If not rad onc, where else would you suggest med students look?

[KHE88]

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Exactly.

The salaries I quoted are for 20s-30s on beam with good payor mix. My academic satellite is so picky about insurance. We turn away so many patients due to non-contracted insurance (1/3? 1/2?), it's insane.

KHE you are a trip. I would move anywhere for over $1 million a year. I looked for a year and couldn't even get a new job interview at all, let alone for that kind of money.

I think we've had this discussion before and it came out that you weren't willing to move anywhere and did have some restrictions on your city. I.e., you aren't going to take the Minot, ND job at any cost.

This is the case in point about what happens when you have restrictions in this field.

But, location is definitely a sticking point for me. My wife/family followed me to nowhere-land for medical school and will probably do the same for residency. At some point I owe it to my family to live in a respectable city and I'm not sure I can commit to a specialty if it really means taking a job anywhere in the country. I'm not restricted to SF or anything, but I know my wife also doesn't want to be forced into Cleveland, OH or Kansas City forever.

This is a non-starter. Hard stop, you need to turn away from this field and never look back. If you can't make large midwestern metros like Cleveland or Kansas City work, which have one of everything you could ever want, then you will not fare well in the your job search. I never understood the obsession with MDs in this country with certain "cities." They have the population stats memorized and can quote metro sizes to the nearest 10k people and view it as some sort of status symbol or pride thing. Having travelled the world, you really learn to appreciate what a privilege it is to be in this country, and even in Minot, ND, that it's better than most other places in the world, and you get to make a million bucks a year to boot.

I just don't get it. I know I've posted this before, but this attitude is absolutely bat---- bonkers insane to me. Like being in Kansas City is basically the same as being in the Yukon Territory or something.

If you're "ok" with making 260k when you are bringing in 600k in collections for your employer as long as you get to live in La Jolla or something, then I'd say your priorities are a little out of whack, as most people go where they have to for the best economic opportunities in other lines of work, but that's just my opinion. Your $4000/month rent payment for a 2 bedroom apartment to live there just became a $32,000/month rent payment when you factor in opportunity cost. Is that really worth it?

The other following posts raise good points. You don't just compromise on salary to go to the big cities that everyone wants to go to. You get exploited in other ways as well. Terrible vacation (4 weeks? Radiologists get 10 -- and there are PP groups in rad onc that respect this and value time off more than money and give you more vacation, but again, not in competitive markets), no position of power or respect in your workplace, overworked, cross covering satellites 60 miles away, basically doing whatever they tell you to because they know there another 500 people who view Cleveland as the end of the earth and will take your spot tomorrow.

And yeah, if your coder is underbilling by 25%, you've obviously not going to be that profitable. But really? I've run a business before, albeit not in medicine, and it's not that hard to run a tight ship. 25% is egregious in any industry. Your pro fees aren't going to come out nearly as low as 200-300k with a full patient load in even the worst payor mix from everything that I know. If someone wants to show me where's that true, I'd love to see it.

 

[KHE88]

A bit of a tangent, but again to the current and future residents: the most important thing for you to protect yourself financially (and perhaps mentally in your future) is to invest as much as you can early into your retirement accounts - this can be as simple as "passively investing" by putting money in index funds. If you are lucky enough to land a job in a desirable area, you can become financially stable and make the money work even if it's not 500k+ per year, and if you're losing your mind in your first job, you can move.

Thank god someone else gets it. I thought I was the only one. The excuse that is always given is... well I can't take those jobs because my spouse would never be ok with it. It's out of MY hands. If you have a partner who refuses to live in a certain town so that you can make $800k/year and secure financial stability for your family with prudent saving and investing after only a few short years, and your partner would instead prefer you to live in San Francisco where you can make a third of that, pay $6000/month for a chic apartment so you have access to a variety of more restaurants and neater scenery to make cooler Instagram pictures, and basically have no money left over each month for savings, YOU CHOSE YOUR PARTNER POORLY. Or else you just come from an insanely privileged and wealthy background and have no financial perspective, which I think is often the case. I simply cannot imaging being married to someone where I presented her/him with 2 choices at the beginning our career when we are starting out:

Honey, we can take one of two jobs:
(1): Private practice in Arkansas/Oklahoma/Indiana/random-other-red-state: A charming town of 150k people, a university in the town, an airport. Private practice that starts at 400k and guarantees partnership after 2 years. Average partner income is $850k. Partners get 8 weeks of vacation, get along great, very family oriented, etc. They even gave me a $50k signing bonus and are going to pay half my loans once I make partner. Check out this real estate, we can get a 5 bedroom 5000 sq ft house for only $450k.
(2): Satellite for major SF-area university system. Starting salary is $225k. Contract renewed yearly. Non-tenure track. 3 weeks of vacation first year. They treat 7-7 and you have to be there for all treatments. Have to cover multiple sites.

And he/she looks you dead in the eyes and screams with excitement: You got the SF job!!!!!!! I'm so happy!!!!!!! We're going to have so much.... FUN!!!!

 

[OTN]

I lived the first 31 years of my life in the Midwest, so I've put my time in. As a result, I don't begrudge anyone wanting to prioritize location over $$. It's also not fair to say someone "chose their partner poorly" when you know nothing about them other than their location preference.

