ASTRO should censure these 3 MSKCC attendings

[scarbrtj]

I fancy myself a proximal seminal vesicle prostate cancer expert.

As we all know there is a vas deferens between a seminal vesicle prostate cancer expert and a testicular cancer expert.

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[Mandelin Rain]

I'd posit that if you start your career as a metastatic only doc for the first 5 years of practice or something, you should never be able to treat a definitive case. Ever. You're done. You've pigeon -holed yourself into strictly palliative cases.

 

[OTN]

I just don’t understand why academic radoncs can treat only such a narrow window of disease. Are they incompetent?

It’s concerning. Perhaps we pp docs need to get a consortium of groups together to determine which academic centers are worthy of tertiary referrals.

We could call it CRAAP: Community Radoncs Assessing Academic Practices, but I’m open to other ideas.

 

[Chartreuse Wombat]

I just don’t understand why academic radoncs can treat only such a narrow window of disease. Are they incompetent?

It’s concerning. Perhaps we pp docs need to get a consortium of groups together to determine which academic centers are worthy of tertiary referrals.

We could call it CRAAP: Community Radoncs Assessing Academic Practices, but I’m open to other ideas.

****- Society to Hate on Incompetent Radiation Therapists

I know Therapist no longer means MD but I am old and the acronym works better

 

[scarbrtj]

****- Society to Hate on Incompetent Radiation Therapists

I know Therapist no longer means MD but I am old and the acronym works better

Society to Hate on Antediluvian Radiation Therapists

 

[Lamount]

I just don’t understand why academic radoncs can treat only such a narrow window of disease. Are they incompetent?

It’s concerning. Perhaps we pp docs need to get a consortium of groups together to determine which academic centers are worthy of tertiary referrals.

We could call it CRAAP: Community Radoncs Assessing Academic Practices, but I’m open to other ideas.

Personally, I stick with thoracic because I always get all of those orifices confused

 

[radOresident]

I just don’t understand why academic radoncs can treat only such a narrow window of disease. Are they incompetent?

exclusive photo of every academic radiation oncologist:

 

[medgator]

exclusive photo of every academic radiation oncologist:

View attachment 330371

Still remember when Bruce Haffty came out as a visiting professor one time... Flat out admitted he couldn't treat anything except breast, save an early glottic or something

 

[FrostyHammer]

I just don’t understand why academic radoncs can treat only such a narrow window of disease. Are they incompetent?

It’s concerning. Perhaps we pp docs need to get a consortium of groups together to determine which academic centers are worthy of tertiary referrals.

We could call it CRAAP: Community Radoncs Assessing Academic Practices, but I’m open to other ideas.

Nice acronym... To be a bit more blunt, the occasion calls for something more like Bloodthirsty & Irritated Radoncs Yelling at Academic Networks & Institutions

 

[drewdog1973]

I sure miss @KHE88. I hope he’s enjoying a flavorful biryani or maybe some kibbee out there in the sticks, with his dump truck full of money

 

[Ray D. Ayshun]

I sure miss @KHE88. I hope he’s enjoying a flavorful biryani or maybe some kibbee out there in the sticks, with his dump truck full of money

I hope that he doesn't lose his nose to frostbite during this arctic blast.

 

[RadOncDoc21]

I hope that he doesn't lose his nose to frostbite during this arctic blast.

I just hope he’s wearing a mask, maybe that will also protect his nose!

 

[Ray D. Ayshun]

I just hope he’s wearing a mask, maybe that will also protect his nose!

That was my way of saying that without using the m-word.

 

[elementaryschooleconomics]

Still remember when Bruce Haffty came out as a visiting professor one time... Flat out admitted he couldn't treat anything except breast, save an early glottic or something

Arno Mundt gave a talk through ASTRO/ARRO/ACRO/one of those groups last year (as a webinar). He said the same thing, something to the extent of "I don't know how these satellite generalists do it, I can only keep up with one or two sites".

 

[OTN]

Being able to treat multiple sites and know so much about the anatomy and physiology of the entire body, along with being sure to know enough to converse intelligently with various sub specialists, has always been one of my favorite parts of the job. Keeping up with all the literature in all sites is also fun, for me at least.

I would not have gone into radonc if one disease site were the only way to practice.

 

[speakeroftruth]

I don't think there is anything wrong with treating one disease site in academics as long as it is "true academics" and the rad onc is doing quality research to push the field forward (and not gaslighting med students to spend a whole year to pump out retrospective chart reviews). It is a huge caveat because we all know what most of academic rad onc jobs have become - basically full time clinical work with an academic title while being paid far less than your professional collections while you scramble to get your minor league retrospective chart review research into a one of the $2500 "open access" rad onc journals. If I sound bitter, I might be. And I'll be the first to admit that my CV is littered with crap retrospective research.

The whole idea of academic rad onc is the research side and to develop things such as quality genomic tests to help us make good clinical decisions or new techniques to expand RT indications. For example, the development of cardiac SBRT is complicated, expensive, requires care coordination, and special expertise. It can initially cost more (than the revenue it brings in) to develop something like cardiac SBRT until all the issues are worked out. This is something that should be developed in academic centers, standardized/streamlined, and then pushed to the private practice/community rad oncs so that we can all offer it to all our patients. And that is why a "true academic" rad onc should only have a disease site or two - they need the time and mental space to help push our field forward by doing quality research.

