This week I am talking to Trevor Cabrera, MD, The Nomadic Pediatrician who choose to pursue locum tenens with CHG Healthcare, straight out of residency. This unusual route comes with a range of benefits and its own set of challenges.
We explore Trevor’s career path and how he ended up chasing to take a non-traditional path once he finished his pediatric residency and set out on a path as a temporary employee in a wide range of locations. Unlike the traveling nurse, this type of temporary work is as an independent contractor (aka 1099) and comes with a wide variability on contract duration and some individual challenges like managing your own pay, benefits, healthcare coverage and liability, and licensure. Alongside this is a wealth of opportunity and experience that has allowed Trevor to become the MacGyver of Medicine starting quickly in any new location.
Along the way, he has developed a more fully rounded picture of patients, and the healthcare system and learned many new skills and clinical capabilities that were not part of the traditional medical school education.
Listen in to hear about his experience, the positive experiences, and opportunities to travel and see other parts of the country and develop skills to cope when resources are limited.
Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next week at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.
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Raw Transcript
Nick van Terheyden
And today I’m delighted to be joined by Dr. Trevor Cabrera. He’s a nomadic pediatrician who has focused on locum tenens over his career. Trevor, thanks for joining me to the today.
Trevor Cabrera
Thank you so much for having me.
Nick van Terheyden
So, as I do always, I think it’s really important to set the stage and get the context of your journey to this point. And it’s a little bit unusual, but you know, contains some elements that I think contribute to your direction. Tell us how you got here and a little bit of that story.
Trevor Cabrera
Yeah, thanks, Nick. I’m so excited to be here today and talking to you. So, you know, my story, I think, like, a lot of people. So my dad was in medicine was a cardiologist. And so I grew up in California. And so growing up, I watched him doing medicine, my mom was a pharmacist, he kind of just naturally had an inclination towards science. So of course, along you know, the path everyone has a different story and how they get into medicine. But regardless the case, I know that when I went that direction, kind of just kept going. And when I applied to medical school, the one out of 26 schools that I ended up getting into was in New Orleans, Louisiana. And so it was a big change for me, I made I stepped out of being in California raised their college there ended up in in the south. And from there that just kind of springboarded everything else in motion. After I ended up in New Orleans, it pushed me towards my residency training, which was in Houston. And I had always wanted to do pediatrics. So that’s what I ended up doing my training in. And, you know, once I started in training, for me, it was always that as a pediatrician, there’s really only a couple of jobs that we really do. We don’t do operations, we don’t do surgeries, we’re either in the hospital, we’re in clinic, something along those lines. And so my second year of residency, we had a locum tenens, a locum tenens, agency come and talk to us. And locum tenens isn’t something I’d heard of until that until that point. And so I remember sitting there and hearing the story of how basically, it’s Moonlighting, frankly, on crack, it’s a new level of traveling around and of working, kind of in this other setting that isn’t traditional. So when I hit my third year of residency, and I was kind of faced with, where do I go from here, you know, I wasn’t quite sure what I wanted to do my options, were doing outpatient medicine, or going to fellowship training. At that point, because I liked everything in pediatrics, I liked intensive care. I liked the neonatal premature babies, I like cardiology, cancer, all these different things, I decided, well, instead of signing a, you know, couple year contract to a clinic, or trying to go straight to a three year fellowship, because that’s how long the training is, I decided I’m gonna do this locum tenens thing that I’d heard about. So I started that when I finished residency and 2020. And I just kept going. And it’s been kind of a nonstop roller coaster since then.
Nick van Terheyden
So I mean, first of all, let’s just detail this, I think some people will have some concept of this, because there’s been a lot of coverage of traveling nurses, which is very similar from a nursing perspective, it’s essentially individuals that travel around the country to fill in for roles that are not full time filled, they quite often they’re either on vacation, sometimes they haven’t been able to fill the the opportunities. I think this is very similar. We had, you know, those experiences through my training and my activities. But it comes with a number of sort of upsides and downsides that I think you’ve navigated through. So, you know, let’s start with, you know, the upsides, what’s been positive about this, and what have you enjoyed?
