ASTRO Town Hall Discussion (Poll % on site)

[drowsy12]

They should support residency contraction. Until they address that issue..I can’t take them seriously.

I think people aren’t upset that they supported supervision..I think people are upset about they way they went about it. Any good leader would have a town hall then write a letter to DC that supports the views of the majority of the group not the other way around.

1) I agree they should support residency contraction. They also have no direct impact on that but could voice their opinion.
2) just because they have not done more to address supply, does NOT mean they should NOT address demand.
3) Agree that the way they did it is awful
4) LOTS of people seem very upset they they did support supervision.

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[Mandelin Rain]

The playbook already exists.

Lobby. PR. Lobby. PR. Lobby. PR.

 

[drowsy12]

so ASTRO is meaningless, unimportant, no one cares what they have to say.

BUT I do NOT WANT THEM TO SAY ANYTHING ABOUT SUPERVISION.

but I also want them to make PR campaigns talking about how great radiation is, that will change everything.

also they released their newsletter this week talking about practical implications of benign RT, led by non-academics! but ASTRO didnt do enough to push this newsletter.


wild.

 

[TheWallnerus]

ASTRO:

on the wrong side on breast IMRT, on the wrong side on protons, on the wrong side on UroRads, on the wrong side on residency expansion, on the wrong side on antitrust nonsense, wrong on its DEI obsession, wrong on ROCR, wrong on APM, on the wrong side on letting IGRT require personal supervision for so many years, and on the wrong side on supervision... again

("Wrong" is a small word that can mean a great many number of things, obv)

 

[communitydoc13]

I understand the easy logic here about "Direct Supervision means a RadOnc has to physically be present means more jobs".

That's not real. That's an illusion.

I think you are thinking of major infrastructural changes...these do not need to occur for radical demand change.

In my own practice, we will find solutions to minimize income loss. With multiple centers and an emphasis on physical presence, this sets a floor for number of docs. This floor goes away once we move to a virtual model.

This floor goes away everywhere, and corporate values will move to efficiency in terms of doctor's hours.

Forget expansion of scope of practice (what we need to do). Forget hour long consults and being the best communicator in oncology. It will be strictly technical virtual work with low level virtual clinical evaluation.

This BTW, is seemingly what lots of people want in their jobs nowadays.

I'm becoming more boomerish by the minute.

 

[elementaryschooleconomics]

I think you are thinking of major infrastructural changes...these do not need to occur for radical demand change.

In my own practice, we will find solutions to minimize income loss. With multiple centers and an emphasis on physical presence, this sets a floor for number of docs. This floor goes away once we move to a virtual model.

This floor goes away everywhere, and corporate values will move to efficiency in terms of doctor's hours.

Forget expansion of scope of practice (what we need to do). Forget hour long consults and being the best communicator in oncology. It will be strictly technical virtual work with low level virtual clinical evaluation.

This BTW, is seemingly what lots of people want in their jobs nowadays.

I'm becoming more boomerish by the minute.

Don't let me forget to return to your Bay Pilots post later on.

You're bringing in more nuance than a thread this active can handle, but it's a great example to discuss.

 

[communitydoc13]

so ASTRO is meaningless, unimportant, no one cares what they have to say.

BUT I do NOT WANT THEM TO SAY ANYTHING ABOUT SUPERVISION.

but I also want them to make PR campaigns talking about how great radiation is, that will change everything.

also they released their newsletter this week talking about practical implications of benign RT, led by non-academics! but ASTRO didnt do enough to push this newsletter.


wild.

Yeah...I'm not a member and the Proton stuff is whack...but some evidence that they are trying.

 

[NotMattSpraker]

I think there are are a lot of folks here who only want to talk about one thing, and that is that large hospital systems make a lot of money.

I have many posts here about this topic and the rise of corporate medicine and its impact on medicine as a whole and rad onc specifically.

but it does make these conversations difficult. see this page. Ultimately, no one has answered or really even addressed your question.

Hey I can answer this question really easily. ASTRO should've said nothing or just agreed with the ACR.

IF one believes that the field must respond in opposition to the ACR, they should have a protocol and process for responding to something like that with member input. They don't have that.

They clearly dont understand the current state of this policy (given their comments on the town hall) and they dont have vision on the shifting sands of healthcare.

Given all of that, they should've stayed quiet. They are failing to tell a good story about what they want.

I appreciated the town hall, but walked away more confused at the end. If I feel that way, think about how someone that isn't a radiation oncologist but instead a congressional representative's 20s year old staffer feels about their position.

This is an objective failure all around.

But at least it generated discussion, right Jeff!