I would estimate that probably 5-8% of academic rad oncs are doing good, quality work. If you think that number is low, I don't count the 231 middle authors on FLASH, cardiac SBRT, or Decipher papers. Let's be honest, there are a few great minds pushing those forward and trust me, it is not the various catfish middle authors on those papers.

What are the rest doing? Playing the academic game. Pumping low quality papers and dumping crap onto reviewers to sift through. Taking the easy way out and running the "easy" rad onc trials (see more on that below). Don't even get me started on the promotions game.

Also, let's acknowledge that due to geographic restrictions, some people need to be in certain places. And in many places increasingly, academic depts have bought local private practices and employed more and more rad oncs. This has allowed depts to take the technical (which they own and should take) and 30-50% of the professional fee (which is straight up stealing from the physician) and they are often the highest costs centers in town. And then some gaslighters write a paper on the financial toxicity of parking fees when they are one of the 11 PPS-exempt sites and thus able to charge insane rates - the hypocrisy and irony are so thick, you can taste it. I digress - then the dept, flush with cash, can hire even more rad oncs at their main site to do "research" or least people who profess who want to do "research" but inevitably realize how difficult it is to do quality work and settle for the easiest investigator initiated trials to slide by the IRB -- RT omission, hypofrac (ultra-hypofrac vs hypofrac is all the rage these days), and quality of life studies. So let's not blame all academics because there are truly some people who just have to be in a certain area for personal/family reasons and we should be sympathetic to that.

Another example of a bad academic practice is essentially a university buying the private practice group or deciding to employ physicians. The problem is, the university should then invest into making it a real academic dept. Instead, they skim the technical and professional fees to divert it to other parts of the university. One example of UTennessee which is also an embarrassingly bad training program and no student should rank it. The difference between the academic practice in the paragraph above is that those places are somewhat or are truly a real academic dept that is just getting greedy and abusing its position in the local market. The UTennessee example is just the university getting greedy and it is not a real academic place by any definition. Both are deplorable but deplorable in different ways.

It hurts to see people make fun of academic rad onc but much of it is deserved. We should continue to call out all the mouth-breathing boomer chairs and so-called "leaders" that are slowly killing our field. Remember that rad onc back in the day did not attract the best as we did ~5 years ago. In fact, many med students didn't know it existed. So the "leaders" in our field today and most current chairs are nowhere near the cream of the crop. Sure, they worked hard and played the academic game better than most but look at their CVs and you'll see a lot of fluff. I would venture that many of them wouldn't even have match ~5 years ago when applicant quality was extremely high. Talk to them and you'll find it awkward because many seem to be on the spectrum and you'll find them to be very ordinary and not particularly bright. Very, very few are true leaders and/or visionaries and it is killing our field.

Edit: Added the paragraph about UTennesssee.

 

[deleted969641]

academic depts have bought local private practices and employed more and more rad oncs. This has allowed depts to take the technical (which they own and should take) and 30-50% of the professional fee (which is straight up stealing from the physician)

This is exactly what I came here to yell about! Great, great post. And it's not just academic departments. Community hospitals now want in on the scam too (which has been entirely a deliberate creation of and by the academic departments through wanton manipulation of residency complements). When I was a resident, at no point did I have the opportunity to learn how rad oncs generate income. It wasn't until the very end of residency when I learned that there was a difference between technical and professional billing. It wasn't until I was out in practice that I learned that the salary and "benefits" I was offered did not even come close to what my professional collections would be and I learned that rad oncs who are not employed are collecting professional fees on their own, and that my employer had been lying to me when they told me the upper limit of my salary was governed by Stark law and earning beyond a certain MGMA percentile was somehow "illegal" regardless of what your professional collections are. I am very sure that I was not alone in being so ignorant/naive when I graduated.

I want all residents to know that they are entitled to all of their professional collections. That is why the payment is split between the professional fee and the facility fee. If the tables turned and there was an undersupply of rad oncs, it would be no more right of me to try and grab some of the facility's fee than it is for them to steal half of my professional fee. They only get away with this through the employment model where they do the billing for you. Hence the shift to podunk hospitals cutting independent physician contracts or buying out end of career private practice rad oncs and posting "new grads welcome" employment ads in Marshfield, WI. Don't take these jobs! If you must, then only do so with an agreement to transparently be compensated with a fixed percentage of your collections (ideally 100% minus the value of whatever your benefits are) without any b.s. RVU/base salary. This will result in income in the 700k - 1200k range. Academic salaries are lower because the amount of clinical work is lower. Yet academic departments want to pay pseudoacademic rad oncs with 30 patients on beam an academic salary. And the dimwit MBAs that run community hospitals now think that applies to their rad onc that is treating 40 as well. Academic salaries for everyone! The scam only works as long we let it. New grads working for hospitals should push as hard as possible for collections-based compensation models. Hospitals shouldn't be surprised when candidates reject their pathetic salary models and ask questions about professional collections. They should expect it.

