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

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In the wheel of life in budhism, the bhavachakra, a rooster, a pig and a snake are all eating eachother in a circle. These represent greed,ignorance and hatred. Our field is being consumed by these forces. Can they be fixed or are we destined to damnation? The horseman of the rad onc apocalypse are here too. Ain’t looking good folks!
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thecarbonionangle said:
In the wheel of life in budhism, the bhavachakra, a rooster, a pig and a snake are all eating eachother in a circle. These represent greed,ignorance and hatred. Our field is being consumed by these forces. Can they be fixed or are we destined to damnation? The horseman of the rad onc apocalypse are here too. Ain’t looking good folks!
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I have so many theories about what it would be like to watch @thecarbonionangle work a clinic day...
 
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Scarb in clinic too... I imagine significantly more graphs and math being shown to patients
 
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I hate being that person, but I don't believe they're eating each other. Rather, they are linked together as the 3 poisons, which are the root of suffering (wanting things to be other than they are). The snake and bird, Aversion and attachment, or hate and greed, are wanting some things that are to not be and some things that are to be permanent. Ignorance in my estimation is the overlying issue, as in, being ignorant of the fact that being averse or attached to something will only make things worse when they do or don't change. If you want to be rid of a snake, should you grip it more tightly or let it go? The circle represents endless cycle of birth and death that the Buddhist (for simplicity's sake) path is meant to escape, and the fact that they feed into each other. I do agree that it is relevant here, though it's relevant always, inasmuch as it's not hard as a radonc, with all the lunacy going on in our field, to find perspective at work on a daily basis inasmuch as impermanence and the contingent manner of existence are on full display.
 
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Ray D. Ayshun said:
I hate being that person, but I don't believe they're eating each other. Rather, they are linked together as the 3 poisons, which are the root of suffering (wanting things to be other than they are). The snake and bird, Aversion and attachment, or hate and greed, are wanting some things that are to not be and some things that are to be permanent. Ignorance in my estimation is the overlying issue, as in, being ignorant of the fact that being averse or attached to something will only make things worse when they do or don't change. If you want to be rid of a snake, should you grip it more tightly or let it go? The circle represents endless cycle of birth and death that the Buddhist (for simplicity's sake) path is meant to escape, and the fact that they feed into each other. I do agree that it is relevant here, though it's relevant always, inasmuch as it's not hard as a radonc, with all the lunacy going on in our field, to find perspective at work on a daily basis inasmuch as impermanence and the contingent manner of existence are on full display.
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I come here to cancel Chairs not gain enlightenment, geez.
 
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Ray D. Ayshun said:
I'm getting paid more than the median salary, which also makes perspective more attainable.
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What part of rural Wisconsin do you work in? Congrats at being somewhere where the MBAs haven't decided it makes more sense to just staff with locums forever, which is the theme for most of these places.

As an example, one of these permalocums hellpits that is always recruiting on the sidelines for someone at the right price, just contacted me through an agency for emergency locums coverage (I am shocked that they ended up needing coverage on short notice, shocked). I had some time to burn, so I bid $8000 for a week ($1600/day). The agency told me they had never placed someone above $2100/day. I've typically worked at $2500/day, and knew they would not pay that. I did not get it even at 1600. So suppose they filled it at $1500/day. $1500/day * 240 days = $360,000/year + agency fee. That's where admin is valuing staffing that place. We all know the quality of locums who accept $1500/day positions in armpits of the country is atrocious and if you have interviewed or worked with these people, you know there is a serious concern they might drop dead on the job. So what incentive does a place like this have to pay a rad onc properly $720k year + benefits, which could be nearly double their locums cost, when they are totally fine setting their bare minimum as someone with a license who can finish out the assignment while still having a pulse?

The upper midwest was the last bastion for an employed rad onc to get paid something approximating their independent predecessors. Until you have a comp of 239k/year in Iowa City.
 
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Moonbeams said:
What part of rural Wisconsin do you work in? Congrats at being somewhere where the MBAs haven't decided it makes more sense to just staff with locums forever, which is the theme for most of these places.

