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Dr. Val, The Traveling Physician: Living La Vida Locums, Part 2

On Assignment In California Vineyard

This post is the continuation of my personal thoughts and reflections about what it’s like to work as a Locum Tenens (traveling temp) physician.

Q: Where are the most favorable locums jobs?

This is an interesting question and depends a little bit upon personal taste and priorities. While most locums physicians choose their work based on location (see this nice survey of locum priorities), more experienced locums docs choose their work based on circumstance. What I mean is that it’s more important WHY the hospital needs you, than where the hospital is physically located. It only takes one really bad assignment to learn that lesson the hard way. For instance, if a hospital is recruiting a locum tenens physician because the place is so bad that no one will stay in the job, then I can pretty much guarantee that it won’t matter how nice the city/town/countryside is nearby, you will not enjoy your time there.

Positive prognostic indicators for a good locums assignment include:

1. The person you’re filling in for needs vacation coverage or are on maternity/paternity leave. They are happy with their job and are eager to come back.

2. The hospital is undergoing a growth phase and needs help staffing new wings/wards.

3. The hospital is operating in the black but happens to be in a rural area where it is challenging to find enough physicians to meet the patient needs.

Red flags:

1. The medical director/staff physician “doesn’t have time” to talk to you about the assignment before you commit to doing it.

2. There is more than a second-long pause when you ask the medical director why he/she would want to work there as a locums.

3. The person you’re filling in for was fired due to incompetence or negligence.

4. The person you’re filling in for is on the verge of a nervous break down from overwork, and a locums agency was called in to prevent implosion/explosion type scenarios.

5. There have been multiple staff (nursing usually) strikes at the hospital in the past 6 months.

7. The group with whom you would work is not culturally diverse – and you can imagine having difficulty gaining acceptance by them.

In my experience, you can enjoy living anywhere temporarily if the people and circumstances are pleasant. A nice post-work dinner/coffee with friendly, competent staff – even in a “backwater” setting – trumps a solo trip to a high end, big city restaurant when you are emotionally and mentally exhausted by the misery of a bad hospital. Trust me on this.

As one locums hospitalist put it: “Generally I’ve found the rural hospitals to be the nicest, especially in the midwest. But I’m never going back to South Dakota in the winter.”

Q: How can I negotiate the best salary?

First of all, you need to know that this is a negotiation. When I first started, I just assumed the salary I was offered required a binary response: “Yes, I’ll accept the position,” or “No I’ll keep looking for other opportunities.” That’s why I’m a physician and not a business woman, I guess! Just ask my husband.

Anyway, after a few experiences of getting paid a lower salary than my peers at the same job, I realized the error of my ways. In many cases you can lobby for up to 25% higher pay rate, so you should keep that in mind. In summary, here is where the salary “wiggle room” is:

1. How much overhead your agency charges. Remember the “platinum” agency I referred to in my last post? If you’re working with one of the agencies that is known to be “expensive” then they have more money that they could share with you. If you’re working with a budget agency who competes based on low overhead fees (such as 20% above your base salary rate), then you’ll never get more than $5-10 more/hour from them.

2. If you have a good track record. Once you’ve proven yourself to be an excellent physician, well-liked by the hospital staff where you’ve been assigned, the agency is going to want to keep sending you to new assignments because you’re more likely to get requests to return and will stay longer at each gig. The agency (and the recruiters) make money based on how many hours you bill, so they’d rather send a “sure thing” to a new client than an unknown. They will be more likely to up your salary to seal the deal, knowing they’ll probably get more hours with you in the long run.

3. How desperate the client/hospital is. This is sad to say, but desperate clients will pay higher rates to fill a need. If you’re being offered an unusually high salary for a certain assignment, don’t rejoice, worry (see notes above about “red flags.”)

4. If you bundle. Some enterprising primary care locums docs get together to negotiate group rates. That means, if you have a friend or two who can agree to travel together to a particular place, the agency can pay a higher salary to each of you because they’re getting a larger volume of hours overall. This works really well for internal medicine locums, for example, where hospitals often need multiple docs at a time. It’s actually a brilliant plan, because the people who do it are already sympatico, they have similar work ethics, can share call, sign out to each other, have built in friends to enjoy after work adventures, and arrive as a well-oiled machine. I think this is probably the future of primary care locums. However, if you’re like me (a specialist in a small field) there’s no way to bundle because no hospital ever needs more than one of you at a time. ;-)

5. If you take longer assignments. This stands to reason. If you are going to be working for months (rather than weeks) at a certain hospital, then you have more room to negotiate a larger hourly rate based on the volume principle I described above.

