Why I Decided Not To Go Perm

My previous post demonstrated all of the good reasons I should become permanent at my current assignment. I’ll now explain why I chose not to go that route.

I actually spent a few days leaning towards going permanent. There are two main reasons that I chose not to. The first reason is that I received my extension bonus and realized after taxes I was only going to take half of it home. This reminded me that one of the main reasons I love working in locum tenens, is that I can alternate between being a W2 employee and being a 1099 contractor. This allows me to deduct more taxes at the end of the year.

I am currently working as a W2 employee and was reminded that I needed to work the remaining 3 months of the year as a 1099 contractor, or else I would be paying $60k in taxes at the end of the year! As much as I love my current job, I don’t think any job is worth working just for your income to go to uncle sam.

The idea of becoming a partner at the clinic initially sparked my interest. I compared my current salary and benefits with those I would earn if I were to become a partner. An experienced nurse practitioner at my job confided in me her current salary, and just by being a traveler I was making $20k more than her. In addition, by being a partner, after the initial raise and the quarterly bonuses, this would equate to an extra $20k. I calculated the cost of my living arrangements for the past year and recognized that my job had paid $20k over the past year for my rent, furniture rental, cable/internet, and electricity.

So just to review, becoming a permanent employee could possibly push me back $20k. Even if it didn’t, becoming a partner wasn’t even worth it because I was already receiving the financial benefit through my covered housing costs alone.

The other main reason I decided not to go permanent is because the longer I stay at my assignment, the more drama I began to notice. I observed that the working environment isn’t always quite fair. Some physicians have an easier case load than others, while the most hard working physicians often go unnoticed. I also had some issues with a couple of my medical assistants, where they get too comfortable with you that they think they don’t need to do their job. I had been working in locums for so long, that I had forgotten about the annoying bureaucratic issues of working at a permanent job.

I asked a handful of people for advice; most people told me that if I liked my job then I should consider staying. I never saw myself settling down in Virginia, but wondered if the job was worth it. We do spend the majority of our time at work. And it would just be a year or two, and I am pretty sure my job would still allow me to travel abroad all of the time.

My sister who knows me best was the only person that told me not to stay permanently and to continue being a traveler. She told me not to think about the patients because they come and go. She told me that I am living the best kind of life being able to travel and have constant new experiences, as well as tons of freedom. She told me that I am still young and should think a bit more selfishly.

That pretty much sums up the main reasons I decided not to stay permanently. What do you guys think? Did I make the right decision?

How I Almost Went Perm

When I realized I only had 1 more month left of my year long assignment, I found myself becoming sad. I was close to my co-workers and I truly cared about the 250+ patients in my panel. I began to wonder if I could see myself working anywhere else.

I mentioned to one of the physicians that it was bittersweet that the end was near. She replied that I should consider becoming permanent. She told me that I wouldn’t have to stay there forever, but could commit to 1 or 2 years. I laughed because I never even thought a permanent job would be an option for me.

Yet, I started to ponder over the idea of staying there permanently. The clinic wanted me to help them open one of their new clinics in Florida afterwards. I thought about how I would have to start all over. I would have to get to know 250+ patients from scratch, in comparison to already knowing my current patient panel pretty well. The most challenging time at my job were the first 6-9 months becoming familiar with the patients and helping them become stable. Afterwards, my patients improved so much, that their frequent visits with me became a breeze.

My patient outcomes were really good, that I could have easily become on track for partner status. Becoming a partner with the firm meant an automatic raise, quarterly bonuses, and some other perks such as an easier referral process.

Although there was a permanent physician starting right after my assignment was ending, I knew me staying would really help the clinic. I could continue to carry my current patient panel, while the new physician accepted all of the new patients. Our clinic was growing very quickly, about 50 new patients per month, and there was no provider for them to go to. Nurse practitioners at my site have a panel of about 250 patients, where as the physicians have a panel of 400 patients.

This meant that I could continue with my current panel since I was already maxed out. I wouldn’t even have to take any new patients. Or the physician gave me the idea that if I agreed to stay permanently, I could discuss with the medical director that I would stay with the possibility of giving a handful of my most complex patients to one of the partner physicians. Since those partner physicians have been there for years, their panel should be really stable since they have a long-term relationship with their patients, and could afford to acquire a few more complex patients to their panel.

This all sounded pretty great, but my next posting will be about the reasons why I did not choose to stay permanently.

South America

My most recent international trip was to South America. I went to Colombia, Argentina, and Chile. I was originally supposed to go to Brazil as well but my visa didn’t make it in time.


My first stop was in Buenos Aires, Argentina. The first day I was there, I witnessed the person next to me get his Iphone stolen from him right out of his hands. This was definitely eye opening since I thought Argentina would be the safest place in South America. My favorite part of Argentina was watching a tango show one evening.

