ARRO now has Fellowship panel

[evilbooyaa]

As a resident, I have seen my fair share of badly mismanaged patients, whether it be from academic or private practice institutions. In my area there are some private practices that I worry about their ability to handle complex cases. However, it's certainly not all and I'm cognizant of my biases on the matter.

I do think that anybody doing shoddy SRS/SBRT with questionable dosing and doing things with IMRT that would 100% fail you on board exams are the reason for this.

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[TomatoMan]

Not sure what that even means. There will always be plenty of qualified medical students willing to fill residency slots. Perhaps the STEP 1 average may go down from around 250 to 230 and the fraction of med students with PhDs may fall from the current ~25% but I doubt there will ever be a shortage of medical students willing to fill radonc residency slots, especially when pulling from a larger pool of adequately qualified students with average STEP scores.

All available rad-onc residency positions will ALWAYS fill EVERY YEAR. If one position slips through the cracks, the spot will be added to subsequent year availability. Institution funding depends on filled residency positions. For this reason, our leaders stated position that self-selection will occur is 100% FALSE.

We desperately need new and better leaders who actually advocate for our future as practicing Radiation Oncologists by reducing the number of residency positions one way or the other. The current state of affairs will soon allow hospital systems to drive many of us and our "out-dated" salaries out in favor of hiring new grads for pennies on the dollar (vs what they generate in professional fees). The newly-minted grads will have no choice but to accept the low-ball offers because of the dramatic oversupply. Trust me, hospital administrators are keenly aware of the financial benefits this will bring to hospital systems and no doubt are influencing our corrupt "leaders".

One of my mentors once told me "when you're unsure what it's about, it's about the money," which I certainly believe to be the case here.

 

[berag]

Not sure what that even means. There will always be plenty of qualified medical students willing to fill residency slots. Perhaps the STEP 1 average may go down from around 250 to 230 and the fraction of med students with PhDs may fall from the current ~25% but I doubt there will ever be a shortage of medical students willing to fill radonc residency slots, especially when pulling from a larger pool of adequately qualified students with average STEP scores.

If the applicant pool quality drops enough the board pass rate will go down. Programs are required to maintain 5 year 1st time pass rate rolling averages of at least 60% so some will be shut down, not because they offer subpar training, but because they can't attract applicants that can pass. This will probably affect the smaller marginal programs while the larger programs will continue adding spots. You could end up with all radoncs in the country trained in something like 25 programs. Maybe that's how the market corrects itself. Maybe that's the goal.

 

[Dare2Dream]

If the applicant pool quality drops enough the board pass rate will go down. Programs are required to maintain 5 year 1st time pass rate rolling averages of at least 60% so some will be shut down, not because they offer subpar training, but because they can't attract applicants that can pass. This will probably affect the smaller marginal programs while the larger programs will continue adding spots. You could end up with all radoncs in the country trained in something like 25 programs. Maybe that's how the market corrects itself. Maybe that's the goal.

That's an interesting point. For the applicant pool quality to drop significantly enough to push the 5 year board pass rate below 60% will likely take a very long time (15+ years), if ever. The medical student pool is a very large one to fill only 200 or so spots. Whether or not any program actually has to close in such as scenario is another variable. And even if a few small programs were to close, it may not dent the supply significantly.

 

[Corgi4Prez]

My other observation for current residents: get involved in quality improvement projects. It's the rage right now. Both academic and private people were eating that stuff. It's not even my focus but everyone is looking for people with quality improvement experience. It can set you apart and make your CV stand out. My former chief resident noticed the same thing last year.

Also a PGY5 that interviewed this year. I hope people don't overlook this comment. It is so true!

 

[medgator]

Also a PGY5 that interviewed this year. I hope people don't overlook this comment. It is so true!

A quality improvement project is required as part of maintaining your board certification with abr

 

[RickyScott]

Quality and Safety are important.

 

[radiaterMike]

PQI projects are no longer required. For PQI, there are other criteria which will now suffice, including attending chart rounds, going through ACR or APEX accreditation, submitting patients to registries (including ROILS) ...

As vilified as Zietman has been on this board lately, I think he (among others such as Lisa Kachinic, Paul Wallner) deserves some credit for simplifying PQI and eliminating the recertification exam.

Edit- this is the link -

ABR

 

[medgator]

This should come in handy for all those residents that will be graduating from all these newly-established questionable/subpar programs in a few years....

2018-2019 Cleveland Clinic Radiation Oncology Fellowship position

The Department of Radiation Oncology at Cleveland Clinic Taussig Cancer Institute offers a one-year post-graduate clinical fellowship position for advanced clinical training in radiation oncology.