 

[scarbrtj]

This is exactly what I came here to yell about! Great, great post. And it's not just academic departments. Community hospitals now want in on the scam too (which has been entirely a deliberate creation of and by the academic departments through wanton manipulation of residency complements). When I was a resident, at no point did I have the opportunity to learn how rad oncs generate income. It wasn't until the very end of residency when I learned that there was a difference between technical and professional billing. It wasn't until I was out in practice that I learned that the salary and "benefits" I was offered did not even come close to what my professional collections would be and I learned that rad oncs who are not employed are collecting professional fees on their own, and that my employer had been lying to me when they told me the upper limit of my salary was governed by Stark law and earning beyond a certain MGMA percentile was somehow "illegal" regardless of what your professional collections are. I am very sure that I was not alone in being so ignorant/naive when I graduated.

I want all residents to know that they are entitled to all of their professional collections. That is why the payment is split between the professional fee and the facility fee. If the tables turned and there was an undersupply of rad oncs, it would be no more right of me to try and grab some of the facility's fee than it is for them to steal half of my professional fee. They only get away with this through the employment model where they do the billing for you. Hence the shift to podunk hospitals cutting independent physician contracts or buying out end of career private practice rad oncs and posting "new grads welcome" employment ads in Marshfield, WI. Don't take these jobs! If you must, then only do so with an agreement to transparently be compensated with a fixed percentage of your collections (ideally 100% minus the value of whatever your benefits are) without any b.s. RVU/base salary. This will result in income in the 700k - 1200k range. Academic salaries are lower because the amount of clinical work is lower. Yet academic departments want to pay pseudoacademic rad oncs with 30 patients on beam an academic salary. And the dimwit MBAs that run community hospitals now think that applies to their rad onc that is treating 40 as well. Academic salaries for everyone! The scam only works as long we let it. New grads working for hospitals should push as hard as possible for collections-based compensation models. Hospitals shouldn't be surprised when candidates reject their pathetic salary models and ask questions about professional collections. They should expect it.

You and @speakeroftruth need to petition @evilbooyaa for stickies IMHO. It may not stem the rising tide of people (rightly) desperate for jobs, but it may abate the information asymmetry problem (see: a lot of "Adam Ruins Everything" episodes).

 

[communitydoc13]

Finally got to read the whole article. Impossible to give it a fair shake after reading this thread but definitely no censure worthy stuff IMO.

Rooted in my own insecurities as a community doc is that I am acutely aware that this type of piece does not get published in this type of place unless it is coming from an august institution. (Even good public academic places probably not getting this published.)

I am also skeptical of making a center like MSKCC a "referral hub" for the vast majority of metastatic cases. I routinely share patients with big tertiary centers and there are certain metastatic patients where I look for guidance and options from them. These are almost uniformly the type of patients who preferentially end up at these places to begin with (relatively young, have resources, have maintained PS through multiple lines or protracted systemic therapy). At present, very rarely does the intervention at these places result in a meaningful change in clinical endpoints like OS, PFS or pain relief. It does however provide psychological value to these patients in knowing that "they have turned over every leaf" as they face the inexorable progression of their disease.

It is only possible once you are in the community to appreciate the level of patient selection that goes into the population that shows up at large tertiary centers, actively pursues experimental care and travels far for care. The non-oncologic factors attributable to these patients is enough to result in notable differences in outcomes relative to the patient who prefers care in their community independent of the care given.

I have no problem whatsoever with MSKCC having a dedicated and discrete metastatic disease program. They have excellent basic science programs dedicated to understanding metastases and integrating these programs The Alan and Sandra Gerry Metastasis and Tumor Ecosystems Center with translational and early clinical radonc initiatives is the only way that we will ever get a solid scientific narrative that lets us say "yes, treating the primary site or high volume metastatic niches impacts natural history of cancer in the metastatic setting". The only really good data for this IMO is in prostate cancer, but this question impacts everything we do, from consolidating lymphomas, to SABRing oligomets, to RNI in locally advanced breast cancer. It is maybe the most important question going forward for radiation oncologists to address as I foresee the future of cancer care being driven by two intellectual viewpoints: first, that many early stage cancers are overtreated and second that cancer should be approached as a chronic disease with an emphasis on incremental and minimally toxic therapies.

Hopefully MSKCC will help us all out.

 

[medgator]

I learned that rad oncs who are not employed are collecting professional fees on their own, and that my employer had been lying to me when they told me the upper limit of my salary was governed by Stark law and earning beyond a certain MGMA percentile was somehow "illegal" regardless of what your professional collections are. I am very sure that I was not alone in being so ignorant/naive when I graduated.

I want all residents to know that they are entitled to all of their professional collections. That is why the payment is split between the professional fee and the facility fee. If the tables turned and there was an undersupply of rad oncs, it would be no more right of me to try and grab some of the facility's fee than it is for them to steal half of my professional fee. They only get away with this through the employment model where they do the billing for you. Hence the shift to podunk hospitals cutting independent physician contracts or buying out end of career private practice rad oncs and posting "new grads welcome" employment ads in Marshfield, WI. Don't take these jobs! If you must, then only do so with an agreement to transparently be compensated with a fixed percentage of your collections (ideally 100% minus the value of whatever your benefits are) without any b.s. RVU/base salary. This will result in income in the 700k - 1200k range. Academic salaries are lower because the amount of clinical work is lower. Yet academic departments want to pay pseudoacademic rad oncs with 30 patients on beam an academic salary. And the dimwit MBAs that run community hospitals now think that applies to their rad onc that is treating 40 as well. Academic salaries for everyone! The scam only works as long we let it. New grads working for hospitals should push as hard as possible for collections-based compensation models. Hospitals shouldn't be surprised when candidates reject their pathetic salary models and ask questions about professional collections. They should expect it.

