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Webinar: How locum tenens works and why to try it

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In this PracticeMatch webinar, experienced locum Ripal H. Patel, MD, MPH gives a deep dive into locum tenens, how it works for him, and why physicians should try it.

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Payton:

Hi. Good evening, everyone. Thank you for joining us for the webinar about introduction to locum tenens and how it works and why you should try it. My name is Payton Jennings, and while everyone is logging on, I just kind of want to give a little introduction about myself. I’m the physician engagement coordinator here at Practice Match, and some of you attending might already know me because I work very closely with Practice Match’s physician promoters. And before Practice Match, I was in an internship role for a local hospital and in that role I realized how much I loved helping physicians navigating through medical school into their internships, residency, and fellowship. With Practice Match, in doing these career fairs and webinars I get to do exactly that and try and make it as easy as I possibly can for them. Hopefully, since you’re here tonight, you already know a little bit about Practice Match and what we have to offer physicians. If not, I just want to highlight a few of the things that we have to make sure that you get the most out of your experience.

We have a free CV review builder and —if you’ve attended our fairs, you probably know that. We have scholarships with the virtual career fairs, we have monthly webinars – we try to have a couple a month — and we have a free physician immigration handbook and a career guidebook. We have a lot more, so if you’re interested, I can link the link to those in the chat for you to look at after this. And if you have any other questions, please reach out to me. Please note that the microphones will be muted throughout this presentation and we’ll have time at the end for a Q&A session. I have a couple of questions for Dr. Patel tonight myself, so after his presentation, we can go into those so if you have any questions just put it in the chat and we’ll get to those. Now I want to introduce you guys to Ripal Patel, and he can tell you a little bit about himself.

Dr. Patel:

Thanks so much for having me. I’ve been a locum physician for about eight years now. I do emergency medicine. I also do academics here in Houston at the Baylor College of Medicine. I started my career out with a big staffing company. I was very naïve to the healthcare climate and even more naive about all the models that existed within medicine and the scope of practice. And so, after about a year, I tried it out and I really hated it and so I sort of took a hiatus for a few months and just did other stuff and tried to see if all these years was a waste or not. I’m sure many people have gone through that journey. And I think I realized it wasn’t so much the job; it was sort of the system. And so, I started traveling a little bit. I met somebody that did it; I thought he was absolutely insane, and as I thought more and more about it, I was like it kind of made a little bit of sense for me. And so, I started doing it, and I started with agencies, and then I formed my own group, and so I sort of do a little hybrid of agency, and then I have our own contracts. I work in about four to five other states, and I pretty much do it fulltime. I really enjoy it. I think it’s one of many options to face burnout and to go back to how you want to practice and think about why you became a doctor, not to let other people control you. So, I’ve been sort of talking with different organizations about it, and I’m just really happy to be here. Thank you.

Payton:

Thank you. Are you ready for the slideshow?

Dr. Patel:

Sure. Yeah. I’m also having Wi-Fi issues so if my Wi-Fi fades out, it’s not because I hate everybody, and I’m like, screw this, just bear with me and I’ll log back in.

Payton:

Can you see my screen now?

Dr. Patel:

Yeah, I can see it.

Payton:

Perfect.

Dr. Patel:

If you’ll go over to the next slide. And I guess one more over. There you go. So, this is just two slides, I really hate slides, they’re kind of boring, so I’m not going to bore you with all these. I think it’s much more interesting just to ask questions. But this is just a very generic, I guess for people that maybe have not done locums. It’s basically temporary assignments. As you guys know it can go from PAs to NPs. It does involve travel but there’s also something call a more regional locum where you can just locum close to your house and I do a little of that and I’m happy to answer questions about that as well. I live in Houston and I can drive over to Louisiana, up north

And they’re always going to have a long term need, and I work in these places where everybody travels to go there including places like northern Arizona, places like Nebraska as well. Agencies help out physicians to get the licenses. The pay rates can vary, very much so — I call it geographical arbitrage — very much where you work can dictate how much you make. I think money is something important to think about. If you’re going to travel and do locums you should be compensated extra for that sacrifice for doing it. Most locums, pretty much all locums I can think of, are 1099s, which I really enjoy. There are great tax benefits, tax write offs, you work for yourself, and generally what most people do is work with agencies so you’re partnered with the agency; you’re not aligned with the hospital. And I sort of like that relationship where the agency is kind of going to bat for you.

You can move to the next slide.

This is the last slide here. I could go on and on about sort of all the benefits of doing it. Flexible scheduling, you make your schedule. It’s funny, I work in Houston with my awesome residents — some of them are on here — and people just don’t understand you can make your own schedule; you can dictate when you want to work. If you want to take a month off, you take a month off. If you want to do days, days, nights, nights, it’s really up to you. I think that’s something a lot of people don’t realize they’re able to do even when they start doing locums work. The compensation is generally higher, and as I mentioned with pre Covid and Covid, it sort of changed a little bit. But now for emergency the rates are very high and as they should be because once again you’re traveling to a new place, learning a new EMR, meeting new staff, so it is challenging. And I think most importantly, you’re leaving your home for that. I started prematurely in locums just doing it because I was like, if I don’t do this I’m just going to quit medicine. I started doing it, and I live here in Texas, and I started work on the border towns, and coincidentally, I was also doing global health work at the Baylor College of Medicine, so it worked out really nicely to see all these refuge crisis issues on the borders, where I started working, and I just really, really enjoyed it. People may know, Houston has one of the largest medical centers in the world, so it doesn’t really need me, whereas I feel like other parts of the country could really use board-trained and board-certified physicians like you guys on here. And so, it’s very nice. I think people are very grateful. You work in tinier hospitals where there’s less politics. And I think for the travel and adventure, to give you an idea how naïve and dumb I was about it, I didn’t even think to start working in other states and my agent, I believe with CompHealth at the time, was like, you should look into New Mexico, and I had just never been, and so I’ve really been using both for higher income, serving world populations, scheduling, but also just travel. I’m working at a new place south of Las Vegas, and so I get to sort of bang out about four or five 12s, and then spend the weekend in Vegas watching shows. It’s really fun, and I wouldn’t probably be able to do that on other schedules. And then I like to travel a lot and other things which I can take weeks off for. So, that’s kind of it. I’ll just sort of turn it over to Q&A after that.

