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

[RadOncDoc.]

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?

Agree. It is not complicated at all

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[jondunn]

What they really want is a URM puppet

correction - a URM puppet that shills for protons. they got one!

edit: didn't see that ricky scott had said the same thing

 

[TheWallnerus]

The MSKCC annual reports put me down a rabbit hole today. In 2020 their clinical revenue was ~$4B but looks on track to be >$6B in 2022. I have been trying to make some estimates of average revenue per patient and average tx length. The national RT fraction average per patient is 17, and it seems the average at MSKCC is around 25; IOW, this suggests MSKCC uses more fractions than the national average. My best guess (I had to make some ratio assumptions) of their average reimbursement per patient is ~$45K for 2020 (range: $38K-$48K), and this would mean the average MSKCC RO doctor is generating ~$5.5m/year in total RO patient revenues on ~120 pts/MD/yr. About 30 percent of their total operating revenue system-wide comes from Medicare. (When I last checked, my average reimbursement per patient was about $15-20K... just informed by finance it was $13,430/pt for 2020)

 

[evilbooyaa]

Dan,

As always, appreciate you coming to the forum. I agree with Neuronix that posting a chapter and then asking for a 1 sentence reply seems a bit condescending.

Despite that I see you engaging... at least with some.

The issue is that the number of graduating residents per year needs to go down. The thought that "well medical students won't match and that'll be the sign" has been ignored by bad programs who SOAP candidates with zero interest in Rad Onc, multiple board failures, etc.

At the end of the day, those individuals may come out as fine doctors. But, there is no market for it. The onus is not on me to prove that. The onus is on chairs (not you given how recent it was, but SCAROP) to justify that this doubling of Rad Onc residents was necessary. Academic chairs increased residency spots because it was easier than hiring a NP/PA, a resident can take call, do volumes, and has less lee-way to leave if poorly treated. Then, they double benefited by being able to hire attendings at a lower starting salary.

I'm sad that any attending physician at U of Mich was ever paid 2xxK. This is a frankly despicable pay for any full-time Radiation Oncologist. The answer to that is not stating 'academic salaries have gone up' because now they pay 300k+, because when the bar is literally underground for a full-time Rad Onc position, there's only one way to go. The salary for other academic positions has gone down as Rad Oncs, who bring in millions and millions for ANY major hospital based on the value of insurance contracts, have lots of cancer center directors and other hospital administrations who reach in and steal a portion of the pie that we have brought in. Doubly so for any PPS-exempt place, which is why the MSKCC/MDACCs of the world can even have as many attendings as they do and treat as few patients as they do.

Doubling the amount of Rad Onc grads has NOT imprved rural care. As others more experienced in rural care have suggested, it may make folks LESS likely to go to a crap place with a crap rural hospital AND get crap pay/independence of practice. The communities actually get worse care by the permalocums garbage, and these hospitals are OK with this, because "they'll eventually get the right guy".

Not many URM wants to go work in rural America, which is where the jobs are currently.

The thought of 'capturing' additional patients as you did at U of Mich and seem to be attempting to do at Case based on your replies has to be done with support from the surgeons you are working with. MDC is just not a thing in the vast majority of places. If you could convince SCAROP/AUA to formulate a joint statement that every prostate cancer patient had to see a Urologist and a Rad Onc and get it into NCCN, that'd probably help, nationally, more than anything else.

 

[RickyScott]

The MSKCC annual reports put me down a rabbit hole today. In 2020 their clinical revenue was ~$4B but looks on track to be >$6B in 2022. I have been trying to make some estimates of average revenue per patient and average tx length. The national RT fraction average per patient is 17, and it seems the average at MSKCC is around 25; IOW, this suggests MSKCC uses more fractions than the national average. My best guess (I had to make some ratio assumptions) of their average reimbursement per patient is ~$45K for 2020 (range: $38K-$48K), and this would mean the average MSKCC RO doctor is generating ~$5.5m/year in total RO patient revenues on ~120 pts/MD/yr. About 30 percent of their total operating revenue system-wide comes from Medicare. (When I last checked, my average reimbursement per patient was about $15-20K... just informed by finance it was $13,430/pt for 2020)

Is the 6 billion from the radonc department?

 

[Mandelin Rain]

As always, appreciate you coming to the forum. I agree with Neuronix that posting a chapter and then asking for a 1 sentence reply seems a bit condescending.

Most of the successful people I've known are the ones who do more talking than listening.
-Donald Trump, possibly

 

[TheWallnerus]

Is the 6 billion from the radonc department?

Haha no. I know you’re joking but some others might not. System wide. But it does seem that the entire MSKCC system proper (Manhattan and the network) accounts for almost 1% of America’s new start RT patients per year.

 

[DoctwoB]

Fifteen years ago nephrectomy was s.o.c. in metastatic kidney cancer. A disease where very little was available in terms of systemic treatment. Nowadays, this has been abandoned and proven not beneficial for the patients in a randomized trial (CARMENA), because systemic treatment simply got better, eliminating the role of nephrectomy for most patients with metastatic disease.

Just to butt in to belabor a point. CARMENA didn't show that cytoreductive nephrectomy is no longer beneficial because systemic treatment got better, the key point is it got different. Even if we take Carmena results as gospel (and there are reasons we shouldn't) that cytoreductive Nx has no benefit in treatment with TKI therapy, the picture is still unclear

(EORTC) 30947 and (SWOG) 8949 showed clear benefit to cytoreductive Nx + IFN

Carmena shows no benefit to cytoreductive Nx with TKIs as first line therapy

Now we treat with combination immunotherapy (closer to IFN?). Is there a benefit? Who knows?

