Rank list help! Question about going into private practice

[TheRock24]

Hey everyone I was hoping for a little help prior to submitting my rank list.

I am leaning towards a career in private practice, although I am open to that changing during residency. When making my rank list I am considering the typical things such as quality of clinical training, location, QOL, cost of living, culture, ect...

How important would you say prestige and name recognition is when going into the private practice world? I am considering ranking a middle tier program that I think has good clinical training higher than a program that is more upper tier and I know has very good clinical training. The middle tier program is closer regionally to where I would like to end up.

I guess what I am asking is what are the important factors you look at when hiring new partners? Especially with all the talk of the tightening job market I want to give myself the best chance to find a good job. I really appreciate your help!

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[RO2019]

This is a reasonable question to ask, but - and I’m sure you knew this when you posted - this is an impossible question to answer. There’s no right answer. So many factors including luck go into the job search your particular year. Would probably also need more specifics to make a reasonable rec.

Just go where you will be the happiest and where you think you will be the most attractive for the future. Looking at where alumni have been able to go is helpful, but also not really because everyone has different preferences. Location matters but so does institution to some extent, haha, so no easy answer.


Follow your gut. Will be fine. Congrats on finding a great field. Feel free to PM more details if you want or ask people in real life.good luck

 

[TheRock24]

This is a reasonable question to ask, but - and I’m sure you knew this when you posted - this is an impossible question to answer. There’s no right answer. So many factors including luck go into the job search your particular year. Would probably also need more specifics to make a reasonable rec.

Just go where you will be the happiest and where you think you will be the most attractive for the future. Looking at where alumni have been able to go is helpful, but also not really because everyone has different preferences. Location matters but so does institution to some extent, haha, so no easy answer.


Follow your gut. Will be fine. Congrats on finding a great field. Feel free to PM more details if you want or ask people in real life.good luck

I am happy to PM you I would love any advice you have. This is naive of me but I can’t figure out how to PM you. Any idea?

 

[RO2019]

Click the username of the person you would like to PM and then hit ‘start a conversation’

 

[Sheldor]

Honestly, in my experience its:

1) Are you from there? Ties to the area? PP want to hire future partners who are invested in the area.
2) Do you have a connection to someone there through a mentor/co-worker?
3) Does your residency meet a minimal threshold? (Usually has everyone heard of it, and not heard anything bad.)
4) Does the timing work out in when you are available?
5) Are you nice? Easy to work with and have a vibe that should get along with referrings?

I haven't been in private practice for a ton of time, but in my experience its the above roughly in that order for most.

 

[TheRock24]

Click the username of the person you would like to PM and then hit ‘start a conversation’

For whatever reason it says I can't start a conversation with you.

 

[Radiator20]

I am considering ranking a middle tier program that I think has good clinical training higher than a program that is more upper tier and I know has very good clinical training. The middle tier program is closer regionally to where I would like to end up.

Do you otherwise have ties to the area in question? If yes, then you might be able to lean on those ties rather than lean on the residency geography to demonstrate your interest.

Residency is the foundation for the rest of your career, so if you feel that the upper tier program would give you better clinical training ("very good" vs "good" in your post), I think that's something to consider strongly. You'll benefit from that no matter where you end up working. Vs., if the other program were weaker, and then your geographic priorities changed or job wasn't available in desired area, you've sacrificed quality of clinical training for a benefit that didn't pan out. It's ultimately for you to decide whether you think there's a true difference in quality of training between these two programs, but if you think there is, something to consider.

 

[evilbooyaa]

Try to end up in a residency in the same geographical region as the area you want to live in. That is priority number one.

In your situation I would rank the middle tier program (that still has good clinical training) higher than the upper tier program that is farther away.

Otherwise, Sheldor's advice is very similar to what I've heard. Private practices ideally want to make sure you're in for the long haul cause hiring replacements is time-consuming and expensive.

