A Word About Locums

Locums are an important segment of the profession, particularly for those of us who work as GPs/Family Practitioners.

This hobbit used to do a lot of locums in his younger days. Mainly because he had mouths to feed and loans to pay. Old coots like me will reminiscence about the bad old days when we were paid as low as $40 an hour, saw 12 to 15 patients per hour etc.

Times have changed. From the chat groups I am in, I hear disturbing stuff about some locums. They may not represent the majority and it is unfair to tar all locums with the same brush. Apparently, there are locums that:

1. Refuse to see more than 4 to 5 patients an hour
2. Refuse to take blood (or perform any procedure) or give injections
3. Refuse to see female patients
4. Refuse to see children
5. Refuse to review lab and radiological reports (even if ordered by the locum)
6. Refuse to turn up the next day (although already booked for say, the entire week) unless you pay him more per hour because the clinic was busier than what the locum thought.

The last point is particularly galling because it is purely a point about lack of honour and professionalism bordering on blackmail. I wonder if our mammoth SMC ECEG covers such unbecoming behaviour.

There are one or two infamous locums in my time that are still circulating perilously in the market now as full-time locums which many GPs are afraid to engage. But most of these stories involve young doctors. They may be full-time or part-time locums.

But this is not another article by an old coot complaining about the state of young doctors and locums. Other than point 6 above, the other five points beg the question – what is the root cause? Is it just bad attitude? Maybe not.

My guess is that maybe it is also due to competency, experience, and risk-averseness.

One cannot but wonder with today’s residency and workload caps, are young doctors trained to cope with high workloads? Also the breadth of experience that the system affords. For example, other than in polyclinics and A&E, many young doctors never see kids after they graduate. In NHG for example, there is no paediatrics or O&G department. With the three clusters now firmly in place and cross-cluster movement of doctors not happening much if at all, how does one get broad-based training?

After all, it doesn’t take much to be a locum. All you need to be is to be fully registered with SMC. But being fully registered doesn’t mean you are comfortable seeing kids or women. The locum may never have been part of a structured training program if he wasn’t a resident.

The other possible explanation is that due to efforts to improve quality and risk-averseness in our public institutions, many things are pushed upwards to more and more senior people and younger people are less and less trained or exposed. This is not new and has been taking place for decades to be sure. In the past, a second year registrar can perform a gastrectomy himself competently. Now, I am not so sure even a second year Associate Consultant can do a gastrectomy all by himself. It’s not entirely a bad thing and its inevitable as society progresses.

But there is a downside when things are carried out too far. I have been told that some locums refuse to take blood because they are “not confident”. And these are not old doctors suffering from failing eyesight or hand tremors. Maybe, it is because many of these “simple” procedures are now carried out by technicians such as phlebotomists and hence the lack of confidence.

Many locums refuse to perform “risky” procedures now (such as H&L injections, ear syringing) because they are not paid adequately if at all to assume the higher risk. They are after all paid by the hour. This is understandable. If I was still locuming, I would maybe do likewise. But taking blood or giving injections and vaccinations are really, really bread and butter.

The point that really needs to be made is that GPs only hire locums because they want their patients to have continuity of care when they aren’t around and that the locums pay for themselves. Yes, the hard truth is that locums have to earn their keep. With locum rates at anywhere from $100 to $120 per hour, a locum has to generate at least $200 to $250 of revenue per hour for the clinic so that it makes hiring the locum worthwhile.

But if a locum refuses to do many things, or caps his work-rate to 4 or 6 patients an hour then it is kind of difficult to justify hiring him. It is really down to the locum’s productivity in dollar and cents. So if a locum wants to stay in the business of locuming (And it is possible to make a very good living by being a full-time locum), he needs to get repeat business from clinics. To achieve this, he has to make more for the clinic than what he takes. It’s that simple.

All of us agree that the quality of locums are really patchy. Sometimes, you really get a locum from hell, and sometimes you get a wonderful one, and all your clinic assistants tell you the locum gets things done with minimal fuss and is even a joy to work with.

