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I’m Now A Per Diem Doctor

I did some per diem work in residency from 2007-2009 until I started my full-time job. I enjoyed that work for many reasons though nothing compares to my full-time job when it came to benefits and income, what a difference!

I have gone back and forth quite a bit since 2015, whether to drop my hours down to part-time, quit altogether or go per diem. I was just itching for some flexibility and more free time but I couldn’t let go of the nice income that came with being full-time.

Finally, in 2016 I have decided to go per diem, to forgo the associate physician role and just work for whomever I want, whenever I want.

It may seem like an easy decision but there are a lot of factors to consider such as the lower income, the schizophrenic schedule, month-to-month variability of income, loss of benefits and needing to overcome my own biases.

 

Advantage Of Being Per Diem

It’s an individual decision because every person’s situation is different. At different stages in life we have different needs, usually needing a higher income early on in our careers to make a dent in the student loan debt and needing time-flexibility later on as we are ready to slow down and enjoy our free time more.

My goal in 2012 was to become financially independent so that I didn’t have to rely on as much income. I wanted to have the option of taking a job with less income as long as it made me happier. Or being able to take large chunks of time off and not have to worry about generating income.

Different Types of Jobs

As an independent per diem physician I still get to enjoy a lot of job stability, especially as a family medicine doctor. There is plenty of work available for docs in my speciality. I can do all or a combination of the following as a family doctor:

Location Independence

If you are someone who loves traveling then a per diem position is favorable because you can work in a new location temporarily or work in multiple locations at the same time.

Even better, with technology advancing and creating more telemedicine opportunities it’s quite possible for many primary care and specialists to be able to do their work from a computer screen. It’s not the same as seeing a patient in-person but it still generates some income and allows you to work from more favorable locations than a windowless dungeon.

Diversifying My Customer Base

As an employed physician I essentially only have one customer, namely my employer. If shit hits the fan with them and I get on someone’s radar I could lose my  job – not much diversification in that.

If I own my own urgent care then I have a ton of customers, my patients. If one hates me there will be others. That’s a good diversification, I’m actually mitigating my risk by running my own business.

If I am a per diem doctor I still have employers but I’m no longer dependent on just one. I can work for several different medical groups and if one office changes their business model or another doesn’t like me then I still have other options.

The Downside Of Being A Per Diem – Losing Benefits

This part will suck, for some reason it’s just a bitter pill to swallow. Even though in a previous post I downgraded the actual value of the employer benefits it still feels like a big loss.

I suspect it’s one of those things that I will get used to especially once I start paying for my own health insurance, cell phone and set aside my income without using a 401k account.

The 401k Argument

I realize that having a 401k is a big one for doctors, rightfully so because the higher the income the higher the taxes. Without a way to decrease one’s taxable income it’s easy for a doctor to lose nearly half of their income to taxes.

With a healthy retirement package a doctor working full-time, making around $300k/year in 2016 can reduce their taxable income by around $50k.

I find myself in a slightly different situation. I have around $500k in retirement accounts, tax-deferred money which I can’t access easily until age 60. And once I access them I still owe income taxes on them.

I’m glad I have these account, they will grow tax-free over the next few years. I just wish I had more in taxable accounts for immediate access. So, moving forward I actually am happy to no longer contribute to retirement accounts.

Finally, let’s not forget about the option to open an individual (solo) 401k. It’s like having a 401k from an employer, except that you can put even more than $18k/year into it.

 

A Per Diem Career Plan

If you’ve ever done per diem work you know how fickle the opportunities can be. Some months you are showered with available shifts and other months you panic because everyone is snatching them up.

It’s important to not overdo it as a per diem. For the most part doctors aren’t very creative when it comes to working per diem, they sign up only for whatever shifts are offered to them. I have developed my own tricks in the 2 years I worked per diem.

1) Haggle for your pay. It doesn’t matter what the going rate is, you can usually haggle the pay a little. For the shifts later in the day or on holidays you can ask for a little more pay.

2) Ask for different hours. Even if you are only offered a morning shift you can suggest that they give you the whole day so that it’s worth your while.

3) Contact clinics directly. Once you start working for a medical group and they like you, don’t wait until the scheduler contacts you. Find the person that submits the availabilities (nurse manager) and email that person directly for shifts. This has worked nearly 100% of the time for me, I got the pick of the litter before anyone else.

4) Pick up last-minute shifts. This is the finest trick of them all. Most doctors like to know their schedule in advance, so they rarely will look for a same-day shift. Not only should you look for last-minute shifts but you should also email your contacts at each clinic the same day you are looking to work… there is always sick-calls, higher patient volumes, scheduling mix-ups etc. Capitalize on this and you even get to name your own price.