 

[KHE88]

If you look at 21st century's website and look at providers in Florida (a warm, coastal highly populated location, what would typically be deemed "desirable" in general), nearly half of the rad oncs come from elite programs in the northeast. Lots of Harvard grads, particularly in the more desirable cities.

Now, a certain individual associated with this organization has authored odd elitist opinions that suggest residents get inferior training at smaller or community programs and that residents should ideally be trained at the big-name large complement programs. Is this a coincidence?

But I think if you applied for an open spot there with a residency from the University of <insert random red flyover cow and/or corn state here>, you probably wouldn't fare well. Just a hunch.

My point is, there certainly seem to be organizations that value pedigree highly, but I think that's not the normal. For most PP, I think it matters how well you sell yourself from a business standpoint, professional and personal affability, and ties to the area (i.e., having something to make it likely you will stay), not some random coastal elite bias against quality of your radbio training. And do you really want to work for someone who thinks like that anyway?

 

[20181121]

I think going with the better program gives you more flexibility down the road. I think it also insulates you from unseen risks (e.g., the CPMC closure). Looking at where recent graduates have gone is always helpful but, as others have said, does not tell the whole story. All of that said, you need to go where you will be happy for 4-5 years.

 

[thecarbonionangle]

Pick top places. You want better education and more options. Do not pick a program which is borderline and may shut down or limit your employment prospects simply because of location.

 

[Radiator20]

Reputation is not the same as actual quality of clinical training.

If one place simply had a bigger academic reputation but equivalent (in your eyes) clinical training, then it may not hold much advantage for you if you do go into PP.

If you think one place actually has better clinical training, and you can deal with living there for 4 years, you should pick that one.

Honestly, would you want to be treated by a doc who says "yeah, I went to a residency that I knew had worse clinical training, but I thought it would help me get a job where I wanted?"

 

[Mandelin Rain]

1-3. Get trained really well.



4. Like where you live.
5. Worry about PP job placement (which will be a crap shoot regardless)


I will say... Everybody LOVES having a doctor who trained at Harvard. (I did not)

 

[DukeNukem]

If you look at 21st century's website and look at providers in Florida (a warm, coastal highly populated location, what would typically be deemed "desirable" in general), nearly half of the rad oncs come from elite programs in the northeast. Lots of Harvard grads, particularly in the more desirable cities.

I trained at a pretty good place. I applied at 21c in SW Florida a few years ago as a new grad. Base salary $180k.

 

[Irradi8or]

1-3. Get trained really well.



4. Like where you live.
5. Worry about PP job placement (which will be a crap shoot regardless)


I will say... Everybody LOVES having a doctor who trained at Harvard. (I did not)

Agree about #1-3. IMHO getting trained well is by far the number 1 thing anyone thinking of entering this field should do. Over the last few years, I have interviewed several new grads for positions in my large multispecialty group that is in a good metro location with extremely high salary and very good balance of QOL. Some on this board say that mid-tier clinically busy programs train the best clinicians, but I haven't found that to be the case. Sure, those grads saw a lot of cases, were in the clinic all the time, and had little/no research, but their actual clinical skills were not necessarily that good. Many of them seemed to be stuck dictating every note in clinic and worked with some questionable faculty, who would do treatments with non-standard approaches. Just my experience so far.

 

[Mandelin Rain]

Agree about #1-3. IMHO getting trained well is by far the number 1 thing anyone thinking of entering this field should do. Over the last few years, I have interviewed several new grads for positions in my large multispecialty group that is in a good metro location with extremely high salary and very good balance of QOL. Some on this board say that mid-tier clinically busy programs train the best clinicians, but I haven't found that to be the case. Sure, those grads saw a lot of cases, were in the clinic all the time, and had little/no research, but their actual clinical skills were not necessarily that good. Many of them seemed to be stuck dictating every note in clinic and worked with some questionable faculty, who would do treatments with non-standard approaches. Just my experience so far.

I would say I have had the opposite experience. We've had new grads from elite centers who couldn't manage a single patient complaint because the PAs/NPs/Pain Service did it all. Or make any decision independently regarding treatment and dictate 4 page tomes for consult notes.

