among older providers (>55 years), gender differences were evident, with women predominating in specialty care (76.2 percent versus 60.5 percent) and men predominating in primary care (12.0 percent versus 7.1 percent) and subspecialty care (27.5 percent versus 16.7 percent); however, these differences were not significant (p=.14). The proportion of providers who reported being board certified in their specialty was 86.3 percent (664), with men (87.5 percent [474]) and women (83.7 percent [190]) reporting almost equal certification. Related to specialty and age, Table 1 shows that 14.1 percent (108) of LT providers had been in practice less than three years, while 39.2 percent (301) had been in practice more than 30 years. Women, because of their younger age, had been practicing for significantly fewer years than men (13.6 versus 26.4 years, t=11.48, df=766, p<.001).

Professional demographic characteristics and comparison to active U.S. physicians

A common theme in the limited LT literature is that expanding opportunities for LT providers reflect changes in the American healthcare system brought about by both restructuring and demographic changes of medical school graduates (Dorsey, Jarjoura, and Rutecki 2003; Newton and Grayson 2003). With this in mind, the LT respondents in the present analysis were compared in terms of age, gender, and specialty with the active U.S. physician population. Data for these comparisons were obtained from the American Medical Association (AMA 2002-2003), the U.S. Census Bureau (2002), the U.S. Bureau of Labor Statistics (2002), and the U.S. Department of Health and Human Services (2001).

The median age of active U.S. physicians was 46 years, but it was 53 years for the LT sample. Women accounted for 30 percent of the LT group but accounted for only 23 percent of active U.S. physicians. Women accounted for 43 percent of the LT group older than 54 years of age but accounted for only 30 percent of the active U.S. physician population in this age group. Small gender differences were found for those participants older than 54 years of age: 41 percent of the women were in primary care, compared with only 19 percent of the men. While the percentage of primary care LT providers (27 percent) was similar to the U.S. physician population (26-34 percent; see Table 2A), selected specialties (radiology, radiation oncology, pathology, emergency medicine, and psychiatry) were disproportionately overrepresented in the LT sample (see Table 2B). Selected specialties and subspecialties were employed less frequently or not at all in the LT group (e.g., nuclear medicine, allergy and immunology, plastic and reconstructive surgery, aerospace medicine, public health, ophthalmology). While 85 percent of the LT sample was board certified, only 65.2 percent of the U.S. active physician group was board certified (AMA 2002-2003). These differences may reflect shortages in specific provider specialties regionally and nationally (Faries 1999). Board certification provides employers with one objective measure of training and competence.

Locum Tenens Career Decisions

How the work of locum tenens fits into a physician's career was an important consideration. Among 15.6 percent (119) of respondents, LT assignment was their first position following residency training. Respondents also began accepting LT assignments during a career transition (29.9 percent) or when they considered themselves to be semiretired (30.1 percent) or retired (11.6 percent). Less frequently, they began LT assignments during or after military service (2.9 percent and 2.5 percent, respectively) or early (<3 years) in their careers (8.5 percent). The primary reason respondents began accepting LT assignments was a desire to practice on a part-time basis (31.5 percent), followed by a desire for flexibility in work schedule (21.1 percent), to increase income (15.5 percent), to travel (9.5 percent), to experience a different practice setting (8.3 percent), to be free from administrative responsibilities (2.9 percent), and other reasons (11.9 percent). The dominant reason for accepting LT assignments among older (>54 years) providers was a desire to practice on a part-time basis (58.1 percent), whereas for younger providers it was a desire for flexibility (31.1 percent), followed by a need for income (19.9 percent). Among women, a desire for practice flexibility (36.7 percent, n = 83) was the dominant reason for taking LT assignments, whereas for men, it was a desire to practice part time (38.4 percent, n = 208).