Payton:

Alright. Perfect. So, I’ve kind of jotted down a few questions to ask you myself, and I see that there might be a few questions in the chat too, so I’ll go ahead and go over those as well in a minute. One of the questions that I have for myself, the first one would be: What are some of the benefits you’ve experienced practicing locum tenens, and what do you like most about doing that work?

Dr. Patel:

I have obvious authority issues working in healthcare. I’ve known that from day one when I would get bad evaluations in medical school. It carried me through, and so emergency, whether people know, it’s getting extremely corporate as are many other specialties. I think some people can work in that environment, and I think emergency, like a lot of specialties, is very high risk and so I like being independent. I like that it’s my time, my contract, my S Corp, and I really like the fact that if things change at a hospital – and I can’t even explain how many variables go into my job every day of new medical director, new assistant medical director, new nursing staff, no nursing staff, new CEO, new this, new that, and things are just always changing. That’s not all my hospitals but a good amount of them, and so I like that option of whenever I feel I can’t do my job or somebody is telling me to move faster. A few months ago I got an email that said I spent too much time on a Wednesday afternoon — I was putting a chest tube into a guy who was unstable — those kind of emails just don’t go well with me, and I don’t think they go well with a lot of people. And so, I had the option of finishing out my run of shifts, and I can’t emphasize enough — you’re a 1099. You’re like a plumber with ten different houses you’re servicing plumbing for; you cannot go back to any one of them after you finish out your run of shifts, and I like that commitment. And I’ve had a pretty stable group of hospitals now. I mentioned before I really like serving the populations where they just have a hard time getting more trained, board-certified physicians to come out there, and as more and more of America is gravitating towards urban cities, I think that need is always going to be there. I live in Houston, we’re close to Austin, and boy are the markets saturated here. There are still jobs, but they are saturated. I want to be paid what I think I’m worth, and I think everybody should say that to yourself: You should be paid what you’re worth, and it’s not fair, and so those are all things to think about as you explore locum work.

Payton:

Nice. And then what are some of the challenges that locum tenens that physicians new to that should consider?

Dr. Patel:

I mean, everybody worries about walking into a train wreck, and there are simple ways around that. Calling, talking to colleagues that work there. If they’re paying you a really high rate, there is probably a reason why they’re paying you a high rate. But things that you can explore before you go into it. And so, I think that’s one fear. I think in almost eight years of doing this, I haven’t really – I can think of maybe one, and it wasn’t as bad as I thought, but I just decided after a month I wasn’t going to go back there. Travel can be hard, and there are a lot of travel hacks to make it much more tolerable. Like I said, I wish I could have everything, but traveling is sort of the price you pay for making your own schedule and being your own entity. And as I mentioned before, things like regional locums, contracts around your home that are maybe an hour drive, are also very viable as well.

Payton:

OK. Since locums are independent contractors and responsible for their own taxes and benefits and retirement and all that, how have you handled that aspect of working with locum tenens?

Dr Patel:

I mean, in emergency a lot of the W2 options, the benefits they offer, I hate to say it, are garbage. I would rather be a 1099 and seek out my own plans. When you’re a 1099, what I have is an S Corp, which is your own corporation. It’s very easy to do, you can LegalZoom to do it, and I don’t get any money from LegalZoom for saying that, but it’s very easy. Then you can basically funnel all of your car stuff, disability, your health insurance, all through your S Corp, and you get tax write offs from it, not to mention all your travel and everything that would be a business expense. And so, I think that’s a hurdle people think about, but it’s really not as hard. As long as you set up the S Corp, one, and then get a good CPA. I’ve done a previous talk with locumstory with two CPAs that pretty much do locums stuff, so there are people out there that can really make your life a lot easier, and that person will do your bookkeeping and your taxes and that’s pretty much it. Once you have everything on cruise control, I think things work pretty well.

Payton:

How do you decide which assignments to take? Which locum assignments.

Dr. Patel:

I think that’s kind of an inward journey of what you want. I think a lot of physicians have a little Stockholm syndrome of this is it, I live here, I can only work with these two places, and locums, really, the world is open to you. I have a friend going to New Zealand. I have a colleague who does anesthesia who just got back from the islands. While he actually lost his job for corporate reasons and decided to do some locum work. So, I think you need to ask yourself what you want out of it. Do you want acuity, do you want to beef up your skills, are you looking for pay, more money, are you looking to travel? One of my hospitalist friends in New Mexico – his mom is ill and so he has a license in Massachusetts — so he’s doing locums out of a hospital near there so he could be there close to his mom. The options are just unlimited on what you could do with it. Personally, I just like a place or two where I can travel. I like working in New Mexico and serving the populations there. I like being close to home as well, so I just sort of mix it up so I have a little bit of everything. And then I spend a week here in Houston working at our county hospital with our residents.

Payton:

Can you give me an example of what the process is when starting a new assignment and entering a new environment? I know you said you like to mix it up a little.

