Locums, Lies, and Admin Eyes: A Survival Guide for New Grads

From Naïve Newbie to Hiring Red Flag Whisperer: My Wild Year in Community Oncology

There are far too many stories of radiation oncologists having a nightmare first job. I cannot say I experienced the same - 3 out of 4 places I’ve worked have been wonderful and I’d recommend to anyone. That being said, I have heard of many issues during the first year out, but my colleague’s experience is the worst I’ve ever heard. He suffered dearly and it affected his family life, confidence and health. Although he is in a better place now, I hope that no fresh grad ever experiences what he did. His candid account and suggestions to avoid such situations should be read by all. The rest of what you read is his account, despite it having my by-line. There are some **** to protect the identity of the author.

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This is me walking into the first practice I joined:

Fresh off a few years of doom and gloom surrounding the job market, and with a pregnant wife ready to deliver our first child any day, I realized I rushed my decision. While there has been a modest reversal in the job market, just because a job fits some of what you need, there can be serious red flags. A talented, but guileless recent grad may miss these their first time around and that is what happened to me.

Radiation oncology remains an amazing field. Like the fringe environmentalists and tin hats postulating about peak oil, the idea that radiation oncology is a dying field is hyper-emotional catastrophizing. Concerns remain about how the field will look in decade’s time, but nearly half or more of all cancer patients will require radiation and we will continue to have excellent employment opportunities in the near future. There is no doubt that the days of private practice jobs with seven figure salaries in a desirable location are behind us, but I still wouldn’t have wanted to match in any other specialty. (Editor’s note: AGREED!)

In the year and a half since I finished residency, I’ve quit my first job and secured a new full-time position. In the interim, I worked at three different community practices as a locums. These experiences confirmed that my first job was in fact an aberration and community practice was actually quite nice. I had an attending who used to tease us for incorrectly answering trivial questions about ancient trials and say things like, “You’ll make a great community doctor.” Well, I became a community doctor, and I wouldn’t change that, either—even if I could recite the chemotherapy dosing for a trial completed 20 years ago (Editor’s note: I bet it was 40 mg/m2). I like to think the past year and a half has been a chance for both growth and introspection—both the bad and the good.

The Bad

Let’s start with the bad. I’m an introvert, and with that comes anxiety about big life decisions that include working with new people. While looking for my first job, I made spreadsheets with pros and cons and consulted co-residents and attendings for advice. The stress of it led to become physically ill and I even went to get a full workup from my PCP. Looking back more than two years later, I’d make different choices. Some of my priorities were typical: location, pay/incentives, and perceived quality of life. There’s that old mantra that you choose between pay, location, and quality of life. For some specialties, you might get all three, but more often than not in RadOnc, you get one and sometimes two. I chose compensation, and to a lesser extent, location. My eventual first job allowed me to live in **** with all the amenities I wanted, while commuting 45 minutes to a job that would pay me a base salary in the 90th percentile as a first-year. It sounded amazing from the perspective of a resident who thought, based on the famous SDN “we’re doomed” post, that finding any job would be difficult.

I did not realize I was a naive resident making bad choices—things didn’t turn out as expected. My work partner left soon after I started, both physicists departed and I was left with 30–40 patients on treatment in a small, rural hospital—without the resources or mentorship I had hoped for, i.e. a complete clusterf*ck. These are the issues that were most glaring during my time at this practice:

Lack of Peer Review:

● Once it became a solo practice, there was an absence of peer review and no assistance from administration to find outside help. As a first year, this was far from ideal.

● No tumor boards or multidisciplinary clinics. A once monthly tumor board existed but it never occurred in my tenure. There was no buy-in from medical oncology or surgery and no accreditation to enforce one.

Patient Safety Concerns:

● For several months, there was no on-site physicist support, affecting treatment planning and patient safety.

● Multiple near misses and a reportable event occurred, highlighting potential risks to patient care.

● Several patients with oncologic emergencies were missed by ER providers, including one case where a patient became paralyzed from a malignant cord compression.

● In this ER and particular state, mid-level providers were able to practice independently. Unfortunately, these adverse outcomes did not change hospital staffing or policies.

