From Fellowship to Full-Time Locums: Transition Plan by Quarter

It’s July 1st. Your fellowship just ended, the institutional badge is turned in, and your first full-time locums contract kicks off this month. You’ve got income coming in, but you also know this: locums can either be a bridge to burnout or a career that actually gives you your life back.

The difference is in your first four quarters.

You are not “just picking up shifts.” You’re building a business. A portable, contract-based clinical career. If you treat this year like residency-with-airports, you’ll regret it. If you treat it like a deliberate transition year, you’ll have leverage, options, and actual control by this time next year.

Let’s walk quarter by quarter, then zoom into months and specific to‑dos.

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Big-Picture Timeline: Your First Year as Full-Time Locums

Here’s the arc:

• Q1 (Months 0–3): Stabilize income and logistics, learn the locums game
• Q2 (Months 4–6): Optimize schedule, pay, and taxes; start building your “brand”
• Q3 (Months 7–9): Consolidate good sites, cut bad ones, negotiate like a grown-up
• Q4 (Months 10–12): Decide: commit to long-term locums model, hybrid, or permanent

Year-One Locums Transition Timeline

Period	Event
Quarter 1 - Month 0	Exit fellowship, sign first contracts
Quarter 1 - Month 1	Start first assignments
Quarter 1 - Month 2-3	Evaluate sites, refine schedule
Quarter 2 - Month 4	Engage CPA, set up LLC or S Corp if needed
Quarter 2 - Month 5-6	Mix of sites, test different models
Quarter 3 - Month 7-8	Drop low value assignments, extend good ones
Quarter 3 - Month 9	Renegotiate rates and schedule
Quarter 4 - Month 10-11	Plan next year mix
Quarter 4 - Month 12	Lock in Q1 assignments for next year

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Quarter 1 (Months 0–3): Stabilize and Learn the Game

At this point you should be laser-focused on three things: income stability, basic systems, and avoiding dumb mistakes that follow you for years (bad contracts, poor documentation, tax chaos).

Month 0: Final Months of Fellowship / “Pre-Launch”

You’re still in training or just finishing. Use this time ruthlessly.

At this point you should:

1. Decide your first 6–9 months strategy

   • One primary site with heavy weeks?
   • Or 2–3 sites rotating monthly?
   • My advice: for your first quarter, stick to 1–2 sites tops. You need repetition more than variety right now.

2. Register with 2–3 locums agencies (not 10)
   Look for:

   • Strong in your specialty (e.g., CompHealth for hospitalist, Weatherby, Jackson & Coker, etc.)
   • Transparent pay discussions upfront
   • Dedicated recruiter who actually returns calls

3. Lock down credentialing pipeline

   • Apply for at least 1 extra state license besides your current one.
   • Get your paperwork “kit” ready:
     • Updated CV in Word format
     • Board cert proof
     • Procedure logs
     • Immunization records
     • 3–5 references who actually answer emails
   • Create a “Locums Docs” folder with PDFs of everything. You’ll be asked for the same document 40 times.

4. Start a basic financial + legal skeleton

   • Open:
     • A separate checking account for locums income
     • A separate savings account for taxes
   • Meet with a CPA who understands physician 1099 income.
   • Decide if you’re starting as:
     • Sole proprietor (fine for first 3–6 months)
     • Or LLC taxed as S-corp (worth it once income is consistently high)

Item	Simple Start (Month 0–3)	Upgrade Later (Month 4–12)
Business form	Sole proprietor	LLC / S-Corp
Banking	1 business checking	Checking + high-yield save
Tax help	Annual tax prep only	Quarterly planning + prep
Bookkeeping	Spreadsheet	Software + bookkeeper

Month 1: First Assignment(s) Begin

You’re on the ground now. New EMR, new nurses, new call system.

At this point you should:

• Track everything from day one

  • Hours worked, shifts by site, travel time
  • Pay rates, bonuses, overtime policies
  • Annoying-but-critical details: call structure, support staff, consultant responsiveness

• Build a “first 5 shifts” checklist for each new site

  • EMR smart phrases / macros
  • Where to find:
    • Protocols (sepsis, stroke, etc.)
    • On-call lists
    • Transfer procedures
  • Who to call when:
    • You can’t get a CT at 3 am
    • You need admin backup for a difficult family/patient

• Start a simple income and expense log

  • Revenue by site
  • Travel reimbursements vs out-of-pocket
  • Meals, mileage, licensing fees, CME

This is boring. Do it anyway. You’re building leverage data.

Month 2–3: Evaluate and Adjust

By now you’ve seen the best and worst of at least one site.

At this point you should:

1. Score each site ruthlessly Use a 1–5 rating on:

   • Pay per actual hour worked (not just “rate per shift”)
   • Staff and consultant support
   • Workload and acuity
   • Safety and medico-legal risk
   • Commute / travel burden

2. Decide which sites are “extension candidates”

   • Good sites: request extensions before the agency brings it up. You want timeline control.
   • Mediocre but tolerable: negotiate better pay or better schedule before extending.
   • Dangerous or miserable: set an exit date and stick to it.

