ASTRO Town Hall Discussion (Poll % on site)

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Necessary percent of time on site for RadOncs

  • 100%

  • 90%

  • 75%

  • 50%

  • 25%

  • 10%

  • 0%

Results are only viewable after voting.
TheWallnerus said:
But, Chicken Little, the sky didn’t fall. For more than 4 years CMS converted the majority of rad onc from direct to general. CMS “review[ed] the codes” in the meantime. The wRVUs did not drop; wRVUs don’t make up the majority of radiation oncology reimbursement anyways… and to really blow people’s minds, CMS values many rad onc codes not by MD presence but by therapist presence (different topic for a different day).

People make a lot of proclamations and predictions around this supervision thing that are easily showable not to be the case.

(But, take the concept of CMS having an opportunity to “cut prices” and lower reimbursement to rad onc given ubiquitous virtual and general supervision as feasible. Welp. That’s now. That’s here. Feasibility fait accompli. Do you think CMS wants to countenance the chance of giving up that opportunity on the basis of some inchoate safety arguments from ASTRO? Arguments they have specifically rejected in 2019 e.g.? Ha.)
Click to expand...


4 years. That’s it. That’s nothing. 3 of which were during the peak of Covid.
 
drowsy12 said:
4 years. That’s it. That’s nothing. 3 of which were during the peak of Covid.
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That’s a long peak. And the direct to general shift had zilch to do with COVID, and CMS never had any reimbursement talk coupled with that shift. And CMS never telegraphed any desire to fiddle with reimbursement in general supervision CAHs pre 2020. Linacs will cost the same and have the same use factors regardless of MD supervision levels.

ALSO… IGRT was under personal supervision from 2006 (when the code first appeared) to 2009. When CMS changed the supervision to a lower direct, the wRVU didn’t change at all. Probably the safety of IGRT was worse though 😉
 
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TheWallnerus said:
That’s a long peak. And the direct to general shift had zilch to do with COVID, and CMS never had any reimbursement talk coupled with that shift. And CMS never telegraphed any desire to fiddle with reimbursement in general supervision CAHs pre 2020. Linacs will cost the same and have the same use factors regardless of MD supervision levels.

ALSO… IGRT was under personal supervision from 2006 (when the code first appeared) to 2009. When CMS changed the supervision to a lower direct, the wRVU didn’t change at all. Probably the safety of IGRT was worse though 😉
Click to expand...

Maybe you’re right that we have no reason to worry.

I take a more conservative view. I’m also very sensitive to the fact that we have super favorable billing codes and RVU equivalents. This should not be taken for granted and should continuously be protected.

Though I don’t pay any dues to AMA, ASTRO, or ACRO, when I did in the past, that was the reason I cared to pay, as we do need to continue to protect the codes. These codes are the only reason any of us enjoys the professional lives that we all do.
 
drowsy12 said:
Maybe you’re right that we have no reason to worry.

I take a more conservative view. I’m also very sensitive to the fact that we have super favorable billing codes and RVU equivalents. This should not be taken for granted and should continuously be protected.

Though I don’t pay any dues to AMA, ASTRO, or ACRO, when I did in the past, that was the reason I cared to pay, as we do need to continue to protect the codes. These codes are the only reason any of us enjoys the professional lives that we all do.
Click to expand...
How do we have "super favorable billing codes"?

You mean in the sense that "cognitive" codes are generally valued less than procedural codes? Or something more specific?

Our codes are a bargain basement deal already.
 
drowsy12 said:
Maybe you’re right that we have no reason to worry.

I take a more conservative view. I’m also very sensitive to the fact that we have super favorable billing codes and RVU equivalents. This should not be taken for granted and should continuously be protected.

Though I don’t pay any dues to AMA, ASTRO, or ACRO, when I did in the past, that was the reason I cared to pay, as we do need to continue to protect the codes. These codes are the only reason any of us enjoys the professional lives that we all do.
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Well they have sucked at maintaining reimbursement right? Much data has been produced showing that CMS has cut rad onc reimbursement by 20% or so the last 20 years.