Back in the day when we were closer to a balance/undersupply, sometimes the rad onc in a podunk hospital situation would get incentivized with a generous % of the global collections (which essentially had the effect of kicking a little technical into the reimbursement).

Not anymore when we are graduating 190+ annually

 

[RadOncG]

I want all residents to know that they are entitled to all of their professional collections.

The sentiment is nice and learning about billing is useful but the quoted statement is false. The labor market is based on supply and demand not "fairness."

We should advocate for ourselves and also expect that the hospital system will do the same. To come into a competitive job offer in a good location and tell them "what I am entitled to" would be unwise.

 

[seper]

Still remember when Bruce Haffty came out as a visiting professor one time... Flat out admitted he couldn't treat anything except breast, save an early glottic or something

Life does funny things sometimes. I know for a fact he was forced to do GYN brachy for a while, circa 2016-17.

 

[deleted969641]

Back in the day when we were closer to a balance/undersupply, sometimes the rad onc in a podunk hospital situation would get incentivized with a generous % of the global collections.

Not anymore when we are graduating 190+ annually

At this point, even in previously difficult-to-recruit areas, you'd be lucky to find a place that pays you anywhere near your actual collections. Not only that, forget about money at this point, but actually treats you well and supports you with what you need to do your job well. Staff members actually respect you because you were valuable and they knew their jobs would be on the line if they pissed off the hard to replace physician. Oh how the tables have turned. Now the physician is in trouble if he pisses off the dosimetrist or department manager, or god forbid his executive overlords upstairs. It used to be that subspecialists like us were valuable and they would do anything to retain us. Now it's like "We know you've done well and been happy here, but here's a new deal of what you will do for us and here's how you will practice. Don't like it? There's the door! We're fine with permalocums for a year or two until somebody else takes our deal."

A theme I've noticed is blaming the grads of lower-tier programs for the rapidly deteriorating job market, leverage to negotiate fair deals, and decline in revenue to established rad oncs through increased competition and dilution of patient volume. I can understand holding a grudge from people who graduate from lower tier programs in the 20s as match data provides pretty damning evidence that these people are lower quality students without much if any interest in rad onc. But I hope that we can remember that those of us who trained in the approximately 2008-2018 peak decade were a different story. All excellent med students, even those who went to bottom tier programs, and didn't go in with the knowledge of the obvious oversupply and inevitability of being taken advantage of in the future because of it. I'd hope this is considered for those of who making lateral career moves in the future. I don't think the residency you trained at matters anymore in terms of aptitude when you're applying for a new job 10 years out, but obviously it does to some I guess just as a marketing feature. For aptitude, maybe year of graduation is a better indicator/screening tool. I think we'll see a trend to the best jobs getting filled by those with 5+ years experience and the expectation that everyone's first job will just suck. And it will just snowball with god awful employers not expecting new hires to stay more than a few years and becoming even more awful as they become totally unconcerned about turnover as they know they have a steady stream of plentiful new grads they can abuse and underpay while they pay their dues and wait for the doors to open to the decent jobs.

 

[speakeroftruth]

But I hope that we can remember that those of us who trained in the approximately 2008-2018 peak decade were a different story.

Absolutely. I might even extend that to the graduating residents of lower ranked programs to 2022. As of 2023, I will think what would #23 Michael Jordan do? He sure as hell wouldn't go into rad onc.

As I have said elsewhere, being a great rad onc is 90% the individual. Going to a great training program can enhance already great baseline qualities but it can't make a crappy doctor who doesn't care into someone who suddenly cares. And if someone went to a lesser known program, it doesn't matter because if you are hardworking and care about your patients, you'll be a great rad onc. As a society, we probably put too much emphasis on pedigree. And as we've seen more recently with the very valid job market concerns, a natural extension of those job market fears is to focus attention on the big name programs (even though there are many other considerations to hiring other than where you trained). Pre-2023, I don't give a f*ck where you went to residency as long as you really care about your patients, are willing to continue learning, can take feedback without getting offended, and are a collegial, affable colleague. And if you love biryani, even better.

For those residents graduating from lower ranked programs in 2023 and beyond, we will have to seriously question not only their clinical ability as an oncologist but their basic ability to make decisions as a human being living in a society. It does not bode well for a future colleague if they ignored all the warning signs and decided to rank or SOAP into a "hell pit" program (citation: @thecarbonionangle) - MUSC, Northwell/North Shore, Columbia, Cornell, NY Methodist, SUNY Brooklyn, SUNY Upstate, Allegheny, Baylor, Texas A&M (Baylor Scott & White), UTHSCSA, Arkansas, Oklahoma, Louisville, Kentucky, Tennessee, Kansas, West Virginia, Jefferson, Kaiser, UC Irvine. I'm probably missing a few as the list seems to keep expanding every year.

