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Evaluating a practice in radiation oncology
Nicholas G Zaorsky, MD
Fox Chase Cancer Center
Department of Radiation Oncology
Daniel M Trifiletti, MD
University of Virginia
Department of Radiation Oncology
Copyright 2017
Correspondence: Nicholas G Zaorsky, MD. nicholaszaorsky[at]gmail.com. @NicholasZaorsky
I. Foreword
A. This is a list of general advice for physicians looking for a job in clinical radiation oncology. Specifically, it
is geared toward young faculty and graduating residents going into academics or private practice.
B. Suggested reading
1. Medical Legal Aspects of Practice Entry
by Terry J Wall, MD/JD. 2016.
2. How to win friends and influence people
by Dale Carnegie. Originally made in 1930s, reprinted
many times over.
3. Evaluating a Radiation Oncology Practice Opportunity
by Daniel F Flynn, MD. 2012.
4. How to make our listeners like us
by Dale Carnegie
5. Getting Past No: Negotiating in Difficult Situations
by William Ury
6. Simone JV. Understanding Academic Medical Centers: Simone’s Maxims.Clin Cancer Res
1999.
7. Chopra V, Edelson DP, Saint S. Mentorship Malpractice. JAMA
. 2016.
8. Dahle J. White Coat Investor.
http://whitecoatinvestor.com/, 2017.
9. US Department of Education. Federal Student Aid. Public Service Loan Forgiveness.
https://studentaid.ed.gov/sa/repay-loans/forgiveness-cancellation/public-service. 2017.
C. Best advice I received:
“Get multiple offers.”
“You get what you negotiate, not what you deserve.”
“If you don’t ask, it’s the only way to guarantee you won't get anything.”
“You can ask a million questions, but you can’t make a million demands.”
“If it ain’t in the contract, it ain’t gonna happen.”
“The vast majority of first jobs are not where people last. Be prepared to be there 4-5 years.”
“Always ask for advice.”
“The most important thing is if you can trust them”
“Remember the golden rule: whoever has the gold makes the rules”
“You want to go to a place that is excited to have you.”
“Offers can be rescinded if you negotiate too aggressively.”
“Be a ‘high yield, low maintenance’ employee.”
“In general, don’t send an email longer than what can be read on the screen of your phone.”
D. Acknowledgements, approval, disclosures
1. We have no financial disclosures. We have no legal training. This document is not meant to
provide legal, financial, or medical advice. We are not using any copyrighted information, patient
photographs, identifiers, or other protected health information in this article. No text, text boxes,
figures, or tables in this article have been previously published or owned by another party.
2. We are thankful for advice of Dr. Timothy N Showalter.
II. Billing components and employment models
A. Most jobs are labeled as academics or private practice, though there is a grey area. Compensation
(billing) is determined differently though different models. In general, PPs can receive technical and
professional fees. Academics is usually at a set salary based mostly on professional fees, and there can
be some change (e.g. incentive) in salary depending on the professional fees.
B. Billing components
1. Professional 30%:
Consult
OTV
Physician treatment planning
Follow-up
Procedures
2. Technical 70%:
Vault
Linac
Utilities
Zaorsky NG and Trifiletti DM. Evaluating a practice in radiation oncology. 2017. Page 1. ©
Physics/dosimetry/nursing/support
Treatment delivery
C. Employment models
1. Academic
a) Usually set salary. Incentive may be based on professional. Usually no technical fee.
2. Academic satellite
a) Your job is to crank through patients to support the main center
b) An academic satellite is built strictly to bring in revenue
c) Note that this is typically not for people who want to do research in lab at main center
3. Employed model in a healthcare plan (e.g. Kaiser)
a) This can be frustrating and revenue generation and cost use
4. Employed model at a hospital
a) 4-fold increase in graduates becoming hospital employees in 2016 vs 2015
b) Aspects
(1) No research
(2) Set salary
(3) Should have productivity bonus model
(4) Downside is that you have a boss.
(5) Buy-ins are unlikely
c) Note that it is illegal (fraud and abuse legislation) to enter into any agreement w the
hospital that calls for such things such as salary, rental of office space, equipment, or
services to be provided on terms other than fair market value.
d) If questions about quality of behavior arise, you might not have luxury of review by your
peers bc hospital administrator can just fire you
e) hospital-employed jobs are not too desirable because they will work you hard and may
not re-sign your contract after 2-3 years. But this may be a good solution for a few years.
Many private practices feel that hospitals are buying practices just to take their profits.
f) Be fearful of certain academic hospitals – where you join up and then you get bought out.
Or at a place that has 5 years to partnership. Or a place that is a factory for patients.
5. Pure private practice (30% of practices)
6. PSA (physician services agreement).
a) These get no technical, only professional revenue.
b) Can be very overworked – be careful.
c) If the hospital contract is lost, you have nothing.
d) Usually they are servicing multiple hospitals to make it.
7. Non PSA
a) 5-7% of practices own some of their technical, and are in free-standing facility.
b) This is a pot of gold and goal.
III. Pre-visit / general advice
A. Early contact should not be discouraged: If you have a dream job, stop by when you’re in town and
meet people just to introduce yourself and get the lay of the land. Let them know when you’re graduating
and get a sense for their timeline and any planned expansions.
