ByDr. Mohammad K. Khan, MD Ph.D

Assistant ProfessorEmory University School of Medicine

m.k.khan@emory.edu

“What I Wish I Knew: Successful Transition from a Resident to an Attending”

Disclaimer*Slides are provided by Dr. Khan for

distribution only to ACRO resident members.

*Residents disseminating these slides to other residents (or junior attendings) should encourage their colleagues to join ACRO before distribution.

Planning for Success Starts Early!

OverviewThe magic “PGY 5” yearPearlsBuilding a successful practiceUnderstanding the “bonus” structureUnderstanding the “promotion” processCME + MOCBalancing work & family

Moe’s Pyramid of SuccessResearch

Clinical

PGY 2-5: Stay FocusedLearn the ART of radiation oncology… Only then, should you

consider doing “other” things!

Think of your self a clinician first!

Partner with a co-resident or at another institutions and teach each other.

Seniors should teach Junior Resident (helps to become an effective teacher in the future)

Research – Collaborate with others! Have them be co-authors on your papers and you become co-authors on theirs builds CV quickly!

The magic“PGY 5” yearSeveral steps before starting:

InterviewingLicensing (ABR steps)

Radbio/PhysicsClinical Written ExamOrals

CredentialingSigning ContractLearning to Transition

The magic“PGY 5” year You have already started transitioning! Learning to manage a busy clinical service Develop a certain “comfort” level in managing all kinds of patients Be diversified in your training (Gamma Knife, HDR brachy, LDR brachy,

Hyperthermia, SBRT, IMRT, IGRT, IntraOp, MammoSite, etc) See LOTS of patients! Learn to handle increased expectations & responsibilities (“Run the show on

a clinical service”, “be the attending” you may get a job at the place you do your residency.. Chairman’s don’t like to loose good residents)

Understand the “whole” integrated workflow and understand the “pros and cons” of your own work environment.

Interview broadly! Look at academic places & private practices (even if you are sure you are staying at the place of your residency, I would still recommend interview just for the experience alone!.. You may need this experience in the future)

Learn to balance research and “other” things (interviewing broadly, finding the right job, signing a contract, preparing for written exams)

Licensing & Credentialing

The magic“PGY 5” yearInterviewing

Start building your CV early- publish/grant/awards/committee service, etc.;

Build a diversity of expertise (GKRS, SBRT, HDR, LDR, Hyperthermia, IntraOp, etc)

Attend & present at national meetings (try and develop a focus for your future job early on during residency if going to academics)

“Know you future interests, early on”Start networking during PGY 4 & PGY 5 years, and start asking

around about potential jobs get input from your senior residents.

Understand Dr. Flynn’s and Dr. Wall’s handouts when job searching.

Use various offers to negotiate your own terms of employment!

The magic“PGY 5” year Credentialing keep electronic copies:

Patient logs! (keep all of them-download from ACGME website when you graduate) Keep track of all HDR & Interstitial cases HDR preceptor authorization form (need some one authorized by NRC to sign off). BLS/CPR or even ACLS card CITI training updated (even for private practices doing clinical trials/IRBs, etc!) Oral & Parenteral Case Logs (Oral administration of I-131 > 33 mCi – 3 cases,

parenteral administration of unsealed beta or photon emission < 150 KeV energy) – to get NRC authorization

Medical School Diploma Passport Copy & Proof of Citizenship Internship Certificate GKRS log (if trying to certify eligibility for GKRS) Draft a Cover Letter (for a Jobs)—I did 3 letters (A general one for ASTRO, one for

“private” practices, and one for “academic” jobs) Letter of Recommendation (for Jobs); Start asking during mid or late PGY 4 year! Proof of “Adequate Physics/Radbio “ lectures need > 200 hours – keep a list of all

the hours/professor/courses you attended, and title of the lectures. Resident Insurance Copy Copy of your State License & DEA license

Light at the end of the tunnel!

Successful “Pre Transitioning”Avoid being seen as a resident! (may help to

move to another institution)Cultivate relationships early on (nurses/house

staff, case managers, social workers, colleagues, referring doctors communication is key)

Let everyone know you are here – don’t lock your self in the office and away from people!

Learn the workflow & billing aspects early on.Seek work-life balancePace your self

PearlsStart early:

Familiarize yourself with the appropriate clinical resources (NCCN guidelines, Textbooks (Gunderson, Perez, Roach, Halperin, etc), PubMed, UpToDate, RTOG website, contouring atlases, Red Journal, etc.)

