Residency Advisor
You roll into a new hospital on a Sunday afternoon, roller bag in one hand, credentialing folder in the other. The recruiter swore “they love locums,” the medical director sounded friendly on the quick call, and the rate is higher than anything you’ve ever seen as a staff doc.
Yet by Tuesday, you can already feel it. The nurses are polite but distant. The scheduler sticks you with the worst shifts. One partner docsplains the EMR like you’ve never seen a computer. You’re covering three services, you don’t have a locker, and somehow you’re the only one working the day after Christmas.
This isn’t random. It’s not “just how it turned out.”
Departments make very deliberate — and very quiet — decisions about how they’re going to treat locums. As a group. In meetings you’ll never be invited to. I’ve been in those rooms. I’ve heard the phrases they don’t say to your face.
Let me walk you through how those decisions are actually made, who pulls the strings, and how to read a department’s locums culture before you sign on for another month of being the disposable fire extinguisher.
The Real Meeting: How the Conversation Starts
The story never begins with you. It starts months earlier in a conference room, when someone says:
“We can’t cover the schedule next quarter. Do we get a locums or push harder on recruitment?”
In that moment, the frame gets set. Are locums viewed as:
- A lifeline that keeps the department from collapsing,
or - An expensive necessary evil they resent and want to minimize?
That frame controls almost everything that follows.
Here’s how those internal meetings typically go.
Small to mid-sized hospital, Tuesday afternoon, department meeting. Only a few people really matter in that room: the chair/medical director, the scheduler (often a power player), the nurse manager, and whatever admin type is pretending to “support” you but is actually watching the budget.
You’ll hear some version of:
- “We’re getting killed on coverage.”
- “Our FTEs are burning out.”
- “Admin wants numbers covered; they don’t care how.”
- “We can’t keep paying $X/hour; this is unsustainable.”
Then someone throws out the word “locums” and everybody’s prior baggage comes right to the surface.
If their last locums doc saved the department during a crisis, they’re already leaning positive. If their last locums vanished mid-contract, no-showed shifts, or left a trail of trash notes, they’re already primed to treat you like a necessary liability.
Departments don’t start neutral. They start with a story.
The Silent Categories: Which Box They Put You In
Departments informally sort locums physicians into categories. They rarely say it directly, but the attitudes are obvious behind closed doors. Here are the three boxes I’ve seen used — explicitly — in more than one group.
1. “Gap Filler — Do Not Invest”
This is the most common. The idea is: “We just need bodies to keep the lights on until we fix the real problem.”
Behind the scenes, the talk sounds like:
- “We’re not orienting locums like our own; waste of time.”
- “Give them just enough info so they don’t hurt anyone.”
- “They’re here for the paycheck, we’re here for coverage. Let’s keep it transactional.”
What this means for your day-to-day:
You get minimal orientation, the worst call, no say in scheduling, and very little help with politics. You’re the pressure valve. They assume you’ll be gone soon and treat you like it.
2. “Potential Recruit — Be Nice, But Not One of Us”
Occasionally, leadership quietly hopes you might be a permanent hire. They’ll never say that on day one, but they’ll say it in meetings:
“She’s solid. If we play this right, she might join.”
Then the tone shifts:
- “Get her on the chat threads.”
- “Loop him into the case conferences.”
- “Let’s make sure he isn’t stuck with all the garbage shifts.”
You’re still not fully trusted. You’re on probation status. But they’ll invest in teaching you subtle workflows and giving you a taste of the culture.
The tell: they care that you’re happy.
3. “Necessary Evil — Use and Contain”
This is the toxic one.
The narrative here is: “Locums cost too much, don’t care about the hospital, and leave messes.” Sometimes this is based on one bad experience. Sometimes it’s pure resentment driven by the CFO whispering about “runaway labor costs.”
Behind the glass door, the comments get sharper:
- “If they’re going to cost triple, they can work triple.”
- “They’re not joining, so don’t dump teaching on them.”
- “Keep them off sensitive cases; they won’t be here to deal with fallout.”
You’ll feel this culture quickly. Cold welcomes. No one uses your first name. You’re given tasks no one else wants but tightly excluded from anything meaningful.
Who Actually Decides How You’re Treated
It’s not the person the recruiter told you about. Not primarily.
There are four real power centers that determine your experience as a locums doc.
1. The Chair / Medical Director
They set the macro-policy: Are locums part of the team or mercenaries?
Chairs fall into a few predictable archetypes.
The “Old Guard Protector”:
Views partners as family, and everyone else as outsiders. You’ll hear, “My first duty is to my full-timers.” Locums here get scraps and suspicion. They’ll praise you to your face and undercut any suggestion of including you in decisions.
The “Pragmatic Operator”:
Doesn’t care how bodies are classified. Cares about throughput, coverage, and quality metrics. If you help those numbers, they’ll fight for you. If not, you’re gone. Locums here can do quite well — if they produce.