Q: How do locums agencies decide how to match you with a given job opportunity?

Based on my experience, the agencies’ order of priorities for matching physicians with clients are:

1. Whoever is available and answers their phone first. The Locums world is very dog-eat-dog for the agencies. It’s a daily race to see who can present physicians to fill needs the fastest.  Hospitals are looking for the lowest cost solution to their staffing gaps, and will shop multiple agencies for the same positions at once. The agency who brings the first acceptable C.V.s wins the work. Sometimes when there is controversy over which agency gets the job, the client has to review email time/date stamps to verify which came first. Sometimes it’s a matter of minutes. So… if your recruiter’s voice sounds a little tense, you’ll understand what’s going on in his/her world. And if you’re hungry for locums work, be sure to respond promptly for consideration.  That being said, once you’ve established a track record with a few agencies, you’ll have turn away business year-round (especially in primary care).

2. Client preference. Once your C.V. has been presented to the client, they will choose their preferred candidate (if there is more than one option). Usually, they are looking for someone local or whomever will generate the lowest travel expenses. I wish that clients delved a little deeper than that, but my experience is that cost trumps coolness for them most of the time. And when I say “coolness” I mean – wouldn’t you rather have a candidate who writes well, has an unusual background (say – someone who has built medical websites and has been a food critic and cartoonist? Ahem?) than just another chem major straight out of IM residency? Apparently most would say no thanks. Just give me the cheaper one.

3. If they know and like you. Let’s say there are two equally qualified physicians for the same position already screened and signed up for work at a certain agency. If one of you has a track record of being flexible and easy to work with (rather than a demanding, entitled brat – like a few doctors you may know) then the recruiter will put the “nice” person’s CV on top and market you more strongly to the client. Why? Because she doesn’t want to receive whiny phone calls every other day during your assignment about how you don’t like the hospital food. The recruiters have “quality of life” issues too. If you’re lucky and you develop a good, long term relationship with your recruiter, they’ll probably even do YOU a favor and give you a head’s up about upcoming opportunities at the “good” hospitals. And we all know what that means.

4. Whoever will take the lowest hourly rate. In the end, it’s still all about the Benjamins so if there are 2 equally qualified physicians who are similarly “non whiny” then if one will work more days or at a lower rate, then they are more likely to get the job (due to recruiter influence on client preference). But given the large number of positions and the small number of locums to choose from, this game is 80% about who’s available first. Then the rest of the variables follow.

Q: What is the licensing and credentialing process like? How do I make it easier?

The state licensing and hospital credentialing is the most painful administrative part of the whole locum tenens assignment process. If you’re considering an opportunity in say, North Dakota, then you’ll need to get a state license there (Unless you already have one?) as well as passing the scrutiny of the rural hospital credentialing committee where you’ll be working. And yes, everyone seems to want original copies of the intern year you did 15 years ago at the hospital that has since closed. You feel my pain?

There is good news and bad news about this. The good news is that the Locums agencies have hired staff to complete the medical license and credentialing paperwork for you. That is part of the “value” they bring to you as an agency. The bad news is that some of their staff can’t spell. Or they get the chronological order of your residency/fellowship years wrong, etc. thus generating MORE work for you in the long run, correcting errors rather than filling in blanks.

The middle road is to fill out the paperwork correctly yourself the first time, and then offer copies to the agency staff for future licensure/credentialing. They can transcribe better than synthesize, so this seems to be the best way to go, IMO.

Hospital credentialing is nuanced, and depends on the culture of the local hospital in terms of how many references they require and how much documentation detail they request. Some hospitals are swift and lean, others comb through your background as if you are a likely convicted felon.

That being said, one thing is certain – if you plan to work several different locums assignments your referrers are going to be nagged TO DEATH. Everyone needs 2-3 professional references who will be called/contacted mercilessly, first by the Locums agency to make sure you’re not a “problem person” (as described in Part 1), then by the hospital who is considering hiring you (not that they’ve committed yet), then by the credentialing committee (if you pass approval in the first round), then by the state licensing body. So for every potential locums assignment, your professional reference will likely be contacted 4 times, and asked to vouch for you verbally or on paper/via fax. Imagine how many assignments you’ll do in a year and the math gets pretty scary. Be sure your references are ok with all this attention… and give them fair warning. If you can, spread the pain and broaden your reference base.

