ASTRO’s role

[scarbrtj]

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If I had to guess, BK and PH are flat out wrong/misleading just like when they say now is the best time ever to go into radonc?

I would also say the legal radiation oncology masterminds who've claimed forever that only radiation oncologists can supervise radiation also are sure that it's illegal and anti-trust to discuss workforce issues.

 

[scarbrtj]

I mean in fairness, they're saying that there needs to be MORE plastic surgeons (Full abstract below, bold emphasis mine), not less. We have precedence with that as Hallahan said it as has been discussed in the reply to Chirag Shah's 2013 editorial. We also have the under/oversupply studies from Ben Smith, Pan et al, etc. We (as a field) have published on it but the ability to DO anything about it has been where people have been hands off and said 'not my problem' and where we get the specter of anti-trust as something that ties everybody's hands.

I get it. Anti-trust to restrict competition. Not anti-trust not to restrict competition. On the other hand, the mere act of setting up a Workforce Task Force certainly puts a society at risk for discovering they might need to restrict the workforce. Seems like ASPS was unafraid or at least legally untrammeled.

 

[thecarbonionangle]

Harari is a typical radiation oncologist: afraid to stick his head out.

Anybody working in a hospital know that surgerons walk at the middle of the of the hallway, their heads up. RadOnc sneak by the walls with their eyes down.

Agreed. The field attracts some very passive personalities. This has been to our grave detriment

 

[winstonfoot5]

I mean the key here is that you need money to lobby. ASTRO PAC is open for business so any critic here is more than welcome to donate and simultaneously state what political issues matter to you. The reason those other lobbies have power is their members are willing and able to contribute a lot of money.

by the way, my favorite part of the CMS rule "Other commenters expressed concerns that allowing general supervision to be the minimum default level of supervision for certain types of services, including radiation therapy, hyperbaric oxygen treatment, and wound care, could put the health and safety of
Medicare beneficiaries receiving these procedures at risk"

Reading between the lines: basically no one pushed back on this rule change except ROgists and HBOgists. Not exactly pharma fighting this one, ASTRO didnt have a chance

 

[thecarbonionangle]

residency expansion is rampant amongst all specialties. it is not true that the number of residency spots is steady in plastics. the 2000 match offered 52 residency spots. the 2020 match has 175 spots. % increase plastics > % increase rad onc. the plastics people are self-servicing themselves with this publication and they know it.

plastics and dermatologists are some of the most confident decisive smartest people i have ever met. We have a lot to learn

 

[evilbooyaa]

residency expansion is rampant amongst all specialties. it is not true that the number of residency spots is steady in plastics. the 2000 match offered 52 residency spots. the 2020 match has 175 spots. % increase plastics > % increase rad onc. the plastics people are self-servicing themselves with this publication and they know it.

Paper is from 2010. There were similar papers to that in Rad Onc 10 years ago:

The future of radiation oncology in the United States from 2010 to 2020: will supply keep pace with demand? - PubMed

Demand for radiation therapy is expected to grow 10 times faster than supply between 2010 and 2020. Research is needed to explore strategies to enhance capacity to deliver quality radiation therapy despite increased patient loads.

www.ncbi.nlm.nih.gov

But this was refuted (same authors) in a more recent publication: https://www.redjournal.org/article/S0360-3016(16)00233-9/fulltext

This is all without considering a change from direct to general supervision, and also didn't really control for changes in fractionation schemes, so I imagine those projections are now more incorrect.

This was addressed in IJROBP 2 years ago, but of course residents know nothing, so nothing was done about it: https://www.redjournal.org/article/S0360-3016(16)33385-5/fulltext

 

[medgator]

residency expansion is rampant amongst all specialties. it is not true that the number of residency spots is steady in plastics. the 2000 match offered 52 residency spots. the 2020 match has 175 spots. % increase plastics > % increase rad onc. the plastics people are self-servicing themselves with this publication and they know it.

Despite that and increases in derm spots also, both are still healthier specialties. You can still go to many decent sized cities and open and run a successful practice. Not true in RO

 

[scarbrtj]

residency expansion is rampant amongst all specialties. it is not true that the number of residency spots is steady in plastics. the 2000 match offered 52 residency spots. the 2020 match has 175 spots. % increase plastics > % increase rad onc. the plastics people are self-servicing themselves with this publication and they know it.

