Radiation Oncology FAQ

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

Gfunk6

And to think . . . I hesitated
Moderator Emeritus
Lifetime Donor
20+ Year Member
Joined
Apr 16, 2004
Messages
4,719
Reaction score
5,293
What is Radiation Oncology?

Overview
To simplify a bit, Radiation Oncology encompasses the selection, treatment, management, and follow-up of patients treated with ionizing radiation. Though the vast majority of what we treat is "cancer" (either benign or malignant) we also treat conditions such as trigeminal neuralgia, keloids, Grave's ophthalmopathy, and even medically refractory psychiatric disorders.

The three big cancers that we treat are breast, prostate, and lung cancer. Other major cancers include head and neck (oral cavity, oropharynx, larnyx, hypopharynx, thyroid), GI (esophagus, gastric, pancreatic, rectal, anal), GU (bladder, penile), CNS (glioma, meningioma, brain mets), and lymphoma.

Training
After medical school we all do one year of "general" something. This is generally an internal medicine or transitional year. Other options include general surgery, pediatrics, or family medicine. Following this we do four years of clinical radiation oncology. One of the unique features of our residency compared to other oncology fellowships (Surgical Oncology, Medical Oncology, etc.) is that we have the most years of "pure" oncologic training.

A Typical Week
Everyone's day is different of course but a typical week generally includes new patient consults, on-treatment visits (where patients you are treating with radiation see you to manage side effects), follow-up visits (for patients who have completed treatment), simulations (where you set up patients for radiation treatments), treatment planning (where you delineate your radiation targets on imaging), and research.

Technology
One of the perks of this field (especially to all you tech-philes) is the rapidly advancing technology. Back in the day we used to use machines with radioactive cobalt to treat patients (note that very few places in the US and many developing countries still have these). Cobalt machines have been supplanted nowadays with flesh-searing relativistic particle cannons linear accelerators which generate photons electrically. These have the benefit of having an on-off switch (you can't "turn off" radioactive decay), multiple beam energies, and more accurate field shaping.

There are many other modalities including radiosurgery (basically delivering very high radiation doses to relatively small areas) which can be administered by a variety of methods including a Gamma Knife, Cyber Knife, or by a specially adapted linear accelerator (e.g. Varian Triology). Protons are also available in an increasingly large number of centers which have some advantages over photons in terms of dose distribution.

Finally, there is brachtherapy which is the insertion of radioactive sources near (intracavitary) or inside (interstitial) a tumor. There are many ways to deliver this either using permanent implants such as I-125 or Pd-103 or high-dose rate temporary implants like Ir-192.

Applying to Rad Onc

What are the average Step I scores?
For the 2010 application cycle (the last year data was reported by the NRMP) the mean Step I score was 240. However there was a *wide* variation in scores.
Source: http://www.nrmp.org/data/chartingoutcomes2011.pdf

But my Step I scores are nowhere near that? Am I screwed?
Not necessarily. The beauty of applying to Rad Onc is that Step I scores are not the be-all, end-all like Dermatology or Integrated Plastics. By way of example, in 2010 for US Seniors with Step I scores between 181-220, the majority matched. Yes, you read that correctly. Rad Onc is competitive but a lot of it is self-selection. If you have a strong interest in the field but have average/below-average Step I scores you can still get in.

Everyone says research is critical . . . is this true?
Yes, this is absolutely correct. In 2010 the mean number of abstracts, presentations, and publications for US seniors was 8.3. The number of MD/PhDs who matched were about 22% of the total applicant pool. Of 181 total US seniors applying only 1 student matched who had ZERO research experiences (published or non-published).

So what are residency directors looking for?
Two things which distinguish Rad Onc from other fields are the importance of research (see above) and letters of recommendation. Rad Onc is a small field and strong letters from heavy hitters in the field carry weight in admissions. Other important factors are strong clinical grades and good Step I scores (see above). Based on some applicants' experiences, it appears that volunteer work is not as highly prized as some other fields.

OK . . . research is key I get it. But what kind of research?
Painting with a broad brush basic (translational) > clinical > physics. Conversely (again over-simplifying a bit), the level of effort to get abstracts/publications/presentations is roughly ordered physics > clinical > basic (translational). If you have a lot of time on your hands (interested in Rad Onc as an MS-1 or MS-2) then it's good to throw a wide net and work on multiple projects. You never know which research projects will go bust and which will be high yield. Nothing looks worse than a year or more of research without the requisite publication (or abstract) to show for it . . . it makes you look like a slacker. Ideally, the research should be in Radiation Oncology but the exception is if you are doing a PhD or HHMI/DD. In those cases, basic research applicable to cancer is fine. If you do research in an area completely unrelated to cancer it may not help you very much . . . mainly because most Rad Onc attendings on admissions committess are not sophisticated enough to figure out what you actually did.

Preliminary Medicine/Surgery year or Transitional year for internship?
First off, the titles "Preliminary" year and "Transitional" year have quite a bit of institutional variablity so let me be a bit more precise in my definition. A traditional "Preliminary" year consists predominantly of several general medicine ward months, a couple of sub-speciality medicine ward months, a month or so of ICU, a month or so of ambulatory medicine (or ER), and perhaps a month of elective. A traditional "Transitional" year consists of a couple of general medicine ward months, a couple of general surgery ward months, and a whole lot of electives. Generally Transitional > Preliminary as far as being cush goes. However, you should do what you prefer as it makes little difference to a practicing Radiation Oncologist. The benefits of a "Preliminary" year are practicing "real" medicine and prestige whereas the benefits of a "Transitional" year are the diversity of clinical experiences that you get. If a program director asks you what you want to do, 9 times out of 10 the answer they are looking for is "I am doing a preliminary medicine or surgery year in an academic medical center." Otherwise, it may make you look like a slacker. When rank list time comes however, rank whatever you want of course . . . :smuggrin:

Can a DO or FMG get into Rad Onc?
Yes and yes, it happens every year. However, the road is difficult. I can tell you honestly that DO and FMG candidates who are seriously considered for Rad Onc are superior to the average MD candidate. The reason for this is, of course, the preceived stigma of being a DO or FMG in the first place. In addition to copious amounts of research, you should work in a Rad Onc department (preferably the one you are most interested in) to generate face time and make connections. And YES I am aware that Paul Wallner DO is a diety in our field and an ASTRO Gold Medal winner. However, you are not Paul Wallner. :laugh:

Should I schedule away electives?
Absolutely, yes! Even if you are a MS at a top-notch program it will help you to do away rotations provided that you (1) do not have a toxic personality and (2) you are willing to work hard and (3) you are not an ass-kisser [trust me, we notice and we don't like it]. If you have a strong home Rad Onc program (obviously strong means that you at least have a residency program) then one away is sufficient. If you don' t have a home program or if your home program is not taking applicants your year then two aways is a good idea. If you do two, generally one should be at a program that you feel you have a reasonable chance of getting into and the second should be at a "reach" place to procure good letters of recommendation.