 

[deleted969641]

The sentiment is nice and learning about billing is useful but the quoted statement is false. The labor market is based on supply and demand not "fairness."

We should advocate for ourselves and also expect that the hospital system will do the same. To come into a competitive job offer in a good location and tell them "what I am entitled to" would be unwise.

Sure... in a truly free market. But we're not operating in a truly free market. If you want to practice independently, there are enormous institutionally manufactured hurdles to overcome to do it. It some cases it is just impossible. The only way to practice our craft is rapidly becoming through participating in this racket and working for a large hospital system as an employee at some administrator's mercy. Nobody has advocated for us. ASTRO has been a total failure for the majority of rad oncs. You would think that hospital systems skimming the payments intended to go to the physician for his/her service would be something that the profession's national organization would lobby to prevent/fix.

It is absolutely fair game to ask about collections and inquire about the difference between your proposed income and projected collections. Is there a mutual understanding that you will put in some sweat equity and have your income gradually ramped up to your true collections over time? Or will they just permanently skim. You can, and should, ask them if they think that's fair and why, and then decided if that's fair to you. While the word entitled has a bad sound to it, I agree, it is true inasmuch that it is literally the intent of the professional fee for the service to be paid to the professional (you). Not collected on behalf of and skimmed by a middleman. The degree of pro fee skimming that goes on in rad onc is obscenely disproportionate compared to other specialties. We are seen as low hanging fruit with a lot of fat that can be trimmed to pay for other inefficiencies in the system (countless 400k admin and 1.5 mil CEO salaries for starters). I think you misunderstood my point. It was not that residents should demand to eat what they kill in initial negotiations and then throw a hissy fit when they are offered a flat 350k salary no matter how much work they do. My point was that everyone should understand what's going on here and act accordingly.

This could be ameliorated with legislation that prevents hospitals from directly employing doctors and billing for their professional services or a least a professional organization that gives a god damn about the future of the profession for the vast majority of its practitioners (won't happen).

 

[RadOncG]

My point was that everyone should understand what's going on here and act accordingly.

Agree. And some may decide that being employed is their best option.

Decreasing utilization of RT is huge risk for professional billers only. Just as there are hospital systems that skim professional fees there are also ones that pay more than professional fees alone would generate because they understand the technical fee benefits.

Not as clear cut as employment=bad and independent professional billing=good.

 

[deleted969641]

Agree. And some may decide that being employed is their best option.

Decreasing utilization of RT is huge risk for professional billers only. Just as there are hospital systems that skim professional fees there are also ones that pay more than professional fees alone would generate because they understand the technical fee benefits.

Not as clear cut as employment=bad and independent professional billing=good.

I have not seen this, but I've heard a few stories. My understanding is that doing that would be actually in violation of Stark Law. The whole thing is just so much cleaner when pro billing is out of the hospital's hands and you can employ yourself and decide what benefits make sense for you.

The reason is that professional reimbursement for rad onc services really adds up when treating even moderately above average patient load.

The rule of thumb I was taught would put an average patient load of 20 with collections just above 1 million. I have not seen hospitals offering anywhere near that much and there are reports of hospitals paying higher than this suffering whistleblower lawsuits. Perhaps this is a somewhat outdated ROT, especially with recently enacted cuts. But it seems that you still almost always come out ahead (anybody with a specific example/data otherwise, please prove me wrong). Unless you're treating 10 patients or less, it's highly unlikely that the hospital is paying you in excess of your pro collections with an MGMA median salary.

Agree with your comments on decreasing utilizations as a threat to pro fee only rad oncs. Other factors that would make this less desirable is the trend for hospitals to suddenly cut these contracts and advertise for an employee. It would suck to join a pro fee only group where you don't get collections until after 2 years, then have the contract cut and be offered permanent employment at your pre-partnership salary indefinitely. Still, given the choice of that risk vs. willfully signing up for employment, I'd take the former any day unless we are talking about some place where the location truly is worth it. Marshfield, WI? No. GTFO. Market is not bad enough (yet) to let Marshfield skim 50%.

 

[thecarbonionangle]

Absolutely. I might even extend that to the graduating residents of lower ranked programs to 2022. As of 2023, I will think what would #23 Michael Jordan do? He sure as hell wouldn't go into rad onc.

As I have said elsewhere, being a great rad onc is 90% the individual. Going to a great training program can enhance already great baseline qualities but it can't make a crappy doctor who doesn't care into someone who suddenly cares. And if someone went to a lesser known program, it doesn't matter because if you are hardworking and care about your patients, you'll be a great rad onc. As a society, we probably put too much emphasis on pedigree. And as we've seen more recently with the very valid job market concerns, a natural extension of those job market fears is to focus attention on the big name programs (even though there are many other considerations to hiring other than where you trained). Pre-2023, I don't give a f*ck where you went to residency as long as you really care about your patients, are willing to continue learning, can take feedback without getting offended, and are a collegial, affable colleague. And if you love biryani, even better.

