Home Cover Story Per diem work: Is the grass really greener?

Per diem work: Is the grass really greener?

And how well do PRN doctors work out for groups?

March 2018

AS A RESULT of his first job, Massachusetts-based hospitalist Samad Khan, MD, learned an important lesson: He doesn’t need to be employed to enjoy a busy, lucrative and fulfilling practice. Last summer, Dr. Khan decided to leave his full-time employed job at a hospital and join the small but steady cadre of hospitalists working as independent contractors. Their goal is to put together enough per diem shifts at various hospitals to add up to full-time work.

Call him PRN, locums, float, moonlighter, clean-up crew, hired gun or even rent-a-doc: He embraces every label, and he can’t imagine being underemployed. “Not having work, that is not a thing,” says Dr. Khan. “I don’t fear that at all.” For him, earning premium pay, setting his own schedule, choosing to work as much or as little as he wants, and having the ability to walk away from less-than-ideal work situations together trump job security.

Historically, a doctor who chose this kind of career may have been suspected of having inadequate skills or a troublesome personality. But Dr. Khan doesn’t see his decision as any kind of black mark that could mar future employment prospects. Many hospitalist leaders, sometimes with regret, agree.

 “Not having work, that is not a thing. I don’t fear that at all.”

~ Samad Khan, MD

Although they may prefer not to manage practices that rely on PRN hospitalists, program directors see having a stable of credentialed, trained freelance hospitalists as a necessary and even inevitable staffing arrangement. For them, assembling an on-demand staff may be the only way to avoid the extremely high cost of last-minute calls to a locum agency when staffing shortages occur.

A market opportunity
Evan Soderstrom, MD, agrees that no one thinks that hospitalists who work per diem wouldn’t be able to hold down a steady job. Until this past December, Dr. Soderstrom was hospitalist medical director for Tri-County Medical Associates at Milford Regional Medical Center in Milford, Mass. Of the group’s regular PRN hospitalists, one is a full-time per diem hospitalist, similar to Dr. Khan, while the others are part-time moonlighters employed full or part time elsewhere.

Dr. Soderstrom does point out that hospital administrators often worry that PRN physicians won’t be as dedicated to the institution as they’d like. “But we have found that a significant percent of them are dedicated,” he says, adding that per diem physicians have helped not only his program but others in his region solve temporary staffing shortfalls.

“We welcome their addition in the physician marketplace,” he says. “While permanent hospitalists will always be favorable when hiring, per diems definitely play a role in the profession.”

As for rating both the quality and commitment of the PRN hospitalists he’s worked with, Dr. Soderstrom says he sees “the whole range. We have gotten some wonderful clinicians who I wish would stay full time with us, and we have been successful at recruiting a couple of them.”

“Large numbers of physicians in many specialties are saying they don’t want traditional full-time employment.”


~ Christopher P. Noel
Integrity Locums

At Wellspan Hospitalists in south-central Pennsylvania, long-time medical director William A. Landis, MD, says that the goal of his health system’s leadership has been “zero” per diem hospitalists. That’s due largely to fears about cultural fit and lack of engagement. (More on that later.)

But in his experience, per diems “are not necessarily better or worse than anybody else,” Dr. Landis says. Instead, he sees them as “smart people recognizing a market opportunity. It’s absolutely about supply and demand.”

Turning down traditional employment
Analysts also say that interest in per diem work arrangements is partly generational. “Millennials are less trusting of organizations in general,” explains Rohit Uppal, MD, chief clinical officer for TeamHealth Hospital Medicine, who oversees 200 hospitalist practices around the country. Being part of the gig economy doesn’t seem so extraordinary to this generation.

Research released by Intuit and Emergent Research in 2015 predicted that by 2020, more than 40% of American workers across all professions will be independent contractors, working full time but relying on different sources for their income. Health care is no exception.

Meanwhile, the use of locum tenens companies as temporary staffing solutions is on the rise. A study in the Dec. 5, 2017, issue of the Journal of American Hospital Association found “no significant difference” in the quality of inpatient care provided by locum internal medicine physicians and non-locum internists, at least in terms of 30-day mortality and readmission rates. (The study did find that patients treated by locum doctors had higher Medicare Part B spending and lengths of stay.)

“Large numbers of physicians in many specialties are saying they don’t want traditional full-time employment,” says Christopher P. Noel, managing partner with Integrity Locums, a company he helped found that is based in Denver and Sarasota, Fla. Instead, says Mr. Noel, more physicians just want to focus on clinical work and to not be locked into a long-term employment contract where they might have to contend with “a poor practice culture, burnout or other alignment issues that are often part of hospitalist practice.”

