I’ve worked almost exclusively as a locum contract anesthesiologist for the past 3 years. Because of this website, I’ve talked to more than 50 physicians (mostly anesthesiologists, a few nurses, 1 radiologist, 1 gastroenterologist, and plenty of residents from various specialties). I have gained a good deal of experience so far and I continue to be happy to share that experience with anyone looking for help.

Most important: I don’t want anyone to have any illusions about what they may be getting themselves into or what success might look like if you decide to take this path away from employed (or partnership) work.

If you’ve read any of the original numbered Newsletters, then you know that I come back to the same conclusion:

Locum contracting is not for everyone.

Time and Money

There should be no secret here. This is the real benefit to making the jump and working on your own, as it were.

The Anesthesiology market continues to exhibit an egregious supply/demand mismatch for physician anesthesiologists and nurse anesthetists in most locations.

Hour vs hour, working as a contract physician compensates better. Some locations are better than others, but that should be your expectation if you decide to pursue this route.

Because of this benefit, you can be more selective with how, when, and/or where you work.

But all this flexibility and arbitrage exist on a spectrum.

And the big risk is scheduling inefficiency leading to pay inconsistency.

Scheduling Inefficiency Risk Leading to Pay Inconsistency Reality

It’s pretty simple.

If your schedule is not set more than 1 month or 3 months into the future, then your income isn’t either.

The hospital/group no longer needs you because they hired a new grad or there is a credentialing snafu even after working there for months (this has happened to me). Either way you are out!

The most challenging part of locums is you have to manage what I call Scheduling Inefficiency Risk - the risk you take by working for yourself and being a contract worker for a hospital or group. At any time a job can tell you that today (or next week or next month) is actually your last day working there. But I’d say from my own experience and from talking with people in the industry, you are more likely to be ghosted. Meaning that no one gets back to you about the dates you offer or they stop requesting you.

This costs you lost earnings and it costs you time looking for another position somewhere else.

This is why I advocate for diversifying your opportunities by rotating coverage at 2 places at a time, minimum. All in the name of limiting the devastating effects of short-term income loss.

Worth it for me… but what about you?

It doesn’t matter what my journey has looked like, because it has to work for you. It has to work for your family. It has to work for this season in your life.

Just because you hear stories from friends that have made the leap, doesn’t mean it’s for you.

It hasn’t been an easy 3 years, but I would not trade it for the type of job I had before, at this stage in my life. Similarly, I wouldn’t trade the first 5 years gaining experience at a quarternary care center for how I work now!

Furthermore, I’ve already been lucky enough to have spent cherished time with 2 family members before each of them passing. Time that I wouldn’t have been able to spend if I had worked my old schedule. And, time that I never would have been able to get back.

All I am asking for you is that you be intentional with your decision and you go into it with eyes wide open.

Share

If it isn’t clear from receiving a few hundred such direct messages on LinkedIn, text, and emails….doctors get turned off.

Especially clinicians who are new to the locum contract world or, even worse, are only trying to dip their proverbial toe in and so they’ve put their email out there only to be overwhelmed!



At first all of my attempts to find work came from outbound searches: gaswork.com or filling forms on every recruiter’s website I could get my hands on.

I was desperate and I needed as much contact as possible to find something that might stick.

But once you have your grounding and aren’t in a rush, you wish you could just filter through the noise.



Most of my assignments now come from personal inbound requests.

The 3 most recent positions that I’ve taken have all been by direct referral from either a recruiter I knew already or a former colleague who thought I would be perfect for the role at their institution (or former institution).

I have the luxury at this point of having worked this way for long enough to not have any rush to lock something down – I can afford to take my time; to be picky.



The last position before those 3 was a random cold-call from a recruiter that I had spoken to once (on her first-time cold-calling me) before, this time she called to offer an opportunity at a “random rural hospital that always is desperate…” see above.

The only reason it ended up in a job is because before I got off the phone I told her I really prefered specialty work in my field of Cardiac Anesthesia.

And of course, she has a lucrative position for just that specialty, but for some reason she wasn’t marketing it… It has turned out to be a good contract with great colleagues.



I’ve written before about the ridiculous used car salesman styles of many recruiters (I still have never pursued any position from a male recruiter for whatever reason).

If you’re looking for a better method than the shotgun approach, an approach that cuts out the noise – especially if you are in a position to take your time to find something optimal – I don’t know what that approach is.

Why can’t recruiters just cut out the bologna and be transparent?

Well sometimes they can and many times they can’t because of obligations to their client hospitals.


My Approach is All I Know

My approach used the shotgun approach combined with personal referrals from former colleagues.

I still get dozens of emails each week, and dozens of texts, and random phone calls.

At this point, I probably entertain 5% of all recruiter contacts and of those I’ll probably seriously pursue less than 5%.



It’s not a perfect science, but you have to create enough contact opportunities.

If you don’t, then you are just relying on blind hope that the next thing you find will be perfect.

Hope is not a good plan.


Put up with the frustrations inherent in this industry in order to get what you need out of it.

It will be worth it.

But it is definitely not the easy way to make a career out of anesthesia (or emergency medicine, or hospital medicine, etc.).

We limit ourselves with where we live, how and where we work, who we spend our time with, and how we treat ourselves and the people around us.

Because of our self-imposed limitations, we feel sudden bursts of urgency when we have to make decisions.

That is to say, we experience a feeling of (what seems like) externally applied pressure that clouds our judgement and induces stress.