Trevor Cabrera
That’s a great question, Nick. So first of all, before I jump into that, I want to I want to say the one thing that’s interesting, with the COVID-19 pandemic travel nursing has become pretty well known in the civilian world outside of medicine, but even within the medical world, locum tenens, is still one of those things that I believe is a little less known about for physicians providers. So the Latin phrase locum tenens means to take the place of like you said, just like travel nursing, we’re there to fill in gaps. The difference is unlike travel nursing, where these nurses are part of their employees of these agencies, and they have set contracts that are generally eight to 13 weeks, I’m an independent contractor, I get paid with a 1099. And my contracts have been as short as one day. And as long as well at this point. I’ve been the same job for seven months, and they come recurrent and they kind of come and go and they they’re kind of really interesting. So So one of the things that I feel as a pro or a pro for what I do, and also plays into the General Logistics is I envisioned myself as kind of a black ops like Illuminati of like underground providers. I have gotten phone calls for jobs where I get orientation in the morning, and I start on the ground seeing patients by the afternoon, they teach me the EMR and I go right away, zero to 101 of the pros is this taught me a lot of flexibility. I mean, I get dropped in places so quickly that I don’t get this three week orientation, we don’t get an orientation like that. And I also don’t, I oftentimes the only provider there. So it’s not like I have a lot of people to ask for help. So the thing is, from a training staff clinical standpoint, I’ve gotten better as a someone with resources, I’ve gotten more innovative. I like to say I’ve gotten more resourceful with less resources, and I have been able to get become more flexible. And I’ve also learned that there’s not the right way, there’s not just a single right way of doing things. From an overall perspective, like on a business a steak, I’ve negotiated so many different contracts, I’ve seen different hospitals. And now when I go from place to place, I’ve seen things that are good and bad. And it helps me to have a full more well rounded picture. You know, and the other thing is no matter where you train, and you know for you as well, you’ve trained in different places, you just your your, your your openness is so much different when I worked in New Mexico, 45 minutes from the border, dealing with mothers that would cross the border to deliver, that was one thing versus dealing with the native tribes in North Dakota versus working with the Amish in Maine. So it’s been really interesting from from that standpoint, I’ve also met a lot of really awesome people. And I’ve made these connections all throughout the country. And of course, the obvious thing is, you know, you can see really cool things. I mean, after our interview, today, I’m going to go jump around four or five waterfalls in Central Maine. So you know, those are the pros. Some of the cons and things that are a little bit harder, is that because I am a 1099, I have to deal with figuring out my own insurance. My job is very unstable. And it is very risky from that standpoint of having consistent employment. So I’ve taken a big risk, but it’s been a fairly calculated risk. And of course, on the other the pro side of that the the benefit, I guess to balance that out is the general compensations a little bit better, since I’m going to places now no one really wants to go. And I’m helping out where places where there’s really a need.
Nick van Terheyden
Yeah, so I think there’s some great points in the you’ve sort of covered around that opportunity for learning. One of the things that I say frequently I’ve I’ve had a tremendous privilege of traveling the world. And, you know, the exposure to other people, other experiences, teaches us so much about humanity, and the fact that, in reality, we’re so similar, that, you know, this, this positioning that, you know, sees people as very different is just not valid. In reality, we all have the same similar drivers. But it strikes me that, you know, one of the things that you’re talking about is experience. And you know, that flexibility in I think probably three years ago, people were said, Well, you know, why do you need to care about lack of resources, although, you know, that certainly existed. I think, for the most part, people believed we had, you know, available resources. Here we are three years later, and everybody’s going, wow, you know, the capability for creating a do it yourself respirator, or putting people on to two patients on a single ventilator was something that, you know, the clinical team learned, it strikes me, you must be just extraordinarily well experienced. Looking back what what occurred through all of that you go, wow, I would never have imagined that I had learned or knew or needed to know that, you know, starting out on this journey?
