Residents in a Room

Episode Number: 64

Episode Title: Nontraditional Pathways – Locum Tenens

Recorded: May 2024

(SOUNDBITE OF MUSIC)

VOICE OVER:

This is Residents in a Room, an official podcast of the American Society of Anesthesiologists where we go behind the scenes to explore the world from the point of view of anesthesia residents.

I've definitely noticed the increase in travelers in all aspects of all types of workers, doctors, nurses, etc..

One thing that I thought locums was really good at is exposing you to so many different types of practices and types of anesthesia that we practice.

I would have to learn a lot about, you know, running my own business. These are all skills that we aren't taught in residency.

DR. SARAH EDWARDS:

Welcome to Residents in a Room, the podcast for residents by residents. I'm your host for today's show, Sarah Edwards, a first year anesthesiology resident at the University of Michigan. Looking forward to learning about locum tenants from our guests, Dr. Jennifer Root. We've been hearing a lot about locums, so my fellow resident and I are excited to learn more. Welcome to the show, Dr. Root. Before we jump in, let's meet my fellow resident.

DR. GIDEON LEVINSON:

Hi, my name is Gideon Levinson. I am finishing up my second year of anesthesiology residency at the University of Colorado. Happy to be here.

DR. EDWARDS:

Great. Dr. Root, can you introduce yourself and tell our listeners about your experiences and background?

DR. JENNIFER ROOT:

Thank you so much. Sarah. Hi. My name is Jennifer Root. I live in Columbia, South Carolina. Uh, I've been an anesthesiologist for a large number of years, 27 to be exact, and I have had an interesting path through my career as an anesthesiologist that's a little bit different than most people. When I left residency in 97, uh, my husband and I, who was also an anesthesiologist, initially found a job in a very small town here in South Carolina, working together at a hospital. But within a few years, he got recruited to another town, to a different job, and we were in the middle of trying to figure out how we wanted our lives to be. If we wanted to have kids and how that all looked. And so I took the choice in 2000 to go out and be a locum tenens. Um, but more of a local locum tenens, and I've pretty much done that with a few pit stops along the way for the last 24 years.

DR. LEVINSON:

Amazing. Can you, speaking of, define locums tenants, what is it? But more importantly, what is it?

DR. ROOT:

Not so locum tenens is the Latin for “to hold the place of.” And so this idea historically through medicine was that if someone got sick or if you had an emergent need in your practice, you would reach out to usually companies that would come in and provide that temporary service to help you get through a rough period to help cover for a partner who was out sick, or to just help you in a transition until you could recruit. Now it's become a very different sort of thing, because, in the past it was a short-term sort of fix. It's gotten more and more to be a more incorporated part of the workforce issues that we face and the lifestyle, so to speak, of the different practices and how they, um, flex up to meet the needs. So it's become a very different place in the last 24 years that I've been doing this.

DR. EDWARDS:

That's awesome. Thank you for sharing that insight. I know you talked a little bit about your personal life circumstances that led you to this path, but is there any other, uh, points that attracted you to locum tenens and has it given you what you expected from it?

DR. ROOT:

You know, so it was probably because I had such a very unique position being married to another anesthesiologist. And when you both go out into the world from residency, you know, you're both full of your great education and you want to go out into the world and be this fabulous, important person in a community. But then you also realize that you want to have children and you want to do things in your community. And as your kids grow you you do want to take cupcakes to the, you know, kindergarten. There's a lot of things that drive your time,. And som you start to look at how can we make this work? So you've got to sort of figure out what your goals and priorities are in life, and try to figure this out. And so, as it turned out, the community that I ended up with, with my husband ended up having a lot of needs in a short-term way, and I was able to go out into the community and do so many wildly different things over the years to practice that was kind of cool, because I don't know that had I been put in this position, I'm not sure I would have walked this path and had the really wonderful experiences that I have had. I don't know what I expected from it. From the beginning, it was just my main goal was to stay engaged in medicine, to always practice, to not walk away from something that I loved. But it was kind of interesting through the years how that looked. And it didn't look the same from year to year.