B. Write down what you want:
1. Options: clinic, research, location, salary, schedule, disease site, mentorship, family (inc school
systems, town, proximity to parents), happiness of significant other
2. Pick 2 of these 3: location, type of job, compensation (Salary + benefits, etc). If you find all 3, you
are done
C. Make professional folder
BLS/ACLS card
Diploma copies
TY/Prelim year certificate
Professional photo
DEA license
Zaorsky NG and Trifiletti DM. Evaluating a practice in radiation oncology. 2017. Page 2. ©
Training license
Unrestricted medical license
Unsealed source documentation
HIPAA training/annual training certificates
D. CV
1. Should be evolving over your career
2. Consider these sections:
a) Technical skills (e.g. SBRT, planning software, brachy, etc)
b) Journal referee
c) Mentee education (not uncommon to list students you have mentored)
d) Clinical trials
e) Grants
f) Press releases / news about your research. Link to the webpages
3. Abstracts/presentations have little weight on the CV. It is typically much better to have a paper
and a high impact paper, if you can
E. PGY objectives
1. PGY-2
Start/update CV
Start “Professional folder”
Learn rad onc
Approach research projects cautiously with guidance from senior residents
If there is a very specific geographic region you have in mind, it is never too early to get to know
the practices in that area
2. PGY-3
Update CV
Update “Professional folder”
Learn rad onc
Work on research projects
Read ASTROgram to learn of new opportunities for awards/experiences
Join ASTRO job board to get e-mails of new postings to get a feel for what is out there
If there is a very specific geographic region you have in mind, it is never too early to get to know
the practices in that area
3. PGY-4
Update and polish CV
Update “Professional folder”
Plan meeting schedule early on. Complete projects accordingly. Network at these meetings
If possible, reach out to some grads from your residency in desired geographic area. Find
attendings or other connections in your desired area
Compile list of contacts to send out emails/make calls
Try to schedule some in-person days with practices around the holidays: “I am going to be visiting
family in the area and was wondering if I could spend a day with you.”
E-mail addresses obtained from ASTRO directory, try to find chair/oldest member of group on
website, maybe call a secretary to ask who to direct e-mail to
Expect to hear back at all from about 50%, maybe 10-25% will be looking for someone
Response rates improve if you name drop or cite a connection with the practice
Also don’t be afraid to send a reminder email or 3.
4. PGY-5
See remainder of document
Early in year is seller’s market (favors the programs); later is buyer’s market (favor the applicant),
particularly for academics
CVs and cover letters go out in July/August, right after boards
Interviews typically are September - March.
Most people have a contract signed by February - April.
Zaorsky NG and Trifiletti DM. Evaluating a practice in radiation oncology. 2017. Page 3. ©
F. Email
1. Identify areas / practices you like, send 30+ emails.
2. PDF your cover letter and CV
a) Your CV gets you in the door. Then, they are evaluating how you think, how you act, if
they could work with you.
b) Need activities/interests section on the CV
c) Cover letter should have some personalization -- why do you want to go to this particular
job? Why would they want you? How can you show them that you’re serious about it?
3. Initial e-mail should be generally pretty short and sweet, including your CV and cover letter.
Email to check back 3-4 times over ~3-6 months. If you don’t hear back, cross that group
/practice out.
a) Good reply from the chair/chief will either say there is or is not a position right now
b) Red flag is no message for weeks - months, then email back
4. Don’t be afraid to take interviews and get to offers even in places you would not really want to
work (but be smart if you have limited time off). Benefits: you will look desirable, get practice
interviewing, identify parts of contract you would not have thought of, you will be able to say that
you have had some very generous offers. You negotiate very little in partnership jobs. You
negotiate heavily for all other jobs – that is your only chance to bargain.
G. Ask your mentors
1. Ideally, mentors should be looking for jobs for you during residency, introducing you to others at
meetings, helping you network
2. Mentors can contact practices on your behalf
H. Phone or in-person “meet and greet”
1. This is the typical at-ASTRO interview
2. Typically limited to a few questions: What is the disease site I will treat? Where is the practice?
Who are the other physicians? Where did they train? Etc.
3. Based on previous years’ data, ASTRO interview-to-hire success is 0% (Zero!). Still, it is good to
build connections; the interviewers you meet might connect you to other jobs, or hire you for a job
different that what was advertised at ASTRO
4. Pre-interview dinner questions: informal. Get to know background, interests. Made to be
low-stress
I. Interviews
1. Have a specific interview itinerary (usually emailed to you)
2. Before any interview day, look up all faculty (google, pubmed, etc)
3. 5 - 10 total interviews as a very rough goal. Each requires ~2 days off.
4. Have 3 line spiel mentally prepared for each research project.
5. Be prepared for an on-site presentation, typically on the 2nd visit (usually in academics, not PP)
a) Usually 30-50 minutes
b) Highlight your research, interests
c) All presentations at jobs go on your CV
6. Visit on a day with chart rounds if at all possible.
a) Evaluate how quality of review is. Also get a feel of how cases are treated.
b) Try to plan 1st interview for chart rounds, but if not need to go for 2nd interview.
7. You will be asked: where you have weaknesses in your training?
a) E.g. suburban location with little advanced disease. “That is why I have arranged an
elective rotation at in a more urban location.”
b) “Always trying to improve efficiency”
8. 2nd interview
a) For research, meet with collaborators (e.g. meds oncs, surg oncs, biostatistics,
epidemiology)
b) On the 2nd+ time, come with spouse
(1) Is there an offer for spouse?
(2) Can spouse meet other spouses in the group?
