Social Media and Rad Onc - A tightrope

[Chartreuse Wombat]

Not specifically RadOnc but example #13,489

NYU Langone suspends two doctors over controversial posts tied to Israel attack

Two NYU Langone doctors have been suspended after they each shared controversial social media posts tied to the raging Israel war, The Post has learned.

nypost.com

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[communitydoc13]

Not specifically RadOnc but example #13,489

NYU Langone suspends two doctors over controversial posts tied to Israel attack

Two NYU Langone doctors have been suspended after they each shared controversial social media posts tied to the raging Israel war, The Post has learned.

nypost.com

A shame. Both clearly have skin in the game. The miracle is that there can be peaceful if vociferous protest here, as well as people working and studying along side each other, while deeply invested and divided regarding the most painful of human experience abroad. Now if either compromised care or collegiality within the workspace due to their beliefs, actions must be taken...

The interpretation NYU Langone must have made is that one's X behavior is your workplace behavior. I think this take is pretty common.

IMO, any person who attempts to interfere with the contractual employment status of another person outside of their own institution, outside of the rare circumstance where acting as a whistleblower regarding true clinical negligence, should themselves be relieved of their position.

 

[Rad Onc SK]

Sounds like someone could use an ASTRO materclass in leadership @Rad Onc SK

Not once did Dr Scarborough use the word fraud in his tweet. Very intellectually dishonest stuff

“Also means Mayo/ASTRO president downcodes”

Regarding Dr. Scarbrough's tweet from October 14th, it ignited considerable discussion due to its mention of downcoding, a practice some consider to be questionable in terms of billing. Although I don't engage in downcoding, the issue at hand stems from Dr. Scarbrough's inclusion of my employer's name, Mayo, which escalated the situation.

The matter, in my opinion, has been exaggerated. I did offer the necessary background when asked and sought clarification from Dr. Scarbrough. However, his delayed response did not alter the unfolding events.

I initially deemed the tweet inconsequential, but the decision to act on it was beyond my control. Mayo's PR team chose to address it at the corporate level, a decision beyond my authority.

I believe Dr. Scarbrough had no ill intent with his tweet. I've communicated as much to our compliance team. It's part of my job to weather criticism, but bringing Mayo into the conversation invites additional scrutiny, which is out of my hands.

In summary, had Mayo not been mentioned by Dr. Scarbrough, this likely wouldn't have unfolded as it did.

I have traded messages back and forth with Dr. Scarbrough and this matter is closed, from my perspective.

 

[TheWallnerus]

“Also means Mayo/ASTRO president downcodes”

Regarding Dr. Scarbrough's tweet from October 14th, it ignited considerable discussion due to its mention of downcoding, a practice some consider to be questionable in terms of billing. Although I don't engage in downcoding, the issue at hand stems from Dr. Scarbrough's inclusion of my employer's name, Mayo, which escalated the situation.

The matter, in my opinion, has been exaggerated. I did offer the necessary background when asked and sought clarification from Dr. Scarbrough. However, his delayed response did not alter the unfolding events.

I initially deemed the tweet inconsequential, but the decision to act on it was beyond my control. Mayo's PR team chose to address it at the corporate level, a decision beyond my authority.

I believe Dr. Scarbrough had no ill intent with his tweet. I've communicated as much to our compliance team. It's part of my job to weather criticism, but bringing Mayo into the conversation invites additional scrutiny, which is out of my hands.

In summary, had Mayo not been mentioned by Dr. Scarbrough, this likely wouldn't have unfolded as it did.

I have traded messages back and forth with Dr. Scarbrough and this matter is closed, from my perspective.

The quote in its full extent, in my eyes, to be precise, said "Ron advice means... Mayo/ASTRO president downcodes." It didn't simply say "Also means Mayo/ASTRO president downcodes." (Here, Ron refers to Ron Digiamo I think.)

Reading comprehension should be, like, right up a PR person's alley!

 

[drowsy12]

I thought the post by Todd S. was a bit off, this post by Dr. Beyer is spot on, they’re not the same at all. Not that either is morally wrong, but quite clearly lowering a negotiated listed price is different than changing the code that you are billing.

But alas unfortunate that social media and a non important throw away tweet again led to unnecessary overreactions.

 

[TheWallnerus]

I thought the post by Todd S. was a bit off, this post by Dr. Beyer is spot on, they’re not the same at all. Not that either is morally wrong, but quite clearly lowering a negotiated listed price is different than changing the code that you are billing.

But alas unfortunate that social media and a non important throw away tweet again led to unnecessary overreactions.

Is Beyer "spot on"? What is the planning code for intensity modulated proton therapy? (Narrator's voice: it's the same CPT code if you do IMRT photons.) Isn't that reporting an IMRT CPT (planning) code, but doing protons? True, there is no proton planning code. But what if one reported an IMRT treatment code (about 1/3 the price of a proton treatment code by Medicare pricing) for proton treatment when an insurance company is denying protons for a case in which the doctor thinks protons are best. Are we to believe that charging 1/3 the proton price, i.e. the IMRT price, but doing protons and writing a proton CPT on the billing sheet is not wrong... but charging the same amount, and obtaining the same amount of money, but writing 5 different CPT numbers on the billing sheet, is wrong? It doesn't make great sense. In other words, the fraud is not the money, or amount that was billed, it's a "clerical error" of CPT coding. Again, doesn't make great sense. And I'm not sure there could be an effective case except within the realm of inducement, etc. But, going back to the hypotheticals, isn't the billing the lower amount the inducement, and not the "mistaken" CPT code?

 

[drowsy12]

‘But what if one reported an IMRT treatment code (about 1/3 the price of a proton treatment code by Medicare pricing) for proton treatment when an insurance company is denying protons for a case in which the doctor thinks protons are best.’


That is quite literally a different thing than charging IMRT prices for proton therapy from the start while appropriately billing a proton code. You’re making Beyer’s point, right?

