Can locum tenens work solve physician burnout?

It’s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction, burnout and even suicide. In fact, some believe that up to a third of the US physician work force is planning to leave the profession in the next 3 years — an alarming statistic.

Direct primary care practices are touted as the best way to restore patient and provider satisfaction. Those brave enough to cut out the “middle man” (i.e. health insurers, both public and private) find a remarkable reduction in billing paperwork, unrecovered fees, and electronic documentation requirements. I know many physicians who have made the switch and are extremely happy to be able to spend most of their time in direct patient care, unfettered by most rules, regulations, and coding systems. They can solve problems via phone, email, text, video chat, or in-office as the need arises without having to worry about whether or not their manner of interaction will be reimbursed.

Direct primary care is probably the best way to find freedom and happiness in practicing outpatient medicine. But where does that leave physicians who are tied to hospital care due to the nature of their specialty (surgeons, intensivists, anesthesiologists, etc.)? Is there any way for them to find a brighter way forward?

I have found that working as a locum tenens hospital-based physician has dramatically improved my work satisfaction, and it may do so for you too. Here’s why:

1. You can take as much time off as you want, anytime you want. Do not underestimate the power of frequent vacations on your mental health. The frenetic pace of the hospital is much more tolerable in short doses. My attitude, stamina, and ability to stay focused is dramatically improved by working only 2-3 week stretches at a time. When I feel good, I can spread the cheerfulness, and I am happy to spend longer hours at work to give my patients more of my time.

2. You can avoid most political drama. Hospitals are incredibly stressful environments filled with hierarchical and territorial land mines. Being a short-timer allows you to avoid many conflicts. Administrators never nag you, or hold you responsible for perceived departmental deficiencies. You don’t need to attend committee meetings or become involved in personality quirk arbitrage. You can stay above the fray, focusing purely on the patients.

3. You learn all kinds of new things. Exposure to different patient populations, hospital expertise and different peer groups exposes you to a broader swath of technology and humanity. No longer will you be tied to the regional practice idiosyncrasies of a single hospital — you’ll learn how to tackle problems from many different angles. That knowledge earns you respect, and serves to cross-pollinate your own specialty, making you — and those you learn from — better doctors.

4. You are free to leave. There’s something refreshing about knowing that you can leave a place that you don’t like without any repercussions. No matter how unpleasant a locums assignment, it will end, and you can saunter off to brighter pastures.

5. You make more money. Believe it or not, locums work can be quite lucrative if you find the right assignments. I know a team of hospitalists who travel the country together, negotiating higher rates since they are a “one stop” solution. Their housing, travel, and cars are paid for by the agency, and they have take home pay (before taxes) around $350,000 per year. I personally think that working that many hours as a locum tenens physician kind of defeats the purpose of avoiding burnout, but some people like to do it that way.

6. You can live in the warm states in the winter, and the cold ones in the summer. Enough said.

7. You can try before you buy. Maybe you’re not sure where you want to sink down career roots. Or maybe you’re not sure you’ll like living in a certain city or part of the world? Maybe your family isn’t sure they want to move to a new location? Locum tenens assignments are the perfect way to try before you buy.

8. You can use your experience to become an excellent consultant. With long term exposure to various hospital systems, you are in a unique position to develop an encyclopedic knowledge of best practices. Sharing how other hospitals have solved their challenges can spark reform at other institutions. You can become a real force for positive change, not just on a micro level, but system and state-wide.

Working as a locum tenens physician may enhance your career satisfaction and promote professional advancement. What it will not solve, however, is the following:

1. You still have to work within the framework of bureaucracy endemic to hospitals. You’ll need to learn to use multiple different EMR systems and fill out most of the same paperwork that you do as a full-timer. This is painful at first, but once you’ve mastered the most common EMR systems (I’ve only really encountered 5 different ones in 2 years of locum tenens work) you’ll find a clinical rhythm that fits into most frameworks.

2. You will be living out of a suitcase. If the disruption of frequent travel is too much for you (or your family) to bear, then perhaps the locums lifestyle is not for you.

3. You will be annoyed by the process of getting multiple medical licenses and hospital credentialing. Agencies try to help with this burden, but mostly, you’ll need to suffer through this part yourself.

4. You will have to live with some degree of uncertainty. Part of the nature of working as a locum tenens physician is that clients (hospitals) change their minds frequently. They try to fill open positions with local staff or hire additional full-timers, using locums as their more expensive back ups. Assignments fall through frequently, so you’ll need to be ready to change course quickly.

Overall, I believe that locum tenens work can provide the practice freedom that many hospital-based physicians crave. If you’re eager to get off the unrelenting clinical treadmill, this is an easy way to do it. At a recent assignment near New Hampshire, I mused at the license plates that I passed on my way to work: “Live free or die” is their state motto. And I think it captures my sentiments exactly.

