Welcome. You're in the right place if you're interested in locum tenens work or you're curious to learn more about it. This session is Thriving in Locum Tenens, Unlocking Exciting Career Adventures in PM&R. I don't have any disclosures. Just to go over the schedule, I'll be giving the first lecture, and then Dr. Val Jones will be bringing in some statistics and industry data, and then followed by Erickson Brano, who will discuss work-life balance. And then at the end, we have a 15-minute segment for Q&A, so we can field some of your questions. These are learning objectives. You can skip those. Show of hands, has anyone done a locum job? Here. Okay, Catherine, I know you have. You've done one? All right, a couple. I got one in the back. All right. Who's interested in doing a locum job? I'm guessing everyone else. Yeah, okay. Any industry people, like locum tenens companies or agents? No? They're just taking all our names and numbers down in the background. Okay. Mary was talking about showing up, so just FYI. Oh, okay. Okay. So who am I, and why should you listen to what I'm saying right now? Well, first of all, I had these glamour shots done at the mall, so that should form instant trust. I'm just kidding. These are outside, obviously. I graduated in 2020, and I've been doing locums full-time for the past four years. I've done more than 15 assignments. Ninety-three percent of those facilities have asked me back. I have 11 state licenses, and I've worked kind of everything, inpatient, freestanding unit, within a hospital system, outpatient, academic facilities, and also the VA. Most of my contracts have been direct contracts with an occasional locum agency, and we'll kind of get more into that as we go through the presentation. And then I've done a few W-2 positions that are per diem, so there's a little bit of a difference there. So I'm going to try to give you a broad overview about what is locum tenens from a physiatry standpoint. The basics are that it's a Latin term that means to hold the place, and it's where a physician works in the place of a regular scheduled physician. When I was doing some research on my history slide, I found that in Greece, in 1640, is where the first locum physician term came from. So physicians traveling to low-resource areas, and then in the 1860s, when we had settlers going west, we had a lot of physicians that needed to cover these smaller towns, so they employed a lot of traveling physicians. And then interestingly, in 1970, in Utah, there was a response to a lot of burnout for physicians in this area, and they developed...one of the hospital systems there developed a cohort or a network of locum physicians to cover those doctors that were burnt out and, you know, spending a lot of time in the rural areas. And interestingly, a lot of the locum agencies that we see now, like CompHealth, are based out of Utah, and that's where that origin is from. Today, more than 85% of healthcare facilities rely on locum tenants providers in all 50 states. The next point is, who needs locum coverage? So why would a facility potentially need a traveling physician to cover? Maternity leave, we see a lot. Medical leave, family emergencies, vacation coverage certainly, expansion of a unit. So if a hospital is getting larger, adding more beds, or maybe it's brand new, a lot of times before they can get a permanent physician, they'll have a locum doctor come in and just fill in until they can get someone full-time. Conference coverage, I turned down maybe three or four jobs for this week to cover the conference so that I could be here. So that happens quite a bit. And then timeframe-wise, the jobs are usually...the classic, I would say, timeframe is a two-week on, two-week off model, but it really can be any variety of timeframes. I've done one-week contracts. I've done six-week contracts. It's really up to what you have availability-wise and what you're willing to offer that facility. Who provides locum coverage? So any medical specialty can actually provide locum coverage or travel medicine. So not just PNR, but any medical specialty, and not just physicians. A lot of us have probably heard of travel nurses. So I'll tell a lot of people, I'm like a travel nurse, but a doctor. And you can do this as a physical therapist, an occupational therapist. I actually worked in Alaska with a travel case manager. Didn't know that was a thing until I met her. And then, of course, there's all different varieties of rehab that you can practice as a travel physician. Inpatient is the majority of what I do, probably 80% of what I do. Some outpatient, and then there's a lot of opportunities for interventional pain. That pays particularly well. Pediatric, PNR, EMG focus, which...missed me on that one. Academic, private practice, and then the VA. There's opportunities throughout all of these areas. So why might someone do travel medicine or be a locum tenens physician? Well, for me, it's about adventure and getting paid to travel. When I was first learning about locum tenens medicine and realizing that the flight's covered, the housing's covered, the rental car, and I get to keep all the points and then get paid on top of that, I was like, okay, I'll sign up. A lot of people like it for the autonomy, being in control of your schedule as we go through training. Obviously, we are not having a lot of control over where we're going and when we're working and when we're off. And so this gives us a lot of schedule flexibility that people are attracted to. Burnout can happen at any phase of medical training or our career. So we see physicians from all backgrounds that are just ready for something different. And then definitely the better pay and student loan payoff. So it's kind of known or notorious that locum tenens physicians get paid better than or paid more than a permanent position would. And so far, I have found that that's true. This is a picture of my husband and my dog. We're on an assignment in South Carolina. This was her first time at the beach. I'm on call here in California looking over a river, like literally had Pedro in my hand. This is Montana. And like 10 minutes after this picture, I saw my first rattlesnake. That was terrifying. I ran. This is in Alaska at a Christmas market with some friends I went to and they had a llama, as you would at a Christmas market. Last time I was in Anchorage, I did a flight around Denali that was incredible. This was a picture from the Ring doorbell at the Airbnb I stayed at in Alaska. So moose are actually more dangerous than bears, which is something I found out while I was in Alaska. So you've got bear spray and it also doubles as moose spray if you need it. This is a sunset in Montana. I actually go back to this assignment on Sunday. So I fly out from here to go back to Montana and work this job. This one is Eastern Kentucky. So I'm based out of Louisville, Kentucky. I probably didn't mention that, but this one was about two and a half hours from my home. So horse country, if you're from Kentucky. This is a picture from the actual hospital. It's just beautiful country. And then here's dog and husband in Greenville, South Carolina, where I was working a job over the holidays, probably two years ago or so. So I'm just showing you those pictures because there's so much adventure to be had not only while you're on assignment, but in between assignments. So actually my husband and I