And ASTRO is concerned about 77427 reimbursement. Again… ha. The biggest cut to 77427 in rad onc has been hypofractionation (citations can be provided on request).
 
elementaryschooleconomics said:
How do we have "super favorable billing codes"?

You mean in the sense that "cognitive" codes are generally valued less than procedural codes? Or something more specific?

Our codes are a bargain basement deal already.
Click to expand...

Not only are procedural codes billed better than cognitive codes, our specific procedures are incredibly in our favor when you compare an 20/5 bone met to other procedures, such as idk, complex IR biopsies or total laryngectomies with reconstruction.
 
drowsy12 said:
Maybe you’re right that we have no reason to worry.

I take a more conservative view. I’m also very sensitive to the fact that we have super favorable billing codes and RVU equivalents. This should not be taken for granted and should continuously be protected.

Though I don’t pay any dues to AMA, ASTRO, or ACRO, when I did in the past, that was the reason I cared to pay, as we do need to continue to protect the codes. These codes are the only reason any of us enjoys the professional lives that we all do.
Click to expand...
Salaries of employed radonc are not based on professional codes.
 
drowsy12 said:
specific procedures are incredibly in our favor when you compare an 20/5 bone met to other procedures, such as idk, complex IR biopsies or total laryngectomies with reconstruction.
Click to expand...
Because of machine costs and other tangibles

Not because of supervision!
 
TheWallnerus said:
But, Chicken Little, the sky didn’t fall. For more than 4 years CMS converted the majority of rad onc from direct to general. CMS “review[ed] the codes” in the meantime. The wRVUs did not drop; wRVUs don’t make up the majority of radiation oncology reimbursement anyways*… and to really blow people’s minds, CMS values many rad onc codes not by MD presence but by therapist presence (different topic for a different day).

People make a lot of proclamations and predictions around this supervision thing that are easily showable not to be the case.

(But, take the concept of CMS having an opportunity to “cut prices” and lower reimbursement to rad onc given ubiquitous virtual and general supervision as feasible. Welp. That’s now. That’s here. Feasibility fait accompli. Do you think CMS wants to countenance the chance of giving up that opportunity on the basis of some inchoate safety arguments from ASTRO? Arguments they have specifically rejected in 2019 e.g.? Ha.)

* the reimbursement for IMRT, a technical/non wRVU charge and rad onc’s most important money-maker, had fallen >50% in the era of 100% direct supervision
Click to expand...
IMRT dropped quickly as it skyrocketed on the list of CMS costs. If you are on the top, you are the target. To CMS credit, IMRT also got easier over time with less equipment/time necessary.

I actually think you pointing to IMRT is pretty analogous to my point. If things get easier, CMS will drop individual wRVUs. How long to get to this point with IMRT? It is not crazy to see CMS start to drop rad onc code 2 to 5 percent down per year.

We are definitely early in this cycle.
 
udrag14 said:
My total comp is based on professional codes. Most have a wRVU target for their salary. If that changes, comp will have to adjust.
Click to expand...

Kind of both are right, no? The common contract is based on RVUs and it’s also not.

The $/RVU is whatever they want it to be, “they”, the surveys and companies and “market”.

The target is the same.

I know someone who got a pay cut to “bring them to market median”. Haha ok, what? This person wasn’t even that mad because they were previously “overpaid”.

So many quotes. I’m sure CMS rates could impact pay, but it may for some and not for others. Certainly for most (employed) rad oncs, that company filter has a big impact.
 
udrag14 said:
My total comp is based on professional codes. Most have a wRVU target for their salary. If that changes, comp will have to adjust.
Click to expand...
Not really. Your total comp is based on supply and demand and then $/rvu are adjusted. That’s why psych may have the same salary as you with 3500 rvus, and ortho paid a lot more with 8k rvus.
 
forums.studentdoctor.net

How much do you make in a year as a psychiatrist?