Q. What advice do you have for Locums agencies?

1. Physicians talk. Whatever sneaky deal-making you’re doing (such as paying people different rates for the same gig or getting a 50% premium at a desperate hospital and then not sharing it with us in salary upgrade) is going to come to light at some point, so keep your nose clean. Please be honest about problem hospitals and work conditions. I know that clients mislead you about work conditions and expectations so as to lure locums to their facility – but try to go the extra mile to figure out in advance if the doctors are really going to be asked to see 16 patients a day or 26 patients a day. Because if we get to the site and we’re being abused and overworked, we associate the negative experience with the agency that put us there. Then you try to wheedle and cajole us into finishing the assignment based on the contract we signed so you can make your cut. Meanwhile we’re putting our careers in danger because we can’t do a thorough job and might miss something important. Not good for physician retention. Better yet, just say no to crisis clients. The money isn’t worth it.

2. Treat us right and you’ll make more money in the long run. I know you’re under pressure to save money on our travel and hotels, but you also have some flexibility in the room rate that you’ll consider. Put us in a nicer hotel for a few bucks extra per night and the whole experience will seem a little brighter. Put us on the preferred rental car program so we don’t have to wait for 2 hours in a rental car line after a full day of cross-country travel. Upgrade us to a full size car rather than the beige Corolla we have to live in for months.  These little things end up costing you only a few hours of our total billing, but make your agency our go-to employer.

3. Pay us on time. It’s so simple, and costs you nothing. If an agency takes 3-4 months to pay me for an assignment, and then the billing is inaccurate (missing hours)… I’m going to choose another agency next time. Your value to me is partly in the ease of payment – a direct deposit a week from when I fax my time sheets sends me the message that you have your act together and are respectful of my time. Making me sift through miss-billed records from half a year ago is just not acceptable.

4. Try to understand why we whine. Locums work is not easy. We are often separated from our friends and family, in an unfamiliar setting, learning complicated hospital processes with patients who are sick and dying. We don’t know if the nurses or consultants are competent while we ourselves are under intense scrutiny until the staff gets to know us. We have to build trust, navigate complicated electronic medical records systems, satisfy hospital coding and billing demands, and keep a ward full of patients (with their team of specialists whom we’ve yet to meet) on the path to healing. All this, and we are legally responsible for everything that goes on in the lives of those under our care. When we get home to our Days Inn at the end of our 15 hour shift in our beige Toyota Corolla to find their exercise equipment broken and the lobby overrun with monster-truck rally participants, we may be a tad whiny. Please don’t think ill of us for that. Just do what you can to help us feel better. We, and our patients, will thank you.

***

Dr. Jones is available on a consulting basis through Better Health LLC. She may be reached at val.jones@getbetterhealth.com

Dr. Val, The Traveling Physician: Living La Vida Locums

On Assignment In Idaho

It’s been a couple of months since my last post because I’ve been traveling around the United States working as a locum tenens (in Latin, “place holder” – a more elegant name than “temp”) physician. We’ve all heard of traveling nurses, but more and more physicians are also “living la vida locums,” as it were. There are actually over 100 agencies who find/provide temporary physician coverage for hospitals who need to fill gaps in their full timers’ schedules. You can find out more about these agencies at their trade organization site, the National Association of Locum Tenens Organizations (NALTO).

For those of my peers who’ve been curious about locums work, but haven’t tried it, I thought I’d provide you with some personal thoughts and insights in the form of Q&A. Please feel free to ask your own questions in the comments section and maybe we can generate a nice, interdisciplinary discussion about locums work. I’d love to hear from others who have worked locums!

Q: Why should I work as a locum tenens physician?

If you don’t mind travel and are a fairly adaptable individual (i.e. can learn new EMR systems, staff idiosyncrasies, and navigate hospital politics without excessive angst), then you can expect to make at least 33% more in salary working as a locum (with professional liability insurance, housing and travel covered included). In addition, you have no administrative or teaching responsibilities, coding/billing hassles, or staff management issues. You’re paid an hourly rate for a minimum number of hours, with overtime negotiable. You get to see different parts of the country, and can control where you go and how much you work. (E.g. Summers in Sonoma, winters in Florida… not a bad lifestyle choice.)

Q: What kind of physicians do locums work?