3. Clean up your admin life

   • Are you saving every contract and addendum?
   • Do you have your malpractice certificates per site?
   • Did you set up:
     • Password manager (you will have 10+ EMR logins)
     • Cloud backup for your important documents

Locums Site Evaluation Scores (End of Q1)

Category	Value
Site A	4.5
Site B	3.2
Site C	2.1

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Quarter 2 (Months 4–6): Optimize Schedule, Pay, and Taxes

You’ve proven you can survive. Now we stop acting like a temp worker and start acting like a consultant.

Month 4: Lock in a Baseline Schedule

At this point you should stop “saying yes to everything” and start designing your calendar.

At this point you should:

• Define your monthly targets

  • Desired net take-home per month
  • Maximum number of clinical days you’re willing to work
  • Days blocked for:
    • Travel home
    • Family/relationships
    • CME or board prep (if relevant)

• Structure your Q2–Q3 backbone

  • Aim for:
    • 1 “anchor” site providing ~60–70% of shifts
    • Optionally 1 backup site for flexibility and leverage
  • Don’t juggle 4–5 hospitals yet. You’ll bleed energy in transitions.

• Start saying “no”

  • To:
    • Random last-minute shifts that destroy your rest days
    • Long stretches (>10–12 days) without a break unless the pay is absurd

Month 5: Get Serious About Taxes and Business Structure

This is where a lot of locums docs get burned. First year feels great. Then the tax bill hits.

At this point you should:

1. Hire a CPA or tax firm that sees 1099 physicians all the time

   • Ask directly:
     • How many independent contractor physicians do you handle?
     • How do you structure reasonable S-corp salaries?
     • How do you handle multi-state income?

2. Decide on entity structure

   • If annualized income is heading north of ~$250k–300k:
     • Strongly consider an LLC taxed as S-corp.
   • If you’re unsure or income is variable:
     • Start as sole prop but set quarterly tax estimates now.

3. Set up quarterly tax payments

   • Open a separate high-yield savings just for tax money.
   • Auto-transfer 25–35% of each paycheck into it.
   • Pay your first or second estimated payment this quarter.

Month 6: Refine Your Niche and “Brand”

Not in the social media sense. In the “what kind of locums doc are you” sense.

At this point you should:

• Clarify your clinical positioning

  • Hospitalist who likes open ICU?
  • Outpatient IM who can handle high-volume walk-ins?
  • Anesthesiologist okay with solo rooms but not hearts?
  • Be explicit. Communicate that to recruiters. It reduces bad-fit offers.

• Develop a one-page “Locums CV / profile”

  • Bullet points:
    • Procedures you actually do independently
    • Environments you’re comfortable in (rural critical access, tertiary center, etc.)
    • Ideal schedule patterns (7-on/7-off, blocks of 5, strictly days/no nights, etc.)

• Begin tracking your effective hourly rate by site

  • Take:
    • Total pay for that assignment
    • Divide by total hours on site (including call, notes finished after shift)
  • Drop or renegotiate anything with low effective hourly rate unless there’s a very good reason (location, family proximity, etc.).

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Quarter 3 (Months 7–9): Consolidate, Negotiate, and Protect Yourself

This is the quarter where a lot of people either level up or stall out.

Month 7: Cut the Dead Weight

You know which sites are a problem. Stop pretending you don’t.

At this point you should:

• Formally exit bad assignments

  • Give clear, professional notice.
  • No drama, no bridge burning, but also no guilt.
  • “Due to scheduling changes, I’ll be unable to extend beyond [date]. I’ve appreciated working with the team.”

• Prioritize repeat assignments at your best sites

  • Continuity matters:
    • Staff knows you.
    • You move faster in their EMR.
    • You reduce risk because you actually understand their system.

• Start watching for “perm pressure”

  • Some sites will start nudging you:
    • “Have you thought about joining us full-time?”
  • Decide ahead of time:
    • Are you open to this within the next year?
    • Or are you firmly locums-only for now?

Month 8: Renegotiate Rates and Terms

You’re no longer a brand-new fellow. You’ve got a track record.

At this point you should:

1. Review all current and upcoming contracts

   • Look for:
     • Outdated rates compared to newer offers
     • Unpaid call
     • Cancellation terms that favor the hospital only

2. Go back to your agent (or hospital directly) with concrete asks Examples:

   • “I’ve done 60 shifts here in the last 6 months. For extensions, I’d like to move from $180/hour to $200/hour given the volume and night coverage.”
   • “Current call structure doesn’t reflect the actual burden. I’d like a call stipend of $X per night, or a minimum hour guarantee.”

3. Use your data

   • Show:
     • Shifts completed
     • Quality feedback (if you’ve gotten emails/thanks from leadership, keep them)
     • Consistency and willingness to cover tough blocks

Month 9: Risk Management Checkpoint

You’re exposed in ways W-2 docs are not. Handle that.