The key takehome point is that the interaction of local therapy with systemic therapy is probably more complicated then "better" systemic therapy is more or less synergistic with local therapy, but rather each form of systemic therapy may benefit differently from local therapy, which will also probably vary by disease site.

 

[jondunn]

@Dan Spratt - what is your opinion on proton, now that you chair a department with proton therapy available? Are you a supporter of proton therapy for prostate cancer? I'm genuinely curious on your take as probably THE leading GU rad onc voice

 

[radoncle]

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

The problem in one word or sentence is the culture of the leadership in radiation oncology.

It’s the self-serving, close-minded, elitist (despite most of the leadership entering the field when anyone with a pulse could be a rad onc) culture that our leadership has embraced.

I have heard Wally Curran say that patients should only be treated at academic centers with site specialized rad oncs (only to turn around to lead a dumpster fire of community practices). We’ve all heard leadership deny the fact that we are producing too many rad oncs and there is a job shortage. We’ve seen our leadership suggest that our board certification isn’t enough to allow us to know how to treat patients. Major academic centers are deluded women into driving hours at odd hours to receive proton beam RT for stage I right-sided breast cancer. This toxicity does not exist in any other field of which I am aware. I have never seen or experienced as many toxic personality disorders as I have in rad onc leadership. My friends in ortho, derm, GI, etc. don’t experience any of this toxicity with their academic “leaders.”

This field has deteriorated due to the culture of our leadership.

How do we fix rad onc? I don’t know that I believe it is fixable in the career span of any currently working rad onc. The first step, assuming we can’t oust every “leader,” would be to dramatically cut the training spots.

 

[TheWallnerus]

@Dan Spratt - what is your opinion on proton, now that you chair a department with proton therapy available? Are you a supporter of proton therapy for prostate cancer? I'm genuinely curious on your take as probably THE leading GU rad onc voice

We all know what we've said about that... once you have protons, you LOVE protons

I would LOVE protons too if a 45 fraction course could reimburse close to $750K *per patient* (even the CAR-T guys are jealous)

 

[RickyScott]

The problem in one word or sentence is the culture of the leadership in radiation oncology.

It’s the self-serving, close-minded, elitist (despite most of the leadership entering the field when anyone with a pulse could be a rad onc) culture that our leadership has embraced.

I have heard Wally Curran say that patients should only be treated at academic centers with site specialized rad oncs (only to turn around to lead a dumpster fire of community practices). We’ve all heard leadership deny the fact that we are producing too many rad oncs and there is a job shortage. We’ve seen our leadership suggest that our board certification isn’t enough to allow us to know how to treat patients. Major academic centers are deluded women into driving hours at odd hours to receive proton beam RT for stage I right-sided breast cancer. This toxicity does not exist in any other field of which I am aware. I have never seen or experienced as many toxic personality disorders as I have in rad onc leadership. My friends in ortho, derm, GI, etc. don’t experience any of this toxicity with their academic “leaders.”

This field has deteriorated due to the culture of our leadership.

How do we fix rad onc? I don’t know that I believe it is fixable in the career span of any currently working rad onc. The first step, assuming we can’t oust every “leader,” would be to dramatically cut the training spots.

Absolutely. Self promotion does not equal leadership.

 

[pikachu]

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

OK I'll bite. First of all if you have time to write 2700 words over two separate posts I'm sure you have time to read more than "one short sentence" about why the number of US grads applying into rad onc is dropping. That said, I will echo what others have said about this being a simple problem, not a twisted and mysterious conundrum. For an increasing number of med students, the career opportunities in radiation oncology simply do not justify the risks and opportunity costs of a 5-year training program that in the end often does not net you a job with geographic flexibility, high salary (or a good salary-to-professional demand ratio), or professional/intellectual satisfaction. People will give up one or two of these aspects but not three. SO for example that Urorads job in Tampa that pays $450k for a 3-day work week may be boring as all hell but they will find someone because at least items 1 and 2 are fulfilled. Same with a junior faculty job at Michigan that pays at the bottom 25th percentile of the academic pay scale (since you get item 3 which is enough for many people and can potentially fulfill 2 if there is ample protected time for research). Recall that there are prohibitively high barriers to retraining in any other specialty and the proliferation of *non-ACGME accredited* fellowships does nothing to broaden your skills or allow you to practice in areas outside your training if you don't get a job in rad onc. This is why nephrologists and endocrinologists, despite what I understand are serious limitations in their job markets, are in better shape than we are because they have IM training as a fallback for practice. The plain fact is that medical students who have already given up 4 years of their lives and in many cases gone hundreds of thousands of dollars into debt are hardly going to rush into a field that provides no outlet whatsoever for people who can't find a satisfactory job after 5 years of training. This is a huge risk and med students, who are not dumb, clearly understand the tradeoffs.

Solutions? In addition to the imperative of cutting spots, we need to think seriously as a specialty about ways to broaden our scope of practice. Please don't @ me about how rad oncs don't want to take call, or take care of inpatients, or manage complications from systemic therapy, or give radionuclides, or, or, or...We can't expect to remain valued as a specialty if we don't provide needed services. This is I think where SCAROP can help. It is going to take a concerted effort likely over many years to break down the existing barriers but I think our only path to a brighter future is similar to the UK clinical oncology model. Yes, this will require more IM training and yes it will require a very different approach to our clinical practice. If we don't start soon though the field will die the death of a thousand cuts and I think we are only seeing the start of it now.

 

[RickyScott]

Re radionuclides. At the several large/top hospitals I am intimately familiar with, radonc is about as likely to get privileges as vascular surgeons/or ir will get cath lab privileges.

 

[maruchan]

I will echo @Bequerel, @pikachu et al.

