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

[Dan Spratt]

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.

Great points. I think radonc needs to expand more like how clinical oncologists have done in the UK to give systemic therapies, and at minimum radiopharm. I may be fortunate, but have spoken to many private practice radoncs who do the same, but I write for all oral ARSIs and are getting our hot lab up in radonc to deliver 177Lu-PSMA. I am also lucky, but lead many drug trials and work with pharma to help inform future work with combination drug-RT, and radoncs are uniquely suited for many of these roles given our vast knowledge of cancers across the body and various treatments. We also have more and more biomarkers being developed and play important roles at tumor boards.

I just worked with our newest faculty recruit who is amazing to put out 2 papers in PRO on how to use radiopharm and stressed the importance of radonc being involved. Hope they come online soon.

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[TheWallnerus]

Nick Z confirmed that the data he presented is largely misrepresented, but he can speak for himself on why he feels this is true.

Hope he didn't say he's misrepresented just to placate someone. He got on a podcast as I recall and gave zero impression he had been misrepresented. This was his data: 58% of American RT centers are low volume (treat the lowest quartile of patients), breast is by far the most common RT patient, and 58% of centers may consult on less than two breast patients per week (and ~50% of the low volume centers, or ~25 to 30% of US centers overall, may see less than 1 new breast patient a week)... and that is their most common consult. He said verbatim on twitter: the majority of US centers are low volume. And if that premise is true, other premises naturally follow.

 

[RickyScott]

Great points. I think radonc needs to expand more like how clinical oncologists have done in the UK to give systemic therapies, and at minimum radiopharm. I may be fortunate, but have spoken to many private practice radoncs who do the same, but I write for all oral ARSIs and are getting our hot lab up in radonc to deliver 177Lu-PSMA. I am also lucky, but lead many drug trials and work with pharma to help inform future work with combination drug-RT, and radoncs are uniquely suited for many of these roles given our vast knowledge of cancers across the body and various treatments. We also have more and more biomarkers being developed and play important roles at tumor boards.

I just worked with our newest faculty recruit who is amazing to put out 2 papers in PRO on how to use radiopharm and stressed the importance of radonc being involved. Hope they come online soon.

I heard a rumor that many years ago Luther Brady tried to create a clincal oncology fellowship for radoncs to deliver chemo because he was sick of dealing with medoncs. We will owe and enormous debt to whoever is able to achieve this. Gynoncs always praise Phil DiSaia for not backing down when it came to chemotherapy, when he created the specialty.

 

[xrt123]

Great points. I think radonc needs to expand more like how clinical oncologists have done in the UK to give systemic therapies, and at minimum radiopharm. I may be fortunate, but have spoken to many private practice radoncs who do the same, but I write for all oral ARSIs and are getting our hot lab up in radonc to deliver 177Lu-PSMA. I am also lucky, but lead many drug trials and work with pharma to help inform future work with combination drug-RT, and radoncs are uniquely suited for many of these roles given our vast knowledge of cancers across the body and various treatments. We also have more and more biomarkers being developed and play important roles at tumor boards.

I just worked with our newest faculty recruit who is amazing to put out 2 papers in PRO on how to use radiopharm and stressed the importance of radonc being involved. Hope they come online soon.

First,
Kudos to any chair that non-anonymously shows up to this forum.

Second,
Are these 2 PRO papers published? We are working with Nuc Med for PSMA-LU and have some other novel agents (Her2, FAP) that are in the pipeline for trials.

 

[maruchan]

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.

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.

No such paper exists. Historically, even trying to reach step 0 of acknowledging that a problem exists would be met with borderline derision from "the leadership" (see the article + thread: Bloodbath in the red journal).

In order to operationalize a solution, the relevant actors must first acknowledge that a problem exists. But until quite recently, the people with any potential power to enact solutions have strongly denied the existence of an issue and derided those who voiced it.

So you can imagine why no one has published a paper like the one being asked for, or even gotten close.

That is also the answer why all discourse on this topic is permeated with such negativity. It's a reaction to the negativity that came before from the other side. It's unfortunate and maybe counterproductive, but that's the reality.

 

[thecarbonionangle]

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

The bad programs are well known. Some of these places have been around since 1980s/1990s. How many probations or slaps on wrist must they get? They have had DECADES to improve and they didn’t lol. Some of them cannot even match. Close these hellpits and then cut other spots.