Trevor Cabrera
Well, that’s a really good question. You know, I think the biggest thing is what I’ve learned, you know, in training, most most residency trainings in the United States or in big cities, and so you have all the resources there with COVID-19. We ran into that issue of rehabbing, not many of those resources in these big cities. But realistically, you look more worldly and farther farther away from the big cities and people have dealt with not having some resources for a long time. So I think one of those kind of pivotal thoughts I had was I was in a small hospital in Texas, south of Houston and for babies that are born premature, we we’ll do, we’ll use something called nasal CPAP, a lot of times to help their lungs to with oxygen and ventilation. And that’s something now it’s become standard of care in big cities. This, this hospital didn’t have that nasal CPAP didn’t have the prongs that we put in the nose to help get that oxygen. So I remember going through with the respiratory therapists trying to figure out how to do this because they never did this. And it was going to be an inevitable delivery of a baby that was premature that we weren’t able to transfer. And it wasn’t too crazy of a situation. But it was something that was a little bit different. And I remember us we had to rig, a little mask, it was really small, you know about the size of maybe diameter of a coke can or a little bit bigger than that to some hoses that we hooked up to an old style ventilator. Because back back in the day, this ventilator was only used for babies that were intubated that had tubes down their throat to help them breathe. But we’ve come a far way that we don’t need to, we know that we don’t need to put the tube down the throat of all the babies to help them breathe, we can just use the nasal part. So it’s one of those things, we had to get creative. And it was it was such an interesting experience. And it’s really that, you know, the outside of the actual physical resources, I just don’t have the experienced resources to teams. I was in another small hospital in Central Maine and we had a delivery of a baby that was, you know, about 1200 grams. So for what for pounds and ounces, what about two and a half pounds are pretty small, very premature emergency delivery. And at that hospital, I didn’t have people that were trained in neonatal care. I had had some training as a resident, but I wasn’t you know, an expert at it. But I remember running that team and trying to teach that team on the fly how we were going to do this. And it was a hard it was a hard airway is one of those things, it was difficult to to put a tube into the throat to help the baby breathe. And so what we ended up doing was we ended up doing a having a mask, something that we call bag mask, ventilation, we’d squeeze the bag, like you see on TV to help the baby to breathe. And we did that for 53 minutes until we could have a helicopter with the neonatal team come transport and back us up. And so they showed up at 53 minutes old. And they were able with a couple of tries actually to intubate the baby. But it was one of those things that it was it was interesting learning experience. It was stuff that you know, outside of the physical resources, having the team resources, or having the knowledge that expertise, the consultants that just isn’t there.
Nick van Terheyden
So for those of you just joining, I’m Dr. Nick the incrementalist today I’m talking to Dr. Trevor Cabrera. He’s the nomadic pediatrician, we were just talking about experiences and all of the amazing opportunities that you’ve had to really make a difference in communities that are underserved, reminds me a lot of my career. You know, in those experiences, one of the things that I really I appreciated so much was the level of gratitude that you receive just really gives you that boost. Certainly, from my perspective, I imagine that you’re seen as a real hero in many of these settings. You know, I as I’m listening to you, I’m thinking the MacGyver of medicine. And I know I’m dating myself with the original series, but there’s a new series, you know, so I think, you know, tremendous sort of scope. But obviously, it’s not all perfect. And you know, a couple of the things that you talked about are not insignificant, and let’s deal with one that’s very US centric. That’s the state regulations and being licensed. Has that been a challenge? Have you found that to be relatively smooth? Or how how’s that going? And are you licensed in all the states at this point?
