A recent series of articles in the Sydney Morning Herald highlighted the rising rate of medical locum doctor usage in Australia. The articles indicated that an average of 16.5% of doctors working in the NSW Health system are locums. So it seems there is a trend towards locumming as either a career or a break in one's career in Medicine. In this article, I would like to briefly cover how you can become a locum but then address a more important issue in my opinion which is staying current and registered as a locum doctor.
So firstly what are the basic requirements for locumming as a doctor in Australia? The key requirements are that you either have general registration and/or specialist registration. You can either locum as a Specialist (includes General Practice) in which case you need specialist registration. Or you can locum against a vacant hospital role (usually a trainee role) in which case you need general registration. By their very nature locum positions are temporary and therefore not open to doctors on other types of registration because they require a level of independent practice. So this means as a minimum you will need to be at postgraduate year 2 and have your general registration. Beyond this basic requirement, you will need to be a citizen or permanent resident, which is most locum doctors in Australia. Or possibly be on a visa which permits you to work as a locum. You will most likely need to register with at least one medical recruitment or locum agency. You will probably need to either not be currently employed as a doctor or on a break from your role. And you will likely need to consider setting up a limited company to collect payments that you make as a locum doctor.
Beyond these basic requirements, there are a number of other considerations, which I will now go into.
As we have noted the nature of locum jobs is that they are temporary and time-limited and notwithstanding the current reporting on their usage, they are not generally seen as a permanent workforce solution. Locums are also often seen as quick and urgent solutions to filling a gap due to an unforeseen circumstance. For these reasons, it is generally not possible to set up a locum appointment for anyone who may need one of the special types of registrations available under the Medical Board of Australia where certain supervisory requirements may need to be demonstrated to be in place. In fact, often the reason a locum is being sought is that there is a lack of supervisors available. So this generally means that International Medical Graduates can generally not obtain a locum position. Although there have been some limited circumstances where it has been possible. This has generally been around deputizing services for general practice where medical recruitment agencies themselves have set up a service and essentially employ the IMG doctor.
Locum positions (even ones for trainee doctors) are often advertised with a request for the locum to have a provider number. This may be just for referring purposes or for billing purposes as well. Performing locums in private practice, such as general practice is fairly impossible without a provider number as you will not be able to charge patients Medicare fees for the services you provide and the locum position will therefore not be viable.
Provider numbers can be quite confusing and complex. Part of the problem is that each provider number is generally linked to one medical practitioner and one location. Technically you need a provider number for each and every location that you provide services at or from. This can obviously be hard to predict if you are locumming. There are some solutions to this issue in relation to general practice but often what needs to occur is to fill in a form for another provider number. As it takes time for Medicare to approve this as a locum you need to be on to this issue promptly.
Other Skill and Experience Requirements
Services advertising for Specialist Locums are generally happy to accept anyone with the appropriate Fellowship (although there are some exceptions). For general locums, the amount of experience you have as a doctor will count towards how eligible you are for a locum as well as how much you will be paid. Having additional skills such as the various advanced life support training certificates or experience in paediatric emergencies will also open up the number of posts available to you as well as the rates you can collect. So, whilst you can technically locum as a PGY2 your prospects may be even better if you wait until PGY3 or PGY4.
Working as a Locum On a Visa
As mentioned above there are limited circumstances where a locum doctor may be able to work under a visa arrangement. Generally speaking, this would occur when you have general registration or specialist registration and the medical recruitment agency can obtain a visa on your behalf.
In most cases, you are probably better off working under a more secure form of employment until you are able to apply for permanent residency and then looking into locum work. This way you will not be obligated to one particular locum company.
Working With Medical Recruitment (Locum) Agencies
I've previously written in more detail about working with medical recruitment agencies. However, a key question about becoming a locum is whether you can work with a locum agency. This is because whilst it is possible to directly contract yourself for locum roles. Most doctors do find it easier and more productive to engage with a locum agency.
For the most part, most doctors find working with a locum agent to be a valued and essential part of the role. Someone who understands their requirements and negotiates on their behalf. But this is not always the experience. If you are not the sort of person who is good at negotiating conditions of employment you may find locum work difficult. Locum agents play a difficult role in attempting to keep the employer and doctor happy at the same time. Sometimes the conditions of the job are not as agreed to initially or sometimes you may feel pressured to take on a role that you don't wish to do. So being able to stand up for yourself in this situation is an important consideration.
Can You Work As a Locum Whilst Employed?