I think a lot of people get this wrong. Everything is negotiable. You do not have to automatically give your agent 3% to sell your home. Have a multi million dollar home in a nice area? You think you can't tell your agent to take a hike and then find someone else willing to sell your home for 2...
forums.studentdoctor.net forums.studentdoctor.net


Lets have clarity about the things we speak about



 
drowsy12 said:
forums.studentdoctor.net

How much do you make in a year as a psychiatrist?

I think a lot of people get this wrong. Everything is negotiable. You do not have to automatically give your agent 3% to sell your home. Have a multi million dollar home in a nice area? You think you can't tell your agent to take a hike and then find someone else willing to sell your home for 2...
forums.studentdoctor.net forums.studentdoctor.net


Lets have clarity about the things we speak about
Click to expand...
Psych is less desirable locations- where most radonc jobs are available- earns around 400k. Anyway, supply and demand underlies prices/salaries at the end of the day.
 
RickyScott said:
Psych is less desirable locations- where most radonc jobs are available- earns around 400k in
Click to expand...

And you are saying that rad oncs working in undesirable locations should expect to make 400k, and I would disagree.
 
udrag14 said:
I actually think you pointing to IMRT is pretty analogous to my point. If things get easier, CMS will drop individual wRVUs.
Click to expand...
When you talk about IMRT and wRVU about the only thing you can talk about is CPT 77301.

In 2003, 77301 had 8.00 wRVUs, reimbursing ~$392.

In 2023, 77301 had 7.99 wRVUs, reimbursing ~$423.

Search the Physician Fee Schedule | CMS

www.cms.gov www.cms.gov
 
drowsy12 said:
And you are saying that rad oncs working in undesirable locations should expect to make 400k, and I would disagree.
Click to expand...
My main point is your salary is much more linked to Astro pumping out residents than cms adjusting proffesional reimbursements. In fact, technical is so high for many large academic centers, that salaries wouldn’t be impacted if proffesional went to O.
 
RickyScott said:
My main point is your salary is much more linked to Astro pumping out residents than cms adjusting proffesional reimbursements. In fact, technical is so high for many large academic centers, that salaries wouldn’t be impacted if proffesional went to O.
Click to expand...
1712415037187.png
 
TheWallnerus said:
When you talk about IMRT and wRVU about the only thing you can talk about is CPT 77301.

In 2003, 77301 had 8.00 wRVUs, reimbursing ~$392.

In 2023, 77301 had 7.99 wRVUs, reimbursing ~$423.

Search the Physician Fee Schedule | CMS

www.cms.gov www.cms.gov
Click to expand...

$392 in 2003 equals $643.14 in 2023 when adjusted for inflation. In other words we lost about 55% of revenue for that code.​

 
One answer in @CurbYourExpectations poll that was not present is 40% on site. The LCD for IMRT for TX, CO, NJ, and a few other states says a rad onc needs to provide direct supervision 40% of the time (2 days a week) and see OTVs at least once a week. And check/sign IGRT images before the next fraction or within 24 hours. This LCD has been in place since 2021.
 
Can you imagine if ASTRo and ACRO poured as much effort into demonstrating our value (relative to other oncologic specialties, particularly med onc and their associated costly, yet minimally effective drugs) and hammering the fact that we’ve already taken the largest (?) reimbursement cut in medicine over the past two decades?

These should be the only talking points. Nothing else. We do good work. We don’t cost much. We’ve been decimated by cuts. Give us a raise.
 
Cuts to zero don’t matter apparently. Find a new slant.
 
drowsy12 said:
Cuts to zero don’t matter apparently. Find a new slant.
Click to expand...

Cuts matter. Its important to talk about them specifically though, and in context to other medical specialities. That is how everyone else talks about them. A good example that includes Rad Onc is United Specialists for Patient Access showing how freestanding offices of procedural based specialties have suffered more than others in recent years. United Specialists for Patient Access

Note I am not arguing we should all start talking and caring about freestanding, Im just giving an example.

