	After Years and Years, What Are the Options?

Medical education and training is very intense, long, and expensive. When nearing the end of training, it is time to select a career path. In the hematology and oncology fields, there are a variety of paths which fellows can explore depending on their area of interest. To help you narrow down your options, it is important to determine whether you are interested in a clinical or nonclinical position.

Clinical practice can be broadly divided into careers that are 1) academic or 2) nonacademic.

Academic careers can be further subdivided into the clinical track, scientist track, or clinical scientist track.

 Involves mostly patient care and education of fellows and other staff, with zero to minimal research and some administrative tasks.

 This job consists almost entirely of research, with a very minimal amount of patient care. Research may be laboratory based or clinical trials and involve grant writing, protocol writing, and manuscript preparations as well as presentation of research at conferences at national and international conferences.

Involves a combination of patient care and research.

Nonacademic clinical practice options include working for a private practice or accepting a position as an employee of a hospital.

Once very popular, this model of practice is becoming less lucrative due to health care reform and the buyout of small private practices by larger groups and hospitals. The focus of private practice is to generate revenue through patient evaluation while keeping overhead costs low.

Many private practices have onsite laboratory services, imaging capabilities, and radiation oncology services to keep revenue within the practice. Additionally, most private practices have their own infusion center because infusion service time charges and profits on drugs generate decent revenue. In most private practices, an average of 60% of income is generated through drugs and infusion services, compared with 40% from evaluation and management.

Successful private practice requires business and administration skills. With an increase in the number of developed oral drugs, and the rise in drug prices, most practices now utilize specialty pharmacy rather than the method of buying and billing the insurers because of increased inventory costs. Consequently, this has decreased drug and infusion revenue.

One has to be very careful before joining private practice. If it’s an extremely large group, you may experience abuse by senior partners during the beginning of your career, and you may never become a partner. Another major factor to consider in becom- ing a partner is the high buy-in cost. If joining a solo practitioner, the overhead costs could be intimidating. A group of 3 to 4 physicians is ideal because the chance of abuse is low and overhead costs and calls are shared among all physicians.

No matter what, it is essential to market yourself and network with other physicians to increase the chances of referral during the beginning of your career.

This model of employment has become increasingly popular. The buyout of small practices by large hospitals or groups and the resultant decrease of referrals to private practice, decrease in revenue from oral and expensive oncology drugs, and increase in overhead costs are a few reasons why.

The starting salary of a hospital-employed position is lucrative and includes attractive bonuses. You work as an employee of the hospital and in most places the salary is guaranteed for a couple of years, after which you are switched to productivity-based payment.

If the referral in the hospital or group is very strict, you will likely keep getting patients because of referral patterns and you probably do not need to aggressively market yourself. In the event that the referral system is not strong, you will want to market yourself aggressively because after your guaranteed salary time period you may lose money.

Some important private/hospital employed practice factors to consider are:

		Number of patients per day including new versus old patients

		Onsite infusion, labs, radiation, and imaging capabilities

		Inpatient coverage by hospitalist versus hematology/oncology

		Rounding on inpatient (rotation policy or everyone rounds on own patients)

		Boards exam coverage and license coverage

		Production relative value unit (RVU) based? How is RVU calculated?

Non-clinical positions can include working within the pharmaceutical industry, health insurance sector, for the US Food and Drug Administration (FDA), or for a managed care organization.

Pharmaceutical industry careers vary. Job descriptions may include positions for providing active scientific contributions to teams developing a compound being studied for new hematology and oncology applications or becoming a liaison between a company and clinical investigators running a clinical trial and monitoring adverse events. Other positions available include project management, regulatory affairs, data management, medical writing, biostatistics, medical affairs, clinical pharmacology biomarkers, transla- tional medicine, patient-reported outcomes, and health economics.

The FDA regulates and approves the drugs in the United States. The FDA has a variety of divisions including biologics, small molecule, immunology, and medical device, among others. A position with the FDA includes reviewing the variety of new drug or equipment applications, evaluating clinical trial data, and collecting post marketing data for adverse events. After extensive review and research, the new drugs are approved through vote of committee. The compensation is typically low, but comes with good government benefits and stability. The work experience of the FDA is of immense importance, especially in the pharmaceutical industry. Most physicians will work in the FDA for a few years and then enter into the pharmaceutical industry for far better financial compensation.

Job opportunities with managed care organizations can vary and include clinical and nonclinical responsibilities. Positions mainly involve contract negotiations with practices and hospitals, reviews of claims, and review processes for the approval of oncology drugs prescribed by physicians, as well as laboratory and imaging investigations requested by physicians.

Factors including the implementation of the Affordable Care Act, also known as Obamacare, and its unknown consequences, the decreasing reimbursements in Medicare and other insurance companies following the Medicare path, and the drying up of research dollars from government as well as nongovernment grants all make the future of health care seem uncertain. One has to be extremely careful when choosing a career path.

Vishal Ranpura, MD, is a practicing hematology/oncology fellow at the Washington Cancer Institute.

Articles

Medical education and training is very intense, long, and expensive. When nearing the end of training, it is time to select a career path.

Vishal Ranpura, MD

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Selecting Your Career Path