A healthy economy supplies abundant jobs, high incomes, and sexy investment returns. This is when doctors get comfortable enough in their positions to start looking around and seeing how they can improve their work-life balance.

During blooming markets medical groups start expanding. They open more urgent cares, add more staff, build more medical clinics and hospitals.

It makes sense to drop down to part-time or per diem. For some, it might even be the right time to start their own practice and scratch that entrepreneur itch.

I stepped down slowly, first from full-time to part-time and then down to per diem at Kaiser Permanente. In hindsight I would have signed up with a few more per diems instead of relying on just 1 company for my income. I’ll address that in more detail.

Working Part-time vs Full-time

For the Family Medicine physician or Primary Care doctor who is interested in having a more flexible schedule I really don’t see going part-time as a good idea.

The main point to consider here is whether you can have enough income as a part-time physician to make it worthwhile. For the young doctor the answer is usually no.

You might go down to part-time but constantly will feel the pressure to pick up more shifts which defeats the purpose of going part-time.

In summary, part-time work gives you all the undesirable responsibility of still being tied to a specific schedule and it decreases your chances of having enough flexibility to pick up per diem gigs on the side.

Ideal Part-Time Consideration

I think part-time makes sense if you have no desire to navigate the per diem waters and don’t want to be responsible for making your own hours to provide enough income.

You also may not like worrying about estimated taxes and figuring out how much of your gross income is yours to keep and how much needs to be set aside for taxes.

Finally, a part-time position often provides vacation, health insurance, disability insurance, and a few other benefits such as retirement contributions which you’d have to figure out for yourself as a per diem.

The physician who is going to gravitate towards a per diem role will want more freedom of time, work flexibility, and a higher income.

Working As a Per Diem Physician

Let’s now talk about going per diem as a physician. I know I didn’t spend a lot of words breaking down part-time vs full-time work but I hope my sentiment regarding how ass-backwards part-time medicine is in Primary Care came across.

By the way, the reason I say ‘physician’ is that the majority of those who comment on this blog or email me are physicians. I wish that more PA’s and NP’s would gravitate toward this personal finance stuff but that doesn’t seem to be the case with my readers.

For the physician who is interested in going per diem I’ll break the topics into:

1. Income
2. Income Consistency
3. Structuring Benefits
4. Job Security
5. Work Flexibility

1. Income

“Can I earn enough to compared to my full-time job? I can’t afford to not have enough income, I have baby momma’s to please!”

I get emails from readers who are interested in making a career transition and one of the main concerns is the income. Let’s address this topic first because it will transition nicely to other relevant factors.

There will be plenty of income for you in a per diem role. Your full-time role guarantees you a salary but doesn’t guarantee you a job as some of my colleagues have found out the hard way.

The part-time roles are intentionally designed to be undesirable in order to drive more physicians into full-time roles. They are mostly there to give the illusion that you have plenty of options at the competing medical group. But in reality your hours won’t be ideal as a part-time physician in Primary Care and in the Urgent Care they will probably want you to do too many weekends/Mondays.

Upper management will want to reduce the number of doctors in part-time roles because when they are getting the same benefits as a full-time physician then it will cost the medical group more money.

Per Diem Income

There aren’t a whole lot of per diem roles in Primary Care but there are abundant jobs available for the per diem physician in the Urgent Care.

By Urgent Care I mean the acute care, walk-in, or same-day clinics – whether in person or virtual. I focus a little more on the telemedicine side because it’s one of the easier and more lucrative aspects of medicine currently.

What’s important to understand is that medical groups have the following problems when it comes to their per diem pool:

• high turnover of providers
• low competency or problem-physicians
• poor documentation because of lack of engagement
• low throughput
• high-maintenance providers

In order to attract the better doctors these companies might offer you a pay incentive if you pick up extra shifts with them or they will offer you more shifts than other providers. They realize how important work flexibility is.

