Practice Environments, Locum Tenens

Ode to Local Tenens: Lessons from the Real World

The search for a job out of residency can be an extremely daunting task. Dozens of employment models and practice settings exist, and it is difficult to decide which of these will ultimately fulfill your career aspirations while staying in-line with your values. Academics? Hospital-based employee? Independent contractor? Democratic group? Freestanding ED? Urban? Suburban? Rural? It is enough to make your head spin.

Fresh out of the residency pipeline, I simply wanted to work hard, find a good group of physicians to learn from, and retire after a fulfilling career. What I didn't realize is that 70% of physicians across all specialties change jobs within their first 2 years out of residency. I too became part of that statistic.

Some wonderful learning took place in those first 2 years out of residency on many fronts, but the learning curve regarding the ”˜business' side of medicine was particularly steep. I was a full-time, W-2 employee in a community group, yet I struggled to see the benefits. We were able to seek very fair compensation based on relative value units (RVUs), but I was not provided health insurance, disability insurance, or retirement benefits. In addition, I was expected to pay $50,000 tail coverage on malpractice insurance if I decided to quit the group and work somewhere else. I also felt a constant pressure to work more shifts and to fill open shifts last-minute, not to mention many weekends and holidays. Needless to say, I did not feel that this model was a fit for me.

I did a little soul-searching and wrote down my three main goals:

  1. Gain control of my schedule

  2. Optimize my pay

  3. Survey prospective employers by practicing in a variety of settings

Then it dawned on me: What would stop me from credentialing with multiple hospitals and groups in the area and working as an independent contractor (1099 status) to fill their open shifts? The idea of “local tenens” (my own phrase, not to be confused with locum tenens) materialized. In that one decision to transition from a W-2 to a 1099 employee, I gained more control over my schedule, optimized my pay (actually doubled it), and experienced how other hospitals operated. I knew my worth and negotiated for a rate that reflected this. I did not rely on anyone else to advocate for me.

Of course, “local tenens” will not work in every market and is certainly not the best choice for everybody. There are plenty of high-quality groups out there that offer great benefits. However, the take-home is that in today's physician marketplace, demand far exceeds supply. Do not feel bad about seizing the opportunity to craft a career that is flexible, balanced, and sustainable. Having a life and identity outside of medicine is the best for you, your family, your career, and your patients”¦yes, in that order, because if you don't take care of the first then the rest will surely suffer.

*Editor's note: Interested in learning from Dr. Larson about contract negotiation? Check out his blog on