 

[Irradi8or]

I would say I have had the opposite experience. We've had new grads from elite centers who couldn't manage a single patient complaint because the PAs/NPs/Pain Service did it all. Or make any decision independently regarding treatment and dictate 4 page tomes for consult notes.

Interesting - it perhaps comes down to the individual who trained at each institution. We recently hired a new grad from one of the big institutions and this new hire has been one of the best hires we've made in the last 5-10 years or so. Then again, this person has clearly made use of their time during clinical training, and didn't just rely on extensive ancillary services to take care of patient issues. This person's breath of skills were pretty impressive, and essentially runs the stereotactic and brachy programs in our group now. On the other hand, a few years ago we mutually parted ways with another new grad that had been trained at a mid-tier institution but had appeared to have trained at a high-volume practice. This person struggled with even a middle sized load, and we received many patient complaints regarding lack of communication (i.e. not calling patients back) and patients asking to transfer to another rad onc. The inner drive and motivation of the graduate probably trumps training environment, but again it's just an n of 1 experience.

 

[KHE88]

I trained at a pretty good place. I applied at 21c in SW Florida a few years ago as a new grad. Base salary $180k.

Wow.

If you go and look up the billings to medicare from providers in SW Florida, which is publicly available, it's some of the highest in the nation. Like 2+ million.

There's nothing fishy going on here and with the ABR leadership... at all.

 

[seper]

It's just likely 21C pay structure used to be heavy on individual productivity bonus, that's all.

Wow.

If you go and look up the billings to medicare from providers in SW Florida, which is publicly available, it's some of the highest in the nation. Like 2+ million.

There's nothing fishy going on here and with the ABR leadership... at all.

 

[medgator]

It's just likely 21C pay structure used to be heavy on individual productivity bonus, that's all.

Correct. They are heavily incentivized AFAIK starting from day 1

 

[Mandelin Rain]

Interesting - it perhaps comes down to the individual who trained at each institution. We recently hired a new grad from one of the big institutions and this new hire has been one of the best hires we've made in the last 5-10 years or so. Then again, this person has clearly made use of their time during clinical training, and didn't just rely on extensive ancillary services to take care of patient issues. This person's breath of skills were pretty impressive, and essentially runs the stereotactic and brachy programs in our group now. On the other hand, a few years ago we mutually parted ways with another new grad that had been trained at a mid-tier institution but had appeared to have trained at a high-volume practice. This person struggled with even a middle sized load, and we received many patient complaints regarding lack of communication (i.e. not calling patients back) and patients asking to transfer to another rad onc. The inner drive and motivation of the graduate probably trumps training environment, but again it's just an n of 1 experience.

Agreed. Unfortunately, the low n can bias heavily! Certainly the case in my example.

 

[medgator]

Agreed. Unfortunately, the low n can bias heavily! Certainly the case in my example.

Fwiw, I hear that mskcc residents work surgical hours. I'm sure they are studs anywhere

At other upper /upper mid programs I won't name, I hear that every attending has an NP or PA that does scut, sees F/U patients etc while the residents are babied. I think there is a balance that exists, and is hard to find.

At the end of the day though, I think people grow more in their first 1-2 years of practice than they do through all of residency, at least clinically, getting used to managing patients on your own and preparing for oral and that growth occurs regardless of program and is more dependent on the individual themselves

 

[Irradi8or]

Fwiw, I hear that mskcc residents work surgical hours. I'm sure they are studs anywhere

At other programs I won't name, I hear that every attending has an NP or PA that does scut, sees F/U patients etc while the residents are babied. I think there is a balance that exists, and is hard to find.

At the end of the day though, I think people grow more in their first 1-2 years of practice than they do through all of residency, at least clinically, getting used to managing patients on your own and preparing for orals.

