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Is Sameer Telling the Whole Truth and Nothing But the Truth?
Started by TheWallnerus
Below is who presented to the RUC. Things jumping out at me right now whilst I peruse:
1) Jahraus own a freestanding center. He advocated to delete 77014 to the RUC. He lost IGRT technical. Is he very stupid?
2) These guys estimate that the total number of external beam FRACTIONS to Medicare patients per year will be ~1.5 million. Doesn't that seem... low?
ed. note: throughout all the RUC meetings, ROCR casts what appears to an unhelpful miasma (smegma?) across every code discussion
Neuronix (moderator) edit 5/11/26: After discussion with the other moderators, we decided to delete a factually inaccurate part of this post based on rebuttal in post #8.
1) Jahraus own a freestanding center. He advocated to delete 77014 to the RUC. He lost IGRT technical. Is he very stupid?
2) These guys estimate that the total number of external beam FRACTIONS to Medicare patients per year will be ~1.5 million. Doesn't that seem... low?
ed. note: throughout all the RUC meetings, ROCR casts what appears to an unhelpful miasma (smegma?) across every code discussion
Neuronix (moderator) edit 5/11/26: After discussion with the other moderators, we decided to delete a factually inaccurate part of this post based on rebuttal in post #8.
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I don't know everyone's situation, but Chris was very pro-active and managed to adjust his rates. He is doing fine. Not selling center that I’m aware of 🙂 He actually went out of his way to help my practice. I am very grateful for his guidance.
The rest of it .. yah, I'm not sold on any of it. It doesn't pass smell test.
The rest of it .. yah, I'm not sold on any of it. It doesn't pass smell test.
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Do you think his plan was get IGRT technical deleted for freestanding and then go back and hope to get rates adjusted back to normal but still come out way less for Medicare
Or maybe like the Racoon … he didn’t have time to think through the minutiae of the plan
Sameer is no friend of PP. Long history as the head of ASTRO PAC working the exact opposite angle
Ridiculous Moments in Rad Onc History
Sameer reminds me of that line from Macbeth to beware the daggers in men’s smiles
First off, thank you WildRivers for your comment! I am totally committed to freestanding (I'd better be, since I am one!). So, for the record, I am Chris Jahraus, a freestanding attending radiation oncologist in suburban (almost the rural edges) Birmingham, Alabama. I am the RUC advisor to the AMA for ACRO, and while I can't discuss things that aren't public, in this case, I don't have to.
I would welcome "TheWallnerus" to share his actual identity...but then is there really much question? Kind of odd to be posting this on a "Student Doctor" website too, but I digress.
As for the original post...the challenge here is that your facts are tremendously mistaken. Take a look just a little earlier in the post. There you will see that it states "The specialty society continued to advocate for the RUC recommended values and direct PE inputs for the existing CPT codes. In September 2023, the RAW reviewed the action plan for CPT codes G6012-G6015 and noted that in 2022 the CMS Innovation Center delayed the RO Model. The American Society for Radiation Oncology (ASTRO) began developing an episode-based alternative payment approach for radiation therapy services called Radiation Oncology Case Rate (ROCR). Thus, the specialty societies initially requested maintaining the inputs for all the codes in the radiation treatment delivery family and removing them from this CMS/Other screen. The RAW disagreed and noted that the inputs for these services were last reviewed in 2014, CMS did not accept the RUC recommendations, and the inputs may not represent the services as they are currently performed." So, clearly, as evidenced by AMA's own record, neither I, my ACRO colleague, nor my counterparts at ASTRO wanted any change. But why let facts stand in the way of a wonderful blame game, right? Anyway, neither I, nor anyone else from radiation oncology advocated for doing away with 77014.
Now, as to the question of whether or not I am stupid...forget the libelous nature of that statement. I don't think I'm stupid, and neither does the American Board of Radiology, or American Mensa...but what do they know?
