APRT madness

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yesmaster

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www.sroa.org

The Advanced Practice Radiation Therapist

This blog post is adapted from the Q&A “Introducing the Advanced Practice Radiation Therapist” published in Radiation Oncology News for Administrators, Vol 33, No. 5.
www.sroa.org www.sroa.org

Is ASTRO seriously considering scope creep because some rad onc faculty and residents at Mount Sinai are too damn lazy to see their own inpatients? Why do hospital based practices get all sorts of advantages over freestanding if their docs are too lazy to actually step foot in the hospital

Gosh the depth of problems our field has because faculty are too lazy to do their jobs just baffles me. Faculty that can’t or don’t want to write their own notes, contour, see inpatients, or teach.

And is it surprising that Mount Sinai is the same garbage institution to which Arpit Chhabra of Bridge Oncology belongs?
 
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yesmaster said:
www.sroa.org

The Advanced Practice Radiation Therapist

This blog post is adapted from the Q&A “Introducing the Advanced Practice Radiation Therapist” published in Radiation Oncology News for Administrators, Vol 33, No. 5.
www.sroa.org www.sroa.org

Are we seriously getting ASTRO looking into supporting scope creep because some rad onc faculty and residents at Mount Sinai are too damn lazy to see their own inpatients? Why do hospital based practices get all sorts of advantages over freestanding if their docs are too lazy to actually step foot in the hospital

Gosh the depth of problems our field has because faculty are too lazy to do their jobs just baffles me. Faculty that can’t or don’t want to write their own notes, contour, see inpatients, or teach.

And is it surprising that Mount Sinai is the same garbage institution to which Arpit Chhabra of Bridge Oncology belongs?
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Agreed, but I don't think that doc is in support of it. Could be wrong.

This is the reason I quit listening to the Accelerators podcast, they have been pushing it too. @NotMattSpraker

angry season 3 GIF

 
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yesmaster said:
www.sroa.org

The Advanced Practice Radiation Therapist

This blog post is adapted from the Q&A “Introducing the Advanced Practice Radiation Therapist” published in Radiation Oncology News for Administrators, Vol 33, No. 5.
www.sroa.org www.sroa.org

Is ASTRO seriously considering scope creep because some rad onc faculty and residents at Mount Sinai are too damn lazy to see their own inpatients? Why do hospital based practices get all sorts of advantages over freestanding if their docs are too lazy to actually step foot in the hospital

Gosh the depth of problems our field has because faculty are too lazy to do their jobs just baffles me. Faculty that can’t or don’t want to write their own notes, contour, see inpatients, or teach.

And is it surprising that Mount Sinai is the same garbage institution to which Arpit Chhabra of Bridge Oncology belongs?
Click to expand...
"The APRT is the go-to for troubleshooting technical issues at the machine."

Wut?
 
yesmaster said:
www.sroa.org

The Advanced Practice Radiation Therapist

This blog post is adapted from the Q&A “Introducing the Advanced Practice Radiation Therapist” published in Radiation Oncology News for Administrators, Vol 33, No. 5.
www.sroa.org www.sroa.org

Is ASTRO seriously considering scope creep because some rad onc faculty and residents at Mount Sinai are too damn lazy to see their own inpatients? Why do hospital based practices get all sorts of advantages over freestanding if their docs are too lazy to actually step foot in the hospital

Gosh the depth of problems our field has because faculty are too lazy to do their jobs just baffles me. Faculty that can’t or don’t want to write their own notes, contour, see inpatients, or teach.

And is it surprising that Mount Sinai is the same garbage institution to which Arpit Chhabra of Bridge Oncology belongs?
Click to expand...
What wrong with Arpit lol
 
NotMattSpraker said:
Check out our latest episode. “What Workforce Challenges Exist”: APRT Revisited With Marsha and Join - The Accelerators Podcast

View attachment 406170
Click to expand...
Eh, you still kind of hedged a bit, can't endorse the podcast, lol. Maybe it's because there is the new partner on the podcast and you don't want to hurt feelings or anything, which I get. Join and Marsha did great though. Join pretty much nailed the pitfalls and why it doesn't make sense in the US.

All of these roles are already set in the United States. The APRT movement is saying "in some countries people can do everything", and they are hedging for anything possible, as long as they encroach. There is not a need for it though in the US, they are either encroaching on the dosimetrists, the APPs, or on us, and it's not necessary. There is a shortage of RTs, there is not a shortage of any of those other positions, just... stop, please 😢
 
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Marsha kinda touched on an interesting point regarding what this says about the need for training, which in my mind, translates to this position suggesting that we really don't need to go to medical school and aren't doctors. I suspect the aprt attainment process won't be too different from the virtual np mills. The therapist on the podcast spoke of wanting more fulfillment. Don't we all? Maybe they can converse with my patients who think cancer is a metabolic and not genetic disease that should be treated with ivermectin and bacon.
 