Zaorsky NG and Trifiletti DM. Evaluating a practice in radiation oncology. 2017. Page 4. ©
9. Ask yourself: am I “overqualified” for the current job?
10. Making a decision
a) Usually 7-10 days after you get the final contract
b) Timing is critical: after you receive the contract (after 2nd interview), practices want a fairly
quick answer. So, delay the second interview scheduling if you need to.
c) “Thank you for the opportunity to learn more about your practice. I have decided to
pursue another opportunity. I wish you the best of luck in the future.”
J. Identifying red flags
1. Bullying:
a) Remember that you have to work with these people! Behavior during the application
process is probably when they’re at their best.
b) “we have another candidate who we are considering if you are not ready.”
c) “If you don’t take the job to [build this clinic / start this research program / etc], someone
else will.”
2. Using various forms of communication (e.g. email, text messages, phone). Everything should be
in the contract. Nothing in an email or text is legit.
a) Even worse: midnight texts/emails telling you to "commit to signing"
3. Taking too long to make changes to the offer letter or contract. Most changes take 1-2 weeks
max.
4. Unclear terms over phone or via email. “Potentially” “up to” “(salary range)”. The offer letter and
contract do not have these terms. There is just a number.
5. No response for weeks - months.
6. Avoiding meetings with certain attendings, residents, staff, etc.
7. Poor reviews from prior attendings, residents, staff, etc.
8. Making you pay for the visit, esp at the last minute.
9. Arrogance / overconfidence at the interview
10. Even one unfavorable interview with a staff member should be considered carefully in your
impression of the position. They are probably trying to tell you something.
IV. Visit - Questions you should ask the practice
A. General questions for practice
1. What are your goals for me?
2. Where do you see me in 5 years? 10?
3. Is there anyone who left before partnering? Look at old ASTRO directories – I see that XXX was
listed with this practice, do they still work here? If not, investigate why. Contact that person and
ask.
4. Where is the department heading?
B. Hospital system
1. Are there any metrics to meet? Can I please see the specific criteria sheet for me? Are my
salary/incentives based on this? (there should be specific criteria sheet)
2. How responsive is hospital to staffing issues?
3. Who are the competing institutions?
4. Who has budgetary control?
a) E.g. who determines when we get a new CT sim?
5. Is the hospital actively buying surrounding referrings/medical groups?
a) Who is in the group? Physicians only? Therapists, business managers, nurses?
C. Administrative evaluation
1. Background
a) Avg number of
(1) hospitals where patients are seen: 2.3 (1-7)
(2) RT facilities: 2 (1-4)
b) What is ratio of square feet to # patients
(1) ~150 is average
(2) <100 is too small
Zaorsky NG and Trifiletti DM. Evaluating a practice in radiation oncology. 2017. Page 5. ©
(3) >300 is too large
2. What are state licensure requirements? Timing?
3. ACR/ASTRO accreditation?
4. Is there a quality improvement program? Do I participate? What are the specific criteria I need to
meet?
5. MANTA for small business info (investments, net worth)
6. How big is the practice?
7. How are sims done? Who schedules them? (Walk me through it.)
8. Where are the areas of change?
9. Do you have EMR? What kind? If I am at a satellite, is it the same EMR?
10. Is travel involved (from center to center)? Does a physician have to be at all centers? Is there
extra reimbursement with this?
11. What are the distances between satellites?
a) Can patients be followed at any satellite?
12. How does billing work? How are RVUs determined? (Does this relate to my salary/incentive?)
13. How are cases assigned?
14. During what hours are patients treated?
15. What are my administrative duties?
16. Am I responsible for hiring the coders?
17. What is measured, reported? How am I being compensated compared to others?
18. Get copies of all RVU reports when you start. See how your RVUs compare to goals.
D. Physicians questions
1. Meet all attendings, including chair
2. Find physicians who left in past 5-10 years. Why did they leave?
3. Talk to individuals seriously recruited but who did not join the practice (this is harder to do). Ask
around at meetings (ACRO, ARS, ASTRO)
4. Ask to meet referring physicians. E.g. surgeons, medical oncology
a) This will give you an idea of what people think of the group.
b) Are surgeons fellowship trained?
5. Ask about pending lawsuits against the group
6. Ask about Medicare/Medicaid fraud prevention compliance program
a) This ensures conformity with Medicare Fraud and Abuse Litigation
7. Talk to competing groups
8. Do physicians cover more than one site?
9. Do physicians carry pagers?
10. Do physicians come in on weekends to see patients?
11. Do physicians admit patients to rad onc service for implants?
12. Where did MDs train?
13. Call responsibilities and frequency? Is it assigned to each attending or rotating?
14. How do you handle vacation – cover other sites or hire locums?
15. Who goes to tumor boards? How frequent? Which ones will I go to?
16. Who comes to chart rounds?
E. Equipment
1. Simulator? Do you do 4DCT?
2. IMRT to 3DCRT ratio?
3. Brachy equipment
4. SRS equipment
5. Who does the implants? HDR or LDR?
6. Do you own your own equipment?
a) If radiology buys MRs and CTs, do they buy simulators and LINACS too?
7. What treatment planning system? (emphasize your experience).
8. Is there a dedicated conference room?
9. What is estimated downtime?
Zaorsky NG and Trifiletti DM. Evaluating a practice in radiation oncology. 2017. Page 6. ©
10. Evaluate the actual quality of the sim
11. What is age of equipment? Avg is 10-12 years.
12. Is it serviced regularly?
13. Evaluate quality of computer support
14. Medical library?
F. Patients
1. How many are on treatment?
a) Note that you need ~13 on treat to break even for a rad onc. ~20 is an average number.
