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One of the most common questions I receive is regarding the stability of being a locum tenens nurse practitioner. Is there consistent work? Are there periods or gaps with no jobs available? Looking back at the past year, 2017, one thing is clear. I worked way too much! More so, I worked more than I originally planned. I meant to spend most of 2017 traveling abroad but accidentally got caught up in work.

As soon as I finished my assignment in Virginia and needed to be home in Miami after Hurricane Irma, I was able to start working on another assignment. The only ‘gap’ was the 1 week road trip I purposely took on my way down to Florida. Once I completed my assignment in Miami, I had another assignment waiting for me, in which I started the following Monday.

To further illustrate the consistency and abundance of locum tenens job, is how quickly I was able to obtain an assignment after leaving the site in Tampa, Florida. I decided to leave that assignment early (I made this decision on a Wednesday). The following day, Thursday, I notified my recruiters that I would be available for another assignment. Friday was my last day in Tampa, FL, and during my lunch break I was already being interviewed for another job. By Friday afternoon, I had already been offered and accepted my next assignment. This new job started the following week. Luckily, it was right after new years so I had Monday off to recuperate.

My family and friends were impressed about how quickly I was able to get a new assignment. Personally, I wasn’t surprised because that’s just part of being a traveling nurse practitioner. I work with about a dozen recruiters at any given time to provide me with as many job prospects as possible. That’s why I always encourage my readers to credential with various agencies, and not limit yourselves to just one or two. There is a primary care provider shortage in America – someone is bound to have a job opening for us! J

As a quick summary, I spent the past year working in Virginia for a geriatric clinic that follows a preventative care model. I am currently working in Florida for the same clinic, as they have clinics in multiple states and continue to expand.

My previous post animated part of a discussion I had with the Chief Medical Officer of the company, in regards to nurse practitioners. The main purpose of the conversation though, was for the CMO to see what my goals were and if the company could hire me as their internal locums/traveler.

I alluded to having a similar conversation previously with their Chief Financial Officer. And how I told him that I wanted to continue with my current agency for now, until I had a better grasp of the various markets.

The CMO told me that he definitely sees the value in having an internal locums, especially as they continue to grow. He said he would love to invest in me to develop into a leadership role eventually. Meaning I would either oversee a larger traveling team in the future, or even manage all other nurse practitioners in the market. He said as a contractor it wouldn’t make sense for him to invest in me, so that is one of the main reasons he wants me to become directly employed with the company.

He asked me what I was currently being paid and told me he could increase that. (Side note, I already get paid significantly more than the permanent nurse practitioners, even those with 20 years of experience, since I am a traveler). He said he could also offer me a sign on bonus and yearly bonuses as well. The company would of course cover all of my travel, lodging and licensing fees. He said they would also provide me with a weekly dining stipend, and cover flights whenever I wanted to go home in the middle of an assignment.

In addition, I would have the same benefits as the other employees such as 401K, health insurance, CME allowance, and PTO. The company would also guarantee me with a yearly schedule where I am in a different location every 3 months or less.

After the CMO made all of these offers, I think he was surprised to hear me say “we’ll see”. Financially he was offering me a whole lot, but my priority has always been freedom and flexibility. Although I would continue being a traveler, I would be restricted to practicing in locations the company has clinics in. On the bright side, they are continuing to expand and are opening up new centers in several different states by mid next year.

At the end of our meeting, we agreed to allow me some time to feel out the new center I was in and to think things through. We set up an appointment to meet again next month.

I am extremely grateful for the offers he made me, and especially for the fact that he sees something in me that would make him want to invest in me as a leader. I would be honored to manage and help other travelers and nurse practitioners.

It honestly seems like an unbelievable opportunity for me to grow in an incredible company. My main hesitation is how much flexibility will I have? Will I still be able to take time off in between or during assignments to travel abroad? Perhaps I could negotiate this in my contract. The average PCP has about 4 weeks of PTO but I will definitely need more than that even if it’s unpaid. Will I still be able to leave an assignment early if I absolutely hate the place (whether it’s the people or location)? Maybe I can have them agree that if I don’t like a center I can give a 30-day notice the same way I do with my agency.

