Bloodbath in Red Journal

[Mandelin Rain]

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.

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[Gfunk6]

Personally, I think Dr. Shah was very correct in his editorial. I think the critical comments from faculty are fascinating, most notably:

One of us (P.W.) served as a faculty advisor to the Association of Residents in Radiation Oncology from 2006 to 2012 and was never aware of the pathos Dr Shah ascribes to our trainees regarding their job opportunities or quality of training. Instead, they seemed most focused on adding new and exciting dimensions to that training. Ultimately the marketplace will determine the growth or shrinkage of our resident pool, and not the organizations charged with the quality of training and evaluation of that training.

The bolded statement is completely at odds with the last sentence. If there is market oversaturation and the residents can't find jobs, how in the world will that translate into a change in residency slots? I guess one way would be a horrendous job market which is known by all potential residency applicants, thereby limiting applications. See the Pathology forum for a preview of what that's like . . .

Also, I think Dr. Shah's reply to the above comments was excellent.

With regard to the Accreditation Council for Graduate Medical Education (ACGME), I acknowledge that as it currently stands the ACGME is not able to address workforce issues as part of its scope. However, the ACGME mission is for healthcare system improvement; how is this goal met if residents from accredited programs are unable to find positions after training? Although I understand that there are concerns regarding regional shortages of radiation oncologists, radiation oncology, like many medical specialties, has more of a maldistribution problem than a shortage problem. Therefore, the specialty does not need programs to expand or to create new training programs in underserved regions but instead to drive graduates on the basis of increased salaries and benefits to areas that are underserved.

Have we not learned from the problems of our Diagnostic Radiology colleagues?

 

[lazers]

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.

Can you send me a link to the article?

 

[Gfunk6]

Original article is here.

 

[deleted4401]

Just goes to show you how removed academics are from the real world. Just because the mission of the ACGME happens to not weigh labor issues in its decisions to increase training positions doesn't mean it shouldn't. Unbelievable that 2-3 of those letters said the same thing. If the mission of our department was not to deliver cost effective, evidence based care, that doesn't mean we shouldn't change the mission.

93 to 171 is a big change. Who knows what we will need in the future? We are seeing drops in our numbers of patients being treated daily due to several factors, active surveillance and hypofractionation being 2 of the more obvious things. There may be a point when IORT becomes a standard of care for breast cancer. There may be a point when 5 fraction treatment becomes a standard of care for prostate (ASTRO's statement says it is a reasonable treatment option). And, at the same time reimbursements are going down. So, to maintain financial stability, cancer centers will have to consolidate and increase volumes per physicians. Then what do we do with all these graduates?

I'd like to see a response from physicians in the bigger private practice groups - perhaps someone from SERO or Princeton or Sacramento will chime in.

 

[BobbyHeenan]

I too thought Dr. Shah had an excellent response and was proud of him for a well thought out reply to some of the biggest names in our field.

It's disappointing to see the academic leaders largely ignoring the main issue here - how to solve a maldistribution problem, not a shortage problem. To me, the maldistribution issue was grossly overlooked (never even discussed) in the oft-cited JCO paper in 2010 that used SEER data to project a shortage.

Sure, it's possible that increasing some number or starting targeted regional expansion may be part of a remedy to the maldistribution issue, but across the board expansion just doesn't seem like the right thing to do.

 

[medgator]

Original article is here.

That link didn't work, so I logged in. Maybe this one will work?

http://www.redjournal.org/article/S...efuid=S0360-3016(13)00215-0&refissn=0360-3016

International Journal of Radiation Oncology * Biology * Physics

Volume 85, Issue 5 , Pages 1157-1158, 1 April 2013

Expanding the Number of Trainees in Radiation Oncology: Has the Pendulum Swung Too Far?

To the Editor: After reading the recent opinion article from Dr. Shah (1), I am compelled to respond. Although I am the current Chair of the Radiation Oncology Review Committee (RC) for the Accreditation Council for Graduate Medical Education (ACGME), I write this letter as an individual physician. The mission of the ACGME is to improve healthcare by assessing and advancing the quality of resident education through accreditation. Dr. Shah correctly notes that the ACGME has not acted "to regulate the increase in residency positions," and he then encourages the ACGME to consider the "real impact" of increased resident positions in the future. Policy decisions as to the appropriate size of the physician workforce are outside of the purview of the ACGME. In fact, the ACGME forbids RC members from considering workforce issues in accreditation decisions. Since the beginning of the organization, ACGME policy has stated "that in the accrediting process, the ACGME is not intent upon establishing numbers of practicing physicians in the various specialties in the country, but rather that the purpose of accrediting by the ACGME is to accredit those programs which meet the minimum standards as outlined in the institutional and program requirements."

