ASTRO Workforce Study

[RadOncMegatron]

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I think the time is right for someone to take a strong stance. Hope he does. We need a leader. What kind of rotten field would punish a resident for pointing out that relentless residency expansion in the face of shrinking XRT demand is bad? Disgusting. Let’s see any of these people stand up and defend expansion publicly.

Don't forget what happened to Dr. Shah when he spoke out on this issue, thus the concern this resident will back pedal - I hope not!

Bloodbath in Red Journal

Anyone catch the beat down this kid at Wash U took in the most recent Red Journal? When your department is expanding it's residency, probably best not to call out the process in the specialty's primary journal. Especially if you graduated last year.

forums.studentdoctor.net

 

[scarbrtj]

I don't think it makes the field look good if some of "the best work our field has done" led to exactly 0% increase in survival.

It was breast hypofx that really opened the hypofx floodgates. It was not an overnight thing. And in the early days all those winds of change blew from beyond our shores (or beyond our northern border... a Chinook? a Squamish?). If this is good work by "our field," and I agree it was for sure, us folks in America shouldn't use the word "our" without some sense of the irony of the word. There used to be a real skepticism toward non-American data and thankfully those days are done. Regarding the increase in survival thing... well, we all know if being truly honest in our hearts of hearts that we are as unlikely to be victors in the survival improving business by varying radiotherapeutic approaches as surgeons could be by varying surgical approaches. Certainly (and maybe in my opinion only) there will never be a radiotherapeutic equivalent of Herceptin, e.g. At the turn of the last century Lord Kelvin said that there was nothing left in physics except to extend all measurements to six significant digits. Perhaps all that's left in rad onc is to further decrease cost, decrease patient inconvenience, and decrease toxicities. This is not nihilist (or misanthropic), it's simply "our" reality... one only need read the latest ToC of the Red or Green Journal to see it's so. This can be our best work: lowering patients' damn bills. And maybe their damn bells too. Do they ring bells over in the chemo suite?

 

[Mandelin Rain]

Lord Kelvin was quite incorrect however.

 

[deleted774703]

Unlikely he will open himself up to the floodgates after Dr. Shah

Also not sure it matters as chairs don’t give AF. Subsided labor will always win out for them

 

[Lamount]

It's easy to be divorced from the reality of RO labor when you carry less pts (10-20/MD) than those of us out in the real world (25-35/MD minimum, 35-40 is not unheard of as some on this forum will attest to), while treating 1-2 disease sites and being covered by a resident, and sometimes even an NP/fellow in certain circumstances

If 5 fractions yields the same outcomes and toxicity as 44 fractions, then the 'reality' is that fewer physicians are needed to treat prostate cancer. The data are the data regardless of the impacts on the 'labor force'. The purpose of the radiation oncology is not to provide us with employment.

 

[RickyScott]

It's easy to be divorced from the reality of RO labor when you carry less pts (10-20/MD) than those of us out in the real world (25-35/MD minimum, 35-40 is not unheard of as some on this forum will attest to), while treating 1-2 disease sites and being covered by a resident, and sometimes even an NP/fellow in certain circumstances

In fairness to them, I find it a lot harder to get anything done when I am not very busy.

 

[medgator]

If 5 fractions yields the same outcomes and toxicity as 44 fractions, then the 'reality' is that fewer physicians are needed to treat prostate cancer. The data are the data regardless of the impacts on the 'labor force'. The purpose of the radiation oncology is not to provide us with employment.

Correct. The people that need to hear that are not those of us in practice, but rather those of us in academics who don't seem to understand the situation but are in positions of power to regulate supply.

We literally have a "thought leader" on Twitter telling us hypofx will not lead to a change in the number of ROs needed to treat a given population of patients. It's completely absurd and disconnected from clinical reality.

 

[deleted774703]

What we need is the following:

1) Chairs to stop being so damn greedy
2) All academics need to stop hiding behind antitrust argument - it is frankly very lazy
3) Residents need to stop drinking Kool Aid

I get esp annoyed when attendings try to sell you on “resident led services” or “residents make the dept run”. Ultimately the attending is most responsible for the patient and makes final call. Also Hire more damn attendings if that is the case!