However, in the bright open light of day, the ASPS did set up a Workforce Task Force. It seems to be ASTRO’s assertion that even setting up a task force would be illegal because task forces can find you need more folks (fine?), the same (fine?), or less (anti-trust?).

 

[imhopeful432]

However, in the bright open light of day, the ASPS did set up a Workforce Task Force. It seems to be ASTRO’s assertion that even setting up a task force would be illegal because task forces can find you need more folks (fine?), the same (fine?), or less (anti-trust?).

ASTRO did have a workforce task force. You can see the report of the task force here: The American Society for Radiation Oncology 2017 Radiation Oncologist Workforce Study. - PubMed - NCBI

 

[scarbrtj]

ASTRO did have a workforce task force. You can see the report of the task force here: The American Society for Radiation Oncology 2017 Radiation Oncologist Workforce Study. - PubMed - NCBI

But in contradistinction to ASTRO's milquetoast workforce "survey"...

"The aim of this study is to report the American Society for Radiation Oncology 2017 radiation oncologist (RO) workforce survey results; identify demographic, technology utilization, and employment trends; and assess the profession's ability to meet patients' needs, offer job satisfaction, and attract high-caliber trainees"

...the ASPS's goals were an order of magnitude more audacious (to make a recommendation!), centered around a "task force"...

"The American Society of Plastic Surgeons (ASPS) formed the Plastic Surgery Workforce Task Force to study the size of the plastic surgery workforce and make recommendations about future workforce needs."

 

[Chartreuse Wombat]

But in contradistinction to ASTRO's milquetoast workforce "survey"...

"The aim of this study is to report the American Society for Radiation Oncology 2017 radiation oncologist (RO) workforce survey results; identify demographic, technology utilization, and employment trends; and assess the profession's ability to meet patients' needs, offer job satisfaction, and attract high-caliber trainees"

...the ASPS's goals were an order of magnitude more audacious (to make a recommendation!), centered around a "task force"...

"The American Society of Plastic Surgeons (ASPS) formed the Plastic Surgery Workforce Task Force to study the size of the plastic surgery workforce and make recommendations about future workforce needs."

Verbatim from the "Task Force"

More respondents were concerned about an RO oversupply rather than shortage.

 

[scarbrtj]

Verbatim from the "Task Force"

More respondents were concerned about an RO oversupply rather than shortage.

I wouldn't call ASTRO's endeavors task forces. By definition task forces make recommendations. ASTRO has workforce "studies" with a Talmudic recitation of survey findings clothed in a snoozy past exonerative tense. The word "recommend" or any of its roots appears exactly zero times in the recent ASTRO "task force" report.

 

[Chartreuse Wombat]

I wouldn't call ASTRO's endeavors task forces. By definition task forces make recommendations. ASTRO has workforce "studies" with a Talmudic recitation of survey findings clothed in a snoozy past exonerative tense. The word "recommend" or any of its roots appears exactly zero times in the recent ASTRO "task force" report.

Hence the scare quotes.

 

[RadOncMegatron]

Paper is from 2010. There were similar papers to that in Rad Onc 10 years ago:

The future of radiation oncology in the United States from 2010 to 2020: will supply keep pace with demand? - PubMed

Demand for radiation therapy is expected to grow 10 times faster than supply between 2010 and 2020. Research is needed to explore strategies to enhance capacity to deliver quality radiation therapy despite increased patient loads.

www.ncbi.nlm.nih.gov

But this was refuted (same authors) in a more recent publication: https://www.redjournal.org/article/S0360-3016(16)00233-9/fulltext


This is all without considering a change from direct to general supervision, and also didn't really control for changes in fractionation schemes, so I imagine those projections are now more incorrect.

This was addressed in IJROBP 2 years ago, but of course residents know nothing, so nothing was done about it: https://www.redjournal.org/article/S0360-3016(16)33385-5/fulltext

“It's tough to make predictions, especially about the future.”