I am in college/high school/middle school/elementary school/kindergarten/in utero and am REALLY interested in Rad Onc!! Is there anything I can do now to prepare myself

Jumping the gun a little bit are we? The most important thing to do is to enjoy yourself at your current level of training and do all the hobbies and activities that you always wanted to try. To get into Rad Onc one of the most important factors is to get into a medical school that has a strong Rad Onc department. However, there are so many other more important, relevant factors when choosing medical school: the tuition (and how much you get in the way of grants/scholarships), the curriculum, the location, the students, the faculty, etc. etc. Besides, most people who want to go into a field end up changing their mind. I always wanted to be a Neurosurgeon but that ended the day my 3rd year Surgery rotation started. Still, the simple fact that you are even aware of the existence of this field puts you ahead of many medical students.

What are good books for medical students doing Rad Onc rotations?

The top three books for residents and med students are:
1. The Hansen/Roach Handbook
2. The Haffty/Wilson Handbook
3. Radiation Oncology: A Question-Based Review

You should peruse each and determine which complements your learning style best.

Also for a broader overview of cancer management a good textbook (available for free online) is Cancer Management: A Multidisciplinary Approach

Another superb (free) resource is the Radiation Oncology Wikibook.

What are typical interview dates?

For interview dates in 2010, see the following thread.

I didn't match the first time around, is there anyway I can find programs with PGY-2 openings?

The ARRO website is a good place to start.

Questions about the field of Rad Onc

Isn't Rad Onc a dying field?
I try hard not to laugh when I hear this question. For one, NOBODY CAN PREDICT THE FUTURE. Secondly, someone in a field is unlikely to admit to an anonymous person on the Internet his field is dying (even if it is!). Third, the question belies a strong (albeit understandable, you ARE reading this FAQ :) ) ignorance of this field. My friends, long gone are the days when you took a piece of radioactive cobalt, suspended it over a patient, crudely drew out a treatment field (e.g. "right lung field," "pancreas field," "brain field," etc) and pulled the patient away when you thought he was irradiated sufficiently. Nowadays we are in the era of robotic radiosurgery, linear accelerators delievering multiple/dynamic/conformal arcs, and proton-producing machines that can sit on a table top. Impressed you, eh? I love writing a progress note that reads, "your inpatient was treated by dose-painted intensity-modulated radiation therapy using nine non-opposed coplanar beams using combined 5 mV/10 mV photon energies. The gross tumor volume is receiving 7000 cGy in 35 fractions prescribed to the 98% isodose line." Their reaction is priceless! :D

But I digress . . .

Radiation Oncology is an evolving field and as such has areas which are dying off and areas which are emerging. For example, our steroetactic body radiosurgery machines are capable of controlling early-stage lung cancer just as well as a thoracic surgeon's lobar resection . . . a fact that does not endear us to them. On the other hand we have turf wars with Nuclear Medicine and Medical Oncology about delivering radio-iostope conjugated antibodies.

Furthermore, Radiation Oncology is a complementary modality with Surgical Oncology and Medical Oncology. Many disease (advanced head & neck cancers, advanced lung cancers, many primary brain tumors) require all three modalities for standard of care. In some cases radiation alone is perfectly sufficient (early stage larynx cancer, early stage prostate cancer, brain metastases). In other cases radiation is not generally indicated (most stages of colon cancer). The technology is improving all the time. I can confidently say that the field will be much different 20 years from now than it is today because of technology/scientific advancement. But dying? Pish-posh.

Isn't all that radiation exposure bad for you?
Well if I decided to see my on-treatment patients WHILE THE MACHINE WAS ON, this might be a problem. But you see, state and federal regulatory agencies have this "thing" about unecessarily irradiating bystanders near treatment vaults. You know that most treatment machines are in the basement right? Well if Uncle Joe was buying a gift for his niece in the gift shop, I don't think he would appreciate being irradiated with the 2.12 Gy that Ms. Sullivan was recieving downstairs. So we have lead and concrete shielding, and massive vault doors made of borated polyethylene to prevent just such incidents. Also, the radiation therapists are the ones who actually operate the machines and position the patients giving you another "layer" of protection. Finally we all wear dosimetry film badges which are carefully audited for exposure. All in all I would say we actually have significantly LESS exposure then fields like interventional cards/rads where they use radiation with fluoroscopic abandon.

What are the starting salaries like?
From the ARRO 2012 survey, starting salaries are as follows:

Average = $285,000/year
Median = $301,000/year
Range = $180,000/year - $450,000/year

Any tips for studying for Radiation Physics and Radiobiology written boards?

The SDN community has come up with a nice guide.

Also be sure to check out the official Rad Bio study guides.

Do you have any advice for the job search?

Yes, please see here and here.

The Holman Pathway

What is the Holman Pathway?
For a full description click here.

Briefly, the Holman Pathway is an option offered to Radiation Oncology residents by The American Board of Radiology (ABR). The ABR is responsible for granting board eligibility, board certificaiton, and maintenance of certification to all Radiation Oncology residents/faculty in the United States. The Holman Pathway is an option for residents who are highly motivated and qualified for academic careers. It allows you to perform 18-21 months of research during your residency (80% research & 20% clinical during the pathway months) without increasing the total length of your residency. In other words, it allows you to do abbreviated clinical training and substitute it with a qualified research project. To apply you need the full support of your Chair, Program Director and potential mentor and need to write up a brief application specifiying your aims and containing letters of support from the aforementioned individuals.

Is it difficult to obtain the Holman Pathway? If so, why?

