Canaries in a Coal Mine

[Gfunk6]

This is Stone Age thinking. The area of single specialty practice is circling the toilet. Join with the Med Oncs, embrace your differences and let those differences enhance the both of you. They do the grunt work, bring in the patients and you all share technical fees. Win win


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[BobbyHeenan]

This is Stone Age thinking. The area of single specialty practice is circling the toilet. Join with the Med Oncs, embrace your differences and let those differences enhance the both of you. They do the grunt work, bring in the patients and you all share technical fees. Win win


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I agree this would be nice, but it's not possible in all markets. I practice in a CON state in a market with an indepedent surg onc group (part of a large surgical specialty practice), independent GI docs, and a hand full of both hospital-owned med oncs and independent med oncs. The hospitals however control the CONs and linacs.

 

[Dare2Dream]

This is Stone Age thinking. The area of single specialty practice is circling the toilet. Join with the Med Oncs, embrace your differences and let those differences enhance the both of you. They do the grunt work, bring in the patients and you all share technical fees. Win win


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That may work well in many cases but the long term impact of changing reimbursement models as well as the advent of newer cancer treatments on Radiation oncology as a field also needs to be considered. Will Medoncs over the long term end up pushing less patients to Radoncs and thus such mixed groups may hire less Radoncs over the long term? Seems like Radiation Oncology as a field has a lot of risk tied to the fact that Medoncs are the gatekeepers, especially at a time when so much of the focus is on new techniques like immunotherapy.

 

[medgator]

That may work well in many cases but the long term impact of changing reimbursement models as well as the advent of newer cancer treatments on Radiation oncology as a field also needs to be considered. Will Medoncs over the long term end up pushing less patients to Radoncs and thus such mixed groups may hire less Radoncs over the long term? Seems like Radiation Oncology as a field has a lot of risk tied to the fact that Medoncs are the gatekeepers, especially at a time when so much of the focus is on new techniques like immunotherapy.

Depends on the practice environment. In pp, breast/ent/uro surgeons. GI, pulmonary, derm etc can be as important, if not more important, than med onc for referrals.

I do worry about oncology home and bundled payment models where med onc would be allowed to steer the ship instead of it being a joint decision between both specialties, esp when it comes to palliative treatment

 

[US_MD_Applicant]

These are good proposals for our field, similar to what I mentioned earlier about overall increasing Rad Onc awareness and having a seat at the table:

1) Include radiation oncology on clinical trials panel
-If the moonshot is to succeed, it should include not only surgeons and medical oncologists. All the NCI-sponsored cooperative groups include radiation oncology - some representation will give a more comprehensive assessment of proposals.

-Link: https://cancerresearchideas.cancer....ncology-on-clinical-trials-panel/180296-39827

2) Where's Radiation Oncology?
-Radiation Oncology should have Panel representation, or, the Moonshot Panel must have Radiation Oncologist representation.

-Link: https://cancerresearchideas.cancer.gov/a/dtd/Where-s-Radiation-Oncology/181338-39827

 

[DebtRising]

http://www.redjournal.org/article/S0360-3016(16)30289-9/abstract

 

[scarbrtj]

One of the problems with our specialty is that 1) a large proportion of our specialty practice in academics versus non-academics, 2) in academics the "realities of life" are completely skewed versus what we see in private practice, 3) as a specialty we have somewhat kowtowed to the viewpoints of the academics, and 4) not enough non-academic physicians are in leadership positions at ASTRO levels. Hell, even the acronym SCAROP specifically excludes a non-academic rad onc member.

 

[RadOncDoc21]

I had a one month return visit cancelled to see me by the patient's primary physician. They stated that insurance would not allow him to see me. I thought this was very odd and find out their practice is managed by a group of physicians (mainly IM/Family docs) that oversees the primary care provider's funding and is responsible for the overall "management" of the patient. This same group prefers mastectomies over BCT because it's "cost effective with similar outcomes."

I've had a lot of issues working with this group as they constantly deny things like IMRT for lung and Esophagus (even when I am able to reasonably justify my plan comparing them with 3D plans). I even had one doc tell me radiation should be used for "palliative intent" when the guy was just locally advanced and would only approve 15 fractions when I needed 30.

Has anybody else come across this in their practice?

 

[smq123]

I had a one month return visit cancelled to see me by the patient's primary physician. They stated that insurance would not allow him to see me. I thought this was very odd and find out their practice is managed by a group of physicians (mainly IM/Family docs) that oversees the primary care provider's funding and is responsible for the overall "management" of the patient. This same group prefers mastectomies over BCT because it's "cost effective with similar outcomes."

I've had a lot of issues working with this group as they constantly deny things like IMRT for lung and Esophagus (even when I am able to reasonably justify my plan comparing them with 3D plans). I even had one doc tell me radiation should be used for "palliative intent" when the guy was just locally advanced and would only approve 15 fractions when I needed 30.

Has anybody else come across this in their practice?

Yes, although from the PCP side.

I don't know where your practice is - I practice in the St. Pete/Tampa area.