The most common 2 pressures that we all experience:

- Time Pressure

- Money Pressure

Stop trapping yourself

Locum contract work as a clinician requires you to be flexible, disciplined, diversified, and prepared.

It also means you have to be brutally honest with yourself in order to determine your limits and values as applied to the intersection of your personal and work lives.

The worst thing you can do as a contract or per diem clinician is to artificially limit yourself because of fear.

You can’t be in a rush to get a lackluster contract and you can’t be desperate for the income.

Patience is a virtue, but you need the personality and the bank account to make things work.

That’s why the biggest limitation facing those that reach out to discuss their situation is financial.

Here’s an example of a friend of mine that I posted on LinkedIn recently:

3 car payments ~$2k + insurance (leased G wagon, 2 other financed high end luxury cars)
$15k+ mortgage (Very High Cost of Living area in NYC outer tri-state area)
average household monthly spend is ~$10k/month
spouse doesn’t work

If everything rides on you making almost $50k/month before taxes JUST TO BREAK EVEN then maybe this line of work isn’t for you.

When your income isn’t guaranteed and when contracts come and go... this is too risky.

There is no urgency

Any and every feeling of pressure is entirely your own creation: you could have spent less, you could have worked less, you could have better chosen your spouse, you could have planned your exit in advance, etc.

However you got to the locum contract world - SLOW DOWN. Time is on your side and so is the money, but not if you let the tail wag the dog.

Get your finances, family, and house in order first.

Disclaimer*:

This isn’t for everyone; do what’s best for your family and your risk tolerance.

Locum contracting VS Employment

More schedule flexibility, more pay for my time....but at the expense of security

More job security....but at the expense of my personal sovereignty

The problem with looking at the respective worlds in this way is that you trap yourself in a box.

- Everyone who has analyzed their options and chosen inaction, continuing to complain at the job that sucks them dry while working there.

- Everyone who has analyzed their options and chosen to stick it out solely in the locum arena, in spite of the stress inherent to short-term contracts.

There are no dilemmas in life.

There are always more than 2 choices. There is always something less extreme than what is readily apparent.

My hybrid evolution

The solution that works best for me now took some time to discover.

99% of the physician workforce lives a 1-dimensional career: they find a job and they work.

They don’t second-guess and they don’t try to find something better until they have to.

But some of us break out of that mold or we are in the 1% that wants for something more.

I knew I had to find something else when I looked to my left and to my right while working full-time at a quarternary care academic center in a major metro.

All I saw were the pale faces of peers with the same complaints day-in and day-out, but no desire to improve things.

Helpless.

I knew that life was no longer for me after 11 years of residency, fellowship, and attending.

And so my pendulum swung completely in the other direction: the salvation of locum contract work.

Contracts come and contracts go. Crazy things can happen.

The hybrid method

I wouldn’t allow the stresses of locum contract work to accumulate with time and gnaw at me like the stresses (albeit very different) of full-time, big hospital employment.

So I did something crazy.

I found a part-time job at the Veterans Health Administration.

It pays less, it requires off-hours.

But it’s a small monthly time commitment. And it’s a consistent paycheck. And I can get health insurance. And I’m helping veterans!

Not only that, but I’ve been successful keeping at least 2 locum contract opportunities going simultaneously for more than a year.

I don’t plan on stopping there.

The hybrid method is interweaving multiple complementary opportunities - whether w2 or 1099, local or travel, etc - to get the lowest stress end result possible.

The solution to the job security piece is to diversify your opportunities and what better way than a small piece coming from a biweekly paycheck?

But if that sounds anathema to your vision of total personal sovereignty, then make sure to have multiple locum contracts simultaneously to mitigate risk.

There is no one-size-fits-all approach to life

So stop trying to force yourself into a situation or a personality that doesn’t fit you.

Find your own path.

Take a hybrid approach.

It’s not enough to tell them about your intentions and your plans and your goals, etc.

The only way is to show someone.

And similarly the only way to prove it to yourself is to show yourself.

You have to put the time in day after day.

You have to accumulate proof born of your consistency.

Too many clinicians don’t have self-respect in that they walk into work hoping to get the job done.

They hope to perform when the time comes.

But that is doing a disservice to both their patients and to themselves.

You can’t expect results you didn’t earn from work you didn’t do.

Respect yourself enough to create the conditions for success.

Preparation. 

What have you learned this year? How have you improved? Have you taken the feedback you’ve received earnestly?

Have the self-respect to be a true professional and to take yourself seriously.

Lifestyle locum mercenary? - Great, be an excellent clinician, be a great teammate, add value wherever you go.

Full-time w2 employee? - Great, be an excellent clinician, be a great teammate, add value.

Whatever your lifestyle, you owe it to yourself to not waste your workplace interactions or your career mailing it in.

Life’s too short to be mediocre.

The second hurdle they face is geographic - “What do I do if the staffing needs are not in my immediate vicinity?! HELP. I HAVE CHILDREN...THINK OF THE CHILDREN”

Newsflash: if all the great locum positions were located within a 30 minute drive from where you already live, there wouldn’t be a staffing supply vs demand mismatch because you’d likely already work there!

Don’t fear travel

In order to make the most of locum contract opportunities, you have to be available.

You have to cast a wide net, gather all the information that you can, and make an informed decision about where/how you spend your time.

Travel can be scary to some: there are a lot of unknowns.

