I certainly wouldn't disagree with some of what you say in regards to lack of medical student and resident education and exposure leading to our field staying in the shadows, but I've been in the field and practice long enough to know that sadly many if not most practicing radiation oncologist and certainly a very large proportion of those in academics prefer it that way.
No matter how well the ED physician or hospitalist is educated in regards to our field he is going to call medical oncology ... can any current or recent residents imagine the response from your attending if you called him at 3am to say "the ED attending paged me because there is a patient with a history of locally advanced lung cancer now presenting with symptoms and CT consistent with multiple brain metastasizes ... he was going to page medical oncology, as he has a hundred times, but i recently educated him to the fact that we too are oncologists and in many situations, such as this one, we are actually the primary oncologist who does all the work so he paged us instead. I am so happy that we are finally getting the respect that we deserve as oncologist just like medical and surgical oncology!"
My friends we can't have it both ways. If we want to be taken seriously as equals we have to jump in the trenches with everybody else. Otherwise while we are comfortably enjoying our sleep and lifestyle hospitalists and ED physicians will be paging medical oncology who will reply to situations like this with "ok, please start steroids at this dose, I will be in around 6:30am to admit before my clinic starts at 7:30 and I will let rad onc know when they get in at 8-8:30."
See my post from 5/18 for my "wake up call"
Let's be honest about how the work flow is now. In academic medical centers, the call from the ED actually goes like this:
1. To the covering / admitting internal medicine resident. This person then usually does almost all of the work of 'admitting'
2. If it is something urgent / or there is a question of diagnostic workup that needs to happen immediately the fellow is paged, possibly. When I was in IM this was discouraged.
Done
There are emergencies where chemotherapy needs to be given that night or odd presentations- it's only 1-2% more likely then the calls for spinal cord compression and at the institution I did IM at and rotated, I saw emergent chemotherapy happen once in 3 months. The fellow left after the orders were signed. Your experience may vary, of course.
With the expansion / borderline abuse of the residency system across fields, the use of the heme/onc fellow as essentially a second tier resident, and overnight hospitalists and FNPs, there are many, many layers of labor to get through before that med/onc attending 'gets in the trenches'. As a resident, I wouldn't mind getting some of those management calls or admitting patients - its not hard, it would hone our oncology experience and previous general training, and that night IM resident isn't longitudinally following the patient either.
I have gotten calls from med onc fellows, who are home and haven't even seen the patient, for brain mets / bone mets / SVC, just relaying a call from the ED while the IM resident who called them is admitting the patient. I saw those patients long before the med onc attending came by, and FNPs / PAs with a night hospitalist were the people taking care of the patient for the evening.
This is 2016, and the health care system (in large academic centers) has learned to fully exploit the resident / midlevel labor force and use of full time hospitalists (I say this is less of an exploit as they are paid well). So saying 'we need to get into the trenches' implies that the medical oncologist is constantly in there, managing these things. He or she is not, just like practicing family and community IM docs no longer admit or manage their patients in the hospital. But the referral pattern is so set, and internal medicine has a pocket of captive labor that is spread to cover admissions from almost every ED imaginable, that it gives this impression.
If the argument becomes 'well the med/onc attending completed an IM residency' let's make it 2 years of IM prior to Rad/onc, and revert back to the 3 year residency, which worked fine until the senior physicians of the early to mid 90s era decided to destroy the job market for the first time.
It wasn't too bad though, got to stroll into the ICU like a real doctor.
