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:

• primary care
• urgent care
• emergency medicine
• hospitalist
• cosmetics
• supervise PA’s
• telemedicine
• consultation
• my own office

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.