People are scared to go somewhere new, travel somewhere new, rent a car, stay in a hotel/airbnb, or take a flight.

This all stacks on top of the anxiety of meeting new colleagues, new nurses, and new surgeons or getting acquainted with new workflows, EMR’s and infusion pumps

Those fears are only holding you back; the fundamentals stay the same wherever you practice clinical medicine.

The more sanguine your view of the challenges that lie before you, the better the chance that you will succeed.

Let’s do some math

So let’s say you balk at the idea of flying or driving somewhere to work because you say that the long commute negates any benefit in making better money or working every other week.

It takes me 3 hours each way to drive to a smaller, rural/exurban hospital for a 5 day week of working.

When I’m staying locally at a small hotel chain or Airbnb, it only takes me 10 minutes each way to get to the local hospital.

My full week of commuting: 6 hours to the locale and 100 minutes of daily driving, totals 460 minutes each week or about 45 minutes each way (90 minutes round trip) each work day.

Do you know anyone in the greater NYC, Philadelphia, Boston, Chicago, LA, San Francisco, Houston, Atlanta, or Miami areas whose commute is 40+ minutes each way?

(My entire readership raises their respective hands.)

I know a half dozen people who spend that time alone underground commuting on subway cars from Brooklyn to Manhattan before you even factor in their walk!

The average commute time for all Americans is just under 30 minutes, whereas for major metro areas like those above usually average ~35 minutes.

And let’s remember that these data are provided by self-reporting surveys where individuals are likely to round down, under-reporting their total daily suffering... I mean commuting.

Don’t dismiss a position because it takes some travel to get there.

I strongly recommend considering anywhere that’s a direct flight <90 minutes in the air or a drive <4 hours.

Home and Away

If you don’t want to sleep anywhere but in your own bed, then I hope you live central to a major metro area with plenty of hospitals and surgery centers.

But in the locum contract world we have to make trade offs.

And one such trade off, as the saying goes, is that ‘beggars can’t be choosers.’

That is to say: if you want better pay for your time or the ability to pick your own schedule or to never have to work a holiday again or to spend more time at home, then you have to go where the demand is.

No matter whether you fly or drive - just be sure to get credit for all the points/miles/awards as a perk of traveling for business.

The contractor lifestyle definitely is not for the faint of heart. It takes a certain personality to deal with the ups and downs of locum contract work.

So let’s specifically flesh out who should and shouldn’t do this.

The traits we want:

• incentive driven

• willing to question assumptions and the status quo

• able to work and excel in new environments

• comfortable going it alone

• willing to try new things

If I had to design the personality that would be the least suited towards this way of going about making a career in medicine, it would be easy.

I’d just take the traits of most physicians (but this can apply to nurses and PA’s as well):

• low in risk taking

• head-down, driven

• long-term goal oriented

• ego-centric

• concerned with appearances

• unlikely to question the status quo

• care about their patients

They don’t look bad at all, but these traits are ideal if you are looking to create a terrific career-physician.

Someone who will grind it out day-in and day-out, help patients, do the extra work, and go the extra mile.

All they need in return is the white coat, the title, and maybe an office.

They are happy to play the part in their personal lives as well by spending ~40% of their income on a mortgage and leasing a black Range Rover Sport (*to be discussed soon).

The traits you have to have

Locum contract work is unique to the standard physician’s personality traits above.

Contractors have to feel comfortable with the uncertainty present in their line of work.

It has to be worth it to them to forgo the legal protections of full-time employment and the benefits.

Alice, from Newsletter #019, is an example of a physician anesthesiologist who probably doesn’t have the stomach for the locum contract life.

But you have to be honest with yourself because not everyone has the personality required to strike out on their own and feel like you are on the riskier path than your colleagues.

Whereas employed friends can be rigid and stuck-in-their-ways, you must be willing to be flexible.

You must question the status quo, otherwise you wouldn’t leave the secure confines of employment for the uncertain contract life.

So the next time you hear a colleague say, “Can you believe these locum/travel/contractor rates? I should do that/You should do that!”... think long and hard about who you are and what you want before making the jump.

Whether or not your job is secure in medicine, at least you feel like it is.

And given the uptick in demand for procedural services, and healthcare in general given our aging population, it’s easy to feel confident that you have control over your employment assuming you stay on the straight and narrow.

But as we have discussed before, your trade for being an employee and enjoying greater job security is a certain degree of autonomy, your time, or your pay.

Risk mitigation

The downside of the locum contract way of life (or at least one of the major downsides) is that you have no such level of job security.

Newsletter #009 - Locum Horror Stories included this sentiment in the case of Natalia who learned the hard way the limits of contract work.

The take home messages were:

• credential at multiple places

• have privileges at multiple places

• supplement with a part-time w2 job

• vet each opportunity better before signing on

This advice still stands.

If you don’t take this advice, you might be lucky for a while, but eventually your luck will run out.

But what happens if you do?

What happens if you always try to keep 2 or 3 or 4 positions available to you at a time?

Well, things can get quite sticky, if not plain busy.

A good problem to have

I know that I made the leap into locum contract work in order to spend less time working and more time with family, friends, and myself.

But some of you are in it for the money.

There can be a terrific discrepancy in pay between employed and contract work in many specialties. (In anesthesiology it is regularly as large as 50% more earned per hour).

If you fall into that camp, then the more work you have the better.

But if you’re like me, then you begin to complicate your life very quickly the more opportunities you take on.