It depends how you define "difficult." If your definition is the number of applicants accepted into the Holman pathway divided by the number who apply then the answer is no, it is not difficult as the value is close to 1.0.

If you define "difficult" as (a) matching at a residency that is actually receptive to residents doing the Holman pathway (very few), (b) finding a mentor who is willing to take you on, (c) having a residency that is willing to tackle the hardships of having a resident mostly out of the clinic for 18-21 months then the answer is yes, it is difficult to get all of your ducks in a row.

I imagine it is more troublesome to assimilate the Radiation Oncology knowledge base when faced with other committments, to what extent is this true? Do you think the Holman pathway detracts from clinical competency?

This is a controversial question. If you ask non-Holman residents (the vast majority of Rad Onc residents) the answer to them would be an obvious "yes it detracts from your clinical competency." Maybe even, "hell yes! It detracts from your clinical competency."

As a resident who has completed the Holman pathway, who has talked to other residents going through it at other institutions, and directly interacted with faculty who completed it I'd say, "in the short term it may detract from your clinical competency, but in the end you will be as competent." My reasons for this are (a) you have to be above average as deemed by your PD and Chair to enter the Holman pathway in the first place and (b) people who do Holman tend to be aggressively "beef up" their clinical knowledge base in the last year or so of residency.

I noted a requirement for 21 months of research time... Is there a requirement for the number of publications that should be generated during this time?

First off the research time can be as short as 18 months and still qualify for Holman. Second, when you apply to the Holman pathway you are simply asking the ABR to allow you to remain board eligible in Radiation Oncology with abbreviated clinical training for the purposes of meritorious research. That's it, nothing more and nothing less. The ABR relies heavily on your PD, Chair and mentor to ensure that you are qualifed to do Holman and only vetoes your application in unusual circumstances. There are no requirements once you are in the Holman pathway other than submitting annual progress reports to the ABR.

Residency Program Websites

Sometimes programs make it REALLY difficult to find their residency websites. Listed below are all the websites I could find, feel free to PM me about updates, broken links, or additions.

Allegheny
Arizona
Baylor
Case Western Reserve
City of Hope
Cleveland Clinic
Columbia
Cornell
Duke
Emory
Fox Chase
Harvard
Henry Ford
Indiana
Johns Hopkins
Kaiser LA
Loma Linda (could not locate)
Mayo (Rochester)
Mayo (Jacksonville)
MD Anderson
Memorial Sloan Kettering
Michigan
Moffitt
Mt. Sinai
MUSC
Northwestern
OHSU
Pittsburgh
Roswell Park
Stanford
SUNY Downstate (under construction)
Thomas Jefferson
U Colorado
U Chicago
UC Davis
UC Irvine
UCLA
UCSD
UCSF
U Florida
U Iowa
U Maryland
U Minnesota
UMDNJ-RWJ
U Miami
UNC
U Penn
U Rochester
UTHSC (UTSA)
UTSW
U Washington
U Wisconsin
Utah
Vanderbilt
VCU
Washington U
Wayne State
William Beaumont
Yale

Members don't see this ad.
 
Last edited:
  • Like
  • Haha
Reactions: 3 users
Update #4 complete (added sections on recommended texts for rotations and salaries)

Gfunk, I really tell med students to focus on overall oncology management rather than just rad onc specific things (which I feel like Haffty and Roach emphasize). I feel like it's more important for them to know that SCLC gets cisplatin etoposide with XRT, rather than the fact that we have data for 45 Gy BID.

For that purpose, I generally recommend the Multidisciplinary Cancer Management Handbook (which interestingly was edited by Lawrence Coia -- the guy who wrote the original infamous red handbook that many of us had heard about when we first started, along with a medical and surgical oncologist).

http://www.cancernetwork.com/cancer-management-12
 
Last edited:
Thanks for putting this FAQ together, it has been super helpful. I am a second year medical student and I've been getting really interested in rad/onc. Can anyone tell me more about what a typical day is like in rad/onc. What do you actually do? How much patient time is there? I read the 'typical week' in the FAQ, but can anyone expound a little? I would really appreciate it. Thanks in advance
 
Members don't see this ad :)
I've cut and pasted this from an old thread. Hopefully it will answer your questions.

1. All oncology patients are referred to RadOnc. Therefore, it is best to have cordial relationships with other oncologists and surgeons.

2. At the initial consultation the patient is seen by the attending (sometimes preceded by resident and/or med student). At this time, the attending takes a full history and physical. Prior to the consult, appropriate labs, films, and medical history are reviewed. The attending gives the pt options and we go to the next step if pt wants to proceed with radiotherapy. The choice of treatment depends on what the current literature says, institutional hardware, and the attending's own experiences.

3. Pt is "simmed." Rad techs position the patient in the machine and "simulate" an actual treatment. This way attending can verify the regional anatomy (both bony landmarks and soft tissue critical structures) and make adjustments as necessary.

4. Pt is "planned." Now that the images are on disk, the patient's tumor volumes and critical structures are "contoured" by the resident and/or attending. Once the attending is satisfied with the area covered by radiation (including extra margins for tumor not apparent on imaging) then the plan goes to the dosimetrists.

5. Dosimetrists (w/ or w/o resident) calculates plan including beam angles, doses, and fractionation. Generally, there is some degree of back and forth b/w the attending and dosimetrist with regard to plan optimization. Physics also looks at the plan and approves it.

6. Pt is brought back for first treatment. Everything is set-up and pt is "simmed" one more time to ensure quality treatment. If everything looks good, pt receives first treatment.

7. During the course of treatment pt receives so called "portal films." (usually 1/week) These are images taken with the treatment machine to verify that you are actually irradiating the correct area. Also, patients see the attendings to report any side-effects or if they have any questions 1/week or so -- though obviously immediately for pressing issues.

8. Pt is seen @ follow-up clinics periodically for up to several years post-RT. Generally, the attending reviews scans to evaluate recurrence of disease as well as a physical exam.

That's more or less the sequence.
 
  • Like
Reactions: 1 user
Okay, the title of this thread is a little over the top, I'll admit. :laugh:

However, this thread is officially #2,000 in this forum, so I thought I would make it something special.

