Dear locums/PRN docs

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There is a huge middle ground for EM that is often overlooked. It’s small to medium sized cities. Pay in large cities can sometimes be terrible. Rural areas are unattractive for most to live in and no one wants to constantly travel. There also isn’t a large enough population of high acuity patients to equate to decent billing without subsidy. In small to medium sized cities, you can still find amenities, great jobs and great pay even in very desirable states. These positions may become saturated in the next 5-10 years, but for now I would grab one up if I was a new grad.
 
RustedFox said:
I hear you, but you can choose when you come -after- the full-timers have their schedules made.
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Trust me, I’ve now been on both sides.
I get the FT side as well with not wanting the left overs, the impact of scheduling, retention etc.

But self scheduling on your preference is one of the benefits of locums life. Again, if I am not seeing my family for 5 days to a week , and you are, I’m coming when I want, or I’m not coming at all.

I have sympathy for both
 
Mount Asclepius said:
There is a huge middle ground for EM that is often overlooked. It’s small to medium sized cities. Pay in large cities can sometimes be terrible. Rural areas are unattractive for most to live in and no one wants to constantly travel. There also isn’t a large enough population of high acuity patients to equate to decent billing without subsidy. In small to medium sized cities, you can still find amenities, great jobs and great pay even in very desirable states. These positions may become saturated in the next 5-10 years, but for now I would grab one up if I was a new grad.
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Can you give an idea of what cities you are referring to? Dont have to name your city but curious what you mean here.
 
NYEMMED said:
Trust me, I’ve now been on both sides.
I get the FT side as well with not wanting the left overs, the impact of scheduling, retention etc.

But self scheduling on your preference is one of the benefits of locums life. Again, if I am not seeing my family for 5 days to a week , and you are, I’m coming when I want, or I’m not coming at all.

I have sympathy for both
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This is sort of funny to me as a non locums person and someone who only when I was moonlighting did I ever work with locums people directly.

Sure you are away from your family but you make more (often much more) and yet you want to stick it to the FT docs.

I think like many of these issues. It comes down to how desperate the site is and what the FT docs will take. I cant imagine being stuck with a craptastic schedule so some locums person can have what they want especially knowing they would be outearning me.

Some EM docs I have met are loyal to a crazy fault and dont understand that this is a business. The hospital and your CMG employer have no loyalty to you.

I do agree that I see the other side but it seems to me that unless very temporary it is a disaster waiting to happen.
 
EctopicFetus said:
Can you give an idea of what cities you are referring to? Dont have to name your city but curious what you mean here.
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I thought it was fairly self explanatory so maybe I don’t understand your question. Technically the definition would be ~50-500k people, but I think the more desirable cities with decent jobs are in the 100k-1M range (still not large cities). You can find $500k+ FT SDG jobs in desirable states in cities of this size.
 
Mount Asclepius said:
I thought it was fairly self explanatory so maybe I don’t understand your question. Technically the definition would be ~50-500k people, but I think the more desirable cities with decent jobs are in the 100k-1M range (still not large cities). You can find $500k+ FT SDG jobs in desirable states in cities of this size.
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Name the cities..
 
Porfirio said:
Just move, no point in working with that. So many other options right now. I know so many docs flying out of the city to work (same for Colorado).
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Ohh I travel and work in the midwest for 300/hr rate for shifts.

But there are plenty of docs who are willing to pick up those shifts.
 
It will be interesting to see what happens with the new annual 100K H1B fees.

Assuming there's no exception for docs it will affect lots of IMG heavy programs.
 
Real question do we care? Seemingly will make this more US focused and may result in lesser qualified docs cause hard to imagine anyone is dropping 100k to hire a resident when they can have another one for free.
 
EctopicFetus said:
Real question do we care? Seemingly will make this more US focused and may result in lesser qualified docs cause hard to imagine anyone is dropping 100k to hire a resident when they can have another one for free.
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Better job security for US docs. Opponents to the new rule are saying more mid level use but I still prefer mid levels to hiring foreign docs who will do a 400k job for 200k. And I don’t think midlevels would replace docs where they would be required.
 
EMdoc235 said:
Better job security for US docs. Opponents to the new rule are saying more mid level use but I still prefer mid levels to hiring foreign docs who will do a 400k job for 200k. And I don’t think midlevels would replace docs where they would be required.
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Politics aside I find it humorous that this EO comes out and there's immediately a thread hypothesizing the multiple ways it plays out for EM docs, all bad mind you.