On the plus side, they will give me a schedule so I can actually plan where I will be in advance for once. Am I ready for a commitment? I guess worse comes to worse I can always quit and become a regular locum tenens nurse practitioner again J

I would love to know your thoughts! Should I go for it???

In between completing my assignment in Virginia and starting the one in Tampa, Florida (with the same company), I sent the CMO of the company a letter about my experiences working in Virginia. I had met him several times before and thought it would be a good way to share my experience at each clinic, both good and bad.

He was appreciative of my feedback and requested a meeting with me to see what my goals are and how the company could expand an internal traveling PCP program.

As our conversation began, I could tell how new the concept of having nurse practitioners was to the CMO. When he elaborated about the collaborative agreement between nurse practitioners and physicians, he also stated that there is a wide spectrum on preparation of nurse practitioners. He said that they have observed there can be some amazing, knowledgeable, and competent nurse practitioners; but on the other hand there can also be some inexperienced, insecure, and non-proficient nurse practitioners. Personally I agree, but it’s the same thing in any profession.

The CMO continued to ask me what was the perception of nurse practitioners from the patient’s point of view. He asked how my previous patients handled having a nurse practitioner as a PCP. I told him that the concept of nurse practitioners is something new to a lot of people, especially the elderly population. Many times they do not know what a nurse practitioner is, yet once they see that we practice similarly to physicians at a holistic level, they are fine with it. I told him that of course there are patients who automatically say they do not want to see a nurse practitioner and feel as if they need to be seen by a physician. He asked me, in my experience, what percentage of patients would I say did not want to see the nurse practitioner? I responded with 5% of patients or less. Perhaps other people’s experiences vary from mine.

I found his questions to be intriguing because like I said before, the concept of nurse practitioners is so new, even to a big shot CMO like him.

I updated the other nurse practitioners at my clinic on our conversation. I emphasized the fact that only WE can be our own advocates. That we have to speak up for ourselves when either management or patients try to suppress us. For instance, any time a recruiter or manager calls a nurse practitioner a “mid-level provider”, I make sure to correct them.

In addition, when a patient calls to be seen by their PCP the day of, the front desk will tell them “Your doctor doesn’t have an openings, but you can see the nurse practitioner.” I personally don’t like the way it is said, because it insinuates that the nurse practitioner is the next best thing, and not as good. So I am trying to encourage the front desk to say instead “We can accommodate you today but you will unlikely be seen by your PCP, and may have to be seen by another provider.”

Besides being our own advocate, I think as nurse practitioners, we need to have confidence. Sometimes I hear nurse practitioners turn down a job because they are afraid they are not well trained or competent enough for the position. Of course anything new is scary, but as long as you put in the effort and the time, I feel like you can excel in anything. Physicians will look up things they are not familiar with; we can do the same without being embarrassed by it.

In my next post I will elaborate on the second major part of my conversation with the CMO.

Remember I mentioned I couldn’t work with my favorite recruiter at the Occupational Health Clinic because I needed a 1099 job? Fortunately, going back to this geriatric clinic meant I could go back to my favorite recruiter as well!

As promised on my previous post, I sent her some flowers and she called me in tears! I think it is extremely important to make incredible people feel appreciated. J

When I asked for my new agreement with the Tampa clinic, I noticed that the pay rate was $2/h more than I was making previously. I honestly thought it was an accident because no one mentioned anything to me and I hadn’t even asked for a raise. I asked my recruiter and she said ‘I always try to get you the best rate, and even though it doesn’t always work, this time it did!”

I was really surprised and grateful! Sure $2/h doesn’t sound like much but over 3 months it’s an extra $1000.

Perhaps some of you are wondering why I didn’t ask for an incentive to work at another market for the same company. To be honest, the company has always treated me really well and I almost consider them to be family. For instance, they gave me a $5000 bonus just for extending another 3 months. When I worked 10 hours of overtime a week, they never questioned me about it. They house me in expensive hotels (such as the Westin) and don’t mind flying me home every 1-3 months. They even randomly give me gift cards occasionally for no reason (such as Starbucks and Walmart).