After a few days I went to Santiago, Chile. Ironically, it had been the last place I was looking forward to going to but ended up liking it the most. I think the combination of being in a big city with snow capped mountains and awesome seafood did the trick! The weather was a bit cold but I enjoyed being outside with the awesome scenery.

To end the trip, I went to Cartagena, Colombia, which is a small town on the coast. The people were very friendly and hard workers. No one begged for money, but everyone was hustling and trying to sell you something. I had a lot of fun and enjoyed visiting Castillo San Felipe de Barajas, which is a super-fort built long ago by the Spanish.

This was my second time in South America (I had gone to Peru a few years ago). As always, I enjoyed learning about the local culture and trying new things. I hope to get back down there to visit Brazil once my visa comes through.

Locums Make Stronger Nurse Practitioners

There is a new nurse practitioner that was recently hired at my current site. Watching her find her place during her first year of working as a nurse practitioner, reminded me how working as a locum tenens nurse practitioner has made me a stronger health care provider.

Working in various clinical settings and with different populations, we are constantly learning something new. Something new that we can apply to our future practice. I have gained some skill sets such as doing incision and drainages, joint injections, and skin biopsies. With much experience, I have also improved my differential diagnoses, and prescribing methods. I can think outside the box and see my patient holistically.

Being one of the first nurse practitioners to work at my current site, I could see that the new nurse practitioner did not have the support system she needed, being a new grad. Sometimes she would see my patients as walk-ins. I noticed she would give solumedrol IM injection for acute pain. In another instance, she saw my patient as a hospital discharge and failed to document that a chest xray done in the hospital incidentally noted a lung mass, which needed surveillance in 6 months.

I used these examples as teachable moments. For example: avoid solumedrol unless the patient has respiratory symptoms, especially in my diabetic patients. Read hospital records thoroughly and as nurses we are usually more thorough with our documentation in comparison to our peers. And how overlooking a diagnostic finding could lead to malpractice.

I also addressed my concern with the Medical Director. Virginia is not a full practice authority state. Thus, the new NP has a supervising physician. Besides being a name on a piece of paper, I believe the new NP definitely needed closer supervision. Even as an experienced nurse practitioner, some states I travel to may require physicians to review 5% of my charts or the first few dozen notes. The Medical Director assured me that the new NP’s supervising physician will play a closer role.

Most importantly, it is important to promote an encouraging vibe in the workplace setting. Luckily, after discussing some of my patients and concerns with the new NP, she started to ask me questions she was unsure about instead of proceeding with a wrong decision. For instance, she had a diabetic patient that could not tolerate metformin due to chronic kidney disease stage 4, and was unsure if she should add glimepiride to the patient’s plane of care, whom was already on glipizide. I discussed with her that the patient should not be on both due to increased risk of hypoglycemia, but as the patient was on a low dose of glipizide, she can titrate up.

It is not our duty to judge new nurse practitioners, as we all started somewhere. Even physicians can admit their first year working in medicine is challenging. Yet, many people are still unfamiliar with the role of a nurse practitioner. Which is why I believe it is crucial we make sure we provide competent care. This can be done by trying your foot in locum tenens to make you a stronger nurse practitioner, and to make sure we continue to mentor novice NP’s.

Appreciated

 

I just posted about my final extension at my current site. Moreover, I wanted to share some kind words that were said to me during the final weeks of my previous extension.

“You have changed the way I see locum tenens.” The Medical Director told me this when asking for my final extension. She said she was previously apprehensive about hiring locum tenens providers but now sees it can work with the right fit. They even hired 2 locum tenens physicians after I started to help with a maternity leave and walk-ins at some of the other clinics.

“In my eyes you are a physician. There are some nurse practitioners that work better than some physicians, and you are one of them.” The physician lead at my clinic mentioned this to me as her eyes filled with tears just thinking of the possibility of me leaving. I will always be a nurse at heart but it is nice to be appreciated by a physician and for them to recognize the benefits of having nurse practitioners at their clinics.

After telling my patient his Diabetic A1c improved from 17% to 8% in only 3 months he said: “That is thanks to you. I appreciate you looking out for me, going above and beyond and doing more things for me than most doctors.”

I sent one of my new patients, whom was completely healthy and on no medications for a routine colonoscopy. The colonoscopy was positive for colon cancer and imaging confirmed an additional renal cancer. Luckily he was able to undergo a partial colectomy and nephrectomy and recuperated really well. After seeing him post-op, he said to me: “Thank you! I wouldn’t be alive here today if it wasn’t for you!”

