Canadian patients coming to US for RT

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NotMattSpraker said:
These are good points. Of all the "bad bosses" I've heard about from friends, the absolute worst one was in a well known community practice. People do abuse juniors in both settings.

Just for your consideration though... there is a power imbalance and in my opinion, this seems to be leveraged more in RO than other fields. Academic affiliated people exert a lot of control over collective issues in this field; they do all the training, credentialing, and hold the vast majority of the society board positions. They also now hire >50% of new grads. In this position, they often model bad behavior.

I've seen so many academic ROs point to the greedy community RO doing 37.5 in 15 for palliation then turn around and treat a G6 prostate on protons or boost a 100 year old lady with breast cancer. Maybe I just feel this way because I have yet to be accepted to the Penn Palliative Network, I'm really trying. Or maybe Im just a little salty that more than one person told me "leaving academics" for a really great job was ruining my career.

I stand by my original post that they need an intervention. With great power comes great responsibility right?
Click to expand...

They get to treat things with proton and I get to treat 15 fx palliation and the world should have been big enough for both of them. The empty moralizing continues.
 
NotMattSpraker said:
With great power comes great responsibility right?
Click to expand...
I agree.

If I were to ascribe a reason for academics leveraging their power in such a sh%$ty way, it is their inability to see what the field really is. This has been compounded by the fact that external beam radiation is an enormous financial winner for academic centers and that radonc was able to recruit incredibly accomplished residents for a period of roughly 15 years. Incredibly accomplished residents don't become humble over time. They were sold on the narrative that they were going to be the docs who change the standard of care in oncology. The fact that the only way radonc is doing this is by eliminating or reducing radiation as a treatment modality is not as important as the fact that they are fulfilling their academic destiny. Other avenues to academic prominence also do nothing for the practicing radiation clinician. (Disparity research, fundamental molecular oncology, becoming a chair somewhere (a chair needs residents)).

I like to think of it as an ambition/opportunity mismatch. Sort of like a V/Q mismatch. It results in an agonal existence and ultimately death.

So what is radonc? It is the good lifestyle oncology field that gives one drug (XRT). It is a device oriented field and not a pharmaceutical oriented one. It is highly technical but almost certainly not as vulnerable, in terms of outcomes, to personal expertise as surgery. The consequences of clinical incompetence typically become evident late and often not at all. As it is a one trick pony, outcomes are improved incrementally through technical innovation. Although ion therapy has been sold as a paradigm change (a new drug?), it is not. FLASH could be, but likely won't be. As a recent abstract noted, the toxicity of 3D, standard fractionation prostate XRT is pretty reasonable.

Radonc, in the global oncologic world, where the pharmaceutical management of cancer is improving and indications for adjuvant treatment are becoming more refined, will become less. It is becoming less. We in the community know it.

Academic radonc has responded by making itself a larger portion of the smaller pie, by marketing regionally or nationally, by subsuming regional community practices, by believing that their one drug, fundamentally the same as the community doc's one drug, is somehow better, and by pursuing high cost and at best very marginal value innovations to distinguish themselves from the community.

It's just not a healthy field, and won't be until it becomes a different field.

In a healthy field, most of the work is done in the community and academics are there to explore experimental care or take on the toughest cases.

Academic medoncs never want to keep a patient from local care unless on protocol or receiving transplant level care. They have essentially infinite opportunities for progressive clinical trials at this point. A routine patient takes away from their academic mission.

Academic neurosurgeons are fine when their academic colleagues take $$$ PP jobs. These jobs help preserve their own market value.

What would a healthy radonc academic culture do? Cut spots and look for a strategy to expand the clinical scope of radiation oncology.
 
communitydoc13 said:
I agree.

If I were to ascribe a reason for academics leveraging their power in such a sh%$ty way, it is their inability to see what the field really is. This has been compounded by the fact that external beam radiation is an enormous financial winner for academic centers and that radonc was able to recruit incredibly accomplished residents for a period of roughly 15 years. Incredibly accomplished residents don't become humble over time. They were sold on the narrative that they were going to be the docs who change the standard of care in oncology. The fact that the only way radonc is doing this is by eliminating or reducing radiation as a treatment modality is not as important as the fact that they are fulfilling their academic destiny. Other avenues to academic prominence also do nothing for the practicing radiation clinician. (Disparity research, fundamental molecular oncology, becoming a chair somewhere (a chair needs residents)).