There are no feelings to protect or hurt and everyone should expect the academics will talk out of both sides of their mouths on scope creep, just like they do on every controversial rad onc topic.

I am supportive of an "advanced" therapist role for supervised contouring of on table adaptive radiation. This may be coming for our practice. I like the Wash U model where this person is trained internally for free and working under the usual RTT license. While OTA billing is a little wild west, this role does not definitively pay additional RVUs to a physician right now. Its not clear it will in the future.

If we hired a physician for this role in our practice, that would be a very crappy job. It would dilute the RVU load of the current physicians and be very unfulfilling for the new physician. If we did not hire anyone and did it ourselves, it would kill the morale of our current physicians.

Alternatively, if we gave one of our RTTs a raise to do this advanced role, that is great for them. An "APRT" is a pretty practical answer to this very niche scope of work for all parties.

APRTs seem impractical for the US for basically everything else in that list.

If you are upset the therapists/ASRT are pushing this effort and you give money to ASTRO, ACRO, or the ACR, your gripe is with them. They are supposedly the mechanism for collective statements on these kinds of issues.

We did these episodes in part because ASRT is out there publishing like crazy, and the radiation oncologist societies are conspicuously silent.
 
Great points. Thanks. I wish I knew what groups stances were, I like the ASTRO people in general and think most of them have good and well intentioned interests (unpopular opinion, I know), and I assume it is very difficult to come up with the perfect thing to say that everyone will agree with. I don't want that job of having to say the right thing and having half the field mad at you, I do want my clinical practice job and to retire when I am good and ready and not have extensive scope creep when it isn't needed.
 
CurbYourExpectations said:
Great points. Thanks. I wish I knew what groups stances were, I like the ASTRO people in general and think most of them have good and well intentioned interests (unpopular opinion, I know), and I assume it is very difficult to come up with the perfect thing to say that everyone will agree with. I don't want that job of having to say the right thing and having half the field mad at you, I do want my clinical practice job and to retire when I am good and ready and not have extensive scope creep when it isn't needed.
Click to expand...

Ask them.
 
At ESTRO, I attended the APRT symposium and I thought it was well put together. It is still a work in progress and ESTRO has created a cooperative group for this purpose. As others had mentioned above, the primary driving purposes are:

1. Find a better workflow for adaptive RT as rapid decisions need to happen on the machine to expedite. The physician is not divorced from this workflow, he remains the "captain of the ship."
2. Create educational programs to train and give RTTs experience in developing countries

APRT work is remains mainly tehcnical and on the linac. I don't recall seeing anything about seeing inpatients and such.
 
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Join Luh is on-point in the Accelerators episode. Everything he says is great and eloquent. Grateful for his work in California as well to oppose midlevel creep.

RTT’s should work with AAPM to offload physicist responsibilities. There is a well documented shortage of physicists that tracks with reality.

I did not like how Marsha Haley and Cameron Tharp pushed back on Join Luh, who correctly stated there is no shortage of radiation oncologists and there is in fact an oversupply. The ASTRO opinion piece the RTT cited is bogus.

Marsha Haley’s response article on midlevel creep seems like it was good.

Pay RTT’s more to do RTT work. It would make more sense to pay RTT’s more if there’s a shortage of RTT’s than to support scope creep.
 
Gfunk6 said:
At ESTRO, I attended the APRT symposium and I thought it was well put together. It is still a work in progress and ESTRO has created a cooperative group for this purpose. As others had mentioned above, the primary driving purposes are:

1. Find a better workflow for adaptive RT as rapid decisions need to happen on the machine to expedite. The physician is not divorced from this workflow, he remains the "captain of the ship."
2. Create educational workflows to train and give RTTs experience in developing countries

APRT work is remains mainly tehcnical and on the linac. I don't recall seeing anything about seeing in patients and such.
Click to expand...

This has been confusing. I think part of the confusion is that there is no unified international "APRT" definition, so this will vary based on who you are talking to.

The episode came out of this issue of Radiation Therapist, which is the ASRT magazine. I just noticed this was incorrectly linked in the show notes and have fixed it.


It is worth reading the whole issue. The derm article is nuts. The table discussed on the show starts on page 38 and outlines the scope of practice as per these authors from MDACC.

