What is the problem...can one define it? Let your voice be heard...

[Dan Spratt]

It has been a while since I have jumped on SDN and was hoping to gain additional vantage points and perspectives on a hot topic on SDN. I realize there are many posts/threads, papers, tweets, etc on this, but wanted to try to get the discussion going in a different way than I have seen (if I missed it please shoot me a link to the relevant thread). The impetus for this post is that I am speaking as a panel member at the upcoming SCAROP meeting in a few weeks on the issue of interest in our field/applicant numbers.

Normally I start any project with identifying the problem clearly and concisely, and then doing a root cause analysis to the upstream and downstream effects, causes, correlations to understand how to study and fix it. I am struggling to identify and appropriately characterize what the issue is exactly. I do not mean this to say there is no issue, but I am struggling to consicely convey what the problem is that gets discussed so passionately. This 1st step is so critical as you cant solve something, or even appropriately study it if you cant define it.

Many discuss the concept of this problem frequently, but what is it exactly?
-Is it reduced interest in our field? Some would say that interest is still there of those that apply, so it cant be just interest. Applicant numbers are reduced, so is it general interest perhaps is reduced? Is lack of more broad interest itself a problem? Is it a lack of positivity in our field or promotion of our field the problem? Furthermore, is reduced applicants an actual problem for a field? Reflexively many people say yes, but why? Reduced applicants means fewer residents to train (assuming SOAP did not occur) and this may be natural market forces balancing of supply and demand. However, as SOAP does occur, then is the problem we have people entering our field without prior radonc interest (or as much interest)? I then ask what is the problem that this results in? I did not know about radonc until a few months before I applied and never did an away rotation. My appreciation for radonc grew stronger over time, so I am not convinced that it is a problem in and of itself. Or is it the caliber of people who SOAP in not sufficient? I again challenge this as does having someone publish a nature paper with a Step 1 score of 270 from Harvard mean they will be a better clinical radonc than someone who did no research in med school, got a 220 from a state school? Not sure that this is the actual problem either.
-Is it the change of the job market as a result of the changes in healthcare (consolidation of practices, fewer and fewer solo practices, etc)? What is the unique problem that radonc faces that other specialties do not with these changes? Jobs are more now than ever part of bigger and bigger centers/companies and what was independent practices are now community affiliate positions. Is this the problem? This is happening across healthcare, so is this unique to radonc?
-Is it that residents are graduating and they are not getting a job after years of school, training, and debt? What is the best data for this to graduates truly not having any open positions to apply to. I say this as right now in Northeast Ohio alone I know of one group using a locums looking to hire a permanent doc, another using 3 locums trying to find 2-3 permanent positions, and another using 2 locums that needs 3 permanent docs. These are all centers not part of my institution. I have hired 8 physicians in 12 months and am recruiting 6 more. So is it that there are in fact jobs, but they are not the types of jobs people want (community vs main or solo vs multi-provider practice or academic vs non-academic or salary level or research or city vs rural or middle america vs coasts)? Totally understand not everyone wants to move to some of these centers in the rural midwest, or the environment is not what they want, but they are jobs. This difference matters in order to address the issue. Or is it number of jobs and the types of jobs? Is it a mismatch in we have tried to attract hyper academic, many MD/PhDs, to a market that supports having very few of them and so there is a mismatch of applicants wants and job availability? If we recruited mainly people who wanted to be community radoncs across the country would we have the same discussions?
-Is it the expansion of medschools/slots and residency programs/slots and this goes back to is there truly an oversupply and not enough demand? Or the demand is there does not match the interests of the applicants (ie tons of people graduating in Cali and NYC but jobs are needed in middle america)?
-Is it a DEI issue (or at least in part)? Our applicant pool is dominated by non-URM males so we are missing out on hundreds (or thousands) of women and URM that are applying to derm, radiology, etc. While this should absolutely be addressed and likely a contributing factor, it doesnt appear that the diversity in radonc is rapidly declining to explain the sudden change from when I applied to radonc in 2010 and by 3 years after I graduated in 2018 applicant numbers seemed to be dropping. If anything I thought I saw in recent papers some improvements in some components of diversity (at least gender) in radonc faculty.
-Is it a generational (I am a millennial technically too) or a manifestation of social media in that issues can now be brought out into the light to mass audiences more easily? I hope this audience can appreciate at times there has been disrespectful and unproductive comments on SDN, twitter, etc, often highly personal, about how bad they believe radonc is and people should run from it....that of course would impact potentially interested people in radonc. Perhaps this is the goal of these people, to sound the alarm to whatever the problem is and help these individuals go into another field. However, data will show that most other providers in medicine work longer hours for less pay and debatable have less impact as curing or palliating cancer...I realize many may disagree but I can tell you that I as Chair talk with many other Chairs whose faculty make far less and work more. However, I would think the generational and social media impact would impact all specialties fairly equally. So what appears unique to radonc? Or is this unique to radonc?
-Is it declines in private/community practice compensation with healthcare consolidation? In most academic university centers salaries have gone up (they were in the low $200k at U of M for new grads 10+ years ago and now are >$300k...I realize inflation is brutal recently but salaries went up). However, the days of private groups owning their equipment and getting the tech revenue is uncommon now, so the >$1m salaries (more than even almost every single Chair makes in the country based on SCAROP data) are hard to come by. However, salaries have tanked in dermatology (my wife is one and our family friend who just retired at 70yo from derm cleared $1m a year easily much of his career and now most derms (not all) make $250-400k...same major declines in general surgery, radiology, etc. So is this unique to radonc?

These are just some examples, but I would genuinely appreciate people who often write passionately about the decline of our field on this forum, and what the core problem is. Of course it is multi-factorial the cause, but what is the problem. This should be able to be clear and concise. Again, the causes and effects will be complex, but how would you state what the problem is in 1 short sentence.

I realize I am entering the lions den and I have read many of the incredibly negative and frankly disrespectful threads about me or my friends on SDN from people that have minimal to no personal knowledge or context to the things they write about. Not sure peoples motives for personal attack or how I have wronged them in my short career as faculty (~6.5 years)....but my name is Daniel so I hope my mom and dad were right giving me that name as the den has been entered!

If you would like for your anonymous voices to potentially be heard by the academic chairs across the country in Washington DC, let it rip.


Thanks
Dan

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[Chartreuse Wombat]

The RO job market is weak (for a number of reasons-1) mostly geographic given the requirement of being tied to a machine 2) increasing trainees by nearly 200% over two decades 3) declining indications 4) falling reimbursement).

Medical students know this and are acting accordingly.

I know more than one sentence but that is my summary.

 

[RO28]

Yep, I agree with the above. To further elaborate on point #1, if you are living in a place where you have family support, etc and generally like the area but there are multiple challenges to your job, you have ZERO (or close to zero or very limited) options to make a lateral move, depending on the location.

 

[OTN]

Sentence 1: A dramatic increase in the resident complement over the last decade has significantly eroded the bargaining power of individual radiation oncologists in the marketplace, leading to a drop in quality of life and professional happiness.

Sentence 2: Academic radiation oncologists have abrogated their duty to advance the field, instead focusing on social science research and non-inferiority studies which have done nothing to either improve patient survival or side effect profiles.

 

[Bequerel]

It’s really not that complicated. Medical students follow money and lifestyle. It’s not a coincidence that the hardest specialties to match are the most lucrative. 10 years ago there were countless private practice job opportunities in desirable locations with 600k+ salaries. Hence, the MD/PHD, AOA, 270+ USMLE typical applicant. Since then there are double the number of trainees and no desirable jobs being advertised. What don’t you really get?

 

[elementaryschooleconomics]

I agree with what @Chartreuse Wombat and @RO28 said.

Specific problems to RadOnc, in bullet-point brevity:

• We are tied to the linear accelerator, which is one of (if not the) most expensive single pieces of equipment in modern medicine. In the majority of states, you must have government permission to install a new linear accelerator, even if you have the money. We cannot do our job without a linear accelerator, and there is nothing else like this in medicine. This is the root of the geographic issues.
  
