Off-Topic Discards

[couchkick]

This is a dying field. See you at the funeral!!

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[OTN]

This is a dying field. See you at the funeral!!

I disagree. The field itself is fine. We have plenty of indications for treatment, we're seeing some expanding options (SBRT for oligomets, maybe VTach in the future), and technologic improvements over the last 15 years have allowed us to treat patients with far fewer side effects than in the past. Immunotherapy has, as we were hoping, driven patients back to radonc for either local primary control or SBRT.

If "we" hadn't nearly doubled residency spots in 10 years we'd still be one of the most competitive specialties around, and these discussions would still be about new studies, clinical questions, and what used to be ubiquitous "will I match" posts.

 

[scarbrtj]

The field itself is fine. We have plenty of indications for treatment, we're seeing some expanding options (SBRT for oligomets, maybe VTach in the future)

Cardiac SBRT is the horse I'm betting on to save the field. THAT would increase RT indications. HOWEVER... even there (because I'm a huge pessimist at heart) I have doubts. At least on paper, at a federal level, there is no barrier to a cardiologist buying a linear accelerator and treating patients with it. (State rules can be different.) Now in theory urologists could've done this too; they didn't. Neurosurgeons could buy a CyberKnife and operate it themselves--again, at least on paper, and why that hasn't happened more I couldn't say but it probably represents unwillingness to break taboos than legal barriers per se. Why would you need a rad onc for Zap??? Aren't they trying to essentially eliminate the rad onc??? But if heart takes off.......
1) You know how ASTRO was with UroRads? I mean UroRads was the literal devil to ASTRO. Will ASTRO be that way with CardioRads? (The answer is YES.) Cardiologists WILL buy linear accelerators and WILL hire rad oncs at a minimum. This is not an an if, it's a when. Controversies there are coming.
2) What will we call a radiation oncologist who never treats a cancer patient? Why would a guy go through a very cancer-heavy 4 year residency to get board certified in radiation oncology and never treat a cancer patient? Think we are one trick ponies now? How one trick will the CardioRads guy be?

Anyway. Just pondering the future.

technologic improvements over the last 15 years have allowed us to treat patients with far fewer side effects than in the past.

Another thought: how medically necessary is seeing every patient once a week? If patients are having fewer and fewer side effects how is this a good use of healthcare dollars? Why don't we have to justify medical necessity of seeing and charging a weekly visit? Will insurance or Medicare ever "get wise" to this somewhat questionable blanket policy? I know it would cause wailing and gnashing of teeth if this ever got questioned, but that hasn't ever really prevented us from getting screwed before.

 

[OTN]

Cardiac SBRT is the horse I'm betting on to save the field. THAT would increase RT indications. HOWEVER... even there (because I'm a huge pessimist at heart) I have doubts. At least on paper, at a federal level, there is no barrier to a cardiologist buying a linear accelerator and treating patients with it. (State rules can be different.) Now in theory urologists could've done this too; they didn't. Neurosurgeons could buy a CyberKnife and operate it themselves--again, at least on paper, and why that hasn't happened more I couldn't say but it probably represents unwillingness to break taboos than legal barriers per se. Why would you need a rad onc for Zap??? Aren't they trying to essentially eliminate the rad onc??? But if heart takes off.......
1) You know how ASTRO was with UroRads? I mean UroRads was the literal devil to ASTRO. Will ASTRO be that way with CardioRads? (The answer is YES.) Cardiologists WILL buy linear accelerators and WILL hire rad oncs at a minimum. This is not an an if, it's a when. Controversies there are coming.
2) What will we call a radiation oncologist who never treats a cancer patient? Why would a guy go through a very cancer-heavy 4 year residency to get board certified in radiation oncology and never treat a cancer patient? Think we are one trick ponies now? How one trick will the CardioRads guy be?

Anyway. Just pondering the future.

Another thought: how medically necessary is seeing every patient once a week? If patients are having fewer and fewer side effects how is this a good use of healthcare dollars? Why don't we have to justify medical necessity of seeing and charging a weekly visit? Will insurance or Medicare ever "get wise" to this somewhat questionable blanket policy? I know it would cause wailing and gnashing of teeth if this ever got questioned, but that hasn't ever really prevented us from getting screwed before.

