APRT madness

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RTTs performing brachytherapy? 90% of rad oncs can't even do that.

This can't be real. For real this time.

We (or ASTRO) have become a bunch of ****s, sitting in the corner watching strangers with no skin in the game do our wife job. And getting really, really excited about it.
 
Neuronix said:
I was expecting "Do you support the creation of an ASRT pathway?" or a similar actual vote of the membership.

Instead, I view this as tailored questions to gather support for their foregone conclusions and directions.

As an ASTRO member, this is a major reason why I have been skeptical of a number of ASTRO initiatives. Initiatives are pushed forward without much public discussion, and all messaging is tightly controlled in their meetings and forums.

What ever happened to transparency and openness in organizations?
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The survey is a disaster, but there are free text boxes at the end. I am sharing my response, if others might find it useful as a starting point for their own answer.

"RTTs are technicians and not physicians. They lack physician level training in basic principles and practice of medicine, clinical oncology, radiobiology, and radiation physics and as such are simply not qualified to perform tasks that are the physician's responsibility, such as patient evaluation, counseling, consenting, and treatment planning/plan evaluation, no matter how 'routine'. I strongly oppose expanding RTT scope of practice in this way."

(eta: typo)
 
pikachu said:
The survey is a disaster, but there are free text boxes at the end. I am sharing my response, if others might find it useful as a starting point for their own answer.

"RTTs are technicians and not physicians. They lack physician level training in basic principles and practice of medicine, clinical oncology, radiobiology, and radiation physics and as such are simply not qualified to perform tasks that are the physician's responsibility, such as patient evaluation, counseling, consenting, and treatment planning/plan evaluation, no matter how 'routine'. I strongly oppose expanding RTT scope of practice in this way."

(eta: typo)
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Here's a site with plenty of info to help RT(T)s expand their scope:

www.aamc.org

Tomorrow's Doctors, Tomorrow's Cures

The AAMC is dedicated to transforming health care through innovative medical education, cutting-edge patient care, and groundbreaking medical research.
www.aamc.org www.aamc.org
 
I don’t know what to make of ASTRO. Is Sameer Keole trying to be inclusive and get community input for initiatives like ASRT? It also seems odd that the person he ran against for prez, Neha Vapiwala was the only or one of a few physician coauthors on the ASRT white paper.

Paying for ASTRO membership is like paying your personal CPA $775 for them to figure out how to get you to pay the government or your neighbor more money. You pay them but they don’t work for you.

Anyways I don’t have an ASTRO membership, my CME funds I will figure something else out. If I could travel I would go to ESMO or ESTRO, or the ASCO disease site meetings, or ABS or radium society or arro. I would love for a podcast like the Accelerators to get really big and host an annual summit like the All-In tech guys and I could use my cme funds for that. No membership fee, just once a year CME with industry sponsors, key talks, social events, poker. Astro annual meeting is fun and job board can be helpful but not sure what other value they provide.
 
yesmaster said:
Paying for ASTRO membership is like paying your personal CPA $775 for them to figure out how to get you to pay the government or your neighbor more money. You pay them but they don’t work for you.
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Paying ASTRO is like digging your own grave. As more people exit ASTRO, look forward to ever increasing fees for membership, annual meeting, and various "service charges" as their revenue begins to circle the toilet.
 
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alwaysbeIMRTing said:
We (or ASTRO) have become a bunch of ****s, sitting in the corner watching strangers with no skin in the game do our wife job. And getting really, really excited about it.
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unfiltered, brutally honest and a bit crude but can't argue with the messaging.

ASTRO seems to have a cow about other physicians or their own physicians having linac skin in the game though. That seems to have been consistent. We are good enough to babysit directly but not good enough to have ownership in the machine itself
 


I don't get it. So, hire new Canadian rad onc grads to do adaptive RT for US rad onc faculty in a 'fellowship' while David Palma is using their APRT for contouring, set up, plan approvals, and running clinical trials. What is it? Do you need a medical degree and residency or a RT(T)? Is there too much or too little work? Cool cool cool
 
Astro doesn’t want rad onc’s to have technical ownership? Where do they say that?
 
Aptamer said:


I don't get it. So, hire new Canadian rad onc grads to do adaptive RT for US rad onc faculty in a 'fellowship' while David Palma is using their APRT for contouring, set up, plan approvals, and running clinical trials. What is it? Do you need a medical degree and residency or a RT(T)? Is there too much or too little work? Cool cool cool
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You've got it. Both situations are designed to minimize the amount of time an attending (and I'd guess a physicist as well) in the dept has to devote to sitting on the adaptive machine.
 