  
• We are not able to do our jobs without significant help from other people with specialized skills and certification, to a much more severe degree than anyone else in medicine. Unlike much of the rest of the world with "Clinical Oncologists", we do not prescribe systemic therapy. We only perform radiotherapy. However, the vast majority of Radiation Oncologists are unable to perform actual treatment planning, and rely on Dosimetrists. We are unable to maintain or troubleshoot the linac, and cannot QA the treatment plans created by Dosimetry, we rely on Medical Physicists. We do not deliver the actual treatment, we rely on Radiation Therapists. While it can be argued that a surgeon cannot operate without a staffed OR, at the end of the day, they're holding the scalpel. If surgeons did their jobs like we do ours, they would sit off to the side of the OR and tell someone else where and how to cut and suture.
  
  
• The research and clinical trials with the biggest impact from Radiation Oncology have been aimed at reducing or omitting radiotherapy. To be clear, the motivation behind this is improved patient care (lower toxicity, physical and financial), and should be applauded. However, no other field has pursued reducing their own footprint as relentlessly as RadOnc while simultaneously doubling the output of physicians.

Everything else affecting us affects other specialties to varying degrees of severity (reimbursement cuts, admin oversight, inflation, etc).

American Radiation Oncology is uniquely troubled by its physicians being tied to a government-regulated, multi-million dollar piece of equipment that we don't know how to use outside of tracing structures on a DICOM file while spending the past 20 years pursuing research aimed at reducing or omitting the use of radiotherapy while doubling the number of new Radiation Oncologists produced.

 

[TheWallnerus]

It has been a while since I have jumped on SDN and was hoping to gain additional vantage points and perspectives on a hot topic on SDN. I realize there are many posts/threads, papers, tweets, etc on this, but wanted to try to get the discussion going in a different way than I have seen (if I missed it please shoot me a link to the relevant thread). The impetus for this post is that I am speaking as a panel member at the upcoming SCAROP meeting in a few weeks on the issue of interest in our field/applicant numbers.

Normally I start any project with identifying the problem clearly and concisely, and then doing a root cause analysis to the upstream and downstream effects, causes, correlations to understand how to study and fix it. I am struggling to identify and appropriately characterize what the issue is exactly. I do not mean this to say there is no issue, but I am struggling to consicely convey what the problem is that gets discussed so passionately. This 1st step is so critical as you cant solve something, or even appropriately study it if you cant define it.

Many discuss the concept of this problem frequently, but what is it exactly?
-Is it reduced interest in our field? Some would say that interest is still there of those that apply, so it cant be just interest. Applicant numbers are reduced, so is it general interest perhaps is reduced? Is lack of more broad interest itself a problem? Is it a lack of positivity in our field or promotion of our field the problem? Furthermore, is reduced applicants an actual problem for a field? Reflexively many people say yes, but why? Reduced applicants means fewer residents to train (assuming SOAP did not occur) and this may be natural market forces balancing of supply and demand. However, as SOAP does occur, then is the problem we have people entering our field without prior radonc interest (or as much interest)? I then ask what is the problem that this results in? I did not know about radonc until a few months before I applied and never did an away rotation. My appreciation for radonc grew stronger over time, so I am not convinced that it is a problem in and of itself. Or is it the caliber of people who SOAP in not sufficient? I again challenge this as does having someone publish a nature paper with a Step 1 score of 270 from Harvard mean they will be a better clinical radonc than someone who did no research in med school, got a 220 from a state school? Not sure that this is the actual problem either.
-Is it the change of the job market as a result of the changes in healthcare (consolidation of practices, fewer and fewer solo practices, etc)? What is the unique problem that radonc faces that other specialties do not with these changes? Jobs are more now than ever part of bigger and bigger centers/companies and what was independent practices are now community affiliate positions. Is this the problem? This is happening across healthcare, so is this unique to radonc?
-Is it that residents are graduating and they are not getting a job after years of school, training, and debt? What is the best data for this to graduates truly not having any open positions to apply to. I say this as right now in Northeast Ohio alone I know of one group using a locums looking to hire a permanent doc, another using 3 locums trying to find 2-3 permanent positions, and another using 2 locums that needs 3 permanent docs. These are all centers not part of my institution. I have hired 8 physicians in 12 months and am recruiting 6 more. So is it that there are in fact jobs, but they are not the types of jobs people want (community vs main or solo vs multi-provider practice or academic vs non-academic or salary level or research or city vs rural or middle america vs coasts)? Totally understand not everyone wants to move to some of these centers in the rural midwest, or the environment is not what they want, but they are jobs. This difference matters in order to address the issue. Or is it number of jobs and the types of jobs? Is it a mismatch in we have tried to attract hyper academic, many MD/PhDs, to a market that supports having very few of them and so there is a mismatch of applicants wants and job availability? If we recruited mainly people who wanted to be community radoncs across the country would we have the same discussions?
-Is it the expansion of medschools/slots and residency programs/slots and this goes back to is there truly an oversupply and not enough demand? Or the demand is there does not match the interests of the applicants (ie tons of people graduating in Cali and NYC but jobs are needed in middle america)?
-Is it a DEI issue (or at least in part)? Our applicant pool is dominated by non-URM males so we are missing out on hundreds (or thousands) of women and URM that are applying to derm, radiology, etc. While this should absolutely be addressed and likely a contributing factor, it doesnt appear that the diversity in radonc is rapidly declining to explain the sudden change from when I applied to radonc in 2010 and by 3 years after I graduated in 2018 applicant numbers seemed to be dropping. If anything I thought I saw in recent papers some improvements in some components of diversity (at least gender) in radonc faculty.
-Is it a generational (I am a millennial technically too) or a manifestation of social media in that issues can now be brought out into the light to mass audiences more easily? I hope this audience can appreciate at times there has been disrespectful and unproductive comments on SDN, twitter, etc, often highly personal, about how bad they believe radonc is and people should run from it....that of course would impact potentially interested people in radonc. Perhaps this is the goal of these people, to sound the alarm to whatever the problem is and help these individuals go into another field. However, data will show that most other providers in medicine work longer hours for less pay and debatable have less impact as curing or palliating cancer...I realize many may disagree but I can tell you that I as Chair talk with many other Chairs whose faculty make far less and work more. However, I would think the generational and social media impact would impact all specialties fairly equally. So what appears unique to radonc? Or is this unique to radonc?
-Is it declines in private/community practice compensation with healthcare consolidation? In most academic university centers salaries have gone up (they were in the low $200k at U of M for new grads 10+ years ago and now are >$300k...I realize inflation is brutal recently but salaries went up). However, the days of private groups owning their equipment and getting the tech revenue is uncommon now, so the >$1m salaries (more than even almost every single Chair makes in the country based on SCAROP data) are hard to come by. However, salaries have tanked in dermatology (my wife is one and our family friend who just retired at 70yo from derm cleared $1m a year easily much of his career and now most derms (not all) make $250-400k...same major declines in general surgery, radiology, etc. So is this unique to radonc?

These are just some examples, but I would genuinely appreciate people who often write passionately about the decline of our field on this forum, and what the core problem is. Of course it is multi-factorial the cause, but what is the problem. This should be able to be clear and concise. Again, the causes and effects will be complex, but how would you state what the problem is in 1 short sentence.

I realize I am entering the lions den and I have read many of the incredibly negative and frankly disrespectful threads about me or my friends on SDN from people that have minimal to no personal knowledge or context to the things they write about. Not sure peoples motives for personal attack or how I have wronged them in my short career as faculty (~6.5 years)....but my name is Daniel so I hope my mom and dad were right giving me that name as the den has been entered!

If you would like for your anonymous voices to potentially be heard by the academic chairs across the country in Washington DC, let it rip.


Thanks
Dan

Thanks for coming by and asking, Dan.

