2019 ERAS Data Release

[medgator]

Clearly offering high pay may not solve the issue either.

If it was high enough, it might. Seven figures for a few years to FIRE would definitely entice someone over there

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[medgator]

If you can get a good lamb Biriyani in Morgantown is clearly the issue here

Not all of us want mayo and pimento cheese on wonderbread and a moonpie, ok?

There's a kernel of truth to every joke though, and the lack of cuisine options likely correlates to a lack of something else.

 

[evilbooyaa]

Let's try and stay on-topic. Nothing deleted as of yet, but the focus of this is mostly on the number of applicants, not as much on the programs. You guys really love to take things said in one thread and discussing it in another. Why not just keep thread discussions within threads?

On a non-stern dad (AKA mod) note - I think not having access to ethnic cuisine of types is a valid factor for somebody to consider in regards of where to live. It's OK if that's not in each individual's decision tree, but it's a reasonable factor to consider, like almost all other factors are for an individual person making the best decision for them and their family.

 

[RickyScott]

I don’t think training people in a state many find “undesirable” will necessarily ensure that people will stay there. Clearly offering high pay may not solve the issue either.

US MDs - 235 in 2017, 221 --> 190 --> 152 in 2019.

Surprised that IMGs is not increasing on a year-to-year basis. Maybe lag time due to need for research, lack of exposure to the field?

Another down year for radonc applications. 220 total applicants last year, 190 this year. And what I think is a crazier stat is that in 2018 programs received an average of ~160 applications each, now down to ~100.

https://www.aamc.org/system/files/2019-10/services-eras-preliminary-data-counts-residency-applicants-specialty-year-10172019.xlsx

I really wouldnt get too hung up on number of applications. Yes, it seems medstudents have taken notice of the issue, and they certainly dont seem to believe SCADROP. Applications will recover, and we will just start attracting lesser applicants as word gets out that field is less competitive. Some of the granstanders on twitter/redjournal may start to talk more about how grades/scores/american med schools dont 1:1 correlate with how good a doctor an applicant will be. And that may be partially true, but like the price of a stock, it is a vote on the future health of the field.

What matters is that the positions will mostly full with bodies, and the job market will be a mess for a 10-20 years per Steinberg at ASTRO- who then went on to argue that we are being too hard on ourselves and shouldnt regulate spots.

Lastly, what this field is facing is very different than Emergency Medicine and others that are dealing with increased supply. We are also undergoing a big change in demand (less fractions) and CMS stating there is a lot of overutilization in free-standing centers that they plan to cut down on with a new reimbursement model.

 

[KHE88]

Show us that they don't? I trained in the rustbelt and went back to a coastal metro. Many others have done the same.

If these programs aren't attaching guarantees/contracts to their trainees, they are simply flooding the market with too many grads. Anyone can suck it up for four years anywhere and many of us did during the golden era of rad onc last decade. Apparently that's completely lost on you though.

But that's ok because those training programs are where you want them to be

No. The burden of proof is on you as common sense and empirical data suggest that people will stay near where they trained or in similar types of programs that they matched into (even in the most competitive years, most people didn't fall to the bottom of their rank list, and believe it or not some people actually want to be at these midwest programs).

I also find it ironic you are so prejudiced against these new midwestern programs because you think the grads just want to flee back to the coast when you admit that is exactly what you did and just assume everyone else wants the exact same things you do.

And dude, do you think I like the fact that my only non-steakhouse restaurant options are Little Caesars and Panda Express? I can buy any ingredient and cook whatever I want though and travel on the weekend to eat at a fancy restaurant if I want. I don't understand why this is a big deal as some make it out to be.

 

[beamotherapy]

US MDs - 235 in 2017, 221 --> 190 --> 152 in 2019.

Surprised that IMGs is not increasing on a year-to-year basis. Maybe lag time due to need for research, lack of exposure to the field?

Dang! That's a drop of 35% in the number of applicants in a matter of only 2 years. Thanks for posting the data. I gotta believe most of that is due to poor job prospects and the boards fiasco. At least there seems to have been a correction in the boards pass rates this year.