 

[Bequerel]

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

Where were all of the root cause analyses when residencies were expanded? Chairs and program directors just said we have enough patients to justify more residents and added spots.

Imagine how things could have been different if half of the mental masturbation being put into the resistance of the obvious need for contraction was used before programs decided to expand!

Dan, if you want to make a meaningful difference in our field, then argue for a significant contraction in the number of residents being trained at the chairperson meaning. It’s just common sense.

 

[TheWallnerus]

Dan, if you want to make a meaningful difference in our field, then argue for a significant contraction in the number of residents being trained at the chairperson meaning.

If it actually came to be (resident contraction) we would see med student interest pick back up. Another thing that keeps getting overlooked in our discussions is how med students are not willful dummies. Rad onc chairs may not want to really understand what we are saying, but med students sure do. I think this thread has been courteous and fact-filled btw.

 

[TheWallnerus]

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

Between 2007 and 2018, resident case log experience:

1) Residents up by 66% (p< 1 divided by a lot)
2) Mean total (SBRT included) EBRT cases per resident down 13% (p<0.001); per resident, peds down 19%, heme cases down 31%, lung cases down 26%, GU cases down 24% (all p<0.001)
3) SBRTing up about 10-fold per resident (p<0.001), metastatic work up 8% (p<0.001)

Do these stats mean anything to anyone? How often have they been talked about at the SCAROP meeting? My root cause analysis: too many residents.

 

[maruchan]

If it actually came to be (resident contraction) we would see med student interest pick back up. Another thing that keeps getting overlooked in our discussions is how med students are not willful dummies. Rad onc chairs may not want to really understand what we are saying, but med students sure do. I think this thread has been courteous and fact-filled btw.

Absolutely true re: resident contraction.

 

[Mandelin Rain]

Root Cause: Non-data driven, unwarranted residency expansion (note: this was likely, at least in part, to drive attending salaries down and increase ease of hiring)
Solution: Contract spots to the point that salaries go high enough that it's no longer economically advantageous to create extensive "academic networks" that exist to drive up the cost of health care and push out private practitioner competition.

It's simple. It's not easy.

Put another way: The academic mission transparently became profit.

 

[OTN]

Dan,

You'll have to excuse our hesitation to welcome anyone with open arms. We've been ridiculed in the Red Journal, on Twitter, and on whiteboards in videos to medical students. We've seen ASTRO "leadership" repeatedly deny an issue exists, then simply state there's nothing they legally can do and throw their hands up once they were forced to admit there may be a slight problem. We were told the "market" would correct when students decided not to go into the field, then we watched helplessly while programs SOAPed candidates to fill. We're now being told adjustments to residency program requirements will do the trick, but none of us realistically think this is going to lead to any significant change.

I'm glad you came here to at least engage with the topic. That's a great first step. However, writing thousands of words here means nothing if it's not followed by meaningful action at the national level.

 

[Mandelin Rain]

This main question this thread has left me with is; does Dan Spratt really not have enough time to put mustard on a hot dog?

 

[Ray D. Ayshun]

This main question this thread has left me with is; does Dan Spratt really not have enough time to put mustard on a hot dog?

 

[Tumba]

Great points. I think radonc needs to expand more like how clinical oncologists have done in the UK to give systemic therapies, and at minimum radiopharm. I may be fortunate, but have spoken to many private practice radoncs who do the same, but I write for all oral ARSIs and are getting our hot lab up in radonc to deliver 177Lu-PSMA. I am also lucky, but lead many drug trials and work with pharma to help inform future work with combination drug-RT, and radoncs are uniquely suited for many of these roles given our vast knowledge of cancers across the body and various treatments. We also have more and more biomarkers being developed and play important roles at tumor boards.

I just worked with our newest faculty recruit who is amazing to put out 2 papers in PRO on how to use radiopharm and stressed the importance of radonc being involved. Hope they come online soon

Bruh.