 

[elementaryschooleconomics]

“Also means Mayo/ASTRO president downcodes”

Regarding Dr. Scarbrough's tweet from October 14th, it ignited considerable discussion due to its mention of downcoding, a practice some consider to be questionable in terms of billing. Although I don't engage in downcoding, the issue at hand stems from Dr. Scarbrough's inclusion of my employer's name, Mayo, which escalated the situation.

The matter, in my opinion, has been exaggerated. I did offer the necessary background when asked and sought clarification from Dr. Scarbrough. However, his delayed response did not alter the unfolding events.

I initially deemed the tweet inconsequential, but the decision to act on it was beyond my control. Mayo's PR team chose to address it at the corporate level, a decision beyond my authority.

I believe Dr. Scarbrough had no ill intent with his tweet. I've communicated as much to our compliance team. It's part of my job to weather criticism, but bringing Mayo into the conversation invites additional scrutiny, which is out of my hands.

In summary, had Mayo not been mentioned by Dr. Scarbrough, this likely wouldn't have unfolded as it did.

I have traded messages back and forth with Dr. Scarbrough and this matter is closed, from my perspective.

It's good for everyone to be on the same page, so here's what he's talking about:

I would note that Sameer's post has 14,000 impressions for a single like/repost.

For those not familiar with X/Twitter, it is very unusual to see that particular ratio of engagement metrics.

Regardless, there are two different debates here:

1) The content of the posts, as in, underbilling/"down-coding" etc.
2) Who accused who of fraud, if at all.

Personally I find this whole thing very bizarre, but that's just me.

 

[A_DeMichele]

what is going on exactly? Mayo vs. insurance?

 

[TheWallnerus]

‘But what if one reported an IMRT treatment code (about 1/3 the price of a proton treatment code by Medicare pricing) for proton treatment when an insurance company is denying protons for a case in which the doctor thinks protons are best.’


That is quite literally a different thing than charging IMRT prices for proton therapy from the start while appropriately billing a proton code. You’re making Beyer’s point, right?

"But what if one reported an IMRT treatment code (about 1/3 the price of a proton treatment code by Medicare pricing) for proton treatment "

Making an opposite point. I hope. In that, what is the inappropriateness? The money is the same. The outcome is the same. We simply have a different code on the billing sheet. When a code on the billing sheet doesn't affect the remuneration (versus another coding method), what is the wrong-doing?

"Doing protons, calling it protons, but take IMRT money"... good. "Doing protons, calling it not protons, and taking IMRT money"... bad.

 

[NotMattSpraker]

Yuan James Rao is a good follow, hes posting a lot of interesting stuff these days.

Hope hes able to continue, this field is nuts.

 

[drowsy12]

@TheWallnerus I understand. I said there’s no moral difference. We aren’t talking about morals. The whole discussion was ‘fraud’, as defined by external forces, not you nor I.

 

[deleted1111261]

what is going on exactly? Mayo vs. insurance?

What is going on is people at ASTRO and Big RadOnc are drunk on power.

- removed VVPN video with me in it (the speech transcripted here)
- blocked several posts on ROHUB that were polite but critical and then banned members
- changed the rules for SCAROP salary survey the day Dr. Spraker tried to buy it and then literally changing the website that evening (we have receipts)
- calling a town hall meeting for ROCR and not letting several people ask questions / speak (including me and my colleagues)
- ramming RO-APM down our throats even though nobody wanted it, and then pretending they weren’t for it to begin with
- continually promoting proton centers and ignoring lies / misinformation (I specifically sent the UMaryland info graphic to Dr. Michalski)
- blocking me from committees (have screenshots of this - “Dr Parikh is too controversial… blah blah blah”
- Dr. SK a few years ago invited me to participate in a committee. I paid my dues for the first time in years and was told I’d get payor relations. Blocked for a volunteer position.
- continuing to ignore questions about ROCR from Beckta and others
- calling the brightest residents in the specialty’s history as “decreasing in quality” and then never addressing this
- I have a little story about tomorrow’s ROVER that I will share later that is ridiculous. It’s not too spicy, but just will enlighten you on how these people behave.

I would consider believing the above explanation if even some of above were untrue. Add to this that SDN mods were contacted by the president-elect (at work, I hear!) and they were not wanting to be de-anonymized…

I’ve worked for Banner which has 60k employees and said far more inflammatory things (but never mean or lies or bullying) and not once did any institution and never heard a thing. Multicare had 20k employees and only time I heard something was from a third party PA company and they were wrong, but it was handled very politely and reasonably, so I took it down. I’ve talked so much about UPMC in a negative way and I think they hate me now, but never once was I approached by them or my own employer.

Institutions of this size just don’t have time to scour the web for this type of stuff. Not only that, no one reading that would consider off hand that Todd had said a word about Mayo being fraud. I’ve said the exact same thing about Mayo charging IMRT prices for protons and no one said a word to me.

Todd, because of his past, has a massive target on his back and he gets bullied a lot. People who don’t know him ask me “why do you talk to that guy?” I have my reasons - but it’s why I talk to all of you - I like smart people and I like to learn and I like to engage. How easy it is for the strong see “fraud” and “Todd” and just try to blast him for kicks. That’s what people do to him.

Before someone says “are you accusing me…” and telling my mommy and daddy, note that I haven’t accused anyone of anything (like Todd).

Ironically, the moderators were told by president - elect that there was cyber bullying happening here… that’s just rich.

Read Beckta’s timeline.

Think through this. Understand the organization and its behavior. It’s clear to see these people will literally stop at nothing to advance their own causes and stomp on those weaker than them.

This is why I was so outspoken and why I will continue to do so. Others simply can’t due to fear. I can and I’ve got your backs.

 

[TheWallnerus]

@TheWallnerus I understand. I said there’s no moral difference. We aren’t talking about morals. The whole discussion was ‘fraud’, as defined by external forces, not you nor I.

