Career Resources articles posted on NEJM CareerCenter are produced by freelance health care writers as an advertising service of the publishing division of the Massachusetts Medical Society and should not be construed as coming from the New England Journal of Medicine, nor do they represent the views of the New England Journal of Medicine or the Massachusetts Medical Society.
Career Resources Editor’s Note: Surprisingly, more than a third of U.S. physicians worked locum tenens in 2008. Young physicians and those who have the retirement horizon in sight remain prime candidates to find temporary work in geographic and practice setting locations of their choice. Minimal nuclear family commitments, a flexible, independent mindset, and a hands-on approach to evaluating career transition options facilitate and drive successful locums experiences. Locums physicians must also be prepared to maintain meticulous financial records, be responsible for their personal health insurance, and deal emotionally with the initiation and eventual termination of time-limited professional relationships.
— John A. Fromson, M.D.
Physicians at all stages of their careers are exploring the flexible, portable practice option.
By Bonnie Darves, a Seattle-based freelance health care writer
A decade ago, physicians who elected the free-spirited locum tenens lifestyle — as a way to try out practice settings or merely explore new places — tended to cluster at either end of the career spectrum: doctors just out of training and those nearing retirement.
Those two groups still account for the majority of medical professionals who take temporary assignments, an estimated 60 percent, but there’s a shift afoot. Surveys conducted in recent years have found that a growing number of physicians who might be deemed “mid-career” are looking to locums as either a bridge to a potential career change or a semi-permanent practice option.
For New York City internist and infectious disease specialist John L. Ho, MD, locums has proved a good foundation for making his move from a 22-year stint in academia to the next chapter — whatever that may be. He is working as a hospitalist at Southern Maine Medical Center in Biddeford, filling in for a physician who is currently serving in the National Guard. He landed in coastal Maine after completing his first Staff Care assignment at rural Eastern Maine Medical Center.
“I always maintained my love of acute care medicine, even though my major activity at Cornell was research based. I truly got tired of running from grant to grant,” Dr. Ho said. “I am enjoying these assignments and all of the patient interactions I have now,” said Dr. Ho. He also likes the non-urban setting far more than he expected. His colleagues have been welcoming and collegial, and the patients surprisingly cordial, based on his previous experience in a large urban center. “They’re much more grateful. They actually say ‘thank you’ — and that has been gratifying,” he said.
Marci Malone, MD, is among the growing number of physicians who take locum tenens assignments regularly in addition to working full time in a practice. In fact, many colleagues look at the New York anesthesiologist quizzically when she talks about spending her “vacation” working locum tenens in remote corners of the Southwest. Since 2001, she has spent roughly a month each year working at Indian Health Service (IHS) hospitals in places like Gallup, New Mexico, and isolated Chinle, Arizona, where she has gone several times. “I have a hard time taking a vacation, so this is my idea of what to do with my spare time,” Dr. Malone said.
She finds both the work and the setting a welcome reprieve from the urban rat race, and the facilities, contrary to what some physicians might expect, she observed, are modern and well run. “The facilities may not be completely computerized, but from the anesthesia standpoint, they have almost all of the toys any of us could want,” she said. “The case load is different at IHS hospitals than at urban centers, however, because we’re not usually dealing with typical ER patients. The cases can be less demanding because most of the patients who need surgery, even if they have four comorbidities, have received a lot of regular and preventive care.”
The OR workday is often slightly shorter than her typical New York shift, but the call duty can offset that plus. “It can be just as brutal at times,” she said. Those challenges are easier to deal with, she added, because she enjoys the patients. She has grown especially fond of the Navajo Nation patients she cares for during her Arizona assignments. “They are very gracious people who have little but are willing to share what they have. Working with them helps me reset my expectations about life,” Dr. Malone said.
Survey Offers Snapshot of Changing Marketplace
The 2008 report on temporary staffing trends from Staff Care, Inc., of Irving, Texas, captures the changing demographics in locum tenens: last year, 48 percent of physician respondents to a nationwide survey indicated their intention to continue working locums for more than three years, up from 39 percent five years earlier. Similarly, 35 percent of respondents reported that they expect to remain in locums work for up to three years, compared to 25 percent in 2003. In addition, 55 percent of the physicians who participated in the survey had been in practice for more than 20 years, more than double the number (26 percent) from the 2003 report.
Following are other key findings from the 2008 Staff Care report and other sources:
- An estimated 36 percent of U.S. physicians worked locums at some point in 2008, up from 30 percent in 2003. Of physicians new to locum tenens work, the breakdown is roughly half primary care and half specialty care, rather than predominantly primary care doctors.
