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Yes. This was an Astro thing.
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ASTRO Town Hall Discussion (Poll % on site)
Started by CurbYourExpectations
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Yes. This was an Astro thing.
Gotta get those salaries down.
ASTRO continually asks themselves: “what’s the best thing for us big academic centers and how can we make the community centers pay for it?”
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I was extremely disappointed by ACRO’s representation and stance in this meeting. He clearly was in bed with ASTRO on this and perhaps much more.
Do you have a link?
I guess the part I’m confused by is how this helps major academic centers. If anything it would make it easier to centrally control more sites without having to worry about paying a doc for every site to chill and make a full salary with less than ten on beam.
If I’m a conspiracy theorist and believe that Astro expanded residencies to centrally
Control and depress physician salaries (does not pass the smell test for a second if you have spent any time with people in leadership, they aren’t that organized lol) then they should also want virtual supervision more than anyone else.
There’s an Academic center not too far from me that could take over some of the sites in our system easily and not have to worry about hiring us or as many of us if virtual supervision was taken to its full potential
Nah, the president of astro published the quiet part out loud over a decade ago. Linked physician salary to physician supply (a concept you can’t seem to grasp) via residency expansion in the Red Journal. While it likely wasn’t an organized effort, each site certainly saw it as beneficial to their self interest and so it went.
As to the other question, the academic centers need to make the community centers non viable so they can close them or take them over, Jack up the prices to profitable rates, and then staff them with some poor soul at 50% of 2013 salary. Once the competition is gone, I bet general supervision will suddenly become VERY safe.
As to the other question, the academic centers need to make the community centers non viable so they can close them or take them over, Jack up the prices to profitable rates, and then staff them with some poor soul at 50% of 2013 salary. Once the competition is gone, I bet general supervision will suddenly become VERY safe.
Couldn't actually tune in for the whole thing, really disappointing to hear though. Did they even come up with any kind of position statement that was concrete?
1) of course supply matters. What you seem to be missing is demand matters too.
2) ‘While it likely wasn’t an organized effort,’
Well that’s kind of the entire point. Which makes the grand cabal conspiracy theories sort of laughable.
So all of these random programs that opened over the last decade were just every chair out for themselves? Maybe. Prisoners dilemma? Maybe.
You don't think other chairs have the exact same mentality as Dennis hallahan at wash u?
Scarop is a clandestine and secretive organization that actively tries to obscure its proceedings and reports, @NotMattSpraker has discussed this before
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1. Artificial and disingenuous demand is tenuous demand, at best.
2. I doubt ASTRO sent out a missive stating “Increase your residencies now!” But I have no doubt that chairs discussed rising salaries in the 00s amongst themselves and figured that increasing supply was the best way to combat. They also engage in price fixing by sharing salary metrics ONLY amongst themselves. ASTRO just allowed a permission structure by shouting “anti trust” at anyone requesting work force analysis that is… until suddenly they stopped and did a work force analysis. No suit has been raised to my knowledge.
That ‘artificial and disingenuous’ demand has kept many of us employed for decades. I feel like I’m taking crazy pills here.
If some of you think you’re going to pull of what Wallnernus described with the 2 million dollar salary covering 4 sites - god speed.
If some of you think you’re going to pull of what Wallnernus described with the 2 million dollar salary covering 4 sites - god speed.
No one is thinking that. I've said it previously in this thread. Patients and referrings won't stand for it unless we are talking a single practice in a captive market in bfe. @TheWallnerus was being tongue-in-cheek about it, I think
There is no “conspiracy,” just a tragedy of the commons. Remember these guys expanded residencies more than every other specialty, making them a total outlier.
hospitals/groups will stop employing docs for redundancy/vacation. Ie centers that had 3 docs to cover 2 centers (for redundancy/vacation) will now only employ 2.
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Just a point of clarification. ASTRO and their leadership are highly disorganized and seem to have very little clout on the hill. I never envision movie-style government cover up conspiracy stuff with them.
But if a chair literally says that they will expand in order to combat rising salaries in the flagship journal of the society, is it fair to call it a conspiracy theory? haha
This idea is not central to everything they do, but the point is there is a clear conflict of interest. They seem to be unable to recognize and/or address the problem that the supervision policy differentially impacts centers around the country and this impacts the market, broadly speaking.