DR. LEVINSON:

Thanks for sharing. Clearly you've been a part of this job and specific career field for so long. What do you see now as some of the main pros and cons of locums work?

DR. ROOT:

Sure. So I think that a lot of people hear the pros and and I will admit the the number one pro is the flexibility. And so if you are raising kids, that's a huge plus to work in kind of a locum situation. A local locums, though not where you're traveling away from your family. Um, there might be a time in your life where you're taking care of sick or elderly parents and doing something where you have the ultimate control over what days you work, where you work, how long you work. It does have, in a lot of ways, the ultimate flexibility working as locums. Another plus is, I have truly never gotten bored because it seems like just going through my own career every couple of years, I seem to have radically changed sort of what I'm doing and the kind of medicine I've practiced. For example, you know, one year would find me literally sitting on the stool personally performing anesthesia in a pediatric ENT center. And the next year it found me at a VA hospital doing the really sick veterans, you know, doing thoracic epidurals and putting in double lumen tubes and doing large X laps. And it was it was always interesting to me to constant change and dichotomy of the different facets that I got the pleasure of, of getting to participate with. And I never got bored or stuck in a rut. So that was one thing that I thought locums was really good at, is exposing you to so many different types of practices and types of anesthesia that we practice.

I think the cons are real, though, and I don't believe that we're talking about them enough. I think that people see the money as being a pro, but realistically, when you dive down into the money and you start comparing apples to apples, I'm not 100% that the money is actually that much better because you end up as a 1099, putting a lot more money out of your own pocket to cover certain expenses. You're putting your own money into your retirement. Um, you know, you may have to cover your own health care. There's a lot of expenses on the 1099 side, plus the fact that you're paying your own self-employment taxes, which, you know, instead of the 7.5% out of your paycheck, it becomes 15. So that's also something you have to factor in as you compare locums versus like a job with benefits as an employee or in a practice as a partner. So the money might look better up front, but you've got to make sure as you evaluate it, you're actually comparing apples to apples.

There's a couple other downsides I think you have to consider. For example, I've always carried really high malpractice premiums because I'm always the low hanging fruit. Anytime I'm in a practice and it's not mine, everybody doesn't always know who I am. The surgeons don't necessarily have that relationship with me. If something bad happens, you're the kind of the easy one to chuck under the bus. And so you've got to really be mindful, as you do a locums career, to make sure that you're covering yourself and your own financial assets with enough malpractice. So that's something that people don't think about. Is your policy big enough to protect what you have?

Um, the other thing that I've found traveling around is there's really not a huge support system. So if you were in a practice with partners and you had a bad outcome, they're all your good buddies and friends. And so, like, they would be right there with you. When you come into a practice and they don't know you or you're traveling around, you don't necessarily have that relationship with people when things go bad and you need that emotional support. Um, I think that you have to be really careful in the locums world because I think burnout is definitely a thing. You just don't have the social supports.

I think also it limits your ability to engage--one of the things I've loved as a physician through my career is getting to engage with communities, state medical associations, legislators, other things that are very community based. And I have had the privilege to be able to do this because I have been a local locums throughout most of my career. I don't travel from state to state. I've stayed within my state through the years, and I love the fact that I've still been able to be a part of my state medical association, and I've still been able to engage on legislative issues because, you know, no matter where I am in what part of the state, it's all kind of the same collective things that matter to a state. And I feel like that one of the downsides with locums, if you're traveling around to different parts of the country, you. You don't ever get to really establish that community or your tribe, right? And you don't get to participate in a lot of things that will help with, um, your growth as a physician and your growth in your career.

DR. EDWARDS:

Thank you so much. That makes a lot of sense. It sounds like you definitely get a wide breadth of practice, but you also have to be your own advocate. So how does being hired by a local agency differ from being hired directly by a practice or hospital? And can you talk about the process and consequences of each?