recently got an RV this summer and we road tripped from Anchorage, Alaska to San Diego to be at this conference. It took us 11 days and 4,500 miles. This picture is in Glacier National Park. And I really added these pictures into the PowerPoint to highlight that there's so much adventure to be had when you're not working or in between working and you have this ample time off. I don't know if this is a caribou or what this is, this horned animal here, but it was cool. It was just on the side of the road. Lots of bison. And then this was a picture I took at six in the morning in the Yukon. It was negative three degrees about two weeks ago there, in case you were wondering. Types of locum tenens contracts. So you can do work through a locum agency and a lot of times I will, when I'm giving advice or counseling new physicians or new attendings on locum tenens work, to try through an agency at first because a lot of the kinks can get worked out when you're working through an agency. They do a lot of the logistics, the planning, the travel. And that can be a 1099 situation through if you have an LLC or as a sole prop if you're just using your social security number. When I first started that's what I did until I formed my LLC. Direct contracts are typically 1099, so that means you have to call the CEO at the rehab hospital and say, hey, I'm so and so and I can, you know, work a temporary position for you while you get a permanent doctor. So yes, you have to talk to CEOs. No, it's not that scary. Per diem work is also something that we see in the locum world, W-2 and 1099. So that's also an option, but you don't get any, there's no fund benefits associated with that, even though it says W-2. Where to find locum jobs. I get asked this a lot and my secret website that I love to use is New England Journal of Medicine. They have a career center where you can go and filter jobs by permanent or locum and find all the jobs across the country whether they're through an agency or directly through the hospital. And I look at both permanent and locum positions because if they're looking for a permanent physician they might need someone on the interim side of things until they get the permanent person hired. Locum agency websites, of course, is a great place to start. Some hospital websites will advertise their jobs, some won't. Job boards, word of mouth, this conference. In fact, I was at a booth yesterday, the Aspire booth, which is kind of like the revamped job and fellowship job board for AAP Menar and it's called Aspire now and you can sign up by location to get updated when there's new jobs in a specific area. Quickly, what is covered? Like I mentioned before, your flight, housing, whether that's a hotel or Airbnb, rental car, licensing and credentialing is covered and also malpractice. You do have to make sure you're getting the right malpractice coverage and that it includes tail coverage and things like that. So there's some nuances there. But all of these things are covered when you're working a locum job and the cool thing is you get to keep the points if the locum agency books it for you. You just give them your rapid rewards number or whatever and then you get to have the points but not pay for it. A lot of the direct contracts I do, I will pay for it myself and then be reimbursed by the hospital at a later time. Hopefully not too much later. What's not covered and why do I know this? Because I ask these embarrassing questions when I was just starting out doing locum work. Student loans are not covered when you're doing locum tenants work. I asked that to a recruiter. I think she probably wanted to hang up at first but those are not covered. Personal health care isn't covered either so locum physicians either have to have coverage through a spouse or get private insurance. Food stipend, if you have a doctor's lounge and the food is free, that's great. Otherwise, you're on your own. Retirement, I put an asterisk by this because there's no retirement fund per se but if you form an LLC or an S-Corp, you are eligible for things like a simplified employee pension 401K. So I can contribute yearly as an employer and an employee to my own 401K. So that's pretty cool that we get to have those benefits as an LLC. I almost forgot to put this slide in about how much we actually make because everyone wants to know, like, how much are we making as locum physicians? There's a huge range and I've taken jobs for less than this. I've taken jobs for more than this and it changes throughout the years and Dr. Jens will talk about this a little bit more as well. Typically in this time frame, 2024, I'm seeing rates of $1,600 to $2,000 for an 8-hour day and then overtime is anything above 8 hours and that's usually what I've seen, $200 to $275. I classically see holiday pay as a time and a half and then a pager fee or overnight call and I negotiate every contract that I take. So there's only one that I've ever taken that I didn't negotiate because it was just that good. So you can always negotiate if someone gives you a really low rate, but that's kind of a whole other lecture. Another reason why I love locum tenens physiatry is you get to see different populations of people, not only people, but different disease types. So I've worked with Mennonites in Ohio, which are different than Hutterites of Montana, which I had never heard of before, but they just have different belief systems and you do kind of take care of them slightly differently from a cultural respect standpoint. Native Alaskan tribes, Alaskans just in general are born different, like made different, so that's an interesting population to work with. Coal miners and then interestingly seeing all the different homeless populations across different states and how states have resources or don't have resources for their homeless population has been really eye-opening and interesting. And you learn a lot from these different places that you're taking to the next assignment. Geographically, I'd only read about valley fever in textbooks till I came to Southern California. And then when I saw my first disseminated valley fever, I was pretty amazed at how much it impacts mobility and cognition. And so I probably had four or five of these disseminated valley fever patients with severe neurological deficits that I had never seen before. So there's a lot of learning that happens as the physician traveling and you're also bringing a lot of education or new practices to where you're going. So there's a lot of information back and forth. Frostbite, rattlesnakes, never seen...hadn't seen those before I went out west. Moose attacks. Let's see, a couple of weeks ago I had someone that was head butted by a cow or some kind of ruminating animal and fractured a bunch of ribs and had a hip fracture. So that was a first for me too. I put this one in there. Ikhmik is a type of tobacco that is used in some western Alaskan...Native Alaskan cultures, which was interesting. I'd never seen that before, but there's a lot of respiratory issues that come along with this type of tobacco and you're more susceptible for stroke, heart attack, things like that. But from a cultural standpoint, it's very hard to convince a Native Alaskan to stop using this type of tobacco because it's used in rituals and ceremonies. So there's just been a lot of interesting moving parts of being a locum physician. All in all, it is definitely