Canadian patients coming to US for RT

[Fpg1245]

These are good points. Of all the "bad bosses" I've heard about from friends, the absolute worst one was in a well known community practice. People do abuse juniors in both settings.

Just for your consideration though... there is a power imbalance and in my opinion, this seems to be leveraged more in RO than other fields. Academic affiliated people exert a lot of control over collective issues in this field; they do all the training, credentialing, and hold the vast majority of the society board positions. They also now hire >50% of new grads. In this position, they often model bad behavior.

I've seen so many academic ROs point to the greedy community RO doing 37.5 in 15 for palliation then turn around and treat a G6 prostate on protons or boost a 100 year old lady with breast cancer. Maybe I just feel this way because I have yet to be accepted to the Penn Palliative Network, I'm really trying. Or maybe Im just a little salty that more than one person told me "leaving academics" for a really great job was ruining my career.

I stand by my original post that they need an intervention. With great power comes great responsibility right?

They get to treat things with proton and I get to treat 15 fx palliation and the world should have been big enough for both of them. The empty moralizing continues.

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[communitydoc13]

With great power comes great responsibility right?

I agree.

If I were to ascribe a reason for academics leveraging their power in such a sh%$ty way, it is their inability to see what the field really is. This has been compounded by the fact that external beam radiation is an enormous financial winner for academic centers and that radonc was able to recruit incredibly accomplished residents for a period of roughly 15 years. Incredibly accomplished residents don't become humble over time. They were sold on the narrative that they were going to be the docs who change the standard of care in oncology. The fact that the only way radonc is doing this is by eliminating or reducing radiation as a treatment modality is not as important as the fact that they are fulfilling their academic destiny. Other avenues to academic prominence also do nothing for the practicing radiation clinician. (Disparity research, fundamental molecular oncology, becoming a chair somewhere (a chair needs residents)).

I like to think of it as an ambition/opportunity mismatch. Sort of like a V/Q mismatch. It results in an agonal existence and ultimately death.

So what is radonc? It is the good lifestyle oncology field that gives one drug (XRT). It is a device oriented field and not a pharmaceutical oriented one. It is highly technical but almost certainly not as vulnerable, in terms of outcomes, to personal expertise as surgery. The consequences of clinical incompetence typically become evident late and often not at all. As it is a one trick pony, outcomes are improved incrementally through technical innovation. Although ion therapy has been sold as a paradigm change (a new drug?), it is not. FLASH could be, but likely won't be. As a recent abstract noted, the toxicity of 3D, standard fractionation prostate XRT is pretty reasonable.

Radonc, in the global oncologic world, where the pharmaceutical management of cancer is improving and indications for adjuvant treatment are becoming more refined, will become less. It is becoming less. We in the community know it.

Academic radonc has responded by making itself a larger portion of the smaller pie, by marketing regionally or nationally, by subsuming regional community practices, by believing that their one drug, fundamentally the same as the community doc's one drug, is somehow better, and by pursuing high cost and at best very marginal value innovations to distinguish themselves from the community.

It's just not a healthy field, and won't be until it becomes a different field.

In a healthy field, most of the work is done in the community and academics are there to explore experimental care or take on the toughest cases.

Academic medoncs never want to keep a patient from local care unless on protocol or receiving transplant level care. They have essentially infinite opportunities for progressive clinical trials at this point. A routine patient takes away from their academic mission.

Academic neurosurgeons are fine when their academic colleagues take $$$ PP jobs. These jobs help preserve their own market value.

What would a healthy radonc academic culture do? Cut spots and look for a strategy to expand the clinical scope of radiation oncology.

 

[deleted1111261]

I agree.

If I were to ascribe a reason for academics leveraging their power in such a sh%$ty way, it is their inability to see what the field really is. This has been compounded by the fact that external beam radiation is an enormous financial winner for academic centers and that radonc was able to recruit incredibly accomplished residents for a period of roughly 15 years. Incredibly accomplished residents don't become humble over time. They were sold on the narrative that they were going to be the docs who change the standard of care in oncology. The fact that the only way radonc is doing this is by eliminating or reducing radiation as a treatment modality is not as important as the fact that they are fulfilling their academic destiny. Other avenues to academic prominence also do nothing for the practicing radiation clinician. (Disparity research, fundamental molecular oncology, becoming a chair somewhere (a chair needs residents)).

I like to think of it as an ambition/opportunity mismatch. Sort of like a V/Q mismatch. It results in an agonal existence and ultimately death.