1) Math (using any simple, predictive model) implies job situation will worsen: rising supply in rad oncs, declining RT utilization, declining incidences in the top cancers (lung especially), declining fractionations (and reimbursement)... the raw number of new RT patients per year has actually fallen over the last 20y.
2) Medicare data shows reimbursement per rad onc declining, and Royce et al data show declining salaries of rad oncs last decade (IRS data); now factor in APM.
3) Geographic options suck in rad onc (ARRO data), recent ARRO data showed the avg grad gets 2 firm job offers, 20% get just one, and ~5% got none; this is a p<0.000001 difference vs other specialties. Plus the number of "apprentices" (ARRO data) significantly increased 2021 vs 2020: these are not gainfully employed grads.


Sorry couldn't constrain to one sentence. Let's just start with these three. No hyperlinks (*citation needed), but will supply if you wish. You are shielded because you are in a high volume center (they are doing very well), which tends to get more high-volume-y in time (1/3 of all rad oncs in America are now employed in just 90 systems), and these high volume centers get phenomenal insurance reimbursements.

 

[jondunn]

To add to ESE's summary which I agree with every word of - another tricky part of the problem is that we want patients to be able to get cancer care in their local communities, which basically necessitates some really lightly used machines. I think this is tough to sustain. There are three options:

1) stick with status quo, each rad onc in their small community site just has fewer and fewer on beam as the years go on (as standard schedules get shorter and shorter, the ship has sailed on this, time to accept it). To make this financially make sense, need some bundled payment system, a much improved APM.

2) get rid of our approach of a linac on every corner, and move towards central RT where patients have to travel to and insurance/govt pays for lodging

3) keep linacs in people's communities, but keep the rad oncs more centrally located, who virtually meet the patients, plan the patients virtually, and have NPs be the 'on site' overseer of stuff. in this version of the future, we would review cone beams virtually for sbrt patients, etc. we arent really that far away from being able to do this.


you pick which one makes the most sense

 

[Ray D. Ayshun]

Haha. The problem is that people in charge are using a lot of words to discuss an exceedingly simple scenario in a free society.

 

[deleted1116990]

It’s really not that complicated. Medical students follow money and lifestyle. It’s not a coincidence that the hardest specialties to match are the most lucrative. 10 years ago there were countless private practice job opportunities in desirable locations with 600k+ salaries. Hence, the MD/PHD, AOA, 270+ USMLE typical applicant. Since then there are double the number of trainees and no desirable jobs being advertised. What don’t you really get?

Exactly. Convince med students there is a reliable pathway to early career 600-800k income with a reasonable lifestyle with a choice of metro area and things will go back to the way they were. That pathway was blown by overtraining by >2X.

Right now, the only people offering that is Avera in the middle of nowhere Iowa with a contract that locks you in for 5 years with a 6 figure penalty for leaving and a salary that decreases by a fixed percentage every year. You think med students want to sign up for that?

 

[Doctorer]

To add a different spin:

Because great medical students can go in to any specialty they want, and radiation oncology is currently a poor choice with respect to autonomy/lifestyle/pay/quality of life in comparison to their other options.

 

[TheWallnerus]

To add to ESE's summary which I agree with every word of - another tricky part of the problem is that we want patients to be able to get cancer care in their local communities, which basically necessitates some really lightly used machines. I think this is tough to sustain. There are three options:

1) stick with status quo, each rad onc in their small community site just has fewer and fewer on beam as the years go on (as standard schedules get shorter and shorter, the ship has sailed on this, time to accept it). To make this financially make sense, need some bundled payment system, a much improved APM.

2) get rid of our approach of a linac on every corner, and move towards central RT where patients have to travel to and insurance/govt pays for lodging

3) keep linacs in people's communities, but keep the rad oncs more centrally located, who virtually meet the patients, plan the patients virtually, and have NPs be the 'on site' overseer of stuff. in this version of the future, we would review cone beams virtually for sbrt patients, etc. we arent really that far away from being able to do this.


you pick which one makes the most sense

3

1 will not save us, because the bundles will not be big enough (and to be big enough the payors would have to be chumps)

2 is kind of mean-spirited toward patients, and tax-payers

3 is actually cost-effective and gives rad oncs flexibility in a lot of ways

Exactly. Convince med students there is a reliable pathway to early career 600-800k income with a reasonable lifestyle with a choice of metro area and things will go back to the way they were. That pathway was blown by overtraining by >2X.

Right now, the only people offering that is Avera in the middle of nowhere Iowa with a contract that locks you in for 5 years with a 6 figure penalty for leaving and a salary that decreases by a fixed percentage every year. You think med students want to sign up for that?

One of rad oncs best features circa 2005-10 was that it was a small club doing wide-ranging, unique work

And then the club got too big for economic realities not to set in

 

[Doctorer]

And to add: telling med students "things are just as bad in derm/ent/urology/etc" does not seem like a winning strategy. First, they aren't. Second, maybe we should focus on figuring out how to get our own house in order instead of trying to put others down?

 

[Mandelin Rain]

The deck is stacked against a medical student who wants to do any/all of the following once they graduate residency; live where they want, work in the practice environment of their choice, earn as much as they care to work, and have a fairly certain professional future.

These are basic "wants" of essentially every physician. We fail on all accounts as a specialty.

 

[TheWallnerus]

live where they want, ⚫⚪⚪⚪⚪
work in the practice environment of their choice, ⚫⚫⚪⚪⚪
earn as much as they care to work, and ⚫⚫⚪⚪⚪
have a fairly certain professional future.⚫⚫⚪⚪⚪

Re: "earn as much as they care to work," @Dan Spratt , even Nick Z showed how new grads (and thus all future rad oncs) have a ~60% chance of winding up in a "low volume" (lowest quartile of "work") center. Why would a med student "risk" that?

 

[medgator]

To add a different spin:

Because great medical students can go in to any specialty they want, and radiation oncology is currently a poor choice with respect to autonomy/lifestyle/pay/quality of life in comparison to their other options.

You can actually find a lot of that in a job but essentially take a BIG hit on geography. There are simply less "good" jobs in desirable coastal and Sunbelt metros compared to other procedural/surgical specialties like ENT and urology.

Geographic determinability is the overriding concern for many and rad onc sucks at that more than most, even when the job market was better than it is now @Dan Spratt

I would do rads, med onc or GU in a heartbeat if i was graduating in 2022 with the grades and USMLE i had when i was applying to rad onc after the turn of the century. By a mile.

Bottom line Dan, cut the damn spots by half at your program and every program that gives a damn that you can talk to at SCAROP. The field is sick and graduating nearly 200 a year isn't helping the problem.

I sincerely hope you came here to help fix our field and aren't BS'ing us. For all the **** that gets talked about re: SDN rad onc by Twitter rad onc, Chirag Shah and us were right and they were wrong. At this point rad onc acadmia needs to put up, shut up and cut spots like they did in the 90s. Not hard

 

[Doctorer]

You can actually find a lot of that in a job but essentially take a BIG hit on geography. There are simply less "good" jobs in desirable coastal and Sunbelt metros compared to other procedural/surgical specialties like ENT and urology.

Geographic determinability is the overriding concern for many and rad onc sucks at that more than most, even when the job market was better than it is now @Dan Spratt

I would do rads, med onc or GU in a heartbeat if i was graduating in 2022 with the grades and USMLE i had when i was applying to rad onc. By a mile

Sure, but point stands. Include geography under "lifestyle/quality of life." Top med students don't want to live in Salina, KS, no matter how much autonomy they have.

 

[TheWallnerus]

@Dan Spratt , Emergency Med docs now get pay offers of $21/hr

I am not so good at math and charts... how close is Emergency Med to rad onc on the graph

I kid. Or do I.

 

[GapCalc]

If SCAROP is interested in transparency, they should allow non-chairs (i.e. regular ASTRO attendees) to attend their meetings. Even better, stream it live for those of us covering machines in busy and not-so-busy community practices...

