Job market this year

[neutron reaper]

Anybody have an impression of the job market this year? Seems a little slow. Perhaps because of the proposed Medicare cuts?

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[deleted4401]

Yeah... I think until that is finalized, people will be very deliberate.

I've given some advice in the past, but the one thing I will stress is to not feel forced to make a decision, and not to worry if your peers already have jobs/contracts. It's still somewhat our market, and you can take your time and decide. As long as you sort things out by March-April, you can get your license to start by July-August (except for a few states). So, don't worry and don't rush. A lot of stuff will pop up in January-March.

S

 

[medgator]

Yeah... I think until that is finalized, people will be very deliberate.

I've given some advice in the past, but the one thing I will stress is to not feel forced to make a decision, and not to worry if your peers already have jobs/contracts. It's still somewhat our market, and you can take your time and decide. As long as you sort things out by March-April, you can get your license to start by July-August (except for a few states). So, don't worry and don't rush. A lot of stuff will pop up in January-March.

S

Good advice. I remember some of the large groups telling me that they really wouldn't have a sense of things until ~6 months out from July/august of when most people would start with them. This is still a little early.

Try to make all of the contacts you can now until ASTRO and hopefully you can touch base with people there and finalize more formal interview plans later in the year.

 

[napoleondynamite]

My own experience was the jobs that were "less desirable" were the ones that were putting the pressure on me to have a decision by ASTRO. The more sought after jobs I was considering were certainly more deliberate about the process and took their time deciding. In the end I was very glad I held out because I secured the job of my dreams.

I agree with above, take your time. Feel no pressure.I also agree that I started to hear about some great opportunities in the Spring time. So if you are one of the few who does not have a job by then, may make things easier for you instead of harder as you will have less competition.

 

[medgator]

Hearing through the grapevine it's a little tighter this year, Job market-wise. Anyone else hearing anything different?

I am guessing the looming medicare cuts are playing a role here.

 

[BraggPeak]

When is the final vote on this medicare stuff?

 

[BraggPeak]

Has anyone ever used one of the services that organizes and obtains all the info needed to get your full medical license? I've heard some residents mentioning that they started using a service like that by fall/winter of their senior year to make sure there would be no delays come july, even if they didnt have a job lined up.

 

[deleted4401]

It could be helpful if you're cutting it close, but it honestly wasn't that hard - atleast for Maryland.
If you get the offer, you might be able to get the group to pay for the service. I didn't find licensing as hard as privileging. But, your group will help you with that.

 

[Reaganite]

Job market is always tight in desirable areas, and in many instances, the openings that do come up are never advertised. Id hear about people getting hired in california, for example, but never saw any ads for the positions. I personally held out during residency and did locums around the area I was interested in after graduating. I met a ton of people and ended up being offered a position at a really sweet spot that was never advertised.

 

[RadRadRad]

It is interesting that for the last few years there have been suggestions of a weak job market for radonc, yet we continue to increase the number of residency spots. With more Radoncs being hospital employees, one wonders if supply vs demand economics will play a bigger role in the ability to negotiate a favorable contract. I've seen the JCO paper suggesting demand will go up, but think predicting the future is pretty difficult.

That being said, good luck and agree with being patient. Think this was covered at ASTRO resident seminar where polling of recent grads suggested over 50%, in hindsight, thought they signed their contracts too early in the PGY5 year (and should have continued looking into the spring).

 

[deleted4401]

Agree - time to cap spots or even reduce. I'm not sure in the value of adding more rad-oncs. They think it will help with underserved areas, but they just end up increasing the supply in urban/suburban areas. I'm not sure what can be done. In the small town jobs, the pay is incredible and the workload is manageable, yet there are tons of openings in the midwest and south.

Interesting enough, one of the groups in the DC area increased their partnership track to 5 years. We extended ours, as well. So, maybe instead of obvious, drastic pay decreases, the trend might be to not offer partnership until later (as far as private practices go) and keep people on as employees for as long as possible. Hospitals will continue to just exert downward pressure on salary, while increasing workload.

 

[seper]

5 years - so long - does that include buy-in period?

 

[deleted4401]

Don't think they have a buy in. Most practices here are pro only or global percentage.

 

[medgator]

5 years - so long - does that include buy-in period?

Don't think they have a buy in. Most practices here are pro only or global percentage.