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PIMA didn’t become law though

Paul Harari sounds like a whiny little boy
 
yesmaster said:
Astro doesn’t want rad onc’s to have technical ownership? Where do they say that?
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yesmaster said:
PIMA didn’t become law though

Paul Harari sounds like a whiny little boy
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Now you're moving the goalposts

Thankfully a lot of terrible ASTRO thoughts and proposals don't become law
 
Aptamer said:


I don't get it. So, hire new Canadian rad onc grads to do adaptive RT for US rad onc faculty in a 'fellowship' while David Palma is using their APRT for contouring, set up, plan approvals, and running clinical trials. What is it? Do you need a medical degree and residency or a RT(T)? Is there too much or too little work? Cool cool cool
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Sweet glasses
 
Astro is a complete joke/clown show/dumpster fire of an organization. I genuinely feel embarrassed for all these MDs “donating” time to them. I’m still a member because the CME stuff is still
useful for myself and the maintenance of my medical license. I wish ASCO offered the same. Otherwise I really don’t understand how people willingly give time to this organization.
 
fiji128 said:
Astro is a complete joke/clown show/dumpster fire of an organization. I genuinely feel embarrassed for all these MDs “donating” time to them. I’m still a member because the CME stuff is still
useful for myself and the maintenance of my medical license. I wish ASCO offered the same. Otherwise I really don’t understand how people willingly give time to this organization.
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Is it just a small minority online that feel this way? How has ASTRO leadership not been voted out yet? From 2019-2022 everything I saw about the field said it was in ruins and ASTRO was largely to blame. Did leadership change during all of that?
 
allseasons said:
Is it just a small minority online that feel this way? How has ASTRO leadership not been voted out yet? From 2019-2022 everything I saw about the field said it was in ruins and ASTRO was largely to blame. Did leadership change during all of that?
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Nope. Are you surprised? Who do you think makes up most of the membership at this point?
 
medgator said:
Nope. Are you surprised? Who do you think makes up most of the membership at this point?
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Why is there no movement in the field to change them? Isn't it just a matter of getting membership and voting. Is membership really expensive? With the sheer amount of negativity I see, I just don't understand how rad onc doesn't have new leadership.
 
Also it’s funny that a community rad onc might win the presidency (election ended Friday). But then you find out it’s…… Connie Mantz.
 
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allseasons said:
Why is there no movement in the field to change them? Isn't it just a matter of getting membership and voting. Is membership really expensive? With the sheer amount of negativity I see, I just don't understand how rad onc doesn't have new leadership.
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ASTRO is well supported by large academic group leadership and large practice leadership. SCAROP supports ASTRO unequivocally and SCAROP has unequivocally supported a nonsensical resident expansion because it helped their departments bottom line. This has persisted no matter who has been at the helm. A lot of “membership” is not representative of people supporting ASTRO but the need for CME and the fact that as practices have consolidated these people control inordinate power in the field. A lot of ASTRO funding is from said large practices, which means it gets funded by a small minority who have control of most of the money. Having a small population of membership to begin with makes this easier. In Emergency Medicine their main society / academic leaders basically ruined large parts of the field due to overexpansion to benefit themselves, but due to the size other societies have popped up and gained some clout.

Adaptive therapy and advanced RTTs is a good concept for advancement within the scope of managing small things already planned and checked. Just like everything else, if you are in power or have financial leverage you will try and exploit this as much as possible. Can’t imagine how many department chairs would salivate at expanding RTT role to cut from any other job title that currently pays more. It is an every man / woman for themselves environment.
 
DebtRising said:
ASTRO is well supported by large academic group leadership and large practice leadership. SCAROP supports ASTRO unequivocally and SCAROP has unequivocally supported a nonsensical resident expansion because it helped their departments bottom line.
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You're right of course, and it shows how (broken record!) bad at business our rad onc leaders were/are. This was a short-term gain/long-term loss maneuver. Now the long-term loss is coming home to roost and you see flailing efforts like ROCR, proton use with no good data, etc.
 
TheWallnerus said:
You're right of course, and it shows how (broken record!) bad at business our rad onc leaders were/are. This was a short-term gain/long-term loss maneuver. Now the long-term loss is coming home to roost and you see flailing efforts like ROCR, proton use with no good data, etc.
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I disagree. For them, all win. They presented department budgets and hired for practices “they” (ie a huge hospital system) acquired at below market rates due to expanding captured labor at the resident and then subsequent young attending level. We lost, they won. A lot of private docs happily sold those practices for large buyouts, and then some stayed on and leveraged resident labor for their continued benefit. It was a strategy that spanned gender and ethnicity and more defined by era and age.


