Night Shift: Job Security

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“Come to our town.  Run this ER.  Raise your families here. As long as I live, you will have this contract,” said the vice president who recruited us.  My friend from residency and I were thrilled and honored to be offered a contract to run an emergency department in a nearby town.  But there were detractors.

It was years ago and emergency medicine was still in its infancy.  So the old guard at the hospital was suspicious, even hostile toward two young guys coming to run the ED.  It seemed like there was a fight about everything, credentialing, billing, referrals, you name it.  A self proclaimed “cardiologist,” with no actual training for that specialty, came to the hospital president screaming about all the money he had lost because of the new ER group.

He complained that his patients were coming to the ED with chest pain instead of calling his office for an appointment.  And “the ER staff was seeing them before calling him!!!”  What gall.  A local general surgeon had spent decades taking the appendix out of anyone with the billfold until we came to town. One of the privileged elder statesmen of the hospital wanted the unit secretary and me fired because she did not give up her seat to him to write his note.  And I supported her.


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It became almost comical.  But we weren’t concerned.  The VP always had our backs.  We started to recruit a talented staff.  We began building a new state-of-the-art ED.  We were in the news constantly for lives saved and the improvement in care that was the talk of the town.  I even bought one of the grand old homes of the town previously owned by one of the city fathers and began the long and expensive task of bringing it back to its former glory.  We were planning to raise our family there.

And then one snowy January day, the VP died.  And everything changed.

The hospital executive staff had no appetite for the hard work of changing the minds of entrenched medical staff.  The contract renewal was a fraction of the one offered to get us to come to town.  But we still thought that quality care and an improved reputation for the hospital would win the day.


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We were wrong.  Call it poor negotiating skills, youthful naiveté or just stubbornness.  But two months later, on April Fool’s Day, we got the news that our contract was up and we had one month to clear out.

I was so distressed I took the first job available at a massive pay cut and moved my eight-month pregnant wife and two children into a tiny apartment so that we could still pay the mortgage on the massive home we left behind.  It would be a decade before I recovered financially and emotionally.  It spurred me to go to law school in my spare time because I had the nagging fear that after all the years and sacrifice to become an emergency physician, emergency medicine just might not work out for me.

I discovered more unscrupulous hospital administrators, duplicitous ED directors and promises of partnership that just never seemed to pan out.  Then in an act of desperation I sent out a fax to a group of local EDs saying that I was available for part-time hours.  I got a call back in 30 minutes asking if I could work the next day if they could push temporary credentialing though.  I was shocked.  Partially with the timing.  But also with their willingness to pay the rate I was charging, which was about 50% higher than I was currently being paid.  And thus began a 25-year career as a locum tenens EM physician.  I found that hospitals that were in a staffing crunch would pay not only my increased rate, but airfare, hotels, meals and even car service to the airport.  The joke in our family is that during that time I put five million miles on my American Airlines card.

Don’t get me wrong.  Locum tenens life can be lonely, incredibly tiring and you have to prove yourself at every new institution. My point here is not to promote locum tenens practice.  But there was one incredibly important difference that was really empowering.  Because of the huge need for qualified EPs, which by the way still remains, the balance of power was strongly shifted in my direction.  I chose to work the toughest shifts in some difficult or out of the way places.  But I worked when I wanted.  And charged what I thought was fair.  I took long periods off for travel and leisure — months sometimes.  I had true freedom.  I was kind to the administrators and nurses.  I worked hard.  But if I didn’t like a place I just simply didn’t go back.


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Young docs often ask me about my career choice and I emphasize that full time locum tennens practice may not be for everyone.  But what I do recommend to every emergency physician is to use part time and locum tenens as an opportunity to see other hospitals, departments, cities and parts of the country.  You simply cannot find the right fit based on a few criterion and a weekend interview.  Directors know that.  That’s why they will most often hire from within their own network of physicians.  They get a chance to see a doctor in action.  They see personality, intelligence, as well as social and emotional talents that would never emerge in an interview, no matter how rigorous.  And let’s face it.  Every ED looks and largely behaves the same.  But it’s the people that make the difference.

An interview might go extremely well with the director and executive staff.  But it is on the night shift that you find out how he or she has treated the members of the group.  Not until you spend a few shifts at a hospital do you find out that the patients per hour number that is advertised is deeply impacted by the patient acuity and the high admission rate.  But even more important than looking behind the curtain to see what a hospital ED is really all about is the freedom that having privileges at multiple hospitals gives you.

You may be a square peg in a round hole and you simply don’t know it.  Or maybe you do and you just don’t want to go through the trauma and risk of leaving your current safe position to go looking for the perfect job for you.  You don’t have to.

If there is a location or institution that you have always wanted to look at, apply for part time work.  Neither party needs to make any commitments.  Every ED needs a bench of part time physicians to cover holes in the calendar.  So most smart ED directors will be happy to sign you up.  It’s the emergency medicine version of “It’s Just Lunch.”

A more experienced emergency physician would probably have seen that we were on thin ice back years ago and made contingency plans based on that.  But many instances of job insecurity are not always obvious.  A contract with a hospital may be lost, not because anything you or your colleagues have done wrong.  But that doesn’t protect you from the fallout of someone else’s decision.

Having options is empowering.  Explore the world of emergency medicine.  You might realize that you already have the perfect job for you.  Or you might discover that another group, another city, another area of the country is the home to which you were meant to return.  Either way, you will be the one who decides that.  And that is real job security.

4 Comments

  1. Mitchell Farrell on

    Private hospital administrators are very fickle. It is the nature of the beast. No wonder so many great EM physicians look to free-standing EDs or urgent care centers. At least they then have some control of their destinies.

  2. Jerry R Baskerville on

    This scenario has played out hundreds of times across the country! Very heart breaking but oh so true.
    In my view, when a physician takes a full time position there should always be a “Severance Package” agreed upon and signed. This protects both sides.

  3. wayne warrington on

    wondering if you cover your own med mal for this type of work since it appears you are not using a recruiter.

  4. I left the country to practice overseas and returned planning to do just this as what is described. That is how it was when I left 8 years ago. But, that is not what I am finding now, at least in my local area. CMGs have all the contracts and have their own ‘firefighters’ to cover short term needs. Therefore, IMHO simply to prove their power over you as the locum doc, the credentialing processes have become multiple month insanity contests of them asking for things like proof of insurance from short term jobs that occurred two decades ago. They send you piles of blank forms, or, if you use a locum agency to fill out the forms, your already decreasing pay is further decreased. I think the glory years of EM coming about have mostly ended. I think the glory years of locum are in the process of ending. The years of being a basic employee for a massive company only interested in the bottom line seem to be upon us.

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