 

[medgator]

Great points. I think radonc needs to expand more like how clinical oncologists have done in the UK to give systemic therapies, and at minimum radiopharm. I may be fortunate, but have spoken to many private practice radoncs who do the same, but I write for all oral ARSIs and are getting our hot lab up in radonc to deliver 177Lu-PSMA. I am also lucky, but lead many drug trials and work with pharma to help inform future work with combination drug-RT, and radoncs are uniquely suited for many of these roles given our vast knowledge of cancers across the body and various treatments. We also have more and more biomarkers being developed and play important roles at tumor boards.

I just worked with our newest faculty recruit who is amazing to put out 2 papers in PRO on how to use radiopharm and stressed the importance of radonc being involved. Hope they come online soon.

Where does it end though, Dan? Are you doing prolia infusions in your office when a long term eligard pt requires it? For some of us with a good relationship with MO, much easier to offload it to them when we start getting past the basic ADT etc

 

[BobbyHeenan]

A lot of the radiopharm and ARSI stuff is so job-specific.

I have a prof services agreement and bill pro fees. I work in a reasonably sized cancer network/hospital system. Some urology groups in town are employed by a big hospital system, another group is a huge group that has their own pharmacy contracts. I'd get lambasted if I tried to Rx ARSI - the urologists already rioted when med onc tried to do this.

Re: Radiopharm. Would like to hear others thoughts......but the last I checked, the professional billing on it is abysmal. Like 8 Gy X 1 bone met reimburses better than radiopharm. I do it for the patients and the cancer network, but at some point I can't just spend a ton of time on it unless something with my set up changes. There really needs to be new CPT codes because the codes for more advanced radiopharm are not reflective of the work that goes in (ie this ain't sumarium). Probably on the hospital/technical side they're reaping benefits, but from the physician standpoint it is a good bit of work and little reimbursement.

 

[Dan Spratt]

So, Nick says things publicly on the podcast and doesn't refute what Todd says ... but, when he is done, he tells his boss that his data was misrepresented? We gave him the platform, we don't censor, we have a very light hand on editing, and we let him talk. He was given lots of time to talk. This is fascinating stuff. Interestingly, he basically copied Todd's graphs and updated his tweets soon after. Soon, after Todd is blocked by the good chairman.

Does this sound like someone that wants to learn? A chairman blocking one of the thought leaders in the area that the chairman purportedly wants to learn about? That is really interesting to me. I would think that a newbie would want to learn from an expert. It is like me wanting to learn about prostate cancer, then blocking Dan.

Nick is a great guy and heard nothing but positive things about being on the podcast. My understanding is people keep focusing on the % of practices that he labeled as "low volume", but this was based I believe simply on quartile without any a priori determination of what a true low volume practice should be defined as. For example if you are at the 40th percentile of volume you likely are not in an absolute sense low volume, rather you are "lower" volume compared to other practices. Also, his data he said cant factor in true cFTE numbers, which is very relevant given NCDB captures likely all academic centers. This in no way reflects the podcast but rather the frequent discussions/comments he sees about the paper. Thats all.

 

[winstonfoot5]

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

It comes down to uncertainty. There is substantial uncertainty in the field of radiation oncology (not the modality, per se, but the field). For all the reasons highlighted in this forum/thread and in concise papers. The field has a confidence crisis. Its like a stock being valued not on its current performance but potential for future returns/growth. Medical students aren't buying (uncompensated risk) and many feel we've haven't seen the bottom yet.
Chicken Little or Goose-is-Cooked? The State of the US Radiation Oncology Workforce: Workforce Concerns in US Radiation Oncology

 

[TheWallnerus]

but this was based I believe simply on quartile without any a priori determination of what a true low volume practice should be defined as. For example if you are at the 40th percentile of volume you likely are not in an absolute sense low volume, rather you are "lower" volume compared to other practices

Forget about the quartiles and definitions then. Don't let that confuse the issue. Put it however you want, but Nick's data showed:
1) If you randomly pick (put the name of every center Nick looked at in a bag and draw a name from the bag) a radiation center in America, the chance that it will be <=25%ile in volume is 58%; the chance that it will be <=12.5% in volume is about 25%; the chance that it will be >=75%ile in patient volume is 7%. (In a normally distributed sample, 75% of the data points will be within the interquartile range, IQR, and the IQR is a good descriptive stat of data dispersion. In rad onc, just 34% of all centers are within the IQR for patient volume. Patient volume in rad onc is maldistributed and has significant skewness/kurtosis.)
2) If you randomly pick a radiation center in America, the chance that it is starting <=2.0 breast cancer patients on treatment a week is 58%, and breast cancer patients are the most common (in the range of 1:1::breast:everything else) RT patients in America.

