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.

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What follows is the step-by-step approach I took to go from no knowledge to entertaining my first locum opportunity. These are basic steps. This is meant to provide a framework to show that if I can do this then you can do this too.

I did this while post-call, nights, and weekends. It spread out over nearly 12 months, but it really should have taken me only a few weeks to execute assuming I wasn’t working 80 hour weeks in the ICU back-to-back…wait, a minute...

At the time, I only knew of one person who had taken the leap. We had spoken maybe two times before around the hospital. But after sharing my thoughts with other friends, I found other contacts. That was my start.

Maybe you don’t know anyone to talk to about the process.

But, actually, you do. I can help. This is why I’ve made these resources, to help you find a better path. Message me on the socials (link at the bottom of each page) and we can set up a time to discuss for 30 minutes. No catch.

Ok, so what did I do?

Background Research

I talked to the only 3 people who I knew personally who had made the complete leap to locum tenens doctoring - 1 acquaintance in Pulm/Critical Care who is a decade my senior who found a way to work one week a month upstate and yet be around her teenage children at their Brooklyn home more than she ever had when working at our mutual prior employer , 1 friend from medical school who, straight out of residency, joined an emergency medicine locum group that covered a couple dozen ER’s across New Jersey, 1 current close friend general Anesthesiologist who jumped ship from our mutual prior employer and could give me actionable info regarding our specific metro area.

I googled everything about the process I could find. I searched Reddit, Student Doctor Network, and GasWorks listings. Find the forums and job boards for your specialty. The truth is out there.

After doing copious research, you must have a sense of hourly pay for your specialty. And not only for your specialty, but also for the specific state and region. When you look through jobs later in the process, you will need to be armed with knowledge of what you are willing to accept. Similarly, you will need to give specific parameters for your agencies to find you locum gigs.

Family Decision

I discussed the options before me with my wife, my brother, etc. I made sure that my wife and my expectations’ were aligned. I wanted her to know that there would be more uncertainties going down this path. She was adamant that I find a way to claw back my time and shed my misery. I love her.

Find Agencies

I went on the NALTO (National Association of Locum Tenens Organizations) website members directory to find agencies who at least said they had good ethics and wanted to be part of such a membership/listing. I contacted every one of them either by the listed email contact or a webform with a pre written short script (and yes, I know it was not very good and it evolved rapidly since then!):

“I’m interested in locum options as an anesthesiologist and am interested in working anywhere in the country that offers a great opportunity covering any adult case types. I am Board Certified in Anesthesiology, Critical Care, and Perioperative Transesophageal Echocardiography. I have been in practice for almost 5 years at a major quaternary care medical center taking care of very sick patients as a Cardiac Anesthesiologist (50%) and Intensivist (50%).”

I did in fact contact every listed member on the NALTO directory at the time I searched. The marginal cost to contacting an additional agency is very small after you’ve contacted a dozen.

Do your homework, don’t settle, don’t leave things undone. This is your life and career.

Create a Work Email, You Will Thank Me Later

Only use a specific locum/independent work email because you will be flooded. Do not use your work email or work phone for searching or communicating with potential job opportunities. In fact, do not use any of your current employer’s resources to do so as it is likely in violation of your terms of employment. That means no wifi, no office desktop. Do this on your own time or on your own data connection.

If you have access to a separate phone number, for the same reason, use it instead. I refused to answer, and still refuse to answer random calls, instead I only talk if we have planned to talk ahead of the phone call.

Talk to Agents and Tell Them What You Do

You will find that some are learned and understand your specific skill set and what you do fairly well. Mostly, however, you will be talking to someone young and inexperienced. The worst are the hard sales types who think they have to convince me to take a job. The benefit to talking with many recruiters/agencies/agents is that you get to ask questions and gain insight into the process: I wanted to learn as much as I could about the process, what standards in the industry were, etc.

Hopefully you will find somewhere between a handful and a dozen that you will pursue discussions with for whatever reasons. I wanted people to be professional and knowledgeable. It turns out the majority are women and the majority of the good ones are women. I think this is just the demographics of the job. It might also be that all the men I am continually contacted by are too pushy, too “used car salesman” when the jobs sell themselves.

Work with the agents/recruiters you choose. Set parameters on what you are, or are not, willing to do. You might say, “I’m looking for jobs that pay at least X... I am not willing to cover pediatric patients below the age of 8... I will only travel for positions that are less than an hour from the airport... I am not willing to cover (as an anesthesiologist) 1:4, my maximum rooms to cover is 3...”

Be specific. Ask for what you want. Be clear.

DON’T RUSH

I had a mental timeline of when a reasonable time to leave my full-time job would be and I wanted to give at least 100 days of notice. This was my desire so as to limit how much negative externalities there were for my, soon to be, former colleagues. (You are not required to give a period of notice prior to leaving a job if you are employed “at-will.”) From first contact with agencies, to signing my first agreement it took about 6 or 7 weeks.