It's going to get interesting with respect to EP, I agree, especially when one considers we radoncs cannot draw the target volumes ourselves. At all. At the moment I don't think the VTach volume is quite enough of their overall field for them to be able to justify the capital expenditure necessary to be able to provide cardiac SBRT. However, there IS some preliminary data about SBRT working for AFib...

 

[taserlaser]

Vtach volume isn’t great. Went to the WashU at St Louis Symposium this fall. Learned a lot and was time well spent. Treated our first patient a few weeks back.

Cool treatment that stands to positively impact patients, but even the local EP doc our centre worked with didn’t think there would a large amount of referrals. For instance, we planned our second oatient but clinically has been stable so EP doesnt want to pull trigger on the SBRT gun just yet. Not as much guys at the end of the catheter ablation rope as one might think.

If the evidence pans out, if people start choosing SBRT for the non invasive aspect of it (which I should clarify, most places will make the substrate map *invasively*. The non invasive vest approach is still the vast minority of EP docs as I understand) then it may change in a handful of years and drive indications and referrals further. But for the short to medium term, I see this more as a novelty treatment and certainly not a signifant portion of one’s practice.

As for defining a CTV and EP buying a linac - I don’t see cards doing this on their own. Too technical and different than their training. SBRT *is* technical, especially when you account for cardiac and respiratory motion, and single shot does have the potential for grade 4/5 toxicity if not done thoughtfully. There was a thought at using the 17 segment model as a common language + functional imaging fusions to define a CTV, and that common language may get to the point where an experienced RO may generate a plan and EP will just glance and give their blessing from afar. Even that is a long ways away. But I definitely don’t see them co-opting this treatment.

 

[Palex80]

Cardiac SBRT is the horse I'm betting on to save the field. THAT would increase RT indications.

Cardiac SBRT as it is right now has been used only for patients with VT which have failed the other "conventional" approaches.
It's not like treatment-refractory VT is as common as breast/prostate cancer.

It's a "nice to have" indication for SBRT, but certainly won't "save the field".
Our cardiologists (and we have the biggest department in a 1 million metropolitan area) think we may have 4-5 cases / year eligible for SBRT.

Why would you need a rad onc for Zap??? Aren't they trying to essentially eliminate the rad onc??? But if heart takes off.......

Zap on the other hand is an issue. Zap seems easy to use, and we may lose radiosurgery patients to neurosurgeons (and perhaps neurologists/endocrinologists in the future, if more benign indications start getting treatment with it). It's so compact that you can practically put it in a normal office, so if a couple of specialists team up they could buy one and leave radiation oncology out of the loop.



My personal opinion on what will "save" the field are patients getting
a) older
b) staying alive for a longer time

The ages of patients we treat has increased over time. I hardly remember so many 85-90 year olds getting treatment in the past as it is today. Patients and relatives are becoming more and more demanding and want to have more treatment nowadays than before.

The second thing that has evolved is the amount of patients we see for second, third, fourth treatments and so on.
A myeloma patient of mine passed away recently. Over 7 years I saw him for 14 courses of radiation, treating a total of 27 individual volumes (a few of which I treated more than once)... He received every single available drug for myeloma and had 3 stem cell transplants.
The number of patients I have seen for repeat chest wall irradiation in breast cancer has also increased. The same can be said for multiple courses of SRS in patients with NSCLC or melanoma, simply because many of these patients no longer die within a year but survive longer due to immunotherapy/targetted therapy. Aggressively treating oligometastasis/oligoprogression and repeat courses of radiation are going to keep the field alive.

 

[medgator]

.




Zap on the other hand is an issue. Zap seems easy to use, and we may lose radiosurgery patients to neurosurgeons (and perhaps neurologists/endocrinologists in the future, if more benign indications start getting treatment with it). It's so compact that you can practically put it in a normal office, so if a couple of specialists team up they could buy one and leave radiation oncology out of the loop.

Why wouldn't rad onc be involved in zap? It's linac based is it not? It just wouldn't have the same physical presence requirements as gamma knife, at least here in the states.

Neurosurgery and neurology aren't cutting us out of linac based radiosurgery and srt now, not sure how zap will be different?