The absolute core problem is that radiation oncology has poor job market options (considering geography/salary/lifestyle/job type) when compared to other alternative specialties in medicine. Additionally, due to huge residency expansion and oversupply, it is felt to be extremely likely that these job market options will be worse, potentially way worse, by the time an incoming resident graduates.

As a result, medical student interest in the field has cratered.

I'll note that it doesn't matter whether you personally agree with this projection of the job market continuing to worsen. Through a Bayesian lens, no matter how you slice it, the probability that the job market worsens is significant. Some people might assign a higher probability and some a lower probability, but for a medical student, there's no reason to risk it. Put yourself in the shoes of a medical student with the world open to them. Most don't want to toil through 4 years medical school 5 years residency only to end up in a job where you have to sacrifice and compromise. Most don't want to risk that at all -- and why would they when many other good specialties exist?

Everything else mentioned in the thread (leadership, indications, culture, etc etc) is an upstream/downstream issue. The job market/oversupply issue is the one core issue.

 

[pikachu]

OK I'll bite. First of all if you have time to write 2700 words over two separate posts I'm sure you have time to read more than "one short sentence" about why the number of US grads applying into rad onc is dropping. That said, I will echo what others have said about this being a simple problem, not a twisted and mysterious conundrum. For an increasing number of med students, the career opportunities in radiation oncology simply do not justify the risks and opportunity costs of a 5-year training program that in the end often does not net you a job with geographic flexibility, high salary (or a good salary-to-professional demand ratio), or professional/intellectual satisfaction. People will give up one or two of these aspects but not three. SO for example that Urorads job in Tampa that pays $450k for a 3-day work week may be boring as all hell but they will find someone because at least items 1 and 2 are fulfilled. Same with a junior faculty job at Michigan that pays at the bottom 25th percentile of the academic pay scale (since you get item 3 which is enough for many people and can potentially fulfill 2 if there is ample protected time for research). Recall that there are prohibitively high barriers to retraining in any other specialty and the proliferation of *non-ACGME accredited* fellowships does nothing to broaden your skills or allow you to practice in areas outside your training if you don't get a job in rad onc. This is why nephrologists and endocrinologists, despite what I understand are serious limitations in their job markets, are in better shape than we are because they have IM training as a fallback for practice. The plain fact is that medical students who have already given up 4 years of their lives and in many cases gone hundreds of thousands of dollars into debt are hardly going to rush into a field that provides no outlet whatsoever for people who can't find a satisfactory job after 5 years of training. This is a huge risk and med students, who are not dumb, clearly understand the tradeoffs.

Solutions? In addition to the imperative of cutting spots, we need to think seriously as a specialty about ways to broaden our scope of practice. Please don't @ me about how rad oncs don't want to take call, or take care of inpatients, or manage complications from systemic therapy, or give radionuclides, or, or, or...We can't expect to remain valued as a specialty if we don't provide needed services. This is I think where SCAROP can help. It is going to take a concerted effort likely over many years to break down the existing barriers but I think our only path to a brighter future is similar to the UK clinical oncology model. Yes, this will require more IM training and yes it will require a very different approach to our clinical practice. If we don't start soon though the field will die the death of a thousand cuts and I think we are only seeing the start of it now.

Oh and one more thing. We cannot deny our way out of this. NO amount of "enhanced outreach" in preclinical years or any other PR maneuver will fix these problems. Lipstick on a pig and all that. The academics will get service points for educational efforts, the students will listen politely...and still won't apply to rad onc. Students are voting with their feet for systemic reasons that strike at the heart of our specialty...it behooves us to heed the warning and not dig the hole deeper than it already is.

 

[communitydoc13]

Nothing to add. All the right answers are here and were here before.

Time to make the field small.

I need to find a way to help hire a medonc or two, a urologist, more general surgeons and ENT into my community hospital. Also need more OR staff and office staff. Inpatient nursing also a problem (hemorrhaged with covid). There aren't enough workers around for many jobs in healthcare away from the biggest cities. Plenty of radiation oncologists around however.

 

[radoncle]

I will echo @Bequerel, @pikachu et al.

The absolute core problem is that radiation oncology has poor job market options (considering geography/salary/lifestyle/job type) when compared to other alternative specialties in medicine. Additionally, due to huge residency expansion and oversupply, it is felt to be extremely likely that these job market options will be worse, potentially way worse, by the time an incoming resident graduates.

As a result, medical student interest in the field has cratered.

I'll note that it doesn't matter whether you personally agree with this projection of the job market continuing to worsen. Through a Bayesian lens, no matter how you slice it, the probability that the job market worsens is significant. Some people might assign a higher probability and some a lower probability, but for a medical student, there's no reason to risk it. Put yourself in the shoes of a medical student with the world open to them. Most don't want to toil through 4 years medical school 5 years residency only to end up in a job where you have to sacrifice and compromise. Most don't want to risk that at all -- and why would they when many other good specialties exist?

Everything else mentioned in the thread (leadership, indications, culture, etc etc) is an upstream/downstream issue. The job market/oversupply issue is the one core issue.

I disagree. The leadership culture is what allowed the job shortage to develop. Self-interest, denial, close-mindedness, refusal to listen to others (eg. Chirag Shah), blacklisting of those with dissenting opinions, etc.

Lousy short-sited self-interested leadership led to the job shortage.

 

[medgator]

Re radionuclides. At the several large/top hospitals I am intimately familiar with, radonc is about as likely to get privileges as vascular surgeons/or ir will get cath lab privileges.

And out in the real world, some of us don't want to deal with the logistics and financial risk of having to administer radiopharmaceuticals. It's simply not going to move the needle that much for us and if you screw up the billing, can really become a financial disaster fairly quickly

 

[RickyScott]

Lutathera is a loss leader and a lot of effort.