As an example, one of these permalocums hellpits that is always recruiting on the sidelines for someone at the right price, just contacted me through an agency for emergency locums coverage (I am shocked that they ended up needing coverage on short notice, shocked). I had some time to burn, so I bid $8000 for a week ($1600/day). The agency told me they had never placed someone above $2100/day. I've typically worked at $2500/day, and knew they would not pay that. I did not get it even at 1600. So suppose they filled it at $1500/day. $1500/day * 240 days = $360,000/year + agency fee. That's where admin is valuing staffing that place. We all know the quality of locums who accept $1500/day positions in armpits of the country is atrocious and if you have interviewed or worked with these people, you know there is a serious concern they might drop dead on the job. So what incentive does a place like this have to pay a rad onc properly $720k year + benefits, which could be nearly double their locums cost, when they are totally fine setting their bare minimum as someone with a license who can finish out the assignment while still having a pulse?

The upper midwest was the last bastion for an employed rad onc to get paid something approximating their independent predecessors. Until you have a comp of 239k/year in Iowa City.
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All of which when combined with the fact that Heme Onc is getting $5000+/day or $25K a week in the BFE locales...

MED STUDENTS! Choose Wisely. The price of a rad onc is becoming pegged to LUNA.
 
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"So what incentive does a place like this have to pay a rad onc properly $720k year + benefits, which could be nearly double their locums cost, when they are totally fine setting their bare minimum as someone with a license who can finish out the assignment while still having a pulse?"

A smart administrator would realize that incentivizing a radonc to increase production would also raise their bottom line by a greater degree. Having met a few administrators of radonc departments, I am not surprised in the least they don't do that.
 
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OTN said:
"So what incentive does a place like this have to pay a rad onc properly $720k year + benefits, which could be nearly double their locums cost, when they are totally fine setting their bare minimum as someone with a license who can finish out the assignment while still having a pulse?"

A smart administrator would realize that incentivizing a radonc to increase production would also raise their bottom line by a greater degree. Having met a few administrators of radonc departments, I am not surprised in the least they don't do that.
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I had tweeted and deleted about this earlier. The daily fee to the locums company is about a $1000!

So, that $1600 for doc is $2600 for administrator

So, that is $676,000. Plus, you have to pay for a lot of administrative costs / flights / housing. Let's low ball and say $75,000. So, ~$750,000k

Full time doc getting paid $600k and with $100k benefit package is still cheaper.

If they are truly "cost conscious" even with lack of growth (as @OTN pointed out with benefit hospital greatly), this makes no sense to low ball like this.
 
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OTN said:
A smart administrator would realize that incentivizing a radonc to increase production would also raise their bottom line by a greater degree. Having met a few administrators of radonc departments, I am not surprised in the least they don't do that.
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I grew up listening to a lot of heavy metal. Megadeth had a song with a line "military intelligence... two words combined that can't make sense..."

Unfortunately smart administrator doesn't rhyme well enough, but same principle.

I was actively deincentivized to increase production when I was employed. That meant they would have to pay me a bonus, and paying me extra was the worst thing that could possibly happen. I realized quickly that no matter how much I worked, they would see that the RVUs came out so that I was always stuck at my base. So, my subconscious incentive became to keep on treatment numbers as low as possible, kind of in the way interns try to "win the game" by discharging their entire rounding list.
 
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The technical fees remain so high. It is mind-blowing.

I have seen several collected amounts of $150k+ for head and neck treatment. Considering that average HNC RVUs is about 75 per case, that means if you are RVU based and getting $60/RVU, $4500 to the doc and $105,000 to the institution.
 
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OTN said:
"So what incentive does a place like this have to pay a rad onc properly $720k year + benefits, which could be nearly double their locums cost, when they are totally fine setting their bare minimum as someone with a license who can finish out the assignment while still having a pulse?"

A smart administrator would realize that incentivizing a radonc to increase production would also raise their bottom line by a greater degree. Having met a few administrators of radonc departments, I am not surprised in the least they don't do that.
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You know I think the smartness is cutting both ways as it were.

On one hand, many admins are not smart. They don't realize the value of a truly stellar rad onc. However, there's a "but." With the rising tide of rad oncs, the number of possible patients per rad onc is falling. (Don't "at" me Dan with BUT NEW INDICATIONS.) So the ability to up patient numbers is getting more and more difficult even for the stellar rad oncs. Plus, Evicore (and eventually APM), and hypofx practice patterns, are constraining the ability for "productive" rad oncs to generate profit too. We all see this, right?