I thought it would be nice to shares these kind words. It is easy to get burnt out in medicine, but if you remember why you got into the healthcare field in the first place, it should keep you motivated. As a PCP we are constantly hearing ‘complaints’ all day. “My back hurts; I have difficulty breathing; I have no energy” etc. So hearing words of appreciation really makes our day J

Final Extension

Although I initially enjoyed my current assignment, after extending 3 times (for a total of 9 months), I knew it was time for a change. I needed a change in scenery both state-wise and job-wise.

The site asked if I was interested in another extension. I kindly declined and told them I was ready for a change. They hired a physician to take over my patient panel and would like for me to stay an extra 3 months to help transition my panel over to the new physician.

The Medical Director set up a meeting with me titled “What Can We Do to Keep You Longer?” She wanted to respect my wishes to move on but also to make me feel like I was appreciated. She offered me her first and second born children as a joke. She even offered me to house-sit while she went on vacation (she has a beautiful home on the lake with kayaks and jet skis etc.).

Although I knew I was ready to leave, I spent several weeks with an inner turmoil contemplating what I should do. There are normally 4 PCP’s in my clinic, one of them was approaching maternity leave, while another one was having surgery in the upcoming weeks. I felt guilty knowing 1 PCP would be all-alone in the clinic if I were to leave. When 1 PCP is out, it’s manageable. When 2 PCP’s are out it’s a disaster. Think about the walk-ins, phone messages, medication refills, reading of PT/INRs, and paperwork that needs to be completed.

I also thought about my patient panel. When I had taken over for their previous PCP, the patients had been pretty neglected for a few months since their previous PCP had gone on sick leave. I thought about the connections I had formed with these patients since they come to the clinic at least on a monthly basis. I thought about how far these patients had come after first meeting them. The uncontrolled hypertensions now well controlled, improved diabetic A1cs, resolved heart failures, controlled depression, weaning them off their opioid dependencies, and encouraging health screenings to help with early detection of newly diagnosed cancers.

My patience and level of contentment were starting to decline, as I became blasé with this routine lifestyle. The cure to this was to move onto another assignment. But for the reasons above I knew that I had to stay. Another 3 months wouldn’t kill anyone right?

In return for my final extension the site offered me a $5000 bonus. This is equivalent to an extra $10/h over 3 months. They also agreed that I did not have to continue seeing new patients, and can focus on my current patient panel since they are already very complex. The agency I work for offered me an extra round trip flight home and proactive licensing in other states.

The site is hoping when I am doing with this final extension, that I will help them open their new clinics in Florida.

Bad Interviews

For the majority of locum tenens positions, a phone interview is done prior to a site offering you a position. They are typically less nerve wrenching in comparison to in-person interviews. In fact, I don’t even think twice about them anymore.

They typically start the same way where the company summarizes how they work and why they have a need at this time. Then they want you to talk about yourself and your background. Sometimes they may ask a few clinical questions as well.

It’s always funny to hear about interviews that went wrong. One of my close friends recited a story to me about an odd interview she had for a locum tenens position. Apparently the interviewer kept talking down to her, making my friend feel like she was on trial. The interviewer made it seem like she was not interested in offering a position to my friend. Then 5 minutes later, she called back asking if it was true that my friend was fluent in Spanish. My friend said yes, and the interviewer said ‘you got the job!’ Of course my friend did not accept.

One of my readers shared her experience interviewing for a locum tenens position. The interviewer told her that when she sees the word “locum tenens on a CV” she thinks to herself “what’s wrong with them, why can’t they get a job?” This didn’t make any sense considering that site was looking for a locum tenens provider, so should be well aware of how locum tenens can fit the needs of a practice.

Fortunately, I’ve had only one bad interviewing experience. The interviewer asked me tons of insurance specific questions that I couldn’t answer. She made me feel like an idiot for not knowing those answers. I didn’t care since my job is to treat patients, not to know the specific details for different health insurance providers. At the end, she still offered me the position, in which I declined.

I think the most important aspect of the interview is to feel like the site will be welcoming, patient, and understanding with you. Considering I will be joining them to provide help, I wouldn’t want to work somewhere that does not give off a positive vibe.

Anyone want to share some weird interview experiences?

Thailand and Dubai

I recently returned from a 3-week trip to Thailand and the United Arab Emirates with my family. Since Thailand is so far, I was able to get a free stopover in Dubai for a few days. We flew Emirates for the first time, which is the most luxurious plane with the best service! Our plane was two stories and we had access to the bar. We really enjoyed our 14-hour flight from Fort Lauderdale, FL to Dubai.

It was our first time in the Middle East, and we actually come from a Lebanese background, so it was exciting to be in Dubai. The Middle Eastern food was delicious! The city was really clean and modern. Our favorite day was when we went on the desert safari excursion. We went sand dune riding in the desert and rode ATV wheelers. We also visited a camel farm and rode on some camels.