 

[metallica81788]

Lutathera is a loss leader and a lot of effort.

It may or may not be revolutionary but my single radonc community place doesn't have the time or effort for that stuff nor do I want it; I'll send it to the bigger players

 

[medgator]

Lutathera is a loss leader and a lot of effort.

Yep... Xofigo and samarium are/were much easier in comparison. Just a real time suck for the staff and physicists involved

 

[CaesarRO]

Lutathera is a loss leader and a lot of effort.

I always thought the term loss leader implied a good thing.

Short term pain/cost for long term benefits. Key thing is to make sure the long term benefits come.

 

[maruchan]

-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?

The reduced interest is reflective of a growing, legitimate concern regarding the job market and the direction it is heading.
If you talk to prospective medical students, they are extremely concerned about the job market and this is by far the #1 reason for people not applying to rad onc.

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.

The problem is that the quality and prestige of our field goes down.

If you tell a medical school classmate in 2000-2010 that you matched in radiation oncology, their gut reaction is that you are a smart, impressive individual. You are worthy of respect.
If you are graduating in the class of 2022 and tell your classmate you matched in radiation oncology, their gut reaction is that you might have been desperate. They'll be mildly concerned about your job market. This is not an exaggeration -- talk to current medical students.

You could argue whether you should care about the respect that radiation oncology as a field gets. I would say that actually yes, this is definitely an issue that the leadership of any field in medicine should care about.

Theoretically, lower quality applicants/matriculants would also decrease the rate of advancement in the field, although this is probably not actually true.

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.

Definite fallacy. On a case by case basis, of course any individual could turn out to be a better rad onc than a different individual. On average though, the better applicant will be a better rad onc. Otherwise why do we even have a residency selection process instead of choosing randomly?

-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?

The problem is residency overexpansion. No other specialty in medicine, especially one as tiny as radiation oncology, has expanded the supply of residents so quickly.

Consolidation has probably actually helped cushion the supply shock of residency oversupply. But eventually that cushion will run out.

-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?

Medical students want a reasonable balance of geography/salary/lifestyle/job type. They have to sacrifice too much now and the rational expectation is that it will only get worse.

There's no way to recruit only or even mainly people who want to be community rad oncs in rural areas. That thought is out of touch with how medical students think and how medical student recruitment works.

-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)?

Yes, there is truly an oversupply. If residency spots double and indications are flat and job market options are poor, there is an oversupply. Compared to almost every other field in medicine, the supply of graduating residents to availability of radiation oncology positions is far out of whack. Compared to almost every other field in medicine, the job market options available to a graduating radiation oncology resident is poor.

This is the central premise that needs to be accepted to have a reasonable discussion about solutions.

I will point out also that even many people who want to be in middle America want to be in a specific metro area to be near family, and that proposition is dicey for graduating residents. If you try to recruit only people who are truly open to going anywhere in America, you end up scraping the bottom of the barrel, because that's not a lot of people.

 

[jondunn]

what can SCAROP do to stop Drew Moghanaki

 

[pikachu]

The reduced interest is reflective of a growing, legitimate concern regarding the job market and the direction it is heading.
If you talk to prospective medical students, they are extremely concerned about the job market and this is by far the #1 reason for people not applying to rad onc.


The problem is that the quality and prestige of our field goes down.

If you tell a medical school classmate in 2000-2010 that you matched in radiation oncology, their gut reaction is that you are a smart, impressive individual. You are worthy of respect.
If you are graduating in the class of 2022 and tell your classmate you matched in radiation oncology, their gut reaction is that you might have been desperate. They'll be mildly concerned about your job market. This is not an exaggeration -- talk to current medical students.

You could argue whether you should care about the respect that radiation oncology as a field gets. I would say that actually yes, this is definitely an issue that the leadership of any field in medicine should care about.

Theoretically, lower quality applicants/matriculants would also decrease the rate of advancement in the field, although this is probably not actually true.


Definite fallacy. On a case by case basis, of course any individual could turn out to be a better rad onc than a different individual. On average though, the better applicant will be a better rad onc. Otherwise why do we even have a residency selection process instead of choosing randomly?


The problem is residency overexpansion. No other specialty in medicine, especially one as tiny as radiation oncology, has expanded the supply of residents so quickly.

Consolidation has probably actually helped cushion the supply shock of residency oversupply. But eventually that cushion will run out.


Medical students want a reasonable balance of geography/salary/lifestyle/job type. They have to sacrifice too much now and the rational expectation is that it will only get worse.

There's no way to recruit only or even mainly people who want to be community rad oncs in rural areas. That thought is out of touch with how medical students think and how medical student recruitment works.


Yes, there is truly an oversupply. If residency spots double and indications are flat and job market options are poor, there is an oversupply. Compared to almost every other field in medicine, the supply of graduating residents to availability of radiation oncology positions is far out of whack. Compared to almost every other field in medicine, the job market options available to a graduating radiation oncology resident is poor.

This is the central premise that needs to be accepted to have a reasonable discussion about solutions.

I will point out also that even many people who want to be in middle America want to be in a specific metro area to be near family, and that proposition is dicey for graduating residents. If you try to recruit only people who are truly open to going anywhere in America, you end up scraping the bottom of the barrel, because that's not a lot of people.

Clearly you have never been to middle america...a place where the space time continuum warps to destroy any notion of actual place, allowing you to be both everywhere and nowhere all at once...The consequence of this, of course, is that new grads should be grateful to have any job at all.

 

[RickyScott]

If the Astro president is stating that new grads should be grateful for any job, why is there any debate that market sucks?

 

[RadOncDoc21]

Yep, you guys are serious suckers. Good thoughts but definitely should have known nothing would be gained. Reminds me of Lucy and the football.