Income and preferred locum tenens assignments

Providers were asked where LT-derived income fit into their income in general. While only 15.5 percent of respondents selected income as their primary reason for accepting LT assignments, LT income was the main source of income for 39.4 percent (300) of respondents, a secondary source of income for 31.2 percent (238), and a complement to retirement income for 28.9 percent (224). Female providers were significantly more likely to indicate that LT income was the principal source of income, in contrast to male providers (63.9 percent [145] versus 29.1 percent [155], chi sq=92.33, df=2, p<.001). Male providers principally used LT work as a secondary income source (33.4 percent) or to augment retirement income sources (37.5 percent). As might be expected, LT income was a primary income source for younger providers (56.5 percent [226]) and a supplement to retirement income for older providers (58.3 percent [210]). Among primary care providers, LT income was the main source of income for 61.5 percent (126), whereas for specialists and subspecialists, the dominant use of LT income was more likely to be as a secondary source of income or to supplement retirement income (chi sq=70.01, df=4, p<.001).

LT providers were asked what was their most desired practice setting. For 39.4 percent (304) of respondents, the practice setting did not matter. Among providers for whom it did matter (60.6 percent [469]), the most desired setting was the hospital (42.2 percent [198]), followed by a clinic (31.6 percent [148]), a single specialty group practice (17.3 percent [81]), and a multispecialty group practice (9.0 percent [42]). Men were significantly more likely to prefer hospital settings than women (34.8 percent [54] versus 45.8 percent [143], p.<.05). Women expressed a preference for clinic settings in contrast to men (36.8 percent [57] versus 28.8 percent [90], p<.05). As might be expected, specialists and subspecialists were significantly more likely to express a preference for practicing in a hospital than primary care providers (42.3 percent [30], 56.6 percent [150], 13.5 percent [18], p<.001), whereas primary care providers wished to practice in clinic settings significantly more than specialists and subspecialists (51.1 percent [68], 27.2 percent [7], 11.3 percent [8], p<.001). Practice setting was not affected by practitioner age.

The career locum The ultimate expression of the LT pattern of employment is the "career locum," defined here as a physician who agreed with the statement, "I have made locum tenens work my career and plan to continue this work pattern indefinitely." This was noted by 258 (33.3 percent) of the respondents. These physicians have made sequential temporary assignments a career pattern--going from assignment to assignment for varying lengths of time with no apparent intention of remaining in one place permanently but with no intention of retiring either. This pattern was more common in women (36.2 percent [83]) than men (32.2 percent [175]) and significantly more common among older (>54 years; 37.9 percent [139]) than younger (<55 years) providers (29.1 percent [118], chi sq= 6.61, df=l, p< 0.01). Specialists were significantly more likely to view LT positions as a viable career option (38.3 percent [158], chi sq=9.97, df=2, p<.01) than either primary care (27.8 percent [58]) or subspecialty (27.5 percent [42]) providers.

Role of the locum tenens placement agency

Sixty-two percent (470) of respondents had registered with more than one placement agency in the three years before the survey, and 42.3 percent (355) had actually worked for more than one agency in that time period. The number of placement agencies used was not related to age, gender, or specialty category. While 62.2 percent (480) of respondents had been placed exclusively through LT placement agencies, 37.8 percent (292) had also arranged for assignments through other, more traditional or informal means. Because participation in this study required at least one assignment from one agency, the percentage of providers accepting placement outside of the agency system is probably underestimated.

Frequency and Length of Locum Tenens Assignments

The respondents in this study are active LT participants, as 33.7 percent (256) of them had accepted five or more assignments in the previous 12 months and 40.0 percent (304) had accepted one to two assignments. The most common LT assignment length was less than one month in duration (47.6 percent [364]), followed by one- to three-month assignments (34.6 percent [265]). The least common assignment length was four months to one year (17.8 percent [136]). Female providers were significantly (p<.001) more likely to accept longer (>one month) assignments than men, who tended to accept shorter assignments (

Locum tenens work as a link to permanent employment One common perception is that LT physicians use LT assignments as an introduction to a permanent position (Smith 1989). Practice settings requesting LT providers frequently use the LT physician's assignment as a trial period before offering the physician a permanent position (Dearth 1992). However, a "try before you buy" orientation was not a common goal of LT physicians in this sample. Only 16.3 percent (126) of respondents were using LT assignments to secure a permanent position. This practice was significantly more common for those under 55 (24.9 percent [101]) than for the older providers (6.8 percent [25], chi sq=46.11, df=l, p<0.001) and for female providers (21.4 percent [49]) than for male providers (14.0 percent [76], chi sq=6.45, df=1, p<.05).

