Why I did not take the Perm Traveling gig

Last December I had shared an offer I received for a really great permanent traveling position. If you aren’t already aware, it was a “permanent traveling” position, because I would still be able to travel to multiple states but I would be working as a permanent employee to one employer. No more agencies.

As some of you may have noticed, I did not accept their incredible offer. Here are the main reasons why:

  • I loved working for their clinics in Virginia. Yet, I hated working for some of their clinics in Florida. This showed me that all of their clinics are not equally enjoyable to work in.
  • I am not ready for such a commitment. I am turning 30 years old at the end of this year and I don’t want any restraints on my vacation time. I am planning on many wonderful trips abroad and don’t think 6 weeks PTO (including holidays) is going to cut it.
  • I do not want to give up my tax breaks. I have often highlighted the pros of working both 1099 and W2 as a locum tenens nurse practitioner. If I became a permanent W2 employee, the taxes I would be paying would almost double.
  • I don’t want to become a slave to healthcare. Unfortunately, healthcare in the USA doesn’t allow providers with enough time with their patients, resulting in less than optimal outcomes for patients. It is a high demanding environment, leading to increased stress and work hours. No thank you.

As amazing as the opportunity was, I knew in my gut I had to turn it down. On the bright side, that opportunity will always be there, if I am ever ready for it.

Aruba Trip

After completing my assignment at the FQHC in Southern Florida, I was ecstatic because I finally had time to go on a trip! I hadn’t been abroad since last summer since Hurricane Irma had other plans for me.

After living in cold Virginia for one year, I lost all of my color. Thus, I knew my first trip of 2018 would need to be somewhere with plenty of sunshine!

I decided to go to Aruba because since it is close to the equator that meant it is warm year round. Even though it was February, I knew the water in Aruba would still be warm enough to swim in.

I went on the trip with my sister, who was also mentally exhausted from recently changing jobs. We definitely enjoyed our brief getaway, which allowed us to catch up on sleep, sunbathing, and relaxation.

We also enjoyed snorkeling and hanging out at the beach with these fun birds:

I was very interested in seeing the culture of Aruba. The natives spoke an Afro-Portugese creole language, called Papiamento. However, I was most impressed that the majority of them also spoke English, Dutch, Spanish, and even sometimes French. They were very friendly and we ended up being there during their “Carnival”. This is a dance party/parade that runs on main streets throughout the island, lasting days. I have to admit that the Haitian Carnival is way more chaotic ;).

Our last day in Aruba, I made sure to enjoy a Dutch Pancake, and it did not disappoint! It reminded me of a thicker version of a French crepe. I would recommend Aruba for a quick getaway (it was only a 3 hour flight from Miami) and the water was warm as expected.

Onto The Next One

After I decided to leave the assignment in Tampa, FL early, I was planning on just taking a vacation. However, one of my recruiters insisted he had the perfect assignment for me. It would only be 3 weeks long (covering an FMLA) and would consist of working with a migrant community of mostly Hispanics and Haitians. Since I speak some Spanish and Haitian Creole, I figured why not.

The agency had already submitted 10 candidates that the site was reviewing. My recruiter was confident that I still had a chance because of my work experience and language skills. They selected me as one of the top 3 candidates and proceeded with a phone interview. It seemed like a good place to work, so when they offered me the job I said yes.

The site was about 2 hours from my home in Miami, FL so I was provided with a hotel during the weekdays, and I went home during the weekend. I was reimbursed for daily mileage to work and mileage home each weekend. Since I had a long commute, the site even allowed me to leave 1 hour early each day (paid for full shift) to make up for it.

This is a community medical center, one of the goods ones as I portrayed in my previous post. Since it was a brief assignment, I didn’t expect an extensive training. My first day, I completed the mandatory OSHA/HIPPA etc. training during the morning. In the afternoon, I was introduced to the EHR system. The funny thing is they originally offered me a scribe. Meaning, I wouldn’t have to document, there would be someone following me and documenting my encounter with the patient. I thought, wow that’s neat. Some of the providers here have scribes, if they aren’t comfortable or too slow with the EHR. That’s a nice gesture to support their PCPs.

I told the manager that I didn’t need a scribe, as I am used to jumping into places and learning the systems quickly.

They used Athena EHR which was straightforward, and by the next day I was already pretty competent. They also had an IT person on site available to me in case I needed any assistance.

I really enjoyed working at this community medical center. I had two medical assistants, which meant I never had to wait or look for help. The patients were pleasant, not as demanding as the previous practice I was at. My schedule was fair – I averaged about 12-14 patients per day (of course there were no shows).

Another funny thing is that everyone was so impressed. They were surprised how quick I was, and told me that the patients were used to waiting 2-3 hours to be seen. They were also amazed by how quickly I learned how to use the EHR system. I have been used to working with such a complex elderly population over the past 1.5 years that these average patients seemed so ‘basic’ to me.

I forgot how easy it is to manage a 40 year old patient with just hypertension and hyperlipidemia versus managing an 82 year old patient with hypertension, hyperlipidemia, diabetes, heart failure, angina, arthritis, hepatitis C, cancer, depression, insomnia, obesity, glaucoma, kidney disease. No joke!