 

[thecarbonionangle]

Bad culture and leadership are precisely an upstream issue from lack of action on expansion, bad programs and job market. To think otherwise is obtuse folks. It is all interconnected, quite simple.

 

[Ray D. Ayshun]

It looks like 9/50 of the threads on the first page of this forum are clinical. Not sure what the right number is, but that pretty much seems representative of the problem. Perhaps the ratio of clinical threads can be somewhat of a decipher score. Or the converse, as in, our decipher score is 82. sounds bad.

edit: I randomly picked pain, which looks to have a decipher of 46

 

[Mandelin Rain]

Yup. This site used to be interesting/challenging cases, recent practice changing trials, and "will I match" threads.

 

[Ray D. Ayshun]

Yup. This site used to be interesting/challenging cases, recent practice changing trials, and "will I match" threads.

Eh well, maybe we're the dinguses (wanted a movie reference)

 

[Mandelin Rain]

Swingers/Made Vince was the best Vince.

 

[TheWallnerus]

You guys (and me) let him prod us into writing the same stuff we have been writing for 8-10 years… if this is new to chairman - if any of this is new to any chairman including Dan, just tells you they have zero idea of what’s going on for a decade.

@Dan Spratt - thanks for the epic trolling here. You got us good!!

Yep, you guys are serious suckers. Good thoughts but definitely should have known nothing would be gained. Reminds me of Lucy and the football.

View attachment 354317

What can Dan really do. To voice open support for the things we say might be asking him to walk a plank. That’s a big ask.

And if he’s not an honest person and is just trolling… Isaac Newton said every trolling has an equal and opposite reaction. Imagine how informative this thread is to a med student making decisions right now. People notice non responses (math… how does it work?) almost as much as a response.

Also we learned MSKCC SBRTs 1000 spines a year. Choose Wisely for thee but not for me!

 

[salubalu]

I’ve seen rad onc programs offer stipends for visiting medical students…now that’s new

 

[RadOncDoc21]

I’ve seen rad onc programs offer stipends for visiting medical students…now that’s new

I guess it makes up a little for not being able to offer them jobs in the future.

 

[deleted1111261]

What can Dan really do. To voice open support for the things we say might be asking him to walk a plank. That’s a big ask.

And if he’s not an honest person and is just trolling… Isaac Newton said every trolling has an equal and opposite reaction. Imagine how informative this thread is to a med student making decisions right now. People notice non responses (math… how does it work?) almost as much as a response.

Also we learned MSKCC SBRTs 1000 spines a year. Choose Wisely for thee but not for me!

Medical spending seems incredible there, even for a PPS exempt place. It appears they extract every bit they can from the system.
1000 SBRTs for bone mets. They have a paper on this, something like 40% of their bone mets get SBRT.

 

[TheWallnerus]

something like 40% of their bone mets get SBRT.

Ha right. They wrote a paper about how some/many rad oncs give >10 fractions for bone mets too.

Funny how there’s not really a paper on “too much reimbursement” (sans fractions) for bone mets. It’s gotta be quite the thrilling tingle that runs up one’s leg when getting ultrareimbursed AND getting to fraction shame others at the same time.

 

[thecarbonionangle]

It really is amazing how much the landscape has changed. When i applied years back, the wisdom was be happy you end you end up anywhere. Even securing away rotations was very difficult and stressful.

True story from those days: applicant received multiple invites for a rotation and chose the “best” program (the other programs Of course got mad and rejected their app). Applicant proceeded to book their hotel and flights, thousands of dollars. About 2 weeks later the coordinator called telling them a mistake had been made and they were overbooked. They were basically told “sorry”. PD and chair at time could not care whatsoever. By this point, not much was left and they scrambled to get another rotation in a hellpit. Things there were as bad as people say. They knew first week a huge mistake had been made, yet still cost them about 3k.


Thinking back, taking out extra loans for interviews, away rotations, trying so hard to get letters from famous people who sucked, what a complete waste of time this was. The field is in complete free fall now with places practically begging people to rotate with money and chairs shilling on twitter for rotators to rank them high. So many declining fools who “lead” this field.

Just be happy you get A job, ANYWHERE folks!

 

[thecarbonionangle]

Ha right. They wrote a paper about how some/many rad oncs give >10 fractions for bone mets too.

Funny how there’s not really a paper on “too much reimbursement” (sans fractions) for bone mets. It’s gotta be quite the thrilling tingle that runs up one’s leg when getting ultrareimbursed AND getting to fraction shame others at the same time.

Chris mathews of rad onc?

 

[TheWallnerus]

Crank up the spine SBRT, liver RT, and radiopharm service boys and @Dan Spratt

we are gonna need em

 

[Dan Spratt]

In 2020, MSKCC Manhattan started 4173 patients spread among 34 attendings by my count.

In 2020, American rad oncs started 1.06m patients spread among ~5500 rad oncs.

MSKCC sees significantly less patients per rad onc than the national average.

The avg MSKCC rad onc is seeing 2.5 new patients a week, yet they (MSKCC rad onc itself, not the attendings per se) seem to be doing VERY well. I wonder why that is... maybe their reimbursement is different than what I see. Or maybe they use procedures that reimburse very well a lot more than I do. IDK. I am not an economist.