 

[Gfunk6]

This should come in handy for all those residents that will be graduating from all these newly-established questionable/subpar programs in a few years....

2018-2019 Cleveland Clinic Radiation Oncology Fellowship position

It's not all bad. At least you can now attend a fellowship from the comfort of your own home!

Telecommuting is allowed.

 

[evilbooyaa]

If I knew an American grad that went to this program, I would personally lose respect for that person. Cleveland Clinic is a great place, but still.

 

[scarbrtj]

If I knew an American grad that went to this program, I would personally lose respect for that person. Cleveland Clinic is a great place, but still.

Better that than jobless? These fellowships might be a buffer to stabilize/forfend poor post-residency job prospects (on the residents' side; on the attendings' side, obvious pluses as well).

 

[seper]

Not the worst RadOnc department to spend a year hanging around. For sure better than being jobless. Who knows, maybe this position was created with a specific candidate in mind.

 

[evilbooyaa]

Not the worst RadOnc department to spend a year hanging around. For sure better than being jobless. Who knows, maybe this position was created with a specific candidate in mind.

It's existed previously. I know of at least one Rad Onc from India who came to CCF to do a 1-year fellowship to learn more. I think it's fine for that, to learn additional skills to then take back to a 3rd world country.

The fact that we're discussing whether to do this fellowship or go jobless for a recent grad (and that people seem to be OK with doing a fellowship instead of going jobless) speaks volumes for how we've all crumbled. Radiology, here we come!

 

[medgator]

It's existed previously. I know of at least one Rad Onc from India who came to CCF to do a 1-year fellowship to learn more. I think it's fine for that, to learn additional skills to then take back to a 3rd world country.

The fact that we're discussing whether to do this fellowship or go jobless for a recent grad (and that people seem to be OK with doing a fellowship instead of going jobless) speaks volumes for how we've all crumbled. Radiology, here we come!

Radiology sounds like it is on the up and up lately... I'm concerned we may heading more towards pathology if things remain on course the next few years (between hypo-fx and the shameless expansion in spots).

 

[RickyScott]

It's existed previously. I know of at least one Rad Onc from India who came to CCF to do a 1-year fellowship to learn more. I think it's fine for that, to learn additional skills to then take back to a 3rd world country.

The fact that we're discussing whether to do this fellowship or go jobless for a recent grad (and that people seem to be OK with doing a fellowship instead of going jobless) speaks volumes for how we've all crumbled. Radiology, here we come!

Regarding Fellowship: lets not kid ourselves-what techniques does an Indian have to gain from coming here? (other than cultural experience of spending year in the us) There are plenty of truebeams/eclipse/elekta in India and they have larger/higher volume centers? Everyone in the world has similar machine platforms and computer planning. Everything is on the internet... I think they come over here, and write a paper or 2 to establish some prestige at home, but I am not sure why they should gain much educationally.

 

[seper]

Foreigners who seek a fellowship that requires patient-contact privileges ultimately want a job in the US. I know personally a few that took this route.

Regarding Fellowship: lets not kid ourselves-what techniques does an Indian have to gain from coming here? (other than cultural experience of spending year in the us) There are plenty of truebeams/eclipse/elekta in India and they have larger/higher volume centers? Everyone in the world has similar machine platforms and computer planning. Everything is on the internet... I think they come over here, and write a paper or 2 to establish some prestige at home, but I am not sure why they should gain much educationally.

 

[RickyScott]

so do I.

 

[seper]

Hopefully, you gained much educationally.

 

[evilbooyaa]

Regarding Fellowship: lets not kid ourselves-what techniques does an Indian have to gain from coming here? (other than cultural experience of spending year in the us) There are plenty of truebeams/eclipse/elekta in India and they have larger/higher volume centers? Everyone in the world has similar machine platforms and computer planning. Everything is on the internet... I think they come over here, and write a paper or 2 to establish some prestige at home, but I am not sure why they should gain much educationally.

Did you see the most recent Indian published trial? - http://ascopubs.org/doi/full/10.1200/JCO.2017.74.9457

A trial at a large tertiary referral center in a big city in India treated head and neck cancer adjuvantly. 1 patient out of 300 received IMRT. The other 299 received 2D-RT (using a conventional simulator).

You really think there's nothing to learn with the technological advances in the means of how we treat with radiation that are present in this country compared to a 3rd world country? Even relatively recent trials from Europe are using 3D-CRT.

I wonder how much SRS/SBRT they're doing in India? If I had zero exposure to IMRT/SRS/SBRT I'd definitely consider going somewhere to learn some techniques with (at least stated) a goal of bringing that capability back to my facility.