There is a fine balance to be struck, especially if you find multiple enjoyable assignments locally.

So what can you do if you’ve hedged the ever-present impending end to one assignment by credentialing at 2 others? Furthermore, what do you do when that first job never ends? How do you fit all the options into your schedule when you were supposed to be taking time for yourself and your family?

My advice is you take what you can, when you can.

It’s the fickle nature of contract work that necessitates this way of mitigating the risk inherent to the lifestyle.

This is the trade-off that you’ve signed up for.

There will be both feast and famine in exchange for a level of personal/professional sovereignty.

It’s a good problem to have.

And at this point, I am not willing to trade sovereignty for security.

And through the phone consultations that I provide to clinicians I have found that a great many of us have a common shared humanity.

We are not so different after all.

Take stock as you read this: no matter where you live, your upbringing, your class level as a child vs now, your specialty and profession, etc. - I’ll bet that you still struggle with many of the existential concerns that humans have struggled with for all time:

• How do I find meaning in my daily life?

• What do I want to do with my time?

• What sort of person should I be?

• Where should I live?

• How can I create/maintain close personal relationships?

Help is out there

The reality is that we all grapple with issues like this throughout our lives, but some of us glide past them.

Whereas a few with an inclination for analysis, introspection, and self-reflection, will constantly find themselves in turmoil somehow.

The vast majority of us usually face most of these issues in adolescence and young adulthood - the times where we exercise choice.

But many of us in medicine will have extended that period farther into adulthood, into our 30’s and sometimes 40’s. And in medicine, we have many intervals of training at which we might find ourselves at a crossroads: the transition from college to medical school, medical school to residency, residency to fellowships vs jobs, etc.

I was lucky enough to have this week chatted with an individual who was in such a place.

He is facing the mighty decision of “what kind of a life he should live?”

And since he was blessed, or cursed like some of us can be, to be one of those highly curious and introspective persons, he is struggling with some decisions.

Shared humanity

There are people out there that understand your plight if only you might allow them.

Stop thinking you are so unique and special that only a small slice of mankind could ever understand you; we are more alike than different.

We share enough of our humanity with others that a great many of us have something to offer to those around us.

We can all be teachers, mentors, confidants, peers to people in different fields from different parts of the country (or the world).

But first you have to humbly offer to hear their story and humbly subvert your own unique and special life circumstance that made you who you are to offer advice and thoughtful consideration.

I’ve previously written about the challenges of Where to Look for Mentors in Medicine:

Most clinicians have spent so much time focused on moving forward on the path of medicine that they have indoctrinated themselves into a certain expectation about how they can and, moreover, should spend their time.

Most just keep going; it’s rare for someone in their 30’s and early 40’s to actively throttle back after having redlined for a decade to make it this far.

Moreover, almost everyone you know has been through the same indoctrination by their over-worked and out-of-shape mentors.

Not everyone you work with will be willing or able to hear you out and offer their unbiased perspective.

Not everyone wants to contemplate a path different than their own.

Very few people will care to argue against their own position in order to help you through your situation.

Even if they went through the same dilemma you face now, they might lack the self-reflection necessary to consider having made a different choice.

But you won’t know until you’ve tried them out.

Everyone has something to offer if you let them.

It’s unfortunate that so many hide the true expression of who they are behind the baggage of their past choices.

Make yourself available to others because you have something to offer.

Seek out help from everyone you can because you might share more than you think.

I had heard rustlings of higher pay and a better schedule out there in the ether.

But something like that was so foreign to what I was doing at the time that I could easily shake it out of my sight like a mirage.

But do you know why everyone you know works in the same way for the same pay?

It’s the same reason that you haven’t found a new job after years of complaining or dipped your toe into independent contracting or taken control of your life outside work.

Fear

You’re afraid to take the risk required to try something new.

But what’s worse is that you convince yourself that the proof required to stand pat is the observation that everyone around you stands with you.

They haven’t traded up for a better w2 job, they haven’t made the leap to contracting, and they haven’t cleaned up their diet, sleep, or habits.

Therefore making a change must be incredibly difficult.

Wrong.

What you don’t see is that everyone there shares the same fear.

This isn’t the first time we’ve discussed fear in the context of this Newsletter and it won’t be the last.

The reality is that most people don’t have a very good reason to do what they do or to think what they think.

They lack insight.

You don’t because you want more.

The promised land

So what’s the secret then?

Simple: there isn’t one.

There is no secret that is stopping your from getting what you want.

There is no magical threshold you have to cross to reach the promised land.

The only thing between you and where you want to be is to begin.

That’s it.

And guess what doesn’t count as beginning, what doesn’t count as shortening that distance between now and your future?

Answer: Reading newsletters and articles and forums on the internet. Neither does talking to your friends or spouse about it.

So go get started.

(Inspired by Chris Williamson on the Modern Wisdom Podcast.)

That evening I created a spreadsheet in Google Drive that I still reference titled “lists of reasons why/not...”

It was the first time I had ever documented my considerations for leaving my job to work somewhere else.

My first entry:

• to change to different job

• better compensation for my time

• less variability in length of my day

• less/no overnights

• less/no weekends

I remember looking at this list a few times that holiday season and then putting it away for months.

Spring 2021 I added:

• no feeling frustrated before even seeing the next day’s schedule just knowing i’m 2nd call on a thursday

• no worrying about last-minute, arbitrary schedule changes

• not having to query the call teams in hopes that someone will step-up and take my room so I can get home

What started as just vague generalities, gains specificity.

