Private consultation in forensic pathology, part 9 — should young forensic pathologists do locum tenens?

A commenter on one of my recent posts noted that many offices are dealing with the inability to recruit forensic pathologists by hiring locum tenens pathologists, and some pathologists have chosen to do *only* locums work rather than getting a regular job in a ME office.   I started to reply at length to this excellent comment, but it got so long that I decided to make it into a post.

I am a fan of locum tenens — I work three days a month doing locum tenens at a local ME office to supplement my retirement and consultation income.  But… I’m not sure that it’s a good idea for a younger pathologist to do only locum tenens work.  Here’s why:

First, I’m not sure the money differential is as good as it feels. I think it’s mostly that you *see* the money doing locums (before it’s taken away) and you don’t see it when you work at a ME office because its taken away before you see it.  I feel like I make a lot of money doing a few consults and a few locums to supplement my retirement — until I cut that $12K check every three months to send to the IRS, pay my malpractice insurance, etc.

First, look at the real income from working for a ME office.  The average salary in the spreadsheet I recently posted is $277K nominal dollars on average.  But, as I’ve noted on mailinglists before, the NAME average on the job board understates the “real” average, at least to some degree. The reason is that the higher paying jobs fill more quickly, and the lower paying jobs fill more slowly.  That means that the jobs list is overweighted by the lower paying jobs.  In other words, while the average on the job list may be $277K, the “real” average is likely closer to $285K-$300K.  I’ll post my statistical model for this in a few days.   So… that means for a 250 autopsy equivalent year, you are making, say, about $1100-$1200 per autopsy equivalent.  But wait, there’s more.  People forget that there are a number of perqs associated with working for a ME office — different offices offer different things, but there is usually some sort of retirement support, now usually 401K or equivalent matching rather than defined pension plan, paying license fees, travel support, malpractice insurance, whatever.   In addition, government offices often have *multiple* ways to sock away pre-tax money for old age.  Back when I worked at East Carolina University, I put money in both a 401K and 403b fund.  When I worked at Knox County, TN, there was a 401a, 457, and a health fund that reverted to 401K equivalent upon retirement — so I could essentially triple dip. Knox matched 6% in both the 401a and 457, for a potential total of 12% of salary.   The number I keep hearing is that this is worth about an additional 20-30 percent of salary.  So, that $1100-$1200 becomes $1430-$1560 per autopsy.

I don’t know about a lot of places, but the locums offers I’ve seen tends to run about $2500 – $3500 per day or around $1000 per autopsy in places that pay per autopsy.   I make $3500 per day doing locums and do, on average, about four autopsy equivalents per day.  So, I’m getting paid $876 per autopsy, more or less.  From that, I have to pay my own malpractice insurance, license fees, etc.  I just finished my taxes.  Last year, I deducted about $17,000 in business expenses for both my locums and consult work combined.  Now, that includes costs for my consults, and as we all know, a lot of things are deductible for a business that are not deductible for an employee, but I’ll estimate about $7K of that cost is for my locums work.  I’m old, so I don’t contribute to a self-defined 401K or equivalent.   So, for me at least, doing locums does *not* pay as well as full-time employment on a per-autopsy basis.  I think it feels a lot more when you are working locums because nothing is taken out — no health insurance, no witholding, etc.  But it’s illusory, I think.

So, from a financial point of view, I think that it’s at best a wash, and is more likely better to be an employee.  I’m not going to be dogmatic about that, though.  If you were to say to me “Hey Bill, I’ve run the numbers and I’m a lot better off doing locum tenens,” I’ll believe you.  But you really should run the numbers carefully.

The money, though, is secondary to me.  The more important thing to me is the experience.  The things that defined me as a forensic pathologist had nothing to do with money.  When I started out in the Army, I did image analysis and worked on problems for the DIA, AFOSI, CIS, CIA, FBI, and agencies from Canada, Australia, Japan, Israel, individual state offices in the US and others.  I had my own personal mini-supercomputer.  I had a 3D visualization table.  I did work on early 3D scene reconstruction algorithms.  I ran a military computer network.  And on and on.  I got an international reputation, albeit in a small pool of people, for what I did.   Then my unit was disestablished, and I walked away —  but with experiences I could have gotten nowhere else.  I left and got a job with the Georgia Bureau of Investigation, where I basically ran the ME side of a very small crime lab in northwest Georgia.   I learned about management, dealing with DAs, funding, human resources stuff, and all the sausage-making of making an organization work.  As part of that, the GBI encouraged me to get formal training in management and I ended up getting a Masters in Justice Administration paid for by the GBI.  I left there to be the Director of Autopsy and Forensic Services at East Carolina University, where I was head of a larger office, and learned how to deal with academic issues, teaching, state-level budgeting/political/administrative issues, established a Fellowship, and wrote and executed a good-sized grant.  I wasn’t always successful, and I made a *lot* of mistakes, but at each stage I grew a lot professionally and as an individual.