Same goes for ROCR and residency expansion.
It's not tin foil hat to simply point out some of these leaders have serious COI that is not being managed well.
I absolutely agree both that individual members of ASTRO have COI, as does the group as a whole. See the proton guidelines as the latest example.
My point moreso here is that along those same lines it seems to me that ASTRO, if there is a conflict of interest conspiracy to be espoused here, has more reason to want virtual supervision to go through than not.
My point moreso here is that along those same lines it seems to me that ASTRO, if there is a conflict of interest conspiracy to be espoused here, has more reason to want virtual supervision to go through than not.
For whatever reason (and I have my take) “leaders” in radonc are incredibly self interested and flawed vs other specialties in which they typically act as responsible stewards. The extent of residency expansion and emphasis on decreased utilization (hypofract/ommission) are unique.
You could easily pull off 4 sites one rad onc and 2 million
If there were like 1000 rad oncs total in the US
You could pull off one site one rad onc and 2 million 20 years ago
Society won’t mind paying a few people a lot, but it will wind up paying a lot of people not a lot if given the stress/chance
Have these cuts actually come to fruition meaningfully?
How much have colonoscopies been cut in the past 30 years?
This is exactly what I think.
Over the years, I've asked many Chairs and senior academic faculty specifically about this topic. Either, "do you feel like it was reasonable to expand given the current concerns", or "would you ever consider decreasing spots", etc.
Obviously, this was primarily before or during the Great Crash of 2018/2019.
Always, always, always, I got two answers:
1) "We believe we give excellent training here."
- This would then be followed by some further justification about how if they cut their "excellent" training, the newer/"lower quality" programs would not, thus, they were doing the "right" thing by making sure residents could get quality training.
- Editor's Note: their programs were NEVER as good as they thought they were.
2) "We've seen increased patient volume at XYZ University RadOnc, and expanded our residents accordingly."
- This is a weird one. I never, ever heard this argument in isolation - it was always accompanied by the "we give quality training" song and dance. But what this was actually saying was "we increased our cheap resident labor so the faculty workload didn't increase in a 1:1 ratio".
Remember, the ASTRO CEO who is now retiring - she's been there for 22 years.
Just...think about that.
In those 22 years, we've essentially seen the same crew of people (SCAROP and their disciples) rotate through the same leadership positions.
The size of an echo chamber you can build in two decades is immense.
What we're witnessing now is the late-stage collapse of the empire. 22 years ago was the rise of IMRT. None of these current leaders did anything to earn what made RadOnc competitive or "good". Thus, they had no idea what good stewardship/leadership looks like. They were lucky.
When the wheels started to come off, that lack of skill was glaring ("the residents are getting dumber, that's why they failed the basic science board exams more").
Friday's Town Hall was just a tour de force of "please retire, all of you".
Ummm the amount of money that a colonoscopy pays has fallen by a ton over the past 30 years.
I have close family that were GI docs. The late 80s and early 90s were like stealing money lol (only kind of joking). Once the uptake of screening colonoscopies really skyrocketed, the per procedure pay declined.
Thanks! I wasn't asking out of disagreement. Just curiosity
Take the 90%. 80% might have been nice, but 90% is something and gives docs at smaller places some legitimacy regarding pushback on doctors hours and draconian admins/toxic RTT culture.
I like docs on site. Take this away and our value plummets in aggregate. Very simple IMO.
This is the last thing I want to sh%t on ASTRO about. It's proton guidelines, attempts at carveouts and residency expansion.
I like docs on site. Take this away and our value plummets in aggregate. Very simple IMO.
I don't know. The scale of the institutions overwhelmingly represented by ASTRO leadership makes supervision moot. Also, the typical expansion model favors these places (lots of docs, hire one (often a recent grad) to be chained to new site with periodic coverage from mothership). Virtual would open a bidding war for these types of contracts. Nobody really wants national competition for providing local/regional care...I sure don't.
This is the last thing I want to sh%t on ASTRO about. It's proton guidelines, attempts at carveouts and residency expansion.
I was always concerned if gay marriage became legal, everyone would go gay and quit marrying the opposite sex. Family life would break down, population would plummet, Gerber’s would go bankrupt, etc. I don’t think gay marriage has been legal long enough yet to know for sure this WON’T happen.