DISCUSSION

A number of social and economic forces have facilitated the emergence of the LT physician provider workforce (Fallick 1999). These factors include an increase in the number of women physicians (Croasdale 2002), many of whom want a flexible work schedule not available in traditional practice settings; physician shortages or maldistribution in selected specialties and subspecialties (Greene 2001); an apparent increase in the number of partially retired physicians (Greene 2001); and an increasing number of younger physician providers whose overall desire is for a healthier, more controllable lifestyle (Croasdale 2002; Dorsey, Jarjoura, and Rutecki 2003). In addition, given the increase in LT options and compensation (Sipkoff 2001), traditional informal placement and recruiting methods appear to be failing to provide for the increase in the number of practice settings needing specialty and subspecialty providers. Another contributing factor is the increasing hassle of administrating a medical practice (Sipkoff 2001), which detracts from patient care and the practice of medicine.

Certainly, the results of this survey of LT providers confirm the effect of these forces in the decisions to accept LT assignments. Among older providers, there was a desire to practice part time (58.1 percent), whereas younger providers desired greater flexibility, especially female providers (36.7 percent). LT providers who are planning to make locum tenens work their career work pattern (33.3 percent) support the trend toward more controllable lifestyles (Dorsey, Jarjoura, and Rutecki 2003; Croasdale 2002). Older providers moving into retirement and women desiring more options for family needs and personal enrichment are seeking to gain greater control of their personal lives. However, the increase in female providers desiring part-time practice options caused concern among human resources analysts over whether enough providers will be practicing in the future (Croasdale 2002).

In terms of the management of healthcare settings--whether a clinic or hospital--and the use of LT providers, specialist and subspecialist providers in this study preferred a hospital setting, while primary care providers would rather practice in a clinic. LT providers in areas of highest demand--pediatrics, primary care, psychiatry, radiology, anesthesiology, and emergency medicine--are used in both hospital and clinic settings and reflect an overall national staffing shortage. Administrators in these settings can benefit from the advantages offered by LT providers: cover for vacations and continuing education; management of staffing costs; management of seasonal demands for services; testing of new service options; prevention of loss of patients and revenue as a result of provider departures, illness, death, or delayed relocation; and trial of a potential provider before hiring (Smith 1989; Thompson 2000). The use of LT providers comes with little risk because of the high quality of LT providers willing to provide LT services, especially considering that a greater proportion of LT providers are board certified in their respective specialty areas than are physician providers in general. In addition, combining the credentialing infrastructure of the LT placement agency and that of the hospital, licensure status and sanctions or other irregularities can be thoroughly evaluated. This maintenance of quality comes at about the same cost as employing permanent providers (Thompson 2000). In one Australian study (Hoyal 1998), reservations about LT providers did not revolve around their skill or competency level but focused on their attitude, cultural acclimatization, and communication skills. These latter concerns can be addressed by planning, training, and communication between the provider and administrator (Maniscalco 2003; Tepper 2,303). In the current staffing-shortage environment, administrators may have few options but to turn to LT providers.

While the results of this study are consistent with recent provider trends, because of the selection criteria for entry into this study, one cannot conclude that all segments of the contingent physician provider workforce are fully and proportionately represented. The precise size or growth rate of LT physician providers is unknown (Maniscalco 2003). As noted previously, providers register with multiple placement agencies; this confounds comparisons with the total sample of LT providers. In addition, a proportion of providers arrange their own LT assignments. Furthermore, it is not known if the specialty profile of the respondents to this study is representative of the entire temporary placement industry or simply of this one agency's recruitment efforts and its clients' requirements.