Everybody has their own path, and there’s absolutely nothing wrong with saying “I just want to do autopsies and nothing else for the next 30 years.”   However, working in an office will *necessarily* provide opportunities for other things that are related to your profession.  Whether it’s becoming a Deputy Chief, working with task forces on child death or suicide or whatever, getting involved in cooperative research, or doing interesting things at an academic office, these are all opportunities that you will have more difficulty doing if you just do locums work.  It’s not all about the money.  You might say “I have absolutely no interest in admin stuff, or academics, or policy/advocacy in child deaths, or anything like that.”   Not now.  But, I’ll tell you this, you may not know that you do have an interest until you are exposed to it.  Also, a lot of time your interest in something arrives as you grow in your job.  I had no interest in getting involved in national policy issues as a 30-year-old pathologist, but I was very interested in my 50s.

The other thing that this kind of experience buys you is reputation.  Again, that may not be important, but it can allow you to get involved in all sorts of interesting things that are not offered to other folk.  I always think of two of my role models — Jack Edland and Robert Kirshner.  Dr. Edland is best known for the stand he took regarding the Attica prison riots and the price he paid.  Dr. Kirschner was known for his work exposing human rights abuses in Argentina during the days of the military junta. Dr. Edland was a role model because of his sacrificial role.  He taught me that prinicple was worth paying the price.  Dr. Kirschner taught me of the importance of using your knowledge for good.  And there are many others I have looked up to — Vince DiMao, John Butts, Page Hudson, Dick Froede, Bill Gormley, Kris Sperry, and on and on and on.   Working at an office put me in contact with these people.  Working in an office made *me* a known commodity, so that once I became a known commodity, I was offered opportunites to work on interesting and important projects — human rights abuses during the Gulf War and Afghanistan War periods, creating standards and best practices, advising on national cases, helping make policy, etc.  None of that would have happened if I had not worked at an office.

Finally, working locums limits your exposure to interesting cases.  In almost all of the locums opportunities I’ve seen, the part-time pathologist does not do homicides and other cases likely to end up in court.  Very recently, I was told that I could no longer work homicides where I do locums.  Why?  Because of money.  In my contract, a testimony day counts as an autopsy day, and neither the office nor the DAs want to pay that.  Until recently, a full-time pathologist was allowed to testify on my cases, but because of the recent Smith decision by the Supreme Court, that is no longer the case.  So, no homicides.  From what I’ve heard, this is very common for locums work.  It’s not a big deal for me.  I’ve been doing this for 40 years, and I’ve done a zillion homicides.  But if I were a young pathologist who only did locums, that would mean that I would not have very important experience in my most formative years.

So, even if the money did work out, I think doing only locums stand the risk of stunting your maturation as a forensic pathologist.

Are there advantages to doing locums only as a young pathologist?  Sure.  A lot of them.  You work only as much as you want, which leaves plenty of time for doing other things.  It may be perfect for a female pathologist who wants to take a few years off to raise a new child.   You get to see a lot of different places.  Doing a locums in a vacation spot means that you get to mix business and pleasure.  Work in Las Vegas or Reno and do a little gambling.  Work in Hawaii and see the beach.  Work in Denver or Salt Lake City in the winter and go skiing.  Sounds like fun.

But…  it really means that you are not focused on being the best pathologist you can be, it seems to me.  That’s a very basic philosophic issue.  As a Christian, I believe in callings and that vocations are callings from God just as much as being a pastor or minister.  As Paul wrote in his letter to the Colossians, “Whatever you do, work heartily, as for the Lord and not for men,”  and in Ephesians ” I therefore, a prisoner for the Lord, urge you to walk in a manner worthy of the calling to which you have been called, with all humility and gentleness, with patience, bearing with one another in love, eager to maintain the unity of the Spirit in the bond of peace.”  Remember that work is part of the plan of God.  At the creation, He put Adam and Eve in the Garden with the purpose of work.  As it says in Genesis, “The Lord God took the man and put him in the garden of Eden to work it and keep it.”  Work is all part of the plan.

Of course, some people live to work and others work to live and some are in-between.  It may be that your calling is not to be a forensic pathologist, but that Forensic Pathology is what you can to in order to pursue your “real” calling.  You want to write that Great American Novel or that world changing podcast projet or be the next great Country and Western musician.  In that case, it’s fine to sacrifice your maturation as a pathologist in order to fund and benefit that calling. Just know that you are paying a price.  And nothing lasts forever — maybe you will just do locums for a few years.   But if you are called to be a forensic pathologist, then you should be the best one you can be, and to enjoy that calling to the fullest.  As Solomon wrote in Ecclesiastes, “Also that everyone should eat and drink and take pleasure in all his toil—this is God’s gift to man.”   We are blessed to live in a time when most of us can choose what we do and not have it imposed on us as slaves, which was the plight of most of humanity for thousands of years.  That is a blessing from God and we should not dismiss it.