- In a recent Merritt Hawkins survey of 12,000 physicians, 7.5 percent indicated their intention to work as locums in the next one to three years. Prorated over the entire physician population, that translates into approximately 60,000 doctors.
- The biggest demand for locum tenens physicians is in primary care, which accounted for 40 percent of Staff Care’s requests in 2008, up from 20 percent five years earlier.
- Sixty (60) percent of physicians working as locum tenens take one to three assignments annually, and 24 percent accept four to six.
- The vast majority (79 percent) of locums doctors cite flexible scheduling options as the chief attraction to locums work.
On an anecdotal level, many mid-career doctors seeking locums assignments candidly cite personal reasons, according to Katie Abby, executive vice president of Vista Staffing Solutions in Salt Lake City, Utah, and immediate past president of the National Association of Locum Tenens Organizations (NALTO). “When we recent[ly] surveyed our doctors, more than half said they had chosen locums practice as a way to avoid burnout,” she said. “That’s not something we heard as much in the past. Of course, we’re still seeing many older physicians who choose locums because they view it as a great way to extend their careers.”
Groups, Hospitals Eye Locums for Short- and Longer-Term Needs
From the hiring-entity standpoint, most practices and facilities bring in locums doctors to address temporary needs, such as covering for physicians on maternity leave or those called for active military duty. But changes are taking place in this area, as well, as health care organizations attempt to cope with market issues, noted Aaron Ray, senior vice president of Staff Care. “In most cases, hospitals and groups are using locums physicians to maintain revenue and services while they seek permanent candidates, who are increasingly difficult to find,” Mr. Ray explained. In the Staff Care survey, 65 percent of respondents who hire locums cited that dilemma as a key reason for using locums, and 53 percent pointed to preventing revenue loss.
Primary care remains the key source of demand for locums physicians, with the hospitalist, anesthesia and behavioral health sectors not far behind, Mr. Ray noted. He added that opportunities are on the rise in the fast-evolving telemedicine arena, including dermatology, radiology, and pathology jobs, among others. “Telemedicine is actually the only new niche we’re seeing,” he said.
The current economic downturn appears to have little negative effect on the locum tenens market in terms of job opportunities. In fact, the economic climate actually appears to be spurring demand in some sectors, Ms. Abby observed. “What we’re seeing is a trend in which large medical groups are bringing in locum tenens physicians on a longer-term basis, possibly because they are reluctant to make a permanent hire in the current economy,” she said.
One perennial source of assignments — government health care facilities such as the Indian Health Service and Veteran Affairs — has seen some growth in recent years, Ms. Abby added. “These assignments also tend to be very gratifying for the physicians who take them,” she said.
Physicians’ Reasons for Choosing Temp Assignments Run Gamut
Most physicians who take locums assignments cite both personal and professional reasons. Among young doctors, the biggest attraction is the opportunity to see the country — or the world — and to experience different practice settings at the same time.
That’s what led North Carolina native and emergency medicine physician Mark Hill, MD, to the Bay of Plenty in Tauranga, New Zealand. “Locums attracted me because I wanted to get a taste for the different types of jobs out there, and I like traveling,” said Dr. Hill, who has been working locums since completing his residency in 2006. “I also appreciate being able to see different types of patient populations.” He practiced in central California and the San Francisco Bay Area and in coastal Virginia and North Carolina before taking the yearlong New Zealand assignment.
Dr. Hill admits that the itinerant lifestyle has its ups and downs. “Locums is great, and I’d recommend it to any newly minted doctor who is free and single. But now that I’m married with a kid, it works less well,” he said.
For Brooklyn, New York, internist and hospitalist Alice So, MD, the locums tenens lifestyle is the perfect personal and professional fit. “I like change, and I’m always looking for something new to do. So this works well for me, because it’s dynamic, and it gets me to parts of the country I might not see otherwise,” she said. “I’ve worked in the Finger Lakes [region of New York] and rural northern New Hampshire, and this summer I’ll start an assignment in Indiana.”
On the professional side, the locums practice enables Dr. So to devote half of her time to her medical-legal consulting business, which she launched in 2005. The exposure she receives as a locums to different hospitals, management, and operational structures has proved a somewhat unexpected asset to her business, which focuses on reviewing plaintiffs’ malpractice cases to determine whether or not they should proceed to court. And she thinks locums practice is a valuable experience for any hospitalist who is considering eventually going into program management.
Like Dr. Hill, Dr. So thinks locums work is best suited to single physicians because of the constant moving and the potential stress on personal relationships. But she cautions that any physician considering locums should thoroughly research both the assignment and the location before accepting the job. “If you’re going to relocate your family, definitely go and check out the location first. As a single person, I also check the national census data for crime rates in any place I’m considering — and I only go to safe places,” she said.