Of course we're all aware of the non-US trained fellowship (or multiple) --> attending loophole that was jumped through frequently in the past. However, hasn't that been closed and the only way to become BC/BE is to complete a US rad onc residency? If not, we should probably start there, outside of those that have been grandfathered in.

 

[RickyScott]

in a lot of poorer countries, many public hospitals have inadequate, 40 year old technology, but the wealthy centers have every bell and whistle, and while 800 million Indians/Chinese may only have access to cobalt/old linacs, there are probably 200 mill+ that can afford everything we have.
I see a lot of pts who were treated at private centers in "s-hole" countries and when they bring records, it always amazes me how current everything is, sometimes more so than what I have. Ehtically, I sometimes tell them not to waste their money over here.

 

[deleted18755]

in a lot of poorer countries, many public hospitals have inadequate, 40 year old technology, but the wealthy centers have every bell and whistle, and while 800 million Indians/Chinese may only have access to cobalt/old linacs, there are probably 200 mill+ that can afford everything we have.
I see a lot of pts who were treated at private centers in "s-hole" countries and when they bring records, it always amazes me how current everything is, sometimes more so than what I have. Ehtically, I sometimes tell them not to waste their money over here.

I don’t know about China but in India it’s more like 30% have access to nothing (not even pain meds), 69%have access to cobalt/2D planning and administration, and 1% pay cash for Tomotherapy, Truebeams, etc for simple bone mets.

I have family who trained or at least practiced in the US for decades and then returned to India to practice for a few years before retiring and they describe volunteering in government hospitals where people are actively dying/laying in rows of beds in an open air gymnasium without even a curtain for privacy then working in private clinics where people show up with briefcases full of US cash like in the movies and get private rooms nicer than anything you’d see in the US (and often transfer to the UK or Dubai or Singapore afterwards). Crazy

 

[medgator]

I don’t know about China but in India it’s more like 30% have access to nothing (not even pain meds), 69%have access to cobalt/2D planning and administration, and 1% pay cash for Tomotherapy, Truebeams, etc for simple bone mets.

I have family who trained or at least practiced in the US for decades and then returned to India to practice for a few years before retiring and they describe volunteering in government hospitals where people are actively dying/laying in rows of beds in an open air gymnasium without even a curtain for privacy then working in private clinics where people show up with briefcases full of US cash like in the movies and get private rooms nicer than anything you’d see in the US (and often transfer to the UK or Dubai or Singapore afterwards). Crazy

All true. And you pay as you go in those private clinics of course...

 

[nkmiami]

I think the larger point is that knowledge has been significantly democratized in our specialty over the past 10 years. As was said before, today with the internet, many books, forums,econtouring resources and the fact that most departments have similar technology platforms, the difference in training between programs has really narrowed. (the world is flat..) Together with the fact that almost all residents are highly motivated achievers, fellowship has become an increasingly worthless proposition for Americans and much of the world.

It is similar to med school education- do you think Harvard provides significantly better med school/resident training than a midwestern state school. (It may have better research etc and more "polished" students/residents on average.) Again, I want to contrast this with when I was a resident in the early 2000s and there were 2 text books, astro tapes, no electronic journals, and a lot of individual institutional variability in planning techniques/ways of approaching cases. You relied more on the faculty to train you. I did not even know about NCCN guidelines when I was a resident. Many top centers had homegrown planning systems and technologies/techniques and there were also some really weak people in the field.

I know absolutely nothing about Arkansas or West Virginia, but I am sure they are just as capable of treating/training lung or brain stereo with a truebeam as a top 3 cancer center. The residents will learn from forums like this, the astro videos, nccn guidelines , electronic journals, contouring seminars and programs etc, and the sad reality of the present situation, is that high caliber docs are going to enter these programs, receive good training and some will likely languish in fellowships/derm rads/urorads....

 

[DrfluffyMD]

I find it hard to believe that radonc cannot come up with fellowship that is truly value added.

 

[medgator]

I find it hard to believe that radonc cannot come up with fellowship that is truly value added.

Brachy, peds, protons.

I would add that imo fellowships are really more useful if you are seeking to go into academics to focus on one of the above areas. I see no point to them for private practice outside of making up for deficient training in a subsite or something

 

[nkmiami]

I find it hard to believe that radonc cannot come up with fellowship that is truly value added.

Save peds or brachy, I cant see how a resident would receive deficient training, unless they were unmotivated.

 

[medgator]

Save peds or brachy, I cant see how a resident would receive deficient training, unless they were unmotivated.