 

[deleted18755]

Thank god someone else gets it. I thought I was the only one. The excuse that is always given is... well I can't take those jobs because my spouse would never be ok with it. It's out of MY hands. If you have a partner who refuses to live in a certain town so that you can make $800k/year and secure financial stability for your family with prudent saving and investing after only a few short years, and your partner would instead prefer you to live in San Francisco where you can make a third of that, pay $6000/month for a chic apartment so you have access to a variety of more restaurants and neater scenery to make cooler Instagram pictures, and basically have no money left over each month for savings, YOU CHOSE YOUR PARTNER POORLY. Or else you just come from an insanely privileged and wealthy background and have no financial perspective, which I think is often the case. I simply cannot imaging being married to someone where I presented her/him with 2 choices at the beginning our career when we are starting out:

Honey, we can take one of two jobs:
(1): Private practice in Arkansas/Oklahoma/Indiana/random-other-red-state: A charming town of 150k people, a university in the town, an airport. Private practice that starts at 400k and guarantees partnership after 2 years. Average partner income is $850k. Partners get 8 weeks of vacation, get along great, very family oriented, etc. They even gave me a $50k signing bonus and are going to pay half my loans once I make partner. Check out this real estate, we can get a 5 bedroom 5000 sq ft house for only $450k.
(2): Satellite for major SF-area university system. Starting salary is $225k. Contract renewed yearly. Non-tenure track. 3 weeks of vacation first year. They treat 7-7 and you have to be there for all treatments. Have to cover multiple sites.

And he/she looks you dead in the eyes and screams with excitement: You got the SF job!!!!!!! I'm so happy!!!!!!! We're going to have so much.... FUN!!!!

While I agree with you for the most part, I have come across more than a few people who really are geographically restricted because of their partner's job restrictions (the radiation oncologist has to take a job in San Francisco because their husband works in IT, job in NYC because he works on Wall Street, or DC because wife works for federal government, etc). There could also be elderly/sick parents, custody issues, or somewhat extreme examples like people from the LBGTQ community who would very strongly prefer living in San Francisco vs rural Alabama. Other than that I agree.

I definitely think things are moving in the wrong direction and would caution a medical student 7-8+ years out from their first job but at this very moment, with flexibility, things are great outside of the very major cities and highly desirable areas (but that has always been the case and always will be so).

I have no idea, other than selection bias and/or exaggerating (maybe a little trolling), why are the numbers for current offers all over the board on this forum. People are quoting $225k to over $1- 2 million/years!!!

 

[scarbrtj]

Thank god someone else gets it. I thought I was the only one. The excuse that is always given is... well I can't take those jobs because my spouse would never be ok with it. It's out of MY hands. If you have a partner who refuses to live in a certain town so that you can make $800k/year and secure financial stability for your family with prudent saving and investing after only a few short years, and your partner would instead prefer you to live in San Francisco where you can make a third of that, pay $6000/month for a chic apartment so you have access to a variety of more restaurants and neater scenery to make cooler Instagram pictures, and basically have no money left over each month for savings, YOU CHOSE YOUR PARTNER POORLY. Or else you just come from an insanely privileged and wealthy background and have no financial perspective, which I think is often the case. I simply cannot imaging being married to someone where I presented her/him with 2 choices at the beginning our career when we are starting out:

Honey, we can take one of two jobs:
(1): Private practice in Arkansas/Oklahoma/Indiana/random-other-red-state: A charming town of 150k people, a university in the town, an airport. Private practice that starts at 400k and guarantees partnership after 2 years. Average partner income is $850k. Partners get 8 weeks of vacation, get along great, very family oriented, etc. They even gave me a $50k signing bonus and are going to pay half my loans once I make partner. Check out this real estate, we can get a 5 bedroom 5000 sq ft house for only $450k.
(2): Satellite for major SF-area university system. Starting salary is $225k. Contract renewed yearly. Non-tenure track. 3 weeks of vacation first year. They treat 7-7 and you have to be there for all treatments. Have to cover multiple sites.

And he/she looks you dead in the eyes and screams with excitement: You got the SF job!!!!!!! I'm so happy!!!!!!! We're going to have so much.... FUN!!!!

The academic ranks have grown by a multiple of about 2.5 over the last 15 years; the private practice ranks by a multiple of 1.25. Cold, hard math: the private practice opportunities are significantly shrinking in relation to the academic opportunities. It's #2 that's the growth market in your scenarios above, not #1. And heh heh... as we all know number two is literally some sh*!t.
But it's not that I don't get your point(s). They're well made, and you have a... point. Yet in a certain way you're actually making the opposite point of what you're trying to make.

 

[deleted947887]

The academic ranks have grown by a multiple of about 2.5 over the last 15 years; the private practice ranks by a multiple of 1.25. Cold, hard math: the private practice opportunities are significantly shrinking in relation to the academic opportunities. It's #2 that's the growth market in your scenarios above, not #1. And heh heh... as we all know number two is literally some sh*!t.
But it's not that I don't get your point(s). They're well made, and you have a... point. Yet in a certain way you're actually making the opposite point of what you're trying to make.

Thank god someone else gets it.

 

[scarbrtj]

I have no idea, other than selection bias and/or exaggerating (maybe a little trolling), why are the numbers for current offers all over the board on this forum. People are quoting $225k to over $1- 2 million/years!!!

Even $2 million is not the correct high end and a bit dishonest. Radiation oncologists can make hundreds of millions.

 

[RadOncDoc21]

Even $2 million is not the correct high end and a bit dishonest. Radiation oncologists can make hundreds of millions.

If it's not at least 4 million a year, I aint signing!

