Dear locums/PRN docs

[bravotwozero]

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That is so, so so sad. I would never invest in HCA, it's like breaking into my friend's house that works at one of those places and stealing his money

HCA employees can buy shares in HCA at discounted prices.

 

[RustedFox]

HCA employees can buy shares in HCA at discounted prices.

that's a load-bearing "employees" there, bro.

 

[EMdoc235]

Anyone else noticing that the locum market sucks right now? I live in a big city and nothing new within 2 hours. Pretty sure my current close by gig will dry up by summer. Only options are 4 hours away. Back in 2023 there were 4 sites at least near me offering $325/hour+.

Talked to a recruiter today about something just over 2 hours away and pay was $280/hour and people were signing up. My full time job pays that smh.

 

[RustedFox]

Anyone else noticing that the locum market sucks right now? I live in a big city and nothing new within 2 hours. Pretty sure my current close by gig will dry up by summer. Only options are 4 hours away. Back in 2023 there were 4 sites at least near me offering $325/hour+.

Talked to a recruiter today about something just over 2 hours away and pay was $280/hour and people were signing up. My full time job pays that smh.

I get emails with offers at 315-325 for sites all around me for low volume FSEDs where you sleep at night.

I get better by negotiating directly with my CMG as a bro.

 

[EMdoc235]

I get emails with offers at 315-325 for sites all around me for low volume FSEDs where you sleep at night.

I get better by negotiating directly with my CMG as a bro.

Maybe I should move to Florida. Weather is better too. Midwest doesn’t pay well in the big cities. People in Detroit are working for half what you quoted.

 

[EctopicFetus]

Maybe I should move to Florida. Weather is better too. Midwest doesn’t pay well in the big cities. People in Detroit are working for half what you quoted.

Yikes. Plus state income taxes, weather and Detroit. Sorry homies.

 

[RustedFox]

Maybe I should move to Florida. Weather is better too. Midwest doesn’t pay well in the big cities. People in Detroit are working for half what you quoted.

Everything is wet here. I walk out of a shift and my entire car is wet. I drive with the wipers on all the way home and it's not raining.
I hate it.

 

[EMdoc235]

Yikes. Plus state income taxes, weather and Detroit. Sorry homies.

Luckily I don’t live in Detroit and it’s better here, but property and income taxes are rough. Plus I’m starting to get tired of the cold weather. A swamp doesn’t sound bad.

 

[WhatJobDoIPick]

Anyone else noticing that the locum market sucks right now? I live in a big city and nothing new within 2 hours. Pretty sure my current close by gig will dry up by summer. Only options are 4 hours away. Back in 2023 there were 4 sites at least near me offering $325/hour+.

Talked to a recruiter today about something just over 2 hours away and pay was $280/hour and people were signing up. My full time job pays that smh.

Rates I see are atrocious. Equal to or nominally higher than what you make on the partner track of my group.

I'm sure there's room for negotiation, but honestly you could pay me 600/hr and it wouldn't be worth it to me.

 

[JacobMcCandles]

The locums man giveth and the locums man taketh away. Doing locums probably shouldn’t be a part of anyone’s long term plan.

 

[AlmostAnMD]

The locums man giveth and the locums man taketh away. Doing locums probably shouldn’t be a part of anyone’s long term plan.

If you've got no kids, no spouse, no geographic ties it's probably ideal

I know a guy that just lives permanent bachelor mode and dgaf

I know someone else with all of those things who only saw $$$$$ in his eyeballs ala cartoon characters and quit after a year.

Family

Locums

pick one

 

[JacobMcCandles]

If you've got no kids, no spouse, no geographic ties it's probably ideal

I know a guy that just lives permanent bachelor mode and dgaf

I know someone else with all of those things who only saw $$$$$ in his eyeballs ala cartoon characters and quit after a year.

Family

Locums

pick one

Even when I was single I was always a big proponent of sleeping in my own bed. Obviously, everyone is different but I'd prefer steady hours and then I can travel where I want and not have to worry about prolonged periods of time away from home or working while on "vacation".

 

[Porfirio]

Locums is tough because you have a middleman who has to get his too. Inflation goes up, they have to get more too. Hospitals (for profits) are preparing for more uninsured patients because of the Obamacare issues. Lots of downward pressure this year. Hospital profits are the last thing to always go down.

