Satellite Doc Experience

[PhotonBomb]

Really nice thread from SimulD

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[medgator]

Tough transition imo to go from PP to a satellite esp mdacc where everything is protocol/algorithm driven with minimal deviation and not necessarily inline with what everyone else does.

I don't think I could do it

 

[radiation]

Satellite positions on this board often get denigrated, but would be curious to see if anybody has done the formal analysis to see what happens to net number of jobs after a academic center takes over a private practice or opens new satellite.

My impression is that, even in community satellites, academics have less pts on beam per attending, thus usually have more attendings per center than a pure private practice would. Theoretically satellite docs are given an academic day, so that may play into it. But would interesting to see if academic satellites have a net plus/minus on jobs overall

 

[RickyScott]

It probably really depends on the system. Some want everything done certain way to a t and others just want within standard of care

 

[medgator]

Satellite positions on this board often get denigrated, but would be curious to see if anybody has done the formal analysis to see what happens to net number of jobs after a academic center takes over a private practice or opens new satellite.

My impression is that, even in community satellites, academics have less pts on beam per attending, thus usually have more attendings per center than a pure private practice would. Theoretically satellite docs are given an academic day, so that may play into it. But would interesting to see if academic satellites have a net plus/minus on jobs overall

Jobs up, but probably pay down, more so than would be expected otherwise

 

[OTN]

MDACC needs to explain why their phase II data trumps RCTs that show 5FU and MMC is better than Cis/5FU.

 

[elementaryschooleconomics]

MDACC needs to explain why their phase II data trumps RCTs that show 5FU and MMC is better than Cis/5FU.

I had the same thought - fascinating claim by them.

 

[PhotonBomb]

MDACC needs to explain why their phase II data trumps RCTs that show 5FU and MMC is better than Cis/5FU.

MDACC does some goofy stuff for sure, but I actually think there is some potential rationale for cisplatin. This post by CC sums it up nicely (theMednet - Login)

but basically ACT II showed no difference, and 98-11 muddied the waters by adding in the induction chemotherapy part which is believed to have worsened outcomes, as also seen in the ACCORD trial.

Since ACT II showed equal outcomes, but it was NOT a non-inferiority trial, MMC is SOC. But I think if you're not doing the induction cis part, you can probably safely assume that it works about as well.

I've never done it, but if I had a frail patient and the med onc wanted to do it, I wouldn't have an issue.

 

[OTN]

My issue with the recent satellite center PR push is that when an academic satellite center opens up in a location, they use their state tax dollars and (in MDACC’s case, their selective exclusion from billing experiments) as a kind of crony capitalism to overwhelm any practices already in the market. Then, what happens to the docs who were already there? If they lose their jobs, will MDACC hire them? Probably not, as they don’t know the “MDACC way.” Will they have to uproot their family and move? Probably? Will they find a job in today’s market? Maybe.

 

[PhotonBomb]

My issue with the recent satellite center PR push is that when an academic satellite center opens up in a location, they use their state tax dollars and (in MDACC’s case, their selective exclusion from billing experiments) as a kind of crony capitalism to overwhelm any practices already in the market. Then, what happens to the docs who were already there? If they lose their jobs, will MDACC hire them? Probably not, as they don’t know the “MDACC way.” Will they have to uproot their family and move? Probably? Will they find a job in today’s market? Maybe.

oh i agree. the continued growth of the Corporate Medical Empire has no limits though. We will all be forced to submit or die.

the emperor palpatine isn't a physician. It's a freaking MBA somewhere.

 

[RickyScott]

My issue with the recent satellite center PR push is that when an academic satellite center opens up in a location, they use their state tax dollars and (in MDACC’s case, their selective exclusion from billing experiments) as a kind of crony capitalism to overwhelm any practices already in the market. Then, what happens to the docs who were already there? If they lose their jobs, will MDACC hire them? Probably not, as they don’t know the “MDACC way.” Will they have to uproot their family and move? Probably? Will they find a job in today’s market? Maybe.

those 11 centers have now every reason to buy/ expand satellites as the satellite is worth more to them than to you or your hospital.obviously this increase costs overall when these centers expand.

 

[Burt Radnolds]

MDACC does some goofy stuff for sure, but I actually think there is some potential rationale for cisplatin. This post by CC sums it up nicely (theMednet - Login)

but basically ACT II showed no difference, and 98-11 muddied the waters by adding in the induction chemotherapy part which is believed to have worsened outcomes, as also seen in the ACCORD trial.