Clearly I was motivated by some frustrations.

Fall of 2021 I wrote:

• not getting sick/rundown when doing nights or first call (getting unlucky)

I remember I caught a bad stretch of luck on my 1st call nights covering cardiac anesthesia call.

Even though I didn’t take it that often, 4 of 5 consecutive 1st calls ended up the same way: around 4 or 5 in the afternoon things seemed swell.

But an emergency/transplant would be added such that my team would be working straight through to morning.

Bad luck.

Spring of 2022 I remember covering the ICU (in-house) a certain weekend.

Because of staffing challenges the next week for the anesthesia half of my job, I wouldn’t be able to take any post-call days for the 7-day stretch I had just worked until later in the week.

• to not get nonsensical messages from surgeons on Sundays when they don’t even have the information that they are pretending to convey to me

• to get more messaging on Sundays about changing the cases and the order and the add-ons and all sorts of nonsense

• All at the detriment of patient care because of poor planning on the part of someone involved in the surgical team

Time passes

I share all this to show the evolution of thought that takes place slowly over time (and maybe the accelerating exasperation as well!).

Most of us are too busy with our work, family - with life - to be able to reflect on our present situation with full clarity.

But you don’t have to do it all - from conception to execution - in the same breath.

The slow accumulation of feelings, thoughts, experiences, and daily decisions lead us to some future intersection with fate.

Over time, we can refine our reasons and our feelings for thinking what we think and doing what we do.

I encourage you to slowly document your reactions and reflections to all aspects of your life.

Through the changes in language on the page, you can identify the ways in which you have subtly changed over the months and years.

Difficult decisions are difficult to make all at once.

So don’t.

Most clinicians work Monday through Friday.

Most have to cover holidays, weekends, and nights.

As a result, they work when they would prefer to be doing something else.

I know I’ve missed half a dozen weddings (that I would have liked to attend), the funeral of a grandparent, and innumerable holiday and birthday parties over the decades because of my work schedule.

When you are in training or just starting out, you can’t get choosy with your schedule.

But for those of you with more experience at your full-time job, working part-time, or locum/per diem you have the rare opportunity to create a schedule that works for you.

Think outside the box

I’ve been pretty adamant about trying to find a better work-life balance through working less overall as an independent contract physician.

But maybe your goal is to make as much money as possible like my friend Steve.

- Who says you need to hold 1 contract at a time?

Instead of scaling back his total hours, locum contracting allows him to chunk his work weeks to make the most money in the shortest amount of time.

He weaves together multiple locum contracts at the same time: a 3 day weekend in upstate NY covering OR and OB (as an anesthesiologist) call nonstop from a hotel room, then he flies to NYC Monday, works Tuesday through Friday at a local hospital (with one or two of those nights on call added), he flies to the mid-west over the weekend and works the following week with a few calls added before he returns home.

It’s a lot to type and it’s even more to fathom!

But in that time he’s able to log about 300 hours at an average rate of ~$250/hr (depending on hours and how many cases he gets “called in” for from the hotel), for a total of ~$75,000 in less than 3 weeks.

It doesn’t sound relaxing.

But for someone with the right disposition, it offers an opportunity to pad the checking account and accumulate frequent flier miles in short order.

More is more

What if you want to squeeze a bit more juice out of your current schedule.

Let’s say you have a pretty cush full-time w2 job working as an anesthesiologist from 7 to 3, five days each week (apparently they are out there!).

You wish it paid more, but you can’t complain.

What can you do?

Find a way to augment your schedule helping out an overworked hospital or ambulatory surgery center nearby from 3pm to 8pm once or twice each week.

They could probably use the help for what is likely an overworked staff and you might as well get paid well for your time.

Somebody has to work weekends

A close family friend of ours is a Family Nurse Practitioner who was looking for a way out of her 3 twelves each week at a hospital in town.

She wanted to work remotely, but was worried about the trade to working 5 days each week (the 5-day schedule fear is real, if all you’ve known for 2 decades is 13 shifts each month!).

Instead, she found a better option for her: a remote position that only required 4 ten hour shifts each week as long as she worked each weekend (she could choose the 2 weekdays and no holidays were required).

Working 8 hours each weekend day wasn’t ideal, but the job consistency would allow for easier child-care (compared to her previous position which had no set days), and it paid 15% more plus no commuting time wasted!

Summary

None of these examples above sound enticing to me, but that’s not the point:

Alternative schedules do exist.

And some of them might even meet your and your family’s needs better than the cookie-cutter approach that most clinicians accept.

Deliberately choose how you spend your time.

When was the last time you had the summer off?

I’ll assume that, like me, you had just received your learner’s permit somewhere in the first half of high school.

I haven’t had 10 weeks off in a row since I was in high school, let alone the whole summer.

That was two decades ago.

Hell, I haven’t had more than 2 weeks in a row off since college winter break.

Between junior and senior year of high school was the last time I played organized baseball, which until then, had consumed the majority of my free time and thought.

For my high school affiliated American Legion team, I hit something like 8 triples (summer means no fences in the northeast for all the field sports to share the space) in 15 games that summer.

I pitched for the first time since I was 9 (a great athletic regret would be why I didn’t pitch throughout my youth) and struck out 5 batters in 6 innings. I also gave up a bomb, but it was to my step-cousin - so I can’t be too mad.