My job search officially concluded last week and I couldn't be happier with the outcome. The journey, however, has been long and difficult and I thought it would be worth sharing with all of you. Please keep in mind that this post represents a single person's experience and should be taken with a healthy dose of skepticism and a critical eye. Hopefully, others will add to this thread which will increase utility.

OK, here goes . . .

---------------------------------------------------------

One of my main recommendations to senior residents is to clearly establish what type of job you want. A problem I encountered was I had no freaking idea what I wanted to do. Honestly, some days I felt like doing a 2 year lab research-based post-doc and others going into a partnership-track private group. Because of this indecision, I ended up interviewing at a broad range of practice settings from the top academic centers to private groups to physician-employee hospital positions.

This breath of experience leads me to my first observation,

OBSERVATION #1: It is not terribly useful to simply divide jobs into academics vs private practice because there is so much more to each job than a simple "label." Therefore, it is better to make a list of things that you enjoy about the field and try to identify the job which will give you most of them.

For instance, here was my list:

1. I enjoyed the academic environment - working with trainees, discussing complex cases in a multi-disciplinary setting, and having colleagues well-versed in the literature.

2. I did not like the academic grind - constantly working on publishing the next paper, writing the next grant, sitting on another committee all while seeing a ton of patients.

3. I wanted to practice in an ethical manner - no gratuitously increasing the # of fractions for financial gain (and no pressure to do so), the freedom to r/c against XRT in borderline cases, and the freedom to choose the most appropriate modality (not just IMRT by default)

4. I wanted to work in a merit-based environment - if an employee was incompetent or was otherwise a poor-fit, I wanted to be able to fire them; I didn't want to keep poor workers just because of union rules or seniority; note this includes radiation oncologists

5. I had specific geographic restrictions and an order of preference between them

6. I wanted to benefit financially from my work - if I am going to work like a dog, then I want a cut of the profits or fair compensation from it

7. If possible, I wanted the majority of my work to be in SRS, SBRT, and Neuro-Oncology

As you can see, there a number of practice types that could fit into the above model including clinical academic positions and certain private groups or hospital physician-employed jobs.

---------------------------------------------------------

I started my job search early. I put together my CV in February of my PGY-4 year and started sending out cover letters and applications in April. For the most part, it was low yield to start this early as very few places are able to predict their employment needs 15 months in advance. Nevertheless, I had a few hits and went on a few early interviews. Starting in about late August or so, things began to escalate and things picked up. In the week before ASTRO, there was another burst of activity and by early December things died down again.

With that said, here is my second observation,

OBSERVATION #2: Use a diverse, multi-pronged approach in your job search. I wrote down academic places I would like to work and sent my CV and cover letter to the Chair. I got a 90% response rate (both positive and negative) from doing this. I also spoke to residents/attendings in areas I was applying to private jobs and sent my CV and cover letter to the managing partner or deparment head. Also, I made liberal use of head hunting firms. This was not particularly high-yield, but I figured what the hell since it was free. Finally, the ASTRO job center is quite good and user-friendly. I checked it daily.

Many of the best places that offered me an interview did not advertise. The Chairs/Partners at those places told me that great applicants are always breaking down their door for a position, so why would they bother to advertise? Some of these places tend to be very elitist (e.g. they don't consider applicants from non-top programs). Still, I would apply everywhere because the worst you'll get is a politely worded rejection.

---------------------------------------------------------

Even if you are totally confident what type of position you want, I strongly encourage you to apply to at least one or two other practice types. For instance, even if you are 100% certain you will be a physician scientist, why not apply to a few private groups just to see what you are turning down? Even if nothing comes from it, you can at least be certain you considered alternatives.

OBSERVATION #3: Apply to at least a couple of positions which sound interesting, but you would not consider otherwise. You will learn something.

---------------------------------------------------------

Med students and residents always want to know about salary. Ironically, I found such conversations counter-productive. No matter how much you are paid, you will not be happy in a practice that doesn't suit you. However, if you find a dream position, salary might be a deal breaker so you should know what you're worth and what the regional salaries are. Also, new grads generally don't have much leeway when negotiating salaries.

OBSERVATION #4: Have some idea of what salaries to expect for the job you want. That way, you can gloss over salary until negotiation time.

For academic positions (clinical or physician-scientist) starting salaries are generally in the range of $220K - $250K for assistant professors. Anecdotally, I've heard that some places (notably MDACC and MSKCC) offer $300K+. Obviously, though, people don't go to these places for the money though it is a nice bonus.

If you are in a partnership track for a private group, the salary range is a bit wider than for academics. I've seen $200K - $300K. These salaries are largely a function of regional variance. You will get paid much higher living in Idaho than San Diego. For three year partnership tracks, your salary usually goes up $25K per year. The national mean for partnership revenue per person is $450k for multi-specialty groups and $650K for Rad Onc only groups.

If you accept a physician-employed position then your starting salary will be higher than the above. At a minimum it will be $300K and I've seen as high as $410K. However, this is a salary and they will not let you touch technical fees. Generally, some incentives are built in for productivity but your salary will not usually be as high as partners in private groups.
 
Last edited:
OK, I'll be the first to admit that I was intimidated by a lot of interviews. Seriously, I was just a PGY-5 peon interviewing with some of the brightest minds in our field (to be their potential colleague :eek: ). I think this is fairly normal. Harness this feeling and remain humble. No matter how much you think you know, your interviewers have been doing this for years and should be afforded respect.

OBSERVATION #5: Despite feelings of inadequacy, don't be afraid to ask practices tough questions and, when negotiation time arrives, to bargain aggressively.

If you are interviewing at a top academic place and you have concerns about carving out a research niche for yourselves in the presence of faculty titians, say so! At one place, I flat out told a faculty member that I was "awed" to be interviewing with him and queried how I could find my way. He assured me that all junior faculty had the same misgivings and that the environment was nurturing (despite outward appearances). He further noted that any potential junior faculty who did not have such misgivings was probably deluding themselves.

When the happy (yet stressful) moment comes and you get an employment contract, don't rest on your laurels! Again, the tendency is to think, hey, these guys are doing me a favor by hiring me. Also, I really like them and don't want to piss them off so I'll just accept all their terms without question. Don't do it! Negotiate aggressively! Ask for more research time, administrative support, salary or incentives. Obviously, a lawyer is mandatory to help you hammer out some of these demands. The key is to be reasonable and (if possible) evidence-based in your demands.