To the Editor: Although Dr Shah has been a member of the faculty at Washington University, his opinion expressed in "Expanding the number of trainees in radiation oncology: has the pendulum swung too far?" (1) is not the opinion of this institution. Our opinion is that there is a growing need for radiation oncologists in the United States. More importantly, there is a need for new training programs in the midwest and south. The demand for radiation oncologists has outpaced the supply. This shortfall of radiation oncologists is especially problematic in the midwestern and southern regions of the United States. As an example, the state of Missouri has only one training program. This shortage has, in part, resulted in an increase in salaries for radiation oncologists in academic programs, as demonstrated by the Association of American Medical Colleges faculty salary survey report (2). To address the growing need for radiation oncologists, Washington University (Mallinckrodt Institute of Radiology and Siteman Cancer Center) has applied for an increase in our number of residents. We are also actively collaborating with Saint Louis University to initiate a residency in radiation oncology.

I definitely echo the comments in this thread that the above needs to change. SimulD also brings up the very valid point of practice and treatment philosophy changes going forward.

In addition, somehow, an example of "Missouri" was translated into "shortfall of radiation oncologists is especially problematic in the midwestern and southern regions of the United States" This doesn't make a lot of sense to me.

Finally, the reason salaries in academics has gone up is to try and reach closer to what is seen in private practice, as that has been luring new grads away, not because there is a shortage of rad oncs. Just ask any academic center what their surrounding private competition is like

 

[RadOncMegatron]

Fascinating read. I wish the red journal put in a "big name" to support Dr. Shah, instead they have some big guns (including the editor-n-chief himself) knock him down.

I think Dr. Shah is on the money. Why shouldn't those accrediting bodies think about such things?

 

[deleted4401]

Well, maybe a lot of little guns! Everyone should write a letter ...

 

[Member223232]

More residency slots = more free labor paid for by medicare. Instead of hiring a PA that they have to pay 100,000 per year for and who probably is limited in what they can do, they can instead get residents which dont cost a dime and instead come with 100,000 dollars from the government and who can work basically unlimited number of hours and do almost anything that an attending can do.......

And if the job market gets tough, even better! There will be more competition for jobs and the universities can pay junior attendings less and threaten to replace them if anyone complains. It really is win win for them. All of these issues are couched in terms related to patient care (access to care etc.) but they are ultimately all about money. Ultimately, we are just little rafts in the waves of socio-economic change. We just hope that during our careers, the wind is blowing in our favor.....

Dr. Shah did a brave thing, at considerable risk to his own career, but I don't know if it will change the minds of anyone in power....

 

[doctwo]

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.

Although I did read the responses to Dr. Shah's well thought out article addressing a major potential issue within our field, I did not "catch the beatdown." I did however, read several responses from out of touch insular individuals who clearly have no regard for the challenges faced by graduating residents who have invested 13+ years not to mention taken extensive loans with the expectation of being able to follow their passion to practice radiation oncology upon graduation. The responses published in the Red Journal demonstrate a true ignorance to both the sacrifices made in becoming a radiation oncologist as well as the challenges faced by graduating seniors.
I hope that more young radiation oncologists will follow the path taken by Dr. Shah in addressing issues important to us and that less will continue to blindly follow the doctrine of "big names" out of fear and inability to think for oneself as Mandelin Rain insinuates we should do.

 

[Scatter]

Bravado. #callaspadeaspade I completely agree with Dr. Shah and commend him on pointing out the 900 pound gorilla in the room. Just because one is called a "big shot" does not guarantee they have their finger on the pulse of things. The job market is ridic these days.

 

[Ursus Martimus]

Training with the author of the article I can surely attest that he is amongst one of the smartest people I have ever met. At least in an academic sense. He is no longer at WashU, and I am sure that there is much more to him leaving than this article. In fact, for those worried about a field shredding those critical of the establishment, he passed his boards this year, I am sure he crushed them. He has indeed left for a practice in a smaller community, although not sure it would be considered an underserved issue.

I think Dr. Zeitman felt compelled to weign in on the situtation and I think his response is well tempered. However this forum contains a number of incorrect statements that only add fuel to the fire. For instance....

More residency slots = more free labor paid for by medicare. Instead of hiring a PA that they have to pay 100,000 per year for and who probably is limited in what they can do, they can instead get residents which dont cost a dime and instead come with 100,000 dollars from the government and who can work basically unlimited number of hours and do almost anything that an attending can do...........

For the record, it costs $140,000 to $150,000 a year to train a resident, with Medicare paying $90,000 and the teaching hospital picking up the remainder.

http://www.amednews.com/article/20121210/business/312109978/7/

As well, everyone who has turned attending realizes that. although residents are high functioning in the department, perhaps more so than in other disciplines, ultimately all billing requires an attending.

Is it right to hold the ACGME responsible for what might more rightly a 25% increase in training spots? I think it is fair to entrust someone with that responsibility, however clearly as of now, no one has been empowered to do so.

I can say with some certainity that I do not know of any unemployed American Graduate Radiation Onocologists. There are indeed many postions out there. And those in less desireable locales do seem to compensate quite nicely. Not everyone can get the $350,000/yr job in a metro area with an academic day. These days are gone.

Although the number of residency slots may ultimately wittle down reimbercements, the current changes in our healthcare envirenment are, by far. a much greater threat.

 

[Palex80]

Well, it is called the RED Journal, so why not have a bloodbath?

