Products of academia, most radiologists-in-training have many questions about how private practices operate and how to assess whether a group is a good fit. One evening in early September, interventional neuroradiologist Cuong Nguyen, MD, Mecklenburg Radiology Associates (MRA), Charlotte, NC, expertly moderated a panel discussion featuring five early-career, private-practice radiologists who aimed to help residents and fellows prepare for and land their private practice dream jobs.

The diverse practice settings and experiences of the panelists made clear one fact: Each private practice is unique and reflects not just its geographic setting and book of business, but also the interests and aspirations of its individual shareholders—one of the rewards of the model.

James Banks is a musculoskeletal (MSK) radiologist in a medium-sized 30-radiologist practice in Florida. The group provides diagnostic, interventional, and neuro-interventional for XX HCA hospitals and provides training to residents in a hybrid private-academic model.

"I read a little bit of everything by nature of that size of our group," said Dr. Banks. "I do breast imaging I donukes, peds, neuro, trauma chest, body, all of it. So, yes, it's, it's fun, it's always interesting, every day is different. interacting with the residents and the students definitely keeps it keeps it exciting and keeps it fresh."

Nick Falconer did both his residency and MSK fellowship training at the University of Virginia and ended up inAtlanta with Quantum Radiology, a 90-radiologist group, because he liked the city and connected with the practice.

"It's a little more specialized at Quantum," he shared. "I do a mix of MSK and body, but, at our practice, all of the mammo and neuro is done by those subspecialists. I also do some MSK procedures. We're scattered all around Atlanta, with a mix of hospitals and imaging centers."

Pranav Moudgil, MD, diagnostic and interventional radiologist with 60-radiologist Huron Valley Radiology, grewup near Ann Arbor in Southeast Michigan where HVR is headquartered and did most of his training in Michigan. He was in the first graduating class of the relatively new combined diagnostic and interventional radiology residency at William Beaumont University Hospital.

"My day-to-day looks mostly like IR with a little bit of diagnostic intermixed; some days I only do diagnostic," he shared. "We're fairly subspecialized in that we have a major/minor model in which most of our radiologists do the majority of their work in their subspecialty but also spend some time in one or maybe two other subspecialties. We are tightly aligned with the Trinity Health system in Michigan and elsewhere."

Sarah Nobles, MD, abdominal imager with Northwest Radiologists (NR), grew up in Mississippi, but headed West to train at Virginia Mason in Seattle, WA. After connecting with several radiologist at NR, she moved to Bellingham, WA, to join the practice following fellowship.

"I wanted to get out of the city and into a smaller town," Dr. Nobles said. "We're on the smaller side with 20 radiologists, so we all practice general radiology: Everybody takes call and reads general. Not everyone does breast imaging but, for the most part, we function as true general radiologists doing minor procedures."

Stephanie Wu, MD, is a neuroradiologist at Wake Radiology, a medium-sized practice in Raleigh, NC. "We have about 50 radiologists, so I do 70% to 75% neuroradiology; the rest is a mix of general diagnostic and mammography.

Dr. Wu's husband is a body radiologist at Wake. "We thought the radiologists took pride in the work they put out and the area is wonderful, too," she said. "We have two kids, so when you're looking for jobs, think about where you can see yourself long term."

Moderator Cuong Nguyen, MD, confessed to ageing out of the early career category and pushing mid-career, but as the recruiting lead for MRA, he has learned a great deal about what to do and not do in the job search process. "Hopefully, we can give you a broad perspective of how this process works and perhaps a bit of a perspective on what we look for from the private practice side."

Finding the Openings

All panelists used the ACR job board when job hunting but reported that sorting through the listings can be tedious and sometimes confusing in these times of abundant openings. "There were almost 2,000 jobs posting the last time I checked; some of them say they are independent practices but they are owned by private equity," Dr. Cuong noted.

Your personal network is probably your most valuable resource, advised Dr. Banks. "Leverage your contacts, including people you know through your program, the chief resident in year one, anyone you've met along the way," he urged. "Finding the right fit from the beginning is key so that you don't have to uproot your family or go through the process all over again. It can be expensive, time consuming, and frustrating."

Dr. Banks added that it is never too early to test the waters when seeking a position in private practice, especially if an applicant is tied to a particular geographic area. "I know a lot of residents who locked in jobs in their 3rd year because the job market is so good right now," he said. "But a lot of groups, especially smaller ones, won't hire until it gets closer to when they need a body to be there. Your dream job may not post until 90 days before they want that position to be filled."

Working one's network is an effective strategy for both applicant and practice, agreed Dr. Cuong.  "It's good to get your name out there and mine your contacts," he advised. "It's also very helpful from the practice side; that's how we find a lot of our partners—by going back to our programs and working our contacts."

Evaluating Job Offers

Beyond location, there are many other important practice aspects to assess, beginning with the preferences of the individual trainee. For Dr. Faulconer, that began with independence: "I really wanted to be in a physician-owned group to maintain control."