It cannot be overstated, do not rush the start. Do not be desperate.

If you have the choice, don’t jump. I understand if you are reading this and you are desperate, but the last thing you want to do is to “rush into a gunfight” as they say. Jobs are desperate for locum work and pay handily because others can’t, won’t, or shouldn’t work there. Your job is to stay calm until you have a reasonable answer for all three questions after vetting as best you can. Don’t be afraid to ask for contact information for someone placed there in a similar capacity in the past or currently. As an anesthesiologist, I have spoken to nurse anesthetists to give me the real nitty gritty on an operating room culture since my agency didn’t have any MD’s placed there recently.

Your recruiter/agent from the agency, and the agency themselves, make money when you make money. Usually, the hospital contracts them for a set rate and your total compensation (pay, travel, etc.) is taken out of that. The remainder is for the agency. They have an incentive for you to find a good fit where you can be successful and satisfied.

Getting started at locum tenens and finding a desireable locum assignment aren’t hard tasks. It just seems daunting from the outside. There will always be things you don’t know in everything you do. Don’t let them stop you from getting what you want.

There are unwritten and undiscussed rules to any game. You’ve learned much of what goes unspoken in the workplace through experience and one-on-one conversations. Working as an independent contractor in locum tenens assignments is no different. You just need the experience. I’ve expanded on some of these rules as they apply to the world of locum tenens in this post “The Unwritten Rules of Locum Tenens”:

Just a short time ago I was sitting in your seat, but from an academic hospital job making the leap seems impossible: How does it work? Where do I find jobs? Isn’t credentialing a pain? I don’t get healthcare coverage!? What if it doesn’t work out?

You don’t know what you don’t know.

It is scary.

It will feel anathema to your current job because it is.

Working for yourself, controlling your own schedule, avoiding hospital politics - there’s a reason why you are here. Maybe you realize that your inputs (blood, sweat, tears, prolonged patient family conversations, finishing charts from home at 10pm, etc.) don’t yield improvements in outputs (no bonus, no increased compensation, no leadership roles, no improved vacation times).

Maybe you realize that you will, more or less, continue to make the same income with the same vacation for the next 20 or 30 years. To some physicians and nurses, that is a blessing. To others, that is a curse. You’ve peaked: you continue toiling and punching the clock until you retire just like many other blue and white collar jobs around the country - only yours requires odd hours, the neglect of your health and sleep, immense stresses, and the inevitably of being sued for doing your job.

If you could snap your fingers and make the perfect balance of life and work and pay, what would it be?

How many days each week would you work? What would you do with the other days?

How much sleep would you get? How often would you workout, run, swim, bike?

Would you pick your kids up from school?

Would you work holidays and weekends and nights anymore?

Would you be able to make all those weddings and parties that you’ve missed over the course of your training and career?

How refreshed would you be to see patients, to help, and to listen to them?

How much time would you take with each one? With teaching?

Would you take a pay cut to make some of this a reality?

If you could snap your fingers to make your life better would you do it?

Of course you would.

But are you willing to work for it? Are you willing to do things that the people around you aren’t willing to do? Stop being miserable and stop commiserating with your work friends about how frustrating the situation is. Change the workplace for the better or leave - voice or exit.

Choose a better life.

When you’re new to something, the absolute best thing you can do is just get started.

Keep Calm and Carry On.

• Where could I buy my own plan?

• Can I scale down full-time coverage to just 2 days a month?

• What do you do when you have a per diem need for medical malpractice as a physician anesthesiologist or nurse anesthetist (crna)?

Overview and Resources for Medical Malpractice Insurance

The basics regarding the need for generous medical malpractice insurance, state-specific and specialty-specific coverage nuances, tail coverage strategies, and the rest are best discussed elsewhere.

I specifically recommend the following resources to educate yourself further:

The White Coat Investor

Aegis Malpractice

Anesthesia and Pain Medicine Success Podcast

The Anesthesia and Pain Medicine Success podcast offers much to learn not only for anesthesiologists, but for all clinicians more broadly. On the topic of medical malpractice specifically check out this episode:

Most locum tenens opportunities include medical malpractice insurance either provided by the client hospital/practice/group or by the locum agency itself.

But for someone looking to staff a small practice a handful of times per month, like my local GI office, what options are there?

But Is There a Per Diem Malpractice Insurance Option?

I found just one option specifically for anesthesiologists and nurse anesthetists: Nationwide Anesthesia Services, Inc. (NASI) Per Diem Malpractice Insurance. They promise an “A rated claims-made policy with built in tail coverage.” Their credentialing department can turn a completed application around for approval in “approximately 2-3 business days.” They do require multiple letters of recommendation from within the past two years of association. There is an annual credentialing fee of $150 and a fee per day worked of $175 as of Summer 2023.

Coverage by a staffing company does seem concerning. So I spoke to the contacts at NASI and confirmed that the policy is underwritten by a major A rated insurance carrier (at the time of this post I can’t remember the company from that phone discussion). I was satisfied after a phone call with their contact and had all my questions answered. I suggest you do the same if you are interested.

