Locums or no?

[Kevin Bacon]

Hello everyone –

First off, I want to THANK all the long time posters (Dr. McNinja, WCI, EmergentMD, Veers, Birdstrike and the list goes on). I’ve been lurking here since undergrad and I can’t say enough how much I’ve gained from your unfiltered thoughts and opinions. That being said:

I'm entering my final year of residency and I'm looking for some guidance in planning out my career over the next 1-3 years.

My goal is to work 3-5 non-consecutive months then travel/explore outside interests the rest of the year. My target income is $275,000 to $300,000.

My thought is to get credentialed at 3-6 hospitals within a 3hour radius of Houston or Dallas. Build a relationship with said hospitals over the course of a year, then pick and choose when/where to work, maximizing my per hour earnings by negotiating aggressively.

The roadblock I have now is: Locums or no?

My concerns with Locums are:
- Being significantly shortchanged in my per hour earnings (one attending actually told me they’d negotiate BETTER rates for me as they have more bargaining power)
- Non-compete clauses; as in, if I don’t like where they’re placing me, how difficult would it be from that point to start pursuing my own work within the state?

And my final question: To decompress, I thought it would be a good idea to have a work option lined up where I can show up, have an easier time and still collect a pay check (I would accept a lower hourly rate; but still at least $250/hr ). What does that look like in Texas? A rural setting? A FSED? A place with residents? Urgent care?

Thank you all!!!

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[DarkHorse22]

I too am a resident. So grain of salt etc. But I would imagine it is tricky to make 300K in 3-5 months without working 20+ shifts a month. Even at texas rates.

 

[RustedFox]

300K/year divided by 5 months = 60K/month.

Each month, if you worked 150 hours/month (which is a sure recipe for burnout), that's an hourly requirement of 400/hour.

I will only add that nobody is going to hire you full time to work "only 3-5 nonconsecutive months"... so your only option is locums.

GLMF.

 

[erdoc00]

I think you will be doing yourself and your patients a disservice if you come right out of residency and attempt to only work 3 to 5 months a year.

I understand the desire to get some of your free time back after residency but if you get right out and even only work 5 months over the year, your skills will be garbage and you will be dangerous.

I would get at least a year under your belt as an attending before trying to cut back as much as you are wanting to. You could work 9 shifts x 12 hours per month and still have plenty of free time to do whatever you'd like and also easily earn around the $300k mark. You could probably sweeten the deal to prospective jobs by offering to work nights and/or weekends to get more money or a more desirable location.

As far as locums vs traditional job, I don't think it really matters so long as you avoid working at a poorly managed ER/hospital.

I think the first few years out of residency are actually more important than residency itself. Others can give their input but I think you would be making a huge mistake to come right out residency and work as little as you are intending.

 

[GeneralVeers]

I second the above. The learning continues during your first years out of residency. It took me about 3 years working full-time (at least 1400 hours per year) before I was really proficient and comfortable, not just with clinical medicine, but with patient flow, speaking with attendings, and learning how to deal with difficult patients. At that point you will also have an idea of what you want your career trajectory to be. I think locums is bad to start off with, unless you really need the cash. Going full time for the first two years will give you a stable group of doctors and a medical director who can possibly help guide you. When you do locums, you are often on your own with no one to fall back on for medical or financial advice.

 

[deleted109597]

Third. Yes, it's doable. No, it's not a good idea. Not early in your career. You'll need to build your professional contacts up to do it without locums companies.

 

[Groove]

As others have said, it would be a terrible idea to only work 3-5 months/yr fresh out of residency for all the reasons listed. Personally, I don't have a fundamental problem with locums, especially if your goal is to feel out various practice environments, but I would shy away from FSED or any environment which predisposes you to skill atrophy and doesn't challenge you professionally while stimulating growth. There is a fair amount of tempering and polish that goes on during your first 1-3 years out of residency before you are seasoned and truly capable of handling any situation (clinically or political) with competence and finesse. Don't shortchange yourself.

Why not work 12 shifts/mo doing locums or taking a local gig and block off 7-10d off each month to travel?

 

[da8s0859q]

OP, I'm finishing up my first year as an attending and will back up what the more experienced folks above me have said. There is a certain kind of polishing and refining that happens as an early attending that is best experienced in a more stable/"predictable" environment. Totally get why people say you grow into your own in the first couple or so years out.

 

[emergentmd]

300k for 5 mo of work is very doable esp if you do Locums. That is 60k/mo. At a very easy to find 325/hrx12 hrs, that is alittle over 15 shifts a month.

But as a new resident, I also would never do this. There is alot of EM other than medical knowledge. It take awhile to become efficient and thus a good EM doc. You need to know how to learn the game and gain confidence.