 

[Palex80]

Why wouldn't rad onc be involved in zap? It's linac based is it not? It just wouldn't have the same physical presence requirements as gamma knife, at least here in the states.

Neurosurgery and neurology aren't cutting us out of linac based radiosurgery and srt now, not sure how zap will be different?

I am not familiar with the US regulations, but yes, I presume you would still need a radiation oncologist. I fear however, that you may only need one to sign off the plans.

The point, I am trying to make is that Zap seems so easy to install and operate that you will need less infrastructure than today.
Zap is not designed to be put inside a radiation oncology department.

 

[Sheldor]

I find it curious how many comments in these threads talk about these other specialties co-opting any radiation treatments, especially SBRT. I mean, even the smartest of docs I know have ZERO clue about anything radiation related, and the idea that they would all of a sudden pick up a new procedure, in a foreign modality, with a large liabilty and decreasing profits from APM is nuts.

Also, at least in the US, the reason other specialties can't do SRS isn't because its hard its because a radiation oncologist is required to be there. I see no reason that would change, just like I don't see it suddenly changing that we can go do a surgical procedure without a new residency.

I get that we are steeped in radiation and so it can sometime seem "easy" but just remember back to how you felt on your first day of rad onc residency, and then think about the point you felt truly comfortable with the amazingly complex things we do.

 

[Sheldor]

I am not familiar with the US regulations, but yes, I presume you would still need a radiation oncologist. I fear however, that you may only need one to sign off the plans.

The point, I am trying to make is that Zap seems so easy to install and operate that you will need less infrastructure than today.
Zap is not designed to be put inside a radiation oncology department.

Not needing a vault doesn't equal no longer needing a radiation oncologist. Also, in the US, medicare wouldn't pay with no rad onc. Also, Stark law. Etc. etc.

 

[Mandelin Rain]

APM (as currently proposed) will kill SRS/SBRT specific platforms like ZAP, GammaKnife, and CyberKnife.

 

[Neuronix]

APM (as currently proposed) will kill SRS/SBRT specific platforms like ZAP, GammaKnife, and CyberKnife.

How so? They are good platforms for fast high dose treatments.

 

[Mandelin Rain]

How so? They are good platforms for fast high dose treatments.

I guess, if you have plenty of volume. But APM (as currently written) is going to pay pennies on the current dollar for SRS and met SBRT.

Also I can treat most SBRT/SRS in a 20 minute time slot on a TrueBeam. Not sure how these things can ever be any faster. Granted I don't do any functional CNS treatments and multiple brain mets I usually do over consecutive days.

 

[Neuronix]

It's just a question of things like cones, MLC size, fiducials, real-time image guidance, etc for specific body site SRS/SBRT applications. GK and CK are pretty bulletproof for a number of applications.

I'll agree that you can do just about anything on a Truebeam/Edge nowadays if you know what you're doing and have the appropriate Truebeam upgrade packages and expertise.

 

[radiaterMike]

There may be some fear based upon dermatologists co-opting skin cancer treatment using SRT or EBT. To some extent this backfired when reimbursements dropped. But if safe and effective technologies are developed with very low energy photons (that fall outside the purview of NRC or state regulations for radiation) the fear may be justifiable. From what I can see, Zap is 2.7 MV, so well within the range in which those outside of radiation oncology cannot use it without a radiation oncologist on board. As there are are not currently "Gamma-RADs" or "Cyber-RADs" practices owned by neurosurgeons, I would not worry about the blossoming of "Zap-RAD" or "Neuro-RAD" practices.

I find it curious how many comments in these threads talk about these other specialties co-opting any radiation treatments, especially SBRT. I mean, even the smartest of docs I know have ZERO clue about anything radiation related, and the idea that they would all of a sudden pick up a new procedure, in a foreign modality, with a large liabilty and decreasing profits from APM is nuts.

Also, at least in the US, the reason other specialties can't do SRS isn't because its hard its because a radiation oncologist is required to be there. I see no reason that would change, just like I don't see it suddenly changing that we can go do a surgical procedure without a new residency.

I get that we are steeped in radiation and so it can sometime seem "easy" but just remember back to how you felt on your first day of rad onc residency, and then think about the point you felt truly comfortable with the amazingly complex things we do.

