Bloodbath in Red Journal

[medgator]

It's a nice study.
"Integrated" is defined in Discussion (VA or HMO).
Conclusion is pretty much that freestanding centers and independent hospitals milk palliation.

Some palliative lung schedules I see in practice are simply ridiculous (59.4/33, 60/30).

Seems like they are just treating palliative patients definitively. Ridiculous

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[deleted4401]

Seper,

Milk is quite perjorative. You seem astute, so I understand you know how statistics work. The study indicates that a free standing center appears to be more likely to deliver more fractions for palliation than an integrated center. They don't separate things. Do freestanding centers see more high KPS patients? I'm not cowed by your insults of being unethical, but I know I'm more likely to recommend 30 Gy in 10 to my patients rather than 20 Gy in 5 or 15/2. This is because they walk into my clinic and aren't on ventilators as inpatients. So, my average fractions will be higher than the academic guys. Nature of my patients. I give 20 in 5 fx for a bone met because the cost as compared to 8/1 is not much higher, but it saves me re treatment.

Some freestanding centers are milking the system. Some integrated centers are, too. More free standing centers may do it. Don't lump all of them together. It's unbecoming and no need to grind an axe that doesn't need grinding.

 

[OTN]

Here is somebody willing to "call it out":

http://www.ascopost.com/issues/march-15,-2013/sidebar-value-based-effective-care.aspx

OK. Time for me to finally weigh in on this single-fraction palliation stuff.

I usually treat bone mets to 30 Gy in 10 fractions, unless other factors are present which influence my decision. Why? The retreatment rate was twice as high with 8 Gy x 1 vs. 30 Gy in 10 fractions in the RTOG study: 18% vs. 9%. This NEVER gets mentioned by those who try and use the rate of multi-fraction bone palliation as an argument to suggest we're treating based purely on financial renumeration. It's the best example of cherry-picking data to make a point I can come up with.

Importantly, I've never seen a single true econometric analysis suggesting 8 Gy x 1 is cheaper than 30 Gy in 10 fractions. Given a two-fold increase in retreatment (with resulting E+M charges, simulation charges, treatment planning charges, possible hospitalizations, cost of pain medications, etc), I don't believe it's quite as cut-and-dry that 8 Gy x 1 saves money in the long run.

6% usage of 8 Gy x 1 sounds about right to me. About 5-10% of the time other factors are present (very poor prognosis, etc) that do make me head in that direction. The other 95-90% of the time? I'm going to use the dosing and fractionation schedule that has been proven to have a two-fold decrease in retreatment. It's what I would want as a patient, and it's what I recommend as a radiation oncologist.

 

[Gfunk6]

OK. Time for me to finally weigh in on this single-fraction palliation stuff.

I usually treat bone mets to 30 Gy in 10 fractions, unless other factors are present which influence my decision. Why? The retreatment rate was twice as high with 8 Gy x 1 vs. 30 Gy in 10 fractions in the RTOG study: 18% vs. 9%. This NEVER gets mentioned by those who try and use the rate of multi-fraction bone palliation as an argument to suggest we're treating based purely on financial renumeration. It's the best example of cherry-picking data to make a point I can come up with.

This issue was discussed by the authors of RTOG 97-14:

The only difference in outcomes between the two arms was the rate of re-treatment, with substantially more patients in the 8-Gy arm receiving retreatment than in the 30-Gy arm. This observation may be an indication that the 8-Gy treatment is less effective than the longer course of 30 Gy in 10 treatment fractions. However, rates of pain relief, narcotic use, and pathologic fracture incidence were equivalent in the two treatment arms. There may be other factors involved in the decision to re-treat a patient, such as potential physician bias ( 36 ) . There may be more willingness to give another treatment after a single-dose treatment than after a higher-dose treatment, especially retreating areas adjacent to sensitive critical normal structures (such as spinal cord, bowels, or lungs). There may be less willingness to give another treatment after a treatment of 30 Gy in 10 fractions because of the higher acute toxicity associated with that regimen. Even if there is a real increase in the need for retreatment among patients receiving a single-dose treatment, this problem may be counterbalanced by the reduced rate of acute toxicity in these patients.

Importantly, I've never seen a single true econometric analysis suggesting 8 Gy x 1 is cheaper than 30 Gy in 10 fractions..

A couple of relevant articles:

1. Palliative radiotherapy practice within Western European countries: impact of the radiotherapy financing system?
2. Continuing reluctance to use single fractions of radiotherapy for metastatic bone pain: an Australian and New Zealand practice survey and literature review.

