ACRO Resident Webinar August 25, 2016| Residency Expansion: Facts and Myths

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ACRO Resident Webinar August 25, 2016| Residency Expansion: Facts and Myths

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Title: Residency Expansion: Facts and Myths

Presenters: Drs. Craig Stevens, Benjamin Falit, and Hubert Pan

Description: ACRO is proud to present a panel discussion on residency expansion. The goal of this webinar is to inform the radiation oncology community about the facts and myths around residency expansion and job market concerns. This panel will be a moderated question and answer session with multiple experts in the field. Please email questions to [email protected]. We will take limited questions on the day of the panel. This webinar will be open to ACRO members and non-members.

Date & Time: Thursday, August 25, 2016 at 6:00PM EDT

This webinar is complimentary to all those that attend.

 

DebtRising

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I think this is a great topic. I wanted to put a few objective data points here to give the foundation on why there is so much negativity from certain parts of our community on this issue. All of these are found in other threats.

1. Radiation oncology demand:
Supply and Demand for Radiation Oncology in the United States: Updated Projections for 2015 to 2025.
http://www.ncbi.nlm.nih.gov/pubmed/27209499

This is a revision to a model published in 2014. I am going to copy and paste part of the abstract (we all have the full article, abstracts are free to view and thus can be posted)
"Between 2015 and 2025, the annual total number of patients receiving radiation therapy during their initial treatment course is expected to increase by 19%, from 490,000 to 580,000. Assuming a graduating resident class size of 200, the number of FTE physicians is expected to increase by 27%, from 3903 to 4965. In comparison with prior projections, the new projected demand for radiation therapy in 2020 dropped by 24,000 cases (a 4% relative decline). This decrease is attributable to an overall reduction in the use of radiation to treat cancer, from 28% of all newly diagnosed cancers in the prior projections down to 26% for the new projections. By contrast, the new projected supply of radiation oncologists in 2020 increased by 275 FTEs in comparison with the prior projection for 2020 (a 7% relative increase), attributable to rising residency class sizes."

In other words - due solely to residency expansion and based on a now rescinded model we are already training more radiation oncologists than are needed.
A potential argument could be that the tide will turn - radiation services will expand. In this current climate where we are the de-factor enemy (we being physicians), and the studies that show that oncologic care is superior in the US are either picked apart or not discussed (while those discussing absolute mortality numbers are held up as fact... which is insane when the correct metric should be cause-specific mortality rates), I submit there is almost no chance radiation services will increase.

2. The job market circa 2014
Employment After Radiation Oncology Residency: A Survey of the Class of 2014
http://www.ncbi.nlm.nih.gov/pubmed/26194674
Employment information was found for 163 / 167 graduates but only 60% responded to survey
Some very sobering stats
128 slots in 2006 -> 200 2015
33% found no job openings in there geographic area of interest
Of those who found a job, 16% wanted academic practice but could not find a position
7/97 of respondents could not find a job (7% could not find a job!!!)**

**All of these results are freely available when I google/pull up the article on my smart phone on a personal device that does not have red journal subscription typed in. If this is an error and they should not be shared to those people who do not have a red journal subscription please let me know. I say this only because there is no listed abstract on pubmed. But I would not post if I could not obtain this information freely at this time.

This is data from 2014. Let that sink in. Again, a potential argument is that a snapshot in time does not give a full picture of employment. I counter that argument with the fact that massive medicare changes are supposedly coming, of which there seems to be little advanced notice, and uncertainty in payment is unlikely to foster healthy hiring in the future.

3. At least some in the field, outside those of us who joined this field when ASTRO had the old model and 'Demand is expected to increase!!!!' plastered on their website, are becoming aware of this and seem to actually care about residents.
The Radiation Oncology Job Market: The Economics and Policy of Workforce Regulation
http://www.redjournal.org/article/S0360-3016(16)30289-9/abstract
"Examinations of the US radiation oncology workforce offer inconsistent conclusions, but recent data raise significant concerns about an oversupply of physicians. Despite these concerns, residency slots continue to expand at an unprecedented pace. Employed radiation oncologists and professional corporations with weak contracts or loose ties to hospital administrators would be expected to suffer the greatest harm from an oversupply. The reduced cost of labor, however, would be expected to increase profitability for equipment owners, technology vendors and entrenched professional groups. Policymakers must recognize that the number of practicing radiation oncologists is a poor surrogate for clinical capacity. There is likely to be significant opportunity to augment capacity without increasing the number of radiation oncologists by improving clinic efficiency and offering targeted incentives for geographic redistribution"

Thank you for taking the time to write this Dr. Falit. I truly feel that the senior physicians in this field could care less about the labor market, much like what happened with radiology (ie: Oh I care about my residents... but if you're residents can't find a job that's not a concern for me).

4. Fellowships, which are not accredited, required, or seem to truly advance knowledge (outside a TRUE proton or pediatric situation) are expanding.
The ARRO fellowship directory is attached to this post
21 fellowships. 21!!
Some of the descriptions don't even have a clear focus of interest, leaving it up to the applicant (though I do submit, this is an ARRO accrued list and not official material from the program).
There is a lymphoma fellowship at MSKCC. Are there really residency programs where Hodgkin's lymphoma is not taught well? The website also lists lymphoma and myeloma... not sites with a lot of complexity on our side. Everyone at MSKCC may be smarter and more accomplished than I am, though I will put my work ethic against anyone's. But with that said, how is that defensible? It is either an implicit acknowledgment that there are deficient training programs in our country, or a play to get people desperate for NYC into a pseudo-job at below market rates. And I don't mean to pick on MSKCC.... their fellowship page was just the first search result when I googled.

5. Medicine is in decline. We are being told to accept lower reimbursement, see more patients, jump through more hoops from government mandates and private insurance companies, and a large part of the population wants a 'public option' insurance type pushed. Yet none of these people are offering to pay our student loans or cost of education (as is done in all the countries with said policies), lower our paper work / administrative time, or offer meaningful tort reform (less relevant to our field unless we really examine follow up imaging ordering). That is a whole other discussion but I doubt anyone here would argue my premise - we are the enemies (whole field / health costs), we have no unified voice, and there is a good chance things will get worse.
Basically, as we pump out more graduates that our specific field and society doesn't need, we are adding more weight to a ship that overall is sinking, and may be sinking quickly.
I would even argue that this will not reduce costs or salaries - but more radiation services will be offered to justify positions. Every bone met will be treated, every lung nodule will be SBRT'd, every prostatectomy path with EPE will be radiated (for some reason referrals at this point seem to never get held up.... :).