 

[deleted4401]

Um, this is rad onc. We're not really useful labor. The best PGY-2 only triples the workload (ref: HoG). An attending could bang out whole his work in an 8 hour day. But, with residents doing their contours, then having to edit them, seeing the patients after the resident sees them, teaching, going to morning conference, it gets to be a lot of work. My academic friends work way more than my private practice friends. The only benefit is they don't have to dictate. Not quite the same as your PGY-3 medicine resident that's taking care of all hell breaking loose in the ICU or the surgical interns managing the entire floor.

I don't think that's the reason we are expanding. It's just a total blindness to reality and it's disappointing that the very people that should be advocating for us are doing the exact opposite.

S

 

[beemer]

I think most of us agree that indiscriminately expanding residency programs is detrimental to the trainees and the field overall. However, I am not sure ACGME and RRCs should be entrusted with the job of controlling residency positions based on demand. Imagine a situation where a hospital starts a new residency program that is first rate but is turned down because there is not enough demand in that state and a barely acceptable program is approved in a different state for "demand" reasons. The role of the ACGME should be solely to make sure program meet "minimum" requirements to start / run a residency program. There is no doubt that we need to have a body that regulates overall number of programs / trainees. In my opinion, that body needs to be an independent entity that will not have a conflict of interest. We already have certain fields like dermatology that heavily control number of training positions to artificially keep salaries high although the wait period to see a dermatologist in this country is super long (just as an example). Since all of us would love to be in demand and make a million dollars, we inherently have a conflict of interest in this issue and may not make decisions keeping the best interest of the patient. I am not sure who should be making those decisions though.

 

[Radonc90]

Shah article is timely and interesting but I'd like to make a few comments...

1. Controlling the workforce (supply vs demand) is always a challenge given the fact that it takes many many years to have an effect.
- For those who live near the Missouri river, once you partially close the upstream dam gates (e.g. Gavins Point Dam), it takes a long time for water level to settle down.
- The opposite is also true, in the Summer of 2011, the Army Corps of Engineers released massive amount of water (due to heavy amount of snow melt and heavy rain), causing massive flooding in Iowa, Missouri etc.

The bottom line is: any changes implemented now will take years to see an effect. Anesthesia went through this in the 1990s.


2. ACGME and RC (or RRC) exist to make sure residency programs' standards are high, thus producing high-quality physicians to serve the public.
The ACGME and RC do not regulate "water flow".

In fact, the "water flow" is regulated by mostly Chairmen/PDs via "recommendations". Basically they discuss this issue of supply vs demand and make the recommendations to training programs to increase/decrease # training positions.

The last paragraph in the article showed that the author (Shah) does not understand the healthcare politics:

"Unfortunately, the ABR and ACGME have not acted to regulate the increase in residency positions. Moving forward, it is imperative that the ABR, ACGME, and ASTRO evaluate the real impact of the increase in trainees on our specialty, to prevent history from repeating itself."

If we make an analogy to Joint Commission (formerly JCAHO), then JC inspects hospitals for compliance, but JC will never make a recommendation to open or close hospitals based on patient demand. The market dictates this.

Anyway, the replies by Drs. Lee, Wallner and Shrieve were right on target.
BTW, this is not a bloodbath, rather this is a slap on the wrist for the young kid LOL.

 

[radiaterMike]

A question that nobody here has really addressed- What is the evidence that there is a job shortage ? or an impending job shortage ? Maybe this exists but I have not seen it. There is so much anxiety here over perceived possibilities that there might not be jobs. Certainly there will be shortages of positions making 600k working 4 days a week with 3 months vacation, but unless there is evidence showing otherwise, there will be jobs when you graduate. Even in the years with fewer graduates, there was never a guarantee that someone would get a job where they wanted, with all of the perks they wanted. Rad. Onc has always been a small field meaning that any given practice/group/univeristy would not be hiring every year. The sky may be falling with health care reform, but probably not with job availability. .

 

[deleted4401]

We have a big group of 15 docs (mostly full time partners and associates and a few salaried, non partner track). We had a very sudden tragic death of a partner, and despite this loss, we have no plans to hire, as everything is already tightening up.

That's the sort of thing that will happen - a group of 6 docs might have one retire and not hire another. If they on average treat 120 patients, then instead of 20 per doc, there will be 24 per doc. Not a huge increase in workload, but enough to make up for the reimbursement declines and volume drops that we will be facing.

I don't suspect it's happening in great numbers yet, so there is no "evidence" but with the example in my group and the thinking behind it, I presume many practices will behave similarly.

 

[medgator]

We have a big group of 15 docs (mostly full time partners and associates and a few salaried, non partner track). We had a very sudden tragic death of a partner, and despite this loss, we have no plans to hire, as everything is already tightening up.

That's the sort of thing that will happen - a group of 6 docs might have one retire and not hire another. If they on average treat 120 patients, then instead of 20 per doc, there will be 24 per doc. Not a huge increase in workload, but enough to make up for the reimbursement declines and volume drops that we will be facing.

I don't suspect it's happening in great numbers yet, so there is no "evidence" but with the example in my group and the thinking behind it, I presume many practices will behave similarly.