 

[thecarbonionangle]

If it was high enough, it might. Seven figures for a few years to FIRE would definitely entice someone over there

K so how high? cause Quincy cannot fill at 700k, Carlsbad cannot fill at 600k. 1 million? is there any legal obstacles to offering 7 figures?

 

[evilbooyaa]

Are residency slots per listed in that document or just applicant numbers per year?

This. Applicants =/ Open spots.

Yea you’re right I’m getting my sources mixed up. Charting the Match 2019 shows year over year increases in derm positions offered (table 7): https://mk0nrmp3oyqui6wqfm.kinstacd...NRMP-Results-and-Data-2019_04112019_final.pdf

385 + 22 to 447 + 30 from 2015 to 2019 is a 17% increase for Derm

Rad Onc went from 176 + 7 + 17 to 192 + 4 + 15 which is a 5% increase for Rad Onc.

It's a small sample size but your point checks out for the past 4 years.

As a reference, number of yearly graduating residents (different than number of applicants) went from 114 in 2007 to 189 in 2018 for Rad Onc (65% increase)

 

[KHE88]

K so how high? cause Quincy cannot fill at 700k, Carlsbad cannot fill at 600k. 1 million? is there any legal obstacles to offering 7 figures?

Yes, you will run into legal problems at most hospitals. They will tell you they can't pay you more than 80% MGMA or so because this puts them at risk for Stark Law violation by paying you more than fair market value.

I know of a rural rad onc making 750k with about 8-10 on beam. There is NO way he is covering his salary with professional fees with such a low volume. However, he is not losing the hospital money. So the argument would be that part of his compensation is coming from ancillary tests he is ordering within the system such as imaging or referrals to other providers. When in reality he's just eating into the hospital's share of technical revenue. So I'm not aware of this argument ever legally holding up, but it's what the hospital will use to try and cap your salary in the 600-700k range. They will say it legally puts you and them at more risk. Good luck finding a place that will go higher than that.

 

[medgator]

K so how high? cause Quincy cannot fill at 700k, Carlsbad cannot fill at 600k. 1 million? is there any legal obstacles to offering 7 figures?

Yes, you will run into legal problems at most hospitals. They will tell you they can't pay you more than 80% MGMA or so because this puts them at risk for Stark Law violation by paying you more than fair market value.

I know of a rural rad onc making 750k with about 8-10 on beam. There is NO way he is covering his salary with professional fees with such a low volume. However, he is not losing the hospital money. So the argument would be that part of his compensation is coming from ancillary tests he is ordering within the system such as imaging or referrals to other providers. When in reality he's just eating into the hospital's share of technical revenue. So I'm not aware of this argument ever legally holding up, but it's what the hospital will use to try and cap your salary in the 600-700k range. They will say it legally puts you and them at more risk. Good luck finding a place that will go higher than that.

No reason hospital can't just let you bill global with a nice professional rate (essentially kicking back some of the technical through professional compensation). Would not violate mgma issue I believe as the reimbursement is tied directly to physician work/CPT codes billed

 

[KHE88]

No reason hospital can't just let you bill global with a nice professional rate (essentially kicking back some of the technical through professional compensation). Would not violate mgma issue I believe as the reimbursement is tied directly to physician work/CPT codes billed

Again, good luck with that.
In my experience the hospital gets annoyed if you know anything about billing, pro vs. tech fees, incident to coverage requirements, charge lists, payor reimbursements, profit margins, etc.
They want you as ignorant as possible on the numbers.
They like to gaslight you into believing that you are greedy and putting them out of business with your salary by saying things like "we're already paying you half a MILLION dollars, most people don't make anywhere near that, etc."

 

[Mandelin Rain]

I have no data, but based on my extensive life experience, most married male docs will end up where the wife's family is from. Most single male or female doc will end up in large cities, likely in academia. Married women docs also will gravitate toward hometown, but are more accomodating of husband's career aspirations.

Location of residency never mattered, because until now, people couldn't be picky about where they trained.

 

[medgator]

Again, good luck with that.
In my experience the hospital gets annoyed if you know anything about billing, pro vs. tech fees, incident to coverage requirements, charge lists, payor reimbursements, profit margins, etc.
They want you as ignorant as possible on the numbers.
They like to gaslight you into believing that you are greedy and putting them out of business with your salary by saying things like "we're already paying you half a MILLION dollars, most people don't make anywhere near that, etc."

