Navigating anti-locum sentiment

In my first year as a locum, I was wandering past a resus bay where a consultant had 3 RMOs and a few nurses huddled around a ventilator. They were teaching the basics: how to turn the vent on, how to change the settings, and when and how to start someone on BiPAP.

It was a rare day where the waiting room was empty, and the only patient I was looking after was humming along awaiting an ultrasound. I poked my head into the bay and watched from the back, keen to soak up as much as I could while the department was in order.

The SMO looked up and said:

"Josh, locums aren't welcome for teaching. I'll get you to leave the bay."

Embarrassingly, I thought they were joking, and laughed this off. They were an otherwise agreeable and friendly person, and I thought it was banter. But they doubled-down 5 seconds later, and I put my tail between my legs and walked away, as red as a tomato.

By that point I was already well familiar with the notion that locums shouldn't expect any of the perks of the job that permanent staff get, such as organised teaching, prioritisation for procedural skills and long lunch breaks on quiet days.

But this wasn't either of those — it was an opportunistic mini-tutorial while the circumstances allowed. There was no-one waiting to be seen. It was drive-by teaching.

I would eventually find out that this consultant (and many others I would later encounter) was known to have a bee in their bonnet regarding the mere presence of locums in their unit. For example, they wouldn't issue references despite longstanding working relationships and would routinely speak ill of locums in general. This was painfully ironic given the high locum needs of the department they worked in.

Locums aren't owed anything extra

To be clear, I think it's completely reasonable that locums should get the long end of the stick while on shift. If anyone's seeing an extra patient or dealing with a troublesome situation, I think it should be a locum. And if anyone's getting a rare early mark, it should definitely be the permanent staff. After all, our role in the system is to provide relief for understaffed departments. We are not owed anything "extra" by the units we work in.

But if you hang around long enough you will absolutely encounter consultants who enforce their moralistic views on locum work to an unnecessary degree that borders on unprofessional at times. It's simply not necessary, and likely drives staff away from their department in the long-term.

I've also seen consultants who will only provide references for their rotational registrars if they are applying to permanent jobs, not locum work. In my opinion this amounts to what is essentially a paternalistic abuse of the medical hierarchy. A reference is a chance to speak to a doctor's skills (or lack thereof), not a lever to control their career choices.

Where the sentiment comes from

At the same time, I can understand why some doctors and NUMs think this way. I have worked alongside locums who give the whole scene a bad wrap:

• trying to get by doing the bare minimum
• cherry-picking low complexity patients
• not embracing the local protocols and respecting the local staff
• openly complaining about their pay
• and perhaps most concerningly, not being competent in their role

This was further compounded by the explosion of premium rates during the pandemic border closures, when temporary staff were getting $200–300 per hour to work in COVID wards and pop-up vaccination clinics. And while this was arguably necessary at first given the risks involved, in my opinion these pay conditions persisted far longer than were perhaps necessary. All this did was fuel the idea that greedy locums are out there to pillage the earth.

There may be other assumptions that you come across as well. For example, that you aren't fully committed to your career, or that you aren't interested in learning more medicine, or that you're only motivated by money.

People in this mindset miss all of the downsides of locum work, though:

• the time away from home
• the lack of guarantees about shifts
• the nights in dingy motels
• the risks associated with practising in an unfamiliar environment all the time
• the lack of paid annual leave and professional development

And yes, locum rates are higher, especially when things are very urgent, but for lots of "routine" locum work the pay rate is actually not that much more than Sunday rates in many states. I suspect that in many cases, naysayers overlook this and drastically overestimate how much an individual locum is being paid given the cost-cutting after the pandemic.

A framework for navigating anti-locum sentiment

With all this in mind, I've developed an opinionated framework for navigating anti-locum sentiment when you eventually come across it:

1. Don't take it personally. It's not a statement against you, it's a problem with the person themselves.
2. Don't try to win the argument. Most of the time you won't change their mind, and I wouldn't bother trying. I've gently challenged people's beliefs on a case-by-case basis, with mixed results. I'm not sure what game we're playing here, though.
3. Be one of the "good" locums. This should really go without saying: turn up on time, be reliable (do not cancel unless absolutely necessary, especially not at late notice), work hard, leave the department in a better state than you found it. Be professional. The department doesn't owe you anything.
4. Follow the local protocols and standards of care (when it is safe to do so). This includes going to sufficient lengths to learn about and understand them, such as actively reading onboarding materials if they're provided.
5. Don't talk openly about rates. Don't complain about them, and certainly don't brag about them. Not because it's secret information, but because when people hear it, you fuel the assumptions mentioned above. It is also simply a number in a vacuum, and does not communicate what is required for a given locum to get that rate.
6. Side-step the naysayers. For every dud you'll encounter, there are 4–5 others who understand the role of locums in the system, and the reasons why a person may choose locum work for a period of time. Lean into those people, especially for references.
7. Consider contributing to quality improvement. In situations where you have an ongoing long-term relationship with a department, this can start small: communicating problems you've noticed with relevant decision makers and working with them behind the scenes to form a resolution. It can also take the form of creating handover documents about given roles and so on. While this type of work can get out of hand if you aren't careful, you can also use work time on it when it's sensible to do so. I have seen strong references issued off the back of this, when they otherwise wouldn't have been.

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