5) Do favors, be regular and be flexible. Don’t complain if you get dropped from a shift or if they need to move you around, do it happily and be nice about it. If they desperately need you one day then say yes even if it’s an inconvenience. My goal was to do this once a month when I was a per diem. Finally, try to be consistent, if they can rely on you to regularly pick up shifts then the schedulers are likely to consider you first because they know you are a repeat customer – they can depend on you, so they want you to depend on them.

 

Come Up With An Income Goal

If I am going to work per diem then I know that the income will vary from month to month. The best way to audit your income is to have a rolling 3-month income cycle and decide how much I need to make each quarter to meet my annual income needs.

This helps keep me on track and prevents me from burning out. Over the years I have learned to work backwards from my retirement date, my investment goals, and my desired lifestyle/expenses to determine how much I need to work and save now.

 

Benefits Of Working Per Diem

1) Make great connections. The more locations you work the more doctors and nurses you will meet. The more people you meet, the more friends you will make and the more opportunities will come your way. Over my 2 years of moonlighting I was offered to go in on a concierge group, to switch residencies by a program director and to invest in real estate.

2) Apply for a permanent position. At one urgent care that I frequented in Long Beach I met a doctor who was retiring and all he did was supervise a wound clinic, run by RN’s. He offered me the position if I was willing to train for 6 months with him – it was a nice gig.

So if you come across something great that interests you then be flexible, consider applying for it, you have nothing to lose. What’s the worst thing that will happen? You simply can fall back on your per diem work.

 

Telemedicine Per Diem

When I first wrote this post, it was 2016 and now, 2018, I’ve been earning all my money from doing telemedicine with various companies.

I’ve successfully put these income streams to test while traveling overseas. By having multiple telemedicine companies to work for, I am less worried about not having enough patient volume or having shitty bosses to deal with.

I was able to earn $2k in one day doing telemedicine. That’s how much I spend the entire month – this is going to be a sustainable mode of income for me for the foreseeable future.

The advantage of telemedicine has also been that I am able to pursue all the other things I love such as teaching and writing.

 

Feel free to pick my brain if you would like to pursue something similar. I charge a fee for my phone consults, though I think everything you need is already on this blog. If you prefer more detailed guidance then I’m sure I can provide you with more value than what you’ll pay me.

 

10 replies on “I’m Now A Per Diem Doctor”

You may know this already, but if you’re a self employed per diem doc, you can still have an individual 401k and contribute $53,000 per year at your age. That’s a great tax deduction even though it locks up your money.

I will look into this again and run it by my CPA but I was under the assumption that only applies to 1099 income and not a w2.

Yes your CPA is correct. It has to be 1099 income to be able to use an i401- k. Why aren’t they paying you as an independent contractor with 1099 income? Would’t it be better for you to just be paid as an independent contractor and get 1099 income, rather than W2. Than you could deduct business expenses and do an i401-k which would help lower your taxes. Is there some reason you’re being paid as an employee even though you aren’t getting benefits?

It’s how their HR department prefers it done. But agreed, I’d much rather have a 1099. But thanks for clarifying that, I think I’ll bring it up with them again.

Actually, I’m fine not contributing more money to my 401k. I’m not planning on having a high income over the next couple of years. And I would rather have easier access to whatever I’m setting aside. Sure, there is a tax benefit but at the lower tax bracket which I will be in, it won’t make much of a dent.
The main reason for a 1099 however would be to get the easier and better write-offs. I would be responsible for the entire portion of the payroll but it’s worth it based on the math I did.

That’s a good plan to just deposit the profit to a taxable brokerage account rather than individual 401k if you want to have quick access to the funds and you’ll be in a low tax bracket anyway. It might still be nice to be getting 1099 income rather than W2, just to get the write offs. If you can monetize your blog than you can still do write offs on your blog income!

Thanks for your blog. I am a solo FP physician for the past 17 yrs and I am near-burnout. Something you may wish to consider just a part of your retirement is Health Savings Account. I am 56 y.o. and have been putting in the maximum amount plus the “catch up” amount. I don’t pay for my medical expenses from the HSA, but instead, it is invested within the account. It is a called a triple tax benefit. I am assuming you have to pay for your own health insurance, so with the higher deductible of HSA eligible insurance, it is less costly.

That burnout – it’s a rampant disease. Any plans to address the burnout or is it too overwhelming to address at the moment?

HSA is definitely a good option. I got my own health insurance for a couple of months and then decided to get rid of health insurance completely in the US and have it now in Europe. I’m okay paying the tax penalties on it but don’t want my money going to an insurance company for services I won’t utilize.

I love the catch-up amounts however for people over age 50. I’ve written in the past about cutting back on work and contributions between age 40-50 and then resuming at age 50 due to the tax benefits at that age.

Currently looking at per diem urgent care in Caifornia, around LA.
what is a good Hourly rate vs average rate?

Per diem urgent care should be minimum $100/hr but usually you can get $120/hr and plenty of places pay $140 and even $160. In this current environment taking less than $120 seems unreasonable.

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