Anyway, back to the original questions...I just love the "cloak and dagger" sound of this part..."Do you think his plan was get IGRT technical deleted for freestanding and then go back and hope to get rates adjusted back to normal but still come out way less for Medicare." Yep, that's me, Dr. Evil himself, right? Because I really wanted to destroy my own ability to make a living...as if I or any other advisor to the CPT or RUC had anywhere near that much power. Sorry TheWallnerus, it seems you really are not very well informed about how these things work. I might suggest delving into the subject so you could use your enthusiasm more beneficially for everyone in the specialty of radiation oncology.
Finally, there's the sentence you highlighted in the AMA summary...of course that neglects the entirety of my third paragraph above. The CPT asked for deletion of the old codes because failure to do so would have resulted in a bigger mess than you can imagine. At that point, the choice was out of radiation oncologists' hands.
Now, I must admit, I have no plans to respond further to this post as it is generally being propagated by its own author, and that sort of sounds like someone who likes to hear his own voice...even if it is in text. Alas, radiation oncology seems not enough for the doctor who posted this rant...but this is only one of many rants of his. In the event there are any actual student doctors interested in learning more about the code development process, I'd be thrilled to discuss. As for any more threads form TheWallnerus, I think I'll pass.
Thanks again to WildRivers for setting the record straight!
Oh, and I'm not trying to sell my practice either...but I agree that the economics have become more and more challenging, though not for lack of effort on the part of ACRO and ASTRO.
Now try to look at the bright side of what we do...to TheWallnerus, I suspect you would really benefit from that! There is no field in medicine more exciting than radiation oncology...focus on the patient, but advocate with words and thoughts that are informed and effective.
I would welcome "TheWallnerus" to share his actual identity...but then is there really much question? Kind of odd to be posting this on a "Student Doctor" website too, but I digress.
As for the original post...the challenge here is that your facts are tremendously mistaken. Take a look just a little earlier in the post. There you will see that it states "The specialty society continued to advocate for the RUC recommended values and direct PE inputs for the existing CPT codes. In September 2023, the RAW reviewed the action plan for CPT codes G6012-G6015 and noted that in 2022 the CMS Innovation Center delayed the RO Model. The American Society for Radiation Oncology (ASTRO) began developing an episode-based alternative payment approach for radiation therapy services called Radiation Oncology Case Rate (ROCR). Thus, the specialty societies initially requested maintaining the inputs for all the codes in the radiation treatment delivery family and removing them from this CMS/Other screen. The RAW disagreed and noted that the inputs for these services were last reviewed in 2014, CMS did not accept the RUC recommendations, and the inputs may not represent the services as they are currently performed." So, clearly, as evidenced by AMA's own record, neither I, my ACRO colleague, nor my counterparts at ASTRO wanted any change. But why let facts stand in the way of a wonderful blame game, right? Anyway, neither I, nor anyone else from radiation oncology advocated for doing away with 77014.
Now, as to the question of whether or not I am stupid...forget the libelous nature of that statement. I don't think I'm stupid, and neither does the American Board of Radiology, or American Mensa...but what do they know?
Anyway, back to the original questions...I just love the "cloak and dagger" sound of this part..."Do you think his plan was get IGRT technical deleted for freestanding and then go back and hope to get rates adjusted back to normal but still come out way less for Medicare." Yep, that's me, Dr. Evil himself, right? Because I really wanted to destroy my own ability to make a living...as if I or any other advisor to the CPT or RUC had anywhere near that much power. Sorry TheWallnerus, it seems you really are not very well informed about how these things work. I might suggest delving into the subject so you could use your enthusiasm more beneficially for everyone in the specialty of radiation oncology.
Finally, there's the sentence you highlighted in the AMA summary...of course that neglects the entirety of my third paragraph above. The CPT asked for deletion of the old codes because failure to do so would have resulted in a bigger mess than you can imagine. At that point, the choice was out of radiation oncologists' hands.
Now, I must admit, I have no plans to respond further to this post as it is generally being propagated by its own author, and that sort of sounds like someone who likes to hear his own voice...even if it is in text. Alas, radiation oncology seems not enough for the doctor who posted this rant...but this is only one of many rants of his. In the event there are any actual student doctors interested in learning more about the code development process, I'd be thrilled to discuss. As for any more threads form TheWallnerus, I think I'll pass.