So the admins have "real world data": they can pay a locums $1000 a day, or they can pay a locums $2500 a day. They get the same patient numbers either way, the same patient satisfaction and outcomes as best as they can tell, but they get a little more profit if they pay the rad onc less. Same kind of logic will begin to globally apply for employed rad oncs (Why pay more if we don't have to?) as well.

It's never quite as much rocket science as we think things are! It's... elementary school economics.
Moonbeams said:
Unfortunately smart administrator doesn't rhyme well enough, but same principle.
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Administrator cogitator
 
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RealSimulD said:
The technical fees remain so high. It is mind-blowing.

I have seen several collected amounts of $150k+ for head and neck treatment. Considering that average HNC RVUs is about 75 per case, that means if you are RVU based and getting $60/RVU, $4500 to the doc and $105,000 to the institution.
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$4500 to the doc and $145,500 to the institution!
 
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RealSimulD said:
I had tweeted and deleted about this earlier. The daily fee to the locums company is about a $1000!

So, that $1600 for doc is $2600 for administrator

So, that is $676,000. Plus, you have to pay for a lot of administrative costs / flights / housing. Let's low ball and say $75,000. So, ~$750,000k

Full time doc getting paid $600k and with $100k benefit package is still cheaper.

If they are truly "cost conscious" even with lack of growth (as @OTN pointed out with benefit hospital greatly), this makes no sense to low ball like this.
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The fee to the locums agency covers all of the rad onc's expenses as far as I know. What I have seen is long term negotiated direct arrangements without the agency. And I have seen locums accept agency rates even without going through an agency, a huge win for the administrators. These retired guys who don't need the money and just won't hang it up and will take any ridiculous offer setting stupid floors for the market.

I don't fully understand it either, but there really is no other explanation other than Occam's razor. Low-bid locums are cheaper than paying a 90%-tile MGMA, which is what is needed to recruit to a truly rural position.
 
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TheWallnerus said:
You know I think the smartness is cutting both ways as it were.

On one hand, many admins are not smart. They don't realize the value of a truly stellar rad onc. However, there's a "but." With the rising tide of rad oncs, the number of possible patients per rad onc is falling. (Don't "at" me Dan with BUT NEW INDICATIONS.) So the ability to up patient numbers is getting more and more difficult even for the stellar rad oncs. Plus, Evicore (and eventually APM), and hypofx practice patterns, are constraining the ability for "productive" rad oncs to generate profit too. We all see this, right?

So the admins have "real world data": they can pay a locums $1000 a day, or they can pay a locums $2500 a day. They get the same patient numbers either way, the same patient satisfaction and outcomes as best as they can tell, but they get a little more profit if they pay the rad onc less. Same kind of logic will begin to globally apply for employed rad oncs (Why pay more if we don't have to?) as well.

It's never quite as much rocket science as we think things are! It's... elementary school economics.

Administrator cogitator
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So you're saying, "It's the oversupply, stupid"?
 
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RealSimulD said:
I had tweeted and deleted about this earlier. The daily fee to the locums company is about a $1000!

So, that $1600 for doc is $2600 for administrator

So, that is $676,000. Plus, you have to pay for a lot of administrative costs / flights / housing. Let's low ball and say $75,000. So, ~$750,000k

Full time doc getting paid $600k and with $100k benefit package is still cheaper.

If they are truly "cost conscious" even with lack of growth (as @OTN pointed out with benefit hospital greatly), this makes no sense to low ball like this.
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Paying a single doc $750K (or even $650K) just becomes largesse/kindness-to-strangers if you can pay a firm $750K who will: background, handle credentialing and malpractice, handle expenses, etc. Plus as an admin you gain more flexibility through rad onc MD fungibility versus hitching your wagon to one guy. You keep the locums firm handy and they can swap a rad onc in/out for you at almost a moment's notice.
 