30 is busy. >40 is very busy. >50 is usually uncontrollable Patient types on treat should
be taken into account: prostate, breast usually have few issues
b) What is the high and low # over the last year?
c) What is projected?
d) At what point do you hire another faculty?
e) PA or NP available? These are needed patient assessment, phone calls
f) Observe actual patient treatment
2. Parking lot for patients? Small practice should be 3-6K sq feet; large should be 12 K sq feet
3. How is the patient population?
4. What is the geographic area patients come from?
5. Service area and service population
a) E.g. in 100K people, 5% will have new cancer (i.e. 500). 240 of these will get RT
b) Avg length of tx = 6 weeks, so 8.7, average, in-week treatment courses (8.7 x 6 = 52)
c) 40 additional patients per year are re-tx
d) Thus, 32 patients (280 / 8.7) receive RT on average each day for a service area
e) One full time equivalent (FTE) rad onc treats 200-250 patients/year
f) If “new patients” is specified rather than “patients”, then retreatments have not been
counted, and these constitute another 20%
6. What fraction is locked into Managed Care? What is the “market share” i.e. the fraction of area
population covered by the practice?
7. Sample patients
a) How is spinal cord compression treated? Emergency or next regular work day? Who is
present while emergency patient is treated? Physician? RTT? Physicist?
b) Brain mets. When is the patient’s first interaction with rad onc? On tx table? Or through
prior consult with pt and family?
c) How would you treat a pelvic tumor definitively?
(1) APPA vs high energy. Blocks or not? Computer plan or not? EBRT and or boost?
d) How are bone and brain mets treated? Is treatment the same for all patients?
8. What is policy for self-pay or uninsured?
9. Review charts of patients under treatment
G. RNs, secretaries
1. RNs
a) How is your nursing staff?
b) Do you have one on one nursing? One on one secretaries?
c) RNs? LPNs? Aides?Sit down and talk to RNs!
d) Is it one on one?
2. Have any support staff spots been open but not filled? How many months?
3. Who does dictation?
4. Who checks dosimetry in charts? Therapist? Dosimetrist? Physicist?
5. Dietician? Speech and swallow?
H. Physics/dosimetry
1. How many dosimetrists and physicists? Is there full-time dosimetry/physics at all sites? Is sim
done at each site (not off-site – where you can wire, bolus, etc?)
2. Who does air gap calculations?
3. Do physics and dosimetrists check each other's calculations?
Zaorsky NG and Trifiletti DM. Evaluating a practice in radiation oncology. 2017. Page 7. ©
4. Are physicists certified by ABRT or ABMP? Do dosimetrists have CMD?
5. Does physicist handle details of safety for implants?
6. What tech is available for dose verification?
7. Talk to physics privately
a) Strong role in patient management?
b) Attend clinical conferences?
8. Are RTTs on call? Do they have pagers?
I. Research
1. Specific project ideas
a) Meet with epidemiologist, biostatistician, basic science, etc.
2. Are there residents/med students available to do research projects?
3. Projects w industry? Computer companies? Pharma?
4. Pre-submission grant review resources?
5. Note that for clinical trials / big research program, the following need funding or may be included
in the contract (also, see the “ask letter” of this document):
a) Database manager
b) Research RN
c) Research assistant
d) Laboratory space
e) Database programmer
f) Junior data entry person
g) Statistician
h) Office space for all these
i) Office space for coordinators
j) Needs over the next 3-5 years
k) Travel funds?
l) Maintaining medical license?
m) Leaving the clinic for research
n) Is desk, computer, etc included
o) Parking
p) Cell phone
V. Academic- and PP-specific questions
A. Academics
1. Clinical
a) Must visit all satellites where I may be assigned?
2. Research
a) What are my research responsibilities?
b) How much time available for research?
c) Be upfront about what you want to do research-wise. Agree to enroll patients on
protocols. keep quality of life data, etc
3. Teaching
a) Teaching responsibilities?
4. How are junior faculty mentored?
a) Who will be my mentor?
b) How often do we meet? Monthly ideal with main mentor.
c) Standing meetings with chair (or service chief, cancer center director, etc, if possible)
q3-6 months.
5. Promotion and tenure policy?
a) Most people will start as assistant professor. What are promotion requirements for
Associate? Full? Time to promotion? Get all details Which publications count? If unable
to do prospective research, retrospective is too low yield, basic science may not be
possible. Epidemiologist and biostatistician then necessary.
(1) Note associate professor typically means national recognition.
Zaorsky NG and Trifiletti DM. Evaluating a practice in radiation oncology. 2017. Page 8. ©
(2) Full professor means international recognition.
(3) Adjunct position may be at a satellite. May not have any promotion or tenure
options.
(4) “Tenure track” positions: favorable title for getting grants because it means the
institutions is committed to your success.
b) Suggested references to gauge rank, promotion, success:
(1) Choi et al. Citation-based estimation of scholarly activity among domestic
academic radiation oncologists: 5-year update. J Rad Oncol.
2014.
(2) Quigley et al. Distribution of the h-index in radiation oncology conforms to a
variation of power law: implications for assessing academic productivity. J
Cancer Ed.
2012.
(3) Zhang. Factors associated with increased academic productivity among US
academic radiation oncology faculty. PRO
. 2017.
(4) Get your stats: scholar.google.com; Scopus
(5) Is your next paper going to raise your h-index? How will the h-index change
overtime? http://klab.smpp.northwestern.edu/h-index.html
(a) In general, once you have 10-20 publications, another low impact paper
(e.g. impact factor < 5) will not boost your h-index. The next goal is a
high impact journal (shoot for impact factor > 8) and a journal you have
never published in
c) Not everyone at a high ranking institution will succeed. Your chances might be better in
an institution with a better fit. See talk by Malcolm Gladwell on Elite Institution Cognitive
Disorder.
