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Every cancer program in the country is competing for the same shrinking pool of ABR-certified medical physicists. The shortage isn't new, but the curve has steepened. Retirements are outpacing residency output. The programs producing physicists haven't materially expanded in a decade. And demand keeps climbing as proton centers, SBRT programs, and new community oncology builds come online.

Generic recruiting tactics — posting on Indeed, calling the same five physicists everyone calls, escalating offers in $5K increments — aren't moving the needle. Here are five approaches we're seeing actually work in 2026.

1. Lead with the program, not the package.

Compensation matters, but it's stopped being a differentiator. Senior physicists evaluating offers in 2026 are nearly always looking at three or four packages within a $20–30K band of each other. What separates the offer they take from the offers they pass on is rarely the salary line.

What does separate them: the work itself. Equipment generation. Treatment planning system platforms. Volume of complex cases — SBRT, SRS, HDR brachytherapy, MR-linac. Whether the role includes research time, teaching, or program-development authority. Whether the chief physicist is someone they want to learn from.

Programs that lead recruitment conversations with these specifics close faster than programs that lead with comp. The physicists who matter most have already decided they'll be paid fairly. They're choosing where to spend the next ten years of their professional life.

2. Stop treating the chief physicist search like a staff search.

The mistake we see most often: programs running a chief physicist search through the same pipeline they use to fill staff roles. Same job board, same screening committee, same offer template, same timeline.

It doesn't work. Chief physicist candidates rarely respond to job postings. They aren't actively looking. The strong ones are placed through targeted outreach, often involving a year or more of relationship-building before any role discussion. By the time you "post" the role, the candidate pool has already self-selected to people who weren't on anyone's short list.

Retained search exists for exactly this reason. Programs that treat senior leadership as retained — with dedicated researcher time, candidate research that goes beyond LinkedIn, and a structured outreach campaign — fill those roles. Programs that hope a job posting will surface them don't.

3. Use locum bridges to protect the permanent decision.

The single fastest way to make a bad permanent hire is to be desperate. When a chief physicist gives notice and the program faces a coverage gap, the temptation is to compress the search timeline and pick from whoever is available right now.

That's where locum bridges become structurally important. A qualified locum physicist — credentialed, malpractice-covered, ready in two to four weeks — keeps the schedule running while the permanent search runs at the pace it actually needs. The permanent decision gets made well, not fast. The team isn't covering double shifts. The clinical schedule doesn't take a hit.

Programs that have built relationships with a small group of trusted locum physicists move through transitions far more cleanly than programs scrambling to find coverage when the gap appears.

4. Open the geographic aperture early, not late.

Most programs run their first 60 days of search local. They go national only after the local pipeline runs dry. That's backwards.

The strongest physicist candidates are open to relocation if the program and equipment are right — but the conversation has to start before they've already accepted somewhere else. Programs that open geographic aperture from week one fill 30–45 days faster than programs that wait. The cost is essentially the same: relocation packages for senior physicists are a known number, and the math almost always works versus extending vacancy.

5. Treat the offer like a closing, not a transaction.

The offer stage is where good searches go to die. The candidate has been through screening, multiple interviews, possibly a site visit. Then the offer comes through HR with a 5-business-day response window and no context.

The programs winning offers in this market handle the offer differently. The chief physicist or department director makes the offer call personally — not HR. The verbal walkthrough happens before the written offer goes out. Compensation is one slide of a longer conversation about the program, the team, and what the first year looks like. Counter-offers from current employers are anticipated, named, and addressed proactively.

Acceptance rates climb 15–25 points when the offer stage is treated this way. Same package, different choreography.

What we tell programs.

The shortage is real and it isn't easing. But the programs filling these roles in 2026 share a pattern: they treat physicist recruiting as a multi-year discipline, not a series of reactive searches. They invest in relationships before they have an opening. They use locum bridges to protect the permanent decision. They lead with substance over package, and they treat senior offers as closings.

The programs still running the same playbook from 2019 are the ones with vacancies open eight months later.

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Locum-to-perm conversion is one of the most useful tools in oncology hiring. It's also one of the most over-used and under-managed. Done well, it produces a hire who's already proven themselves in your environment, with your equipment, with your team. Done poorly, it produces a six-month vacancy and a damaged relationship with a clinician you'd otherwise have hired.

Here's the pattern we've seen across hundreds of conversion conversations.

When it works.

The role was permanent from day one — locum was just the entry path.

The cleanest conversions happen when the program knows it has a permanent need, the candidate knows that permanent role exists, and the locum stretch is just a runway to credentialing finalization, relocation logistics, or contract finalization. Both sides go into the engagement with conversion as the explicit goal, not as a maybe.

These conversions almost always close. The "trial period" framing isn't really a trial — it's a structured handoff with the paperwork built in.

The candidate was open to relocation but cautious about the program.

Senior physicists and physicians evaluating a relocation to an unfamiliar program often want to actually work in the environment before they uproot a family. Locum stretches of 90–180 days give them that exposure. If the program is what was advertised, conversion is straightforward. If something's off — leadership culture, equipment realities, case volume — they self-select out before anyone has overcommitted.

This is a healthy pattern. The candidate gets confidence, the program gets a real-world audition, and the worst case is an amicable exit before either side is invested.

The program needed to validate the role itself.

Sometimes the question isn't whether a specific candidate is a fit — it's whether the role as scoped is actually a real role. A new SBRT program, a satellite expansion, a service-line build. Bringing in a locum specialist for a defined period lets the program test demand, refine workflows, and validate the FTE before committing to a permanent line.

When it backfires.