The only challenge for me at this site was getting accustomed to the diagnostic coding and billing sections again. I had been working in a ‘managed care’ setting over the past 1.5 years so the diagnostic coding is much different. For instance, at this community medical center I had to make sure I specified physical exam with or without abnormal findings, normal or abnormal BMI (and which value). In comparison to the managed care setting, we didn’t use those diagnoses much. We mostly focused on HCC codes, which are codes that can bill at a higher rate and represent how sick our patient is. So if a patient was overweight, it didn’t matter as much as if a patient was morbidly obese, if that makes sense (billing wise, not medically).

Like anything though, the more you start to do something again the more it becomes familiar. It was the same with doing well child check ups. I was so used to treating complex geriatric patients that I had to do a few well child exams before I was confident in them again.

In conclusion, this assignment deserves an A+. On my last day, the CEO came all the way to our clinic just to meet me and tell me “I have heard such great things about you!” He came prepared to make me a permanent offer, but I told him (in a nice way) not to even bother J. He told me they would love to have me again when there is another need. I definitely wouldn’t mind helping them again. I hope other sites can take a lesson from this one – PCPs like to be appreciated!

 

 

FQHC’s Aren’t All Bad

Whenever I meet other nurse practitioners or physicians on assignment, they’ll talk about their prior experience working in a Federally Qualified Health Center (FQHC)/community health centers.

They will tell stories about seeing over 30 patients a day, being mistreated and unappreciated, and places that are really disorganized. As a traveling nurse practitioner, I have already worked at 5 different FQHCs. And guess what, they aren’t all bad!

When I tell the other providers that there are actually some really great FQHCs out there, they look at me in shock. I do agree that most of them are pretty awful because “it’s all about the numbers”. However, I have come across 2 so far that are incredible!

For those of you that have been following me since the beginning, you may recall my first assignment out of Florida. This was a FQHC in Washington State that was extremely organized and well-run. Patient per day ratios were fair, about 14-18 patients per day. They allotted 30 minutes for new patient appointments. There were standard protocols in place that allowed medical assistants to help PCPs with immunizations, acute rapid testing, and even health screenings. PCPs were given admin time, 1 day a week where they could catch up on medication refills and paperwork.

After my awful experience working in Tampa, Florida, I ended up taking a brief assignment in a FQHC in south Florida. I felt spoiled having 2 medical assistants just for me, and seeing a fair 14-16 patients per day. The EHR was straightforward and there was an IT person on-site daily to help if needed. If there was an issue, such as having too many physicals scheduled in one day, the staff quickly corrected this without push-back. Leadership was amazing too. The center manager and medical director made themselves available and constantly offered positive feedback.

It’s such a wonderful feeling to look forward to going to work and being enabled to provide the appropriate care you strive for. So don’t be afraid of traveling as a nurse practitioner. Sure you may stumble upon some awful assignments, but most of them you can handle for the brief 3 months. If there is one you do not feel comfortable staying at any longer, you can just leave. Although there are some bad assignments, there are definitely plenty of great places too.

 

Mileage

When traveling to a new assignment, you have the option to fly to the site and be provided with a rental car, or you can choose to drive your own car. If you decide to drive your own car to the site then agencies will reimburse you with the mileage it took to get there. They will also provide you with the mileage it takes for you to return home (even if you end up just going to another assignment from there). If you choose this route, you will likely make a profit.

For example, if your site is 500 miles away and you were reimbursed $0.545/mile then you will get $270. After deducting $100 that you spent on gas, you will profit $170.

Another mileage benefit that some agencies provide is mileage to and from the site while you are on assignment. That means even though the agency is housing you, they will reimburse you mileage each time you drive to and from the site from your temporary apartment or hotel. Daily mileage is often given when you are doing a local assignment. However, depending on the agency, some will provide this benefit even when you are away on an assignment.

I wouldn’t necessarily expect this from all agencies, but it is a nice benefit when an agency does offer this. It will typically be listed on your contract as general “mileage”. Some agencies may specify your home city and your destination city to display that you will only receive mileage from this commute.

I am used to living about 5-10 minutes away from work so having daily mileage isn’t always essential. Yet, there was an instance where I worked for a rural community health center and the closest hotel was 1 hour away. I wasn’t thrilled about commuting 1 hour each way, but the daily mileage definitely made up for it. I made an extra $300+ each week from mileage alone. After deducting the cost of gas, I profited $200/week. Not bad, especially since it is tax free.

Proving Myself as a Locums

To my fellow locums out there, I don’t know about you but each time I tackle a new assignment I feel like I have to “prove myself”. I have to prove that I am a good locum tenens provider. That I am a quick learner, that I can see a lot of patients, that I can be thorough – covering health maintenance and quality measures; and that I can document well – not missing any important codes.

The funny thing is often the site has low expectations. They just need someone that’s going to be able to jump in and provide coverage while they recruit someone permanent or their permanent provider returns. Most of the time they aren’t expecting superman or superwoman.