Thanks again to WildRivers for setting the record straight!
Oh, and I'm not trying to sell my practice either...but I agree that the economics have become more and more challenging, though not for lack of effort on the part of ACRO and ASTRO.
Now try to look at the bright side of what we do...to TheWallnerus, I suspect you would really benefit from that! There is no field in medicine more exciting than radiation oncology...focus on the patient, but advocate with words and thoughts that are informed and effective.
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Chris I noted in the RUC minutes that 77387 contained a technical. What happened with that.
Why did the estimated reimbursement impact get so wildly miscalculated by you and the developers of the code overhauls? Could you all not see the huge impact coming? It was clear based on all pre 2026 talks and town halls etc no one predicted such a huge hit to the field at the “higher up” level. The bundling of IGRT technical into the delivery codes but then making the (IMRT) delivery codes not be more valuable than in the past seemed like a recipe for disaster at the freestanding level. And in fact it was a recipe.
Selling your practice was the “word on the street” so I just repeated what I’d heard. As far as calling someone stupid being libel, maybe. David Letterman never got sued as far as I know (not even by any pets). But if the “crisis” (ASTRO’s phrase) continues and isn’t fixed, surely we can call someone stupid for causing it? Soylent Green is people. So are bad policy decisions. “Change had to happen” but surely ASTRO/ACRO had a hand in what that change would be.
Was bundling IGRT in to delivery forced? Was defining IMRT and 3D in the same code forced? Was making essentially all brand new treatment delivery codes and then not explaining those to payors beforehand anything anyone saw as problematic?
EDIT: we should go back and remind ourselves that Amar and Sameer in the video town hall about 9 months ago were saying the new codes were a “win” for rad onc. Now we have Chris saying “it was out of our hands.” At the very least it all seems very goofy and disheartening.
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I’m just a resident, so I’m not gonna get into technical details because I frankly lack the knowledge. However, I have one question: what is being done to prevent our field from getting utterly destroyed so I wouldn’t have to take a job in middle of nowhere just to be able to pay my loans back?
Edit: And have at least some sort of autonomy
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Nothing. We aren't med onc. We don't have PhRMA lobbyists
Evidently the answer is: CMS forced rad onc into a financial abyss but ASTRO asked them not to do it. And extreme yada yada CMS did it anyway. Now that we are in the abyss, we are going back to the people who put us here to beg them to remove us from the abyss. Or we will ask congress to pass a law to REALLY change up billing and coding (which currently sits at a predicted 0% chance of passing).
Those two seem to be the whole plan.
You wont like hearing this but overall really nothing substantive. ROCR is the plan and has zero chance of passing. Im not aware of any plan outside of this besides like continuing lobbying etc.
Come on The Accelerators Podcast. You are always welcome and I have a lot of questions about ROCR v2 that no one seems to want to answer.
RFK is more interested in a racoon penis than helping rad onc.
Supposedly hospital income has dropped ~16% last few years and freestanding ~34%. But with that has been associated almost equal increase in rad onc MGMA median salaries! I quit trying to make economic sense of this a long time ago. So what's coming with ~10%/20-25% more decreases? Your department is gonna go bankrupt. But you'll get a raise.
He should come on. Chris called my posts "rants," and well hi kettle this is pot, but one must rant because there's nothing to rave about. (He also doesn't seem to understand that rad onc student doctor network is to student doctors what the Buena Vista Social Club is to social clubs.)
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Okay so really there is zero chance of that happening.
There was a time when all the official people came on TAP and we had a mega podcast about RO-APM. We covered a lot, tons of history and info, very open discussion.
I could never imagine that today.
If we were hypothetically on a podcast, especially after reading the posts above, I might ask... so what is going on with discussions between ASTRO/ACRO and CMS?
There was a time when all the official people came on TAP and we had a mega podcast about RO-APM. We covered a lot, tons of history and info, very open discussion.
I could never imagine that today.
