Miechia Esco, MD, PhD, MBA, RPVI, FACS – Locum Tenens Explained: Flexibility, Physician Shortages, & the Future of Healthcare

Board-certified vascular surgeon and chief medical resource advisor at Locum Tenens Dr. Miechia Esco joins Dr. Michael Jerkins for an in-depth conversation on the realities—and misconceptions—of locum tenens medicine. Drawing from a career that spans academia, military medicine, private practice, and locum work, Dr. Esco offers a firsthand look at how locum physicians adapt across diverse clinical environments and why experience, not transience, defines the field.

The discussion highlights the critical role locum physicians play in underserved rural and urban communities, helping to bridge gaps created by physician shortages and hospital closures. Dr. Esco and Dr. Jerkins explore the growing demand for locum physicians across all specialties, the flexibility and autonomy locum work can provide, and how it compares to traditional employment in today’s evolving healthcare landscape. They also touch on the influence of technology and AI while reinforcing why human judgment, compassion, and trust remain irreplaceable in patient care.

What does it really take to succeed as a locum physician? And how can mission, ethics, and culture shape a more sustainable future for healthcare?

Dr. Esco closes with advice for physicians considering locum work, reflections on legacy and leadership, and a reminder that meaningful impact in medicine often comes from meeting communities where they need you most.

Here are 5 main takeaways from the discussion with Dr. Esco:

1. Understanding Locum Tenens

Locum tenens, which translates to “placeholder” in Latin, was established in the 1970s at the University of Utah to support overworked rural physicians. Initially funded by the Robert Wood Johnson Foundation, it has grown into a crucial component of the healthcare system. Locum tenens provides physicians with the flexibility to choose their work environments and schedules, while also addressing staffing shortages in various medical facilities, particularly in underserved areas.

2. Dispelling Myths

Dr. Esco challenges the stereotypes surrounding locum tenens physicians, who are often perceived as less competent or unable to secure permanent positions. In reality, many locum tenens doctors are seasoned professionals with extensive experience. They are highly adaptable and often sought after by facilities for their expertise and ability to integrate quickly into new environments, providing high-quality care.

3. Financial Realities

While locum tenens can offer lucrative opportunities, Dr. Esco emphasizes the need for financial literacy among physicians. Understanding the tax implications of being an independent contractor is crucial. She advises forming an LLC to manage income and expenses effectively, allowing physicians to maximize their earnings while planning for retirement and other financial goals.

4. Impact on Underserved Communities

Locum tenens physicians are instrumental in delivering healthcare to underserved populations, both in rural and urban settings. Dr. Esco shares stories of how locum tenens have made significant impacts, such as providing critical care in remote areas where resources are scarce. This work not only addresses immediate healthcare needs but also contributes to the overall well-being of these communities by supporting local healthcare systems.

5. Future of Healthcare and Technology

Despite the rise of AI and technological advancements in healthcare, Dr. Esco underscores the irreplaceable role of human elements like compassion, intuition, and ethical decision-making. While technology can enhance efficiency and streamline processes, the nuanced understanding and empathy that physicians bring to patient care remain essential, ensuring that healthcare remains patient-centered.

Transcript

Dr. Miechia Esco:
I think everyone in medicine right now is serving the underserved. There’s so much changing in medicine—global economic factors, regulatory instability. What we can control is what we focus on, and that’s where our energy has to go. Going back to the floor, it almost feels automatic: I can help the underserved. I can spend a little more time doing what I can to take care of that community.

Dr. Michael Jerkins:
Welcome back to another episode of The Podcast for Doctors (By Doctors). I’m Dr. Michael Jerkins. Once again, I’m here solo, and we have an interesting topic today—one we actually haven’t talked about much on this podcast—which is how and where physicians work.

There’s a growing number of physicians opting for very different career structures. For some, that’s full-time employment. For others, it’s owning a practice. And for more and more physicians, it’s working short-term contracts called locums, either exclusively or alongside employed work.

I have a lot of questions today because we’re joined by someone with deep expertise in this space—a vascular surgeon who has been working locums for a long time and brings a lot of insight. We’ll cover practical tips and considerations for anyone thinking about locums work. So without further ado, let’s get to the interview.