I like to think of it as an ambition/opportunity mismatch. Sort of like a V/Q mismatch. It results in an agonal existence and ultimately death.

So what is radonc? It is the good lifestyle oncology field that gives one drug (XRT). It is a device oriented field and not a pharmaceutical oriented one. It is highly technical but almost certainly not as vulnerable, in terms of outcomes, to personal expertise as surgery. The consequences of clinical incompetence typically become evident late and often not at all. As it is a one trick pony, outcomes are improved incrementally through technical innovation. Although ion therapy has been sold as a paradigm change (a new drug?), it is not. FLASH could be, but likely won't be. As a recent abstract noted, the toxicity of 3D, standard fractionation prostate XRT is pretty reasonable.

Radonc, in the global oncologic world, where the pharmaceutical management of cancer is improving and indications for adjuvant treatment are becoming more refined, will become less. It is becoming less. We in the community know it.

Academic radonc has responded by making itself a larger portion of the smaller pie, by marketing regionally or nationally, by subsuming regional community practices, by believing that their one drug, fundamentally the same as the community doc's one drug, is somehow better, and by pursuing high cost and at best very marginal value innovations to distinguish themselves from the community.

It's just not a healthy field, and won't be until it becomes a different field.

In a healthy field, most of the work is done in the community and academics are there to explore experimental care or take on the toughest cases.

Academic medoncs never want to keep a patient from local care unless on protocol or receiving transplant level care. They have essentially infinite opportunities for progressive clinical trials at this point. A routine patient takes away from their academic mission.

Academic neurosurgeons are fine when their academic colleagues take $$$ PP jobs. These jobs help preserve their own market value.

What would a healthy radonc academic culture do? Cut spots and look for a strategy to expand the clinical scope of radiation oncology.
Click to expand...
Like many takes on SDN, a great one with nuance, but without vitriol.

Interestingly, due to algorithm or muting (probably both), much of my Twitter stuff goes unseen and people have been told not to engage with me (the views have gone tremendously down). I know how ASTRO feels about me - having blocked several times for volunteer positions and even though was considered for Early Career by the people participating, was removed due to "being controversial". There are various other examples and people that see it occurring.

Point is not, Woe is Simul. It's that SDN will become the only place to see critique and honest discussion of the future. They figured out how to stop our presence on Twitter. It's all that's left is you all here.

And, eventually, they will try to figure out a way to get people to not want to come here ("miscreants", "misinformation", angry internet people, etc.), and there truly will be an information vacuum.

It is going to be interesting for the next decade or so. The one thing multiple PDs have said (anonymously, of course) is that there are a subset of trainees - larger than before - that simply cannot handle residency with their level of knowledge/background.
 
RealSimulD said:
It is going to be interesting for the next decade or so. The one thing multiple PDs have said (anonymously, of course) is that there are a subset of trainees - larger than before - that simply cannot handle residency with their level of knowledge/background.
Click to expand...

This is not surprising - so many programs out there didn't teach for diddly squat. They had "exceptional" residents that taught themselves and learned by doing for years. The education stays the same but the quality of trainees goes down... anyone can guess the results.
 
Fpg1245 said:
They get to treat things with proton and I get to treat 15 fx palliation and the world should have been big enough for both of them. The empty moralizing continues.
Click to expand...

Worst/Best move I ever made (depending on who you ask) was to meet a bunch of non-academic ROs and learn about the business of medicine. The moralizing just hits different.

I think it was the best move 🙂

metallica81788 said:
This is not surprising - so many programs out there didn't teach for diddly squat. They had "exceptional" residents that taught themselves and learned by doing for years. The education stays the same but the quality of trainees goes down... anyone can guess the results.
Click to expand...

From a medical education standpoint this is a very interesting take. Step 1 scores are not a great tool for evaluating someone's ability to be a good doctor, but they do reflect one's ability to self-study and learn a large amount of material.

Rad Onc training is objectively heterogeneous, but one thing that seems consistent across programs is that there is a lot of self-study and residents teaching residents.
 
RealSimulD said:
It's that SDN will become the only place to see critique and honest discussion of the future.
Click to expand...