 

[drowsy12]

Yeah...I'm not a member and the Proton stuff is whack...but some evidence that they are trying.

I really don’t care about Astro. I think what differentiates me is I’m not obsessed with being anti them?

Like if as ESE says, EVERYONE knows that virtual supervision will crash the demand for rad onc, then it would seem wildly idiotic for ASTRO (and ACRO who is in lockstep with them on this) to not try to stop it.

 

[elementaryschooleconomics]

so ASTRO is meaningless, unimportant, no one cares what they have to say.

BUT I do NOT WANT THEM TO SAY ANYTHING ABOUT SUPERVISION.

but I also want them to make PR campaigns talking about how great radiation is, that will change everything.

also they released their newsletter this week talking about practical implications of benign RT, led by non-academics! but ASTRO didnt do enough to push this newsletter.


wild.

ASTRO has a weight class. The butterfly effect exists.

There are effective ways for individuals and organizations to have an impact in the world.

They've been making choices like they're the AMA.

They forget RadOnc is smaller than some high schools.

 

[elementaryschooleconomics]

I really don’t care about Astro. I think what differentiates me is I’m not obsessed with being anti them?

Like if as ESE says, EVERYONE knows that virtual supervision will crash the demand for rad onc, then it would seem wildly idiotic for ASTRO (and ACRO who is in lockstep with them on this) to not try to stop it.

Whoa whoa whoa there partner, that's not what I'm saying.

I don't think demand will "crash".

I think it goes in the column of hypofrac and omission, opposite the side of residency expansion.

This is not black and white. I wish it was, it would be easier.

None of us can see the future. But Virtual Supervision is a single variable, and we can't consider it in a vacuum.

Don't forget the looming threat of AI!

 

[drowsy12]

Hey I can answer this question really easily. ASTRO should've said nothing or just agreed with the ACR.

But I don't understand why you think it's wise for ASTRO to not speak out about one of the few things they should have an opinion on. Something that it seems most people here agree will crash the field.

I've said this before and will say it again - anyone who thinks they should have done something to stop residency expansion but does not think they should have an opinion on supervision - this does not compute to me. Please explain.

I agree that sending a letter and then trying to walk it back with a town hall after it has already been sent is silly.

 

[drowsy12]

Whoa whoa whoa there partner, that's not what I'm saying.

I don't think demand will "crash".

t
well this is semantics. You said no one disagreed that it would 'undeniably change the workforce landscape incredibly'

To me this, for whoever agrees, falls into 'YOU HAVE ONE JOB' territory for ASTRO.

 

[OTN]

If this passed the way ASTRO wanted, would dermatologists with machines have to hire radoncs?

 

[Mandelin Rain]

What happens to demand for rad oncs when all those (hundreds of ?) small community linacs treating 5-12 patients close down because they are completely non-viable under direct supervision?

 

[Mandelin Rain]

If this passed the way ASTRO wanted, would dermatologists with machines have to hire radoncs?

LOL. The derms would be like, "cool story, bro."

 

[TheWallnerus]

But I don't understand why you think it's wise for ASTRO to not speak out about one of the few things they should have an opinion on. Something that it seems most people here agree will crash the field.

I've said this before and will say it again - anyone who thinks they should have done something to stop residency expansion but does not think they should have an opinion on supervision - this does not compute to me. Please explain.

I agree that sending a letter and then trying to walk it back with a town hall after it has already been sent is silly.

Because if there were only 1000 rad oncs in America virtual and general supervision flexibilities would be a brilliancy that Deep Blue would be proud of… and we all would have GREAT job security.

I’m speaking hyperbolically but you have to quit throwing good money after bad, eventually, and ASTRO is just… not helping. Paraphrasing the poet Ludacris, “Move, ASTRO, get out the way.”

 

[Mandelin Rain]

This makes no sense, why would taking some of the money from having a RadOnc on site and shifting it to the pockets of a middle man and a lower paid virtual RadOnc help in this situation?

What are you even talking about?

I think many people are in a bubble a don't realize that currently (today, right now!) docs staff multiple sites each week to make ends meet, all without Jordan Johnson's help. If those sites needed to hire a full time doctor, they'd simply close and require no doctor. That would do nothing to increase demand for rad oncs. Quite the opposite.

 

[drowsy12]

Because if there were only 1000 rad oncs in America virtual and general supervision flexibilities would be a brilliancy that Deep Blue would be proud of… and we all would have GREAT job security.

I’m speaking hyperbolically but you have to quit throwing good money after bad, eventually, and ASTRO is just… not helping. Paraphrasing the poet Ludacris, “Move, ASTRO, get out the way.”

this is at least a reasonable reply. I see where you are coming from.