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TheWallnerus said:
Paying a single doc $750K (or even $650K) just becomes largesse/kindness-to-strangers if you can pay a firm $750K who will: background, handle credentialing and malpractice, handle expenses, etc. Plus as an admin you gain more flexibility through rad onc MD fungibility versus hitching your wagon to one guy. You keep the locums firm handy and they can swap a rad onc in/out for you at almost a moment's notice.
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Even if it's a financial wash (which I don't believe), locums absolves admin of having to deal with vacation coverage, removes them of being accountable to the rad onc for delivering on their recruiting promises and keeping them happy in an undesirable location, minimizes staff complaints about being overworked (rejecting plans, making therapists stay late, etc) because locums just approves everything and overtime is not allowed, and allows admin to keep clinic running with bare bones operational expenses as no MD is there with a vested interest pushing in capital expenditures for things that are right for patients.

I learned this all the hard way as a naive new grad who thought he would be valued in a place like that. Surely they will treat me well if their only other option is locums. Wrong. Locums was actually preferable. They made no serious efforts to recruit after I left and I don't think they have any intention to.
 
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There are market inefficiencies where rad oncs are significantly underpaid relative to production/revenue generation on the technical side. So salaries are down, but revenue generation theoretically has not changed to the same degree. What would it take to overcome barrier entry for physician owned practices given high overhead costs and strong bias towards consolidated practices and hospital systems? At some point the delta between revenue generated and salary given will be high enough where it will push towards physician ownership. Rad onc has never been a specialty where it was easy to "hang a shingle". The current system strongly discourages that, but maybe that is something that can be worked on (in addition to cutting residency spots etc)
 
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radiation said:
There are market inefficiencies where rad oncs are significantly underpaid relative to production/revenue generation on the technical side. So salaries are down, but revenue generation theoretically has not changed to the same degree. What would it take to overcome barrier entry for physician owned practices given high overhead costs and strong bias towards consolidated practices and hospital systems? At some point the delta between revenue generated and salary given will be high enough where it will push towards physician ownership. Rad onc has never been a specialty where it was easy to "hang a shingle". The current system strongly discourages that, but maybe that is something that can be worked on (in addition to cutting residency spots etc)
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EXCELLENT points.

It's just so hard to break, or cut in on, existing referral patterns. Add in CON and solo or small group rad onc ownership is HARD.

The richest American radiation oncologists in America's history all had technical side ownership.
 
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Moonbeams said:
Even if it's a financial wash (which I don't believe), locums absolves admin of having to deal with vacation coverage, removes them of being accountable to the rad onc for delivering on their recruiting promises and keeping them happy in an undesirable location, minimizes staff complaints about being overworked (rejecting plans, making therapists stay late, etc) because locums just approves everything and overtime is not allowed, and allows admin to keep clinic running with bare bones operational expenses as no MD is there with a vested interest pushing in capital expenditures for things that are right for patients.

I learned this all the hard way as a naive new grad who thought he would be valued in a place like that. Surely they will treat me well if their only other option is locums. Wrong. Locums was actually preferable. They made no serious efforts to recruit after I left and I don't think they have any intention to.
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i think it depends on how close the competition is. If your 4 hours from anyone, it is perhaps not hard to get patients thru the door, though you could also find someone interested in establishing an arthritis program in that scenario, which you wouldn't get from a locums. in any case, if there's competition within an hour or so, having a permalocums is a bad idea.
 
TheWallnerus said:
EXCELLENT points.

It's just so hard to break, or cut in on, existing referral patterns. Add in CON and solo or small group rad onc ownership is HARD.

The richest American radiation oncologists in America's history all had technical side ownership.
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The income disparity between the average radonc in true private practice and an employed radonc in either academia or a hospital-based practice has to be one of the largest in any field of medicine.

I certainly understand why large systems continue to try to push pp out, because they can make an absolute fortune on technical fees which used to go to the docs. Such a shame our own helped make it happen. So it goes.
 
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I’ve said it before and I’ll say it again: those ARRO employment surveys are not benign. They are not interested in understanding, much less tackling, any problems with the job market or employment outcomes for graduating residents. They are trawling for data to support the status quo.

A lot of the ARRO folks are nice and hardworking residents, and I don’t know their advisors, but I suspect their advisors are nice and hardworking as well. However, those surveys lack nuance and granularity, and it is way too easy to misappropriate their data.

From the perspective of some individuals, there is no problem whatsoever with an excess of residency graduates. Regardless, academic centers will collect the technical fees and benefit from talented labor.