Some residencies are located in areas where they have aggressive derms, dealing with private urorads groups etc. in addition to the brachy and peds issues you already brought up. Kinda makes you wonder why the ACGME isn't focusing on deficient programs rather than letting all these new ones open up, but I digress....

 

[deleted18755]

Some residencies are located in areas where they have aggressive derms, dealing with private urorads groups etc. in addition to the brachy and peds issues you already brought up. Kinda makes you wonder why the ACGME isn't focusing on deficient programs rather than letting all these new ones open up, but I digress....

I honestly didn’t know that was the case and never thought about it. It seems ridiculous that somebody could finish a four year residency but not know how to treat prostate cancer because the major academic center where they trained did not receive enough cases (because they all went to the local urorad down the street) but if that couldn’t be resolved then a few months of elective time someplace else should be plenty (and a week long elective or an afternoon in the library in the case of non brachy skin cancer).

 

[evilbooyaa]

Brachy, peds, protons.

I would add that imo fellowships are really more useful if you are seeking to go into academics to focus on one of the above areas. I see no point to them for private practice outside of making up for deficient training in a subsite or something

To me brachy should have sufficient exposure in residency that you should feel comfortable doing it asn attending without a fellowship. Peds and Protons I agree with.

 

[medgator]

To me brachy should have sufficient exposure in residency that you should feel comfortable doing it asn attending without a fellowship. Peds and Protons I agree with.

There's data to show that prostate brachy decreased in usage since the turn of the century, probably related to lots of factors (not the least of which is reimbursement...bundled payments may bring it back again, along with the high risk data).

Gyn brachy, sarcoma brachy, h&n brachy (I did all three in training) really depend on those specialists being in the hospital system where your residency is located.

I agree though, I think it would help curtail this unnecessary expansion in spots if we could hold programs accountable for providing decent brachy training at their institutions

 

[medgator]

https://www.redjournal.org/article/S0360-3016(18)30685-0/fulltext

Of all graduates who did fellowships in protons, pediatrics, or brachytherapy, 63% held jobs using these skills, versus 37% who did not (P = .0559).

Limitations of this analysis are that the data presented are mostly self-reported by programs or found via online search engines and thus subject to recall and selection bias. Additionally, without official accreditation, the transient nature of some fellowship programs may subject the analysis to under-ascertainment of fellowship graduates. Importantly, these data do not address the motivation for pursuing a fellowship, nor the satisfaction of fellowship graduates with their additional training, nor the readiness of residency graduates in these areas of subspecialization, nor the “quality” or quantity of job offers after fellowship. In the setting of well-documented residency and fellowship expansion, RO geographic maldistribution, and a potential looming oversupply of radiation oncologists (1, 5, 6, 7), further study of the motivation for fellowship training in RO would be of interest

 

[medgator]

A fellowship by any other name?

Thoracic Radiation Oncology Instructor

This will be a mentored junior attending position

 

[RadOncDoc21]

A fellowship by any other name?

Thoracic Radiation Oncology Instructor

Yikes!

 

[evilbooyaa]

A fellowship by any other name?

Thoracic Radiation Oncology Instructor

As long as they pay over 200k I'm sure people will sign up for it. Of course I'm sure they're offering less than 100k salary to live in Palo Alto.

 

[medgator]

As long as they pay over 200k I'm sure people will sign up for it. Of course I'm sure they're offering less than 100k salary to live in Palo Alto.

Should be more than enough for ramen and a microwave, after rent

 

[Gfunk6]

Maybe one of the attendings will help you defray costs by letting you camp in the backyard?

Bay Area Man Rents Camping Tent in Backyard at $900 a Month

 

[KHE88]

Board certification is required, huh? And here I was hoping there would be more fellowships for the 1/3 of us who failed our bio boards this year and are incompetent to practice according to the ABR!

ABR, can you guys work on getting some rad bio fellowships for us? Teach us the real important rad bio stuff so we will be competent to fill these mentored junior positions treating palliative cases.

 

[radiaterMike]

Not sure I understand the problem with this. Stanford, like MGH and some other academic institutions start faculty off at the instructor level. Usually this is for a short duration before being promoted to assistant professor. Board certification is NOT required but being at least board eligible is (which includes all graduating residents - even those who failed rad bio). The pay probably sucks but that is not a new phenomenon with coastal academic positions. It wouldn’t be PGY6 pay though. For all of the griping about no jobs being available in ‘desirable’ locations, this should be a little reassuring.

 

[RadOncDoc21]

“To call a rose by another name would smell as sweet.”