Trevor Cabrera
Oh, man, that is a actually very relevant question for the exact day that I’m kind of stuck in. So you know, something important also to give this difference because a lot of people hopefully listening if they met a travel nurse, for nursing, they have something called a compact license, it makes it easy for nurses to have a license and a license to practice in multiple states. For physicians that doesn’t quite exist. There is something that’s a compact license, it’s called the The I MLC which I forget the exact definition of that. I think it’s the interstate medical licensure. And this what this does is it has a fast track to getting the license for physicians, but it still doesn’t it doesn’t mean that you don’t have to apply for the state itself. So for example, if you possess the IML See, as a provider, you still have to go through all the steps for that state licensing, but it shortcuts it so instead of it taking six months, maybe it takes four months. Now I don’t even have the IRA LLC, but instead I’ve just gone through and gotten licenses individually. So I currently have Eight medical licenses. And I am in the process I just submitted for a ninth medical license in North Carolina. And then I’m currently working on getting my 10th one for Massachusetts. And the Massachusetts Medical License is one of the most tedious licenses that I’ve ever, ever tried to obtain. The most licenses, I’ve heard any provider hold as a locum tenens is, I believe, 48 or 49 states. And that was, I believe, one of my recruiters told me it was a radiologist, which is the only field I think it’s reasonable to practice remotely. But for me, I it would make the most sense if you’re doing locum tenens. For a long time, you can get this i MLC compact license to help accelerate the process. But still, it’s very difficult, you have to get an individual state license, and every single state is different. So it is a big problem. And then on top of that the cost, I mean, to give you an idea of the difference across the country, the state license for Texas, I believe, is around $400, the state license for North Carolina is about the same. And then Pennsylvania and I believe Missouri, where something like 35 or $75, under $100. And then California $1,200. So it’s just it doesn’t make any sense. But it’s you know, one of those things, it’s a it’s that difference between inter and intra, I guess state licensure is just such a pain. Now, we’re all medically licensed as far as our my and actual US medical license trained provider. But that’s different than having state law regulated licenses to practice.
Nick van Terheyden
Yeah, so it’s always struck me, obviously, as a foreign medical graduate coming into this system. You know, just for context, I arrived into Australia, I handed in my UK certificate and the licensing authority handed me an Australian certificate. That doesn’t happen anymore, sadly, but it was a very good feeling. And I will tell you that medicine did not seem to be different, except for an occasional accent and the fact that I was upon the doctor to the locals. It just, it doesn’t make sense. And I would love to see some of that disappear. As you think about the way that this could be perhaps Incorporated. Is this a an opportunity? Should we be doing more of this with our medical graduates who I think struggle with experience with exposure? You know, there’s some of that going on? But are we doing enough? Should people be doing more?
Trevor Cabrera
Do you mean, like, should we, I guess, in some regard require have people kind of, at some point in training go out to these rural areas? Yes, exactly. Um, I think that’s an interesting question. So I’ve thought about that a lot. And it’s really, it’s really one of those things that I’ve got a friend that she’s finishing her training in Tunisia. And when I spoke talked to her about it, you know, she said that after they finish, there’s some obligation to work for the government, and that no matter what, as a medical graduate, as a resident graduate there, there’s some obligation there practice for some amount of time, wherever they throw you, I think in the United States, you’re gonna find that almost impossible to enforce just by the American mindset as a general thing, which not to get started on the political aspect, but you’re not gonna get an American to do anything outside of their own freedom, and telling them to do things. But that being said, you know, in the United States, too, as much as I think there’s some value to it, it’s not necessarily for everyone. Because if you’re, if you’re planning your entire life, to stay in academics, or to stay at a big city, it may actually not be very useful for you to have these experiences. Now, I do think it would help as a, from a social aspect, and from an aspect of a referral center trying to navigate those places. But realistically, somebody that has all resources in a big city isn’t going to need necessarily the innovation, and that some of those skills that come with being alone out in the country, they’re going to need other skills, and they’re going to be able to use their resources. So just a quick example of that, I remember, I was in a situation where I was trying to figure out if I needed to, excuse me, if it was going to be necessary to order an echocardiogram or an ultrasound of the heart of a baby. At the hospital that I was at, we didn’t have that resource. But then when I spoke to one of my directors at another hospital I work at it’s a tertiary care center. You know, she kind of laughed, she said, Oh, we have that resource overnight. That’s not an issue. We can always get it. And so the point being, you know, and this I think about this a lot. Is it necessary for someone to have that rural training? Not necessarily if you’re planning to work somewhere that you not going to, you’re going to need to know how to use the resources. So for my director, she needs to know when and how to easily do the resources at her institution in a big city, versus, you know, if you’re going to be more rural, you need to learn how to work without. So I think it’s kind of, you know, melding into whatever you’re going to do for the rest of your life. Now, I do think, yeah, like I said, just to repeat that, I do think that it gives you a better experience and makes you more well rounded. But it’s kind of questionable if in the long run, that’s really important. In other words, is it really that important for all medical trainees to, to in the United States get an undergraduate degree where they have to take an English class, or they have to take a sociology class or something that they’re never going to use in their life and medicine? I think that’s a that’s a very good question. It doesn’t, it makes you a more narrow person to only do what you practice. But that’s your personal decision. And I don’t think it necessarily influences everything. I mean, you can make the argument that as a provider outside of the sciences, part of it, that being rural, like you said earlier, you kind of learned, we’re all human, you learn better patient interaction. But from a technical standpoint, I don’t know if that changes practice, per se.