 

[RickyScott]

Thank god someone else gets it. I thought I was the only one. The excuse that is always given is... well I can't take those jobs because my spouse would never be ok with it. It's out of MY hands. If you have a partner who refuses to live in a certain town so that you can make $800k/year and secure financial stability for your family with prudent saving and investing after only a few short years, and your partner would instead prefer you to live in San Francisco where you can make a third of that, pay $6000/month for a chic apartment so you have access to a variety of more restaurants and neater scenery to make cooler Instagram pictures, and basically have no money left over each month for savings, YOU CHOSE YOUR PARTNER POORLY. Or else you just come from an insanely privileged and wealthy background and have no financial perspective, which I think is often the case. I simply cannot imaging being married to someone where I presented her/him with 2 choices at the beginning our career when we are starting out:

Honey, we can take one of two jobs:
(1): Private practice in Arkansas/Oklahoma/Indiana/random-other-red-state: A charming town of 150k people, a university in the town, an airport. Private practice that starts at 400k and guarantees partnership after 2 years. Average partner income is $850k. Partners get 8 weeks of vacation, get along great, very family oriented, etc. They even gave me a $50k signing bonus and are going to pay half my loans once I make partner. Check out this real estate, we can get a 5 bedroom 5000 sq ft house for only $450k.
(2): Satellite for major SF-area university system. Starting salary is $225k. Contract renewed yearly. Non-tenure track. 3 weeks of vacation first year. They treat 7-7 and you have to be there for all treatments. Have to cover multiple sites.

And he/she looks you dead in the eyes and screams with excitement: You got the SF job!!!!!!! I'm so happy!!!!!!! We're going to have so much.... FUN!!!!

Regarding the wife. It is not just the money. They may have a phD with postdoc or law degree, or another career (along with parents who want highly educated daughter to do something) that they have invested heavily in and are not willing to walk away from something that they had been pursuing their whole life. This is major issue with geographic restriction.

And this why disadvantaged minorities and women should think extra hard about this field, as geography is more likely to be a problem for them vs white male. The hypocrates on twitter are ironically doing these groups a total disservice. A disadvantaged minority may have harder time in Trump country, and women are more likely to have a husband who wont be a stay at home dad than visa-verse.

 

[KHE88]

I lived the first 31 years of my life in the Midwest, so I've put my time in. As a result, I don't begrudge anyone wanting to prioritize location over $$. It's also not fair to say someone "chose their partner poorly" when you know nothing about them other than their location preference.

I feel completely confident in stating that you made a poor partner choice if your partner either doesn't care, doesn't value, or doesn't understand the objective financial importance of taking a $850k/year job vs. a $225k/year job in your 30s. So yeah, I'm going to stand by that.

99% of Americans, even those with graduate degrees, will never have a chance to make $850k/year in their life no matter how hard they work. How anyone could turn that opportunity down all for the sake of living in a hipper city is beyond me.

 

[KHE88]

Regarding the wife. It is not just the money. They may have a phD with postdoc or law degree, or another career (along with parents who want highly educated daughter to do something) that they have invested heavily in and are not willing to walk away from something that they had been pursuing their whole life. This is major issue with geographic restriction.

One career becomes objectively financially more important. If your spouse doesn't get this, you chose poorly, and that's a big problem. If you have to take a job that pays $225k/year instead of one that pays $850k/year all so your spouse can take his/her perfect academic PhD job that pays $90k/year rather than transitioning into something else that may pay a little less or taking a little hit to your ego with a less prestigious job, then you are making objectively poor compromises as a couple or else just lack some basic math skills.

 

[RickyScott]

I feel completely confident in stating that you made a poor partner choice if your partner either doesn't care, doesn't value, or doesn't understand the objective financial importance of taking a $850k/year job vs. a $225k/year job in your 30s. So yeah, I'm going to stand by that.

99% of Americans, even those with graduate degrees, will never have a chance to make $850k/year in their life no matter how hard they work. How anyone could turn that opportunity down all for the sake of living in a hipper city is beyond me.

Again, you have a point, but didnt someone post a survey from mckesson stating geography was the most important consideration for 99% of residents. Also, in terms of the science of happiness, multiple studies show a threshold of around 125-150 (obviously you need to adjust for cost of living) where more money does not more happiness, but this seems very elusive, because I do still care about it......

And lastly, if my wife could earn 2 million dollars in BFE, I am not sure I would agree to be a stay at home dad. (dont think that would be very manly)

 

[DukeNukem]

KHE I'm calling BS. I've watched our residency program's recent grads move into rural America against their will for far less than you're posting. I've been looking for and very willing to take a high paying rural job for years myself. My spouse actually wants to get the hell out of where we live and is willing to move to a wide number of locations. I appreciated that you sent me some potential opportunities before. I can't give a lot of personal details about who I am because I do fear that I will get fired from my job if they find out I'm looking. And then where will I be? Anyway, I knew a lot of the people already from the jobs you sent to me and are referring to now. I've had phone interviews with several of them before and after we PMed.

There isn't some magic job out there that will pay $850k+. I wish there was--I'd be all over it. I've had a couple PMs from people on here trying to help and I appreciate it. They know so and so who's hiring. Their practice is hiring. Guess what--it never works out. Turns out the job wasn't really available or the word of mouth was much, much better than reality. The numbers are not these kinds of numbers you're throwing around. Ok there probably is something wrong with me, but if there is, there's something wrong with a lot of people out there. You have to be very lucky or connected to get these jobs you're talking about.

I gave up looking. I can't deal with the disappointment anymore. But I also can't deal with this false narrative of "oh just move rural and you can make a million dollars a year." Maybe that used to exist once upon a time. But now it is simply not available for new or recent grads, even if we are willing to do it.

 

[RickyScott]

KHE I'm calling BS. I've watched our residency program's recent grads move into rural America against their will for far less than you're posting. I've been looking for and very willing to take a high paying rural job for years myself. My spouse actually wants to get the hell out of where we live and is willing to move to a wide number of locations. I appreciated that you sent me some potential opportunities before. I can't give a lot of personal details about who I am because I do fear that I will get fired from my job if they find out I'm looking. And then where will I be? Anyway, I knew a lot of the people already from the jobs you sent to me and are referring to now. I've had phone interviews with several of them before and after we PMed.

