Is life better in locum? A locum tenens ID physician shares her story

Paul Sax: [00:00:12] Hi, this is Paul Sax. I'm editor in chief of CID. And welcome to the next Let's Talk ID podcast. Joining me today is Dr. Allison Nazinitsky, and she's an ID specialist based in Oklahoma. I've invited her on as part of my exploration of alternative pathways to successful careers in ID. Allison, welcome.

Allison Nazinitsky: [00:00:30] Thank you so much for having me on this podcast.

Paul Sax: [00:00:33] Well, listen, you know, I like to start these off by people telling us a little bit about themselves. We know that you're based in Oklahoma, but nothing else. Who is Allison Nazinitsky?

Allison Nazinitsky: [00:00:42] So I finished med school in 2010. I did my infectious disease fellowship at Washington University and finished in 2015, and I currently practice locum tenens and telemedicine infectious disease. I do a lot of other things as well, but my goal in doing this interview was to bring awareness to locum tenens infectious disease as a sustainable career path for really good work life balance in ID. And then also to discuss how we as ID physicians should be compensated for our time and expertise.

Paul Sax: [00:01:11] Well, that's terrific. I'm really looking forward to hearing what you're going to tell us. I want to follow up on locum tenens. What does that actually mean?

Allison Nazinitsky: [00:01:18] Locum tenens is typically when there's a vacancy or a hospital is trying to hire an infectious disease doctor or when an infectious disease doctor goes out on maternity leave and they need to cover that position, they hire a temporary doctor. It's pretty much temporary work.

Paul Sax: [00:01:35] Got it. So we'll get back to that in a minute. But I want to go back to your decision to become an ID doctor and maybe become a doctor at all. What was the motivating force behind your choosing medicine? And then ID in particular.

Allison Nazinitsky: [00:01:48] I love infectious disease, so this is a personal story but I would not be alive today if it wasn't for an infectious disease doctor. I was very, very ill in the intensive care unit. No one had any idea what was wrong with me. The infectious disease doctor, she came in, she was confident, she was calming and really got to the bottom of what was wrong and put me on the right treatment. And that's really how I got my interest in infectious disease. And ever since then, I knew I wanted to be an infectious disease doctor.

Paul Sax: [00:02:19] Were there any other specialties under consideration?

Allison Nazinitsky: [00:02:22] You know, I think we all go through the thought process and of what to do with our lives. But I also do practice some hospitalist medicine. I like to keep up my hospitalist skills. But in the end, as a premed and as a med school student, I always wanted to do infectious disease.

Paul Sax: [00:02:38] Okay, so then you do medical residency and then you decide, I'm going to do ID, So what was your fellowship like?

Allison Nazinitsky: [00:02:44] Well, it was very busy and it was pretty tough, but it was wonderful. And I had just such a great clinical experience. It was wonderful.

Paul Sax: [00:02:54] Were you predominantly a clinical ID fellow or did you do clinical research or did you do any kind of other activities or was it just a solid clinical training?

Allison Nazinitsky: [00:03:02] So I actually was clinical, but I wanted to do transplant infectious disease. So I did clinical transplant infectious disease as a fellow. So my second year I did do some research and some publications, but mostly I spent extra clinical time as a second year fellow. So our first year was all clinical work and then our second year was mostly dedicated for research. But instead of doing all research, I was able to spend about, I think, eight extra months of clinical time with the transplant program. So it was really awesome just being able to do that. Excellent.

Paul Sax: [00:03:38] There's a ID fellowship. Obviously you can finish your ID fellowship in two years and so that means that part of the year too, for people who are doing a two year fellowship is really preparing for your first, quote, real job. And I was wondering if you received any career guidance during your fellowship and what it was like and then what you wish you would received.

Allison Nazinitsky: [00:04:00] I can't remember specific guidance other than just to keep every opportunity open and interview and really see what was out there as far as jobs. And there really are an overabundance of jobs out there. There's such a abundance. And so I interviewed at least at 12, I would say 12 places after fellowship, and I don't remember specific guidance.

Paul Sax: [00:04:23] Do you wish you had guidance during fellowship?