A lot of the insurances in this area sold through the Obamacare Exchange Marketplace (and, actually, some of the Medicare plans) have switched to "full risk" models. These go by a bunch of names, including "shared risk" and "global risk." What that means is that the insurance pays the PCP a set amount of money each year for each patient on the panel. (This is all kind of simplified, but it gives you the basic gist.)

Now, if the patient never sees a healthcare provider all year, the PCP gets to keep all the money, which is pure profit. Great!

But, if the patient uses ANY outside healthcare resources - the ER, urgent care, specialists, etc. - then the PCP loses that money, because the money to pay those specialty services comes out of the lump sum that they got at the beginning of the year. And if the patient uses a LOT of those resources, then the PCP could, potentially, owe the insurance company money.

So the big private practice PCP groups have spent a lot of time making sure that their patients use as few outside healthcare resources as possible. This means that many PCP groups have instructed their answering services to never send patients to the ER, even if the patient is practically on death's door. That also means that you never refer your patient to a dermatologist, you biopsy that suspicion lesion yourself. You never refer your patient to the cardiologist, you manage that A-fib yourself. One of the local corporate private practice groups even had IV infusion centers at all their offices, so that you'd never have to send a patient to the ER for dehydration, you could just give them IV fluids yourself. The PCPs at these practices are instructed to never turn a patient away - even if they are 3 hours late, even if they arrive 2 minutes before the office closes for the day....because that means that the patient might go to the ER, and you would cause the practice to lose money.

For clarification, my practice does not do that, but I work for a community health center that sees mostly Medicaid, and not a lot of Medicare. We get funding from other sources as well, so our priorities are different. I do have a friend who worked for one of these types of practices - she summed it up as "you make a lot of money, but it sure is hard to sleep at night."

Welcome to the new world of managed care.

 

[RadOncDoc21]

Yes, although from the PCP side.

I don't know where your practice is - I practice in the St. Pete/Tampa area.

A lot of the insurances in this area sold through the Obamacare Exchange Marketplace (and, actually, some of the Medicare plans) have switched to "full risk" models. These go by a bunch of names, including "shared risk" and "global risk." What that means is that the insurance pays the PCP a set amount of money each year for each patient on the panel. (This is all kind of simplified, but it gives you the basic gist.)

Now, if the patient never sees a healthcare provider all year, the PCP gets to keep all the money, which is pure profit. Great!

But, if the patient uses ANY outside healthcare resources - the ER, urgent care, specialists, etc. - then the PCP loses that money, because the money to pay those specialty services comes out of the lump sum that they got at the beginning of the year. And if the patient uses a LOT of those resources, then the PCP could, potentially, owe the insurance company money.

So the big private practice PCP groups have spent a lot of time making sure that their patients use as few outside healthcare resources as possible. This means that many PCP groups have instructed their answering services to never send patients to the ER, even if the patient is practically on death's door. That also means that you never refer your patient to a dermatologist, you biopsy that suspicion lesion yourself. You never refer your patient to the cardiologist, you manage that A-fib yourself. One of the local corporate private practice groups even had IV infusion centers at all their offices, so that you'd never have to send a patient to the ER for dehydration, you could just give them IV fluids yourself. The PCPs at these practices are instructed to never turn a patient away - even if they are 3 hours late, even if they arrive 2 minutes before the office closes for the day....because that means that the patient might go to the ER, and you would cause the practice to lose money.

For clarification, my practice does not do that, but I work for a community health center that sees mostly Medicaid, and not a lot of Medicare. We get funding from other sources as well, so our priorities are different. I do have a friend who worked for one of these types of practices - she summed it up as "you make a lot of money, but it sure is hard to sleep at night."

Welcome to the new world of managed care.

Thank you so much for the detailed response and it makes sense because that is what I've experienced in my practice. I think it will only get worse once the Medical Oncologist becomes the QB in regards to the patient's cancer care. Does this mean I need to be taking the primary care providers out to eat more?

 

[smq123]

Thank you so much for the detailed response and it makes sense because that is what I've experienced in my practice. I think it will only get worse once the Medical Oncologist becomes the QB in regards to the patient's cancer care. Does this mean I need to be taking the primary care providers out to eat more?

It doesn't hurt to butter up your local PCPs, but it may not help much. As long as you are "outside" of their organization, they will financially be responsible for any charges that you incur for the patient's care. They will have no motivation to refer to you unless it is really really dire. You may just lose money by taking them out to eat, without much benefit.

The Med Oncs may soon suffer from this as well - the PCPs see a financial cut if they refer to anyone, whether that is derm, or psych, or med onc, or cardiology, or pulmonology.

This is why ACOs are taking off. The PCP can refer to an med onc (or a rad onc) that practices in the same ACO, and not suffer any financial penalties from the insurance company.

 

[smq123]

I should probably clarify....this is not "new," per se. If you've heard of people talking about capitated plans, then this is the type of thing that they are referring to. Most of us didn't train in that model - we trained in the "fee for service" model, where the insurance company paid separately for each procedure or test done.