 

[OTN]

Correct. The people that need to hear that are not those of us in practice, but rather those of us in academics who don't seem to understand the situation but are in positions of power to regulate supply.

We literally have a "thought leader" on Twitter telling us hypofx will not lead to a change in the number of ROs needed to treat a given population of patients. It's completely absurd and disconnected from clinical reality.

I have been debating internally for awhile whether I should create a twitter account and start to jump into these discussions full-tilt. I’ve been following them closely. The problem as well all know is that this is a very small field, and I, as a practicing private practice radonc, really don’t benefit too much from entering the fray. I still have a few irons in the fire that would benefit from academic collaboration, and the last thing I want is for a twitter debate to scuttle that.

I have no doubt I will not be hiring a radonc to replace my partner when she retires, due to APMs and hypofx. So, while I’m only an N of 1, there’s one less job which will be available in the future.

 

[medgator]

I have no doubt I will not be hiring a radonc to replace my partner when she retires, due to APMs and hypofx. So, while I’m only an N of 1, there’s one less job which will be available in the future.

We didn't. We just used one of our retired partners, when they retired, to help cover the linac for vacations.

Way cheaper than using a locums company or hiring a new associate, since hypofx allows existing rad oncs to treat more patients, we just need physical presence coverage by an RO while one of us is out. I guess no one in academia will believe me until I get that published in the red journal though

 

[scarbrtj]

Just to be fair to Dr O he said "[Hypofx] doesn’t change the need for RadOnc"... not that hypofx doesn't change the need for more, or less, rad onc docs. Just to be fair 🙂

 

[medgator]

Just to be fair to Dr O he said "[Hypofx] doesn’t change the need for RadOnc"... not that hypofx doesn't change the need for more, or less, rad onc docs. Just to be fair 🙂

He ignored commenting on increased surveillance in breast and prostate which, when done appropriately, is good for patients and society. That does change the need for the rad onc 🙂

 

[RadOncDoc21]

We didn't. We just used one of our retired partners, when they retired, to help cover the linac for vacations.

Way cheaper than using a locums company or hiring a new associate, since hypofx allows existing rad oncs to treat more patients, we just need physical presence coverage by an RO while one of us is out. I guess no one in academia will believe me until I get that published in the red journal though

We do the same thing but I find it ironic that an old retired rad onc who literally does nothing will still beat out a new grad every time.

 

[medgator]

We do the same thing but I find it ironic that an old retired rad onc who literally does nothing will still beat out a new grad every time.

Those boomers and septogenarians in academics know how to help out their PP brethren

 

[xrthopeful]

Just to be fair to Dr O he said "[Hypofx] doesn’t change the need for RadOnc"... not that hypofx doesn't change the need for more, or less, rad onc docs. Just to be fair 🙂

Post of the thread. I’ve been confused what all of this discussion has been about

 

[RickyScott]

Actually that is the PRECISE purpose of a residency program - to produce employed physicians to serve Americans who need them. This is why academic medical centers receive fat subsidies to train residents.

Any excess physician who is trained is a waste of Medicare funds that would be better served on treating patients.

If treatments are declining, so should trainees. Not doing so is a betrayal of the public trust.

This point highlights ASTRO's Anti-trust misinformation: Antitrust law and standards are about what is in the public interest, not whether a "trust" exists. Dont let them mislead you by stating that it could be legally challenged (so can just about anything). It is sickening that ASTRO wont take a position on this in contrast to Emergency Medicine Society.

(Judge Robert Bork's writings on antitrust law (particularly The Antitrust Paradox), along with those of Richard Posner and other law and economics thinkers, were heavily influential in causing a shift in the U.S. Supreme Court's approach to antitrust laws since the 1970s, to be focused solely on what is best for the consumer rather than the company's practices.[45]

Limiting residency supply is clearly in the public interest for so many reasons.

 

[OTN]

Post of the thread. I’ve been confused what all of this discussion has been about

If you see “need” as a 0 or 1 binary variable, sure. However, demand for radiation oncologists is not a binary variable and should not be treated as such.