They won't be annoyed anymore, at least for a little while, with 200 grads hitting the market annually the next few years

 

[KHE88]

They won't be annoyed anymore, at least for a little while, with 200 grads hitting the market annually the next few years

Shhh... I'm trying to keep that a secret.

 

[medgator]

Shhh... I'm trying to keep that a secret.

Good luck.... I'm pretty sure the cold calls are going everywhere

 

[deleted1002574]

If you can get a good lamb Biriyani in Morgantown is clearly the issue here

I love lamb biryani. Who doesn’t love lamb biryani? I’m surprised that we all aren’t having lamb biryani right now.

 

[medgator]

No. The burden of proof is on you as common sense and empirical data suggest that people will stay near where they trained or in similar types of programs that they matched into (even in the most competitive years, most people didn't fall to the bottom of their rank list, and believe it or not some people actually want to be at these midwest programs).

I also find it ironic you are so prejudiced against these new midwestern programs because you think the grads just want to flee back to the coast when you admit that is exactly what you did and just assume everyone else wants the exact same things you do.

Location of residency never mattered, because until now, people couldn't be picky about where they trained.

Nope, KHE88 still doesn't get it. Rural hospitals have to pay more to recruit and retain docs for a reason.

 

[RickyScott]

This. Applicants =/ Open spots.



385 + 22 to 447 + 30 from 2015 to 2019 is a 17% increase for Derm

Rad Onc went from 176 + 7 + 17 to 192 + 4 + 15 which is a 5% increase for Rad Onc.

It's a small sample size but your point checks out for the past 4 years.

As a reference, number of yearly graduating residents (different than number of applicants) went from 114 in 2007 to 189 in 2018 for Rad Onc (65% increase)

Back of the envelope, this is shocking for someone in practice. Ratio of derm to radonc spots is like 2.1- 2.2! This is nothing like it is in the real world where you have far more derm docs in a community than 2:1 ratio. Similar principle is true for urology where you have like 325 residency positions. It shows you what a mess this has become. Does the country need to be producing 2 radiation oncologist for every 3 urologists? That is so unreasonable and unsustainable. So out of line with what you see in the community. Thoughts from others in practice?

 

[medgator]

Back of the envelope, this is shocking for someone in practice. Ratio of derm to radonc spots is like 2.1- 2.2. Nothing like it is in the real world where you have far more derm docs in a community than 2:1 ratio. Similar principle is true for urology where you have like residency 325 positions. It shows you what a mess this has become. Does the country need to be producing 2 radiation oncologist for every 3 urologists. This is so out of line with what you see in the community. Thoughts from others in practice?

Completely agree. Plus that growth has coincided with hypofrac/sbrt compounding the problem

 

[PleaseRemainCalm]

So why does California and New York and Texas get so many dozens of spots but West Virginia and Arkansas aren't allowed to have even one a year? Again, they are not the problem, and your hatred towards them is misdirected.

MCG/Regents/Augusta/Whatever their name is now... yeah I'll give you that one, but I am not even sure they have any residents anymore.

Programs that shouldn't be filling based on the behaviors of their leaders:
Mayo
Michigan
UPMC
Chicago
Columbia

And whoever else who has a PD or chair that is active with the Twitter virtue-signalling mob or hung the class of 2019 out to dry with the ABR.

California Texas and New York have a lot more population than West Virginia so it should theoretically be much easier to get enough patient volume to train a resident. That's not to say the current ratio is correct but they should always have more spots. Same reasoning by which some states have a dozen med schools and some states have zero.

Residency spots allocated at each institution should be driven by which places are able to give best training to each resident they have, not how we feel about their social media presence. Total spots globally should be driven by the job market.

 

[KHE88]

Residency spots allocated at each institution should be driven by which places are able to give best training to each resident they have, not how we feel about their social media presence. Total spots globally should be driven by the job market.