Dr. Patel:

I’ve seen so many locum docs do this in so many different ways, and I guess people are just more bold than I am. I put it down to an equation and it’s not complicated. There’s only certain EMRs I will work with; I will not work with certain EMRs because they’re terrible, and so I know about four or five EMRs. I think once you know the EMR, you’re pretty gold on starting at a hospital. I always say go a day before. I’m starting at a new hospital next month and I always say spend one day, go there, get familiar with the ER, for me, know where everything is, meet everybody so it’s not weird the first day, and then make sure your logins work. It’s simple stuff, but if you start the first day to roll on in and they give you your logins over email, I mean, and it doesn’t work, boy it’s going to be a rough start. So, spend a day, call the doctors there and make sure it’s a good place to work and know how coverage works. I wrote this article about a checklist. I just use a little checklist and I just check, check, check. What is your EMR? What’s your video scope? Who is on call? What do I do with pediatric patients? All this simple stuff and I’ve been using that same one for seven or eight years. It’s all on the locumstory blog post. It’s pretty much gotten me through anything I need to know. I can’t stress enough, just give yourself one day for shadow shift, and everything should be pretty easy to go. That list, I think I put on there, it’s been over years of painful mistakes I’ve made where, oh my login doesn’t work, oh I need to read an X-ray and radiology is not going to read it but I don’t know how to login, oh I have an obese patient that needs to be intubated, oh God you don’t have a video scope. So, just things to think about so that your first day is pretty smooth. And I think on the flipside, when you go in there and you do really well on your first day, it feels pretty good, and the hospitals will really want you to come back.

Payton:

Do you recommend this to early-on physicians?

Dr. Patel:

Yeah, my children, I call them, my residents, who I love to death, they ask me this question all the time. I don’t see why not. I know people look at it a couple different ways, and its specialty specific as well. I know for emergency the variation is you’re going to work in places with minimal backup, so the buck stops at you, basically. I know emergency medicine residents that come out from programs in the U.S. are pretty stinking good, so I don’t see why you wouldn’t be able to do it, especially with your skillset, being so close to your boards and everything. I tell my residents, start maybe part time and do maybe part-time PRN around your city and maybe some part time locums, and then see if you like it. It may not be for you. You may not like the travel, you may not like running your own sort of business, and you’re sort of a freelance, free-agent physician is what you are, and some people love that autonomy, some people don’t. I enjoy it personally, but it’s not for everybody for sure. But I say, give it a try, try with an agency. I call agencies like training wheels and they will guide you through sort of what’s available, how the credentialing will work, all that stuff. And once you get your feet wet and you like it see if you want to do more, maybe get two locum contracts, maybe get a few. I know some docs that are credentialed at ten hospitals in four states and they have an Excel spreadsheet. There’s so much expansion that you can do with it. I think a lot of it — go back to your lifestyle. I have one of my docs I work with in D.C. tailors around his kids. Him and his wife have Google calendars based on their children’s events and soccer games. And one of my friends likes to travel and sail, so he works six months on and six months off. I can’t emphasis enough, it’s unlimited options for what you can do with it.

Payton:

How do you maintain your physical and mental health in doing this?

Dr. Patel:

I guess taking weeks off like this. I think temporary burnout is really rough, and I think all of us, everybody, 125 people on here got a bad end of it with Covid. I think Covid really just killed a lot of careers, and I really don’t blame them, to be honest. Emergency was really hard for us because not only were we exposed and we didn’t have our PPE, the hospitals were cutting our pay, they were cutting our shifts, and it was horrible. And so, I think whenever I feel burned out, I can take time off and that’s one thing I like. If you’re with a group, a democratic group, if you’re in a group with a private, equity-backed staffing company, if you want to take a month off, it sort of burdens the group. I know you don’t want to do that to you colleagues, whatever your loyalty is to the corporation is another story. I think with locums you can tell all your clients, hey, I’m just not available. If you want to travel through Italy for three weeks, sorry, I’m just not available right now, or if you just need some time off. I think it’s really important because in that sense you can also dictate how much money you want to make a year. If I don’t get a week of work, which right now it doesn’t happen, but I’m not really that upset about it, to be honest. It’s just a week off where I can sleep in and go do my whatever gym classes, I don’t know. Just having that time off and being able to control my schedule. I also, when I work, I really try to work, and I don’t have much time when I do shifts, so it’s kind of, shift, try to go to the gym, and then go home and sleep. A lot of people ask me about down time during locums, there isn’t really that much, so it doesn’t bother me as much being away from home, if that makes sense.

Payton:

Yeah. You brought up Covid just a second ago, and that was actually my next question. I wanted to know how the pandemic affected locums.

Dr. Patel:

Yeah, I think it affected locums, it affected everybody. I think for locums wise the contracts went way down, and what happened, as I’m sure everybody on here knows, is the volumes in the ED went down, hospitals were shutting down, outpatient surgeries. So, then what the hospitals did is they cut back on the staffing in the emergency rooms, and that then meant people getting their shifts cut. And then there was a very awkward, and if there are any emergency physicians on here [inaudible], there was an awkward transition where there were surges coming back in the ED, but the hospitals weren’t properly staffing the ER. Because that would be a terrible thing, right? To have an overstaffed ER, how horrible to have an extra doctor there, but they didn’t want to do it, and so that made some places I worked at sort of not safe to work at because my APPs, my NPs weren’t there because they had been furloughed. And I think it really jaded a lot of healthcare providers, but I think in a good way, it sort of shook us a little bit and made us step back and say, I need to kind of reassess my career. I thought my career was pretty stable, and the pandemic really showed me — we’re always going to have a job in healthcare, but it just wasn’t as stable as I thought it would be, and I sort of restructured my locums practice sort of around what happened during the pandemic.

