Iris Publishers: Iris Publishers-Open access Journal of Anaesthesia & Surgery

Monday, August 15, 2022

Iris Publishers-Open access Journal of Anaesthesia & Surgery | Locum Lifestyle

Authored by Daniel Laury*,

Abstract

There are approximately 40,000 locum tenens physicians currently working in the United States. The author presents his experience in the industry. Additionally, various topics are explored including liability issues, financial reimbursement, travel, and psychological adaptations. Suggestions are presented to improve the chances of success as a locum tenens provider. This article is written for the current and curious provider in mind giving real world advice.

Review

How does working less, making a good living wage, traveling more and being more happy [1] sound right now? Attractive? If so, consider doing locum tenens work. Here are some pointers gleaned from seven years of experience. The purpose of the locum provider is literally in the Latin definition; for “one holding a place” [2]. I look at it as a temporary employment to help the clinic or hospital fill a need. Common reasons for needing a locum provider include provider retirement, medical/maternity coverage, expansion and just giving on site practitioners a break. Once, while on international vacation, I cut it short to fly back to fill a vacancy secondary to an unexpected physician death. Some even use locum coverage as a working interview. What better way for each party to learn about each other? It certainly makes more sense than spending a day doing real estate drive-bys, going through multiple interviews and walking endless hospital and clinic hallways while trying to remember too many new names. You can do locum coverage as a source of extra income, to keep skills current, for fun or just as a transitional test between your current and your future situation. The age of locum physicians is all over the place so do not automatically count yourself out.

From A Provider’s Perspective There Are Also Significant Benefits

Experiential

I get to see different parts of the country; immersing myself in a way that a vacation can never reproduce. I am exposed to new cultural environments, geography, and foods. Would I have experienced mud racing in Washington, trail running in the Blue Ridge Mountains, listening to Appalachian banjo music, scuba diving with giant octopuses, mountain biking in western deserts, going to a Quinceañera, talked to old time farmers about their heirloom apple trees, snowshoeing at subzero temperatures, trying Shoefly pie and sweet potato cheese cake, hearing about gravity waves presented by the team at LIGO who discovered them…? Doubtful. I also interact with all sort of providers; good and bad, old, and young. This gives me a continuous education more varied than during my residency. You may also find that your foreign language skills are improved thanks to your patients; perhaps, as I did, learning Spanish in Oregon, polishing some French near the Canadian border, dabbling in Haitian Creole, Russian or German depending on location. Additionally, making new friends and acquaintances is a nice way to mitigate boredom or loneliness.

Financially

Informally surveying other providers, I found that the daily rate can be higher than what one can expect as an employee. That comes with the understanding that many benefits will not be available to you. Do not expect life, health or disability insurance, retirement plan options or paid leave time. You will be getting lodging (more about that later), a vehicle rental, coverage for medical malpractice and some transportation reimbursement. It is customary to receive loyalty points from hotel chains, airlines and some car rental companies however you will need to be proactive. Get your programs activated before going on assignment. Keep in mind that some companies will not give you points because they consider it business rather than personal, e.g. Avis car rental will not allow points, but Enterprise will. U.S. tax laws are fluid however generally there are significant benefits to locum work. Talk to your CPA for specific details related to your personal vehicle use, how long you can work at one assignment before you lose the benefits, per diem food reimbursement rates, etc. I have met physicians who travel with their tax-deductible RVs, those who bring along their spouses using accrued loyalty points or upgrade on flights and those who have negotiated pet friendly lodging. Certain things are negotiable, others not. If you are at a location for an extended amount of time, advocate for cookware and extra luggage allowance. You may be able to negotiate for driving your personal vehicle to and from an assignment even if it costs more than a flight. In terms of daily rate there are generally two systems; flat and base with hours worked. I don’t like flat as typically the overall reimbursement is lower, and a bad night will bring down your per hour equivalent to internship levels. Though certain providers, for example in emergency medicine or high risk OB, can do well if the per shift rate is high enough. In the second instance, you negotiate a base rate then add pager carry fee, per hour rates after certain number of hours worked, clinic hours, etc. Let us also address the financial stability issues. You can certainly find months long jobs which provide consistent income streams however generally, I work a few days at a time up to a few weeks per month. The process from application to start date tends to be around three months so advanced planning is critical. Pay is negotiable however it is clear that certain fields are better reimbursed than others, e.g. ED providers make more than we OBGs. Rural jobs pay more. According to recent data from CHG Healthcare, on average across all specialties, physicians who work locum tenens full-time make $32.45 per hour more than permanent-only doctors. Expect to make between $90 and $300/hr. It is also important to realize that you are paid as an independent contractor receiving a 1099 (though advanced practice providers can get W-2s). The locum companies tend to pay through direct deposit weekly provided correct billing is submitted on time. You will get a year-end tax document which delineates how much you made in each state, critical for tax preparation. Consider getting a business only credit card to simplify things further.