For those residents graduating from lower ranked programs in 2023 and beyond, we will have to seriously question not only their clinical ability as an oncologist but their basic ability to make decisions as a human being living in a society. It does not bode well for a future colleague if they ignored all the warning signs and decided to rank or SOAP into a "hell pit" program (citation: @thecarbonionangle) - MUSC, Northwell/North Shore, Columbia, Cornell, NY Methodist, SUNY Brooklyn, SUNY Upstate, Allegheny, Baylor, Texas A&M (Baylor Scott & White), UTHSCSA, Arkansas, Oklahoma, Louisville, Kentucky, Tennessee, Kansas, West Virginia, Jefferson, Kaiser, UC Irvine. I'm probably missing a few as the list seems to keep expanding every year.

Refer to original bad residency experience thread for full list.

applicants you have been warned.

 

[RadOncG]

My understanding is that doing that would be actually in violation of Stark Law.

No Stark law in this situation refers to paying above fair market value for reasons such as the referral business you provide downstream i.e. the imaging you order for example. Fair market value is established via MGMA, AAMC and others. As you have mentioned above it is often misinterpreted as a negotiation strategy by hospitals.

average patient load of 20 with collections just above 1 million.

Would be nice but no. Off by hundreds of thousands pending payors, how much sbrt/srs, brachy etc. but not this high unless your 20 on treat is all sbrt.

Unless you're treating 10 patients or less, it's highly unlikely that the hospital is paying you in excess of your pro collections with an MGMA median salary.

Many small departments at this volume. They don't pay their radiation oncologist 200k. Exactly 50% of radiation oncologists are treating less than the average radiation oncologist.

I think we agree in general. It is just not this simplistic. There are different levels of risk for each type of employment. So it should make sense that independent pro fee groups should make more on average than employee and facility owner should make more than either.

 

[RadOncMegatron]

I don't think there is anything wrong with treating one disease site in academics as long as it is "true academics" and the rad onc is doing quality research to push the field forward (and not gaslighting med students to spend a whole year to pump out retrospective chart reviews). It is a huge caveat because we all know what most of academic rad onc jobs have become - basically full time clinical work with an academic title while being paid far less than your professional collections while you scramble to get your minor league retrospective chart review research into a one of the $2500 "open access" rad onc journals. If I sound bitter, I might be. And I'll be the first to admit that my CV is littered with crap retrospective research.

The whole idea of academic rad onc is the research side and to develop things such as quality genomic tests to help us make good clinical decisions or new techniques to expand RT indications. For example, the development of cardiac SBRT is complicated, expensive, requires care coordination, and special expertise. It can initially cost more (than the revenue it brings in) to develop something like cardiac SBRT until all the issues are worked out. This is something that should be developed in academic centers, standardized/streamlined, and then pushed to the private practice/community rad oncs so that we can all offer it to all our patients. And that is why a "true academic" rad onc should only have a disease site or two - they need the time and mental space to help push our field forward by doing quality research.

I would estimate that probably 5-8% of academic rad oncs are doing good, quality work. If you think that number is low, I don't count the 231 middle authors on FLASH, cardiac SBRT, or Decipher papers. Let's be honest, there are a few great minds pushing those forward and trust me, it is not the various catfish middle authors on those papers.

What are the rest doing? Playing the academic game. Pumping low quality papers and dumping crap onto reviewers to sift through. Taking the easy way out and running the "easy" rad onc trials (see more on that below). Don't even get me started on the promotions game.

Also, let's acknowledge that due to geographic restrictions, some people need to be in certain places. And in many places increasingly, academic depts have bought local private practices and employed more and more rad oncs. This has allowed depts to take the technical (which they own and should take) and 30-50% of the professional fee (which is straight up stealing from the physician) and they are often the highest costs centers in town. And then some gaslighters write a paper on the financial toxicity of parking fees when they are one of the 11 PPS-exempt sites and thus able to charge insane rates - the hypocrisy and irony are so thick, you can taste it. I digress - then the dept, flush with cash, can hire even more rad oncs at their main site to do "research" or least people who profess who want to do "research" but inevitably realize how difficult it is to do quality work and settle for the easiest investigator initiated trials to slide by the IRB -- RT omission, hypofrac (ultra-hypofrac vs hypofrac is all the rage these days), and quality of life studies. So let's not blame all academics because there are truly some people who just have to be in a certain area for personal/family reasons and we should be sympathetic to that.

Another example of a bad academic practice is essentially a university buying the private practice group or deciding to employ physicians. The problem is, the university should then invest into making it a real academic dept. Instead, they skim the technical and professional fees to divert it to other parts of the university. One example of UTennessee which is also an embarrassingly bad training program and no student should rank it. The difference between the academic practice in the paragraph above is that those places are somewhat or are truly a real academic dept that is just getting greedy and abusing its position in the local market. The UTennessee example is just the university getting greedy and it is not a real academic place by any definition. Both are deplorable but deplorable in different ways.

It hurts to see people make fun of academic rad onc but much of it is deserved. We should continue to call out all the mouth-breathing boomer chairs and so-called "leaders" that are slowly killing our field. Remember that rad onc back in the day did not attract the best as we did ~5 years ago. In fact, many med students didn't know it existed. So the "leaders" in our field today and most current chairs are nowhere near the cream of the crop. Sure, they worked hard and played the academic game better than most but look at their CVs and you'll see a lot of fluff. I would venture that many of them wouldn't even have match ~5 years ago when applicant quality was extremely high. Talk to them and you'll find it awkward because many seem to be on the spectrum and you'll find them to be very ordinary and not particularly bright. Very, very few are true leaders and/or visionaries and it is killing our field.