On the contractual side, Dr. So advises physicians to set parameters regarding what they will and won’t do and to obtain a highly detailed job description in writing before accepting an assignment. “This is crucial, because you don’t want to end up in a situation in which you’re being treated like a house doc, or where the schedule or call is not what you were told,” she said. “And don’t be afraid to ask questions about those details.”
Dr. Ho offered several nuggets of advice for anyone considering locum tenens assignments for the first time. First, be clear about why you’re seeking locums work, “whether it’s financial, professional, or personal,” he said, and set your practice parameters before you start evaluating assignments. He also advised physicians to interview with several agencies to get a sense of how they work and the types of assignments they have before making a commitment. Finally, he urges doctors eyeing locums to take a longer look at the “temp” life before jumping in. “I think it’s very important to think about how you will turn the locums experience into a positive one,” he said.
Working Locums: Upsides, Downsides, and Misconceptions
Working locums tenens offers physicians considerable flexibility, but working freelance also means doctors have to take care of many details they might not have handled when they worked in permanent positions. For starters, a locums physician must purchase his or her own health and disability insurance, pay taxes on a quarterly basis and keep meticulous financial records, and create a personal retirement plan. And, of course, there’s no such thing as vacation pay or other benefits. For these reasons, physicians contemplating a switch to locums practice should consider working with an advisor to ensure that personal financial and retirement planning needs are addressed proactively.
On the plus side, locums firms handle contract negotiations and credentialing and licensing details and costs. Compensation, paid on a per-diem basis, tends to be competitive, with commensurate physician salaries according to specialty and region, and in most cases, is nonnegotiable. Medical malpractice insurance and tail coverage costs are assumed by the locum tenens firm. Some agencies assist with practical issues such as securing housing (usually a hotel or extended-stay apartment) and transportation at the assignment location, and some contracts include housing, travel costs, and other relocation resources. However, physicians should be prepared to do that legwork themselves, especially if they have special needs or circumstances.
Locums tenens industry executives and physicians dispel the following commonly held myths about the “temp” practice life:
Myth: Practice opportunities are scarce. Reality: It was once assumed that locums assignments usually involved either undesirable locations or practice environments, but that’s not the case anymore. With the possible exception of places like Manhattan or downtown San Francisco, assignments are available in most parts of the country — in rural, suburban, and urban locales — and, increasingly, in international locations, as well. Most locums firms go to considerable effort to place physicians in locations of their choosing, especially if the physicians are working locums full time.
Myth: The locums lifestyle suits most physician personality types. Reality: All sources interviewed for this article agreed that locums practice is a poor fit for physicians who either require a great deal of direction or desire a consistent work structure, and being personable and prepared to fit in are musts. “It’s not for physicians who want to be coddled,” Dr. Malone maintained, or, Dr. Hill added, for those “who aren’t comfortable living in a hotel or out of a suitcase.” Dr. Hill advises locum tenens physicians to actually go out of their way to fit into the new environment by taking cookies to the nursing staff or setting up social gatherings with colleagues.
Myth: Locums attracts physicians with poor work history and competency issues. Reality: This is far from the truth. Physicians who work locums must have a good practice record and documentable skills and are as thoroughly vetted by hiring agencies as their counterparts seeking permanent positions. In addition, surveys show that hiring facilities routinely rate locums’ skills as very good. Respondents in the 2007 Staff Care survey readily acknowledged that locum tenens doctors treat as many or more patients as their permanent colleagues and tend to spend more time with patients, as well.
Locums physicians are expected to work hard wherever they go, contrary to what some doctors may think. “Some people in academia think locums is for people who ‘can’t do it anywhere else,’ but the truth is that you have to be at the top of your game to do this work — and you’re expected to be able to go right to work in most cases,” Dr. Malone explained. “It’s almost a different set of skills that you need, because you have to step up to the plate immediately.”
Myth: Locum tenens doctors won’t be accepted by their “permanent” colleagues. Reality: This might have been an issue three decades ago, but that rarely happens now. For the most part, colleagues are often so desperate for help or so concerned about the impact of short staffing on patient care that they welcome locums physicians wholeheartedly. In the recent Staff Care survey, two-thirds of respondents reported that locums physicians were accepted by their colleagues and administration. Nonetheless, it behooves a doctor working as a locums to ensure his or her prospective colleagues are aware of the situation and have been briefed on the locums physician’s assignment and expected duties. Ideally, the physician contemplating a several-month assignment will have had either on-site or extensive phone discussions with prospective physician colleagues.
National Association of Locum Tenens Organizations (NALTO): (407) 774-7880; www.nalto.org.