 

[RickyScott]

Problem is oversupply constraining the job market, made worse by knowledge that future indications for radiation are declining. Many over focus on salary, not geography, but surveys consistently show that geography is the number one factor in a physican job search. It is a total myth that radiation always had geographic limitations.

When I graduated (from a not very good program), jobs (not necessarily good ones) were available in almost every city, and part of what made specialty so competitive. We often have working spouses with their own geographic limitations. Let’s say a woman’s partner is an engineer, or PhD, should he become a stay at home dad when they move to Montana.

 

[RickyScott]

Re: "earn as much as they care to work," @Dan Spratt , even Nick Z showed how new grads (and thus all future rad oncs) have a ~60% chance of winding up in a "low volume" (lowest quartile of "work") center. Why would a med student "risk" that?

Dan, Didn’t you just hire Nick Z?

How do you think productive docs from good programs initially end up at total dumps like Hershey? Have you been to Harrisburg? When I graduated, someone like Nick would have been taken by a major academic player in a desirable city.

 

[jondunn]

My name is Daniel Too!


Damn Daniel!

 

[Dan Spratt]

The way the question is written is not in a way that seeks truth.

The questions that are self-answered.

Remember, to chairmen, we are a monolith and I am allegedly the leader of “a fringe group”. (We can presume many of you are net positive on me, but certainly no one ever calls me their leader).

Remember, the head of SCAROP was on a panel with me, and sneers that there are any issues at all ($1.7m salary).

Remember chairmen that complain they are getting cancelled because they are disagreed with.

Remember chairs saying that salaries are high and more residents can help with that.

Remember the substance abusing chairs and those that abuse residents.

What trust do you have with these people?

They can read the forum, listen to our podcasts, read on twitter, etc. All of you are re-writing things we’ve written 1000 times. Maybe let them do a little homework? Their residents come to me and complain. Why is that? They come to my friends to talk about being bullied in residency. Etc. I’m not optimistic and wonder what the true agenda is, because all of the information he wants is available.

Simul-
If your post is to say the problem with radonc is academic Chairs or leadership of our field, that is a point I welcome to hear and would like you to expand on. I do find it ironic that the second I go from faculty to Chair though I now become part of the problem but I am open to learn.

However, I think it is odd Simul to assume that SCAROP speaks for all Chairs. Just because I or many newly hired Chairs are now invited, it in no way means we agree with every other Chair on the thousands of issues our field faces. I am sure even many senior Chairs disagree on funds flow models, recruitment/staffing metrics, etc. Just as ASTRO's leadership or executive board doesnt represent every radonc, even those that are members. I am of course 1 year into this, but I am sure you can appreciate that not all Chairs have drinking problems and are not fired, not all Chairs say there are no issues with our field, not all Chairs think we need more residents and should abuse residents.

You have a voice to help direct people towards solutions, and my post is sincere. You helped sound some of the initial alarms, but like any movement and change it takes persistence, consistency, positivity, cooperation, open mindedness, etc. Change is not made from calling people out, saying things are terrible, assigning blame, and then hoping it all fixes itself. It comes from those who stay open minded, try to understand all sides, understand solutions to complex issues, and bring people together and not push them away.

As with any root cause analysis you must be able to clearly and simply state the problem. Anyone who has been part of lean or quality improvement training knows this (pick your method of learning from defects, RCA, A3s, SSS, etc). I have spent time reading your posts, papers from multiple people, etc, and am still no expert, but have not found the problem clearly stated as you would if truly trying to solve the problem. Hence, why I come on here to people that are very passionate and vocal on the topic. The question is sincere and seeks peoples opinions. I am sure you dont think that every single person in our field will define it the same. I seek the diversity of viewpoints, and most as you have seen from the posts struggle too with pinpointing the problem. It is a common reflex to point to solutions (cut programs in half...which may be the answer), but without identifying the clear problem you cant study it and understand it. By cutting programs in half you may make the already underserved rural communities have no access to radoncs. This is a bad thing. Perhaps it should be to limit programs in regions with oversupply? One must model the impact this would have. I hate to state the obvious, but changing the reputation and interest in an entire specialty is not something easy to implement. Just as it took years of decisions to bring us to this point. Every decision has an after effect (ie attract top researchers, MD/PhDs seemed like a great idea...promote discovery...however many simply went into private practice to make lots of $$$, many had no interest in seeing patients and there were too few jobs for them, and before you know it you have people that are approaching 40 yo when exiting residency with tons of research experience to find out there are not 50 physician scientist jobs available each year and some years closer to 5).

So when someone asks to hear peoples views to incorporate them in to a talk to radonc Chairs, and the opportunity is met with your post....how are you helping solve the problem? Easy to point out problems left and right. Just as its easy to say there is no problem while sitting on top. However, there are many people interested in helping our field. Many are on this forum. So while I appreciate your vantage points, I would respectfully request for you to hold off maybe 1 week of your reflexive negativity that will result in blunting those who want to help our field from speaking up here so their message can be conveyed.

Much of what I posted initially, including the comments about social media and negativity on forums like SDN I believe contributes to the rapid decline in applicant numbers. However, I believe this is a result not the cause. There are upstream issues, I mentioned multiple but not all. It is a genuine post, and while SDN is great at promoting free speech, I do respectfully ask to not use your leadership on SDN to deter people from voicing their opinions, but rather encourage them to share.

To those who want the SCAROP meeting to be public, this is my 1st one so cant speak to if that makes sense or not. When I speak to the FDA, or NCI, or closed session NRG meetings, or institutional Chair meetings....these are not public and there are other forums that are public for a reason. Most of these there is good reasons to not be public. I dont know yet what is discussed to determine if it should be open to the public or not. 1st timer. They are inviting representatives from ACGME, ARRO, and ASTRO who are vocal proponents to the current issues, and as I am the only Chair on the panel speaking on the topic (all chairs will discuss of course) I want to try to represent diverse inputs.

So to your post:
I have not increased resident slots despite our program growing now by almost 30% in patient volume and even more in faculty/staff volume (our main campus will have 50% more physicians in the next 6 months than when I started). We hired 3 more APPs and 4 nurses and no extra residents. I think if you ask our residents today (cant speak to the past before I joined) I am vocal about trying to improve education vs service balance and crank up very high newer forms of education/leadership training/mentorship. Not perfect but trying to improve. I rarely drink alcohol (I am boring) so doubt it is even possible to show up to work drunk. I dont make millions and say there is no problem. I am trying hard to reimagine what a large institution radonc department looks like, how people are compensated, etc. Salaries have been increased to 75th percentile in a city that is cheap to live. I dont pay $800k, but for a good job for someone 5-25 years out I pay $500k to $650k now (feel free to ask Nick Z to those who mentioned his name who I hired if this is true). Added more support for physicians (staff and software automation...you know about Medlever already which is amazing). With all of that I am flawed, still learning every day, make mistakes. I am not an enemy. I am someone trying to do my part, imperfect, but trying.

I think our field is great and is filled with many brilliant people that I am confident can make radical changes. Wont happen overnight, but from 5 years ago when many totally ignored there is any issue, I think there is a growing number of leaders and programs thanks to people who spoke out who want to make a difference.

I knew I would be met with the regulars who bash me on SDN, so I knew what I was getting into. Thanks to those who have replied. It is sincerely very helpful.

Best,
Dan

 

[thecarbonionangle]

I will not repeat what has been said here by others so i will keep it simple.

The problem with this field is warranted resentment and lack of leadership.

Take the major organizations in this field. It is a total circle jerk of the same institutions with little input from community. It is very hard to get involved meaningfully unless you are in that group. There is a lot of arrogance in this field and hubris. People who worked their butts off deeply resent that. Now anyone with a pulse joins.

We resent that the oversupply stuff has been ignored. All the hellpits filled in SOAP. Many took people with little to no interest in oncology, rejects from other fields. The canary died a while back and nobody listened. So when I see “leaders” suggesting there is no issue i resent that. When i see the same groups of people making all decisions which affect all of us, i resent that (almost always same cabal of academics). Lets be honest many places need to contract and shut down. Some of these places are lead by your friends, and perhaps even you.