Today on The Podcast for Doctors (By Doctors), we’re joined by Dr. Miechia Esco, a board-certified locum tenens vascular surgeon and Chief Medical Resource Advisor at locumtenants.com. Dr. Esco is licensed in 15 U.S. states and territories and has been practicing locums medicine for over a decade, with a focus on delivering high-quality care to underserved communities.

She has trained and practiced across a wide range of environments, including academia, military medicine, and private practice, with expertise in vascular surgery and wound care pathologies. Over the course of her career, Dr. Esco has helped enhance vascular surgery service lines and improve access to care for patients.

She currently applies her clinical and operational expertise to positively impact the healthcare staffing industry and locum tenens medicine, playing a key role in launching strategic technology initiatives and improving clinician and associate experiences.

Prior to her current role, Dr. Esco served as a consultative member on locumtenants.com’s Customer Advisory Board for several years. She began her clinical career in private practice and is a former major in the United States Air Force.

Dr. Esco earned her bachelor’s degree in molecular biology from Hampton University, completed an MD-PhD in cell biology at Wayne State University, and finished postgraduate training in general surgery at the University of Massachusetts, thoracic surgery at Kessler Air Force Base and Biloxi VA Hospital, and vascular surgery at the Detroit Medical Center. She also earned an MBA from Brandeis University.

She has received numerous awards and was named National Staffing Employee of the Year by the American Staffing Association in 2023. Dr. Esco is a member of the American College of Surgeons, the Society for Vascular Surgery, and the Sigma Chi Scientific Research Society. Dr. Esco, welcome to the podcast.

ME:
Thank you so much for having me. I really appreciate it. It’s an honor. You all are kind of infamous in our circles, so this is a big deal.

MJ:
I’ll take infamous. You’re probably the most qualified physician we’ve had on the podcast, and I’m really glad you’re here. Locums is something many physicians—myself included during residency—knew absolutely nothing about.

So let’s start there. When physicians hear “locum tenens,” what’s something they usually misunderstand or get wrong?

ME:
Honestly, a lot. First, locum tenens comes from Latin and means “placeholder,” but it’s far more than that. It actually started in the 1970s at the University of Utah. Two physicians recognized that rural doctors were completely burned out—working 24/7, 365 days a year, covering everything. They wanted to find a way to support them.

The model was eventually funded by the Robert Wood Johnson Foundation, and it grew rapidly from there. Today, there are a couple big myths. One is that locums physicians aren’t competent—that they couldn’t get a permanent job. That couldn’t be further from the truth. Over 70% of locums physicians have 20 or more years of experience. They’re highly trained, highly adaptable, and often asked to return to the same facilities.

Another major myth is financial. People assume locums physicians make a huge amount of money, but when you break it down hourly and factor in costs like health insurance and retirement, it’s a different picture. On the health system side, people think locums are too expensive, but when you compare that cost to coverage gaps and lost billable revenue, it often balances out very differently.

MJ:
That makes sense. I didn’t know the history started in Utah. One of the biggest questions I hear is about logistics—things like malpractice and licensing. If someone finds a job in a state they’re not licensed in yet, how does that work?

ME:
It’s definitely a process, but we help manage it. With locumtenants.com, we assist with licensing. Facilities typically cover malpractice insurance. Travel, lodging, and logistics are also usually covered by the agency.

On the back end, physicians are paid as independent contractors—so 1099 income—which has tax implications. You’re responsible for managing that income properly. If you’re doing locums consistently, there are retirement strategies like cash balance plans. I always recommend forming an LLC so you’re technically employed by your own company. That opens up more control over compensation, retirement, and taxes.

MJ:
I’ve seen people get surprised by tax bills when they weren’t prepared for 1099 income. Planning ahead is critical. The LLC model seems to be catching on, and I’m all for empowering physicians to have more control.

ME:
Absolutely. Physicians aren’t trained in business or finance, so it’s essential to have a strong team—an accountant, attorney, fiduciary, payroll support—so everything runs on autopilot and there are no surprises at the end of the year.

MJ:
You’ve been doing locums for over a decade. How did you get started, and what’s kept you on this path?