I am at 15+ yrs working in super busy/high acuity EDs. I just started doing full locums and even after 2 wks not doing a hard shift, I feel alittle rusty. 3 months off and I would feel like starting over again.

If you want a bunch of long vacations, I would just Pick up 6 shifts a month or 72 shifts a year and would hit right under 300K for the year.

When you want to take a month off in Jan/Feb, do 6 shifts the 1st week of Jan. Take you 6 wks vacation then work 6 shifts the last part of Feb.

Or if you want to take 2 months of in Feb/March. Work 12 shifts in Jan and 12 shifts in April.

No matter how you slice it, just hit your 72 shifts a year. Seems pretty simple.

But you need to do Locums as no one will want you otherwise.

 

[HooliganSnail]

Another important thing to consider...

Locums gives you a great hourly rate, and they will cover your med-mal, but you get no health insurance, no disability, no 401k match, no dental.

You will need to pay that all out of pocket, which will take a chunk out of your bottom line.

Especially the retirement account. I think it would be prudent to hit the ground running when you are fresh out of residency, where 12-14 shifts a month is still significantly less than what we are used to working, make your money, get on the right track with loans and retirement savings, then gradually dile down the working as you progress through your career.

 

[deleted109597]

Another important thing to consider...

Locums gives you a great hourly rate, and they will cover your med-mal, but you get no health insurance, no disability, no 401k match, no dental.

You will need to pay that all out of pocket, which will take a chunk out of your bottom line.

Especially the retirement account. I think it would be prudent to hit the ground running when you are fresh out of residency, where 12-14 shifts a month is still significantly less than what we are used to working, make your money, get on the right track with loans and retirement savings, then gradually dile down the working as you progress through your career.

Counterpoint is that ~80% of the jobs out there are CMG, and they are all 1099 positions, so they are the same as far as health insurance, disability, and retirement go.

 

[sonofva]

No real input here except that this thread should have been titled "Locums of Nocums?"

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[e30ftw]

Especially the retirement account. I think it would be prudent to hit the ground running when you are fresh out of residency, where 12-14 shifts a month is still significantly less than what we are used to working, make your money, get on the right track with loans and retirement savings, then gradually dile down the working as you progress through your career.

W-2 401k pretax contributions max at 18k for 2017 tax year. An emergency physician starting his/her career at age ~30 presumably with limited prior retirement contributions should be saving at least 40-50k/year for retirement. Few jobs nowadays offer a 401k match afaik, so if you want to contribute more you'll either have to enroll in a separate program or invest post-tax income in for example a 3-fund index ETF portfolio.

1099 employers can form a SEP IRA with a $54k tax deferred limit for 2017, which offers some advantages to the above scenario.

Really limited difference in ability to save for retirement between W2 and 1099, the advantage probably goes to the independent contractor..

The reasons I would not suggest doing locums straight out of residency are:

1. The environment of locums tenens may not be conducive to growing as a new attending and learning all the stuff you missed in residency.

2. It is helpful for your career to have a few years of stable employment at a large hospital system, to establish a pattern of safe/reliable patient care and form relationships with your medical director and coworkers prior to going out into the great unknown of locums.

 

[WilcoWorld]

Many claims above that learning does not stop after residency.

This suggests the following question: Should extend the length of EM residency? Or is the post-graduation learning that the above posters refer to impossible to acquire during residency?

 

[bravotwozero]

My answer would be a resounding NO. Everything you need to know you learned in residency.


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[deleted109597]

My answer would be a resounding NO. Everything you need to know you learned in residency.


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Allow me to fix that for you. Everything you need to know about being a doctor you should learn in your internship. The rest is honing the craft. This continues more than a decade after residency.

 

[e30ftw]

Many claims above that learning does not stop after residency.

This suggests the following question: Should extend the length of EM residency? Or is the post-graduation learning that the above posters refer to impossible to acquire during residency?

I would agree with the latter.

Looking back on residency, I had a bit of a bimodal learning distribution. Intern year was intense; learning procedures, ICU months, lots of exposure to sick patients with a fair amount of autonomy. Second year I kind of coasted, got more efficient and comfortable functioning in the ED, definitely learned a lot but overall not an especially challenging year. Third year I began moonlighting and those experiences definitely enhanced my last year of residency. The actual moonlighting shifts were fairly straightforward, however working on my own changed the way I viewed my residency patients. PD's tell you, "take ownership of your patients" from the beginning but I don't think it really sinks in for many residents while under supervision. Third year I began to view every patient I saw during residency shifts as my own, and began solidifying a work up approach and treatment plan for each complaint, and if my attending wanted something different, I critically examined the reason for the change in management and changed my own approach to the complaint if it was valid. This is something you can certainly do without moonlighting but for me, having that experience definitely enhanced the last year of supervised practice.