I resent the petiness and inability to have a discourse of ideas. It seems many “leaders” in this field would rather crush dissent rather than face it and engage it and do something about it. People seem incredibly thin skinned, insecure and disingenuous. When i talk to people at meetings, i hear the same ideas of frustration, disillusionment, etc. it is a malaise which is not getting better but getting worst.

 

[jondunn]

Dan - You know what that’s a pretty darn good post/reply. I do respect you coming on here. Good luck at the meeting.

 

[Dan Spratt]

Dan, Didn’t you just hire Nick Z?

How do you think productive docs from good programs initially end up at total dumps like Hershey? Have you been to Harrisburg? When I graduated, someone like Nick would have been taken by a major academic player in a desirable city.

I will ask him. I can tell you personally I had zero desire to work in a major city and chose the small town of Ann Arbor. People in NYC and Boston thought I was nuts to leave NYC and MSKCC. However, I believe I demonstrated you can be very productive outside of a city or major academic place. I actually mentored Nick Z when he was looking for jobs out of residency and he had other options. However, Penn State gave him a massive startup, far bigger than mine was and if I were to guess he knew that if he had the resources he had the drive and talent to succeed anywhere. He proved that to be true.

Many forget that working at MDACC or MSKCC doesnt mean you will do great research. In fact, majority of the docs do none or very little. However, select few do incredible work and are part of an amazing environment. There is practice changing work done in small and big centers and it is the people not the place almost always. Nick Z is a great example where people know Nick Z as an awesome person, researcher, mentor, etc. Most dont even know where he works. He had the confidence to take the biggest and best offer at a less known place and crush it. I love it!

Nick joined me here, and lets be honest. University Hospitals Seidman Cancer Center/CWRU does not have the name recognition radonc as MSKCC, Hopkins, MDACC, etc. However, the people make the place and Nick I think will tell you that the 8 new faculty recruits, the 30+ new physicists and dosimetrists and RTTs, and the immense focus on culture and teamwork, will create an environment that he will continue to prosper and grow to even new heights. The goal isnt to have the biggest name, but to be the best place for patients to come and people to work. I do believe that what we as a team accomplish will change the viewpoint of what our program is, just as Nick Z elevated the Pennstate program while he was there.

Nick was being actively recruited to 2-3 other big name places, but chose to join our program. Sometimes I think people choose the opportunity over the name. I hope to prove he made the right decision

 

[jondunn]

Thanks, Dan, for again being insulting to me publicly. It tells us far more about you than me.

My reflexive negativity? Ask your own graduating residents from Michigan if I’m reflexively negative. Have you listened to the work we have created? Is someone who is reflexively negative about the specialty going to commit hours to promoting the bright lights in our field, like your faculty member Nick Z? To have voices that no one else has and give them a spotlight? To give lectures to dozens of programs and help with the job search? To take calls from residents and students to help them get from point A to B? I’m not faculty and never have been, but these folks come to me. Why is that? Because I hate radonc?

Your condescension and arrogance makes it hard to believe your sincerity. Every single response above has been stated before in many forms. Every contributor here is committed to the specialty, even if we don’t agree with each other. That’s why this community matters.

Also, if you have questions about my career moves, how about you DM instead of gossiping to others? I’ll tell you all about it, “buddy”

Did I miss him posting about your job moves? Did he delete it?

 

[jondunn]

This can be easily solved on the podcast - come on boys!

Nick Z can be back on there as well. Throw in my brotha Todd S while you at it and baby we have ourselves a stew!

 

[Baws]

The tangible issues are:
-Residency expansion and job market fears (most medical student will not rotate in our department based on hearsay on social media; a simple search on doccafe shows the stark contrast between medonc v. radonc in desirable metro areas)
-The fact we have 4 board exams (medical student who do rotate in our department are immediately taken aback by this concept; Wallner's and Kachnic's response are posted and framed in our resident lounge (rightfully so I believe))
-APM and how everything will be 1-5 fractions

More generally:
-This generation of medical students/residents view radiation oncology leadership to be that of Ralph Weichselbaum (old men who have watched this specialty falter and did nothing, apart from counting their millions while stating that junior faculy make too much and should be paid like pediatricians)

 

[deleted1111261]

I can’t help but play this ridiculous game.

The number one problem is the way academics have poisoned their relationship between themselves and the community.

Faculty commonly say things like “Dr So and So in the community does ____” mocking them when talking to residents. I’ve experienced it and every single resident has heard faculty speak this way.

Academic centers have bought out practices and decreased quality of care and increased prices, but shame the freestanding guys for treating standard of care (as listed by NCCN guidelines). I don’t fractionate like @medgator but I defend his right to do it that way, he’s still cheaper than the U.

The board has failed us - the certification exams are a waste of time and only under duress have they changed them in any meaningful way. Failing 40% of residents and blaming them for it - this is not attractive to students.

The field promotes research that minimizes our footprint and the RJ is turning into a social science journal. I came here to learn oncology. Now, it’s off to the next culture war discussion, instead of trying to cure cancer. Mudit is my boy and I’m proud of the work he’s done, but a report on paternity leave (near to my heart) is neither radiation nor oncology. But, the ship has sailed and the journal is going in direction.

It is respect - or lack of it - that drives most of this. There are good people out there, but it’s the ones with humility and kindness that will move the needle. I have a lot of optimism and I know it will get better, despite the leadership that currently exists.

 

[Lamount]

Dan, appreciate you coming on here. Clearly there is a lot of frustration. Some of the posters here were the first to raise the alarm on the workforce collapse we are facing… and some here are on the front lines, trapped in jobs and cities they don’t want because of lack of available positions. For years, their concerns have been met with sneers, chuckles and eye rolls (some from myself not too long ago), and some from people who hold the same title as yourself. These posters here were right and people like me were wrong. This is all to say… acknowledging that folks here shouldn’t have been gas-lit for years, and their concerns should have been taken seriously would probably go a long way to starting a productive conversation.

 

[medgator]

and while SDN is great at promoting free speech, I do respectfully ask to not use your leadership on SDN to deter people from voicing their opinions, but rather encourage them to share.

Not trying to be a dick here, Dan, but what in the f are you referring to here? None of that makes any sense.

No one is a "leader" here and i certainly have not seen any examples of opinions being deterred by simul either. My hope is you're being intellectually honest by coming to our "den" and getting perspectives other than your own. We all love our jobs and love this specialty but academics like Dennis H and Ralph W have by and large farked it up and it falls to people like you to fix up the house.

What you've done so far at case sounds good for faculty and residents. We need to return to 2000-2010 levels of residency slots full stop. That'll start to fix many of the problems immediately

 

[jondunn]

Not trying to be a dick here, Dan, but what in the f are you referring to here? None of that makes any sense

hes talking to Simul.

 

[medgator]

hes talking to Simul.

You think Simul is the leader of this forum? Is he squelching free speech here? It's nonsense and an unnecessary ad hominem from Dan imo which really detracts from his messaging and says more about him than Simul.

Most of us on here are set, with good jobs, families etc. But we know how far the wheels have come off and it's a sad thing to see.

Hopefully @Dan Spratt and other chairs can open their eyes to what we are saying. We have been here before (1996) and back then they made hard decisions then too

 

[jondunn]

You think Simul is the leader of this forum? Is he squelching free speech here? It's nonsense and an unnecessary ad hominem from Dan imo

lmao I certainly dont see simul as any sort of leader of SDN. i remember when he rage quit like a year ago on his former user name.

the good thing about SDN is there are no chairmen. no leader.

just saying that was who Dan was referring to, but I guess you knew that, you added more to the post afterwards.