Compare,
How about an extra $20k in salary? I'm not sure I can move to [place] without it.

vs.

At the ARRO practice seminar, I learned the median salary for starting Rad Oncs was $278K. I noticed that your offer was quite a bit below that. Would you be willing to increase my base to match it?

Also, have a long list of demands with alternatives. For example, they may not increase your salary but perhaps they could give you a sign-on bonus or more CME $$. As the saying goes, if you get everything you asked for, you didn't ask for enough.

---------------------------------------------------------

References. Everybody wants references. But here's the problem . . . any applicant with an ounce of common sense will ask faculty with whom they shared a good rapport for a reference. Employers know this and therefore will almost certainly contact other people in your department including non-faculty. Remember that dosimetrist or therapist you pissed off last year? Well, if your employer knows and calls them about you, you might be out one job.

OBSERVATION #6: As much as you are able, maintain cordial relationships with everyone in your department. Use the Golden Rule. Even if a faculty member treat you like crap, don't retaliate, it won't help your future job prospects. Ditto to staff.

Also, employers will talk with each other. If you tell Dr. A one thing and Dr. B another it may come back to bite you. On interviews try to maintain consistency or, at least, don't be self-contradictory.
 
Last edited:
Geographic issues. Most people are not willing to work anywhere and have a clear idea exactly where they want to start their career. First, the good news. If your desired local is in the Mid-West (exception: Chicago), the Southeast, or Mountain States, Montana, or Idaho then you will probably not have a hard time finding a job where you want. If you want to work in the NE, West Coast, Pacific NW, Chicago metro, or DC metro then you will have your work cut out for you.

OBSERVATION #7: It is highly unsafe to solely look for jobs in a single, geographic area. I recommend a broader search to start with a narrowing to follow once you start getting hits.

If you want a job in a particular region it is best if you did your residency there. This shows employers that you can live there in relative happiness and plus you will know about the area and what it offers. Second best is if you grew up in the area or otherwise lived their for years and want to move back. If you have never lived where you want to work, boy-howdy it will be tough. You have to convince people you will be happy there and won't flake out after a year or two.

I know this will generate controversy, but I believe pedigree matters . . . a lot. If you train at a top place, you will have a much easier time getting interview spots, that's life. However, pedigree won't get you the job, your personality and abilities will do that. Some places (as I've alluded above) won't look at people with a sub-optimal pedigree. I don't think this is fair or right, but that's life.

---------------------------------------------------------

For current med students applying . . . remember all of your co-applicants. They will be your best friends and resources in four years. I've talked to a ton of my co-PGY-5's and the conversations have been enlightening, frightening, and tremendously useful.

OBSERVATION #8: Keep in touch with your co-residents at other programs. They may be instrumental in getting you the job you want.

Here's a perfect example. A resident I know, interviewed at many of the same places as me. However, he/she chose a job earlier than me and was able to give me detailed feedback on programs that he/she considered including what interview questions they asked. Invaluable.
 
Last edited:
Good job, Gfunk. Definitely a lot of good info there for prospective job seekers in training now.

As for:

I know this will generate controversy, but I believe pedigree matters . . . a lot. If you train at a top place, you will have a much easier time getting interview spots, that's life. However, pedigree won't get you the job, your personality and abilities will do that. Some places (as I've alluded above) won't look at people with a sub-optimal pedigree. I don't think this is fair or right, but that's life.

I've heard similar things regarding some practices in the the geographically sought-after areas, but at the same time, personality can often trump those things, especially in private practice.

I think the ARRO talk about the 3 "A's" (Availability, Affability, and ability, in that order) plays a big role in the PP setting. Many groups want to make sure you'll have the right fit for them and for referring MDs, and no pedigree in the world will matter if you're the type to not fit in well with the group and grow the business.
 
Thanks for the info, which is very helpful for the current PGY-4 class. Did you ultimately decide on academics or private practice?
 
Thank you for the write-up, and congratulations. Sound like you're going for "academic light" kind of a place? Agree, such practices are the best deal overall.

The question I have for everybody, is it customary for the practice to take care of the new doc's "paperwork" (obtaining unrestricted state license, DEA #, getting insurance privileges and paying the corresponding fees)? Is it useful to have it spelled out in the contract?
 
Members don't see this ad :)
The question I have for everybody, is it customary for the practice to take care of the new doc's "paperwork" (obtaining unrestricted state license, DEA #, getting insurance privileges and paying the corresponding fees)? Is it useful to have it spelled out in the contract?

All practices should pay for fees related to state licences and DEA numbers. They will almost always help you with the paperwork as well. Ditto with getting insurance privileges.

I don't think helping with paperwork needs to be spelled out in the contract. Obviously, anyone you sign with wants you to get started working ASAP so it is both of your best interests to speed things along.

However, I've heard cases of AA's messing up attending paperwork so I think it helps to be familiar with the process yourself.
 
Never heard of anyone not paying for that stuff...
I even had em pay my ABR fees for the year so I can take my orals.

Licensing/privileges/etc. takes forever. I'm 5.5 months in and still haven't finished staff privileges for one of the hospitals. I never go there to see any inpatients, so hasn't held me back but sheesh...

S
 
I would also add:

Ask to spend time with therapists and dosimetrists. You can get a very good idea of the type of group you are joining (ability and ethics) by asking them questions you may find awkward asking doctors (e.g. 25 fraction whole brain with concurrent chemo, IMRT for all breast cancers, a dosimetrist who doesn't know how to turn the collimator to put a larynx block on a low anterior neck field.) Often, they don't know what they are doing is outside the norm and will freely divulge information.
 
Great post, GFunk.
I'm glad you got the job you wanted, and I hope it ends up being everything you want it to be.
 
I need your collective wisdom re: telling your PD and/or chairman about your interviews. Do you recommend telling them before or after the interview, if at all? What if your chairman already offered you a job? Thanks.
 
It depends on the relationship you have with your PD/Chair. If good, keep them updated every now and then (especially if you listed them as references). If bad, stay mum.

If your Chair offers you a position, he shouldn't restrict you from interviewing elsewhere. If that's the case, you probably don't want to work under him anyway.
 