Here is one clear "non-technical" example that is obvious scope creep into the role of radiation oncologists.

"Autonomously deliver care to patients in the unique categories of radiation oncology treatment for specific diseases (eg, palliation,breast and prostate cancer)."
 
“Our preliminary survey results indicate that many physicians appreciate the care coordination aspect—creating continuity for inpatients from end to end—which is something we didn’t have before,” says Skubish. “Also, because many patients’ care is complex, being able to have a point person that communicates with the multiple providers involved has really helped streamline communication.”

Mount Sinai doctors were not able to provide continuity of care for their inpatients and they or their teams cannot communicate with multiple providers? In another paragraph it says consulting an inpatient can take their physicians three hours? Seems to me the justification of an APRT stems from the Mount Sinai Department of Radiation Oncology being fundamentally bad at providing care.
 
OTN said:
“Our preliminary survey results indicate that many physicians appreciate the care coordination aspect—creating continuity for inpatients from end to end—which is something we didn’t have before,” says Skubish. “Also, because many patients’ care is complex, being able to have a point person that communicates with the multiple providers involved has really helped streamline communication.”

Mount Sinai doctors were not able to provide continuity of care for their inpatients and they or their teams cannot communicate with multiple providers? In another paragraph it says consulting an inpatient can take their physicians three hours? Seems to me the justification of an APRT stems from the Mount Sinai Department of Radiation Oncology being fundamentally bad at providing care.
Click to expand...
Btw skubish is a nightmare
 
APRT to help with adaptive - makes sense, kind of a mix between a RTT and a dosi doing some contouring and stuff at the machine.

APRT to function like.... a NP who sees inpt consults? Why woudl this ever be a RTT? Why not just hire one of 8 bajillion NPs that are being generated yearly to do the same thing? Why would you take someone that has even LESS knowledge about medicine/oncology than a NP (who alreayd has WAY less knowledge about medicine/oncology than a Rad Onc physician) and put them in this role?
 
evilbooyaa said:
Why would you take someone that has even LESS knowledge about medicine/oncology than a NP (who alreayd has WAY less knowledge about medicine/oncology than a Rad Onc physician) and put them in this role?
Click to expand...

Because they are cheaper. If things are cheaper, there is more profit. Duh.

This is exactly why people say physicians cant run hospitals. /s
 
OTN said:
Seems to me the justification of an APRT stems from the Mount Sinai Department of Radiation Oncology being fundamentally bad at providing care.
Click to expand...
I think some blame has to be assigned to that resident room. I'm sure things have changed, but man that was a horror show.
 

A Solution in Search of a Problem: Why the Current Advanced Practice Radiation Therapist Model Doesn’t Fit the United States Health Care Landscape​

Arpit M. Chhabra, Bridget F. Koontz, Jordan Johnson, Mudit Chowdhary, Casey Chollet-Lipscomb, James E. Bates, Michael Weisman, Chirag Shah, Join Y. Luh

 
The bottom line from article above:

"

Overlapping responsibilities​

International APRT models have been successful because they function in the absence of radiation support personnel ubiquitous in the United States, such as dosimetrists—a profession that is uniquely American.5 In many countries, radiation therapists (RTTs) perform the function that in the United States has been filled by certified medical dosimetrists–organs-at-risk contouring and treatment planning. Moreover, medical physicists in these settings often assume a much broader role in treatment planning, including tasks typically performed by dosimetrists or physicians in the United States. In contrast, the United States workflow is segmented, with dosimetrists playing a central role in treatment planning, which further reduces the clinical and operational need for radiation therapists to expand into these areas.
The core responsibilities being proposed for APRTs—ranging from patient assessment and on-treatment management to target delineation—are currently performed at the physician level in the United States. Shifting core responsibilities to an APRT would create redundancy, risk duplication of effort, and siphon away tasks anchored into the radiation oncologist’s purview given their unique and extensive training."
 
Doctorer said:
I think some blame has to be assigned to that resident room. I'm sure things have changed, but man that was a horror show.
Click to expand...

.... are you blaming the residents for being bad at in-patient Radiation Oncology? Isn't that... the point of residency? Where are the attendings?
 
NotMattSpraker said:
There are no feelings to protect or hurt and everyone should expect the academics will talk out of both sides of their mouths on scope creep, just like they do on every controversial rad onc topic.