Edit: Added the paragraph about UTennesssee.

Beautifully written. I want to just add that the PP and Academic divide was once one of respect. Now, it seems for many of us it is a competition for the same pie of patients. The academics, are now being advertised by the universities marketing team (not the physicians' fault), as the best in the region. Academics now are a direct threat to the PP as they are being sold as the best in a particular field (you don't want to get treated by any old doctor, don't you want a specialist?). Since 99% of academics don't do worthwhile research (to be fair this is every field in academia), the hospital is branding their university docs as the best in the region, thus every patient who wants the best care should be treated at Univ of XYZ. Subspecialization is another way that academics can bolster that they are the best.

What really was concerning for us is that, ok maybe, we can concede for SRS for 10+ brain mets, brachytherapy, re-irradiation, or rare cases that academic institutions are better at, but for a PALLATIVE CARE NETWORK and metastatic sub-sub(-sub?)-speciality. There has to be a line that is too far to cross and we are seeing, as Charlie Murphy told Rick James, academics as habitual line steppers.

 

[deleted969641]

No Stark law in this situation refers to paying above fair market value for reasons such as the referral business you provide downstream i.e. the imaging you order for example. Fair market value is established via MGMA, AAMC and others. As you have mentioned above it is often misinterpreted as a negotiation strategy by hospitals.


Would be nice but no. Off by hundreds of thousands pending payors, how much sbrt/srs, brachy etc. but not this high unless your 20 on treat is all sbrt.


Many small departments at this volume. They don't pay their radiation oncologist 200k. Exactly 50% of radiation oncologists are treating less than the average radiation oncologist.

I think we agree in general. It is just not this simplistic. There are different levels of risk for each type of employment. So it should make sense that independent pro fee groups should make more on average than employee and facility owner should make more than either.

The ROT I'm using based on discussions with rad oncs that have done this is $4500 per patient per month. So 20 patients = $90,000/month = 1M/year. Obviously depends on a lot of factors like you mention as I have known rad oncs that generated above this amount with that number of patients and rad oncs that generated that amount but had 40 patients instead of 20. Maybe the ROT sucks. Regardless, I think we agree these numbers are going down and the ROT is going to suck even more.

The question I have is whether it's possible to actually violate stark law (commit medicare fraud) if your compensation from the hospital is less than your actual collections. Even if your compensation is at the 95th percentile (1 million?), if your collections were 1.3 million, I don't see how you wouldn't be in the clear. I have brought this up to hospitals only to be shot down and told that it doesn't matter, only MGMA matters in combination with some secret algorithm in a black box that an outside consultant signs off on, and the magic number is somewhere around the 75th percentile. My retort is that that means that 25% of rad oncs are violating stark law. To which I am showed the door if I don't like it at that point. To me it is overwhelmingly obvious that yes, this is a negotiating tactic used to trick rad oncs into accepting lower pay (hey, it's out of our hands because Stark Law) under the guise of trying to protect themselves legally by using an outside consultant that refuses to sign off on anything that exposes them to a shred of liability so set absurdly conservative limits. So is there any possible way that one could be found in violation of Stark Law with a compensation model as an employee that reimburses 90-95% of ones actual collections with a provision that total compensation including value of benefits cannot be greater than 100% of collections for the year? Hospitals say yes. I call b.s. but would be open to be proven wrong from someone with more legal knowledge than I. Obviously you can't be in violation of start law if you are billing and collecting on your own.

 

[RadOncG]

So is there any possible way that one could be found in violation of Stark Law with a compensation model as an employee that reimburses 90-95% of ones actual collections with a provision that total compensation including value of benefits cannot be greater than 100% of collections for the year?

Not an attorney but I say no. Hospitals are overly conservative for a variety of reasons but not the least of which is that it saves them money here.

There are clearly hospitals that pay more than professional collections. The 10 patient per day place in the middle of nowhere is not paying 300K which I think is a more reasonable estimate of professional fees (20 patient per day about 600K +/- 200k depending on treatment techniques used, payor mix, etc.)

 

[Reaganite]

The ROT I'm using based on discussions with rad oncs that have done this is $4500 per patient per month. So 20 patients = $90,000/month = 1M/year. Obviously depends on a lot of factors like you mention as I have known rad oncs that generated above this amount with that number of patients and rad oncs that generated that amount but had 40 patients instead of 20. Maybe the ROT sucks. Regardless, I think we agree these numbers are going down and the ROT is going to suck even more.

The question I have is whether it's possible to actually violate stark law (commit medicare fraud) if your compensation from the hospital is less than your actual collections. Even if your compensation is at the 95th percentile (1 million?), if your collections were 1.3 million, I don't see how you wouldn't be in the clear. I have brought this up to hospitals only to be shot down and told that it doesn't matter, only MGMA matters in combination with some secret algorithm in a black box that an outside consultant signs off on, and the magic number is somewhere around the 75th percentile. My retort is that that means that 25% of rad oncs are violating stark law. To which I am showed the door if I don't like it at that point. To me it is overwhelmingly obvious that yes, this is a negotiating tactic used to trick rad oncs into accepting lower pay (hey, it's out of our hands because Stark Law) under the guise of trying to protect themselves legally by using an outside consultant that refuses to sign off on anything that exposes them to a shred of liability so set absurdly conservative limits. So is there any possible way that one could be found in violation of Stark Law with a compensation model as an employee that reimburses 90-95% of ones actual collections with a provision that total compensation including value of benefits cannot be greater than 100% of collections for the year? Hospitals say yes. I call b.s. but would be open to be proven wrong from someone with more legal knowledge than I. Obviously you can't be in violation of start law if you are billing and collecting on your own.