A vague fear of future cuts, "trust me bro", does not matter to anyone.

Mandelin Rain said:
Can you imagine if ASTRo and ACRO poured as much effort into demonstrating our value (relative to other oncologic specialties, particularly med onc and their associated costly, yet minimally effective drugs) and hammering the fact that we’ve already taken the largest (?) reimbursement cut in medicine over the past two decades?

These should be the only talking points. Nothing else. We do good work. We don’t cost much. We’ve been decimated by cuts. Give us a raise.
Click to expand...

If you really care about cuts to our codes, you should realize that it is inherently subjective and political. You should listen to @Mandelin Rain.
 
NotMattSpraker said:
If you really care about cuts to our codes, you should realize that it is inherently subjective and political.
Click to expand...

yes as I have been saying.

protecting our role is of the utmost importance. how this is defined is wildly subjective, clearly, across disciplines. But what is consistent is physician effort, which is defined in specific ways. The ways in which this is defined and the analyses that CMS does are in part based on human time.


my point was directed to Ricky Scott's point saying that all that matters is supply and demand however and that pro fees could be cut to zero with minimal impact to salaries.

some of you are only coming at this from the perspective of personal grievances with ASTRO or their former bosses. I really could care less about that aspect of it.
 
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Reaganite said:
I think you should be on site as much as you need to be, and I don't think there's a set % for that. I personally support the current system with the option for virtual direct and telehealth OTV without specified percentages. I think it's the cleanest and gives a lot less wiggle room for disgruntled therapists and staff to try to pull a qui tam on you. I don't want to be reported for being on site only 89% of the time. I trust the majority of rad oncs are smart and ethical enough to determine the appropriate level of on site supervision for their practice. I have no concerns about massive proliferation of telehealth-only rad onc practices because I believe, as others have stated here, that cancer patients want to see their doctors in person and a telehealth-only operation is going to be at a significant competitive disadvantage in most geographies. Even at the height of COVID, I was still doing 90+ % of my consults in person at patients' requests. I just want the option to leave my clinic for tumor boards, maybe make a dentist appointment, leave a little early on a Friday afternoon, etc. without fear of being reported for fraud. More than anything, though, I want those pompous pricks at ASTRO to fail.
Click to expand...
They have been failing plenty. Urologists and rad oncs can still own linacs together, CMS still went to general/virtual, ASTRO was dragged into considering payment bundles now after the freestanding community had been begging for them for decades etc.

Wrong side on everything. Supervision will turn out to be no different
 
drowsy12 said:
yes as I have been saying.

protecting our role is of the utmost importance. how this is defined is wildly subjective, clearly, across disciplines. But what is consistent is physician effort, which is defined in specific ways. The ways in which this is defined and the analyses that CMS does are in part based on human time.


my point was directed to Ricky Scott's point saying that all that matters is supply and demand however and that pro fees could be cut to zero with minimal impact to salaries.
Click to expand...
Human time and effort, not human location. I literally could virtual at home all morning and never leave my desk/multi monitor workstation

And if ASTRO cared about our role, a free pass would not be given to APPs now and potential advanced RTTs in the future
 
drowsy12 said:
yes as I have been saying.

protecting our role is of the utmost importance. how this is defined is wildly subjective, clearly, across disciplines. But what is consistent is physician effort, which is defined in specific ways. The ways in which this is defined and the analyses that CMS does are in part based on human time.


my point was directed to Ricky Scott's point saying that all that matters is supply and demand however and that pro fees could be cut to zero with minimal impact to salaries.

some of you are only coming at this from the perspective of personal grievances with ASTRO or their former bosses. I really could care less about that aspect of it.
Click to expand...

No. I really strongly dislike current ASTRO leadership but I think you are also misunderstanding the point that others are making.

ASTRO is not making an argument about our value, they are feigning an argument about quality and safety because they are worried about our job security and pay, just very broadly defined. In this argument, they say things like "we are facing a serious threat of cuts". The one time Sameer personally called me, he spent a long time trying to convince me that if 77263 is cut, I will personally be harmed.