It just means we are in a world of hurt for a while, before somehow magically we end up at 1000 Rad Oncs again?

you're almost done soon I imagine. it's the rest of us that will be caught holding the bag.

 

[Mandelin Rain]

Couldn't those docs, just have a single slightly busier site? I'm confused. Where is the job that is being created by having docs that cover multiple sites?

Doubtful. Those patients would either; not receive care or go to regional academic medical complex 2 hours away where they'd be divvyed up among the 12 employed docs already hired.

 

[TheWallnerus]

this is at least a reasonable reply. I see where you are coming from.

It just means we are in a world of hurt for a while, before somehow magically we end up at 1000 Rad Oncs again?

you're almost done soon I imagine. it's the rest of us that will be caught holding the bag.

This is where the serenity prayer, changing things you can change, and the second law of thermodynamics comes in to play.

 

[deleted1180461]

Whoa whoa whoa there partner, that's not what I'm saying.

I don't think demand will "crash".

I think it goes in the column of hypofrac and omission, opposite the side of residency expansion.

This is not black and white. I wish it was, it would be easier.

None of us can see the future. But Virtual Supervision is a single variable, and we can't consider it in a vacuum.

Don't forget the looming threat of AI!

Demand may not crash, but cuts are inevitable. There will come a point when the government is forced to cut spending, and medicare is a very big target. This point seems to be rapidly accelerating. This supervision stuff is trying to put a finger in the dike, but there will be bigger problems to deal with when that time comes.

That said, watching the recording, Michalski is basically telling me that the way I practice is wrong. Who the hell is he to make that call for the rest of the specialty or determine what schedule is appropriate for my rural clinic he knows nothing about? The level of arrogance is astounding and reflected in his tone of voice and general demeanor.

 

[TheWallnerus]

Demand may not crash, but cuts are inevitable. There will come a point when the government is forced to cut spending, and medicare is a very big target. This point seems to be rapidly accelerating. This supervision stuff is trying to put a finger in the dike, but there will be bigger problems to deal with when that time comes.

That said, watching the recording, Michalski is basically telling me that the way I practice is wrong. Who the hell is he to make that call for the rest of the specialty or determine what schedule is appropriate for my rural clinic he knows nothing about? The level of arrogance is astounding and reflected in his tone of voice and general demeanor.

I think there is certainly some reasonableness to thinking the government wants to cut spending on healthcare. But…

Next year the federal government will pay private insurance companies a record breaking $500 billion to move Medicare patients to Medicare Advantage. And there is no clear savings to the government for doing this (and it’s accelerating). UnitedHealth is the largest employer of physicians in the US, and their biggest profit center is Medicare Advantage (ie, they profit from the government and our taxes… what a country!).

 

[deleted1180461]

What happens to demand for rad oncs when all those (hundreds of ?) small community linacs treating 5-12 patients close down because they are completely non-viable under direct supervision?

I will tell you exactly what happens. At least half of those patients would not get radiation treatment. These people will not or cannot travel to cities for radiation.

Part-time radiation oncology is necessary for many of these sites to remain viable, let alone ensure a competent rad onc is managing the care.
The ivory tower is both out of touch and doesn't care. You think they want to drive out and cover these sites themselves? Oh they'll do that a few weeks a year once they are retired and bored, sure. That's the wrong way to provide care in rural America.

The CAH exemption is not good enough. Most CAH cannot support radiation. They can barely support an ED.

 

[drowsy12]

carveouts already exist for many of these situations, and for the ones that don't fit, they should be expanded.

I think what some of us think would be a good idea are some sort of guardrails that would prevent a significant impact to the demand for Rad Oncs.

If we really do think it is undeniable that a major impact is coming if virtual supervision is taken to the greatest impact, you would have to be either:

1) retiring
2) a dummy
3) callous

to not care.

 

[TheWallnerus]

carveouts already exist for many of these situations,

Explain

 

[drowsy12]

Explain

I will admit I don't know the exact rules or terminology of this, but I have multiple friends that work in groups that are multi-site multi hospital, and one of the sites is classified as rural enough that a rad onc doc is only needed one day a week, and this has been ongoing for at least a decade. What is this called?

 

[deleted1180461]

carveouts already exist for many of these situations, and for the ones that don't fit, they should be expanded.

I think what some of us think would be a good idea are some sort of guardrails that would prevent a significant impact to the demand for Rad Oncs.

Metropolitan statistical area - Wikipedia

en.wikipedia.org

There are 387 metropolitan statistical areas in the US. My center is not in any of them, or even a micropolitan statistical area.