There isn't some magic job out there that will pay $850k+. I wish there was--I'd be all over it. I've had a couple PMs from people on here trying to help and I appreciate it. They know so and so who's hiring. Their practice is hiring. Guess what--it never works out. Turns out the job wasn't really available or the word of mouth was much, much better than reality. The numbers are not these kinds of numbers you're throwing around. Ok there probably is something wrong with me, but if there is, there's something wrong with a lot of people out there. You have to be very lucky or connected to get these jobs you're talking about.

I gave up looking. I can't deal with the disappointment anymore. But I can't deal with this false narrative of "oh just move rural and you can make a million dollars a year." Maybe that used to exist once upon a time. But now it is simply not available for new or recent grads, even if we are willing to do it.

I am well connected in this field and dont know of anyone who would offer me 850. Have seen some opportunities for mid 6s with one -2 year guarantee, but there were major stability issues with the practice, and stability is key with an imploding job market.

 

[KHE88]

KHE I'm calling BS. I've watched our residency program's recent grads move into rural America against their will for far less than you're posting. I've been looking for and very willing to take a high paying rural job for years myself. My spouse actually wants to get the hell out of where we live and is willing to move to a wide number of locations. I appreciated that you sent me some potential opportunities before. I can't give a lot of personal details about who I am because I do fear that I will get fired from my job if they find out I'm looking. And then where will I be? Anyway, I knew a lot of the people already from the jobs you sent to me and are referring to now. I've had phone interviews with several of them before and after we PMed.

There isn't some magic job out there that will pay $850k+. I wish there was--I'd be all over it. I've had a couple PMs from people on here trying to help and I appreciate it. They know so and so who's hiring. Their practice is hiring. Guess what--it never works out. Turns out the job wasn't really available or the word of mouth was much, much better than reality. The numbers are not these kinds of numbers you're throwing around. Ok there probably is something wrong with me, but if there is, there's something wrong with a lot of people out there. You have to be very lucky or connected to get these jobs you're talking about.

I gave up looking. I can't deal with the disappointment anymore. But I also can't deal with this false narrative of "oh just move rural and you can make a million dollars a year." Maybe that used to exist once upon a time. But now it is simply not available for new or recent grads, even if we are willing to do it.

On this last thread like this you weren't willing to consider truly rural jobs if I remember correctly. If that's changed, and you really would consider the dozen or so rural and small midwestern town names that are mentioned over and over and others like them I think you would have a shot there. If not, something's up because these places have been advertising for over a year.

If you've talked to these places and they declined to interview you, or didn't offer a contract after an interview, I would call each of them and ask them point blank what their reservation was. Maybe they get the sense you are not going to stay there or don't want to really be there? If they get a whiff of that, they're not going to bother. All of these places bide their time with locums until they get a local guy or someone they are sure will stay for the long haul.

I am well connected in this field and dont know of anyone who would offer me 850. Have seen some opportunities for mid 6s with one -2 year guarantee, but there were major stability issues with the practice, and stability is key with an imploding job market.

To be fair I also have not heard of straight salaries that high. I have however heard of salary guarantees as high as 600-700 with RVU bonuses such that 12,000 wRVUs or so would put you in the 850-900 range.
I am also aware of numerous PPs where partners make at least that much. And PSAs where very busy rad oncs are collecting close to a million/year.
For hospital employed jobs, I'd look at the bonus structure, and for PPs, I'd look at the details of partnership, not so much about the year one salary in either case. Because, sure, yeah, nobody is just going to write you a contract that guarantees you $850k year 1 in 26 annual installments no matter what you do.

 

[scarbrtj]

To be fair I also have not heard of straight salaries that high. I have however heard of salary guarantees as high as 600-700 with RVU bonuses such that 12,000 wRVUs or so would put you in the 850-900 range.
I am also aware of numerous PPs where partners make at least that much.
For hospital employed jobs, I'd look at the bonus structure, and for PPs, I'd look at the details of partnership, not so much about the year one salary in either case. Because, sure, yeah, nobody is just going to write you a contract that guarantees you $850k year 1 in 26 annual installments no matter what you do.

One reason this is ridiculous-to-semi-wishful thinking is that hospitals/health systems are very wont to trot out the federal legal liabilities they face if they pay beyond the 75%ile in current salary data (and bonuses are part of your "salary," ie go on the W2, in the hospital employed setting). That number is about $550-600K.

 

[von Matterhorn]

I think we've had this discussion before and it came out that you weren't willing to move anywhere and did have some restrictions on your city. I.e., you aren't going to take the Minot, ND job at any cost.

This is the case in point about what happens when you have restrictions in this field.



This is a non-starter. Hard stop, you need to turn away from this field and never look back. If you can't make large midwestern metros like Cleveland or Kansas City work, which have one of everything you could ever want, then you will not fare well in the your job search. I never understood the obsession with MDs in this country with certain "cities." They have the population stats memorized and can quote metro sizes to the nearest 10k people and view it as some sort of status symbol or pride thing. Having travelled the world, you really learn to appreciate what a privilege it is to be in this country, and even in Minot, ND, that it's better than most other places in the world, and you get to make a million bucks a year to boot.

I just don't get it. I know I've posted this before, but this attitude is absolutely bat---- bonkers insane to me. Like being in Kansas City is basically the same as being in the Yukon Territory or something.

If you're "ok" with making 260k when you are bringing in 600k in collections for your employer as long as you get to live in La Jolla or something, then I'd say your priorities are a little out of whack, as most people go where they have to for the best economic opportunities in other lines of work, but that's just my opinion. Your $4000/month rent payment for a 2 bedroom apartment to live there just became a $32,000/month rent payment when you factor in opportunity cost. Is that really worth it?