The APRT concept is the same thing. There have been natural ways to advance RTTs for years by promoting either Dosimetry or RN training depending on someone’s goals. Departments would have had someone who understands multiple roles and could fill them.

Instead proposals to expand APRT to complete billable tasks way outside their scope of training is less about advancement pathways (which could have been setup decades ago) and more about finding ways to exploit the system for departmental or leadership budget purposes. I only posted to highlight why ASTRO still exists and how this dovetails with their (and SCAROPs) existing management strategy.

That Palma supports this is also not surprising as the Canadian system is built on heavier overtraining of resident or captive labor to keep the system afloat, which they have exported to the US long before the current political environment because they accepted the cost of their system was Canadian trainees either not having jobs or requiring multiple fellowships before landing one. I am no longer familiar enough with the Canadian system to know if this has changed (the resident part, the philosophy has not).
 
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DebtRising said:
. In Emergency Medicine their main society / academic leaders basically ruined large parts of the field due to overexpansion to benefit themselves, but due to the size other societies have popped up and gained some clout.
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Not sure that's accurate. EM leadership didn't push for expansion not in the way RO chairs and leadership did afaik.

It was hospitals like HCA who were already pushing APPs that also looked to open new residency training programs to increase the supply of EM docs.

The end result from the greedy HCAs and scarop chairs was the same however, a degradation in those collective specialties which now rank at the bottom of competitiveness
 
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There is not a need in RadOnc for this to be happening, that is the worst part of it all. I have been wanting to start a FIRE discussion in this forum, about financials and trying to become financially independent as soon as able, as hard times will befall the field in the near future. Maybe someone else in here would be able to do it better.

And some users in here are pretty spot on in their assertions IMO.
 
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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).
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Is this the entire survey?
 
allseasons said:
Is it just a small minority online that feel this way? How has ASTRO leadership not been voted out yet? From 2019-2022 everything I saw about the field said it was in ruins and ASTRO was largely to blame. Did leadership change during all of that?
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The election aren’t real elections, all the candidates are nominated and approved by Astro. So the election are basically do you want academic insider candidate A or B? Irrelevant to most rad oncs, which is why the participation in the elections is ridiculous low.
 
allseasons said:
Why is there no movement in the field to change them? Isn't it just a matter of getting membership and voting. Is membership really expensive? With the sheer amount of negativity I see, I just don't understand how rad onc doesn't have new leadership.
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Astro membership is like $800/year. To get into “leadership” or whatever, you need to donate significant hours over years or decades to the organization to move up. This is basically only realistic for “academic” types.
 
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Gfunk6 said:
Sweet glasses
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So now we have a "Precision Radiation Oncology Fellowship"? Do their residents not get trained in "Precision" radiation oncology? Is there "Imprecise Radiation Oncology" I don't know about? (Insert LDRT joke here referencing the other thread, we're getting meta here.)

Adaptive RT* is mentioned. Do residents not get trained in adaptive RT during training? What does this fellowship offer the fellow on top of traditional residency training? Would UTSW offer a job to someone which does include adaptive RT to someone who did not complete their fellowship? If UTSW thinks adaptive RT is so critical, shouldn't that be taught in residency rather than in a separate fellowship?

(*Yes, I am once again asking for the data supporting widespread use of adaptive RT.)
 
OTN said:
(*Yes, I am once again asking for the data supporting widespread use of adaptive RT.)
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Question - what is the history of IGRT codes? When did they come about?

To some extent I wonder if some of this stuff is just going to happen with the momentum of time and billing codes.

For example, at some point (someone older please correct me if I’m wrong!) there was no standard daily IGRT done nor were there codes.

Likely when many of us were in training, we learned this to be normal and it just made common sense to us. Perhaps there were older people back then that said ‘what data is there to support daily IGRT?’ I do think things are more polarized now and there’s more mistrust and discontent than there was back then, but perhaps it occurred.

So now there are a new group of trainees that will be used to ‘adaptive’ (even if little to no change is made day to day) and that number of trainees feeling that way and prevalence will increase.

At some point there will be enough of them graduating with enough machines coming out that that just have that as part of standard offerings. And there will be billing codes for it. And it will just be normal and what people accept as part of their billing.

And then CMS will downgrade it and cut it and they’ll have to find the next thing.

Med oncs get drugs. We get new billing codes?
 
drowsy12 said:
Question - what is the history of IGRT codes? When did they come about?

To some extent I wonder if some of this stuff is just going to happen with the momentum of time and billing codes.