In my experience, there are four kinds of people who do locums work: 1) Retirees – those who have essentially retired from full time medicine and want to keep their hand in clinically without overwhelming responsibilities and work hours 2) Salary Seekers – those who want to make 33-50% more salary and don’t care where they live to do it (they work 22 days/month or more as a locums doc) 3) Dabblers – those who want to work part time because they are busy with another job or family responsibilities and 4) Problem People – those who have personality issues and/or a legal history that make it difficult to hold down a regular job.

I don’t know the relative numbers of these 4 subtypes of physicians who do locums, but I’d guess that 20% are Retirees (Rs), about 10% are Salary Seekers (SS’s), 60% are Dabblers (D’s), and 10% are Problem People (PP’s). I’m a D, and I have met Rs, SSs, and PPs on the work circuit. I’ve also spent time talking to internists and specialists who work as locums physicians so I have an idea of what others outside my specialty are up to.

Q: What’s the difference between locums agencies?

Each locums agency has its own “corporate culture” and some are more attentive to their physicians than others. For example, when you’re traveling en route to an assignment and your flight gets cancelled on a weekend, you suddenly realize how nice it is to have a responsive agency to help with travel triage. Choosing an agency is more than just finding the one that offers the best hourly wage, it’s about how they choose and negotiate with clients (hospitals), how many staff they have to help with payroll and travel, and if the recruiters themselves are patient and attentive. All of this is primarily learned by trial and error – alas. And I think it’s probably time to create a “Yelp” destination of sorts for physicians who are interested in locums work. I wish I had had one!

That being said, what I’ve learned is that agencies vary A LOT in what they offer you and that there is usually about 25% wiggle room in hourly rate negotiation, especially for highly-sought after specialties such as Internal Medicine. In one case, a client (hospital) confirmed to me that two different locums agencies presented the same candidate to them – one was charging $90/hour more for the physician, but the physician had been quoted the same hourly rate by both agencies.

One would think that there would be an advantage to being represented by the “Platinum level” locums agency because they’d negotiate higher pay rates for you, but what happens is that they negotiate high pay rates and then don’t pass it along. In the end, the only hospitals that use those companies are ones who’ve exhausted every other avenue. So if you work for a Platinum agency, you end up with an average salary working in the most difficult situations (i.e. where no one else would go and the hospital, in an act of desperation, had to pay through the nose for you.) In addition, I’ve had a Platinum agency take 3 months to pay me, whereas another agency regularly turned my time sheet into direct pay in 7 days.

So be forewarned – the biggest, shiniest agency might not be your best bet.

Unfortunately, smaller agencies (who may be more generous with salary rates) sometimes suffer from skeleton crew staffing and fall short of being able to triage travel disasters and manage client-related problems (e.g. the hospital said you’d see 12 patients a day but when you arrive they ask you to see 24) as needed.

When it comes to a locum agency, you want someone who’s not too big, not too small, and where you can establish a relationship with a recruiter who is responsive and smart. I cannot stress this enough. Your recruiter is your lifeline while you are on the job. Recruiters don’t just spend their time finding physicians to fill positions, they are the key point of contact between you and the hospital where you work. Their role is to lobby for you, and keep the hospital accountable for your work load and work environment. If the hospital promised that you’d only need to see X number of patients/day, then your recruiter is the one to hold them to that standard. If you are concerned about patient safety because staff members are incompetent in some way, then (believe it or not) your recruiter will convey those concerns to the hospital and get the problem solved.

So overall, your locums experience depends on the corporate culture of your agency, the size and number of travel/credentialing staff they have available 24/7, and the quality of recruiter assigned to your case.

In my next post I’ll cover the following questions:

Q: Where are the most favorable locums jobs?

Q: How can I negotiate the best salary?

Q: How do locums agencies decide how to match you with a given job opportunity?

Q: What is the licensing and credentialing process like? How do I make it easier?

Are Doctors’ Orders Less Likely To Be Followed If The Doctor Is Overweight?

A recent, 358-person survey conducted by researchers at Yale University (and published in the International Journal of Obesity) suggested that patients may be less likely to follow the medical advice of overweight and obese physicians. Survey respondents were 57% female, 70% Caucasian, 51% had BMIs in the normal or underweight category (31% overweight and 17% obese), and were an average age of 37 years old.