DR. ROOT:

So I think that's a great question. Um, locums agencies certainly fill in need, right? When a practice finds themselves desperately needing help, there are these corporate businesses and it's their job to bring people into your practice. I have personally never worked for a corporate entity. I've always worked for myself. Um, I've been self-employed and I always went out and found my own jobs through through my state. But I think that it differs a little bit, probably because what I've seen when I've talked to my colleagues that work for the agencies, there's slightly less control. And and what I mean by that is, for example, they give you malpractice insurance. So you're covered. But they're the ones who decide, right? You don't get to go out and pick your own product. Um, if you move into the town—I just had this recently with a friend of mine who's working with a locums company—and, you know, they tell you, okay, we're going to put you in this hotel and we're going to give you X amount to spend. And so it becomes a bit of a process. If it turns out that the hotel is not what you would like to stay in, and maybe you want to go somewhere that costs more. And then so there's a lot of negotiations that take place. So it's just you don't end up with as much overall kind of control of the situation necessarily. I think that's probably the main difference. The way I've done it, it's been 100% in my control. I think working for outside corporations, you do get to decide where you work and when you work, but you don't always get to define the conditions as much. So that's the only thing I would say that's slightly different with the companies.

DR. LEVINSON:

So locums, tenans, workers are making up a larger percentage of the health care industry now than in the past, as you mentioned earlier. Why do you think this pathway is more attractive now?

DR. ROOT:

I kind of wonder if some of this isn't been really accelerated by the post Covid world that we found ourselves in. There seems to be, at least in my feeling, in the health care industry, between the burnout and the anxiety that's really crept into the medical profession, there's this this idea of, well, I'm not sure if I want to go and live in this community and practice. Maybe I'll just go take a locums job so I can go check out the community. Right? I can go see if that's a place I want to live. I want to go see if that's a hospital I'm interested in working at. And so I think that there's just a larger group of people going into locums from the idea that they want to just check things out and kind of look before they leap, so to speak, maybe not feel as comfortable just kind of walking in to a practice on faith anymore. And I'm not quite sure what's driving that, but I think that's what I'm seeing is just a different emotional approach to practice. Quite frankly, when I was going through medical school and residency, I mean, you just knew that you would go out and, um, send out your resumes and go interview at a bunch of different places in a part of the world that that you kind of were interested in living, and then you would accept one of the jobs and move into the community and go. And it seems that there's a lot of people that have more concern about, you know, will I be accepted in this community? Will I fit in? Is this the hospital administration I want to work with? Are these surgeons I want to work with and to help them get some sort of a sense of whether that would be a great place to settle down, buy a house and practice long term.

DR. EDWARDS:

That makes sense. I know you touched on this a little bit, but what motivates organizations to hire locums tenans workers, besides what you said about there being shortages in their respective hospitals? And what do you think are primary motivators for anesthesiologists and other healthcare workers?

DR. ROOT:

I think what's happening at the hospital side or in the large system side is just simply workforce. They just need people. And if they can't get them through the more traditional routes of, um, going out and recruiting and hiring and bringing in, you know, the permanent staff, then they absolutely have to go out and bring in the temporary staff because, you know, at the end of the day, these organizations have to take care of patients and have to get the surgeries done. It was something that was happening, I thought more and more frequently over the last decade, but it just seemed to get really accelerated with Covid when all of a sudden you saw the pay scale for the locums, because people were then short staffed and the pay scale went through the roof because, you know, we were all exposing ourselves, um, to what at the time, you know, with the pandemic, we weren't really sure what was going on. And so the, the pay scale started rising. And then people started thinking, oh, well, you know, hey, why don't I go travel because I can make a third more in some cases traveling. And this isn't just for physicians. I mean, this is for nurses and techs and everyone. Um, the pay scales went way up to try to attract people into these spots where they couldn't get workers. And I think that was kind of the primary push that really accelerated everything. And I think it was it was mainly financially driven. And I think on the side of the worker, it was also financially driven because, I mean, that was kind of a neat way to, to make extra money. And, um, I don't know if, you know, people were out of work and how long they were out of work, but they felt like they needed to go out and make up a certain amount of money to help their family's finances. And then I think people discovered it was a viable way to go make a living quite possibly, depending on what their social circumstances were. So I think it's kind of here to stay for quite some time. I'm not sure we're headed back to the older models of coverage. Um, I have a feeling that we're going to see a lot more of a fluid, uh, transitory workforce just simply due to a lot of social and economic factors currently.