A separate paragraph herein is dedicated to food

Will all candor this is a huge issue for us epicures. Though most locum companies will attempt to put you up where you have access to a kitchen(ette), I found that this is rarely successful in rural locations. You will have a microwave and a small refrigerator. You will be surrounded by fast food establishments. If you have dietary restrictions be aware of potential difficulties. Salt restrictive diets, kosher, halal, vegetarian, gluten free… all will require careful planning. Short stints will be easier if you bring your own food however you will be queried by TSA as to why you have multiple Butternut squashes in your carryon (true story). Cookware will be available variably and will take up significant checked-in baggage space if you bring your own. Weight gain is a constant peril when Hampton Inn for example puts out warm cookies at 5 PM or Holiday Inn Express provides free (and high caloric) breakfast. Some hospitals supplement their providers’ diet, others not at all. Good food may be 30 minutes or more away which is beyond the time radius agreed upon based on the medical field. On the other hand, you may end up experimenting with different foods (think fried green tomatoes, Jamaican jerk tofu).

Exercise and health

We all know that physical exercise is important on many levels. It can be difficult though to go for a run when you are tired from an all-nighter or if you are stationed in a sketchy part of town (currently as I write this, the local park where I jog has used syringes, ziploc drug baggies and condoms on the trail). Some hospitals have exercise rooms to use, others have arrangements with the local YMCA or health clubs. Sometimes the hotels will have a fitness room or likewise comp a membership nearby. Generally, I have been disappointed with the quality and type of equipment so consider bringing a jump rope, yoga mat, etc.

Sleep management is critical. Hotels are not all conducive to restful sleep. Noisy neighbors, uncomfortable beds and excessive light incursion are common problems. It gets worse when sleeping at the hospital; accommodations can be little more than an unused patient room or, in one place, directly under the hospital pneumatic tube system. And you can’t wear earplugs as that would also limit your ability to hear your pager or phones. So, do not bring your Ambien but do pack a white/pink noise generator. Which brings up the next point. Many hospitals allow personal phone as an appropriate means of access however check with your carrier on coverage. When I was working in upstate NY, my cell phone would use Canadian towers preferentially costing me international rates. Surprisingly often, personal cell phones may not work in hospitals nor at some rural lodgings. Some opportunities afford lots of sleep and time off, others are brutal. Remember that getting paid twice the normal rate because of high volume then losing the next 24 hours recuperating brings your income back to a standard rate. Some places will also not allow back to back calls, others allow two or three weeks on call straight.

Psychological

Locum is certainly not for everyone. Good candidates are independent, creative and have exceptional people skills, but by far the most important quality that I hear about is flexibility. No, you will not have all of your preferred surgical instruments. Nor will many studies/tests be available promptly or at all. Consultants may be hours away. You will go up against local traditions that may be at odds with nationally recognized standards. Your intelligence will be taxed, for example I am currently trained on 11 different EMR platforms (not counting various builds). The quality of training is all over the board. I have been sent to a large IT class for two days (Wake Forest) and another time have been told that I should ask around if I have problems. Keep in mind that often you are called in to cover weekends and help staff are not readily accessible so get comfortable with the EMR early, ask appropriate questions and keep the help desk numbers handy. Remember that you are compensated for your training. Loneliness can also be difficult. Skype, Whatsapp, etc. help but if that is not enough you can accept only nearby locations that your family can travel to. You are likely to miss some important family dates like birthdays and graduations as well as the unexpected accidents and other crises. You can try to schedule yourself around events however the reality is that often you take what is available because of the insecurity of reliable future work. Your normal support group will also be distant when there are the inevitable professional stressors. Your pets, toys, hobbies, garden … are all at home.