Thanks, Gfunk. The relationship is good. I was planning on telling them after, but one junior faculty member said it's "bad" if they hear it from someone else ... I wasn't sure what to make of that. What are some of of the questions you asked of people in the academic vs private practice vs hospital employee setting? You mentioned you talked to some other residents who interviewed before you and gained insight what to ask. Please share.

I second others' sentiments re: the entire post -- very helpful for the rest of us, and congrats to you! Good karma ... :) Thank you.
 
Thanks, Gfunk. The relationship is good. I was planning on telling them after, but one junior faculty member said it's "bad" if they hear it from someone else ... I wasn't sure what to make of that.

The main issue is that when you get a job, the recommendations of your faculty references generally played a large role. Thus, it is good etiquette to let those particular faculty know when you secure a position. Also, if your chair offered you a position, you should obviously tell him ASAP if you decide to go elsewhere.

What are some of of the questions you asked of people in the academic vs private practice vs hospital employee setting?

Academic: In my experience, the best people to talk to are very junior faculty (e.g. those who are one year ahead of you, who have yet to take oral boards). They can give you their recent, first-hand experiences between the faculty recruitment hype and reality. Also, they can tell you a lot about other academic programs and their interview experiences with them. Specific questions to ask chairs are:

1. Exactly how many days per week do I get for research? Are those days really free of clinical responsibilities?
2. Which subsites will I be focusing on? Can I get an assurance that my subsites won't change after two years?
3. What are the requirements for promotion from Asst --> Assoc? How many publications? How many first-author?
4. What is faculty mentorship like? Is it formalized?
5. Does your institution have strong leadership in clinical trial groups? If so, can those faculty facilitate my involvement as a co-PI?
6. Which faculty are planning to retire soon? How you will manage their clinical case load once they leave?

Private Practice: The best person to talk to is the one making all the decisions. Usually big issues (e.g. your potential employment) are put up to a vote among the partners, but the managing partner runs the show and is usually the best to talk to.

1. Establish exactly how partnership works, (a) how many years does it take, (b) is there a buy-in, and how much, (c) what is the median income of the partners, (d) if a multi-specialty group, how do you reconcile the fact that Rad Onc reimubursement > Med Onc reimubursement?
2. Was anyone on a partnership track and denied when their time came? How many people? Why? Can I have their phone numbers so I may talk with them?
3. What are you looking for in a potential partner?
4. Do you feel obligated to r/c XRT in borderline cases because of $$$? Do you feel compelled to add fractions because of $$$?
5. Who's your main competition? How is your relationship with them?
6. What are you plans for preparing for the future of Rad Onc in terms of new hardware purchases?

Hospital-Employee You will interview with several business types, often the CEO of the Hospital. This may seem weird to many as these are not the types of interviews we are used to having. In other cases, the hospital administration may cede all the power to the department head and so the interview process will be more like private practice.

1. Instead of paying me a flat salary, would you consider instead giving me professional plus some % of technical fees. The answer will almost always be no, but it doesn't hurt to ask.
2. What incentives do I get? How do they work? What additional income do the current physicians get with the incentive plans?
3. Is there a pension plan? How does it work?
4. How receptive is the administration to buying new equipment? How receptive are they to recommendations to changes in staff?
5. Have you laid off any Rad Oncs in the last 10 years? Why?
6. How much say will I have in molding the Rad Onc department?

You mentioned you talked to some other residents who interviewed before you and gained insight what to ask. Please share.

The following info (if they are willing to give it) was important to me:

1. Specific questions they were asked
2. Timeline for making a decision on a candidate
3. Any negative vibes
 
Last edited:
  • Like
Reactions: 1 user
Can anyone comment on jobs offering help with student loans? Either private or hospital? I am assuming academic wont...but then again I am not sure. Currently I am a resident and struggling to decide if I should just pay off the interest on my loans for tax deductions or try and actually start paying them off and spend way less on rec activities and travel each year (which is never fun). What I don't want to happen is to get out into private or hospital practice and have them say "oh, we have a program to pay your monthly loan payment for you" and then kick myself for wasting all this very scarce money in residency when it could have been paid for me in the future. Thoughts?
 
The only formalized program that I'm aware of to pay back student loans is the NIH Loan Repayment Program. However, to be eligible for this, you need to in a primarily research based career with a non-profit institution either within or outside the NIH. This is commonly used by MDs who complete residencies and go on to 2-year post-docs.

For regular jobs (academic/PP/hospital) of all stripes, I never noticed a loan repayment program. Since your salary is much higher than a resident, repayment of loans should not be a problem. Also, your employers have no compelling reason to repay your loans as this would subtract from their bottom line. The only instance where it would make sense would be if they were giving you a sub-optimal salary to start (e.g. like a post-doc would get).

I guess it's possible to negotiate this into your salary, but I would rather just take the money and have the freedom to do what I wished with it rather than being forced to use it for a single purpose.
 
The main issue is that when you get a job, the recommendations of your faculty references generally played a large role. Thus, it is good etiquette to let those particular faculty know when you secure a position. Also, if your chair offered you a position, you should obviously tell him ASAP if you decide to go elsewhere.



Academic: In my experience, the best people to talk to are very junior faculty (e.g. those who are one year ahead of you, who have yet to take oral boards). They can give you their recent, first-hand experiences between the faculty recruitment hype and reality. Also, they can tell you a lot about other academic programs and their interview experiences with them. Specific questions to ask chairs are:

1. Exactly how many days per week do I get for research? Are those days really free of clinical responsibilities?
2. Which subsites will I be focusing on? Can I get an assurance that my subsites won't change after two years?
3. What are the requirements for promotion from Asst --> Assoc? How many publications? How many first-author?
4. What is faculty mentorship like? Is it formalized?
5. Does your institution have strong leadership in clinical trial groups? If so, can those faculty facilitate my involvement as a co-PI?
6. Which faculty are planning to retire soon? How you will manage their clinical case load once they leave?

Private Practice: The best person to talk to is the one making all the decisions. Usually big issues (e.g. your potential employment) are put up to a vote among the partners, but the managing partner runs the show and is usually the best to talk to.

