The Journey of the Locum Tenens

There are no books written by, or even about, locum tenens psychiatrists. Why is that? Why is their story-the story of psychiatrists who "hold a place," participate a bit, and then move on-not shared? Is there nothing in their experience worth sharing? Are locum tenens psychiatrists merely "rolling stones" who not only gather no moss but also have no wish to leave a mark? My experience suggests otherwise. Here are some observations from one psychiatrist-trained in psychoanalytical psychotherapy only to be retooled, first as a psychopharmacologist and then as an HMO-era warrior-who abruptly shook off the moss and started rolling.

It was not adventure or time for travel I craved when I initially signed on. I was neither hungry to observe novel treatments nor to experience fresh insights; that just happened along the way. And I was not looking to compare practices in different behavioral health care settings. I simply wanted time to think and a chance to practice psychiatric medicine somewhere away from all the commotion.

Initially, I thought I would retire. After all, I had been a director of education and a medical director. I had practiced for many years in my community, in both the public and private sectors. I was board-certified, had done research, and had even published. I had also felt, for quite a while, out of touch with the wonder and satisfaction that used to accompany our ceremonies of healing. But I did not want to become a sort of movable patch, either-one view of the locum's function. On the other hand, a nurse practitioner had just replaced me at the clinic where I had been a staff psychiatrist for 18 years. That meant I had some serious thinking to do, and getting away to do it seemed the ticket.

I had not anticipated, in this new landscape, finding myself practicing psychiatry in ways that ran against the grain of my prior training and intuition. To my surprise, I found myself doing so with equanimity. For example, while working with veterans at a Veterans' Affairs facility in southern Arizona, I learned an important lesson about dealing with trauma. Some traumatized patients benefit by facing their pain, thereby gaining insight and wisdom. But others do better by turning away from that pain. Rather than seeking wisdom, these patients seek only life, light, and laughter-that is their path to healing.

While working in Appalachia, I had an epiphany: sometimes behaving well without insight takes priority over misbehaving with insight. I remember the woodsman who lost a leg, started using cocaine, and became increasingly withdrawn and needy over the years. Finally, his wife, who had invited their daughter to come home to have her baby there, ordered him to pull himself together or leave-no matter that he had just been hospitalized with a major depression and thoughts of suicide. His depression disappeared overnight. He was bright and upbeat the next morning, socializing and eager to return home and help out. Neither husband nor wife blinked when I told them his admission urine was positive for cocaine. Neither was interested in continuing the hospitalization to process and understand what had just happened (as if it all came down to behavior anyway). Changed behavior, I came to recognize, is as likely to be followed by a change in thinking as the other way around.

While working in a public hospital in New England, I observed the wondrous corrective power of staff "splitting" and the gratifying benefits to the patient when a doctor "manipulates" him or her effectively. I am thinking of one woman with a character disorder who kept losing hospital privileges because of her destructive behavior. She continued to behave destructively because her privileges were repeatedly taken away, trapping her and the hospital in an interminable, self-defeating cycle. She was as unlikely to control her destructive behavior as the hospital was to bend the rules.

I blustered to her about how such rules were impossible and unfair ("How can you stand it here?"). With annoyance in my voice, I vowed I would do something about it for her (seeking not only to own her distress but to "steal" her issue as well). I stormed in and out of my meetings with her, manifesting anguish as I updated her on my travails against "the system." Meanwhile, she quietly dropped that bone, behaved herself, followed the rules, regained her privileges, and was discharged home unconditionally the following week. She remained stable, well functioning, and "under the radar" when I checked on her many months later.

When I practiced in Massachusetts, I never felt right about comforting a patient with a touch and had scrupulously avoided doing so. Yet while working with Native Americans in the Southwest, I intuitively and genuinely responded to a request for a hug with a hug. I believe it was my work in the unfamiliar milieu of the American Indian nations of the Southwest, in fact, that began breaking up my old ways of thinking and stimulating new ones. There I found myself increasingly inspired to reexamine some of the knotty clinical problems that crossed my path, which, in turn, encouraged me both to think and to act "outside the box." And not only did I feel good doing this, I also felt right about it afterward. Locum psychiatry became my new practice.

I now travel with my wife as my companion and scout. Sometimes we take along Rosie, our English Springer Spaniel. We decide which part of the country we wish to visit, when, and for how long. I then select the type of psychiatric facility I want, submit my application, and wait for offers. Looking back, I see how invigorating my initial encounters with locum practice were for me, both in New England and in the Southwest. In the course of my subsequent assignments, I have watched clog dancing in North Carolina, taken a jeep tour up and down the steep hillsides of an old mining town, gone on a Navajo-guided horseback tour of Canyon de Chelly in Arizona, and visited artists' studios in New Hampshire.

I still ponder whether there is something about locum practice per se that facilitates thinking outside the box, especially for a conservative psychiatrist such as myself? For instance, might being the outsider-outside the loop of local culture-help shake up one's thinking? If so, being an outsider clearly has an upside. Or maybe it is my feeling that colleagues give me space and cut me some slack, allowing me to turn down the distracting noise of "old tapes" with their many shoulds and oughts. (In all my locum experiences, I have yet to hear the word "productivity.") It is as if the observing participant within me, free of such distracting noise, becomes more receptive, more observant of what my patients are showing me. Indeed, I experience a sort of paradox as a locum; my sense of professional isolation actually heightens my connection with both my own sensibilities and those of my patients. When I feel that pull to "connect," to be touched by another, or simply to be in touch with my inner self, I feel it more keenly.

These are just my own experiences, of course. Locums are, after all, an invisible brotherhood, devoid of a communications network, organization, competition, or rank.

The locums I have met are mainly established clinicians with varying reasons for putting themselves through the detailed and annoying credentialing and licensing processes that go with locum practice. Their reasons range from finding temporary work between permanent positions to wanting to go where it is warm every winter; from wanting to be near family part of each year to wanting to visit America; from avoiding the onerous practices of managed care to rethinking career options (as in my case). In any event, we are invariably welcomed where our planes land, urged to stay on, thanked for our contribution, and nearly always invited to return.

Moreover, locum practice offers me a pleasant procession of "secondary learning curves," acquainting me with numerous cultural, historical, and spiritual aspects of American life. And somewhere along the way, my locum experience has renewed that sense of wonder and satisfaction in psychiatric practice that I had lost. My locum work has also inspired me to begin writing again-particularly about encounters with people who teach me something or scare me; who make me smile or confound me; or who simply bring tears to my eyes.

And if psychiatric locums are indeed rolling stones, it seems we do leave a mark: a clinic keeps its certification, an inpatient unit brings down its census, a colleague gets much-needed time off, or an administrator catches up on sleep-all because patients are seen. Seeing patients, after all, is at the heart of locum practice. And patients are seen because we hold a place-perhaps a place for them.