 

[RickyScott]

I will ask him. I can tell you personally I had zero desire to work in a major city and chose the small town of Ann Arbor. People in NYC and Boston thought I was nuts to leave NYC and MSKCC. However, I believe I demonstrated you can be very productive outside of a city or major academic place. I actually mentored Nick Z when he was looking for jobs out of residency and he had other options. However, Penn State gave him a massive startup, far bigger than mine was and if I were to guess he knew that if he had the resources he had the drive and talent to succeed anywhere. He proved that to be true.

Many forget that working at MDACC or MSKCC doesnt mean you will do great research. In fact, majority of the docs do none or very little. However, select few do incredible work and are part of an amazing environment. There is practice changing work done in small and big centers and it is the people not the place almost always. Nick Z is a great example where people know Nick Z as an awesome person, researcher, mentor, etc. Most dont even know where he works. He had the confidence to take the biggest and best offer at a less known place and crush it. I love it!

Nick joined me here, and lets be honest. University Hospitals Seidman Cancer Center/CWRU does not have the name recognition radonc as MSKCC, Hopkins, MDACC, etc. However, the people make the place and Nick I think will tell you that the 8 new faculty recruits, the 30+ new physicists and dosimetrists and RTTs, and the immense focus on culture and teamwork, will create an environment that he will continue to prosper and grow to even new heights. The goal isnt to have the biggest name, but to be the best place for patients to come and people to work. I do believe that what we as a team accomplish will change the viewpoint of what our program is, just as Nick Z elevated the Pennstate program while he was there.

Nick was being actively recruited to 2-3 other big name places, but chose to join our program. Sometimes I think people choose the opportunity over the name. I hope to prove he made the right decision

At the end of the day, it is undisputed that the percentage increase in radoncs over last 20 years is greater than every other specialty, while indications are at best flat. Why would any medstudent even entertain the risk? The whole notion that they first need “data to prove beyond a reasonable doubt that there is a problem w/unemployment ” is so misguided. It’s just not how risk/benefit decisions are made. (And burden of proof/data lies with justifying the most extreme expansion of all specialties not visa verse) Plenty of vibrant alternative specialties out there, including medonc. We can discuss this to death, but can’t fault the logic of someone who takes a pass on radonc.

 

[elementaryschooleconomics]

I am equally interested in the inverse question -

@Dan Spratt, can you concisely explain, in one or two sentences, why medical students should choose to dedicate their careers to Radiation Oncology?

Personally, I love RadOnc. It's amazing and fulfilling.

If I had to do it all over again, I definitely would not. I enjoyed many of my rotations in med school; RadOnc isn't special.

Putting aside all of the other issues in the field: being married to the linac is more limiting than a medical student could possibly understand.

 

[Ray D. Ayshun]

If there's something besides residents we need less of, it's this thread.

 

[TheWallnerus]

Simul-
If your post is to say the problem with radonc is academic Chairs or leadership of our field, that is a point I welcome to hear and would like you to expand on. I do find it ironic that the second I go from faculty to Chair though I now become part of the problem but I am open to learn.

However, I think it is odd Simul to assume that SCAROP speaks for all Chairs. Just because I or many newly hired Chairs are now invited, it in no way means we agree with every other Chair on the thousands of issues our field faces. I am sure even many senior Chairs disagree on funds flow models, recruitment/staffing metrics, etc. Just as ASTRO's leadership or executive board doesnt represent every radonc, even those that are members. I am of course 1 year into this, but I am sure you can appreciate that not all Chairs have drinking problems and are not fired, not all Chairs say there are no issues with our field, not all Chairs think we need more residents and should abuse residents.

You have a voice to help direct people towards solutions, and my post is sincere. You helped sound some of the initial alarms, but like any movement and change it takes persistence, consistency, positivity, cooperation, open mindedness, etc. Change is not made from calling people out, saying things are terrible, assigning blame, and then hoping it all fixes itself. It comes from those who stay open minded, try to understand all sides, understand solutions to complex issues, and bring people together and not push them away.

As with any root cause analysis you must be able to clearly and simply state the problem. Anyone who has been part of lean or quality improvement training knows this (pick your method of learning from defects, RCA, A3s, SSS, etc). I have spent time reading your posts, papers from multiple people, etc, and am still no expert, but have not found the problem clearly stated as you would if truly trying to solve the problem. Hence, why I come on here to people that are very passionate and vocal on the topic. The question is sincere and seeks peoples opinions. I am sure you dont think that every single person in our field will define it the same. I seek the diversity of viewpoints, and most as you have seen from the posts struggle too with pinpointing the problem. It is a common reflex to point to solutions (cut programs in half...which may be the answer), but without identifying the clear problem you cant study it and understand it. By cutting programs in half you may make the already underserved rural communities have no access to radoncs. This is a bad thing. Perhaps it should be to limit programs in regions with oversupply? One must model the impact this would have. I hate to state the obvious, but changing the reputation and interest in an entire specialty is not something easy to implement. Just as it took years of decisions to bring us to this point. Every decision has an after effect (ie attract top researchers, MD/PhDs seemed like a great idea...promote discovery...however many simply went into private practice to make lots of $$$, many had no interest in seeing patients and there were too few jobs for them, and before you know it you have people that are approaching 40 yo when exiting residency with tons of research experience to find out there are not 50 physician scientist jobs available each year and some years closer to 5).

So when someone asks to hear peoples views to incorporate them in to a talk to radonc Chairs, and the opportunity is met with your post....how are you helping solve the problem? Easy to point out problems left and right. Just as its easy to say there is no problem while sitting on top. However, there are many people interested in helping our field. Many are on this forum. So while I appreciate your vantage points, I would respectfully request for you to hold off maybe 1 week of your reflexive negativity that will result in blunting those who want to help our field from speaking up here so their message can be conveyed.

Much of what I posted initially, including the comments about social media and negativity on forums like SDN I believe contributes to the rapid decline in applicant numbers. However, I believe this is a result not the cause. There are upstream issues, I mentioned multiple but not all. It is a genuine post, and while SDN is great at promoting free speech, I do respectfully ask to not use your leadership on SDN to deter people from voicing their opinions, but rather encourage them to share.

To those who want the SCAROP meeting to be public, this is my 1st one so cant speak to if that makes sense or not. When I speak to the FDA, or NCI, or closed session NRG meetings, or institutional Chair meetings....these are not public and there are other forums that are public for a reason. Most of these there is good reasons to not be public. I dont know yet what is discussed to determine if it should be open to the public or not. 1st timer. They are inviting representatives from ACGME, ARRO, and ASTRO who are vocal proponents to the current issues, and as I am the only Chair on the panel speaking on the topic (all chairs will discuss of course) I want to try to represent diverse inputs.

So to your post:
I have not increased resident slots despite our program growing now by almost 30% in patient volume and even more in faculty/staff volume (our main campus will have 50% more physicians in the next 6 months than when I started). We hired 3 more APPs and 4 nurses and no extra residents. I think if you ask our residents today (cant speak to the past before I joined) I am vocal about trying to improve education vs service balance and crank up very high newer forms of education/leadership training/mentorship. Not perfect but trying to improve. I rarely drink alcohol (I am boring) so doubt it is even possible to show up to work drunk. I dont make millions and say there is no problem. I am trying hard to reimagine what a large institution radonc department looks like, how people are compensated, etc. Salaries have been increased to 75th percentile in a city that is cheap to live. I dont pay $800k, but for a good job for someone 5-25 years out I pay $500k to $650k now (feel free to ask Nick Z to those who mentioned his name who I hired if this is true). Added more support for physicians (staff and software automation...you know about Medlever already which is amazing). With all of that I am flawed, still learning every day, make mistakes. I am not an enemy. I am someone trying to do my part, imperfect, but trying.

I think our field is great and is filled with many brilliant people that I am confident can make radical changes. Wont happen overnight, but from 5 years ago when many totally ignored there is any issue, I think there is a growing number of leaders and programs thanks to people who spoke out who want to make a difference.

I knew I would be met with the regulars who bash me on SDN, so I knew what I was getting into. Thanks to those who have replied. It is sincerely very helpful.