We are a similar situation to you, SimulD. One partner looking at retiring soon, and we are not looking to replace that partner anytime soon unless there is significant growth in the practice. It will make it tighter for vacation coverage so we will likely have to hire a locums, but that's what's looking to be the best option right now.

 

[BobbyHeenan]

I dont know if there is hard data, it would be pretty tough to come by it. That being said I think that the experiences of those going into the job market over the last few years is that it is getting tougher with fewer big city jobs available, lower initial salary offers, etc. To me one of the big concerns is not only availability of positions but quality positions in the academic and private side of things, I think these are decreasing in light of larger numbers of graduates in combination with declining reimbursement. We aren't at the point where grads cant find jobs but we are the point where a fair number, even grads of top 10 programs, are settling for whats available.

Very anecdotal, but look at the ASTRO job board or careerMD oncology rad onc job openings. I've been looking for two years now, and the vast majority of jobs as I recall have been in rural areas.

Someone could probably get at least an ASTRO poster by going back and looking at those job boards and plotting them out on a map. Obviously, the best practices often won't need to post their openings, but it is at least some "scientific" way to assess maldistribution, and IMO is just as "scientific" as using SEER data like they did in the JCO article in 2010 everyone cites as predicting a shortage.

In addition, I will pile on as knowing about the phenomena of group practices not hiring replacements for outgoing partners. I've seen places taking on more patients per doc, sometimes hiring PA's/NP's to help in the clinic, and attempting to streamline to make up for reimbursement cuts.

 

[MOHS_01]

I think most of us agree that indiscriminately expanding residency programs is detrimental to the trainees and the field overall. However, I am not sure ACGME and RRCs should be entrusted with the job of controlling residency positions based on demand. Imagine a situation where a hospital starts a new residency program that is first rate but is turned down because there is not enough demand in that state and a barely acceptable program is approved in a different state for "demand" reasons. The role of the ACGME should be solely to make sure program meet "minimum" requirements to start / run a residency program. There is no doubt that we need to have a body that regulates overall number of programs / trainees. In my opinion, that body needs to be an independent entity that will not have a conflict of interest. We already have certain fields like dermatology that heavily control number of training positions to artificially keep salaries high although the wait period to see a dermatologist in this country is super long (just as an example). Since all of us would love to be in demand and make a million dollars, we inherently have a conflict of interest in this issue and may not make decisions keeping the best interest of the patient. I am not sure who should be making those decisions though.

With any and all due respect, you're flat wrong on this today. As in not a little wrong, but way wrong. Derm has experienced an increase in residency slots over the past decade that, on a relative basis, is well beyond that of any other specialty. When I started medical school in the mid/late 90's, we turned out fewer than 200 / year. By the time I graduated medical school in 2001, there were 228 potential slots. Do you know how many there were last year? 363, I believe. You do the math. You radonc guys are supposed to be pretty good at math and general science, so you tell me what this increase does to equilibrium dynamics. The argument over the expansion of dermatology residency positions has been going on for a decade; I believe the correct side lost and the cloistered (friendly term, I have several more appropriate terms) academics won out. It has paid the expected dividends in the job market -- whereas I received many, many, many job offers, current residents are entering a very different market.

we need someone to start controlling this as it is getting out of hand. We shouldn't be looking primarily at a state by state or region by region but as a whole specialty in this country. The big problem is maldistribution, we have too many in big cities and not enough in less dense areas. Pumping out more trainees won't directly help that situation. I would argue that no more positions should be added unless spots elsewhere are removed until a thorough independent analysis is done to look at what number our specialty really need. I would think that ASTRO could work with the ACGME to do this as ASTRO is supposed to represent the interests of our specialty as a whole.

As for dermatology, what they do makes a lot of sense in a supply and demand system. I don't want to see cancer patients waiting but I think that is unlikely to happen. What makes sense is to cut the number of residnts such that when we have Medicare cuts, ACA changes, etc. practicing rad oncs can stay afloat by having enough volume to offset the losses. It makes no sense to train residents who then cant get quality jobs. Sure its good for big centers to have lots of trainees but is it good for the specialty as a whole...not so much. Problem is that most of those in power represent the interests of academic centers not both sides of the coin

See above. So many myths...

The problem has always been one of distribution... and the solution has always been additional rent seeking to turn out more. It's a fool's solution.

Worse still, they refuse to recognize, acknowledge, or discuss that very real factors drive this distribution -- yet they refuse to tackle those problems in any meaningful or direct way.

 

[stems]

With any and all due respect, you're flat wrong on this today. As in not a little wrong, but way wrong. Derm has experienced an increase in residency slots over the past decade that, on a relative basis, is well beyond that of any other specialty. When I started medical school in the mid/late 90's, we turned out fewer than 200 / year. By the time I graduated medical school in 2001, there were 228 potential slots. Do you know how many there were last year? 363, I believe. You do the math. You radonc guys are supposed to be pretty good at math and general science, so you tell me what this increase does to equilibrium dynamics. The argument over the expansion of dermatology residency positions has been going on for a decade; I believe the correct side lost and the cloistered (friendly term, I have several more appropriate terms) academics won out. It has paid the expected dividends in the job market -- whereas I received many, many, many job offers, current residents are entering a very different market.