Perpetual doom and gloom here.
 
hoot504 said:
Politics aside I find it humorous that this EO comes out and there's immediately a thread hypothesizing the multiple ways it plays out for EM docs, all bad mind you.

Perpetual doom and gloom here.
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Yesterday: there’s too many ED docs.

Today: there’s going to be less ED docs.
 
EctopicFetus said:
This is sort of funny to me as a non locums person and someone who only when I was moonlighting did I ever work with locums people directly.

Sure you are away from your family but you make more (often much more) and yet you want to stick it to the FT docs.

I think like many of these issues. It comes down to how desperate the site is and what the FT docs will take. I cant imagine being stuck with a craptastic schedule so some locums person can have what they want especially knowing they would be outearning me.

Some EM docs I have met are loyal to a crazy fault and dont understand that this is a business. The hospital and your CMG employer have no loyalty to you.

I do agree that I see the other side but it seems to me that unless very temporary it is a disaster waiting to happen.
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It’s not about sticking it to anyone.
Again, I get it. Being a FT doc now with locums at my site, yes it sucks having to work around their schedule.

But I think there is also a difference between a CMG employed locums vs a true locums. For a true locums, they are getting paid more and are usually pick up shifts here or there.

For a CMG employed FT traveler. Yes, doing 15 shifts a month flying away from home, should make their own schedule ahead of time.

The locums doc is why FT docs don’t have to work 25 shifts a month. So should be happy for that

And locums can help out when needed too.
One of my frequent travel sites got hit with a hurricane years back, town took lots of damage. I flew in and worked 7 days so the FT docs could be at home helping their families and repairing
 
As somebody who has done both locums and now FT (and likely locums/PT again in the future), I can't imagine a world where the locums doesn't have first dibs at the most desirable shifts.

Oh, you don't want to give me the weekday 9-5 shifts? I think my other 4 sites have shifts for me; have fun working 20 shifts this month.
 
Maybe I have a different definition of Locums. Where I have done Locums, the schedule gets filled by Full timers. Then they put shifts out for prns with bonuses attached which I pick up when the amount works.

But If I were a Locums not getting any financial bonus, then yeah I am not doing night/weekends.
 
NYEMMED said:
It’s not about sticking it to anyone.
Again, I get it. Being a FT doc now with locums at my site, yes it sucks having to work around their schedule.

But I think there is also a difference between a CMG employed locums vs a true locums. For a true locums, they are getting paid more and are usually pick up shifts here or there.

For a CMG employed FT traveler. Yes, doing 15 shifts a month flying away from home, should make their own schedule ahead of time.

The locums doc is why FT docs don’t have to work 25 shifts a month. So should be happy for that

And locums can help out when needed too.
One of my frequent travel sites got hit with a hurricane years back, town took lots of damage. I flew in and worked 7 days so the FT docs could be at home helping their families and repairing
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Im so confused. So if the locums doc doesnt work those shifts what would “force” those FT to work 25? Even more importantly if the chose to do so the money they could demand would be spectacular. I disagree with this idea. Let’s be honest, the locums docs work for a higher wage. Why? Simple lots of dough. If they didnt exist the $$ would be even higher. Simple supply / demand economics with a sprinkle of price gouging. It happens in reverse as well. Saturated market.. CMG lowers pay..
 
I think giving the locums their choice of schedule is ridiculous. Treat the full timers right or else you’ll have even more open shifts. Increase the rate for the unfilled shifts and offer them to the full timers first then open it up to locums. Rinse and repeat until the schedule is filled.
 
GatorCHOMPions said:
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Not surprised by that result and in fact I was probably a part of that data set.* When I was doing locums for USACS I didn't care if I dictated a level 5 chart, probably didn't chart well enough for them to bill for a lot of extras, and rarely claimed critical care. Why would I? I get the same $400/hr either way. If they sent me "coder comms" later asking me to buff my chart for some extra billing I always clicked "unable to elaborate". Why waste my time logging in remotely, reading the chart, and then making the changes. I'm sure most of their locums were the same. Interesting though that by all their other quality measures locums was as good as their regulars.(Maybe says more about the regulars?)

Back to the original point. I'm not cherry picking the best shifts. I"m just telling you when I'm available. If you want me then great. We both win. If you don't I go on with my life.