Respondents rated overweight and obese physicians as less credible than normal weight doctors, and stated that they would be less likely to follow advice (including guidance about diet, exercise, smoking cessation, preventive health screenings, and medication compliance) from such physicians. Although credibility and trust scores differed between the hypothetical overweight and obese providers and normal weight colleagues, the respondents predicted less of a difference between them in terms of empathy and bedside manner. Respondents said they’d be more likely to switch physicians based on their weight alone. There was no less bias against overweight and obese physicians found in respondents who were themselves overweight or obese.

The study authors note that this survey is the first of its kind – assessing potential weight bias against physicians by patients of different weights. Previous studies (by Puhl, Heuer, and others) have documented weight bias against patients by physicians.

While the study has some significant limitations (such as the respondents being disproportionately Caucasian, thin, and female), I think it raises some interesting questions about weight bias and physicians’ ability to influence patients to adopt healthier lifestyles.

Considering the expansion of pay-for-performance measures (where physicians receive higher compensation from Medicare/Medicaid when their patients achieve certain health goals -such as improved blood sugar levels), being overweight or obese could reduce practice profit margins. If patients are less likely to follow advice from overweight or obese doctors, then it stands to reason that patients’ health outcomes could suffer along with the doctors’ income.

I’m certainly not suggesting that CMS monitor physician waist circumferences in an attempt to improve patient compliance with healthy lifestyle choices (Oh no, did I just give the bureaucrats a new regulatory idea?), but rather that physicians redouble their efforts to practice what they preach as part of a commitment to being good clinicians.

Some will say that the problem here is not expanding provider waistlines, but bias against the overweight and obese. While I agree that weight has little to do with intellectual competence, it does have to do with disease risk. Normalizing and destigmatizing unhealthiness is not the way to solve the weight bias problem. We know instinctively that carrying around a lot of extra pounds is damaging to our health. It’s important to show grace and kindness to one another as we join together on the same health journey – a struggle to make good lifestyle choices in a challenging environment that tempts us to eat poorly and cease exercising.

To doctors I say, let’s fight the good fight and model healthy behaviors to our patients. To patients I say, show grace to your doctors who carry extra pounds – don’t assume that they are less competent or knowledgeable because of a weight problem. And to thin, female, 30-something, Caucasian survey respondents I say – Wait till you hit menopause before you judge people who are overweight! ;-)

True Medical Detective Stories: A Great Little Book

I just finished reading True Medical Detective Stories, Dr. Clifton Meador’s personal collection of medical mysteries. Dr. Meador is a prolific writer and the former dean of the University of Alabama School of Medicine and professor at Vanderbilt School of Medicine. His 50+ years in the academic arena have exposed him to some delightfully rare and bizarre medical cases, and he shares his top 18 in this pithy little book.

Dr. Meador was inspired by Berton Roueché, a staff writer at The New Yorker, who helped to popularize the medical detective story genre in the 1940′s and beyond. Each vignette is between 3-5 pages in length, making for a very quick and entertaining read. In choosing to review this book I was very tempted to give away details of some of the cases in order to entice you to read it, but I have resisted the urge so as not to spoil the fun.

Broadly speaking, the stories include a rare case of intractable hiccups, a bizarre infection caused by sexually deviant behavior, and several examples of the power of the mind to inflict bodily harm on oneself and others. In each situation, the underlying cause of the symptoms or disease is uncovered through careful listening and analysis. Often, human shame and fear must be managed before the truth can bubble to the surface.

I highly recommend this book to healthcare professionals, skeptics, and anyone interested in a fascinating look at some of the most unusual medical cases described in one book. Perhaps we can all learn to become better listeners, or true “medical detectives,” from Dr. Meador’s stories. You can find his book here at Amazon.com. Enjoy!

New Heart Rate Monitor Wirelessly Syncs To The iPhone

Post image for First heart rate monitor to utilize new bluetooth technology and iPhone sync hits the market

The start of January has some exciting new technologies on the horizon. Recently, Wahoo Fitness announced their new product, BlueHR — a fitness heart rate monitor — can sync to your iPhone 4s via bluetooth and without the need for addition adaptors.

All users have to do with the BlueHR device  is to strap it around their sternum, and they will be able to monitor stats such as their heart rate and the number of calories they are burning via their smartphone. It currently uses Bluetooth 4.0 technology, and as such, the only smartphone that currently has that capability is the iPhone 4S.

We wrote an in-depth article about Bluetooth 4.0 when the iPhone 4s was released, commenting on how it could be a boom for mobile health devices due to the following features of the protocol: Read more »

*This blog post was originally published at iMedicalApps*

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