1. Establish exactly how partnership works, (a) how many years does it take, (b) is there a buy-in, and how much, (c) what is the median income of the partners, (d) if a multi-specialty group, how do you reconcile the fact that Rad Onc reimubursement > Med Onc reimubursement?
2. Was anyone on a partnership track and denied when their time came? How many people? Why? Can I have their phone numbers so I may talk with them?
3. What are you looking for in a potential partner?
4. Do you feel obligated to r/c XRT in borderline cases because of $$$? Do you feel compelled to add fractions because of $$$?
5. Who's your main competition? How is your relationship with them?
6. What are you plans for preparing for the future of Rad Onc in terms of new hardware purchases?

Hospital-Employee You will interview with several business types, often the CEO of the Hospital. This may seem weird to many as these are not the types of interviews we are used to having. In other cases, the hospital administration may cede all the power to the department head and so the interview process will be more like private practice.

1. Instead of paying me a flat salary, would you consider instead giving me professional plus some % of technical fees. The answer will almost always be no, but it doesn't hurt to ask.
2. What incentives do I get? How do they work? What additional income do the current physicians get with the incentive plans?
3. Is there a pension plan? How does it work?
4. How receptive is the administration to buying new equipment? How receptive are they to recommendations to changes in staff?
5. Have you laid off any Rad Oncs in the last 10 years? Why?
6. How much say will I have in molding the Rad Onc department?



The following info (if they are willing to give it) was important to me:

1. Specific questions they were asked
2. Timeline for making a decision on a candidate
3. Any negative vibes

Very helpful, esp. questions. Thanks very much. Telling them after you've secured a position is, of course, the right thing to do. I'm just not sure I want to broadcast that I'm going to interview at an XYZ place until after the fact (i.e., interview, not job offer). But, a part of me does want to sit down with them and be, like, "I'm going to interview at XYZ, any advice?". Je ne sais pas ... :shrug:
 
Other private practice tips ...

1) Try to schedule the interview on the day of chart rounds. You can check all the charts, and see if there is any funny business going on - 40 Gy/20 fx for a hip met using IMRT. Also, you can get a feeling of how people interact with each other - physicians with nurses, RTs, physicists.

2) Try to schedule the interview when they have a tumor board. Good way to see how the multidisciplinary discussions go. That helped a lot. I met a referring urologist, and I talked to him privately - he really made me feel good about the group and the region.

3) There should be no significant buy-in if there is no technical. You shouldn't have to pay for "good-will". This you can learn more about at the ARRO career seminars. There will be a significant buy-in if there is technical.

4) Don't believe a word about technology upgrades until you are looking at a CBCT image yourself. Unless the technology they mention is already on site, assume that what you see is what you get. If that makes you uncomfortable/unhappy, find another practice.

5) Find out what clinics you will cover and/or if you have to split days between clinics. I thought it would suck and really didn't want a job where I had to be at different clinics or split days, but I like it now. Nice break to get in the car, and I get the variety of two staffs, many more referring doctors, etc.

6) Compensation is very difficult to talk about, and can be positively and negatively misleading. My starting salary was below median ASTRO survey, but I was told to expect that because it was good group and big city, etc. I got a Christmas bonus I was not told I was getting. For tax purposes, the partners may have to contribute a significant amount annually into the non-partner's 401k (can be $15k or more some times). There are HSA contributions, which could be a couple thousand/year. There are entertaining expenses (to take out referrings, etc). There are disability insurance contributions that you didn't even think about, but $5k is $5k. And for partnership, salary isn't the only thing to consider. Some places offer $50k to $100k or more a year into your pension plan, and that isn't calculated as "salary". You can try to get details, but it can be hard - for whatever reason, even if a good group, people are loathe to talk hard numbers.

7) Partnership means different things to different people. Make sure you get a very clear understanding of it. We are completely egalitarian - all partners make split the whole pot equally. Everyone works similar amounts, so there is no worries about that. Other places pay you by production, which to me, sets up inter-group competition. So, see what fits your personality and choose that.

8) Evaluating the competition is very difficult. I guess you can go by the group's quote on how many patient's the treat quarterly over a span of X years, but aside from a few localities, it is very difficult to plan too far ahead. The minute you sign your contract, a UroRad may be breaking ground. CON states offer some advantages, but some disadvantages. The best you can do is see how long your group has been around and how long most of the people have stayed. If >15 years, and most people stick around for a long time, that probably is a good sign.

Good luck!

Private Practice: The best person to talk to is the one making all the decisions. Usually big issues (e.g. your potential employment) are put up to a vote among the partners, but the managing partner runs the show and is usually the best to talk to.

1. Establish exactly how partnership works, (a) how many years does it take, (b) is there a buy-in, and how much, (c) what is the median income of the partners, (d) if a multi-specialty group, how do you reconcile the fact that Rad Onc reimubursement > Med Onc reimubursement?
2. Was anyone on a partnership track and denied when their time came? How many people? Why? Can I have their phone numbers so I may talk with them?
3. What are you looking for in a potential partner?
4. Do you feel obligated to r/c XRT in borderline cases because of $$$? Do you feel compelled to add fractions because of $$$?
5. Who's your main competition? How is your relationship with them?
6. What are you plans for preparing for the future of Rad Onc in terms of new hardware purchases?
 
Other private practice tips ...

1) Try to schedule the interview on the day of chart rounds.

2) Try to schedule the interview when they have a tumor board.

3) There should be no significant buy-in if there is no technical.

4) Don't believe a word about technology upgrades until you are looking at a CBCT image yourself.

5) Find out what clinics you will cover and/or if you have to split days between clinics.

6) Compensation is very difficult to talk about, and can be positively and negatively misleading.

7) Partnership means different things to different people.

8) Evaluating the competition is very difficult.

Good luck!

All excellent points. I'm on the other side at this point and try to make these kinds of points as clear as possible early. We didn't find the right candidate yet that fits #7, but for both new associate and partners it's a long-term relationship that should be the right fit.
 
Does anyone have tips for what kind of practice might be best for someone who wants to do translational research as well as rad onc clinical practice, but does not want the insecurity of the traditional "academic grind", i.e. job and livelihood depending on publications and grants? Especially in today's funding climate... I am thinking that a part-time clinical practice at an institution that has research infrastructure and potential collaborators could be one solution, but I don't know how much it exists. I wouldn't want the type of position where I am the "clinical" person with no time or energy left for research. I think I may be too picky and will never find the type of position I am imagining. :xf:
 
If you want to do translational research that involves (I presume) some bench component then you will need to work either in a major university or academic cancer center. Only these types of organizations have the resources and expertise you need. You need funding and for funding you need data and for data you need money and for money you need grants (e.g. the great circle of funding).

