Any chances for rad onc to merge with radiology in the future?

[redalert]

Current radiology resident who was initially interested in rad onc in med school but chose rads due to job concerns. However, I still feel that outside of the jobs thing, rad onc is still the best specialty in medicine. If, a big if, rad onc becomes a subspecialty under rads I'd happily do a rad onc fellowship. Is there a remote possibility that this could happen?

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[jondunn]

Current radiology resident who was initially interested in rad onc in med school but chose rads due to job concerns. However, I still feel that outside of the jobs thing, rad onc is still the best specialty in medicine. If, a big if, rad onc becomes a subspecialty under rads I'd happily do a rad onc fellowship. Is there a remote possibility that this could happen?

Not on the docket for the foreseeable future.

 

[RickyScott]

Radonc will have to change/merge to be viable and avoid large scale underemployment (excessive fellowships). Makes most sense to be involved with systemic therapy, but logistically may be easier with rads given same board.

 

[elementaryschooleconomics]

It would require a complete restructuring of the current system, and it's not easy to turn the Titanic. In the absence of an urgent catalyst, if the appropriate people at the relevant organizations started considering this like, tomorrow, I imagine we're still 10 years out from seeing it happen.

Since, as far as I know, the appropriate people at the relevant organizations aren't even considering it...I would guess longer, or never.

 

[RaptorA]

Radiation oncologists are much more oncologists, than they are radiologists. Just by doing a 1-year fellowship following completion of radiology residency, you would only be able to scratch the surface, with very limited knowledge of oncology in general. In short, you would be investing more time for less productivity. Many decades ago, when radiation oncology was starting to take off and was too primitive as a standalone discipline, it made sense to integrate it with radiology, but both radiology and rad.oncology have advanced so much since that they are now completely different fields.

The only way forward, IMO, is to become more integrated into medical oncology like it is the case in Europe. That is a proven method that works well.

 

[TheWallnerus]

Wallner, Hahn, and Zietman saying that rad onc and radiology should merge went over, evidently, like a lead balloon 3 years ago. At least these three prominent leaders had the intellectual honesty to point out that the ABR gives 100% legitimacy (by virtue of its board certification training requirements) to the fact that one can become a fully clinically trained radiation oncologist in 2.25 years.

True hybrid programs blending DR and RO training from the outset have also been proposed. RO clinical training can now be completed in 27 months, as on the Holman Research Pathway. It may thus be possible to couple this abbreviated training with perhaps 16 months of nuclear medicine, or the 3-year DR core training, the latter being “thinned out” to reduce nononcologic work. It will be for individual institutions to define the program details and make proposals, but careful coordination with the ACGME and ABR will be essential to ensure that all requirements for program accreditation by the ACGME are met and that all requirements for initial certification eligibility by the ABR are fulfilled. Overall training would, of necessity, be longer than that for nonhybrid specialists, and it is likely that initially this will be a path chosen by few but with the potential for future growth.

Many RO programs have 6 or fewer residents, and we recognize that these suggestions may represent a challenge to many departments; some might even see them as an existential threat. Additional time devoted to image-based training may, realistically, require a reduction in time commitments to other elements of the program, entail time away from RO clinical responsibilities, likely produce a need for some time away from host programs, necessitate dialogue and rapprochement with our DR colleagues, and, potentially, add some cost to host departments. In an era of reliance on image guidance for RO, how can we not accept these modest burdens? A question beyond the scope of this editorial, but of intense current discussion and consideration, is how advances in artificial intelligence might affect any of these issues, and indeed, the clinical practices of RO and DR. A recent conference sponsored by the National Academies of Sciences, Engineering, and Medicine suggested that greater collaboration would also benefit DR trainees and providers. As did Ruth and Naomi, we must once again walk together.

