Several years ago, while on assignment in a remote Alaskan area, I learned the hard way what it takes to make life as a locum tenens successful. I had accepted the assignment in the hope of seeing some of the beautiful Alaskan landscape and wildlife. Instead, I saw the clinic. Just days into my stay, the village residents informed me that I was not allowed to venture more than 10 minutes from the clinic, in case an emergency should arise. If I strayed too far, the village police were to detain me immediately and return me to the clinic. Apparently this was the result of some bizarre agreement between the practice and the locum tenens placement company, which had placed me there without relaying this very important detail. I was virtually a prisoner — and a tired one at that. I never had more than two hours of continuous sleep in any 24-hour period. It was difficult and busy being a solo family physician in this remote Alaskan village, but I had no out clause in my agreement and remained there for the full tenure. It was a mistake.

I share this story not to frighten physicians away from locum tenens work but to illustrate one very important rule for anyone considering such work: Protect yourself. If you stick to that mantra, working as a locum tenens can offer a rewarding practice experience.

What it is

Physicians are always asking me what the locum tenens experience is like. Some are simply curious; others think they may want to try it some-day after closing their practices or as a means of evaluating future practice opportunities. Very simply, locum tenens work consists of a physician working temporarily in another practice, not his or her own. That practice may be in the physician's hometown or even in another state. The practice demands may include clinic or hospital care or a combination of both. Typically practices using “locums” are in more remote areas where the local supply of physicians cannot accommodate a vacancy. Locum tenens work is designed to fill these vacancies on an interim basis. Assignments can vary in length from just a few weeks to many months.

Although a practice or hospital may contract directly with a locum tenens physician to meet its needs, this is rare. Normally, the practice or hospital contracts with a third party, a locums company, which keeps a file of physicians who do locums work and have appropriate state licenses. The locums company usually supplies the physician with malpractice insurance, covers travel expenses and pays an hourly rate for the assignment. Before accepting the assignment, the physician must sign an agreement with the locums company that spells out all the details of the relationship. As I discovered in Alaska, this agreement can make or break the experience.

The rules

While life as a locum tenens certainly isn't for everyone, it can be a fulfilling experience for the physician who observes just a few basic guidelines. Rule No. 1 is to remember that the locums company works for the practice to meet the practice's needs, not yours. The locums company is the practice's agent (after all, the practice is the one footing the bill), so it is simple to see where the company's loyalty lies. Do not expect them to protect you. Instead, you will have to protect your own interests. To do that you will almost certainly have to negotiate changes to the contract that the company offers you.

The agreement should include provisions that protect your receipt of payment, cover your travel and other extraordinary expenses, supply appropriate lodging and provide malpractice insurance. You will also want to make sure that the agreement offers a system to equitably address any conflicts and allows you an escape route if the assignment is abusive. To keep yourself from being locked into a bad situation, try to have assignments limited to just one or two weeks initially, with an option to extend the assignment if you and the practice are compatible and pleased with each other. Remember that the locums company's main interest is to place you in the practice; that's how it makes money. The company's employees are not physicians. They do not know how to judge a practice's needs. And they tend to rely solely on what they are told. Meanwhile, the practice is often desperate for a physician and will oversell its positive features just to get someone on board. In many cases, as a locums physician you will find yourself working with a practice administration that has not done its job well. If it had, there might not have been a need for a locums physician. So beware, and do not make a long-term commitment until the compatibility index has been tested practically. If the practice is a miserable environment, perhaps with overbearing and demanding workers or patients, you will not want to endure this for long

Recently, I did a locums assignment in the Midwest in a practice that had no previous experience with locum tenens. A third party requested that I take the assignment and said the work would not be overly demanding. I accepted. I arrived and met the administrator. I knew I was in trouble. She treated me as an indentured servant, demanded that I complete three requests for temporary hospital privileges and dismissed me to go care for patients. Three days later, one of the physicians left the practice. Two days later, two other physicians went on vacation. I was very busy. Things didn't improve. Fortunately, I had written a one-week termination clause into the agreement, so I gave notice. The practice experience was not as it had been described to me.

Payment terms are another important factor in locum tenens work. It took me two years to collect payment for the demanding Alaskan assignment. In fact, I had to sue the locums company just to collect the money due me. I figured if the company was withholding money from me, it was probably doing the same to others and needed to be held accountable. It was. But the two-year delay in payment and the costs of litigation could have been avoided.

One way to protect yourself is by adding to the contract a simple provision that requires the practice to pay you weekly. If the practice pays you directly, the intermediary does not have the opportunity to withhold or delay payment. This arrangement also allows the practice to see the amount you are actually being paid. Traditionally, when a practice contracts with a locums company, it pays the company for the physician's services. The practice's staff might assume the locums physician is getting “big bucks” because that's what the practice is paying the company. If staff members understand that the locums company is taking a significant percentage of this money, they will be less likely to treat you as an opportunist. Naturally, this will make your stay more enjoyable.

Travel arrangements and expenses should also be stipulated in the agreement. At the very least, the practice should be responsible for all travel expenses and lodging. Some locums companies will ask for your credit card number, so they can use it to purchase your airline tickets. They'll tell you that they will reimburse you later. It's a nice deal for the locums companies. They get to use your money and don't have to spend their own. Don't let this happen. Tell the locums company that it or the practice must purchase the tickets, and request that all return tickets be open tickets. You may need to return sooner than anticipated, and this will ensure that you are not stuck with additional travel expenses.

If you will be needing a rental car, the locums company may also ask you to put it on your credit card. Again, do not agree to this. The locums company should have a national contract with a rental car company, so the car rental can be billed directly to it. Although the rental company will want to see your credit card for security purposes, it should not be used for billing. Why should you incur the liability?

Lodging can be a delicate subject. I have been lodged everywhere from massively spider-infested cabins to non-air-conditioned rooming houses in which the temperature was always in the 90s. Be particularly careful that you specify in the agreement the type of lodging you expect. At least express minimal standards. I recommend that you ask for a small apartment, which will allow you privacy and access to a kitchen, so you'll be able to control your diet. Eating out is expensive and can be unhealthy. Typically, locums companies will not cover your food expenses, but if they do not supply you with lodging that allows you to control your food expenses, they should contribute to the costs. Put this in the agreement. And again, make sure the cost of lodging is billed directly to the client, not placed on your credit card.

Another important but often overlooked detail that you should specify in the agreement is the type of non-work-related experience you expect to have. If one of your reasons for doing a particular assignment is to experience a new part of the country, make sure all parties agree to that objective. Of course you will want to meet the practice's needs in caring for patients, but you should also have time to accomplish personal goals.

Malpractice insurance should be supplied by the locums company or the practice. If they do not specify occurrence type, make sure you write into the agreement that they are responsible for the tail. Also make sure they send you proof of malpractice coverage before you leave for the assignment.

Get it in ink

When making changes to the agreement with the locums company, follow these few basic rules. When deleting a paragraph or phrase, cross it out with a single line, and initial and date the deletion. When adding verbiage, print the information clearly and initial and date the addition. Each page of the agreement should be numbered and initialed by you in one of the lower corners. When you are through making changes, present it to the company for its review. Do not start an assignment until you have received a countersigned agreement from the practice or locums company signifying that they have accepted your changes to the agreement. The company may push you to begin an assignment without a signed agreement. Don't. If you do, you may never see a signed agreement.

Follow the above guidelines, and you will have an opportunity to enjoy a locums assignment that satisfies both the practice's needs and your own. Good luck.