Is there a mechanism to do this? Anywhere? In any context?
The pathway to leadership requires joining committees and going down a particular pathway to the board and then nomination. There are two candidates. There is no "primary" system or any way to assess if someone is viewed as effective or popular. There is no way to be eligible to be on the board without going through that path. Now, this may sound like me saying I want in. I wouldn't mind, but this is not the issue. As mentioned, someone like Chirag can challenge the system and rally the troops, but almost no way to get there for him there without a decade plus of committee work. There are many other smart people that could assist in leadership and would have popular support. I get that a society is allowed to make the rules it feels are fit, but this mechanism keeps it as insiders that have to be very agreeable to all things that leadership support, rather than what membership support. If leadership is considered truly ineffectual and terrible, there is no opening for an insurgent or reform-minded candidate.
Regarding our present crises. Is there a thought leader who would have made a difference?
Good question. I don't know the answer to that is yes. But having most presidents and board members be champion of proton centers or being from PPS exempt center does not make it "feel" like anyone is looking out for us. Just as an example, Jason Beckta is extremely knowledgeable about policy / economics / payment reform. I can't speak for him, but I presume if called to serve, despite antipathy towards organization, he would provide competent and sound advice. As mentioned, Chirag would be excellent. Other folks are out there - but, because of the pathway to leadership and seniority driven structure, it keeps out people that would be unique and dare I say it, "diverse" voices.
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?
Yes! I don't want my organization to say "We get paid a lot, maybe unfairly. Let's change that." I've said here or other places - the way to success is not to bring other specialties down. We should be trying to raise up everyone's salaries. I do want a Roy Cohn. Are you saying that the current board memberships should say openly - "we are here to bring salaries down?" Because if you think that's the goal (I can't tell from your wording, so please do correct me if I'm wrong), I don't think you can win an election that way. That would mean the candidates are lying to us. If you want this or others want this, that's fine. I don't. I am not in the business of tearing them (or us) down. I want everyone to do better. ASTRO should be for our specialty, not all of health care. We are a tiny portion (1.5%) of the small sliver (physician revenue is about 10-15% of health care spending) of the financial issues in American medicine. We can halve our salaries and not make a dent.
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.
Yes, this is an area of debate and I have a reasonable concern about "race to the bottom" with case rates (less IGRT/SGRT, less complex treatments like Flame in favor of simple 36.25 in 5 to prostate without a spacer or DIL. Throughput becomes paramount if higher tech/more fractions are no longer a variable. I'm not saying FFS is perfect, but the incentives of case rates are the exact reverse. Let's talk about that! Why do they refuse to discuss the drawbacks of a case rate? You will not see in one release or discussion from leadership a steelmanned defense of ROCR where you evaluate all the arguments against it - and there are many. This is why it feels half baked.
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).
I agree with you, but I think this is out of context. I am not saying that medicine should not have some level of groupthink. I am saying organizing bodies should have less of it. I think there is a general consensus from non-rural practitioners that there are too many of us. But, leadership has literally silenced discussion on this. It is not spoken about. When Shah et al hired that consultancy for workforce and presented it at ASTRO, the talk was literally removed. They erased it! They longer talk about it. This is groupthink. When they say that we can't change PPS exemption or proton payment to allow them to be in a case rate program (which would help us feel everyone has skin in the game) due to it being an Act of Congress, while currently awaiting an Act of Congress to fix our problems, this is groupthink. When the organization unilaterally asks CMS to make us directly supervise against the wishes of majority of members, this leadership is forcing their board level groupthink that direct supervision is desirable onto the general membership. And, that was finally an act that led to rebellion.
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.
You won't get an argument from me on making efforts to reduce the workforce! But, again, context. I don't think medicine should be run like Nvidia (although, love Jensen's "call out" of mistakes and having thousands of people hear about it). I do think we can learn from high performing companies, however. I think the organization would benefit from a more agile, proactive approach, rather than old-school domination by senior leaders who haven't done anything of importance in decades. What have the current presidents done for our specialty in the last few years? Can you name something tangible Keole has done? Vapiwala? Sandler? Eichler? Michalski? Have they written game changing studies? What have they supported and gotten done? Have they championed us in a meaningful way where you can say "Man, without ___, we would be worse off." The purpose of these organizations appear to be to sustain themselves. I cannot rattle of a list of achievements of this organization in the last decade that have benefited my patients or my practice. But, what about a guy like Dan Spratt? Not my biggest fan, of course, but a true thinker in GU, has published and taught meaningfully (read his TheMedNet answers), actively turning around a once mediocre cancer program. We may not share a hot dog and ketchup ever, but I'd be supportive of someone who has accomplished things of value for our field. And many others out there. Does an ASTRO board member or president have to be American? I think there was a Canadian president in the past. If allowed, what about Shankar Siva or David Palma or people that have actually done something.
Modeling appears to have been bad. But remember Elon predicted close to zero new Covid cases by end of April 2020.
Not a strong comparison. Unknown event that has never occurred before and limited understanding of a newish disease and it's one person. We had literal numbers from Medicare and commercial payors and entered into a spreadsheet last years numbers and compared the revenue. This is not "modeling" - I used the wrong wording - this is just math. If you cut IGRT tech, reduce the payment for the single most used code (IMRT tx delivery), there is no way to make it add up. This is not pandemic prediction of a new disease. This is accounting.
Anyway, I am not professing to be right. Just on person's opinion. You make very good points and there is no gold standard of truth here. I am truly open to the consideration that what we have is the best possible outcome. I just didn't want Candide to be real and it may well be.