That's not what I meant/said. What I meant was that if I were a med student, I wouldn't be ranking programs with virtue signalling and/or bullying leaders in social media and in the literature. I would be asking myself if I really want to work for/with these individuals. Whether or not they should have as many slots as they do is a different issue, and it seems I disagree with many here in that I believe that there is some merit in training people at institutions other than in large urban centers. Rad onc applicants couldn't be picky in the past, true, but they could be somewhat picky. Most people still matched somewhere near the top of the list, and it's not like all the midwest programs were full of people who had them ranked last. Plenty of people from the midwest want to stay around there for training and their careers. At least from what I've seen.

 

[KHE88]

Nope, KHE88 still doesn't get it. Rural hospitals have to pay more to recruit and retain docs for a reason.

I get it. What you don't get is the number of training spots at small midwestern programs vs. number of training spots in large cities. While the midwestern programs might preferentially fill midwestern cities, who do you think is more likely to take a job in Fort Smith, Arkansas? The graduate from AR's residency or a graduate from UCLA? Seriously?

 

[Mandelin Rain]

I get it. What you don't get is the number of training spots at small midwestern programs vs. number of training spots in large cities. While the midwestern programs might preferentially fill midwestern cities, who do you think is more likely to take a job in Fort Smith, Arkansas? The graduate from AR's residency or a graduate from UCLA? Seriously?

If the graduate of University of Arkansas is from LA, and the graduate from UCLA is from Fort Smith, I guarantee it's the UCLA grad.

A person's hometown is most likely to decide where the settle down. Not where they transiently spent 4 years renting and working 80 hours a week, that they arrived at via a computer algorithm driven "match" that they had minimal input into.

 

[deleted1002574]

Maybe an Arkansan who received good training at UCSF (changed from UCLA because that’s just a so so program) and then came back home to treat Arkansans would be better than an program an Arkansas with very little in the way of infrastructure, history of training residents, research , collaboration with other institutions, heavy clinical volume and no institutional history of the quality of teaching.

What you’re saying makes some intuitive sense, but little practical sense.

We have 12 of us, not one of us trained in this state.

There is another problem with expansion other than job issues. Yes, I agree that training in our field is heavily resident dependent, but the nuances off the field, the institutional wisdom and data, the off-hand rationale for various treatment variation and the reasons for them - this comes from large institutions. Also, you don’t know what you don’t know (Rummy’s “unknown unknowns”).

There are good and bad residents from top programs, but there are more good than bad. This is just the way it is. If you train at a place that has never had residents and traditionally functions like a private practice (never mind the location), then it’s not the same and the quality is not high.

I didn’t get to train with AV D’Amico, Adam Garden, Nancy Lee, Avi Eisbruch, Rahul Tendulkar, or Chris Crane, but you’d better believe those residents that did got to have a little bit “extra”. Again, this is not “hard and fast”. There are good and bad at all programs. But, in my opinion, if we are going to have 200 residents a year, I’d rather have them come out of 50 programs rather than 100.

 

[KHE88]

This is a pointless debate. Make residency requirements far higher and more stringent, as Neha Vapiwala is working to do, and close any spots that don’t fill in the match.

Let the ability of the program to attract and train high quality residents determine where programs open and close. If Arkansas or WVU can attract and train residents better than a diploma mill like Yale, then they should have residents and Yale should not.

In the era of hypofrac/SBRT I frankly have no sympathy for the argument that we need a bunch of rural practitioners. In fact as the number on beam falls the expected result will be that you need more concentrated population centers to sustain the overhead of a linac.

People can get a hotel in the nearest big city for their 1-2 weeks of RT and this will be a lower net cost to society and have increased quality.As people have said, if jobs won’t fill just pay people more. Eventually they will fill. Everyone has a price at which they’re willing to give up Lamb Biryani. Hell, at some threshold, you can just hire your own Biryani chef.

This is something you really have to see and experience firsthand. When you have a patient population, the majority of whom, either are unable or unwilling to travel more than 15 minutes for treatment. When you are a 6 hour drive from the nearest big city. Not everyone can get treated in a large academic center in a big city, no matter how ultra-hypofractionated the treatment is. That's just the way it is.

And it probably comes as no surprise that I have no idea what biryani is, but being the bleeding heart liberal I am, the idea of eating tortured baby sheep never really appealed to me.

 

[deleted1002574]

It doesn't taste good if it isn't tortured. Duh.