 

[AlmostAnMD]

Locums is tough because you have a middleman who has to get his too. Inflation goes up, they have to get more too. Hospitals (for profits) are preparing for more uninsured patients because of the Obamacare issues. Lots of downward pressure this year. Hospital profits are the last thing to always go down.

Insurance is the last profit to go down, not hospitals

When medicaid cuts hit medicaid payors will definite deny enough coverage to make up for the cuts and pass that onto hospitals/docs. They don't plan on taking a cut. They won't say it out loud, but I guarantee they want the same profit margins with less money

Spent the last year building a moat around our system for this very reason. 2028 is going to rock hospitals harder than they realize, 30% loss from Medicaid is a conservative estimate. And I wouldn't poopoo their dollars....as a secondary payor and by sheer volume this is not an unsubstantial revenue loss.

 

[EctopicFetus]

For the locums proponents (I am not one) how much time do you spend negotiating, emails, planning etc. Seems like an uncalculated “cost” of the job, plus the time lost to travel sucks. I cant wrap my head around doing it. Even for an extra $50/hr meh.. not sleeping in my bed, being in some crappy town (often) just the lost hours of my life seem not to make it worthwhile. I put my requests online and boom i get my schedule. Seems much simpler, i see my kids, i sleep in my bed, i go to restaurants i know and like, i work with nurses i know (some I like and some i dont). I do well $$ wise but i think if i had a typical job at what point would i do locums. I cant come up with the answer. Plus when the $ drops i guess you just dont work? Seems like the market is decelerating pretty slowly now but thats about to change IMO. I called it in 2022. I said we would see things slow by 2026/2027 and then it would accelerate into a complete mess.

It’s the advice i give residents. Keep in mind even if you dont believe the ACEP workforce data 2 major issues come out of there.

1) even if docs are quitting younger we have more and more young docs. 2) that also means your career wont be long 3) they didnt take into account the opening of even more residencies in those studies and thats happened. The number of spots is growing and the number of positions needed hasnt at all. Now more places are looking to the noctor only model.

Im in the back half of my career so it matters less to me but is this a matter of being an ostrich with your head in the sand? A plan to maximize money and get out like others apparently have? My personal experience with people i know is women are leaving EM, men not so much. Maybe some other shoe drops but it appears in my small world that the new grads want to work fewer hours, will work more years and the ability to find a semi functional job is dramatically falling. People are working either bad jobs or are in a good group but it is requiring them to travel for a few years before they hit the read money pot which has its own set of issues.

back in the day when things were simpler it seemed like a new grads came out and sprinted like crazy for a few years and then settled into their comfort zone for work. Now it seems like they just start at the comfort zone, plug along for a bit and then???? Idk.. we will see.

 

[EctopicFetus]

Insurance is the last profit to go down, not hospitals

When medicaid cuts hit medicaid payors will definite deny enough coverage to make up for the cuts and pass that onto hospitals/docs. They don't plan on taking a cut. They won't say it out loud, but I guarantee they want the same profit margins with less money

Spent the last year building a moat around our system for this very reason. 2028 is going to rock hospitals harder than they realize, 30% loss from Medicaid is a conservative estimate. And I wouldn't poopoo their dollars....as a secondary payor and by sheer volume this is not an unsubstantial revenue loss.

Issue here is at some point doctors wont work. I am not saying we are close to that number but there are more than a few docs in various specialities who work due to the golden handcuffs. Hospitals can add MLPs to help keep wages up but in the end something is gonna have to give. Cut the pay of EM low enough and you’ll have a major need thereby driving rates up again. It’s how it all works.

 

[AlmostAnMD]

Issue here is at some point doctors wont work. I am not saying we are close to that number but there are more than a few docs in various specialities who work due to the golden handcuffs. Hospitals can add MLPs to help keep wages up but in the end something is gonna have to give. Cut the pay of EM low enough and you’ll have a major need thereby driving rates up again. It’s how it all works.

Maybe

I still hold the pessimistic view hospitals in general will be okay with staffing EDs with midlevels or with bare minimum docs in purely supervisory/nominal roles.