ME:
I’ve done a lot. I completed an MD-PhD program, so you’d expect I’d go straight into academic medicine. That was the plan, and I thought it would be great. I finished that and then did general surgery at UMass. My mentor at the time just happened to be an astronaut, which is kind of wild.

So I thought, why don’t I do that? Why not? I joined the Air Force with the intention of going into the astronaut training program, but I was a third-year general surgery resident at the time. And anyone who knows general surgery residency knows it’s brutal. I was told that if I left and wasn’t accepted, I’d have to start all over. There were a lot of unknowns, so I decided not to pursue it — but I was already in the Air Force.

From there, I decided to do thoracic surgery in the Air Force. I completed a thoracic fellowship and practiced thoracic surgery in Mississippi, a little after Hurricane Katrina, which was a very busy and interesting time. Then I decided I wanted to be a vascular surgeon. So I went back and did a full vascular fellowship in Detroit. Why not, right?

After finishing, I returned to the Air Force for two years. When my commitment was ending, I was recruited to a small private practice. I joined, but I realized their moral compass didn’t really align with mine. That made me hesitant about joining another practice, so I took some time to think and reset after everything I’d done up to that point.

Recruiters started calling and suggesting I try locums — just try it for a weekend. That was almost 11 or 12 years ago.

It’s been incredibly rewarding. I have autonomy. I call it pure medicine because I go in, operate, and leave. I don’t sit in administrative meetings. I can focus on taking care of people, and it’s allowed me to pursue other meaningful activities outside of medicine as well. That’s the five-minute version of my life.

I love it.

I have so many questions. I can’t imagine what it was like being a vascular fellow after all that training — you’d already had so much experience.

ME:
I try to stay humble about it. Everyone has their own skill set and talent — this just happens to be my groove. I learn from everyone. And when I say learn, I really mean it. Some people are excellent in ways I’m not.

The key in surgery is knowing how to get out of trouble — problem-solving and being several steps ahead. Some attendings may not have had the same technical training, but their decision-making from years of experience was invaluable.

This isn’t on the script, but I’m excited to ask you this. Someone sent me a clip of Elon Musk saying robots are going to replace all surgeons and that people shouldn’t go to medical school. I think we both have strong feelings about that. I’m not a surgeon — but you are someone with decades of experience. How do you respond to that? Do you think robots will actually replace surgeons?

ME:
Technically, maybe someday for very straightforward cases. But surgery relies heavily on instinct — problem-solving in real time. Maybe in 100 years, robots could be programmed with something like instinct, but how do you program compassion? Patience? Judgment?

Just because you can do something doesn’t mean you should, and that’s a human decision.

A lot of surgery is about getting out of trouble. Once you open someone up, the number of variables explodes. Anatomy doesn’t always match the textbook. People have unexpected branches or variations, and you have to adapt instantly. I don’t know how you program that.

MJ:
As my anatomy professor used to say, not everyone read the book.

I want to go back to something you said earlier. You found your path, and what stood out to me was not having to sit in administrative meetings — unpaid labor — and being able to focus on patient care.

You also mentioned working in underserved areas. Walk us through what that’s been like and what it’s meant to you.

ME:
The term underserved has changed over time. There’s rural underserved with very few resources, and inner-city underserved where resources exist but access is the issue. I’ve worked in both.

In rural medicine, I once saw a CT scan with a critical finding and said we needed to get the patient in immediately. We couldn’t reach him. Eventually we contacted his primary care physician, who explained the patient lived in the mountains with no running water or electricity. Once or twice a month, the PCP physically went up to check on him and bring him into town if needed. That’s a different level of underserved.

In inner-city settings, it’s transportation, finances, and access to medications. Both experiences have been eye-opening and rewarding.

When you help someone in a rural community, you’re often helping the entire community. You might be helping the third-grade teacher — and that impacts everyone.

I’ve worked in both settings too, and I’d love your perspective on the current state of rural hospitals. Many people outside medicine don’t realize how limited specialty coverage can be. I saw data showing about a third of rural hospitals are financially on the brink. What are you seeing on the ground?

ME:
It’s devastating. Many rural hospitals lack basic specialty care like OB-GYN or cardiology. You might have one small hospital with 20 beds serving a catchment area of nearly 100,000 people. If that hospital closes, those people have no access to care.