Travel

You will likely generate lots of loyalty points which can be used for more travel upgrades, free luggage allotment, etc. At times, your one checked in piece can be reimbursed but ask the specific locum company. If you travel heavy, you may be incurring extra expenses. They will pay for economy seating and usually will purchase your ticket within 30 days of travel so you can expect limited seating options. If you miss a connection or weather causes cancelations you will have access to travel experts. This will require patience and creativity. I once had to drive hours through a blizzard from Spokane, WA as that was the only way to get to work on time.

Entertainment

Some locales are just wonderful to work in. I have fond memories of taking call from a beach not far from the hospital, or trail running in the mountains at 5000 feet elevation adjacent to the clinic. Try to get a local library card, learn about events nearby, go to lectures, restart Duolingo, use your rental car to explore the environs, go to fairs and festivals, write that article that you have always wanted to (wink wink), binge watch shows, get invited to other staffs’ homes, splurge on a Thai massage, read about the local history… You may be limited secondary to distance when on call but work with it. Another fringe for you autophiles, you get to try multiple different vehicles. I get to test the latest electronics that my old truck at home doesn’t have. I get to live with a car while on assignment, essentially doing a long test drive. Four-wheel drive will be standard depending on locale and season.

The others left behind

Let’s not ignore the other side of you being gone, namely who you leave behind. Your family will need to learn skills that you may have been doing previously. Paying the bills, cutting the lawn, changing a tire, whatever the work distribution was previously may be changed. This can lead to conflict and stress. There needs to be honesty in the relationship as well. Remember Oscar Wilde who stated, “I can resist anything except temptation.”

Success predictors

In preparing for this article, I queried ancillary staff to get their perspectives. Unsurprisingly, flexibility came up as number one. Next, they value provider patience and politeness. They reminded me that I am the outsider there and that they will preferentially advocate for their patients. Good communication skills came up including clarity of intent and language proficiency. They prefer personable providers who are clear in terms of their preferences (though no guarantee that you will get what you request). Respect for their clinical skills was a big one; if a nurse calls you to come in, it is not meant to antagonize you. You will need to be clinically competent and responsive to your patients to flourish. After a while, certain more difficult providers get a reputation on the circuit and find it hard to get future jobs. It is a surprisingly small community; I will sometimes get eight different companies calling on a new opening or I will sign out to the same providers at different sites.

I also talked with various recruiters; they also offered some thoughts. For example, one recalls setting up a physician for a job where he later presented telling the staff how he was going to run the assignment and how the practice did things wrong. Obviously, he was not invited back but it also reflects poorly on the agency and representative. Another huge faux pas is canceling an assignment after accepting it. This puts a great deal of strain on the facility and looks bad for the locum company. As the rep put it, doing that is like the “kiss of death” for future assignments. Admittedly, emergencies do occur but that should be a rarity. Many providers are used to the special treatment afforded to them by their status. From a recruiter perspective, this can make things difficult when setting up lodging and travel arrangements. You will be getting basic flight seats and local reasonable hotels. Expecting a fancy suite for your family, first class seats or a more expensive hotel near the hospital will cause stress on the relationship. No prima donnas please are the recruiter’s request. Treat your rep professionally and you will be amply rewarded. They will fight for you when the inevitable miscommunications occur (my on-calls have been changed at the last minute many times, I have been assigned to clinic though the agreement was call only, hotels don’t expect you…), they will try to get you the best reimbursement, they will help fine tune your CV and get reimbursement for unexpected expenses (the heating system in a rental in winter suddenly died so they reimbursed me for the space heaters, lots of flat tires …). They can be your best friend; put them on speed dial, get to know them, thank them for their help.

Privacy

Being a locum means giving up a lot of privacy. You will be asked pointed questions about felonies, alimony, drug and mental health issues, privileging problems… The National Database will likely be queried, your CV and application will be seen by many people, the nurses will have already Googled you before you show up, gossip happens… I know more than one provider who needed medical attention while on assignment opening up their medical history to local scrutiny despite HIPAA rules. Forget about trying to hide non-salubrious habits; again, I know plenty of providers who were called in to work unexpectedly while imbibing or under the influence. You will be fingerprinted, drug screened, ran through predatory databases, etc. Some hospitals are better than others just like some states and yes, it is invasive and demeaning. We went into medicine to help people not to be treated like criminals.