“A lot of physicians have joined hospitalist groups and felt like they got a bait-and-switch.”

Rohit Uppal, MD
TeamHealth Hospital Medicine

Further, a lot of physicians don’t love being an employee, and the private practice model has all but disappeared. “They are skeptical of jobs that say, ‘I want you to come in and grind for a year and then I’ll make you a partner next year.’ ”

According to TeamHealth’s Dr. Uppal, about 25% of his company’s 4,300 hospital medicine clinicians are PRN. “I think a lot of physicians have joined hospitalist groups and felt like they got a bait-and-switch,” he says. “The job they signed up for didn’t turn out the way they expected.” Rather than get burned again, some are remaining independent, particularly when there is so much economic uncertainty in health care right now.

A career and business model
That “bait-and-switch” reality rings true for Dr. Khan. He decided to opt for per diem work after the hospital where he had been employed began planning to close its ICU—the open ICU, he says, was what attracted him to the position in the first place—and change physicians’ bonus structure.

Another Massachusetts-based physician, Suneel Dhand, MD, has been working as a hospitalist since 2008. Dr. Dhand became sold on the concept of working independently after several disappointing situations in which changes in management, employment conditions or expectations quickly turned a great job into a frustrating one.

“I personally think that being a hospitalist is the best job in the world and one of the most important in health care, but when you have a system where hospitalists work in stressful and unstable environments, it can go bad quickly,” he says. “A hospitalist program is like a house of cards: Take one card away, and the whole thing can come tumbling down. I have seen this happen in multiple programs.”

The final straw for him in the last group where he worked was new hospital leadership and revised shifts that resulted in several senior hospitalists jumping ship. Rather than stick around to see what happened next, he gave notice, became credentialed at a number of area hospitals and started picking up shifts at them all. He usually opts for a mix of day and admitting shifts, and he has had no trouble finding enough work. “As long as the market stays the way it is, it’s not precarious work.”

In addition, Dr. Dhand joined with three colleagues to start a business—www.DocsDox.com—to help doctors find moonlighting and per diem opportunities without going through a locum agency or third-party recruiter. He likens the company’s service to online dating where hospitalists can register for free and, for a nominal fee, hospitals can connect with doctors directly via an online portal. The two parties then negotiate their own terms.

Tracking performance
As for group leaders, they say that PRN hospitalists usually mean extra work. First are scheduling hassles: Putting a puzzle together with many different-sized pieces is time-consuming. In fact, says Dr. Soderstrom, scheduling became so burdensome that his hospital leadership funded extra administrative support.

“A hospitalist program is like a house of cards: Take one card away, and the whole thing can come tumbling down.”

~ Suneel Dhand, MD

Second are the logistics of credentialing, privileging, license-tracking, compliance and training requirements for human resources, compliance, IT and other back-office departments. “PRN physicians may round with you every one to two months,” Dr. Landis points out, “but you still have to chase them down for flu shots.” You also have to track their infection control or advanced cardiac life support training and make sure they have an up-to-date license and CME.

Hospitalist leaders also need to manage temporary physicians’ performance. That can take time, energy and a different kind of finesse than managing employed staff.

“Locum doctors are gone after a finite time, so you are not necessarily trying to grow them for the next period they might work,” explains TeamHealth’s Dr. Uppal. But with PRN doctors, “you want them to keep improving because you know they are coming back. We absolutely do measure performance and give these clinicians opportunities to grow and improve, just like full-time staff.”

Go the extra mile?
The biggest knock against per diem hospitalists is that they may tend to be less engaged than employees; while they may be excellent clinicians, they still work on an hourly basis. So it is a rare per diem hospitalist who attends group meetings, works on hospital committees or quality improvement, or even commits to working the most difficult-to-fill shifts. As a result, employed clinicians can resent per diems who, they think, never go the extra mile or take one for the team. That leaves group leadership thinking about commitment and how to promote collegiality.

Consider Connecticut’s Middlesex Hospital. “Our four part-time per diem providers are outstanding, but they don’t want to be employed,” explains John Machado, DO, hospital medicine section chief. That’s in part because “they do not have to commit to mandatory back-up call, as do our full-time and part-time hospitalists.” When resentment among the employed staff flared, Middlesex last fall gave its per diems an ultimatum: If they wanted PRN shifts going forward, they would have to commit to working one holiday as well as three weekends a year.