a balancing act, especially if you're working with a locum agency. So the locum agency has a client and it's not you. It's the healthcare facility that they are working with and they are placing you with their client. So thinking about that, you're representing a locum agency. You're also an ambassador of physiatry and to yourself, but there's a balancing act, right, where you have to stand up for what your beliefs are from a rehab medical standpoint, practice good medicine, but keep in mind that healthcare is a business and you are part of this balancing act. Mentorship-wise, so I love doing locum tenants' work. I found that it was tricky at first to get a lot of information. Luckily, I found some great mentors along the way, Dr. Dalton specifically, Dr. Jones, Dr. Simbrano. We all shared information with each other when we were first...or when I was first starting out and with that mentorship is where I got a lot of really good information. So I actually started a website with some blog posts there where you can get some more information or reach out if you want some of your questions answered or are interested in trying out some of the travel medicine jobs. And then finally, these are my references and this was me getting ready to go night hiking in Anchorage. That was the first and the last time I did that. That was a lot. But if you want, you can scan this QR code and it will bring up my Instagram and website if you're interested in getting a little more information. And that's all I got. Thank you. Okay. I'm going to... Okay. So next, I'm going to bring up Dr. Val Jones. She is currently an adjunct associate professor of PUMNR at the University of Missouri. She has spent the majority of her career as a locum tenens physician, has 22 state licenses from Alaska to Florida. She has enjoyed the flexibility that Living Levita Locums has provided and spends her free time growing her non-profit adventure travel company for people with disabilities. She has a booth in the exhibitors pavilion number 1332. It's really cool. It's got a really cool adaptive bike there. It's next to the dog park. And there are prizes and lots of videos and beautiful pictures of the Swiss mountains. So Dr. Jones, please come up. All right. I have nothing to disclose. Why do we do locums? Well, I have a confession. The reason why I do it is because I'm a workaholic. And if I didn't do it, I would be burnt out because I love to practice medicine all in. I love my patients. I care about them. When I leave work, I worry about them. I check their labs. I'm that kind of girl. I don't know what to tell you. So I like this quote, the best way to treat a problem is to keep it from happening. And so if you're thinking that way and you're trying to keep problems from happening, it is hard work. But that's just how I practice medicine. And I think that locums has kept me sane. You can always turn off the work. You work hard and then you take time off. And that's really just worked for me. So if any of you can relate to that, then locums may be for you. Most of my time, I worked with agencies. So I have just a little slightly different perspective maybe than Genevieve. And I wanted to tell you this story about why your recruiter matters. As a workaholic, I was working at a locums assignment and was getting sicker and sicker and sicker and would not leave my post until I was carted away and hospitalized with a partial small bowel obstruction. So I felt it was important to let my recruiter know that I had to leave the assignment and I was terribly sorry and apologetic. Here I am in the hospital still wearing my scrubs from work. And so I let Mary know about that and she said, do you have any friends or family near the hospital where you're going? And I said, no. And she said, that's crazy. I'm going to come and see you and I'm going to take care of you. And she's like, what do you need? And I said, I don't know what I need. I'm NPO. I guess they're going to start me on a clear liquid diet eventually. I said, how about some broth? So this recruiter went to the Signature Ramen shop in Atlanta, Georgia and came with like eight different varieties of delicious broth. This was one sample. And here I am pretty psyched to get it in the hospital, but she was being a dear friend and I just think it shows that, you know, doctors who love their job do a great job and recruiters who love their job do a great job. And it was sure great to have a friend like that. So just overall, you probably, if you've done any locums or been interested, put your name out there. You've probably gotten, you know, 12, 15 different agencies contacting you and you wonder like, who is this person? Where are they in the scheme of things? So just in general, you should know that there are two companies that have 50% of the market share. So the first is CHG and that's an umbrella company for CompHealth and Weatherby and a few others. And then there's Jackson and Coker, which is the umbrella company for locumtenance.com and Locumtenance and CompHealth both have booths here, so you'll be able to talk to them if you're interested. And then there's everybody else. So there's a lot of different mom and pop agencies and other agencies that you'll recognize. But just so you know, those are the two big ones that have most of the clients. So the demand for PM&R locums is high and it's still growing. This is data that I got from a source at Jackson and Coker. So year over year, it's been, you know, growing 52%, 2020 to 21. Got higher in the COVID era and is still growing at a pace of 68%. So there's a lot of need for PM&R locums. And by the way, I do inpatient rehab specifically, personally. So PM&R supply appears to be extremely limited. I was very interested in this. I wanted to get a sense of how many of us do locums at this point, you know. And so I asked my friends at Jackson and Coker and they said that they had an algorithm that actually tried to predict who would be interested in doing locums. And so they went to their database that had 12,000 plus physiatrists and they applied the algorithm and they came up with 2.39% of us are probably likely to do locums, which I think might be a little low, but that translates to only 300 physiatrists. Do any of you know how many IRFs there are in America? I bet you do. Can you guess? There are about 1,200, 1,200 and change. So 300 people available in the market to cover absences in 1,200 IRFs potentially if those were all inpatient jobs, for example. Okay. So Genevieve covered this a little bit, but the average daily rates... This is from Jackson and Coker in particular, have been growing year over year. You see now we're around... The average rate is around 1,700. And of course you know that the benefits of doing locums are that maybe your daily rate, but then there are all kinds of additional value adds that include covering your flights and your parking and your hotel and licensing, credentialing. And just parenthetically, I found out interestingly that our professional liability insurance is actually pretty expensive if you're out on your own. For me, inpatient working part-time, it cost me without an agency around $40,000. So that is a big benefit to have that covered for you by the agency. And there's a little secret that we aren't telling you about the rates and that is they don't include overtime. So you think you're going to a facility, you're not