Although they need me more than I need them, it’s good for me to have an option in multiple states that I can consider at any time. They are also an amazing company that I would probably work for the day I decide to go permanent (if that day ever comes).

They also agreed to fly me up to Virginia for the annual holiday party, which is sweet and more for me than for them.

After taking a brief break from the geriatric facility in Virginia, I agreed to help them out at some of their clinics in Tampa, Florida. Being in Florida during this time fall/winter is especially beautiful because it’s not too hot and not too cold. The drive up here from Miami was about 4 hours.

My first day at the new center was okay. I sort of knew what to expect since I had worked at their centers before. Upon arrival, everyone was gregarious and it was nice to see an LPN that I knew from Virginia. She had transferred to that market a few months prior.

I initially was a bit sad because it felt strange to work in a familiar setting with completely different people. The Medical Director was friendly but he didn’t nurture me the way the previous one did. The center manager was welcoming but wasn’t prepared with my laptop, new ID, and lab coats the way the previous one had been. I think I took for granted that the Virginia clinic treated us for lunch almost every day!

I thought I would jump in and start seeing patients, but I spent the majority of the morning on the phone with IT trying to set up my login and computer etc. I also called a few of my patients from Virginia to check in on them. They were extremely happy to hear from me and mentioned that they felt neglected from the clinic since I left.

Originally, the Tampa clinic wanted me to help out 3 months ago when they were short staffed. It seems like since then they have recruited A LOT of PCPs. So I sort of wondered why I was there and if I was even needed anymore. I felt like I should be at the clinic in Virginia, but knew I couldn’t go back there yet.

By the end of the day, I tried to keep a positive mindset. The clinic was new so it wasn’t nearly as busy as the ones in Virginia. Therefore, at least it was unlikely I would feel overwhelmed some days like I did in Virginia. In addition, I was mostly going to be helping with walk-ins and overflow for the PCPs. This meant I wasn’t going to have my own panel the way I did in Virginia. This was a good thing because I wouldn’t have as much responsibility or have to work overtime as I did before. The only bad thing is that I wouldn’t be able to develop relationships with the patients. But considering I spent a year in Virginia, I am glad it turned out this way because at least I can put in my 2-3 months and move on without feeling guilty.

As easy and stress free this job has been at the airport, of course it has its own set of problems.

When working for an occupational health clinic there can sometimes be some conflict between providers and the employer. The employer has this clinic to evaluate injured workers so that they can reduce costs by avoiding them from having to go to the ER or urgent care, and to have them be evaluated quickly so they can return to work. The goal is for them to get back to work as quickly as possible!

Thus, it is a big ‘no-no’ to recommend the patient go home without work. For instance, lets say a patient had a back injury from lifting heavy baggage, and shouldn’t continue to lift heavy baggage for the next few days. The employer would rather you provide the patient with work restrictions, including avoiding heavy lifting >10 lbs, walking and standing for up to 1 hour each shift etc. This way, the employee’s supervisor can find an alternative duty for that employee such as desk work or scanning bags etc. Of course they would rather have the patient at work doing something, than going home with partial pay for no work.

This is understandable, but as a nurse practitioner, my patient will always come first. There are times I do send my patients home unable to work. And a case manager from the employer would call me trying to find out why and insist I change my recommendations. These case managers are non-medical so I am rarely influenced by their comments.

Originally I didn’t think it was a big deal to receive their phone calls, but then they started to complain about the minutest things. In a world with so much chaos and injustice, I do not think these complaints are that serious. I would rather not waste 15 minutes of my day discussing these cases with the case managers.

There was one case where a worker twisted her back while moving a 70 lb bag, then accidentally fell and injured her back. She had trouble sitting during the exam but was comfortable with standing and walking. I put her on restrictions, which included no heavy lifting and “no sitting”. The case manager called me to ask why I put “no sitting”, just because the patient could not sit during the visit doesn’t mean I have to advise her NOT to sit. That didn’t make any sense. I kindly said I couldn’t advise someone to do something they are unable to do.