See above. So many myths...

The problem has always been one of distribution... and the solution has always been additional rent seeking to turn out more. It's a fool's solution.

Worse still, they refuse to recognize, acknowledge, or discuss that very real factors drive this distribution -- yet they refuse to tackle those problems in any meaningful or direct way.

I guess Derm guys aren't very good at math so let me spell it out for you:

Derm over 20 years: 200 -> 363 which equals: 3% expansion per year
Radonc over 10 years: 93 --> 171 which equals: 6% expansion per year

The residency slots for Radonc are growing twice as fast as Derm which is very concerning. Hope that helps your math troubles Mohs_01.

 

[Pointless]

I guess Derm guys aren't very good at math so let me spell it out for you:

Derm over 20 years: 200 -> 363 which equals: 3% expansion per year
Radonc over 10 years: 93 --> 171 which equals: 6% expansion per year

The residency slots for Radonc are growing twice as fast as Derm which is very concerning. Hope that helps your math troubles Mohs_01.

Kind of a know-it-all type response to legitimate input from someone in another field, so I will just point out that you are again doing the same thing that the author of the original article in question did... using an aberrational number of slots (93) that does not accurately reflect the actual number of trainees at that period of time. Dr. Zietman makes an excellent point in his critique that the number of trainees in 1995 was 135... yielding less than 2% growth per year.

As someone who just went through the job search, I have to disagree with the prevailing commentary on this board that the field is oversaturated. Granted, I wasn't looking in San Fran or NYC, but no amount of tampering with residency slots is going to make those places easy to find employment in.

By my estimation, this sounds more like the typical response of our generation to any form of adversity: "This is too hard, somebody should fix this for me because it isn't fair and I deserve so much more!".

Nothing in life worth getting is supposed to be easy and I am frankly a little shocked that so many people on this board would wholeheartedly agree that the number of residency positions should be artificially capped in order to make the job market a little more user-friendly, especially when you consider the potential expense of further limiting patient access to care.

 

[deleted4401]

I think this sounds like a know it all response from someone that has hardly worked.
Two things - 1) increasing numbers just pumps more people into the urban suburban areas, not helping things at all in terms of access. 2) when you start your job, start going over the financials. Almost everyone I talked to has seen a large drop this year. It's not solely about income - it's about being able to meet the budget, keep hired staff, buy new and upgrade older equipment, be able to treat patients that don't have insurance (which we do all the time). When Wash U graduates another extra resident, he does not go to Rhinelander in WI or Central IL or Frederick, MD (some jobs I always see posted). In areas like Phoenix or parts of FL or TX, Linacs are treating 10-15 patients a day. It's insane.

My thought is if you add a spot, it should be part of a federal or state program to promise 4-5 years in a designated under served area. That fixes the problem.

And it's annoying to hear that ACGME or ABR doesn't have a role in this. Fine. Maybe they should. Just because they don't doesnt mean they shouldn't.

Anyway, it's like spraying more water at a fire in a house and increasing the volume and pressure of water on the lower level while ignoring the master bedroom and then saying "Well, we threw more water at the problem, figured that would solve it."

 

[medgator]

I think this sounds like a know it all response from someone that has hardly worked.
Two things - 1) increasing numbers just pumps more people into the urban suburban areas, not helping things at all in terms of access. 2) when you start your job, start going over the financials. Almost everyone I talked to has seen a large drop this year. It's not solely about income - it's about being able to meet the budget, keep hired staff, buy new and upgrade older equipment, be able to treat patients that don't have insurance (which we do all the time). When Wash U graduates another extra resident, he does not go to Rhinelander in WI or Central IL or Frederick, MD (some jobs I always see posted). In areas like Phoenix or parts of FL or TX, Linacs are treating 10-15 patients a day. It's insane.

Keep in mind, at least in fl, some of those linacs are "seasonal linacs" that'll pop up to 20-25 when the snowbirds make their trip down

 

[Pointless]

Simul, I usually agree with most everything you post on this board, but in this case I am failing to comprehend your point here. The modest increase in residency slots over the past 15 or so years is now the cause of declining reimbursement? I recognize that I don't have the experience of working in the real world just yet, but this still makes no sense to me. And if we are going to be resorting to qualifying the validity of one's argument based on their particular stage of training or practice, than I would note again that I JUST went through the job search process and you are at least a few years removed, so I would think that my opinion on the matter would be just as relevant, if not more so, than yours.

At any rate, I am in no way advocating a continued increase in residency training spots, just simply attempting to refute the idea that there has been some ridiculous explosion of spots that has made finding a quality job insanely difficult. And I do agree with the idea to create special programs that require service in underserved areas.

 

[deleted4401]

Thank you for saying that - I'm glad you agree with me, as I think I'm right so that's always a good sign. Kidding (sort of!).