Val Jones is founder and CEO, Better Health.

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  • SteveCaley

    I believe that the explosion of locum tenens work is a symptom of the healthcare system becoming more rickety, and will make things come apart at the seams. Stating this, I believe that the hospitalist is one of the few positions where locum tenens might work well.

    It seems to have passed into the medical insurance and corporate culture that locum tenens physicians are a good discount, as opposed to hiring. A 1099 physician demands no benefits, gets no time off, has no retirement and can usually be terminated at-will, for whatever displeasure they cause the client.

    Consequently, even though some organizations appear to be advertising for employed physicians, the HR department actually gets more money AND less work by not filling the employed slots; rather, they fill with pre-determined locum tenens contracts at 10-20% savings. The locums companies are lovin’ it – they get to pocket the 10-20% ‘contract negotiation fee’ for placing the warm body in the locum tenens slot. The salary difference comes back to the hiring agency; and HR doesn’t have to do a thing!

    It’s spiffy except for one type of person involved. THE PATIENT. If a patient is in a high-demand, high-intensity situation like in a hospital, the continuity of care is less important. But if Grandma’s never seen the same doctor twice, and it’s always Dr. du Jour who came from Michigan and then went to Oregon after the next followup, you can bet that Grandma’s been seeing locum tenens docs again.

    Loyalty comes from who’s buying your lunch. So if Grandma’s family pitch a fit about her increasing confusion and want an MRI, you might get fired for ordering one; but you only have to stall them for six weeks before it’s off to another place. That produces cost savings, see?

    Locum tenens, like many other concepts in medicine, is originally very good. But when the corporate types get it, they decide locum tenens equals “wholesale price,” just like they call NP’s “discount docs” and put them unfairly under scope of practice pressure. Being a locum is fine – and given the impersonal character of Wal-Medicine that we’re going towards, there will be national Physician Supply Companies that bundle and ship your doctors to you, with an approved Brand Name. Wal-Mart plans to have the most clinics in the US by 2020, and will do it by the equivalent of locum tenens.
    But when issues arise like “do we operate for this apparent appendicitis, or give antibiotics,” there’s going to be less personal urgency about the matter from the McDoctor.

    • Frank Lehman

      You said:

      ” Anything that WalMart does, it’s a symptom of Big Retail, and maybe for garden hoses, it works. But not medical care.So, when issues arise at 2AM like “do we operate for this apparent appendicitis, or give antibiotics,” there’s going to be less personal urgency about the matter from the McDoctor, sorry to say.”

      What is your basis for that statement? How do you know that there will be “less personal urgency?”

      • SteveCaley

        Thank you, Frank, but it’s speculative. If one has a long-term committed relationship with a primary care patient – something that’s now quite rare – it’s a different feeling discussing matters than it is regarding some primary care patient on some panel in the town in the state you happen to be working at. I’m not suggesting that people will not get the legal limit of permissible or tolerable care. But they’re not getting what was once in the relationship.

    • drval

      The “McDoctor” issue is a fair question. There is a risk of harm to the continuity of care in locums practice (esp outpatient med). But consider this: most of the doctors you see during a hospital stay don’t follow you as an outpatient anyway. What you want is a thoughtful, happy, well-rested and highly experienced physician to take care of you as an inpatient. The kind of person who has been exposed to medical practice in many different states – who is not bound by regional idiosyncrasies, internal politics, or cronyism. Locums physicians are probably less biased by peer practice or referral expectations – and free to do what evidence-based medicine dictates rather than cave to protocols that maximize institutional billing.
      Sure, there are bad locum docs – but they don’t get offered repeat assignments and eventually drop out of the pool. As more people choose to do locums, I think the quality will improve through competition for choice assignments. A great doctor takes responsibility for her care quality, regardless if she’s working at “WalMart” or at Harvard. It’s a matter of personal character – and locums is a neat way to enjoy a great quality of life while practicing medicine at the standard you set for yourself. Locum tenens may not be a “race to the bottom” phenomenon, but rather a Darwinian survival of the fittest. It’s just too early to tell.

      • SteveCaley

        Thanks, Val. It is good to have an excellent, rested and cheerful doctor providing hospital care – no matter what their employment and pay method is.

        There’s nothing wrong with boosterism for locums tenens work, but I’m not at all sure that all these wonderful things really turn out with locums. Contracting in general is coming to the forefront, 1099 vs. W-2 employees, and it’s not so that everyone doing this is working out of the contract box based on their desires for flexibility. Most people I’ve run across who are stuck on the 1099 side of the fence WANT to be employees. Then they’d have healthcare and benefits.
        I’m not so sure that more “evolutionary pressure” on physicians to weed out the “bad apples,” as you offer, is going to help everyone by selecting the fittest locum in the fish tanks.