I do IDK all the time. It’s easier than 20/5.
How about 8 gray in one fraction?!
Dr Potters on line 1
Yes this is why there will never be a contraction. Hellpits believe they have amazing programs. Even if they admit that things used to be bad, they point out that things are “improving”. They point to the volume and highlight they could actually support more residents so they are already showing restraint by not expanding. The places that are good at providing education, also do not want to contract and point to places that should to do the right thing. Nothing is ever fixed. SOAP continues and they all get a warm body.
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Disagree completely. This percentage idea is nonsense. Either direct supervision is needed for certain codes in certain settings or it's not. There is no credible argument I have heard for direct supervision of 3D and IMRT treatments in a hospital-based setting. I need to be immediately available? For what exactly? The photons got stuck in the patient and I have to remove them? I need to approve the images in person before each treatment? Literally nobody has ever done that for non-stereo cases. It's asinine.
Of course, I am biased. What ASTRO is trying to do is an existential threat for my current position that I literally just moved for and started. If I have to be here 8-5 M-F, I will likely not be able to continue this as it will not be worth it to me unless the hospital increases my salary guarantee to 7 figures or gives me a share of technical revenue. So I will leave and the hospital will have to staff with locums or someone desperate for any job because of issues. It's a lose-lose, but ASTRO doesn't give a rats asz about rural centers. We've known that for a long time. I thought I had FINALLY found a decent gig in this dumpster fire of a specialty self-inflicted by ASTRO and the academics, and then they come out with this hot garbage.
Does anybody know how to write a letter directly to CMS? I suspect my letter to Jeff Michalski was promptly printed and used as toilet paper.
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Yes - there are several of us.
I've wanted to see how ASTRO would react to the reaction of THEIR letter first, and/or see how CMS reacts to like, everyone else in medicine supporting Virtual Direct.
RadOnc already looks like the Dunce in the House of Medicine, and I don't want to author some letter that arrives the day CMS announces permanent Virtual Direct, for example.
CMS already rolls their eyes whenever a letter from Radiation Oncology crosses their desk - trying to not make it more obvious how much of a dumpster fire we are...
Of course they don't.
How many rural centers are there in Canada?...which is a freaking rural country.
Their position (if somewhat tacit) is undoubtedly one in which they view centers that are potentially not staffed by docs every day as being centers that are not providing the highest level of care.
They almost certainly think that these centers should be shut down with XRT services provided by the nearest reasonably large center operating at a scale they are comfortable with.
Although, I suspect ASTRO would claim that their real position is that even rural patients deserve a doc on site everyday. In fact, they deserve a doc living in the community...and despite the perversion of the only doc in some of these communities being a radonc, this is better than none at all.
There is a darker narrative regarding whether urban academics and professionals in general care about rural people. This narrative has of course dramatically impacted our national discourse on all matters and is particularly important in the setting of our present electoral system.
But, for those not personally invested in these situations, a general cultural shift away from in-person supervision (once it is perceived as generally reasonable) will devastate the market.
I think some folks are looking at this in terms of personal behavior...they are wrong. Only a few individual docs will abuse a change in policy...as has already been shown.
I have no doubt that @elementaryschooleconomics and @MidwestRadOnc will remain conscientious docs who provide reasonable supervision under any regulatory environment.
However, medicine is largely corporate at this point (non-profits in medicine behave in a very corporate manner). That next merger or PSA with an academic place 100 miles away...doc comes down twice a week with virtual only all other days.
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It's been generally reasonable for nearly 5 years, and the protection is through accreditation. If academic center XYZ wants its fancy pants urban center and satellites to be accredited by whoever, then you can staff on site 5 days a week and do the incident-to babysitting charade and let the rural hospitals do what's in their best interests to staff appropriately rather than try and cram what's best for you on everyone else from the top down because you're worried the RVUs for your codes might get cut.
This is the rub...is it? It's not the cultural norm at most places that are fairly well populated (83% of the country).
I’ll sign that letter. Include the hot garbage that ROCR is and the threats it poses to small businesses and rural centers in particular
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Yes, because you are talking about taking away something greatly beneficial to rural centers (10% of rad onc delivery) to protect against theoretical threats to rad onc demand everywhere else. There are ways to protect the market value of rad oncs in competitive urban environments, but creating a specious safety argument with the supervision boogey-man that throws the 10% rural minority under the bus is not the right way to do that.