We definitely should establish precise definitions of underbilling vs downcoding going forward. Historically, what I was familiar with, was for a code that had "levels of complexity," ie say level 2 vs level 5 consult, billing level 2 but doing level 5 was a downcode. I'm not aware that IMRT is of higher complexity than 3D... or of lower compexity than non-pencil beam scan protons e.g. I'm not aware Medicare or insurances have defined complexity strata for the radiation treatments. We have in our own minds. But is that a legal basis?

In Yuan's poll/thread, it seemed people were kind of using downcoding and underbilling interchangeably.

Once Todd posted the Mayo quote, all of a sudden people got some come-to-Jesus nuance. Which is kind of funny.

EDIT: Must remember to have my people reach out to Dr. Ryckman's institution soon for accusing all of us on this forum of fraud.

https://x.com/jryckman3/status/1713165701790274037?s=20

 

[Chartreuse Wombat]

What is going on is people at ASTRO and Big RadOnc are drunk on power.

- removed VVPN video with me in it (the speech transcripted here)
- blocked several posts on ROHUB that were polite but critical and then banned members
- changed the rules for SCAROP salary survey the day Dr. Spraker tried to buy it and then literally changing the website that evening (we have receipts)
- calling a town hall meeting for ROCR and not letting several people ask questions / speak (including me and my colleagues)
- ramming RO-APM down our throats even though nobody wanted it, and then pretending they weren’t for it to begin with
- continually promoting proton centers and ignoring lies / misinformation (I specifically sent the UMaryland info graphic to Dr. Michalski)
- blocking me from committees (have screenshots of this - “Dr Parikh is too controversial… blah blah blah”
- Dr. SK a few years ago invited me to participate in a committee. I paid my dues for the first time in years and was told I’d get payor relations. Blocked for a volunteer position.
- continuing to ignore questions about ROCR from Beckta and others
- calling the brightest residents in the specialty’s history as “decreasing in quality” and then never addressing this
- I have a little story about tomorrow’s ROVER that I will share later that is ridiculous. It’s not too spicy, but just will enlighten you on how these people behave.

I would consider believing the above explanation if even some of above were untrue. Add to this that SDN mods were contacted by the president-elect (at work, I hear!) and they were not wanting to be de-anonymized…

I’ve worked for Banner which has 60k employees and said far more inflammatory things (but never mean or lies or bullying) and not once did any institution and never heard a thing. Multicare had 20k employees and only time I heard something was from a third party PA company and they were wrong, but it was handled very politely and reasonably, so I took it down. I’ve talked so much about UPMC in a negative way and I think they hate me now, but never once was I approached by them or my own employer.

Institutions of this size just don’t have time to scour the web for this type of stuff. Not only that, no one reading that would consider off hand that Todd had said a word about Mayo being fraud. I’ve said the exact same thing about Mayo charging IMRT prices for protons and no one said a word to me.

Todd, because of his past, has a massive target on his back and he gets bullied a lot. People who don’t know him ask me “why do you talk to that guy?” I have my reasons - but it’s why I talk to all of you - I like smart people and I like to learn and I like to engage. How easy it is for the strong see “fraud” and “Todd” and just try to blast him for kicks. That’s what people do to him.

Before someone says “are you accusing me…” and telling my mommy and daddy, note that I haven’t accused anyone of anything (like Todd).

Ironically, the moderators were told by president - elect that there was cyber bullying happening here… that’s just rich.

Read Beckta’s timeline.

Think through this. Understand the organization and its behavior. It’s clear to see these people will literally stop at nothing to advance their own causes and stomp on those weaker than them.

This is why I was so outspoken and why I will continue to do so. Others simply can’t due to fear. I can and I’ve got your backs.

I could add to this but enough to justify not paying dues. I am late to the game and tried to work within but too much smugness and animosity on the part of ASTRO.

 

[drowsy12]

Is Michalski the William king hale of the whole operation?

 

[Lamount]

Is Beyer "spot on"? What is the planning code for intensity modulated proton therapy? (Narrator's voice: it's the same CPT code if you do IMRT photons.) Isn't that reporting an IMRT CPT (planning) code, but doing protons? True, there is no proton planning code. But what if one reported an IMRT treatment code (about 1/3 the price of a proton treatment code by Medicare pricing) for proton treatment when an insurance company is denying protons for a case in which the doctor thinks protons are best. Are we to believe that charging 1/3 the proton price, i.e. the IMRT price, but doing protons and writing a proton CPT on the billing sheet is not wrong... but charging the same amount, and obtaining the same amount of money, but writing 5 different CPT numbers on the billing sheet, is wrong? It doesn't make great sense. In other words, the fraud is not the money, or amount that was billed, it's a "clerical error" of CPT coding. Again, doesn't make great sense. And I'm not sure there could be an effective case except within the realm of inducement, etc. But, going back to the hypotheticals, isn't the billing the lower amount the inducement, and not the "mistaken" CPT code?

View attachment 378630

My, perhaps misinformed, understanding was that it is ok to downcode if it is done systematically (I.e. billing all proton as IMRT) but it is not ok to do this on a case-by-case basis.

 

[TheWallnerus]

Is Michalski the William king hale of the whole operation?

William King Hale - Wikipedia

en.wikipedia.org

 

[TheWallnerus]

My, perhaps misinformed, understanding was that it is ok to downcode if it is done systematically (I.e. billing all proton as IMRT) but it is not ok to do this on a case-by-case basis.

This is a very interesting opinion. Since it's a new one of the hundreds on the matter thus far expressed, we should welcome it.