The above perfectly match medicare data e.g. where we find that the median reimbursement per RO is $150K, but the average is about $330K, and almost 1/3 of all rad oncs get reimbursed by Medicare <=$100K/yr. When measured against other specialties, RO is yet again an outlier in this arena too... and we are one of the, if not *the*, most Medicare reliant specialties in terms of patient volume.

 

[RickyScott]

Forget about the quartiles and definitions then. Don't let that confuse the issue. Put it however you want, but Nick's data showed:
1) If you randomly pick (put the name of every center Nick looked at in a bag and draw a name from the bag) a radiation center in America, the chance that it will be <=25%ile in volume is 58%; the chance that it will be <=12.5% in volume is about 25%; the chance that it will be >=75%ile in patient volume is 7%. (In a normally distributed sample, 75% of the data points will be within the interquartile range, IQR, and the IQR is a good descriptive stat of data dispersion. In rad onc, just 34% of all centers are within the IQR for patient volume. Patient volume in rad onc is maldistributed and has significant skewness/kurtosis.)
2) If you randomly pick a radiation center in America, the chance that it is starting <=2.0 breast cancer patients on treatment a week is 58%, and breast cancer patients are the most common RT patients in America.

The above perfectly match medicare data e.g. where we find that the median reimbursement per RO is $150K, but the average is about $330K, and almost 1/3 of all rad oncs get reimbursed by Medicare <=$100K/yr.

It just goes back to Pareto like distributions. No bell curve at work here. 2 breast per week is critically anemic for an entire center.

 

[communitydoc13]

The above perfectly match medicare data e.g. where we find that the median reimbursement per RO is $150K, but the average is about $330K, and almost 1/3 of all rad oncs get reimbursed by Medicare <=$100K/yr.

The numbers are what they are. The point I was getting from DS is that there may be very little correlation between number of radoncs and clinical FTEs at many academic places. To what extent does this skew the national numbers? I'm not sure, but there are probably not many PP docs out there billing less than 100k/year unless they are old timers covering or part timers. As has been mentioned before, even the total number of docs in practice is not a really easy number to pin down. In addition, academic docs are a much bigger piece of the total radonc pie than they used to be.

The fact that there is very little correlation between number of academic radoncs and number of academic cFTEs is not a good look in my opinion, but probably keeps a fair number of academics happy. I believe academic radoncs still make much more than 0.4 FTE academic medoncs by a long shot. I defer to DS on this issue and how this happens. (My suspicion is the mad negotiated rates allow for this disparity).

Of course, a few years of the field matching 50 med studs total would completely change things for the better.

 

[RickyScott]

My suspicion is the mad negotiated rates allow for this disparity).

Oversupply in a nutshell. So much of job market based on this, not clinical need.

 

[TheWallnerus]

little correlation between number of radoncs and clinical FTEs at many academic places.

I understand. But one hopes that the workforce issues aren't only looked at through the academic places' prism.

I'm not sure, but there are probably not many PP docs out there billing less than 100k/year unless they are old timers covering or part timers.

I get that too of course, but the relative proportion/percent of *all* ROs in the $0-$100K Medicare reimbursement bin keeps growing over time (putting us all at risk), and in new grads' first year or two of full practice, approximately 7.5% will achieve above the median, and only 1% or so achieve above the average. I was *very* busy my first full year of practice, and there is nothing that special or work brickle about me.

 

[jondunn]

The point I was getting from DS is that there may be very little correlation between number of radoncs and clinical FTEs at many academic places. To what extent does this skew the national numbers?

agree. but the interesting thing is I think academic numbers skew the national numbers more and more every year. i don't think that trend will stop soon - academic rad onc IS increasingly becoming rad onc.

percentage goes up yearly.

 

[TheWallnerus]

agree. but the interesting thing is I think academic numbers skew the national numbers more and more every year. i don't think that trend will stop soon - academic rad onc IS increasingly becoming rad onc.

percentage goes up yearly.

Bubble.

 

[RSAOaky]

Dan,

I always have to give you kudos for stepping into the lion's den.