For example, at some point (someone older please correct me if I’m wrong!) there was no standard daily IGRT done nor were there codes.

Likely when many of us were in training, we learned this to be normal and it just made common sense to us. Perhaps there were older people back then that said ‘what data is there to support daily IGRT?’
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You don't like to image your target before treatment? Prefer old school ports? Missing that light box?
 
drowsy12 said:
Question - what is the history of IGRT codes? When did they come about?
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The first *dedicated* 77xxx IGRT code was 77421 and appeared January 1, 2006. It was anteceded by a C code. I could get a lot wordier on this, but I’ll stop there.
 
Comparing IGRT and adaptive is too big of a leap. The benefits to IGRT are obvious, and we do have data. Plenty of studies showing decreased setup margins leads to decreased side effects. Not so with adaptive.

Adaptive, given the amount of work it requires in a department, should have a higher bar to clear. It has not yet cleared that bar, or, from what I can tell, its proponents simply refuse to acknowledge it should exist.
 
OTN said:
Plenty of studies showing decreased setup margins leads to decreased side effects. Not so with adaptive.
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To play Devil's advocate, the barrier is much higher now to show improvement, since we do so well with IGRT, and you have example of the MRI linac trial showing this decreased toxicity.

I dont have adaptive capabilities nor am I advocating for it. I'm just pointing out that it's clear the momentum is going this way. and once there are billing codes and the standard Varian software solutions allow for some sort of 'adaptive' and you can bill for it, it will just be the norm. It was more of a question/comment than anything else but it seems clear to me if you read the tea leaves. fast forward ten years from now.
 
fiji128 said:
Astro membership is like $800/year. To get into “leadership” or whatever, you need to donate significant hours over years or decades to the organization to move up. This is basically only realistic for “academic” types.
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Wait so not just any member can run?? Like if you’re a rad onc MD, and you hate current leadership, you can’t just declare candidacy and ask for votes from people who share your vision?

Damn, man.
 
allseasons said:
Wait so not just any member can run?? Like if you’re a rad onc MD, and you hate current leadership, you can’t just declare candidacy and ask for votes from people who share your vision?

Damn, man.
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Any ASTRO member can run. Just like I “can” run for President of the United States in the next election.
 
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allseasons said:
Wait so not just any member can run?? Like if you’re a rad onc MD, and you hate current leadership, you can’t just declare candidacy and ask for votes from people who share your vision?

Damn, man.
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In case you are interested, here are the requirements.

I think in the last few years, there was a member push to get someone elected to the Education director spot. I cant remember now who was running and who the members pushed through, but I want to guess Kachnic was the ASTRO "chosen" candidate and the members instead pushed through Chelsea Pinnix?

1752520528792.png
 
NotMattSpraker said:
In case you are interested, here are the requirements.

I think in the last few years, there was a member push to get someone elected to the Education director spot. I cant remember now who was running and who the members pushed through, but I want to guess Kachnic was the ASTRO "chosen" candidate and the members instead pushed through Chelsea Pinnix?

View attachment 406571
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Im currently in the process of deciding whether to apply for Rad Onc as an M4 but will keep in mind in 15 years 😭
 
Late to the game, but happy to weigh in as an academic. First and foremost, an advanced therapists role should still be therapy related in my mind. The scope described or questioned appears way too broad. Trials? Consults? No. There is no way to describe that role other than using cheep labor to cover necessary clinical FTEs in my mind. Hire doctors to do doctor jobs. If you don't have enough clinical staff to protect your research time...sorry. You are short staffed precisely because administration thinks you can do more with less. This path just proves them right and they are always going to ask for more.

That said, I've been at 3 midsized academic centers (residency and 2 faculty positions) with 8-10 main site faculty members and as the field is going, there is a limited role for APRTs for operational purposes. On paper, 8-10 faculty is way in excess of what you need to manage 100 patients under beam. And globally, it is! But the issue is we keep finding more things that need immediate supervision. If you have multiple machines doing SBRTs, a gamma knife, and adaptive machine, and a busy HDR service, its fairly common to need 4-5 folks immediately available in clinic to avoid delays when simultaneous activities come up. Add on satellite coverage with acquisitions, teaching assignments, and protected research time, PTO, you often don't have that many people immediately available in clinic at any one time. Overall, you have more than enough people. It can just be tricky to have enough in the right place at the right time. This is where I think an APRT makes sense. They can potentially help with operational issues immediately related to therapy and delivery on an as needed basis.

My biggest issue that I see is how many of these do we need? Not that many. But I suspect we will train more than that and see scope creep 😕
 
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