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

1. “What I Wish I Knew: Successful Transition from a Resident to an Attending” By Dr. Mohammad K. Khan, MD Ph.DAssistant Professor Emory University School of Medicine m.k.khan@emory.edu

2. 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.

3. Planning for Success Starts Early!

4. Overview • The magic “PGY 5” year • Pearls • Building a successful practice • Understanding the “bonus” structure • Understanding the “promotion” process • CME + MOC • Balancing work & family

5. Moe’s Pyramid of Success Research Clinical

6. 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 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!

7. 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

8. 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

9. 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!

10. 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

11. Light at the end of the tunnel!

12. 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 balance • Pace your self

13. Pearls • 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.

14. Pearls • 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.

15. Pearls • 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, etc) • 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.

16. 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 effectively • Serve on departmental committees • Seek recognition outside your department at local and national level • Serve on institutional committees (collaborate with others outside your department) • 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!.

17. Pearl • Ok to say “No”

18. 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 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

19. 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

20. 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 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.

21. 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 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.

22. “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)

23. “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 anyof 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.

24. CME & MOC • 6 Essential Competencies • Medical Knowledge • Patient Care and Procedure Skills • Interpersonal Communication Skills • Professionalism • Practice-Based Learing and Improvement • Systems Based Practice

25. MOC & CME • 4 Components used to evaluate the 6 competencies • Evidence of professional standing (maintain un-restricedlicensure 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.

26. Balancing Work & Family

27. 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?

28. 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?

29. From Dr. Flynn’s Handout for ACRO