 

[medgator]

It doesn't hurt to butter up your local PCPs, but it may not help much. As long as you are "outside" of their organization, they will financially be responsible for any charges that you incur for the patient's care. They will have no motivation to refer to you unless it is really really dire. You may just lose money by taking them out to eat, without much benefit.

The Med Oncs may soon suffer from this as well - the PCPs see a financial cut if they refer to anyone, whether that is derm, or psych, or med onc, or cardiology, or pulmonology.

This is why ACOs are taking off. The PCP can refer to an med onc (or a rad onc) that practices in the same ACO, and not suffer any financial penalties from the insurance company.

With the way targeted and immunotherapies are going financially, the med oncs prob have more to fear than even we do in the brave new world. Just give everyone carbo/taxol :-/

 

[Neuronix]

With the way targeted and immunotherapies are going financially, the med oncs prob have more to fear than even we do in the brave new world. Just give everyone carbo/taxol :-/

I also wonder what will happen to second, third, fourth, etc lines of chemo in that world... When the carbo/taxol or whatever is cheap fails, is the patient just doomed? No more, "let's try X" ? Heck, do they even put them on hospice?

Where does the race to the bottom end? I'm very concerned about this pendulum swinging too far the other way towards cost control (and biggest profits for those who save the most), much to the detriment of patients.

 

[RadOncDoc21]

With the way targeted and immunotherapies are going financially, the med oncs prob have more to fear than even we do in the brave new world. Just give everyone carbo/taxol :-/

One of my med oncs told me that it's because of the radiation side of the practice that we are able to keep the lights on. The cost of chemotherapy drugs is ridiculous and not a money maker as it once was for them.

 

[medgator]

One of my med oncs told me that it's because of the radiation side of the practice that we are able to keep the lights on. The cost of chemotherapy drugs is ridiculous and not a money maker as it once was for them.

Yup, high $ cost, low margin. Chemo used to bill well in the 90s, until ASP came along, now it's like 3-4% margins (after paying costs) I think, and that's before you have to call up an insurance company and get an authorization (in some cases). With such small margins, screwing up one chemo can erase the profits from 20 other administrations.

Plus there was this proposal from medicare recently http://www.npr.org/sections/health-...ut-drug-costs-by-changing-how-it-pays-doctors

 

[smq123]

I had a one month return visit cancelled to see me by the patient's primary physician. They stated that insurance would not allow him to see me. I thought this was very odd and find out their practice is managed by a group of physicians (mainly IM/Family docs) that oversees the primary care provider's funding and is responsible for the overall "management" of the patient. This same group prefers mastectomies over BCT because it's "cost effective with similar outcomes."

I've had a lot of issues working with this group as they constantly deny things like IMRT for lung and Esophagus (even when I am able to reasonably justify my plan comparing them with 3D plans). I even had one doc tell me radiation should be used for "palliative intent" when the guy was just locally advanced and would only approve 15 fractions when I needed 30.

Has anybody else come across this in their practice?

Out of curiosity, how do you plan on discussing this with the patient? If I were the patient, I would be livid. A general IM/FM doctor, telling my oncologist what treatment is best for me? That would certainly push me to find another PCP, that isn't as motivated by money, or change my insurance.

 

[smq123]

I also wonder what will happen to second, third, fourth, etc lines of chemo in that world... When the carbo/taxol or whatever is cheap fails, is the patient just doomed? No more, "let's try X" ? Heck, do they even put them on hospice?

Where does the race to the bottom end? I'm very concerned about this pendulum swinging too far the other way towards cost control (and biggest profits for those who save the most), much to the detriment of patients.

What I'd love to see is more practices refuse to take any of these Full Risk plans, or at least severely limit the number of patients that they agree to see from these plans. Fewer patients will (I hope) buy these plans if they can't find a PCP/specialist within a 25 mile radius. I mean, sure, it's good to limit unnecessary use of the ER or over-ordering MRIs for every single "back pain" complaint, but sometimes it's ridiculous.

 

[RadOncDoc21]

Out of curiosity, how do you plan on discussing this with the patient? If I were the patient, I would be livid. A general IM/FM doctor, telling my oncologist what treatment is best for me? That would certainly push me to find another PCP, that isn't as motivated by money, or change my insurance.

It's a very fine line to discuss especially when it is something that directly involves their care. I usually tell them what I would prefer to do and then discuss the options I'm able to do and how it would affect them whether it be prognosis or toxicities associated with the treatment.

I try not to speak too bad about the other docs but don't stick up for them either if the patient gets upset and wants to express their feelings. It's extremely hard to go against a referring physician even if they continue to manage the patient wrong.

I just saw a patient today who had a growing mass in the pancreas that was being monitored for over a year. I'm guessing a biopsy would have cost too much.

 

[medgator]

It's a very fine line to discuss especially when it is something that directly involves their care. I usually tell them what I would prefer to do and then discuss the options I'm able to do and how it would affect them whether it be prognosis or toxicities associated with the treatment.