Another challenge is that patients in rural communities often struggle to leave their town for care. Even traveling 100 miles feels impossible and terrifying. Some have never left their town before.

We need to be sensitive to that and provide better resources. Telemedicine has helped a lot, especially after the pandemic. Maybe technology — even robotics — can help deliver medications or support services. If it helps patients, I’m all for it.

MJ:
I’d love to get your perspective on health systems. Most physicians are employed by them now. The word “stability” is often used to scare physicians away from locums — implying locums is risky or unstable. How do you counter that narrative?

ME:
Sure.

ME:
Medicine isn’t stable no matter where you are. It’s not. In some ways, locums is more stable because all the cards are on the table. We’re going to give you X amount of money for this amount of days and these are your responsibilities. Nothing beyond that is guaranteed because it’s very delineated.

In traditional medicine, you deal with mergers and acquisitions, hospital closures, regulation changes, reimbursement issues, increased demands, and metrics that may be placed on you — all those administrative burdens. How can you keep up, and how can anyone call that stable when at any moment one of those factors can hurt your career?

MJ:
Yeah, now you mentioned earlier that a high percentage of locum physicians have a lot of experience. Are you seeing a trend of earlier-career physicians opting for this route?

ME:
Yes, we are. It’s becoming well-known, and the traditional path has become more challenging. We also have to consider generational expectations for careers and life, and how they want to spend time outside work. When I did med school, it was like: you go to school, then residency, then hang a shingle — that was it. It was a great life, but now with more options, people are saying, “Hey, let me try this. I can spend more time with my family, travel, open a bakery — whatever it is.” It gives flexibility and doesn’t dilute the quality of care. Just because it’s not traditional doesn’t mean the quality is diminished.

MJ:
Makes sense. I think generally we’re seeing earlier-career physicians trying to do things differently — how they practice, where they practice, or maybe starting their own thing. There’s definitely growing momentum for people taking more control over how their careers look and feel.

MJ:
I was going to give you another soapbox to stand on.

ME:
Thank you.

MJ:
One other thing I’ve heard, and I think you touched on this, is that people worry locums contributes to care that doesn’t have as much continuity. I have my own thoughts, but how do you respond to that concern?

ME:
The reason a locum physician is there is usually to fill a coverage gap. It’s better to have someone providing care, even if it’s not always the same person, than to have no one at all.

One thing that’s critical is that if hospitals have the right processes, policies, and efficiencies, that continuity isn’t really lost. There’s always some overlap with APPs or other staff, and the EMR helps a lot.

MJ:
Given your experience working in so many systems, what are your tips for quickly building trust with staff, patients, and administration?

ME:
You have to be authentic — just be yourself. Be calm when you come in, don’t be erratic or panicked. Communicate, listen, and be honest. Hold yourself to high standards and have strong confidence without ego.

You come in, say, “This is what I do. I know what I’m doing. I’m here to work as part of your team,” regardless of the resources available. That goes a long way.

MJ:
Not every doctor has that humility. I imagine that builds a lot of rapport. Given your experience enhancing vascular surgery service lines, what are most hospitals getting wrong about trying to grow and maintain specialty care?

ME:
They don’t have the big picture. For example, with vascular surgery, a hospital might think, “We’ll make X in reimbursements with this service line.” But they don’t account for the resources required — financial, human capital, infrastructure, regulatory requirements — or the system-wide effects.

ME:
Specialty care affects ICU, hospitalists, ER, radiology, cardiology, even trauma designation. Hospitals sometimes don’t realize it’s a heavy lift. You need more than just a surgeon — maybe three more hospitalists, more staff, and so on. It’s a comprehensive effort, not just a line on an Excel sheet.

MJ:
Are there trends in which specialties are seeing more demand in the locum space?

ME:
All of them. There’s a broad physician shortage. Primary care is most pressing — they’re the front door of healthcare — but all specialties are affected. Many physicians are retiring, creating gaps. There’s also more interest in alternative ways to practice, so demand is increasing across the board.

MJ:
I love your perspective. One thing I noticed is you have an MBA. I don’t, but a lot of doctors I know consider getting one. What led you to pursue that, and how has it been applicable?