But in 2023, at the ripe age of 37, I completed a summer to my own devices - I can’t be the only one who always wished they had more time, who would do things differently if they could just get a breather from work.

Thankfully, I had the opportunity.

Here’s what I learned after more than two months off as a thirty-seven year old, physician, and husband:

Time Waits for No Man

The summer of 2023 is over now. It will never come back.

You will never have the time back.

You will never have the advantages of youth on your side: you will never be younger than you are right now.

The best time to plant a tree was 20 years ago. The next best time is now.

Currently, there are no known methods to stop senescence.

I can already tell that my body does not respond the same as it did 5, let alone 10, years ago to things like variations in diet, exercise, and sleep quality.

Everything takes more time to reclaim as we age. And there is the challenge: time is finite.

Invest your time wisely.

Attention is the cash value of time. Everything is valuable only to the extent of how much attention you could pay to it...Sam Harris

Sunshine is Special

Not having to pray for good weather between night shifts, enjoying my time outdoors, less time forcing a tan and I’m sure my skin will thank me for that.

Prioritize Relationships

My wife and I have become closer than we have ever been after knowing each other for a decade.

We have continued to invest time in our shared vision for us in the present and the future.

Save Your Money

I haven’t gotten paid.

I am not working a contract, that’s how it works - Save your money!

Otherwise, this lifestyle can be a nightmare and not a personal improvement opportunity.

We don’t live paycheck-to-paycheck, we have no debt, our cars are paid for, our housing is reasonable, and we are aligned on what is and what is not worth spending money on.

Sleep is Golden

I’ve never been an easy sleeper, a good sleeper.

I shudder to judge so harshly, but it’s the truth.

This past summer, even with my mild baseline insomnia, I woke up to an alarm less than a handful of times - most of those only to catch early flights.

It has been remarkable how enjoyable it is to leave your phone in another room each night.

I have nothing to think about besides sleeping my fill and then starting the day.

When was the last time you had the summer off?

What type of lifestyle would you like to live, but you feel that you can’t?

Find a way to fit it in before it’s too late.

Contracting gave me the summer off even if I hadn’t planned for it in advance.

Deliberately choose the life you want.

Now is the time to plan for the summer of 2024.

This isn’t really a vacation even though I do happen to be staying in a splurge-worthy hotel and don’t have any real itinerary for the weekend.

It makes me wonder how I might have made this happen a few years ago: how would my wife and I go on a mid-winter, quick getaway at the last minute? I mean we didn’t book the flights until the week prior and I didn’t have a hotel reservation until we walked up to the front desk and asked for one!

Now the old me of 2 years ago wouldn’t have been able to make this happen.

I wouldn’t have had a 5 day weekend already on the books with nothing planned in advance. (I mean who really wants to wake up early after a rowdy Super Bowl party every year for your entire life! It should be a national holiday, but I digress.)

My schedule, and my desire for more time, allows me to be flexible.

I don’t get greedy; I want my sleep and my peace of mind, while at the same time doing my work and helping patients.

The me of 2 years ago wouldn’t have been able to just say “let’s get some good weather and visit my 17 month old nephew.”

Time is finite and family-time is precious - hence this website, the coaching, and the career change.

Let me encourage you to take a quick trip - take a quick break.

And if you can spend time with your loved ones - even if they are annoying - it will be worth it in the end.

Because no matter your age, you will never be younger or healthier than you are right now, and neither will the loved ones you could be visiting.

And so I took one Saturday morning to renew all of my medical society memberships and maintenance of certification (MOC) in my specialties.

All-in I spent roughly $3,000 - on 2 anesthesiology societies, 2 sub-specialty societies, and annual enrollment in MOC for 3 board certifications.

My first reaction was, “Man, that wasn’t cheap!”

In years past, I would have had the great majority of that paid for by my previous employer (as part of my non-salary compensation - which is why it can be difficult to determine your hourly rate).

But, in the next moment, a grin came across my face as I felt a certain satisfaction: what a small price to pay for a large gain in freedom.

When you compare one job to the next, or one way of working (employed) to another (independent contractor), you might forget many things that would weigh the scales in favor of one choice over the other.

Paying for my own society memberships and MOC each year were not things that I had priced into my calculus when I decided to make the jump and leave full-time employment.

But the satisfaction that I felt that morning at my laptop - sitting at my kitchen table, while the winter sun streamed across the room, listening to music from my stereo, while my wife mixed her homemade pancakes - was priceless.

It was the very dream I had previously hoped for - to have time. To have weekends off. To no longer need to simultaneously cherish and cram everything from a week into 1 or 2 days.

I just wanted to enjoy a Saturday morning at home.

It’s not that I couldn’t before when I would consistently work 55-80 hour weeks.

It’s that now I can let them sneak up on me. I don’t have to try so hard to “make the most of my time.”

Peace of mind

Let this week’s newsletter serve as a reminder to you that there will be unexpected trade-offs, both beneficial and costly, with any future choice.

No matter how much you get paid or how fancy your title, you might still find yourself grasping for something you can’t have.

I used to think it was just time, but really it was the feeling of having time - the feeling of not being pressured.

It’s hard to put a price on your autonomy, your sovereignty, or your peace of mind.

So don’t.

“I just want to work; I plan to finish residency and go straight into independent locum contract work.”

“Do you think going straight into locum work from training makes sense?”

Half of my audience for this newsletter and on the website comes from medical residents and fellows.

So let me consolidate my thoughts for the next generation considering making the leap when they finish their training.

