Locum Tenens in the ICU: Is the Higher Pay Worth the Lack of Stability?
The math seems simple: locum tenens ICU APPs can earn $100-150/hour compared to $60-80/hour for permanent positions. But before you hand in your resignation, let's dig into the full picture.
What Locum Tenens Actually Looks Like in Critical Care
The Typical Arrangement
- Contract length: 4-13 weeks (sometimes longer)
- Schedule: Often block scheduling (7 on/7 off or similar)
- Housing: Usually provided or stipend given
- Travel: Paid to and from assignment
- Credentialing: Handled by agency, but you do the paperwork
Where ICU Locum Positions Exist
- Rural hospitals struggling to recruit permanent staff
- Urban hospitals with unexpected vacancies
- Health systems during seasonal surges
- Facilities awaiting permanent hires
The Financial Reality: True Earnings Comparison
Locum Tenens (Estimated Annual)
| Item | Amount |
|---|---|
| Hourly rate | $120/hour |
| Hours worked | 1,800/year |
| Gross income | $216,000 |
| Self-employment tax | -$16,500 |
| Health insurance | -$12,000 |
| Malpractice (tail) | -$3,000 |
| Retirement contributions | $0 (no match) |
| CME | -$3,000 (self-funded) |
| Net effective income | ~$181,500 |
Permanent Position (Estimated Annual)
| Item | Amount |
|---|---|
| Base salary | $140,000 |
| Employer benefits value | +$25,000 |
| 401k match (4%) | +$5,600 |
| PTO value (4 weeks) | +$10,800 |
| CME allowance | +$3,000 |
| Malpractice (employer paid) | +$8,000 |
| Total compensation | ~$192,400 |
The gap is smaller than the hourly rates suggest.
Pros of Locum Tenens ICU Work
1. Flexibility and Autonomy
- Choose when and where you work
- Take extended time off between assignments
- Escape toxic workplace cultures easily
2. Diverse Experience
- Work in different ICU settings (academic, community, trauma)
- Learn various EMR systems
- Expand your clinical skill set
3. Higher Gross Pay
- Significantly higher hourly rates
- Premium rates for holidays and hard-to-fill shifts
- Potential for overtime
4. Travel and Exploration
- Live in different cities and regions
- Housing often provided
- See the country while working
5. Escape Workplace Politics
- Less investment in committee work
- Avoid long-term interpersonal conflicts
- Focus purely on clinical care
Cons of Locum Tenens ICU Work
1. No Benefits Safety Net
- Must secure own health insurance
- No employer-sponsored retirement
- No paid time off
- No short/long-term disability (unless you purchase it)
2. Credentialing Hassles
- New credentialing for every facility
- Repetitive paperwork
- Potential gaps between assignments
3. Always the "New Person"
- Learning new systems, protocols, and cultures repeatedly
- May not be included in team activities
- Building relationships is harder
4. Clinical Limitations
- May not be allowed to do certain procedures
- Limited autonomy as a temporary provider
- Less influence on patient longitudinal care
5. Tax Complexity
- Self-employment taxes (additional 7.65%)
- Quarterly estimated payments
- Need to track all expenses
- State tax complications from multi-state work
6. Isolation and Burnout
- Away from family and friends
- Temporary housing can feel lonely
- Constant adaptation is exhausting
Who Thrives in Locum Tenens Work?
Good Candidates
- Early career APPs wanting diverse experience
- APPs with working spouses who have benefits
- Those paying off loans aggressively
- Empty nesters seeking adventure
- Anyone testing the waters before a big move
Not Ideal For
- Those with young children or aging parents nearby
- APPs who value deep team relationships
- Those who need routine and stability
- Anyone uncomfortable with constant change
Making Locum Work Financially Smart
If you decide to pursue locum tenens:
- Set up an LLC or S-Corp: Potential tax advantages
- Open a Solo 401k: Contribute up to $66,000/year (2026)
- Get an HSA-eligible health plan: Triple tax advantage
- Track every expense: Mileage, licensing fees, scrubs—it all counts
- Negotiate housing stipends over provided housing: More control, potential savings
- Build an emergency fund: 6+ months expenses for gaps between contracts
Hybrid Approaches
Consider middle-ground options:
PRN with Benefits
Some hospitals offer PRN positions with partial benefits. Lower commitment than full-time, more stability than pure locum.
Part-Time Permanent + Locum
Work a 0.5-0.75 FTE permanent position for benefits, supplement with locum shifts.
Seasonal Locum
Take 2-3 month locum assignments during slow seasons at your home institution.
Questions to Ask Before Going Locum
- Can I secure affordable health insurance?
- Do I have enough savings for gaps between assignments?
- Am I comfortable with constant change?
- What does my family think about the lifestyle?
- Have I talked to APPs currently doing locum work?
The Bottom Line
Locum tenens offers genuine advantages: flexibility, variety, and higher gross pay. But it's not the financial windfall it appears on the surface. When you factor in self-funded benefits, taxes, and the intangible costs of instability, the calculus changes.
Locum work is a lifestyle choice as much as a financial one. Make sure it fits your life, not just your bank account.