Nick van Terheyden
Yeah, I fully respect, you know, the notion that you can’t impose or force, a behavior or a requirement, that’s, you know, it’s the antithesis of sort of American behavior. But I think encouraging and, you know, really pushing, and there is a lot of that with, you know, let’s try and get folks out to underserved communities with payoffs for loans and so forth. But, you know, it really sounds like there’s more, I unfortunately, we don’t have time to dive into the requirements of the additional degree. And the extra four years of time spent doing all of that, which, you know, questionable in contribution with, essentially, the whole of the United Kingdom training system is direct entry, which doesn’t require any of that you go straight into medical school. In the closing minutes, tell us the parts of this that really, you know, you’ve struggled with and the parts that you’re really excited about.
Trevor Cabrera
So the parts that it’s kind of twofold, I will say, I am constantly on the move, because I do this full time. Now, I think it’s very important for anyone listening to know that a lot of people can do locum tenens, in addition to having a full time job, it’s very common for people to work one or two weeks a month, and then do a weekend covering somewhere, but I do it nonstop, I traveled 320 days and 2021. And as of July this year, I’ve already traveled over 200 days. So for me, part of it is I am constantly, you know, on the grind, I am never truly off because I always am working on getting my next job. It’s very unstable, my jobs are only confirmed out to 30 days in advance, and actually happened where I was set to have a start a big job. And a couple months from now, that was going to be around 10 or 11 shifts per month, and it fell through. So there’s a lot of job instability if you do it at the loved one doing it. But on the divet, you know, the dividend is if I get that work, it’s it’s fairly, it pays off in a lot of different ways. I think I would say that’s been a big issue. And also navigating to because I’m an independent contractor, the normal things that go with an independent contractor, which is taking care of my own taxes, taking care of my own benefits. And in that regard, going from state to state has a lot of traveling, which I do like but as it makes it hard. So I think those are some of the challenges that I run into, specifically doing what I do. But on the flip side, what I get really excited about is I’m always going to somewhere new and I’m always seeing new things. So it’s kind of a balance and finding that balance is the hardest part of doing it full time and doing it professionally the way I do.
Nick van Terheyden
Yeah, I think great sort of summarization of the challenge, you know, even in your sort of title, the nomadic pediatrician, you know, there’s an element of that that sort of brings, you know, some uncertainty, but also, you never know what the future brings. And, you know, if you don’t like where you are this year, you’re in great shape to be able to move on to somewhere else. But that instability must be very challenging. But I think, you know, tremendous opportunity, unfortunately, as we do each week, we’ve run out of time. So just remains for me to thank you, Trevor, for joining us and sharing your experiences. Thanks very much.
Trevor Cabrera
Thank you so much, Nick. And then of course, you know, for anyone listening I’m happy to keep sharing my experiences in my travels on my blog and nomadic pediatrician.com