-Yogi Berra

 

[scarbrtj]

"The Council on Graduate Medical Education is governed by the Federal Advisory Committee Act, Public Law 92-463 §1 (5 U.S.C. Appendix 2), as amended, which sets forth the standards for the formation and use of advisory committees. Originally authorized in 1986 for ten years, the Council has been extended through various legislative enactments... The charge to COGME is broader than the name would imply. Title VII of the Public Health Service Act, as amended, requires COGME to provide advice and recommendations to the HHS Secretary and Congress on the following issues:

1. The supply and distribution of physicians in the United States.
2. Current and future shortages or excesses of physicians in medical and surgical specialties and subspecialties.
3. Issues relating to international medical school graduates.
4. Appropriate federal policies with respect to the matters specified in items 1-3, including policies concerning changes in the financing of undergraduate and graduate medical education (GME) programs and changes in the types of medical education training in GME programs.
5. Appropriate efforts to be carried out by hospitals, schools of medicine, schools of osteopathy, and accrediting bodies with respect to the matters specified in items 1-3, including efforts for changes in undergraduate and GME programs.
6. Deficiencies and needs for improvements in data bases concerning the supply and distribution of, and postgraduate training programs for, physicians in the United States and steps that should be taken to eliminate those deficiencies.

In addition, the legislation calls for the Council to encourage entities providing GME to implement the recommendations of the Council specified in item 5, above."

ASTRO doesn't provide GME (yet it is an "accrediting body" of some sort). However clearly ASTRO has tons of individual members who do provide GME. Can't ASTRO 1) have concerns re: oversupply, and 2) voice its concerns to COGME? Anybody in Chapel Hill or Boston reading this? Go talk to Dr. Tsai (vice-chair of COGME) or Dr. Fraher (chair of COGME). Go ask him or her what's up with anti-trust etc. Couldn't ASTRO talk to these folks too?

Did Congress create COGME in violation of anti-trust? Or would it seem Congress (and by extension laws enacted) has encouraged other doctors and groups to constantly be exploring these physician supply issues? Is not doing so a willful laziness on our and ASTRO's part? Maybe ASTRO could just go to this council, have them write a two-plus-two-equals-four report on the U.S. rad onc state of affairs, and... the "entities providing GME [would] implement the recommendations of the Council." Maybe.

 

[RickyScott]

“It's tough to make predictions, especially about the future.”

-Yogi Berra

Well it is and isn’t. Some predictions like the sun coming up or a recession in the next 10 years can be made with great accuracy. I can also predict that if you double residency positions that the supply of residents will in fact double and that it will indeed impact supply and demand.

 

[Mandelin Rain]

Willful laziness? Maybe. Willful ignorance? Definitely.

"It is difficult to get a man to understand something when his salary depends upon his not understanding it."

 

[evilbooyaa]

"The Council on Graduate Medical Education is governed by the Federal Advisory Committee Act, Public Law 92-463 §1 (5 U.S.C. Appendix 2), as amended, which sets forth the standards for the formation and use of advisory committees. Originally authorized in 1986 for ten years, the Council has been extended through various legislative enactments... The charge to COGME is broader than the name would imply. Title VII of the Public Health Service Act, as amended, requires COGME to provide advice and recommendations to the HHS Secretary and Congress on the following issues:

1. The supply and distribution of physicians in the United States.
2. Current and future shortages or excesses of physicians in medical and surgical specialties and subspecialties.
3. Issues relating to international medical school graduates.
4. Appropriate federal policies with respect to the matters specified in items 1-3, including policies concerning changes in the financing of undergraduate and graduate medical education (GME) programs and changes in the types of medical education training in GME programs.
5. Appropriate efforts to be carried out by hospitals, schools of medicine, schools of osteopathy, and accrediting bodies with respect to the matters specified in items 1-3, including efforts for changes in undergraduate and GME programs.
6. Deficiencies and needs for improvements in data bases concerning the supply and distribution of, and postgraduate training programs for, physicians in the United States and steps that should be taken to eliminate those deficiencies.

In addition, the legislation calls for the Council to encourage entities providing GME to implement the recommendations of the Council specified in item 5, above."

ASTRO doesn't provide GME (yet it is an "accrediting body" of some sort). However clearly ASTRO has tons of individual members who do provide GME. Can't ASTRO 1) have concerns re: oversupply, and 2) voice its concerns to COGME? Anybody in Chapel Hill or Boston reading this? Go talk to Dr. Tsai (vice-chair of COGME) or Dr. Fraher (chair of COGME). Go ask him or her what's up with anti-trust etc. Couldn't ASTRO talk to these folks too?

Did Congress create COGME in violation of anti-trust? Or would it seem Congress (and by extension laws enacted) has encouraged other doctors and groups to constantly be exploring these physician supply issues? Is not doing so a willful laziness on our and ASTRO's part? Maybe ASTRO could just go to this council, have them write a two-plus-two-equals-four report on the U.S. rad onc state of affairs, and... the "entities providing GME [would] implement the recommendations of the Council." Maybe.