The case manager asked me if I thought the patient had not been sitting this entire time since being seen, like at home. I responded with: I am unsure as I have not seen the patient since the initial visit, but she is coming in tomorrow and I will surely re-evaluate her then. The case manager proceeded to tell me that I don’t seem to have a good understanding of restriction recommendations. I proceeded to tell her that she does not seem to have a good understanding of medical recommendations. She responded that she would escalate the request to the medical director.

My initial thinking was the patient is still able to work with restrictions, she is even able to stand and walk with no problem, which in my opinion is better than sitting for the employer. She was to follow up the next day, so unsure if changing the recommendations was a big deal for 1 day of work? Lastly, the case manager is non-medical so she doesn’t understand that some musculoskeletal injuries cause patients to find their “new” comfortable position. Whether it is sleeping in a sitting position or standing with a side bending position etc.

Too bad the dream job has its own share of headaches.
I do have a new founded respect for the fleet service crew. They often work every day and more than 8 hours per day, doing strenuous activities.

 

I just added a new page to my blog entitled “Travel Credit Cards“. You can find it on the home page next to scope of practice. The more I started traveling for a living, the more I realized having travel reward credit cards were worth it. Of course I make sure to pay off my balances at the end of each month to ensure I am not paying any interest or fees. Having these travel credit cards makes it easy to accumulate miles and points, and comes with plenty of benefits.

For example, one of my favorite cards, the Chase Sapphire Preferred credit card allows me to earn 2x points on dining and travel, provides primary car rental insurance, and baggage or trip delay reimbursement/protection. If your checked baggage is delayed more than 6 hours, the card will reimburse you  $100/day for purchases made of any essentials while waiting for your bag to arrive. I used this benefit before while going to one of my assignments. Although I made sure to pack essentials in my carry-on, once my luggage was delayed for more than 6 hours, I went on a mini shopping spree and purchased clothes and toiletries up to $100/day.

Currently this card is offering a 60,000 points bonus for signing up. It comes with an annual fee of $95 which is more than worth all of the perks. The sign up bonus alone can get you up over $1000+ worth of free travel. I personally used my bonus before to fly my brother and I to Hawaii, which saved us $1400 in flights. If you do not see a point in paying the annual fee after one year, you can always downgrade to a no-annual fee card afterwards.

My “Travel Credit Cards” page will list a few of my favorite credit cards and why. If interested, please use my referral link to ensure that we both get bonus points for you signing up! I also wouldn’t mind helping you figure out how to use your bonus points for travel, when the time comes. If there becomes enough of an interest, I will start regularly posting best ways to earn and redeem points.

Check out the new page: Travel Credit Cards – Traveling NP

I accepted an assignment in Miami, FL for one month because Hurricane Irma did some minor damages to my house. I needed time down there to make repairs. Fortunately, there was an assignment available that was brief and was from a 1099 agency (which is what I needed).

I was excited to begin this new assignment because it was an occupational health clinic for a major airline. It was something different in comparison to the chronic disease management I had been used to this past year. I was initially a bit nervous to start because it was the first occupational health site I have worked in. Fortunately, things transpired well.

The clinic is located in Miami International Airport. I made sure that I would be reimbursed for parking because parking fees are $17/day. Since the site didn’t have to pay for lodging, they were ok with paying for mileage and parking.

It has been an interesting experience so far. I mostly see on-site work related injuries such as musculoskeletal injuries, clogged ears, and lacerations. I sometimes see minor acute episodes that need to be treated quickly so the employees can return to work.
Examples of these are UTI, cold symptoms, rash, STDs etc.

The workload is relaxed, I mostly see about 4 patients a shift, on a busy day I see up to 8. The patients are gregarious and appreciative! The staff is friendly, and there is always another provider working with me. The center manager is nice and flexible; she even allowed me to change my work hours to accommodate me so I wouldn’t have to be stuck in Miami traffic.

It’s a really great gig, and I hope others are fortunate to find an assignment like this when they want to return home for a short period of time. If I were on the brink of retirement I would stay at this job permanently. Since I am young, I still need adventure and a challenge so will continue to work as a locum tenens nurse practitioner.