-Juliet Capulet

 

[RO2019]

Not sure I understand the problem with this. Stanford, like MGH and some other academic institutions start faculty off at the instructor level. Usually this is for a short duration before being promoted to assistant professor. Board certification is NOT required but being at least board eligible is (which includes all graduating residents - even those who failed rad bio). The pay probably sucks but that is not a new phenomenon with coastal academic positions. It wouldn’t be PGY6 pay though. For all of the griping about no jobs being available in ‘desirable’ locations, this should be a little reassuring.

I agree, I thought the same.

The issue would of course be fairly low pay for living in Palo Alto, but this doesn't seem to be exploitative in any way nor a fellowship, nor anything new. Like you said clinical instructor has been a known thing for a long time.

 

[nkmiami]

I agree, I thought the same.

The issue would of course be fairly low pay for living in Palo Alto, but this doesn't seem to be exploitative in any way nor a fellowship, nor anything new. Like you said clinical instructor has been a known thing for a long time.

I would agree the position may not be inherently exploitative, but I recall they do offer a "head and neck" fellowship, which I would argue is a disgrace. Have been out of the loop for a while, but I thought that the Harvards and Stanfords had gotten away from " instructors", or just issued the title until board certification, so it may be reappearing as a way to knock down salaries?

EDIT: after reading the description, it sounds like a fellowship as it is a 2 year position: "This will be a mentored junior attending position that offers a focused experience in advanced Thoracic Radiation Oncology, including 4-D image-guided radiation Therapy with a particular emphasis on stereotactic ablative radiotherapy."
Couldnt you teach a first year resident (or a random person off the street) this stuff in 2-3 weeks?
This is better than a fellowship for Stanford, because you can pay 100-150k and the doc will bill and see pts on his own.

 

[fiji128]

I saw the ad this morning and was wondering is this a real attending job or an advanced resident who can sign off on plans and other paper work job. When they mention mentoring I assumed the later. If the pay is not enough to afford a reasonable life style in the Bay Area and service your student loan debt I would have severe reservation about it.

 

[RickyScott]

I saw the ad this morning and was wondering is this a real attending job or an advanced resident who can sign off on plans and other paper work job. When they mention mentoring I assumed the later. If the pay is not enough to afford a reasonable life style in the Bay Area and service your student loan debt I would have severe reservation about it.

It is for "up to 2 years," during which Billy W Loo will teach you how to contour a nodule the correct way, the Stanford way.

 

[RadOncDoc21]

Do they use quadratic or linear interpolation for their contours? I never learned which one to use in residency. That might be worth two years,

 

[seper]

I'd do it if my spouse is pulling real tech wages in the area

 

[KHE88]

In other fields when there have been simultaneous concerns about overtraining, quality of education, and a poor job market, this has led to creation of fellowships paid at PGY levels to the point where one's only real option out of residency is fellowship (or sometimes multiple fellowships). There is a real push by some leaders in our field to expand the prevalence and scope of fellowships. We already have concerns about over training and a poor job market, and now there is an apparent effort by the ABR to fabricate a perception of poor education quality and resident aptitude, especially at small programs without access to "recalls" needed to pass the ridiculous bio and physics exam this year.

Yes, the Stanford position does not appear to be a true fellowship, but it's concerning and can only fuel the biased argument that we are not trained well enough to practice independently out of residency so that we need to create more fellowships and sub-assistant level faculty positions, which are financially exploitative. I think it is correct to be on the constant lookout for this kind of behavior in our field as there is no reason we couldn't possibly slip down this slope that other fields have in the past.

 

[evilbooyaa]

^ I think most people are being facetious in saying that this is not a predatory job.

Places like Stanford can offer to this and still get some schmuck who really wants to live in SF for < 100k a year. It's a joke and a failure of leadership to the residents, but the chairpeople of rad onc departments and their corporate overlords love it. Just like they love expanding residencies. It's not even limited to just academics - see the private practice that started a proton fellowship

 

[nkmiami]

A fellow/instructor must be worth his weight in platinum there. Stanford charges private insurers $25,000 for a pediatric mri (see below) including 16,000+ for the technical scan. What are they charging for lung stereo?

The problem is the prices

 

[RickyScott]

A fellow/instructor must be worth his weight in platinum there. Stanford charges private insurers $25,000 for a pediatric mri (see below) including 16,000+ for the technical scan. What are they charging for lung stereo?

The problem is the prices

probably 70,000-80,000 based on answer on mednet about what mayo charges and financial toxicity. Health care bills are a/the leading cause of bankruptcy (even among the insured) destroying millions of families. This doesnt exist in the rest of the world. Dont want to go too far off topic, but the large academic/monopolistic systems, prices, expanding fellowships and residencies- all represented by ASTRO- are interwoven. None of this is in our interest or good for society.

Do Medical Bills Really Bankrupt America's Families?