If you have a permanent position with an employer, such as a hospital, it may still be possible to do the odd shift or week of locumming. But beyond this and even including this it can get difficult. Apart from the fact that you obviously need to have the time off work to do locum shifts. There is also the need to consider that you will probably be working in a situation of conflict of interest. Most employers have a process whereby full-time employees are obliged under the code of conduct to declare any additional work undertaken with the option for the employer to indicate to the doctor that they cannot undertake that additional employment if it conflicts with them completing their other duties.
Even if you work part-time it may be difficult to work part-time in a permanent position and locum as most locums are done in blocks of weeks rather than days.
So essentially whilst you may be able to do a small amount of locuming whilst employed. If you are planning on doing more than a little bit you cannot really do this whilst also employed.
Getting Paid As a Locum
There are essentially two options here and sometimes it comes down to the employer's choice. Some employers will opt to pay you through payroll in which case they will also pay the ATO the requisite amount of tax on your behalf and should also pay superannuation on your behalf. Your Locum Agency then charges them an additional fee for placement. Others will pay you a set amount as part of an invoice you submit for the contract. This is often paid directly to the locum agency where the agency takes out its commission and then pays you out.
If there is a choice between PAYG and invoicing you can opt for either option.
As a locum, you are not going to be paid a regular fortnightly salary. So this means that you need to be prepared for being paid late, having to chase up on income every now and then and have some amount of cash in the bank to keep up all your regular payments (rent, mortgage, food, car, telephone bill etc…) in the interim.
You will also most likely need to set aside some of your income for tax purposes. Otherwise, you will get hit with a large bill come tax time and needing to take out a loan to pay it.
Some doctors find financial management a hassle. Good locum agencies will generally help you by chasing up on payments and providing your reports. But if you like a less complex set of financial circumstances then locumming is probably not for you.
Running a Company
Eventually, most doctors who locum set up a company in which to collect their earnings. There are several reasons for this. Part of which is that some health services like Queensland will not pay locums as what is called a sole trader. The other main reasons are to reduce tax obligations and protect your personal assets.
Running a company does not need to be overly complex. Most accountants will gladly help you to set up a simple company for a small fee. You do need to do some regular book-keeping and complete some additional tax forms quarterly and annually. It makes sense to set up a separate company bank out to make the book work easier.
Many doctors actually find the idea of being the Managing Director of their own company a little bit exciting. You get to pick your own company name and you can even get a logo, letterhead and website if you really want to. But if you have aspirations to be a Company Director you might find this aspect of locum work that leads you to question whether you want to be a locum.
You will probably need to revise your medical indemnity upwards if you engage in locum work. When you work as a locum for a public hospital you should probably still be state government employer indemnified. But it is important to check arrangements each and every time.
On a personal level becoming a locum generally means traveling around a lot. Spending time on the road in the car or at the airport. Living out of a suitcase in a hotel or serviced apartment. If you have regular activities like sporting, academic or social pursuits these can be severely disrupted by locum work.
If you have a family you may have some options for them to travel with you to locums. Depending on how needy the hospital or employer is they may even upgrade your accommodation to family accommodation at no extra cost. But at the minimum, you will probably have to pay for them to travel with you. Additional costs such as extra food will probably reduce the financial benefit of doing locums with your family in tow.
Maintaining Registration and Professional Development
I wanted to spend the remainder of this post discussing the issues around continuing professional development for locums.
The Medical Board of Australia has signaled that it will take an increasingly active stance in the process of revalidating doctors (confirming their ongoing suitability to practice) in order to uphold community expectations for quality and safety.
Locum doctors are often left in a vulnerable area when it comes to continuing professional development and demonstrating their ongoing fitness to practice.
And. By the way. As a locum doctor, you are going to also have to think about how you pay for your CPD. Because the hospital is not going to pay for it.
On the other hand, you are probably saving heaps in College fees.
Specialist locums can generally maintain their continuing professional development through their college's CPD program.
However, locum doctors without fellowship who are simply relying on their general registration face a more difficult set of circumstances as there is generally no professional organization that can fully support their professional development requirements.
All doctors will:
– have a CPD home and participate in its CPD programMedical Board of Australia
– do CPD that is relevant to their scope of practice
– base their CPD on a personal professional development plan
– do at least 50 hours of CPD per year, that includes a mix of:reviewing performance
measuring outcomes, and educational activities.
The current Medical Board requirements for medical practitioners who have general registration only (i.e. do not have specialist registration) indicate that such doctors must
- complete a minimum of 50 hours of CPD per year (self-directed program), which must include
- at least one practice-based reflective element; clinical audit or peer review or performance appraisal, as well as participation in activities to enhance knowledge such as courses, conferences and online learning, or
- meet the CPD requirements of a specialist medical college that is relevant to their scope of practice.