If I've learned anything on the money side, it's that it's money first, everything else second.

I desperately want to be wrong

 

[WhatJobDoIPick]

For the locums proponents (I am not one) how much time do you spend negotiating, emails, planning etc. Seems like an uncalculated “cost” of the job, plus the time lost to travel sucks. I cant wrap my head around doing it. Even for an extra $50/hr meh.. not sleeping in my bed, being in some crappy town (often) just the lost hours of my life seem not to make it worthwhile. I put my requests online and boom i get my schedule. Seems much simpler, i see my kids, i sleep in my bed, i go to restaurants i know and like, i work with nurses i know (some I like and some i dont). I do well $$ wise but i think if i had a typical job at what point would i do locums. I cant come up with the answer. Plus when the $ drops i guess you just dont work? Seems like the market is decelerating pretty slowly now but thats about to change IMO. I called it in 2022. I said we would see things slow by 2026/2027 and then it would accelerate into a complete mess.

It’s the advice i give residents. Keep in mind even if you dont believe the ACEP workforce data 2 major issues come out of there.

1) even if docs are quitting younger we have more and more young docs. 2) that also means your career wont be long 3) they didnt take into account the opening of even more residencies in those studies and thats happened. The number of spots is growing and the number of positions needed hasnt at all. Now more places are looking to the noctor only model.

Im in the back half of my career so it matters less to me but is this a matter of being an ostrich with your head in the sand? A plan to maximize money and get out like others apparently have? My personal experience with people i know is women are leaving EM, men not so much. Maybe some other shoe drops but it appears in my small world that the new grads want to work fewer hours, will work more years and the ability to find a semi functional job is dramatically falling. People are working either bad jobs or are in a good group but it is requiring them to travel for a few years before they hit the read money pot which has its own set of issues.

back in the day when things were simpler it seemed like a new grads came out and sprinted like crazy for a few years and then settled into their comfort zone for work. Now it seems like they just start at the comfort zone, plug along for a bit and then???? Idk.. we will see.

I agree that I think there's a huge financial reckoning coming for medicine. Beyond federal level Medicare and Medicaid cuts, my state loves to suck off private insurance and underfund Medicaid.

You have to be very misguided to go into medicine now, unless the education is free / cheap / funded for you, and absolutely insane to go into EM today.

 

[RustedFox]

Maybe I should move to Florida. Weather is better too. Midwest doesn’t pay well in the big cities. People in Detroit are working for half what you quoted.

Screw Detroit from top to bottom.
I want to move somewhere drier and cooler; but the wife is NOT on board with that , and it's hard to walk away from my current arrangement because it really is a good work environment for several reasons that will remain undisclosed here.

 

[EctopicFetus]

Maybe

I still hold the pessimistic view hospitals in general will be okay with staffing EDs with midlevels or with bare minimum docs in purely supervisory/nominal roles.

If I've learned anything on the money side, it's that it's money first, everything else second.

I desperately want to be wrong

For sure.. in the end tho the midlevels will lead to bad outcomes and bad care especially in the ED. I had a meeting a few weeks ago with a hospital CEO and CMO. they moved to this model in one of their very low volume EDs. Now this is a very functional leadership team which is the minority of hospital leadership teams I have interacted with. The CEO said "I lose sleep at night" thinking about sick patients being managed in a rural ED by a noctor. They are gonna go to a physician approach again. The ED is a money maker at most places indirectly. Start with your volumes dropping, radiology being overwhelmed, insurance complaining and guess what things will change. I dont think there is any world or realistic setup where money isnt first. A good functional ED is a money maker. Additionally, push out the docs and they will be willing to work for less. See Denver and many other desireable locations as proof that docs will work hard for low wages.

 

[AlmostAnMD]

For sure.. in the end tho the midlevels will lead to bad outcomes and bad care especially in the ED. I had a meeting a few weeks ago with a hospital CEO and CMO. they moved to this model in one of their very low volume EDs. Now this is a very functional leadership team which is the minority of hospital leadership teams I have interacted with. The CEO said "I lose sleep at night" thinking about sick patients being managed in a rural ED by a noctor. They are gonna go to a physician approach again. The ED is a money maker at most places indirectly. Start with your volumes dropping, radiology being overwhelmed, insurance complaining and guess what things will change. I dont think there is any world or realistic setup where money isnt first. A good functional ED is a money maker. Additionally, push out the docs and they will be willing to work for less. See Denver and many other desireable locations as proof that docs will work hard for low wages.