So many awesome points to discuss. Please note that of 34 providers my guess is there is closer to 20 cFTEs. My co-resident Dr. John Cuaron who a few years ago was nearly purely clinical (now has growing leadership roles) was treating ~450 new starts per year. My other co-resident, Dr. Sam Bakhoum who is a highly funded physician-scientist treats ~50 patients per year. Similar at U of M. I was 80% grant funded, Drs. Pierce, Jagsi, Wahl, Speers, Lawrence, Green, etc all work ~0.5 to 1 day of clinic per week, so those 6 faculty really are closer to 1.5-2 cFTE combined. The average new starts per 1.0 cFTE at U of M was >300 (~2500 new starts per year, about 8 .0 cFTE = 312). I treated for example at 0.2-0.4 cFTE 330 patients my last year (feel free to ask the residents), and most of my clinical peers treated >250/yr and most were 0.6-0.8 cFTE based on grants and leadership roles and so similarly hit >300 new starts per 1.0 cFTE.

This is something lost in so many calculations who talk about how many radoncs are in the workforce. We have multiple (by choice) PRN and part time radoncs, multiple funded and have reduced clinical time. Across our >10 sites, even the more rural ones, they all treat per 1.0 about 250-400 new starts per radonc. We treat ~3700 new patients per year and have 15 docs at ~9 cFTE = 411 new starts per 1.0 cFTE. This is a bit too high and so we are hiring more.

None of this is to say we dont have a workforce/job market problem. Just saying the math is over simplified and doesnt account for people do admin, research, part time, PRN, etc, which is a sizable part of academic centers and medical directors of community and private practice.

 

[TheWallnerus]

admin, research, part time, PRN

The Pareto distribution (20% of the people doing 80% of the work) is found everywhere. Unfortunately as Nick Z has shown now the work and patients are getting concentrated in not just the top-tier people but the top-tier and top-volume centers. "Admin and research" can never be (much of) a thing in the community. There is a HUGE chasm between the wants/needs/reimbursement of a system like yours and small clinics and small community or regional hospitals.

But again just go back to patient numbers. Take cFTE out of it. MSKCC had 4031 new starts in 2013 and 4173 in 2020. Did MSKCC Manhattan increase MDs between 2013 and 2020? And if it's true that America as a country had less new RT starts in 2020 vs 2003, isn't that worthy for some discussion?* Now factor in virtual supervision, APM (will only affect centers where MDs *don't* do research at first), declining indications (we just lost postop lung N2 and are losing chemoRT in Stage III rapidly as well; I have a new thing I'm harping on it seems almost every week), declining fractionation, and horrible geographic mobility...

The average new starts per 1.0 cFTE at U of M was >300 (~2500 new starts per year, about 8 .0 cFTE = 312)

I treated for example at 0.2-0.4 cFTE 330 patients my last year (feel free to ask the residents),

We treat ~3700 new patients per year and have 15 docs at ~9 cFTE = 411 new starts per 1.0 cFTE.

Sometimes your denominator is just 1.0 cFTEs (as if a sub-1 sees zero patients, but you're a non-1.0 cFTE and see as much as a 1.0 cFTE) and sometimes not. In general, we have to assume every non-academic RO is a 1.0 cFTE, and I also believe we must assume every RO trainee is "at risk" of being a 1.0 cFTE. As your own example shows, the association between the cFTE metric and actual work may not be strong. For your purposes as chairman, of course you have to get bogged down in FTE minutiae. For our purposes of zooming out and looking at the big picture, we need to look at such things a little less IMHO. Keep in mind the economics where you assign all the work to 2/3 of your docs and zero to the other third ("We treat ~3700 new patients per year and have 15 docs at ~9 cFTE = 411 new starts per 1.0 cFTE"), whether in your head or IRL, doesn't work outside the walls where super high reimbursements let these kinds of economics work. The IQR for Medicare reimbursement per RO physician shrunk from $341K to $245K from 2013 to 2019. Nationwide, *at least* 30% of rad onc's patient load is Medicare.

If nationwide every rad onc was carrying a Dan Spratt workload (330 pts/yr), consider the math:

1) Of the ~1.9m new cancer cases per year, ~31% (and falling) need RT. That's 589K people, and 589K divided by 330 is 1768 (rad oncs per 330 pts/RO). We have 5500+ rad oncs in America.
2) Of the ~1.1m new RT starts per year in the US, that number divided by 330 is 3333. Again, we have 5500+ rad oncs in America. We can't assume that 2000+ rad oncs in America either want or need admin or research work. (Proton centers don't even know how to proforma admin and research work!)

Across our >10 sites, even the more rural ones, they all treat per 1.0 about 250-400 new starts per radonc.

250 to 400 is a wiiiiide gap! We need to have much more precise and accurate data to have really fruitful discussions about the rad onc workforce and trends over time.

Just saying the math is over simplified

Read a CBO report. Or Johnson & Johnson annual report. Or even an IPCC report. They always start with the big picture and the simple math first. Then they get more detailed and complicated from there. Start with easy and simple first. Remember how as a PGY2 we always wanted to make things more complicated than they really were? (And later you learn, yeah, they're complicated... but you have to see the forest before the trees.)

*Patient volume in the non-Manhattan MSKCC Network (has it grown in terms of sites? it must have?) has increased a lot though.

 

[Dan Spratt]

@Dan Spratt - what is your opinion on proton, now that you chair a department with proton therapy available? Are you a supporter of proton therapy for prostate cancer? I'm genuinely curious on your take as probably THE leading GU rad onc voice

I have not treated a single prostate patient with protons since I have been here. I have written even while as chair about protons for prostate cancer in IJROBP and my stance has not changed. Excited to see results from the only real study on the topic (PartiQOL) in the next 1-2 years. I view protons as a service to our community as Cleveland has one single vault to cover all of northeast ohio, which is about right and our proton unit is attached to our peds hospital.

 

[elementaryschooleconomics]

I treated for example at 0.2-0.4 cFTE 330 patients my last year (feel free to ask the residents)

1) I believe you really did this, no need to verify!