 

[radiaterMike]

Mayo has negotiated IMRT-level reimbursement for proton treatments for some insurers but (presumably) they always code it properly. As others have mentioned on this forum, the rates are still high. U Maryland has done the same and I think Oklahoma has done so as well. I assume out of network insurers would be billed at standard proton rates (though this may not be the case). Either way it is not downcoding if the correct codes are submitted. And either way the reimbursement is what is negotiated - which is the case for all medical procedures that are negotiated with insurers. IMRT rates for protons just means a lower negotiated rate with a specific benchmark. While Todd did not say ‘fraud’ he said ‘downcodes’ which is a fraudulent practice even if nobody really cares. It is only an issue if your downcoding undersells competition - but that’s highly unlikely to happen and unlikely to prove and even then unlikely for anyone to notice or care. The only person who seems to be clamoring about the evils of downcoding is that Ron character and when Todd presses him for concrete data on it being enforced, he seems to smugly say he just knows that it is. I’d wager most do not downcode IMRT to 3d and if you downcode 3d to 2d you can argue that the definition of what’s 3d is fuzzy (everything we do is 3d and which OARs are you really sparing ?). I’d also wager that IGRT is performed and not billed most of the time that it’s denied since it is often part of the routine workflow. Medicine really is a crazy business.

 

[TheWallnerus]

Mayo has negotiated IMRT-level reimbursement for proton treatments for some insurers but (presumably) they always code it properly. As others have mentioned on this forum, the rates are still high. U Maryland has done the same and I think Oklahoma has done so as well. I assume out of network insurers would be billed at standard proton rates (though this may not be the case). Either way it is not downcoding if the correct codes are submitted. And either way the reimbursement is what is negotiated - which is the case for all medical procedures that are negotiated with insurers. IMRT rates for protons just means a lower negotiated rate with a specific benchmark. While Todd did not say ‘fraud’ he said ‘downcodes’ which is a fraudulent practice even if nobody really cares. It is only an issue if your downcoding undersells competition - but that’s highly unlikely to happen and unlikely to prove and even then unlikely for anyone to notice or care. The only person who seems to be clamoring about the evils of downcoding is that Ron character and when Todd presses him for concrete data on it being enforced, he seems to smugly say he just knows that it is. I’d wager most do not downcode IMRT to 3d and if you downcode 3d to 2d you can argue that the definition of what’s 3d is fuzzy (everything we do is 3d and which OARs are you really sparing ?). I’d also wager that IGRT is performed and not billed most of the time that it’s denied since it is often part of the routine workflow. Medicine really is a crazy business.

Keep in mind: downcoding is only fraudulent if a doctor or hospital does it. If a payor does it, it's fine.

This whole discussion is dripping with fraud now. We all may go to jail.

 

[sirspamalot]

I can and I’ve got your backs.

Thanks.

And as to others.. well..they have a severe severe case of douchebagitis that nothing can cure. Its burned in for lyfe.

 

[NotMattSpraker]

Mayo has negotiated IMRT-level reimbursement for proton treatments for some insurers but (presumably) they always code it properly. As others have mentioned on this forum, the rates are still high. U Maryland has done the same and I think Oklahoma has done so as well. I assume out of network insurers would be billed at standard proton rates (though this may not be the case). Either way it is not downcoding if the correct codes are submitted. And either way the reimbursement is what is negotiated - which is the case for all medical procedures that are negotiated with insurers. IMRT rates for protons just means a lower negotiated rate with a specific benchmark. While Todd did not say ‘fraud’ he said ‘downcodes’ which is a fraudulent practice even if nobody really cares. It is only an issue if your downcoding undersells competition - but that’s highly unlikely to happen and unlikely to prove and even then unlikely for anyone to notice or care. The only person who seems to be clamoring about the evils of downcoding is that Ron character and when Todd presses him for concrete data on it being enforced, he seems to smugly say he just knows that it is. I’d wager most do not downcode IMRT to 3d and if you downcode 3d to 2d you can argue that the definition of what’s 3d is fuzzy (everything we do is 3d and which OARs are you really sparing ?). I’d also wager that IGRT is performed and not billed most of the time that it’s denied since it is often part of the routine workflow. Medicine really is a crazy business.

In my opinion, you have to work pretty hard to make the case that Todd did anything wrong with that tweet. It is reasonable to not like the tweet of course, that happens sometimes with Todd's tweets. But the reaction is pretty concerning.

I could add to this but enough to justify not paying dues. I am late to the game and tried to work within but too much smugness and animosity on the part of ASTRO.

I made my ASTRO story into a podcast. I got a lot of feedback and heard a lot of stories that go way back. Maybe it was like this from the beginning.

I think organizations have culture and sometimes it is not good. It can be very hard to change it. This may be especially true for a medical society, where rising in the organization personally helps one's career. There is motivation to be a yes-person. Just to be totally clear so no one is offended, orgs with bad culture can have some good people inside and being part of it doesn't make those people bad. You all know that hopefully. Also, obviously "not good" is my subjective opinion. Please do not put me in Twitter jail.

In these orgs, when stuff like this happens, theres always some explanation. It's a misunderstanding. Oh it was out of my control. That's just how it is. It will get better once X person leaves. Don't listen to the haters, they are just negative. Not a lot of reflecting though...

If I could go back to my PGY-5 self and teach one thing it's that actions matter. If an org shows you their culture, believe them. I spent a ton of mental effort and lived with a lot of anger through the start of my career trying to find ways to prove to myself that a bad organization is good.

All I had to do was stop listening to people explain away behavior and just go find the good organizations. This seems so obvious but I guess it took me a while to get it. Maybe this gets one person there sooner

Stay safe online!

 

[elementaryschooleconomics]

If I could go back to my PGY-5 self and teach one thing it's that actions matter. If an org shows you their culture, believe them. I spent a ton of mental effort and lived with a lot of anger through the start of my career trying to find ways to prove to myself that a bad organization is good.

All I had to do was stop listening to people explain away behavior and just go find the good organizations. This seems so obvious but I guess it took me a while to get it. Maybe this gets one person there sooner

While I'm sure there's a billion reasons that could be debated till the end of time:

My personal hypothesis/theory is that RadOnc is so small, and America in general (and Medicine in particular) has gotten so hyper-focused on "credentialism", that we evolved our current phenotype where ASTRO is synonymous with RadOnc.