 

[maxxor]

Wallner, Hahn, and Zietman saying that rad onc and radiology should merge went over, evidently, like a lead balloon 3 years ago. At least theses three prominent leaders had the intellectual honesty to point out that the ABR gives 100% legitimacy (by virtue of its board certification training requirements) to the fact that one can become a fully clinically trained radiation oncologist in 2.25 years.

True hybrid programs blending DR and RO training from the outset have also been proposed. RO clinical training can now be completed in 27 months, as on the Holman Research Pathway. It may thus be possible to couple this abbreviated training with perhaps 16 months of nuclear medicine, or the 3-year DR core training, the latter being “thinned out” to reduce nononcologic work. It will be for individual institutions to define the program details and make proposals, but careful coordination with the ACGME and ABR will be essential to ensure that all requirements for program accreditation by the ACGME are met and that all requirements for initial certification eligibility by the ABR are fulfilled. Overall training would, of necessity, be longer than that for nonhybrid specialists, and it is likely that initially this will be a path chosen by few but with the potential for future growth.

Many RO programs have 6 or fewer residents, and we recognize that these suggestions may represent a challenge to many departments; some might even see them as an existential threat. Additional time devoted to image-based training may, realistically, require a reduction in time commitments to other elements of the program, entail time away from RO clinical responsibilities, likely produce a need for some time away from host programs, necessitate dialogue and rapprochement with our DR colleagues, and, potentially, add some cost to host departments. In an era of reliance on image guidance for RO, how can we not accept these modest burdens? A question beyond the scope of this editorial, but of intense current discussion and consideration, is how advances in artificial intelligence might affect any of these issues, and indeed, the clinical practices of RO and DR. A recent conference sponsored by the National Academies of Sciences, Engineering, and Medicine suggested that greater collaboration would also benefit DR trainees and providers. As did Ruth and Naomi, we must once again walk together.

Zietman should have approached MGH rads about this if he was serious about it. MGH radiology is already effectively a 3 year program with the 4th year treated as an enfolded fellowship. For years people have done DR+2 year fellowship in 5 years (IR and Neuroradiology). Scrape out the 3 IR months and give them to Radonc and you’ve got your Holman length RO program combined with DR in 6 years including internship. If you really want academic legitimacy, have them do MGH Med prelim and then squeeze 2 months from there for Rad or Radonc rotations. The dedicated IR residents have to do MGH surgery already.

 

[jondunn]

what you are proposing in turning a 5 year residency into a 7 year one (intern plus 6 years of DR/RO) would be similar to what they did in the 90s in turning the 4 year residency into a 5 in order to fix oversupply


I don't favor the method at all, but would have an effect!

 

[medgator]

what you are proposing in turning a 5 year residency into a 7 year one (intern plus 6 years of DR/RO) would be similar to what they did in the 90s in turning the 4 year residency into a 5 in order to fix oversupply


I don't favor the method at all, but would have an effect!

It was turning a 3 year into a 4 year residency. Internship year didn't change. This was accompanied by a number of program closures and spot reductions

 

[maxxor]

what you are proposing in turning a 5 year residency into a 7 year one (intern plus 6 years of DR/RO) would be similar to what they did in the 90s in turning the 4 year residency into a 5 in order to fix oversupply


I don't favor the method at all, but would have an effect!

Doesn’t need to be 7, especially since Radonc has a dedicated research year and the Holman allows for 27 months.

Workin with a program who doesn’t use residents as call slave labor and is actually focused on education, you can create a combined program.

I think the Radonc Talmudic study of statistics can be replaced with combined imaging and therapeutic clinicians who can both interpret and treat. It’s a lot like the IR model.

 

[medgator]

Doesn’t need to be 7, especially since Radonc has a dedicated research year and the Holman allows for 27 months.

Workin with a program who doesn’t use residents as call slave labor and is actually focused on education, you can create a combined program.

I think the Radonc Talmudic study of statistics can be replaced with combined imaging and therapeutic clinicians who can both interpret and treat. It’s a lot like the IR model.