On the way back from Thailand we stopped in Abu Dhabi to break up the flight. We went to visit the Sheikh Zayed Mosque, which was absolutely stunning!

Bangkok was a pretty crazy city. Our first day there we rode on a tuk-tuk and it was the funniest experience. Our driver didn’t speak English so he would just bring us to all of these random places instead of where we needed to go

Thailand was incredibly cheap! We would get 1-2 hour massages for $8 almost every day. A 45 min taxi ride cost about $5-6. A family of four ate for about $20-40/dinner.

I have always been intrigued by the Buddhist religion and enjoyed visiting various Buddha temples. My favorite Buddha was the reclining Buddha!

We visited the old capital of Thailand, Ayutthaya. It was interesting to see the ruins of the city and learn how this Buddha head ended up in this tree:

It turns out that the Buddha head fell off the statue during an invasion of the city. As the Buddha head lay on the floor, birds pooped around it. Eventually a tree started to grow and the Buddha head grew with it.

My favorite food besides sushi is Thai food. We ate tons of good food during the trip! And I never thought I would say this, but by the end of the trip I was actually tired of Thai food.

As much as I loved seeing all of the Buddha’s, the best part of Thailand was going to Phuket and the Phi Phi Islands. We had an incredible time swimming in beautiful water, snorkeling with a variety of fish, and sailing on a speed boat. We literally felt like we were in paradise.

Losing a Patient

I write this post with humility.

After returning from a 3-week vacation, I was a bit nervous about how much work waited for me (lab/imaging results to review, medication refills, phone messages etc). Surprisingly, my first day back went pretty smoothly. My schedule wasn’t too crazy. My co-workers were ecstatic to see me, and my patients were relieved that I was back.

At the end of the day I was skimming through hundreds of work emails, deleting most, keeping the important ones. I came across some emails about one of my patients being in the hospital for a heart attack. I wrote down his name on my to-do list, so that I could give him a call and see how he was doing.

As I continued going over my emails, I was in disbelief when I read “patient expired. Sorry for your loss.” It turns out that the patient that had a heart attack in the hospital was discharged home a few days later in stable condition. The following day he passed away at home. It was a complex situation, as he had a history of severe coronary artery disease and other co-morbidities. Even though you know all that could have been done, was done for him, you still feel like it wasn’t enough.

I immediately started crying like crazy, as I had never cried before. He was actually one of my favorite patients, and one of the first patients I developed a relationship with at my clinic. A very pleasant man and compliant with all medical recommendations. During the 6 months of working at this clinic, I had seen him at least 10 times.

My co-workers tried to comfort me, explaining that all of our patients are much older and much more sick than the average person. They tried to reassure me that at least he is no longer in pain and was able to pass away in the comfort of his home.

It was so hard for me because I had seen him right before I went on my trip, not knowing it would be the last time. I had also wished I was here when he passed so that I could have at least attended his funeral.

The following day I was still grieving and wasn’t sure how I was going to face my other patients. I thought to myself, what is the point of all this? I had a busy day and it was actually a good thing. It distracted me and also reminded me that there were still other patients that needed me.

It has been so hard for me because I have never had anyone close to me pass away before. Although I also worked with a geriatric population in Miami for several years, none of my patients ever died while under my care. They didn’t seem to be as sick as my current patients. As a child I had distant relatives pass away, but death seemed so foreign as a kid.

The other providers told me that the first few patients they lost were really hard. But after a while, you have to learn to become less emotionally invested. I think the passing of my patient reminded me how near, death truly is. Death is inevitable. I realize I cannot promise my patients that they will never die. But I can help them to live a comfortable life and gain more time to spend with their loved ones.

May he rest in peace.

Continuing Education Reimbursement


I enjoy sharing benefits of working as a traveling nurse practitioners and any incentives provided by agencies with my readers.

I am currently working with Comp Health for my assignment in Virginia. I was contacted over the phone last month to go over my annual review. I have worked with Comp Health on and off over the past year.

When I was done with the review, I was notified that after working 500 hours with Comp Health, I am eligible to receive up to $500 in reimbursement for continuing education. Working one 3-month assignment with Comp Health automatically makes you qualify for the 500 hours minimum requirement. However, there is a stipulation where you will be reimbursed for your CEU’s as long as you are committed to your next assignment with Comp Health.

In my case, I met the 500 hours of working with Comp Health, and since I extended my current assignment, this qualified me to receive up to $500 in reimbursement for CEU’s. This can include conference registration fees, nursing membership organization fees, and all certification fees.

This year I am due to renew my Family Nurse Practitioner certificate through the ANCC. This comes with a hefty fee of $350. Luckily this certification is reimbursable through the $500 CEU credit.

This is definitely a nice little perk because permanent positions often cover CEU costs. So it is nice to have these benefits without having to commit to a full-time position.