I try not to speak too bad about the other docs but don't stick up for them either if the patient gets upset and wants to express their feelings. It's extremely hard to go against a referring physician even if they continue to manage the patient wrong.

I just saw a patient today who had a growing mass in the pancreas that was being monitored for over a year. I'm guessing a biopsy would have cost too much.

Is your practice environment/geography such that you have to be in-network with those capitated plans/groups? I would think that at some point, those PCPs will cross an ethical boundary that will become a medico-legal issue that you may end up being indirectly tied up with.

Kaiser Permanente is a good example of a healthcare conglomerate that is super-focused on costs (by doing things in house rather than appropriately sending someone elsewhere) sometimes to a fault: http://www.sfgate.com/health/article/SAN-FRANCISCO-Scathing-report-on-Kaiser-kidney-2532538.php

http://articles.latimes.com/2009/apr/17/local/me-kaiser17

 

[Mandelin Rain]

I think we just all need to come to grips with how lousy a moment in history it is to be a physician.

The bureaucracy of government and insurers, the greed and cost containment of hospitals and explosion of administrators who produce no revenue, the threat of litigation, the internet and Dr. Oz turning every patient's sister into an expert, the declining reimbursement and associated need to see more patient/work longer hours to maintain, increased paperwork and other administrative duties, the declining public respect for our profession.....

This is not unique to Rad Onc. All docs are are dealing with it.

 

[RadOncDoc21]

Is your practice environment/geography such that you have to be in-network with those capitated plans/groups? I would think that at some point, those PCPs will cross an ethical boundary that will become a medico-legal issue that you may end up being indirectly tied up with.

Kaiser Permanente is a good example of a healthcare conglomerate that is super-focused on costs (by doing things in house rather than appropriately sending someone elsewhere) sometimes to a fault: http://www.sfgate.com/health/article/SAN-FRANCISCO-Scathing-report-on-Kaiser-kidney-2532538.php

http://articles.latimes.com/2009/apr/17/local/me-kaiser17

That's scary and I can definitely see how easily that can happen. I do work with a lot of HMO carriers and I have to say one insurance group keeps coming up time and time again. I'm currently not in the position to set things up differently (employed) but would once I am able to do it. As Mandelin Rain stated, this is a terrible time to be a physician and I don't see things changing anytime soon.

 

[thecarbonionangle]

The explosion of administrators who are not physicians, do not know a thing about medicine, do not share the calling for patient care, who get to leave at 4pm and come in at 9am and do no work weekends, who write our rules, and who just care about the "bottom line", beancounting, is of the worst things ever. They would often call me as an intern and try to force me to discharge a patient who had a clear medical reason to be in the hospital because some "criteria" was not met, or they simply wanted me to send them to their deaths out in the streets because they were uninsured, was absolutely horrible. Even despite our efforts, these administrators would often win.

 

[smq123]

The explosion of administrators who are not physicians, do not know a thing about medicine, do not share the calling for patient care, who get to leave at 4pm and come in at 9am and do no work weekends, who write our rules, and who just care about the "bottom line", beancounting, is of the worst things ever. They would often call me as an intern and try to force me to discharge a patient who had a clear medical reason to be in the hospital because some "criteria" was not met, or they simply wanted me to send them to their deaths out in the streets because they were uninsured, was absolutely horrible. Even despite our efforts, these administrators would often win.

I will say that it got particularly bad with the Obamacare plans. Whatever your feelings for Obamacare, the plans that were produced in response, at least in Florida, were atrocious. I had never seen things so ridiculous.

HumanaX was the worst. They required insurance authorization for routine mammograms. Everything that the specialist ordered had to be "approved" by the PCP. Some of these requests were ludicrous. Pt. s/p laryngectomy, with a G-tube - does his PCP approve of his oncologist ordering Jevity? Pt. has metastatic breast cancer - does her PCP think that the patient should get the chemo that her med onc ordered? Patient has an ejection fraction of 5% (yes, FIVE percent) - do you authorize the cardiologist's request to have patient fitted for an LVAD?

We ran into the same problems that Kaiser ran into - our referrals staff just could not keep up. When we complained to HumanaX, though, their local VP just looked me in the face and blandly said, "Well, Dr. SMQ, we expect the PCPs to be the gatekeepers for our patients." Screw you, it's not your license on the line when there's a delay in treatment because we couldn't process your paperwork fast enough.

 

[canadianoutlaw]

I think we just all need to come to grips with how lousy a moment in history it is to be a physician.

The bureaucracy of government and insurers, the greed and cost containment of hospitals and explosion of administrators who produce no revenue, the threat of litigation, the internet and Dr. Oz turning every patient's sister into an expert, the declining reimbursement and associated need to see more patient/work longer hours to maintain, increased paperwork and other administrative duties, the declining public respect for our profession.....

This is not unique to Rad Onc. All docs are are dealing with it.

This is exactly right. Health care reform is going to impact all specialties. The difference is that, because it has been so good for rad oncs, we have farther to fall...