I've heard of some practices having a graduated partnership, where you get professional partnership say at 3-4 years, and then after an additional year, you get a chance to buy into the technical part of the practice.

 

[DrAwsome]

Agree - time to cap spots or even reduce. I'm not sure in the value of adding more rad-oncs. They think it will help with underserved areas, but they just end up increasing the supply in urban/suburban areas. I'm not sure what can be done. In the small town jobs, the pay is incredible and the workload is manageable, yet there are tons of openings in the midwest and south.

Interesting enough, one of the groups in the DC area increased their partnership track to 5 years. We extended ours, as well. So, maybe instead of obvious, drastic pay decreases, the trend might be to not offer partnership until later (as far as private practices go) and keep people on as employees for as long as possible. Hospitals will continue to just exert downward pressure on salary, while increasing workload.

Is that really a good idea though? Remember that the higher the pay, the more likely CMS is going to say oh these docs make too much, let's cut their pay. Also reducing #'s is also dangerous. Just look at what's happened when demand is greater than supply-midlevels enter the picture. Look at what's happening in derm, where PA/NP midlevels are practicing alongside doctors, as well as anesthesia. There is a great need for radoncs in a large number of places, and if we cut spots, others will be happy to meet that need somehow. I think it's dangerous to say oh let's cut spots to keep our pay up. If anything I think spots should be increased a bit. Where I am, there is a huge need for rad oncs, with vacancies going unmet. I would be careful of propagating a situation like in derm for example where that huge need is being met by midlevels. And with midlevels comes not just field erosion, but decreasing pay.

 

[seper]

Can't meet RadOnc demand by mid-levels.

 

[DrAwsome]

Can't meet RadOnc demand by mid-levels.

You would think so, but midlevels can be trained in just about anything. I woudln't think midlevels would encroach derm or GI or gas either, but they are. We already have radiation therapists who do the nitty gritty work, as well as dosimetrists. You really think it's that difficult to have a model where one rad onc "supervises" "radiation assistants" or something of that nature to work alongside a team? Not really. And when your pay is too high, CMS notices and your pay will be artificially reduced in countless creative ways- look at the fight that radiologists are waging. It makes sense to look at the issues other specialties have gone through and learn from them imo.

 

[DrAwsome]

Was waiting for someone to step in and bring up midlevels and how they steal jobs. DrAwsome to the rescue!!!!

Happy to oblige

Nevertheless, they DO not only steal jobs but also lower pay, which is even worse. I think rad onc has not yet experienced what other specialties have in terms of midlevels encroaching, but given the system in place currently, I don't think it's that hard of a situation to occur. I think learning from the past is a good thing. I personally would not mind in the future earning a little less so that the demand is met by a fellow MD vs. a midlevel.

 

[seper]

True RadOnc midlevels are still like minimum 10 years away. Not a threat.

You would think so, but midlevels can be trained in just about anything. I woudln't think midlevels would encroach derm or GI or gas either, but they are. We already have radiation therapists who do the nitty gritty work, as well as dosimetrists. You really think it's that difficult to have a model where one rad onc "supervises" "radiation assistants" or something of that nature to work alongside a team? Not really. And when your pay is too high, CMS notices and your pay will be artificially reduced in countless creative ways- look at the fight that radiologists are waging. It makes sense to look at the issues other specialties have gone through and learn from them imo.

 

[DrAwsome]

True RadOnc midlevels are still like minimum 10 years away. Not a threat.

I sadly disagree with you for one. And even if that was the case, do we want our future colleagues to have to deal with midlevels vs. making a little less now to preserve our field? I'm sure that anesthesia thought the same thing ago 15+ years ago when they first introduced midlevels. Now the current generation of grads is kinda screwed and blames the older generation of anesthesiologists for their greed. Do we want that for our future rad onc colleagues? I certainly don't. As a group we make quite a bit of $$ already, making a bit less to preserve our field to me makes sense. Greed however will lead to its erosion, like it is in many other specialties.

 

[deleted4401]

Miss what I had said? Increasing numbers just continues to over supply the resource/physician-rich areas, not fulfill vacancies in rural areas. Chicago, DC, LA continue to get saturated, while there is like 3 open positions in Iowa right now on ASTRO website. With radonc, redistribution of practice location would be more efficient than just increasing numbers.