Working as a traveling nurse practitioner for almost 3 years now, I have come across several other locum tenens providers. It’s interesting to see the variety from the locum tenens pool. Many other locum tenens providers are fine doing the bare minimum. Some don’t pay attention during our meetings or read their emails to learn how they can improve their documentation or care for the patients at this particular site.

I think it is the overachiever in me that feels like I need to exceed expectations. I guess I should take the pressure off of myself. In fact, locum tenens means filling a temporary need. The site and staff are usually so happy to have us helping out that they don’t even bother judging us.

 

 

Am I a Diva?

I am wondering if my “I don’t take bs” attitude translates into me being a diva. As demonstrated in my prior experiences, I often stand up for others and myself. I think since I have worked in so many different settings, I know what a GOOD work environment is. I know that it is absolutely possible to work somewhere that is pleasant and not overwhelming. I also know what a GOOD recruiter is and what a GOOD deal looks like, so I do not want to settle.

There are 2 main aspects of working locum tenens that sometimes irritates me and causes my “inner diva” to come out.

  1. Being overwhelmed at work. Whether it is due to being scheduled with too many patients, lack of leadership in the office, no admin time, or lack of assistive staff.
  2. When recruiters speak to me as a car salesman, acting like taking this job is equivalent to buying a car. They say things like: even though this job doesn’t pay well nor is it in an ideal location, at least you will have work.

My responses to these problems:

  1. When asked to see certain patients (last minute) I will say NO just to make a point. I will request a change from either management or from my agency. If they are reluctant to change anything I will use the “it’s my license on the line” talk. In the back of my mind, I always consider just leaving if things do not improve.
  2. “At least you will have work”. Hi, I am not desperate. I’ll just say NO if I don’t like something. For instance, sometimes a recruiter will try to get away with giving you poor housing options, such as staying at a motel 8 (ew). When you demand better options they will say “can you at least stay there for this week until we find something else?” The answer is NO. No, I will not travel all the way there for a “possibility”.

Do I overreact sometimes? Yes, I am human. But who else will speak up for myself if not me?

So am I a Diva? Perhaps at times 😛

 

Health Insurance

I receive many questions about health insurance as a traveling nurse practitioner so I thought it deserved its own post. As a locum tenens provider, you have two main options to obtain health insurance (besides getting it through your spouse).

If you are working with a 1099 agency then you will have to purchase private health insurance. These plans can be costly, sometimes $300-400+ each month. The good thing is you can deduct these premiums on your taxes at the end of the year. The bad thing is that both premiums and deductibles are high.

If you choose to work through a W2 agency, then these agencies will provide you with health insurance. They usually offer 3 insurances to choose from, each of them is affordable. For instance, now I am using health insurance from my W2 agency and I pay $34/week, so $136/month is not bad. This insurance plan allows me to find an in-network doctor in each state I am working in.

Another good thing about W2 agencies that provide health insurance is that if you stop working with them for up to 30 days, you are still covered under their plan. So this is nice for those of us that like to take breaks in between assignments or time off to travel abroad. You won’t lose coverage for taking a few weeks off. However, they will retroactively deduct payments on your upcoming pay checks.

As I alternate between W2 and 1099 agencies frequently, my health insurance also changes. As long as I provide “proof of loss” of insurance, I can enroll in a new plan mid-year.

I can’t tell you which option is better for you. This varies depending on your age, medical history, and preferred method of payment. For instance, a healthy 25 year old may opt for increased paid through a 1099 agency and less benefits; versus a 48 year old may prefer paying higher taxes with a W2 agency in order to have good health insurance.

Locum Tenens Myth

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

Part 4: How I became a “Martyr”

Just one week after I left, I already heard from the other nurse practitioners that things were changing for the better. There was an announcement that all walk-ins and hospital discharges are supposed to be seen by their PCPs. If only that had been implemented while I was there, it would have prevented a whole lot of problems.

There is a new nurse practitioner there, in which this is her first job practicing as an NP. I had told the CMO that they were scheduling her with way too many patients and that no one is available for her to ask questions. (Note: she worked at the other clinic from me, not mine, otherwise I would have helped her). She told me that after I left, the Medical Director told her that she was seeing too many patients, and they were going to start giving her 30 minutes per patient. He also told her that if she had any questions she could ask any of the doctors including him.

Lastly, another major announcement is that the Medical Director will actually be stepping down and there will be a new Medical Director taking his place within the next 3 months.

Although I would have preferred to avoid the recent past turmoil, I am glad that by me speaking up for my peers and myself, circumstances are improving for them. Sometimes you have to sacrifice yourself in order to help others.

As far as working with this company again in the future, it is definitely a possibility. I think it was insinuated that I would not be taking the permanent traveling gig at this time. Considering the Tampa/Lakeland market was mainly for me to make sure other markets were just as great as the Virginia one, but it clearly didn’t work out. Nonetheless, the CMO clearly took my concerns seriously and did not waste any time to implement change. He has my utmost respect and I hope to work with him again in the future.