If we were hypothetically on a podcast, especially after reading the posts above, I might ask... so what is going on with discussions between ASTRO/ACRO and CMS?
Threads like this are kinda useful. It's good to have someone involved rebut conspiratorial thinking.
I am completely ignorant regarding the "sausage making" process of payment reform. But I think there are some truisms out there that are evident just from a macro analysis of what's going on. If anyone on here thinks there is a good rebuttal to any of these...I would definitely be interested.
1. CMS is looking for cost savings (as it should). There is only so much cost savings that can occur without payment reduction. We just experienced payment reduction.
2. ASTRO, ACRO etc. have very limited leverage with CMS. This is likely (at least in part) related to the scale of our specialty (including vendor operations).
3. Markets are affected by outliers (think Spirit airlines). Highly compensated PP docs impacted the compensation standards for all radiation oncologists. As this group declines, one could expect a decline or at least change in distribution of compensation across our specialty.
4. While most of us are not compensated directly in relation to total payments (technical plus professional) as we are employed or work under a PSA, this amount is critical to the hospitals for whom we work. It will impact our compensation over time (leverage when negotiating new PSA or salary). It may contribute to some degree to further hospital consolidation.
5. Consolidation reduces diversity of opportunity. IMO, it is associated with decreased job satisfaction among the employed class (most of us).
6. The rest of the world does not see a national radiation oncology service line, staffed by 100% employed docs making ~400K a year as a tragedy at all. They may see this as normalization of our compensation and a more rational model for a niche, technical specialty.
7. (Only controversial point IMO). Radiation oncology is not the most exciting field in medicine. It is a rewarding field with grateful patients, a controlled schedule and good QOL. The future of oncology is actively being driven by various forms of molecular medicine. Our work will continue to be dynamically contextualized by the molecular oncologists...not the other way around. Unless you are doing Evan Thomas level stuff, treating benign disease with radiation is not exciting.
If there is a pointed critique of ASTRO in this, it is the insistence on differential value in ROCR as it applies to protons and the perpetuation of the PPS exempt phenomenon. Overall, protons are a colossal boondoggle that provide very limited differential clinical value. They are a niche tool that has been grotesquely misrepresented to the public. (Understood that roughly 4.x percent of patients get cancer surgery at PPS exempt places and ~2% of patients get protons. However, at the regional level, preferential treatment of protons and PPS exempt places can dramatically impact the viability of community cancer centers).
I am completely ignorant regarding the "sausage making" process of payment reform. But I think there are some truisms out there that are evident just from a macro analysis of what's going on. If anyone on here thinks there is a good rebuttal to any of these...I would definitely be interested.
1. CMS is looking for cost savings (as it should). There is only so much cost savings that can occur without payment reduction. We just experienced payment reduction.
2. ASTRO, ACRO etc. have very limited leverage with CMS. This is likely (at least in part) related to the scale of our specialty (including vendor operations).
3. Markets are affected by outliers (think Spirit airlines). Highly compensated PP docs impacted the compensation standards for all radiation oncologists. As this group declines, one could expect a decline or at least change in distribution of compensation across our specialty.
4. While most of us are not compensated directly in relation to total payments (technical plus professional) as we are employed or work under a PSA, this amount is critical to the hospitals for whom we work. It will impact our compensation over time (leverage when negotiating new PSA or salary). It may contribute to some degree to further hospital consolidation.
5. Consolidation reduces diversity of opportunity. IMO, it is associated with decreased job satisfaction among the employed class (most of us).
6. The rest of the world does not see a national radiation oncology service line, staffed by 100% employed docs making ~400K a year as a tragedy at all. They may see this as normalization of our compensation and a more rational model for a niche, technical specialty.
7. (Only controversial point IMO). Radiation oncology is not the most exciting field in medicine. It is a rewarding field with grateful patients, a controlled schedule and good QOL. The future of oncology is actively being driven by various forms of molecular medicine. Our work will continue to be dynamically contextualized by the molecular oncologists...not the other way around. Unless you are doing Evan Thomas level stuff, treating benign disease with radiation is not exciting.