Best,
Dan

Your greatest virtue as far as I can tell is putting yourself in a situation where you engage. No matter the motives someone might ascribe to you, you engage, and this is a million times more than most.

Dan, rad onc is facing a crisis. But right now, from your viewpoint, all is well. I get that the salad days are upon you and your program. But all these wonderful anecdotes you are mentioning (you're hiring, your volume is up, etc) mean, because rad onc is "zero summing" itself in terms of patient workloads and numbers, that there are that many more bad anecdotes out there in our specialty as a whole in proportion to the good anecdotes. One-fourth of American rad oncs are new-starting less than 20 Medicare patients per year (and as you know Medicare patients make up about a third of all RT patients nationally). I can't think of many good analogies for this, but something like the movie "Don't Look Up" does come to mind.

The job market in rad onc is very brittle. No matter good program or bad program, when you get a job as a grad you feel lucky. And if you have to find another job and do so in a few years you feel doubly lucky. The rad onc job market is tough compared to other specialties.

Price transparency laws have shown us centers like yours can get *reimbursed* $100K-$250K for a conventionally fractionated prostate case. No wonder you guys can hire and expand. According to Medicare data, about 12,000 beneficiaries total get proton therapy a year; these 3% of Medicare patients are responsible for 15% of all of Medicare's rad onc Part B spending. What do you think those figures might be on the private insurance side where there are no hard ceilings for reimbursement like there are in Medicare? UTSW in Dallas has an Adaptive Radiotherapy Center with MRgRT units, PET-linac units, and Ethos's. They are charging multiply multiple IMRT plans per patient and can get $10K (or more) per plan from good payors. When will all these bubbles burst? If they burst, who will be left holding the bag?

Rad onc is facing utilization challenges. In the Lancet Onc just today there is an article harping on OVER-utilization of RT in rectal cancer. Lymphoma remains a section on the boards and as a generalist I see one case a year, maybe; in training, I did much more. The number of EBRT patients per resident continues to trend down per ACGME data. Stage III lung cancer is going away. Stage I lung cancer is happening more, but it can't keep up with the Stage III decline. Five fraction breast will happen ubiquitously this decade if single fraction breast doesn't catch on first. Almost half of all definitive EBRT patients in America are breast... one small change in RT care patterns in breast is a BFD, one would think. And prostate, your bailiwick? It's the second most common definitive cancer we treat now, but JAMA Onc in 2021 predicted that it will be the 14th most common in 2040. All these aforementioned changes are happening quickly. Are we agile enough to keep up?

Yes, I ascribe most of our specialty's problems to rad onc over-supply. There is no way to prove it, but I can make some arguments that in a world where there were 3500 U.S. rad oncs instead of 5500-6000 as we have now, total rad onc spending would have decreased much more than it has over the last decade. The rationale for Evicore maybe wouldn't have been there and neither would have the rationale for the APM. All the consolidation maybe wouldn't have been as great, and the juicy private practice opportunities maybe more plentiful. With less rad oncs, maybe all rad oncs would have been working more and there'd have been less time for RT omission trials. With less rad oncs there would have been more stable salaries overall (your academic experiences notwithstanding) and less geographic restrictions. And there would have been better opportunities for those wishing to make intracareer switch-a-roos.

So the lowest hanging fruit I see is: cut the number of rad oncs nationally. We should try it. The biggest change mathematically in rad onc 2002-2022 is the number of rad oncs in America... not the number of rad onc patients, not the amount of rad onc work, not the amount of rad onc pay and reimbursement. The rise of the number of rad oncs has in fact been inversely proportional with a great many things IMHO.

I have <1% confidence those in your position and with your experience see it this way. We will need to have much higher new grad unemployment rates.* Then I guess if that happens I will say "I told you so" and maybe get rewarded with some people clicking "like" next to my told-you-so post and you eating a little crow if we ever bump into each other at a conference... both of which will be pleasant, but bittersweet.

EDIT:
In 2021 vs 2020 a total of 10 vs 3 new grads had no offers and/or took non-ACGME accredited underemployment (p<0.05). I have an anecdote: one URM took a fellowship because she couldn't find a job. Who knows if this will be a blip... or a trend.

 

[thesauce]

Oversupply is the root of all of the problems.

It is the reason for the bad job market, declining wages, fraction-shaming/jealousy, poor quality applicants, lack of interest from URMs, and pretty much everything else you mentioned.

 

[CaesarRO]

You are looking for a way to frame the "problem" simply, in one sentence. I think as you've noted, there are multiple problems with multifactorial causes. There are factors that are outside our control that are definitely contributing to the issues and there are factors that are in our control that are likely (but maybe not conclusively) contributing to the problem.

ElementarySchoolEconomics did a great job summarizing the factors that are more extrinsic to our control and intrinsic to our specialty. With some of those I think many chairs would throw up their hands and say "not much we can do about that," and either dismiss the issues as beyond our specialty or beyond their control.

What SCAROP should care about are the things that are within their control.

I think the problem summed up simply and worthy of a root cause analysis/SCAROP attention would be:
There is an intrinsic conflict of interest between a chairs goal of expanding their department as much as possible and the well being of the field as a whole.
(ETA: you clearly got a big package in your new role to hire all the faculty that you are bringing on board. It's great that you are able to do this, but is also a microcosm of the issue in that 1) your institution invested a lot in you which most institutions are not, and 2) it's worth asking yourself what are the knock-on effects for jobs in the Cleveland area from UH's major expansion of Rad Onc services?)

and the question that might be most fruitful if answered by SCAROP is: What can SCAROP do to balance the pressures on individual chairs and enable them to take risks in the broader interest of the field when that might go against local pressures within their department?

There was an excellent thread once that gave a long history of the Rad Onc job market and correlation with residency highlighting the similar job concerns in the early 90s, subsequent extension of training by 1 year and contraction followed by the boom in IMRT and the expectation that the same will happen again. I can't find it anymore but consider it a must read. I think we have to act now based on the current data, without the expectation of a new IMRT around the corner.

I don't think any discussion of the topic can be complete without highlighting the figure below (link to RJ paper) demonstrating the increase in residency programs and positions, a discussion of the two supply/demand papers with Ben Smith famously projecting a shortage of Rad Oncs in 2010 and then reversing course in 2016 (and importantly understanding the changes in oncology and the field that led to this sharp swing in the projections). The published response by the chair at WUSTL Dennis Hallahan in the RJ to his own junior faculty noting that there is a correlation between supply/demand and salaries is also frequent cited as a must-read and highlights some of the distrust as to the role of Department Chairs and potential conflicts of interest.

After raising some of these concerns with my own chairman over the years, I have heard "nah, there can't be that many more residents today than there were when I was training" and "but we have a phenomenal training program, why would I reduce spots and deprive people of this experience?" Both came across as extremely self-serving statements and emphasize the need to highlight to the chairman the real trends and that their own institutions greatness isn't an excuse to ignore what's going on in the field. I think it's also worth pointing out explicitly that the "we have great training" argument is a strawman so they can see why they can't fall back on it.

Aside from the above citations which all come down to the question of what should departments be doing with their residency programs (where self-interest would lead to expansion) there is also the question of research direction. I think the DEBRA trial NRG-BR007 is a perfect example of the frustrations on this board and on twitter with academics. I think there are increasing spaces in oncology where medical oncology is pushing expensive drugs or therapies that have marginal benefits, yet the trials with radiation only explore excluding ourselves. We need to be comparing radiation with those marginal drugs from an efficacy, toxicity and a cost-effectiveness standpoint to really prove our worth. We need to demand that medical oncology explore their own toxicities to the extent that the radiation literature has done so. Instead, they brush their own SMN risk under the carpet and point to our own data to exclude us from patient care.