S

 

[DrAwsome]

Miss what I had said? Increasing numbers just continues to over supply the resource/physician-rich areas, not fulfill vacancies in rural areas. Chicago, DC, LA continue to get saturated, while there is like 3 open positions in Iowa right now on ASTRO website. With radonc, redistribution of practice location would be more efficient than just increasing numbers.

S

Unfortunately redistribution does not really work. You can't force people to work where they don't want. I'm not suggesting we triple our spots, I'm suggesting that undersupplying is dangerous. I think supply needs to keep up with demand that's all. We want to keep our numbers sufficiently strong to meet demand, keep midlevels out, and the gov happy sort of.

Btw-where are the jobs in IA, I have a buddy who's looking in that area.

 

[DrAwsome]

Disagree with you. We are better offer tailoring our numbers to demands rather than overtraining out of fear of midelvels. It is ridiculous how many programs have expanded and new programs at smaller unproven centers have opened up in the past five years. I would think we are better keeping the number of grads in the 100-110 range per year.

How's that working for other specialties? Not so well.

 

[deleted4401]

Best to let first year residents transitioned from other specialties having never worked a day in ours predict the acute and chronic shortage/oversupply issues affecting our field and predict the development of yet undefined provider that can somehow get NRC licensure to become authorized users...

It's not about the money. It's about having linacs all over Houston that treat 11 patients daily. It's about having 3 CyberKnives in Dade-Broward-West Palm. It's about having 4 rad oncs from 4 separate groups fighting over patients at an Atlanta tumor board, with the one that will treat anything even if it's inappropriate getting all the business. It's a waste of resources.

The shortage is there, but the biggest issue is not numbers. It's geographic distribution. We can't convince people to do those jobs for $750k. If we have more doctors, the salaries will be driven even lower. Here is the rationale: right now, if rural area A is giving $600k salary and urban area B is giving $300k, you might be able to convince someone to take the job. You drop another 25% physicians in, and now the numbers per doc drop, so the income per doc drops. Now rural area A is able to offer $450k and urban area B offers $250. Now, it looks less appealing and less people take the rural job. You dump more docs into the system, and the numbers narrow even more...

 

[DrAwsome]

Best to let first year residents transitioned from other specialties having never worked a day in ours predict the acute and chronic shortage/oversupply issues affecting our field and predict the development of yet undefined provider that can somehow get NRC licensure to become authorized users...

It's not about the money. It's about having linacs all over Houston that treat 11 patients daily. It's about having 3 CyberKnives in Dade-Broward-West Palm. It's about having 4 rad oncs from 4 separate groups fighting over patients at an Atlanta tumor board, with the one that will treat anything even if it's inappropriate getting all the business. It's a waste of resources.

The shortage is there, but the biggest issue is not numbers. It's geographic distribution. We can't convince people to do those jobs for $750k. If we have more doctors, the salaries will be driven even lower. Here is the rationale: right now, if rural area A is giving $600k salary and urban area B is giving $300k, you might be able to convince someone to take the job. You drop another 25% physicians in, and now the numbers per doc drop, so the income per doc drops. Now rural area A is able to offer $450k and urban area B offers $250. Now, it looks less appealing and less people take the rural job. You dump more docs into the system, and the numbers narrow even more...

Being kinda harsh, but to address your point, I think we've seen this happen to a number of good specialties. I think by keeping numbers too low, we'll run into the same problem. Sure, I'm not a full fledged rad onc just yet, and sure I may not have your experience or that of other attendings in the field of rad onc. But greed is killing a number of specialties. And if we need to pay people in rural areas double or more just to work there, I think this is the kind of stuff that also gets noticed by the gov and artificially brings cuts. Again, if someone needs 750k to work at a rural place, there is something wrong here.

When people feel so entitled to such huge amounts of money, others come in and say hey I'll do it for half or whatever. Look at anesthesia, look at derm, etc. We are not immune. If we don't meet the need, I can guarantee you that someone else will. It may not be today or tomorrow, but sooner or later, it will happen if we don't protect the field.

I'm not suggesting, again, that we triple our positions or anything crazy like that. I'm suggesting that we keep numbers in line with demand. Rad onc has already a huge target on its back, with conceptions of huge amounts of $$ for little work. Rad onc has become the new derm in terms of $$ and lifestyle, with the exception that rad onc makes more and has less grads. Take an example from Mohs for example. Mohs surgeons used to rake it in, they've now reduced those salaries to about half or less due to cuts. CMS has noticed the salaries of rad onc and is proposing what, 15% cut? Hopefully that won't happen, but there is a huge target on our backs. Just saying, greed is the downfall of many specialties.

