The Toxic Letter of Reference

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I read a residency application this cycle which seemed basically fine.  Reasonable experience, fair letter of intent, decent interest, etc.  Then I got to the letters of reference.  One of them basically said, “Don’t take this person.”  That was it.  Their application immediately made it into the “do not rank” list.  Does the applicant know they have such a letter of reference in their pile?  I doubt it.  This is the toxic letter of reference.

Ostensibly, letters of reference are functionally designed as another check to ensure someone you are hiring is competent and good to work with.  For residency and intern applicants, the letters of reference have been documented as being the most important part of an application.  Most students stress and worry about their grades and GPA and class rank, never realizing that their combative attitudes with faculty about grades are probably actually worsening their chances of matching due to the negative impact of their attitude on the possibility of getting a good letter of recommendation.  But I digress.  The point is, letters of reference are extremely important.  They signal to the people reviewing your application that you are “like them” and can do the job.

I recommend that, when you ask for a letter of recommendation, you specifically say, “Can you write me a GOOD (or strong) letter of recommendation?”  If you ask a faculty member who may not feel that you did a very good job and just say, “Can you write a letter of recommendation for me?” they could very authentically say “yes” and then not write a good letter.  It is much harder to tell someone “yes, I will write you a good letter” and then write a bad letter of recommendation.  I can only imagine someone doing that if they want to deliberately undermine the applicant, which I have a hard time believing would happen in veterinary medicine.  However, I can imagine someone writing a _generally_ good letter of reference but with a couple of “areas for improvement”.  That doesn’t necessarily make it a bad letter of reference- we all have areas to grow.  But if one of those “areas for improvement” is exactly what the people need in an applicant, it could sink their chances.  It becomes a toxic letter.

I applied for a few jobs for which I was eminently qualified.  I interviewed for two of them and ultimately did not get an offer for either.  I also didn’t even get an interview for a job that I thought I would be a shoe-in for.  Now, it’s entirely possible that these places want someone different from what I bring.  But I had to pause and ask myself if one of my letters was toxic.  Not bad, per se, but maybe they said something specific that the readers interpreted as, “This person is not for us.”  How do you identify a toxic letter of reference?

First, you have to recognize the possibility.  Could this explain why your application isn’t going through?  Have you applied to vet school four times, gotten positive file reviews, and still not gotten an acceptance?  Maybe you have a toxic letter.  Have you done an internship, specialty internship, second specialty internship, have several publications, a nice personality, and still not getting a residency?  Maybe this is because of a toxic letter.  When things just don’t feel “right” or you are looking at your application and comparing it with others and yours is WAY behind in terms of progressing your career, consider the possibility it may be because of a toxic letter.  Of course, it can also be the vagaries of the selection process, so you never really know.

Next, can you identify if you have a toxic letter?  This is obviously difficult to do, as asking the people who wrote you the letters is unlikely to yield a positive result.  However, you certainly could send a politely worded email along the lines of, “I am having difficulty matching for a position.  Do you think there is anything in your letter that could be misconstrued or taken in a negative light?”  Depending on how prickly the letter writer is, they would be fine dismissing your fears or could take umbrage.  A slightly safer method may be to ask someone who has seen your application packet- such as an acquaintance, mentor, or colleague- and ask if they see any problems with any of your letters.  Don’t ask for specifics (“whose is it?”), just get a sense of if there might be a problem.  If they say, “No everything looks great” I would take them at their word.  If they say, “It may be worthwhile to get different letters”, then do so.

Finally, what do you do about this situation?  You have two possibilities.  One is to replace a single letter writer, if you are able to identify the specific one you think could be a problem.  The other is to do a complete swap out- find 3-4 totally different people to write you a letter.  Obviously, replacing 3-4 good letters of reference can be quite challenging, so I recommend this only as a last resort.  However, if you have good relationships with a lot of colleagues and bosses, it may be a reasonable choice.

It is immensely frustrating to feel qualified for a position but continue to get turned down.  It is most likely this is due to the vagaries of who is reviewing applicants and what they are looking for.  But it is possible that you have a toxic letter somewhere in your references.  Consider the possibility, but don’t spend too much energy worrying about it.  I think it is exceedingly rare.

Better is the Enemy of Good

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You all know I strongly advocate that you Aim for Zero.  The basic premise is that those who aim to excel (to be a +1) often fall flat and end up being a liability (a -1).  I heard one of our surgeons telling his resident a line that really stuck with me, “Better is the enemy of good.”  The resident had done a perfectly fine job of dissecting out a mass.  But they wanted to get it _even cleaner_ than it was.  In doing so, they ended up tearing some important vessels which set it to bleeding.  It wasn’t catastrophic- the patient did fine- but there was blood loss that was unnecessary.  The resident had done a good job.  They messed it up by trying to make it better.