Another criterion is the level of practice specialization. "I struggled with that a because some of the jobs I looked at were completely general and one was 100% MSK," he said. "I didn't think I wanted to do 100% MSK straight out of the gate. I enjoy reading body and other subspecialties, and that's why I settled somewhere in between."

Call responsibility is another consideration. "Initially, I hoped I wouldn't have to do any nights, but in our practice, we all cover nights and split them amongst the group," he said. "I thought that would be a drawback, but now I don't really mind it. You do one or two weeks a year, and we maintain the quality because we get to control those decisions."

Daily schedule and workload are important aspects of any job, so be sure to solicit information about shift hours and the group's expectations for productivity; typically RVUs-per-shift or number of studies read per day. "I had lived in Atlanta before, so I was a little apprehensive about the traffic," he said. "At Quantum, our daytime shift is 8 AM to 4 PM, so that alleviates enough traffic that I end up getting home before 5:00 PM most days."

"I would take all of those things into consideration and put it all together," he concluded "But it helps if you're more flexible versus having a really narrow focus of what you want to do."

Dr. Cuong agreed: "It is important to make sure that your needs and the needs of the practice align because, from the practice side, what we're looking for is flexibility. In many ways, the more flexible you are, the better."

Ask Questions

You will answer plenty of questions about yourself on a job interview, but it is important to ask some as well. The question at the top of Dr. Moudgil's list was this: How do you help trainees transition from academics to private practice?

"It is important to ask questions about the expectations of the day-to-day and maybe the yearly workload, call responsibilities, and, of course, salaries, benefits, and vacation," he said. "But we train in academic centers and institutions, and those practices are just inherently very different from private practices."

Dr. Moudgil suggested asking how a practice determines who the partners are, who qualifies for a leadership role (and who doesn't), and who makes decisions, because large groups typically have a smaller executive board. "You might want to know how those people are selected and how long they've been in those roles to figure out how comfortable you would be with them corralling the herd so to speak," he noted.

It's also a good idea to ask why the group hiring. "Maybe someone left the group, and they need to fill a gap and maybe you're the person to fill that gap or maybe you aren't," he said. "Knowing why that person left and on what terms they left on might help you decide whether that practice is a good fit for you."

"The process is not so much like a match to be won," Dr. Moudgil continued. "It's more of a match to be made between the group and the person looking for the job. You want to make sure that you are fitting into the puzzle."

If interviewing for a position that has been vacated, ask to speak to the person who left. "Our practice gives the contact information, so that the interviewee can talk to that person if they want to," he said. "It's super disruptive to have people come and go, and this is especially true for partnership track hires. It's like a marriage, you know: If we hire someone, we want them to be there for 30+ years. If a practice is slippery about letting you talk to their employees or people that have left, I would be wary of that."

Evaluating Practice Offers

In this market, it is not unusual for a resident to have multiple offers, so when it comes down to choosing which offer you want to accept, your best consult is with yourself, said Dr. Nobles. "I think you have to be honest with yourself," she recommended. "One mistake people make is listening to other people about what might be important. You have to do some soul searching and figure out what is important to you because like everyone has said, every job is so different, it's almost impossible to compare them."

Determine your top priorities and career objectives and take time to reflect on this before you begin the job search, Dr. Nobles advised. "You might refine that as you start talking to practices and realize how things are set up and what a private practice job will look like," she added.

She also cautioned against getting so relaxed during the interview that you forget to get the information you need. "Where I was interviewing, the interviews were very casual," she shared. "Everyone was very conversational and nice, so you can lose sight of your objectives and forget to ask all of these important questions that we've talked about. You want to make sure that they're not just interviewing you, you're interviewing them."

Use your powers of observation as well, Dr. Nguyen said. "When you meet with physicians at the practice, watch how the radiologists interact with each other and how they interact with the technologists and the nurses," he advised. "When you go to dinner, watch their interactions. Do they actually like being around each other, or are they awkward and not really talking? When we all show up to a dinner, that's our chance to get to hang out, and it's great. Those are some of the intangibles."

Another attribute to evaluate is the composition of the practice. "If it is top heavy, the direction and priorities of the practice are going to be different than if it's primarily mid- to early-career radiologists.," Dr. Nguyen said. "There's a higher risk of selling if it's top heavy because it is much more attractive for a late-career person to sell out than it is for a person with 20 to 30 years."

The single best source of information about a practice is the people who work there, said Dr. Nguyen. "If you have no connection to the practice, find someone that you can relate to and then try to get information from them about the practice," he suggested. "I did that when I was in the process of applying at MRA, and then I became that person for a lot of the young applicants who apply here."

Understanding the Contract

Unless the trainee has a previous career in law, Contract review and negotiation is foreign to most applicants. Dr. Wu recommends taking your time to evaluate the contract. "I personally think it's a red flag if a practice offers you a contract and says you have to sign within a week," she said. "That seems like an awfully short time."

Dr. Wu's did not consult an attorney for contract review because her husband had previous experience and because the Wake contract was straightforward and general. "With the more straightforward general contracts, what you look for is that the contract is consistent with what they're telling you verbally,' she said. "If they promise you x number of weeks of vacation, make sure that is written out. Same for compensation, partnership track timetable, any of the benefits should be written out in your contract or your offer letter."