Allison Nazinitsky: [00:04:25] I definitely wish I had more guidance, but I don't know. I think a lot of a lot of ID physicians don't have a lot of experience in general of negotiations and being able to find the right jobs. And a lot of academic centers, the doctors stay there. And so they don't really have a lot of experience outside of their institution to really be able to speak on behalf of what is out there and different opportunities.

Paul Sax: [00:04:52] Well, you know, I mean, one thing that IDSA is trying to do is to provide some of this guidance. And, you know, IDSA is has one-on-one physician compensation sessions right now for ID fellows, and soon they're going to make it available to everyone who's an IDSA member. So you're in your fellowship, you're in your second year. And I assume you interviewed during your second year for your first positions. Tell us a little bit about your first post fellowship job.

Allison Nazinitsky: [00:05:20] So it ended up being just 24/7 work, work, work. I Would average at least 80 hours a week of work. I did not have much time for myself or family or friends, typically waking up, you know, 5 a.m. and I was at the hospital till 7 p.m. at maybe the earliest. I was on call every day and even being woken up at midnight multiple nights because that's when the hospital's lab called criticals. It was really tough and I was not prepared for that aspect because I had always been told residency was going to be the hardest time of my life or my career or fellowship was going to be the hardest time of my career. But in reality it ended up being my first job that ended up being the toughest part of my career.

Paul Sax: [00:06:09] Wow. Was there no kind of understanding upfront about how this was unsustainable? Do the people who hired you know what you were going through?

Allison Nazinitsky: [00:06:18] You know, it ended up being such a whirlwind. And looking back on it now, no, it doesn't make a lot of sense. But as I was recovering from that, this process, I actually met a lot of other physicians that went through similar experiences in their first jobs. And I realized I wasn't alone. It's hard to believe, how could you get to this point where you're working all the time? But it happened.

Paul Sax: [00:06:40] And so things like call schedule, weekends off, all those things, were they discussed ahead of time when you looked at this job?

Allison Nazinitsky: [00:06:48] So what I wish I would have known is that if it's not in writing in your contract, it is not guaranteed. So if you don't have 40 hours a week in your contract as what is your work schedule, you will most likely work more than 40 hours a week If you do not have a specific clause about call schedule, you most likely will be taking uncompensated call. And if you don't have a dedicated clause about weekends, most likely you will be working more than enough weekends. That's really the biggest flaw from when I came out is really not realizing that component of everything.

Paul Sax: [00:07:25] Maybe you don't have to tell us exactly where you worked, but you can give me the sort of context. Was it an academic setting? Was it a government setting? Was it a private practice?

Allison Nazinitsky: [00:07:34] It was a community hospital.

Paul Sax: [00:07:37] Well, listen, I'm glad you got out of it. I don't know how long you were in that position. It sounds unsustainable, as I mentioned. What did you do after that? Take some time off. Did you regroup? What was next, Alison?

Allison Nazinitsky: [00:07:49] So I did. I took I took some time to regroup. I used locum tenens as a bridge. It was not supposed to be permanent, and it was not ideally the career choice because there's so much stigma around locums. So initially it was used as a bridge. Multiple people told me to stay away from locums that only bad physicians go into locums. How it's a red flag for doing locums. Pretty much everybody told me to stay away from it. So initially when I was trying to figure out a better work life balance, I used it as a bridge. But then I realized after starting at some of these hospitals that I was enjoying it. I enjoyed it a lot and I was able to have really good work-life balance and I was able to choose dates that worked for me. And not only that, but because these hospitals were so short-staffed, I was appreciated. That's my number one is always being appreciated, not just by the patients. And I feel like our patients are very, very appreciative of what we do, but just being appreciated in general, being appreciated by colleagues, being appreciated by administration. And I was appreciated and I felt so rewarded that I continued on with this pathway.

Paul Sax: [00:09:08] So how does it work? Does an agency come out and get you? Do you do you go to a company? Does the hospital?