If there is a pointed critique of ASTRO in this, it is the insistence on differential value in ROCR as it applies to protons and the perpetuation of the PPS exempt phenomenon. Overall, protons are a colossal boondoggle that provide very limited differential clinical value. They are a niche tool that has been grotesquely misrepresented to the public. (Understood that roughly 4.x percent of patients get cancer surgery at PPS exempt places and ~2% of patients get protons. However, at the regional level, preferential treatment of protons and PPS exempt places can dramatically impact the viability of community cancer centers).
We post on here not because we are student doctors, but because the field has stifled criticism to an extreme degree, requiring the use of pen names in an anonymous forum in order for dissent to occur.
Wild that the criticism is directed towards those trying to dissent rather than the institution/specialty as a whole which requires such extreme anonymity in order to do so.
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thanks OTN but am I even dissenting
I am expressing confusion. Bewilderment. And suspicion... not suspicion of anything nefarious per se (besides dishonesty or dissembling, which I guess are kinda nefarious) but rather suspicion of complete fecklessness and incompetency. Incompetency that no one can seem to own up to.
These are mysteries. Mysteries to which we may never have an answer:
1) Who put forward at the Sept 2024 CPT panel meeting that 77014 should be deleted? Was it ASTRO/ACRO? Or the CPT panel itself? Did ASTRO/ACRO have a say? Was there a negotiation? If no negotiation was it forced? Could in theory "good negotiators" have done something different at any time in this process? Did anyone at the society level at that time know that IGRT technical was on the chopping block for freestanding and if they did why was this not announced and if they didn't why didn't they know it?
2) How do we square RUC meeting minutes "The specialty societies ... requested that CMS delete the related G codes" and "neither I, my ACRO colleague, nor my counterparts at ASTRO wanted any change"? The ordinary rules of logic and English reading proficiency make these two ideas mutually incompatible. Am I stupid? Can I sue me for libel?
3) How was everything so reasonably "cheery" at the society levels prior to Jan 2026 knowing the changes coming. I talked to Lally... he was like "this is good" (I'm paraphrasing). Listen to Amar and Sameer... is there any hint of aortic aneurysm levels of impending doom in their narrative or voice(narrator: no, there is not)? Was ASTRO's prediction of the 2026 billing/coding changes being a "net positive impact" wrong? If so, why? Was it incompetence, or lack of information, or what?
I do want to find someone to blame (either at CMS or the RUC or AMA or ASTRO, although I think we'd have more pull at ASTRO), but it's not a game. It's because I want to try and make sure they're never near this process again. And someone different tries their hand at this. Because this is a disaster, or disASTRO, or both.
if we are greedy and incompetent and full of uniquely bad actors that we are a complete outlier when it comes to residency expansion, of course we will f--- everything else up as well. bad people do bad stuff.
. Most centers and most radoncs are not very busy (pareto distribution presented by Zarosky and commented on by wallnerus). This is not a tragedy for pts. Consolidation is probably justified. A squeeze on the job market could come from reimbursement changes, but it could just as easily come from change in practice (losing early breast or prostate or advances in systemic treatments)
Radonc leadership is very different than counterparts in neurosurgery, optho, urology etc. .
. Most centers and most radoncs are not very busy (pareto distribution presented by Zarosky and commented on by wallnerus). This is not a tragedy for pts. Consolidation is probably justified. A squeeze on the job market could come from reimbursement changes, but it could just as easily come from change in practice (losing early breast or prostate or advances in systemic treatments)
Radonc leadership is very different than counterparts in neurosurgery, optho, urology etc. .
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Unlike rad onc those have traditionally been more competitive specialties to match into consistently while rad onc has seen more of a boom bust cycle. People that matched before the turn of the century or the last few years are not the same as those who matched 2003-2018 when you look at things like research, letters, step scores etc
This: "Radonc leadership is very different than counterparts in neurosurgery, optho, urology etc." These other specialties take their stewardship much more seriously then rad onc (ie standards for admittance/training are not lowered simply because it can be done to help the bottom line of a department).