EctopicFetus said:
Im so confused. So if the locums doc doesnt work those shifts what would “force” those FT to work 25? Even more importantly if the chose to do so the money they could demand would be spectacular.
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As for Ectopic's question about how the CMG's force the regulars to pick up extra shifts the answer is simple. They just do. That's why I finally quit USACS. It was a year of asking for 80 hours every month and being given 120-140. You either take the over scheduling or quit. I quit but if you like the town and your kids are happy in their school and the CMG controls the whole town not everyone can quit so they just keep sucking it up and working 60 hours more than they wanted. Doubt they can push it to 25 shifts a month but If USACS can push 3 extra shifts on every one of their physicians every month without a problematic increase in attrition they can save millions every month over the cost of locums and giving everyone their ideal schedule.

*Just checked the dates of their data set. I wasn't doing locums with USACS then so it wasn't me dragging them down.🙂
 
ERMudPhud said:
I quit but if you like the town and your kids are happy in their school and the CMG controls the whole town not everyone can quit so they just keep sucking it up and working 60 hours more than they wanted. Doubt they can push it to 25 shifts a month but If USACS can push 3 extra shifts on every one of their physicians every month without a problematic increase in attrition they can save millions every month over the cost of locums and giving everyone their ideal schedule.
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This is 100% what the malignant sdg near me did. Took over the entire town minus the parts controlled by an equally bad cmg and just said, this is how many shifts you are gonna work.

It ultimately had two effects. The smarter docs (imo) left. The weaker docs or docs too indecisive in life or groveling for a "leadership" position held the line.

Neither were appealing to me and I couldn't leave the area so I wfh now with an infinite increase in QoL. But yes, group bullying and intimidation is definitely a tactic that saves money and keeps weak minds in line. Especially when you consider what has already happened to our speciality we have got to be the most spineless docs around.

All started decades ago when abim said we can't do their fellowships imo
 
I have just never worked in a situation like this thankfully. In my brief time of working in CMG land I did nt work extra and when i helped at all it was for more money and thats before I truly understood the economics of EM and our labor.
 
Apollyon said:
What is the largest US city without a big 4 sports team (NFL, NBA, NHL, MLB)?

Austin TX
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Ft. Worth.

If you’re talking about metro then apparently it’s the Riverside-San Bernardino-Ontario CA metro area. I don’t know who’s making the rules.
 
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EctopicFetus said:
Im so confused. So if the locums doc doesnt work those shifts what would “force” those FT to work 25? Even more importantly if the chose to do so the money they could demand would be spectacular. I disagree with this idea. Let’s be honest, the locums docs work for a higher wage. Why? Simple lots of dough. If they didnt exist the $$ would be even higher. Simple supply / demand economics with a sprinkle of price gouging. It happens in reverse as well. Saturated market.. CMG lowers pay..
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Someone has to work the shifts or the hospital will find another company to do the job.

The FT staff face a larger consequence to not filling those shifts than the locums do.
 
Siggy said:
Someone has to work the shifts or the hospital will find another company to do the job.

The FT staff face a larger consequence to not filling those shifts than the locums do.
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I’m not sure about that. It’ll be the same pit docs but a new “company”. If it’s a tough place to staff the full timers who are there aren’t going to go anywhere no matter who has the contract.
 
My experience with CMGs has been if no Locums/PRN/FT doc works the shift they go to a midlevel and if no midlevel then the shift goes unfilled or the CMG pressures the site director or assistant medical director to take the shift. If it goes unfilled the CMG moves the hours/coverage around to hurt the people who are on shift to cover the hole.

The CMG will just pocket the extra money from not filling the shift.
 
Porfirio said:
My experience with CMGs has been if no Locums/PRN/FT doc works the shift they go to a midlevel and if no midlevel then the shift goes unfilled or the CMG pressures the site director or assistant medical director to take the shift. If it goes unfilled the CMG moves the hours/coverage around to hurt the people who are on shift to cover the hole.

The CMG will just pocket the extra money from not filling the shift.
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Man this would be brutal and do it enough time would create more holes as full timers start to quit. Some places I work would be down right criminal with just one doc working.
 
Porfirio said:
My experience with CMGs has been if no Locums/PRN/FT doc works the shift they go to a midlevel and if no midlevel then the shift goes unfilled or the CMG pressures the site director or assistant medical director to take the shift. If it goes unfilled the CMG moves the hours/coverage around to hurt the people who are on shift to cover the hole.

The CMG will just pocket the extra money from not filling the shift.
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Yep this happened a lot when I would work locums at two particular sites. I’d just stop seeing everyone non-critical. It wasn’t bad.
 