Payton:

That’s all my questions. I’ve kind of been taking notes throughout this. We have a couple of questions in the chat box. Tasha wanted you to elaborate on the CPA aspect of things so if you can elaborate on that?

Dr. Patel:

The CPA aspect. I am by no means a financial — I’m not the white coat investor my any means, but I do know you want to look into finding a good firm and a good organization that is familiar with how locums works and how multi-state taxes work. And I’ll keep it as simple as possible because my mind is not tax oriented. A lot of companies don’t do it well, and I made the mistake of using one or two which were not that great. And I think the other advice I would give is — I just basically Googled and I think we’ve done a talk about this — I’m sure they can find a link for, but there are several CPA firms that will specialize in this, and they will educate you in how it works, setting up the S Corp, how to do your taxes, maximize your deductions, you’ll be the president of your company and ways that you can minimize your tax burden, basically. The other thing I’ll say is the nice thing about some of these companies I’ve seen and the one that I have is your bookkeeper who is managing your payroll and your CPA are sort of in one shop, and when they’re communicating with each other, it prevents mistakes from happening. I’ll just leave it at that. It has less people to talk to, less people to link in together, and I found out that mistake the hard way as well. But ask around — I know the locum staffing agencies can recommend a few; talk to them. It’s not as complicated as people think. I think until you start working in multiple states and then again, you just want somebody smart who is in your corner, who knows how it works with experience that can sort of teach you and guide you along the way.

Payton:

The next question: Katie Ramos wants to know on the part of the decision, how do you manage the having to consider a whole lot of things?

Dr. Patel:

How to consider like travel?

Payton:

I’m assuming everything.

Dr. Patel:

Everything. Well, my memoir will be coming out next year — no, I’m just kidding. That’s a really good question. I guess the way I do it is I go back to the finance aspect because I think it’s important that we all be financially stable. We all earn that for everything from PAs to NPs to everybody on this chat. I sort of structure my yearly goals of how much income our group wants to generate, and I really don’t want to work anymore beyond that. I don’t think I need to. And if I do, it’s great. I think that then backlogs to what I do, and what we do is I divide the year out into four-month blocks and in that four-month block, I try to hit a certain income target, and when I sort of fit that out, I sort of see where I can take more time off to go to family events, to travel abroad, to get involved in stuff here in Houston at our medical school. And so, that’s kind of a guiding force for me, just to make sure I’m hitting the targets for retirement, for savings, for little, small things like savings accounts and stuff, and then with that I can then structure my travel stuff when I’m going to be out of the country, and structure my work schedule around that. It does get a little trickier when you have a lot of hospitals you’re working at, and most of the hospital I work at book pretty far in advance, and so I can basically have my schedule done a few months before I’ll start there. But there will be hiccups where you may have a week where you don’t have work, but as you do it more, you PRN at more hospitals, you locum at more places, some more options become available.

Payton:

I know you kind of just went over that, but I’m just going to highlight the next question that we had from Kelsey Jones. She wanted to know what are the things to consider when taking a new job, and how do you manage things when you have so many variations?

Dr. Patel:

Yeah, like I said, people think locums is very chaotic. It’s actually really, very, very structured. I will fly out at X time, I will get there at this time, I leave little suitcases with all the stuff I need. Back to sanity, I like to cook all my meals, I figure out where the little gym is, and then I’ll show up there, I’ll do my shifts, and then I’ll come home. It’s very structured, I like to work a structured schedule and if you like that — if you want to be just the night guy from Tuesday to Friday, then that’s what you tell the agency, that’s all I want to do. If you only want to work weekends so you could have the weekdays off for your kids, that’s what I want to do. And so, I have a very structured week one academics, next three weeks usually locums, and then occasionally I’ll take my vacation sometimes in between there. But it’s actually added more structure than I probably would have had working at a regular job. Barring that, I think the health part I talked about. I try to stay fit and cooking meals and stuff, I try to minimize my travel. I used to do crazy stuff and fly to Vermont, and you have connections and driving two hours. I try to minimize it now, where it’s a connecting flight, less than an hour drive, and I think if you can do that, it makes it easier. If you can drive, boy that makes life a lot easier as well.

Payton:

The next question in the chat is from Melinda. She want to know how you manage the stress accompanied with working and what if taking time off comes with lots of uncertainty like when to complete the stuff that is on your desk.

Dr. Patel:

Stuff on my desk, like just general admin stuff? Sorry, ask me the question again?

Payton:

Melinda wants to know how you manage the stress accompanied with working and then what if taking time off comes with lots of certainty about when to complete the stuff that’s on your desk? I’m assuming when you get back to work, how to complete all that stuff to catch up, kind of.