Stay up to date (read latest journals – IJROBP, NEJM, JCO, -nice mobile apps!, know the latest studies that impact your own practice).

Make friends with attending's and co-residents (they serve an integral part of your future job as well as second or third opinion on complex cases)

Understand your future interests (Academic or Private Practice, enroll patients on clinical trials, writing your own investigator initiated clinical trials, grant writing, serving on national boards, teaching and mentoring residents & medical students, expected work hours, finding a happy medium, etc)

Keep contact information/emails/phone numbers, etc when you move.

PearlsAs a Junior Attending:

Keep a patient list- sorted by diagnosis & tasks needing to be done.

Always seek input from your colleagues Be ready to provide your own input when asked (so how did

you do it at “Cleveland Clinic?”, “Emory?” etc.)Attend as many tumor boards as possible – look for

opportunities to teach & learn from referring doctors (and collaborate with them)

Attend all faculty meetings and chart rounds (try and lead the chart rounds provide helpful insights when appropriate)

Continuously find ways to be involved and help out.Don’t over commit (complete those you already started)!Understand the “promotion” or “bonus” structureUnder promise and over deliver.

PearlsDevelop managerial & leadership skills early on

Lead by example- work hardLearn to be independent – resident will love you and respect you! –

teach them along the way.Be respectful and authoritative and give timely feedback.Be “political” when trying to change things and give feedback.Try and “foresee” problems before they happen.Educate those around you (nurses, patients, residents, physicists,

therapists, etc)Establish a “positive” environmentLearn to delegate responsibilities (avoid micromanaging)Avoid “gossip” around the work place (don’t criticize the new place)Give positive feedback to everyone when deserved!Find a Mentor or Two (Clinical & Research)- meet regularly with

them;Stay in touch with your previous mentors and colleagues.

Pearls Seek recognition within your department:

Provide outstanding care to your patients (your referring docs will love you!)

Build strong relationship with your referring doctors & colleagues; Offer to help out and cover when needed;

Strive to teach effectivelyServe on departmental committees

Seek recognition outside your department at local and national levelServe on institutional committees (collaborate with others outside your

department)Serve on national committees ( RTOG, ACRO, ACR, AMA, etc).Research & PublishAttend national conferences & network.Write grants and open clinical trials (especially if you are in academics). An RO1 grant is the epitome or a radiation oncologist.. Only 1% of

academic radiation oncologist get R0-1s!.

Pearl

Ok to say “No”

Building a Successful PracticeAs a Junior Attending:

Always put patient’s first. A happy patient goes a long way!

Give you business card to every patient you see.Communicate with patient in a “patient” specific

manner- some want simple/layman explanations while others want complex answers.

Avoid false reassurances. Be honest and direct.Always ask the patient if they “understand”, and

have them repeat back to you what they understood.Be sensitive and empathetic to patient’s needs.Three “A’s = Affability, Availability, & Ability

Building a Successful PracticeThree “E’s” = Efficiency, Engaged, & EffectivePrepare to be flexible! Your clinical workflow may not be what

you expectedBe ready to learn “new” skills & don’t make radical changes!Communicate Effectively

Always keep your referring doctors informed (cc’ them on your notes, email, call them, etc.). Always be available to help them out when needed.

Keep everyone on the entire team informed (nursing, residents, therapists, physicists, referring docs, NPs, secretaries, etc.)

Make your own access easy for your patients and for your team. (Always let them know they can reach you at anytime, be respectful of everyone)

Be humble! No one wants a cocky arrogant junior attending who thinks they have all of the answers– ask for help when needed, ask questions! Knowing now may prevent future disasters.

Be prompt! Don’t wait days to complete your notes or return patient’s or referring doctor’s phone calls.

Track if things around you are getting done to your expectations

Building a Successful Practice Establish relationships with your referring doctors (Avoid saying

anything bad about them especially in front of patients. Try and appraise them when appropriate!)

Be flexible and availableOffer to see patients and take on tasks even on your academic daysAdd on same day patients Accept to see any patients even “outside the scope of your clinical

duties” but run it over with you clinical director and the faculty you are covering from (avoid “Turf” battles)

Get input from you colleagues that you are covering to get reassurance that it is ok and your “management” is appropriate with the institutional protocol

Avoid criticizing your colleagues. Speak with the physics and dosimetry to understand the turn around

time for treatment plans and how to make things efficient (don’t stress out a busy system with same day add ons that can wait)

Work with the therapist to find out what works and what does not.