Really hard to sum this all up in one sentence, but here's my best shot.

The specialty has become less rewarding, faces increasing risks of marginalization and job market collapse, and the people with any power to change this have mostly made their buck already and so they either pretend there is no problem or have conflicts of interest with the potential solutions.

Is it reduced interest in our field?

Yes. Consider this, even in the glory days of radonc when we were getting great jobs with technical partnership making bank working 4 days a week with minimal call and no weekends, we only ever managed to attract ~200-250 applicants to a year. This was in the glory days when radonc actually WAS awesome. I've heard people blame SDN over the last few years for radonc's PR problem, but this is a problem that existed long before the SDN detractors. So why the decline in interest? Well, we used to attract the smartest medical students in the country, and the smartest medical students in the country have decided there is enough reason to stay away. This is a field on the decline by every single measure. We are working harder for less money, less autonomy, and with limited opportunities for jobs in desirable locations (i.e. not NE Ohio, no offense). You can argue that medicine as a whole is on the decline, but if you have to choose to be stuck on a sinking ship then at least with other specialties you get to choose which ocean you're gonna drown in.

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?

The unique problem is that we have simultaneously torpedoed our demand (hypofrac, omission, TORS, advances in systemic therapy) while raising the supply (resident expansion). Good jobs are limited, good jobs in good cities are even more limited. Everyone wants them, they are all salaried, and you have no negotiating power.

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.

It's not about where you start your career. Leadership obsesses over the ARRO job surveys as a measure of job market strength but it's all artificial. We're going through a period of consolidation. You know the game. Small hospitals and private practices are being bought out and big hospital systems are opening up satellites with 10-15 on beam trying to squeeze out the competition. Older physicians who were making $600k+ are being replaced by new grads making $350k. 2 years down the line your not so new grad wants to know when they're getting a raise. Unfortunately, it's hard to justify paying them more than $350k when they only have 10-15 on treatment. If we wait until new grads are going unemployed to fix the supply problem, we will have waited too long.

-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)?

There is both an oversupply and a geographic maldistribution. No one wants to go to rural America unless they are from rural America and even then it's a stretch. Statistically speaking, few people from rural America are making it into medical school and even fewer of those people are making it into radonc. That being said, everyone has a number. When you start to see the salaries in rural America go down, you know that there is an oversupply of radoncs. Spoiler: Salaries in rural America are going down.

-Is it a DEI issue (or at least in part)?

I once made the mistake of bringing my wife to an ASTRO party. She was ogled at and flirted with by residents and people I would consider leaders in our field to the point of extreme discomfort and an early exit. Historically, this field has been filled with a bunch of awkward nerdy dudes. Every year, we all get together at ASTRO where awkward old white men who wouldn't be given a second thought by the rest of society are wined and dined by industry and treated like celebrities by their peers and contemporaries. We perpetuate this pervasive elitism, stroke each others' egos, and make it impossible for anyone that's not like us to break in. That was all accepted/acceptable because radonc was in high demand and so when an attending you were trying to impress took a proverbial dump on your chest you'd simply tell them "thank you sir, may I have another." Now that no one wants to touch us, we start asking if radonc has a DEI problem?

-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.

This is part of it. I have said before, we've raised the floor and dropped the ceiling. Eventually, we will drop the ceiling further. I am a generalist at an academic satellite doing 90th+ percentile productivity (~13k RVUs) for 75th percentile compensation (~$650k). I hypofractionate 90% of my prostates and breasts and I work for every one of those dollars.

My colleague works at a satellite of one of the largest academic institutions in the country, in my same region, which employs ~40 radoncs. He has all sorts of administrative responsibilities, works 5 days a week, struggles to find coverage for vacations, and generates as many RVUs as I do for median compensation ($550k). I'm very happy with my situation. I'd be very unhappy with his.

We are two of the most productive radoncs in the country and neither of us are even sniffing $1MM. Meanwhile, both of our institutions have senior academic professors making as much as we do, seeing minimal patients, and producing zero meaningful research. He is a fantastic clinical physician who will ultimately be pushed to industry because we eat our young to subsidize the fat at the top. I attend 7 tumor boards a week, am on call 26 weeks a year, and am constantly asked to take on more responsibility for free. There is constant downward pressure on my salary. Most of us aren't trying to make $1MM, we just want to be compensated fairly. As of right now, I absolutely believe that I am, but my responsibilities are only going up and my salary is only going down.