 

[Mandelin Rain]

My favorite Obamacare plans are the ones with literally no network because they charge patients private insurance type premiums and refuse to reimburse providers at rates higher than Medicare. The poor patients who sign up for these "plans" because they were the cheapest online can't really find a doc to see them.

 

[medgator]

My favorite Obamacare plans are the ones with literally no network because they charge patients private insurance type premiums and refuse to reimburse providers at rates higher than Medicare. The poor patients who sign up for these "plans" because they were the cheapest online can't really find a doc to see them.

Getting 100% of Medicare isn't a bad deal necessarily, especially in some saturated parts of the country. Most of the ACA plans i've seen are paying less than medicare.

 

[Mandelin Rain]

Getting 100% of Medicare isn't a bad deal necessarily, especially in some saturated parts of the country. Most of the ACA plans i've seen are paying less than medicare.

Really? That seems odd to me.

 

[mpdoc2]

Really? That seems odd to me.

Odd but true. If the guy next doors accepting less than Medicare, guess how much you'll be making

 

[medgator]

Really? That seems odd to me.

It's unfortunate, but there are situations like that, especially with more "options" for insurers to contract with in highly saturated areas. I've heard rumors of 60-80% of Medicare being accepted by freestanding centers in SoCal.

It becomes a race to the bottom if you aren't too careful, and really this is where physicians and groups need to have some dignity and draw a line/take a stand against becoming a commodity.

 

[mpdoc2]

It's unfortunate, but there are situations like that, especially with more "options" for insurers to contract with in highly saturated areas. I've heard rumors of 60-80% of Medicare being accepted by freestanding centers in SoCal.

It becomes a race to the bottom if you aren't too careful, and really this is where physicians and groups need to have some dignity and draw a line/take a stand against becoming a commodity.

Physicians and health care have been a commodity for a long time now. You may need to draw the line so that you don't end up being in the red though.

 

[Mandelin Rain]

I guess I didn't realize what happens when several free standing centers are competing. Not the type of practices in my area. Obviously, the hospitals aren't taking that; so it's the private guys eating each other? I guess I see that. If you own the center and it's going to be open from 7 to 4 anyway, each additional patient treated doesn't really cost you much of anything. 80% of Medicare more that covers the electricity to the linac.

 

[subatomicdoc]

These are good proposals for our field, similar to what I mentioned earlier about overall increasing Rad Onc awareness and having a seat at the table:

1) Include radiation oncology on clinical trials panel
-If the moonshot is to succeed, it should include not only surgeons and medical oncologists. All the NCI-sponsored cooperative groups include radiation oncology - some representation will give a more comprehensive assessment of proposals.

-Link: https://cancerresearchideas.cancer....ncology-on-clinical-trials-panel/180296-39827

Thanks for noticing! Since they didn't include a radiation oncologist on the panel, I submitted 18 different ideas. We have to speak up for them to see we have value.
https://cancerresearchideas.cancer.gov/a/pmd/2881955-39827?

 

[subatomicdoc]

That is exactly what I was getting at above. I've heard it being repeated many times that Radoncs get the most oncology training and there is a need to educate other doctors about it but what does it translate into clinically? Are Radoncs willing to be in the trenches like Medoncs in managing patients throughout their oncology treatment? If the goal is to continue to mainly stick to conventional Radonc work and not diversify, then it is difficult to address the risks to the fields with Medoncs acting as gatekeepers and making decisions on treatment that may negatively impact Radoncs over the long run.

It doesn't matter if radiation oncology trains more time if it's not focused on patients and clinical medicine. Subtract the research year from that metric, and think about how much time we train in supportive care/symptom management, communications skills, survivorship care, systems based practice.

Much of what we do is clinically very important but highly technical. We need to establish ourselves as cancer doctors, not technicians. If we can't explain and effectively show our value to patients, primary care and others, then we won't be valued.

 

[Neuronix]

Subtract the research year from that metric

How many programs actually give a full year of research? Currently, there are very few. Most programs give about 6 months these days, some even less. Most med onc fellowships have at least six months of research built into their own programs.

how much time we train in supportive care/symptom management, communications skills, survivorship care, systems based practice.

I felt like I received good training in these. Believe me, the med oncs where I trained were doing their best as well to offload anything but chemo decision making onto midlevels and special clinics like "survivorship". We worked hand in hand at times with med onc fellows, and when I'd really focus in on a good history and physical to show them we can do them in rad onc too, they'd just laugh and talk about how their attendings never lay hands on patients.

I don't think we should discount our radiation oncology training. I absolutely agree that it shouldn't be strictly technical, but I think I got solid training in supportive care/symptom management, communications, survivorship care, and systems based practice. Maybe that was just my program, but I doubt it.

We need to establish ourselves as cancer doctors, not technicians. If we can't explain and effectively show our value to patients, primary care and others, then we won't be valued.

The problem is that after the diagnosis is made, there are just more indications for chemo than there are for radiation. We also don't manage liquid malignancies. Even if we tried to establish ourselves as the specialty to refer all solid malignancies, what would we do with all the diffusely metastatic nightmares that med onc gets referred? When I suggest strontium/samarium these days I tend to get laughed out of the room.