Since ACT II showed equal outcomes, but it was NOT a non-inferiority trial, MMC is SOC. But I think if you're not doing the induction cis part, you can probably safely assume that it works about as well.

I've never done it, but if I had a frail patient and the med onc wanted to do it, I wouldn't have an issue.

This is spot on. ACT II essentially showed equivalence but cis did not usurp mmc as standard of care due to trial design. Cis actually had much less hematologic toxicity but it's a 4 hour infusion with the need for hydration etc instead of 15 mins MMC push so would be more chair time/ more resources in a nation with socialized medicine. I have no problem with anyone giving cis.

 

[deleted1002574]

Anal cancer regimen? It’s reasonable and some people use it and it’s NCCN allowed. A lot of people here do things that are seem odd, but are still considered “a standard of care (not even 5 years ago, STILL had long standing, respected members of this board saying they would not hypofx DCIS)

Out of state satellites are not exempt and fall under regular hospital / freestanding billing rule. At least the way MDACC has done it, they bill under the hospital - be it Scripps, Cooper, Banner, Baptist. None of those are PPS exempt. All of them are possibly going to be lottery losers of APM, I’m predicting 40%

They absorb those that are there, let them have the option of learning “the way”. No firing goes on... You guys sound kind of tin hat... Even some of the usually more reasonable posters.

 

[deleted1002574]

This is spot on. ACT II essentially showed equivalence but cis did not usurp mmc as standard of care due to trial design. Cis actually had much less hematologic toxicity but it's a 4 hour infusion with the need for hydration etc instead of 15 mins MMC push so would be more chair time/ more resources in a nation with socialized medicine. I have no problem with anyone giving cis.

Yeah didn’t want to wade into this debate, because MMC people will be intolerable about it. Try cis for your next 5 patients, I overwhelmingly think you and your med onc will rue the day you used MMC. No matter... it’s a SOC, and if you don’t do it, I don’t think you’re a meanie for giving more toxicity

 

[PhotonBomb]

Anal cancer regimen? It’s reasonable and some people use it and it’s NCCN allowed. A lot of people here do things that are seem odd, but are still considered “a standard of care (not even 5 years ago, STILL had long standing, respected members of this board saying they would not hypofx DCIS)

Out of state satellites are not exempt and fall under regular hospital / freestanding billing rule. At least the way MDACC has done it, they bill under the hospital - be it Scripps, Cooper, Banner, Baptist. None of those are PPS exempt. All of them are possibly going to be lottery losers of APM, I’m predicting 40%

They absorb those that are there, let them have the option of learning “the way”. No firing goes on... You guys sound kind of tin hat... Even some of the usually more reasonable posters.

agree that firing does not go on, BUT older docs who have the inability to transition and fall in line with modern requirements (not just treatment decsions, but stuff like increased documentation, peer review etc that they may not have had to do when solo) force SOME people into retirement.

personally that last part is a bonus of this, probably the only good thing, is it forces dinosaurs who don't want to do the work out.

 

[RickyScott]

Anal cancer regimen? It’s reasonable and some people use it and it’s NCCN allowed. A lot of people here do things that are seem odd, but are still considered “a standard of care (not even 5 years ago, STILL had long standing, respected members of this board saying they would not hypofx DCIS)

Out of state satellites are not exempt and fall under regular hospital / freestanding billing rule. At least the way MDACC has done it, they bill under the hospital - be it Scripps, Cooper, Banner, Baptist. None of those are PPS exempt. All of them are possibly going to be lottery losers of APM, I’m predicting 40%

They absorb those that are there, let them have the option of learning “the way”. No firing goes on... You guys sound kind of tin hat... Even some of the usually more reasonable posters.

Affiliates don’t get to bill under mothership but satellites do.

 

[deleted1002574]

Affiliates don’t get to bill under mothership but satellites do.

You sure that Sugar Land doesn’t bill under St. Luke’s? It’s at St Luke’s hospital, and they are submitting a charge under MDACC Texas Medical Center? I find this very hard to believe.