Dr. Patel:

Right. No, that’s a really good question. Like life admin, basically. I think when you do locums work – when you work in so many — I use this in emergency, but I think this could really apply to a lot of specialties. When you work in so many places, I think I’ve worked in over 40 ERs in my eight years between agencies and then direct contracts, places that stopped having needs, and so I feel like I’ve worked in so many places, I’ve seen so many practice models, nothing really surprises me that much anymore, and so I feel a lot more comfortable going into work knowing I may not have OB, I may not have general surgery on call, the EMR might go down. I guess I’ve just been enough places, and locums really pushes you to that limit. I work in one place where the doctors complain and complain, we don’t have this, that doesn’t work, I’m so stressed, and they’ve all been at that same hospital for I think almost ten years, so they don’t really have the exposure of how it’s like everywhere else. I walk in and I’m like, thank God there is electricity, I’m so glad the nurses came today and cardiology gen is actually going to do catheterization. So, I think traveling gives you that confidence. I know a lot of PAs and NPs and some of the docs like locums because of the challenges it brings based on the locations you work at. That life admin is actually a really great question because I mention when I work it’s basically work a shift and I try to do — I’m not a fan of 12-hour shifts, but I’ve become more of a fan because you basically can make more money on the hourly while you’re there, but there’s just not much time after when you’re done with your 12-hour shifts because 12 always turns into 13 or 14. I try to do my life admin, managing the practice while I’m working, meaning not at work, after I finish work I’ll come back to the hotel or Airbnb, and I’ll spend about 15 – 20 minutes finishing out emails, texts, any contract stuff, CPA stuff, so that when I’m off on my weekends or this week, I’m off. I can just enjoy the time off. I will say, in full disclosure, I think every day I spend at least 15, maybe 20, sometimes 30, not so much 30, I do a little bit every day to make sure everything is in order. It’s kind of the price you pay. You’re a small business owner, you’re running your own practice and sort of the little admin stuff you have to do to make it work. It’s enjoyable to me because it’s your practice and it’s your profession now that you’re taking control of.

Payton:

The next question: Joanna wants to know for fear of uncertainty, like in a situation that you do get laid off, what do you do next?

Dr. Patel:

I would say look at your locum career like a very diversified stock portfolio, diversify, diversify, diversify so if you do get laid off at one place, you have another option. I tell my residents, they’re starting a job at this place in Houston, X hospital in Houston, always have a back-up job just in case something happens. All the variables that go into my profession, maybe not in other professions, but I know in my profession, there are just too many for you to put all your eggs in one basket. That’s a great question. During Covid, I got furloughed for a week. I have a few places in Houston I can just PRN at. The rate isn’t as good, but they always have a need. I think the more options you have, the less likely it’s going to affect you. And I think if you go in that mindset of breaking out your year into quarterly or however you want to do it but having some financial target of how much money do you, your spouse, kids, really need, then when these weeks happen you can look at it as it’s just a week off now and I’m not forced to work. I think that makes it a lot more liberating, in my opinion.

Payton:

Next question. Julia wants to know on the aspect of financial management, how do you go about that?

Dr. Patel:

That’s a great question. I have a financial planner. They are fee only, if you don’t know what that is, I think we do Dr. Dahl’s talk a lot for the White Coat Investor, a lot of other great financial blogs to read about, but what I do is I just read books about finance. People told me to do it in residency, and I just ignored them. Whatever, I don’t have time for that, I have to take my boards. Many years later, I kept ignoring like an idiot, and finally I read just tons and tons of books. I like listening to personal finance podcasts, so I think I’m at the level of fluency where I can manage most things, but I do need help because I’m not an expert by any means. So, I think getting knowledgeable about the basics. One of my favorite books is called The Index Card. It’s a very simple book about personal finance that makes it as simple as an index card. But getting knowledgeable and then finding people that can basically guide you through it, and just saving. Like I said, you’ll make more with locum money. You’ll get a lot of good tax write offs. Just get educated; don’t be a fool. I tell my residents now, start learning a little bit now, so you know the basics of rent versus buy, doing your mortgage, your disability insurance. And like I said, all that stuff bores me to tears. I have absolutely no desire to start any financial blog. It’s so boring — let somebody else do it — but learn from what they teach you, so you can go back to practicing medicine.

Payton:

The next question is from Ashley. She wants to know what advice you have for physicians when it comes to credentialing for locums, and are there certain documents that they need to keep gathered in a folder to make the process easier for themselves, and if so, what documents do you recommend?

Dr. Patel:

That’s a really great question. As you start your locum journey in whatever specialty that you’re in, every document you have, create an online drive. Do Google drive, do whatever drive you have, scan it, and name it, and put it in a credentialing folder. What I do, and it’s funny, when I go to our national conference every year and talk to locum docs, we all do the same thing, we just fill that folder with everything under the sun — your DNA code, your credentialing forums, I don’t care what it is, your romantic interest, put it in that folder — and then send it to the credentialing person and let them sort it out. But I have all my ACLS, ATLS, panels, scan it, put it in that folder, and then when they need all the forms, just send it to them, and then let them get back to you on what is still missing from that. I also tell them if I’m going to work they should be prefilling out your credentialing forms. I just did one for a state I’m working in next month. They prefilled out everything. I just signed, signed, signed, signed, here’s my folder, see you later, I’m going hiking. And that’s pretty much it, and it makes it a lot less painful. As the years go on, you’re going to get people asking you for the craziest stuff. You can’t even believe the things people want. They want case logs, they want high school class ranking — I’m not kidding — so just find it, save it, and try to work with your credentialing person. And also realize if you do locums — I just learned this this year — the credentialing office may not be as big as you think. It took me eight months to credential at one hospital I’m working at now, and when I went to visit, the hospital office was like a closet, and the woman who was doing credentialing works in the lab. So, it wasn’t she was ignoring me; she just didn’t have time. But yeah, keep everything in a folder, and it will make your life a lot easier, and have people prefill it out for you.

Payton:

The next question — and this is the last one — that I see on there is Katherine wants to know, how do you encourage the savings habit?