6. Guidelines for conferences, travel, book/subscription allowanced, professional dues
7. Look for faculty who left in last 5-10 years
8. The “ask letter”:
a) The ask letter is the rationale behind you asking the chairperson, “Are there startup funds
available?”
b) Typically a few pages on your clinical and research objectives. Should outline everything
you need and why. For example what is your clinical mission? What do you want to do
on a national or international level? How can you do this given your past work? Similarly,
what are your research objectives? What do you need to succeed? What do you need in
the lab? You can’t just like a PhD level biostatistician without having a reason to support
it.
c) Ask for more than you need. My mentor got 300K for 3 years, and that was in 2006. For
a strong person coming out of academics in 2016, should be asking for 1 M. If you are
luck you can get there. Basic scientists will need more than clinical researchers, in
general.
d) Remember the difference between asking for something and demanding it. Even more
important, be clear about which you are doing.
B. Private practice
1. What are you looking for at the time of partnership?
a) Avg time to partnership is 1.5 to 3 years.
2. Ask questions with enough knowledge and open-ended, esp in regard to business set-up.
3. How long have you been contracted with the hospital?
4. Is medical oncology private?
5. Have you felt any pressure to join hospital staff?
6. Length of contract?
7. How long have you been contracted? < 5 years is too short
8. Know all details of buy-in.
a) Most practices private groups that are contracted. This compared to employee-based
model that almost always has higher salary with integrated performance bonus. You
should expect them to expect you to get to that number – that is why bonus is there. You
Zaorsky NG and Trifiletti DM. Evaluating a practice in radiation oncology. 2017. Page 9. ©
may feel like you lost some clinical autonomy/freedom when in employed model – ask
freedom for fractionation, etc. Is everyone an equitable partner?
b) This is based on fair market value of all assets of company. PSA buy in should not be
more than 150,000.
c) Technical practice buy-in will be $2,000,000-3,000,000 (as of ~2012). Your chance at
partnership is directly proportional to the number of partners. You want a group with 5-10
partners.
d) You need to convey to the partners that you think like they so that you would be more
likely to vote like them when issues arise.
e) You should always have an independent appraisal.
9. Average time to vest is 2.6 years
10. Insurance
a) 100% offer malpractice
b) 59% offer disability
c) 60% offer life
11. Median educational allowance is ~$5,000 / y
VI. Family / city
A. Meet with a realtor in the area (most practices set up this for you)
B. How are the schools in the area?
C. Crime?
D. Taxes? Income tax (state, local)? School tax?
VII. Contract
A. Background
1. Anything important to you should be in the contract, including things you want to avoid
2. The first document you receive is called an offer letter.
a) Should be 2-3 pages. If it is long (e.g. 20 pages, then this is a red flag -- see Simone’s
Maxims)
b) You can discuss / negotiate a few changes, possible 1-2 times for revision. >2-3 is
pushing it.
c) Offer letter is followed by full contract, which can be many many pages long
3. Trojan Horses and Supremacy Clauses: many contracts have language indicating you will
comply w all policies. If there is a particular issue of interest to you, such as the ownership of
intellectual property, you may want specific contract language rather than the “Standard policy” to
apply.
4. Exhibits “by reference”
a) Ask if these are present.
b) Used in contracts to specify duties, fringe benefits, etc.
c) Make sure the contract itself contains the magic legal words “incorporating by reference”
those exhibits and by specifying that the exhibits can only be changed by written mutual
consent.
d) Review the exhibits in detail.
5. Intellectual property
a) Important for academics
b) Who owns what physician may develop? Articles? Devices?
c) Need to consider if you will generate intellectual property during employment and have
contractual guarantees that my expectations will not be overturned by institutional policy
changes
B. The 13 aspects of the contract
1. Direct compensation
a) Salary
(1) Signing bonus
(2) Base
(3) Advances in income
Zaorsky NG and Trifiletti DM. Evaluating a practice in radiation oncology. 2017. Page 10. ©
(4) Max incentive compensation, rules affecting forfeiture if i leave
(5) Cost of living calculator to really compare salary.
(a) bestplaces.net
(b) CNN cost of living / salary calculator
(c) Need to account for all benefit value, including insurance and retirement,
as these can vary widely.
(6) Salary comparison:
MGMA
Sullivan Cotter
Merritt Hawkins
Modern Healthcare
b) Compensation
c) Parity: normal full salary obtained by a completely integrated physician. What is the full
parity, length of time necessary to get to this point?
(1) How do you keep the workload in your group equal?
d) 501(3)c? Need this for loan repayment and PSLF. If not, need for salary to compensate
e) Reimbursement for moving and relocation expenses
What is the payor mix?
Payor
Classic
Managed care
Medicare. Pays 80% of approved
amount. 20% paid by co insurer or additional
coverage
Part A: to hospital. Aka Technical
Part B: to professional. E.g. physicians
60
20
Medicaid
5
5
BC/BS and other
15
2.5
Other commercial
20
2.5
Managed capitated
35
Managed non cap
25
PPO
10
HMO may pay only 95% of what Medicare pays for middle-aged patient. This is called a “discounted” rate
2. Deferred compensation.
a) Qualified: 401k/403b; (e.g. Pension and profit-sharing plans)
(1) What type of retirement and deferred compensation plans do you have?
(2) What types are available?
(a) Profit sharing
(b) 401K
(3) Time to vesting of each?