The simplest way to put it is that the RUC/Medicare RVU per CPT is a factor but not the only factor that determines how I am paid. Similar to most ROs, I am employed with a salary plus a $/RVU production bonus that is completely made up by my company. They can change this at any time for any reason. If RVUs go down, the ratio can go up to maintain my salary or not. If RVUs go up but they realize the market is flooded with rad oncs, they can drop the ratio and still hire just fine.

My point is that it all matters in a complicated way and it varies broadly for rad oncs across the US because most RO's pay is not directly defined by CMS.

You better believe our internal discussion of supervision considered many things around safety, quality, and work life balance, but also what it might do to FTE and that ratio.

I do not feel that ASTRO has communicated their understanding that this is how it works for employed Rad Oncs, the majority of the speciality.

Their argument about cuts is fearmongering that does not even directly apply to most ROs unless they add some specificity to their argument.
 
To be clear - I agree that none of this has been clearly defined or explained. The point is that this is not about safety.

I don't have any skin in the game with ASTRO, but I agree with the other posters who have said that ASTRO is coming at this from the point of view of protecting the role of the rad onc, whether it is a good idea or not. But they aren't framing it as such for obvious reasons.

As has been posted a lot on this forum - some of us here are worried about the implications of making it easier for places to hire fewer physicians as well as the way in which CMS will respond.

I just took a gander at the Diagnostic Rads forum and there are posts where it is being openly discussed that the rise in pay right now because of increased studies being ordered will be counteracted with CMS cuts. This is the story we have seen over the last 30 years. Ask GI docs from the early 90s about colonoscopies. When something is made much easier or more commonly ordered, CMS cuts. I could be wrong, I totally admit that, but to me, when I envision what an admin in the government thinks, I can't imagine they like the idea of a doctor being paid the same to oversee things from home rather than have to spend human capital and time to be present. That's my thought on the matter.

We are all just shooting the **** and theorizing.

I will tell you that I agree with you that payments and salaries are complicated and multi-factorial, but I do believe it is not JUST supply and demand. The favorable RVU assignments (which we know are totally arbitrary) to our work we do is why rad onc has been so well compensated for the last 30 years.
 
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TheWallnerus said:
But, Chicken Little, the sky didn’t fall. For more than 4 years CMS converted the majority of rad onc from direct to general. CMS “review[ed] the codes” in the meantime. The wRVUs did not drop; wRVUs don’t make up the majority of radiation oncology reimbursement anyways*… and to really blow people’s minds, CMS values many rad onc codes not by MD presence but by therapist presence (different topic for a different day).

People make a lot of proclamations and predictions around this supervision thing that are easily showable not to be the case.

(But, take the concept of CMS having an opportunity to “cut prices” and lower reimbursement to rad onc given ubiquitous virtual and general supervision as feasible. Welp. That’s now. That’s here. Feasibility fait accompli. Do you think CMS wants to countenance the chance of giving up that opportunity on the basis of some inchoate safety arguments from ASTRO? Arguments they have specifically rejected in 2019 e.g.? Ha.)

* the reimbursement for IMRT, a technical/non wRVU charge and rad onc’s most important money-maker, had fallen >50% in the era of 100% direct supervision
Click to expand...
This is such an important point that people seem to be glossing over. I don’t know if it’s because of the recent attention that Bridge Oncology has drawn or ASTRO’s fear mongering efforts, but the change in supervision requirement has been around for over four years and the sky has not fallen. There have been zero reports of safety related issues as result of the change in supervision. As someone else pointed out, the most public safety related issue in radiation oncology recently was the incident at GenesisCare where they treated the wrong breast. This has nothing to do with general versus direct supervision. Additionally, physicians are not running around abusing the supervision laws, at least to my understanding.