I see this constantly.  Novice researchers will take an idea that is good and then tack on a bunch of other ideas and bells and whistles to make it the “perfect research project”.  Then it’s either too complicated to do the project, or they start it and something happens because of the additions, or the data is too complicated to analyze simply.  

Students on the anesthesia rotation want all of their patient’s vital signs to be “perfect”.  They want to normalize HR, normalize BP, normalize ETCO2, everything.  The problem is, in trying to make one number perfect, you often upset another number.  Rather than trying to make the patient’s BP to be 120/80, I ask them, “well, is it acceptable?”  Yes, the BP is acceptable.  But it could be better!  Now they’re using inotropes to get the BP “normal” and the patient’s suffering tachycardia as a result.

Those applying to vet school suffer from this a lot.  The competition is so fierce that they are trying to eke the last 1% of improvement out of their application.  This is most obvious in the essays and letters of intent.  Students have asked, “The essay has a word limit of 2000 and I’ve only used 1800!  Is that OK?”  I’ve also seen students who have written an essay and then revised and revised and gotten feedback and revised some more and are still unhappy with it.  Why are you unhappy?  Because you don’t think it’s “perfect”?  

Here’s the problem: there is no such thing as perfect.  Everyone evaluates applications in a subjective manner, because evaluators are human.  I’ve done research studies which show that even experienced evaluators differ on what they think is a good essay.  There is no perfect essay for all evaluators.  Stop trying to make one.  Is it good?  Is it reasonable?  Is it your own voice, and reflects who you are and what you think?  Did you do SOME editing and make sure SOMEONE looked over it?  Then you’re done.

Put down the pen, walk away from the keyboard.  Don’t agonize over getting the perfect application.  There is no such thing, and you have less control than you think over whether you get into vet school or get a certain position.  Very qualified candidates don’t get selected and very unqualified ones do.  It’s the nature of the world.  Do what you can, but be content with good.  Trying to make it better will likely only fall flat.

Before I Die

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My wife and I were walking around downtown Asheville, NC several years ago and there was a whole fence made into a blackboard on which you could write with some provided chalk.  There was a prompt on the board, “Before I die, I want to…”  People had written all kinds of interesting things.  “Fall in love” “See Vietnam” “Visit my brother” “Change the world” “Create something beautiful” “Help my friend Angie” “Get sober”  Hundreds of these were written there.  My wife took up the chalk and wrote the best answer.

I’ve thought about that wall a lot since encountering it, specifically with regards to how we can use the lesson to improve our lives and our professional progression.  I teach personal finances to the vet students, and a segment is about retirement planning.  One of the questions is, “If you didn’t have to worry about money, how would you spend your time?”

I think this question is really important for determining your life priorities.  Would they finish vet school?  Would they go be a veterinary clinician and help animals?  Would they travel the world?  Spend time with friends and family?  Donate the money to help the less fortunate?

Both of these questions help us distill down what is actually, truly, really important to us.  So often we get sucked into the natural progression of our career.  Finish high school.  Go to college.  Finish college.  Go to vet school.  Finish vet school.  Go to practice or do an internship.  Finish internship.  Get a residency.  Finish residency.  Get a private practice job or become an assistant professor.  Become an associate professor.  Get promoted.  Become a full professor.

It is an almost endless series of if-then statements about our life.  Some of these may happen in your personal life, too.  Get a decent job.  Get married.  Have kids.  Send kids to school.  Retire.  Die.

So here’s the question.  Before you die, what do you want to do with your life?  We all only have a finite amount of time on this planet.  You.  Will.  Die.  How do you want to spend your finite amount of time?  Do you want to spend it in school for 8 (or 12…) years?  Do you want to help others?  Do you want to have a wide variety of experiences?  Do you want to create a great family setting for your kids?  What do you want?

There’s no right answer, and everyone’s answer will differ.  But I think this exercise is important, especially for those who struggle with whether they want to be a veterinarian.  Or to specialize.  Or to enter academia.  Or with any other major decision in our lives.  If you never ask the question, you are likely to just be swept along the current our society (or your family, or your friends) dictates.  You won’t carve your own path.

If you answer this question now, a priori, it will help you make all future decisions.  You can refer back to your answer to this question when you are faced with a decision.  Will saying “yes” to that decision further you along the path you decided you want to pursue before you die?  It’s similar to having a mission statement– it relieves the burden of deciding as much in the moment.

Fortunately for me, my wife’s answer perfectly guides our decision making in life.  “Before I die, I want to keep doing this.”