For primary care docs, we don't perform biopsies. Our referrings in surgery know that is how they control patients. I was trained in how to do prostate biopsies both by urologists and some forward thinking rad oncs who were forced by the institution to stop doing them, but lord have mercy if I tried to do a prostate biopsy in the real world.

About the only thing we can get direct referrals on is skin, since PCPs biopsy them. Some rad oncs tried to fight for those referrals. Good luck winning that against derm.


I'm just playing devil's advocate here. I know and believe in my value to patients and the healthcare system. But until we're the primary management of a large percentage of cancer patients, I don't know how we can assert ourselves more. I just don't know how to (or even if we should) get there.

 

[medgator]

How many programs actually give a full year of research? Currently, there are very few. Most programs give about 6 months these days, some even less. Most med onc fellowships have at least six months of research built into their own programs.



I felt like I received good training in these. Believe me, the med oncs where I trained were doing their best as well to offload anything but chemo decision making onto midlevels and special clinics like "survivorship". We worked hand in hand at times with med onc fellows, and when I'd really focus in on a good history and physical to show them we can do them in rad onc too, they'd just laugh and talk about how their attendings never lay hands on patients.

I don't think we should discount our radiation oncology training. I absolutely agree that it shouldn't be strictly technical, but I think I got solid training in supportive care/symptom management, communications, survivorship care, and systems based practice. Maybe that was just my program, but I doubt it.




The problem is that after the diagnosis is made, there are just more indications for chemo than there are for radiation. We also don't manage liquid malignancies. Even if we tried to establish ourselves as the specialty to refer all solid malignancies, what would we do with all the diffusely metastatic nightmares that med onc gets referred? When I suggest strontium/samarium these days I tend to get laughed out of the room.

For primary care docs, we don't perform biopsies. Our referrings in surgery know that is how they control patients. I was trained in how to do prostate biopsies both by urologists and some forward thinking rad oncs who were forced by the institution to stop doing them, but lord have mercy if I tried to do a prostate biopsy in the real world.

About the only thing we can get direct referrals on is skin, since PCPs biopsy them. Some rad oncs tried to fight for those referrals. Good luck winning that against derm.


I'm just playing devil's advocate here. I know and believe in my value to patients and the healthcare system. But until we're the primary management of a large percentage of cancer patients, I don't know how we can assert ourselves more. I just don't know how to (or even if we should) get there.

Outside of perhaps prostate and lymphoma, everything else is open season imo.

I often get dual referrals with med onc/thoracic surg for locally advanced lung pts and medically inoperable pts, respectively, from pulmonologists. Every once in a blue moon, I get a lung mass referral from a pcp and send to radiology or pulmonary for biopsy depending on my review of the imaging/location. And sometimes it's a pt with frank hemoptysis/cough, path pending that shows up in my office the next day after a bronch, no MO involved (yet).

Pcps generally get the abnormal mammo results and order the u/s or stereo bx to get a tissue diagnosis before a surgeon lays a single finger on the pt. That's actually the best way for the referral to unfold as some unscrupulous and/or uneducated general surgeons do excisional biopsies without sending them to radiology first.

There is no ent available in one of the centers I work at, no joke, the pcp sent me a pt with neck mass and bot mass on CT, and I made a triple referral to ent, MO and surgery (PEG+/-port). A neck mass can be FNA'd and a PET ordered before the pt sees ent.

Heck even the prostate ca referrals can come our way if the pcp is educated and they understand that shady urologists sometimes cut, cryo and hifu inappropriately.

We have to embrace our clinical training and be comfortable writing for narcs, decadron, sending patients to hospice appropriately etc. (One of our retiring partners never wrote for narcs or bzds, it was embarrassing, very common from that era) We also need to embrace our strengths in radiology and oncology training. Surgeons, pulm etc respect me because they know I read scans, not reports, unlike many med oncs. And we all know med oncs don't generally do dre's, pelvics, h&n/npl exams etc.

Again, this can be a function of geography and referral patterns, but in the right setting, it is absolutely possible to see variety of referring sources in RO, although such referral patterns can take years to cultivate.

 

[Krukenberg]

If we really wanted to educate primary referring docs (PCPs, pulm, etc) without individual rad oncs pissing off surgeons and Med oncs, ASTRO could do a national publicity campaign a la Targeting Cancer: www.targetingcancer.com.au. The precedent is there.


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[subatomicdoc]

I don't think we should discount our radiation oncology training. I absolutely agree that it shouldn't be strictly technical, but I think I got solid training in supportive care/symptom management, communications, survivorship care, and systems based practice. Maybe that was just my program, but I doubt it.

Thanks for the thoughtful reply. Maybe it's just selection bias of who I've met and what seems to be valued, but our field seems to have trended to be overly weighted toward research rather than direct patient care.

When I was in training, my residency program director and chairman fully supported careers in both community practice and academics. That is no longer the case, now private practice is not valued much. It's gratifying to hear that may not be the case in all residency programs.