 

[Ursus Martimus]

There is an interesting argument to make for hypo fractionated radiation in the setting of palliation. For those who have experience interacting with hospice providers, a more protracted schedule will all but eliminate any radiation for a patient in the "peri-hospice" setting. Hospices are eager to get patient's into care. Unfortunately, although mandate to be provided by hospices, the per diem rate that hospices get from providers are <$200/day. This all but precludes radiation, once the patient is in hospice. There are some tricks one could use, like de-enrolling from hospice for a radiation treatment, but that creates a headache for the hospice. I have found a more reasonable approach by enlisting palliative care providers to identify patients who might benefit by xrt, and try to faciliate a hypofractionated course, be it 8 gyx 1 or 5 x 4Gy for brain mets prior to completing the enrollment to hospice. With a protracted course, the patient delays their hospice care and may be swept up before they ever get the opportunity to get any RT. I think we risk losing thosed patients who might benefit the most by not engaging paliiative care providers with frctionation schedules that don't help them expedite hospice enrollment.

 

[deleted4401]

Very good point, UM.

What GFunk says is true. The re-treatment rate isn't because it is less effective, at least based on the major studies findings. There was no change in pain relief or narcotic usage. It's just when you give 8 Gy in 1, it's easy to give one more fraction without worrying that they will get sick. After 30 Gy in 10, most of us feel they've reached tolerance.

As far as cost, 30 Gy in 10 fx leads to one extra OTV and 9 additional treatments. Even it was true that 16% actually needed retreatment vs 8% in single fraction arm, if you had 100 patients and 50 got 30 Gy in 10 and 50 got 8 Gy in 1, 4 of the 30 Gy patients would get additional RT and 8 of the single fraction would need retreat (let's guess each retreat was 5 fractions). I never re-sim for a re-treatment bone met - it's just at follow-up, if they hurt, use same iso and same plan. That's my own bias, though.

30 Gy group = 520 total fractions, 104 OTV visits
8 Gy group = 90 total fractions, 58 OTV visits

If you consider that the reimbursement for consult, sim, devices, etc. are all the same between groups, there is still a substantial difference in cost. I don't think we need a study to show this At least how we are paid, the majority of the reimbursement is for treatment delivery and OTV. If it is case based like Kaiser, then it certainly wouldn't cost more, you could do 40 Gy in 20 fx if you want, but you'd just be using more resources without proven benefit and your staff has to treat many more total fractions.

However, I have a bias against 8 Gy/1 fx, it doesn't seem to work for me. So, I use 20 Gy in 5. I don't think "retreatment" rate is higher, but let's say it is just as high as 8 Gy in 1. Still 520 fx vs 290 fx. 108 OTV vs 58. I am certain there are some cost savings.

I don't think 30 Gy in 10 is wrong. It's a community standard. Just seems too long for me, but that's my bias.

S

 

[seper]

I also work in a "non-integrated" center and know exactly what "milking" means. Don't take it personally.

In my view, 30 Gy/10 for bone mets is appropriate. > 15 fx for chest palliation is inappropriate and look at Fig 3 in the study we are discussing.

Seper,

Milk is quite perjorative. You seem astute, so I understand you know how statistics work. The study indicates that a free standing center appears to be more likely to deliver more fractions for palliation than an integrated center. They don't separate things. Do freestanding centers see more high KPS patients? I'm not cowed by your insults of being unethical, but I know I'm more likely to recommend 30 Gy in 10 to my patients rather than 20 Gy in 5 or 15/2. This is because they walk into my clinic and aren't on ventilators as inpatients. So, my average fractions will be higher than the academic guys. Nature of my patients. I give 20 in 5 fx for a bone met because the cost as compared to 8/1 is not much higher, but it saves me re treatment.

Some freestanding centers are milking the system. Some integrated centers are, too. More free standing centers may do it. Don't lump all of them together. It's unbecoming and no need to grind an axe that doesn't need grinding.

 

[OTN]

This issue was discussed by the authors of RTOG 97-14:





A couple of relevant articles:

1. Palliative radiotherapy practice within Western European countries: impact of the radiotherapy financing system?
2. Continuing reluctance to use single fractions of radiotherapy for metastatic bone pain: an Australian and New Zealand practice survey and literature review.

Too many maybes and guessing in the RTOG analysis for me to buy it. You can retreat after 30 Gy in 10 fractions, certainly with 8 Gy x 1 if you're not comfortable giving 30 Gy again. I've done it, the literature supports it, so their conjecture as to why the retreatment rate was higher is just that- conjecture. Not enough for me to make the leap to "and you should only treat 8 Gy x 1, even though the retreatment rate was double 30 Gy in 10 fx and was, in fact, close to 20%."

As far as an econometric analysis, I do agree that it's a very good possibility that 8 Gy x 1 will still be cheaper, but without the proper study done, there's simply no way to know for sure. What if more of the 8 Gy patients went to the ER? What if a few did? Only way to know for sure is to do the study.

