Independent locum tenens physicians savor life without an agency

About six years ago, John Bolton, MD, a pediatrician in San Francisco, wanted to go back to clinical practice after several years in retirement. He didn't want to return to full-time work, but had no interest in giving a portion of his salary to a locum tenens agency that might arrange part-time or short-term assignments in locations he had no desire to go to.

"I don't really want to live in a motel room watching TV at night, wishing I was back home," Dr. Bolton said.

So he became an independent locum tenens physician. He covers vacations, sick days and trips to medical meetings for three practices of four to six pediatricians each in the San Francisco area. He averages a few days a week, some weeks busier than others.

"Being a fly fisherman, I enjoy doing that in the spring and in the fall," Dr. Bolton said. "If a physician wants to go to the beach in the summer or in winter wants to go skiing, I'm your man."

The number of independent locum tenens physicians is believed to be small. Doctors who work this way say it can be done -- if you can handle all the legwork and other possible hassles an agency otherwise would do on your behalf.

According to a survey of hundreds of locum tenens physicians issued Feb. 16 by Staff Care, only 6% worked without an agency in 2005. The number grew to 14% in 2007, dropped back down to 9% in 2009, and went up again to 11% in 2010. Staff Care is a locum tenens agency within AMN Healthcare based in Irving, Texas.

Physicians who work with an agency are paid directly by it and are the agency's independent contractor. Hospitals or health systems that bring in an agency locum physician pay the agency for the physician's work. The percentage will vary widely, but a portion of the money covers the agency's services. This includes a physician's paperwork for licensing, credentialing and liability insurance that can be complicated and differ significantly by state.

Even without a staffing agency, most locums still need the services of an accountant, a lawyer or other professionals, and finding assignments can take effort. Some large health care facilities have exclusive contracts with a staffing agency, which may make it hard for independent physicians to break in. In addition, a physician may have little recourse or options for support if difficulties develop.

"We try to take a lot of these things off physicians' hands," said Gary Hart, divisional vice president for the Staff Care office in Salt Lake City. "And we try to handle any problems before they even get to the physician. We really try to make it so that physicians can do what they do best: See patients and care for their immediate needs."

But physicians who work as independent locums say that they like two things they get in exchange for taking on the paperwork: higher pay, because they don't have any fees taken out by an agency, and greater freedom to decide where and when to work.

"Agencies play a very important part for physicians who cannot or do not want to do it independently, but I know how to do the paperwork," said Dorothy Nemec, MD, a nephrologist who started working as an independent locum tenens physician more than 15 years ago in the middle of her career, when she decided she no longer wanted to work at a large clinic. "Once you get started, you can build a reputation fairly quickly. You can do it on your own." She lives part of the year in Punta Gorda, Fla., and travels with her husband, Larry Rand, PA, who also works on a locum basis. They wrote the book Finding Private Locums: A Guide to Independent Locums.

Older physicians with established networks may be able to do this more easily than younger ones. Physicians who don't live in metropolitan areas may find they must travel to get enough assignments, but this may be part of the appeal.

"A physician would have to have an entrepreneurial mindset and be well-organized," Hart said. "It's not impossible, but physicians really have to be on top of everything."

For example, Dr. Bolton finds work locally through physicians he knows in full-time practice. Dr. Nemec contacts institutions that are advertising permanent positions and offers to fill in until they find someone who wants to stay longer. She enjoys traveling around the country for various assignments.

"I prefer to go directly to the hiring physician or the hospital, and I tell them I can help tide them over," Dr. Nemec said. "And the more rural, the better."

Dr. Bolton kept up his medical license after he retired and does not work outside California, so he doesn't have to worry about the requirements of other states. Dr. Nemec, who goes out of state, maintains necessary documents on her computer that she sends as needed to various institutions and state licensing boards.

Physicians need to ensure that they have liability coverage. Dr. Bolton's is provided by the practices, which call their insurance providers for temporary riders to cover him. Dr. Nemec is also covered by the institutions where she works.

But Dr. Nemec has the additional wrinkle of needing a home and transportation when she takes an assignment. This is another issue that staffing agencies handle. To have housing and transportation, Dr. Nemec and Rand travel in an RV, sometimes parking in the hospital lot.

"We've got our own stuff," Rand said. "We have our own house with us. This makes it extremely simple for the people who hire us. They don't have to find us a place to live."

Dr. Bolton's life, however, is not without travel, although not for locum tenens assignments. In many ways, he said, working as an independent locum has allowed him the best of both retirement and clinical practice. He spends a great deal of time at his cabin in Montana and recently caught -- and released -- 35 trout in a single day. And when he's at his home base in San Francisco, he has the opportunity to care for some of the children of his original patients without being on call or carrying out hospital rounds.

"It's fun," Dr. Bolton said. "I'm not trying to build my own practice."

Before working with a locum tenens agency, he said, "I would certainly try it first on my own to see what I could turn up."