2) That is not realistic outside of the environments you've practiced in. Sloan, Michigan, your current department - these are all massive academic shops with tremendous resources. If you have skilled Dosimetrists/Anatomists contouring your OARs and giving you great treatment plans needing minimal revision, and have residents and mid-levels providing support by fielding phone calls and various patient issues, then sure, this is possible.

For everyone else in smaller community settings, or even small academic departments - 330 new starts per year is far more than 0.2-0.4 FTE, especially since they're seeing more than breast and prostate.

I think anyone in leadership positions at ASTRO and elsewhere should do an away rotation with a community generalist and see a different perspective. The fact that ASTRO is dominated almost exclusively by academicians drives a lot of issues in the field.

 

[deleted1116990]

Ha right. They wrote a paper about how some/many rad oncs give >10 fractions for bone mets too.

Funny how there’s not really a paper on “too much reimbursement” (sans fractions) for bone mets. It’s gotta be quite the thrilling tingle that runs up one’s leg when getting ultrareimbursed AND getting to fraction shame others at the same time.

How can places routinely give SBRT for bone mets and I have to waste my time in PP arguing why I should get paid for a 3D instead of 2D 5 fraction palliative plan? Especially when those physicians are seeing 3 consults a week as you claim and I saw 16 last week? I'm the bad guy (Hint: I'm not making 5X as much money)? If I saw 3 consults a week I would be out of a job here.

 

[Gfunk6]

None of this is to say we dont have a workforce/job market problem. Just saying the math is over simplified and doesnt account for people do admin, research, part time, PRN, etc, which is a sizable part of academic centers and medical directors of community and private practice.

Translation: There is not a workforce/job market problem per se. Just spend the time that you trained for x9 years to do and do something else. IT'S THAT SIMPLE - it ain't brain surgery folks!

New grads ought to consider cross training as radiation therapists. I am only partially joking - the more experienced ones are pulling in more money than "clinical assistant professors" at academic centers.

Practicing Rad Onc: "I remember a time when Rad Onc was competitive and jobs were available all around the country."

Dan Spratt:

 

[Dan Spratt]

You guys (and me) let him prod us into writing the same stuff we have been writing for 8-10 years… if this is new to chairman - if any of this is new to any chairman including Dan, just tells you they have zero idea of what’s going on for a decade.

@Dan Spratt - thanks for the epic trolling here. You got us good!!

Simul-
I find it odd that I am invited around the world to educate people, faculty radoncs included, about prostate cancer, clinical trials, biomarkers, etc. Just as you are in your realm of expertise. Should I simply tell them I and other have written hundreds of articles, book chapters, review papers, recorded talks and to not ask for help? Tell them they are lazy? I havent even been a radonc for 8-10 years Simul and this has not been my area of focus, just as your area has not been to lead clinical trials around the world or biomarker discovery. Different paths and different knowledge and skill sets.

I started with saying I am not an expert on this and have read a moderate amount in preparation of being a Chair and for the SCAROP meeting, but much of it is venting, back and forth arguing, and not a comprehensive root cause analysis with evidence-based data driven solutions that are clearly actionable. I have many limitations and understanding the complexities of every aspect of our field I do not have anywhere near mastery of. My focus is largely on my team and my patients, and as I grow into this role to have a larger voice I want to better understand the issues which is why I entered this forum (and are met with your comments basically implying chairs are terrible and I am too lazy or dumb or dont care).

I am sure you like most of us appreciate when someone with more knowledge or someone who has put more thought into it or someone who has led a podcast on the topic could be a great resource. Just as many find that thousands of hours and years I have focused on prostate cancer to be helpful to those who spend less time comprehensively understanding it.

I want to do my part of the specialty, and right now trying to reimagine and dramatically change a large program is my major contribution if successful that I hope will inspire other departments/programs to rethink about QOL/compensation/culture/teamwork by leading by example. Chairs are nothing special, their job description specifically is to their department/hospital. Just as a faculty's job description is. However, many rise above, you included, to try to impact things more broadly.

I respect your opinions and appreciate the info you provided, but I still am perplexed why asking a question is met with so much negativity. Trying to understand and represent peoples voices.

I wrote hundreds of words and asked for a sentence not to silence anyone. It is because I could not come up with the sentence myself as you can tell from the word vomit of complexities I tried to describe. I need this to frame the issue in a root cause analysis and demonstrate the many branching cause and effects and then to discuss the impact of various solutions that need to be studied. My mind naturally agrees with many of you that we have too many slots. So do we close them regionally do we close them at places that cant provide comprehensive training in the many things available in radonc, do we close the ones that are small, do we close some slots in larger programs. How do you operationalize this?

In healthcare they estimate close to 80% of the current work of a physicians job will be replaced by APPs and other staff combined with AI (that number is pan-specialty and not radonc specific as I dont have that number). This is different than 80% of jobs will go away, but that we must pivot to overseeing more aspects of care, technology development, quality, etc, and cant just focus on 1 patient and write 1 note. How do we factor in this to the solution? Does our training need to be more focused on leadership skills, integration/IT/engineering, team management? How does virtual care impact things given I now see patients all over the state and country and even world virtually now.

If you can send me a paper that addresses all of this with solutions please send as most of the work has been brief editorials, pieces of data on small components, and not a comprehensive synthesis of the problem, cause/effect, and complexity of AI, APPs, workforce changes, APM/reimbursement changes, virtual care, assistant bots that help with symptom management, etc.

Vilify me all you want, but you know me well enough that I am going to keep pushing to better understand this topic as I try to not opine and speak or lead groups by talking out my @ss. I try to understand it well enough to bring people together who are motivated to make change.