What about Australia/NZ/etc? I'm a bit of an economist by schooling (back in the day, obviously), so I do believe you have to look at all the incentives in these survey-based studies when considering the results. If you're a practicing radiation oncologist in these countries, getting paid not based on how many treatments the patients are getting, but by some other mechanism, treating to 8 Gy x 1 instead of 30 in 10 for bone mets is going to lead to decreased patient load on the machines and decreased clinic coverage time requirements for physicians and staff...resulting in MDs getting paid the same for less work, effectively increasing their $/hr pay rate. Are radoncs in these countries choosing dosing and fractionation schedules which may be less effective in order to make their workday easier, rather than what's truly efficacious? I truly think the answer is "no", but it's a bias that's never addressed. The only negative assumption that's ever made about radonc prescribing tendencies is the one regarding financial gain. While, as mentioned in my previous post, I have no doubt this does occur, I don't think it's 100% correct to assume that in other countries other incentives don't exist which could also change the way XRT is prescribed and delivered. Would those biases be as large as those we face in the U.S.? Probably not, I agree, but those studies don't necessarily tell us what the "best" fractionation scheme is. Rather, they tell us how incentives from payors/gov't can drive dosing and fractionation schedules.

 

[seper]

While on the subject of palliation, here is a question:

Receipt of chemotherapy within 30 days of death is a measure of poor quality of care. Do you think the same applies to RT ?

 

[deleted4401]

Boom! Cost analysis of single fx vs multiple fx: http://jnci.oxfordjournals.org/content/95/3/222.short

Good points, OTN - makes a lot of sense that it isn't just simply over-billing, but it's also the opposite effect of under-utilization in single-payor systems. My thoughts on studies like that is when it the lower fx treatment is equal or not obviously worse, it takes a long time to become a standard of care, while if a dose escalation trial is positive (prostate, boost for breast CA), then it becomes adopted much more quickly in a private system, while the opposite happens in a public system. I don't think it's economics - I think it's that American doctors that can't get it out of their head that more is better, and unless unequivocally less is better, people don't make the change. In Canada, the opposite is thought - minimalist and cheaper is better, and unless there is a reason to do more, let's stay with what we have. One example were lower fractions were better (not just equal) is glottic larynx, and I think most people give 28-29 fx, instead of 33fx.

Seper - I certainly think that's a good point. It happens more than I'd like to admit. The worst is a palliative patient dying on treatment. Such a waste. I'm starting to have to fill out this quality things on my billing sheets. I think that is a very rationale one to have for rad-oncs. But, at the same time, for emergency cases, it will be really hard to say no treatment.

 

[medgator]

There is an interesting argument to make for hypo fractionated radiation in the setting of palliation. For those who have experience interacting with hospice providers, a more protracted schedule will all but eliminate any radiation for a patient in the "peri-hospice" setting. Hospices are eager to get patient's into care. Unfortunately, although mandate to be provided by hospices, the per diem rate that hospices get from providers are <$200/day. This all but precludes radiation, once the patient is in hospice. There are some tricks one could use, like de-enrolling from hospice for a radiation treatment, but that creates a headache for the hospice. I have found a more reasonable approach by enlisting palliative care providers to identify patients who might benefit by xrt, and try to faciliate a hypofractionated course, be it 8 gyx 1 or 5 x 4Gy for brain mets prior to completing the enrollment to hospice. With a protracted course, the patient delays their hospice care and may be swept up before they ever get the opportunity to get any RT. I think we risk losing thosed patients who might benefit the most by not engaging paliiative care providers with frctionation schedules that don't help them expedite hospice enrollment.

In my neck of the woods, hospice will pay for up 10 Fx if it is truly "palliative" and Sx directed, and the patient wants to undergo it. Not sure how that reimbursement ends up working out though

I don't think 30 Gy in 10 is wrong. It's a community standard. Just seems too long for me, but that's my bias.

S

For palliative lungs/pelvises and such, I think it's closer to 15 Fx as a "community" standard in a good PS patient.

I've seen 4-5 week regimens too, but that seems excessive to me.

I also work in a "non-integrated" center and know exactly what "milking" means. Don't take it personally.

In my view, 30 Gy/10 for bone mets is appropriate. > 15 fx for chest palliation is inappropriate and look at Fig 3 in the study we are discussing.

Agreed. Anything >3 weeks for palliation is milking in my view, unless we are talking about definitive primary Tx in select pts with oligomets which are also being addressed.

While on the subject of palliation, here is a question:

Receipt of chemotherapy within 30 days of death is a measure of poor quality of care. Do you think the same applies to RT ?