6. This is a catastrophic setup, and this just happened in radiology. To make it even better... we keep expanding! I forget which - did Arkansas just come online? What about W. Va? How can anyone justify opening new residencies in this environment? There should be a hybrid solution, targeting areas of need (like I posted before a hybrid position between Arkansas and a Texas program, or between W. Va and UPMC where a slot is created and shared to recruit someone to these 'underserved' areas and the resident rotates at both places before accepting a position in geographic region X... absolutely would offer superior clinical training without creating a new slot in perpetuity AND would attract people who are interested in being in region X at the outset). But as reimbursements fall, it is hard to cut back on a very cheap and very flexible labor source.

I wish I was more senior and involved in health policy, but I am not. What I can do is post the few objective data points there are to show how bad things are, and posit a few arguments that I doubt anyone can fully refute to make the point clear. This is where the negativity about the job market comes from. And this is why anyone who is seriously considering entering this field needs to investigate this further, as much as they can, because it is not a given you will have a job. It wasn't in 2014.
 

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Mandelin Rain

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Nice write up of the state of the angst. I looked at the fellowship offerings and they are hilarious. Also, you unfortunately miscounted the number of available fellowships. Harvard alone is offering 5. There are a couple other programs offering multiples.
 
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OTN

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The fellowship thing is just the worst. NO need to do a fellowship in radonc unless your training program was garbage or unless you want to do exclusively peds. I don't even count "proton" fellowships as worthwhile. The proton guys would love for us all to think there's something magical in their sauce, but in reality it's just another treatment paradigm/program you need to learn. In my opinion easier to learn than SBRT/SRS/etc. These academic programs offering all these spots should be ashamed.
 

Mandelin Rain

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You have to think that the fellowship explosion is a coordinated effort. It's not like every high powered academic institution suddenly and independently decided to offer a fellowship(s) in the past 24 months.

The intention is two fold.

1. Justify continued residency expansion by preventing new graduate unemployment/having "open positions" that "need" to be filled.
2. Eventually force all residents into another year or two of cheap labor at academic centers, like what radiology did.
 

RadOncDoc21

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You have to think that the fellowship explosion is a coordinated effort. It's not like every high powered academic institution suddenly and independently decided to offer a fellowship(s) in the past 24 months.

The intention is two fold.

1. Justify continued residency expansion by preventing new graduate unemployment/having "open positions" that "need" to be filled.
2. Eventually force all residents into another year or two of cheap labor at academic centers, like what radiology did.
That's sad but not surprising. My last two years of residency was filled with cross-coverage of services because my attendings could not function without a resident. I guess now they will have fellows dictating their notes.
 

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This is so sad. I graduated about a decade ago and have been working in "underserved" areas since. I remember several of my attendings and "mentors" trying to get me to stay by telling me "you can always go into private practice if things don't work out in academics but if you go into private practice you'll never be able to return to academics." I'm so happy I didn't take their advice and now realize it was a just a (very arrogant and selfish) scare tactic.

I currently have 37 patients under treatment at two centers ... I'm sure I could jump into an "academic" position treating only 18-20 patients in a single disease site like GI while publishing some nonsense retrospective review every few years (I bet the trainees do half the work anyway) but can you imagine your attendings who can't function without residents, PA's etc managing 30-35+ patients (most of whom are very nice, decent people but of limited resources)?

This is so sad...
 
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thecarbonionangle

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The current state of "academic" radiation oncology is an absolute JOKE. For those who have been out of residency for a while, I tell you double coverage is almost the norm in many programs and TRIPLE coverage is not unheard of. It is absolutely crazy having witnessed these "top institution" attendings being absolutely unable to move a finger without residents, PAs. Some have ZERO idea how to contour, never bothered to learn the contouring program. Residents learning suffers, many are frankly too tired to even bother to learn anything. The best you get from the residents at interview in some of these places is absolute indifference, not a good sign I tell you folks. Residency is not supposed to be easy but the focus of the residency programs is to educate residents, to train the next generation of radiation oncologists to be clinically competent and well versed in information to offer patients the most up to date treatment approaches based on the evidence. At many places, you are there to work first. You are on your own for education. Words like "self driven" are thrown around. The ABR fee is almost 700 with a late fee of 100!. Hearing about the "clinical" boards sickens me even further. These money grubbing boomers are sucking us dry. And they sit in the ivory tower looking down on private practice, looking down on the majority of programs as not even being worthy of existing, scheming ways to expand residency programs to avoid hiring PAs and nurses who require a higher salary, unionize and demand things like a 401k with matching contributions. The whole thing is disgusting. I have zero faith in these "leaders" trying to throw us a rope to get us out of this hole.
 
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Neuronix

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Nice write up of the state of the angst. I looked at the fellowship offerings and they are hilarious. Also, you unfortunately miscounted the number of available fellowships. Harvard alone is offering 5. There are a couple other programs offering multiples.
In DebtRising's defense, it's hard to get a good count because many fellowships are not well advertised, and there is no one central place for listing them. Also, programs seem happy to create fellowships practically out of thin air, given that they're unaccredited, easy to create, and lucrative. These fellowship positions also tend to disappear back from however they were listed or advertised when they don't fill for the sake of the egos of the programs that created them. That is, many programs don't want it to be too obvious that they have unfilled fellowship positions because it mihjt make th

Thus, the fellowship scheme is amorphous. The only limit to these fellowships is actually qualified applicants to fill them. The more residents without jobs, the more fellowships will pop up. The better the job market, the fewer fellowship positions will exist, down to some small baseline of legit fellowships (peds, brachytherapy) or people who need them for some reason like marginal residency training.
 

oldking

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Triple coverage!?!

I can see why the lazy senior attendings would want residents to do their work for them and why Chairs are even happier to increase residency positions. After all they are senior attendings too and I'm sure fearful residents go the extra mile to do everything for their 4-5 on treatment patients so the chair doesn't have to lift a finger then the Chair wins again when that resident graduates and can't find a job so he can pay even less salary to the junior attending and soon enough he can hire a "fellow" for even less!!!

I'm curious though what goes on in resident meetings? Doesn't the residency director look out for the best interest of resident education anymore? When I was a resident ours always had our back and we weren't expected to cover two attendings (unless we were on a service that had two part-time attendings but in that case it was in the interest of our education not attending coverage). let alone three
 

Mandelin Rain

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In the last decade, how many practice changing studies of radiosensitizers, radioprotectors, altered fractionation, enhanced physical properties of dose delivery, etc... have been published from US academic centers?
 