        The current habit is to focus all the quality of care on the personal character of the physician, so your comment that a great doctor takes responsibility for her care quality, regardless if she’s working at “WalMart” or at Harvard might sting a bit for some physicians staying up until 8pm and then going home to their kids – wouldn’t 9:30pm really be what a great doctor would do?
        All in all, your discussion makes me a but unsatisfied. Great things happen when great things happen, that’s true. But that doesn’t mean that great things happen always. Ask the one with the residency of her dreams if she knows she’s fortunate.

        • Bradford Lacy

          I’ll respectfully disagree with you on one point–most of the physicians that I speak with prefer to be 10-99 Independent Contractors. They will often incorporate themselves and form an LLC. I am not a tax professional but they tell me they receive many tax advantages by doing it this way. They can then simply buy the healthcare they wish and get an IRA if they choose.

          • SteveCaley

            I credit you for speaking with far more docs about the topic than I have, certainly. The model can be benign; but it also has the potential for turning very mean under our current reform direction.

  • The Patient Doc

    I’m currently doing locums and love it. After spending two years working at a horrible practice, I thought I was going to leave medicine and go back to school. I was planning on taking a couple months off, but then a recruiter called. Position was ver close to home, part-time, and only a three month assignment so I accepted. Not having to deal with administration is awesome, pay is decent for the work, and I can take whenever I want off. I loved it so much, I extended for another six months. I think locums is a great option, especially since I was terrified of joining another miserable practice. The freedom is refreshing. I am married which does make it hard to travel, but there are short assignments- one week- which are reasonable. Also there are assignments everywhere, so it’s nice to do as a chance to visit my family in other states. The thing I do dislike is not being able to have a continuity with patients, which is why I am more interested in locums to perm options.

  • Bradford Lacy

    All excellent points. It is worth mentioning that some physicians decide to cut their hours back to part time at their permanent job and work the rest of their availability as a locums physician. This gives them some stability every month with the freedom to enjoy the benefits mentioned in the article. On the flip side, some healthcare organizations (such as mine) have decided to cut out or scale back the middleman agency and contract their own locums. This cuts down on the cost of using locums and (sometimes) those savings lead to better pay rates for the physicians.

    • The Patient Doc

      How do physicians go about searching for these jobs without the staffing agency? How are the organizations recruiting?

      • Bradford Lacy

        While my purpose of being on here is not self-promotion, I will say that my company decided to hire recruiters to specifically find locums physicians to contract directly with the hospital instead of using a third party agency. We can now place hospitalist and emergency medicine physicians almost anywhere where we are short staffed. We are certainly not the first to do this, and other hospitals and health systems will sometimes advertise their locums positions directly on their website. It does take a little bit more research and work, but I know a lot a physicians who prefer to find their own locums work.

        • SteveCaley

          What is the difference between a “locums” and a “regular” physician then? The “locums” that you are describing seem to be recruited to work for some entity covering several hospitals. They appear to contract with the hospital, rather than be employed. Is work in your geographic area that seasonal, that the need for physicians is so cyclical? How does this work?

    • SteveCaley

      What is the difference between a “locums” and a “regular” physician then?

      • Bradford Lacy

        The locums are recruited as Independent Contractors to cover “holes” in the schedule until permanent clinicians can be placed. Most of the time these locums physicians are coming from out of town and a majority of the time the help is needed in more rural areas. They get all of the advantages listed in the article, except we recruit them directly instead of going through an agency. Sometimes, if it is a good match, we can convince the locums physician to stay and transition into a permanent role, but usually once permanent staffing is recruited we no longer have a need for that locums physician at that site. Often enough we can find work for them at another site that is having trouble with permanent recruiting.

        • SteveCaley

          That is a pre-employment model, glad you explained it. Other people see locums as a means to travel about to many different places. A third model is Permanent Contract – permanent 1099 physicians.
          Those three models are certainly apples and oranges. The pre-employment model seems the most benign of the three, I’d say.

  • JR

    I worked in fast food for years, and… you do develop relationships with the people you serve.

    “Give me some of that weak coffee!”

    No, don’t make him a fresh pot. Yes, I realize it’s been sitting there on the back burner all day… he likes it that way. He hates fresh coffee.

  • Isis M

    I’ve found in my time doing locum tenens is that the places that need them the most (say 80% of the hospitalists are loccums) are places that have severe leadership issues. The problem is that unless the leadership has an epiphany or get fired the problem persists. While things fall through, most of the time there is work at these place.
    Since I’m boarded in Family medicine, I want to keep my broad skills base so I have a part time urgent care position as a W2 and do hospitalist locums assignment. Since get benefits though my husband, I get money, keep up my skills and none of the adminstrative drama.

    • SteveCaley

      Thank you. There seems to be no way to treat the disease, just palliate the symptoms. Having a locum base rather than community physicians and employed hospitalists, seems like tapping ascites over and over and over and over again.

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