Seper - I certainly think that's a good point. It happens more than I'd like to admit. The worst is a palliative patient dying on treatment. Such a waste. I'm starting to have to fill out this quality things on my billing sheets. I think that is a very rationale one to have for rad-oncs. But, at the same time, for emergency cases, it will be really hard to say no treatment.

I'm with Simul on this. Sicker pts can't get chemo, but they still may be candidates for radiation. If someone comes in actively hemorrhaging/obstructing from tumor, there's a role for palliative RT IMO, even if the patient only lives a few months or less. This isn't a laminectomy or a thoracotomy we are talking about, or even the myelotoxicity of chemo. Especially in someone who was in reasonably good shape until their admission.

I just treated palliative pancreatic pt under 50 who came in with duodenal perforation from tumor with hematemsis that had progressed on "alternative, non chemo" therapy. Do I think he was going to live more than a few months? No. Would I deny him palliative RT? No way. I wouldn't have the heart to sit there and tell his parents, "sorry there is nothing I can do to help your son that's actively coughing up blood from his CA"

 

[Ursus Martimus]

In my neck of the woods, hospice will pay for up 10 Fx if it is truly "palliative" and Sx directed, and the patient wants to undergo it. Not sure how that reimbursement ends up working out though "

I am truly skeptical about your neck of the woods. The major payer of hospice is medicare and A hospice is paid the routine home care rate (about $153 per day in 2013) for each day the
patient is enrolled in hospice. That hospice would go bust with just transporting the patient to treatments.

 

[medgator]

I am truly skeptical about your neck of the woods. The major payer of hospice is medicare and A hospice is paid the routine home care rate (about $153 per day in 2013) for each day the
patient is enrolled in hospice. That hospice would go bust with just transporting the patient to treatments.

I'll find out some financial info and get back to thread. They do pay, however. I am guessing we accept some lowball amount so as to not completely decimate their reimbursement from insurance.

edit: spoke with our practice manager. At least for Vitas, we send them a contract and a treatment plan with our customary charges and get paid essentially medicare rates. They pay for 10 Fx, and we do 2D/3D obviously (can't imagine anyone doing IMRT on a hospice patient, but I am sure such craziness exists.... doubt they'd get paid though).

I don't know how much hopsice gets paid from medicare or any other insurance company, but I can definitely confirm we get paid

 

[Ursus Martimus]

I don't doubt it, there are high end insurance plans that will pay for RT, it is however, an exceptional few.

 

[medgator]

I don't doubt it, there are high end insurance plans that will pay for RT, it is however, an exceptional few.

The last hospice pt I treated was medicaid, actually. Perhaps hospice funding differs at a state-to-state level?

 

[Sheldor]

The last hospice pt I treated was medicaid, actually. Perhaps hospice funding differs at a state-to-state level?

It really does. I recently changed states from medical school to intern, and was surprised to learn about this variability .

In the state where I did medical school hospice would pay for radiation as long as it was palliative in nature and for symptomatic management.

In the state I'm in now they won't pay for it at all for any reason, so you have to get your radiation and then go on hospice.

 

[seper]

I feel the same. Not all XRT within 30 days of death is inappropriate.

Where I work, we just tell hospice service to hold off placement until short course palliative RT is over. Often pt goes on hospice the next day after completion.

 

[OTN]

Good catch on the econometric analysis, SimuLD! Once again you have outdone me. After reading the paper, it kind of jives with what I thought: Single-fraction XRT is more cost-effective than Multi-fraction XRT, but not by a ton. In fact, the "societal costs" weren't statistically significantly different (p=.06, I know, I know).

Interesting discussion, especially considering we started with the "Red Journal Bloodbath".

 

[Gfunk6]

I still don't see how we are making any progress toward getting that lonely spot in Rhinelander filled by decreasing the number of grads, hence my comment about limited access for patients.

It's baaaack . . .

 

[deleted4401]

Ha. It's 4 hours from Twin Cities, 3 hours to Madison, and still a full 2.5 hours to get to a Packer's game. I'd imagine they'd have to pay a lotta cheddar to get someone to take that job...

 

[ortho2014]

While everyone has a right to their own opinion, sad that WashU administration totally disowned him in such a public forum with their reply. Was completely unnecessary, don't think the author mentioned WashU anywhere in his commentary..don't know why the Chairman felt the need to come out publicly to defend his institution's stance at the expense of one of his own. Makes you wonder how they treat their own within house...no surprise he left WashU

I don't think Chirag said anything too unreasonable to deserve some of the replies he received from some of the leaders in the field..it's a legit concern..look at what is happening to the job markets in radiology and pathology and clinical volume is much less in rad onc than rads and path...rad onc is next..and one of the replies is correct, med students do often take current job prospects into account and it is going to steer many of the high quality applicants away from the field ultimately

 

[medgator]

Sounds like another residency program is coming online at WVU to address the perpetual shortages in Rhinelander WI and Salina KS lol

http://careers.astro.org/jobs/6968235/radiation-oncology-program-director

 

[domestique]

That WVU job is a repost also. I'm not at WVU but I've heard that starting a residency program has been talked about there for a long time. I'm not sure they are actually any closer.