 

[BraggPeak]

I agree with you, but can we please wait to expand programs until I have a job that I love?

I do have to say that patients are much more likely to feel
Comfortable seeing a mid level for their derm issues as
Compared to seeing a midlevel when you have stage 3 lung, etc.

Rad Onc makes up a very small percentage of the total Medicare budget ( less than 5 percent). Even if hey slash our reimbursement by 50%, it doesn't help the bottom line for congress.

Now if we start doing proton therapy right and left,
Things will change.

 

[DrAwsome]

I agree with you, but can we please wait to expand programs until I have a job that I love?

I do have to say that patients are much more likely to feel
Comfortable seeing a mid level for their derm issues as
Compared to seeing a midlevel when you have stage 3 lung, etc.

Rad Onc makes up a very small percentage of the total Medicare budget ( less than 5 percent). Even if hey slash our reimbursement by 50%, it doesn't help the bottom line for congress.

Now if we start doing proton therapy right and left,
Things will change.

I personally also would not feel comfortable by having my life in the hands of a nurse when it comes to anesthesia, but sure enough, it's happening. I am in the same boat as you, not even having started rad onc residency yet, but just my thoughts on the delicate balance between excessive program expansion, excessive salaries that get noticed and chopped, and simultaneously the need to provide enough grads to meet the need.

 

[DrAwsome]

I certainly understand your concerns about midlevel encroachment and job security but job security means nothing if you're getting paid dog ****. One thing that protects us for many rad onc applications is the NRC (brachy, GK, etc) and when using a linac, I dont foreseeing a way for a midlevel to be allowed to sign off on anything when a hospital is running things. Sure you could have NPs who do H+Ps/follow ups in our field but to some degree that is there now and hasnt changed how many rad oncs we need because they can't do treatment planning, signing plans, review images.

You are new to the game, have not gone through the job search, have not seen the job search evolve over hte past 5 years or more, so you need a little perspective. Sure, we have a target on our back right now, but we are better off putting our efforts into evidenced based research documenting our cost-efficacy for new techniques rather than training more rad oncs and saturating our market. Simul hit the nail on the head when he said we have a maldistribution rather than a shortage; adding more (from what i have seen close to a 30% increase in the last 5 years or so) trainees just makes competitive markets worse and reduces salaries and does little to fix the maldistribution other than force lower end graduates into poor jobs secondayr to location, poor pay structure/group, etc. I would take his word, I do, as he has more experience than myself. As for the expansions, I see more merit in a great program expanding versus some of the new programs that have popped up. You have to wonder what level of training some of these residents are getting with limited numbers of faculty, limited numbers of patients and techniques available and no real research set up

So how do you suppose that we redistribute rad oncs in areas that are desperately needing them? I know a number of places that have been searching for months! If we have to pay 600k for someone to go work out there, it seems a little excessive imo, and not sustainable. Getting paid 300-400k is hardly dog caca. Not sure what you suggest is dog caca in terms of salary.

Getting paid over half a million dollars is something that is not only not sustainable, but something that is seen as outrageous and ultimately leads to cuts. And yes as you suggest, I am new to this field, but I come from a field that has had the exact same thing happen - huge $$, serious protection of spots, with a dire need in certain areas that has not been met, which has lead to midlevels, reduced pay, etc.

Also, you have to realize that many of our medical colleagues in other specialties work for far less, with much worse schedules. Having to justify 500/600k salaries seems a little crazy imo.

 

[deleted4401]

The numbers were for example. The point is, people are not going to those areas and producing more rad oncs will not improve the situation. It's not about the money, as I said. Big cities are super saturated and good docs are pushed to practice bad medicine. In rural areas, people don't have a doctor that isn't locums or uncertified. It's short sighted to think that increasing supply will fix the problem. I'm sorry for being a jerk when trying to make a point.

 

[Pointless]

Getting paid over half a million dollars is something that is not only not sustainable, but something that is seen as outrageous and ultimately leads to cuts. And yes as you suggest, I am new to this field, but I come from a field that has had the exact same thing happen - huge $$, serious protection of spots, with a dire need in certain areas that has not been met, which has lead to midlevels, reduced pay, etc.

Also, you have to realize that many of our medical colleagues in other specialties work for far less, with much worse schedules. Having to justify 500/600k salaries seems a little crazy imo.