 

[imhopeful432]

If someone brings up this anti-trust BS this at the ASTRO panel I truly hope that some brave soul stands up and corrects it publicly. This transparent nonsense excuse should not be allowed any longer to provide cover for inaction.

Its the ASTRO lawyers that have advised ASTRO leadership about the anti-trust issue, not the other way around. Second, the only real way of explicitly, openly restricting supply that makes sense to me would for the ACGME residency review committee for rad onc becoming more restrictive/state they will not approve additional residency positions. And there has been some case law in the area of anti-trust from restricting physician supply. See here: Restrictive Practices in Accreditation of Medical Schools: An Antitrust Analysis Note 51 Southern California Law Review 1977-1978

If you really believe the anti-trust argument is BS...stating it at the panel at ASTRO will just sound like someone who is uninformed about law.

The better way to do it would be to team up with a lawyer who specializes in this area and write it up as an editorial for the red journal/PRO/a blog post/anywhere. If you can provide a cogent, legal argument for why it is legal for rad onc to restrict supply and how (specifically) to do it, I would love to read that.

 

[Chartreuse Wombat]

Its the ASTRO lawyers that have advised ASTRO leadership about the anti-trust issue, not the other way around. Second, the only real way of explicitly, openly restricting supply that makes sense to me would for the ACGME residency review committee for rad onc becoming more restrictive/state they will not approve additional residency positions. And there has been some case law in the area of anti-trust from restricting physician supply. See here: Restrictive Practices in Accreditation of Medical Schools: An Antitrust Analysis Note 51 Southern California Law Review 1977-1978

If you really believe the anti-trust argument is BS...stating it at the panel at ASTRO will just sound like someone who is uninformed about law.

The better way to do it would be to team up with a lawyer who specializes in this area and write it up as an editorial for the red journal/PRO/a blog post/anywhere. If you can provide a cogent, legal argument for why it is legal for rad onc to restrict supply and how (specifically) to do it, I would love to read that.

The ACGME lawyers tell the same story to the RRC. Day 1 of orientation you are told "thou shalt not discuss workforce issues as it relates to accreditation decisions".

 

[imhopeful432]

It’s been done:

The National Resident Matching Program and Antitrust Law

In May 2002, a group of physicians filed a class action lawsuit alleging that the National Resident Matching Program (NRMP) violates antitrust laws. The plaintiffs contend that NRMP practices have stabilized lower-than-competitive wages and imposed exhausting working conditions on residents. They...

jamanetwork.com

“...In contrast, antitrust law has proved quite solicitous to the professional judgments of physicians and their associations. Cases (almost invariably brought by private parties) challenging accreditation by medical societies and boards and questioning hospital staff privilege determinations have been almost uniformly unsuccessful. In addition, the US Supreme Court has occasionally given the signal, as it did in its most recent antitrust decision, that where market imperfections are present in a business sector such as health care, restraints of trade involving professionals might warrant somewhat greater leniency.”

The paper you cited doesn't include anything about a professional society responsible for educational accreditation working to restrict supply (which would in turn increase wages...and you could argue not be in the "public interest"). The article is primarily about the NRMP process artificially keeping wages lower.

The final portion of the article which states "restraints of trade involving professionals might warrant somewhat greater leniency" cites a decision about members of the California Dental Association getting desirable insurance and preferential financing arrangements for its members. Not exactly the same as what you are proposing (which I assume is allowing the ACGME RRC to not approve any further residency spots for the explicit reason of workforce issues).

I'm not a lawyer - and its not totally unreasonable you are right that anti-trust is BS. But I'm going to believe ASTRO/ACGME lawyers on this one. If you truly believe this (and can find some reputable lawyers to co-write the article with you), I'm happy to change my mind. Hell, I would even be happy to be a co-author and work with you on that!

 

[RickyScott]

First off, if this issue cant be addressed, the field is totally screwed, and ASTRO should then make a public service announcement to prospective medstudents. It is very telling, it seems that many who argue that ASTROs hands are tied here, also argue that supply issues are overblown. Logically, if you truly believe ASTROs/ACGME etc hands are tied, you should be screaming RUNNNNN!