It would benefit you to elevate yourself to this higher status per diem because it will earn you a higher income, more work flexibility, and a better overall experience. You can do so if you:

• send less complain emails to the back office team
• see patients faster
• document better
• have better customer satisfaction
• make the medical group look good
• be consistent in picking up shifts
• pick up more shifts than others

Within a couple of months you’ll be identified as the efficient and productive provider. Usually the medical director will reach out to you during this time and ask you to come on part-time or full-time or ask what they can do to help you more. Your ideal reply:

1. ask for higher per-patient-pay
2. ask for more shifts if you need them
3. ask to be licensed in other states
4. ask for the medical group to pay for your licenses in those states
5. ask for incentive pay during high-demand times

How Much Can You Earn?

Besides Urgent Care, Primary Care, and Pediatrics in telemedicine there is also Dermatology, Psychiatry, and Sports Medicine popping up.

I don’t want to spend too much time talking about face-to-face medicine because there is a huge need for per diem doctors in these roles. If you are having a hard time finding these gigs then I would recommend calling a recruiter or calling the large medical groups and forwarding your resume to the HR department. Even if a medical group isn’t advertising a job for per diems, they are always hiring for that position.

For telemedicine gigs expect to earn about $30/patient. This will go up with time but for now CMS isn’t reimbursing all that much for virtual visits and it’s still a relatively new healthcare wave.

I pointed out in previous posts that my lazy ass can earn about $15,000/month by doing about 2 hours of work a day – 1 hour in the morning still laying in my comfy bed with a cup of coffee and 1 hour at night, back in my bed with my teeth brushed and under the blankets.

This morning I saw 15 patients in a span of about 70 minutes. That’s $420 – very fitting for Portland… don’t pretend like you don’t know what I’m talking about.

Let’s break down this $15,000/month telemedicine per diem income:

• $28/patient
• 8-12 patients/hr
• 2 hours = $500
• 30 days = $15,000

2. Income Consistency

“Will there be enough shifts available? Will there be enough patients to see for me to earn a decent income?”

I want to point out something very important when it comes to per diem income. Most per diem physicians  aren’t very resilient nor determined. By that I mean, if they work for a medical group and a week goes by when they aren’t earning much money then they’ll give up quickly.

This is true about any per diem job whether you’re a doctor or a per diem mechanic. I would recommend flexing those resilience muscles and trying to outlast the other doctors.

Few doctors turn to a per diem career by choice. Many have been let go from their full-time jobs or are problem-doctors in other ways.

You’ll suddenly see that even though you had an anemic few days or even month of income, the next couple of months will have a lot more volume than you can handle.

The physicians who make it through the lulls and perseveres will be recognized by the medical group and the schedulers and it’s something you can later capitalize on.

3. Structuring Benefits

“But will I still have my Cadillac health plan, my 457, my pension, my 401k, and my CME stipend?”

Structuring benefits for a physician involves the following:

• health insurance
• disability insurance
• retirement benefits
• vacation

If you can figure out the value of your work benefits – actually putting a dollar value on it – then it becomes really easy to decide whether it’s worth giving up your full-time or part-time gig for a per diem role.

Health Insurance

You’re often offered a Cadillac plan which is much more healthcare than you’ll ever use or need.

You can create your own efficient health insurance option by shopping the private marketplace and adding an HSA on a high deductible health plan which will save you quite a bit of money.

Much more important than healthcare is your health. Having health insurance doesn’t equate to being healthy. It’s a proven fact that the more healthcare you utilize the less healthy you’ll be in the United States – why else would a Family Medicine doctor like myself earn $300,000/yr?

Disability Insurance

Read the Godfather’s posts on disability insurance and you’ll get every nugget of truth that you need. That topic is so exhaustively boring that we are all very fortunate for him to cover it in such a digestible manner.

Your group disability policy is likely an ineffective one. By that I mean that it might not cover you as well as you think. Sure, it’s cheap but you want the right coverage and not cheap coverage.

For around $500-700/month you can get a top-of-the-line disability policy which you can deduct on your taxes as a per diem physician.