IR is too technician focused and lack oncology training... Like a general surgeon who uses imaging to do their work without considering whether it is clinically appropriate. IRs locally ablate/tace a lot of stuff in lung and liver inappropriately without talking to referring med oncs, pulm etc. Lung bx referrals getting offered rfa without referring back to pulm, liver bx referrals getting inappropriate sirs spheres/tace etc

 

[maxxor]

IR is too technician focused... Like a general surgeon who uses imaging to do their work. IRs locally ablate a lot of stuff in lung and liver inappropriately without talking to referring med oncs, pulm etc

Their practice style notwithstanding, that doesn’t mean Radonc style practice can’t happen. My point is that the time required and role is similar.

IRs tend to that practice style because that’s what pays the bills. It’s harder for IR/DR to bill EM codes for “reasons”. We also don’t get crazy payments per fraction which allow relatively luxurious clinic schedules.

 

[medgator]

Their practice style notwithstanding, that doesn’t mean Radonc style practice can’t happen. My point is that the time required and role is similar.

IRs tend to that practice style because that’s what pays the bills. It’s harder for IR/DR to bill EM codes for “reasons”. We also don’t get crazy payments per fraction which allow relatively luxurious clinic schedules.

All the more reason to keep a foot doing DR work to pay the bills, not inappropriate tace/rfa

 

[RadOncDoc21]

There is a lot more being a rad onc then fractions… think oncologist… 4 yrs of training (more then any other field).

 

[maxxor]

There is a lot more being a rad onc then fractions… think oncologist… 4 yrs of training (more then any other field).

1 is research. Don’t count that.

 

[jondunn]

It was turning a 3 year into a 4 year residency. Internship year didn't change. This was accompanied by a number of program closures and spot reductions

right i was going by total years. 4 to 5. but 3 to 4 for RO, yes.

 

[DebtRising]

Current radiology resident who was initially interested in rad onc in med school but chose rads due to job concerns. However, I still feel that outside of the jobs thing, rad onc is still the best specialty in medicine. If, a big if, rad onc becomes a subspecialty under rads I'd happily do a rad onc fellowship. Is there a remote possibility that this could happen?

Unless you are independently wealthy, all that medicine is - is a job. You pay 100-500k to get into the “club” and pay another indirect 200-500k lost income / investment opportunities during the time your equally driven colleagues outside medicine are earning income and retirement. Oh yea and the time.

So unless you are independently wealthy, there is no radiation oncology speciality without the jobs thing. And all we are becoming are human capital that can be increasingly be ground up due to supply and demand. So even if it could be a fellowship, what are you going to do? Honest question.

There is a huge cognitive disconnect between “ rad onc is so cool” and “it’s a job with no future and employers / academics intentionally grinding down the workforce so they can brag to admin that labor costs are cheaper”

 

[jondunn]

There is a lot more being a rad onc then fractions… think oncologist… 4 yrs of training (more then any other field).

thank you. i am proud of our general solid tumor oncology flexibility and knowledge

how many of us have med onc colleagues that call us, knowing that we know, when they have imaging questions, anatomy questions, questions about another disease site that they may not see as much?

 

[maxxor]

thank you. i am proud of our general solid tumor oncology flexibility and knowledge

how many of us have med onc colleagues that call us, knowing that we know, when they have imaging questions, anatomy questions, questions about another disease site that they may not see as much?

While this may give you a professional and personal fulfillment, it does not help the field. It doesn’t pay the bills nor does it increase indications for radiation.

 

[medgator]

1 is research. Don’t count that.

Not at my program! Pretty much no One gets/got that much unless you are at a research heavy top tier place

 

[RadOncDoc21]

Not at my program! Pretty much no One gets/got that much unless you are at a research heavy top tier place

It sounds like he/she doesn’t know much about the field and has a negative opinion about it so I doubt there is an indication to continue this argument.