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One question I have, and perhaps it is a dumb one, is why the elements of the work that make IMRT a more "valuable" service than 3D, especially patient specific QA, are not given codes of their own?
Who knows. But if you’re going to get leeway from CPT panel and RUC to make 2D two isocenter XRT the most valuable external beam code of all, surely there would have been leeway to do what you suggest.
Because the move is towards bundling. Like igrt technical and special physics etc.
Not dumb. Don't forget this is all super, super secret and only the coolest Rad Oncs get to hear about policy and the RUC.
Anyway, I asked the chat bot because in my experience it lies and hallucinates less than our society leadership! Bazinga.
The short answer is that it's always been bundled into IMRT planning and continuous physics (weekly) checks.
Here is OpenEvidence's full answer for completeness:
A 2012 AAPM presentation on the history of medical physics reimbursement by Hevezi describes how, as IMRT planning and delivery codes were developed, the "concomitant plan verification work" was incorporated into the IMRT planning and delivery code family (77301, 77338) during the RUC valuation process. [1] When ASTRO and AAPM brought IMRT procedures forward for reimbursement consideration, the work of patient-specific QA was included in the physician work surveys used to value these codes — meaning the time and intensity of plan verification was factored into the work RVUs assigned to the planning codes.
You can find the presentation abstract and a subsequent write up here:
MO-D-213AB-01: A Brief History of Medical Physics Reimbursement - PubMed
1. Understand where medical physics reimbursement came from in radiation oncology 2. Understand the arrangement of our societies and interaction with reimbursement entities 3. Understand how medical physics workforce and remuneration for services is structured 4. Understand what the future may...
pubmed.ncbi.nlm.nih.gov
A brief history of IMRT plan verification reimbursement - PubMed
A brief history of IMRT plan verification reimbursement
pubmed.ncbi.nlm.nih.gov
I am sad to report that ASTRO’s request to meet with Oz and RFK Jr were just denied
Thank you for your attention to this matter
Thank you for your attention to this matter
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shocked pikachu face . jpg
Bit loony then that when the IMRT and 3D codes were rolled together there was no move to try to recover at least some of this effort with a new code reflecting work effort for verification/QA. This is a totally separate process unique to IMRT/SBRT - Unbelievable really that it's not being reimbursed at all.Not dumb. Don't forget this is all super, super secret and only the coolest Rad Oncs get to hear about policy and the RUC.
Anyway, I asked the chat bot because in my experience it lies and hallucinates less than our society leadership! Bazinga.
The short answer is that it's always been bundled into IMRT planning and continuous physics (weekly) checks.
Here is OpenEvidence's full answer for completeness:
A 2012 AAPM presentation on the history of medical physics reimbursement by Hevezi describes how, as IMRT planning and delivery codes were developed, the "concomitant plan verification work" was incorporated into the IMRT planning and delivery code family (77301, 77338) during the RUC valuation process. [1] When ASTRO and AAPM brought IMRT procedures forward for reimbursement consideration, the work of patient-specific QA was included in the physician work surveys used to value these codes — meaning the time and intensity of plan verification was factored into the work RVUs assigned to the planning codes.
You can find the presentation abstract and a subsequent write up here:
MO-D-213AB-01: A Brief History of Medical Physics Reimbursement - PubMed
1. Understand where medical physics reimbursement came from in radiation oncology 2. Understand the arrangement of our societies and interaction with reimbursement entities 3. Understand how medical physics workforce and remuneration for services is structured 4. Understand what the future may...A brief history of IMRT plan verification reimbursement - PubMed
A brief history of IMRT plan verification reimbursement
You can do a search for the 2002 RUC meeting minutes on the extreme amount of work and thinking that went into making this code (77301) and giving it good value to us that still pays dividends to this day. It was Hevezi and Wallner and Potters and somebody else. Just four dudes making the most important code in rad onc. I can say in retrospect they did good work.Not dumb. Don't forget this is all super, super secret and only the coolest Rad Oncs get to hear about policy and the RUC.
Anyway, I asked the chat bot because in my experience it lies and hallucinates less than our society leadership! Bazinga.