The other part that I don’t understand is this debate about 20% versus 40% versus 80% versus 90% direct supervision. There are two options - general versus direct supervision. If you’re OK with anything less than 100% on-site supervision, you’re a proponent of general. Physicians need to use their own judgment to determine what is appropriate and that will undeniably vary from one clinic to the next.
 
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drowsy12 said:
To be clear - I agree that none of this has been clearly defined or explained. The point is that this is not about safety.

I don't have any skin in the game with ASTRO, but I agree with the other posters who have said that ASTRO is coming at this from the point of view of protecting the role of the physician, whether it is a good idea or not. But they aren't framing it as such for obvious reasons.
Click to expand...
Why can’t the “role of the physician” be to oversee four rural centers with the aid of virtual supervision and make 2 million a year while doing so.

Some very smart, ethical, well-intentioned rad oncs have seen this as a role.

"In China they are working on 'washing machine' radiation. Four buttons will do the treatment with a remote doctor: one doctor, 70 clinics, 70 million people."

 
drowsy12 said:
To be clear - I agree that none of this has been clearly defined or explained. The point is that this is not about safety.

I don't have any skin in the game with ASTRO, but I agree with the other posters who have said that ASTRO is coming at this from the point of view of protecting the role of the physician, whether it is a good idea or not. But they aren't framing it as such for obvious reasons.
Click to expand...
The idea that ASTRO is trying to protect the role of radiation oncologists is a fallacy. If ASTRO cared about protecting the role of rad oncs, the simple solution would be not to overtrain our specialty as other specialties have succeeded in doing and have thereby maintained their roles, their job markets, and their competitiveness.
 
radoncle said:
The idea that ASTRO is trying to protect the role of radiation oncologists is a fallacy. If ASTRO cared about protecting the role of rad oncs, the simple solution would be not to overtrain our specialty as other specialties have succeeded in doing and have thereby maintained their roles, their job markets, and their competitiveness.
Click to expand...

Of course we shouldn’t over train.

But I don’t see how one thing being bad means that we can’t also not do another bad thing.
 
TheWallnerus said:
Why can’t the “role of the physician” be to oversee four rural centers with the aid of virtual supervision and make 2 million a year while doing so.

Some very smart, ethical, well-intentioned rad oncs have seen this as a role.

"In China they are working on 'washing machine' radiation. Four buttons will do the treatment with a remote doctor: one doctor, 70 clinics, 70 million people."

Click to expand...


Sure maybe. But that also means making a bunch of unemployed rad oncs in the process.

The comparisons to residency expansion are apt. The collective vs the individual.

Ultimately what you describe is the way it may end up becoming in the future, but I’ll tell you what - the rad onc won’t make 2 million.

Don’t make me laugh!

Ask an anesthesiologist how this works.
 
drowsy12 said:
Of course we shouldn’t over train.

But I don’t see how one thing being bad means that we can’t also not do another bad thing.
Click to expand...
ASTRO has clear conflicts of interest. They’ve expressly stated and made policies suggesting that palliative radiation should not take place in the community and should be directed to self proclaimed experts at academic centers. They have also suggested that proton being radiation offered at academic centers provides superior care to photon radiation delivered in the community without any clinical evidence to support this. Do you genuinely think they care about the solo docs practicing in the community? Or do you think they would prefer perhaps for every patient to drive whatever the distance may be to the closest academic center and receive treatment? I don’t see this behavior of academics claiming superiority over the community physicians or trying to end community practices to this degree in any other specialty. This is uniquely a radiation oncology issue.
 
radoncle said:
ASTRO has clear conflicts of interest. They’ve expressly stated and made policies suggesting that palliative radiation should not take place in the community and should be directed to self proclaimed experts at academic centers. They have also suggested that proton being radiation offered at academic centers provides superior care to photon radiation delivered in the community without any clinical evidence to support this. Do you genuinely think they care about the solo docs practicing in the community? Or do you think they would prefer perhaps for every patient to drive whatever the distance may be to the closest academic center and receive treatment? I don’t see this behavior of academics claiming superiority over the community physicians or trying to end community practices to this degree in any other specialty. This is uniquely a radiation oncology issue.
Click to expand...