 

[BobbyHeenan]

That WVU job is a repost also. I'm not at WVU but I've heard that starting a residency program has been talked about there for a long time. I'm not sure they are actually any closer.

I too am not at WVU, but I believe they have partnered with (?or maybe bought out?) a few local satellite clinics/adjacent hospitals. They also hired a department chair (Dr. Geraldine Jacobson - she is active in ASTRO, serves as the ASTRO Government Relations Chair for ASTRO and was previously the PD at Iowa). I think they'll have a program.

However, I'm in agreement with Dr. Shah (the original author of the Red Journal commentary) that the pendulum has swung too far. Our colleagues in path and diagnostic rads are having major issues with this, and I fear we're not far behind. As previously mentioned in this thread, ASTRO and ACRO need to create and fund a subcommittee to study this - using input from private as well as academic centers. This phenomenon of partners retiring and the group not re-hiring is real. Docs are taking on more volume to keep up their pay checks to make up for cuts in reimbursement. In some cases they're replacing docs with mid-levels to cover follow ups and help keep the clinic visits manageable. I'm not saying this is good or bad, it's just a reality.

As also previously discussed, we have a maldistribution problem in rad onc, not an under supply problem. You don't fix the lack of a rad onc in Rhinelander, WI or London, KY by opening up more programs and slots - we've been doing this for 10 years now and those spots are still hard to fill. How about you give some sort of incentive for someone to live and work in these places - be it loan repayment, high reimbursement, or tie specific program/slot expansion to underserved areas post-residency?

The academics in the article say it's not the role of the ACGME or ABR to worry about total resident output - just that the education is quality. Then whose role is it? Are we really leaving this all up to the department PD/Chairman to make this call, because if so that's insane. There is a HUGE incentive for academics to have more and more residents in their department as long as they can secure funding for them.

 

[Burt Radnolds]

The continued increase in resident output is basically self destruction of the specialty. From a very basic level, supply is being increased while demand is not. At the same time, hospitals are gaining control and directly employing more and more physicians. Soon, they will be able to hire on the cheap because people are just going to want jobs that aren't in Rhinelander. Our negotiation power will be minimal.

Some will argue that patient numbers are increasing, due to increasing cancer rates, increasing population, and increasing age of population. While this may be true, I believe that these factors will be negated by the rise of hypofractionation, bundling, an increase in midlevel providers, and an overall willingness to see more patients to maintain compensation.

Honestly, this is why doctors are doomed across the board in a microcosm. Too few physicians are able to see the big picture, as we are continually squeezed by lawmakers and hospital administrators while we maintain the attitude that our job is to solely take care of patients and not worry about the system. Many would rather sit in their protected academic bubble, thinking they are above the fray, while things melt down. I wholeheartedly agree that my absolute primary objective is to provide my patients with the absolute highest quality of care, but we all have an obligation to upkeep the specialty as well.

 

[RadOncMegatron]

Let me echo the resentment felt by the "real" radiation oncologist here not those in the high hallowed halls of academia. The market will be saturated and that will mainly hurt the radiation oncologist that are outside academia. I cannot understand how anyone thinks this is a good idea. Academic medicine (as those here on SDN have acutely reminded us) is biased towards guess what academic medicine. In our current climate there is a dog-eat-dog mentality and if you think the academic center is happy to see your patients for second opinion and refer them back to you , then you must be early in your training or very naive. The only thing I can say is that we (those not in academics) are not making much noise (yet). Are we really going to ask ASTRO filled with academics to cut the amount of academic programs and resident spots?

 

[medgator]

Let me echo the resentment felt by the "real" radiation oncologist here not those in the high hallowed halls of academia. The market will be saturated and that will mainly hurt the radiation oncologist that are outside academia.

The market is already saturating in many desirable and semi-desirable areas. Just ask graduates from the last 2-3 years what their search was like.

 

[Burt Radnolds]

The job market is tight in many surprising geographical regions, not just the east and west coast. Radiation Oncology in general is in a unique situation where very small fluctuations in available practitioners vs available positions can reverberate across the job market.

This is due to several reasons. One is the overall small number of positions available at any given time, meaning each new physician in the field represents a higher proportion to the total than say an internist. The second is the massive amount of infrastructure needed to support a rad onc, including equipment and support staff.

The end result is that there is a finite amount of positions for a relatively small, but expanding, group of physicians. We don't have the luxury of digging our heads into the sand and hoping things work out. If programs keep expanding, an already touchy job market is going to get really bad, with no obvious solution. You will see a lot more graduates going into "fellowships" because they have nowhere else to go.