Which is bad.

30-40 years ago, when you had doctors around who had seen the birth of MedOnc, and board certification was not functionally mandated, and private practice was still a thing...ASTRO was understood to be a choice. Well...more than today, at least.

The only true "alternative", ACRO, has some interesting origins and continues to attract quirky folks.

I certainly felt this way. When I was in grad school and residency, I basically assumed ASTRO meant RadOnc. I don't know how to explain that any better because I never even stopped to think about it. It's just like...when it snows, I know eventually the roads will be plowed. That's just how it is. But actually, who plows the roads (city/state/private), who pays for it, what route is driven...it's not just "snow means plows".

I'm not "anti-ASTRO", I'm against this current culture and behavior of this particular mix of ASTRO staff and members, and how they interact with each other, and outsiders, and how they interpret policies, etc. I don't think it's "broken" forever, and I think the vast majority of the people causing problematic choices within the superstructure of the organization are good people who make better choices in their own lives, or in their own institutions, or with their own families, etc.

The only thing that matters is never forgetting all of this is a choice. If you choose to not be an ASTRO member, nothing bad happens to you. No one cares. You can still be the greatest RadOnc in the modern era. Or, you can choose to be a member and think "no, ESE is wrong, I can fix this place!"

Fly on, little starfighter. You do you.

As long as you're making the choice you want to make, for yourself, and not because you think it's what "should" be done.

 

[deleted1111261]

I work PA

There is no issue with treating with IMRT even if not approved, instead they take 3D rates, while treating with an IMRT plan. This is not a “gray” area. I tell the docs that all the time. People in our field live in the world of theoretical, while ignoring the reality of the practical world. Breast has been treated with IMRT but compensated by 3D for decade plus.

You can squint and look at interpretation of rules, but the reality is clear as day.

 

[RickyScott]

I work PA

There is no issue with treating with IMRT even if not approved, instead they take 3D rates, while treating with an IMRT plan. This is not a “gray” area. I tell the docs that all the time. People in our field live in the world of theoretical, while ignoring the reality of the practical world. Breast has been treated with IMRT but compensated by 3D for decade plus.

You can squint and look at interpretation of rules, but the reality is clear as day.

Let’s say you treat with imrt and do not have formal oar or dvh, are you obligated to charge 2d?

 

[sirspamalot]

We're so screwed as a specialty we focus on this nonsense and everyone piles in.

The truth is - someone forgot to close the door to applicant slots. And was asleep at the wheel to fend off more cuts (again).

RO leadership is without merit. Full stop. Without wholesale change, its going to be more of the same.

Would you like fries with that?

 

[deleted1111261]

Let’s say you treat with imrt and do not have formal oar or dvh, are you obligated to charge 2d?

Lol. No. But how would you do imrt plan without any structures to avoid?

 

[Neuronix]

What is going on is people at ASTRO and Big RadOnc are drunk on power.

- removed VVPN video with me in it (the speech transcripted here)
- blocked several posts on ROHUB that were polite but critical and then banned members
- changed the rules for SCAROP salary survey the day Dr. Spraker tried to buy it and then literally changing the website that evening (we have receipts)
- calling a town hall meeting for ROCR and not letting several people ask questions / speak (including me and my colleagues)
- ramming RO-APM down our throats even though nobody wanted it, and then pretending they weren’t for it to begin with
- continually promoting proton centers and ignoring lies / misinformation (I specifically sent the UMaryland info graphic to Dr. Michalski)
- blocking me from committees (have screenshots of this - “Dr Parikh is too controversial… blah blah blah”
- Dr. SK a few years ago invited me to participate in a committee. I paid my dues for the first time in years and was told I’d get payor relations. Blocked for a volunteer position.
- continuing to ignore questions about ROCR from Beckta and others
- calling the brightest residents in the specialty’s history as “decreasing in quality” and then never addressing this

We should add this to the transcription sticky. You are doing a fantastic job of summarizing and documenting the abuse of this specialty by its leadership.

 

[sirspamalot]

IMRT definition to PA:

"Instant Money Rack Time"

3D definition to PA:

"3 players in this game: me, you and your professional society. You losers make up 2 out of 3.. lets call it.. 2D... 2 dumb to know how to win"


the only way to win is to just appeal to the government administrators.. the "paid" 3rd party reviewers for protons know where their bread is buttered. its like arbitration lol. And you're the consumer.

That said, for the record, I did proton reviews for awhile years ago for a 3rd party - and I denied every single one of them - except for a few that were actually legitimate use. Was paid very very well for my time.

Then, one day, it just stopped. Thats lyfe. No ragrets.

 

[NotMattSpraker]

We should add this to the transcription sticky. You are doing a fantastic job of summarizing and documenting the abuse of this specialty by its leadership.

I recently searched for it to share it with a young one in this field and couldnt believe that video is gone. VVPN isn't even officially ASTRO as far as I know. Very disappointing.

Im glad SDN is preserving this info.

Let’s say you treat with imrt and do not have formal oar or dvh, are you obligated to charge 2d?

If Im treating with IMRT and somehow my dosimetrist doesnt produce a DVH, were going to have a serious talk.

 

[sirspamalot]

a) whats VVPN

and

b) whats a DVH

 

[RickyScott]

Lol. No. But how would you do imrt plan without any structures to avoid?

You could use rings/artificial avoidance structures. etc, just no oars, or use normal tissue fall off optimization.

 

[deleted1111261]

You could use rings/artificial avoidance structures. etc, just no oars, or use normal tissue fall off optimization.

I guess you could

But why?

If doing something “higher” than code given, I’m not going to go back and audit. The money has been saved.

 

[TheWallnerus]

Let’s say you treat with imrt and do not have formal oar or dvh, are you obligated to charge 2d?