Dr. Patel:

I don’t know. I’m just a saver. I don’t know. I love my family to death, but they didn’t make the best financial decisions, so spending money just terrifies me. I think I’ve called myself an idiot like ten times now on this talk, but lets just go with the eleventh time here. When I was a resident, I graduated, and I think I just put all my money in my bank account, not even think about things like inflation and just stupid stuff. After the contracts, and I go back to this yearly goal of what you plan to make, and then I basically sit down — I like a lot of financial books. I think Dave Ramsey is one a lot of locum docs like to go with. It’s not perfect; it’s not a bad roadmap for basic stuff, which a lot of these financial blogs talk about having an emergency fund, tackling your student loans, saving for things like your house, your mortgage, kids college funds, and your retirement. I think those are some of your basic — and I know Dr. Dahl talks about, I think in one of his books he talks about starting with your basic basics like disability, which I think is just something else to think about as well. I think after I’ve met all the basic stuff, the mortgage stuff, the loan stuff, and the house stuff, then I start thinking about where you are going to invest the money. I think that’s up to you to find a good person that’s a fee-only advisor, which I think a lot of people would recommend to you who is not working on any kind of commission for anything, they’re just there to guide you and to help you manage your money. And again, I’m not a CPA by any means or any financial advisor, but I think pretty much the generic advice would be low-cost index funds. I’m not an exciting investor at all, and I really don’t think as physicians who work and make really good incomes you need to get too crazy about trying to play the market or playing these stocks. I think you should focus on your career, enjoy it, you’ll make a good income, and then do proper savings from that. But I have some savings accounts. I have all the boring stuff everybody has. I have a SEP IRA, which is very advantageous if you’re a 1099. I have an HSA because I have a high-deductible health insurance plan, and I have just general, low-cost index funds. It’s really simple, but people make it out to be so complicated, and they all want you to do the DDDs. If you don’t know what the DDD is, it’s called the Dumb Doctor Decisions. If you see your general surgeon who is like 102 still working, he probably made a DDD. He probably made a decision he shouldn’t have or got into some get rich quick scheme. And that’s just me, take my opinion for what it’s worth. I’m sure some people are into passive real estate and other crazy stuff — and passive real estate is not crazy — other more high-risk investments, but that’s kind of how I do it. As I said, as I’ve been doing it more, you come to realize once you’ve put money in all the areas you need to put in and you have a road map, you’ll sort of get to a point of how much you need to generate, and then you can backtrack to how much locum work do you really want to do. Do you want to work more, or do you want to work less, do you want to take more time off? And then you can really focus. I can’t emphasize enough; I think locums is great for all the reasons I outlined, but it’s also great because you can prioritize your personal life first and then your work life can come second. You can prioritize your kid stuff, your family, your parents, your spouse, partner, whatever, whenever you want to travel, hobbies, and then you can build your locum contracts around that. But always remember, it’s a two-way street: You give them the availability; the hospitals may or may not take the dates. Most of the time, in my experience, they will because they’re really in need.

Payton:

We actually had two more questions come in, but I’m going to say this one first even though it just came in just because it ties in with that topic. Katherine wants to know if you suggest that they have a separate account for all the saving plans such as retirement, having a separate account for that, kids’ college, and all that.

Dr. Patel:

You know, those kind of questions I would probably divert to somebody more experienced. What I do is you can open up your 529 for a kids’ college fund, you can open up basically high-interest savings accounts, which I have, which are basically some liquid savings accounts that I can put money in, but I know I’m going to pull that money out within a year’s time. In that savings account, I have my home stuff, my home repair stuff, or just things I know is going to come out of that pretty quickly. And the question was about savings accounts in general?

Payton:

Yeah, just if you suggested that they have separate accounts for every type of savings plan.

Dr. Patel:

You’re going to have to have a SEP IRA, though there’s ways you can work around doing a 401k, but that’s going to be your retirement. You’re going to have a separate HSA, you’re going to have a separate liquid savings accounts, and the college funds for the kids will all be separated out. And those are things your CPA can help you with and guide you with. It’s not viable to merge them all together into one because really you get tax write offs for doing each one individually.

Payton:

And then another question, Lauren wants to know how you decide which company to go with. Do you recommend signing up with several, or how do you go about that?

Dr. Patel:

Yeah, that’s a really great question. I would go and always ask your agent how experienced they are and how long they’ve been doing this. There are a lot of locum agencies out there, there are a ton, and I’m sure you’re getting called and texted and emailed, so ask them how much experience they have. Some of the docs I work with really just go by the rates, and please, if nothing else, know that all of these rates are negotiable. You can always negotiate the rate, and the worst they can say is no. So, always look at the costs, and usually the agencies — not usually, they generally will cover all the travel for you, but those are completely negotiable stuff. There are some big locum agencies, there are some tiny locum agencies, know their experience. I like the bigger ones. Now in disclosure, I do write for locumstory, which is a part of CHG, but I just like the bigger ones because they are more experienced, they have more people, they have all the bells and whistles to help you with your travel, if you have any problems there, and they have more familiarity with these hospitals and the contracts. But just understand there are a ton out there. The plus of working with an agency is remember if you’re not working, they’re not making money, and so it’s a good relationship in the sense they want to get you work, so I think starting with one or two is never a bad idea, maybe with two different agencies, and then see how you like it and go from there. And oftentimes, if you work with a really good agent — and I’ve worked with great agents really across the sector. I’ve also had a lot of really bad agents too, but I have a lot of good agents who I’ve stuck with. I’ve stuck with one of my agents for almost eight years when I started doing locums, and they will basically be there for you. And when they can see a need may go down or something they’ll be like, hey, we’ve got another hospital, lets get you credentialed there, and so you can start that process, so you’ll have two options or if this one dies out. I know some docs work with all agencies — they credential with all of them — they have like ten different places they work at, and then they can sort of pick and choose where they want to go. And I know some people who do hybrid like me where they have one or two, but they do some of their direct contracts or direct to client, and the nice thing about that is unfortunately a lot of hospitals want to get permanent staffing, and so if you come in at a rate that is not as high, more viable to the hospital, you’ll have longer longevity there. I will say, and I don’t think we talked a lot about the downsides of locums, but I think one of them is you become really close with the people you work with. I’ve made just some of the most incredible friends, seen the best nurses and PAs and NPs I’ve worked with, and met just great friends, but when you stop going to a place, you don’t really get to go back, unless they need you again, and so you sort of miss all the families you’ve made in all the places you’ve traveled to. One of the reasons I started doing more direct was just because I was getting tired of not being able to go back to some of the hospitals because they didn’t have a need for us. That’s something to talk about with your agency. Ask them is there a place that has perpetual locum needs? One hospital I work at in New Mexico always uses locums pretty much, and so I always get to go there. Just things to think about, and things you will sort of learn along the way as you take the journey.