The other following posts raise good points. You don't just compromise on salary to go to the big cities that everyone wants to go to. You get exploited in other ways as well. Terrible vacation (4 weeks? Radiologists get 10 -- and there are PP groups in rad onc that respect this and value time off more than money and give you more vacation, but again, not in competitive markets), no position of power or respect in your workplace, overworked, cross covering satellites 60 miles away, basically doing whatever they tell you to because they know there another 500 people who view Cleveland as the end of the earth and will take your spot tomorrow.

I think you're throwing out some fairly unfounded assumptions and projecting your own wants in life, personally. I do not have 'population stats' memorized and I am not obsessed with SF, NYC, and all of the other major cities constantly glamorized on HGTV. I spent ~32 years of my life living in the Midwest and don't mind it in the slightest. In fact, I was born and raised in nowhere South Dakota with a pop <25k, so you'll have to forgive me if I can't help but smile when you tell me I need to learn to appreciate Minot, ND and its staggering 40k+ pop! I could live the rest of my life in kansas city and not bat an eye. That said, my wife is born and raised from the west coast (and not even SF, imagine that) and has all of her family and roots there. If you can't understand why someone would want to move back to where they're from, I'm not sure what to tell ya. As I said in my OP, my wife has moved around for me, and I do not want to condemn her to a life of never having a say in living back near her own family and friends at some point. I do think it's a little strange that you would suggest my priorities are 'out of whack' because I don't absolutely desire to make a ton of money and live in a trade-off city just because you might prefer that. Everyone has their preferences in life and it seems a little 'out of whack' to me for someone to be so shocked and appalled that someone else might want different things out of life.

Also, I only said salary wasn't of major importance to me because everyone else was commenting on declining salaries being a major reason to avoid rad onc. I certainly understand salary is one component of a much bigger picture.

Anyways, this thread has been largely helpful and I will give med onc more of a chance than I had previously. It's good to know that the IM lifestyle doesn't have to be pervasive to onc.

 

[KHE88]

One reason this is ridiculous-to-semi-wishful thinking is that hospitals/health systems are very wont to trot out the federal legal liabilities they face if they pay beyond the 75%ile in current salary data (and bonuses are part of your salary in the hospital employed setting). That number is about $550-600K.

One reason this is ridiculous-to-semi-wishful thinking is that hospitals/health systems are very wont to trot out the federal legal liabilities they face if they pay beyond the 75%ile in current salary data (and bonuses are part of your salary in the hospital employed setting). That number is about $550-600K.

You are absolutely correct as I know multiple people who have gone through this in negotiations. The consultants hired by the hospital tend to have a problem above the 75th percentile and generally don't want to get near 90th. You can get a little more than 75th, but they won't sign off on it otherwise.
So it's a little higher than what you quote, but not a lot higher.

Of course there's nothing stopping a hospital from offering you a 1 million dollar salary and nothing inherently illegal about it. They just can't get an outside consultant to sign off on it and release their liability to some degree with evidence that that income isn't coming from in-system referrals for imaging and tests and consults you order.

But that's just for your salary guarantee and wRVU conversion factor. Not your maximum income potential as that just depends on how much you work.
There is no stark law violation if you produce 15000 wRVUs and are compensated 1.1 million @ 72/wRVU, which IIRC is around 75th percentile, even though 1.1 million is >90th percentile total compensation.

But some especially shady hospitals (I encountered one) will try to put an upper limit on your wRVU production (so you're basically working for free after you hit 11,000 wRVUs or something).

 

[scarbrtj]

I think you're throwing out some fairly unfounded assumptions and projecting your own wants in life, personally. I do not have 'population stats' memorized and I am not obsessed with SF, NYC, and all of the other major cities constantly glamorized on HGTV. I spent ~32 years of my life living in the Midwest and don't mind it in the slightest. In fact, I was born and raised in nowhere South Dakota with a pop <25k, so you'll have to forgive me if I can't help but smile when you tell me I need to learn to appreciate Minot, ND and its staggering 40k+ pop! I could live the rest of my life in kansas city and not bat an eye. That said, my wife is born and raised from the west coast (and not even SF, imagine that) and has all of her family and roots there. If you can't understand why someone would want to move back to where they're from, I'm not sure what to tell ya. As I said in my OP, my wife has moved around for me, and I do not want to condemn her to a life of never having a say in living back near her own family and friends at some point. I do think it's a little strange that you would suggest my priorities are 'out of whack' because I don't absolutely desire to make a ton of money and live in a trade-off city just because you might prefer that. Everyone has their preferences in life and it seems a little 'out of whack' to me for someone to be so shocked and appalled that someone else might want different things out of life.

Also, I only said salary wasn't of major importance to me because everyone else was commenting on declining salaries being a major reason to avoid rad onc. I certainly understand salary is one component of a much bigger picture.

Anyways, this thread has been largely helpful and I will give med onc more of a chance than I had previously. It's good to know that the IM lifestyle doesn't have to be pervasive to onc.

Go on some website like Practicelink e.g. Search for non-clinical jobs for med oncs; you'll find a bunch. They sound sorta fun, companies like Bayer, McKesson, etc. Real varied positions.
Do same such search for similar jobs looking for rad oncs. Annnnnnd scene.

 

[seper]

A rural hospital is accused by DOJ of bribing physicians via paying employed salaries higher than published data:

Department of Justice Accuses Wheeling Hospital of Violating Stark Law, Anti-Kickback Statute

Read the Department of Justice’s lawsuit against Wheeling Hospital by clicking here WHEELING — The Department of Justice on Monday intervened in a whistleblower lawsuit against Wheeling Hospital Inc., R & V Associates Ltd. and hospital CEO Ronald Violi for allegedly violating the Stark Law and...

www.theintelligencer.net

 

[scarbrtj]

Of course there's nothing stopping a hospital from offering you a 1 million dollar salary and nothing inherently illegal about it. They just can't get an outside consultant to sign off on it and release their liability to some degree with evidence that that income isn't coming from in-system referrals for imaging and tests and consults you order.