As good a deal as I have, it is nothing close to those that came before me, and I can guarantee that the person who comes after me will be worse off.

 

[Mandelin Rain]

The more academic centers have replicated private practice models and expansion adventurism, the worse it's become for both "academicians" and private practitioners.

Is there any difference at all? Just the symbol on the white coat?

I'm sure the deans love it and the tenured professors are still doing fine. But the average newly minted rad onc? Options suck.

 

[Chartreuse Wombat]

The more academic centers have replicated private practice models and expansion adventurism, the worse it's become for both academicians and private practitioners.

Is there any difference at all?

The difference is that some academic centers are PPS exempt and most academic centers have negotiated higher rates than are available in the community. This allows them to "meet their academic mission" although it is arguable that at least in the research realm radiation oncology is mediocre

 

[Mandelin Rain]

The difference is that some academic centers are PPS exempt and most academic centers have negotiated higher rates than are available in the community. This allows them to "meet their academic mission" although it is arguable that at least in the research realm radiation oncology is mediocre

Last truly practice changing study from the the USA?

 

[deleted1111261]

It must be challenging to be in a world where people don’t take your currency. Like where I am - people’s credentials, publications, titles, grants - are incredibly meaningless to me. When these folks talk about invited lectures and endowed professorships that they did or didn’t get, I completely glaze over. It’s as if someone came into my clinic with suitcases full of Lira. It’s great and all, but it has no inherent value to me. Might as well hand me a bucket of warm piss.

In our world, we care about kindness, politeness. About a phone call with the referral and timely notes. We care about mutual respect at tumor board and about patients that say: “That chemo doc you sent me to had such warm bedside manner. Thank you for that.” The physicians that have earned my respect have few credentials. They read the literature, they take my phone calls, they practice standard of care and they respect my opinion, even when we disagree.

That’s why community medicine can be so rewarding and at least we have that going for us.

 

[medgator]

Last truly practice changing study from the the USA?

Acute and Short-Term Toxicities of Conventionally Fractionated Versus Hypofractionated Whole Breast Irradiation in a Prospective, Randomized Trial

The most appropriate dose-fractionation for whole breast irradiation (WBI) remains uncertain.To assess acute and six-month toxicity and quality of life (QoL) with conventionally fractionated WBI (CF-WBI) versus hypofractionated WBI (HF-WBI).Unblinded ...

www.ncbi.nlm.nih.gov

 

[TheWallnerus]

Last truly practice changing study from the the USA?

Changed my practice!

 

[Neuronix]

It must be challenging to be in a world where people don’t take your currency. Like where I am - people’s credentials, publications, titles, grants - are incredibly meaningless to me. When these folks talk about invited lectures and endowed professorships that they did or didn’t get, I completely glaze over. It’s as if someone came into my clinic with suitcases full of Lira. It’s great and all, but it has no inherent value to me. Might as well hand me a bucket of warm piss.

If you're trying to run a research lab and clinical trials, this stuff is important because you need funding and positions where you can lead these groups. But yeah if you're not running a research lab or clinical trials, it's not really important. Maybe some papers to get promoted, but it's not some major currency that people really care about.

In our world, we care about kindness, politeness. About a phone call with the referral and timely notes. We care about mutual respect at tumor board and about patients that say: “That chemo doc you sent me to had such warm bedside manner. Thank you for that.” The physicians that have earned my respect have few credentials. They read the literature, they take my phone calls, they practice standard of care and they respect my opinion, even when we disagree.

That’s why community medicine can be so rewarding and at least we have that going for us.

I'm not sure why you think it's any different among academic medical centers. Most of the faculty are clinical-track people anyway, many of whom transition between academic and non-academic worlds. So do you really think that most people in academics don't respect each other, have cold bedside manners, or don't care about those things? That's not the case.

Today a private rad onc called one of my referring surgeons to yell at him for referring a patient for a second opinion with me at patient's request. The patient decided to be treated by me instead of the private rad onc. I'm not going to sit here and stereotype private guys as hyper-competitive and greedy. There are some guys like that in my community. It's not fair to stereotype everyone like that.