Let’s say you didn’t QA the IMRT plan on the machine before treatment

Almost every IMRT LCD says you must do this

Many places, academic included, no longer do this… patient specific QA on the machine (in silico QA won’t count)… “in violation of Medicare law”

 

[TheWallnerus]

Lol. No. But how would you do imrt plan without any structures to avoid?

Just put two opposing tangents on a breast and tell the computer to homogenize dose in the irradiated volume

This is the simplest inverse optimization of which I know

 

[RickyScott]

Let’s say you didn’t QA the IMRT plan on the machine before treatment

Almost every IMRT LCD says you must do this

Many places, academic included, no longer do this… patient specific QA on the machine (in silico QA won’t count)… “in violation of Medicare law”

Mskcc does not do pt specific qa

 

[TheWallnerus]

Mskcc does not do pt specific qa

An entrepreneurial or industrious insider would have a potential goldmine on their hands tbh

Sort of surprising this doesn’t happen more often given how much people like money

 

[sirspamalot]

An entrepreneurial or industrious insider would have a potential goldmine on their hands tbh

Sort of surprising this doesn’t happen more often given how much people like money

Said every relator..

 

[IonsAreOurFuture]

I try to stay within the borders of what I consider the "mission" of OOTB, namely, decreasing information asymmetry in Radiation Medicine.

I don't think it's healthy if a very small group of individuals are making most/all of the impactful decisions. Worse, the majority of "everyone else" barely understands the decisions, or barely understands the reasons those decisions are even needed.

So, while some may be flabbergasted to hear me say this, I have zero desire to "stir the pot" - which the kids now call "trolling", I guess.

And in that spirit, I know the exact details of what happened, and have no plans for a podcast about it. I'm fairly certain half the country knows at this point, and if you don't, just give it some time...you will.

No information asymmetry to alleviate!



This is very true, to a degree. Especially for residents, please wait until you're done with the board certification process and have some independent practice experience under your belt.

This most recent poor behavior example of our colleagues is not the first time I've seen it. I've seen it over and over and over. And I expect to see it again.

I'm doing what I'm doing these days because it would be impossible to truly enact change if everyone remains anonymous.

I keep the majority of my stories to myself, because I think gossip hurts us all. I think it's far more acceptable for people to have dissenting opinions than even 5 years ago, but it's not without risk.

While my opinions are often the counter-establishment type, I'm not doing that to be reactionary: I'm just willing to actually think about data. But because of that, there could be an elusive third (or fourth, or fifth) opinion I'm not seeing. I'm very interested in opinions that aren't mine, or the establishment - but I also don't want people to torch their careers on accident.

Feel free to use any anonymous method to DM me here, or X/Twitter, or [email protected]

There's a reason my most recent episode went over-the-top with economic theory and how divergent opinions create efficient markets...

The marketplace of ideas is really the most valuable of all markets, and it's interesting to me whenever people try to suppress an idea, or a proponent of an idea, as if they can make it go away. This is because ideas, especially true ones, cannot be extinguished. By their very existence, they change the nature of our reality.

"Nothing is more powerful than an idea whose time has come" - Victor Hugo. It was true of the French Revolution, Nelson Mandela vs apartheid, and the Rad Onc job market coverup - the old regime will continue to prop up the old regime until it is impossible to continue to do so.

 

[Ray D. Ayshun]

The marketplace of ideas is really the most valuable of all markets, and it's interesting to me whenever people try to suppress an idea, or a proponent of an idea, as if they can make it go away. This is because ideas, especially true ones, cannot be extinguished. By their very existence, they change the nature of our reality.

"Nothing is more powerful than an idea whose time has come" - Victor Hugo. It was true of the French Revolution, Nelson Mandela vs apartheid, and the Rad Onc job market coverup - the old regime will continue to prop up the old regime until it is impossible to continue to do so.

Or, the reasonable are just driven out. There's no marketplace of ideas in Russia or astro.

 

[deleted1111261]

I’ll also point out -

The employer of Todd’s that was called - there is no way anyone would know where he works - there is no evidence of his association with them. Only someone that has spoken with him and knows this would be able to find this out. Mayo would not have been able to find this by looking at tweets, SDN messages or Google.

 

[medgator]

I’ll also point out -

The employer of Todd’s that was called - there is no way anyone would know where he works - there is no evidence of his association with them. Only someone that has spoken with him and knows this would be able to find this out. Mayo would not have been able to find this by looking at tweets, SDN messages or Google.

Speaks volumes regarding the individual who decided to call his employer

 

[elementaryschooleconomics]

I’ll also point out -

The employer of Todd’s that was called - there is no way anyone would know where he works - there is no evidence of his association with them. Only someone that has spoken with him and knows this would be able to find this out. Mayo would not have been able to find this by looking at tweets, SDN messages or Google.

Just to echo this -

Again, everyone should read the Twitter timeline from earlier in this thread.

To look at Sameer's explanation:

“Also means Mayo/ASTRO president downcodes”

Regarding Dr. Scarbrough's tweet from October 14th, it ignited considerable discussion due to its mention of downcoding, a practice some consider to be questionable in terms of billing. Although I don't engage in downcoding, the issue at hand stems from Dr. Scarbrough's inclusion of my employer's name, Mayo, which escalated the situation.

The matter, in my opinion, has been exaggerated. I did offer the necessary background when asked and sought clarification from Dr. Scarbrough. However, his delayed response did not alter the unfolding events.

I initially deemed the tweet inconsequential, but the decision to act on it was beyond my control. Mayo's PR team chose to address it at the corporate level, a decision beyond my authority.

I believe Dr. Scarbrough had no ill intent with his tweet. I've communicated as much to our compliance team. It's part of my job to weather criticism, but bringing Mayo into the conversation invites additional scrutiny, which is out of my hands.

In summary, had Mayo not been mentioned by Dr. Scarbrough, this likely wouldn't have unfolded as it did.

I have traded messages back and forth with Dr. Scarbrough and this matter is closed, from my perspective.