 

[Member223232]

The official match statistics are out, there were 176 PGY 2 positions and 17 PGY-1 positions for a total of 193 spots for the 2015 match. In 2011, there were 155+ 16= 171 positions. This represents a 13% increase in 4 years. If the experience of the PGY-5 residents at my institution are of any guidance, the job market is steadily getting worse by the year. Right now, unless you are from a top 10 program, you can forget about a major city, anywhere in the country (even if you are lucky enough to get a job in NY or Chicago, you are likely going to sacrifice salary/autonomy etc to claw your way in). If you are from a mid tier program like me, your realistic hope is a job anywhere in the country that is not completely screwing you over.

From this year's match results with radonc still being as competitive as ever, I think most medical students dont have a good idea of what the reality is out there since they are considered an "outsider" to the field, to which we on the "inside"loathe to to reveal the true state of things.

 

[xrthopeful]

There were actually 188 spots this year total.

your point stands though

 

[Sheldor]

We also need to remember that less physicians have been retiring the last few years after the big recession we dealt with.

Most people's portfolios are just now recovering, so imagine we'll see some of the older docs start to retire again over the next few years. Pair that with the boomers getting to the age where they will need our service and demand will go up somewhat.

Clearly we need to stop making more positions, but there are some "good" things that will attempt to balance the bad of more and more residents graduating.

 

[thesauce]

It's amazing that the WashU machine (or was it just one person who claims to represent them all?) spoke out so vehemently against Shaw's article and now the job market is showing that he was completely spot-on. It's time for them to admit they were wrong and become part of the solution. Some of our most prominent experts understand what's been happening, but they seem to have been shushed by the more vocal ones.

 

[deleted18755]

I can basically personally attest to and agree with most everything above.

One quick question (perhaps just out of curiousity): when did you guys realize that this trend was happening? At least on this forum it seems like many are just becoming aware of these challenges and the future outlook. I can remember specific conversations with residents having trouble finding jobs in desirable areas as far back as an ASTRO in Philly (2006?), with one friend having to leave his wife and kid to take a job 500 miles away, and every program director I interviewed with the following year or two talking about how we need to expand residency programs asap to accommodate the aging baby boomers at the same time the market crashed and all the attending (even the ones in their 50's at the time) were talking about how they will never retire.

I'm specifically curious whether in your experiences this is a topic that was never discussed or one that was actively denied by your attendings, mentors, program directors, etc

 

[jjborden101]

not sure why everyone is beating around the bush about this issue. It is very obvious what is happening. Yes, part of the problem is overfilling residency slots. But that isnt the problem yet, very far from it. The real problem is the boomers that wont retire. They are sticking around in part time slots, filling time they cant commit with locums, and often doing a subpar job treating patients. Additionally, they control these practices so they are making extra bucks selling the practice or consolidating it or offering terrible starting positions (5 years to "partner"! employment only just because!). Even the boomers in academics are piling on the pressure for what reason, who knows. So is it really surprising these boomers come out to oppose a very rational editorial that favors the new generation of doctors? Shouldnt be, these are some of the most greedy people in the history of mankind that have hijacked medicine in the US and turned delivery to the deplorable state it is today.

 

[baculum1]

Due to the quality of life of the specialty there are so many attendings that stick around past 60 and well into their 70s and even 80s. Hard to tell some of these guys to stop raking it in (touchy subject it seems). As an applicant this year, it was alarming how almost every program I visited had plans for expansion already in place. Just look at how many residency spots have opened up post-match over the past few months (some in areas that are laughably oversaturated). It seems that in the world of academics, program size is often equated with success so everyone seems to want to grow their program. Are residents cheaper than hiring a PA or an NP? I've been looking at the average salaries for NPs and PAs and they are well above the cost of the salary for a resident. Am I missing something here?

 

[Reaganite]

not sure why everyone is beating around the bush about this issue. It is very obvious what is happening. Yes, part of the problem is overfilling residency slots. But that isnt the problem yet, very far from it. The real problem is the boomers that wont retire. They are sticking around in part time slots, filling time they cant commit with locums, and often doing a subpar job treating patients. Additionally, they control these practices so they are making extra bucks selling the practice or consolidating it or offering terrible starting positions (5 years to "partner"! employment only just because!). Even the boomers in academics are piling on the pressure for what reason, who knows. So is it really surprising these boomers come out to oppose a very rational editorial that favors the new generation of doctors? Shouldnt be, these are some of the most greedy people in the history of mankind that have hijacked medicine in the US and turned delivery to the deplorable state it is today.