But that's just for your salary guarantee and wRVU conversion factor. Not your maximum income potential as that just depends on how much you work.
There is no stark law violation if you produce 15000 wRVUs and are compensated 1.1 million @ 72/wRVU, which IIRC is around 75th percentile, even though 1.1 million is >90th percentile total compensation.

Do you know who would win the argument between you and the hospital attorney. Hospital attorney: "Gee, you've really changed my mind on this whole thing. We've been thinking about this the wrong way. We can bonus doctors as much as we want!"
I would love to think as you do. I really would. But unfortunately reality hits you hard bro.

 

[RickyScott]

A rural hospital is accused by DOJ of bribing physicians via paying employed salaries higher than published data:

Department of Justice Accuses Wheeling Hospital of Violating Stark Law, Anti-Kickback Statute

Read the Department of Justice’s lawsuit against Wheeling Hospital by clicking here WHEELING — The Department of Justice on Monday intervened in a whistleblower lawsuit against Wheeling Hospital Inc., R & V Associates Ltd. and hospital CEO Ronald Violi for allegedly violating the Stark Law and...

www.theintelligencer.net

Yes, but those payments are so out of line for the specialty. Also in radiation, we dont really generate much downstream compared to other specialties, so hard to make argument re "quid pro quo,"

 

[medgator]

A rural hospital is accused by DOJ of bribing physicians via paying employed salaries higher than published data:

Department of Justice Accuses Wheeling Hospital of Violating Stark Law, Anti-Kickback Statute

Read the Department of Justice’s lawsuit against Wheeling Hospital by clicking here WHEELING — The Department of Justice on Monday intervened in a whistleblower lawsuit against Wheeling Hospital Inc., R & V Associates Ltd. and hospital CEO Ronald Violi for allegedly violating the Stark Law and...

www.theintelligencer.net

Key problem:

"paid kickbacks to doctors and also made “incentive” payments to doctors based on how much patient business they referred back to the hospital."

The actual salary paid isn't the problem. It's how it is calculated

 

[KHE88]

I think you're throwing out some fairly unfounded assumptions and projecting your own wants in life, personally. I do not have 'population stats' memorized and I am not obsessed with SF, NYC, and all of the other major cities constantly glamorized on HGTV. I spent ~32 years of my life living in the Midwest and don't mind it in the slightest. In fact, I was born and raised in nowhere South Dakota with a pop <25k, so you'll have to forgive me if I can't help but smile when you tell me I need to learn to appreciate Minot, ND and its staggering 40k+ pop! I could live the rest of my life in kansas city and not bat an eye. That said, my wife is born and raised from the west coast (and not even SF, imagine that) and has all of her family and roots there. If you can't understand why someone would want to move back to where they're from, I'm not sure what to tell ya. As I said in my OP, my wife has moved around for me, and I do not want to condemn her to a life of never having a say in living back near her own family and friends at some point. I do think it's a little strange that you would suggest my priorities are 'out of whack' because I don't absolutely desire to make a ton of money and live in a trade-off city just because you might prefer that. Everyone has their preferences in life and it seems a little 'out of whack' to me for someone to be so shocked and appalled that someone else might want different things out of life.

Also, I only said salary wasn't of major importance to me because everyone else was commenting on declining salaries being a major reason to avoid rad onc. I certainly understand salary is one component of a much bigger picture.

Anyways, this thread has been largely helpful and I will give med onc more of a chance than I had previously. It's good to know that the IM lifestyle doesn't have to be pervasive to onc.

Fair enough, but I'll just simply say that this is not the field for you.

My frustration stems not necessarily from what you wrote, but largely out of an extremely common, elitist, and frankly hypocritically prejudiced viewpoint of midwesterners and southerners as cultureless biogots who hate outsiders who are not like them. As if you can avoid prejudice and closed-mindedness in the big cities -- some of the worst racism and bigotry I've ever encountered has been in progressive large cities and not always from white men wearing red hats. And also from prior partners of my own who wanted to eat their cake and have it too and not have to make adult decisions about financial realities because the idea that one person's job was more important was too damaging to their ego and desire to live in their perfect city and have every little thing in life just exactly they way that they want it. I had one partner who only wanted to live in NYC and one day revealed to me that her solution for our future after residency was to get a job in NYC and if I couldn't for me to live in upstate new york, subsidize an apartment for "us" in manhattan, and then drive to see her on the weekends, forever I suppose. Her job made probably $30k/year. Sociopathic/narcissistic behavior like this really leaves you questioning people. When you find someone who finally understands reality and doesn't take everything personally, it is such a breath of fresh air.

It is endearing that you are willing to put your wife first. In a perfect relationship, each partner would be willing to sacrifice just about anything for the other partner, but the other partner wouldn't let them. Hopefully your wife respects that that following her back home to her family, you'll be giving up income potential, and proximity to your friends, family, and home.

 

[medgator]

Yes, but those payments are so out of line for the specialty. Also in radiation, we dont really generate much downstream compared to other specialties, so hard to make argument re "quid pro quo,"

We order a lot of imaging, plus the technical generated from the machines

 

[scarbrtj]

Yes, but those payments are so out of line for the specialty. Also in radiation, we dont really generate much downstream compared to other specialties, so hard to make argument re "quid pro quo,"

Every patient you "refer" to the hospital's linear accelerator(s) (where the MD gets 0% for tx, and the hospital 100% of the $$$) is the ultimate in downstream, though, yes?

 

[KHE88]

Key problem:

"paid kickbacks to doctors and also made “incentive” payments to doctors based on how much patient business they referred back to the hospital."