So what is radonc? It is the good lifestyle oncology field that gives one drug (XRT). It is a device oriented field and not a pharmaceutical oriented one. It is highly technical but almost certainly not as vulnerable, in terms of outcomes, to personal expertise as surgery. The consequences of clinical incompetence typically become evident late and often not at all. As it is a one trick pony, outcomes are improved incrementally through technical innovation. Although ion therapy has been sold as a paradigm change (a new drug?), it is not. FLASH could be, but likely won't be. As a recent abstract noted, the toxicity of 3D, standard fractionation prostate XRT is pretty reasonable.

Radonc, in the global oncologic world, where the pharmaceutical management of cancer is improving and indications for adjuvant treatment are becoming more refined, will become less. It is becoming less. We in the community know it.

Academic radonc has responded by making itself a larger portion of the smaller pie, by marketing regionally or nationally, by subsuming regional community practices, by believing that their one drug, fundamentally the same as the community doc's one drug, is somehow better, and by pursuing high cost and at best very marginal value innovations to distinguish themselves from the community.

It's just not a healthy field, and won't be until it becomes a different field.

In a healthy field, most of the work is done in the community and academics are there to explore experimental care or take on the toughest cases.

Academic medoncs never want to keep a patient from local care unless on protocol or receiving transplant level care. They have essentially infinite opportunities for progressive clinical trials at this point. A routine patient takes away from their academic mission.

Academic neurosurgeons are fine when their academic colleagues take $$$ PP jobs. These jobs help preserve their own market value.

What would a healthy radonc academic culture do? Cut spots and look for a strategy to expand the clinical scope of radiation oncology.

Like many takes on SDN, a great one with nuance, but without vitriol.

Interestingly, due to algorithm or muting (probably both), much of my Twitter stuff goes unseen and people have been told not to engage with me (the views have gone tremendously down). I know how ASTRO feels about me - having blocked several times for volunteer positions and even though was considered for Early Career by the people participating, was removed due to "being controversial". There are various other examples and people that see it occurring.

Point is not, Woe is Simul. It's that SDN will become the only place to see critique and honest discussion of the future. They figured out how to stop our presence on Twitter. It's all that's left is you all here.

And, eventually, they will try to figure out a way to get people to not want to come here ("miscreants", "misinformation", angry internet people, etc.), and there truly will be an information vacuum.

It is going to be interesting for the next decade or so. The one thing multiple PDs have said (anonymously, of course) is that there are a subset of trainees - larger than before - that simply cannot handle residency with their level of knowledge/background.

 

[metallica81788]

It is going to be interesting for the next decade or so. The one thing multiple PDs have said (anonymously, of course) is that there are a subset of trainees - larger than before - that simply cannot handle residency with their level of knowledge/background.

This is not surprising - so many programs out there didn't teach for diddly squat. They had "exceptional" residents that taught themselves and learned by doing for years. The education stays the same but the quality of trainees goes down... anyone can guess the results.

 

[NotMattSpraker]

They get to treat things with proton and I get to treat 15 fx palliation and the world should have been big enough for both of them. The empty moralizing continues.

Worst/Best move I ever made (depending on who you ask) was to meet a bunch of non-academic ROs and learn about the business of medicine. The moralizing just hits different.

I think it was the best move

This is not surprising - so many programs out there didn't teach for diddly squat. They had "exceptional" residents that taught themselves and learned by doing for years. The education stays the same but the quality of trainees goes down... anyone can guess the results.

From a medical education standpoint this is a very interesting take. Step 1 scores are not a great tool for evaluating someone's ability to be a good doctor, but they do reflect one's ability to self-study and learn a large amount of material.

Rad Onc training is objectively heterogeneous, but one thing that seems consistent across programs is that there is a lot of self-study and residents teaching residents.

 

[NotMattSpraker]

It's that SDN will become the only place to see critique and honest discussion of the future.

Totally agree. I think we are already there, and thats why I actually upgraded my membership on renewal today.

SDN is a very important forum for Rad Onc discourse.

 

[Chartreuse Wombat]

Worst/Best move I ever made (depending on who you ask) was to meet a bunch of non-academic ROs and learn about the business of medicine. The moralizing just hits different.

I think it was the best move



From a medical education standpoint this is a very interesting take. Step 1 scores are not a great tool for evaluating someone's ability to be a good doctor, but they do reflect one's ability to self-study and learn a large amount of material.

Rad Onc training is objectively heterogeneous, but one thing that seems consistent across programs is that there is a lot of self-study and residents teaching residents.

Yes but Step 1 is pass/fail now

 

[medgator]

Totally agree. I think we are already there, and thats why I actually upgraded my membership on renewal today.

SDN is a very important forum for Rad Onc discourse.

Would encourage everyone to just do the lifetime donor thing. Not a lot of money and certainly much better spent than on anything ASTRO. North Korean news service needs counterpoint when it comes to medical student interest in the field

 

[Baws]

The Class of 2024 is the last great class. I'm sure there are exceptions (perhaps 25-50) after them per class, but Jesus: we have matched some very poor quality folks in our program.