The short answer is that it's always been bundled into IMRT planning and continuous physics (weekly) checks.
Here is OpenEvidence's full answer for completeness:
A 2012 AAPM presentation on the history of medical physics reimbursement by Hevezi describes how, as IMRT planning and delivery codes were developed, the "concomitant plan verification work" was incorporated into the IMRT planning and delivery code family (77301, 77338) during the RUC valuation process. [1] When ASTRO and AAPM brought IMRT procedures forward for reimbursement consideration, the work of patient-specific QA was included in the physician work surveys used to value these codes — meaning the time and intensity of plan verification was factored into the work RVUs assigned to the planning codes.
You can find the presentation abstract and a subsequent write up here:
MO-D-213AB-01: A Brief History of Medical Physics Reimbursement - PubMed
1. Understand where medical physics reimbursement came from in radiation oncology 2. Understand the arrangement of our societies and interaction with reimbursement entities 3. Understand how medical physics workforce and remuneration for services is structured 4. Understand what the future may...A brief history of IMRT plan verification reimbursement - PubMed
A brief history of IMRT plan verification reimbursement
I, personally, don't see the value of calling individual people stupid on this forum and expecting to get a quality conversation. Or nitpicking on words from other people. I have as much frustration as the next guy. There are some "targets" I aim it towards, but frankly, it ain't the MDs. These board members and presidents are rotating in and out and have very limited authority or power. It is giving them far too much credit to think that Sameer can do anything. He is powerless and not competent at modeling, because no one would have called this a success or act like mission is accomplished. I know he doesn't care for me (despite me reaching out several months ago and saying we needed to start over; they are quite brittle over at central - Adler still pissed about a comment made years ago about how the CEO of ASTRO had been there too long), but is he a stupid person? No, I don't think that at all. Having lived all of 47 years, I've met a lot of truly stupid people. If this is your definition of stupid, then 95% of Americans you meet are stupid and life must be a constant challenge of calling everyone and everything stupid.
Are all of these people in way over their head? Yes, obviously. If they wanted to actually have thought leaders involved, they'd have done that. But the mechanism of leadership at ASTRO is antithetical to getting the best people in the right positions. It's seniority, being in full agreement, never dissenting, never criticizing. You simply won't see Chirag Shah get elected president, because he won't be a wallflower and pretend everything is okay. Sameer and others have basically swallowed the Kool Aid and in exchange they get leadership positions. Not because they are better or they are smarter or more competent. But, because loss of self-thinking is critical in the pathway to leadership in this society. Inherently, ASTRO will be a failure of a society because they not only are susceptible to groupthink, but they seek it. Any internal or external criticism causes severe consternation and ruffling of feathers. This is not like a Tech company where challenging premises is not only accepted, but desirable to achieve goals.
It is a dysfunctional society. Chris was never the problem, nor is he stupid. Sameer was not capable to do what was needed, but that does not make him a bad person or stupid. Incompetence is in a different category altogether and it is rarely malignant. The "autopsy" that is needed is not going to happen. Wallnerus is not going to be as objective. He has made up his mind, so priors are set. An external audit of what happened from 2008 to 2026 would be very valuable to understand it. I am trying my best at putting this together, but man is it complicated.
I can say though in working through this, I am understanding that modern ASTRO leaders are not individually culpable. They just aren't strong or capable enough to be the primary cause of our failures.
Are all of these people in way over their head? Yes, obviously. If they wanted to actually have thought leaders involved, they'd have done that. But the mechanism of leadership at ASTRO is antithetical to getting the best people in the right positions. It's seniority, being in full agreement, never dissenting, never criticizing. You simply won't see Chirag Shah get elected president, because he won't be a wallflower and pretend everything is okay. Sameer and others have basically swallowed the Kool Aid and in exchange they get leadership positions. Not because they are better or they are smarter or more competent. But, because loss of self-thinking is critical in the pathway to leadership in this society. Inherently, ASTRO will be a failure of a society because they not only are susceptible to groupthink, but they seek it. Any internal or external criticism causes severe consternation and ruffling of feathers. This is not like a Tech company where challenging premises is not only accepted, but desirable to achieve goals.