My Experience with AI

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In the early 1800s, some textile workers in England opposed the use of certain automated machinery in their work.  They destroyed machines in organized raids and were eventually defeated by the powers that be.  They called themselves “Luddites” after a mythical character named Ned Ludd.  I am a luddite.  I did not have a phone with a screen until well after they became common.  I have never owned a tablet.  I am generally skeptical of new technology.

When new technology is presented, there is a curve of adoption.  The innovators are the ones who create the technology and work through the initial bugs.  The early adopters are technologically savvy people who want the best and new stuff- think of the people who line up for the latest iPhone.  Once a piece of technology has been proven, the early majority are a large bulk of the population who begin to use it and the late majority lag behind due to finances, opportunity, or lack of interest.  Finally, the laggards are the ones who resist the technology and only adopt it when it’s necessary for their functioning in society.

To be honest, on some things I am an early adopter.  I had a bulletin board system (BBS) that I was the sysadmin for in the early 90s (this was an early version of the internet, very cutting edge at the time).  I got on Facebook and Gmail as soon as I could in the early 2000s.  I am an Excel and Word super user.  We bought an EV last year when less than 8% of cars sold were EVs.  I have this love-hate relationship with technology.  So, when AI came out, my initial response was “Meh”.

Being somewhat into technology growing up, I was always fascinated with the Turing Test and sci-fi depictions of the future.  When ChatGPT came to prominence in 2022 and I thought, “Dang, this thing can absolutely pass the Turing Test”, I was impressed.  And then I ignored it.

I have always said, “A smart monkey and a good computer program can do my job as a clinician”.  Seriously.  Medicine is just a huge list of if-then statements.  If you had the patience to program it, you could absolutely put every variable about a patient and situation and come up with a decision tree for every circumstance.  I do this on a micro scale for the students- I trace out flow charts for common complications such as hypotension and a vocalizing dog post-op.  Once I saw how well ChatGPT did, I thought, “That will definitely replace us some time in the future.”

Fortunately, that future is not tomorrow, and maybe not even in 10 years.  It would require someone being very intentional to give an AI enough information to make good clinical decisions.  I’m sure it will happen, but I think “veterinary anesthesia” is a pretty low-interest domain to be working on.  By extension, I think veterinary medicine is a relatively low priority.  They might have decision-helping AI in human medicine relatively soon, but given the conditions and species we have to deal with, I think it will be a while for us.

However, that was all speculation until I decided to play with it.  My university has a deal with Microsoft Copilot such that the data is kept on a separate server and isn’t used to further Copilot’s algorithms.  One of my concerns about AI had been how the data I enter is used, and also I didn’t want to give them my email address.  So this summer I opened up Copilot and played with it.

Someone suggested AI can be used to plan travel itineraries.  I asked it to create a 5-day itinerary in London for someone interested in breweries, Neil Gaiman, and the Rivers of London books and didn’t like to visit typical tourist locations.  What it came up with was… fine.  Nothing that I couldn’t have done with a little bit of searching with Google Maps (my usual way to create an itinerary) and also nothing particularly interesting or remarkable.  It didn’t give me any sites related to Neverwhere or the Rivers of London series, for example.  It was fairly generic.

Another suggestion I got was using AI to start a letter of recommendation.  Although this may feel inauthentic, in reality most of us who write letters pull up an old letter we wrote for someone else, rework the details, and call it good.  Is that so different from starting with an AI template?  I asked Copilot to write a five-paragraph letter of recommendation for a student with such and such characteristics.  What I got was, again, basically fine.  It used a fair number of catchy words and phrases, which is fine, but not my preferred writing style.  I had to rework a fair amount of it.

Finally, I was asked to write a letter of support for a grant application.  I don’t do grant applications.  So I went to Copilot and asked it to write such a letter, and gave it the organization, the name of the project, the discipline, etc.  It produced a letter that was probably decent.  I read it, then went and wrote my own.  It gave me a good starting point.  It gave me some ideas to use as a jumping off point.  But I definitely did not want to use it even as a template- it was just too sterile and, again, used a lot of catchy phrases.

I also asked Copilot to make some novel images with a variety of prompts.  These were fine, but there was always something not quite what I wanted in them.  But for creating images to use in lectures, rather than searching for hours on Google, it might be a good alternative.

Ultimately, I was pretty unimpressed with Copilot.  It certainly wasn’t magic.  Yes, it could pass the Turing Test.  But that didn’t mean the output was usable off-the-shelf for me.  It’s likely that the prompts I gave it were not up to the task to produce what I really wanted- prompt writing is its own separate (and difficult!) skill.  I find using AI can be good for inspiration or to build a template.  But it will definitely not replace my default method of writing.