On the other hand, Dr. Nguyen had no previous experience and did choose to consult an attorney. "The contract is written to protect the practice, not the individual radiologist, so keep that in mind," he said. "I think it's always a good practice to get an attorney who's familiar with health care contracting to look it over, even if it's a straightforward simple one. I'm in health care, I don't speak legalese, so was it was really nice to have somebody explain all that to me."

The previous president of MRA advised Dr. Nguyen to retain a lawyer. "He said, 'Go get a lawyer, have them look at this, and they're going to come back with all of these suggestions, and we make zero changes, but you should still get a lawyer anyway'," Dr. Nguyen recalled.

"I think this was great advice just to make me feel comfortable with what I was signing," he continued. "Most practices are not going change anything in the contract. I pulled out my contract that was given to me almost ten years ago and compared it to the contracts of the radiologists hired this past year. It's the exact same thing. Different practices have different amounts of wiffle room for what can be negotiated."

Real-World Radiology Prep

Competition is intense for radiologists emerging from training and as a result, many trainees are securing positions well before they complete fellowship. Dr. Faulconer had a few suggestions for those radiologists: Use your final year to focus on gaps in your skill set or ask your group if you can moonlight the overflow from a particular section. "That's a good way to make some extra money and also get comfortable with final signing studies, which is an adjustment for most people when you first get to practice," he said.

Dr. Banks agreed that moonlighting is important. "It not only makes you more comfortable reading on your own, but it also makes you more comfortable with the hustle," he said. "In a lot of private practices, you have to go fast but maintain accuracy and not equivocate on findings or struggle with figuring out what something means that you should already know. So, while you're in training, take as much volume as you can because every day you have people backing up so it's not like you are going to miss something terrible."

He also advised keeping your trusted contacts from your training years on tap because you will come across something you haven't seen before, and you may be reluctant to ask people in the new group that you just joined. "You can text them a picture and ask, 'What is this bone tumor,' and they can back you up that way you so that you don't struggle as much as you're getting your feet on the ground," he suggested.

Dr. Nguyen recommended that trainees with contracts check in with their new group in advance.  "If you're an R-4 and you have your fellowship lined up, but you haven't locked in your mini fellowship, you could reach out to your practice to find out what other skills you will need," suggested Dr. Nguyen. "Every practice needs something a little bit different. For instance, at MRA, we want somebody coming into the neuro section to have head and neck experience."

Dr. Nobles agreed that moonlighting was the best preparation during fellowship for private practice. "People who didn't do that definitely struggled a little bit more in the beginning," she said. "You can eventually catch up in a few months, but I think you're better prepared to hit the ground running if you're comfortable with that process."

An additional benefit of moonlighting for the practice you will join is that you will have all your Powerscribe macros and your hanging protocols set up, added Dr. Nguyen.

If your goal is to join a private practice, it's a good idea to work on developing a concise reporting style. "In private practice, we have be more succinct," Dr. Nguyen explained. "We're not going to spend a paragraph describing something, we're just going to say what it is. Nobody wants to read a novel. You have to be succinct, to the point, and clinically relevant. Reports must be actionable."

Dr. Wu went outside the imaging and procedural perspective with her recommendation: "Get your finances in order to prepare for financial planning. Going from fellowship salary to an attending salary, whether it's an academics or private practice, is a huge jump, so think about utilizing all the benefits the practice offers, whether or not you're thinking about renting or buying a house, and think about retirement."

Last Words and a Final Tip

The panelist concluded the hour with a quick round robin of tips, including a recommendation to limit your search to the most desirable places on your list. "With so many jobs out there, it's tempting to apply to 50 or a hundred of them, but you're going to hate yourself," Dr. Banks promised. "It'll be like a bee's nest of emails coming back. All of them are going to want you to be there in person to meet with them." 

"You're not going be given a lot of time off for those purposes, and you're going to use all your vacation time, so you really want to tailor that as much as possible. That means doing your due diligence beforehand, maybe talking to multiple people in those practices by phone or video interview to get more of a 360-degree perspective."

The panel moderator concluded by urging trainees to pay close attention to the people factor. "It is the people you work with that will be the most important satisfaction factor," Dr. Nguyen said. "If that doesn't feel right, trust your gut."

Along those same lines, Dr. Nguyen provided a particularly helpful tip. "Be nice to everyone, because if you're not, people will know," he advised. "You should be nice anyway, but if that's not inherent, pretend to be nice. Treat everyone nicely, from the technologist to the nurses. We reach out to the techs and the nurses as references. So just something to know. If you're not nice to everyone, we will find out, and that's one way to not make a partner at our practice."

"This would be my last piece of advice," said Dr. Nguyen. "Thank you so much for taking the time to join us today. As you can tell, we're super proud of our practices and the work that we do for our patients and in trying to stay independent. We are here for you guys, so if you have questions, reach out!"

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