Locuming

With Dr Robert Gerber, Cardiologist, Physician and Interventional Cardiologist currently working in regional Victoria, Australia 

Introduction

There are many reasons why locum work may appeal to doctors looking for career flexibility or want to fill gaps between jobs or explore different parts of Australia while earning an income. Each year our healthcare system relies on locums to fulfill roles in rural and remote areas and providing emergency relief for all grades and specialties.

Please tell us about how your career path and how locuming fitted into this path.

I finished medical school in the UK and did most of my training in the UK, including locuming. I completed my fellowship in Italy for a year and after working within the NHS for 25 years, I took a sabbatical in New Zealand which led me to decide to work in New Zealand and Australia. I chose this location based on the different working environment and it being slightly less pressurised than the NHS. This was one of the reasons why I found it useful to locum. Global Medics have been excellent for locuming in both Australia and New Zealand. I also maintained my credentialing and expertise intermittently. I was led to rural Victoria where I could deliver heart attack services as my sub specialty within Cardiology, and because I wanted to maintain my interest in general medicine and general cardiology, I am doing this is Wangaratta and North Eastern Health.

Locuming fitted into various parts of your career. When and why did you decide locum work was right for you when you were a junior doctor?

I remember when I was in training one of the Professors in London told us as a group that our generation would be one where we would be working more flexibly and in different roles than ever. The model of the medical profession globally has always been that you go to one hospital, and you stay there until you retire. I don’t think that fits for contemporary life or for doctors wanting to gain clinical experience and career progression while being paid. Locuming can fill this need in terms of introducing you to different sub-specialties, different colleagues, and different parts of the world that you wouldn’t previously consider, and maintain direction of travel. It gives you the opportunity to try other things, especially as your life changes (e.g. starting a family). I did a period of research where I was doing less clinical work and locuming gave me the opportunity to boost my income and maintain my skills. You can elect certain places where you may want to explore the culture, learn about medicine in different parts of the world and see different pathology. Overall, it is a good experience and enriches your practice when you are back home.

You mentioned that as a junior doctor you were looking for more flexibility in practice. What were the factors that contributed to your decision to locum?

My first experience in locuming was as an SHO in London. Between the SHO jobs where you are working on rotations for up to a year or 18 months, you have a gap and then the next job starts. Most doctors feel like they should fill this gap, but you can fill these gaps with intermittent short term or long term locuming – this does not look bad in any way on your CV. I have been on interview panels where candidates for Cardiology have experience in locuming doing Dermatology. You may wonder how this may be relevant to Cardiology but there are many cardiac medications that may cause dermatological complications that you may not recognise without dermatology experience. Most cardiologists have no experience in dermatology. I have had experience at the Royal Free Hospital (a large dermatological centre in London) which has assisted my daily practice. For example, I was able to identify late angiooedema in a patient on an ACE inhibitor. This experience was not only exciting, but also assisted me in being able to identify skin cancers, including melanoma. Locuming has flexible working hours which can be useful when you have young children. It can be used to improve and enhance your career as well as bridge gaps and earn money. Research requires long periods of writing which can be tedious – locuming can also be useful during this time.

You have touched on my experience in speaking to young doctors as they are concerned that with the choice of locuming it may be difficult to return to a conventional career path. Your experience as an SHO is equivalent to an resident medical officer or senior resident medical officer. My experience is that it has diversified young doctors’ clinical experience and skill set, giving an advantage when applying for their next role. The ability to do locuming while doing research assists in maintaining skills/ credentialing. What are your favourite destinations to locum and have there been any additional positive experiences that you had not considered previously?

I’ve been locuming in Wangaratta or the northeastern side of Victoria. It is a beautiful part of a Victoria/ Australia, spanning an Alpine region to a corridor of towns and villages running to a town called Bright which has beautiful mountain scenery. Bright is famous for holding the Alpine classic cycle races which I had not heard of previously. At the end of one day after cycling at Mount Buffalo in the Summer I met other cyclists who recommended I do other events such as the Seven Peaks Challenge, Victoria, where you cycle up the rough terrain of seven peaks. Once you start you’re inclined to finish, from completing the easy paths to the difficult challenge of Mount Baw Baw which is the most exciting. In New Zealand, there is the ninety-mile beach in Northland which was also memorable. One occasion where I was sitting with one of the clinical managers I said I had never been up to the top of New Zealand, to Cape Reinga. The clinical manager offered to let me off at about 2.30-3pm to see Cape Reinga if I came in earlier to see a few extra patients. When I went to Cape Reinga I experienced an incredible beach and the native bush land. Locuming in the UK, there is the opportunity to locum rurally and experience the villages and country pubs. The atmosphere and the walks in the countryside are unique.

There are many doctors out there that are interested and would like to start locuming. How do you think they should get started?

It is important to be comfortable with the agency you are with. I started by speaking to colleagues that had done locuming and asking what they had done and where the best place to locum was. It was interesting that within the locuming world if a place is not looking after its doctors well then locums don’t tend to go there. As we know as trainees, some doctors are posted in roles they have to do as part of their training where there is less balance between clinical service provision and training. That is the benefit of locuming, where you can find out through your agent and through other people who have worked in various places, whether you want to work in a hospital. It is not likely you will work in a place where you will likely become exhausted due to ‘market forces’.

The next step is getting the right shifts and finding the right balance. I found that when I had my second child and I was locuming I preferred to run my shifts back to back and have a rest. This is something I wouldn’t be able to do if I was a normal trainee. As a locum I could work a shift then have a rest and repeat this, and then have a day off. It was much more preferable for me to have a day off as I had two children and this would help my wife.