Fundamentals over everything

The only step that absolutely can’t be skipped is this one.

Without it you won’t have any chance for longevity outside of the friendly confines of a large, academic medical center as a salaried employee.

Your primary calling card is your skill at providing safe care to patients.

In order to do this, you must merry knowledge, experience, and procedural skill (I’m talking: line placement, surgery, intubation, examination, etc.).

Knowledge is mostly what you immerse yourself in on your own time: reading textbooks and studies, going to conferences, watching YouTube videos, etc.

Experience requires you to put the time and effort in over the course of your 3-7 years of residency training for physicians, or for PA’s and nurses, those first few years of practice.

If you don’t have the reps under your belt to learn what needs to be learned when you are junior, you can learn it later, but you will be behind the proverbial eight-ball.

Procedural skill requires doing. It requires even more reps. It requires failing in a safe environment with someone to co-pilot you through.

You can also learn procedural skills later, but it’s even harder to do and the risk of learning “on the job” is huge.

Chances are you won’t be even a roughly polished version of yourself immediately out of residency/fellowship or an NP/CRNA program.

It takes time to sharpen your fundamentals. So take the time. Don’t rush.

Be a good teammate

You know who gets called first when openings arise and the need for another contractor comes up?

The known quantity - the person who already has a relationship with the hospital or practice.

Your goal is to be that known quantity.

And, even more than that, it’s to be a known quantity that people like to have around.

Can you hang? Can you pass the vibe check?

Do the nurses like you? What about the doctors, surgeons, secretaries, techs, nurses aides?

If there is any team dynamic to your job, you need to be proactive especially in the most difficult or emergency scenarios.

Be memorable, but not only that. You have to make life easier for everyone when you are there.

Coming out of training it’s hard to be that slick - it takes time to finely tune your social dynamic within your respective environment.

Again, don’t rush this.

Learn to lead

Most graduating anesthesia residents haven’t had practice medically directing/supervising nurse anesthetists who might have their own way of doing things (while also having decades more of both age and experience).

The same goes for a graduating nurse practitioner in an ICU full of more sage and senior bedside nurses.

Whatever your specific role, you probably don’t have significant experience taking responsibility for other, lower in the hierarchy, members of the care team.

That is to say: as a newly minted doc/nurse/etc you now have the duty to take on a majority of the responsibility, but with much less direct patient contact and control.

You have to learn to trust. To communicate. To compromise.

When do you jump in and do things yourself? When do you criticize?

Moreover, how can you when it’s your first day at a new hospital, in a foreign city?

Leadership is a skill that takes both deliberate practice and time.

That might be tough to do while on assignment and without the security of a contract that lasts longer than 30 days.

Again, take your time to grow in a safe environment for months to years before diving straight into locum work.

Summary

1. Polish your fundamentals first and foremost. Get as much experience as you can, especially with the hard things.

2. Be a teammate who is both useful and a net positive person to be around. Life as a contractor requires being wanted and relationships matter.

3. Learn to lead. No matter your role, you have to navigate the hierarchy that exists in your profession to be effective and provide safe, quality care to patients.

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If you’ve ever lived in a place for a time and then moved away, I would bet that you might regret how you spent - or didn’t spend - your time there.

Nothing catastrophic - hopefully nothing you will take to the grave.

Just regretting the types of things that you, only in retrospect, realize might never come your way again.

Maybe you worked in Southern California for 6 months, but never tried surfing or playing beach volleyball.

Maybe you lived an hour or 2 from a major national park or mountain range, but never visited.

Or maybe you should have made a go at a relationship when you had the chance, but you held out for a better time.

I had a leased car with an allowance of 12,000 miles per year while living in Atlanta for 2 years of fellowships.

But I would only put 9,000 miles on the car in total at the end of the 2 years.

I never drove to the Gulf Coast, I only drove up to the mountains once, and the same for one weekend in Charleston, SC.

Sure I was busy with work, but not that busy for nearly 200 weekends.

When we are living back in that place, we put things off, we get too busy.

After we move through space and time - to the present - we look back and wish we could have done more when we had the chance.

Back then we didn’t realize that time was “our chance.”

“I won’t make that mistake again. I’ll enjoy my time in the present.”

Yeah, right.

We all have flashes of clarity, but consciousness is fickle and easily distracted by all the shiny objects that surround us.

Certain seasons in life don’t recur.

Sometimes there is magic at the intersection of a time and space in which we find ourselves. But the rub is that we can only realize it through the rear view mirror.

You have to choose - and in so doing, you are choosing your regrets with each decision.

What are you missing out on right now?

What opportunity is sitting next to you, but you aren’t taking advantage of?

Many of us wish we took advantage of abundant opportunities just a few years ago: lower interest rates, early-internet economies-of-scale, to start a family sooner, or later, to leave home, or come back to it, to choose a different path through medicine, or even to bypass it completely, etc.

Are you happy with your career path so far?

Has it afforded you the life you’ve wanted?

The life with less stress and the freedom to take advantage of the here and now.

Do you feel like you’ve made it?

If not, then why not? What’s holding you back? What do you feel like you are leaving on the table?

If someone many years from now, in some far distant place, were to ask you about what you did here and now - would you have regrets?

I hope you consistently reflect on the present and that you deliberately pursue what is important to you.

(Inspired by the Christopher Hitchens quote: “You have to choose your future regrets.”)