Things first year attendings will learn such as how to function in different environments with various resources, primary care stuff, improving communication with other physicians at an attending level, maximizing efficiency/charting while keeping patients satisfied, etc, are not really essential to a residency experience imo and are better learned in practice.

 

[Belleza156]

Does anyone have a contract group they are especially happy with? Are all locums companies created the same?

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[emergentmd]

W-2 401k pretax contributions max at 18k for 2017 tax year. An emergency physician starting his/her career at age ~30 presumably with limited prior retirement contributions should be saving at least 40-50k/year for retirement. Few jobs nowadays offer a 401k match afaik, so if you want to contribute more you'll either have to enroll in a separate program or invest post-tax income in for example a 3-fund index ETF portfolio.

1099 employers can form a SEP IRA with a $54k tax deferred limit for 2017, which offers some advantages to the above scenario.

Really limited difference in ability to save for retirement between W2 and 1099, the advantage probably goes to the independent contractor..

The reasons I would not suggest doing locums straight out of residency are:

1. The environment of locums tenens may not be conducive to growing as a new attending and learning all the stuff you missed in residency.

2. It is helpful for your career to have a few years of stable employment at a large hospital system, to establish a pattern of safe/reliable patient care and form relationships with your medical director and coworkers prior to going out into the great unknown of locums.

I will even one up you on retirement. You can have a W2 and a 1099 job and put 18k in 401k and 54k in SEP. I do this. The W2 job can be part time, prn, or full time. I plan on putting 72K away yearly going forward and have never put in less than 50K a year in a SEP for the past 15 yrs.

 

[LostinLift]

I will even one up you on retirement. You can have a W2 and a 1099 job and put 18k in 401k and 54k in SEP. I do this. The W2 job can be part time, prn, or full time. I plan on putting 72K away yearly going forward and have never put in less than 50K a year in a SEP for the past 15 yrs.

So can one have a nice full time SDG/CMG job and contribute to their 401k and then do locums with 1099 and earn, let's say, 60k in locums, I can put 15k of that in the SEP IRA because the rule is 54k max or 25% of earnings? Or is the 25% of earnings applied to my total income, not just the 1099 and thus you can max out your SEP IRA despite only earning 60k 1099 money?

 

[emergentmd]

So can one have a nice full time SDG/CMG job and contribute to their 401k and then do locums with 1099 and earn, let's say, 60k in locums, I can put 15k of that in the SEP IRA because the rule is 54k max or 25% of earnings? Or is the 25% of earnings applied to my total income, not just the 1099 and thus you can max out your SEP IRA despite only earning 60k 1099 money?

When I did this, I had questions but every CPA I have used states this is no issue. They have alot of docs that has a W2 plus 1099 that does both.

Its straightforward. The W2 18K has no Percent amount. I put the first 18K of pay straight into my 401K. The Sep has the 25% rule and independent of the W2 income.

But to your questions. Yes, you can have a full time W2 + 1099 and contribute to both.

 

[deleted109597]

I do the same with my W2, except it's a 403b. 88% (the most they'll let me) goes into it. Everything else is SEP worthy.

 

[wook]

One point to consider about locums is any activities that you might be required to attend and does the locums company cover it....

For example, I recently stopped doing locums after receiving a subpeona to testify as a witness in a criminal trial on a patient I cared for. The locums company said that they would not cover the time spent in court (even after telling me verbally it was when I initially started to work for them). The hospital site advised that this was not something they covered either.

Soooo, clarify this with any locums company you are thinking of working for AND GET IT IN WRITING. I know a criminal trial which went 8 months (the jury was sequestered for those 8 months)....I don't know how long they had the medical people testify, but I would not want to have to testify for multiple days/weeks without pay. Some states will pay a stipend, but it is usually minimal (I believe it is $8/day in Massachusetts).

Just another point to consider as you weight/consider the options.


Thanks.


Wook

 

[Kevin Bacon]

Locums it is! Thanks for the feedback everybody.

Although it's more than a year off, I'll make it a point to report back on my experiences and drop whatever pearls I can.

Besides the pay, part of the reason I'm choosing Texas is the malpractice environment. Like most doctors, I genuinely want to do right by my patients. At least there I’ll be somewhat shielded by unscrupulous patients and lawyers.

Finally, there was a strong commentary regarding stunting my professional growth by working so little. I think it’s a fair critique. As cliché as it is, I’m going to be a lifelong learner whether I’m 1 year or 10 years out of residency.

Regret is a powerful thing, and if I don’t take responsibility for my own happiness and take a (calculated) risk; then really I’m failing myself. Fortune favors the bold!

PS – I’m with you all on maxing out the retirement vehicles in low cost index funds I see you WCI!!