 

[CurbYourExpectations]

Solid Oncologists: Focus on one area by the end of training. 2 years of a combination of medical wards and heme/onc, 1 year radonc cycling through different sites and then deciding on a site and doing 3 years focused with 1-1.5 years dedicated to radiology reading in that area and contouring, and the rest radiation and systemic medication based training to consolidate it all. About 6 years of training and you can treat any brain cancers and know enough about radiology to be able to spot specific other types of pathologies in that site and set the patient en route to receiving the proper treatment.

Pretty much 3 years broad training and learning and then deciding what you're most interested in and then 3 years of focus in radiology, medonc and radiation to that one specific site.

Or...just fix the supply to meet the demand, which appears to be around 130 serious applicants right now

PS: Solid Oncologists might be the coolest specialty name as well

 

[RickyScott]

IR is too technician focused and lack oncology training... Like a general surgeon who uses imaging to do their work without considering whether it is clinically appropriate. IRs locally ablate/tace a lot of stuff in lung and liver inappropriately without talking to referring med oncs, pulm etc. Lung bx referrals getting offered rfa without referring back to pulm, liver bx referrals getting inappropriate sirs spheres/tace etc

I think with the status quo and radonc moving towards 1-5 fractions, we also will become technicians. Slam, bam, see me
again if you get another met or problem..

 

[RickyScott]

thank you. i am proud of our general solid tumor oncology flexibility and knowledge

how many of us have med onc colleagues that call us, knowing that we know, when they have imaging questions, anatomy questions, questions about another disease site that they may not see as much?

I have a similar sentiment, but work with some smart AF medoncs. I usually call them. Over the years, I have been surprised how many times I have disagreed with them on management, and in the end I was wrong.

 

[maxxor]

It sounds like he/she doesn’t know much about the field and has a negative opinion about it so I doubt there is an indication to continue this argument.

i don’t have a negative opinion of your field.

But I do think the only chance you have of saving it is merging with someone or learning a new skillset. The incentives are such that no programs will close because they will keep filling.

 

[medgator]

I think with the status quo and radonc moving towards 1-5 fractions, we also will become technicians. Slam, bam, see me
again if you get another met or problem..

We don't have to be that way even if our treatments become shorter. We have the training to be more than just technicians

 

[RadOncDoc21]

i don’t have a negative opinion of your field.

But I do think the only chance you have of saving it is merging with someone or learning a new skillset. The incentives are such that no programs will close because they will keep filling.

Oncology is the “skill set,” we just need to be more vocal on being involved earlier in the patients care vs allowing surgeons, med oncs, IR to do their thing in a narrow window.

 

[maxxor]

I am skeptical

Oncology is the “skill set,” we just need to be more vocal on being involved earlier in the patients care vs allowing surgeons, med oncs, IR to do their thing in a narrow window.

This only is a reality if you merge with Med onc and give chemo and manage an inpatient service. If you don’t go all the way on this, you can’t expect to get all primary cancer referrals.

Given that merging with MedOnc will take strategic moves far in excess of anything ever before done by the field, I think you might as well move to Europe if that’s how you want to practice.

Merging with another field that shares the same specialty board is actually within the realm of possibility.

 

[jondunn]

it's not like merging with radiology is much of a possiblity or of interest to the vast majority of rad oncs either, so dont get it twisted. we are talking about sub-5 percent interest level.

 

[RickyScott]

it's not like merging with radiology is much of a possiblity or of interest to the vast majority of rad oncs either, so dont get it twisted. we are talking about sub-5 percent interest level.

True. I hate rads and would totally suck at both ir and dr, but when jobs vanish, many will be desperate.

 

[medgator]

This only is a reality if you merge with Med onc and give chemo and manage an inpatient service. If you don’t go all the way on this, you can’t expect to get all primary cancer referrals.

Wrong.... No reason for derm, ent, uro etc to send primary RT cases to a med onc. None. A clinical oncology pathway similar to what happens in the UK makes a lot more sense than trying to merge back with DR/IR

Many of us get primary cancer referrals IRL.