sure what your census is going to be. Maybe they love to give late admissions and you get there and you're working longer than eight hours. Well, you get paid for that, you know, every hour over the eight hours. So the 1,700 a day is really a low-ball kind of estimate. But it's important for you to see kind of what the range is, because a lot of folks have anxiety over, well, do I need to be tough and advocate for myself and really try to get the best rate? Like what is the best rate? Should I fight for a higher rate or whatever? You know, you are competing against your peers who are going to come in with lower rates potentially and then get the job. So you don't want to be too aggressive necessarily on your base rate, because the base rate doesn't matter that much if you're at a busy facility where you're going to have extra overtime. So just keep that in mind, I'd say. So why are we needed? I think the answer may be obvious, but I got this source from CompHealth. We are desperately needed to meet patient demand. So 82% of healthcare organizations using locums do so to fill in during a provider's search. So it's really tough to find full-time physiatrists for inpatient rehab, for example, and it takes a while to locate that right person. And during that time, locums are often used to fill in the gap. And then the other reason, of course, is to prevent revenue loss. So if you don't have an inpatient physiatrist, you have to shut down the unit. That's not okay, right? So it's kind of... We're pretty desperately needed. And so when someone goes to... When they turn to locums, it's not because... It's not a desperate situation. So the catch-22 is that we're needed for revenue preservation and to keep the units open, but they complain mostly that we cost too much. So the common concerns about using locum tenants providers are listed below. The number one concern is that we cost more than permanent physicians and that the other concerns include being unfamiliar with the department that you're covering. They're concerned that you may not be a quality physician. They're concerned about the continuity of patient care and they're concerned about you might make a mistake because they don't know you. So this is what's in the mind of the facility that you're going to and it's important to be aware of that. So it's always good to have situational awareness. Keep in mind when you go on a locums assignment, you're a choice made in desperation. They're afraid you won't adapt. They're afraid you won't be a good doctor. They're afraid you'll make a mistake. So you're going into a high-stress situation where this is the fear of the hospital that you're going to. So it's important to be able to disarm the situation. I would say, work hard because you're expensive, be kind, they don't know you, gain trust, be respectful, be careful and avoid mistakes. But you should not be surprised if you're walking into a crisis situation. One of my very first locums, I had to cross the picket line to get in to my assignment. The nurses were on strike and when I got into the facility, I found the person I was supposed to meet and I said, hi, I'm Dr. Jones, I'm your physiatrist to take care of the inpatient rehab unit. It seems like there might be some interesting activity today and they were like, please follow me, Dr. Jones, right away. I said, okay. I followed the lady and she said, I'd like you to just stand in here. I was like, okay. And she opened the door and it was a broom closet. She said, you need to stand in here and don't come out because the Department of Health is investigating us and you don't know anything and you're probably going to say something stupid and we'll get in trouble. So that was one of my first locums experiences where I was standing in a broom closet trying not to get in trouble. And I was like, well, you know, I'm getting paid for this. It's kind of interesting. So you just never know. So don't be surprised if the client cancels on you at the last minute because they find a local candidate, the dreaded local candidate. So you keep your schedule available and you plan in advance and you're going to be covering at this facility and the week prior they're like, oh, Dr. Jones, I'm so sorry, but they found a local candidate. And you don't have the time to reschedule and find something else to do with that time that you plan to be at the facility. So keep in mind that that will happen. It's just one of the downsides to locums. And then, of course, they always say that there isn't that much work, but when you get there they'll say the census is 17. Onboarding is often limited. I mean the places that you go are, you know, as I said, they're on the desperate side at times and so they don't do a lot of onboarding. They're just like, hey, there were four admissions last night and here they are. One's in the hallway. Could you just please do the H&P because it's due in four hours and you're like, wow, okay, sure. At first staff may be leery of you. They're scared. They had a bad experience with a previous fill-in doctor and they were, you know, not the greatest and they were mean to patients and you come in and they're like, who's this lady? I don't know. You know, so they may be a little leery. EMR access rarely works on day one, so just know you're not going to get into the computer system. But, you know, with all of that, just remember this is your opportunity to save lives, save programs, surprise your doubters, make friends in a crisis, refine your clinical skills and grow as a person. So you know, people used to say to me, well, do you really feel fulfilled in your career as a locums if you're just traveling from place to place and you're not growing an academic reputation or doing research or whatever? And I said, you know, locums is what you make of it. There's opportunities for leadership. There's opportunities to break new ground. This is me as a locums starting up a new inpatient rehab facility from scratch near Palm Beach, Florida. And that was challenging. It was exciting. People looked to me for leadership to make the program excellent and I really enjoyed that and it was something that you wouldn't think that locums would offer you the opportunity to do. And everyone has to have their Alaska story. Alaska is not a place that is easy to recruit permanent employees to. So I'm afraid I've been there in Alaska too and had a great time. This was an interesting case where I had a patient who, you know, was so sick she really almost died and she made a promise to herself that if she lived and if she got through this, she wanted to do the polar plunge in Anchorage in December. And so closer to the time that she was going to be released, she let me know that, you know, she still needed a walker for ambulation and they didn't allow walkers on the ice. And so she said that she would need me for stability. I was like, oh no, no, please no. But yes, I would accommodate that. And so here we are standing at the polar plunge about to jump into this ice water with Arctic men in Arctic wetsuits and fulfill her dream, which we did. Other favored memories that I had were there was a facility that had a company called Zoo to You. And so we would get out in the courtyard with the rehab patients and we would get to play with or visit with all of these very exotic animals as pet therapy. So this was a lemur that came to visit us. They also had