 

[Neuronix]

Not at all. I’m just saying the overall values are different. In your world, people that are unkind have a higher likelihood of success than that same behavior in the community. Does that make sense? Like if you sent your CV to me, but I heard you were rude to people, I’d be hesitant to hire you. But we know countless people in academic departments that are very rude, known to be that way, and still get promoted.

We're not hiring anyone who has a reputation for being rude either... Nobody wants to work with those types.

I don't know countless people in academic departments who are very rude, and I've spent my whole life in academics.

The reason I said that is that the good chair prefaced his remarks with all of that stuff. I don’t see the relevance of it when trying to tease out what the point of this exercise is. Many of us have an idea who you are. Without doxxing, you are quite successful in your own right, but I have not seen you once brag about it. I admire that.

We all have our strengths and weaknesses. I'm no different.

 

[deleted1111261]

We're not hiring anyone who has a reputation for being rude either... Nobody wants to work with those types.

I don't know countless people in academic departments who are very rude, and I've spent my whole life in academics.

You’re very lucky! I had a chairman that called me a jihadi for not shaving!

 

[communitydoc13]

Changed my practice!

NOOOOOOOOO!!!

Come on. Keep that bell ringing. Even the authors said keep the bell ringing. We all need to face and embrace the trauma!

 

[deleted941485]

Riskiest Doctor Specialties | Med School Insiders

Part of the appeal of becoming a doctor is job security; however, this may no longer be the case for some specialties. Here are the specialties most at risk.

medschoolinsiders.com

Guess who is number 1.

 

[TheWallnerus]

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.

Riskiest Doctor Specialties | Med School Insiders

Part of the appeal of becoming a doctor is job security; however, this may no longer be the case for some specialties. Here are the specialties most at risk.

medschoolinsiders.com

Guess who is number 1.

Yikes. Dan make sure you mention medschoolinsider.com along with SDN and Twitter at SCAROP... this video's received 138K views

 

[Lamount]

Last truly practice changing study from the the USA?

PACIFIC, CRA

 

[DebtRising]

Why are Med students not choosing rad onc - supply and demand

Why are chairs asking why Med students are not choosing rad onc instead of acting on the obvious - because chairs do better when they drive down labor costs and shove new faculty in far off satellites with no chance for advancement but charge the patients the academic rates if they can.

No one at SCAROP is hurt but oversupply. They benefit. Rinse and repeat year after year

 

[evilbooyaa]

Last truly practice changing study from the the USA?

Will give credit to OPRA for putting up some pretty good numbers in a prospective fashion. Do you mean a practice changing study lead by a Rad Onc? From the US? Oh. Probably RTOG 9804, but practice changing for likely the wrong reasons...

 

[RadOncMegatron]

If it actually came to be (resident contraction) we would see med student interest pick back up. Another thing that keeps getting overlooked in our discussions is how med students are not willful dummies. Rad onc chairs may not want to really understand what we are saying, but med students sure do. I think this thread has been courteous and fact-filled btw.

It's so sad that this is THE answer, but everyone outside of SDN scratching their heads and looking into the clouds for a magic signal. CONTRACT THE RESIDENCY SPOTS. The YouTube video summed up the last 10 years of rad onc SDN in like 1 min.

The problem is that no one can force residency spots to close and the academic programs are not willing to do it. When they do contract it's some top tier program where we greatly appreciate their effort and being a role model, but they are not the problem. Academic institutions hold the key to the only way to fix things and are unwilling to perform the much needed sacrifice of significant contraction.

 

[deleted1111261]

Very little out there.

When the Dane presented PMRT study outcome, there was literal thunderous applause. What comes out now barely gets warrants much but a yawn.

 

[maruchan]

Would really recommend reading this thread if serious about operationalizing:

Voluntary residency contraction and the development of IMRT saved the field in the early 2000s: an analysis of the past 30 years

As an upfront warning: this might be the longest post in the history of Student Doctor Network (probably not true - but this is a dissertation). Something I’ve heard a lot in both real life and online is the sentiment that the “sky has always been falling in Radiation Oncology”. Indeed, there...

forums.studentdoctor.net

The really ironic thing is that this exact arc already played out in history yet in the modern day residency contraction is being called unfeasible.
- Due to job market concerns and declining medical student interest, rad onc went from 90% of spots being matched in 1995 to 70% in 1998. Sound familiar?
- In 1998, programs moved to 4 years instead of 3 and many programs closed. Over the course of 5 years, the field went from 61 programs to 47 programs and from 99 residents to 81 residents.