 

[deleted774703]

I’m still surprised ppl want a GK at all

-Non versatile machine
-Have to block off a chunk of your day while pt is being treated
-NSGY the true lead more so than RO

Same principles for ZAP.

Just get a truebeam and upgrade it

 

[Neuronix]

As there are are not currently "Gamma-RADs" or "Cyber-RADs" practices owned by neurosurgeons

I know of one that is owned by a neurosurgeon who calls all the shots, does some truly bizzare stuff, and the local PP rad oncs sign off on everything. There are certainly some neurosurgeon run departments out there where the rad oncs basically have no say in what goes on. These practices are excited to have products where they can cut down on the amount of rad onc involvement.

I've seen several hospital and academic departments where rad onc tried to get rid of Gammaknife for linac SRS only to have neurosurgery block it. Neurosurgeons are the referrings and they usually have more sway in hospital systems.

 

[OTN]

I know of one that is owned by a neurosurgeon who calls all the shots, does some truly bizzare stuff, and the local PP rad oncs sign off on everything. There are certainly some neurosurgeon run departments out there where the rad oncs basically have no say in what goes on. These practices are excited to have products where they can cut down on the amount of rad onc involvement.

I've seen several hospital and academic departments where rad onc tried to get rid of Gammaknife for linac SRS only to have neurosurgery block it. Neurosurgeons are the referrings and they usually have more sway in hospital systems.

In my experience they're also one-trick ponies. The local neurosurgeons here were raised on CyberKnife, so that's all they want to use for SRS.

 

[seper]

Easy to appropriate and run, comes out of Neurosurgery budget as other noted.

I’m still surprised ppl want a GK at all

-Non versatile machine
-Have to block off a chunk of your day while pt is being treated
-NSGY the true lead more so than RO

Same principles for ZAP.

Just get a truebeam and upgrade it

 

[Neuronix]

In my experience they're also one-trick ponies. The local neurosurgeons here were raised on CyberKnife, so that's all they want to use for SRS.

Yeah, and if rad onc isn't involved sufficiently or doesn't care to intervene, then you end up with some really crazy stuff since GK/CK doesn't do conventionally fractionated radiotherapy. They'll just GK/CK everything 1-5 fractions even when it isn't appropriate.

 

[Mandelin Rain]

If I had a huge hospital system with volume and neurosurgical support to accommodate, I still think GK is the best delivery system out there for any radiation oncology treatment. Better than beam/cyber/brachy/whatever. Just an elegant machine, IMO.

 

[medgator]

If I had a huge hospital system with volume and neurosurgical support to accommodate, I still think GK is the best delivery system out there for any radiation oncology treatment. Better than beam/cyber/brachy/whatever. Just an elegant machine, IMO.

Yup very simple planning, MR based

 

[Mandelin Rain]

I also like that it's the OG. Leksell was like 50 years ahead of his time.

 

[scarbrtj]

Also, at least in the US, the reason other specialties can't do SRS isn't because its hard its because a radiation oncologist is required to be there.

No judgment re: easy/hard/high liability. (It's all the things you said.) But a rad onc not "required." Open to being proven wrong/debating the point. But just like an orthopedic surgeon can put in an MRI in his office, do MRI w/ contrast, and not have a radiologist on site, *in theory* a non-rad onc MD could also put radiotherapy equipment in his office and legally administer the XRT. A non-rad onc giving radiation legally would be true for Medicare patients. Private insurance might be different (could still legally admin it, but getting paid another issue) because private insurance usually requires board certification for payment.

I know I come off like a total wackadoo/paranoiac talking like this. And chances of it happening are miniscule. But notion that only a rad onc can do radiation has no strictly legal basis any more than, say, an ENT can't do a tooth extraction... or a family practitioner can't deliver a baby... or an internist can't do cardiac ECG... or endocrinologist can't admin radioactive iodine e.g.

Also, in the US, medicare wouldn't pay with no rad onc.

They would and currently do.

 

[medgator]

No judgment re: easy/hard/high liability. (It's all the things you said.) But a rad onc not "required." Open to being proven wrong/debating the point. But just like an orthopedic surgeon can put in an MRI in his office, do MRI w/ contrast, and not have a radiologist on site, *in theory* a non-rad onc MD could also put radiotherapy equipment in his office and legally administer the XRT. A non-rad onc giving radiation legally would be true for Medicare patients. Private insurance might be different (could still legally admin it, but getting paid another issue) because private insurance usually requires board certification for payment.