The clinic I worked for in Virginia called me this week to find out when I will start working at their Florida clinics. After working at this stress-free job, I am somewhat reluctant to jump back in to care for such a complex population.

 

Sometimes when searching for your next assignment, you can end up with more than one offer on your lap. I personally like having multiple offers so I can choose the best one. However, I am sort of a commitment-phobe so when I have multiple offers, I end up overwhelming myself and have a hard time choosing. How should we choose between multiple assignments?

When looking for an assignment, I mentally note what my priority is at the moment. Do I HAVE to be in Florida because winter is coming? Is a HIGH pay rate important this time so I can save up for a major purchase? Am I physically drained from my last job and need a lighter work load? It’s important to evaluate what you value most in your next assignment because it will facilitate the decision making process.

My needs often vary. Sometimes I care more about the location so I am willing to take a lower pay, other times I sacrifice the location I want to work in because I do not feel like seeing 30 patients a day.

During my most recent assignment search, I ended up with several options:

1. Brief local assignment in my home base – Miami, FL. Pay lower than usual. Light patient load.

2. Brief assignment in California, in a rural setting. Pay was my usual rate. Fair patient load.

3. 3 month assignment in North Carolina, major city. Pay was my usual rate. Moderate-heavy patient load, and I would be the sole provider at the clinic.

4. Transitioning with my previous site (in Virginia) to work in their clinic in Florida (not in Miami). Same pay. Same load as before.

How did I end up choosing number 1? I think it is easier to narrow down your choice through the process of elimination. I knew I wasn’t ready for #4 because I needed a break from working at this type of setting with very complex geriatric patients. Thus, I eliminated #4 as an option. I originally thought it would be neat to go back to California for a short period of time to catch up with some friends. When I began researching flights from Virginia (where I was at that time), I realized it would take 13 hours of flying for me to reach that rural destination. I didn’t think a 3-week gig was worth the amount of flying time it takes to get to Europe or the Middle East. Thus, I also eliminated #2 as an option.

Finally, I was left with option #1 and #3. Option #1 was safe, I could just go home for a bit, which is never a bad idea. #3 was more exciting because I could live in a new state. I had traveled to North Carolina before and really liked it. Eventually, I decided to go with #1.

Foremost, I needed to be home to oversee some repairs on my house after Hurricane Irma. Although the pay was lower than usual, it was something I was able to overlook because the patient load was light, and the assignment period brief. I eliminated #3 as an option additionally because it is not ideal for me to be the sole provider at a really busy clinic.

I always think it’s good to have multiple options for your next assignment, so in case one falls through you can have a backup. Yet, it can be a challenging process to choose one assignment
from multiple great offers. How have you chosen between multiple assignment offers in the past?

 

I currently have 5 active state licenses. Many of you have asked how I am able to manage having multiple licenses (for cost and time reasons). I usually work on obtaining about 2 new states licenses every 6 months.

I actually allow some state licenses to expire. There are state licenses that expire after one year (which can be annoying). Some people may think it’s a bad idea due to all the work that went into getting them in the first place. But the truth is, reactivating licenses is pretty easy.

I allowed my California licenses to expire. Yes, the same licenses that took more than 4 months to obtain. The fees are costly though, since you have to renew 3 licenses. I think having a California license is always a good idea because there are plenty of jobs there. I had one agency I worked with prior renew the licenses for me. It was a piece of cake. The agency’s licensing team did all of the work and paid for my renewal fees. I just had to sign a form agreeing to work with them initially with the new license.

In case I end up working with a different agency in California, I would just have them pay back the other agency for that license. It’s no big deal. Not to mention the renewal process only took 2 weeks!

I had also allowed my Texas licenses to expire. The same agency renewed the Texas licenses for me. It was nice having the licensing team work with me because they would call the board of nursing to follow up on my application. This process also only took 2 weeks!

I allowed my Washington state license to expire. Washington is really far from Miami, so I didn’t see myself going back there anytime soon.

Lastly, I always renew my Florida license because that’s my home state and initial license upon examination.

Some people may have more trouble managing their multiple licenses than me. I recommend having some agencies invest in applying for or renewing licenses for you. It facilitates the process and covers the costs upfront.