Payton:

We actually have about five or six more questions. I know it’s getting close to the time but for some reason it wasn’t notifying me in the Q&A, but Lauren wants to know: If a hospital wants to hire you, have you seen issues with the noncompete clause?

Dr. Patel:

That’s a really great question. People will say that states are a right to work state and so it’s not enforceable. I would say: Just don’t play that game. If you go with an agency, remember when they present you, that’s usually the point that they’re representing you, and to some degree that’s their client, and so they are presenting you there, and so on their end they don’t want you to go directly, which is fair. But once you start working with an agency and you stop, usually there’s a one-to-two-year noncompete clause for not being able to go back. And so, what’s happened to me, some of the hospitals I worked at four years ago just contacted me randomly and said, hey do you want to come back here, you’re close by to home, whatever. But that noncompete clause is something to think about. It’s never been an issue really anywhere I’ve ever worked, and it’s a very good question because if you are an oncologist and you live in Houston, Houston is dominated by MD Anderson, so that noncompete is a huge deal if you don’t work with MD Anderson anymore. But I think for locums, there are just so many options, so many states and cities, it’s not as big of a deal. By the way, the nice thing about locums too is the hospital can always buy you out of your locum contract, and so what that means if you really like working somewhere the hospital can say, we want to buy you out of this contract so you can come work with us part time or full time. It’s kind of like leasing a car, I guess. I’ve had a lot of my colleagues have done that because they just really liked the place they worked at, and so they arranged their own set up at the hospital.

Payton:

And you did highlight a little bit of the advantages of working in locums. Do you have any disadvantages or challenges that really stick out to you?

Dr. Patel:

Yeah, great question. I think I wrote a post about this called locum horror stories. I mean, like I said, walking into train wrecks is something you think about. It hasn’t happened to me as much. Your shifts can get cancelled — that’s happened to me and that’s why it’s really incumbent upon your agent to make sure that doesn’t happen and the guarantee of those shifts. Traveling is always hard, but for emergency I say, you’re going to always lose time either sleeping or traveling, meaning flipping day/night, night/day or just sticking to all days or all nights and just traveling and getting it done. I think just being away from home is always tough as well as what I mentioned before about your contracts sort of drying up, the work drying up. It’s undefined your work. I think some people may not like working for themselves, which is totally fine. You don’t have to make a crusade out of being the locums practice of America. A lot of my friends just live in Houston and work with the big staffing company here and just move on with their lives, and that’s fine and they’re OK with that, and some people just don’t want to do that. Those are the big ones, but I think for every negative, there’s always a way out of it, which is why I probably stuck around doing it for eight years. There’s still politics in locums — it happens still — the difference is you don’t have to go back, so when they get new directors, new this, new that, you don’t have to go back anymore. A lot of my ERs are under resourced, so they don’t have the stuff that I need, but I go back to the 1099 clause of incorporation that you can purchase your own equipment. One big thing for me is emergency ultrasound, so I just bought an ultrasound, and I can travel with it. I just started a new contract where they don’t have a proper video scope, so I’ve had my own video scope for years, and that’s all a tax write off because it’s part of your business. So, those are the big ones I can think off the top of my head, and the nightmare issue as I mentioned, you can call people, feel out the hospital, talk to people, and see what it’s like, and if you do your week there and you hate it, again, you don’t have to go back. That’s the best part about it.

Payton:

And before I move on to the next question, I just want to highlight to everyone that Liz is linking Dr. Patel’s locum stories and all those in the chat, so if you want to save those links, so you can go through and look.

Dr. Patel:

Shameless promotion here, I didn’t mean to do it. I was going to say two other things just briefly about rates. One thing that really irks me in emergency is the RVU number, and it happens to my residents where the companies will promise you a certain rate but that rate is really an RVU estimate, and I really appreciate and it sounds so asinine to say, but when I started working with my first agency, the money I was going to get paid is exactly what I got paid. It’s an hourly rate; there’s no productivity bonuses. You’re there to work. You’re going to work, and this is how much you’re going to make, and if the volumes are low or right now with boarding right now in emergency rooms where we can’t get any patients back, if you’re on an RVU model or 100% RVU, I mean, what a nightmare if you’re worrying about paying off your mortgage or all these simple things. Some providers like working with APPs. I enjoy it; I think they’re great. Some providers don’t like working with APPs, so you’ll have the choice where you work if they’re independent or if you sign off on their charts. And so, again, all these variables of things. I work in New Mexico with APPs; they’re fantastic, but they’re completely independent, but they consult us if they need us. So, all these little things that may irk you about your practice, you can sort of feel out at the hospital you end up going to if you decide to do locums.