“We said the alternative would be to hire a full-time person and get all our shifts covered by employees,” Dr. Machado recalls. “Then we wouldn’t need them any more.”

While some per diems initially pushed back, they all signed new contracts that included that obligation. “I feel we are committed to them and they can count on us for a certain amount of salary, so they could commit to us too,” he says. “I think there is better team camaraderie as a result.”

But Drs. Dhand and Khan both point out that employment doesn’t necessarily translate to engagement. They have both worked with employed hospitalists who never go above and beyond the (minimum) call of duty either. “You can bring people to meetings and committees, but you can’t make them care,” Dr. Dhand says. “You can’t force people to be engaged if they are not going to be.”

“PRN physicians may round with you every one to two months, but you still have to chase them down for flu shots.”

William A. Landis, MD
Wellspan Hospitalists

At the same time, he notes that per diem hospitalists have an incentive to do a good job and provide desired services. After all, PRN hospitalists who underperform or disappoint can be gotten rid of easily: They just won’t be scheduled for another shift.

More control
When he helps hospitalist practices fill their rosters, hospital medicine consultant Martin B. Buser, MP—a founding partner of Hospitalist Management Resources LLC, which is based in Del Mar, Calif., Pensacola, Fla., and Colorado Springs, Colo.— says he not infrequently encounters hospitalists who request independent contractor status instead of employment. But most hospitalist groups he works with frown on that, he adds, due partly to IRS and CMS rules concerning taxes and billing.

Mr. Buser interprets the physicians’ wish as “probably related to burnout. There is a feeling that maybe now I will have a little more control of my life by being an independent contractor. You feel like more of a free agent if you run into bad management in a program.”

This is not to say that joining the gig economy appeals to all hospitalists. As Mr. Noel points out, many doctors are not interested in managing the logistics of paying taxes and arranging their own schedules. “And there are people who like being part of one group at one hospital and feeling they are part of a team.”

Hospitalist Maytee Boonyapredee, MD, points out that working per diem requires a stomach strong enough to weather economic instability and a spirit that thrives on hustle and change. After working per diem for about a year, both independently and through a locums company, he recently joined— happily—a private hospitalist group in suburban Chicago.

The “absolute independence” of choosing where and when to work was great, says Dr. Boonyapredee. “But this is better because there is more security and benefits. You always have to have a back-up plan because you don’t know when the hospital won’t want you anymore.”

Although he always knew it could happen, it still was a professional (and financial) shock when the hospital where he had been working per diem called to say, “this is going to be your last shift here.” They had hired a full-timer.

Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.

How to find per diem work
IN METROPOLITAN AREAS with multiple hospitals, hospitalists can usually arrange per diem shifts on their own without using intermediaries like staffing agencies. But if hospitalists want to work shifts in different locations or at rural hospitals, it is often easier to organize them through locum tenens companies, which typically take care of travel and housing. In addition, says Christopher P. Noel, managing partner with Integrity Locums, a staffing company based in Denver and Sarasota, Fla., some doctors worry that it might not look good on a resume to appear to jump from job to job.

It is, however, common to see multiple affiliations on hospitalist CVs now “as many hospitalists prefer to work locum tenens in between permanent positions and before they decide to commit to long-term employment contracts,” Mr. Noel says. The key is “finding the right temporary clinicians who can provide continuity and also fit both the clinical and the practice culture.”

Working per diem, Massachusetts-based hospitalist Samad Khan, MD, spends a week each month away from his home at a large hospital in Albuquerque—shifts arranged through a locum tenens company. But he also does shifts at a small hospital in upstate New York where he began moonlighting nearly four years ago on days off from a full-time job. And he pulls some shifts at two small and mid-sized hospitals in Massachusetts.

Other than the hospital in Albuquerque, he learned about those opportunities through word of mouth, and he arranges the logistics himself. At two of the hospitals, he is paid as a 1099 independent contractor; at the others, he has signed W-2-type occasional work contracts. He plans his schedules three months in advance, and this winter opted to not schedule any shifts in February so he could travel and do lots of snowboarding.

“I don’t feel like I am missing anything by not being an employee,” Dr. Khan says. In fact, he thinks he may need to branch out from the four hospitals where he now works “to see what else is out there.”

Samad Khan, MD (center, in red jacket), snowboarding with friends during his down time.
Published in the March 2018 issue of Today’s Hospitalist
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