I was halfway through reviewing what looked like an excellent locums opportunity when I realized the hourly rate was the least important number in the agreement. The compensation was strong. The schedule was flexible. Travel was covered. On the surface, it seemed straightforward.
But what ultimately determined whether the opportunity made sense had very little to do with pay. It had to do with clarity.
The difference between conversations and contracts
Locums conversations are often grounded in good faith. Recruiters talk about flexibility, partnership, and shared goals. Most of them genuinely want placements to succeed.
But contracts are not written to govern intent. They are written to govern what happens when circumstances change: when schedules shift, when billing is delayed, or when operational pressures surface. That difference matters. It is not about distrust. It is about understanding how written agreements allocate responsibility when expectations are tested.
When “outside our control” becomes ambiguous
In one contract review, I asked what would happen if documentation was completed appropriately but a downstream administrative issue arose between the hospital and the agency. The response was reasonable: “That is outside our control.”
Operationally, that may be accurate. Contractually, however, the question becomes: If something is outside one party’s control, who is explicitly responsible for protecting the physician?
When agreements are silent, ambiguity remains. And ambiguity, in practice, tends to be resolved by whoever has the least leverage. This is rarely intentional. It is often simply how standardized agreements are written to function at scale.
How structure influences who says yes
Hospitals and agencies understandably design contracts to preserve flexibility and manage institutional risk. From a systems perspective, that makes sense. But structure shapes behavior.
Agreements that leave certain contingencies undefined may feel acceptable to some physicians and uncomfortable to others. Often, it is not the hourly rate that determines whether a senior clinician proceeds; it is whether responsibilities are clearly allocated when disruptions occur.
When physicians decline late in the process, compensation is often assumed to be the issue. Sometimes it is. Often, it is clarity.
Verbal reassurance has limits
“We will work it out.”
That phrase is reassuring in conversation. It reflects good intent. But once an agreement is signed, the written document governs outcomes. This is not about anticipating conflict. It is about recognizing that health care systems operate under financial, regulatory, and administrative pressures. When those pressures intensify, written terms matter.
What physicians should look at before the rate
Before focusing on the hourly number, physicians might consider:
- Who explicitly bears financial responsibility if an assignment is canceled?
- Is payment guaranteed for work already performed?
- What triggers immediate termination?
- Are contingencies addressed clearly, or left open to interpretation?
These are not adversarial questions. They are alignment questions.
A systems issue, not a moral one
Most locums agreements are not drafted in bad faith. They are drafted to function across many placements and many environments. But scalability and clarity are not identical.
The hourly rate may open the door. Understanding how responsibilities are defined in writing determines whether stepping through it makes sense.
Sriman Swarup is a board-certified hematologist-oncologist and the cofounder of OncoNexus, an AI-driven oncology workflow platform focused on improving efficiency and care delivery. He also leads Swarup Medical PLLC, where he consults on clinical systems design, health equity, and digital health transformation. Practicing in rural Arizona, Dr. Swarup manages more than 3,000 patient encounters each year while advising startups and health systems on innovation and health care strategy. He writes about medicine, technology, and health care leadership at his website.