Payton:

Dean wants to know if it is advisable for someone with a young family with all the traveling that you would do.

Dr. Patel:

That’s a really great question. I go back to you got to be happy with your job. I personally like traveling. I think looking at happiness studies — I don’t know why I’m looking up happiness studies these days — but I think longevity is a lot built on sort of changing up environments and meeting new people. I was doing a talk with locumstory today just about how I really appreciate going and seeing new people all the time, meeting new people, working with different docs, seeing how people do things. Emergency is fun, but it does get a little routine after a while, and so just having new faces and new things is exciting. I think the idea of me being in one ER every day for the rest of my life is not something I could do. Again, it’s not great, but I’ve tried to minimize my travel to where it’s not as burdensome as people think it is. But I have a lot of colleagues that do it that have kids. A lot of my colleagues’ wives work remotely so they can travel with them; they can Facetime their kids. And the big pro for them is one of my friends takes the whole summer off to be with his kids, and that’s just awesome to travel, go to all the sports events and everything. Again, things to think about with your partner.

Payton:

Dominique wants to know how to go about finding a reputable locum company in their area.

Dr. Patel:

They’re a dime a dozen. I’m telling you: Your grandma probably has a locum agency; they’ve all got them. Find the big ones, I think the biggest ones right now are Weatherby and CompHealth. I might not be correct on that, but the bigger agencies are always better. Reputable is tough. I would ask them how long they’ve been around and the contracts they’re offering you. Like I said, they’re there to help you, and they’re also there to also get you a good position because you’ll then come back to them for future contracts as well. But I think the experience is very important because there’s a lot of agencies that just don’t have as much, and this is your career on the line. I’ll give you one example of idiot #12 here for me where I was working in the northern United States, and I didn’t realize my agent wasn’t doing my reimbursements, and so I think like six month backlog of no reimbursements for my Airbnb and my travel, and this was just me not being smart about checking my finances. So, just look around, ask around, going to career fairs is very important to talk to them. I would look at the agency, but I would also see what they can offer you in the hospital and ask simple questions: How long have they been there? What’s the relationship with the hospital? How many other physicians PAs do you manage? Things like that. And just going back to the life admin question, which I think was a great question. I actually, through the 1099 our group hired somebody, so when I travel, we have somebody that helps manage our home stuff because we can all wait around all day for Xfinity to come, right? Home stuff and email stuff and contract stuff so we sort of turfed out that stuff to somebody, and we just pay them to manage our contracts and emails and stuff, and we have somebody also that manages our stuff we can’t do because we’re traveling: car maintenance, house maintenance, errands, things like that so when we come home — that’s money I’m willing to spend so I can get more time with my parents and people here and my friends and stuff — so when I come back home most of that stuff is already done, so I can just enjoy the time off. Again, if you’re your own S Corp, your own entity, you can hire somebody as a 1099 through your group as a personal assistant or an executive assistant to do those kind of things, and I find that very useful.

Payton:

And then one last question: Liz wants to know what is one of your favorite locum memories patient care related and/or location?

Dr. Patel:

That’s tough, that’s really tough. I would have to say working in Vermont was probably one of my favorite places to work. Though I just started working around Las Vegas. I don’t gamble, but man I love those shows. But I was in Vermont in this rural hospital, and this really nice woman came in and she needed a paracentesis, which is like a draining of somebody’s abdomen from fluid because they have liver disease, and so we had to travel miles to go get it up to Burlington, and so when she came there, I did it for her. I was going there pretty regularly, so I’d see her pretty regularly. I’d drain her out, nicest woman ever, and it sort of broke my heart. I came back and that hospital got bought out by another hospital, so they didn’t really need me anymore. She called me — a lot of my patients like that where I do procedures on, I’ll give them my card with my cell number on it, and I’ll say if you need anything just call me — and the poor woman called me and she was like, are you working this week? I need to get drained. I’m really swollen, and I don’t think I’m going to make it to Burlington. It really broke my heart because I wasn’t there, and the doctor there was a family doc who didn’t really do paracentesis. I can’t emphasis enough: It’s really nice to bring all of your skill sets to people who I think really appreciate it and need it, and it makes you better, and it sort of reconnects you back to why you became a doctor, really, to me. I think when you get all of that horrible background noise of this horrific healthcare system out, or just make it tolerable, and you get back to reading about stuff of your specialty that you enjoy, I think you’ll be better. I’m not saying it’s perfect, and I’m not saying I found the answer, but it’s kept me through going now for eight years, and I think EM has got a pretty high burnout rate, so I’ve been chugging along. We’ll see tomorrow.

Payton:

I think that does it for all the questions. I’ve tried to go through the chat. Oh, Lauren said thank you so much for your work towards humanity. You are inspiring. A lot of great feedback here.

Dr. Patel:

I’ll tell my mom that. She’ll be proud.

Payton:

Thank you so much for your time this evening, Dr. Patel, and thank you all for attending and giving us questions to answer and getting the feedback you need. If you enjoyed this webinar, we do have more coming up. The next one will actually be on July 19. It is a glimpse into multispecialty, integrated practice model with the [inaudible] Medical Group and if you just search our website too, we have all the other ones after that as well for upcoming ones. Thank you all.

Dr. Patel:

And if anyone has any questions or wants to contact me, I’m always open to chat over email or whatever, so feel free.

Payton:

Yeah, awesome. I have these links from Liz in the chat, and I can send those to you as well after the webinar is over.

Dr. Patel:

Perfect. Great.

Payton:

Thank you all and thank you again Dr. Patel. Have a good night.

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