Autonomy

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I’m reading a book right now about habits– how and why they form and how to use them.  In it, the author cites a study in college students where they are put in a room with freshly baked cookies and told not to eat them for 5 minutes.  Then, they have to complete a willpower test.  There were two groups.  One was asked to please not eat the cookies and was treated kindly, with respect, and they were asked to share any ideas about how to improve the research.  The other was ordered to not eat the cookies, and that is all.

Neither group ate the cookies.  But the group who was ordered to eat the cookies performed much worse on the willpower test.  The researchers supposed it was because participants had a small degree of autonomy in the research.  When students were treated like machines, they didn’t do as well as when they were treated like humans.

Humans LOVE autonomy.  We HATE being told what to do.  This is one of the core tenets of Self-Determination Theory (SDT), which I have discussed before.  Study after study has demonstrated that, when you take people’s autonomy away, they perform worse, and when you give them autonomy, they do better.

For example, one study had college students construct Erector sets.  One group was given a variety of options for approaching construction and the other was given very specific steps and goals to meet.  The group with the greater autonomy reported more interest, satisfaction, and persistence than the group with less autonomy.  This study was published over 40 years ago, and there have been hundreds confirming the results since then.  So why do we keep telling people- for The Vetducator context, students and veterinarians- what to do and how to do it and with whom to do it?  Why in the world don’t we embrace autonomy?  I have some ideas.

First, America has Puritanical underpinnings and the protestant work ethic pervades our culture.  I’m not a sociologist, but my impression is that these beliefs often focus around punishment and rewards, and doing what you are told to do.  Puritans have rules, and by gum we will follow them.

Second, restricting people’s autonomy and telling them what to do “makes sense”.  It’s assumed that those in positions of power are better, and therefore more able to dictate how to do a thing.  I’m the expert, or the teacher, so I know best, and you do what I tell you.

Third, it feels good.  Who doesn’t love ordering others around?  Have your every whim met?  There’s a reason slavery predates written history and was practiced in almost every ancient civilization; when people focus more on their individual interests than the collective good, it’s easy to fall into the habit of exerting your will over others’.

Fourth, restricting autonomy works… in certain circumstances.  On an assembly line, you want everyone doing their correct steps.  In the operating room, you want everyone following the checklist.  It reduces error and improves outcomes.  However, an important caveat is that the _best_ systems ALSO incorporate autonomy with strict rules.  For example, the ability to shut down an entire assembly line if a worker feels something is unsafe or not working.  Toyota used this to great effect when they embraced the principle of Kaizen.

Fifth, we tend to see things in black and white.  Humans love right and wrong, yes and no.  Total autonomy?  All chaos!  Total control?  Absolute smoothness!  But that’s not what giving autonomy is.  In the Toyota example, they still had to follow the rules, but just that little bit of extra autonomy made all the difference.  You don’t have to go whole hog, even a little more autonomy makes people feel more in control of their lives.

All right, so autonomy is awesome and we should do more of it, but humans are not great at embracing autonomy.  So what do we do about it?

Teachers – Give students as much choice as possible.  Let them choose from a variety of assignments.  Let them choose the topic to cover.  Let them decide who to work with (including only themselves!).  Give them choices for which questions to answer.  The ACVAA specialty written exam embraced this principle years ago- you had to answer 5 out of 8 essays.  Consider giving them the choice on when to submit assignments.  Wherever you can and it makes sense, give students choice.  I realize that all of this might read as “chaos”, but I assure you it can be done in a controlled manner which does not throw your entire semester into disarray.

Bosses – Allow employees to decide how to spend their time, what to work on, with whom, and how.  Maybe not all the time, probably not for every task.  For clinical faculty, someone has to be on clinic duty- we can’t all be off doing different fun research projects, but the faculty can decide who is going to cover that block.  Again, it’s not all or nothing.  Give credit for peer-reviewed publications regardless of the “impact factor” or “robustness” or if it’s medical or educational in focus.  This allows faculty to explore their interests, rather than feeling compelled to constantly pursue projects that will only get into high impact factor journals.  Let people set their own schedules and deadlines.  Wherever it’s not absolutely essential, do not impose rules.

Students – Unfortunately, you don’t get a lot of control over your own autonomy.  Sorry.  So, try to do what you can within the confines of the rules you have been given, and find autonomy wherever you can. Enjoy looking through and choosing electives. When sitting in a restrictive class, remember that you CHOSE to go to vet school.  Choose when to study, how, and with whom.  Recognize that you control when during the day and week you work on a project, even if it has a specific deadline.  On a group project, work with the others to choose roles most suited to each member.

Once you realize the importance of autonomy, you start to see everywhere- situations where people have autonomy and where they don’t.  You can see people who don’t have a lot of autonomy- they’re just going through the grind day to day, almost with a sense of hopelessness.  When you see people who have some autonomy, you see that they engage with their tasks in a more substantive way.  Having autonomy isn’t a panacea- there are still days that suck- but having some is better than having none.