OTN

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In the last decade, how many practice changing studies of radiosensitizers, radioprotectors, altered fractionation, enhanced physical properties of dose delivery, etc... have been published from US academic centers?
GOOD question. Jeff Bradley's dose (de?)escalation study for Stage III NSCLC certainly could count, but after that the waters get kind of murky. Where are the dose de-escalation data for HPV-associated scca of the H+N? I'm seeing some fairly worthless retrospective/phase III stuff, but no randomized data at all. Anyone going to try dose escalation for definitive ChemoRT for esophageal cancer again? Nope? We're still just going to take a carcinoma to ~50 Gy? If it were HPV-associated scca like anal cancer I could understand it, but it's not. Oh well.

I think one of the more egregious failures must be how behind-the-ball radonc is with respect to combined immunotherapy + radiation. We've known about the abscopal effect for DECADES, but now that immunotherapy is finally to the fore, do we have ANY clinical data that can guide us to take advantage of the effect? Nope. None. Great pre-clinical stuff, sure, but nothing clinical at all. How academic radoncs couldn't see it coming is beyond me.
 

Krukenberg

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GOOD question. Jeff Bradley's dose (de?)escalation study for Stage III NSCLC certainly could count, but after that the waters get kind of murky. Where are the dose de-escalation data for HPV-associated scca of the H+N? I'm seeing some fairly worthless retrospective/phase III stuff, but no randomized data at all. Anyone going to try dose escalation for definitive ChemoRT for esophageal cancer again? Nope? We're still just going to take a carcinoma to ~50 Gy? If it were HPV-associated scca like anal cancer I could understand it, but it's not. Oh well.

I think one of the more egregious failures must be how behind-the-ball radonc is with respect to combined immunotherapy + radiation. We've known about the abscopal effect for DECADES, but now that immunotherapy is finally to the fore, do we have ANY clinical data that can guide us to take advantage of the effect? Nope. None. Great pre-clinical stuff, sure, but nothing clinical at all. How academic radoncs couldn't see it coming is beyond me.
Just want to point out that on clinical trials.gov there are a ton of phase 2 trials trying different immuno agents, fractionation schemes, and sequencing in various cancers in the works. Not worth it to start a phase 3 trial until you know the best treatment scheme.


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medgator

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It's all about funding. The drug companies pay and push for many and large immunotherapy trials. It's very difficult to get anyone to pay for radiotherapy trials.
Yup. Was 0617 funded because of Bristol/Lilly owning cetuximab?
 

OTN

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Yup. Was 0617 funded because of Bristol/Lilly owning cetuximab?
There are other funding avenues- write a proposal for either NIH- or foundation-sponsored grants, for example. Sure, chemotherapy trials are easier to find funding for, but writing grant proposals to get funding is precisely what an academic physician should be doing.
 

Mandelin Rain

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To be fair, if a practice-changing study has been reported in the past decade, it was likely funded with pre-recession dollars when it was a LITTLE looser. The med onc are getting the dollars now, because they are doing something worthwhile.

Regardless, isn't that part of the function of academic medicine? To provide support to investigators such that they can get initial data worthy of a grant? All I know is that the flood of MD/PhDs, focus on "academics" (whatever that means), expanded residencies of an improved pool of applicants, greater resident coverage for attendings to protect their time, etc.... hasn't ushered in a gilded age of radiation oncology research. Quite the opposite.

But... how many satellite clinics have academic centers gobbled up in the same decade-long time frame?
 
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The current state of "academic" radiation oncology is an absolute JOKE. For those who have been out of residency for a while, I tell you double coverage is almost the norm in many programs and TRIPLE coverage is not unheard of. It is absolutely crazy having witnessed these "top institution" attendings being absolutely unable to move a finger without residents, PAs. Some have ZERO idea how to contour, never bothered to learn the contouring program. Residents learning suffers, many are frankly too tired to even bother to learn anything. The best you get from the residents at interview in some of these places is absolute indifference, not a good sign I tell you folks. Residency is not supposed to be easy but the focus of the residency programs is to educate residents, to train the next generation of radiation oncologists to be clinically competent and well versed in information to offer patients the most up to date treatment approaches based on the evidence. At many places, you are there to work first. You are on your own for education. Words like "self driven" are thrown around. The ABR fee is almost 700 with a late fee of 100!. Hearing about the "clinical" boards sickens me even further. These money grubbing boomers are sucking us dry. And they sit in the ivory tower looking down on private practice, looking down on the majority of programs as not even being worthy of existing, scheming ways to expand residency programs to avoid hiring PAs and nurses who require a higher salary, unionize and demand things like a 401k with matching contributions. The whole thing is disgusting. I have zero faith in these "leaders" trying to throw us a rope to get us out of this hole.

Im glad to see more people finally being aware of the joke that academic rad onc has become and the detriment it is causing to peoples lives. I realized this many years ago and I was one of the first to start posting dissenting arguments here but was summarily shouted down by the same people who are in full support now. I dont mind though, I know change takes time.

I think the state of the field remains strong however. Other fields have lagged in developing good clinicians to atrocious levels. Rad Onc still allows you to become a great clinician which is an art significantly lost on a young generation as similar problems exist in other fields too (the residents are just blind to the transformation that has really happened). The filth that was our field many years ago remains in place and will continue to degrade our generation from the top. Best defense is understanding this and working to make it better. Dont become the scum that they are. Dont buy into their crap, dont publish stupid **** articles that have 0 value. Return honor to medicine for the vows that you have taken regardless where you practice. Take great care of patients and dont feel bad if your attendings guilt trip you for not doing enough of their work the way they want it done. Oppose expanding residencies and tell your med school colleagues the situation so these slots and many others go unfilled. It is the only way we can fight back in a concerted manner.
 
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Fpg1245

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Im glad to see more people finally being aware of the joke that academic rad onc has become and the detriment it is causing to peoples lives. I realized this many years ago and I was one of the first to start posting dissenting arguments here but was summarily shouted down by the same people who are in full support now. I dont mind though, I know change takes time.