 

[RickyScott]

The Class of 2024 is the last great class. I'm sure there are exceptions (perhaps 25-50) after them per class, but Jesus: we have matched some very poor quality folks in our program.

I am still at a loss to explain how there could be almost anybody of quality in subsequent classes.

 

[medgator]

The Class of 2024 is the last great class. I'm sure there are exceptions (perhaps 25-50) after them per class, but Jesus: we have matched some very poor quality folks

Fairly certain the last couple of classes are already going to show declining quality. We've been SOAPing bottom of the barrel for a few years now

 

[HolySmokes]

The Class of 2024 is the last great class. I'm sure there are exceptions (perhaps 25-50) after them per class, but Jesus: we have matched some very poor quality folks in our program.

Disagree, I think cracks were starting to show in the class of 2022 for more bottom tier programs. Unless someone came from MDACC, MSKCC, etc I wouldn't touch a grad from 2022 or later.

 

[deleted1111261]

So what happens?
We all work til we are 80?
Oh wait …

 

[Fpg1245]

So what happens?
We all work til we are 80?
Oh wait …

Watching somebody like that practice is painful and I’ve seen it more than enough times.

 

[medgator]

Watching somebody like that practice is painful and I’ve seen it more than enough times.

You hate to see it....

 

[thecarbonionangle]

Disagree, I think cracks were starting to show in the class of 2022 for more bottom tier programs. Unless someone came from MDACC, MSKCC, etc I wouldn't touch a grad from 2022 or later.

Why do you say this? Tell us more!

 

[sirspamalot]

I agree.

If I were to ascribe a reason for academics leveraging their power in such a sh%$ty way, it is their inability to see what the field really is. This has been compounded by the fact that external beam radiation is an enormous financial winner for academic centers and that radonc was able to recruit incredibly accomplished residents for a period of roughly 15 years. Incredibly accomplished residents don't become humble over time. They were sold on the narrative that they were going to be the docs who change the standard of care in oncology. The fact that the only way radonc is doing this is by eliminating or reducing radiation as a treatment modality is not as important as the fact that they are fulfilling their academic destiny. Other avenues to academic prominence also do nothing for the practicing radiation clinician. (Disparity research, fundamental molecular oncology, becoming a chair somewhere (a chair needs residents)).

I like to think of it as an ambition/opportunity mismatch. Sort of like a V/Q mismatch. It results in an agonal existence and ultimately death.

So what is radonc? It is the good lifestyle oncology field that gives one drug (XRT). It is a device oriented field and not a pharmaceutical oriented one. It is highly technical but almost certainly not as vulnerable, in terms of outcomes, to personal expertise as surgery. The consequences of clinical incompetence typically become evident late and often not at all. As it is a one trick pony, outcomes are improved incrementally through technical innovation. Although ion therapy has been sold as a paradigm change (a new drug?), it is not. FLASH could be, but likely won't be. As a recent abstract noted, the toxicity of 3D, standard fractionation prostate XRT is pretty reasonable.

Radonc, in the global oncologic world, where the pharmaceutical management of cancer is improving and indications for adjuvant treatment are becoming more refined, will become less. It is becoming less. We in the community know it.

Academic radonc has responded by making itself a larger portion of the smaller pie, by marketing regionally or nationally, by subsuming regional community practices, by believing that their one drug, fundamentally the same as the community doc's one drug, is somehow better, and by pursuing high cost and at best very marginal value innovations to distinguish themselves from the community.

It's just not a healthy field, and won't be until it becomes a different field.

In a healthy field, most of the work is done in the community and academics are there to explore experimental care or take on the toughest cases.

Academic medoncs never want to keep a patient from local care unless on protocol or receiving transplant level care. They have essentially infinite opportunities for progressive clinical trials at this point. A routine patient takes away from their academic mission.

Academic neurosurgeons are fine when their academic colleagues take $$$ PP jobs. These jobs help preserve their own market value.

What would a healthy radonc academic culture do? Cut spots and look for a strategy to expand the clinical scope of radiation oncology.

One of the best posts I've ever read here on SDN for Radonc.

I don't think there is an escape hatch for our specialty..

Only way is to just not go in... someone needs to remake this one:

https://www.reddit.com/r/funny/comments/14js20v/deeeeeeeeeep/

 

[HolySmokes]

Why do you say this? Tell us more!

Just my own observations about the quality of people who received interviews, how far down the applicant list programs had to go just to fill their interview slots, and how far down on rank lists they went to match. There's still plenty of good people in that class, but I think it was probably the first objectively worse cycle. And as everyone here knows it has only gotten worse.