So true. There are soooo many old guys who refuse to retire. I'd say a least half the attendings in my area are pushing 70+. I know a couple of guys pushing 80 who don't even know what 3D conformal therapy is. Many of these guys have no clue how to contour for IMRT. They draw PTVs outside the patient, haven't heard of an RTOG contouring atlas, etc.

 

[OTN]

So true. There are soooo many old guys who refuse to retire. I'd say a least half the attendings in my area are pushing 70+. I know a couple of guys pushing 80 who don't even know what 3D conformal therapy is. Many of these guys have no clue how to contour for IMRT. They draw PTVs outside the patient, haven't heard of an RTOG contouring atlas, etc.

YIKES. And these are the ones who are "grandfathered" (if they're in their 80s, it could even be "great-grandfathered") into board certification. Great.

 

[deleted18755]

I thought it was just in my area.

There are two physicians in my area who are literally 82 and 84 (trained as radiologists literally in the 1950's and then transitioned into "theuropeutic radiology" and they can practice radiation oncology until the day they die without having to take boards or anything because they are "grandfathered" in to the specialty). The dosimetrist's hate to work with him because it's not that he doesn't just know how to plan IMRT treatments, he simply does not know what volume based treatment even means. He will literally have the dosimetrist print out the DRR from the CT sim, draw fields on it with a marker, and then tell them to plan 70 Gy "IMRT". If they try to explain that they need him to contour volumes he stares at them like THEY are stupid and says "I gave you the fields right there (while he points to a piece of paper). He also prescribes the supraclav field to 3cm even if the patient is 250lbs and the dosimetrist suggests prescribing to a greater depth and even shows him the isodose lines with improved coverage. He either blindly signs it or says "I've been doing this longer than you have been alive, just do what I say!"

I agree that this rapid expansion of residency spots needs to slow down, but I think this is a much bigger issue.

Honestly guys, I'm really torn. Like the rest of you I bitch and complain when the insurance company makes me jump through hopes to treat a breast with simple tangents but at the same time I know (I personally know) that there are physicians like the guys above who are out of control and walk around all day preaching to physicians and lay people about how insurance companies and hospital administrators are telling doctors what to do and not letting him do what is best for the patient because THEY are only in it for profit. Oh yeah, there used to a third guy in his 80's who was just like these two . . . until (after making who knows maybe $500-$600,000/year for decades) sold his practice to the hospital for millions more.

I don't know what to do about this problem but just waiting for these guys to retire isn't going to work since there are plenty maybe not this bad but like them in their 60's who could work another 15-20 years.

 

[Dare2Dream]

Great post oldking!

 

[DL23]

Very sobering to read these posts as an MS3 interested in radonc. I go to a top 5 med school, but would you all discourage future students from entering the field if they have very specific geographic interests (CA)? My constraints are due to SO's job and family. It seems like the job market is on the path to getting worse in the next 5-10 years?

Also it seems like residency spots were contracted in 1995 due to the poor job market. Has the job market not gotten sufficiently bad enough yet for that to happen again?

 

[BobbyHeenan]

Very sobering to read these posts as an MS3 interested in radonc. I go to a top 5 med school, but would you all discourage future students from entering the field if they have very specific geographic interests (CA)? My constraints are due to SO's job and family. It seems like the job market is on the path to getting worse in the next 5-10 years?

Also it seems like residency spots were contracted in 1995 due to the poor job market. Has the job market not gotten sufficiently bad enough yet for that to happen again?

Discouraging/encouraging is a very personal decision based on a number of factors. Having a specific geographic location in mind and being a radiation oncologist is a slightly risky endeavor, in my opinion. It may be difficult to find a job in a particular location any given year, and even long term if some areas are covered by young(er), healthy docs then there may be limited to zero turnover in that area. However, it is certainly possible to have both (location and rad onc), but in order to increase success rate I would try to train close to where you want to be, at the perceived best residency program in that area, and establish contact during residency with the local practicing rad oncs to make known your desire to live in that particular area.

Some things about this field are awesome and very unlikely to change: not having to sleep in the hospital or work weekends (other than inpatient consults), very appreciative patients, awesome tools, good combo of clinic and computer work, and getting to work alongside other oncologic specialists. I think as a whole rad oncs love our jobs.

The downsides, though not isolated to rad onc, are starting to mount more so they than they were 10 years ago in my opinion. These include more potential for reimbursement changes (?bundling, ?cuts, all possibilities), an ever tightening job market, and the implementation of proton therapy at a much higher prevalence than ever seen before - and how that may effect our field, overall reimbursement, or competition within markets.

Regarding contracting of spots - I'm not personally in favor of that (yet). I believe ASTRO/ACRO need to put a 1 year freeze on any further expansion and fund a committee to study the market, trends, and get input from private and academic centers. A simple blanket SEER analysis and "baby boomer"-hand-waving-aging-population-calculation is not sufficient. Before we go and destroy our job market just take one year to study this in depth and give an opinion about residency slots.