20 on treatment per month is not the same as 20 new patients a month unless your average length of treatment is 1 month.. And there is no 1 month treatment I am aware of that generates 4500 in prof fees at 100% of medicare. Maybe 5 weeks of IMRT comes close? As others have said, this is all highly dependent on contracts, payor mix, types of treatments (IMRT vs. 3D vs SBRT). The range is enormously broad, and there is simply no absolute proportionate relationship that holds true to all geographies.

 

[RickyScott]

Not an attorney but I say no. Hospitals are overly conservative for a variety of reasons but not the least of which is that it saves them money here.

There are clearly hospitals that pay more than professional collections. The 10 patient per day place in the middle of nowhere is not paying 300K which I think is a more reasonable estimate of professional fees (20 patient per day about 600K +/- 200k depending on treatment techniques used, payor mix, etc.)

Very hard to know true professional collections as they can vary between 3 to 5+ x Medicare per recent price transparency. Obviously, large hospital systems that can negotiate 3-5x Medicare professional prices are not staffed by private groups. Hospitals risk stark violations in extreme cases where they are paying several standard deviations above average for that amount of work.

 

[ramsesthenice]

Life does funny things sometimes. I know for a fact he was forced to do GYN brachy for a while, circa 2016-17.

No lie, I know first hand at a top tier academic place physics caught a cylinder in a butt hole at the time of planning for a case being cross covered by an old timer. Im not talking about Bruce. But I don't want anyone who doesn't do brachy regularly near my suite.

 

[ramsesthenice]

The ROT I'm using based on discussions with rad oncs that have done this is $4500 per patient per month. So 20 patients = $90,000/month = 1M/year. Obviously depends on a lot of factors like you mention as I have known rad oncs that generated above this amount with that number of patients and rad oncs that generated that amount but had 40 patients instead of 20. Maybe the ROT sucks. Regardless, I think we agree these numbers are going down and the ROT is going to suck even more.

The question I have is whether it's possible to actually violate stark law (commit medicare fraud) if your compensation from the hospital is less than your actual collections. Even if your compensation is at the 95th percentile (1 million?), if your collections were 1.3 million, I don't see how you wouldn't be in the clear. I have brought this up to hospitals only to be shot down and told that it doesn't matter, only MGMA matters in combination with some secret algorithm in a black box that an outside consultant signs off on, and the magic number is somewhere around the 75th percentile. My retort is that that means that 25% of rad oncs are violating stark law. To which I am showed the door if I don't like it at that point. To me it is overwhelmingly obvious that yes, this is a negotiating tactic used to trick rad oncs into accepting lower pay (hey, it's out of our hands because Stark Law) under the guise of trying to protect themselves legally by using an outside consultant that refuses to sign off on anything that exposes them to a shred of liability so set absurdly conservative limits. So is there any possible way that one could be found in violation of Stark Law with a compensation model as an employee that reimburses 90-95% of ones actual collections with a provision that total compensation including value of benefits cannot be greater than 100% of collections for the year? Hospitals say yes. I call b.s. but would be open to be proven wrong from someone with more legal knowledge than I. Obviously you can't be in violation of start law if you are billing and collecting on your own.

I am bar none the worst kind of academic when it comes to this stuff. I started as the naive person that just wanted to treat patients and do my science. Curiosity is getting to me in this regard but it seems too late. I’ve read Flowers for Algernon and seen the Steven King adaptation Lawnmower Man. At some point a person is probably better off remaining oblivious ☹️

 

[scarbrtj]

I am bar none the worst kind of academic when it comes to this stuff. I started as the naive person that just wanted to treat patients and do my science. Curiosity is getting to me in this regard but it seems too late. I’ve read Flowers for Algernon and seen the Steven King adaptation Lawnmower Man. At some point a person is probably better off remaining oblivious ☹️

just a minor cinematic point of order

 

[ramsesthenice]

just a minor cinematic point of order

I had not seen this one. It honestly sounds like a little better take on the whole story.

But it makes my point. I enjoy my job. I am happy with how much I bring home. Deep down, I know my admins are like Charley’s “friends” who enjoy screwing the guy who is oblivious to their torment. Knowing the full extent of it without being willing to leave has no real upside.

 

[scarbrtj]

I had not seen this one. It honestly sounds like a little better take on the whole story.

But it makes my point. I enjoy my job. I am happy with how much I bring home. Deep down, I know my admins are like Charley’s “friends” who enjoy screwing the guy who is oblivious to their torment. Knowing the full extent of it without being willing to leave has no real upside.

Gives a real gut punch. Cliff Robertson aka Peter Parker's uncle aka "with great power comes great responsibility" won the Oscar that year for it.