ME:
I’ve been doing locums full-time for a long time. I have my own business and do consulting. Core work is with locumtenants.com as chief medical advisor. Medicine is a business. Talking to doctors, administrators, and the C-suite showed me it’s a different world. To navigate medicine effectively, I needed to learn more, so I did the MBA. It opens doors and allows me to work on both clinical and administrative sides effectively.

MJ:
That makes sense. I saw something recently — a fellowship for primary care docs to learn simple urological procedures to fill a gap. Are you seeing training evolve to fill shortages like this?

ME:
Yes. Some primary care specialties are being trained in smaller procedural fields like urology or nephrology. It’s a necessity given physician shortages and access issues. For example, in a rural community, if a patient has to drive 100 miles to see a specialist, having primary care fill some of that gap is efficient and saves resources.

Specialists with decades of training may resist, but there’s enough pathology to go around, and physicians need to set aside ego to take care of patients.

MJ:
Exactly. With the patient shortage, what operational change could make the biggest impact for underserved communities?

ME:
It’s not just operational — policy, culture, and mission matter. Many healthcare entities lack a clear mission, ethics, or robust culture. With those three elements, you can really change how care is delivered. Strong culture drives compassionate care, and a mission provides direction and goals. Even from a financial standpoint — say you’re applying for a grant — you need to know your mission and what you’re doing.

ME:
So those things are critical. I think two other things are really important: creating safe environments for patients and physicians so they can carry out the Hippocratic Oath, and doing everything possible to protect the doctor-patient relationship. It’s a very sacred relationship and a very sacred time, even if it’s just three minutes. Whatever patients trust us with, the facility should protect that. With a strong mission and culture, you can really shift a lot in healthcare.

MJ:
Yeah, that’s interesting. Normally, when I think about that question, I think macro — big federal changes — but there’s a lot on the micro scale that can really move the needle. That makes sense. In your experience with underserved communities, rural and urban, how would you encourage more doctors to serve these populations?

ME:
I think everyone in medicine now is serving the underserved. I really do. Think back to the Hippocratic Oath — that’s what we signed up for as first-year medical students. You commit yourself to something fundamental.

With so much changing in medicine, so much instability with global economics and regulations, you have to focus on what you can control. Going back to the core, it becomes almost automatic: “I can help the underserved. I can spend a little more time to do what I can for that community.”

MJ:
Makes sense. Do you work more with physician assistants and nurse practitioners in the locum setting than in permanent staffing models?

ME:
There’s definitely an increase in APPs in the locum space. Traditionally, permanent settings have more APPs and PAs, but for instance at locumtenants.com, we have a segment where APPs do locums work. It’s increasing for sure.

MJ:
And we’ve talked about this — meaning and establishing relationships with patients is sacred. How do you build a meaningful legacy without staying in one place clinically?

ME:
Legacy isn’t about time. It’s about impact and how you’re remembered. That can happen in three minutes. You can walk in, make an incredible impact, and you’ll be remembered.

I’ve gone to places for a week, and a year or two later, I might get a call from a nurse: “Hey, Dr. Esco, how’s it going? Mr. Jones asked when you were coming back.” I’ve had patients follow me to another state to continue care, even though I spent only a short time there. Legacy is about intention, connection, and delivering high-quality, compassionate care. If you do that and stay excellent in your craft, legacy can be created in minutes.

MJ:
I love that. You’re also focused on pure medicine — no bureaucratic distractions — just you and the patient delivering excellent care. That’s powerful.

I have a question I get from early-career attendings: how can you build optionality in your career without burning bridges?

Have you seen that cartoon of a bird? Close-up, he’s holding the cage, but when you zoom out, he’s really just holding onto a tiny section — there’s no cage around him.

ME:
You have options. The key is integrity, excellence in your craft, authenticity, and honesty. Then you won’t burn bridges.

Medicine is dynamic. If a young physician is excellent, builds strong relationships, and is authentic while taking care of patients, they can pursue different opportunities and even come back later. Everyone wants high-quality clinicians. If you’re that person, bridges aren’t burned. If you’re a disaster, well… that’s another story.