kangaroos and golden bears and all kinds of crazy creatures and that sure was a lot of fun. I enjoyed that. This is just an illustration of the clinical liaisons at a freestanding rehab in Georgia who were a lot of fun to work with. I took that photo from the head of the table and as you can see, we were having a great old time being the leader as a locums in that facility. So locums has taught me to roll with it. This is a bomb threat that came across my phone when I was sitting in my office at a facility that was also a little bit wild west. They had a difficult time recruiting and retaining employees. Just prior to the bomb threat, a few days before that, I came on board and they let me know that the speech therapist had just punched the case manager in the face. So as their medical director, what would I do? I was like, well, I guess we need to take this up with each other. Long story short, they were afraid to do anything about it because the person who committed the act of violence had guns and they were worried that she would go postal. So it would be better to just let it go. It was a wild place. I did not actually stay there very long. But the best thing about locums is that you have the opportunity to control your time and give yourself as much time as you need for your other pursuits. For me, my nonprofit company called Accessible Alpine Adventure Tours has been a dream come true where we take folks with disabilities and give them the trip of a lifetime in the Alps with the help of adaptive mountain bikes and able-bodied volunteers. We do about 10 to 12 day tours and it's been wildly successful and appreciated. This idea came when, I think, for the hundredth time, you meet a patient who just went through hell. They just got out of a terrible wreck, car accident, came to the rehab unit and were trying to rebuild their life and just feeling frightened about what is my future going to be like? Am I going to walk again? Am I going to be okay? And so I really wanted to have something to give them that's hope and joy and knowing that life is not over. There are great things that you can do. You're going to be, in a year from now, you'll be in a helicopter touring the Matterhorn. You'll be flying down the trails in an adaptive mountain bike. Anything is possible with the right effort. So I do have this booth. Come see me. It's a great venture and thanks to LOCUMS I've been able to achieve that. you. Thank you, Dr. Jones. Bomb threat, that's a first. I haven't had that experience. Next up we have Dr. Eric Zimbrano, who has worked both academic and non-academic settings for the last 12 years after residency and fellowship training. Currently, he is doing travel medicine as a physiatrist in inpatient rehab facilities. And for the past year and a half, he has been thriving with a young family, a part-time working wife, a toddler, and an infant. Dr. Zimbrano, please come up. Unfortunately, I don't have an Alaska story for you. I don't have any financial disclosures. If I mention anything about legal or taxes, I'm not a legal or tax professional, so make sure that you consult your own professional. That's my disclaimer. So can you do locums with young family? Will you do travel medicine if you have a young family? So I'll be sharing my story, my experience. So pre-locums from 2012 to 2023, after graduating from training, I started in University of Minnesota. I was there for five years. A great time, made a lot of friends, learned a lot of things. That was my first job and moved to the New England area. For six years, I was working for a freestanding rehab hospital. Life was great, right? Things were doing well. And then I got married during that time, and then we had our first born child. This was 2022. And early 2023, we got a news that we are expecting our second baby. But around that time as well, I wanted a change. My work was okay, right? But I was looking for something more, looking for more growth, satisfaction. I wanted to be recognized for the things that I do and more time back. Since starting the medical journey, right, amongst all of us, from then on up to now, we've given so much time. And I wanted to regain that time for myself and my family. And in addition, I wanted to feel like I'm compensated fairly. So what did I do at that time? So I connected to people that I know doing different things, from SNF work, private practice, to those doing locums. And I decided to dive into locums. So June 22, 2023, I remember this day. It was a Thursday. That's my last day at the W2. What did I do that morning? So I brought them donuts from a local bakery. I love my staff. They're the best therapists I've worked with up to this day. And then at lunchtime, they gave me a pizza farewell party, which I much appreciated. At the end of the day, I cleaned out my office and left what I needed to leave. And in July, I started doing locums. I flew out to my first assignment from Boston to Montana. So I do have a Montana story, but I don't have an Alaska. And I was there for I think seven, nine days for my first assignment. And when I started, Dr. Jacobs may have mentioned it, I started as myself. I'm a sole proprietor, no LLC, no entity. Basically what that means is that you work as yourself. Your personal and your independent contractor work is the same. You're paid as a 1099 by your agency. Your net earnings are subject to the self-employment tax. If you are familiar, that includes both Social Security and Medicare taxes up to a cap. Every year, there's a Social Security cap for 2024. It's $168,800. So you pay that self-employment tax 15.3% up to that cap. And your taxes flow through your personal taxes. So I keep going back and forth to my first assignment in Montana. I do seven to nine days at a time from July to December. In the fall of 2023, I formed an entity as an LLC. And in my opinion, there's really not much a big benefit of having an entity if you just form it as such. And that's my personal opinion. The main difference is you'll be paid as a 1099 through your LLC now. There's some paper separation about your personal and business. And it's still a disregarded entity. So your taxes still flows through your personal taxes. So what did we do in between assignments from July to December during that year in 2023? We traveled and did adventures with me and my wife and our kid. At that time, we had one from New Hampshire, White Mountains to beaches, parks, state parks to visiting grandparents in Connecticut. And I was fortunate to be involved with their swim classes. Visited friends from Maine and friends visiting me from South Carolina, Maine, New Hampshire. So I had more time to kind of go out and meet with my friends. And I had my personal time. So the very first picture, I was able to complete a half marathon at the end of 2023. The backstory to that is I injured my calf early 2023. But with more time, I was able to focus on recovery and training for that. I transitioned my office now to home. And if the weather's good, it's in my backyard. I was able to read non-medical books. I must admit, I'm not a big reader. I read to survive during med school and residency. But with having more time, I was able to ease into my interest, my non-medical interest, and read many different books. So October 16, our second baby came. The question I have at the back of my mind when I did locums is, is this really the best year to do it? I'll