The “Burned Chair”:
Had a locums disaster: patient complaint, lawsuit, ghosting, or PR mess. Now all locums are guilty until proven innocent. You’ll feel this in the credentialing interrogations and in the unnecessary micromanagement.
2. The Scheduler / Chief Resident / Admin Coordinator
Underestimate this person and you’ll regret it.
They decide:
- Who works nights and weekends
- Who gets random holes in their schedule
- Who’s always “available” to plug gaps
They often carry deep resentment about being the one holding the staffing disaster together. Locums are either their salvation or their punching bag.
If they feel you’re easy, flexible, and low-drama, you’ll get more shifts and sometimes slightly better ones. If you push back — especially early — you get branded as “difficult” and the full-timers will quietly thank you for taking their worst slots.
3. Nursing Leadership
Nursing has a longer memory than physicians. They remember every bad locums they’ve ever had.
One nurse manager can poison your entire experience.
In leadership meetings, they’ll say things like:
- “Last locums didn’t answer pages.”
- “They don’t know our protocols; it’s unsafe.”
- “Our nurses have to babysit them.”
If the nurse manager dislikes the idea of locums, you’ll feel it as subtle friction: slow responses to requests, no help with unspoken norms, no protection when things get political. If they like you, they can also rehabilitate your status faster than any doc: “This one’s good. We want more like her.”
4. The Group Culture Before You Arrive
Some groups built their entire survival model on locums. Others are proud they “never used locums until COVID.” That history matters.
If a department has been chronically understaffed for years, permanent docs often burn out on training yet another revolving door of temps. They stop investing emotionally. They mute their friendliness. Not because of you, but because they’ve seen fifty of you.
On the flip side, in some rural hospitals, locums are the only reason vacations exist. Those places often treat you like royalty — because you’re the reason they can see their kids’ soccer game.
The Math They Never Show You: Why Resentment Builds
Behind every “we hate paying for locums” rant, there’s a spreadsheet.
| Category | Value |
|---|---|
| Locums Hourly | 250 |
| Employed Hourly (salary only) | 150 |
| Employed Total (with benefits) | 190 |
Here’s what really happens.
CFO prints a report:
Each locums shift is billed at, say, $250/hour. The employed docs, when you divide salary by hours, are at $150/hour. That gap gets weaponized in every conversation:
“Why are we paying 1.5x or 2x for someone who isn’t even staying?”
What no one bothers to mention in that room:
- The locums doesn’t get benefits, retirement match, CME budget, paid meetings, or job security.
- They’re absorbing travel hassle, housing uncertainty, unstable schedules, and higher personal risk.
- The premium is the price of flexibility and instant availability.
But the feeling in that room is simple: “We’re being ripped off.” And that feeling leaks onto you, whether they say it aloud or not.
So when you ask for a small accommodation — consistent OR block, slightly fewer nights, even a key card — that resentment colors the response:
“At that rate, they can walk from the parking garage.”
You’re not arguing with logic. You’re arguing with a budget narrative you never saw.
Orientation, Access, and “Accidental” Sabotage
One of the clearest windows into how a department has decided to treat locums is your first 48 hours.
Look at three things: orientation, access, and who they pair you with.
| Signal Type | Positive Sign | Red Flag |
|---|---|---|
| Orientation | Structured schedule with named contact | “Just shadow whoever is around” |
| Access | EMR, dictation, order sets ready on day 1 | Still waiting on logins after arrival |
| Scheduling | Mix of decent and tough shifts | All nights/holidays with no variation |
Orientation: How Much Do They Bother?
If they’ve decided you’re a gap filler:
You get a rushed 20-minute EMR crash course, a binder no one has updated in three years, and phrases like “you’ll figure it out” thrown at complex workflows.
If they’ve decided you’re a potential long-term asset:
You get: “Here’s our internal guidelines. Let’s walk you through how we handle borderline admits, sepsis alerts, stroke call, consult etiquette.” Someone sits with you for a few cases and gives real-time feedback.
This isn’t workload. It’s intent.
Access: The Hidden Power Move
Watch for these:
- Do your EMR credentials work the first time?
- Do you have dictation access, communication tools (like secure chat), and order sets?
- Do they set up your badge, parking, and lounge access without you begging?
I’ve seen departments “forget” to finish locums access for three days. You’re stuck calling others to put in orders, can’t see imaging, can’t message consultants. Then they complain, “Locums slow everything down.”
Sometimes it’s incompetence. Sometimes it’s benign neglect. Occasionally it’s not an accident. If leadership resents having to use locums, they don’t rush to make your life smooth.
Who They Pair You With
Strong departments deliberately assign a senior, patient partner to mentor new locums for the first few shifts. “Stick with Dr. Lee. She’ll show you how we really do things.”