Porfirio said:
My experience with CMGs has been if no Locums/PRN/FT doc works the shift they go to a midlevel and if no midlevel then the shift goes unfilled or the CMG pressures the site director or assistant medical director to take the shift. If it goes unfilled the CMG moves the hours/coverage around to hurt the people who are on shift to cover the hole.

The CMG will just pocket the extra money from not filling the shift.
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I've seen that too. Suddenly a schedule that had 7 doc and 6 APPS had 5 docs and 5 APP's. I would just add a few hours of overtime to my already extended shift and dare them to blink. They always paid the overtime. They still win though because their full timers were banned from requesting overtime and cutting two doc shifts and an APP shift from the schedule saved them a ton of money.

It feels like the CMG's have some business intelligence people calculating for each market what is the lowest we can pay and still have 80% or our hours covered with a manageable amount of provider turn over. They have no incentive to pay more to get to 100% as that would cost extra. Better to just use the above shenanigans to get close to 100% coverage and then fill in with locums making 150+% of the going rate for the last little bit. Cheaper to pay them 150% than to raise everyone else's pay 10%
 
I don’t understand how anyone would want to work for a CMG. Please don't come back to me with the geographic limitation argument.

In a SDG, you have complete control over your staffing/schedule and no one takes money off the top.
 
Mount Asclepius said:
I don’t understand how anyone would want to work for a CMG. Please don't come back to me with the geographic limitation argument.

In a SDG, you have complete control over your staffing/schedule and no one takes money off the top.
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My experience at a malignant sdg disagrees


Greed hits everyone at some point

I think the larger the sdg the more cmg-like the behavior becomes. If its a single site hospital, probably less likely. Control a region? Playing with fire


My specific rebuttals:
"Complete control over schedule" = senior docs work am and no nights, a process that evolved over years back when the sdg was small, so now new docs will essentially work 1 or 2 am shifts a month and it stays that way for years

"No one takes money off the top" = "director bonuses"

"Control over staffing" = site director that works 2 days a month clinically and only in the morning telling you to stop complaining about night shift staffing
 
AlmostAnMD said:
My experience at a malignant sdg disagrees


Greed hits everyone at some point

I think the larger the sdg the more cmg-like the behavior becomes. If its a single site hospital, probably less likely. Control a region? Playing with fire


My specific rebuttals:
"Complete control over schedule" = senior docs work am and no nights, a process that evolved over years back when the sdg was small, so now new docs will essentially work 1 or 2 am shifts a month and it stays that way for years

"No one takes money off the top" = "director bonuses"

"Control over staffing" = site director that works 2 days a month clinically and only in the morning telling you to stop complaining about night shift staffing
Click to expand...
New doc who rocks the boat gets let go to the sea.
 
When you work for a CMG does it really matter which one? Thats a serious question. If I were FT for a CMG I wouldnt do anything extra especially if they were bringing in locums. Let the place burn. Cause what would happen, new CMG comes in and I still have a job. For the CMgs. As noted above it’s simply a business decision. A local site here that was staffed by APP is now staffed by one of the lesser known CMGs. They pay so terribly that their model in a 50k-ish volume ED is on occassion 1 doc supervising 5 mlps. You can always hire MLPs.

I know a few docs who tried to work there for whatever reason and literally none of them have gone back. Terms like “dangerous”, “crazy”, “understaffed” etc are thrown around.
 
I don’t see the point of being a travel CMG if you’re locum, you could specify things like I will only work with place that has epic or OB/GYN.

Plus you make a good rate plus a bonus
 
EctopicFetus said:
When you work for a CMG does it really matter which one? Thats a serious question. If I were FT for a CMG I wouldnt do anything extra especially if they were bringing in locums. Let the place burn. Cause what would happen, new CMG comes in and I still have a job. For the CMgs. As noted above it’s simply a business decision. A local site here that was staffed by APP is now staffed by one of the lesser known CMGs. They pay so terribly that their model in a 50k-ish volume ED is on occassion 1 doc supervising 5 mlps. You can always hire MLPs.

I know a few docs who tried to work there for whatever reason and literally none of them have gone back. Terms like “dangerous”, “crazy”, “understaffed” etc are thrown around.
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CMG or physician owned is all the same. All the CMGs are basically the same.

This is the model all CMGs/physician owned have wet dreams about (24 hrs doc coverage and full MLP coverage).