I think the state of the field remains strong however. Other fields have lagged in developing good clinicians to atrocious levels. Rad Onc still allows you to become a great clinician which is an art significantly lost on a young generation as similar problems exist in other fields too. That said, the filth that was our field many years ago remains in place and will continue to degrade our generation from the top. Best defense is understanding this and working to make it better. Dont become the scum that they are. Dont buy into their crap, dont publish stupid **** articles that have 0 value. Return honor to medicine for the vows that you have taken regardless where you practice. Take great care of patients and dont feel bad if your attendings guilt trip you for not doing enough of their work the way they want it done. Oppose expanding residencies and tell your med school colleagues the situation so these slots go unfilled. It is the only way we can fight back in a concerted manner.
What inspiring words! Make Radiation Oncology Great [Again?]. But alas, Nothing will change. The programs will expand. They'll find some poor souls to fill the spots. Rest assured the only thing you are certain to get in this field is a front row seat to its destruction. A swan dive straight into the concrete. Careful not to let the splatter ruin your cloths! Seriously, there isn't any reason for anyone to get all riled up anymore. This is the situation:supply>demand. The powers that be will not address it and residents are powerless. If anyone feels as if working hard and taking crap from attendings for 4 years with questionable job prospects sounds like your cup of tea then by all means stay. If not then perhaps you should explore other options.
 

medgator

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What inspiring words! Make Radiation Oncology Great [Again?]. But alas, Nothing will change. The programs will expand. They'll find some poor souls to fill the spots. Rest assured the only thing you are certain to get in this field is a front row seat to its destruction. A swan dive straight into the concrete. Careful not to let the splatter ruin your cloths! Seriously, there isn't any reason for anyone to get all riled up anymore. This is the situation:supply>demand. The powers that be will not address it and residents are powerless. If anyone feels as if working hard and taking crap from attendings for 4 years with questionable job prospects sounds like your cup of tea then by all means stay. If not then perhaps you should explore other options.
Yup. Radiology, and especially, pathology, show what depths this can go to.

Rad Onc couldn't fill 25+ years ago and was full of FMGs. Might be coming around full circle soon. (For now), there will still be many jobs available in rural/Midwest locations, so some will still be interested
 

seper

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thanks for compiling fellowship list
what was the way Radiology and others legitimized their fellowships?
 

medgator

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thanks for compiling fellowship list
what was the way Radiology and others legitimized their fellowships?
The crappy job market? I think trainees and the ABR legitimized it together. Rads jobs got harder to find so people with fellowships started to stand out and so it eventually began.
 

oldking

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I have heard countless times from multiple individuals all over the country about how "radiology and especially pathology" went downhill but I honestly don't know what happened. I assume that too many resident spots were created so that lazy academic attendings could get free labor, then those residents couldn't find jobs so they were further exploited when they were under paid as junior attendings and then even worse essentially required to do a fellowship for even less pay, then the best and brightest stopped applying, and now it is basically accepted as fact that a fellowship is required? Can anybody provide a brief, relatively non-biased, and objective account ?

Also, what is up with cardiology? A family friend's son graduated from medical school a few years after I did and he still isn't an attending. He took an extra year during fellowship for "research" to get into a better program for a year in EP . . . what do you even call that a "fellowship's fellowship"? I wonder if this trend is basically the new norm/ponzy scheme in medicine...
 
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The crappy job market? I think trainees and the ABR legitimized it together. Rads jobs got harder to find so people with fellowships started to stand out and so it eventually began.
Residents will come to programs and ask them to create fellowships specifically for them for various reasons. This has happened to my program. We are not a top program and are not in a particularly geographically desirable area.
 

Mandelin Rain

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That doesn't mean the spots will go unfilled.
For sure. At least not unless the bottom falls out completely like with radiology. But... the quality of the pool will diminish significantly. We can pretend that a primary driver of the increased interest in rad onc as a specialty ~15 years ago wasn't due a sharp rise in salary while maintaining a very reasonable life style. But it was. There are still specialties that exist like that to interest the high level candidates.
 

OTN

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For sure. At least not unless the bottom falls out completely like with radiology. But... the quality of the pool will diminish significantly. We can pretend that a primary driver of the increased interest in rad onc as a specialty ~15 years ago wasn't due a sharp rise in salary while maintaining a very reasonable life style. But it was. There are still specialties that exist like that to interest the high level candidates.
That wasn't all it was for me- as tech improved what we've been able to DO has been much more interesting. Even with the lifestyle aspects of the specialty, I'm not sure I could get fired up about drawing blocks on films with wax pencils all day long. I've always been interested in tech, and this field is a neat way to combine that interest with clinical medicine.

I feel really bad for residents who are going to have a hard time finding employment. That's a worst-case scenario I wouldn't wish on anyone.
 

medgator

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That wasn't all it was for me- as tech improved what we've been able to DO has been much more interesting. Even with the lifestyle aspects of the specialty, I'm not sure I could get fired up about drawing blocks on films with wax pencils all day long. I've always been interested in tech, and this field is a neat way to combine that interest with clinical medicine.

I feel really bad for residents who are going to have a hard time finding employment. That's a worst-case scenario I wouldn't wish on anyone.
Agreed. Would be bored to tears in derm
 
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What inspiring words! Make Radiation Oncology Great [Again?]. But alas, Nothing will change. The programs will expand. They'll find some poor souls to fill the spots. Rest assured the only thing you are certain to get in this field is a front row seat to its destruction. A swan dive straight into the concrete. Careful not to let the splatter ruin your cloths! Seriously, there isn't any reason for anyone to get all riled up anymore. This is the situation:supply>demand. The powers that be will not address it and residents are powerless. If anyone feels as if working hard and taking crap from attendings for 4 years with questionable job prospects sounds like your cup of tea then by all means stay. If not then perhaps you should explore other options.

If I was a med student and all residents were telling me not to go into rad onc there is a high chance I would listen. We should all be in on this together (like the chairmen are on their quest to obliterate our futures), probably even doing AMAs about the subject in the Allopathic forum. It's time to drop the interest in our field as a way for us to sustain ourselves from the viciousness of the older generation and the academic vultures. It won't take effect overnight but over the next 4-5 years we'll see the results and into the future.
 
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If I was a med student and all residents were telling me not to go into rad onc there is a high chance I would listen. We should all be in on this together (like the chairmen are on their quest to obliterate our futures), probably even doing AMAs about the subject in the Allopathic forum. It's time to drop the interest in our field as a way for us to sustain ourselves from the viciousness of the older generation and the academic vultures. It won't take effect overnight but over the next 4-5 years we'll see the results and into the future.
As a first year student, this is valuable to hear. What other fields in medicine would current residents suggest going into that are similar to rad onc?

I was originally drawn to rad onc because there is a nice mix of technology, patient contact, and science/research with respect to oncology.
 
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As a first year student, this is valuable to hear. What other fields in medicine would current residents suggest going into that are similar to rad onc?

I was originally drawn to rad onc because there is a nice mix of technology, patient contact, and science/research with respect to oncology.
We are a proud group and really like radiation oncology and have avoided the truth of our situation for many years bc of this. I and many of us believe rad onc is the best field in medicine. However the reality is that our leaders have failed us and have no incentive to do otherwise in the future

The truth is the same thing is happening in other fields, the residents just aren't as keen to it or at least haven't been in the past. I mean really, surgeons need 2 years of research? Horse**** they do. Its all part of the Ponzi scheme of medicine. Those two years off are the biggest joke and they all just laugh about it bc they aren't keen to what is happening to them. 2 years of income, 2 years of 401K, 2 years of children. It's an incredible travesty to be a crap researcher anyway and publish crap articles. So don't think you can escape this issue in other fields too.