At this point you should:

• Confirm malpractice details site by site

  • Occurrence vs claims-made
  • Tail coverage: who’s paying, and do you have proof?
  • Get your own file with:
    • Policy numbers
    • Coverage periods
    • Confirmation of tail (email or certificate)

• Review your disability and life insurance

  • You’re 1099. No employer safety net.
  • Make sure:
    • Disability policy is in force and adequate
    • Beneficiaries are updated
    • You’re not relying on old “residency” group policies that ended

• Begin building a small emergency fund

  • Goal: 3 months of average living expenses in cash.
  • Locums schedules can evaporate with one admin change.

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Quarter 4 (Months 10–12): Decide Your Long-Term Model and Lock in Next Year

Now you’ve seen enough to make real decisions. It’s not theoretical anymore.

Month 10: Strategic Planning Month

You’re no longer “new.” Time to act like someone running a practice—because you are.

At this point you should:

• Review your entire year’s data

  • Income by site
  • Effective hourly rate by site
  • Time away from home vs at home
  • Which months felt overloaded vs underbooked

• Decide your next-year model Options:

  • Full-time locums as a long-term career
    • Double down on 2–3 anchor sites
    • Maybe add a high-paying “project” every few months
  • Hybrid locums + part-time employed
    • E.g., 0.5 FTE at a group + 6–8 locums shifts/month
  • Use locums as a bridge to a carefully chosen permanent job
    • Target 1–2 systems where you’ve done locums and liked the culture
    • Negotiate perm with actual insider knowledge of workload

Month 11: Lock in Q1 (and Ideally Q2) of Next Year

The worst locums feeling: it’s December 20th and you have nothing scheduled for January.

At this point you should:

• Have at least the next 3 months of work booked

  • Aim for:
    • 70–80% of desired shifts already contracted
    • Room for 20–30% flexibility or high-paying last-minute stuff

• Renegotiate or decline extensions with clarity

  • Decide which sites you’re taking into next year.
  • Communicate early:
    • “I’d like to commit to 7–10 shifts per month Jan–Mar, at [rate].”
    • Or: “I’ll finish the current block, but won’t be taking more dates after [date].”

• Calibrate your annual income target

  • If you overshot this year and felt wrecked:
    • Aim for slight income reduction via better rates, not more shifts.
  • If you undershot:
    • Identify:
      • Underused months
      • Higher paying markets
      • Specialty niches you can credibly step into

Month 12: Annual Review and Reset

This is your “owner’s meeting” with yourself.

At this point you should:

• Do a full financial review with your CPA/bookkeeper

  • Actual gross vs expected
  • Deduction patterns (CME, travel, licensing, home office)
  • Adjust next year’s estimated taxes

• Refine your systems for year two

  • Move from spreadsheets to proper bookkeeping if you haven’t.
  • Standardize:
    • Contract naming and filing
    • Assignment summaries (dates, pay, notes)
    • Travel routines (best airports, hotels with kitchenettes, rental car preferences)

• Re-evaluate your life outside medicine

  • Are you seeing your partner/family enough?
  • Is your time off actually restorative or just recovery?
  • Do you need:
    • More local assignments
    • Longer blocks off
    • Different mix of days vs nights

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Quick Reference: Year-One Locums Milestones

Quarter	Primary Focus	Key Outcomes
Q1	Stabilize & learn systems	Reliable income, 1–2 good sites
Q2	Optimize & structure	Tax plan, defined schedule model
Q3	Consolidate & negotiate	Better rates, dropped bad sites
Q4	Decide & lock next year	Clear long-term model, Q1 booked

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FAQ (Exactly 4 Questions)

1. How many locums agencies should I work with in my first year?
Two to three is the sweet spot. One often limits options and leverage; five just floods you with repetitive, low-quality offers and paperwork. Start with 2–3 that are strong in your specialty and region, then drop any recruiter who consistently lowballs or wastes your time.

2. Should I go straight to an LLC or S-corp before my first assignment?
Not necessarily. For the first 3–6 months, a sole proprietorship is fine while you confirm your income level and commitment to full-time locums. Once you’re clearly on track for high six-figure 1099 income, then shift to an LLC taxed as S-corp with a CPA guiding salary vs distributions. Don’t DIY entity setup based on random forums.

3. Is it a bad sign if a site keeps pushing me to go permanent in the first few months?
It’s a sign they’re desperate. That can mean leverage or red flags. If they’re pushing hard before you’ve even seen a full cycle of their census (e.g., winter for hospitalist, summer for ED), assume they’re trying to lock you in before you understand the real workload. Give it at least a few months—and a full, honest workload assessment—before considering perm.

4. How many different hospitals should I work at during my first locums year?
For most new attendings, 2–3 hospitals total in the first year is ideal. Any more than that and you’re constantly re-learning EMRs and workflows instead of improving your efficiency and negotiating position. Better to become a “regular” at a couple of sites than a confused stranger at six.

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Bottom Line

• Quarter 1 is survival and setup; Quarter 2 is optimization.
• Quarter 3 is where you cut, consolidate, and start being paid what you’re worth.
• Quarter 4 is decision time: long-term locums model, hybrid, or a very intentional permanent job—on your terms, not out of panic.