I am supportive of an "advanced" therapist role for supervised contouring of on table adaptive radiation. This may be coming for our practice. I like the Wash U model where this person is trained internally for free and working under the usual RTT license. While OTA billing is a little wild west, this role does not definitively pay additional RVUs to a physician right now. Its not clear it will in the future.

If we hired a physician for this role in our practice, that would be a very crappy job. It would dilute the RVU load of the current physicians and be very unfulfilling for the new physician. If we did not hire anyone and did it ourselves, it would kill the morale of our current physicians.

Alternatively, if we gave one of our RTTs a raise to do this advanced role, that is great for them. An "APRT" is a pretty practical answer to this very niche scope of work for all parties.

APRTs seem impractical for the US for basically everything else in that list.

If you are upset the therapists/ASRT are pushing this effort and you give money to ASTRO, ACRO, or the ACR, your gripe is with them. They are supposedly the mechanism for collective statements on these kinds of issues.

We did these episodes in part because ASRT is out there publishing like crazy, and the radiation oncologist societies are conspicuously silent.
Click to expand...

I agree with this model referenced by @NotMattSpraker, Dave Palma's model leaves us vulnerable to de-valuation.

There are unquestionably benefits to adaptive RT, but no one has the bandwidth to run to the console to re-contour every time. Increasing the scope of a therapist/dosimetrist (maybe that should be the requirement, holding both certifications) makes a lot of sense for this role...
 
emt409 said:
I agree with this model referenced by @NotMattSpraker, Dave Palma's model leaves us vulnerable to de-valuation.

There are unquestionably benefits to adaptive RT, but no one has the bandwidth to run to the console to re-contour every time. Increasing the scope of a therapist/dosimetrist (maybe that should be the requirement, holding both certifications) makes a lot of sense for this role...
Click to expand...

Billing data would argue Rad Onc physicians as a group nationally have a TON of bandwidth.

I can think of at least 1 clinic where the physician does have bandwidth and you could imagine practice models where OTA is only offered during blocked periods a few times a week. Similar to SBRT for some community clinics.

People really don't even know how to implement OTA yet in the community!

Also worth remembering that this "wash U" model everyone is raving about on X required only internal training of a current licensed RTT. We can do this now with zero discussion, national policy change, or selling masters degrees to underpaid therapists. If we decide an APRT is needed in our department, I will be strongly advocating for this in our network.
 
drowsy12 said:
are they really that much cheaper?
Click to expand...

I dont know.

But say a department has 3 RTT on a Linac and wants to add a mid-level to do OTVs. The 3 RTTs you currently have can probably absorb the additional work of seeing OTVs. If you gave one of them a raise to be an APRT, that would likely be far cheaper than hiring a new NP.
 
What do you think the radio silence about from trainees/med students? Other fields would have had outrage about this by their trainees. People in EM or radiology or anesthesia with the encroachment. Is it happening on reddit? Are they scared about getting people mad at them or are they indoctrinated to think that it's OK that people are suggesting having other groups do everything you trained for? I guess probably too risky for a field like this.

Think about what would happen if they started rolling out mid levels here taking out gallbladders and seeing them in post op/consults/follow ups to task shift the surgeons into no work, there was outrage here in the US when someone did it in Europe. What is with RadOnc? lol

It doesn't look like any academics are talking about it either... don't you have residents you are mentoring?
 
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Fpg1245 said:
I don’t get it. So what exactly are the rad oncs doing in these APRT clinics? Do the rad oncs just want to do research all day and make cameo appearances with the patients on treatment?
Click to expand...
Point of sale glengarry glen ross style.. Get those prostate pts onto protons.
 
CurbYourExpectations said:
You don't understand, it takes them 7 hours to see a single inpatient at that hub.
Click to expand...

the nurse places the consult
CurbYourExpectations said:
What do you think the radio silence about from trainees/med students? Other fields would have had outrage about this by their trainees. People in EM or radiology or anesthesia with the encroachment. Is it happening on reddit? Are they scared about getting people mad at them or are they indoctrinated to think that it's OK that people are suggesting having other groups do everything you trained for? I guess probably too risky for a field like this.

Think about what would happen if they started rolling out mid levels here taking out gallbladders and seeing them in post op/consults/follow ups to task shift the surgeons into no work, there was outrage here in the US when someone did it in Europe. What is with RadOnc? lol

It doesn't look like any academics are talking about it either... don't you have residents you are mentoring?
Click to expand...

Wait where in Europe are midlevels taking out Gallbladders? When did that happen?
 
CurbYourExpectations said:
Are they scared about getting people mad at them
Click to expand...

Yes. If you say anything controversial, there are going to be at least mild negative consequences in academic medicine, especially in rad onc.