Writing External Letters for Promotion and Tenure

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We just went through P&T “season” in academia and I was asked to write about a half dozen external letters and I read several dozen written for our many faculty who were going up for promotion and tenure.  I learned some lessons I wanted to share to make the process easier for you, when the day comes when you get asked to write an external letter.

What is an external letter?

At most institutions, one of the criteria for promotion from Assistant Professor to Associate Professor is developing a regional and national reputation.  For promotion from Associate Professor to full Professor, it is developing a national and international reputation.  There is a lot of data that contributes to this distinction, but one of the most important is external letters.

External letters are solicited from faculty at other institutions, in your discipline, at or above the rank to which you are promoting.  That is, if you are promoting to Associate Professor, external letters from other Associate Professors or Professors will be solicited.  They may know OF you and possibly know you personally but have not worked substantially with you.  This is because the point of the letter is to find out what an unbiased individual in your field knows about you and your work.  In almost all cases, external letters are solicited by the department chair, although one private institution I know of has their faculty contact possible letter writers.

Once an email is sent to a potential letter writer, they respond yea or nay.  If there is a potential or actual conflict of interest, it is brought up at this time.  For example, one faculty member for whom I was asked to write a letter has done several research projects with me and currently had a couple of projects ongoing.  I told the department chair this in replying to their solicitation and they agreed this was too much of a conflict of interest so went on to ask someone else.

The letter writer usually gets the department’s promotion and tenure guidelines and the faculty member’s CV.  They may be given student evaluations, an explanation of what to write, and other supporting documents.

How to write an external letter

If you are provided with directions, follow those carefully.  Some institutions specially ask “would this person be promoted at your institution” and others explicitly direct you to NOT indicate if the person would be promoted at your institution.  Some will provide specific items they want you to comment on.  Some will give you very little direction.  Read and follow the directions.

Something I noticed in several letters I read this year and appreciated was opening with a brief note of thanks.  Something along the lines of, “Thank you for providing me the opportunity to review Dr. X’s application and provide this letter of support.”  It struck me as gracious and generous and I’m going to start doing it.

You should start with how you know the candidate.  Have you ever worked with them on a committee?  Met them at a conference?  Worked on a paper with them?  Know them purely by reputation?  This allows the reader to put your letter into context and make sure a conflict of interest does not exist.

As usual, I like a five-paragraph essay format, so the final sentence in the opening paragraph lists the major items you are going to cover.  This is almost always teaching, research, and service.

Each paragraph then summarizes what the letter writer believes are the most salient points in the applicant’s career that makes them suitable (or not) for promotion.  This assures the reader that the writer actually evaluated the candidate’s application packet.  It also highlights important parts of the candidate’s career so the reader can put the information in context.  Personal experiences and perspectives can reinforce some ideas.  For example, one letter I read this year said, “Dr. Y was the “it” professional at this national conference.”  That suggests the candidate has a solid, wide-reaching reputation.

The conclusion paragraph should include the letter writer’s ultimate recommendation and summary.  Usually, this is “I enthusiastically support Dr. X for promotion to Professor based on…”

If you decide to not recommend the candidate for promotion and/or tenure, you should be explicit and declarative.  The department head needs to be able to understand your reasoning so they can advise the candidate and the faculty at the candidate’s institution.  A negative external letter is a pretty big deal.  It’s not impossible to successfully go through promotion and/or tenure with a negative letter, but it’s going to make the process much more challenging.

Conclusion

Writing external letters is a professional responsibility higher-ranked faculty members have as part of being in academia, similar to doing peer reviews for journals.  It’s an important and serious responsibility which can have significant consequences on the career of other faculty members.  If you agree to write an external letter, take it seriously and make sure to follow the instructions.

You Found This Blog Too Late

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What do you do if you have found this blog after you have submitted your application materials, or after you did an interview, or after you scheduled your clinical year?  You read some of the advice and realize, “Uh oh, I didn’t do that.”  Well, now what?  Fortunately, all is not lost.

First, realize that the information on this blog is just one person’s opinion.  I have a lot of experience, but different people look for different things.  If you read some piece of advice and think, “Dang, I didn’t do that, everyone will think I’m terrible!”  The truth is, they won’t.  There are many people in this world and they all prefer different characteristics in mentees, students, future colleagues, etc.  Don’t beat yourself up because you didn’t do something you read on here.  It’s very likely the people you are interacting with value things other than what I value.

Second, it’s in the past, so it’s beyond your circle of control.  If you’ve already scheduled your senior year and you won’t have essential specialties before the VIRMP applications are due, there isn’t a lot to be done about it.  Your schedule is set.  So don’t stress about it.  It is what it is, make the best of it.