The excess of residency graduates is only a problem with market correction, that is the transparent feedback of employment outcomes to medical students. A decline in number and quality of medical student applicants is a problem for academic rad onc, but the cause of that decline, excessive residency positions, is a core feature to be protected not a bug to be corrected.
 
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OTN said:
The income disparity between the average radonc in true private practice and an employed radonc in either academia or a hospital-based practice has to be one of the largest in any field of medicine.

I certainly understand why large systems continue to try to push pp out, because they can make an absolute fortune on technical fees which used to go to the docs. Such a shame our own helped make it happen. So it goes.
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capitalism baby. large corporations will always seek to increase their revenue. hospitals grow and eat. no different than any other business. this is the health care economy we live in.

solo//private rad oncs are like mom and pop book shops. an economic aberration. a mistake.
 
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jondunn said:
capitalism baby. large corporations will always seek to increase their revenue. hospitals grow and eat. no different than any other business. this is the health care economy we live in.

solo//private rad oncs are like mom and pop book shops. an economic aberration. a mistake.
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Radoncs in a solo practice would not be able to enjoy the income that large pp groups can see, and I was not referring to them. Without capitalism, private ownership of anything would not even be possible.
 
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OTN said:
Radoncs in a solo practice would not be able to enjoy the income that large pp groups can see, and I was not referring to them. Without capitalism, private ownership of anything would not even be possible.
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I know a solo rad onc (hires some locums) who's making in the $5m ballpark per year. She owns two centers though. In a CON state.
 
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OTN said:
Radoncs in a solo practice would not be able to enjoy the income that large pp groups can see, and I was not referring to them. Without capitalism, private ownership of anything would not even be possible.
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Solo or group - I mean both. I mean true private ownership.

There is way too much technical money to be made for corporations not to be able to capitalize.

Capitalism.
 
Two things I learned yesterday evening:

1. Walmart is fast-tracking college grads to store manager roles that pay $210,000 a year

A college grad can make $210,000 a year in Walmart management two years post-college- that would be at age 24. By the time a newly-minted radonc enters the workforce at age 31 (earliest possible), that Walmart associate would have made at least $1.5M. I'm not even going to start on med school debt.


2. In rural areas in which it can be difficult to find coverage, our practice is having to pay medical physics $20,000 a week for locums coverage. $4,000 a day.

I think the data and discussions in these 11 forum pages more than adequately show the disastrous situation we are in. Dan, you started the thread. What's your plan to fix all this?
 
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OTN said:
Two things I learned yesterday evening:

1. Walmart is fast-tracking college grads to store manager roles that pay $210,000 a year

A college grad can make $210,000 a year in Walmart management two years post-college- that would be at age 24. By the time a newly-minted radonc enters the workforce at age 31 (earliest possible), that Walmart associate would have made at least $1.5M. I'm not even going to start on med school debt.


2. In rural areas in which it can be difficult to find coverage, our practice is having to pay medical physics $20,000 a week for locums coverage. $4,000 a day.

I think the data and discussions in these 11 forum pages more than adequately show the disastrous situation we are in. Dan, you started the thread. What's your plan to fix all this?
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this is so depressing

I guess the chairs and most academics and well-off PP people in strong groups think "We will be fine... things are just changing, we have to accept it, we are gonna be OK sucks for the new generation tho"

But nothing is certain... even for the patriciates
 
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OTN said:
Two things I learned yesterday evening:

1. Walmart is fast-tracking college grads to store manager roles that pay $210,000 a year

A college grad can make $210,000 a year in Walmart management two years post-college- that would be at age 24. By the time a newly-minted radonc enters the workforce at age 31 (earliest possible), that Walmart associate would have made at least $1.5M. I'm not even going to start on med school debt.


2. In rural areas in which it can be difficult to find coverage, our practice is having to pay medical physics $20,000 a week for locums coverage. $4,000 a day.

I think the data and discussions in these 11 forum pages more than adequately show the disastrous situation we are in. Dan, you started the thread. What's your plan to fix all this?
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I swallowed my own vomit reading this.
 