All true and indisputable points

the only question that remains is, is the cost of litigation from midlevel care going to be offset by the savings of paying midlevels?


The answer is harder to calculate than you'd think imo

I'm honestly not sure, but I'm generally expecting some large system, at some point, to kick out all the docs and see what happens.

EM is on such an island with poor lobbying I think it's easier for that island to sink and no one notice

 

[RustedFox]

All true and indisputable points

the only question that remains is, is the cost of litigation from midlevel care going to be offset by the savings of paying midlevels?


The answer is harder to calculate than you'd think imo

I'm honestly not sure, but I'm generally expecting some large system, at some point, to kick out all the docs and see what happens.

EM is on such an island with poor lobbying I think it's easier for that island to sink and no one notice

a LOT of the MLPs that I work with think that they're SO good (because they're old), but are really SO bad.
a LOT of them.

 

[AlmostAnMD]

Again

no dispute sir

What I want to have happen, and what I worry will happen, are mutually exclusive here...

 

[RustedFox]

Again

no dispute sir

What I want to have happen, and what I worry will happen, are mutually exclusive here...

Oh, no argument from me bro.
I just had to point out how so many of them think they're "so good" but are so, so Dunning-Kruger'ed.

 

[Brigade4Radiant]

Even for locums to be worth it you have to make 350-375 plus bonuses. I would only do locums for the southeast if I had to. I don't see the point batting snow and having my plane delayed. Many EM docs will also sell out the profession by opening HCA residencies and working for 125 and hour. Now its hard to find straight hourly positions period. Locums is the only that consistently pays hourly most full time jobs have an rvu component.

The ED is the money maker and referral center in moderate income neighborhoods. So you are under pressure for press ganey and length of stay which is just as important as how many patients per hour you see.

 

[Porfirio]

I think EM is done. I got mine (still am $330-$380 per hr, CMG/physician owned contract work) while I could. I am a younger doc but worked double time since finishing residency which makes me a middle aged doctor (lived cheap, saved a much as I could). Thus my financial situation is different from my fellow docs.

New grads (docs/midlevels) are getting weaker and weaker. I am nothing special, but the future looks very bad for medicine in general.

Older elderly docs all retired during COVID. Older docs white knuckled the job and are retiring now or getting close to retirement (decreased hours). Middle docs took/taking the risk of doing other things. Younger docs had no choice but to continue.

Now, the younger docs are looking to get out. Going to be big holes in the ER that will be filled with garbage midlevels. Future for docs is going to be thin staffed and stressful shifts. Pay will go down because profits have to be maintained.

 

[EctopicFetus]

All true and indisputable points

the only question that remains is, is the cost of litigation from midlevel care going to be offset by the savings of paying midlevels?


The answer is harder to calculate than you'd think imo

I'm honestly not sure, but I'm generally expecting some large system, at some point, to kick out all the docs and see what happens.

EM is on such an island with poor lobbying I think it's easier for that island to sink and no one notice

I think ED volumes would drop as Noctors are just not as hard working, order too many things and while nice the misses would be catastrophic leading to severe reputational damage. I might be wrong but i dont think i am. Maybe a bit more MLPs but IMO the $$ backed PE groups have already maximized this. Its inherent in their business model. Its not just lawsuits but the reputation to the hospital that will be severely impacted and with that $$ matters as well. If you think about it the ED has more touches annually than any other hospital group. MOreso than ortho etc. Em is on an island and at risk but i think the market will correct itself. The hospitals and CMGs dont staff with as many docs as they do out of the goodness of their heart. The calculaiton has already been made IMO. i dont think they care too much about litigation IMO. Its just the cost of doing business.

 

[EctopicFetus]

I think EM is done. I got mine (still am $330-$380 per hr, CMG/physician owned contract work) while I could. I am a younger doc but worked double time since finishing residency which makes me a middle aged doctor (lived cheap, saved a much as I could). Thus my financial situation is different from my fellow docs.