The best advice is go wherever will make you happiest. That's the most important thing. Don't buy into the hype of the Ponzi scheme like so many of your classmates will; you will find something interesting in every field. In rad Onc you won't get a choice where you go after and if you're ok with that fine. But don't destroy your life for the Ponzi scheme that is not worth it. The $ and the jobs aren't there to support it. to have bleak job prospects when you're coming out of residency and all your superiors want to take advantage of you bc they are terrible doctors and basically human scum who just see $$ signs, to realize the attendings you looked up to as a resident were just a different breed of the same, its one of the worst feelings in the world.
 
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oldking

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We are a proud group and really like radiation oncology and have avoided the truth of our situation for many years bc of this. I and many of us believe rad onc is the best field in medicine. However the reality is that our leaders have failed us and have no incentive to do otherwise in the future

The truth is the same thing is happening in other fields, the residents just aren't as keen to it or at least haven't been in the past. I mean really, surgeons need 2 years of research? Horse**** they do. Its all part of the Ponzi scheme of medicine. Those two years off are the biggest joke and they all just laugh about it bc they aren't keen to what is happening to them. 2 years of income, 2 years of 401K, 2 years of children. It's an incredible travesty to be a crap researcher anyway and publish crap articles. So don't think you can escape this issue in other fields too.

The best advice is go wherever will make you happiest. That's the most important thing. Don't buy into the hype of the Ponzi scheme like so many of your classmates will; you will find something interesting in every field. In rad Onc you won't get a choice where you go after and if you're ok with that fine. But don't destroy your life for the Ponzi scheme that is not worth it. The $ and the jobs aren't there to support it. to have bleak job prospects when you're coming out of residency and all your superiors want to take advantage of you bc they are terrible doctors and basically human scum who just see $$ signs, to realize the attendings you looked up to as a resident were just a different breed of the same, its one of the worst feelings in the world.
Wow I didn't realize some general surgery residents take two years during their residency for research . . . when the heck did this happen?

I remember talking to a general surgery friend of mine 5-6 years ago who was in his research year and he was almost bragging about how much fun he was having working 30ish hours per week on his research project (which he didn't really care about) while "just taking call and filling in for vacations" and how the year was a joke. I couldn't help but think to myself "doesn't this dude realize that the joke is on him: a 35ish year old man with an MD and 3-4 years of residency under his belt working for barely $50,000/yr but more importantly losing out on a year of attending salary (while student loan interests are accruing)." I lost touch with him but would love to see how he feels about it now.

Two years of research is just unbelievable, especially if they still do any amount of scutwork, call, etc and then still do another 2-3 years of fellowship afterwards.

The greed here is shameful but I just can't believe that such intelligent people can't see it!
 
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Wow I didn't realize some general surgery residents take two years during their residency for research . . . when the heck did this happen?

I remember talking to a general surgery friend of mine 5-6 years ago who was in his research year and he was almost bragging about how much fun he was having working 30ish hours per week on his research project (which he didn't really care about) while "just taking call and filling in for vacations" and how the year was a joke. I couldn't help but think to myself "doesn't this dude realize that the joke is on him: a 35ish year old man with an MD and 3-4 years of residency under his belt working for barely $50,000/yr but more importantly losing out on a year of attending salary (while student loan interests are accruing)." I lost touch with him but would love to see how he feels about it now.

Two years of research is just unbelievable, especially if they still do any amount of scutwork, call, etc and then still do another 2-3 years of fellowship afterwards.

The greed here is shameful but I just can't believe that such intelligent people can't see it!

Medicine is a different type of intelligent and truthfully not one that the world really values highly anymore. Medicine is herd mentality to the nth power and unquestioning devotion. Do you think a person in business school or an entrepreneur would just take an extra year of loosely related work without any negotiation or questioning. How about an extra 2 years?! But the neurosurgeon or general surgeon is delighted to do this because they think their chairman and faculty is looking out for them. Rad onc used to be 4 years. "Of course our residency should be 1 year longer, there is so much more information to learn now!" Chairmen are among the most corrupt in the system, they only care about the bottom line of the department while they rake in private practice salaries by pushing over treatment of patients. 'Oh he's such a wonderful chairman...' Stop worshiping these people

The whole of the medical system all the way down to med school and before that is a corrupt scam. Hospitals put on these beautiful fronts, not because they give a f about medicine and upholding the hippocratic oath. But so they have happy patients who dont question the over treatment and over diagnostics they prescribe. And all that crap trickles down to resident education and med school education creating righteous idiot physicians who are simply influenced by terrible studies that tell them to treat treat treat. People that are part of that system, they arent intelligent people. They simply fall in line in the system and look pretty and act righteous.

In other words medicine is just like any other capitalistic industry and the argument can be made that you cant hate on that given how our system works. All you can do is understand where you stand and protect yourself
 
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Thanks for the Webinar, well constructed summary of the situation. I can't say I feel any better, but the theme seems to be weather the storm and hope the markets change.

One thing I don't understand is what circumstances led to the rapid decline in spots a decade and half ago? We talk a lot about antitrust laws now, but what happened back then that caused such a substantial decline? This may have been covered but I think it warrants a comparison to today's climate.
 

DebtRising

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As a first year student, this is valuable to hear. What other fields in medicine would current residents suggest going into that are similar to rad onc?

I was originally drawn to rad onc because there is a nice mix of technology, patient contact, and science/research with respect to oncology.
The webinar basically said, to me at least, "we have a big problem and no one at the moment is fixing it. Maybe it will get better". Don't get me wrong - I applaud this message for its honesty and had no illusion ground shifting would come from a webinar. The purpose was information, and it was delivered, maybe a bit rosier then I read the situation. But THANK YOU for at least bringing it up and again thank you for the article in the ReDJournal.

So, banana, the short answer is this; no, there is nothing in medicine similiar to the work flow of radiation. It is unique. At the same time, there are very few stand alone fields that are as small. Disruptions in the labor market by training more trainees are going to be felt much more acutely when the pool is small to begin with AND when employment is directly tied to large capital investments (vault, machine, support staff, software).

So what you have to ask yourself is simple; is the uniqueness of radiation oncology worth it for you to go through 5 years of residency after medical school and not have a job? Because that is what is happening - you can't ignore surveys on employment then hold up patient QoL data as the holy grail. And similarly you have to account for the more subtle, potentially worse case - you will be "underemployed" for the first decade of your career. What do I mean by this: you will have a job, at a satellite or a non-partnership private practice, where you will not be able to build your own practice or patient list, or potentially even use the skills that are relevant, because you will be so low down the totem pole that your job is to baby sit remote linac X at site Z until someone above you shifts. Medicine has always worked on seniority, but now you may be so far down the list (because there are so many other grads) that it will take you 5, maybe 10 years to get what a current graduate gets in 1-2. And if during that time, you don't get to do things like SRS, brachytherapy, or certain disease sites, your skills will be so narrowed you will not be able to find a real job.