Inadequate Resources for Complex Cases:

● Although SRS cones were purchased 3 years prior, there were insufficient resources to commission them for use. We did just fine without them, but it was a warning sign of a dysfunctional program.

● No access to Deep Inspiration Breath Hold (DIBH) or Active Breathing Control (ABC), limiting breast treatment options.

● The CT scanner in use had reached the end of its operational life, causing treatment planning concerns (no OMAR, no IV/PO contrast, 4DCT useless for most cases).

● A dosimetrist who worked as a real estate agent by day and dosimetrist by night… this led to long delays, poor plans, and a 14-day simulation to start interval.

Unprofessional Administration:

● A non-clinical administrator dismissed my requests for locum support and software updates, stating “providers come and go” and “this is not an academic center.” (Editor’s note: the amount of times I’ve heard this as an excuse to practice sh*tty medicine is astounding)

● I was vetoed on who to hire as my partner.

● The same administrator also entered a patient room to tell me my request for a video monitor for a nasopharyngoscopy I was doing was denied and not necessary for the procedure. I understand this is how some providers perform the procedure, but it was not the way I was trained and I was not immediately ready to try a new approach.

● I faced an accusation of slander when the hospital could not find my replacement.

● Breach of contract occurred when my pay and bonus were withheld.

● Attempts were made to have my new job contract revoked.

The Good

Now, for the good. I learned a lot, especially how to manage people. The majority of my staff were like me, in our early 30s and most had trained at this hospital. It was, in a sense, an echo chamber of radiation oncology from the year 2000: unnecessary replanning and simulations to enhance billing, lack of IMRT expertise, no comfort with SBRT, no DIBH/ABC for left sided breast, no APBI due to dosimetry limitations, and generally no adherence to strict dose constraints or treatment planning goals. “Good enough” was what they expected me to accept.

It’s hard to explain to people who’ve never left the comforts of an academic institution or large health system, but imagine stripping your academic training center down to 14 people. I was responsible for all simulation and treatment planning documentation, radiation prescriptions, professional CPT codes, prior authorization documentation and appeals, imaging orders, and verification simulation documentation. Today, I’ve come to find that much of this is automated in Aria with care paths and not the physician’s responsibility. Though much of this was new to me, I came away with a great deal of knowledge. I’m something of a coding expert in my new practice.

That’s something I would stress to new grads: get comfortable being uncomfortable. You won’t learn how to run a community practice in residency, but you can always rely on your good training and a sense of when something is wrong. There are a variety of ways to safely treat patients, however lung SBRT 35 Gy in 5 fractions or hand drawn PTVs should sound the alarm. When you are the guardrails, don’t be afraid to take a timeout and re-evaluate the situation and definitely do not proceed if you feel any discomfort. Patients deserve your best.

What I Found Out I Needed In A Practice

• Technology: A well thought out investment plan to improve quality of care. This could be the next year or next 5 years, but a well organized plan to improve quality within and outside the department. I was kept out of the annual budget meeting. In my head, if I worked extra hard and limited my use of locum coverage, then surely the hospital would use those extra funds to help me improve patient care. Unfortunately, that’s not how hospital budgets work. These take time, insight, expertise and communication. Don’t take no for an answer and be present for those discussions! A practice that does not want physician involvement for these decisions may not be a good fit for many of us.

• Administration: It should be clear that there is a defined hierarchy and robust physician leadership. My new department has a site lead, a group lead, an oncology service line lead and they are all radiation oncologists. At the very least, there needs to be physician leadership to foster a safe environment and to bring about constructive change that is not solely focused on dollars. Inexplicably, I did not have a CMO for the first 9 months of my first job. Then when one was hired, they spent more time disciplining physicians than working side by side with us. For some reason, administrators think their first job is to ‘just say no’ to doctors. If this appears to be the case, reconsider the position.