Yes, just let it burn. See patients at your pace and limit MLP exposure - the goal of every shift. The CEO will blame the CMG. The CMG will blame the docs. The CMG will try to replace the docs - fail most of the time or costs too high. Eventually the CEO will pick a different CMG. The hospital might replace the CEO. The cycle will repeat. Best to always have an exit strategy. As the cycle repeats, you can always return later when new faces (CEO/CMG) appear.
 
AlmostAnMD said:
My experience at a malignant sdg disagrees


Greed hits everyone at some point

I think the larger the sdg the more cmg-like the behavior becomes. If its a single site hospital, probably less likely. Control a region? Playing with fire


My specific rebuttals:
"Complete control over schedule" = senior docs work am and no nights, a process that evolved over years back when the sdg was small, so now new docs will essentially work 1 or 2 am shifts a month and it stays that way for years

"No one takes money off the top" = "director bonuses"

"Control over staffing" = site director that works 2 days a month clinically and only in the morning telling you to stop complaining about night shift staffing
Click to expand...
AAEM Certificate of Workplace Fairness
 
AlmostAnMD said:
My experience at a malignant sdg disagrees


Greed hits everyone at some point

I think the larger the sdg the more cmg-like the behavior becomes. If its a single site hospital, probably less likely. Control a region? Playing with fire


My specific rebuttals:
"Complete control over schedule" = senior docs work am and no nights, a process that evolved over years back when the sdg was small, so now new docs will essentially work 1 or 2 am shifts a month and it stays that way for years

"No one takes money off the top" = "director bonuses"

"Control over staffing" = site director that works 2 days a month clinically and only in the morning telling you to stop complaining about night shift staffing
Click to expand...
We don't have any of that crap.

Scheduling parity from day one.

No bonuses for people, just administrative time paid at the regular rate.

Our scheduler works the same crappy shifts as everyone else.
 
Mount Asclepius said:
AAEM Certificate of Workplace Fairness
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lol

If I were still in EM I'd probably consider

They never actually did reveal how much those director bonuses were....considering they gutted staffing horrifically to me seeing 3-4 pph (not including midlevels....err..midlevel, I should say, after the covid cuts) I assume they were substantial given my bonus was only 80k for working a skeleton crew

It's been a year and you can tell I'm still bitter
 
AlmostAnMD said:
lol

If I were still in EM I'd probably consider

They never actually did reveal how much those director bonuses were....considering they gutted staffing horrifically to me seeing 3-4 pph (not including midlevels....err..midlevel, I should say, after the covid cuts) I assume they were substantial given my bonus was only 80k for working a skeleton crew

It's been a year and you can tell I'm still bitter
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I dont know how /why people do it. We hammer our residents about what a job should look like. I also think people dont realize how good it can be and frankly just expect to be abused. I talk to former residents and my colleagues from other parts of life.. I am also lucky to know some great SDGs. I’ll just say… there is money to be made, to be treated fairly, and generally be happy at your job. You can make “good locums” type money plus every shift with the ability to sleep in your bed.

I think the issue is the groups that do this dont advertise to random people, it’s incredibly insular.
 
EctopicFetus said:
When you work for a CMG does it really matter which one? Thats a serious question. If I were FT for a CMG I wouldnt do anything extra especially if they were bringing in locums. Let the place burn. Cause what would happen, new CMG comes in and I still have a job. For the CMgs. As noted above it’s simply a business decision. A local site here that was staffed by APP is now staffed by one of the lesser known CMGs. They pay so terribly that their model in a 50k-ish volume ED is on occassion 1 doc supervising 5 mlps. You can always hire MLPs.

I know a few docs who tried to work there for whatever reason and literally none of them have gone back. Terms like “dangerous”, “crazy”, “understaffed” etc are thrown around.
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I think it’s the fear of which CMG you get next…
IE, you could work for a CMG that’s a pain to work for, but pay is ok etc…
But if that CMG is kicked out, you could be left with what was APP or USACS….
They would just come in, half your staffing from where it already is and half your pay.


Sometimes we are more afraid of what we don’t know….
 
NYEMMED said:
I think it’s the fear of which CMG you get next…
IE, you could work for a CMG that’s a pain to work for, but pay is ok etc…
But if that CMG is kicked out, you could be left with what was APP or USACS….
They would just come in, half your staffing from where it already is and half your pay.


Sometimes we are more afraid of what we don’t know….
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The CMG carousel is never better in my experience. The hospital CEO always looks to save money while saving their job which means replace crappy CMG #1 with diarrhea CMG #2 until finally getting to USACS.

Just stay Locums/PRN and scalp them while on the ride.
 
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