I strongly urge you to consider the data and balance that 'love' against the realities that you need gainful employment for 9+ years of school / training post college to be meaningful. For me, I have begun to email the articles on employment to all the medical students who rotate through the department. People have a right to know, and my posts may be dramatized but the articles available (employment survey 2014, new employment model, and the recent editorial) paint a very specific picture. I encourage anyone who cares to do the same - the people who are really thinking about going into this field should do so eyes wide open. You have a chance of not having a job due to structural issues in the labor market. If SCAROP or anyone else wants to prove me wrong - redo an employment survey and show me the 2014 one was an anomaly, or disprove the other articles I mention. There is just no logical counter argument to make in the face of 7% 'unemployment' in 2014 with continued rabid expansion of slots coupled with decreased utilization of services, and everyone program that can offering non-accredited fellowships which teach absolutely nothing that shouldn't be a standard component of an ACGME accredited program.
 
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Hope everyone who attended enjoyed the webinar. Please fill out the post-webinar survey. We will post the webinar on Youtube either Friday or Monday for those who missed it.

If you would like other specific webinars, please let us know.
 

thecarbonionangle

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A lot of good points being raised. The sad reality is that rad onc is heading in the wrong direction. Once you have that epiphany of how rotten academic institutions are, you never really go into work or look at your attendings the same. The only thing to look forward to are the patients.

As others have pointed out, unfortunately, it is impossible to escape the same driving forces which are leading us straight into doom by joining another specialty. I'll give you the example of specialties like GI and Cardiology. Talk to any current fellow and they will tell you the job market is getting very very tight and it is becoming much harder to find a job in a decent area. I heard a GI fellow openly discourage a resident about joining the field due to the quiet rising concern for jobs. Same driving forces at work here, greed, work your butt off putting off many years of lost income slaving away for academics who do not have your best interest in mind. Browse the dermatology forums and you will find similar themes expressed regarding declining satisfaction with the way you have to practice. The fact about medicine is that it has always been a ponzi scheme. You are overworked and taken advantage of in slave wages with the promise of later benefiting from the system, then you turn around and you do the exact same thing to the posterity and get your cut of the cheese. Other specialties have similar crazy things. Want to do pediatric surgery? prepare to do potentially 3 years of "research" on top of a miserable general surgery residency while literally begging some chairman to let you be their slave for another 2-3 years. Same for plastics after general surgery as well. There is a growing trend to add an extra year in some academic programs for research in speciaties like general surgery, neurosurgery, GI, cardiology, thoracic surgery, etc.

This is another discussion altogether-----this may be one of the worst times to be a physician. Declining respect for the specialty, increasing government regulation and loss of autonomy to "business minds" (ironically the bright minds who rant about "guvment" regulation) who are taking over our specialty who do not care about patient care but only the bottom line and are not physicians, the greed of accrediting bodies which administer boards and tests (the stupid step 2 CS, step 3, see the recent scandal in internal medicine boards, the rising ABR fees, ), the greed of baby boomers who have zero concern for resident wellbeing. One of the saddest things for me as a resident is the realization of how little we matter in this current system. The fact is, nobody cares about us in this system. The public thinks we are overpaid. Hospitals treat us as the lowest common denominators paying us less than nurses and even bean counter secretaries. Having some ignorant bean counter administrator dictate how you take care of your patients is one of the worst things ever. It crushes your soul and makes you super jaded; prepare for it to happen many times and for these things to get worst. More and more non-educational work is being dumped on us while the level of knowledge required to complete a specialty is increasing. Residencies are there to provide cheap labor and decrease healthcare costs by underpaying us while fattening the pockets of those in charge. All of this under the guise of "education".
 
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medgator

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. You have a chance of not having a job due to structural issues in the labor market. If SCAROP or anyone else wants to prove me wrong - redo an employment survey and show me the 2014 one was an anomaly, .
Jobs are there, it's just a question of how remote and rural you want to go.
 

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Pretty good talk overall, thanks for posting it. Dr. Stevens seems like a really nice and caring guy- good for his residents.

I do feel as if the "community generalist" failed those of us who do not believe (at all) that specialization is necessary for radiation oncology. He has to look something up whenever he sees a lung cancer patient? Really? If so that's much more a commentary on his (lack of) skills and ability as a radiation oncologist rather than a statement about radonc generalists overall.
 
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medgator

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Man, as an MS4 applying to the field next month, maybe I should jump ship.
Honestly, it's a question of your love of rad onc vs your love of being in a certain geographic locale. If you absolutely to have to be in a certain city, IM, FP, ER, etc are going to be easier paths in that regard. Other specialties probably struggle with this too (esp saturated ones like path, rads etc.).

You may get that job in SoCal or Boston, but it may not be ideal in terms of quality/hours/salary etc. Or maybe not. Like I said, rural locations seem to be more in demand for rad onc services, better salaries/perks etc.
 

medgator

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I do feel as if the "community generalist" failed those of us who do not believe (at all) that specialization is necessary for radiation oncology. He has to look something up whenever he sees a lung cancer patient? Really? If so that's much more a commentary on his (lack of) skills and ability as a radiation oncologist rather than a statement about radonc generalists overall.
Yeah, not a whole lot has changed in lung in the last few years outside of SBRT in early-stage and the issue of dose-escalation in Stage III NSCLC. I have to look up stuff, but it isn't lung cancer LOL.

As for Dr. Stevens' follow-up comments, generalists serve an important role in the community when the nearest academic center is 1+ hour away for "specialists", I guess "lower quality diluted" general care is better than no care :rolleyes:
 

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I’m glad that the webinar was helpful for folks. The organizers shared this SDN thread before the webinar and I’ve been following it since.

In regard to OTN’s comment, my point was not that I (or any generalist) look things up for every patient. I revisit the literature in the minority of cases, but I am sure I do it more than disease-site experts. Lung cancer may not be the best example because we see so much of it as generalists, but even there I pull data so that I can better counsel patients and offer better advice at tumor boards. A generalist might have to look up the data on tolerability of cis/etop in the elderly; risk associated with palliative chest RT while on nivolumab; quantification of risks when planning metrics can’t be met; pCR rate for superior sulcus tumor; elective nodal volumes on Lung ART trial; risks and planning metrics for re-treatment to the thorax; etc.