 

[RickyScott]

We don't have to be that way even if our treatments become shorter. We have the training to be more than just technicians

We absolutely do, but that is the price we will pay for divorcing ourselves from the pt relationship. Psychologically, I just see Pts not following up and feeling little connection to the radonc department after seeing us once in consult and for a single 2 minute otv.

Say there was a very narrow specialty trained just to put chemo ports into patients, but the docs knew everything about the drugs and indications, but didn’t prescribe the chemo- that is how I see radonc evolving as systemic therapy explodes.

 

[medgator]

We absolutely do, but that is the price we will pay for divorcing ourselves from the pt relationship. Psychologically, I see Pts just not wanting to follow up with us and feel little connection to the radonc department after seeing us once in consult and for a single 2 minute otv.

Say there was a very narrow specialty trained just to put chemo ports into patients, but the docs knew everything about the drugs and indications, but didn’t prescribe the chemo- that is how I see radonc evolving as systemic therapy explodes.

H&n, early lung, anal pts end up following up with me more, med onc just isn't playing as big of a role in primary management. They don't even do a dre on initial eval of an anorectal pt

 

[RickyScott]

H&n, early lung, anal pts end up following up with me more, med onc just isn't playing as big of a role in primary management. They don't even do a dre on initial eval of an anorectal pt

That’s true- was thinking more along the lines of breast and prostate. I hope/probably will never end up reading films or prescribing chemo. I just don’t see any other viable options for incoming workforce. Systemic therapy is overall experiencing a renaissance and the trend is not our friend. When I was in medical school, chemo was toxic, inneffective and rarely given to anyone over 65. In that world, radonc played a much more equitable role to med and surg onc.

 

[maxxor]

That’s true- was thinking more along the lines of breast and prostate.

but which one is the vast majority of your business?

Sure you have meaningful relationships and central role in those cases, but they only represent 20%? 50%?

Breast
Prostate

That’s your money maker. If you confine yourself to these small areas, you need an even bigger contraction that what you guys are calling for. They should shut down all residencies for a decade.

 

[medgator]

but which one is the vast majority of your business?

Sure you have meaningful relationships and central role in those cases, but they only represent 20%? 50%?

Breast
Prostate

That’s your money maker. If you confine yourself to these small areas, you need an even bigger contraction that what you guys are calling for. They should shut down all residencies for a decade.

I get most of my breasts referrals from a surgeon and most of my prostate from urology

 

[jondunn]

That’s true- was thinking more along the lines of breast and prostate. I hope/probably will never end up reading films or prescribing chemo. I just don’t see any other viable options for incoming workforce. Systemic therapy is overall experiencing a renaissance and the trend is not our friend. When I was in medical school, chemo was toxic, inneffective and rarely given to anyone over 65. In that world, radonc played a much more equitable role to med and surg onc.

Prostate? That’s often rad onc driven in terms of followup

 

[TheWallnerus]

We don't have to be that way even if our treatments become shorter. We have the training to be more than just technicians

I don’t know. One of our main members here said they graduated residency not knowing how to treat breast, the #1 indication for RT in America.

 

[dieABRdie]

I've stayed out of this because I know its not real popular, but I want a radiologist with a 1-2 year radiation oncology fellowship treating my family members as much as I want a radiation oncologist with a radiology fellowship reading their imaging studies. IMHO... radiation oncology is much more "oncology" than radiology. Its no dig on them but I haven't met many interventional radiologists that have any business directing a patient's oncologic management.

Then again... I want a radiation oncologist with a 1-2 year medical oncology fellowship managing my family members systemic therapy about as much as I want a medical oncologist with a radiation oncology fellowship designing their radiation plan.

People argue "Well... GYN oncology didn't ASK to prescribe systemic therapy." True... they did not. But I also want a GYN oncologist managing my family members oncologic care about as much as I want a medical oncologist doing their surgery.