probably answer that in a few slides. So the difference between the WTME and the locumsME, this is for illustrative purposes, right? The locumsME, the second half of 2023, I intentionally worked less. My goal was to earn the same as my WT job. What happened was I worked seven weeks in total. I not, I earned more than what I earned the first half of 2023. It's possible. And I had 19 weeks off in between those assignments. One of the other differences is the health insurance. When I was a W-2, I was paying $500 off my paycheck. When we started locums, we transitioned to my wife's, and then eventually got it from the open market when I was paying $1,130 per month. So one of the other differences will be in W-2, you have a disability group insurance, and then I got my own personal disability insurance for $330 per month, just to give you some idea. So how do we make it work with two kids, right? Yeah, we had two kids at that time. So first, your spouse needs to be on board. So my wife makes it work. If my spouse is not on board, I won't be doing travel locums. So she works part-time, two to three days a week. The big help that worked for us is we hired helpers. There was a big chunk of time we were hiring two a day, one for daytime, one for nighttime. Our neighbors helped here and there a couple days a week. And daycare could be very helpful, but unfortunately, we were on the wait list for a very long time. That was our area and our situation, and we didn't get into daycare until 2024. So here's what I'm going to say. Your environment, your network is going to be the key for you if you're going to do this and you have two small kids. That means your friends, your family, your in-laws, your parents, your neighbors, and you need to hire help to patch those gaps. Talking to recruiters, they can help you if you want to travel with your kids and your spouse or nanny. They can be flexible to accommodate your needs. So you need to find a recruiter that will accommodate those needs because they can house you that will accommodate your group or your spouse or your nanny if you want to travel. So in 2024, I continued my locum. I primarily have two sites that I go to, Montana and Florida. And this 2024, I elected as an S-Corp. So it's an S-Corp, it's a taxation election if you have an LLC. And I think this is one of the big benefits of having an LLC. This is just an example. So for example, for this year, if your revenue is $150,000 in total, right, and the expenses are the same, left side column is your sole proprietor LLC. The right side column is your S-Corp election. The biggest difference or the benefit that you'll have is you won't pay your self-employment tax on the distribution profits on your S-Corp. That's why there's a difference between the $19,125 on the sole proprietor left side column and the $11,475 on the S-Corp column. Because that's, the $11,475 is 15.3% of the wages that you gave yourself of $75,000. That's where you make your savings. So the S-Corp potential savings in this scenario is going to be $7,650. Is that worth it? Because electing an S-Corp has more work behind it, and your CPA will probably cost a little bit more, right? But if you're going to do this for 10 years, 20 years, and you're saving this, let's say 10 years, it's going to be sent to $6,500. And if you invest that like your other retirement accounts, it will kind of compound over the years. But it's a personal decision. This is something that you want to do. I just want to illustrate that the S-Corp can be beneficial. So what did I do in between those times in this year? So basically, time and adventure, right? This is so much pictures. Basically, a lot of traveling from Bangor, Maine, Acadia National Park, to Washington, visiting family and friends, Mount Baker, down to Arizona, to the Grand Canyon. I did hike and rode UTVs in the desert, which was amazing. And down to Punta Cana, Dominican Republic. Me and my wife are kids. Did that during the winter, early winter of this year. It was amazing. So you can do that in between your assignments, just like what Dr. Jones and Dr. Jacobs did point out. So what Locums provided me, I regained my time back. I was able to design the life I want to live, especially for this year, which I intentionally tried to work less, just to have my time back spending with my family and kids, right? So I did have flexibility and control of my personal, professional life. And the last one, I was actually surprised. I didn't expect this. When I started Locums, when I'm working, my main role and responsibility is clinical care, patient care. And I enjoyed it. Because when your Locums are temporary, you usually are not involved in the administration and countless meetings. You don't do that anymore. But you can be involved if you want to. If you stay there longer, then you tend to be more involved because they trust you. It just depends on the assignment. As people have helped me when I started and switched to Locums, I'd like to offer the same. If any of you are interested, reach out. I'll be happy to be your guide or anyone else, any of us. When we started, we did have a lot of help, so we would be happy to help as well. Thank you. Thank you so much. Okay, we're going to transition to the Q&A portion of the panel. So if you all have questions, please come up to the mic and then I'll... If you guys want to come up and we can sit here. I think you just press the button to make it... Okay, what you got? Thanks. You've all mentioned having multiple state licenses to do your Locums work. And I have one license and it was quite a process to get that one. So how difficult is the process of obtaining and maintaining, what, a dozen state licenses? And were there any states that were really particularly difficult? Terrible. Yeah, let's see. California was hard. Sorry, anyone from California, that one was rough. Florida was a little hard. They have the IMLC, which is an intercompact state licensing program now. It's in Oregon too, so we had to qualify. Yeah, non-qualifying. Right. It is really difficult to do all of the paperwork. A lot of times when you're partnering with an agency, they have credentialers that are helping you, but there's still a lot of legwork to do from a paperwork standpoint, and you have to stay on top of what needs renewing and if a DEA is getting transferred from state to state. So you are correct. I have a spreadsheet. I had to just make an Excel spreadsheet to keep everything straight. I don't know what your tactics have been. Oh, okay, cool, okay. Yeah, so I have 22 licenses, and I have quite a spreadsheet, but the agencies have... I have four state licenses. What I would say is that in Florida if you inactivate your license, especially if it's inactivated for several years, it's really difficult to activate it again because you need to meet all the requirements of the CME for the past years that you're inactive. That was my experience. And I would also say have a lot of friends on hand to do your references because every state wants peer references. So I owe a lot of drinks and dinners to people across the country. What question do you have? I was curious if you've looked into international locum work or if that's even a possibility. Yeah, definitely a possibility. I know, Dr. Dalton, your first assignment was New Zealand, correct? Yeah. So it's definitely an option. A little bit trickier. There's some