Thinking aloud, maybe it is possible to accredit or certify trained locums on a voluntary basis. Maybe a responsible professional body like the College of Family Physicians Singapore can run courses for people to attend and certify these locums of certain competencies and skills. This training is not about the latest in medical science etc but skills every locum needs – common office procedures, like taking blood, ear syringing, I&D, T&S etc as well as certifying stuff like fitness to drive etc.

One may argue that what the locums really need is to attend the Graduate Diploma in Family Medicine (GDFM) course. But frankly, many locums do not have the opportunity to attend a full diploma course. Maybe a Locum Certificate course is all that he can afford for the time being.

I think many GPs in the market who use locums will welcome such a Locum Certificate course. At the very least, the holder of this Certificate cannot say he does not want to give injections or doesn’t know how to take blood and he may even be able to command a small premium in terms of his hourly locum rate.

This reminds me of an old story. Upon finishing his 5-year bond, a brilliant classmate of mine left town and went for his training in the United States as an internist. He is now professor and head of department in a big hospital there. He underwent training in one of the most famous hospitals there. One night while on call, a distressed nurse called him to inform him she could not insert the IV cannula and wanted to call the phlebotomist on-call (but who was not stationed in hospital). My friend said he will insert the IV cannula. At the bedside, the nurse had an ultrasound machine on standby (thinking that the doctor/resident will insert the IV cannula under ultrasound guidance)

He inserted it on the first try without any fuss, without ultrasound guidance, Singapore style. The nurse was extremely grateful. The next morning, his boss, in front of the entire ward team, clapped his back and congratulated him on his grand endeavour of inserting an IV cannula while on call.

I have a bad feeling Singapore medicine may be heading in this same direction.

One thought on “A Word About Locums

  1. It takes two hands to clap. Being a locum myself before starting a clinic, I will say if one is a bad clinic, good luck and do not hope to get a good locum.

    1) A large proportion of locums are either from the Regional Health Forces of Middle Earth or full-time Great Army Medical Officers. There is a certain need to minimise or even immunise their own medicolegal risk since they are shackled in 5 year slavery contracts after graduation. Even more so when there are Dark Lords in the Regional Health Forces or Great Army threatening to punish them should they be found locum-ing.

    Hence the refusal to do certain things or see certain groups of patients mentioned in your article. Refusing to review labs may actually be protecting the clinic practice especially if the labs were ordered by yourself or another locum. This results in less conflicting patient advise from the subsequent review.

    Unless the locum is a regular locum who comes in frequently, he will not be able to review the labs he has ordered.

    The proper thing to do is to match your clinic requirements with the locum you need. If you need a regular locum, engage the ones who can commit to more regular slots, and engage full time ones.

    2) Pay peanuts and you get monkey. High load busy clinics that doesn’t pay well? The locum is not going to continue to work for you. Heck, even a anchor GP may not continue to work for you if he finds he is not appropriately paid for his job.

    3) Some clinics purposely even pre-register patients and call in the locum only an hour or 2 later, saturating the remaining hours of the session, flooding him with a horde of angry patients who will nevertheless have the impression that the incoming doctor is a sloppy one, thinking that he is arriving to the clinic 2 hours late.

    Worse if these patients were not even informed that the locum was told to come in later.

    Entertaining a horde of angry patients is already a medicolegal risk for any doctor.

    4) Delay of payment, or even missed payment, or even refusal of payment. There are locums who have complained that clinics have not paid for their slots, or refused to pay even though there was adequate documentation of the arrangement of the locum slot. Again, if you delay payment, or you don’t pay, no one is going to work for you. Everyone on Middle Earth needs to survive, needs to find food to eat. If you are stingly clinic owner/employer, the locum is also going to be stingy with you.

    5) It is not really about the adequacy of courses. More relevant is work ethic from both sides.

    Bad employers are going to get bad employees, and vice versa.

    Like

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