“The best way to predict the future is to create it....”

–Abraham Lincoln

The Oxford Dictionary defines “locum” as a person who stands in temporarily for another member of the same profession, especially for a physician, chemist, or member of the clergy.

By its very nature, a locum tenens assignment is temporary. This could entail very short periods (one to two weeks) or perhaps six to 12 months. At times it may be recurring and could be one to two years in length. The time period is dictated by the institution and, of course, by the locum physician.

Why go locum?

There are multiple reasons why a physician would want to choose such a path. As Dr. Philip Morgan wrote in the British Medical Journal “Locum work is flexible and interesting. It gives the doctor the chance to see many aspects of medicine without the requirement of a long-term commitment early in a career,” (BMJ 1997;314:S2-7074). Hence, autonomy, flexibility, and financial incentives are perhaps the three most important reasons to pursue this path (BMJ 1997;314:S2-7074).

Financial enticement was cited in Societe Francaise d'Anesthesie et de Reanimation (SFAR) as the motivation for young anesthesiologists and intensivists (YAI). To quote this article, “Locums are frequently practiced by YAI's who consider this activity greatly beneficial financially but also in their training, complimentary to hospital rotation” (Anaesth Crit Care Pain Med 2019;38:85-6).

In and of itself, autonomy provides the physician with the option of working as many hours as one desires, with the luxury of choosing the institution, city, and state of choice.

With independence, one is not bound by all the rules and regulations of the institution as applied to the permanent staff members, e.g., mandated overtime, participating in committees, etc. The hours of work are set, and if one is so inclined to work beyond the specified hours, the client is obligated to compensate for the extra time. The agreement is delineated in the locum's agency contract, and any changes are handled by the staffing consultant.

Additional reasons for embarking on the locum's journey are a desire for travel and adventure. One might choose an assignment close to home (visit family and friends) or a place where there is time to explore the local environment (be it city life with restaurants, theaters, etc., or outdoor activities such as hiking, camping, rafting, or fishing). Incidentally, assignments in states like Alaska and Colorado may be taken up fairly quickly.

Another important aspect (especially for recent residency and fellowship graduates) is the enhancement and cementing of skills learned in various specialty programs. Not all sites are accepting and embracing. To quote Dr. Phillip Morgan again, “Locums are the Cinderellas of the profession who are rarely liked, badly treated, unrepresented, but always needed” (BMJ 1997;314:S2-7074). The goal is to learn different approaches to medicine in an unfamiliar setting and take as much knowledge and skills afforded by the institution as possible.

Finally, depending upon the number of hours worked, a locum's tenure generally pays substantially more than the permanent position. An important caveat: a 1099 form is issued, and taxes, social security, etc., are not automatically deducted. Healthcare and CME expenses are the responsibility of the physician.

How to proceed

If the locum tenens path has been chosen, there are two ways to proceed. One can contract directly with the hospital or utilize an agency (there are at least 200) that helps with credentialing, travel, and timely reimbursement. It is important to note the agency works for the client and not the physician. With the increase in demand for locum positions, one must negotiate for the most favorable pay package (asamonitor.pub/3yttvyL). A reputable agency will address all concerns and maintain good rapport. Before accepting a locum tenens contract, one should be comfortable with remuneration, travel expenses (including hotels, car rentals, airplane travel), and malpractice insurance coverage. Regarding travel, request the agency book at places where one can get bonus perks. These can amount to complementary hotel stays and car rentals for personal use.

Concerning malpractice insurance, it is imperative to obtain an occurrence policy and not a claims-made (this would suffice if tail coverage were provided). Hence, read the contract diligently.

When negotiating with an agency of choice it is critical that the prospective candidate be aware of what the assignment entails. “The hospital is the most common site for specialist recruitment (37%) followed by ambulatory surgical centers (25%) and trauma centers (17%)” (BMC Health Serv Res 2018;18:981). If indeed one has settled on one of the options above, query the staffing agency about the caseload. The median caseload for the tenure was reported as “between 8 (IQR 5-10) and 10 (IQR 8-15)” (BMC Health Serv Res 2018;18:981). “General surgery cases are the most requested (74%), followed by orthopedics (54%), and OB/GYN (51%)” (BMC Health Serv Res 2018;18:981). In regard to compensation, the hourly rate in the sample was $186.19 (BMC Health Serv Res 2018;18:981). This figure should at least be a negotiating tool.

Once there is an agreement with the agency, and the medical licenses, board certifications, ACLS, PALS, ATLS, DEA, etc., are submitted for credentialing, it will take four to eight weeks for completion of the process (Road Warrior Physician. 2016). To expedite obtaining state medical licenses, use the Interstate Medical Licensure Compact (IMLC). Twenty-eight states participate in this program, and it takes approximately two weeks to be licensed.

Assuming the assignment is on track and the agency has dutifully completed the credentialing process, one has to keep in mind that medical, dental, vision, and life insurance are not covered by the staffing company. Obtaining coverage is the sole responsibility of the contracting physician.

Since there is not a 401K plan, the individual can set up a Simplified Employee Pension (SEP) IRA, which in 2021 has a maximum contribution of $57,000. All the income with expenses are reported on IRS form 1040 Schedule C (asamonitor.pub/3ytjCkO). It is incumbent upon the physician to seek advice from an accountant in regard to claimed deductions and quarterly taxes. For additional information visit www.irs.ustreas.gov.

Get to know your assignment

Prior to the day of assignment, an effort should be made to familiarize oneself with the physical aspects of the institution. This would include the location of the parking lot, hospital entrances, and the anesthesiology department as a whole. Upfront knowledge of these will make for a smoother transition for your assignment.

Before starting your shift, carefully review the schedule to familiarize yourself with each case. In a fee-for-service environment, higher reimbursement cases are typically taken by the permanent staff, and challenging cases are often relegated to the locums. Expect the day to be busy – after all, “good money is being paid to the locum.” Be ever mindful of the patient's welfare and seek consultation as needed.

Not for everyone

In the end, whether one is looking for a temporary position, i.e., working one to two weeks per month/site or trying to transition from locums to permanent status, explore the possibilities and settle for what feels comfortable.

Locum tenens is not for everyone. The isolation, lack of camaraderie, and time spent away from one's home base can be challenging at times. Having said that, the opportunities afforded by a locum's position make it a very viable consideration. Embark on the journey and build your own future.

Ashok C. Kewalramani, DO, DABA, DABFM, Staff Anesthesiologist, University of Minnesota, Minneapolis.

Ashok C. Kewalramani, DO, DABA, DABFM, Staff Anesthesiologist, University of Minnesota, Minneapolis.