This is a bit of a naive view of what is going on in medicine right now. Medicare does not review the salary of individual physicians when deciding to make cuts, they review the value of billing codes, the amount of work that "should" go into billing that code, and then reviews the reimbursement for said code. So, a rural community hospital that throws 500-600k at someone to come out and man a linac is not throwing up a red flag to Medicare, they are simply sharing more of the profit generated by the radiation oncology clinic with the clinician.

I agree with everyone else's opinion that you should gain some experience in the field and go through a job search before commenting on the financial future of the field, much less make bold recommendations regarding the number of trainees required, supply/demand, etc.

 

[DrAwsome]

This is a bit of a naive view of what is going on in medicine right now. Medicare does not review the salary of individual physicians when deciding to make cuts, they review the value of billing codes, the amount of work that "should" go into billing that code, and then reviews the reimbursement for said code. So, a rural community hospital that throws 500-600k at someone to come out and man a linac is not throwing up a red flag to Medicare, they are simply sharing more of the profit generated by the radiation oncology clinic with the clinician.

I agree with everyone else's opinion that you should gain some experience in the field and go through a job search before commenting on the financial future of the field, much less make bold recommendations regarding the number of trainees required, supply/demand, etc.

I didn't say Medicare is like oh Pointless makes 600k, let's cut rates so the salaries go down! But I think it's naive to think that high end salaries *as a whole* don't get noticed. It's happened to both radiology and dermatology, as well as anesthesia. I find it naive that you would not think rad onc is very much a target. Also as a person soon going into rad onc training, gathering from past experience in another field and from the experiences of other colleagues who are going through a tough time given recent changes, I think it makes sense to chime in. I really don't get why you guys are being so caustic and I'm getting such strong reactions here.

The fact that I'm coming from another field has 0 to do with anything. Does that mean that I'm not entitled to have an opinion? Further, one of the things that the PD said at my first rad onc IV was, don't go into rad onc for the money guys, because the current salaries are not sustainable and we will see serious cuts in the coming years. And this was repeated numerous times by other PDs. I guess the PDs should also not chime in then and are delusional. But I'll leave it at that.

 

[DrAwsome]

The numbers were for example. The point is, people are not going to those areas and producing more rad oncs will not improve the situation. It's not about the money, as I said. Big cities are super saturated and good docs are pushed to practice bad medicine. In rural areas, people don't have a doctor that isn't locums or uncertified. It's short sighted to think that increasing supply will fix the problem. I'm sorry for being a jerk when trying to make a point.

I can't tell you you are wrong, but I simply don't agree with your opinion. But since I cannot express my thoughts without being attacked, I guess I'll leave it at that.

 

[DrAwsome]

You got served DrAwsome!!!!!!! http://i2.kym-cdn.com/photos/images/original/000/278/541/15c.gif

Amazingly mature comment, especially coming from an "attending." I guess I cannot express my opinions. Oh well.

 

[RadRadRad]

Regarding midlevels, I don't think they just jump into fields. My understanding is that they are brought into fields by MDs trying to increase volume. In the short term this increases profits. In the long term you begin training someone else to do your job for a fraction of the cost. Before you know it the institute of medicine writes a paper saying the midlevels no longer need your supervision and should receive the same pay per patient as the MD (oh wait this already happened 2 years ago). I think the key is to avoid using midlevels in radonc (which currently isn't much of a problem b/c they can only get reimbursed for radonc follow up appointments the last time I checked).

 

[Gfunk6]

It's not about the money. It's about having linacs all over Houston that treat 11 patients daily. It's about having 3 CyberKnives in Dade-Broward-West Palm. It's about having 4 rad oncs from 4 separate groups fighting over patients at an Atlanta tumor board, with the one that will treat anything even if it's inappropriate getting all the business. It's a waste of resources.

The shortage is there, but the biggest issue is not numbers. It's geographic distribution. We can't convince people to do those jobs for $750k. If we have more doctors, the salaries will be driven even lower. Here is the rationale: right now, if rural area A is giving $600k salary and urban area B is giving $300k, you might be able to convince someone to take the job. You drop another 25% physicians in, and now the numbers per doc drop, so the income per doc drops. Now rural area A is able to offer $450k and urban area B offers $250. Now, it looks less appealing and less people take the rural job. You dump more docs into the system, and the numbers narrow even more...