 

[seper]

Love how thread deteriorated into boomer bashing. Wait until you're 60 and some punks start to push converting Radiation Oncology into telemedicine and automated treatment planning.

 

[medgator]

Love how thread deteriorated into boomer bashing. Wait until you're 60 and some punks start to push converting Radiation Oncology into telemedicine and automated treatment planning.

telemedicine? seriously..... let's not deteriorate this thread even further. This isn't radiology... we actually talk to, manage and examine patients.

I think many of us with older partners in practice (or have covered older partners at other practices when doing locums) can attest to at least some of what has been posted. I don't see it quite as much with the "boomer" crowd but there are definitely some 65-70+ years old out there doing the above.

 

[vokey588]

I thought it was just in my area.

There are two physicians in my area who are literally 82 and 84 (trained as radiologists literally in the 1950's and then transitioned into "theuropeutic radiology" and they can practice radiation oncology until the day they die without having to take boards or anything because they are "grandfathered" in to the specialty). The dosimetrist's hate to work with him because it's not that he doesn't just know how to plan IMRT treatments, he simply does not know what volume based treatment even means. He will literally have the dosimetrist print out the DRR from the CT sim, draw fields on it with a marker, and then tell them to plan 70 Gy "IMRT". If they try to explain that they need him to contour volumes he stares at them like THEY are stupid and says "I gave you the fields right there (while he points to a piece of paper). He also prescribes the supraclav field to 3cm even if the patient is 250lbs and the dosimetrist suggests prescribing to a greater depth and even shows him the isodose lines with improved coverage. He either blindly signs it or says "I've been doing this longer than you have been alive, just do what I say!"

Maybe this is a naive question but do the referring doctors have no idea how behind the times these older attendings are? I would think that at least a urologist would have some level of understanding of IMRT tx of prostate cancer. Unless they are not documenting accurately I would think the rad onc consult notes would suggest something was wrong.

 

[BobbyHeenan]

Maybe this is a naive question but do the referring doctors have no idea how behind the times these older attendings are? I would think that at least a urologist would have some level of understanding of IMRT tx of prostate cancer. Unless they are not documenting accurately I would think the rad onc consult notes would suggest something was wrong.

In some cases - no they don't know.

In other cases referring docs may not have a choice where they refer due to geographic limitations or employment contracts (ie if the med onc/surgeon/urologist are hospital employees they have no choice but to refer to their own in house rad oncs...even if they're geriatric draw-the-field-on-a-DRR-for-everything rad onc).

In other cases the older rad onc may be a very good clinician - he/she manages patients well, manages his side effects well enough that the referring isn't bothered, good bedside manner, patients love/him her...but only the newly trained rad onc knows how inept they are at treatment planning. I have seen this happen in my experience, though I don't think this phenomenon is common.

Lot's of variables that can be going on....

 

[MadRadLad]

Interesting discussion. I remembered that AAMC usually has a breakdown in age-ranges of physicians for each specialty. I got curious and went to check it out. For Rad Onc, with data from 2013:

Under 35: 601
35-44: 1146
45-54:1389
55-64: 1181
65-74: 607
75-99: 108
Over 100: 0

 

[seper]

Those are academics from AAMC survey, right?

 

[seper]

telemedicine? seriously..... let's not deteriorate this thread even further. This isn't radiology... we actually talk to, manage and examine patients.

I think many of us with older partners in practice (or have covered older partners at other practices when doing locums) can attest to at least some of what has been posted. I don't see it quite as much with the "boomer" crowd but there are definitely some 65-70+ years old out there doing the above.

You'd be surprised to hear that in USA telemedicine is a large, growing part of... Neurology. Physical exam is performed by issuing commands from the computer screen. In our specialty, when most new grads don't even bother to carry stethoscope, it'll be here soon.

 

[bluebubbles]

.

 

[medgator]

This thread is interesting. My naive concerns about less-than-anticipated demand for rad/onc services in the face of oversupply include:

-Equivalence of hypofractionation and under-utilization of hypofractionation [1]
-Evidence that "less is more" in regards to certain indications for RT [2]
-Increasingly effective targeted therapies [3] and immunotherapy [4][5] and billions of private and public dollars recently invested into making these modalities even better [6][7]

So...does it look like resident over-training will continue? Alternatively, is rad/onc making any effort to co-opt new therapeutic modalities (thereby giving rad/onc trainees more stuff to do to justify their increased #s), or is rad/onc going to remain a "radiation only" field for the next decades?

Please show me how targeted and/or immunotherapy will have any impact on radiation recommendations, I personally don't see that affecting us at all, it may actually help the field by making local control even more important