In my opinion, it’s virtually impossible for general radiation oncologists to have as comprehensive a grasp of the literature as disease-site experts. However, this does NOT mean that generalists provide inferior care to those who focus on one site. Quite to the contrary, I’m confident that I, and most of the generalists that I’ve known or worked with, provide exceptional care across the spectrum of disease sites. However, we have to work harder than the disease-site experts to stay up to date, and it inevitably requires more time revisiting the literature.

The main point for purposes of the webinar was that being a disease-site expert is more efficient than being a generalist (controlling for all other factors) and that progression toward diseases-site-specific practice models, which may happen with hospital consolidation, could exacerbate an oversupply of radiation oncologists.
 

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I’m glad that the webinar was helpful for folks. The organizers shared this SDN thread before the webinar and I’ve been following it since.

In regard to OTN’s comment, my point was not that I (or any generalist) look things up for every patient. I revisit the literature in the minority of cases, but I am sure I do it more than disease-site experts. Lung cancer may not be the best example because we see so much of it as generalists, but even there I pull data so that I can better counsel patients and offer better advice at tumor boards. A generalist might have to look up the data on tolerability of cis/etop in the elderly; risk associated with palliative chest RT while on nivolumab; quantification of risks when planning metrics can’t be met; pCR rate for superior sulcus tumor; elective nodal volumes on Lung ART trial; risks and planning metrics for re-treatment to the thorax; etc.

In my opinion, it’s virtually impossible for general radiation oncologists to have as comprehensive a grasp of the literature as disease-site experts. However, this does NOT mean that generalists provide inferior care to those who focus on one site. Quite to the contrary, I’m confident that I, and most of the generalists that I’ve known or worked with, provide exceptional care across the spectrum of disease sites. However, we have to work harder than the disease-site experts to stay up to date, and it inevitably requires more time revisiting the literature.

The main point for purposes of the webinar was that being a disease-site expert is more efficient than being a generalist (controlling for all other factors) and that progression toward diseases-site-specific practice models, which may happen with hospital consolidation, could exacerbate an oversupply of radiation oncologists.
Thanks for responding- I didn't mean to take any personal digs, as from your talk it was very clear that you're a good radiation oncologist whom I'm sure takes great care of his patients. Thanks again for participating in the event, as it's very important to the future of our specialty.

I do, however, feel pretty strongly that disease-site specificity is not necessary in order for a radiation oncologist to provide world-class standard-of-care treatment, given the right equipment. Sure, it takes more energy and effort to stay on top of the literature for all disease sites, and from time to time referral to or consultation with the experts makes sense, but that's part of being a community radiation oncologist as you know. For some of us, myself included, the ability to treat multiple different organ systems and interact with such a wide variety of specialists was one of the attractions to the specialty, and I think it would be a great loss if we moved away from that paradigm.

Part of it for me- and why I was so (overly, honestly) sensitive to this issue- is the constant denigration we "generalists" get from the large academic programs. I've had patients who were told there was no I way I was going to be able to do breath-hold treatment for L-sided breast cancer (I was), my treatment for a patient's chest wall sarcoma would be inferior because I'm not a "sarcoma radiation oncologist" (it wasn't), and we have inferior, outdated equipment (we don't). Having a "community" (how do I hate that term) radonc say on a national forum that we have to look up something every time we see a lung cancer patient was, therefore, somewhat disheartening and could help to reinforce the erroneous view that we can't provide the same level of care which is delivered from disease-site-specific radoncs.
 
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DebtRising

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Listened to this a few more times. During the podcast I was still at work and not able to fully listen, or would have asked.

1. The attitude of the field / medical training in general;
I don't think senior physicians appreciate this. One point during the lecture was that jobs dried up in the mid-90s because practicing physicians were uncertain about "Hillary care". I wasn't around then, but stories from the people who were do not suggest that was the only factor (ie talking to people who went through multiple exploitative positions... I have no other way to get better objective data). Regardless, it proves a fundamental point - that external forces can dictate medicine and cause a great deal of anxiety among practitioners. So take that microcosm and fast forward to today- a period in which senior physicians gripe openly and honestly about how medicine has changed (has been at every program, every department I have been to). Further, take a person and make them spend an exorbitant amount of money to get an MD, place them in a situation (in general) where administrative tasks have risen dramatically, where all the uncertainty of payment reform still exists, and in a place where physicians are held in less regard than they were 20 years ago. I agree that some people look at things and see "10% empty vs 90% full".... I also think some people are too insulated and came from a different time where they have no idea how full the cup actually is and will not have to feel the repercussions of it because they had decades+ of previous experience.

2. Hillary care did not get implemented - but if the premise was that its failure opened the job market, then you have to also accept the premise that new passage could cause so much financial stress that physicians in practice do ride it out as long as they can. No, I don't have a crystal ball and you can't plan soley on contingencies - but neither can you plan based on the fact that things will never change. We could easily have 5-6 years of very, very lean hiring if a contemporary 'Hillary care' was enacted. Pair that with record class sizes and even less money for capital investment! That's not a good employment projection. WE already have data now that it is difficult to find a job.

3. The utility / cost savings of a resident. Dr. Stephens you may have an ultra specialized clinic where your NP is fine tuned and you know lung like the back of your hand. But you are at the pinnacle. Maybe a resident really does slow you down in work flow. But I posit that is not true for most and that residents are being used to make up for revenue short falls via increased productivity. My documentation is often used because it is good. As I become senior, my volumes are often used because they are good. It is expected that this is the evolution of a trainee, and that is a good thing all around. But I save my attendings hours upon hours of time per week, easily, and I cost much less than an NP. IF you want to do a residency wide study of the percentage of resident notes and volumes that are used (maybe be tricky to define ~ maybe hours spent by attending normalized by case load and stage?), by site and by level, that would be a great investigation. Because it would prove the level of useful work we do, some of which no mid-level can perform, and then gets to the point that if programs are self funding some of these spots, is this desire to expand coming from a productivity perspective or a love of learning perspective? This is different from other fields - senior surgeons approach autonomy, but they can't perform the whole operation alone then have someone come in to fine tune it in the end. At least I hope not. Also would be interested in seeing the hours spent on academic interning per attending per rotation.