This is what I mean by talking about unrelated issues and grievances. I don’t make the connection for any of those issues to this current topic.

But just to clarify:

1) I don’t agree with palliative radiation networks (was this even an ASTRO thing? Or are we just conflating things)
2) I don’t think patients need to drive to academic centers
3) I don’t think patients need proton therapy

My only bias is that I and many of my friends work in nice jobs that could no longer exist if virtual supervision was taken to its full extent, as TheWallnernus outlines above
 
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radoncle said:
I don’t see this behavior of academics claiming superiority over the community physicians to this degree in any other specialty
Click to expand...
ASTRO's harping on "rural rad onc" recently struck me as some clever, subconscious propaganda. The "rural rad onc" is the clear opposite of the urban, citified, academic rad onc.

The words "villager" and "villain" share a surprisingly common etymology. In Middle English, there was a "villein": a village peasant enslaved to a feudal lord... a farmer working the land whose toil and efforts ultimately flowed upward to the aristocracy. Over time, "villein" became not just a rural peasant but a "very bad hombre" (in the vernacular of Trump), an evil-doer, etc.

A villein... a villain... someone not in the city... a villager... a rural rad onc.
 
Join Luh who I have the utmost respect for is the voice of rural rad onc for ASTRO as far as I am concerned and was publicly vocal about the negative impact of the RO-APM as was planned at the time.
 
drowsy12 said:
This is what I mean by talking about unrelated issues and grievances. I don’t make the connection for any of those issues to this current topic.
Click to expand...
Maybe you should, they are more connected than you realize.

ASTROs initial letter from Michalski was a direct slap in the face of rural rad onc, no blanket exemption or nuance was made in it to address them at all. Rural rad onc centers closing benefits urban centers (where many ASTRO-member docs practice)
 
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TheWallnerus said:
ASTRO's harping on "rural rad onc" recently struck me as some clever, subconscious propaganda. The "rural rad onc" is the clear opposite of the urban, citified, academic rad onc.

The words "villager" and "villain" share a surprisingly common etymology. In Middle English, there was a "villein": a village peasant enslaved to a feudal lord... a farmer working the land whose toil and efforts ultimately flowed upward to the aristocracy. Over time, "villein" became not just a rural peasant but a "very bad hombre" (in the vernacular of Trump), an evil-doer, etc.

A villein... a villain... someone not in the city... a villager... a rural rad onc.
Click to expand...
And yet when pressed, ASTRO didn’t have a clear answer to what defines a center as rural. This seems critical if you’re holding these centers to a different set of rules (not sure why safety would be less important in one center versus another if we’re to believe their argument that direct supervision is for safety purposes).
 
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radoncle said:
And yet when pressed, ASTRO didn’t have a clear answer to what defines a center as rural. This seems critical if you’re treating holding these centers to a different set of rules (not sure why safety would be less important in one center versus another if we’re to believe their argument, that direct supervision is for safety purposes).
Click to expand...
ASTRO didn't really have any answers.

They're more of a "shoot first and hope no one hears the sound" kind of organization.
 
The argument is completely disingenuous.

It’s either safe or not.

It’s not okay to be safe 80% or 90% of the time. Or only be safe in certain geographies while accepting unsafe in others.

Literally no one saying this crap believes it.

They made a mess of the job market and rather than address the mechanism that made the mess, they’d prefer to do something completely stupid.
 
Mandelin Rain said:
The argument is completely disingenuous.

It’s either safe or not.

It’s not okay to be safe 80% or 90% of the time. Or only be safe in certain geographies while accepting unsafe in others.

Literally no one saying this crap believes it.

They made a mess of the job market and rather than address the mechanism that made the mess, they’d prefer to do something completely stupid.
Click to expand...
Was is last year that Michalski/wash u added a resident so that they would have 4 for every class?
 
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