It is a dysfunctional society. Chris was never the problem, nor is he stupid. Sameer was not capable to do what was needed, but that does not make him a bad person or stupid. Incompetence is in a different category altogether and it is rarely malignant. The "autopsy" that is needed is not going to happen. Wallnerus is not going to be as objective. He has made up his mind, so priors are set. An external audit of what happened from 2008 to 2026 would be very valuable to understand it. I am trying my best at putting this together, but man is it complicated.
I can say though in working through this, I am understanding that modern ASTRO leaders are not individually culpable. They just aren't strong or capable enough to be the primary cause of our failures.
This is an exceptional post, I agree 100%.
Just for the record I didn’t call anyone stupid. I questioned if Chris was stupid. He said he’s a Mensa member.
I am not a Mensa member. And many people think I’m stupid.
“At the inauguration many people asked if Marilyn and I would come in behind the Reagans. Instead she and I decided to go out behind the Bushes.”
Is there a mechanism to do this? Anywhere? In any context?
Regarding our present crises. Is there a thought leader who would have made a difference?
Our compensation and coding model represents what I would call "a poorly bound problem". Was it fair to begin with? Did our old model avoid perverse incentives? Did our compensation ever meet standards of fairness as related to how much other doctors make? What really represents the most reasonable payment model (and amounts) for therapeutic radiation?
So, maybe what we are really pining for is not a remarkable, clear eyed, ethical and scientifically astute person but rather our own Roy Cohn?
Agree with @pikachu above that there are discrete circumstances where it feels like compensation for work has just "gone away". On the other hand, case-based payment does this inherently, leaving the amount of work that one does largely to the practitioner's discretion.
Regarding group think, we are presently in an "anti-group think" moment when it comes to federal oversight of scientific and medical issues.
It has resulted in absolutely bizarre $h!&, including tabling of publications that don't fit the new "anti-consensus" dogma and guidelines that no practitioner believes in. It has ravaged morale among federal scientists (and many academic ones).
Good practitioners are overwhelmingly purveyors of group think who question the basis for it. Extraordinary practitioners can recognize those rare occasions where abandoning group think is appropriate. It's not clear to me that there is any statistical tool to discern good from extraordinary. I suspect the same goes for leaders in general.
If we want to apply the ethos of tech to being doctors...than eff it...just cut the workforce by 70% already.
Modeling appears to have been bad. But remember Elon predicted close to zero new Covid cases by end of April 2020.
Disagree. Through its action and inaction at times over the last few decades ASTRO and ASTRO PAC have helped hospitals and PPS and hurt independent and freestanding practices
Whether this was intentional or not is another argument but can't deny what the move to stop physicians from owning linacs meant or how it was perceived by some of the membership who owned linacs 🤷♀️
ASTRO thought it was going after urorads but the collateral damage from those efforts was clear (the flawed argument against urorads notwithstanding... Multi D care that kept pts away from inappropriate RP, cryo, hifu etc).
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Ok, so what are the next steps?
ROCR is very unlikely to pass. All the same people are still working on policy. As far as I can tell there is no plan B and I suspect we have no meaningful relationship with CMS.
Bingo. Amazing how much lip service has been paid to a bill with a near zero % chance of passing
Resident numbers are the only factor under our control. I bring in 2 to 3 x profit that out neurosurgeons bring in. They earn 2 x my salary.
Past exonerative tense.
“Though wise men at their end know dark is right,
Because their words had forked no lightning they
Do not go gentle into that good night.
Good men, the last wave by, crying how bright
Their frail deeds might have danced in a green bay,
Rage, rage against the dying of the light.”
Give me that energy from rad onc at the RUC.
Med oncs probably making more then you are too
And employed medoncs are solely compensated based on e/m rvus. (Came up in discussion how they wooud hate to have a car t program)
This is the easiest and most effective thing we can do to help our field in the long run but residency programs are incentivized to do the opposite!
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