I know I come off like a total wackadoo/paranoiac talking like this. And chances of it happening are miniscule. But notion that only a rad onc can do radiation has no strictly legal basis any more than, say, an ENT can't do a tooth extraction... or a family practitioner can't deliver a baby... or an internist can't do cardiac ECG... or endocrinologist can't admin radioactive iodine e.g.

I don't think anyone would want to test that legally though, just like those in hospital settings could probably use trained NPs to cover igrt but don't

 

[taserlaser]

I doubt a private practice EP could justify the gigantic expense for a 4-5 a year patient treatment, for an in house linac plus physics and therapist support.

 

[Reaganite]

No judgment re: easy/hard/high liability. (It's all the things you said.) But a rad onc not "required." Open to being proven wrong/debating the point. But just like an orthopedic surgeon can put in an MRI in his office, do MRI w/ contrast, and not have a radiologist on site, *in theory* a non-rad onc MD could also put radiotherapy equipment in his office and legally administer the XRT. A non-rad onc giving radiation legally would be true for Medicare patients. Private insurance might be different (could still legally admin it, but getting paid another issue) because private insurance usually requires board certification for payment.

I think this is such a good point re: supervision. By virtue of being doctors, we can technically do whatever the heck we want medicine-related, no? There are PCPs all over the place legally giving botox, doing colonoscopies, excising skin cancers, etc. But OMG a non-rad onc babysitting a linac and maybe checking if some bones or soft tissue align? Impossible. End of the world.

 

[scarbrtj]

I think this is such a good point re: supervision. By virtue of being doctors, we can technically do whatever the heck we want medicine-related, no? There are PCPs all over the place legally giving botox, doing colonoscopies, excising skin cancers, etc. But OMG a non-rad onc babysitting a linac and maybe checking if some bones or soft tissue align? Impossible. End of the world.

~53% of American medical oncologists decide only medical oncologists can supervise chemo. But...
~93% of American radiation oncologists decide only rad oncs can supervise rad onc.
American family practice physicians openly claim they are GREAT at looking at bones and soft tissues on X-ray images.

 

[medgator]

I think this is such a good point re: supervision. By virtue of being doctors, we can technically do whatever the heck we want medicine-related, no? There are PCPs all over the place legally giving botox, doing colonoscopies, excising skin cancers, etc. But OMG a non-rad onc babysitting a linac and maybe checking if some bones or soft tissue align? Impossible. End of the world.

Think of how much worse the job market could be currently without that thought process.... There really would be breadlines graduating 200/year

 

[RadOncDoc21]

Think of how much worse the job market could be currently without that thought process

Seriously, it’s hard enough for me justifying my importance to non-clinicians and proving I know more than Dr. Google! Im sure my staff And the admin really think I just draw circles around the colorful pet+ disease.

 

[Sheldor]

I think this is such a good point re: supervision. By virtue of being doctors, we can technically do whatever the heck we want medicine-related, no? There are PCPs all over the place legally giving botox, doing colonoscopies, excising skin cancers, etc. But OMG a non-rad onc babysitting a linac and maybe checking if some bones or soft tissue align? Impossible. End of the world.

I mean, I guess sure sometimes its as simple as lining up bones, but I think your minimizing how much of our training comes to bare when approving CBCT's for SBRT treatments at the machine. I'm constantly reminded of this when I see what the therapists think is a good alignment. In order to safely supervise these treatments there is a TON of info to learn, that took us all years! Other doctors aren't going to randomly take a weekend course at a Hilton and do the same thing it took us 4+ years to learn, and an extra few beyond that to master.

 

[radoncgrad2019]

I mean, I guess sure sometimes its as simple as lining up bones, but I think your minimizing how much of our training comes to bare when approving CBCT's for SBRT treatments at the machine. I'm constantly reminded of this when I see what the therapists think is a good alignment. In order to safely supervise these treatments there is a TON of info to learn, that took us all years! Other doctors aren't going to randomly take a weekend course at a Hilton and do the same thing it took us 4+ years to learn, and an extra few beyond that to master.

agree.

way too many self-hating rad oncs around here. makes me wonder how some of them choose to practice. Take pride in what you do, because if you are doing it right, it does matter that you are trained and know what you are doing.