SCAROP should explore ways they can empower Chairmen to work towards expanding indications and to encourage faculty to take on a more direct physician rather than technician role. See for instance the recent Accelerator's podcast with Ralph Weichselbaum and his discussion of Rad Onc role with radioisotopes. I think those academic departments with prominent medical schools need to find ways to bring a Rad Onc referral earlier in the work up of patients to put us on a better footing vis a vis medical oncology.

In my opinion, while I think the extrinsic factors are certainly important to fully understand (consolidation of medicine in more corporate structures, linking of our specialty to high-capital equipment, etc.) those are things that SCAROP has much less say in, and the conversation should focus on how to address the above.

Just my $0.02

Also, Dan, since we're being frank in this thread, I want to specifically point out that Ann Arbor may be a "small town" in some sense, but it's close to a major metro, is quite nice as far as college towns go, and has a major prestigious academic institution attached. I don't exactly view that as the huge sacrifice you make it out to be from a job perspective. Likewise, U of M is notorious for having among the lowest salaries in the field, routinely <25th percentile. While it is admirable what you accomplished while there (with a dermatologist spouse, making a dual physician income), I don't think an increase in salaries at U of M is anywhere close to generalizable to the rest of the specialty.

 

[jondunn]

essentially everyone in rad onc is out for number 1 at the end of the day, and why shouldn't we be, so chairmen are of course the same exact way. it's just theyre supposed to be better than that.

but they're not

 

[RickyScott]

Just want to clarify that I do not know Nick z or his circumstances. Have spoken with several colleagues who interviewed at Penn state and were not exactly complimentary of the job.

 

[metallica81788]

Cut residency slots and close bad programs. It's that simple. Nothing will get better until this happens.

The disconnect between big radonc and little radonc will take longer to fix (and honestly probably won't improve until some retire/die) but is secondary to the above.

 

[ROforbetterorworse]

By cutting programs in half you may make the already underserved rural communities have no access to radoncs. This is a bad thing. Perhaps it should be to limit programs in regions with oversupply?

Is there any data to show that increasing residency spots has led to increased employment in underserved rural communities?

Graduates from West Virginia can apply to NYC too...

 

[DebtRising]

Radiation is 5 years of training for a very narrow skill set which is constantly being utilized less and with no leadership looking out for the field.

Case in point - this is a great question Dr Spratt. But, did you need to ask it? The radiation field has a history of over supply. It has a workforce survey conducted based partly on the history of this occurring. The last time it was done, half the field said oversupply and job market concerns were there number one issue. There was essentially no engagement or acknowledgement of this from SCAROP or ASTRO. The field told you and SCAROP what was up 4 (5?) years ago. Nothing substantial happened. Some fringe changes to ACGME requirements may be the well meaning intention of some mid leadership excellent people to address this.

It’s simple math
-more residents, less utilizations, less fractions, higher bar to justify radiation, mandated national bundle payment model, expansion of fellowships, geographic restrictions unmatched in virtually any other field.

Radiotherapy Utilization and Fractionation Patterns During the First Course of Cancer Treatment in the United States From 2004 to 2014 - PubMed

We found a steady decrease in the percent of patients receiving radiotherapy in their first course of treatment, and a global decline in the mean number of fractions delivered per patient receiving EBRT, compared with an increase in systemic therapy and stable surgery utilization. These results...

pubmed.ncbi.nlm.nih.gov

Your post cited anecdotes of other specialty changes. I have colleagues from medical school in radiology with a 6 figure salary higher and work from home 3 days per week. Another in IM-hospital who does work 50% of the year, and chose their locations. Anecdote to anecdote, what a match. Salary, location, lifestyle, we can debate how much of the compassion we have (and are bred to show) should negate our desires to maximize our work. But given the choice, I would both like to be compassionate, and well compensated and flexible for what was put into getting here. If incoming medical students or other humans don’t desire this, then no one is stopping them from entering the field.


The field needs a drastic reduction to match the drastic increase in residency training spots which occurred. It has not happened. It does not look like it will. Supply and demand is undefeated.

 

[Dan Spratt]

I can’t help but play this ridiculous game.

The number one problem is the way academics have poisoned their relationship between themselves and the community.

Faculty commonly say things like “Dr So and So in the community does ____” mocking them when talking to residents. I’ve experienced it and every single resident has heard faculty speak this way.

Academic centers have bought out practices and decreased quality of care and increased prices, but shame the freestanding guys for treating standard of care (as listed by NCCN guidelines). I don’t fractionate like @medgator but I defend his right to do it that way, he’s still cheaper than the U.

The board has failed us - the certification exams are a waste of time and only under duress have they changed them in any meaningful way. Failing 40% of residents and blaming them for it - this is not attractive to students.

The field promotes research that minimizes our footprint and the RJ is turning into a social science journal. I came here to learn oncology. Now, it’s off to the next culture war discussion, instead of trying to cure cancer. Mudit is my boy and I’m proud of the work he’s done, but a report on paternity leave (near to my heart) is neither radiation nor oncology. But, the ship has sailed and the journal is going in direction.

It is respect - or lack of it - that drives most of this. There are good people out there, but it’s the ones with humility and kindness that will move the needle. I have a lot of optimism and I know it will get better, despite the leadership that currently exists.

Very helpful and appreciated. Will add to themes I am making.

 

[ROforbetterorworse]

Dan you seem to be doing a great job at Case

I'm sure you would love to, but come on do you really think you are going to hire 8 people every year?

For the record (not saying this is what you are doing), buying out existing practices doesn't count as global growth for the field

 

[TheWallnerus]

Is there any data to show that increasing residency spots has led to increased employment in underserved rural communities?

Graduates from West Virginia can apply to NYC too...

Yes. And as @Dan Spratt or a statistician should know, the probabilities are two sided. Cutting spots may make the rural jobs so lucrative we won’t be able to turn new grads away. Or we may get “lean” and let one rad onc start remotely covering one or two centers. Constant physician presence is not even mandated by our northern neighbor Canada. But beyond that, published data shows we are not only oversupplied in rad oncs we are over-supplied in linacs. A recent Red J article showed a small minority of Americans (about 12% IIRC) live more than 50 miles from a linac. Access to rad onc care is a problem, but it might get FIXED with less rad oncs and if Medicare makes virtual supervision permanent. DEEP THOUGHTS

 

[Dan Spratt]

Dan you seem to be doing a great job at Case

I'm sure you would love to, but come on do you really think you are going to hire 8 people every year?

For the record (not saying this is what you are doing), buying out existing practices doesn't count as global growth for the field

We haven’t bought a single new practice since I joined but are building another new center in an underserved area to go live in a few years. Growth has been largely from increasing treatment of M1 disease, use of both intact and post op salvage RT for PCa (only 35% of patients nationally get SRT! Huge missed opportunity), about 700% increase in re-RT cases, more pancreas RT and liver RT, more spine RT. I have written before on this but MSKCC treats about 1000 spine sbrt cases I was told per year with ~3+ cFTEs supporting the program. At Michigan we treated about 250+ and used to be 5 per year when I joined. That is the volume of a busy radonc purely organically. Point is there are lots of indications for RT people don’t use it for. Many places now with PET imaging for prostate cancer has doubled their prostate cases as they have a whole new field of oligomets and oligoprogression.

So while I get your point, a lot of patients in northeast Ohio were simply not getting care. Our growth has not come at the expense of the other major player in town, CCF, to my knowledge.

We should be expanding courses of treatment, albeit shorter courses, given many patients can safely get numerous rounds of palliative or MDT. As patients with M1 live longer we now have more and more. Add on the expanded indications for treatment of the primary in nasopharyngx, prostate, soon to open RCC trial, etc. plus radio pharm is critical for radonc to be at the table.

And I sure hope I won’t hire 8 people per year…but if every program drastically increased prostate RT, spine and bone Mets SBRT, pancreas and liver RT, oligoprogression RT, treatment of the primary, and monitored these patients where almost 50% have new lesions in 1 year, I think many programs would need more radoncs. I see tons of places that do very little of the above mentioned treatments, a greater number appear in the community even at academic centers and these treatments need to be offered more broadly.