Allison Nazinitsky: [00:09:15] There's a lot of different ways to do it. So if you go through an agency, there's typically a recruiter. They basically act as your best interest, you know, to try to get you matched to different hospitals. The most important thing I would say about doing locums work, if you're going through an agency, is having a good recruiter, someone that knows what you like, what how you like to work, how many days you like to work so that they can match you with the perfect spots. I got really lucky. I've always had great positions and they take care of everything. They take care of your flights, they take care of your rental cars, your hotels, licensing fees. DEAs. And so I have 15 state licenses which others getting anxious, thinking about keeping up with all of those. But they take care of my licensing and make sure that I'm always up to date.

Paul Sax: [00:10:05] So you're based in Oklahoma, but you're taking positions all around the country? Yes?

Allison Nazinitsky: [00:10:10] Correct. Most of my locums work through agencies are out of state. My most common states are Washington and Illinois.

Paul Sax: [00:10:18] And you leave home. How long are you there for?

Allison Nazinitsky: [00:10:22] Well, it all depends. You can pick how many days you want to work in a row. So there are some locums that like to work 30 days straight. And then there are some of us that now we do about seven days a month or seven days every other month, or you basically get to choose your schedule. And so it can be as much or as little as you want.

Paul Sax: [00:10:43] Describe a typical month for you in your current ID practice.

Allison Nazinitsky: [00:10:46] So I really don't have a typical month, and I think that's the beauty of locums. Some months I will work every day I will. I will work almost every day. I might not be out of town every day, but I will work every day. And then other months I will maybe work 2 to 5 days. And so I really don't have a typical schedule. For example, from July through August, I'm actually not working and I'm traveling to Europe twice and I have multiple vacations planned. But then in September, I'm actually only doing seven days. And so it's variable.

Paul Sax: [00:11:20] And then you also mentioned that you do a lot of telehealth.

Allison Nazinitsky: [00:11:24] I do. I do tele ID, It's predominantly inpatient, but I also do some stewardship via telemedicine. One of my positions is actually through a locums agency and the hospital is open to doing tele infectious disease and then the others are more direct with the hospitals or through the hospital itself.

Paul Sax: [00:11:43] And the hospital that you're doing tele infectious disease for. Are you actually seeing the patients or are you giving advice to the clinicians or both?

Allison Nazinitsky: [00:11:50] Both. I do interprofessional consults. I do full tele ID consults where we have a cart with a video, stethoscope, I document into the EMR. I do pretty much everything and including even stewardship. So I will do stewardship rounds with their pharmacist and we do zoom basically like a zoom where we go through all the patients and run the list of all the broad spectrum antibiotics that we're trying to narrow down.

Paul Sax: [00:12:16] So, you know, you mentioned that you're appreciated, which is great, but I was wondering about the reverse. Do you get to have relationships with your colleagues at these hospitals?

Allison Nazinitsky: [00:12:25] So even though I'm not physically there, we all discuss cases so closely that I have made some very, very close friends. And I've actually gotten to meet some in real life from telemedicine that I have worked with over the phone for 2 to 3 years and we finally met in person. So there's still a lot of interpersonal collaboration and discussing of the cases, and we still have that collegiality.

Paul Sax: [00:12:52] Good, good. You know, some of the time you are there. Yes. You're physically there, so you're staying in a hotel or an Airbnb or something like that. And so there is there's that dislocation as well. I'm hoping I hope that you can have a connection with the people you're working with.

Allison Nazinitsky: [00:13:07] So I tend to be a social person. I'm very social and so I make friends when I'm out of town.

Paul Sax: [00:13:14] Okay. So let's talk specifics now. Ine of the things that, you know, there's a huge concern about our specialty, our fellowships not filling. And frequently it comes down to compensation. People are worried that why should I do this extra training for a job that's going to pay me less than hospitalist work. And that's an understandable it's the quintessential opportunity cost of getting extra training in ID. So how does it relate to what you do?