(a) Average time to vest is 2.6 years
(4) Know how retirement contribution works – is it a match, does it come out of your
salary, or is it outside of your salary? Really need to know when you get vested
in retirement program.
(5) Types
(a) Defined benefit plan (aka a “pension”): rare. You are guaranteed to
benefit, like a health care, when you retire
(b) Defined contribution plans: e.g. 401(k), money purchase plans, or
profit sharing plan. Both employer and employee may contribute to
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these plans, in amounts that are capped by the relevant law, called
ERISA
b) Non-qualified
(1) There are rare and usually are used in other businesses
3. Vacation.
a) How many weeks? Extra pay if unused? Carry over? Do meetings count?
4. Fringe benefits
a) Questions
(1) Which is available? What is deductible? Family coverage?
(2) Group policies are often better than individual policies
b) Accident insurance
c) Health insurance
d) Dental/Eye insurance
e) Life insurance?
(1) Purpose is to cover debts or obligations that would remain if you die and to
replace a lost stream of income that could support your dependents
(2) Who gets proceeds?
(a) It should be your designated beneficiary (e.g. next of kin)
(b) “Key person”? This would be for my replacement
(c) A new will does not “trump” the beneficiary designation in an insurance
contract or most 401(k) beneficiary designations
(3) Life insurance subtypes:
(a) Term
(i) Lasts for a specified period of time, at the expiration of which,
you have no life insurance and no residual value in the policy.
But if you die during the term, you win!
(ii) Tends to be cheaper than permanent product
(iii) The trick is that at the end of the term, your health may have
changed and you may not be able to get a permanent product or
any other term
(iv) Term may be good for extended period of time, like 20 years
(v) There are desirable products called “guaranteed convertible
product” that allows you, at the end of a term, to automatically
go to one of the permanent forms of life insurance without being
“medically underwritten” (i.e. having to pass the physical). Thus,
you want a term policy with a guaranteed convertibility
provision.
(a) Does the term life insurance have a guaranteed
convertibility provision?
(b) Permanent product
(i) The opposite of term, which has multiple subtypes inter alia,
universal, variable, whole life
f) Property insurance / General casualty insurance
(1) Am I named at the insured?
(2) Note that medical malpractice insurance doesn’t cover everything (e.g. slip and
fall cases in your freestanding clinic)
(3) Special riders on “General” insurance are usually needed for computer dta,
employee dishonesty, locums coverage, etc.
(4) If you are running a practice, need to consider
(a) Wrongful termination
(b) Discrimination / harassment claims
(c) Worker’s compensation insurance
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(d) Note that excess liability coverage on your automobile or homeowner’s
policy (i.e. “umbrella policies) are a good idea, for up to 5 million dollars.
Think seriously about always having umbrella coverage equal to your
entire net worth
g) Misc Benefits
(1) Misc. Death benefits.
(2) Entertainment;
(3) CME
(4) locum tenens coverage;
(5) professional membership dues;
(6) books; journals
(7) medical society dues
(8) Fee for applying for participating status w managed care organization
(9) Licensing fees
(10)Car allowances
(11)Subsidy for parking
(12)Pager allowance
(13)Computer / internet allowance
5. Disability insurance
a) Do you offer disability insurance? Is it own occupation? With lifetime benefit? Am I
paying my own disability premium, so the benefits are non-taxable? If I am not, then I
am giving money to the government
b) Background
(1) Your most important asset is your ability to work. This asset needs protection. If
you are between 30-40, you are 5x more likely to be insured and off work for
>90d than you are to be killed. Thus, need to buy all disability insurance you can
get
(2) Who pays premium:
(a) If you pay, may be better w post tax dollars because benefits are not
taxable if you are disabled
(b) If corporation pays, it may be pre-tax, and corporation can legally
reimburse you next year for the cost of this year’s premium
(3) Waiting period / “elimination period”: time of disability until it starts paying.
The longer, the cheaper the premium. Avg 60-90 days. Need to know if group
will continue all or part of our salary until policy kicks in. If not, you have a
“disability war chest” of personal savings to get you through. Disability not paid
until END of month.
(4) Cost of living adjustments policy should correct for effects of inflation
(5) “Guaranteed purchase option” allows you to add coverage without another
medical exam
(a) Does the policy have a clause allowing me to buy more coverage,
without new physical exam, as long as I can show financial necessity to
support the additional coverage?
(6) Own occupation: want a policy that will pay if you cannot practice your own
occupation, which is very important. This is hard to secure
(7) Lifetime benefit: Longest period of disability coverage may be up to age of 65
6. Long term care insurance
a) Do you offer long term care insurance? Is the corporation paying? This is best because
the corporation get s a deduction and any benefit flowing to me will not be recognized as
income
b) Flat rated until about age 40, so get it in late 30s
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c) Medically underwritten, so need to get before health deteriorates. Should get it through
your employer because it is deductible to them and any benefits that flow to you are not
“Recognized” as income.