However, clinical research can be done in academic "light" type places which include large private groups with academically minded physicians. However, you will be largely limited to Phase I/II single arm prospective trials which you can perhaps use to prove that your practices' "experimental" treatments work at least as well as the standard of care. If you pine for large, randomized Phase III trials then again you need to work at a major university or academic cancer center.

Unfortunately, you can't have your cake and eat it too.

The excellent reimbursement for Radiation Oncology in general has caused it to become more difficult to do research. Since your clinical activities generate so much revenue, it is a hard sell to get an 80:20 job. The only places that offer it are larger institutions with the vision that bench research will ultimately advance the field at the expense of an investigator's potential clinical revenue.
 
However, clinical research can be done in academic "light" type places which include large private groups with academically minded physicians. However, you will be largely limited to Phase I/II single arm prospective trials which you can perhaps use to prove that your practices' "experimental" treatments work at least as well as the standard of care. If you pine for large, randomized Phase III trials then again you need to work at a major university or academic cancer center.

While this is true in regards to writing and running a phase III trial, community practices do occasionally maintain an affiliate status with a larger cooperative trial group. I am currently in the process of establishing an affiliation with the NCCTG on behalf of our practice in conjunction with several community med oncs. This will allow us to open a range of NCI designated trials (including RTOG, NSABP etc.) within our community.

Obviously, the resources required for clinical vs. translational research are vastly different. Anything with a significant bench component will not be found outside of major academic centers, as you say.
 
Good point of clarification G'ville. However, I was speaking more along the lines of designing and being a PI on a Phase III trial. I don't think this is generally possible outside a major academic medical center. There are of course exceptions, but these tend to come from academic titans who earned their chops and have since migrated to private practice.

If you are talking about patient enrollment in all stripes of clinical trials then I agree this is possible in many private groups. Like your own practice, my group is a CALGB affiliate and is in the process of joining the RTOG.
 
Good point of clarification G'ville. However, I was speaking more along the lines of designing and being a PI on a Phase III trial. I don't think this is generally possible outside a major academic medical center. There are of course exceptions, but these tend to come from academic titans who earned their chops and have since migrated to private practice.

I think it's harder to become a PI but depends upon what you're ready to do. Most community/private practices aren't going to support that level of academic interest, but if you have a day off you can use it for research. Most people interested in research to that degree stay in academics, but if you're really committed here's what you could consider:

1. Network as much as possible now in the academic community;
2. Look for a private practice that will give you the non-clinic time you're willing to commit to research that others in the group may use for a day off;
3. Don't waste time on ASTRO/ASCO meetings, go to RTOG/CALGB meetings. Get to know the current PIs. If you show interest and persistent activity within a cooperative group.

This is the road less taken, not as certain as the standard academic path. Hope that's helpful!
 
Thanks for the thoughtful advice, guys - I am thinking at this point that it makes the most sense for me to go into academics... but it is very hard to get into a faculty position with research in a desirable location on the West Coast, now - Having the established research infrastructure would be invaluable, as well as mentorship of others who are doing the same thing.

Ah, if only I just wanted to make $$ and drive a fancy car, it would probably be easier...
 
Ah, if only I just wanted to make $$ and drive a fancy car, it would probably be easier...

I know this is partly tongue-in-cheek, but I wanted to caution you of having an overly simplistic generalization of academics vs. private practice. The latter is not an easy ride and always comes with its own unique challenges depending on the circumstances of your employment.
 
so g funk are you going to tell us where you're going next year? Or are you going to go from being completely known to completely anonymous haha. just curious!
 
How common is it to score a 4-day work week straight out of residency? Did anyone out there manage to negotiate that :D

When is the right time to bring something like that up? I assume you would wait until they offer you a position and it is part of contract negotiation? Or should you disclose that as something you are looking for earlier?
 
@napoleondynamite -- good question. I don't know about private practice/pracademia, but I think it's very common (expected?) in academics. Three of our new faculty coming on board are fresh-out-of-training, and at least two of them are going to be in the clinic only 1-2 days/week. Our strictly clinical faculty member that's just starting is going to be in the clinic 4 days/wk.
 
Clinical vs. academic duties breakdown is a different issue. You still work the entire week, although some are allowed to take a research day from home.

To answer napoleon's question, it is very hard to find a practice that would make you a partner, while letting you work less than full time. I only know one person who scored a job like that.... in rural WV. I'd say it would be nearly impossible in a "highly desirable" location.

You can still be a salaried part-timer-clinic workhorse. It was discussed before on this board.
 
At many/most academic institutions, your "academic day" is on Sunday.

With regard to the four day workweek, I would re-emphasize what seper wrote. If all you want is a salaried job then four days is reasonable. However if you see yourself as partner and/or want to advance your academic career you will have to bust your hump. Also, even if you are given one day "off" per week in those scenarios, you will likely spending it working to further your career.
 
What is a practice with a "buy in" vs others? Is there a good resource where I can learn more about these different practice types?
 
A "buy in" assumes that you are actually investing in something physically present (e.g. treatment machines, real estate, etc.). Thus, you share in both the risk and reward.

Practices which are "professional only" are ones where the Rad Oncs staff hospitals but don't actually own the equipment. Those types of practices should not have a buy-in and, if they do, you should be wary IMO.

This website is from the American Academy of Ophthalmology but explains the concept of the buy-in well.
 
Daniel Flynn has a nice packet about looking for a job in rad-onc. I don't know how updated it is, but I read it a few years ago and it was helpful in thinking about how different practices operate. I don't where to find it, though.

-S

A "buy in" assumes that you are actually investing in something physically present (e.g. treatment machines, real estate, etc.). Thus, you share in both the risk and reward.

Practices which are "professional only" are ones where the Rad Oncs staff hospitals but don't actually own the equipment. Those types of practices should not have a buy-in and, if they do, you should be wary IMO.

This website is from the American Academy of Ophthalmology but explains the concept of the buy-in well.
 
Top