I think I may not have articulated well. I don't think the increase in position has led to reimbursement cuts. I think it's another issue - the reimbursement cuts have led to a decrease in hiring, which will lead to difficulty in finding jobs. This new increase in residency positions has led to some perverse outcomes - rural jobs still don't get filled, and jobs in big cities are paying even less. The northern Virginia group is now at a 5 year partnership track. We have changed from 3 to 4. We are not hiring to make up for a loss of a FTE. The solution (if it is even that, my thought is that no one thinks through the issues so it's not really a solution) that is currently proposed is to throw more doctors in, but doesn't fix maldistribution issue. So, in reality, it's worsening things. We are asking the American taxpayer to subsidize more training for people that don't really need it.

Optimally, an astro subcommittee should be studying the distribution issue and putting out a policy paper far before jco does. This paper ideally would discuss the distribution issue and have specific recommendations on how to fix it. They would report this information to the ACGME and let it dictate more and less spots. We've spent enough time on trying to close the stark law loophole for urologists without an equivalent time spent on telling people that 60 Gy in 30 fx is wrong for palliative lung and 40 Gy in 15 is wrong for a bone met. I'd lead this committee, but clearly astro doesn't give a rats behind about private practice (80 percent of rad oncs).

 

[medgator]

Simul, I usually agree with most everything you post on this board, but in this case I am failing to comprehend your point here. The modest increase in residency slots over the past 15 or so years is now the cause of declining reimbursement? I recognize that I don't have the experience of working in the real world just yet, but this still makes no sense to me. And if we are going to be resorting to qualifying the validity of one's argument based on their particular stage of training or practice, than I would note again that I JUST went through the job search process and you are at least a few years removed, so I would think that my opinion on the matter would be just as relevant, if not more so, than yours.

And I do agree with the idea to create special programs that require service in underserved areas.

You yourself said you weren't looking at more populated, desirable areas. The fact is, rural population is decreasing nowadays.

http://m.huffpost.com/us/entry/3433855

If things are saturating in urban and suburban areas, environments then it absolutely makes sense for our governing bodies to evaluate the supply of new grads coming out. Urban areas are where most of the population is and where the market will matter most. I hate to beat a dead horse, but this really does seem like a problem of maldistribution rather than supply

 

[Pointless]

You yourself said you weren't looking at more populated, desirable areas. The fact is, rural population is decreasing nowadays.

What I said myself is that I wasn't looking in New York City or San Francisco. Hard to fathom, but there are a number of cities in between the east and west coast, and some people even live in them and find them "desirable". I didn't take a job in a rural outpost in Arkansas, but rather in a suburb of a large metropolitan city.

That being said, I understand better the argument for capping after a few of the most recent responses by Simul and Wagy. I still don't see how we are making any progress toward getting that lonely spot in Rhinelander filled by decreasing the number of grads, hence my comment about limited access for patients; I think we can all concede that there is no chance of increasing patient access to care by decreasing training spots. I guess my position comes more from a healthy distrust of any intervention or artificial control over something that should be regulated by the free market. If the braintrust that decides how many grads is "optimal" screws the pooch and drastically undershoots, the outcome could be far more disastrous than the alternative, where a few new docs have to expand their job search a little more than they would have otherwise liked.

 

[DukeNukem]

Um, this is rad onc. We're not really useful labor. The best PGY-2 only triples the workload (ref: HoG). An attending could bang out whole his work in an 8 hour day. But, with residents doing their contours, then having to edit them, seeing the patients after the resident sees them, teaching, going to morning conference, it gets to be a lot of work. My academic friends work way more than my private practice friends. The only benefit is they don't have to dictate. Not quite the same as your PGY-3 medicine resident that's taking care of all hell breaking loose in the ICU or the surgical interns managing the entire floor.

I don't think that's the reason we are expanding. It's just a total blindness to reality and it's disappointing that the very people that should be advocating for us are doing the exact opposite.

The HoG quote does not apply to residents:

SHOW ME A BMS (Best Medical Student, a student at the Best Medical School) WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.

In any case, I disagree with you strongly. The amount of clinic patient issues, patient education, H&Ps, dictations, etc that a resident takes care of for an attending lightens their load significantly. At my residency program, the attendings push to have resident coverage as much as possible, and at some of the big name programs the attendings often have 100% resident coverage and cannot even function without a resident. After a few weeks on service, the vast majority of my contours are simply approved without or with minimal attending modifcation. The attending basically says hi to the patient after I have done all of the H&P and consents/orders, and does very little if none of that work themselves.

Maybe being in academics overall makes the workload higher than private practice for the reasons you cite, but having a resident makes things much easier for the academic attending. That time should be repaid in teaching, but in my experience this is only rarely the case. The finances of this are impressive, with the programs being paid to have the residents, instead of the programs paying 100k+ in salary for an equivalent NP/PA who probably would never agree to work as hard.

Anyway, the replies by Drs. Lee, Wallner and Shrieve were right on target.

Case in point: Dr. Shrieve is the only attending at Utah with 100% resident coverage. I interviewed at several programs where the stated goal of the department was to get more residents from the RRC in order to have 100% resident coverage. This is a recruiting tool for academic programs to attract faculty.