Further, it's one thing to complain about private equity as the enemy of EM and rads, it's another to complain about SCAROP.

In the radiology example, people were very vocal. I was not there, but ACR has an open session where members can dialogue with leadership, and I heard the dialogue around RA encroachment was contentious. As a result the ACR passed a resolution defining the scope of practice for RAs and also blocking NPs from interpreting images in 2024. This is not policy, but supports advocates at the state level. I dont have the resolution passed because I am not a member, but maybe someone can link it.

ASTRO is essentially doing the same thing with their survey, just in a less transparent way. Maybe they will publish a policy statement. Hopefully it isn't written by the ASRT.
 
CurbYourExpectations said:
What do you think the radio silence about from trainees/med students? Other fields would have had outrage about this by their trainees. People in EM or radiology or anesthesia with the encroachment. Is it happening on reddit? Are they scared about getting people mad at them or are they indoctrinated to think that it's OK that people are suggesting having other groups do everything you trained for? I guess probably too risky for a field like this.

Think about what would happen if they started rolling out mid levels here taking out gallbladders and seeing them in post op/consults/follow ups to task shift the surgeons into no work, there was outrage here in the US when someone did it in Europe. What is with RadOnc? lol

It doesn't look like any academics are talking about it either... don't you have residents you are mentoring?
Click to expand...
I can't speak for trainees, but for med students, no one even knows what rad onc is anymore. When I bring it up to my classmates, there's a look of confusion on their faces. In the entirety of med school, the only times I have even seen the words rad onc mentioned until this year were in two highlight events that described the field to med students. 0 people replied, and both events were cancelled.
I'm at a T20 med school with a very good rad onc program too. For the past 5 years not a single person has applied rad onc.

Things do seem to be changing now though. We recently had another recruitment event this year, and it went from 0 people to 6 people.
 
allseasons said:
I can't speak for trainees, but for med students, no one even knows what rad onc is anymore. When I bring it up to my classmates, there's a look of confusion on their faces. In the entirety of med school, the only times I have even seen the words rad onc mentioned until this year were in two highlight events that described the field to med students. 0 people replied, and both events were cancelled.
I'm at a T20 med school with a very good rad onc program too. For the past 5 years not a single person has applied rad onc.

Things do seem to be changing now though. We recently had another recruitment event this year, and it went from 0 people to 6 people.
Click to expand...
With academic leadership like we have, I wouldn't apply to rad onc these days either
 
So we are already churning out more graduates than we need, the job market is oversaturated, and depts are overstaffed, but rad oncs need more help to do things like review plans, see inpatients, and approve CBCTs? How does that make sense?
 
It doesn't make sense. I am shocked anyone here is in favor of this, but we've also got ROCR fanbois amongst us.

ASTRO are master gaslighters and will tell you workforce concerns are b.s. I see a future of travelling between midwest rural sites for daily locums rates if you still want to both practice rad onc and earn a good living in this field. I'm not sure what the hundreds of rad oncs in metro areas will even be doing anymore to justify even a modest salary with the resident overtraining, AI contouring and plan generation, NPs for follow-ups, and APRTs for everything on treatment related.
 
alwaysbeIMRTing said:
It doesn't make sense. I am shocked anyone here is in favor of this, but we've also got ROCR fanbois amongst us.

ASTRO are master gaslighters and will tell you workforce concerns are b.s. I see a future of travelling between midwest rural sites for daily locums rates if you still want to both practice rad onc and earn a good living in this field. I'm not sure what the hundreds of rad oncs in metro areas will even be doing anymore to justify even a modest salary with the resident overtraining, AI contouring and plan generation, NPs for follow-ups, and APRTs for everything on treatment related.
Click to expand...
I'm shocked that we all agree on something this much, we have had more intense arguments about breast edema reported on a trial. That one person that voted yes is a plant, jk. Hopefully the ASTRO survey shows the same.
 
Got this survey from Astro. Generally you don’t ever get a survey from them except the yearly How Awesome Are We survey. This might be what gets me to formally exit this org (my employer pays for my membership would never pay my own money).
 

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fiji128 said:
Got this survey from Astro. Generally you don’t ever get a survey from them except the yearly How Awesome Are We survey. This might be what gets me to formally exit this org (my employer pays for my membership would never pay my own money).
Click to expand...
Anyone in community/non-academic practice that pays ASTRO dues is actively funding an organization against their own interests at this point. When people/organizations speak, listen!

This is such an absurd survey, but very on point and on brand for ASTRO
 
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