Allison Nazinitsky: [00:13:41] Being locums, I'm able to create my own schedule and make sure that I have the quality of life I want. I tend to choose hospitals that allow me to spend the time I want with the patients. I'm not seeing 40 patients a day. That's not sustainable for me. I tend to enjoy jobs that are anywhere from 5 to 15 patients a day. As a locums physician, I'm allowed to choose that type of workplace. Some of the hospitals even have infectious disease pharmacists where I'm traveling to, and I love that. So when I'm interviewing at sites, if they have some ancillary support for their ID physicians, it's wonderful. And I get to learn every single day that I'm on at these sites. I would say that, you know, it's very taboo for physicians to discuss compensation. But as an physician, you know, we're paid very well. So you're able to work a fraction of the days to still be able to make what would be considered a full time salary for a physician. It's really good in that perspective and also for just having boundaries, because these sites, everything is done by the hour or by the job or by the call. You know, you're working 8 to 5 and after 5 p.m., if you're still working, you're getting paid overtime that you're on call at night, you will be paid for keeping your phone on if you get called or not. You're getting paid to keep your phone on at night and all ID physicians should be paid and compensated for keeping their phone on at night because it can be very disruptive to be woken up in the middle of the night from a phone call. And so as an ID locum, you really are able to have these boundaries that sometimes get pushed in other settings. And it's expected.

Paul Sax: [00:15:27] Well, I completely agree with you that having your phone on being available to the hospital is completely uncompensated. And it also is uncompensated when you do it on a weekend in a holiday, you know, you would expect maybe you get paid more for that. Do you have a sort of bonus clause in for weekends and holidays?

Allison Nazinitsky: [00:15:46] So as locums they have a list of about ten holidays that are paid 1.5 times the rate, but everything's negotiable. So when we're talking about Christmas through New Year's, when really it's a challenge to fill that spot, sometimes you can actually negotiate higher rates for that, those critical periods of time. And yes, everything's negotiable in the locums world.

Paul Sax: [00:16:07] So let me ask you about the dreaded pandemic that we've gone through, put a real premium on ID expertise. By and large, I think we did a good job in responding to the demands, but I was wondering how someone in your position where you're already in in your locums position when this hit.

Allison Nazinitsky: [00:16:25] Yes. So this is the crazy story is that I was actually pregnant right before the pandemic. I had went into preterm labor the day that Oklahoma shut down, March 15th, 2020, and I was actually out of town working. And so we were in the NICU out of town for over a month during the beginning of the pandemic.

Paul Sax: [00:16:49] What a story.

Allison Nazinitsky: [00:16:50] Yes, being locums, you have to budget and you have to be prepared for being off of work. Maternity leaves are not compensated. So I'm a contractor, so if I'm not working, I'm not getting paid. So fortunately, because I was pregnant, I already had planned to be off until August of 2020. And so I actually felt like I was on the sidelines. I was watching everything happen and I wasn't able to be part of it. I felt left out. I was reaching out constantly to everybody, Oh, my gosh, you know what's going on now? Like, what's it like? But I felt like I missed this massive -

Paul Sax: [00:17:30] Well, you had plenty of opportunity later, didn't you?

Allison Nazinitsky: [00:17:32] - I did. I did. But, you know, from the from the very beginning, I'm like, this is what we all go into ID for. And I was on the sidelines watching it from the sidelines. And I felt like I wasn't a part of it. So I have a I have a different perspective.

Paul Sax: [00:17:47] Well, then you came back in August of 2020, and as I said, there was plenty to do.

Allison Nazinitsky: [00:17:53] So I don't want to brag. Can I tell you about my locums job that I started in August of 2020?

Paul Sax: [00:17:58] Go right ahead and brag.

Allison Nazinitsky: [00:17:59] It was awesome. I actually did not physically go into any room. It was actually a tele medicine infectious disease opportunity. They wanted us physically on site at the hospital, but it was tele medicine, so I had a dedicated office and I flew out once a month for seven days and I did tele ID from an office one week a month from August 2020 through December of 2020.

Paul Sax: [00:18:27] Very interesting. I'm sure you actually over the course of your very diverse geographic locations, you see some remarkable cases, both pandemic related and of course, now non pandemic related. Do you find that there's professional satisfaction in it the same way that you envisioned when you were an ID fellow?

Allison Nazinitsky: [00:18:45] Professional satisfaction in ID locums? Yes. I love being able to go into a site and relieve the physicians of being overworked or whatever it may be. I get to see all the different pathologies. So you know, if I'm in Washington, you see different pathology, or if I'm covering Illinois, different pathology. And I think the most amazing part about doing ID locums is I see so many different practice patterns and I also see a lot of different practice setups of how things are done very well. Things like OPAT, for example, which can be very challenging to have a good OPAT program. But I've seen some of the most fantastic OPAT programs.