 

[thecarbonionangle]

The more pain the better because the catecholamines “soften the meat”. I really think we have an unlikely concensus and that is Biriyani is a must.

 

[thecarbonionangle]

Saying that poor people should just “get a hotel for 2 weeks” is not a good look. Maybe get out more and talk to some poor rural people. See how realistic that is

 

[medgator]

A person's hometown is most likely to decide where the settle down. Not where they transiently spent 4 years renting and working 80 hours a week, that they arrived at via a computer algorithm driven "match" that they had minimal input into.

Bingo

 

[evilbooyaa]

This is a pointless debate. Make residency requirements far higher and more stringent, as Neha Vapiwala is working to do, and close any spots that don’t fill in the match.

Let the ability of the program to attract and train high quality residents determine where programs open and close. If Arkansas or WVU can attract and train residents better than Yale, then they should have residents and Yale should not.

In the era of hypofrac/SBRT I frankly have no sympathy for the argument that we need a bunch of rural practitioners. In fact as the number on beam falls the expected result will be that you need more concentrated population centers to sustain the overhead of a linac.

People can get a hotel in the nearest big city for their 1-2 weeks of RT and this will be a lower net cost to society and have increased quality.As people have said, if jobs won’t fill just pay people more. Eventually they will fill. Everyone has a price at which they’re willing to give up Lamb Biryani. Hell, at some threshold, you can just hire your own Biryani chef.

Agree with this. The rationale for increasing requirements across the board is that small programs that don't have the volume (not mentioning names, just whichever ones don't have the volume) will close rather than arbitrarily picking certain programs. Similarly, some larger programs will be forced to contract. I'm totally on board with contraction as a method to decrease spots. More-so than program closure as I somewhat agree with KHE that specifically targeting new programs without a reason doesn't make much sense to me. I disagree with ROFallingDown that all residency training should be consolidated at large centers.

Have a strict set of requirements and whoever can meet them can go ahead.

 

[deleted1002574]

I said fewer centers, doesn’t have to be larger centers.

It’s a proxy though. Who will have enough faculty, proper radbio/physics teaching, enough curative cases, enough interstitial cases, enough quality SRS/SBRT, enough tumor boards, enough research opportunities? What “small” institution is in the top 10 (or 20, or 30) programs?

 

[Mandelin Rain]

Criteria #1: Faculty led didactics [75% of programs promptly shut down]

 

[evilbooyaa]

I said fewer centers, doesn’t have to be larger centers.

It’s a proxy though. Who will have enough faculty, proper radbio/physics teaching, enough curative cases, enough interstitial cases, enough quality SRS/SBRT, enough tumor boards, enough research opportunities? What “small” institution is in the top 10 (or 20, or 30) programs?

My issue with 'fewer' centers is that how do you know that the resident experience is not getting diluted? If there are 8 attendings, a few of which are say 80% research, and 8 residents are there enough cases to meet hypothetical sharp increases in residency requirements?

There are many NCI-designated comprehensive cancer centers that don't have residencies, and multiple facilities that do not have that designation that do have residencies. Is that the threshold we want to use? Rather than giving preference to a name, I want it to be about meeting a higher threshold of minimum requirements.

The thing is, right now, it is way too easy to 1) start OR 2) expand your residency program, because the requirements to do so are so, so low. Increase the requirements, don't allow residents to get farmed out to satellites across the network at the alarming rates that they are now to 'meet their numbers' and watch residencies 'willingly' contract. Some of the smaller ones may close. Other ones may not.

Mayo Scottsdale (just as an example) has 14 attendings per their website. Obviously unclear if they're all at the main campus or not, but IMO they have the volume to support 2 residents a year for a total of 8, even with hypothetical increases in requirements. Despite the Mayo hate here, I don't think they are going to be the problem in regards to training.

University of Mississippi (just another example) has 6 attendings, 2 of which are instructors, 4 of which are professors. Do they have the volume to support hypothetical increases for a full complement of residents? Per their website they have a PGY-4, a PGY-3, and 2 PGY-2s, which is weird to say the least.

These are 2 examples with 2 relatively new programs. One I near guarantee would still be around. The other one maybe not.