I don't give a crap about virtual direct. It can stay or go and makes no difference to me. This is about the appropriateness of general supervision in HOPDs.
So are you on-site less than 80% of the time?
Are patients treated without MD supervision 2 or more days a week?
Safety arguments are usually based on a zero tolerance principle (airline model). You will never get the stats you want for safety initiatives BTW. 12 commercial airline crashes per year is just about the same as 0...statistically.
Maybe we really are just technicians?
But, I do agree with you and @elementaryschooleconomics that the best course would have been to do nothing about present supervision rules. Most of the US would keep docs on site because it is important in a competitive market and important for preserving perceived value of the doc within a given institution. Leave the the true rural docs with more leeway.
...too late now.
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What is MD supervision? Standing at the machine watching a CCTV of the gantry move?
I am available to answer any therapist questions while patients are getting treated. This is general supervision. If needed, I can and do facetime them and provide real time audiovisual guidance from my office, down the hall, across the street, from South Vietnam, whereever. Same for checking images. The number of days I am in my office providing general supervision is irrelevant.
There if there is a problem. Patient anxious getting on the table due to trach issues, intractable nausea for first time in a brain met patient, code (it happens), patient wants to quit today (and probably shouldn't).
But if there is no real value to being there....eff us all.
I 100% agree with you and am very much in the same position as you. I will also leave if direct supervision becomes the rule and my center will return to filling with locums as they have the past 2 years prior to my joining.
Additionally, apparently per ASTRO, none of us actually work in rural centers. In the meeting, when asked Jeff said they’d define “rural” using RUCC (although he was very vague and ambiguous).
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If anyone knows, can someone please tell us how we can communicate directly with CMS during the comment period?
I would also like to send a letter on behalf of community rad oncs opposing Astro’s position on this. I know we’d have lots of support.
Yeah...this is farcical. He is choosing a convenient and technical definition of rural (they've done this before).
We know rural when we see it. (Although as mentioned above, rural Tennessee and rural Wyoming are different beasts).
If ASTRO leadership might consider a second residence there...but never a primary residence...it's probably rural.
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You're grasping at straws here.
We are talking about hospital settings. There is an ED measured reasonably in feet away. There is a code team. I cannot run a code. Like at all. Can you? I can do CPR. So can everyone else in the clinic as they are all certified. Patient wants to quit today? Put them on the phone with me. Anxious on table? Nurse and RTT can't handle it? I don't have ativan in my clinic anyway. What am I going to do? Talk therapy on the spot beyond what they can do? There is literally nothing I can do in this situation that the other people cannot. I do not have the touch of God nor think that I do. Worst case, they miss treatment and I'll see them tomorrow. We don't treat on the weekends and holidays, so missing a single treatment is prima facie a non-issue.
There is no value to me being in a hospital outpatient rad onc center 5 days a week all day other than simply optics. A surefire way to be miserable in life is wanting something that is not true to somehow be true (or vice versa) and spend all your energy thinking and talking about it.
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Rad Onc: Code Leader
Feature or bug?
Feature or bug?
Heard ASTRO is gonna try to mandate maintenance of ACLS for all radoncs.
I'm in.
This is good. This is not always the case for hospital based treatment BTW. There can be a health campus an ambo drive away. Glad you've got the ER in your pocket.
But what if the patient codes at home? Why were you not THERE doctor? What if they have second thoughts about treatment over the weekend? You both coming into the clinic on Sunday night to discuss?
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Yep @MidwestRadOnc may not realize that hospital based facilities can be "freestanding" within a certain mileage of the hospital and still bill HOPPS like an attached hospital-based RO facility
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I am aware as I am in this boat. The department is not physically connected with walls and a roof, but within feet of the ED. It's still not an issue. Because nobody in the department can run a code or do anything beyond BLS cert stuff, which an MD rad onc is not needed to do. If this is really the argument, then it attacks ALL freestanding community centers. 911 isn't good enough, we need an onsite code team just in case. Radiation does not make patients code. If they are coding here, they would have coded at home or Arby's or whereever.