What is clear, however, is that a large number of physicians representing a reasonable cross-section of the physician workforce in the United States (including most specialties and subspecialties, all age groups, and all career stages) fulfill career and economic goals by working short-term, temporary clinical assignments. While income and fringe benefits may be slightly less than they might receive in a traditional full-time, permanent practice setting, flexibility, quality of life, and retirement income issues obviously are of great importance and by all indications will continue to grow (Dorsey, Jarjoura, and Rutecki 2003; Greene 2001). However, the extreme commodification of medical capital, as represented by LT providers, may give pause for reflection. As Starr (1982) points out, over the course of their history, physicians have tenaciously and successfully defended their autonomy against governments, corporations, drug manufacturers, and insurance companies. To an extent, as Starr predicted, physician autonomy is being eroded somewhat by the LT practice/placement mechanism--albeit willingly--by a very small segment of physician providers, market forces, and the culture of medicine that has sought to train providers to a level of competence that makes them virtually interchangeable.

TABLE 1 
Demographic Variables of the 776 Respondents * 
 
                                              Gender 
          Locum 
          Tenens             Overall       M          F 
        Physicians 
          Group              N    %     N    %     N    % 
 
I. Primary care ([dagger])  209  27.0  108  19.9  101  43.9 
 
II. Specialty care          412  53.2  303  55.7  109  47.4 
 
III. Subspecialty           153  19.8  133  24.4   20   8.7 
    care ([dagger]) 
 
Total ([double dagger])     774   100  544  70.3  230  29.7 
 
                                 Marital Status         Age Group 
          Locum 
          Tenens                M         NM        <45        45-54 
        Physicians 
          Group              N    %     N    %     N    %     N    % 
 
I. Primary care ([dagger])  104  50.0  104  50.0  122  52.1   45  26.0 
 
II. Specialty care          293  71.1  119  28.9   86  36.8   99  57.2 
 
III. Subspecialty           130  84.4  24   15.6   26  11.1   29  16.8 
    care ([dagger]) 
 
Total ([double dagger])     522  68.1  251  31.9  234  30.2  173  22.4 
 
                                       Age Group 
          Locum 
          Tenens              55-64       >64         <3 
        Physicians 
          Group              N    %     N    %     N    % 
 
I. Primary care ([dagger])   17   9.6   25  13.2  67   62.0 
 
II. Specialty care          110  61.8  118  64.4  33   30.6 
 
III. Subspecialty            51  28.7   46  24.3   8    7.4 
    care ([dagger]) 
 
Total ([double dagger])     178  23.0  189  24.4  108  14.0 
 
                                   Years in Practice 
          Locum 
          Tenens               4-10      11-30        >30 
        Physicians 
          Group              N    %     N    %     N    % 
 
I. Primary care ([dagger])  52   43.3  54   22.4   36  12.0 
 
II. Specialty care          53   44.2  132  54.8  191  63.5 
 
III. Subspecialty           15   12.5  55   22.8   74  24.6 
    care ([dagger]) 
 
Total ([double dagger])     120  15.6  241  31.3  301  39.1 
 
* Two respondents did not specify gender, two did not specify age, 
six did not specify years in practice, two did not specify marital 
status 
 
([dagger]) Expressed as a percent of subtotal in each specialty 
category 
 
([double dagger]) Expressed as percent of total sample 
 
TABLE 2 
Comparison of the Specialty Distribution of Active U.S. Physician 
Population with Locum Tenens Respondents 
 
A. Specialties that are equally represented (within 2 percent) in the 
locum tenens physician group compared to the active U.S. physician 
population 
 
                       Percent of Active U.S.    Percent of Locum 
                       Physicians (15, 16, 17)  Tenens Respondents 
 