 

[KHE88]

Oh this is specious sanctimony and you know it. There are loads of mechanisms by which this could be compensated or reimbursed. If a hospital is getting $20,000 for a course of RT they can pony up $100/ night for a hotel, or keep them on site etc. Or the insurer pays it. The VA does this all the time for veterans who are one of the poorest and most rural populations in the country.

At a certain point it is just not economical to have a linac, physicist, dosimetrist, RTT and radonc for every far-flung man woman and child in the country.

Rural populations by definition have low population density meaning that even if you have rural clinics, chances are most people are going to need to drive a long distance to get to them anyway. If you are commuting, is 1 hour to a rural clinic vs 2-3 to the nearest city really THAT different for a 5 day treatment you get once in your life? Good luck trying to put a linac within 15 minutes driving distance of every small town in the United States.

I'm with the alligator on this one. I used to think the same way... oh... anybody can suck up anything for a few weeks.

Then you get to the middle of nowhere, realize how poor people are, how there are literally no resources in terms of transportation (not even taxis let alone things like busses that even the poor in the cities have access to). Even getting meds is hard. The rural hospitals often have < a week of cash on hand and are constantly on the verge of insolvency, so no resources there.

Patients literally cannot travel for treatment, let alone tell them to go to the city 6-7 hours away and stay there for a month. Many are farmers and can't leave their homes as they have to keep the farm going. I have farmers that drive 2 hours each way every day and continue to work full time. Because they have to and they don't have any other choice.

It absolutely is not specious sanctimony. It's real and you really have to be in the middle of it to understand it. Huge difference between urban poor and rural poor. Big city academics are in a bubble and don't get it up in their ivory towers.

 

[dieABRdie]

US MDs - 235 in 2017, 221 --> 190 --> 152 in 2019.

Surprised that IMGs is not increasing on a year-to-year basis. Maybe lag time due to need for research, lack of exposure to the field?

I had felt that it was unlikely for IMGs to flock to this field. One of the few positives to being an IMG is even though you get forced into IM, FM, or psych.... once you are done you can get a job anywhere. Maybe I'm wrong but we will see.

 

[deleted1002574]

Mayo Scottsdale is a really tough example.

But they have incredible infrastructure, faculty led didactics, engaged teachers, protons, fair volume (not amazing), very good research productivity for community program. Overall, if you’re going to start a program, that’s the way to do it.

But they are NOT NEEDED. They just aren’t. They are “literally” training their own competition. A recent grad took a job at their direct competitor in town.

What’s the point of doing this?

I can’t comprehend why they exist. Just because you “can” doesn’t mean you “should”.

 

[PleaseRemainCalm]

This is something you really have to see and experience firsthand. When you have a patient population, the majority of whom, either are unable or unwilling to travel more than 15 minutes for treatment. When you are a 6 hour drive from the nearest big city. Not everyone can get treated in a large academic center in a big city, no matter how ultra-hypofractionated the treatment is. That's just the way it is.

And it probably comes as no surprise that I have no idea what biryani is, but being the bleeding heart liberal I am, the idea of eating tortured baby sheep never really appealed to me.

If patients don't want to travel there are parts of America that are sparse enough that it's probably cheaper for the government or the insurance company to just put them on shuttles and drive them to the big center or pay to put them up in housing. When patients literally have no choice, not just that they choose the closeby specialist over the faraway superspecialist but there is no choice, most of them will travel if there is no financial barrier. It would mean that more patients would make decisions like choosing the mastectomy over the lumpectomy, but again if there was no financial barrier imposed by distant travel I think many patients would still do it.

 

[scarbrtj]

Oh this is specious sanctimony and you know it. There are loads of mechanisms by which this could be compensated or reimbursed. If a hospital is getting $20,000 for a course of RT they can pony up $100/ night for a hotel, or keep them on site etc. Or the insurer pays it. The VA does this all the time for veterans who are one of the poorest and most rural populations in the country.

At a certain point it is just not economical to have a linac, physicist, dosimetrist, RTT and radonc for every far-flung man woman and child in the country.