 

[medgator]

Yeah didn’t want to wade into this debate, because MMC people will be intolerable about it. Try cis for your next 5 patients, I overwhelmingly think you and your med onc will rue the day you used MMC. No matter... it’s a SOC, and if you don’t do it, I don’t think you’re a meanie for giving more toxicity

My *$$hole would prefer MMC assuming I'm in decent shape

 

[RickyScott]

Trump Administration Releases Transparency Rule in Hospital Pricing

For the first time, hospitals and insurers would be forced to disclose their secret negotiated rates under a far-reaching plan released by the Trump administration.

www.google.com

If this comes to pass, going to be a lot of discord in xrt

 

[deleted1002574]

Totally.

Also should publicize who doesn’t take Medicaid and shame them

 

[medgator]

Totally.

Also should publicize who doesn’t take Medicaid and shame them

Probably overlaps with this list a lot

Eleven U.S. cancer centers get to charge more for care

For several decades, certain cancer centers have been allowed by the U.S. government to charge more for the care they give. A new study finds the care given at these centers isn't very different from that received at other top-notch facilities.

www.reuters.com

 

[OTN]

Anal cancer regimen? It’s reasonable and some people use it and it’s NCCN allowed. A lot of people here do things that are seem odd, but are still considered “a standard of care (not even 5 years ago, STILL had long standing, respected members of this board saying they would not hypofx DCIS)

Out of state satellites are not exempt and fall under regular hospital / freestanding billing rule. At least the way MDACC has done it, they bill under the hospital - be it Scripps, Cooper, Banner, Baptist. None of those are PPS exempt. All of them are possibly going to be lottery losers of APM, I’m predicting 40%

They absorb those that are there, let them have the option of learning “the way”. No firing goes on... You guys sound kind of tin hat... Even some of the usually more reasonable posters.

When Duke and UNC bought up all the primary care practices in Raleigh, I don’t remember them hiring any of the USON docs after that practice went down...

 

[Haybrant]

Simuls post is a good example of the type of introspection that’s allows one to adapt well to the situation they find themselves in. It’s looking at the bright side of a situation bc one could easily look at this and easily find the negatives too, that’s a good thing. However Rad onc has become a field where you increasingly can not control your personal narrative (not just job related) any longer and that’s precisely the reason why med students should not enter the field or do so at your own peril. Not only will you be justifying your job situation (no offense but the idea of Banner MDACC sounds terrible) youre at extreme risk of having to do a similar thing w all aspects of your life as well. It’s a hard way to live but many of us, lots and lots and lots of us, are in this exact situation w our lives - sure we adapt bc that’s what humans do and sometimes it’s not so bad- but you don’t have to settle for something like that, just going where the winds decide to blow you. Choose something else for your own self preservation

 

[PhotonBomb]

Simuls post is a good example of the type of introspection that’s allows one to adapt well to the situation they find themselves in. It’s looking at the bright side of a situation bc one could easily look at this and easily find the negatives too. Rad onc has become a field where you increasingly can not control your narrative any longer and that’s precisely the reason why med students should not enter the field or do so at your own peril. Not only will you be justifying your job situation (no offense but the idea of Banner MDACC sounds terrible) youre at extreme risk of having to do a similar thing w all aspects of your life as well. It’s a hard way to live but many of us, lots and lots and lots of us, are in this exact situation w our lives - sure we adapt bc that’s what humans do and sometimes it’s not so bad- but you don’t have to settle for something like that, just going where the winds decide to blow you. Choose something else for your own self preservation

I mean his entire point is that the concept of ‘terrible’ as you describe is all relative.

If making 500k plus living in an metro area while getting to be a radiation oncologist but you have to deal with the disgrace of being ‘employed’ rather than your own guy is ‘terrible’ but you still would take it over being some other field, many fields which a lot of us think would suck to do, that’s the decision you have to make. That’s why his input was good.

 

[Haybrant]

I mean his entire point is that the concept of ‘terrible’ as you describe is all relative.

If making 500k plus living in an metro area while getting to be a radiation oncologist but you have to deal with the disgrace of being ‘employed’ rather than your own guy is ‘terrible’ but you still would take it over being some other field, many fields which a lot of us think would suck to do, that’s the decision you have to make. That’s why his input was good.

And my point is that life isn’t about your job only - one can make justifications and rationalizations to make themselves feel good about their career bc that’s what he is actually doing. To try to do this for your personal life - take the instance of not being able to live with your family and miss your nieces and nephews growing up or with your immediate family even and risk your family dissolving- is an incredibly sad thing to have to do.