more hoops to jump through in terms of credentialing. There's some tax obligations you have to take into consideration. I have not personally done an international position. Sure, Global Med Staffing, that's an agency that I've seen the most international positions, GMS. Hi, everyone. Hi. Hey. Hi. So, I'm Nina Tamayo. I'm also a locum stock. So, my question to you all, and specifically to Dr. Jones, because you talked about being part of like leadership roles. I've had several assignments where I've stayed on for a long time, and I hesitated, you know, because it wasn't in my contract to be paid for that time. So, there'd be like multiple meetings, or it doesn't... My eight-hour day goes beyond that. Like, how do you... Did you negotiate pay for that kind of work in your contract, or did you just do it as overtime? So, it's super important to negotiate well before you start. Okay. I learned that the hard way too. Yeah. But, I mean, if you really think through all the possible things you're going to be asked to do, and you just do time-based billing, and you just... It's great. You don't feel put upon. You don't get burned out. You know, hey, you want to do a late admission? Bring it on. I'm going to be here, and you're paying me, so it's all cool. You know, because burnout really starts when you've got all this uncompensated work that they continue to add, and add, and add to your docket. So, I just really make sure that I come in... I don't get compassion fatigue as much when I feel like I'm being asked to stay late. I just know that's going to be part of the job, and the good news is I can stop the job and it doesn't have to go on forever, and so that's been how I did it. So do you have a separate rate for anything administrative? Or you just roll it into overtime? Or do you just roll it? Hey, I'm still in the hospital. Whatever you're asking me to do that needs doing, I'm doing it, and it is an hour, and this is my hour, and then when I go over eight hours, this is my rate. Gotcha, okay. So you just make sure your overtime is beefy, and you'll be fine. i had a lot of anxiety about that i thought they would push back and be like you're an Yeah, so one of my assignments is really busy, 25-27 patients. So all locums who rotates there have overtime, and they can see pretty much everyone has been putting the hours about the same, about 90 hours or so. So you kind of know that during the average, because I did ask. So if it's busy, they will know that you will need overtime. Yeah, I agree with Dr. Jones. I feel like I haven't had a lot of pushback on overtime. The only scenario where I did was at one facility, but I was primary. There was no internal medicine coverage, so I was doing double duty as medicine and PMR, and that took a lot of extra time with a long census. But once I explained to them what the hours were... In terms of the overtime thing, I did have one client refuse to pay me overtime. Others don't, but in one case they would present me with more work and I'd say, well, I'm happy to do it, but it'll cost you overtime. Then they'd change their mind about it. So hospitals love to have doctors work for free and whenever they're pushing me that way and I remind them about the overtime rates, then they may or may not be okay with it. I wanted to comment on three other things. One has to do with state taxes. So if you're in different states, some want taxes done, some don't. Some treat you as a pass-through entity. There's extra fees to pay. Your accountant needs to be on top of all of that. Or you may get burned with a, you know, sort of a bill for $9,000 a year later for past taxes. Second thing is the issue of both references and trying to keep a track of all of the places you've worked. I've been doing this too long and I didn't do that. I didn't have a spreadsheet. So now when I have to reconstruct my work history and have it match everything that I've been doing, it's difficult, because more and more licenses and hospitals are asking for that and I'm privileged. For the references, they're getting more sticky on that. So the comp health people want my references to say when it was they last saw me, where it was, and we don't remember, you know. So I don't know if I can add that into a spreadsheet to help my references out or not. But those are the, sort of, some of the landmines that I've run across. Yeah, definitely. I agree. I'm on my third CPA right now just because the taxes are so complex from state to state. I'm going to throw in on what he said about references, because usually it has to be someone we worked with in two years. And certainly when you go locums, you start making friends who are also locums and you've worked with them somewhere and we're each other's references. Because we need references a lot, you know. Like I've had, what, four jobs this year? So that means I needed people to fill out reference forms four times this year. So while I make some other people do it or ask them and they're very nice about it, it is, like, those of us that have worked assignment together, we often are each other's references. Right. Fair about, fair play. Yeah. And you need references not just for the state license, but also for the facility a lot of times. And then the DEA, so it's like a reference on a reference on a reference, but. Hi. My name's Alicia. Never been in locums. For those of you that work with recruiters, do you just work with one recruiter or multiple recruiters and any tips on picking a recruiter? Very good question. It's really important to have a great recruiter that you trust. Because they're essentially planning your whole assignment life, where you're staying, how you're getting there, if you're comfortable during that assignment. So it's really critical to. Has an agency provided broth, you know what I'm saying, from a ramen house in Atlanta. Yeah, so do a good job, and it'll benefit you greatly. I would add that, yes, you need to work with multiple agents. It's to your advantage. Even if you don't work for them per se right now, you need to keep in touch with them, because not everyone has all the assignments. And some agencies have more leverage with certain assignments than others. And one—oh, sorry. I was going to say there's one more advantage of sticking— wants to check you out. And if you've done all of that, fill that out. Yeah, that's a good point. I forgot the agency also needs peer references and applications. So one thing that I do, if I find a job, maybe on New England Journal or wherever on the internet, I will send it to an agent that I really like working with and say, are you covering this job, or can you cover this job? And then they can actually apply to represent that position, and then eventually me to go to that job. So I've done that as well, too. Hi, how's it going? My name is Herman Neo, and I'm a senior resident hoping to start my attending career in locums work. Two questions I had are, one, would there be a change in negotiation strategies for a new grad versus an experienced presider? Well, great questions. I think starting out, a lot of new attendings, just like myself, were kind of like, are we ready? Can we do it? Are we capable? You are capable. You're going to do just fine at this new position and you should negotiate accordingly. Now people know that it's your first position and that you haven't been doing it for 12 years, but that doesn't mean that