Finally, take whatever advice you CAN apply now and start to do so!  If you feel you didn’t do well on an interview , work on improving for the next time.  If you messed up your schedule, try to do the best you can with what you have.  There are very few things you can do in your veterinary progression which are fatal flaws.  Almost anything can be dealt with.  Find the advice which can work for you, adapt it for yourself, and apply it for next time.

Veterinary Locums Work

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Image of a plane flying overhead.
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The White Coat Investor blog recently published an article about locum tenens work in human medicine, and it made me realize there are some notable differences from veterinary locum work.  Many people may not know about locum opportunities, and it’s a benefit of academia I’ve mentioned before.  For those who are interested in academia, or even those in private practice who want to spend time teaching, this is an introduction to veterinary locum tenens.

Locum tenens literally means “place holding” and is a short-term work commitment.  Many locums are short- 2-4 weeks- while others are long enough to cover maternity leave- 6-9 months.  Let’s break down how to find locum jobs, what the process is like, and advantages and disadvantages.

Finding Locum Jobs

Most locum jobs will be found in academia, although private practices will also sometimes employ locums, particularly when they’re also searching for a full-time and hard-to-get specialist.  Finding locum positions depends on the discipline.  In anesthesia, an email gets sent out to ACVA-L, to which most anesthesiologists are subscribed.  Other disciplines without a universal listserv may use more specialized listservs (e.g. Society of Veterinary Soft Tissue Surgery), post on Linkedin, post on social media, or put the listing up on the specialty’s job board website.

Personal connections are also a valuable source for locums.  About half of the time I do a locum, it’s because I get an email from someone I know who needs a locum for a specific time frame.  Many institutions which have an open position posted for a new faculty member will be amenable to locums- you just have to email the contact listed on the full-time position posting or reach out to the department head and ask if they are interested in you providing locum coverage.  Some universities may list locum positions on their employment site, although this is uncommon.  As far as I know, there are no third-party companies facilitating locums like there are in human medicine.

Locums Process

At least in anesthesia, once an email goes out to ACVA-L, you only have maybe a day or two to reply before the locum position has been booked up, in my experience.  So you have to be ready to jump on an opportunity that comes up.  Usually, institutions are looking for a locum for specific dates.  If it lines up with your availability (you’re off clinics and don’t have major teaching/research responsibilities), you email the contact person and indicate your willingness to help.  Sometimes, the details of the locum will be provided up front (e.g. pay, what expenses the institution pays vs. what you pay), but many times you have to ask in the email.  Most locums pay between $5-10k/week, and some of them cover your expenses (travel, lodging) while others do not.

Here’s a really important note: some employers will pay you as a W-2 and some will pay you as a 1099.  If you have to pay for your own expenses, and they pay you as a W-2, you CANNOT write off those expenses on your taxes!  I have no idea how institutions justify paying you as a W-2 employee (since you’re obviously a casual contractor, which is what 1099 is designed for), but I paid about $1k more in taxes one year than I had to because of that classification.  Ask before you agree: does the institution pay for your expenses and, if not, are you paid as W-2 or 1099?  At this point in my career, I’ve stopped taking any job which pays me as a W-2 and doesn’t take care of expenses.

Once you have agreed to do the job, some places will send you a contract.  They will walk you through the licensing process. Getting a license in another state can be a significant pain.  You have to get a letter from EVERY state you’ve EVER had a license in to indicate you didn’t do anything bad in that jurisdiction.  The AAVSB can facilitate this- for a fee, of course.  I’ve found it easiest to just pay the AAVSB fee rather than go through the hassle, but if you only have one or two state licenses, it may not be too bad for you to DIY.

If the institution is going to take care of your expenses, they may book lodging for you or you may book it and get reimbursed.  Sometimes, they have a lodging budget so you could book a nicer place and just pay for the difference yourself.  Usually, you will book your own flights.  If you have to pay for a license, you’ll usually get reimbursed.  If there are visa issues (e.g. locum in Canada), the institution’s lawyers will generate the paperwork and get everything set for you.  You may have to pay the fees at the time of the visa (obtained when clearing customs), but they will reimburse you.

If the institution doesn’t take care of your expenses, you have to pay for it all out of pocket and, hopefully, they give you a higher pay to compensate for everything.  I usually budget $1500/week for expenses, although this is highly location- and individual-dependent.  If you don’t mind AirBnBing a room in someone’s house, your expenses will be much lower compared to staying in a hotel.

When you show up on Monday before 8am, you should have a contact person to call who will escort you where you need to go.  Most locums start at 8am on Monday with orientation and paperwork and pharmacy access, then you start clinic responsibilities some time mid-morning.   If you’ve locumed there before, they may skip those steps and you can go right to the clinic area and get started.