The "locum" was secretly a perm role with no perm budget approved.

This is the most common failure pattern. Leadership wants a permanent hire but hasn't gotten finance approval, so they staff the role on locum rates indefinitely with vague conversion promises. The clinician notices. They're paid as a contractor for what's clearly a permanent operating need. Eventually they accept a real permanent offer somewhere else, and the program is back at zero — except now they've burned six months of locum spend and lost the relationship.

If the role is permanent, get the budget approved before you bring someone in on locum framing. Locum-to-perm only works when the perm offer is real and timeline-bounded.

Conversion terms were never written down.

"We'll talk about converting at six months" is not a plan. It's a wish. Without specifics — comp range, conversion fee structure, timeline, performance criteria — both sides drift into different expectations. The clinician thinks the conversion is automatic; the program thinks it's contingent on a new approval cycle.

Good locum-to-perm engagements have the conversion terms in writing on day one. Conversion comp range. Buyout fee or transition structure with the staffing partner. Performance milestones if any. Timeline trigger. None of this is complicated; it just has to exist before the engagement starts.

The program kept the candidate at locum rates too long.

Locum rates are higher than W2 rates by design — they include the contractor's cost of benefits, taxes, and risk. Past 4–6 months in the same role, the clinician starts doing the math on what they'd be making W2 elsewhere. Programs that string locum engagements out for 9–12 months "while we figure out the budget" routinely lose the candidate to a permanent offer with worse base comp but better total package.

What good conversion looks like.

The pattern is simple even if the execution takes discipline:

• Decide upfront whether conversion is the goal. If it is, say so.
• Get the permanent budget approved before the locum starts.
• Put conversion comp, fee structure, and timeline in writing on day one.
• Set the conversion conversation for month three or four — not month nine.
• Treat the locum stretch as the first few months of employment, not a separate transactional engagement.

Programs that do this convert 70%+ of their locum-to-perm engagements. Programs that don't convert 20% and wonder why their permanent searches keep starting over.

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"Locum" doesn't mean "no benefits." It depends entirely on whether you're working as a 1099 contractor or as a W2 employee through an employer-of-record (EOR). The difference is the difference between a real benefits package and tax season anxiety. Same clinical work. Very different financial picture.

If you're considering locum work and the recruiter you're talking to isn't being clear about which structure you're being placed under — that itself is the answer about who you're working with.

What 1099 actually means.

As a 1099 independent contractor, you are — for tax purposes — running your own business. That's a real thing with real implications:

• You handle your own taxes. No withholding. You owe federal income tax plus the full 15.3% self-employment tax (Social Security + Medicare, both halves) on your earnings, paid quarterly to the IRS.
• You handle your own benefits. Health insurance via the marketplace or a private broker. Retirement via Solo 401(k) or SEP-IRA. Disability insurance, life insurance, anything you want — you arrange and pay for it.
• You handle your own malpractice. Some assignments include facility-provided coverage; many don't. Your structure, your responsibility.
• You can deduct legitimate business expenses. Home office, CME, license fees, malpractice premiums, certain travel — properly documented, these reduce your taxable income.

None of this is bad. Many physicists and physicians prefer 1099 specifically for the flexibility, the higher gross rates, and the deduction structure. But it's a different financial life than being a W2 employee, and it requires either real bookkeeping discipline or an accountant who knows physician practices.

What W2 through an EOR means.

When you take a locum assignment as a W2 employee through an employer-of-record, the EOR is your legal employer for the duration of the assignment. The clinical work is the same. The structure is fundamentally different.

• Taxes are withheld from each paycheck. Federal, state, FICA — handled. No quarterly estimated payments.
• You qualify for the EOR's benefits package. Medical, dental, vision through real carriers. 401(k) with match. Life insurance, disability, accident coverage. Coverage that travels with you between assignments as long as you're on a W2 contract.
• Malpractice is provided. Real coverage, real terms, real liability protection — built into the EOR relationship.
• You receive a W-2 at year-end. Tax filing is straightforward. No Schedule C, no quarterly estimates, no chasing 1099s from facilities.

The trade-off is on the gross rate. W2 hourly or daily rates are typically lower than 1099 rates because the EOR is absorbing the employer-side costs (FICA matching, benefits, workers' comp, malpractice). The net comparison once benefits and taxes are factored in is much closer than the gross rates suggest — and for many clinicians, the W2 number actually wins on net.

The question to ask.

When a recruiter pitches you a locum assignment, three questions tell you almost everything:

1. "Is this 1099 or W2?" A clear answer means a clear structure. An evasive answer means run.
2. "If W2, who's the employer-of-record and what carriers do they use?" Real EOR partnerships have named carriers (Cigna, MetLife, Health Equity, Empower) and real plan documents you can review.
3. "What does the malpractice coverage actually look like?" Occurrence vs claims-made, limits, tail provisions. The recruiter should be able to answer this without checking with someone.

If the recruiter can't answer these crisply, the assignment is probably 1099 and the benefits conversation hasn't been thought through. That's not necessarily disqualifying — 1099 is a legitimate structure for many clinicians — but you should be entering the engagement with eyes open about what you're responsible for arranging on your own.

Why this matters more than it used to.

Locum work has historically been treated as a "between jobs" stopgap. That's not the reality anymore. A growing number of radiation oncologists, physicists, dosimetrists, and therapists are building career-length practices around long-term locum work. For that to be sustainable, the benefits structure has to be real — not improvised.

The right answer for any individual depends on tax bracket, family situation, risk tolerance, and how much administrative overhead you want to manage personally. But the answer to "1099 or W2 EOR" should be made deliberately, not by accident.