4. Agree to disagree on fellowships. True pediatrics is exception, as is a classic proton fellowship. But even accepting this - how many pediatric and proton trained radiation oncologists do we need? IS the explosion in fellowships driven by a pending explosion in high level evidence and investment in protons? Did you see the Lymphoma fellowship I referenced? I find it hard to characterize that as anything other than exploitative. And you cannot simply write off the expansion that easily either - all these programs didn't suddenly develop this altruistic love of education in the last ~5 years. That is a hard, objective data point that the labor market is in trouble. Ignoring that, to me, was the biggest error in judgement in the discussion. So is writing off the 2014 survey as people being too picky about geography - psuedo analysis which can just as easily be refuted by pointing out that a full 1/3 of that class couldn't find anything in the area they wanted. That's not insignificant - and I doubt 1/3 of the class all wanted to be Manhattan or SF. Honest education from SCAROP and ASTRO about job availability in cities, which seems to be a given on this board, would also go a long way in helping future students decide.

5. But, there won't be any centrally disseminated info about jobs in cities - because there is no one watching this. No the 2014 survey isn't perfect - but it had to be done by residents to get out there. There is no central body (SCAROP, ASTRO) who feels it is in their scope of duties, or cares enough about future trainees quite frankly, to monitor the labor market. In my previous post I mentioned how in radiology I heard a lot of anecdotes of compartmentalization - ie my residents are doing fine so I don't know why yours can't get a job. There are data points on this only a central body could extract - # of trainee applicants / position by geography and type, # of true new faculty positions offered per / year, # of new satellite positions offered / year, change in reimbursement by site and technique. You are correct that there are flaws with using survey data - but we don't have the influence or ability to get better data (we as residents or outside the 'powers that be'). The webinar was great, but the fact that only a few people in position of influence even seem to have this on their radar is not a positive indicator.
 

thecarbonionangle

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What a joke to think that resident's "slow down" attendings. Attendings peak into consults after I have already asked all the questions and jump right to business allowing them to avoid dealing with the non-sense; they sit in their offices approving films while I answer questions and do consents . They look at my contours and take bites here and there, mostly clinically irrelevant changes that make no difference after the expansion. You guys think I sit around waiting for these passionate well meaning attendings to throw me a bone and teach me something? I count the hours to finish the non-educational work and scut so I can actually go read/rot in a corner and hear my biological clock ticking. Let that sink in.
 

Old rad onc

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Honestly, it's a question of your love of rad onc vs your love of being in a certain geographic locale. If you absolutely to have to be in a certain city, IM, FP, ER, etc are going to be easier paths in that regard. Other specialties probably struggle with this too (esp saturated ones like path, rads etc.).

You may get that job in SoCal or Boston, but it may not be ideal in terms of quality/hours/salary etc. Or maybe not. Like I said, rural locations seem to be more in demand for rad onc services, better salaries/perks etc.

I have been following Sdn rad Onc for many years and it's refreshing and entertaining to see great minds at work and play. I finished in 1995 and work in SoCal as a solo rad Onc. I worked for a guy who promised me partnership after 3 years and took less money for the chance to be near the beach. Worked for him for 6 years and realized I would never be a partner.

I looked for jobs in 2001 but all the jobs in LA wanted me to work for 5 years for a chance at partnership. Only other jobs I found were in Reno or rural Arkansas. So I did what any other pissed off fool would do and was lucky enough to find an empty vault with an old machine and started my own practice. Because of IMRT was able to double down and build a new center a few years later. I was lucky and if I had been smart enough to know the risks, I would have never done it.

But 15 years later still here and the best revenge was not only surviving but thriving. No year has ever been comfortable as competition and bad mouthing are always around. The restrictive covenant will not stand in California unless you were paid to sign it or are a partner. I'm close to retirement but still love my staff, referring docs and most of all the patients. Some of my friends say they will leave in 2019 but I will hold on for a bit longer.

This new era of bundled payments and quality measures bs sure takes the fun out of the next few years but I'm an optimist. Part of the reason I became a rad Onc. The good old days may be over for good financially but I believe if you hang in better days are ahead. I risked my house and everything I owned at 40, but it was better than partnering with a liar and a cheat.

So cheer up young and middle aged rad oncs. I know all of you younglings were the best and the brightest of your class. Rely on your brains and find new avenues without resorting to unneeded IMRT or other gimmicks that some do. When I went into rad Onc I had no idea what my income would be and the residency and fellowship was the same then as it is today. Attendings were the same as today. Of course, easy for me to say but I have been hearing of the demise of medicine since 1984. Stand tall and don't be afraid to take a risk. But just be smart about it.
 
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That residents slow down attendings is one of the great myths also perpetuated to make residents feel inferior. It's a load of crap and they know it. The gall to even say that demonstrates how low and condescending this brand of academicians have become.

Also bs is the data about how many publications it takes to get into the field. It's a source of pride for rad onc to see 14-15 pubs per applicant. You have PDs going around telling med students that's what it takes. Think about that for a second.

I'm also beggining to wonder if that IJROBP piece that showed rad onc cases/need would double by 2020 wasn't also a hit piece designed to placate people and continue to drive people into the field. I often thought 'hey it's going to be alright, demand for my skills will double soon!' It went up so much you're lucky to have a bunch of exploitative crap job offers, congrats

What it comes down to is rad oncs are sharks and have infested our field. If you felt a lot of disconnects going through this system this is why. When you're at astro look around, it's an aquarium of sharks. For med students reading, stay out of shark infested waters. On balance people in other fields (not surgery) have bigger hearts and their leaders are not motivated by greed, you want them on your side.
 
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What a joke to think that resident's "slow down" attendings. Attendings peak into consults after I have already asked all the questions and jump right to business allowing them to avoid dealing with the non-sense; they sit in their offices approving films while I answer questions and do consents . They look at my contours and take bites here and there, mostly clinically irrelevant changes that make no difference after the expansion. You guys think I sit around waiting for these passionate well meaning attendings to throw me a bone and teach me something? I count the hours to finish the non-educational work and scut so I can actually go read/rot in a corner and hear my biological clock ticking. Let that sink in.
I honestly think that these attendings think that residents slow them down. It's a reflection of their arrogance and cluelessness. I'm sure there are attendings who haven't taken a patient from beginning to end in a decade (I don't just mean the consult note and volumes/plan review but all the little, often zero to minimally educational but incredibly time consuming and sometimes soul sucking, things that goes into patient care) but go around complaining how the resident is taking too long in a room or on the phone when in fact they are cobtouring a brachial plexus or LAD that the attending wouldn't bother or arguing with insurance companies while the attending is watching the olympics in his office.

Anyway, I know a lot of you don't want to hear it but at least for now there are good jobs, great staff, and wonderful patients in "undesirable" locations. It's not for everybody but there are many small towns and cities within a 2-3 hour drive of the biggest cities in the US (not necessarily rural Arkansas) that are nice places to live and raise a family. Please consider or at least don't automatically discount them. I would love to live in a larger city especially as my children get older but I will happily stay among my current community then work/live with these arrogant, manipulate, "sharks."
 
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