 

[Doc1981]

Hello everyone –

First off, I want to THANK all the long time posters (Dr. McNinja, WCI, EmergentMD, Veers, Birdstrike and the list goes on). I’ve been lurking here since undergrad and I can’t say enough how much I’ve gained from your unfiltered thoughts and opinions. That being said:

I'm entering my final year of residency and I'm looking for some guidance in planning out my career over the next 1-3 years.

My goal is to work 3-5 non-consecutive months then travel/explore outside interests the rest of the year. My target income is $275,000 to $300,000.

My thought is to get credentialed at 3-6 hospitals within a 3hour radius of Houston or Dallas. Build a relationship with said hospitals over the course of a year, then pick and choose when/where to work, maximizing my per hour earnings by negotiating aggressively.

The roadblock I have now is: Locums or no?

My concerns with Locums are:
- Being significantly shortchanged in my per hour earnings (one attending actually told me they’d negotiate BETTER rates for me as they have more bargaining power)
- Non-compete clauses; as in, if I don’t like where they’re placing me, how difficult would it be from that point to start pursuing my own work within the state?

And my final question: To decompress, I thought it would be a good idea to have a work option lined up where I can show up, have an easier time and still collect a pay check (I would accept a lower hourly rate; but still at least $250/hr ). What does that look like in Texas? A rural setting? A FSED? A place with residents? Urgent care?

Thank you all!!!

I worked in Maryland and had a fantastic experience. You just have to find the right group / company to work for. I made more than $165/hour depending on how many shifts I would sign up for. travel , hotels and everything was taken care of. I can provide more info if you are interested.

 

[miacomet]

One point to consider about locums is any activities that you might be required to attend and does the locums company cover it....

For example, I recently stopped doing locums after receiving a subpeona to testify as a witness in a criminal trial on a patient I cared for. The locums company said that they would not cover the time spent in court (even after telling me verbally it was when I initially started to work for them). The hospital site advised that this was not something they covered either.

Soooo, clarify this with any locums company you are thinking of working for AND GET IT IN WRITING. I know a criminal trial which went 8 months (the jury was sequestered for those 8 months)....I don't know how long they had the medical people testify, but I would not want to have to testify for multiple days/weeks without pay. Some states will pay a stipend, but it is usually minimal (I believe it is $8/day in Massachusetts).

Just another point to consider as you weight/consider the options.


Thanks.


Wook

I just went through this, and my job would not pay. I am employed. Funny, they pay the nurses.

 

[miacomet]

W-2 401k pretax contributions max at 18k for 2017 tax year. An emergency physician starting his/her career at age ~30 presumably with limited prior retirement contributions should be saving at least 40-50k/year for retirement. Few jobs nowadays offer a 401k match afaik, so if you want to contribute more you'll either have to enroll in a separate program or invest post-tax income in for example a 3-fund index ETF portfolio.

1099 employers can form a SEP IRA with a $54k tax deferred limit for 2017, which offers some advantages to the above scenario.

Really limited difference in ability to save for retirement between W2 and 1099, the advantage probably goes to the independent contractor..

The reasons I would not suggest doing locums straight out of residency are:

1. The environment of locums tenens may not be conducive to growing as a new attending and learning all the stuff you missed in residency.

2. It is helpful for your career to have a few years of stable employment at a large hospital system, to establish a pattern of safe/reliable patient care and form relationships with your medical director and coworkers prior to going out into the great unknown of locums.

I love anyone who mentions the three fund portfolio, fellow Boglehead traveler: )

You really do need to be saving AT LEAST 40k a year as a new 30 YO attending. It would be advisable to save 100k a year for a few years. My job offers a tiny match (10k) and I don't know of any employed jobs that don't. You can certainly make up the difference with a Backdoor Roth or after-tax savings.

Who isn't getting a 401k match? That's NUTS if you are employed. Nuts.

 

[GonnaBeADoc2222]

I worked in Maryland and had a fantastic experience. You just have to find the right group / company to work for. I made more than $165/hour depending on how many shifts I would sign up for. travel , hotels and everything was taken care of. I can provide more info if you are interested.

$165/hr? Is that a typo? Or maybe this was many many years ago? I hope so cause that's an awful rate for locums...and pretty bad for a local full time job too.

 

[BoardingDoc]

I worked in Maryland and had a fantastic experience. You just have to find the right group / company to work for. I made more than $165/hour depending on how many shifts I would sign up for. travel , hotels and everything was taken care of. I can provide more info if you are interested.

Echoing what GonnaBeADoc222 said. That rate has to be a typo. It's significantly lower than I would expect to get paid as a W2 employee with benefits. As a locums doc? That rate is just insulting unless you're seeing something like 1 pt every 3 hours.

 

[miacomet]

For the record, that's less than locums for the IHS. That's low. Although I do get many emails with similar rates!