Even in the actual MSAs, there are very clearly some centers that would be very "rural."

Ok, how about the top 50 MSAs require direct and everyone else is general or virtual? For the explicit purposes of protecting the specialty, not some specious safety or quality of care argument, since this is where the most of the rad oncs are anyway. Ok, fine. At least that's a non-insane and honest start. But who sets the line?

 

[Mandelin Rain]

I will admit I don't know the exact rules or terminology of this, but I have multiple friends that work in groups that are multi-site multi hospital, and one of the sites is classified as rural enough that a rad onc doc is only needed one day a week, and this has been ongoing for at least a decade. What is this called?

Good health care.

 

[drowsy12]

Good health care.

sure. not germane but sure.

can you clarify your position. you don't think astro should care about supervision as there will be no impact to the labor force?

 

[Bequerel]

I will admit I don't know the exact rules or terminology of this, but I have multiple friends that work in groups that are multi-site multi hospital, and one of the sites is classified as rural enough that a rad onc doc is only needed one day a week, and this has been ongoing for at least a decade. What is this called?

It sounds like it should be called a system that has been working for at least a decade with no problems so quit trying to fix something that ain’t broke. Instead, go fix one of the million things that are already broken.

 

[drowsy12]

It sounds like it should be called a system that has been working for at least a decade with no problems so quit trying to fix something that ain’t broke. Instead, go fix one of the million things that are already broken.

I don't think you know what you are saying.

 

[Mandelin Rain]

sure. not germane but sure.

can you clarify your position. you don't think astro should care about supervision as there will be no impact to the labor force?

I believe ASTRO's own stated position is that they can't legally care about the labor force.

 

[deleted1180461]

It sounds like it should be called a system that has been working for at least a decade with no problems so quit trying to fix something that ain’t broke. Instead, go fix one of the million things that are already broken.

It's a common theme, punching down on the deplorable poor with 9th grade educations. But hey they probably refused the covid vaccine too, so screw em. At least they came right out and admitted this was about reinstituting direct everywhere, not just eliminating the pandemic workaround.

Rural rad oncs are <10% of us. Our lazy cheat code (presumably how they look at it) to get out of linac babysitting and sleep in on Fridays because there is literally no work to do is not the reason the specialty is burning down. It's because they overexpanded training to benefit themselves and their cushy urban gigs and lifestyles and refuse to admit it, let alone correct it.

 

[elementaryschooleconomics]

I don't think you know what you are saying.

 

[Bequerel]

I don't think you know what you are saying.

I was thinking the same thing when reading your countless posts trying to defend ASTRO. I’m trying to figure out which position you hold in the organization

 

[drowsy12]

I was thinking the same thing when reading your countless posts trying to defend ASTRO. I’m trying to figure out which position you hold in the organization

JFC.

 

[Mandelin Rain]

I was thinking the same thing when reading your countless posts trying to defend ASTRO. I’m trying to figure out which position you hold in the organization

The lack of basic comprehension points to a high level position.

 

[elementaryschooleconomics]

I believe ASTRO's own stated position is that they can't legally care about the labor force.

They really twisted themselves into knots with that one, didn't they?

I think they ended up confusing themselves irrevocably after rolling out the antitrust argument, then trying to find ways to consider the workforce but only in certain ways and...

Well, it would be a good idea for them to get a second opinion from outside counsel about what is, and is not, antitrust.

 

[drowsy12]

ok enough posting for today. Summary seems to be that

- people can't decide on whether there will be an impact to the future market or not
- if there is an impact, they don't care because ASTRO said they should care.
- it is unclear if they would care if astro did not say anything.

 

[Mandelin Rain]

ok enough posting for today. Summary seems to be that

- people can't decide on whether there will be an impact to the future market or not
- if there is an impact, they don't care because ASTRO said they should care.
- it is unclear if they would care if astro did not say anything.

Nailed it, IMO.

 

[elementaryschooleconomics]

ok enough posting for today. Summary seems to be that

- people can't decide on whether there will be an impact to the future market or not
- if there is an impact, they don't care because ASTRO said they should care.
- it is unclear if they would care if astro did not say anything.

1) True, but we should remember all of us are unable to see the future, and most predictions are wrong.

2) False, because we are inferring this is about the workforce. ASTRO's official position is that this is about safety. Unofficially it's about the value of 77427. Then maybe, if you squint real hard, it's about the workforce.

3) Speaking personally, I was wishing ASTRO would say nothing about supervision ever again but...

I recall some line from some movie once about wishing in one hand...

 

[deleted1180461]

ASTRO's official position is that this is about safety.