If I were writing a screenplay, here's a version of the story the audience would find most realistic:

While Todd named Mayo, he did not tag Mayo. He did not say anything about fraud in that post. The post which, again, was actually supporting/defending Mayo.

Sameer tagged Mayo. He escalated the situation.

Once tagged, the Mayo team saw that one of their faculty physicians was defensively asking if he/the institution was being accused of fraud.

This was naturally escalated to "Compliance" or "Risk Management".

"Compliance" either emailed or called Sameer directly to ask about the post.

This was, of course, the intent behind tagging Mayo. This is classic JV academic politicking as old as time. Then you get to deploy the doublespeak of "no, I absolutely did not lodge a formal complaint".

By "sought clarification", Sameer means that because he used a question mark in his inflammatory post, his words are a "two for one" deal.

The specific employing entity that was contacted is, as @RealSimulD notes, not known on any public platform. It's not a secret of course, and we all wear many hats. Either Sameer supplied that information, or the Mayo Compliance Team has Sherlock Holmes level detective skills - and Occam's Razor has a clear winner in choosing between the two.

So yeah, by George Orwell's standard, this explanation from Sameer is the word-for-word truth. But it's not really the truth. I absolutely believe that once the Compliance Team was involved, it was beyond/above his authority.

But there's only one way that the Mayo Compliance Team was even aware of this post, and only one person put the words "fraud" and "Mayo" together - and it definitely wasn't the guy wearing a snorkel in his profile pic.

The most painful twist of this whole thing was that Todd was supporting Mayo's practice. You all can argue the merits of the opinion, or if downcoding is or is not fraud, etc. This was needless, nonsense, "friendly fire".

My point being: ASTRO can proudly support their president-elect as the embodiment of their core values.

 

[sirspamalot]

FASTRO?

Why no.. sir..


ps. SK left the SDN building in a hurry and never returned. I'm gonna go with... we won't be seein him round these parts again, parnder..

pss. I believe the phrase is "You should retract your grievance, as it won't be good for both of you and looks bad for the department" lol

 

[communitydoc13]

their core values

What core values...careerism and academic corporatism?

Our field is small and nobody who really matters in our field (the types of people who can make or break careers) got there without being a careerist and a networker, beholden to a large corporate interest (academic usually). One could argue that a person like Bob Timmerman had a career trajectory rooted in innovation and out of the box thinking, but this is exceptionally rare.

These type of people revile one thing above all other...people jumping in line with their ideas and analyses when they don't have a hell of a lot of career capital. This is true no matter how good these ideas or analyses are.

It's why SDN is the place to be. It should be the place to float serious research ideas as well, although this has not happened so much as of yet.

 

[radiaterMike]

FASTRO?

Why no.. sir..


ps. SK left the SDN building in a hurry and never returned. I'm gonna go with... we won't be seein him round these parts again, parnder..

pss. I believe the phrase is "You should retract your grievance, as it won't be good for both of you and looks bad for the department" lol

FWIW he did return on 11/2/23 to address (seemingly not satisfactorily) the twitter/X/tattling on Todd debacle. Hopefully that was one episode of bad judgement. I do not necessarily fault him for not coming on here (he's busy with his full time job and family) but obviously he will be judged by what he does or does not do in his role. I'll admit to being unclear on what the ASTRO president really does or is supposed to do. This press release makes it sound like the primary role is to oversee the annual meeting - Dr. Sameer Keole voted President-elect of the American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO).

As well all know, ASTRO has a CEO (who is not an MD and gets paid more than most on this board) and a multitude of committees, some of which address policy. From what I gather, all are volunteers except the well-paid CEO and the staff (some of whom have executive titles). So is SK set-up to be a scapegoat for what he cannot really impact ? I truly do not know - I am just asking the question. Who really has the power to elicit change in our field. The term amounts to 4 years (1 year each of president elect, president, Board Chair and Immediate Past Chair) of which 2 seem to kind of fluff. I'd assume the Board Chair actually has the most influence - but that is only 1 year term and does not start unto 2026 for SK.

 

[deleted1111261]

FWIW he did return on 11/2/23 to address (seemingly not satisfactorily) the twitter/X/tattling on Todd debacle. Hopefully that was one episode of bad judgement. I do not necessarily fault him for not coming on here (he's busy with his full time job and family) but obviously he will be judged by what he does or does not do in his role. I'll admit to being unclear on what the ASTRO president really does or is supposed to do. This press release makes it sound like the primary role is to oversee the annual meeting - Dr. Sameer Keole voted President-elect of the American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO).

As well all know, ASTRO has a CEO (who is not an MD and gets paid more than most on this board) and a multitude of committees, some of which address policy. From what I gather, all are volunteers except the well-paid CEO and the staff (some of whom have executive titles). So is SK set-up to be a scapegoat for what he cannot really impact ? I truly do not know - I am just asking the question. Who really has the power to elicit change in our field. The term amounts to 4 years (1 year each of president elect, president, Board Chair and Immediate Past Chair) of which 2 seem to kind of fluff. I'd assume the Board Chair actually has the most influence - but that is only 1 year term and does not start unto 2026 for SK.

This is fair. I think it's fairly ceremonial and symbolic and overly so. Ends up making people think it matters. They just run the big party every fall and set some themes.

So, I did this ROVER thing last Friday, spoke about LD-RT for OA. I wanted to wait until it was done to say this.

Initially, it was supposed to be with The Accelerators with Spraker and Beckta doing a "pre game" on the excitement about benign treatment. There was also going to be the world expert on cardiac SBRT (the two of us were going to be the main educational act). A few weeks before the event, this expert said he couldn't do it. I asked about other dates because I'm flexible - it wasn't about the date, he just couldn't do it (seemingly with me .. or us.. b/c it has been rescheduled for another date, lol). So, because of who the panel had on other than this person, the residents lost out on hearing about that as part of the program b/c of some unidentified issue with the people on the panel. Once I figured out what was happening, I offered to sit this one out - anyone can get my LD-RT for OA spiel by DMing me or emailing me or texting me and then giving me a call - have done this dozens of times - worldwide. To have the one person who does cardiac SBRT is far more important to me - especially in showcasing it to young doctors.

