Fuelled by a global shortage of doctors and shifting employment patterns, many locums are often called in to cover for doctors’ sick days, vacation, or staff vacancies. Hospitalised patients are more likely to get a treatment from these substitute doctors when the regular doctors are away.

But, are locum doctors able to provide the same level of care as regular doctors do?

“They are no less of a physician”

According to a recent study published in the Journal of the American Medical Association (JAMA), it appears that they do. Led by researchers at Harvard Medical School, it analysed 1.8 million Medicare patients hospitalised between 2009 and 2014 who were treated by general internists. There was no significant difference in 30-day mortality rates seen between patients treated by substitute doctors compared to those treated by regular doctors (8.83% versus 8.70%).

“Years ago, locum doctors might’ve had worse outcomes than non-locum docs, but that’s changing. There appears to be very little difference, if there’s any difference at all,” says Dr Anupam Jena, one of the study’s authors.

The research offers a glimpse into the effects of the multi-billion-dollar industry of locum hiring. Many doctors are opting to freelance for many reasons.

Jeff Decker, president of Staff Care, a recruiting firm in the US that connects locum doctors with hospitals, explain that by being a locum, undecided young doctors can have the freedom to explore the different disciplines of medicine before committing to one. For mid-career doctors, being a locum meant taking extra shifts to pay off medical school debts. And for older doctors they can be partially retired, seeing patients and doing what they are passionate about.

“The paradigm is shifted,” said Decker. “They’re a fill-in… but they’re no less of a physician.”

Contrary outcomes: Higher spending, longer hospitalisation

Patients who are treated by locum doctors tend to require longer hospitalisations and subsequently have higher expenditures.
Patients who are treated by locum doctors tend to require longer hospitalisations and subsequently have higher expenditures.

However, whilst there may be no significant differences in which type of doctor treating the patient in terms of mortality rate, the researchers caution that there are some small but statistically significant differences in other factors. Patients treated by locums had higher expenditure and slightly longer hospitalisations.

To support the statement, the researchers analysed a random sample of Medicare fee-for-service beneficiaries hospitalised during 2009 to 2014. They found that patients treated by locum physicians had a significantly longer mean length of stay (5.64 days vs. 5.21 days) and lower 30-day readmissions (22.80% vs. 23.83%) compared to patients treated by non-locum physicians. The patients also found to have significantly higher Part B – covering medically necessary and preventive services – spending compared to patients treated by non-locum physicians (USD1,836 vs. USD1,712).

“It makes sense because locums doctors providing care don’t know the system as well. That might mean inefficient spending in ordering tests or procedures. They may keep patients in hospital longer. The care is more inefficient,” says Jena.

The researchers also noted some limitations in the retrospective study, such as the potential for unmeasured patient confounders and lack of data and understanding on locum physicians’ characteristics, and their clinical positions.

“Our findings so far are reassuring, but some of the trends we found demand that we look more closely at how the system works in a more granular way,” asserts Jena.

“As the market place shifts and employment patterns fluctuate, we owe it to our patients to make sure that the way we cover for doctors who are out of the office is safe and effective,” says Dr Daniel Blumenthal, lead author of the study.

He added that hospitals should find better ways to educate locum doctors to lower costs and boost patients outcomes. At the same time, he said he would like to see further research being conducted on locums in other specialties. MIMS

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