In terms of legal advice, the context matters. Are the lawyers saying that collusion to limit residency supply will be challenged in court and lead to lawsuits- (of course this is true). But, can it be successfully challenged given the standard is clear: what is best for public interest/society. ASTRO/board can certainly fund a legal battle rather than lobbying for proton reimbursement.

Again, the Emergency medicine equivalent of ASTRO just sent a letter calling on stakeholders to address the residency issue.

 

[deleted774703]

ASTRO can’t do anything specifically about residency expansion, but they can make a statement saying they are concerned

It is SCAROP that is the problem. Don’t ever trust a greedy chairman in rad onc

 

[medgator]

ASTRO can’t do anything specifically about residency expansion, but they can make a statement saying they are concerned

It is SCAROP that is the problem. Don’t ever trust a greedy chairman in rad onc

Prisoners dilemma. Greedy academic chairmen are doing what is best for their own interest and actively hurting the entire specialty in the process. ASTRO states its hands are tied. That's basically it

 

[radiaterMike]

But it is the RRC who expanded programs in the early 2000-2010s - not ASTRO.

 

[RickyScott]

But it is the RRC who expanded programs in the early 2000-2010s - not ASTRO.

largely same people different hat. leadership/chairmen drawn from the same clique and ASTRO can certainly take a position for such an important issue facing our field like in Emergency Medicine.

 

[deleted774703]

But it is the RRC who expanded programs in the early 2000-2010s - not ASTRO.

It is not the RRC that expanded programs.

It is greedy individual programs that decided to expand -> RRC can't say no you can't expand as long as 1) program is under good standing by resident reviews 2) meets the minimum RRC criteria

We need ASTRO to take a position on this, even if they cannot specifically stop expansion
We also need the committee members of the RRC to make more stringent criteria for having a program
We also need to hold SCAROP accountable!

 

[BobbyHeenan]

I vote for an ASTRO Plenary yearly where we bring up the chairs that are expanding and make them explain how they aren't hurting the field. Just because you now have more volume because you bought out a local hospital and it's now a satellite that "needs" resident coverage because your numbers are up, does not mean that the U.S. needs more radiation oncologists.

Kidding aside (sort of)...even if ASTRO can't do anything, they need to take a stance. It starts there. If you can't even take a non binding paper stance on this, how the hell is anyone ever going to actually address it?

 

[deleted774703]

I vote for an ASTRO Plenary yearly where we bring up the chairs that are expanding and make them explain how they aren't hurting the field. Just because you now have more volume because you bought out a local hospital and it's now a satellite that "needs" resident coverage because your numbers are up, does not mean that the U.S. needs more radiation oncologists.

Kidding aside (sort of)...even if ASTRO can't do anything, they need to take a stance. It starts there. If you can't even take a non binding paper stance on this, how the hell is anyone ever going to actually address it?

Agree that more residents are not needed just b/c local hospitals are bought out. Hire more attendings or make your attendings more efficient.

Specific areas of the US do need more radiation oncologists. Efforts should shift from increasing overall number of residents to finding ways to recruit ppl to those underserved areas, i.e. loan repayment, higher salaries, etc.

 

[BobbyHeenan]

Agree that more residents are not needed just b/c local hospitals are bought out. Hire more attendings or make your attendings more efficient.

Specific areas of the US do need more radiation oncologists. Efforts should shift from increasing overall number of residents to finding ways to recruit ppl to those underserved areas, i.e. loan repayment, higher salaries, etc.

This was the (now proven correct) stance from Dr. Shah way back when (see "bloodbath in the red journal" threat). He was proven correct while the "leaders in the field" could not have been more wrong. We have a maldistribution problem, not an under supply problem. You fix that with incentives to distribute to under served areas....not just over train to tank the market to where your ONLY choice is an under served area.

 

[RickyScott]

I actually do think we have an oversupply problem, not just maldistribution, and that oversupply is being masked by overutilization. The CMS report for APM stated that freestanding centers were receiving significantly more than their hospital based counterparts despite lower reimbursements per diagnosis, implying overutilization as part of justification for APM. This is first hard evidence of overutilization on a national scale, and when it is taken away, watch out.