I'm hoping to add some interesting data to the workforce debate, soon to submit for the Red Journal.

 

[redoitall]

And here I am reading all this and about to apply to residency...In RadOnc...

 

[McConaughey]

And here I am reading all this and about to apply to residency...In RadOnc...

it's alright - you're no canary, though.


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[ToasterThief]

And here I am reading all this and about to apply to residency...In RadOnc...

If you're having second thoughts, just remember that it's not too late to take some time to decide. It may feel like it is, but it's not, especially when you're talking about the rest of your life.

 

[redoitall]

it's alright - you're no canary, though.


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If you're having second thoughts, just remember that it's not too late to take some time to decide. It may feel like it is, but it's not, especially when you're talking about the rest of your life.

The issue is that aside from RadOnc, there is no other specialty that I want to enter. I enjoyed Radiology though, however it comes with a lot of "buts". There is HemeOnc that I liked a lot as well, however, there are a lot of things about it that don't make it worth the commitment. I have no problem committing to RadOnc. I am just anxious as I am piling up a significant amount of debt. Then thinking I will enter residency (if I am lucky enough to match), to only find out that I can't get a job. That's scary.
But there is no other specialty I want to do more than this one. Luckily for me, I may add that I would work anywhere (preferably in a small/medium city). I don't really care about location (as long as it is not in Alaska). Still, there are reasons to be scared.

 

[medgator]

The issue is that aside from RadOnc, there is no other specialty that I want to enter. I enjoyed Radiology though, however it comes with a lot of "buts". There is HemeOnc that I liked a lot as well, however, there are a lot of things about it that don't make it worth the commitment. I have no problem committing to RadOnc. I am just anxious as I am piling up a significant amount of debt. Then thinking I will enter residency (if I am lucky enough to match), to only find out that I can't get a job. That's scary.
But there is no other specialty I want to do more than this one. Luckily for me, I may add that I would work anywhere (preferably in a small/medium city). I don't really care about location (as long as it is not in Alaska). Still, there are reasons to be scared.

Plenty of decent jobs in medium sized-cities away from the coasts in the lower 48 states

 

[firewicket]

The issue is that aside from RadOnc, there is no other specialty that I want to enter. I enjoyed Radiology though, however it comes with a lot of "buts". There is HemeOnc that I liked a lot as well, however, there are a lot of things about it that don't make it worth the commitment. I have no problem committing to RadOnc. I am just anxious as I am piling up a significant amount of debt. Then thinking I will enter residency (if I am lucky enough to match), to only find out that I can't get a job. That's scary.
But there is no other specialty I want to do more than this one. Luckily for me, I may add that I would work anywhere (preferably in a small/medium city). I don't really care about location (as long as it is not in Alaska). Still, there are reasons to be scared.

Then don't go into the field. There is an increase demand for almost every other medical specialty... Nobody knows what the future holds but recent red journal publication paints the picture quite bleakly.

 

[medgator]

Then don't go into the field. There is an increase demand for almost every other medical specialty... Nobody knows what the future holds but recent red journal publication paints the picture quite bleakly.

Except there is nothing like rad onc. I say this 5+ years out in practice.... I wouldn't do anything else, personally and I'm happy enough with my location as well.

Bottom line, you're going to have to compromise somewhere geographically and if it's rad onc or bust (it probably is for most people), figure out how important geography is vs your eventual occupation

 

[redoitall]

Plenty of decent jobs in medium sized-cities away from the coasts in the lower 48 states

Except there is nothing like rad onc. I say this 5+ years out in practice, but I wouldn't do anything else, personally and I'm happy enough with my location as well.

Bottom line, you're going to have to compromise somewhere geographically and if it's rad onc or bust (it probably is for most people), figure out how important geography is vs your eventual occupation.

Point well received. Then I hope that things will work out. I already have 2 kids, so the desirable, expensive cities where all new fresh docs want to go are not for me. Sure, NY, Boston, Washington, San Francisco are all awesome. I just want an easy going, affordable city where I don't have to shell out 3/4 of a mill to get a 3 bedroom house. Little Rock - Arkansas would work for me. That is to say the extent of my "geographic flexibility"!
Thanks all for the words of wisdom.

 

[Irradi8or]

