How much should a locum care?

I know their gaze — peering though the windows of the high dependency unit, the ‘low stimulus area’ or the ‘intensive treatment area’. Choose your politically correct acronym, the environment is the same. Blank walls, weighted furniture that should be upended proof, no visitors ‘because of COVID’, no leave, no programs. No activities, no therapeutic care except medications called ‘prn’s’. Patients that would be under my care, that know the dance of transitional specialist psychiatrists in the form of locum placement roles better than me. Because they have to live it.

We stare through as locum doctors with our skills and our expertise. We look as if our new patients are exhibits in a zoo. We hear about them at handover with all the emotional overlay of the current shift of nursing staff, and we hear ‘ what the plan is’ which may have varied on a weekly basis for countless months. We empathise with the nursing staff who are as burnt out as us, we try to help them feel like we can appease their distress at work by being enthusiastic and passionate, but not too much so because we have to sustain ourselves as well. After all, that’s why people like myself work in a locum capacity— I’m burnt out from my day job and there is literally no way to find care for me, or get better in the system I work in, so I cleverly work less for more money and take time off.

My first taste of locuming came very early in my career and almost ruined my career. After a heavy intern and resident year, and for many personal issues, including a best friend developing mania, I decided to take a year off. I was expected to be commencing a 1st year psychiatry registrar role in 2002, but I asked if I could start a year later and have a year where I finally felt in control. I was seeing a psychotherapist at the time who really encouraged me to live a life I wanted rather than what others wanted of me. With the support of my supervisors , I headed off to locum as a psychiatry doctor in the UK.

I found out later I would be punished for this request, being unmatched upon my return even as the recipient of the John Cade Medal in psychiatry, the highest accolade as a medical student no less. Despite all the check ins with the training coordinators on a regular basis, they delivered the final blow. The didn’t want me.

During my time away, I worked throughout the UK in various roles in 2002, often way outside my scope of practice. I found out the hard way that international locum agencies were very good at placing locums from Australia, but when we were accepted by the administration we were revered for being able to speak English, communicate, and had the basics of Australian medical training, hence immediately placed in posts that went against our working visa requirements. A blessing and a curse, this was without a doubt the best year I have ever had in 53 of them, with regards work and opportunity, as it should be for a someone who worked hard and played hard like I did.

However, I did learn a terribly difficult lesson that year during a 4 month locum post in the Midlands of the United Kingdom. I was replacing a psychiatry doctor who was answering some very difficult questions in front of the GMC, about his persistent need to provide internal examinations for female aged care patients who, despite their dementia, reported that they had symptoms of thrush. I could see in all the notes of the patients that the entries backed this up. I presumed that I could fill the role until somebody new could be appointed. I can’t describe my horror when I heard he was returning with a chaperone. I dissolved into tears.

I left with the feedback that told I wasn't a very good locum as locums weren’t meant to care. I cared too much.

My lessons continued to be learnt when I came home in 2003 to unemployment. I soon found a registrar role and I to this day do not regret that amazing UK locum year, despite the fallout. It actually did cement my commitment to become a psychiatrist. My friend with mania went on to years of presentations to mental health services. Despite the adversity, and probably because of it, I got through psychiatry training in record time, despite maternity leave, and ventured back to locum work more and more.

Nothing really has changed for 20 years and more. Psychiatry relies so heavily on a locum workforce. This is the case even in metropolitan hospitals to this present day. Like it or not, this is going to be the workforce structure we will have for the next years to come, because of many pertinent factors. All countries rely on a global workforce in psychiatry, and our borders have been closed for two years. Substantive staff have been unable to enter Australia.

Our training college, the RANZCP, has held up trainee progress for 2 years, blaming the pandemic for inherent problems in examination delivery, despite months to find a COVID friendly solution. For the first time in my career, I have worked alongside local trainees who have taken a break in training because of burnout, working as locum registrars. The RANZCP even acknowledges registrars might need a break in training because of burnout, rather than the usual reasons like as maternity leave. What a simple, easy fix. How about we don’t burn them out in the first place? The trainees I have worked alongside in 2021 are, quite frankly, just what this doctor ordered.

We can’t rely on a hierarchy that espouses ‘we will do what we have always done’. We are moving into the third year of a pandemic that has infected, furloughed and fundamentally destroyed morale in an exceptionally needed sector of the medical workforce. We have talked about the mental health pandemic that should have followed the COVID pandemic neatly, however, in fact the two are enmeshed and deserving of imminent action.

Our new reality is a psychiatry workforce staffed by locum doctors such as myself, filling short term posts and exacerbating the problem of lack of continuity of care. Permanent staff will cease to exist, budgets will blow out as executives throw good money after bad, chasing a short term fix with no long term gain. I saw this 20 years ago in the NHS in England and its now my reality here. I made a fortune in 2002, living by the mantra of ‘if they are stupid enough to spend it, I am smart enough to earn it’. Surely those days are over and we can do better, recruiting and retaining permanent staff?

The bitter pill to swallow is that so many permanent roles have been eroded and supervisor roles as well. The last thing I want to see is our best and brightest learn ‘sloppy medicine’, hear terms such as ‘chemical restraint’ and feel this is a standard of care, and treat patients accordingly. Of all of the 65 recommendations of the Victorian Royal Commission into Mental Health Systems, the recruitment and retention of specialist medical staff has not been highlighted to its peril. Newly defined best practice care will not be implemented without a robust, expertly informed psychiatric system. Our trainees deserve better than this as do those patients behind the glass in all of our psychiatry wards.

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Helen Schultz

Finally doing what I wanted to do ‘when I grow up’. Professional author, drawing from years of working as a psychiatrist. Storyteller from the School of Life.