 

[Chartreuse Wombat]

I actually do think we have an oversupply problem, not just maldistribution, and that oversupply is being masked by overutilization. The CMS report for APM stated that freestanding centers were receiving significantly more than their hospital based counterparts despite lower reimbursements per diagnosis, implying overutilization as part of justification for APM. This is first hard evidence of overutilization on a national scale, and when it is taken away, watch out.

https://www.practicalradonc.org/article/S1879-8500(19)30126-2/pdf

"This suggests that there is a decline in interest in the field of radiation oncology among US senior medical students"

The smart medical students may have figured this out. Last year the number of US Seniors enrolled in RadOnc match was about 150, the lowest in the last decade. ERAS opens for programs in a few days. I bet the number of US Seniors is lower still. Many programs are already noting fewer rotators and interested medical students at their program. The 2020 Match may make 2019 look like a picnic.

 

[scarbrtj]

Its the ASTRO lawyers that have advised ASTRO leadership about the anti-trust issue, not the other way around. Second, the only real way of explicitly, openly restricting supply that makes sense to me would for the ACGME residency review committee for rad onc becoming more restrictive/state they will not approve additional residency positions. And there has been some case law in the area of anti-trust from restricting physician supply. See here: Restrictive Practices in Accreditation of Medical Schools: An Antitrust Analysis Note 51 Southern California Law Review 1977-1978

If you really believe the anti-trust argument is BS...stating it at the panel at ASTRO will just sound like someone who is uninformed about law.

The better way to do it would be to team up with a lawyer who specializes in this area and write it up as an editorial for the red journal/PRO/a blog post/anywhere. If you can provide a cogent, legal argument for why it is legal for rad onc to restrict supply and how (specifically) to do it, I would love to read that.

I would love to read that too. And not just the argument as to why restriction might be legal. What if... an anti-trust case was brought re: residency restriction. I'd like to know:
1) Who might bring such a case?
2) What would be the fall-out? would someone go to jail? Would lots of people? Lots of fines? Would the govt take over radiation oncology and start increasing residency slots?
I'm just asking 'cause honestly I don't know. Do ASTRO's or ABR's or ACGME's lawyers ever talk about why manipulation is a risk? If the risk is that the ABR might get officially broken up... .... .... ...
I'm sure this issue is not sui generis to radiation oncology and other specialties' lawyers have advised against workforce manipulation. But, again, what risk are we talking here. Sometimes you want to do something that seems right in principle but potentially and/or technically legally wrong, and sometimes the legal fallout is about zero for doing that. Sometimes it's not.

 

[radiaterMike]

It is not the RRC that expanded programs.

It is greedy individual programs that decided to expand -> RRC can't say no you can't expand as long as 1) program is under good standing by resident reviews 2) meets the minimum RRC criteria

We need ASTRO to take a position on this, even if they cannot specifically stop expansion
We also need the committee members of the RRC to make more stringent criteria for having a program
We also need to hold SCAROP accountable!

In the early 2000s and 2010s the "greedy individual programs" probably did not know the extent of new programs and expansion that was occurring, while the RRC clearly did. As mentioned in this thread and elsewhere (and indeed in your own response above) the RRC does have control over this by virtue of defining the program requirements. Also as mentioned many times on this forum, the antitrust angle (excuse) is dubious- and if it is a legitimate limitation to the RRC's authority,, the RRC was in a position to raise red flags to those who could enact change.

 

[RadOncMegatron]

Prisoners dilemma. Greedy academic chairmen are doing what is best for their own interest and actively hurting the entire specialty in the process. ASTRO states its hands are tied. That's basically it

This sentiment is right (though as a stickler not sure the above instance is a Nash equilibrium ). How can we trust ASTRO to make these decisions and push for something against their own interest? Theoretical it should be an entity that has mostly non-academics with some academics. The academics need "Skin in the Game" ala Nassim Taleb, otherwise they will not do the right thing.

 

[medgator]

In the early 2000s and 2010s the "greedy individual programs" probably did not know the extent of new programs and expansion that was occurring, while the RRC clearly did. As mentioned in this thread and elsewhere (and indeed in your own response above) the RRC does have control over this by virtue of defining the program requirements. Also as mentioned many times on this forum, the antitrust angle (excuse) is dubious- and if it is a legitimate limitation to the RRC's authority,, the RRC was in a position to raise red flags to those who could enact change.