Rural populations by definition have low population density meaning that even if you have rural clinics, chances are most people are going to need to drive a long distance to get to them anyway. If you are commuting, is 1 hour to a rural clinic vs 2-3 to the nearest city really THAT different for a 5 day treatment you get once in your life? Good luck trying to put a linac within 15 minutes driving distance of every small town in the United States.

I may be wrong but I believe it’s illegal to give free stuff of significant value to Medicare patients. Can’t pay for their gas, provide them free transport (ie cover their Uber), certainly can’t pay for a hotel for them. VA has its own rules that makes things like that totally kosher though.

 

[evilbooyaa]

Oh this is specious sanctimony and you know it. There are loads of mechanisms by which this could be compensated or reimbursed. If a hospital is getting $20,000 for a course of RT they can pony up $100/ night for a hotel, or keep them on site etc. Or the insurer pays it. The VA does this all the time for veterans who are one of the poorest and most rural populations in the country.

At a certain point it is just not economical to have a linac, physicist, dosimetrist, RTT and radonc for every far-flung man woman and child in the country.

Rural populations by definition have low population density meaning that even if you have rural clinics, chances are most people are going to need to drive a long distance to get to them anyway. If you are commuting, is 1 hour to a rural clinic vs 2-3 to the nearest city really THAT different for a 5 day treatment you get once in your life? Good luck trying to put a linac within 15 minutes driving distance of every small town in the United States.

The patient will then just not get treatment and die horribly of their disease. You are underestimating the rural population here with their desires to not drive far and their functional inability to do so.

I may be wrong but I believe it’s illegal to give free stuff of significant value to Medicare patients. Can’t pay for their gas, provide them free transport (ie cover their Uber), certainly can’t pay for a hotel for them. VA has its own rules that makes things like that totally kosher though.

I've heard similar things. Not substantiated and would happy to be educated.

 

[deleted1002574]

Totally.

Underestimating poor, rural people’s will to live. That’s just unfortunate. They deserve to be treated with the same level of respect and assumption that they care about their well-being.

W. used to talk about the “soft bigotry of low expectations” when it came to the education of urban youth. Same issue here...

To generalize about an entire group of people because of where they live and what their education is... jeez. They deserve better than that.

 

[radoncgrad2019]

W. Matched rad onc in the 90s

 

[evilbooyaa]

Totally.

Underestimating poor, rural people’s will to live. That’s just unfortunate. They deserve to be treated with the same level of respect and assumption that they care about their well-being.

W. used to talk about the “soft bigotry of low expectations” when it came to the education of urban youth. Same issue here...

To generalize about an entire group of people because of where they live and what their education is... jeez. They deserve better than that.

Consolidation in a few centers works in countries that are not geographically that big, like most of Europe. Do I think all rural patients will die of their cancer due to being unable to go to a treatment facility 5 to 6 hours away? No, of course not. Do I think there will be at least some patients that have delays in their care due to the distance from a cancer treatment facility, and thus progress to metastatic disease and succumb to their disease, when they would've still had a shot at being curable with prompt therapy? Yes.

Patients from rural locations are at high risk for delays in their initial therapy. Do you agree with that statement? If so, do you feel that at least part of that delay is due to the proximity of a facility that can treat them at least somewhat close to home (even if it is a 2-hour drive each way)?

 

[medgator]

Yes but this likely has nothing to do with their proximity to radiation, but moreso their proximity to primary care and diagnostic services.

Where did this hypothetical rural patient get his EBUS? Where did he get his DL?Are there Urologists in every corner of the United States doing MR-targeted prostate biopsies? Where did he get his PET scan?

For that matter, where is he getting his APR when he’s done CRT? Where will he get his cisplatin infusions and IV hydration? Adjuvant Immunotherapy? Follow up scans? These are all a challenge to deliver to rural areas that lack sufficient population density, not just RT.

We luckily have enb ebus etc where I practice, but patients routinely have to travel to the major metro 1-2 hours away for any specialized surgical oncology procedure outside of breast and lung.

And it's better for everyone that way imo, including the local physicians who may not feel comfortable doing a laryngectomy with radical ND, or a Whipple without backup and properly trained hospital and ancillary staff

 

[taserlaser]

Copious data that it is better for patients to have rare complex procedures done at high volume centers. Don’t understand all this sanctimony about how putting linacs in cornfields equates to better care.