Completely agreed - just need to make sure most grads understand that, and put in the necessary time and effort to grow during those first couple of years. I have seen this as an issue for a few of my closer colleagues that went into a highly sub-specialized academic position immediately after graduation (like 1-2 sites only). They passed orals, but when a couple of them tried to transition to a more general academic job a couple of years later, it was a struggle for them. At the end of the day, they did fine a year or so after that transition to the new job but it was like starting over for them.

 

[Reaganite]

Wow.

If you go and look up the billings to medicare from providers in SW Florida, which is publicly available, it's some of the highest in the nation. Like 2+ million.

There's nothing fishy going on here and with the ABR leadership... at all.

Those are likely global billing charges, including the technical. They aren't billing $2 million in prof charges.

 

[medgator]

Completely agreed - just need to make sure most grads understand that, and put in the necessary time and effort to grow during those first couple of years. I have seen this as an issue for a few of my closer colleagues that went into a highly sub-specialized academic position immediately after graduation (like 1-2 sites only). They passed orals, but when a couple of them tried to transition to a more general academic job a couple of years later, it was a struggle for them. At the end of the day, they did fine a year or so after that transition to the new job but it was like starting over for them.

Yup... Agreed. Much harder to transition back from 1-2 sites to full spectrum practice from what I've seen as well after a few years

 

[medgator]

Those are likely global billing charges, including the technical. They aren't billing $2 million in prof charges.

Correct.

The Medicare charges for physicians that are hospital based will show the pro only charges billed to Medicare while the hospital bills the TC, while the physicians in freestanding centers are billing Medicare globally

 

[thecarbonionangle]

I know of multiple “top” programs where residents do not see on treatment/follow ups, NPs/Pas do most of work, dosimetrists contour most things. Would you really want these people in your practice? Be very careful as some programs baby residents to the point of incompetency once they are out on their own.

 

[Irradi8or]

I know of multiple “top” programs where residents do not see on treatment/follow ups, NPs/Pas do most of work, dosimetrists contour most things. Would you really want these people in your practice? Be very careful as some programs baby residents to the point of incompetency once they are out on their own.

Agreed. However, not sure we can use a blanket statement to discuss top vs mid-tier program graduates. Much of it may ultimately come down to the individual candidate. If you're a PP that ends up hiring a top program graduate who essentially only focused on research until he/she figured out there weren't good academic jobs that fit his/her criteria, then you'd need to make sure this candidate has that clinical skill set to thrive in your PP. On the flip side, you don't want a new graduate from a mid-tier program who also doesn't have the skillsets needed to do well in a busy PP clinical practice (which requires some interest in administrative work, financials, ease of getting along with a wide range of patients and referring docs, etc). No one wants a poorly trained graduate, but poorly trained graduates probably exist in all programs to a degree. Also, I certainly don't want a new hire that doesn't end up working out - in general its bad for referrals and practice stability when there's turnover and possibly a longer lasting poor referring physician relationship.

 

[nkmiami]

I chose my program solely on location and expected quality of life in the program. I believe that "teaching" differences between training programs makes very little difference in outcome vs motivation of the resident to read and listen to ASTRO lectures, be active on internet forums, do away rotations. Moreover, if there is a difference- which I highly doubt- it will be erased after 5 years in practice. This is not surgery. but, when I entered training, there was no issue with the job market and that was never a consideration. I cant imagine virtually any differences in training quality between a mid tier vs top tier in this field. There is only so much time in the day, and the residents who are constantly writing papers may not learn as much clinically as the ones reading etc.

 

[20181121]

Anyone can say they offer/received excellent clinical training...

 

[Irradi8or]

Anyone can say they offer/received excellent clinical training...

Yes, but things become more clear when you begin to discuss cases. I've got a partner in my group that feels like he's received excellent training from a mid-tier decently reputable program, but the rest of us know what's real, as we're constantly correcting this person's errors. Typical excuse is, "That's how I was trained...", but I'm certain bilateral neck treatment for a large base of tongue lesion is standard and unilateral neck treatment is not...