When you register with the agency you should get updates regarding your specialities. You must be honest – I would never take a locum role and then not show up. In a permanent role if a locum doesn’t show up most people would struggle. It is rare that this happens, but if you can’t show up it is important to let people know, because usually you are filling in for people’s annual leave or sick leave. Most of the hospitals on the list are usually well experienced in terms of using local agencies and they look after their junior doctors. Some regions in Australia and New Zealand never use locums and when they try to it is usually internal. It may be that these are the hospitals to potentially avoid as they are trying to make it more profitable for them at your expense. Perhaps the accommodation isn’t quite as good or the role is more arduous and slightly less supported.

Is there anything else that should be considered when looking for a locum role, in terms of skills set or location. Should it be different when starting off and choosing a role compared to later?

If I was to do a locum role I would determine whether I was able to do certain procedures as a Cardiologist, considering whether it was an emergency procedure, the risk it carried, and whether there was the right back up/ facilities or connections if I was in a rural centre. If you find yourself in a situation where there is a desire for you to do a procedure or clinic you think is above your clinical skill level, you must communicate whether you require supervision or more training. It is uncomfortable to find yourself in a situation with a patient where you are not sure and have to constantly ask for help. You may experience pathologies in a rural setting that you may have never seen before – this is different. If you were a fellow in Cardiology and were asked to be an Interventionalist, there is clearly a mismatch and this would be wrong. However, if you were a trainee or fellow and you experienced a strange heart murmur, this is fine – you need to use your skills, which is part of locuming, and speak to colleagues to diagnose this patient. You can also experience many different neurological presentations – you can describe it and go through the correct methodology. In Australia you have access to every diagnostic test and who interprets them is different and you can ring someone. This is something you can be mindful of, to know what your clinical limitations are but also to be open to new avenues. This can help financially, as you may be asked to do on calls. On calls are a role that hospitals generally don’t want you to do, but sometimes you do, as they are paid higher. There are nicer while you are away from home as you get to see more clinical cases and you get paid more.

To summarise, it is important to know your limitations and inquire what level of supervision you can expect. It is important to be open as well, as you get to see new pathologies and gain greater expertise. What do you need in order to be eligible to do locum work in Australia?

If you are not Australian trained, you need to go through the AHPRA process. I would forewarn anyone going through this process that it is not easy. This is to ensure doctors are operating at a set standard – this is needed. You need to prove that you have completed your various rotations and gained a set of skills, you need to submit references. In my case as I am an interventionalist, I had to prove that I could do certain procedures. I was fortunate to have worked in countries where there was a regular government audit/ independent audit/ peer review. The AHPRA process can take a while. You need referee checks and police checks – it is very thorough.

As I mentioned, I did my fellowship in Italy in 2007 for a total of 18 months. Once you go through a similar process you get a certificate and it is acknowledged that you are practicing at a set standard. I would give at least 6 months, particularly if you are coming from outside Australia or New Zealand. The Medical Council of New Zealand is also rigorous but the process is slightly faster. You have to maintain your credentialing for both. If you need to locum for a bit longer, for example, for more than a year if you are between work or have children, you can always do an audit. Both AHPRA and the Medical Council link into the Royal College in terms of the credentialing, and one of those is audit in clinical practice and clinical effectiveness. This is very easy to do – you could audit the patients you have seen in clinic with chest pain or how many patients you have seen on ward rounds and their outcomes. You don’t have to consider this as a locum but as a trainee you are encouraged to do more academic work and audit of clinical effectiveness, you can do this yourself for your own clinical governance. If you are not an Australian Citizen or Permanent Resident you will need to get, in parallel, a working visa. If you are from Europe or the UK, it is not automatic that you can just work in the hospital setting. If you have a skill that’s needed in an area, you can get an Essential Skills visa and there are many types of subclasses. Usually if you hold this for a period of time this can convert to permanent residency. It is important to think about this, not necessarily because of your eligibility to reside in Australia and New Zealand, but practically it can be more difficult to buy a house or get a credit card. Banks are not very keen to give you a home loan or a car loan if you are not a permanent resident in Australia. Some of the locum work that you do if it is part of your essential skills visa does link up. This is important to bear I mind as I heard that one my colleagues who was locuming changed his visa number which is not a good idea because as they found out this brings you back to the beginning of the time scale. In general, it is preferable to be working on one visa for at least three years in a region. You need to have a couple of years of experience.

If you have a particular locum agency who is used to overseas roles, they are usually a good resource to ask about what the general experience is and to ultimately seek your independence. How should doctors choose a locum agency?

Global Medacs have been consistently helpful in communicating between different areas that I’ve worked in the world. I was working at trans-Tasman, and both the agents in New Zealand and Australia knew each other because they interact and work as a team. They introduced me and I expressed that I was interested in working rural, and that is how that was initiated. The pay can be packaged flexibly. Most people think about setting up their own small companies so that they are paid through this which means you can claim tax back on your stethoscopes, IT equipment, membership fees, subscription to various journals. They introduce you to a new way of being paid through a salary agency, this helps to claim back some of your expenses. Finally, I haven’t had a problem with accommodation with Global Medics.

Are there any final comments?

You hear alot negativity regarding the hardyards doctors put in, especially with COVID. But I think medicine is a worthwhile profession that locuming can enhance. Choose the areas that you work in wisely and try to obtain a balance. Locuming can give you a different perspective that enhances your normal work – enjoy it.