The actual salary paid isn't the problem. It's how it is calculated

Exactly. I was always highly skeptical of the hospital's claim that they couldn't pay 90% MGMA because that would de jure involve Stark violation. Umm, says who? I get that your consultant doesn't want to sign off on that, but how is that automatically a violation of law?

Now if the contract says that I will get paid an extra amount for every imaging study I order in the system, then yes.

The argument is that if they pay me $800,000/year, but I only bring in $600,000 in professional collections, then that difference must be made up through studies and referrals I am ordering in the system.

Yeah, well what about the technical revenue? Why can't you just consider that I receive part of the technical revenue as part of my compensation and that's where the difference is. Nobody ever wants to talk about that. Of course they are not going to open their books for you and show you what their profit margin is with the technical revenue. That would more than cover it.

 

[RadOncDoc21]

I really don't think knocking folks for wanting to live in a specific location. We all have our reasons for wanting to live or not live in certain areas. Let's just say I don't care if I do get my 8 million a year salary that I'm currently making now, I won't live in an area that gets colder than 30 degrees more than six times a year. I'm a greek god that needs warm weather to survive.

 

[KHE88]

Do you know who would win the argument between you and the hospital attorney. Hospital attorney: "Gee, you've really changed my mind on this whole thing. We've been thinking about this the wrong way. We can bonus doctors as much as we want!"
I would love to think as you do. I really would. But unfortunately reality hits you hard bro.

I'm not sure what you're trying to imply. My contract does not have a cap. I would not sign a contract with one. I would look them in the face and tell them that they are asking me to sign a contract that says I will work for free beyond a certain point and nobody is going to agree to that.

I can theoretically produce 50,000 wRVUs and get paid 50,000 times the conversion factor I negotiated.

 

[medgator]

I really don't think knocking folks for wanting to live in a specific location. We all have our reasons for wanting to live or not live in certain areas. Let's just say I don't care if I do get my 8 million a year salary that I'm currently making now, I won't live in an area that gets colder than 30 degrees more than six times a year. I'm a greek god that needs warm weather to survive.

As someone who lives in the Sunbelt, totally agree. I'll take part of my pay in sunshine

 

[seper]

Exactly. Will see how this lawsuit will play out.
The story may not be so relevant to RadOnc given the state of the job market, though.
It is much harder for a small WV hospital to hire a pain management guy or an OB, than a RadOnc, so premium was so outrageously high.

Every patient you "refer" to the hospital's linear accelerator(s) (where the MD gets 0% for tx, and the hospital 100% of the $$$) is the ultimate in downstream, though, yes?

 

[RickyScott]

Every patient you "refer" to the hospital's linear accelerator(s) (where the MD gets 0% for tx, and the hospital 100% of the $$$) is the ultimate in downstream, though, yes?

I doubt that counts as a "referral" under the stark laws. A lot of this boils down to "reasonabilty" standard. It may be reasonable for a rural hospital to pay in 90% but not 99.9%/many std deviations above or not 90% for someone coming in half a day a week, especially if you can show any evidence of quid pro quo considerations. (we do use a p of 5%/95% in medicine)

It is like the supreme court's definition of pornography- you know it when you see it. If you are in the middle of north dakota, from what I understand it is entirely reasonable and justifiable for hospital to pay in 90% for full time physician. There is misconception (my administrator tried to use it against me and I got a legal opinion) that salary has to exactly match productivity. Example if your center treats 10-15 pts, they are justified in paying you at the 50% because that is what a full time radiation oncologist makes. Certainly, if you are in an employed situation with income far above 90% the hospital needs some justification- rural setting, high productivity, no coverage etc.

 

[RickyScott]

Also wanted to point out the difference between qui tam (someone privately suing on behalf of the us government, hoping to get a third of the proceeds) vs the us attorney/doj actually taking the case. When there is decent evidence/or likelihood of forcing settlement/financial benefit the us attorney will typically take the case. In this case, there is likely some merit if the us attorney intervened. It sounds like there are indications of quid pro quo (administrators discussing downstream revenue in the context of physician contractual renumeration as well as physician salaries that are many std deviations above the mean even for a rural setting- this should at least force a settlement from the hospital)

 

[deleted941485]

Idk I feel like any positive that may be out there could easily be met with equally if not more negative news I’ve gotten. Maybe it’s just institution specific.

With these new APMs getting proposed. Our job market will probably look more like Canada before long if it doesn’t already. And it probably won’t matter where you live or want to live because you’ll be bouncing from fellowship to fellowship until somebody greedy aging boomer finally decides they have enough money to retire or you just happen to find them face down unresponsive at their desk.

 

[RadOncDoc21]

Idk I feel like any positive that may be out there could easily be met with equally if not more negative news I’ve gotten. Maybe it’s just institution specific.

With these new APMs getting proposed. Our job market will probably look more like Canada before long if it doesn’t already. And it probably won’t matter where you live or want to live because you’ll be bouncing from fellowship to fellowship until somebody greedy aging boomer finally decides they have enough money to retire or you just happen to find them face down unresponsive at their desk.

Nah, maybe on the golf course or on an expensive vacation destination location but not likely at their desk or place of work. That’s where you’ll be 7-7.

 

[thecarbonionangle]

I know of multiple desirable practices in my area where I've heard the old partners will basically be carried out in a bag before they retire. The greed of the baby boomer knows no bound!

 

[deleted941485]

I know of multiple desirable practices in my area where I've heard the old partners will basically be carried out in a bag before they retire. The greed of the baby boomer knows no bound!

Best part is they just cannot understand why anybody coming up the ranks can’t get it together. Because they literally suck all the air out of the room

 

[PleaseRemainCalm]

One career becomes objectively financially more important. If your spouse doesn't get this, you chose poorly, and that's a big problem. If you have to take a job that pays $225k/year instead of one that pays $850k/year all so your spouse can take his/her perfect academic PhD job that pays $90k/year rather than transitioning into something else that may pay a little less or taking a little hit to your ego with a less prestigious job, then you are making objectively poor compromises as a couple or else just lack some basic math skills.

