It’s the holiday season again. But before packing any bags, what are the best steps to ensure continuity of care for your patients and your practice’s wellbeing while you are away?
Suzanne Riley is used to speaking with doctors long overdue for a holiday.
But, as manager of locum programs at the NSW Rural Doctors Network, even she was shocked when she recently spoke with a general practitioner and asked him when he had last had a locum.
“I haven’t had a locum”, he said.
“What do you mean?” asked Ms Riley.
“Well, when I got married 12 years ago we moved to this town and we opened up this practice. I’ve worked for 12 years since and now I want to take a break and see my family again.”
Ms Riley says that is the longest stint without a holiday she has come across.
“You don’t get that too often, but you do get it from time to time.”
She also occasionally receives surreptitious phone calls from practice staff who are concerned about a doctor’s health and are trying to find out what’s needed to arrange a holiday.
Earlier this year, a white paper on doctors’ health by the Royal Australasian College of Physicians (RACP) suggested that, at any one time, one in three doctors showed symptoms of burnout, including exhaustion, cynicism and lack of interest.
Taking proper breaks from practice routine has long been identified as an important factor in preventing and treating burnout.
So, how to arrange a holiday for your own health, while also ensuring the continuing wellbeing of your patients and your practice?
The approach varies depending on the style of the practice, whether you are a sole practitioner or part of a group practice, and whether you have commitments to hospital rosters or other similar ongoing obligations.
In all cases, it’s best to begin planning at least 3 months ahead. It allows time to get a locum where required and provides enough notice for those arranging hospital rosters.
At Sydney’s Northbridge Medical Practice, the practice manager, Deborah Whiley, sends out her first enquiries about Christmas holiday dates as early as September.
For some specialties, the lead time can be even longer. For obvious reasons, obstetricians may need to allow 8 or 9 months’ preparation for an extended holiday in order to reduce their patient list and minimise any difficulties for the doctors covering their patients.
For similar reasons, doctors in other specialties should reduce the patient list when going away for an extended period. It helps to simplify the work shared among colleagues staying behind.
“It means not doing anything too complex before going away”, says AMA (NSW) President, Associate Professor Brian Owler. “Trying to time things so that, for professional courtesy, you don’t leave stuff for other people to pick up if you can avoid it.”
Professor Owler is a Sydney-based paediatric neurosurgeon who works across a number of public and private hospitals. He says that whenever he or one of his colleagues goes away, other specialist neurosurgeons working in the area will cover for them in an informal arrangement.
“It’s good for the patient that if you are going away you don’t do anything too big just before you go away, but sometimes that’s just unavoidable.”
In many cases, particularly for smaller general practices, planning a holiday means arranging for a locum to fill the vacancy. Time is also a factor here. Ms Riley advises that 3 months is a good period in which to find and secure a locum for work in a country area.
The NSW Rural Doctors Network and other rural workforce agencies offer a complimentary service to help find locums for those in rural and remote regions, and can provide limited subsidies for travel and other costs. There are also many private locum operators that can provide locum services for urban, regional and remote practices for a fee.
Payment arrangements for a locum are often decided between the practice and the locum directly and can be in the form of a daily fee, of $1,000 to $1,200 per day or more. Alternatively, payment can be determined as a percentage of the practice takings — perhaps, 70 per cent to 30 per cent or 65 per cent to 35 per cent.
On top of this, accommodation must be provided and travel expenses covered.
“You’re never going to make money with a locum”, Ms Riley says, but the benefits will outweigh the costs involved.
Whether you have a formal locum arrangement or an informal agreement with colleagues, it is important to allow for handover and hand back. Handover should introduce the covering doctor to the idiosyncrasies of the practice and patient list. It can be done with a telephone call or, when possible, face to face.
Difficult cases should be explained, and the patient load and expected work hours should be outlined. It’s also an opportunity to discuss any unusual aspects of the position.
Handover also has medicolegal ramifications, as the absent doctor’s patients are considered to be in a temporary shared care arrangement. A handover briefing provides evidence of this arrangement.
From the perspective of patient care, handover also allows continuity of service for patients and guards against misunderstandings or mishandling of difficult patients. In particular, it can help prevent a locum becoming vulnerable to unscrupulous patients targeting the visitor, a frequent occurrence according to Ms Riley.
The hand-back procedure provides the same information when the covering doctor finishes up.
After all the preparation to depart, how important is it to provide some way of being contacted during the break? When possible, leaving a telephone number or email address is good in case of emergency.
But new technology makes it feasible to stay intimately involved in clinical work from just about anywhere on the planet. It’s now practical to reassure patients, make referrals and even check scans from the beach, mountaintop or anywhere in between.
Professor Owler says he sometimes regrets having such close contact while on holidays.
“I have a practice nurse who works with me and she’s often around when I’m away so I will get an email with an update, or a phone call going through the issues, pretty much every day.
“The good thing is that you can respond to problems and sometimes it’s just a matter of reassurance. That’s an easy thing to do. But it means that if there are problems, you sometimes go away and question whether or not you actually are on holiday!”
Nevertheless, Professor Owler says he is still looking forward to the next opportunity to pack up and take a break.
Given the track record of doctors past and present who have embraced such multifaceted careers, with greater recognition and encouragement, the benefits for the individuals involved, the broader health system and society in general could well be significant.
1. Allow time for a handover and hand back.
2. Discuss the expected patient load. Don’t expect the locum to be able to do the usual number of patients per hour because all your patients are new to the locum.
3. Create a referral index including phone numbers for specialists, how to ring the hospital and who to talk to. Have all contact details easily accessible.
4. Provide orientation to the practice software.
5. Put the locums in accommodation that you would stay in. Ensure that if they’re there for an extended period of time they can wash their own clothes and make their own meals.
6. Always ensure there is a written agreement (which can be in an email) between the locum and the practice on what the pay and work hours will be.
7. Try to ensure there is a means to communicate with you (such as mobile number or email) in case the practice needs to contact you.
At the Northbridge Medical Practice on Sydney’s North Shore, plans for who would and wouldn’t work over this Christmas were made in early September.
With nine general practitioners to share the workload, locums aren’t necessary to cover holiday absences, but small adjustments are made by the staff on duty.
“We ensure that we don’t have more than one doctor away at a time”, says practice manager, Deborah Whiley. “Christmas is usually quieter anyway.
“Generally there is not too much demand. People are too busy to go to the doctor.”
It’s a matter of first-in, best-dressed when it comes to determining who can go on holiday at any time of year. The sooner Ms Whiley is told, the sooner the holiday time can be confirmed.
According to practice protocol, if there are two doctors away, no further doctors are able to take leave. “The doctors realise that we need to be able to provide coverage for our patients.”
Ms Whiley gets the ball rolling for the Christmas period at the beginning of September. “I start asking questions: ‘What’s going to happen this Christmas?’ Who’s here?’ ‘Who’s not here?’ ”
She then sends a list of the dates and names around to all the practice doctors in late October to confirm the arrangements and ensure that those who are not going away can commit to the days they have been rostered to work.
When the holidays finally come, the practice is fully computerised so the covering doctors will have easy access to patients’ entire electronic records including specialist letters, pathology reports and images.
“It’s all very straightforward”, she says.
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