DR. LEVINSON:

I've definitely noticed the many hospitals I've been at, even in just my short few years of training, the increase in travelers in all aspects of all types of workers, doctors, nurses, etc. so I'm seeing that also in my hospitals too. As residents that, you know, you're talking to residents now, how would you advise us potentially in considering this option? Are there certain warning signs we should know about or pitfalls that we might not be aware of that we should look out for?

DR. ROOT:

Sure. Probably one of the best things I did for my own locums career is I spent the first three years in a private practice as a partner. And I really needed that experience, because when we go through residency, we do not necessarily learn how to lead the health care team, right? We're too busy getting our education and running a room ourselves. And when you go out into the world, you're expect to be the leader of the team. You're you're supervising now, right? And so that is a completely different role to move into as a supervising anesthesiologist, then as a personally performing sort of doing your own case anesthesiologist, it's a very different scenario. You have to learn a bit of a different skill set. There's a lot of people skills and a lot of management skills. And if you move directly out of residency and go right into locums, you don't ever really get a chance to learn all these things. And the problem is, is you're now going out into a place where you might be there 6 or 8 weeks and you don't ever get comfortable with the people you're supervising, right? You don't ever get to know them. You don't ever get to practice your own skill set. And then next thing you know, you're in another place with a whole new set of people and so on and so on. So I would say as a resident, I don't know that you're doing yourself any favors putting yourself in that position because there's still a part of your own professional life that still has to grow after residency. Um, when it relates to that team based care aspect. So I would say be very careful thinking that this is, you know, an obvious choice because there's still part of your education that that needs to be learned.

The other thing, too, is a lot of the hospitals that have staffing issues have them for a reason. So it may be of place with a very toxic work environment, and they can't keep people working there. And so they keep bringing in locums to fill the gap. But then you're coming into maybe a department that's just not running very well. And then if you come into something like that as a resident, what sort of skill set do you have to be able to deal with that sort of personality challenges that may exist at an institution like that, you know, how well can you navigate that based on your limited experience to this point? So that's kind of another thing to be very careful with the pitfalls of jumping right into a locum sort of career directly out of residency.

DR. EDWARDS:

That makes a lot of sense. And I was going to ask you for our last question, would you advise a resident to do locums right outside of residency?

DR. ROOT:

I understand the urge to do it because there's a lot of unknowns when you go out and you accept jobs somewhere. Um, and so the idea that, oh, I can go dip my toe in the water, and that would be a great way to figure out if I like it and it and it kind of could be. But at the same time, that itinerant sort of lifestyle is very hard, I think. Um, and I'm grateful that I had those first three years, you know, with partners and a practice, um, that I had that kind of support that if I needed help, you know, there wasn't that part in my head going, oh, they'll think I'm terrible if I ask for help, right? Because I they knew me, I knew them, and they they were my backup. And it was really a great experience for me those first three years. Um, it could be problematic to travel around and not be able to develop the relationships you need for your own personal growth in the specialty. So I would just say, as you look at the pluses and minuses of doing something like that right out of residency, um, I, I still believe that you got to learn how to be a supervising anesthesiologist. You've got to get that social support structure around you to help you as you step into sometimes, you know, there's things that maybe you didn't see during residency and what happens when something bad happens. So having that support of the other doctors that are there to advise you, having the support if things go wrong, of that emotional support that you might need. There's a lot of things I think you ought to consider before you jump into that itinerant sort of lifestyle of the locums.

So Gideon and Sarah, is doing locums after graduation, something that you've thought of yourself? And what is kind of making you think either plus minus this sort of career for yourself?

DR. EDWARDS:

That's a great question. As a first year anesthesiology resident, I am very open minded. I don't have a particular path that I definitely want to take at this point. Well, at my medical school, the anesthesiologist were all locum hires, so it was really great to talk to them about their experiences. And one attending in particular I talked to, she did start in locum tenens right outside of residency and has enjoyed it so far. So I see that it can be a wonderful life choice depending on the personal circumstances, but I also see that I would have to learn a lot about, you know, running my own business. You talked about being able to file a 1099 and the self-employment taxes, and these are all skills that we aren't taught in residency. So I would definitely need further, you know, mentorship and guidance to optimize that. If I did choose it.