Well I find the idea that someone might have to sacrifice an entire career because their spouse found a high paying job in the middle of nowhere insane. Quite frankly no one knows what will happen in the future, and in medicine and I'm sure many other fields you are unemployable once you have been out of the workforce long enough--many people would not be willing to put themselves in that situation and give that safety net up.

Also what is the point of making money? To enjoy life. If your living environment makes that impossible then the high salary is beside the point.

Not saying living outside NYC or SF isn't a life worth living haha. I'm saying at some point everyone has a threshold where they think this is bumblef*ck and not worth it. The fact that you have a different threshold or perhaps no threshold doesn't mean their concerns aren't valid.

We can go back and forth on this but these geographical preferences are a longstanding known issue that affect medical students/young physicians and other similarly educated people, so why are there some rad onc attendings that seem so shocked and offended by this? Why should the potential rad onc applicant pool and then the graduating rad onc resident pool be any different from the rest of their peers?

 

[Mandelin Rain]

I think the issue is that radiation oncology seems to have an obscenely high ratio of people who think Cleveland or Kansas City (metro populations >2 million) is bumble ****.

I'm sure everyone has their reasons, but on the whole it's entitled, elitist, and arrogant. It's a bad look.

 

[medgator]

I think the issue is that radiation oncology has an obscenely high ratio of people who think Cleveland or Kansas City is bumble ****.

It's a bad look.

Not as big of a fan of Cleveland but I'd be fine with Pittsburgh or KC making 500+/year. Both are solid cities. There is a fair amount of coastal preference/bias on this forum

 

[Mandelin Rain]

Not as big of a fan of Cleveland but I'd be fine with Pittsburgh or KC making 500+/year. Both are solid cities. There is a fair amount of coastal preference/bias on this forum

Yes. It may be largely this forum's population influencing my view. But I see similar attitudes among people I interview at ASTRO, etc...

 

[Haybrant]

I think the issue is that radiation oncology seems to have an obscenely high ratio of people who think Cleveland or Kansas City (metro populations >2 million) is bumble ****.

I'm sure everyone has their reasons, but on the whole it's entitled, elitist, and arrogant. It's a bad look.

This crowd of people is the worst around here. Do you have a family that you want to grow up around the rest of your family? Is that a crime to want that? Sure just up and leave to KC with 0 network and 0 family support bc Mandelin Rain thinks KC has great restaurants. Its not about food, it’s about choice and flexibility. It’s not that different from saying ok manufacturing jobs are going overseas, are you too good to go live in Mexico why does manufacturing have an obscenely high percent of people that think Oxaca is bumble*** I don’t get it?

 

[Mandelin Rain]

Worse than people who summarily dismiss large metro areas as beneath them despite a crumbling job market? I guess.

You're free to go where ever you want. That's awesome and encouraged. It does help if there's a job there though.

As for the leaving your country to find a job example, see: Canadian radiation oncologists.

 

[thecarbonionangle]

Im shocked by the hate towards pretty decent places like Cleveland, KC, Oaxaca. Funny funny!

We have too many people who think theres nothing beyond SF, NYC, and LA. I always felt in minority but never liked any of those Cities.

 

[deleted18755]

I think the issue is that radiation oncology seems to have an obscenely high ratio of people who think Cleveland or Kansas City (metro populations >2 million) is bumble ****.

I'm sure everyone has their reasons, but on the whole it's entitled, elitist, and arrogant. It's a bad look.

Also probably has to do with the fact that the extremes are exaggerated (or unattainable?) by many: sure it's seems crazy to turn down a relatively easy job that pays $1 million with 8 weeks vacation in North Dakota and take one working twice as hard that pays $225,000 with 3-4 weeks vacation in Boston, but I very strongly suspect that the real compensation/workload numbers for those positions are far closer than that, at least for the vast majority of jobs!

 

[thecarbonionangle]

I would take a true KC, Cleveland partnership track, 300-400k job any day versus some job covering 4 satellites all 40 miles away “close” to some “desirable” city.

 

[Mandelin Rain]

I love many cities including SF and NYC (LA not so much, but San Diego is awesome). Would love to live there. It's aspirational. Sometimes finding a good job and learning to love where you're at has to become the priority though. Damn adulting.

At the very least, you don't have much right to complain about not finding a good job if you're prioritizing 2 dozen things over finding a good job. That's just real talk.

 

[scarbrtj]

The *real* pyramid scheme

 

[thecarbonionangle]

The *real* pyramid scheme

Food is so good there!

 

[Haybrant]

Food is so good there!

Hahaha nicely done.

The issue isn’t that people don’t want to adapt - they won’t have a choice. The awareness is being brought so that people don’t have to adapt, nobody is holding a gun to anyone’s head saying you have to go into rad onc. So for people that don’t fall into the mindset that KC is some new Mecca (which by the way it’s not) they shouldn’t go into Rad Onc, and guess what they aren’t anymore. So to always revert to the argument that people are crazy bc they don’t want to move to the amazing city of Cleveland that isn’t really relevant

This is the power of information sharing. Who is going into car manufacturing now? Who plans to be a taxi driver in the future? It’s not that manufacturing and taxi driving are obsolete they never will be it’s that the environment does not support the current structure. There will be some big change in medicine in the next 5 years on the cataclysmic level of what Uber did to taxis. Will be interesting to see what that is but one thing is clear we can’t rely on ASTRO or our greedy leaders (see the absolutely ridiculous alternative career path article in red journal) to help us when it comes and that is pretty terrifying