Final thought…

Dr Euan Lawson, a portfolio locum GP from Kendal, steps out of the surgery and into the wild to explore the peculiarities of locum craft

I like to think of locums as the Ray Mears of the GP world. All GPs will use a wide variety of skills each day, but locums need to be resourceful and determined to survive and thrive in the primary care jungle.

Never trust a rich GP or a thin survivalist and Ray is a well-fed fellow who looks like he has mastered his art.

Wholly attuned to a hostile yet beautiful environment, Ray declares that bush craft is “the art of the possible”; a useful approach for doctors developing their own locum craft in the modern NHS.

You have to be prepared to rough it a little as a locum. There are some practices where I’ve worked in every single room in the building and I’ve been shunted around like an ugly, unloved occasional table. I once ran a clinic in a toilet block in Bosnia and that was more salubrious than some of the consulting rooms to which I’ve been banished.

Locums have to be hardened to the often disturbing insight into the psyche of the GP on whose territory they are squatting. Foraging is a key skill in locum craft and the ability to track down a microbiology form in teetering tower of QOF paperwork is not something that can be learned in a clinical skills lab. The top drawer of a GP’s desk is a source of rich pickings for essential forms and usually reveals the obligatory packet of tramadol amongst the yellowing vintage sick notes from the 1980s.

There is no doubt that a little resourcefulness goes a long way. Many GPs wonder how locums can manage patients without detailed prior knowledge of their old problems. I won’t dispute the clear advantages of continuity of care, but I think the answer lies in a little used arcane technique deployed by locums known as... history taking.

As essential as an antler-handled knife to Ray, your history-taking skills should be honed to perfection if you want to achieve mastery of the art of locum craft. A locum examining a patient should be reminiscent of a tracker stooped over fresh rhino spoor, but personally I recommend drawing the line at stool inspection in the surgery.

It is worth bearing in mind with locum craft that there are many predators and the natives need to be handled with care. I’ve been winched into a Borneo jungle, but it wasn’t as unnerving as being metaphorically parachuted into a failing practice. The receptionists lurched around like hungry bears rudely woken from hibernation and the patients were practically baying at the door. Even in good practices patients seem to be worryingly prepared to badmouth their own GP to a locum.

My preferred technique is to nod empathetically while simultaneously wobbling and tilting my head in a non-committal fashion. I often try to throw in a little “it’s a rum do” grimace to emphasise my solidarity.

In locum craft there are subtle warning signs of impending danger that should be studied and learned. Some of these will be familiar to all GPs: patients with lists, or anybody on diazepam who attends late on a Friday afternoon.

Occasionally, the storm will strike a locum without warning. This week a patient came into my room with the not uncommon opening gambit of “but you’re not my usual GP” and I feared the worst. I sat quietly and tried manfully to exude empathy as I passed the tissues. Her face crumpled and after a minute or two of repressed sobs she got up and left. I felt like I had just been caught out in the open in a sudden and unexpected deluge.

I paused and reflected for a moment. What would Ray do? What is needed is an early warning system and all practices have them. In fact, they usually have several and the simple act of treating them like human beings will be enough to activate the defence. Making tea for reception staff can even result in adoption as the unofficial practice mascot or introductions to eligible daughters.

So Ray may suggest that “knowledge doesn’t weigh anything” but he has obviously never considered the ultimate survival resource for locums – the senior receptionist. I would guess that neither has he tried carrying the complete collection of Oxford Handbooks around every practice in the county. There’s still room in my bag for a gadget or two and although a satnav may be a touch more Bear Grylls than Mears, I would wager that Ray has never had to juggle an EMIS printout and a dog-eared map as he toured the local council estate in a downpour on a late visit.

Ultimately, any GP can turn up and see a waiting room full of patients, but there is a crucial ecological niche for savvy locums in the general practice wilderness. There will be scant appreciation on the patient satisfaction surveys to show for your locum craft, but it is possible to do much more than just survive the experience. And as Ray almost said: “the great thing about locum craft is that wherever you go, the skills go with you”.