 

[scarbrtj]

I mean, I guess sure sometimes its as simple as lining up bones, but I think your minimizing how much of our training comes to bare when approving CBCT's for SBRT treatments at the machine. I'm constantly reminded of this when I see what the therapists think is a good alignment.

way too many self-hating rad oncs around here.

1) What is "good alignment"?
a) Two different MD human observers blinded to each other doing manual CBCT match, in certain body sites, will differ in 3D space by >2mm ~50% of the time. They will differ >5mm ~10% of the time.*
b) Given (a), this is why automated matching vs manual human matching has less systematic error.
c) To even get close to what "good" matching is you need to measure match means (ie systematic error), SDs (ie random error), possibly do Bland-Altman analysis, etc, on a large group of match points from different match sets.
d) Beyond this, no one has even robustly looked at clinical outcomes for different match methods (or human matchers) in rad onc. Amazing! And yet we feel there are clinical differences! Who truly knows if the MD's manual match is good and the therapist's manual match is bad.
2) Existential musings ≠ self-loathing.

*A 3mm difference in three dimensions equals a >5mm scalar.

 

[Mandelin Rain]

I think the same thing when it comes to contouring. Are my circles around a small lung cancer better or worse than a computer that can detect miniscule HU and/or SUV differences pixel by pixel. I'm thinking they could make a more precise circle than my corrective lens needing rods and cones and steady, yet aging hand/wrist can using a thick lined "pencil" or "pearl" tool via an occasionally jumpy mouse between consults while having to pee and being asked to approve a cone beam.

I know, I did 4 years of residency to draw those circles and the computer did none. Still....

Ultimately, we as docs are the final arbiter of what "good" or "best" is, so it's easy to "win".

 

[MegaVoltagePhoton]

I agree there is an absurd amount of self-hating on here. If your staff/referring physicians view you as a technician, that's on you.

Also, as far as existential musings go...I personally wonder what my reaction would be if my employer submitted a ton of false claims in my name and then was forced to pay millions of dollars to settle. Just saying.

 

[Mandelin Rain]

Yeah, no one views me as a technician. But I view [correctly] much of what I do (at least the stuff that makes me money) as highly technical

Where there is money, there will be outside interest. And Medicare allows for supervising physicians or non-physician providers. There is not a single mention of a radiation oncologist requirement to operate a linac. If we think AI poses a threat to radiology, I think it poses a threat to us as well given how much of what we do is driven by scans. . Maybe you're practicing art when you circle a lung nodule. A true creative lung nodule circling mind. I regrettably am not. I am circling the white thing in the black background and expanding by 5mm. I bet a computer could do that better and faster. I bet it would even do it on all 10 phases of the 4D scan and paste them together and never just use a MIP.

I know that's not all we do of course. But it may be a bigger and bigger portion of what we do in the future. Who knows? I bet a computer could pretty accurately define a prostate on an MRI too.

 

[deleted774703]

Yes there is a lot of self hate here. I try to show exactly what I do so referring providers understand

But we have also all experienced unnecessary hate from Med Oncs too
-oh you do physical exam
-do you follow up pts

Etc etc.

 

[Mandelin Rain]

Is the opposite of self hate just plain hubris? Because I think there is a fair amount of that on this board too.

No one can do what I do.....

 

[medgator]

Where there is money, there will be outside interest. And Medicare allows for supervising physicians or non-physician providers. There is not a single mention of a radiation oncologist requirement to operate a linac.

But to bill for igrt? Yup, at least in the freestanding setting.

 

[medgator]

But we have also all experienced unnecessary hate from Med Oncs too
-oh you do physical exam
-do you follow up pts

Etc etc.

My med oncs never do DREs on anorectal or prostate patients, nor do they document a good exam for h&n pts either. And they admit as much.

 

[Mandelin Rain]

But to bill for igrt? Yup, at least in the freestanding setting.

For sure. But the trend is not exactly toward free standing centers.

 

[medgator]

For sure. But the trend is not exactly toward free standing centers.