Agree on high volume complex procedures. Can’t find any citations right now, but there is definitely data out there showing worse outcomes for patients further away from RT centres (call it around 60 miles). So for general RO practice, there probably is a benefit to patients for better access to routine care, but at a large cost to the system. The question is, is this arrangement the most efficient, or is it worth the personal expense (if they prefer living further away from urban centres as been the most common opinion mentioned) for the RO, and the expense to the system?

 

[DoctwoB]

I may be a card carrying liberal, but what happened to personal responsibility here? The decision to live rurally has pros (more space, cleaner environment, cheaper housing etc) and cons, one of which is more difficult access to high level care. There is not and shouldn’t be a right to tertiary level care in your backyard.

So yes, some patients will defer care, or delay care if they have to travel an hour Or 2 or 3 to see a (linac, urologist, surgical oncologist, etc). That is a personal decision. That doesn’t mean we shouldn’t do our best to help them through telemedicine, consolidating appointments, hypoFx, etc, but at some point we have to accept that we are their doctors, not their parents.

 

[deleted1002574]

Everything is turned around when liberals (even myself) have to explain the actions of choices, consequences, and personal responsibility. People live out there, it’s not anyone’s job to put a linac out there to treat 12 people, it’s not anyone’s job to be the doc that treats on that linac.

Plus, it’s really demeaning to say that they will just say “F it, I’m a goner” because of the drive. People are smarter than that and conscious of their decisions.

Got a guy traveling 1.5-2 hours each way for SCLC, had to do qD for second time in ten years. But, even when I gave the option of omitting PCI, he came for that. Not rich. Not holding a doctorate. Just weighed pros and cons, and made a decision. Like non rural people.

 

[Mandelin Rain]

It’s hard to rectify the idea that urban poor deserve the right to health care access, but rural poor do not.

before, you say, “they should just move out of the farm field.” You have to understand that it’s the exact equivalent of someone saying, “they should just move out of the ghetto.”

poverty is poverty all over my man. If we are saying health care is a basic right it should (must, as moral imperative) be readily and equally available to everyone

 

[Mandelin Rain]

“I may be a card carrying liberal, but what happened to personal responsibility here? The decision to live rurally has pros (more space, cleaner environment, cheaper housing etc) and cons, one of which is more difficult access to high level care. There is not and shouldn’t be a right to tertiary level care in your backyard.”

Reimagined....

Urban poor have lousy school districts. But at some point, it becomes about personal responsibility. The decision to live in the inner city has consequences. It’s not like there can be top tier public high schools everywhere. If they want good schools, they should move to the suburbs.

 

[deleted1002574]

Urban poor have lousy school districts. But at some point, it becomes about personal responsibility. The decision to live in the inner city has consequences. It’s not like there can be top tier public high schools everywhere. If they want good schools, they should move to the suburbs.

Agree. If they can, they should. agreement. If they are choosing to live somewhere with terrible schools and have a way out, but choose not to, that’s their problem.

Is this the same as people who have
money, buy a plot of land 2 hours outside of Denver and expect high level care?

I hear so many times from my long distance patients (1-2 hours away) - “I would never live in ____”. Even though it’s cheaper to live in the city or near it.

 

[Timewinders]

“I may be a card carrying liberal, but what happened to personal responsibility here? The decision to live rurally has pros (more space, cleaner environment, cheaper housing etc) and cons, one of which is more difficult access to high level care. There is not and shouldn’t be a right to tertiary level care in your backyard.”

Reimagined....

Urban poor have lousy school districts. But at some point, it becomes about personal responsibility. The decision to live in the inner city has consequences. It’s not like there can be top tier public high schools everywhere. If they want good schools, they should move to the suburbs.

I mean, this is why so many liberals support desegregation bussing and school consolidation. It saves on costs overall and reduces inequality, at the expense of rich suburbanites having to tolerate their kids going to the same schools as poor people.

But getting back on topic, anyone know what the deal is with psych having less applicants this year overall according to the prelim data? Same number of US applicants but less IMGs. And I know some new residency programs are starting and old ones are expanding so competitiveness actually seems down a bit compared to last year after years of increased competitiveness.