  I found myself in a place where the physicians were not leaders. Neither my partner nor myself were the medical director of our department. I was told I was too young or inexperienced. While this may have been true, this role should not have fallen to a power-hungry non-clinical administrator. Without clear leadership, there was no department hierarchy and we could not identify accountability and ways to improve. This was also a culture of blaming the physician on their way out. The physician I replaced “had problems working with administration.” My partner “had conflicts of interest.” Then similarly, they painted a picture of myself as an ineffective leader who didn’t play well in the sandbox with administration. If they speak poorly about those who have left, consider this a red flag.

  I don’t believe more money or staff turnover was the answer. Three physicians and two physicists left this department in 3 years, and yet the clinic doesn’t have any awareness that the problem lies within? This is a system that kept on chugging along without having any curiosity, without asking questions or evaluating weaknesses and failures. I was not given an exit interview or provided a chance to give feedback to the executive team. That tells me what I need to know about their interest in improvement.

• Cancer Care Coordination: Oncology is a team sport. We need clinical coordinators, nurse navigators, and administration to be on our side. We can’t accomplish our goals without being on the same team. These tumor boards, peer reviews and quality meetings may seem excessive, but they force us to stay up to date and to communicate patient work-up and treatment plans. Without these, you are on an island.

  That first year, I felt like I was isolated and radiation was often the last resort for patients rather than a member of the multi-disciplinary team. I felt obligated to treat people who, frankly, needed better options. I didn’t have a pulmonology group that could do EBUS sampling or navigational bronchoscopies, so most lung cancer patients did not get nodal staging. We lacked oncologic specialty surgeons (ENT, GYN oncology, colorectal surgeons, neurosurgeon, oncologic orthopedics, etc.). My bread and butter were PSA persistence and breast/prostate positive surgical margins. A colleague and friend (and radonc blogger/personality) (Editors note: I wonder if he’s talking about me! Blush) would encourage me to stay and “elevate the radiation oncology care” these patients were receiving. Patient care is my top priority and unfortunately, no matter what I did, it either wasn’t enough or I was so limited by administration that our quality, even as a rural community center, was substandard.

  Rural departments have challenges but should be aspirational. They should seek out fellowship-trained surgeons and compensate them handsomely for working in a small town. A cancer center requires competent diagnostic radiologists and interventional radiologists. Tumor boards should be the minimal level of prospective patient care if multidisciplinary visits are not possible. Investment into the cancer program should be a given. Rather than nickel-and-diming every request, it should be straightforward to obtain devices like lumpectomy cavity markers, prone breast boards, prostate fiducial markers, laryngoscopes and TLDs. The administrators should be pro-patient, pro-physician and have proven competence in cancer care. They should also encourage autonomy and quality in their providers, which I’ll get to next …

• Supported Autonomy: Feeling like your clinical judgment matters is crucial. After graduation, many of us feel imposter syndrome. Do I deserve this job or am I a warm body babysitting the linac? Am I making the right clinical and managerial decisions? Could I inadvertently harm a patient with this plan, because I missed something and no one else is there to back me up? Given the level of quality of radiation oncology residents, most come out ready to practice on day one with some assistance with new and uncomfortable situations. We trained at tertiary centers and are starting our first job with a solid foundation of clinical knowledge. Yet, when I noted errors or tried understand root causes, I was personally criticized and the team made no effort to learn from patient safety issues. I was not perfect in my communication, I can admit that. Today, I would approach patient safety issues and conflicts with other providers with a level head and use ChatGPT to email more effectively. Respect takes time to earn, but the ability to practice with autonomy is sacrosanct - at the end of the day, all accountability and liability falls on the physician. I had soul-crushing administrative oversight rather than mentorship and guidance. There were times I stopped speaking up for fear of disciplinary actions or even termination. Administration relied on “HR Action Plans” on every employee, to allow efficient termination when someone fell out of favor. I saw an administrator daily in our huddles, weekly for physician check ins, and one was present for every staff interview and quality meeting. Didn’t they have more important things to do? In my new job, I have leadership that is physician led, supportive and understands that I am a board certified physician with an excellent reputation. That is what all of us want.