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OTN said:
Two things I learned yesterday evening:

1. Walmart is fast-tracking college grads to store manager roles that pay $210,000 a year

A college grad can make $210,000 a year in Walmart management two years post-college- that would be at age 24. By the time a newly-minted radonc enters the workforce at age 31 (earliest possible), that Walmart associate would have made at least $1.5M. I'm not even going to start on med school debt.


2. In rural areas in which it can be difficult to find coverage, our practice is having to pay medical physics $20,000 a week for locums coverage. $4,000 a day.

I think the data and discussions in these 11 forum pages more than adequately show the disastrous situation we are in. Dan, you started the thread. What's your plan to fix all this?
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You don't need a physicist at a rural facility if there is no rural facility. I'd submit there is a plan in place to fix this.
 
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Ray D. Ayshun said:
You don't need a physicist at a rural facility if there is no rural facility. I'd submit there is a plan in place to fix this.
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Ding!

1-5 fractions for everything at the equivalent of a tertiary center. Community radonc be gone.
 
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Ray D. Ayshun said:
You don't need a physicist at a rural facility if there is no rural facility. I'd submit there is a plan in place to fix this.
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These patients do not have the resources to travel the many hundreds of miles it would take to go to a tertiary center. Despite what academic radonc would like everyone to believe, there is a very real and valuable role for community oncology in this country.
 
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TheWallnerus said:
this is so depressing
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210k for walmart manager is not depressing. That's good.

That nobody seems aware of Louis Brandeis' warning about bigness among the academic medicine crowd is disheartening. I'm guessing lots of them would like Brandeis. Whether they are personally recouping the big money that accompanies big academic (or other) medicine or not is not the issue. They are participating in monopsony and regulatory capture due to issues of bigness. They should not feel morally superior to well paid country docs and in the field of radonc they are successfully eliminating the phenomenon of well paid country docs.
 
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OTN said:
These patients do not have the resources to travel the many hundreds of miles it would take to go to a tertiary center. Despite what academic radonc would like everyone to believe, there is a very real and valuable role for community oncology in this country.
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I don't disagree. I'm at one of those places. But in asking a chair what the plan is, I suspect his decisions will be based upon research. And as far as I can tell, all the research is being done by docs at nci centers and suggests worse care at non-nci centers. The closest these docs ever get to rural rad onc is the planes altitude as they fly over. In turn, the plan is to make it as convenient as possible to go to the nci center.
 
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Ray D. Ayshun said:
I don't disagree. I'm at one of those places. But in asking a chair what the plan is, I suspect his decisions will be based upon research. And as far as I can tell, all the research is being done by docs at nci centers and suggests worse care at non-nci centers. The closest these docs ever get to rural rad onc is the planes altitude as they fly over. In turn, the plan is to make it as convenient as possible to go to the nci center.
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"And as far as I can tell, all the research is being done by docs at nci centers and suggests worse care at non-nci centers."

My wealthiest and healthiest patients are the ones who make it to tertiary care centers. The sicker and poorer ones are those who cannot travel and stay in the community for care. In my opinion the difference in outcome between NCI centers and non-NCI centers is fully explained by socioeconomic factors.
 
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There is a thread on Bogleheads forum asking high earners what they do for a living. It's pretty eye opening.

One of the responses, from 2014, was a nurse anesthetist who reported an income of $260k, again in 2014. I can only imagine what that has ballooned to now in the inflationary wacky covid era. My former neighbor was a nurse anesthetist who did quite well.

Just put that in perspective.

$239k for a full-time rad onc in Iowa City. Or anywhere really. Nuts.
 
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OTN said:
"And as far as I can tell, all the research is being done by docs at nci centers and suggests worse care at non-nci centers."

My wealthiest and healthiest patients are the ones who make it to tertiary care centers. The sicker and poorer ones are those who cannot travel and stay in the community for care. In my opinion the difference in outcome between NCI centers and non-NCI centers is fully explained by socioeconomic factors.
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You're preaching to the choir.
 
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"It's the oversupply stupid."

Limit supply, increase demand, restore the profession. Duh.

Maybe, gone are the days of a small group buying a linac and keeping technical (hint: they're pretty much gone), but we have the tools to each treat more and more patients per unit doctor. This SHOULD drive salaries higher and make the job more appealing for all. Whether that job is community, academic, or true PP. We just need to stop diluting the pool.

It's really simple, it's not easy.
 
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