Totally agree. I think we are already there, and thats why I actually upgraded my membership on renewal today.

SDN is a very important forum for Rad Onc discourse.
 
NotMattSpraker said:
Worst/Best move I ever made (depending on who you ask) was to meet a bunch of non-academic ROs and learn about the business of medicine. The moralizing just hits different.

I think it was the best move 🙂



From a medical education standpoint this is a very interesting take. Step 1 scores are not a great tool for evaluating someone's ability to be a good doctor, but they do reflect one's ability to self-study and learn a large amount of material.

Rad Onc training is objectively heterogeneous, but one thing that seems consistent across programs is that there is a lot of self-study and residents teaching residents.
Click to expand...
Yes but Step 1 is pass/fail now
 
NotMattSpraker said:
Totally agree. I think we are already there, and thats why I actually upgraded my membership on renewal today.

SDN is a very important forum for Rad Onc discourse.
Click to expand...
Would encourage everyone to just do the lifetime donor thing. Not a lot of money and certainly much better spent than on anything ASTRO. North Korean news service needs counterpoint when it comes to medical student interest in the field
 
The Class of 2024 is the last great class. I'm sure there are exceptions (perhaps 25-50) after them per class, but Jesus: we have matched some very poor quality folks in our program.
 
Baws said:
The Class of 2024 is the last great class. I'm sure there are exceptions (perhaps 25-50) after them per class, but Jesus: we have matched some very poor quality folks in our program.
Click to expand...
I am still at a loss to explain how there could be almost anybody of quality in subsequent classes.
 
Baws said:
The Class of 2024 is the last great class. I'm sure there are exceptions (perhaps 25-50) after them per class, but Jesus: we have matched some very poor quality folks
Click to expand...
Fairly certain the last couple of classes are already going to show declining quality. We've been SOAPing bottom of the barrel for a few years now
 
Baws said:
The Class of 2024 is the last great class. I'm sure there are exceptions (perhaps 25-50) after them per class, but Jesus: we have matched some very poor quality folks in our program.
Click to expand...

Disagree, I think cracks were starting to show in the class of 2022 for more bottom tier programs. Unless someone came from MDACC, MSKCC, etc I wouldn't touch a grad from 2022 or later.
 
HolySmokes said:
Disagree, I think cracks were starting to show in the class of 2022 for more bottom tier programs. Unless someone came from MDACC, MSKCC, etc I wouldn't touch a grad from 2022 or later.
Click to expand...
Why do you say this? Tell us more!
 
communitydoc13 said:
I agree.

If I were to ascribe a reason for academics leveraging their power in such a sh%$ty way, it is their inability to see what the field really is. This has been compounded by the fact that external beam radiation is an enormous financial winner for academic centers and that radonc was able to recruit incredibly accomplished residents for a period of roughly 15 years. Incredibly accomplished residents don't become humble over time. They were sold on the narrative that they were going to be the docs who change the standard of care in oncology. The fact that the only way radonc is doing this is by eliminating or reducing radiation as a treatment modality is not as important as the fact that they are fulfilling their academic destiny. Other avenues to academic prominence also do nothing for the practicing radiation clinician. (Disparity research, fundamental molecular oncology, becoming a chair somewhere (a chair needs residents)).

I like to think of it as an ambition/opportunity mismatch. Sort of like a V/Q mismatch. It results in an agonal existence and ultimately death.

So what is radonc? It is the good lifestyle oncology field that gives one drug (XRT). It is a device oriented field and not a pharmaceutical oriented one. It is highly technical but almost certainly not as vulnerable, in terms of outcomes, to personal expertise as surgery. The consequences of clinical incompetence typically become evident late and often not at all. As it is a one trick pony, outcomes are improved incrementally through technical innovation. Although ion therapy has been sold as a paradigm change (a new drug?), it is not. FLASH could be, but likely won't be. As a recent abstract noted, the toxicity of 3D, standard fractionation prostate XRT is pretty reasonable.

Radonc, in the global oncologic world, where the pharmaceutical management of cancer is improving and indications for adjuvant treatment are becoming more refined, will become less. It is becoming less. We in the community know it.