I'd encourage all of those brilliant rad oncs who chose to go into PP to start stepping up into leadership positions - starting with Committees in ASTRO, ACR, ABS, ABR, etc. As is no surprise to anyone here, our field has a relatively high distribution of jobs and power in academics vs PP (even compared to some other fields of medicine), and the vast majority of leadership positions are held by academic chairmen and professors who really aren't at all on the front lines. Unfortunately, they're calling the shots on very big issues that immediately impact all of us. Reimbursement for the same procedure in a freestanding center vs a hospital based center continues to go down, in huge favor of hospital based care. Reimbursements in these so called Alliance of Dedicated Cancer Centers (11 big cancer centers around the country) are sometimes getting reimbursed 200% Medicare and get fee for service for inpatient services too - and these institutions don't even need to report their quality measures and are exempt from many requirements that others need to abide by. Of no surprise, most of the leaders in our fields also come from these powerful institutions. When brought up to ASTRO, you can see that enhancing community based oncology is not high on the ToDo list. Over the last couple of years, I've heard a talk by a couple of previous SCAROP chairs - when residents brought up these issues re: residency expansion, mal-distribution of jobs, look at radiology/pathology/nuclear medicine, etc, they basically said that they are in favor of residency expansion, letting the "market" work itself out (which is not even how this works, since we're not in a free market), legal issues with limiting positions, etc. They think our field will continue to attract the brightest minds - I disagree. I think the select few big name programs or programs in very desirable cities (NYC, SF, etc) will still have good applicants, but the remainder of the programs perhaps will not. In the meantime, a couple of generations of great trainees will get shafted during the "market correction". Of note, these SCAROP chairs were chairmen from big name programs and in very desirable cities. There is no incentive for them to limit spots.

 

[Gfunk6]

I'd encourage all of those brilliant rad oncs who chose to go into PP to start stepping up into leadership positions - starting with Committees in ASTRO, ACR, ABS, ABR, etc. As is no surprise to anyone here, our field has a relatively high distribution of jobs and power in academics vs PP (even compared to some other fields of medicine), and the vast majority of leadership positions are held by academic chairmen and professors who really aren't at all on the front lines.

I hate to ask the obvious question, but why would I (or any other PP doc) do this? These leadership positions are time sponges and are essentially volunteer positions. I require no academic advancement that would justify doing this. And to be completely blunt, just as academic RO MDs will benefit from the resident glut, so will I benefit because people will be desperate for a job in my market.

Essentially, you are asking for a completely beneficent and altruistic commitment at the expense of one's own interests - that's a tall order. This is precisely what you and others are petitioning the academic RO MDs to do - it won't happen. Which is why my position (on post #1 of this thread) is that what Zietman says is true - caveat emptor.

 

[Irradi8or]

I hate to ask the obvious question, but why would I (or any other PP doc) do this? These leadership positions are time sponges and are essentially volunteer positions. I require no academic advancement that would justify doing this. And to be completely blunt, just as academic RO MDs will benefit from the resident glut, so will I benefit because people will be desperate for a job in my market.

Essentially, you are asking for a completely beneficent and altruistic commitment at the expense of one's own interests - that's a tall order. This is precisely what you and others are petitioning the academic RO MDs to do - it won't happen. Which is why my position (on post #1 of this thread) is that what Zietman says is true - caveat emptor.

Thanks GFunk - perhaps you misinterpret my point - I wasn't saying that you need to do so out of a sense of altruism - why would any one do that? Where did I intimate that? In fact, quite the opposite - you'd do it to try to get your own interests advanced. Forget academic advancement. No one else (esp academia) cares about the interests of your or my PP groups. When ASTRO board brings up whether they should go after increasing GME funding or site-neutral payment parity through their lobbying efforts, its no surprise that they'll vote (again) for GME funding rather than payment parity (see this year's Advocacy Day issues), since it's about self-interest of each voting person . I (among others) definitely don't have time either to throw at these endless and never sun-setting committees, and other than the academics who have 5-10 patients on treat and are at conferences/talks more often than seeing patients, no one else really does have the time. In turn, few PP docs show up at the table - most health policy committees I've worked with have vast majority academic docs. The oversupply of residents is just one issue - an issue that employers (PP and academia) will gain from - and an issue that benefits those of us that are in practice now. However, by far, that is not the only issue. There are policy issues that disproportionately affect small to medium community-based oncology groups (site-neutral payments, advanced APMs and MIPS, those with their own infusion centers, linacs, etc), and the academically represented ASTRO rarely steps up to bat for them. If any community-based oncology issues do get represented, they get splintered among ACCC, ACRO, and a few others (who may or may not agree with each other). Anyway, I barely have time to finish my daily notes and treatment planning - but I'm hoping that some like minded individuals will help represent the broader interests of community based oncology so that we're not all swallowed up by the fast growing, large "not for profit" hospital systems that is today's reality.

 

[mpdoc2]

I hate to ask the obvious question, but why would I (or any other PP doc) do this? These leadership positions are time sponges and are essentially volunteer positions. I require no academic advancement that would justify doing this. And to be completely blunt, just as academic RO MDs will benefit from the resident glut, so will I benefit because people will be desperate for a job in my market.

Essentially, you are asking for a completely beneficent and altruistic commitment at the expense of one's own interests - that's a tall order. This is precisely what you and others are petitioning the academic RO MDs to do - it won't happen. Which is why my position (on post #1 of this thread) is that what Zietman says is true - caveat emptor.

I wouldn't feel too comfortable if I was in an independent radonc group in the current market and encouraging the expansion of the radonc labor pool. The hospitals are finding it pretty cheap to hire radoncs instead of working with radonc groups and are therefore bypassing radonc groups and hiring radoncs as employees. I'm an example of a relatively new employee who the hospital found it cheaper to hire as an employee than to work with another local radiation group.