Some locums require you to do primary emergency duty, some require you to be back-up to their residents/staff, and some have no emergency requirements.  Most will require 7-days-a-week coverage of clinic responsibilities, just like your “usual” job.  That is, if you have patients to discharge on Sat or Sun, you have to take care of them.  Some will require you to be on call until 8am the Monday after your week, making it impossible to do a locum week and then do a clinic week back home.  You may be able to finagle things- such as starting the locum on Sat or Sun before your official start date so you can leave on the Sun at the end of the time- if you have worked there before and know the people.

Some locums will give you the specialized communication devices the hospital uses (e.g. Vocera) or a dedicated cell phone for use during your time there.  They’ll provide you with access cards and maybe a name tag.  Some will provide scrubs, but I always bring my own anyway because they usually don’t have many sets in my size.  Otherwise, you should bring your own lab coat, stethoscope, and similar paraphernalia you use in your regular day-to-day clinic work.  Don’t forget to return everything they gave you before you leave on the last day!

You will have set up direct deposit with the institution at some point.  When the pay period after your locum rolls around, presto, the money gets deposited into your account.  If it was a W-2 locum, they will have taken out taxes.  If it was a 1099 locum, you’ll have to pay taxes when you file next year, assuming you have a regular full-time W-2 job.  If all you do is 1099 jobs, you’ll need to file estimated quarterly taxes. 

Advantages

  1. No committee work, politics, classroom teaching, equipment issues, or anything else not related to clinical teaching and patient care.  If all you want to do is be on clinic duty, teach house officers and students, and then leave the job without worrying about everything else normally associated with academia, locum jobs are perfect.
  2. Good pay rate.  If you do 50 weeks of locum work a year, you could earn in the $250k-$500k range.  On a practical level, that’s unlikely given the sporadic nature of locum offerings and coordinating the schedule.  
  3. Working vacation.  Whenever I do a locum, my wife comes along for at least part of the time, and we have a nice little trip.  We obviously can’t go on a hike 4 hours away from the hospital, or take a river cruise, but we can have a grand fun time nonetheless.  We love doing locums in Saskatoon– it’s now one of our favorite places to visit in the summer!
  4. Different types of practice.  I learned to place coccygeal arterial catheters when I spent time at CSU.  I learned how to do TAP blocks at UMN.  Remifentanil is cheaper than fentanyl in Canada, so I use it for large dogs when I’m there and get more experience with it. It’s fun to see how everyone practices differently and try out some drugs and approaches you don’t regularly have access to.
  5. Appreciative admin and coworkers.  Usually, you are solving a problem when you do a locum job that everyone appreciates.  Without you, the full-time people would have had to work more, or a service would have to close, or students wouldn’t get to be on the rotation.  My experience is that people are happy to see you.

Disadvantages

  1. No benefits.  You don’t get a laptop or an office or healthcare or any of a myriad of other benefits associated with full time academic employment.  If you have a regular job, this isn’t a problem.  But, if you’re only doing locums, you have to consider those other expenses in your budget.
  2. Away from home.  If you have pets at home, they will need to be cared for.  If you have children and you can’t bring them with you, or any other responsibility that requires you to be home, it’s hard to do locums.  If everyone comes with you, it can be a grand adventure.
  3. Questionable continuity of care.  You may pick up patients you don’t know about and you may work on patients which you then have to transfer.  I think this is pretty similar to most academic jobs where people rotate being on and off clinics but, at home, you can at least chat with the other specialists since they’re around.
  4. Minimal acclaim.  You won’t earn any teaching awards, or “clinician of the year” awards, or getting approval from your department chair, or similar external validation.  You do the job, you get paid.  That’s it.

One of the many benefits of an academic position is that we get consulting time when we can pursue locum opportunities without having to take annual leave.  At one institution, I had 20 days a year I could do consulting.  At another, I had one week a semester.  This is time you can spend generating extra revenue on top of your already perfectly sufficient academic salary.  You can supercharge your savings, or progress to financial independence, doing locum work.  It’s also a nice potential bridge to early retirement.  I could do 3-4 months of locum work a year to pay for all our expenses, and delay having to dip into my retirement savings.  Even doing 1-2 months would be a significant benefit in terms of income in a partial retirement.  If you haven’t tried it, I definitely recommend it!

Be OK Saying “no”

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Photo by Florian Schmetz on Unsplash

A couple of weekends ago, I presented a CE talk.  It was a one-hour talk which I’ve done before.  I enjoyed giving the talk- the attendees laughed in all the right places and I felt like I dispensed some good advice and information.  The talk was preceded by a four hour drive, and followed by a four hour drive.  All told it was ~9.5 hours out of my day- it took up my entire Sunday.  I didn’t get paid for it.  As I was driving down, I thought, “What in the world am I doing?”  I wasn’t OK saying “no”.