d) “Lifetime benefit”: sometimes sold by a vendor. Typically this long period of coverage is
not cost effective because average survival in long term acute care is 7 years, max 10
e) Disadvantage of stand-alone long term care policy is that if you are very healthy of if you
die young, the benefits may never be needed
f) Combination life + long term care policies are available w permanent life insurance
policies and are cheaper than both separately
7. Malpractice insurance.
a) Background
(1) Traditional company that rates financial health of malpractice carriers is called
AM Best. If no rating here, then check with Fitch’s, or the state insurance
commissioner in the jurisdiction
(a) Rating: Need A rating, but may have to settle for B++ (as of 2016)
(b) Standing: Check with insurance commissioner / state medical society to
make sure the malpractice carrier is in good standing and has a good
claims paying reputation
(2) “bedpan mutuals”: 60% of physicians are insured through small companies,
known as ”bedpan mutuals”
(3) Risk retention group (RRG): can write insurance in multiple states, but only
regulated in the state of their domicile. Almost all domiciled in Vermont, because
Vermont has made it a business to be hospitable to them. The capital required
to start is much lower than regular insurance company, and they are more likely
to fail. RRGs do not have access to state guaranty funds, except in their state of
domicile
(a) If your malpractice carrier is an RRG, most investigate more thoroughly
with regular insurance carrier
(4) Guaranty fund: if insurance company goes broke, the state will step in and
provide coverage for you, but only if your carrier is an “admitted” carrier to that
state’s guaranty fund.
(a) Is the carrier “admitted” in a state with a guaranty fund?
(5) Named insured: You want to be a named insured. If you have strictly an
individual policy, the assets of the group you belong to may not be covered.
Most states have small surcharge to add the name of the corporation to the
policy as an additional insured. Some insurers provide a separate limit for the
corporation.
(6) Settlement provisions: Allows the insurance company to settle a claim, even if
you don’t want to, as long as settlement is within the limits of the policy coverage.
This may be an injustice and may generate extra paperwork for you for years.
(a) Does the carrier allow settlement without my approval?
(b) “Hammer clause”: limits the insurance company's responsibility to the
amount that the claim could have been settled for ir you had consented
to the settlement, making it high risk to pursue the case
(7) Costs of defense: should not be included in the coverage limit
(a) Ask: are costs of defense in the coverage limit? If the answer is yes,
then you need to buy higher limits. If not, you are golden.
(8) Hold harmless clause: you hold your employer harmless for any liability created
by your errors, and this is not good because you incur liability that malpractice
policy will not cover
(9) Questions
(a) What are the premiums?
(b) What are the limits of the policy?
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(c) Are the limits of the policy per practitioner (instead of being per group)?
(d) How portable is the policy if I leave the group?
(e) Is the policy retroactive to provide seamless coverage from the end of my
training coverage?
b) Two types. Ask which type they have
(1) Claims-made
(a) It is almost certain that you will have this policy
(b) Only protects you against suits that are filed in the year of the policy.
Thus, you must have malpractice policy every year for the rest of your
life. Note that statute of limitations does not always apply. Many
jurisdictions have a “discovery rule” that holds that a cause of action (i.e.
legal basis for malpractice suit) does not accrue until the injury is
manifest AND the patient knows that it might be from medical
negligence. In rad onc, this can be decades. Thus, you must never have
an “uncovered period” if you take time off or are in between jobs.
(c) Premiums will start low and increase every year until about years 4-5
when they level out
(d) Need tail insurance / “endorsement coverage” / “tail coverage”
(i) Converts claims-made policy into occurrence policy and covers
you for any occurrence up to that point. It will not cover you if
you come out of retirement or back to work, however
(ii) Some policies will have a tail “for free”. Otherwise, expect that it
will be 200% of your last year’s premium
(iii) Need to ask them:
(a) Do you provide tail coverage? Who does?
(b) Does my own residency program provide tail coverage?
If not, I need to get my own
(2) Occurrence
(a) If you commit malpractice in 2016 when the coverage was effective, no
matter when in the future you are sued, you will be covered (if your
insurance carrier is still in business). This is more expensive than
claims-made insurance, but the tail coverage is not necessary
c) Residency
(1) Ask your PD whether the institution provides reporting endorsement coverage for
you when you leave
(2) Get a copy of your certificate of malpractice insurance from your program
before you leave
8. Term and termination provisions
a) THIS IS THE MOST IMPORTANT ITEM ON THE CHECKLIST
b) This is the specific time after which one hopes for an offer or partnership or tenure.
c) The employment agreement should specify the conditions under which you can be “let
go” before the expiration of that term and dismissal.
(1) “With or without cause”
(a) This is not good for the employee because they can be let go at any time
for any reason
(b) These physicians are typically employed “at will” and can also be fired “at
will”
(2) “For cause only”. This is the best. If the term is 5 years, then you have 5 years
of security Can I be dismissed “for cause only”?
(a) Breach of contract
(b) Conviction of a felony
(c) Loss of narcotics license
(d) Revocation of medical license
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(e) Loss of hospital privileges
(f) death/disability
9. Scope and Definition of Duties
a) What are my expectations?
b) Does this limit outside income?
10. Buy-in provision (Front Door)
a) Background
(1) Some employers in corporation may offer to have your compensation reduced for
several years to offset the stock purchase price, which is touted as an advantage
because you pay for stock with pre-tax dollars. However, IRS may claim that the
value of the stock is actually greater than what you are paying, and treat the
difference as ordinary income, with penalties and interest.
(2) Check w a tax consultant, as “foregone interest” on below-market rate loans is
also taxable
(3) As a general rule: anything that sounds too good to be true is probably a taxable
event.”
(4) The exact formula should be listed in the contract
b) “Valuation of Assets”
(1) Ask: how are assets valued?