The second thing is when I thought things were groovy but it was still after president-elect had contacted SDN moderators - I had asked him if he wanted to join on the ROVER show - because he spoke so much about benign treatment during the campaign, thought it was a great way to bring this to the fore. I talked to him on the phone about this and he said he would get back to me. He did not get back to me - ever - about this. The ROVER folks contacted him, as well, and they said he did not respond. He may have responded and they maybe didn't want to hurt my feelings and may not have wanted to say "That guy doesn't want to be on a panel with you," which I 100% understand from their perspective. And at that point, the other guys didn't even want to be associated (Matt and Jason) so they bailed and it no longer said Accelerators anywhere on there. I didn't really want to do it, either, because despite what people think - I'm not a robot - I have feelings. If these two didn't want to be on the program since I was there and it ends up being a weaker program because they are not present - it's hard to be excited about that. But, a Parikh always pays his debts. When you consider the optics of this - to act in a way to hurts resident education and to weaken the program due to essentially just not liking some of us? If it were the other way, I would never bail just because someone on stage had different views than me. It's anti-intellectual and not brave. In addition, no one had the decency to contact me or clarify.

I don't need to do any of these things any more. I have a platform and a voice, so when they stop inviting me, it's fine. I presume ROVER and ACRO and ARRO will no longer ask me to do things because of this problem from other participants. I don't mind, it does sting a bit, b/c every issue that I care about is to improve things for residents and junior doctors. But, that's their way of doing things. I think the ARRO docs are able to have their eyes wide open - they act one way with official ASTRO function/people, but understand that it can be a bit of a vile organization.

I can't get over the fact that you'd bail on an educational program for residents just because of a personality conflict. And, I can say that I've never spoken to this other physician on the phone or in person. I've sent some well wishes in the past and it has always been cordial. I thought he actually liked me.

If this seems junior-high-ish of me to detail this .. well, that's on me. It's caused me some anguish and soul-searching, for sure. People have literally stopped talking to me or being my friend because I have different opinions about the state of this specialty.

 

[NotJasonBeckta]

This is fair. I think it's fairly ceremonial and symbolic and overly so. Ends up making people think it matters. They just run the big party every fall and set some themes.

So, I did this ROVER thing last Friday, spoke about LD-RT for OA. I wanted to wait until it was done to say this.

Initially, it was supposed to be with The Accelerators with Spraker and Beckta doing a "pre game" on the excitement about benign treatment. There was also going to be the world expert on cardiac SBRT (the two of us were going to be the main educational act). A few weeks before the event, this expert said he couldn't do it. I asked about other dates because I'm flexible - it wasn't about the date, he just couldn't do it (seemingly with me .. or us.. b/c it has been rescheduled for another date, lol). So, because of who the panel had on other than this person, the residents lost out on hearing about that as part of the program b/c of some unidentified issue with the people on the panel. Once I figured out what was happening, I offered to sit this one out - anyone can get my LD-RT for OA spiel by DMing me or emailing me or texting me and then giving me a call - have done this dozens of times - worldwide. To have the one person who does cardiac SBRT is far more important to me - especially in showcasing it to young doctors.

The second thing is when I thought things were groovy but it was still after president-elect had contacted SDN moderators - I had asked him if he wanted to join on the ROVER show - because he spoke so much about benign treatment during the campaign, thought it was a great way to bring this to the fore. I talked to him on the phone about this and he said he would get back to me. He did not get back to me - ever - about this. The ROVER folks contacted him, as well, and they said he did not respond. He may have responded and they maybe didn't want to hurt my feelings and may not have wanted to say "That guy doesn't want to be on a panel with you," which I 100% understand from their perspective. And at that point, the other guys didn't even want to be associated (Matt and Jason) so they bailed and it no longer said Accelerators anywhere on there. I didn't really want to do it, either, because despite what people think - I'm not a robot - I have feelings. If these two didn't want to be on the program since I was there and it ends up being a weaker program because they are not present - it's hard to be excited about that. But, a Parikh always pays his debts. When you consider the optics of this - to act in a way to hurts resident education and to weaken the program due to essentially just not liking some of us? If it were the other way, I would never bail just because someone on stage had different views than me. It's anti-intellectual and not brave. In addition, no one had the decency to contact me or clarify.

I don't need to do any of these things any more. I have a platform and a voice, so when they stop inviting me, it's fine. I presume ROVER and ACRO and ARRO will no longer ask me to do things because of this problem from other participants. I don't mind, it does sting a bit, b/c every issue that I care about is to improve things for residents and junior doctors. But, that's their way of doing things. I think the ARRO docs are able to have their eyes wide open - they act one way with official ASTRO function/people, but understand that it can be a bit of a vile organization.

I can't get over the fact that you'd bail on an educational program for residents just because of a personality conflict. And, I can say that I've never spoken to this other physician on the phone or in person. I've sent some well wishes in the past and it has always been cordial. I thought he actually liked me.

If this seems junior-high-ish of me to detail this .. well, that's on me. It's caused me some anguish and soul-searching, for sure. People have literally stopped talking to me or being my friend because I have different opinions about the state of this specialty.

Just to corroborate this, for what it may (or may not) be worth - this is an accurate recounting of events, as far as I have seen and/or experienced them personally.

On my end, I blocked off the ROVER event on my calendar and told Simul/Matt that I would be as flexible as possible if they needed to change the time and/or day.

Alas, here we are.

 

[sirspamalot]

ASTRO and some of ACRO leadership are juvenile and with serious conflicts of interest.

ACRO, as an entity, does have our specialty's best interest and as such, I do recommend supporting it as an org.