Retirement Benefits

If you’ve read my blog posts then you’ll know that you can set a ton of money aside in retirement accounts as a per diem physician. The current maximum is $54,000/year which doesn’t include the cash balance plans.

Your employer cannot offer you anything that you cannot establish for yourself.

Let me repeat that – your employer cannot offer you anything in terms of retirement benefits which you cannot establish for yourself as a private entity according to our IRS tax code.

You can have a 401k, IRA, cash balance plan, Keogh, pension plan, etc. Sure, you need to do a little bit of legwork to figure out how to do it but that’s what blogs are there for.

Vacation

I guess this section should be about vacation time, sick time, educational leave, and all that other fluff.

Once again, these are work gimmicks. It makes no sense for large medical groups do offer a Primary Care physician such benefits when there are far more patients who are looking for care than there are physicians who can treat them.

When you work a per diem job you have a lot more freedom when it comes to your free time. You can work whenever you want and however much you want – and no, you won’t be stuck with all the weekends and holidays.

I log in early in the mornings and late at night when I’m pretty ineffective doing anything else. I keep the rest of my time to myself to do more interesting things with. I get the best of me, my patients can have the rest.

Who says that you can’t work on your vacation? I dislike the whole notion of a “vacation” anyways but since it exists, take your laptop along and perform a few consults which helps maintain your momentum.

4. Job Security

“Are these telemedicine companies all of a sudden gonna disappear leaving me without a job? Am I gonna be let go as a per diem for them to hire a full-time physician instead? I don’t have the kinda body that lends itself well to trickin’!”

It’s a very valid question to ask when it comes to working as a per diem. I remember in residency at UCLA all my fellow residents who wanted to moonlight would complain that there weren’t enough gigs available.

I remember one particular month when the 3rd years were all jonesing for shifts and going through Kleenex boxes because they couldn’t find anything. It was a December and that month I earned $18,000 from my moonlighting gigs. 

The greatest job security you can have is by having multiple customers – I don’t mean patients but medical groups. As an independent contractor your customers are no longer the patients but the medical groups.

With more customers you can pick and choose whom you’ll work for and when and how much. When Kaiser Permanente is paying you extra to see patients in the clinic during the cold and flu season then you do more of those shifts.

If it’s summertime and you know the Urgent Care at Providence will be stupid slow then maybe it’s best to pick up in-person shifts during that time so that you can sit back and relax.

Right now Teladoc has more patients than they know what to do with so if I need the income then I’ll only do enough at Doctor on Demand to stay in their good graces but I’ll focus my energy on Teladoc.

When I was in Barcelona and doing some remote work I got into a problem with Kaiser and they pulled me off of my shifts. No problem, I still had American Well and then I had a problem with the recruiter at AmWell and lost that one too. But guess what, I still had JustAnswer as a customer and continued earning money with them.

Since then everything with Kaiser and AmWell has resolved but not only do I not need any income from them but I don’t see any need for working with those medical groups again because I don’t find them to be competent when it comes to their per diem pool.

5. Work Flexibility

“If I go per diem will I be able to set my own hours or will I get stuck having to work weekends and busy Mondays or holidays?”

If my work as a per diem physician wasn’t flexible then I would have very little desire to continue it.

The definition of work flexibility is to work when I want, however much I want, on my own terms, and at my own pace. That’s per diem medicine as best as I can describe it.

If living in Barcelona for 3 months and earning my living through telemedicine isn’t a good poster ad for work flexibility as a per diem then your expectations might be too high.

Yesterday I had to clean my condo – the area under the bed had become a biohazard and there was a strange odor from the washer/dryer room which needed attention.

So, I turned on my telemedicine app on my phone, got into some hazmat gear and started detoxing my place. I also made some lunch and even got a wicked shoulder exercise in with my exercise-bands.

Remain flexible. The advanced per diem physician will be comfortable with capitalizing on opportunity when it arises. They will see 30 patients on one day when the volume is there and be content that they were only able to see 5 patients the following day. Work will be that much enjoyable this way.