MJ:
Exactly. Doctors often undervalue themselves. Systems need us more than we realize. If you know your worth, you have more control over how you deliver excellent care. Soapbox moment over.

ME:
I’d encourage everyone: if you’ve been in a system for a while and have a relationship with leadership, ask for simple things — like your billable revenue. “Hey, just give me my numbers.” It shows your contribution. You see, you’ve generated $1 million in revenue — now you know your value and gain leverage if you want to explore other opportunities.

Even if they don’t provide it, the fact that you’re aware is powerful. It empowers doctors to have more information. Systems and payers have tons of data, and individually, we often have very little.

MJ:
I love that tip — we’ll highlight it for sure. Alright, we have some true/false statements. Rapid fire.

ME:
Okay, can I just say one thing? There’s a study I’ll send you. In my free time, I was reading the Administrative Scientific Quarterly — 2009. There’s this article about zookeepers. Hang with me: zookeepers.

MJ:
Yes, please.

ME:
What these social scientists did was go to about 150 zoos across the U.S. and interview around a thousand zookeepers. The article was like A Call of the Wild, about a meaningful career.

The zookeepers said, “It’s a calling for me to take care of these animals. I’ll do everything — self-sacrifice, staying late, hot environments — but the zoo does not value me. I hold the zoo to a high moral standard, just like I hold myself. The zoo needs to have the same level of commitment.”

When there’s a disconnect, the zookeepers become disenchanted. You can draw a corollary to physicians and healthcare systems. With zookeepers, you want good boots, snacks, air conditioning — but when it comes to physicians, the expectation is, “You’re supposed to suffer.” That’s not okay.

MJ:
I love that. It resonates. It’s like, “You’re asking for too much. This is all about patients. How dare you want a tolerable call schedule or a 45-minute break?” Why does that happen? Why do systems act that way?

MJ:
To me, my theory is inertia. Systems are under pressure, so there’s this dehumanization of the provider. You’re just another number in Excel. It’s demeaning.

ME:
Exactly. People would be mortified if that happened at the zoo, right? You treat zookeepers that way — but physicians? Somehow it’s different.

MJ:
Totally agree. All right, first true/false statement: On average, physicians who work locums experience less burnout than those who do not.

ME:
True — if you do it right. You create your own schedule, work as much or as little as you want, and earn accordingly. If you work like a maniac, you’ll burn out.

MJ:
What does “doing it right” mean?

ME:
You need to define your lifestyle: how much time you want, your work-life balance. If you’re extreme, you’ll get burned out.

MJ:
Full-time locums — is there an average number of shifts per month?

ME:
Full-time means it’s your only job, but typically it’s a third to half of your working time. For me, I work 10–14 days a month, give or take.

MJ:
Noted. If done right, locums can give autonomy and reduce burnout. Next: True or false — our health system relies heavily on local physicians.

ME:
Absolutely. Over 90% of healthcare facilities have had some locums involvement in the last few years. Many facilities lack strategic staffing plans, so locums fill critical gaps. With the physician shortage — nearly 100,000 expected by 2036 — locums will always be needed.

MJ:
Next: True or false — with AI, there will be less demand for physician services in the future.

ME:
False. Things may be more efficient, processes more streamlined, but demand will increase. Patients have more access to data — labs, wearables — and will still come to the healthcare system for guidance.

MJ:
Final one: True or false — rural hospitals need locums more than urban hospitals.

ME:
True. Specialty care is more saturated in urban areas. Rural areas may have few specialists — for example, Manhattan had around 100 vascular surgeons at one point; West Virginia had less than 10. APPs help, but locums fill critical gaps in rural care.

MJ:
Awesome. Closing question for every guest: What’s one thing you’ve recently changed your mind about?

ME:
I wouldn’t say I changed my mind, but I’m evolving. Perfection doesn’t exist; it’s a moving target. I’m learning to adapt to that.

MJ:
I love it. Lifelong learning clearly defines your career. Dr. Esco, thank you for your time. Where can listeners find more about you or Locum Tenants?

ME:
Go to welcometenants.com — career options, openings, videos. I don’t have social media; I stay busy.

MJ:
Too busy, I love it. Thank you so much for joining us today.

ME:
Thank you, I really appreciate it. Be well.

MJ:

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