you're any less prepared than another physician. So my first couple of jobs, I took a lower rate only because I didn't know the system well enough, but I think it's definitely worthwhile to negotiate. In terms of LLC, I think we all probably did a similar stepwise algorithm. We signed up as a sole prop, became LLCs, and then eventually looked into doing S-corp. At least that was the path that I took. You don't need an LLC to start with, especially if you want to see if this is right for you. You can just start sole proprietor. I would just simplify that and uncomplicate it for now, unless you really have a good CPA advisor that can advise you on that, especially if you're going to start mid-year. You're LLC? S Corp. You're S Corp. Okay. Hi. I'm on the opposite spectrum of him. 25 years of practice, now wanting to get some time back in terms of trying to spread things out, slow down a little bit, but still be very productive. What is the uptime to get from deciding to do this to actually being able to be available for locums, and then how far in advance do you negotiate these contracts and such so that you're continually productive? What's the timeframes? I negotiated a contract three days ago on our road trip, and they come up pretty instantaneously. All the time you're getting a different job offer or something that's coming through. I think my fastest credentialing time, from hearing about a job to showing up to the job was five days. It can be really fast if you wanted to. Some facilities that maybe are in challenging states or locations where it's hard to get a license, it can take six months or three months or whatever. There's a huge variety. It also depends on how badly they need a physician, because they'll figure it out real fast if they need someone on Monday. Those agencies will be the ones to be taking care of all the paperwork and such? Yeah. If you're working with an agency, they'll help. So yes, there are some...basically you're looking at medical license and the hospital credentialing for just like what you mentioned, if it's an emergent need, they can do emergency privileges, temporary privileges, and that's really fast. Did you mention about negotiation and contracts? You can negotiate any time. Like on your first day, if it's not what you expected and what they told you, you can always negotiate at that time. It's an ongoing, rolling basis. When you negotiate though, it's a give and take, there's an art to it. You can't win everything. Like you can't...you need to give and take. Everyone needs to win. Actually, at one point, I just got tired of sending all my documents back and forth through email, so I made a back page to my website where recruiters can go and download the documents with...it's encrypted and has a password on it. So I just send them a link and give them the specific password and then they can download all the stuff that they need and that's helped me. challenges or barriers for looking for low-content positions in any style of rehab, inpatient rehab, outpatient, that more... out of residency? Yeah, I mean, when I first started out, I didn't really run into issues of, oh, hey, you're a new grad. There wasn't a lot of that, honestly, just starting out for me personally. There are some really good Facebook groups for physicians only. I highly recommend getting on those and filtering through some of the questions that have been asked previously. And it will help give you a feel. My theory is the best way to figure it out is just jump in and try it, which is scary. But once you get some mentorship and talk to enough people, when you get there, you'll figure it out. I just tell them this is my price and if you don't want it, then I'm going somewhere else. But that's a little, you know, that's my aggressive negotiating tactic. It's gonna be 20 that. So just know that if you're trying to figure out you know you don't have the nursing staff and a 20-bed unit, it's going to make your life a lot harder. But if it's, you know, a 10-bed unit, that's, you know, beautiful. You know, your census is going to be capped at 10. So, some things to consider. Anything from your side? Big cities, small cities, usually big cities, it's a supply and demand, right? More people may want to work in a bigger city. Probably the pay may be lower as opposed to... I suppose people use AI these days. I was curious about your home base, you know, if you own a home in one place and then you travel and if your family comes with you every time or if they stay at home while you're out traveling, if you could just comment on that. Sure. My home base is in Louisville, Kentucky, where I train, so I have a house there. I haven't seen it in about three months. But we got an RV recently and I've done a lot of traveling that way to assignments. My husband was in Germany for two years, so I did most of my assignments on my own until recently, so I've kind of done a mix of everything. Sort of whatever you want to make of it. My home base is Boston, Massachusetts. I worked 12 weeks this year, so I'm mostly home. Nice. I worked 12 weeks this year. You had me at that. Wow. It was intentional. That was my intention. It was intentional. Yes, I get it. My home base happens to be. I have two questions, if that's okay. Okay. One is regarding how flexible is it to end an assignment early if something were to come up, whether it be a family emergency or the job just isn't what you expect. There's a litany of bomb threats or whatnot. Yeah. And then secondly, I'm curious, I've heard of folks negotiating directly with the hospital as opposed to with a local agency. How realistic or practical is that in real life? So in terms of how realistic the direct contracting is, it's certainly doable. I think a lot of people are intimidated by administration and CEOs, but at the end of the day, they're just people that you can talk to and negotiate a contract through. So I've found it easier than I expected from my standpoint. I've only stopped one contract early and that was, you know, for specific reasons to protect my license, but I've never, you know, taken a sick day or taken... And you don't have much power to speed that process up because there's no one behind you, it's just you, and it's little you. You know what I mean? So that, if you're okay with that, great. If you're not, you might want to go with an agency. So if you're going to cancel an assignment, make sure that you have a really good reason because your reputation will be on the line if you keep doing that. No one will want to work with you. Having said that, industry standard, there's a 30 days on both parties that they can cancel future assignments, and that's okay as long as you give them a heads up. We're over time, but is there someone coming after us in this room? All right, go ahead. Just one real quick question. Yeah. Hi. Thank. But if you didn't have that option, does having been locums change your hireability? I think I've read that, but I don't know if it's a rumor or not, like that if you want to go back to W-2 that you're less hireable for whatever reasons. I haven't experienced that. Every locum job I've worked, I've been offered the job permanently, usually within the first week, and no one has said, well, you've done all these locum jobs, I wouldn't consider you. So I haven't experienced that personally. But I have heard.

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