Most doctors can make a plan to engage in courses, conferences and online learning. However, the tradition of clinical audit, peer review and performance appraisal is patchy within medicine in general and it's likely that locums with general registration may struggle to revalidate if they are unable to plan for these mandated activities each year and possibly have some support for doing them.
Let's look at each of the mandated practice-based reflections in turn and consider how it might be implemented for a locum doctor.
A clinical audit compares actual clinical practice against established standards of practice. The audit has two main components: An evaluation of the care that the individual practitioner provides, and a quality improvement process. The evidence required by the Medical Board is a certificate confirming completion of clinical audit or a short summary of recommendations and implemented changes or a description of the process that was undertaken and a reflection on what was learnt.
Practically engaging in a clinical audit may be difficult for locum doctors because of time constraints for each placement as well as the ability to access and review clinical records at a later point in time.
Peer review meetings are undertaken by and with peers with the aim of updating knowledge and improving practice through the presentation of one’s own work to one’s peers with the expectation of a free and frank review. Evidence of peer review acceptable to the Medical Board includes documented account of case review or discussion with peer or team and a reflection on what was learned or evidence of log book or diary entry and a reflection on what was learned or a description of peer review activity and a reflection on what was learned.
The practical problem for locum doctors engaging in peer review is coordinating meeting times and locations so that peer group members can regularly attend. This might be overcome with the use of technology and holding peer review meetings online. Although it would be important to consider the security implications of online discussions.
An exciting aspect of a locum peer review group would be the potential to incorporate locum doctors working across a range of specialty areas into a group where one could imagine a breadth of generalist knowledge could be imparted throughout the group.
Performance appraisal incorporates activities that allow the practitioner to review their practice /performance. The Medical Board will accept documentation to show how the practitioner reviewed or improved their practice or performance and a reflection on what was learned or a description of the process undertaken and a reflection of what was learned from the appraisal.
In my opinion, this is probably the simplest of the 3 options for mandated peer-based reflection in order to achieve compliance and could be effectively completed with a performance coach.
What the Medical Board Doesn't Accept as Evidence of CPD
The Medical Board is becoming quite circumspect in relation to CPD evidence. Here is a list of things that the Board will not accept as evidence of 50 hours of CPD per annum.
|Receipts of Courses|
|Non planned and non measured reading online|
|Statutory declarations stating 50 hours of journal reading was undertaken|
|Agendas of journal clubs|
Generally speaking, the Medical Board requires more definitive evidence of the 50 hours of CPD, examples of which would include certificates of attendance, certificates of completion, evidence of questions being attempted and log books of readings.
What Areas of Medicine Can I Locum In?
Locums can pretty much find work in any area of Medicine these days. At a Consultant level hospitals are often looking for locums in all of the common specialties, including Physicians, Surgeons, Psychiatrists, and Critical Care Physicians. There are also a surprising amount of Medical Administration locums advertised on a regular basis. And of course, there is general practice.
At a non-Consultant level, you can also easily find locums in all range of specialties but critical care (mainly emergency) and psychiatry tend to be the most common along with medical registrar roles.
How Do I Choose a Locum Company?
How Long Should I Locum For?
It's difficult to categorically answer this question. Some doctors have turned locumming into a long term career quite successfully. Some doctors go into locumming planning that it will just be a temporary year or two away from training or permanent work but then find themselves enjoying the work and the lifestyle it provides.
Perhaps the question should be “How Long Should I Locum For. Before I Consider Locumming to Be a Career?” As I have indicated above. Whatever part of Medicine you are in it is important to maintain your standards and professional development.
I'd recommend that if you have been locumming for more than two years then you should review your professional development approach.
Even if you are a Specialist and under a College CPD framework you probably want to think about how working as a Specialist Locum affects you differently than working in a permanent role and a team. Establishing a Peer Review group with other Locums in your Specialty may make sense or perhaps joining an existing Peer Review group of Specialists who work in your field in permanent roles.
As a non-registered doctor, there will come a point where it is difficult to maintain your professional development through a College. There are a few alternatives, such as enrolling in Masters programs at University but the CPD from these programs only lasts as long as the program lasts.
Again a Peer Review group probably makes sense as well as organizing for a regular performance assessment. You should also try to develop a CPD plan at the start of each year to address current gaps in skills and knowledge and consider asking your locum employers for feedback on your strengths and weaknesses.
A career coach may be useful in guiding you through some of these processes.
Is it Possible to Make a Career As a Locum?
Yes. One could make a strong argument for obtaining a Fellowship first to support the locum choice. But there are doctors who have forged a career successfully locumming. At the present time, there is high demand for locums and there has never really been a time when a degree of locum doctors have been necessary to compliment doctors working in permanent roles. As we have highlighted above a key consideration is how you stay current in your practice.