Building a Successful PracticeUnderstand the financial aspects (Meet with the billing team

before you start know what the difference are and what can or can not be billed)

Understand “how to bill” some are electronic and some are paper forms.

Understand how your own department’s financial structure is setup (independent, hospital based, private practice, and who keeps the technical and who keeps the professional revenue)

Understand if your own bonus or promotion is tied into “RVU” productivity measures.

Know the billing people and meet with them periodically to see how you are doing compare to your colleagues and if you are meeting compliance and collection regulations.

Get used to speaking with insurance companies and getting preapprovals for procedure and disputing denials.

“Bonus Structure”Several features:

Understand what % of your salary is a “bonus” and how it is distributedProductivity Based (i.e. RVU based; different places have different

weights on RVU and see if it is individual or departmental level?)Quality/Patient Satisfaction MetricsMeeting Hospital Metrics & Imperatives (Patient Access, Service

Management & Patient satisfaction, Referral Management, Quality, Finance for Administration Time, Patient financial services)

“Departmental” specifications being a good “Citizen”, approving portal imagining on time, attending staff meetings, attending grand rounds, etc.

“Individual” metrics varies based on private practice model or academic (mauscripts/grants, committee memberships, clinical trials, teaching, adding new patients, brining in new techniques to practice, etc).

Understand annual “pay raise” structure (try and get a sense of a range of salaries if possible this is not always readily given)

“Promotion” Process Depends on Academic & Private practice Academic

Clinical Track vs. Academic Track Tenured or Non-Tenured Based on some combination of “Scholarship, Teaching and Outstanding

Service” National recognition along any any of these pathways will help. (Become

nationally/regionally recognized) Keep a portfolio of all of these things you will need a teaching/scholarhsip or

Service portfolio for promotion. Private

Partnership Process (understand if you control technical or professional component and how long you have to serve to become a partner)

Be recognized in your community and in your region so that patients will want to come, and others will want to refer them to you.

Maintain an RVU stream that meets or exceeds expectations. Understand the “Buy In” process and who has the “political power” to

remove/add partners or buy equipment, etc. Figure out if it is a “democratic” partnership or a “one man” show.

CME & MOC6 Essential Competencies

Medical KnowledgePatient Care and Procedure SkillsInterpersonal Communication SkillsProfessionalismPractice-Based Learing and ImprovementSystems Based Practice

MOC & CME 4 Components used to evaluate the 6 competencies

Evidence of professional standing (maintain un-restriced licensure in multiple states)

Life long learning and self-assessment (25 category 1 CMEs with 80% related to radiation oncology, and 1 Self Assessment Module, and Pay Annual Fees)

Cognitive Expertise (computer exam within 3 yrs of the 10 year renewal date); cover 13 topics (GI, GU, GYN, Breast, Lymphoma, H&N, Pediatrics, CNS, Sarcoma, Thoracic, Palliation, Radiation/cancer Biology, Physics)

Practice Quality Improvement (PQI) (have 3 PQI projects during the 10 year relevant to patient care, your practice, identifiable metrics, practice guidelines/technical standards, and action plan to address areas for improvement). Some can by Type 1 like enrolling patient on protocols and you get self assessment or a retrospective review of treatment policies/outcomes for a specific disease setting. Type 2 (at least one) contribute to developing a national database relevant to radiation oncology.

Nice 2 hour webinar about MOC on ABR that you could listen to.

Balancing Work & Family

Questions?Knowing a “good” position before interviewing with

them?Taking a private practice position immediately vs.

holding out for an academic position?How to find open jobs?Quality you can project as an applicant?Preparing to be an attending, adjusting as an

attending, and trying to preparing for boards? Is it more difficult for private practitioners?

Due only 60% of applicants pass Orals?Salaries to expect in private practice and

academics? Does it vary by region?

Questions?How to discuss expectations of you with a

practice and anticipating exactly what they want from you?

How long is “too” long for partnership?What if my CV reads academic but I want

private practice?What makes for a good academic job?What is a typical buy in for practice?Reasonable distance for a non-compete

clause?Signs of a misleading contract?Can you start in academic and transition to

private?

From Dr. Flynn’s Handout for ACRO