(2) Many ways this can be done. Need to know the formula specified in the
employment contract
(3) “Blue sky” provision
(a) An intangible asset like “goodwill”. Goodwill can falsely inflate the value
of the partnership or corporation. There should be no goodwill in the
valuation of the practice. Goodwill is intangible.
c) For example, a practice that has a good referral pattern, a LINAC may be valued at 1M,
and the goodwill may be also at 1 M because the support staff is in place, sources of
referral have been developed, there is a telephone number, advertising modes are in
place. A new practitioner saves a lot of time by joining an established practice.
d) Will the buy-in allow the stock purchase price to come out of my pre-tax? Ideal answer is
yes, and you want to know if there are any unfavorable tax ramifications (by checking w a
tax consultant)
11. Buy-out provision (Back Door or Divorce clause)
a) The same formula should be used as from the buy-in, and should be in the contract
12. Dispute resolution
a) How are disputes resolved?
b) Two options
(1) Litigation
(2) Arbitration
c) Who pays for litigation, attorney fees, if necessary?
13. Restrictive covenant, aka Covenant Not to Compete
a) Background
(1) An Agreement wherein an employee agrees not to compete w his or her
employer post termination. This typically applies to a certain geographic area,
certain period of time, and may restrict performance of certain medical
procedures or restrict some combination of these
(2) Accompanied by consents to injunctive relief, which would allow the group to go
to court in a matter of hours to days (vs. years) to obtain a Temporary
Restraining Order. The physician then risks jail if he continues to break the
non-compete clause
(3) Note that in law, law firms cannot, by law, have restrictive covenants in the
employment contracts of their new associates
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(4) On the other hand, they are acceptable if they ONLY apply DURING one’s
employment
b) What to do if contract has restrictive covenant:
(1) Appeal to the group, pointing out ethical problems. If it is there, can it be taken
out of the contract?
(2) If this does not work, ask why they think you would compete with them
(3) Offer “non-solicitation” clause whereby you agree not to solicit your former
patients if you leave; however, if the patients find you independently, you can still
see them. Argue that it is only effective if you are terminated without cause.
(4) If this does not work, negotiate decreases in time, distance, activity, bargain for
severance package to be included, in order to cover your costs of relocation.
Also, some lawyers believe you should be compensated 10-20K for presence of
restrictive covenant.
(5) Note: it is considered unethical for a physician to be prohibited from informing a
patient of their departure, and patients should be given their physician’s
forwarding address
c) Stats:
(1) 75% have restrictive covenant
(2) 13% negotiate the covenant out of the proposed contract
VIII. Legal entities
A. Background
1. Every practice has 1+ legal “houses” that determine the structure and function of the
organization. Professional practice may be housed in a partnership entity, while one freestanding
facility may be a limited partnership and the other a corporation. Graduating resident should ask
series of questions which seek to identify all legal entities with which the practice or its “partners”
are involved that relate to the practice of medicine and to understand ownership in each of those
entities
2. Know your eligibility for partnership
3. Need to know the legal “house” of the practice
B. Examples of legal entities
1. Sole proprietor
2. “Partnership”:
a) Regulated by “Articles of Partnership” document
b) Most states have “Uniform Partnership Act” which regulates certain partnership matters
c) You may be someone’s partner without ever having signed this., as deemed by the law.
This is a particular problem for practictioners who may share call but are not formally in
practice together
d) Benefits: easy legal entity to deal with; no taxation of the entity, unlike corporations
e) Disadvantages: partners are personally liable for the debts and obligations of the
partnership up to the full extent of their personal wealth (excluding certain protected
assets such as state homestead exemption, etc)
3. “Limited partnership”
a) Two types of partners: general partner and limited partner
b) Limited partnership advantage is the ease of operating as a partnership with the bonus of
limited liability to the amount of their investment in that entity
c) Disadvantage is that only general partners have a say in how the business is managed
day to day.
4. Professional Corporation (e.g. PC, PA)
a) Most states allow individuals to form corporations
b) Advantage is that it limits personal liability to physician's ownership interest in the
corporation
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c) Disadvantage: potential for double taxation bc income is taxed as corporate level, then
again when passed to stockholders (though not always, as the corporation can also be
treated as a partnership by certain tax codes)
d) Need to get Articles of Incorporation from Secretary of State’s Office
5. Professional LImited LIability Corporations (LLC)
a) Common legal vehicle in which to “house” a practice
b) Advantages: tax advantages like partnerships to avoid double taxation characteristic of
corporations; preserves Corporate veil that plaintiffs cannot pierce to gain access to
personal assets; one is not a “shareholder,” one is a “member”; one gets a “draw” and not
a salary”. LLCs do not perform tax withholding, so a a “member” has to pay quarterly
estimated taxes from income received, so you should not expect to keep your monthly
draw
6. Limited LIability Partnership (LLP)
7. Limited Liability LImited Partnership (LLP)
8. Non-physician owned
a) Academic
b) Investor owned facility
9. Practice Management Companies: when a rad onc practice associates with a PMC, there is
usually a transfer of stock of the PMC to the existing partners, usually at some multiple of the
practice’s value. The management contract is usually long term, e.g. 40 years. Physicians who
subsequently join will be bound by the terms of the agreement, which will usually include
restrictive covenants, may contain terms that will require physician to continue using company’s
services if they leave the group.
a) Is there a practice manage agreement?
IX. Final parts
A. Signing bonus?
B. Stats
1. Average number of interviews is 4.3
2. Average number of “firm” offers is 2.6
C. Lawyer
1. Should be your lawyer not that of employer
2. Resources: www.lawyers.com, martindale.com
3. Organizations: American College of Legal medicine; National Health Lawyers Association;
American College of Radiology (ACR) has referral service
4. Civil practice versed in health care law
5. ~$700.
6. RSNA resident fellow section
7. Need a lawyer in area the job is in
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