DR. LEVINSON:

I also would say I've worked with a some locums attendings, not very many in the past year. I feel like at my institution we're usually paired with, you know, staff that's on faculty there full time. I haven't given a whole lot of thought to to working locums. And also I feel like as a finishing my second year, about to go into more subspecialty rotations next year now is when I'm really focusing more on career opportunities and options. And I'm personally thinking about a career in pediatric anesthesiology and pursuing that fellowship. Um, I will say that just the idea of having control over your life seems really appealing as a resident. So I can definitely relate to that yearning for just so much control and flexibility when you have what often feels like none. And I totally agree with what Sarah was saying about just it's a whole new skill set that I can't even fathom comprehending. I know I could maybe one day, but there's just so many intraoperative skills I'm still working on, obviously. And so I feel like mentorship, like having locums mentorship would be really important too, which I would love to ask. Did you have any locums mentors when you started, or did you sort of just hadn't had on your own and figure it out?

DR. ROOT:

You know, it's really interesting. So when I finished residency in 1997, there had been this huge workforce study that had come out 2 or 3 years before saying, oh, our hair's on fire. We're making too many anesthesiologists. And so we had this huge drop in jobs. Um, it it was the worst the year before I graduated. I knew residents that could not find jobs. And so in 97, it was still the market had gotten really tight and it was barely opening up. And so people were all of a sudden kind of scared if they could find a job at all. So there was a really interesting event going on at the time when I came out in residency, and I did not have any mentors that were doing locums, you know, matter of fact, back then there just weren't a lot of locums, and it was really kind of a step into the unknown for me. Um, yes. I had to learn a whole lot about taxes and write offs and running my own business. And that was, um, something that I had to sit down with a big book and, and teach myself. You know, I had to go through the do I incorporate am I an S corp, am I a limited liability company or what I ultimately ended up just doing was being a sole proprietor. You had to walk through all the different reasons as to why each one of those, from a business standpoint, made sense. And that, again, you know, we joke in medicine, right, that we get no business experience and we're the world's worst business people. And that's really true. And so there was none of that.

I didn't have anyone where I trained. I was at Duke back then and there was no one there that did locums I knew of, um, a couple of people that would go on occasion to go spend a weekend at a hospital that was about 30 or 40 miles away. Um, there was a guy at the time at this North Carolina hospital that that just needed some help. And so some of the people from Duke would, would go and fill in at this hospital. But that was the extent of what I saw locums as being, um, and I pretty much decided that I, I wanted to practice medicine. I didn't go through everything that you went through to just stop and not do it, and I loved it. Um, but there had to be a way to figure this out and to to make sure I could not be on call at night when somebody needed to be home with the kids. Um, and that I just literally went and talked to all the different practices and worked for everyone when they needed it. There were all kinds of interesting and unique places that I found work through those years, and there was always plenty of it too. There was never a shortage. There's always going to be a need for people who can have that sort of ability. And where we've normally seen it is in the people who move towards retirement. They're the ones who want to cut back, and they're the ones who tend to kind of move into those spots of part time work or peer in work. Um, but it's it's going to be more and more, I think, as we've gotten so much more shift oriented, um, in today's economy than we were, you know, 20, 30 years ago.

DR. LEVINSON:

It's great to hear all these stories of different jobs you've had.

DR. ROOT:

Uh oh. I could go on and on.

DR. EDWARDS:

You've done such an excellent conversation. I definitely learned a lot. And I'm sure our listeners did, too. Thank you so much, Dr. Root, for joining us today. I thank you so much to our listeners. Remember to like, share and follow the podcast and join us for more Residents in a Room, the podcast for residents by residents.

(SOUNDBITE OF MUSIC)

VOICE OVER:

Be the first to find out about new job opportunities. Sign up for alerts at the ASA Anesthesiology Career Center and search hundreds of openings nationwide. Start your search at careers.asahq.org/jobs.

Join us for Residents in a Room where we'll share timely info, advice and resources designed to help residents succeed in residency and beyond. Find us wherever you get your podcasts or visit asahq.org/podcasts for more.