This is the annoying part because literally nobody believes that. They are not arguing in good faith.
Michalski goes on about the value of having a rad onc on site to handle routine questions from patients face-to-face or check a setup question (patient losing weight, mask is looser or something). Sure, it's a nice perk. But to mandate this as a critical necessity and threaten the viability of certain centers? GTFO.

 

[communitydoc13]

This is the annoying part because literally nobody believes that.

I actually believe that in person is better than remote.

As discussed before, this is not easily demonstrable statistically (as is true for all but the most egregious safety issues perpetuated at the largest scales). This does not mean that it is not true.

threaten the viability of certain centers

This is important, and perhaps not well understood by ASTRO (or me).

I have no sense of the absolute scope of centers that require part time but not full time in-person radonc services to function. In other words, centers that are only viable because of the option of part time in-person coverage. They may be much more prevalent in other parts of the country.

Where I am (what I would call rural but coastal, 2 hours from major cities and a retirement destination) it has been easy for even the sleepiest center to staff a full time radonc (but staffing other specialties has been quite challenging). If that center were to close, it would mean a 40 minute drive to the next center. Very few (if any) patients would not receive care because of closure. (This I know, because said center was at one time within my practice and had had multiple temporary closures due to technical issues/upgrades).

 

[Gfunk6]

ok enough posting for today. Summary seems to be that

- people can't decide on whether there will be an impact to the future market or not
- if there is an impact, they don't care because ASTRO said they should care.
- it is unclear if they would care if astro did not say anything.

THANK YOU!

 

[NotMattSpraker]

But I don't understand why you think it's wise for ASTRO to not speak out about one of the few things they should have an opinion on. Something that it seems most people here agree will crash the field.

I've said this before and will say it again - anyone who thinks they should have done something to stop residency expansion but does not think they should have an opinion on supervision - this does not compute to me. Please explain.

I agree that sending a letter and then trying to walk it back with a town hall after it has already been sent is silly.

They cant speak out effectively, so they should have said nothing. I do not think we should use national policy to ensure the job security of people nationally when they can talk to their own centers and ensure it themselves. Thats my opinion. I don't think its unreasonable. I am not scared of Bridge in the highly competitive metro Denver, and at least right now Im feeling secure in my own job (post supervision discussion internally).

Im not a member on purpose. If you support them, go apply for the policy committee. Buddy up with Sameer and Im sure he can get you on. I think they would only benefit from hearing the opinion of anyone outside their weird inner circle of chairs.

Disagreeing with ASTRO and wishing they stayed quiet when they don't have a real policy position... thats not unreasonable.

 

[deleted1180461]

I actually believe that in person is better than remote.

As discussed before, this is not easily demonstrable statistically (as is true for all but the most egregious safety issues perpetuated at the largest scales). This does not mean that it is not true.

Yes, sure, like I said, it's a nice perk. I believe treating with a Truebeam is better than an old Siemens machine. But we aren't mandating Truebeams at the federal level. I can't even get Ativan or Morphine in my clinic if I have a patient with acute pain or anxiety. Is it a nice perk and better for patients? Yes. Should my center be shut down? No.

Where I am (what I would call rural but coastal, 2 hours from major cities and a retirement destination) it has been easy for even the sleepiest center to staff a full time radonc (but staffing other specialties has been quite challenging). If that center were to close, it would mean a 40 minute drive to the next center. Very few (if any) patients would not receive care because of closure. (This I know, because said center was at one time within my practice and had had multiple temporary closures due to technical issues/upgrades).

I believe you, but this is not the case everywhere. It's provable too by the places that have been trying to hire for years and currently staffed with locums. A 3 day per week full time competent BC rad onc is leagues better than random locums every other week babysitting the linac.

 

[NotMattSpraker]

But we aren't mandating Truebeams at the federal level.

Im so hyped for our discussion around this in 2025.

 

[communitydoc13]

A 3 day per week full time competent BC rad onc is leagues better than random locums every other week babysitting the linac.

Alright then!

60% for the truly remote and 90 for everyone else!

I'm down for it.

 

[drowsy12]

‘They cant speak out effectively, so they should have said nothing. I do not think we should use national policy to ensure the job security of people nationally when they can talk to their own centers and ensure it themselves. Thats my opinion. I don't think its unreasonable’

Fair enough. My opinion is that this same language can and has been used to justify not saying anything about residency numbers. They have no power so they shouldn’t say anything. My opinion also is that I don’t know that any harm came from it, even if they can’t do anything about it.


Come to think of it ASTRO needs you! Ha I’m kidding but not really, they do need you.