New grads (docs/midlevels) are getting weaker and weaker. I am nothing special, but the future looks very bad for medicine in general.

Older elderly docs all retired during COVID. Older docs white knuckled the job and are retiring now or getting close to retirement (decreased hours). Middle docs took/taking the risk of doing other things. Younger docs had no choice but to continue.

Now, the younger docs are looking to get out. Going to be big holes in the ER that will be filled with garbage midlevels. Future for docs is going to be thin staffed and stressful shifts. Pay will go down because profits have to be maintained.

A bit of a disagreement. Those new docs are graduating with like 275k in debt. Lets be real as a doc you have no marketable skills outside of patient care. At least not at any scale. yes you can do UM and a bunch of other stuff but the need is fairly small. Your skills are not just not transferable to a corporation outside of healthcare I would argue would be an impendence to a corporate job. You hit the nail on the head about the stupidity of the new grads. Pay will go down because Adam Smith and the supply/demand curve. You dont need garbage midlevels when you can have garbage docs.

 

[Porfirio]

A bit of a disagreement. Those new docs are graduating with like 275k in debt. Lets be real as a doc you have no marketable skills outside of patient care. At least not at any scale. yes you can do UM and a bunch of other stuff but the need is fairly small. Your skills are not just not transferable to a corporation outside of healthcare I would argue would be an impendence to a corporate job. You hit the nail on the head about the stupidity of the new grads. Pay will go down because Adam Smith and the supply/demand curve. You dont need garbage midlevels when you can have garbage docs.

Just because docs graduate with $275k debt does not mean they will make large salaries.

Of course, we only have marketable skills that do with medicine. Just like plumbers can only do plumbing.

Garbage midlevels will always be cheaper than garbage docs.

 

[TeddyBoomBoom]

One of the issues is, unless you’re part of a sdg, if the cmg decides to staff with 1 physician and 37 mid levels in the future, you can either accept it or walk. Both options are terrible for a new grad with loans.

My advice would be one of two extremes: either find/travel/network into a partner track in a sdg, and take the risk, or just do straight up locums. (Full disclosure - I’m a partner in a private group in the SE. Not perfect but wayyyyyy better than the other options.)

 

[EctopicFetus]

Just because docs graduate with $275k debt does not mean they will make large salaries.

Of course, we only have marketable skills that do with medicine. Just like plumbers can only do plumbing.

Garbage midlevels will always be cheaper than garbage docs.

graduiatiung with 275k in debt means you will need to work.. and likely for a long long time. Lawyers have skills beyond law, enginners the same, CPAs the same, MBAs have a broad set of skills. In medicine our skills are super narrow.

 

[EMdoc235]

graduiatiung with 275k in debt means you will need to work.. and likely for a long long time. Lawyers have skills beyond law, enginners the same, CPAs the same, MBAs have a broad set of skills. In medicine our skills are super narrow.

If you have that much debt you should just take a job in some rural location for the first year that pays 500k+, live like a resident and knock it out asap. In the Midwest these jobs are frequently available near St. Louis or Urbana Champaign.

 

[Mount Asclepius]

I completely agree that an expertise in medicine provides you with a skill set that is more limited and difficult to pivot from than other fields. It is a little more guaranteed though if you can stomach less career flexibility for the historical trade off of financial security.

However, you can easily overcome $300K in student loans. I did it years ago in 1.5 years by working hard and living simply. It can still be done today. Then the world is your oyster if you pick the right job/location.

 

[EctopicFetus]

If you have that much debt you should just take a job in some rural location for the first year that pays 500k+, live like a resident and knock it out asap. In the Midwest these jobs are frequently available near St. Louis or Urbana Champaign.

Agreed.. but it is asking people to further delay life. Im not saying you are wrong. Frankly, outside of major cities those jobs can be had for $300/hr for moderately busy rural spots and 250/hr for sleepy locations out an hour or 2. Question is at 250/hr do you want to work 2000 hours a year? I dont think its a huge deal and i averaged just over 160 hours month the first 5 years out at a high acuity location. I just dont see a ton of people doing this especially if married and with kids especially school aged. There is a mentality and im not sure it is wrong that I made it, im an attending and I want to enjoy life some being that they are at youngest around 30.