They know it now. Or should.

 

[deleted774703]

This sentiment is right (though as a stickler not sure the above instance is a Nash equilibrium ). How can we trust ASTRO to make these decisions and push for something against their own interest? Theoretical it should be an entity that has mostly non-academics with some academics. The academics need "Skin in the Game" ala Nassim Taleb, otherwise they will not do the right thing.

That’s why we need more PP docs to run for ASTRO leadership positions.

Though I’m sure it’s hard to break in to the inner circle due to radonc politics

 

[imhopeful432]

That’s why we need more PP docs to run for ASTRO leadership positions.

Though I’m sure it’s hard to break in to the inner circle due to radonc politics

100% agree. Getting on ASTRO committees is the best way to make an impact/be heard

 

[RadOncDoc21]

Imhopeful432 2020?

 

[deleted774703]

Ben Falit hiding behind antitrust again at ARRO day....

 

[GapCalc]

Steinberg saying we’re bad at predicting RO needs so let’s not even try.

This is remarkable.

 

[deleted774703]

They are not even giving a chance for residents to ask questions or speak so far

 

[medgator]

Ben Falit hiding behind antitrust again at ARRO day....

So basically it's up to greedy academic chairs to do the right thing.

Steinberg saying we’re bad at predicting RO needs so let’s not even try.

I.e. let the free market regulate itself like zietman said I guess. Med students, you have been warned.

Can't wait to see the next ASTRO "non" statement and reaction on #radonc Twitter with the results of match 2020.

 

[deleted774703]

Steinberg biggest hater I’ve ever heard lol.

Residents aren’t cost effective LMAO.

Govt literally pays hospitals for our spot. We are FREE labor with an MD

 

[medgator]

Steinberg biggest hater I’ve ever heard lol.

Residents aren’t cost effective LMAO.

Govt literally pays hospitals for our spot. We are FREE labor with an MD

Sounds like he's gaslighting you folks. Seems to be quite a common thing to do these days. Probably would say the same thing about "advanced radiation therapy" fellows too

 

[Krukenberg]

I actually came away convinced. Falit is a lawyer and I believed when he said that he talked to anti-trust specialists about it. The encouraging thing is Vapiwala has a vision for correcting this problem

 

[medgator]

The encouraging thing is Vapiwala has a vision for correcting this problem

Which is?

 

[RadOncDoc21]

Are we still waiting for the response or was this suppose to be a cliff hanger?

 

[GapCalc]

So I was there. I’ll post more later (this exhibit hall is just too thrilling), but my take-away (feel free to disagree) was that Dr. Lee encouraged Dr. Vapiwala to 1) impose stricter requirements for residency programs to ensure good training and 2) stick to her guns once the blowback from those negatively affected inevitably occurs.

Mike Steinberg’s closing statement was that rad oncs are too hard on ourselves and that everything will work out “in a decade or two.”

 

[deleted956486]

So I was there. I’ll post more later (this exhibit hall is just too thrilling), but my take-away (feel free to disagree) was that Dr. Lee encouraged Dr. Vapiwala to 1) impose stricter requirements for residency programs to ensure good training and 2) stick to her guns once the blowback from those negatively affected inevitably occurs.

Mike Steinberg’s closing statement was that rad oncs are too hard on ourselves and that everything will work out “in a decade or two.”

Yes, because he's retiring in 5 years.

 

[Krukenberg]

So I was there. I’ll post more later (this exhibit hall is just too thrilling), but my take-away (feel free to disagree) was that Dr. Lee encouraged Dr. Vapiwala to 1) impose stricter requirements for residency programs to ensure good training and 2) stick to her guns once the blowback from those negatively affected inevitably occurs.

Mike Steinberg’s closing statement was that rad oncs are too hard on ourselves and that everything will work out “in a decade or two.”

It wasn’t just encouragement. She stated that her intention was to set standards that ensure low quality programs close if they don’t shape up. She criticized the RRC for being a “rubber stamp” to programs opening/expanding and clearly stated that was going to change under her.