Paul Sax: [00:19:30] Oh share. Like what?

Allison Nazinitsky: [00:19:32] Oh, there's a hospital in Washington. It's just a well-oiled machine. Their case managers do so much for their program, they run all their insurance before we even are finished and signed off on the patient. They have already scheduled everything for the doctors. And then they do these post hospital visits.

Paul Sax: [00:19:55] You know, I'm going to ask you some practical issues. Let's say you have a patient that you do a consult on in the hospital who needs outpatient ID, follow up. You're really not in a position to offer that. How do you set that up?

Allison Nazinitsky: [00:20:09] So if I'm doing locums, some of the locums hospitals have ID follow up and have a clinic. Other than that, you really have to coordinate with their primary care doctors and work out, you know, discuss with them if this, then this and a lot of times. So when hospitals lose infectious disease doctors, so say a hospital goes from four doctors to one doctor, the first thing to go is the clinic because there's so much overhead with the clinic. And so a lot of these hospitals have functioned without a clinic for years, especially if they've been short staffed for years. Usually it's a primary care physician or sometimes you can get them arranged with another infectious disease doctor. But there's such a shortage of infectious disease doctors, especially in the Midwest, that sometimes it can be a challenge.

Paul Sax: [00:20:59] But that sounds like that's not your responsibility.

Allison Nazinitsky: [00:21:02] It's not my responsibility other than I really make it very clear in my documentation this is what should be done and make it as easy as possible for the primary care or whoever is going to be following that patient.

Paul Sax: [00:21:14] So one question that I have for doctors in practice is how they manage clinician advice calls. They're sometimes called curbsides and how, as a locums ID specialist, how do you manage those?

Allison Nazinitsky: [00:21:28] So I think it's always a challenge getting called over the phone because you can't fully trust what anybody's telling you. I like to see things to believe, you know, to be able to believe them. And oftentimes it's presented in a way that it's not as serious as what it really is. Three days ago, I got called on a patient with a one out of four strep intermedius in the blood. They were getting ready to discharge them and they asked me what antibiotic to send them out on. And the first thing I think is, you know, where's the abscess? Where are we going? Hunting, You know, where are we? Where are we? What's going on? And the first thing I recommended after just discussing with this person, I said, you know, let's get a Cat scan. Well, sure enough, they have a liver abscess. And so curbsides are really challenging. I think all should eventually be a consult for the patient's best interest. But having having it worked out where they are compensated or that you have abilities to review the EMR or fully discuss the case with the referring physician can be very challenging.

Paul Sax: [00:22:32] Okay, so now let's say there's an ID fellow who's hearing this podcast and they're thinking about doing something like what you're doing. What would you advise them?

Allison Nazinitsky: [00:22:42] Well, I want to tell all the fellows that there are some really good infectious disease jobs out there. Dr. Han and her episode discussed how happy she was infectious disease as private practice and anyone that can find that work life balance and find that niche, I'm so excited for her. And I want to say that there are good infectious disease jobs that pay well, that have work-life balance, where they feel supported. And so there are some really good jobs out there. But as an infectious disease locums, it's really flexible. There's just a lot of autonomy, you can spend the time you need with your family. It's enjoyable and rewarding.

Paul Sax: [00:23:21] That's great. So Alison, you've given us a really good insight into a different way of approaching the ID clinical career. So any final words?

Allison Nazinitsky: [00:23:31] Thank you so much for allowing me the opportunity to speak on ID locums as a career path. I think it's underrepresented. There's a lot of stigma, but it is really rewarding and it's wonderful.

Paul Sax: [00:23:44] Great, great. Once again, this is the Let's Talk ID podcast and I've been speaking with Dr. Allison Nazinitsky, who's an ID specialist who does locums work, and she's based in Oklahoma. And I strongly encourage you to reach out to her if you have any further questions. Thanks a lot, Allison.

Allison Nazinitsky: [00:24:00] Thank you.