Best,
Dan

 

[communitydoc13]

Just saying the math is over simplified and doesnt account for people do admin, research, part time, PRN, etc, which is a sizable part of academic centers and medical directors of community and private practice

Dan is right here of course.

Not that this makes a community doc feel more solidarity with the academics. I'm a medical director and have not reduced my clinical load. The task of a medical director is nebulous and often self-defined.

That so many academic radoncs see so few patients is well known. What value they have brought to community practitioners with their 80% grant funded non-clinical time is not so clear.

Thinking how to contextualize even good radonc trials, like the slew of recently published hypo-fractionated breast trials (FAST, FAST-Forward, Livi) is just not as rewarding or interesting as giving a new therapeutic to a patient.

Part of my personal malaise (keep in mind most here (including me) are happy for their jobs and grateful for their circumstances) is that I am not participating in the most interesting parts of cancer care. Medical oncology got a whole lot more interesting clinically in the past 12 years.

I'm a simple community doc. I suspect that many academic radoncs have internalized this as well.

 

[Dan Spratt]

The Pareto distribution (20% of the people doing 80% of the work) is found everywhere. Unfortunately as Nick Z has shown now the work and patients are getting concentrated in not just the top-tier people but the top-tier and top-volume centers. "Admin and research" can never be (much of) a thing in the community. There is a HUGE chasm between the wants/needs/reimbursement of a system like yours and small clinics and small community or regional hospitals.

But again just go back to patient numbers. Take cFTE out of it. MSKCC had 4031 new starts in 2013 and 4173 in 2020. Did MSKCC Manhattan increase MDs between 2013 and 2020? And if it's true that America as a country had less new RT starts in 2020 vs 2003, isn't that worthy for some discussion?* Now factor in virtual supervision, APM (will only affect centers where MDs *don't* do research at first), declining indications (we just lost postop lung N2 and are losing chemoRT in Stage III rapidly as well; I have a new thing I'm harping on it seems almost every week), declining fractionation, and horrible geographic mobility...



Sometimes your denominator is just 1.0 cFTEs (as if a sub-1 sees zero patients, but you're a non-1.0 cFTE and see as much as a 1.0 cFTE) and sometimes not. In general, we have to assume every non-academic RO is a 1.0 cFTE, and I also believe we must assume every RO trainee is "at risk" of being a 1.0 cFTE. As your own example shows, the association between the cFTE metric and actual work may not be strong. For your purposes as chairman, of course you have to get bogged down in FTE minutiae. For our purposes of zooming out and looking at the big picture, we need to look at such things a little less IMHO. Keep in mind the economics where you assign all the work to 2/3 of your docs and zero to the other third ("We treat ~3700 new patients per year and have 15 docs at ~9 cFTE = 411 new starts per 1.0 cFTE"), whether in your head or IRL, doesn't work outside the walls where super high reimbursements let these kinds of economics work. The IQR for Medicare reimbursement per RO physician shrunk from $341K to $245K from 2013 to 2019. Nationwide, *at least* 30% of rad onc's patient load is Medicare.

If nationwide every rad onc was carrying a Dan Spratt workload (330 pts/yr), consider the math:

1) Of the ~1.9m new cancer cases per year, ~31% (and falling) need RT. That's 589K people, and 589K divided by 330 is 1768 (rad oncs per 330 pts/RO). We have 5500+ rad oncs in America.
2) Of the ~1.1m new RT starts per year in the US, that number divided by 330 is 3333. Again, we have 5500+ rad oncs in America. We can't assume that 2000+ rad oncs in America either want or need admin or research work. (Proton centers don't even know how to proforma admin and research work!)

250 to 400 is a wiiiiide gap! We need to have much more precise and accurate data to have really fruitful discussions about the rad onc workforce and trends over time.

Read a CBO report. Or Johnson & Johnson annual report. Or even an IPCC report. They always start with the big picture and the simple math first. Then they get more detailed and complicated from there. Start with easy and simple first. Remember how as a PGY2 we always wanted to make things more complicated than they really were? (And later you learn, yeah, they're complicated... but you have to see the forest before the trees.)

*Patient volume in the non-Manhattan MSKCC Network (has it grown in terms of sites? it must have?) has increased a lot though.

We really need to do a project on this and pull Nick Z and all the claims data in. Sounds fun.

I can tell you that when I joined here there were 4 part time physicians (pure clinical) by choice (I offered multiple to be full time) and 2 PRN physicians. So I do not believe you can say a physician = 1.0 clinical.

When I hire research or leadership positions their clinical time is cut down and we must find other funding sources to make their 1.0 salary whole. Example: I pay an associate professor 5 years out >$500k. If they are 50% protected I have to on my budget provided departmental $$ to cover $250k. So the physician is now benchmarked to a much lower revenue generation expectation and sees intentionally far fewer patients and has far fewer consult slots. This is the exact same if they want to be 0.6 cFTE and work 3 days a week and have 2 days off per week (department just doesnt have to pick up the 2 days per week of their salary as they are not working those days).

I can confirm that a few years ago I was told that of the ~10,000+ patients at MSKCC about 1000 were spine SBRT. Remember MSKCC is not just Manhattan, and I do not know if those data you cite include the >1000 re-RT patients. At Michigan of the 2500 new starts I believe over 500 were re-RT, so significantly fewer unique patients. In our spine program and brain mets programs data shows ~50% of patients develop a new spine or brain met with 12 months of initial treatment, so programs that do q3m MRI end of providing multiple courses to the same patient. This is a good thing, just as medonc gives cycles of chemo, etc.

Email me at [email protected] and happy to try to get our hands on better data. Nick Z confirmed that the data he presented is largely misrepresented, but he can speak for himself on why he feels this is true.

Thanks for the back and forth.

Best,
Dan