 

[Neuronix]

If making 500k plus living in an metro area while getting to be a radiation oncologist

I've never been offered this kind of money. YMMV.

Also, a metro is possible. Which metro? You may not get to choose.

With non competes, single employers buying up whole metros, and the oversupply of new grads, it makes it a lot harder for people to switch jobs or have any bargaining power at all in their position as well.

Super easy to get on Twitter and rah rah rah I love my employer. You aren't going to see anyone bad-mouth their employer in public. I see it in other specialities, but rad onc is too small and the job market is too tight.

 

[PhotonBomb]

I've never been offered this kind of money. YMMV.

Also, a metro is possible. Which metro? You may not get to choose.

With non competes, single employers buying up whole metros, and the oversupply of new grads, it makes it a lot harder for people to switch jobs or have any bargaining power at all in their position as well.

Super easy to get on Twitter and rah rah rah I love my employer. You aren't going to see anyone bad-mouth their employer in public. I see it in other specialities, but rad onc is too small and the job market is too tight.

I was specifically talking about SimulD's Phoenix metro area job (that's where Banner is). easily making 500k plus as a mid-career doc.

also I notice you repeatedly talk about you not being offered 'this' or 'that' kind of money - you are a physician scientist with grant funding with a non-full time clinic schedule. You are in a different category. You see that, right? Plus you have indicated that associate profs where you are make around 450. not bad. congrats on your successful academic career thus far.

 

[Neuronix]

you are a physician scientist with grant funding with a non-full time clinic schedule. You are in a different category. You see that, right? Plus you have indicated that associate profs where you are make around 450. not bad. congrats on your successful academic career thus far.

You misunderstood my path. I started as a 3-4 site satellite doc with full-time RVU target. I met target back then and some. It was the same base pay I make now, except I'm leaving a lot of bonus on the table by seeing fewer patients. Either way I'd be nowhere near $500k. I busted my ass on the side to get grants and primarily work at the main center now, but did not start that way and fought hard for it.

Assoc Prof including all bonus and benefits would be around $450k assuming I go back to mostly clinical. That's still not $500k, and I don't know when or if I'll even crack $400k on my current trajectory.

Thanks for the congratulations. It has not been easy.

 

[seper]

That's unfortunate that Simul's practice ownership did not work out. In this climate, an MDA employed position would do. What I never loved being employed (by lesser entities, I admit) is the process of "performance evaluation".

Separately, doesn't MMC improve colostomy-free survival, which is arguably the most important endpoint?

 

[Burt Radnolds]

Separately, doesn't MMC improve colostomy-free survival, which is arguably the most important endpoint?

Only in 98-11, which was tainted due to changing two variables (induction plus cisplatin). In ACT II, a larger and more modern trial, which had a 2 x 2 randomization, (cis vs MMC, adjuvant vs no adjuvant), there was no difference in any disease control endpoint.

https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045%2813%2970086-X/fulltext

 

[medgator]

Separately, doesn't MMC improve colostomy-free survival, which is arguably the most important endpoint?

My memory banks from a decade ago during oral boards prep still recalls a 20% vs 10% benefit in avoiding colostomy in that regard per the rtog which was ss.

 

[medgator]

Only in 98-11, which was tainted due to changing two variables (induction plus cisplatin). In ACT II, a larger and more modern trial, which had a 2 x 2 randomization, (cis vs MMC, adjuvant vs no adjuvant), there was no difference in any disease control endpoint.

View attachment 286614

https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045%2813%2970086-X/fulltext

Non-MMC regimens continue to be 2B in nccn?

 

[evilbooyaa]

Nothing wrong with 5-FU/Cis for Anal cancer based on ACT-II. MMC is technically the standard the same way that 45 in 1.5Gy BID is technically the standard for LS-SCLC because CONVERT was a superiority rather than a non-inferiority trial (just like ACT-II was).

If it is on the NCCN guidelines, it is not wrong. It is variation in practice. Doesn't matter if it's Cat 1 or 2B. 5-FU/MMC has to be listed as a Cat 1 due to the way that the ACT-II trial was written.

In regards to the Twitter thread - If Simul is really making 500k right now then kudos to him, and that job would be fine. Regardless, the premise of working for an affiliated hospital is kinda whatever. It's fine if he is OK with it, but I certainly would not prefer it to follow instructions from a place in a different state. However, a job like that is allowed to exist.

