Shifting from fellowship to working in private practice requires a lot of decision making, and it is a process that should not be hurried or taken lightly. “It is a risky venture and you really need to examine it carefully,” said Dean Gesme, MD, of Minnesota Oncology in Minneapolis. “All the work you put into it now will serve you well in the future.”

Cultural fit may be one of the most important factors in predicting whether or not a new physician will meet with success and satisfaction when joining a private practice—possibly more so than salary or geographic location.1

“It’s easy to say, ‘I want to live by the mountains or the ocean,’ or ‘I’m going to take the job that pays the most,’ but making sure the cultural fit will be right requires due diligence on the part of the fellow to find out what’s beneath the veneer of the practice,” Dr. Gesme said.

Geographical rigidity can also keep fellows from finding a good fit, said John Cox, DO, of Texas Oncology in Dallas. “There is a workforce shortage looming, but you wouldn’t know it from the stack of CVs [curriculum vitae] we quickly receive when our practice, in the middle of Dallas, has an opening,” he said.

“The fellows are very focused on staying in a metropolitan area. But I would encourage fellows to expand their horizons,” Dr. Cox said. “I think there are many opportunities in mid- to moderate-sized communities.”

Although physicians are considered by many to be the cream of the crop in terms of intelligence and ambition, many lack job-search skills, starting with not allowing enough time for decision making (Table 2).

Table 2. Private Practice Web Resources For Fellows
Starting Out Right: New Series to Help Oncologists Succeed in Private Practice.
Achieving Career Success in Oncology: A Practical Guide. categoryId=14&productId=191.
The Dinosaur Is Extinct: The Demise of Solo Medical Oncology Practice in the United States.
The Dinosaur Is Extinct: The Demise of Solo Medical Oncology Practice in the United States. Podcast.

“As physicians, we are repeatedly reminded that we’re incredibly smart and savvy, but that only applies to our area of expertise,” Dr. Gesme said. “It doesn’t necessarily apply to the areas of job selection or assessing a business opportunity.”

He recommends fellows give themselves a framework that will allow them to make a career decision 6 months before starting work. “That way you will have time to find housing and deal with everything a move requires,” he said.

Dr. Cox suggests fellows take a few lessons from the business community in terms of self-presentation, starting with a professional looking CV and thoughtful letter of introduction. “We often get an email with 2 sentences and a CV attached, but I don’t think many academic CVs stand on their own—that letter of introduction is very important.”

Wearing professional attire to the interview, too, is important. “I really sound like my parents right now, but I don’t think casualness sets the right first impression,” Dr. Cox said.

Doing a bit of homework on the group before the interview is advisable. “Understanding the practice will make the interview process easier and prepare you to ask better questions, and it also impresses the interviewer that you care enough to know how many doctors and offices are in the practice and have a sense of the lay of the land,” Dr. Cox said.

Questions should focus on the expectations of the position now and in the future. “Know whether you’re being recruited to work at 1 site or 6 sites, whether you’re going to be responsible for building your practice from scratch or inheriting a full schedule,” Dr. Cox said.

It’s also important to understand the way the practice is governed. “People don’t realize there are a million different kinds of partnerships, and I’m not talking about legal structures per se,” Dr. Cox said. Are decisions made by consensus or is it an autocratic process? If there’s a board, how are people selected for it? Are there opportunities for leadership in the practice?

“Practices are becoming more business-oriented and are more likely to have written bylaws or set structures on how decisions are made in the practice,” Dr. Cox said. “I rarely hear questions about this in the interview process, yet it’s one of the more difficult things I see new associates trying to adjust to in the first couple of years as they try to define their role in the practice.”

Fellows also may want to inquire how the practice intends to handle shifts in the economic climate. “Oncology practice is changing rapidly, and if you’re a fellow interviewing with a 1-, 2-, or 3-person private oncology practice, you should be asking how they are going to survive in the coming world of accountable care organizations and changing reimbursement schemes,” Dr. Cox said.

This will almost certainly require future collaboration with an institution, hospital, or other practices.2 “The small practice you’re interviewing with today may be changing its structure dramatically in a very short period of time,” Dr. Cox said.

It can be difficult to get an honest perspective on a practice from people who are trying as hard to impress you, as you are them. Dr. Gesme suggests meeting not only with the doctors in the practice, but with nurses and other support staff to get a more rounded sense of the practice culture.

“While you do practice with your partner or partners, most of the time you’re working with the staff, so try to meet with the staff and get their perspective on how the practice runs,” he said. “A few minutes with someone who is not a part of the recruiting team might give you hints on a situation you would enjoy or one you would avoid.”

When it comes to negotiating a financial package, Dr. Gesme recommends seeking guidance from someone who specializes in physician contracts. “Try to find an attorney who works in the health care field and has represented young doctors, or find a consultant.” Consultants can be found through cancer center/practice administrators, advertisements in state and county medical journals, and online.

In the first year or 2 of practice, Dr. Cox recommends fellows be patient with themselves as they adjust to working life, and says they should consider taking a business course. “Learn to read a spreadsheet or balance sheet,” he said. “Those are skills I wish I had learned much earlier in my career.” He also encourages new physicians to volunteer for medical staff committee work to get a better understanding of the role of medical staffs and the governance of the hospitals in which they work.

Dr. Gesme recommends paying attention to the environment and political climate of the practice and communicating effectively, both verbally and in writing. Also, new physicians should be sure to acknowledge those whose support is essential for their success. “We need to thank those who enabled us to get where we’re going—not only the people we are working with, but looking back at all the individuals in the training program,” he said.


  1. Starting Out Right: New Series to Help Oncologists Succeed in Practice Positions.

  2. Fuerst M. Preserving private practice by collaborating with hospitals. Oncology Times. 2010;32(16):23-24.

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