Have yet to see anyone using a "trained" np in a hospital-based setting. Would love to see if there anything in the legal world to back it up though outside of CMS guidelines/white papers

 

[Mandelin Rain]

Have yet to see anyone using a "trained" np in a hospital-based setting. Would love to see if there anything in the legal world to back it up though outside of CMS guidelines/white papers

Yes, I have. I think the bigger concern is just other physicians co-opting the technology for a very specific use. They wouldn't have to learn the whole of radiation oncology (4 year residency, used to be 3, probably could be 3 again) or bio or physics or do retrospective reviews or 6 months of bench research. They would just have to learn how to "zap" a specific clinical indication safely. I've seen plenty of neurosurgeons figure out Gammaknife pretty darn quickly. Take the mystique out of the linac and I bet they could figure that out too.

Arthritis is something we've talked about on this board recently. Could an ortho not put a box around a joint space and tell a patient that there is a low chance of second malignancy just as well as I could? The weekend course would tell him how many to do and how much marrow can be safely irradiated and not to play around if the patient had previous XRT, but really.... how much more is there for that specific indication?

 

[KHE88]

Somebody correct me if I'm wrong, but a midlevel providing incident to coverage can only bill at 85% medicare, correct?

So for a typical day of treatment at a typical hospital-based center with a typical Medicare payor mix, how much lost revenue would that 15% account for?

If the hospital can get a NP to sign charts for $200/day instead of paying a rad onc $2000/day, is that still cost-effective given the reduced billing?

The second question I have is, if the NP is NOT rad onc trained in anyway (for instance, the hospital convinces an ICU nurse who dosen't know what a linac is to sign off on charts by throwing her a few hundred extra dollars rather than hire a locums for vacation coverage), is this an outright violation of the false claims act or is it still a gray area? I.e., do you have to document training to let a midlevel bill?

 

[medgator]

The second question I have is, if the NP is NOT rad onc trained in anyway (for instance, the hospital convinces an ICU nurse who dosen't know what a linac is to sign off on charts by throwing her a few hundred extra dollars rather than hire a locums for vacation coverage), is this an outright violation of the false claims act or is it still a gray area? I.e., do you have to document training to let a midlevel bill?

White paper suggests they have to be able to "furnish assistance" if needed during the procedure

 

[KHE88]

White paper suggests they have to be able to "furnish assistance" if needed during the procedure

Astro's or CMS?

For something like HDR brachytherapy, this is obvious in case of a stuck source or something.
But for external beam treatment, I would say that it is pretty clear that "furnishing assistance" would mean being able to safely make a treat/no-treat decision if a patient isn't lining up correctly.

So if you hypothetically had knowledge that an NP with zero rad onc training had signed off on charts in the past, would that be grounds for a qui tam suit?
My understanding the provider has to be crednetialed to provide radiation therapy services. So either the hospital would have improperly credentialed somebody or they billed under somebody who wasn't credentialed. How illegal is that?

 

[medgator]

Astro's or CMS?

Both?

https://www.astro.org/uploadedFiles/_MAIN_SITE/Daily_Practice/Content_Pieces/SupervisionWhitePaper.pdf

 

[MegaVoltagePhoton]

How is it not a bad idea to openly and publicly speculate about ways our job market could get even worse? I mean let's for arguments sake say you are right, and anyone could take small indications from us. Why pontificate about that in an open public forum? Seems counterproductive.

 

[taserlaser]

More speculation - while the market gets tighter, in an inevitability to become more competitive on tighter margins, a well utilized and skilled NP could bring down a center’s overall cost of care/patient basis. If that trend does get picked up, that certainly would be more work displaced from ROs that would make the oversaturation worse. Not ideal for future ROs.

 

[medgator]

How is it not a bad idea to openly and publicly speculate about ways our job market could get even worse? I mean let's for arguments sake say you are right, and anyone could take small indications from us. Why pontificate about that in an open public forum? Seems counterproductive.

It would probably help reduce the number of candidates matching into the specialty if they understand how much work is being supported by the supervision requirements.

I think information symmetry would be a good thing here.

Supervision reqs, APM, hypofx, SBRT, increasing surveillance in prostate and some breast etc are all indications for reduced RO labor. We should be screaming this at the top of our lungs to anyone who will listen, because no one on #radonc Twitter likely will