His most important point, though IMO:

 

[OTN]

Agree that the job may be fine for some.

I have to admit, however, that if you would have told me while applying for residency that the most likely job I would get would be an academic satellite job, I would have chosen another specialty.

 

[medgator]

Agree that the job may be fine for some.

I have to admit, however, that if you would have told me while applying for residency that the most likely job I would get would be an academic satellite job, I would have chosen another specialty.

Depends... If pay was productivity based and I had autonomy, I'd be ok with it

 

[evilbooyaa]

Agree that the job may be fine for some.

I have to admit, however, that if you would have told me while applying for residency that the most likely job I would get would be an academic satellite job, I would have chosen another specialty.

Eh even now being at a good academic satellite with a bonus structure is something I'd be OK with. It's when it's straight salary and/or without a reasonable production incentive that I have a sour taste in my mouth.

 

[RadOncDoc21]

Eh even now being at a good academic satellite with a bonus structure is something I'd be OK with. It's when it's straight salary and/or without a reasonable production incentive that I have a sour taste in my mouth.

I think I would prefer a straight (Cush) salary because these bonus metrics are never easily feasible and continue to get harder.

Not saying you shouldn’t get rewarded for your work but I rather not worry about it personally.

 

[PhotonBomb]

I think I would prefer a straight (Cush) salary because these bonus metrics are never easily feasible and continue to get harder.

Not saying you shouldn’t get rewarded for your work but I rather not worry about it personally.

Depends on your personality I think, as well as the opportunity.

If you come into a place where patients have historically not gotten radiation who would be good candidates for radiation, tons of room for growth, and it makes sense to be rewarded for it.

 

[Neuronix]

I think I would prefer a straight (Cush) salary because these bonus metrics are never easily feasible and continue to get harder.

Not saying you shouldn’t get rewarded for your work but I rather not worry about it personally.

I've seen both bad situations.

I've seen situations where the base is not very good AND bonus turns out to be impossible to get (targets are impossibly high either because the volume will never be there OR no reasonable doc can pull those numbers), the metrics are overly complicated and it turns out you don't get what you thought (the fine print or vague wording screws you over), or the metrics worsen the longer you're at a place so you end up working harder and harder just to keep the same amount of salary you started with instead of experiencing real salary growth with time and increasing productivity.

But I've also seen the "sleepy" academic satellite where "all our docs get paid the same fair academic salary." The doc is promised one day at the "main center", and yet ends up with 4 days of busy clinic and on the "academic day" is covering their center, another center, or just catching up as they see 10-15 consults a week with 30-50 on beam for their "fair" 25th percentile AAMC assistant professor salary (currently $323k).

I'd love to advise new grads on how to avoid this sort of thing or negotiate better deals, but they have no leverage. It basically comes down to luck.

 

[OTN]

Why don't we start a list of academic satellites that are exploiting recent grads? Not offering academic advancement? Not allowing bonuses for productivity? Threatening to fire and replace with new grads?

In the past we all knew about which private practices were "hire and fire" or "churn and burn" due to discussions on this forum. Looks like it's time to bring that to the new leaders of exploitation.

 

[thecarbonionangle]

Anybody on here that would be willing to send me the 2019 MGMA compensation data for academics and pp? One of the hardest things for residents is the information asymetry. Hard to try to negotiate when you are a tool-less baby monkey

 

[Chartreuse Wombat]

Doubt this is 2019 but this is the information provided to me by HR

 

[medgator]

Anybody on here that would be willing to send me the 2019 MGMA compensation data for academics and pp? One of the hardest things for residents is the information asymetry. Hard to try to negotiate when you are a tool-less baby monkey

Somebody posted this before, but it excludes academics

 

[GapCalc]

Just in case anyone else was wondering, MGMA 'total compensation' is defined as total Medicare wages, on-call compensation, 401k, life insurance, and other pre-taxed deductions. Additional 'fringe' benefits including reimbursements, health/dental benefits, FSA, or employer contributions are not included.
(Source)

 

[seper]

Linked document is hard to interpret. Is incentive bonus included in MGMA totals for non-academic practices? I thought it was.

 

[GapCalc]

Linked document is hard to interpret. Is incentive bonus included in MGMA totals for non-academic practices? I thought it was.

Good question. I'll see if I can find an answer -- that was the only document from MGMA that I could find during my (brief) Google search that mentioned what was and wasn't included in 'total compensation.'