What I Wish I Knew: Transitioning from Residency to Attending

“What I Wish I Knew: Successful
Transition from a Resident to an
Dr. Mohammad K. Khan, MD Ph.D
Assistant Professor
Emory University School of Medicine
[email protected]
 *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!
 The magic “PGY 5” year
 Pearls
 Building a successful practice
 Understanding the “bonus” structure
 Understanding the “promotion” process
 Balancing work & family
PGY 2-5: Stay Focused
 Learn 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
 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” year
 Several steps before starting:
 Interviewing
 Licensing (ABR steps)
 Radbio/Physics
 Clinical Written Exam
 Orals
 Credentialing
 Signing Contract
 Learning 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” year
 Interviewing 
 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
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 balance
Pace your self
 Start 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.
 As 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” structure
Under promise and over deliver.
 Develop managerial & leadership skills early on
 Lead by example- work hard
 Learn 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,
 Establish a “positive” environment
Learn 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.
 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 effectively
 Serve on departmental committees
 Seek recognition outside your department at local and national level
 Serve on institutional committees (collaborate with others outside your
Serve on national committees ( RTOG, ACRO, ACR, AMA, etc).
Research & Publish
Attend 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!.
 Ok to say “
Building a Successful Practice
 As 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
 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 Practice
 Three “E’s” = Efficiency, Engaged, & Effective
 Prepare to be flexible! Your clinical workflow may not be what you expected
 Be 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
 Be flexible and available
 Offer to see patients and take on tasks even on your academic days
 Add 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 Practice
 Understand 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
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 distributed
 Productivity Based (i.e. RVU based; different places have different weights
on RVU and see if it is individual or departmental level?)
Quality/Patient Satisfaction Metrics
Meeting 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.
 6 Essential Competencies
 Medical Knowledge
 Patient Care and Procedure Skills
 Interpersonal Communication Skills
 Professionalism
 Practice-Based Learing and Improvement
 Systems Based Practice
 4 Components used to evaluate the 6 competencies
 Evidence of professional standing (maintain un-restriced licensure in multiple
 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
 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
Due only 60% of applicants pass Orals?
Salaries to expect in private practice and academics? Does it
vary by region?
 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

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