Good find. Bolded my emphasis. Seems like GME should be addressing this very aggressively.

 

[medgator]

Impotent

ASTRO Statement on New CMS Outpatient Supervision Policy
November 12, 2019

On Friday, November 1, 2019, the Centers for Medicare and Medicaid Services (CMS) issued the 2020
Hospital Outpatient Prospective Payment System (HOPPS) Final Rule with a significant, detrimental
change that reduces the supervision requirement for radiation therapy services. The final rule changes
the current supervision policy for therapeutic services delivered in a hospital outpatient setting from
either “direct or general” supervision to a blanket “general” supervision policy.

This new policy does not
impact freestanding facilities.

ASTRO sent a letter to CMS to oppose the proposed HOPPS supervision rule policy change and is disappointedthat CMS chose to disregard ASTRO’s and patient groups’ specific concerns. We contend that reducing the supervision of a patient during therapeutic treatment could potentially endanger
patients due to the irreversible nature of radiation treatment delivery.

Currently, Medicare requires radiation therapy services in an outpatient department to be performed
under the provider’s direct supervision, meaning that the physician must be immediately available, physically present, interruptible and able to furnish assistance and direction throughout the performance of the procedure.

Beginning in 2020, the physician’s presence and availability during
treatment will not be required under the revised definition of general supervision. The policy change
applies to outpatient therapeutic services only, as existing supervision requirements will still apply to
diagnostic services.

ASTRO is opposed to this new policy affecting therapeutic services.
According to the HOPPS final rule, the new general supervision policy does not prevent hospitals from
adopting more stringent supervision policies for particular treatments. It remains ASTRO’s position that
a board-certified/board-eligible radiation oncologist is the clinically appropriate physician to supervise
radiation treatments.

 

[RadRadRad]

Impotent

I think the above statement is a step in the right direction. I would suggest ASTRO promote their policy on supervision and perhaps write something similar to a position paper on the topic signed by leaders in the field. At the end of the day, a lawsuit against your department is going to hinge on testimony from other radoncs, not on CMS guidelines. As a hospital, I would be very nervous to have less supervision present than what was recommended by ASTRO.

Additionally, perhaps ASTRO APEX and ACR accreditation could mandate direct supervision in order to meet accreditation criteria/standards.

 

[seper]

Well, if the rule is final, nothing ASTRO can do for 2020.

 

[medgator]

I think the above statement is a step in the right direction. I would suggest ASTRO promote their policy on supervision and perhaps write something similar to a position paper on the topic signed by leaders in the field. At the end of the day, a lawsuit against your department is going to hinge on testimony from other radoncs, not on CMS guidelines. As a hospital, I would be very nervous to have less supervision present than what was recommended by ASTRO.

Additionally, perhaps ASTRO APEX and ACR accreditation could mandate direct supervision in order to meet accreditation criteria/standards.

Agree for sbrt or brachy, but those can be clustered together.

It'll be a lot easier though for satellite coverage where standard external cases (non sbrt not brachy) are treated and there is likely little ASTRO can do about it, similar to what has been happening at rural/critical access hospitals in this country and abroad all along

 

[scarbrtj]

Impotent

Would it be ASTRO’s position that general supervision is still ok in rural hospitals/CAHs as it has been for years... as it has always been. In other words, why hasn’t ASTRO been lobbying against unsafe generally supervised radiotherapy all this time everywhere in the US. Seems their interest is only piqued now and only for non rural radiotherapy. Unless they’re now in favor of abolishing the previous two tier American supervision system, they’re now in favor of returning to it.

 

[Chartreuse Wombat]

I think the above statement is a step in the right direction. I would suggest ASTRO promote their policy on supervision and perhaps write something similar to a position paper on the topic signed by leaders in the field. At the end of the day, a lawsuit against your department is going to hinge on testimony from other radoncs, not on CMS guidelines. As a hospital, I would be very nervous to have less supervision present than what was recommended by ASTRO.

Additionally, perhaps ASTRO APEX and ACR accreditation could mandate direct supervision in order to meet accreditation criteria/standards.

Yes, but that mandate may reduce demand for accreditation. Another accreditation process may gain market share by remaining silent on supervision. Not saying it is a good thing.

 

[Mandelin Rain]

Any word from ACRO?

 

[nkmiami]

Any word from ACRO?

Historically, ACRO never required a "radiation oncologist" present, just a physician as I understand it.