• The NASI Credentialing Team

• Amanda Griffin

• 877-844-2057

• Amanda.Griffin@nasinc.net

Full disclosure: I did not end up pursuing the local GI office job because of poor suggested compensation. And so I never applied or used the NASI Per Diem Malpractice coverage. But I’m glad to know that it exists, even if it is relatively expensive, just in case an opportunity or need arises.

(December 2023 Update: I have at least 1 personal friend going through the process of obtaining NASI Per Diem coverage.)

(Fall 2025 Update: I do know 3 people that have used it and found the process reasonable.)

Also, if you aren’t familiar with The Unwritten Rules of Locum Tenens read that short article now:

Unfortunately for those that branch out from a “standard” medical practice to locum tenens contract work, you don’t know the rules because you haven’t learned them yet. You unknowingly have accumulated a lifetime of knowledge in being an employee. You know about tax withholding, state and federal. You vaguely know about at-will employment laws.

Contract work is different. You are not employed by an employer - you work for yourself and provide your services to the client. In our case, locum medical contract work, you provide your medical skill and expertise to your client - hospital, office, surgery center, clinic, etc. You will have different legal protections, different taxation, and different pay to those of your employed colleagues earning w2 income.

Resource: Although cumbersome, the IRS site is a one-stop shop since… they make the tax law. I recommend reading through the basics on their site even if you plan on hiring an accountant so that you may be better informed.

Without further ado,

The Unwritten Rules of Locum Tenens work:

1.Never give out your CV unless you want to apply for that specific position.

Safeguarding your CV is the difference between just chatting with recruiters/agencies/direct hospital contacts and formally applying - called the “presentation” or being “presented.” Being “presented” to a client, either via an agency or directly to someone at the practice, starts a sort of “binding” process with that client through that agency, or with that client directly. Some clients, like North American Partners in Anesthesia, have limits on being “presented.”

Even if they decline contracting you after being “presented” with your CV and formally discussed, you may be barred from being “presented” - ie, applying - to other locales under that group’s management for a period of 6 months to 2 years afterwards. And some of these large client groups cover hundreds of locations. Don’t close doors, if you don’t have to.

2. You can work through a single agency or directly with the clinical site, not both.

Casting a wide net is essential to finding contracts to filter through to get the positions you want. The clinical sites do the same thing: they work with many job sites and agencies to help staff as quickly as possible. To ensure that different agencies aren’t presenting the same candidate, you will be “name cleared” - checked against previous employment in that health system, previous contract work with a different agency at that system, or multiple applications from different agencies. They usually require, depending on the agency or the health system, 2 years from the last “presentation” (see rule 1) or contract work or employment in order to “clear.”

The decision to work with an agency vs contracting directly with the hospital is nuanced.

3. Your locum tenens contract specifics are nuanced and unique. Read carefully.

Hire a labor/contract lawyer to go through the details with you carefully when the time comes. But as a non-lawyer, my quick highlights are:

Usually the client site or yourself each have a set number of days (eg, 30) to terminate the contract for any reason. Termination under 30 days requires the client to have a clinical or professionalism issue as reason for zero day notice to get rid of you. Otherwise they have to pay you for your availability offered int that 30 day window.

There need be no discussion, no investigation, no meeting - you are a contracted worker. You have no employment rights because you are not an employee. You have no rights and they have no obligation to offer any recourse. So that means if someone wants you gone, you will be gone without notice.

Usually you will offer “dates of availability” which will be agreed upon in the contract and signed off on by the client site. Or maybe they asked for certain coverage dates and you obliged. Either way, realize these are not set in stone for the duration of your 3 or 6 or 9 month contract. You have agreed to make yourself available for those dates, but if (in the above example) you want to change vacation plans outside of the next 30 days, you may. Your contract can be in flux outside of that 30 day window.

Always have minimum hours per shift listed in the contract in case clinical demand drops and they want to cut your hours.

4. Malpractice insurance must be spelled out.

This should always be explicit. Who will cover: the agency or the hospital/client directly? Get a copy of the coverage policy valid for the time you will work there for you records ASAP after signing the contract.

If you are considering per diem work for a small practice or other scenarios, you may need to directly procure your own malpractice insurance coverage. I wrote an article on Per Diem Malpractice Insurance with specifics for anesthesiologists and CRNAs that may be helpful.

5. You Have No Rights!

You are an independent contractor. A physician for hire. You will receive no employment benefits when you aren’t working. You have no workers compensation in the case that you become injured or ill as a result of your work. Even though most people, let alone physicians, never use any of these benefits, you must realize that you are your own business so you must support yourself in times that the business is at risk.

You are on your own. I suggest that everyone in our line of locum tenens contracting to have:
* Disability covering your current after tax income
* Medical and dental coverage
* Life insurance for your dependents

If you’re Locum Curious, start HERE: