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Location, lifestyle, livelihood. These are the first three topics that everyone making a career decision must confront, and decisions on all three have to be in synch. And then there is that most important quality, especially for physicians: job satisfaction. To find a match in a new position, look inward first. Establish your own priorities before looking at what's out there. Think about why you became a doctor, and what part, or part of oncology, gives you real satisfaction, real joy.
The location of a new practice is more than urban or rural, more than mountains or coast. Distinguish between those aspects that are merely appealing to you and those that are absolutely essential. Do you need a good school system for the kids? How important is climate? Do traffic and commuting times make you crazy? Will your spouse have good career opportunities?
In addition, consider how much you are open to stepping outside your boundaries. Thomas A. Marsland, MD, president of Integrated Community Oncology Network, is one who adapted well to change. He moved to Jacksonville, Florida, from the Northeast, where he had grown up and received his training. “Coming from the sophistication of Boston, it was a culture shock to come to a Southern city that was about 10 years behind the times in many ways, and still is,” he says with a laugh. “But the quality of life—doing things outdoors—is great. We've been here 25 years and would never go back.”
A helpful resource for choosing a location is the Places Rated Almanac available for purchase in bookstores and online. It includes a quiz that helps you identify what factors are most important to you in a place to live, and it ranks metropolitan areas in the United States and Canada on cost of living, transportation, education, health care, climate, and more. Another useful guide is Sperling's Best Places, a Web site that gives school statistics, crime rates, and data on climate and cost of living (www.bestplaces.net).
Academic or private practice—this is a key first choice, and one you may have already made. If you think you are open to either, make sure you have an accurate concept of what each entails. First, you may think you have a good idea about the academic side because of your years in training. But academic institutions vary a great deal, and even within a single institution, there are variations. Most schools offer either a clinical track or a tenure track, which have different criteria for promotion and different requirements for teaching, research, publication, and clinical care. When considering an academic position, investigate the options available, and find out the possibilities for changing from one track to the other in later years.
Angeles Alvarez Secord, MD, a gynecologic oncologist and Assistant Professor at Duke University (Durham, North Carolina), says, “When negotiating an academic position, I would really encourage individuals to see what the median and 25th percentile salary is for their area. This information can be very helpful, and one should be able to request [an academic salary] at least [at] the 25th percentile.” A good resource to find out about academic salaries is the annual Report on Medical School Faculty Salaries, published by the Association of American Medical Colleges (visit www.aamc.org and click on “Publications”). Secord advises, “Everything is negotiable. If you don't ask for something, you're not going to get it. It's always wise to critically assess your needs and your own value to the institution and develop a wish list of things you need in your position.”
Secord completed both her residency and fellowship training at Duke before joining the faculty there. Research is a major part of the mission at Duke, and that matched Secord's own career goals. But taking a position where one trained has a cost, according to Secord. “They may not recognize your value. Even though I am in my fifth year out [from fellowship training], some individuals still may see me as that resident they trained.”
Balancing the demands of clinical, research, or teaching responsibilities is one of the challenges of academic practice. “You don't devote 100% to either one—you feel torn,” Secord says. “Currently, I have 1 to 2 clinical days a week, 1 OR [operation room] day a week, and the rest of the time I do my research.” Expectations of others can add to the challenge, Secord reports. “Your basic science colleagues may not take you as seriously because you're not there all the time doing bench research. On the flipside, sometimes the clinical support staff don't understand why you're not present 100% of the time for patient calls.”
Commenting on the pros and cons of academic and private practice, Secord says that those in private practice “probably work clinically much harder than I do, but they are compensated much better. In the academic research environment, there's a lot of pressure to keep writing grants to get funding to support your lab and your personnel. But on the plus side, I think my schedule is easier in academics. The fellows and residents at Duke are excellent and help me take care of the patients on the clinical service.”
Secord says the rewards in academic practice are many. For her, “It has what I want for my life. It has a perfect balance.” Interestingly, although the research focus at Duke is a major reason for her taking a position there, her greatest job satisfaction “is just the patients themselves. We see them for many years and develop a strong relationship. They have so much gratitude for everything you've done for them. But even bigger than that is the privilege you have as a physician in taking care of these women.”
For a useful comparison of academic oncology and community practice, see the article “Making the Choice Between Academic Oncology and Community Practice,” published in the May 2006 Journal of Oncology Practice (2:132-135, www.jopasco.org).
Most oncologists just starting out are likely to join a group practice or join an oncologist with an established practice. In addition to being either oncology-only or multispecialty, groups can have four different kinds of legal structures:
A fifth arrangement is not truly a group practice, but a collection of two or more solo practitioners who share office space, equipment, and staff, and often share call coverage for one another.
Large multispecialty practices may be able to offer more attractive benefit packages than single-specialty groups, but often pay lower salaries, which usually reflect fewer working hours. Large groups also have the means to employ professional staff with the expertise and training to handle management tasks, which in a smaller group, fall to the physicians. As an example of a large group's management, Marsland's LLC, with 44 oncologists practicing in 10 locations, has a professional team that includes an executive director, a financial director, and a special projects person, plus a billing and collections department. Nevertheless, as president, Marsland puts in about 10 to 15 hours a week on administrative duties, in addition to seeing patients every day.
Phoenix, Arizona, oncologist Albert G. Wendt, MD, has an independent practice and shares office, staff, and call coverage with another independent oncologist with whom he has worked for more than 25 years. “We don't have much leeway in office staff. Every person in our office is a key person—one doing lab, one doing billing and accounting, and a couple [of] receptionists. If one person is out, it's hard to cover.” With only two oncologists, he is on call every other weekend. Over the years, Wendt has purposely limited his practice, and now sees about 50 to 60 patients a week in the office, compared to about 120 to 150 in the office and many in the hospital during his busiest year of practice. “We have more to offer our patients than we used to, and I spend more time with my patients. I am much happier seeing fewer patients,” he comments.
Addressing the pros and cons of small versus large practices, Wendt says, “It's harder for a small practice. In purchasing drugs for instance, we don't have the volume to get the discounts that large groups can get. And when my colleague takes time off, I'm the only person left to cover, and that can be tedious.” The plus side, according to Wendt, is that “you run the show. I make the decisions about which health care plans I accept. And I can take off when I want, and I enjoy that.” In considering large or small groups, examine your own needs for independence and control, as well as your tolerance for hierarchy and group politics.
Marsland agrees that an individual gives up a certain amount of independence with a large group. “You're going to lose some autonomy. And for the people just joining, they're going to have to pay their dues. They're not going to walk into a practice and have a major say in how things are done. But there are many ways to get involved. For example, we have a research committee and a pharmacy committee that looks at protocols and cost-effectiveness.” Marsland points out two other advantages in a large practice—time off and call coverage. Physicians in his group have about 6 weeks a year of vacation, and they are on call only 1 of 5 weekends.
Research and teaching opportunities are available in any size group, if the physicians want them. Wendt and his colleague are members of the Phoenix CCOP and participate in clinical research. In addition, he is involved in teaching medical oncology to internal medicine residents.
Marsland believes that oncology practice of the future calls for diversifying streams of revenue, at least in metropolitan areas that are competitive. Putting his philosophy in practice, a year ago his medical oncology group merged with a radiation oncology group, offering their patients one-stop imaging, chemotherapy, and radiation therapy. “This has added a revenue stream to our practice, but it's also a convenience for the patients, and it has improved the quality of care,” he says. He advises fellows starting out, “Look beyond those first couple of years. How is that practice going to be generating revenue when you're not salaried? What do you envision the practice will be like 3, 4, or 6 years ahead?”
Joining a group practice entails accepting the philosophy and work style of the group. Wendt points out that “the more personalities you mix, the greater the risk of some people not getting along.” Marsland acknowledges that this is true, but points out that a large group like his has “a good range of age. We have some young oncologists with babies and toddlers, and others closing in on 60, whose kids are grown. To a person joining such a group, there's a range of colleagues to mix with.”
Wendt emphasizes the importance of a mentor in the early years of practice. “It's kind of scary to start out in private practice. The friendship and mentoring of my senior associate was exceedingly important to my survival, emotionally and physically, in this demanding field, with all of its sadness.” Marsland adds that shepherding in the administrative side of practice is also important. “Someone considering a position should be asking questions like ‘who will explain the difference between a level 3 and a level 4 office visit to me, and how to code them?'”
In selecting a group that matches what you want in a practice, consider how these factors match your goals and desired practice style:
When joining a group, you usually are offered an employment contract with a guaranteed salary for the first one or two years, which serves as a trial period for both parties. The road to partnership, ownership, or continued employment after that period should be clear in the contract. Sometimes, there is a buy-in requirement to become a full owner. It's important to seek consultation from your own lawyer—one with specific knowledge of the laws of the state being considered and who is familiar with the business of oncology. You are not just looking at an employment contract; you are really in the first stage of buying a business. A lawyer with only employment contract experience is not the best choice. Future articles in the Strategies for Career Success series in the JOP will cover ways to evaluate group practices, contract basics, and negotiating strategies.
In his group, Marsland notes that “pretty much everything is on the table” in negotiating a starting position. That is when knowing your own priorities is especially important.
Most oncologists beginning practice will join an existing group. Even with the plethora of placement ads in medical journals, recruitment firms, and Internet job banks, networking and word-of-mouth should be an essential part of your find-a-job strategy. The more people you tell in person that you are looking, the better your chance of connecting with an opening that suits you. Marsland reports that although his group uses journal advertising to recruit, last year, a graduating fellow who joined the group contacted two friends who were subsequently hired.
Hone a description of what you want that can be easily conveyed to others, such as “a five- or six-person practice in a medium-sized city in the Midwest.” Have business cards printed with contact information so people can get in touch with you. Medical society meetings are great places to network. Make a point to attend ASCO's annual meeting and those of the ASCO state affiliates. Show up at alumni receptions, and be sure to participate in the Oncology Career Fair at ASCO's meeting. Wendt is president of the Arizona Clinical Oncology Society and says, “Our society meets twice a year, and we encourage fellows to attend. It's a good way to find out what's going on in your state, and it gives you the opportunity to meet the doctors in a more casual, less formal manner.”
Physician recruiting firms (hundreds of them) can help you find a position, and staff recruiters are also used by some hospitals and large oncology, HMO, or multispecialty organizations. Acquaint yourself with the recruiting industry's professional standards regarding fees, confidentiality, and conflicts of interest, available from the National Association of Physician Recruiters (www.napr.org)
Does the leg work of searching and may arrange your travel
May have positions not advertised elsewhere
May offer you a bonus for placement
Provides helpful information about the practice and community
Will give advice on interview preparation and provide feedback afterwards
Not comprehensive; many practices do not list with recruitment firms
May oversell a position or gloss over some negatives
May require you to stay in position for several years