It would take major restructuring of either pathway; either significant integration of oncologic management principles into a radiology curriculum... or significant integration of medical training into the radiation oncology curriculum. And god forbid... we might actually have to take responsibility for admitting and managing inpatients (GASP!).

Neither has any impetus or chance of happening in the foreseeable future. It would take some trailblazers who get board certified in both to start our own board and residency training program. Anyone want to go back to intern year with me? Where are you ABRO?

 

[deleted941485]

Current radiology resident who was initially interested in rad onc in med school but chose rads due to job concerns. However, I still feel that outside of the jobs thing, rad onc is still the best specialty in medicine. If, a big if, rad onc becomes a subspecialty under rads I'd happily do a rad onc fellowship. Is there a remote possibility that this could happen?

It’s would require near total absolute destruction and relegation of the field to nothing more than a curiousity for the Astro or ACR to even consider it.

Most docs that would be practicing by the time this happen would have either retrained in another field or retired by then.

It’s simply too complex of a task with too little interest and a hell of a lot of self interested parties to ever make that a thing.

He problem is more likely to take care of itself then to have any intelligent and beneficial planning occur

 

[deleted941485]

I've stayed out of this because I know its not real popular, but I want a radiologist with a 1-2 year radiation oncology fellowship treating my family members as much as I want a radiation oncologist with a radiology fellowship reading their imaging studies. IMHO... radiation oncology is much more "oncology" than radiology. Its no dig on them but I haven't met many interventional radiologists that have any business directing a patient's oncologic management.

Then again... I want a radiation oncologist with a 1-2 year medical oncology fellowship managing my family members systemic therapy about as much as I want a medical oncologist with a radiation oncology fellowship designing their radiation plan.

People argue "Well... GYN oncology didn't ASK to prescribe systemic therapy." True... they did not. But I also want a GYN oncologist managing my family members oncologic care about as much as I want a medical oncologist doing their surgery.

It would take major restructuring of either pathway; either significant integration of oncologic management principles into a radiology curriculum... or significant integration of medical training into the radiation oncology curriculum. And god forbid... we might actually have to take responsibility for admitting and managing inpatients (GASP!).

Neither has any impetus or chance of happening in the foreseeable future. It would take some trailblazers who get board certified in both to start our own board and residency training program. Anyone want to go back to intern year with me? Where are you ABRO?

Rad onc is gonna have to get over being a sweet lifestyle specialty if it wants to remain a specialty

 

[medgator]

Rad onc is gonna have to get over being a sweet lifestyle specialty if it wants to remain a specialty

I don't know.... We can get pretty busy during the week between tumor boards, a busy clinic and the smattering of inpatient consults.

Workflow isn't that different than med onc outside of more inpatient work on their end. Even then, they typically aren't admitting to a service and are only getting called in after the hospitalists admit their patients

 

[deleted941485]

I don't know.... We can get pretty busy during the week between tumor boards, a busy clinic and the smattering of inpatient consults.

Workflow isn't that different than med onc outside of more inpatient work on their end. Even then, they typically aren't admitting to a service and are only getting called in after the hospitalists admit their patients

Med onc rotates in house call. Its not like these guys are covering clinic and the hospital alot of the time especially in the employed setting. I spoke with my hsop employed MOs a few weeks ago as to how they deal with admissions and in house call. Its like every 6-8 weeks they cover in house and they just have the covering doctor admit them. To me it didnt seem so bad.

 

[medgator]

Med onc rotates in house call. Its not like these guys are covering clinic and the hospital alot of the time especially in the employed setting. I spoke with my hsop employed MOs a few weeks ago as to how they deal with admissions and in house call. Its like every 6-8 weeks they cover in house and they just have the covering doctor admit them. To me it didnt seem so bad.

That's my point... No one is magically sending them more outpatient oncology (which is the vast majority of our mutual bread and butter) because they had happen to do a lot of inpatient work..

Most of the consults that show up in inpatient oncology aren't definitive cases and isn't the bread and butter of what most of us see outpatient