1. They don’t know what they want.

2. They don’t know what is important to them.

3. They aren’t sure if locum tenens is right for them because they haven’t thought hard about it, for long enough.

Instead many of them are just chasing the blossoming locum contract market in hopes of big money or cush practices.

Most jobs out there are ‘fine’

The majority of clinicians I work with aren’t sure if it’s even “worth it” to make a change.

They usually find their work to be ‘fine’ even though they are underpaid, overworked, or both.

But because they have been working through the healthcare pipeline for so long, they have become accustomed to working more or for less than they should be.

Some of them can be shown that there are other options out there - options with a better healthcare team, pay, or hours. (Red pill)

Others should stay in the insulated world of medicine and continue to have the security they crave. (Blue pill)

But the problem is that locum contract opportunities are exploding around them and the Blue pill clinicians are finding themselves sucked in.

Analysis by paralysis

A per diem anesthesiologist (Alice) asked me about how to approach an issue with a group they wanted to work with.

Apparently this group wouldn’t talk hours or pay with Alice until they visited the practice in person.

So she wanted to know how I might approach the issue of pay and what she could say/email/text to get a pay rate quote before driving out to the practice.

Before giving an answer to the question of “how do I get them to talk money with me?”, I asked more about the job and it didn’t seem like that great of a position:

• the practice was a roughly 90 minutes drive from Alice’s home

• she had directly asked about pay rates and they turned the question back to her: she told them she needed $350/hr and they replied that was “much higher” than they were willing to pay

• she currently works per diem (w2) and makes ~$250/hr

• she took her current per diem position because, at the time, she was desperate for a job

• the practice was appealing to her only because she had intimate knowledge that it was a very “cush” practice with low-acuity patients and no call/weekends to cover

• they weren’t willing to move forward unless she spent the day with them (she would not be performing any clinical duties) to see “if they were a good fit for each other”

I then asked her more about what she wanted in the wide world of locum contracting and she told me her priorities were:

• no travel - she needed to be near family for the next 2 years

• more pay - she feels like she has been getting underpaid at her per diem position (she is)

This scenario left me with 2 thoughts, both of which I expressed candidly to Alice:

1) This practice sounds... less than ideal.

It’s a back-breaking commute to drive 3 hours each day for 8 hours of work to a practice that will, at best, pay her $50/hour more than her per diem position.

She might as well keep the per diem position and work 2 more hours each shift: that way she would make more money (an extra $250*2 hours vs $50*8 hours) and be home 1 hour sooner (her existing commute to the per diem job is 15 minutes).

Furthermore, they refuse to talk money even though she has already interviewed over the phone and zoom. While at the same time rejecting her ask and offering no counter.

2) The idea of contract work... might not be for her.

She is avoiding other locum positions in the area while being fixated on this specific practice because it is “cush.”

Alice is wary of working through an agency, but is finding it difficult to work directly with the group.

She refuses to consider “travel” assignments that would require her to sleep in a hotel, even though she could get paid more which would in turn allow her to work less overall and spend more time with her parents.

She wants some strong level of job security and as most of you already know, locum contracting is anything but secure.

*Dirty Harry was right

Alice has to make up her mind about what is important to her.

Even though she has been thinking about this position for over a year, it might not be right for her.

In fact, contracting might not be worth it to her - she might do better with expanding her per diem hours or working part-time instead.

But what she can’t do is continue to put all her eggs in one basket.

She can’t fixate on a practice that isn’t willing to communicate with her from the outset, especially in this market where she could do much better closer to home.

You must “know thyself” and determine your level of risk tolerance.

Do your soul searching early because locum tenens isn’t for everyone.

The end of the year is a very appropriate time to think about where you’ve been and where you would like to go.

But what most people get wrong about the “New Year, New You” mentality is that they waste the other 11 months of the year by waiting until now to analyze and reflect.

Deliberate change >>> Luck

The only way to find yourself in a better future situation than you are in now is to:

• Get lucky (win the lottery, accidentally make positive changes, etc.)

• Make positive changes deliberately

That’s it. Just those 2.

We can hope for the first option - ‘get lucky’ - but as many have said:

“Hope is not a good plan.”

This leaves ‘making positive changes deliberately’ as the only method of improving your position over time - with any opportunity to control your situation.

The only way you get to have an effect on the outcome is if you know and control the inputs.

Are you assessing your finances? Your health? Your sleep patterns?

Are you happy with the job? Is your family happy with your job and the effect it has on you?

You can’t expect to reap the rewards of a new result - new job, new living situation, better health, more money, etc. - by doing the same things that have given you poor results in the past.

You have to make a change.

And many times, you will have to deliberately engineer it into your life.

Break the mold

Many of us in healthcare have entire family or friend networks that are over-represented with nurses, doctors, PT’s, OT’s, etc.

And because many of us have grown up in that environment, we get used to people staying in the same job for years, if not decades.

We don’t have friend, brother, mother, or uncle examples of people upgrading their situation - or at the very least, analyzing it and discussing it openly.

(It’s almost unheard of for a nurse or doctor in a metro area to have switched jobs 5 times in 15 years, whereas it would not be unusual in most office jobs.)

Wanting a better job, with more time off or more pay or a better commute, doesn’t have to be a dirty secret.

If you want different results, then you have to break the mold even if that means finding a different path than what your family or friends have done/are on.

It’s your time.

If you need to make a change. If you want for more.

Don’t wait for the new year. Do it now.

Make it happen.