 

[seper]

Concur. Every single academic attending I know loves residents. They do make work easier.
RadOnc job market now is very poor and is going to get worse,

 

[deleted4401]

Is that what it's like at other programs? That would never happen at UPMC. Wow. You were expected to do consults, dictations, try contours, contact referring docs, chase down information/outside records, but never did anything get signed off until an attending reviewed. Never even for palliative cases. That makes me nervous! It sounds like it's worse than being treated at a community cancer center.
S

 

[seper]

Quickly eyballing resdient's conotours over his/her shoulder? Man that happens everywhere.
It's not a bad thing. An eager PGY-3 is more thorough with, let's say, a palliative case than an private attending taking care of 30 patients.

 

[medgator]

Is that what it's like at other programs? That would never happen at UPMC. Wow. You were expected to do consults, dictations, try contours, contact referring docs, chase down information/outside records, but never did anything get signed off until an attending reviewed. Never even for palliative cases. That makes me nervous! It sounds like it's worse than being treated at a community cancer center.
S

Quickly eyballing resdient's conotours over his/her shoulder? Man that happens everywhere.
It's not a bad thing. An eager PGY-3 is more thorough with, let's say, a palliative case than an private attending taking care of 30 patients.

I think Seper is somewhere closer to what happens at most programs IMO, especially for palliative cases. By the time I was a senior resident, we were setting fields, writing the Rx etc. with our attending at the sim with us basically just looking at what we were doing (since we actually would move to iso at the sim after did contours and simple fields for palliative cases). And obviously we dictated everything. It's the way residency should be, especially towards the end of your training.

 

[DukeNukem]

Is that what it's like at other programs? That would never happen at UPMC. Wow. You were expected to do consults, dictations, try contours, contact referring docs, chase down information/outside records, but never did anything get signed off until an attending reviewed. Never even for palliative cases. That makes me nervous! It sounds like it's worse than being treated at a community cancer center.
S

I am glad at our program we don't have to chase down outside records. We have support staff for that. I did rotate at programs that did have residents doing it, and that is pure scut.

i doubt it.
i have a feeling the responses above are mostly residents trying to convince themselves that they were a necessary part of the clinic.

In any case, both of the above are gross misrepresentations of what I wrote.

After a few weeks on service, the vast majority of my contours are simply approved without or with minimal attending modifcation.

The attending approves with minimal modification. Review does happen. However, this takes far less time than drawing.

Maybe being in academics overall makes the workload higher than private practice for the reasons you cite, but having a resident makes things much easier for the academic attending.

I never said I was necessary, but that I make things much easier. The attendings try very hard to have residents as often as possible at my institution. There is not 100% attending coverage, but they are pushing hard for it. We have to push back and it's a constant tug of war for residents not to be pulled into clinic and maintain their academic time. Attendings are the first to admit that residents make their lives much easier for the reasons I wrote. Our program has been expanding, and continues to do so. When I brought up the article to our program director, all they said was that other "low quality" programs should not have residents, but this program is so good that clearly we should be expanding since there are uncovered attendings .

That being said as an attending now, yes a resident decreases my work in terms of dictating, volumes, etc. but I believe those hours have to be repaid teaching so minimal gain.

That is uncommon in my experience. Some attendings do repay their time saved in teaching. Some pay back some of the saved time in teaching. Others basically do very little teaching, and still expect you to do all their work for them.

 

[Freight Train]

Is that what it's like at other programs? That would never happen at UPMC. Wow. You were expected to do consults, dictations, try contours, contact referring docs, chase down information/outside records, but never did anything get signed off until an attending reviewed. Never even for palliative cases. That makes me nervous! It sounds like it's worse than being treated at a community cancer center.
S

Yes, I think a few programs are like this. Our program has 3 sites. 1 is "resident run" with attendings stopping by for a few hours/day to sign plans and say "hello" to consults. They then leave to go back to their private practice site. The other 2 have more supervision, but some attendings only see OTVs/follow-ups if you have questions/problems, and give the obligatory "hello" to all the consults.

We work extremely hard. One site treats 100 patients/day on 2 linacs (7AM-9PM daily). Residents alternate staying late. We do all the notes, contours, doc-to-docs, attend all tumor boards, etc.

Despite this, we are actually very well trained in the end. Granted, the first year/2 is tough. But you are basically running your own clinic your senior year, and all our grads are comfortable going out treating 30+/day on their own.

 

[deleted4401]

Yeah, but what if you're doing stuff wrong and nobody is checking it? Then you go out into the world like that. It's one thing to pass your boards, but its another to be not doing stuff wrong (the goal of every professional).

 

[OTN]

"It sounds like it's worse than being treated at a community cancer center."

Why the slander on us community radoncs? Sounds like someone's drinking the Ivory Tower Kool-Aid...

 

[deleted4401]

"It sounds like it's worse than being treated at a community cancer center."

Why the slander on us community radoncs? Sounds like someone's drinking the Ivory Tower Kool-Aid...

I'm a community doc.

I see how community medicine is practiced, and lets just say it isn't quite evidence based in most of the country, especially rural areas. My point was that the presumption is that academic centers are places of excellence, where people practice evidence based medicine at high levels. But, it sounds like at many places, inexperienced and non-board certified doctors are making decisions, contouring, and approving plans. That scares me.