This is very eloquently stated and rings very true with my own experience. I'd go so far as to say that this is probably the trend in the vast majority of other medical specialties as well.

 

[seper]

All them yuppies wanna live in a city after graduating, what can you do.

 

[deleted4401]

Yeah, but if you're married/have kids your life is basically over so you can live like a baller in, say, Scranton. But yuppies are gonna do what yuppies do- live in urban/semi urban areas, go to farmers markets and eat artisanal mustard at farm to table restaurants. That's how we roll.

 

[Gfunk6]

In some ways, I envy people who have strong familial ties or prefer to live in less densely populated areas in the Midwest, South, and Mountain States. Not as much competition from other oncologists, down to earth patients, higher pay, less taxes, and lower cost of living is really a winning combination.

 

[RadOncMegatron]

Yeah, but if you're married/have kids your life is basically over so you can live like a baller in, say, Scranton. But yuppies are gonna do what yuppies do- live in urban/semi urban areas, go to farmers markets and eat artisanal mustard at farm to table restaurants. That's how we roll.

SimulD. Please please tell me what your quote "I put the team on my back do" means. I cannot figure out what the "do" part and Greg Jennings have in common. BTW your yuppie quote is classic.

 

[medgator]

In some ways, I envy people who have strong familial ties or prefer to live in less densely populated areas in the Midwest, South, and Mountain States. Not as much competition from other oncologists, down to earth patients, higher pay, less taxes, and lower cost of living is really a winning combination.

You would think that, but in FL, despite the huge medicare population, the market is tighter than it has been in years in the bigger metro areas from what I've been hearing from prospective job seekers.

I think the midwest is where the jobs are this year.

 

[Seldon1985]

You would think that, but in FL, despite the huge medicare population, the market is tighter than it has been in years in the bigger metro areas from what I've been hearing from prospective job seekers.

I think the midwest is where the jobs are this year.

In general, what midwest states are best for rad oncs?

 

[Neuronix]

You would think that, but in FL, despite the huge medicare population, the market is tighter than it has been in years in the bigger metro areas from what I've been hearing from prospective job seekers.

Florida is always bad. Southern Florida in particular is not like the rest of the southeastern US. When people talk about the south having a good job market, they mean non-coastal areas of the south outside of Florida.

 

[medgator]

In general, what midwest states are best for rad oncs?

KS, OH, PA, WV, OK, IA come to mind. Especially KS and IA..... I literally have seen openings in those states every single year.

Also, Neuronix is correct in that non-coastal southern areas get represented pretty well for job openings (MS, LA, OK, TX, rural GA).

 

[subatomicdoc]

Interesting enough, one of the groups in the DC area increased their partnership track to 5 years. We extended ours, as well. So, maybe instead of obvious, drastic pay decreases, the trend might be to not offer partnership until later (as far as private practices go) and keep people on as employees for as long as possible.

We haven't changed our time to partnership of two years. We've adjusted slightly the time to getting a day off, but that's it. Then again, we're in New England and not the major metropolitan areas.

 

[FreakFlag]

In some ways, I envy people who have strong familial ties or prefer to live in less densely populated areas in the Midwest, South, and Mountain States. Not as much competition from other oncologists, down to earth patients, higher pay, less taxes, and lower cost of living is really a winning combination.

I totally agree. I didn't anticipate that my extended family making the decision to settle in a major coastal city 20+ years ago would translate into what I'm facing now: greater job competition and difficulty finding an open position in an already saturated market, prospect of lower pay & higher cost of living, and longer commutes as a radiation oncologist.

 

[Scatter]

Yeah, but if you're married/have kids your life is basically over so you can live like a baller in, say, Scranton. But yuppies are gonna do what yuppies do- live in urban/semi urban areas, go to farmers markets and eat artisanal mustard at farm to table restaurants. That's how we roll.

Objection! Those yuppies oohing and aahhing over local Gruyere are just trying to meet someone, so they can be like us married couples.

 

[Scatter]

In some ways, I envy people who have strong familial ties or prefer to live in less densely populated areas in the Midwest, South, and Mountain States. Not as much competition from other oncologists, down to earth patients, higher pay, less taxes, and lower cost of living is really a winning combination.[/QUOTE]

Get a good (paying) job in one of these states, opt for 8 weeks of vacation and get your fix by vacaying all you want in the big cities -- you get the best of both worlds.