Professional skills

Just assume that your skill sets will be altered. As a locum OBG, if I am not at a location for an extended amount of time and not in clinic, I cannot expect to generate much GYN surgery. It is critical to log your procedures and proactively choose opportunities if you find your numbers trending down. Most jobs require a minimal number of procedures to get privileges or even insurance coverages. I have seen locum docs have to sign up somewhere that they normally would prefer not to go just to get “get their numbers up”. Another option to boost your numbers is to do clinic coverage. Research those numbers with your locum company representative carefully. Generally, they count the last 24 months and require documentation. I carry a small notebook where I paste every patient sticker and write in the date, hospital, and procedure as it is my responsibility to prove documentation if requested. In addition, I use online memo apps like Evernote to count up procedures. The hospitals may not accurately count operations as your work was billed out under another practitioner’s name or, commonly, when I proctor another provider, they get “credit” instead of me. It is also important to find out your job descriptions at a new assignment. In my OB world for example, some hospitals expect me to do all the circumcisions, at others it will only be the Pediatricians. Clarify early on if you cannot or won’t do certain procedures like second trimester anatomy ultrasound, robotic hysterectomies or abortions. Remember the difference between comfort level, scope of practice and credentialed privileges.

References and licensure

You will be doing lots of paperwork. Every assignment will need a packet filled out (typically 20-60 pages) and a list of three references at a minimum. You will need to keep up on your certifications and licensures. You can negotiate reimbursement for many of these. When I say lots of paperwork, I have averaged one acceptance for each ten that I have been presented to. They may have filled the spot, they might have been “fishing” for future providers, their bylaws clash with your history, you would cost them too much to fly in (generally they prefer local providers), you are of the wrong gender, they require Russian, Mandarin or Spanish speaking skills, etc. It is the nature of the field. Do not take it too personally. The frustration is that you are doing a tremendous of preparation for a job when there is no guarantee that you will be accepted. I have done required online classes only to be told that the slot is now filled or gone through considerable hassle getting fingerprinted at the local police station on my own time when the job is suddenly not available anymore. Cultivate your references. There is a very real threat of reference burn out. In addition, locum often work solo which limits the number of other potential references.

Other thoughts

I was in private practice for about 20 years and also did a stint as an employed physician. As a locum provider, there are no more hiring and firing demands and no dealing with staff disciplinary issues. I do not have to buy capital equipment, deal with insurance reimbursement negotiations, go to departmental meetings (generally), worry about the landscaping, security, or practice promotion. I do not hire IT, decide on new computer programs, and approve staff time off. It is a lot closer to a pure practice of medicine. You are also much more in control of your time. If your daughter is graduating, you can simply decide that you will not work that week. Going to Europe? Fine, just do not schedule any jobs for that time. You can also work different seasons in different areas to accommodate skiing or beach time in winter as examples. I have even negotiated flights to a vacation spot instead of back home as it was cheaper for the company.

To be clear, you can expect to be “dumped” on. After all, you are there to help them so you will see the patient with a BMI of 50 who needs an endometrial biopsy, the manipulative, difficult, rude, and aggressive patients… You will find that you are quadruple booked and get the newest MA to help. Typically, there will be a practice manager who will be tasked with overworking you to cover your cost to the practice. Keep in mind that you always have the right not to return and most contracts have a 30 day withdrawal clause. I have found that many of the poorly run practices need locum coverage for that exact reason; they cannot keep providers happy who then up and go. You may also find yourself supervising other providers, working with APPs, or teaching students. In my case, that is a big plus but there are those who may feel the time commitment or legal risk outweighs the benefits. Read your contract and discuss your options before showing up for work. Also, it is to your advantage to confirm the locum company’s malpractice limits, coverage and tail if required.

Overall, I am glad that I am doing locum work and will continue doing so. I get to travel more, get varied experience, make a respectable living, and enjoy the flexibility of locum. The positives outweigh the negatives. I like my independence; enjoy the new experiences and I do not feel that my income has been significantly impacted. If you are considering this, there is no need to jump all in at once. Maybe try a few weekends a year to test the waters.

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