A common problem in veterinary medicine is that generally we are giving people.  We want to help.  We want to contribute.  We are all leaders, and the best leaders lead from the front- taking on tasks, solving problems, and making things better.  As a result, a lot of veterinarians end up taking on a lot of responsibilities.  Early career faculty members are especially bombarded with doing things, but even those who get to Associate or full Professor rank often have significant miscellaneous responsibilities.

We chair committees.  We’re on patient review boards.  We do CE for our staff.  We write communication materials and blogs for our clients.  We have hospital director or section chief duties.  We lead interviews.  There’s a whole bunch of Stuff that happens which we take responsibility for, even though it’s largely beyond the scope of responsibilities for our job.  I think it’s because we want to help and we have a hard time saying “no”.

I think saying “no” is hard because we don’t want to let others down.  When someone comes and asks us to help do something, maybe we feel flattered.  “Hey, they asked ME to help!  That means they must think well of me!  I should return that positive regard with a positive answer!”  Maybe we feel we need to have a reason to say “no”, that the default answer should be “yes” unless there’s a “good” reason.  Sometimes we may even feel busy and burdened already and yet say “yes” regardless.

Nearly every email that comes into my inbox I read and think, “Can/should I do that?”  Judge the undergrad poster presentations.  Take on an intern mentee.  Fill out a survey.  Give a CE talk.  Take a locum gig for a few weeks.  Provide feedback to the COE on accreditation standards.  Serve on this regional veterinary symposium subcommittee.  Do an external evaluation for someone’s promotion & tenure.  The asks are nearly endless.

And, until the past year or so, almost all of these I said “yes” to.  They sounded interesting, or I wanted to help, or I felt bad for the organizer because I thought they wouldn’t get many volunteers.  This had several significant effects on my career and life.  One, I had a lot of neat opportunities and interactions and learned a lot of different things.  Two, I kept very busy, with very little downtime.  Three, I sometimes did things that built up my CV and supported my career.  Four, I got a reputation for being someone who is willing to help and take on tasks.

Note that not all of these consequences are bad.  In fact, a lot of them are good.  Perhaps the most important to consider is #2, staying busy.  As a general rule, I’d prefer being more active than more idle.  In contrast, my best friend is unhappy if he has to work more than 20 hours in a week.  So this is something that will differ by person and is worth reflecting on.  I’ve also discovered that it can change.  Early in my career, if I wasn’t in my office most of Saturday and part of Sunday, I don’t know what I would have done with my time.  Nowadays, I like having time for walks or reading or other brain-downtime activities.  So, I have learned to start to say “no” more often.

Now I am being far more selective about the things to which I say “yes”.  I don’t have hard-and-fast rules (those would probably help this process a lot), but now when I look at an email I generally think, “This isn’t my responsibility.  Someone else can do this.”  I don’t think the world will collapse without my participation, but it’s hard telling myself that. Additionally, at this point in my career, I don’t NEED to bolster my education, CV, or reputation. In the example from the beginning of this post, I could have referred the CE opportunity to a junior faculty member who would benefit much more from giving the talk. As we advance in our career, we can say “no” in order to let the newer generation of vets say “yes”.  

It’s OK to say “yes”.  It’s ALSO OK to say “no”.  If you ALWAYS say “no”, I think you may miss out on some cool opportunities.  If you ALWAYS say “yes”, I think you may get burned out.  So, it’s a balance.  But most veterinarians have a harder time saying “no”.  So I encourage you to reflect on that and give yourself permission to say “no”.

Four Year Anniversary!

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Well, the blog is going well even though, honestly, I haven’t been doing as much as I would like to do with it.  It looks like we’re reaching more people, which is fantastic.  I’ve had some positive emails from people who have gotten faculty positions and house officer positions who found the blog valuable.

I’m still mostly reaching pre-vet students through the Facebook APVMA group.  There’s no centralized house officer group to reach out to, unfortunately.

I have lots of ideas and think there’s still more advice to give.  I would love to write several “Complete Guide” posts which summarize everything for people applying to vet school, internships, residencies, and faculty positions.  I only got 14 posts in this year, which is definitely not enough to keep traffic continuing to flow.  I thought I was posting less because I wasn’t flying as much, and I originally wrote the blog when flying.  But I’ve done several long trips lately and still nothing.  

I’m not sure why.  Maybe it feels a bit more like work than fun, and I feel all my best advice is already out there.  Here’s to hoping this next year brings some fresh inspiration and enthusiasm to this endeavor!

Thank you all for reading and if any of you would like to contribute a Guest Post, please let me know!