 

[medgator]

"It sounds like it's worse than being treated at a community cancer center."

Why the slander on us community radoncs? Sounds like someone's drinking the Ivory Tower Kool-Aid...

Agreed. There are solid community practices out there that can rival anything in academics. Look down the RTOG enrollment sites on the various protocols and see how many "community" sites pop up. It's nothing to sneeze at

I'm a community doc.

I see how community medicine is practiced, and lets just say it isn't quite evidence based in most of the country, especially rural areas.

"Community" practices like the AOS group in Arizona are some of the biggest RTOG enrollment sites. Are you saying that they practice non EBM? I get what you're going for SImulD, but the fact is, there are bad docs in both the private and academic side. Who do you think staffs some of the less desirable satellite positions in rural academic programs? Solid docs are going to be in desirable locations in both the academic and private side IMO. No need to assume that not being in academics somehow makes your quality of medicine, or vice versa for that matter.

 

[deleted4401]

It's not that community doctors are bad and academic doctors are good, I phrased it poorly initially, so let's get past that.

As a community doc, nobody sends a difficult case to me for a second opinion. It goes the other way, I sent something up the road to the University of Maryland today. I'm pretty good, but if someone does breast cancer all day long, you know what, if I have a toughie, it's going up the road. If there is a challenging prostate case that I see, I email Tony D'Amico. But, let me tell you, he doesn't email me about a challenging case. People aren't presenting to me on Chartrounds.com. In fact, I present a case to experts that work at academic centers. That's the point I'm trying to make. I'm pretty good out here. I'm sure most of you all are, too. It's just if I was really sick, I'd go to MDACC or MSKCC, and I think many of us would rather do that then go to see me.

What I'm reading here that residents are essentially treating unsupervised, with minimal supervision at early levels of their training. So, that gives me pause. Should I not send these patients up the road when some PGY-3 is going to do the contours and approve the plan? They haven't passed their boards yet, sounds like nobody is checking their work, and I'd rather keep the patient in my hands. If people think that lack of supervision makes for good training or good patient care, that's their opinion. Just declaring my differing point of view.

And how does enrolling patients onto RTOG trials equate to anything other than being good at enrolling patients onto RTOG trials? The biggest radonc group in Florida enrolls a ton of patients and is sketchy as heck... and who's parent company just went out of business.

 

[OTN]

Ah, I see what you're saying. I do agree that large, tertiary-care academic medical centers can be good for second opinions in rare cases, but I do think I wouldn't, myself, necessarily go to an academic medical center if I were diagnosed.

I think what you're getting at is that there's a large variation in quality between community centers- agreed. There's also a large variety in quality in academic centers as well, which is what you were getting at initially.

I think we can all agree that things tend to get a bit out of hand down in Florida. Scalp-sparing IMRT for brain mets? I had never even heard of it before I went down to the Sunshine State...

 

[deleted4401]

People are doing it gently.
For example, there is an early release in JCO that show that freestanding sites give longer palliative radiation for lung cancer, compared to integrated centers. UPMC also reported that the community sites gave longer treatments for bone mets compared to the academic sites. But vocal ball-busting doesn't happen in medicine

 

[seper]

Interesting. Do you have a link to JCO abstract?

 

[deleted4401]

http://www.ncbi.nlm.nih.gov/pubmed/23295799
I got the wording wrong. It compared "integrated" sites to non-integrated. But, I think that's the same as what I meant?
S

 

[Tanner]

http://www.ncbi.nlm.nih.gov/pubmed/23295799
I got the wording wrong. It compared "integrated" sites to non-integrated. But, I think that's the same as what I meant?
S

I am curious how they define "integrated networks". Do they mean an integrated health system where it includes both health insurance and service lines, like the Kaiser system, or an integrated service- like in a multispeciality group...

 

[seper]

It's a nice study.
"Integrated" is defined in Discussion (VA or HMO).
Conclusion is pretty much that freestanding centers and independent hospitals milk palliation.

Some palliative lung schedules I see in practice are simply ridiculous (59.4/33, 60/30).

 

[wagon]

Part of the problem is that we as rad oncs don't call each other out on things like that...you think some of those docs would be using IMRT for whole brain if it got out amongst their own peers that they were doing it and were then called out for it. I mean calling a spade a spade at a regional and national level. Seems like there aren't many people willing to stomach the trouble that would come from that but it seems thats the only way to get some of our colleagues to act right.

Here is somebody willing to "call it out":

http://www.ascopost.com/issues/march-15,-2013/sidebar-value-based-effective-care.aspx

 

[thesauce]

It's a nice study.
"Integrated" is defined in Discussion (VA or HMO).
Conclusion is pretty much that freestanding centers and independent hospitals milk palliation.

Some palliative lung schedules I see in practice are simply ridiculous (59.4/33, 60/30).

I could be wrong, but it seems to me that the problem with this analysis is that VAs and HMOs essentially work in capitation systems. Their financial incentive is the opposite - the quicker they push through patients, the less time and money it costs them. And in the case of HMOs - the more they keep. So it makes sense that they would use fewer fractions (for the same reason that FSCs use more).