Toxic departments pair you with the most burned-out doc on staff. The one already angry about locums. Then headset back:
“Let them figure it out together.”
You can guess how that goes.
Loyalty, Blame, and Whose Side You’re On
Here’s the most uncomfortable truth: many departments view locums as politically expendable.
When something goes wrong — an angry family, a complication, a complaint to admin — the calculus is simple:
- Permanent doc: we have to live with them, support them, or at least manage the politics.
- Locums: gone in 2 weeks. Easy to sacrifice.
You’ll see this in morbidity and mortality discussions, email wording after an incident, and which cases get quietly pinned on “the locums coverage” even if the system failed them.
I’ve seen chairs flat-out say in QA meetings:
“We can adjust the schedule so this case falls under the locums shift. Cleaner for us.”
That’s the dark side of being temporary. You’re convenient to blame. You’re not in the room six months later when the story gets retold.
On the flip side, if you perform well, cover tough gaps, and are not constantly on the radar for nonsense, some chairs will shield you more than they shield low-performing full-timers. Because you’re solving their biggest headache: coverage.
They’ll fight to renew your contract. They’ll push back on admin trying to cut locums costs. They’ll say, “No, this one stays. We build around them.”
Different side of the same coin. You’re a tool in their political battles.
How Departments Quietly Rate Locums (And Talk About You)
No one hands out scorecards, but they exist. Not always on paper — often just in quiet hallway conversations.
The categories are shockingly consistent:
- Clinical reliability (Do they miss stuff?)
- Speed (Do they tank throughput?)
- Drama level (Do they generate conflict?)
- System fit (Do they follow our norms?)
- Will we be embarrassed if we keep using them?
After a few shifts, the leadership subgroup will have a mini-debrief.
It sounds like:
- “He’s slow but safe. Use on lower-volume shifts.”
- “She’s fast but makes nursing nervous.”
- “Techs say he’s rude. I’d pass on extending.”
- “She’s great; if she wants more weeks, give them to her.”
Those informal ratings decide whether you get invited back, how your schedule looks, and whether anyone invests in making your life easier.
You almost never hear this feedback directly. That’s the problem. You just feel it.
Reading the Room: How to Tell in Week One What Box You’re In
You can’t control their history with locums, but you can read the environment fast and decide if it’s worth staying.
Pay attention to small details:
Who meets you on day one?
If it’s a senior partner or the medical director, there’s at least a chance they care. If it’s a frazzled charge nurse who says, “Oh, you’re the locums? Didn’t know you were coming today,” you’re already an afterthought.
Do they use your name or just “the locums doc”?
If you hear staff say “the locums” instead of your name, that’s not just shorthand. It’s a category. You’re interchangeable by design.
How do they talk about previous locums?
Listen carefully. If every story starts with “we had this terrible locums who…”, that tells you how they’ll talk about you when you’re gone. And how much benefit of the doubt you’ll get.
What happens when something small goes wrong?
EMR glitch, admission disagreement, family upset. Does leadership default to: “Thanks for flagging that, let’s fix the system,” or do they immediately side-eye you? That reaction tells you where you stand.
How High-Value Locums Get Treated Differently
There’s one more layer to this: once you’ve proven you’re not a disaster, some departments quietly upgrade your category.
You go from “gap filler” to “asset” if you hit a few marks:
- You show up reliably. No drama around travel.
- Your notes don’t create billing or compliance headaches.
- Nurses say, “We like working with them.”
- You don’t dump on daytime, you actually close loops.
- You quietly absorb some extra work when they’re in a bind.
When that happens, the internal discussion shifts to:
“We want this person back. How do we keep them happy without pissing off our full-timers?”
That’s when you might see:
- Better schedule offers
- Earlier access to next month’s shifts
- A little more flexibility on your requests
- Invitations to internal chats or case reviews
- Subtle courtship to go permanent
Just understand the game: they’re still protecting their core group first. You’ll rarely get the best shifts; you’ll get the best of what they consider “locums-acceptable.”
Final Word: What Really Matters Behind Those Doors
There’s a lot of noise in how departments talk about locums. Underneath it, the decisions are simpler and much colder than anyone admits to your face.
Three things to carry with you:
Every department has already decided how they feel about locums before you arrive. You’re fighting their past experiences, budget resentment, and group culture — not just your own behavior.
Power over your day-to-day life sits with a handful of people: the chair, the scheduler, nursing leadership, and whoever controls your access. Watch them closely. Their attitude is your reality.
Once you understand which box they’ve put you in — gap filler, potential recruit, or necessary evil — you can make clear-eyed decisions: stay and milk the paycheck, invest and build a long-term relationship, or walk away and find a place that treats you like a colleague instead of a disposable patch.
You can’t control what they say behind closed doors. But you can stop being surprised by it.