Why was it possible to take action toward residency contraction 25 years ago but not today? Culture?

It's really impossible to accept that residency contraction is that difficult, when it already happened in our same field not all that long ago.

 

[deleted1111261]

What is the expectation? That Dan goes back to the meeting and says

“99% of the discord is because there are probably too many residents. Let’s cut spots, Bob? How about you, Mike? Okay, fine, maybe not you, but Ted you can drop 1, right? Albert, I know you’ve at least tried, but gimme one more, please? Fine, you’re right, we should probably ask Dan up the road in Houston, as well. Oh, ****, you’re here Dan - congrats on the new position, yah dropping a spot probably not helpful for your career. Alright, Ronnie- you’re at least paying your squad well, how about just one total not one a year? Ok fine, you’re right, I get it. John, I’d ask you but then I’d probably have to cut one, so forget about us - we have the best two programs in Cleveland, amirite?” Cut to a bunch of old men and two ladies, laughing hysterically, throwing needles into voodoo dolls of me and SchweddieBalls and Lemmi.

Fan fiction… presented to you by Me!

 

[evilbooyaa]

What is the expectation? That Dan goes back to the meeting and says

“99% of the discord is because there are probably too many residents. Let’s cut spots, Bob? How about you, Mike? Okay, fine, maybe not you, but Ted you can drop 1, right? Albert, I know you’ve at least tried, but gimme one more, please? Fine, you’re right, we should probably ask Dan up the road in Houston, as well. Oh, ****, you’re here Dan - congrats on the new position, yah dropping a spot probably not helpful for your career. Alright, Ronnie- you’re at least paying your squad well, how about just one total not one a year? Ok fine, you’re right, I get it. John, I’d ask you but then I’d probably have to cut one, so forget about us - we have the best two programs in Cleveland, amirite?” Cut to a bunch of white men and two ladies, laughing hysterically, throwing needles into voodoo dolls of me and SchweddieBalls and Lemmi.

Fan fiction… presented to you by Me!

Don't forget CRT and JJ

 

[deleted1111261]

Don't forget CRT and JJ

Ah crap. I like them both!!

 

[RSAOaky]

What is the expectation? That Dan goes back to the meeting and says

“99% of the discord is because there are probably too many residents. Let’s cut spots, Bob? How about you, Mike? Okay, fine, maybe not you, but Ted you can drop 1, right? Albert, I know you’ve at least tried, but gimme one more, please? Fine, you’re right, we should probably ask Dan up the road in Houston, as well. Oh, ****, you’re here Dan - congrats on the new position, yah dropping a spot probably not helpful for your career. Alright, Ronnie- you’re at least paying your squad well, how about just one total not one a year? Ok fine, you’re right, I get it. John, I’d ask you but then I’d probably have to cut one, so forget about us - we have the best two programs in Cleveland, amirite?” Cut to a bunch of old men and two ladies, laughing hysterically, throwing needles into voodoo dolls of me and SchweddieBalls and Lemmi.

Fan fiction… presented to you by Me!

It's the hope that kills you.

I haven't been in this field for that long, but it's certainly been long enough to expect absolutely nothing. However, regardless of what you think of his motives or your critiques of him as a person, critiques that I have certainly shared, you have to give the guy credit for entering a hostile environment to engage in some sort of a discussion. It's more than 99% of chairs have done.

I certainly don't expect things to change and I know that if anything ever does it will be too slow to matter, but you have to start somewhere.

 

[fiji128]

Great discussion here. Problem is obvious. We are increasing the supply of rad oncs in a world where the need for them is decreasing. Med students with options are voting with their feet. "Leadership" wants to keep their collective heads in the sand and wants to explain it away by citing anything other then the actual reality.

As an example, I will note that Case Western Reserve increased their official resident compliment from 6 to 7 between 2019 to 2021. Case Western did not match in 2019 for 2 and in 2020 for 1 position. They currently have 7 total residents enrolled for 7 total position. There it is in a nut shell.