Primary care (all)            26.5-34.3                27.0 
  Family practice              9.2-10.7                11.6 
  Internal medicine           11.7-16.1                9.6 
  Pediatrics                   5.8-8.0                 5.7 
Anesthesiology                 3.7-4.4                 5.0 
General surgery                3.7-4.9                 2.7 
Neurology                      1.1-1.2                 1.2 
Urologic surgery               1.1-1.3                 1.7 
Orthopedic surgery             2.4-2.7                 3.2 
Gastroenterology               1.1-1.3                 1.7 
Cardiology                     2.2-2.5                 3.2 
Obstetrics/gynecology          4.3-4.9                 6.3 
 
B. Specialties that are overrepresented (>2 percent) in the locum 
tenens physician population compared to the active U.S. physician 
population 
 
                       Percent of Active U.S.    Percent of Locum 
                       Physicians (15, 16, 17)  Tenens Respondents 
 
Diagnostic radiology           1.0-2.6                 12.7 
Psychiatry                     3.4-4.9                 12.1 
Anatomic pathology             1.4-2.3                 4.4 
Emergency medicine             1.9-2.8                 5.3 
Radiation oncology               0.5                   5.3 

Acknowledgments

The authors gratefully acknowledge the assistance of John Genna, Sarah LoPrinzi, Angel Macas, and Christopher Sibbet in data acquisition. Our appreciation to CompHealth for assistance in contacting potential respondents and for in-kind support.

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PRACTITIONER APPLICATION

Glenn Miller, FACHE, president, Resource Line, Inc., St. Louis, Missouri

Does the term "locum tenens" still conjure up a negative image? Trends in the methods available for effective delivery of patient care may refocus hospital administrators' views.

Hospital administrators have traditionally been challenged with the balance and mix of physicians on their medical staff. Changes in the methodologies and practices of patient care; medical (sub)specialties; physician malpractice; reimbursement; and a transient, aging populous have caused a recent inequitable distribution of physician providers. In fact, some administrators are experiencing physician shortages.

This unique and revealing study of the temporary physician staffing industry identifies the factors associated with choosing the locum tenens (LT) physician practice as an alternative to traditional practice choices. The article details this study and such findings. While representation by sex, age, specialty, and delivery setting varies, the LT physician as a professional alternative is on the rise.

The article uncovers common motivational factors for becoming an LT physician. Many physicians today find a real appeal to flexibility in their practice. They also find controllability of their quality of life and income irresistible. As a result, LT physicians have fashioned their lifestyle into a respected professional workforce. These LT physicians, when properly placed, can professionally and successfully complement their permanent medical staff counterparts.

The hospital administrator can surely benefit by realizing LT physicians have permanence in the delivery of quality medical care. LT physicians have often covered for vacations, continuing education, short-term leaves, and seasonal demands. Some administrators use the LT physician practice methodology as a "trial period" prior to permanent placement and staff privileges. Specialty shortages in some areas have forced administrators to resort to using LT physicians just to avoid catastrophic downturns in medical coverage. In fact, hospital administrators have repeatedly used LT physicians for a multitude of reasons.

Furthermore, there are valid reasons for using "permanent" LT physicians. Physicians that select the LT option are choosing a healthier and more controllable lifestyle in their own mind-set. This can lead to the development of a content, loyal, and long-term staff member. The competencies of the LT physicians have increased to the point that most are board certified. (The article states that 85 percent of the LT physicians sampled in the study were board certified.) Administrators who search for LT physician candidates can objectively use board certification as a measure of their competency and training. Shortcomings that could arise from cultural, environmental, and peer attitudes can be overcome by proper planning, direction, communication, and goal setting in coordination with the medical staff. LT physicians are now, more than ever, an effective tool for administrators to balance the medical mix, protect revenues, deliver new services, and maintain quality patient care in today's complex healthcare system.

The LT physician may be yet another erosion factor to that autonomous bliss physicians tenaciously defend, but as the article states, it is no cause for alarm. In conclusion, LT physicians may be seen more as a benefit to the future delivery of healthcare than once viewed. This is a vision many hospital administrators could welcome these days.

Arthur B. Simon, M.D., Dean Health System, Madison, Wisconsin, and Angelo A. Alonzo, Ph.D., Ohio State University, Columbus

COPYRIGHT 2004 American College of Healthcare Executives