Epilogue

I’ve only been in my new position a few weeks, but it’s been a refreshing start. I’m near a desirable city, working with a supportive group of 3-4 radiation oncologists, making a median MGMA salary, with a protected admin day that can be taken from home. I can already tell from my first few tumor boards and peer reviews that my opinion is respected, but the other specialists understand oncology. There are no non-clinical administrators in our physician meetings or daily huddles. Almost all the protocols and work flows for dosimetry, physics and physicians that I became accustomed to in residency are already in place. I wish I had started at a center like this.

I’d will finish with some pointers that I had wish someone had given to me.

(Editor’s note: wish he’d asked this personality/blogger fella more about this kind of stuff; I’ve— I mean — that guy experienced many of these same situations.)

Is There A Perfect Job

How do we find that perfect job? I’m not convinced the perfect job exists, but you can get a lot closer than I did. There are certain commonly used tactics used to screw over new grades — 4 months notice (Editor’s note: 60-90 days is standard), unfair termination clauses, partnership tracks that never come to fruition and dishonest negotiations. My other mistakes came from taking people at their word and not following up on discrepancies during the 10 months between signing my contract and my start date. Much can change in that time, and you don’t want to be left out of the conversation. I came in with a priority of developing the brachytherapy program. Before I arrived, the admin had changed and they decommissioned our HDR unit since it wasn’t actively being used. I was not present for the capital budget meeting and so I didn’t have a say in the following year’s budget. I found myself in a tough situation that wasn’t totally avoidable, but there were signs like this that I ignored. The perfect job does not exist, but as I have described above, there if there are certain structures and processes in place, it is more likely than not to be a fulfilling place to work.

Key Questions to Ask

I never thought the following questions would be necessary in a job search, and they probably won’t be for most jobs. But after my experience, I believe these questions are crucial:

• Who handles billing and coding for the department? If it’s the physician, will they purchase the ASTRO coding resource for you or provide necessary training?

• How are new consults split between attendings? We may be incentivized by RVUs, but maybe you are okay taking a lighter load to emphasize quality of life and/or family time. These things should be discussed.

• If you will be in solo practice, how successful has the hospital been at finding a locum tenens or new physician? I would strongly recommend being involved in vetting the applicants and if they do not let you, that is a red-flag.

• Do a full review of the department and assess for missing technology or workflows. Discuss these issues with management and ask about the timeline for addressing them. Try to attend chart rounds or departmental meetings during the interview process. Ideally, this is done before signing to avoid challenging situations in the future.

• Evaluate previously addressed issues and ask how long it took and what steps were taken. This includes asking about why previous physicians left. And if you’re not satisfied with the answer, seek it out. I had dozens of applicants call me personally to ask about the practice I was leaving. I was always happy to share my point of view, but I also offered additional people as resources.

• Always ask to reach out to physicians that have left. If they refuse, that’s a red-flag. If they happily give you the contacts of the last few to leave, that’s a good sign. Call them and ask questions. They may or may not be forthright, but at least you attempted due diligence.

• After all that, imagine the worst-case scenario. Could the partner(s) retire or quit? Could the primary referring specialists leave the system? Could the hospital be acquired by a larger system? Would administration be impossible to work with? Does the hospital have a plan in place, and would you be okay with this situation?

Finally...

Including locums work, I held five positions in the first 15 months after residency. In contrast, my mother, a highly skilled subspecialist surgeon, worked for the same two hospitals for over 30 years. Healthcare and hospitals have evolved in that time, and so too have the expectations of the modern physician. We have seen a tremendous amount of greed in healthcare and there may be tragic consequences. You may not be able to change the direction of where we are headed, but you certainly can choose which train you board and where and when you get off. Over 70% of radiation oncologists will change positions within their first 3 years of practice. That tells me change is okay and finding the perfect job right out of residency is possible but not probable. It is okay to leave your first job, even after just one year. But with persistence, things will often work out in your favor. Here I am on admin day, looking at the beautiful **** (Editor’s note: think mountains or ocean or lake or strip mall), having achieved everything I thought was a dream. I hope my story either helps you find a job that works for you or helps you escape a horrible one. Best of luck!

Editors’ final note:

Love you all,

Sim