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Life in Emergistan

Life in Emergistan

The High but Worthwhile Price of Freedom

Leap, Edwin MD

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doi: 10.1097/01.EEM.0000461010.00212.db

    Well, I know it wasn't you who held me down

    Heaven knows it wasn't you who set me free

    So often times it happens that we live our lives in chains

    And we never even know we have the key.

    “Already Gone,” The Eagles

    I had a great conversation with a fellow locum tenens doctor while I was attending the ACEP Scientific Assembly in Chicago. We colluded and laughed about the trials, hassles, and travel. But we came around to something else. We agreed on a mission statement, as it were. It could serve as the motto of every physician who works as an independent contractor, has his own practice, or is an independent business owner. Freedom isn't free, but it's worth the price.

    Working in the locums world is a fine way to make a living, but it has its own set of struggles and problems. Travel in itself is a delight; I love seeing different parts of the country. I've been in five states so far, from the South Carolina low country to the mountains of Colorado. America is incredible, a place of breathtaking beauty. But leaving my wife and kids behind? That always stings a little. Amazing places are always best shared with those we love.

    The logistics of travel pose their own problems, of course. Flights can be delayed (or missed, full disclosure). Baggage can be lost. Rental cars unpredictable. Hotels can be ... scary. And food in some locations can be, well, uninspiring.

    Another issue? Credentialing is an enormous pain. Between hospitals and state medical boards, I've answered questions, filled out forms, been background checked and fingerprinted, and otherwise evaluated so many times I'm starting to feel like I have something to hide.

    There are also the endless requests for ATLS, PALS, ACLS, BLS, and all the other LSs. Medical school, residency, and board certification aren't nearly as important as a one-day course passed by pretty much every nurse in the country! (That stings a little, too.)

    And there's the challenge of changing locations. Each hospital has its own culture, its own power structure. And each typically has some vestige of old, archaic, and labyrinthine rules to follow that mesh of unnecessary paperwork, inadequate EMRs, and generally inflexible medical staff and nursing offices. This can be quite frustrating to navigate, but each hospital is its own continent to explore and conquer if one likes an adventure.

    One of the greatest challenges, however, is actually financial because the good old U.S. of A. isn't all that keen on independent contractors. The self-employment tax is pretty high, given that I'm paying income tax as well as all of my own Social Security and Medicare costs, along with business taxes, disability, and health insurance. Our family health insurance was slated for a pretty impressive increase this year. We were insured through the South Carolina Medical Association, which was trying to clear out everyone in its individual market. My monthly premium of $1600 (with a $6000 deductible) would have increased in January to $3000-$4000 per month. (Yes, you read that correctly.)

    But the point is that the financial and non-financial costs of this sort of life are remarkable. On the other hand, there remains the freedom. Freedom means that I work when, where, and as much or as little as I desire. Freedom means I don't have to go back to a hospital whose rules and culture are unpleasant or unfavorable. Freedom means that I arrange my life in the way that is best for my wife and children, my health, my sanity, my ethics, and my financial gain.

    I can take a month off as long as I can afford it. I can travel the world. I am, in fact, my most important customer. I please me and those most important to me. I am wildly unfettered in my pursuit of the best possible “me satisfaction score.”

    Those of us who practice locums medicine may keep it up or may change next year. We may take a new job with a new group and stay put or travel. But we don't have to do any of it. Whatever we do, we know the precious truth. We have valuable skills and flexibility.

    Once you've experienced freedom, a thing too many physicians have never known, it's tough to go back. Freedom is always out there, calling, offering adventure and opportunity, and breaking long-forged but largely imaginary chains. It's all there as long as you believe the benefits outweigh the costs. Freedom is very expensive, but I believe it's worth the price.

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