Academic radonc has responded by making itself a larger portion of the smaller pie, by marketing regionally or nationally, by subsuming regional community practices, by believing that their one drug, fundamentally the same as the community doc's one drug, is somehow better, and by pursuing high cost and at best very marginal value innovations to distinguish themselves from the community.

It's just not a healthy field, and won't be until it becomes a different field.

In a healthy field, most of the work is done in the community and academics are there to explore experimental care or take on the toughest cases.

Academic medoncs never want to keep a patient from local care unless on protocol or receiving transplant level care. They have essentially infinite opportunities for progressive clinical trials at this point. A routine patient takes away from their academic mission.

Academic neurosurgeons are fine when their academic colleagues take $$$ PP jobs. These jobs help preserve their own market value.

What would a healthy radonc academic culture do? Cut spots and look for a strategy to expand the clinical scope of radiation oncology.
Click to expand...
One of the best posts I've ever read here on SDN for Radonc.

I don't think there is an escape hatch for our specialty..

Only way is to just not go in... someone needs to remake this one:

https://www.reddit.com/r/funny/comments/14js20v/deeeeeeeeeep/
 
thecarbonionangle said:
Why do you say this? Tell us more!
Click to expand...
Just my own observations about the quality of people who received interviews, how far down the applicant list programs had to go just to fill their interview slots, and how far down on rank lists they went to match. There's still plenty of good people in that class, but I think it was probably the first objectively worse cycle. And as everyone here knows it has only gotten worse.
 
drowsy12 said:
What do you attribute it to? Maldistribution and docs not wanting to live in that province?
Click to expand...
Alberta is not fee for service, but rather contracted per unit time (eg service day). Combine that and the health authority/government not wanting to fund additional oncology spots to keep up with demand, alongside decaying reimbursement against inflation, whereas other provinces now pay more, AB is the least. Cost of living has crept up last few years, and there is a pretty anti-MD government. Boom wait lists of months. I could go on and on but that’s my perspective.

Mostly has to do with not funding enough attending positions I think though, and leadership being on the late reactionary part of the spectrum
 
medgator said:
globalnews.ca

Alberta cancer patients left waiting for care over lack of oncologists | Globalnews.ca

Albertans diagnosed with cancer are waiting three to four times longer than recommended standards to see a cancer specialist, according to the Alberta Medical Association.
globalnews.ca globalnews.ca

13 weeks to see a rad onc in Alberta
Click to expand...
 
OTN said:
It's almost like central planning does a terrible job of allocating human capital in a market.
Click to expand...
Bernie likes the Danish system. This is universal healthcare that is decentralized.

Scale is so important.
 
communitydoc13 said:
Bernie likes the Danish system. This is universal healthcare that is decentralized.

Scale is so important.
Click to expand...

Disagree- the system Bernie Sanders proposed was dramatically centralized, banned private practice from existing*, and never even came close to working out mathematically. It was a fugazi from the get-go.

(*The Danish system does allow residents to buy coverage above the government's plan, does allow private practitioners to exist, etc)
 
OTN said:
Disagree- the system Bernie Sanders proposed was dramatically centralized, banned private practice from existing*, and never even came close to working out mathematically. It was a fugazi from the get-go.

(*The Danish system does allow residents to buy coverage above the government's plan, does allow private practitioners to exist, etc)
Click to expand...
I think you are referencing the "medicare for all " proposal from 2020. Agree, that was very centralized. He repeatedly referenced the Danish system, which is not.
 
communitydoc13 said:
I think you are referencing the "medicare for all " proposal from 2020. Agree, that was very centralized. He repeatedly referenced the Danish system, which is not.
Click to expand...

That was his proposal, yep. He can "reference" anything he wants, but the proof was in the very nasty Medicare for All pudding.
 
OTN said:
very nasty Medicare for All
Click to expand...
Ha! Definitely lots of stuff in the proposal that didn't make sense to me.

TheWallnerus said:
The same??? Something like 98% of all Americans live within 50 miles of a linac, 90% within 25 miles, 80% within 12.5 miles.
Click to expand...

We should acknowledge that despite living in an incredibly rich country, our public health care ranking is pretty poor (great place to get sick if you have good insurance). My personal belief is that decentralizing, along with universal healthcare, (In Denmark you basically have municipalities on the order of 1 mil persons making healthcare spending decisions) would be beneficial for a number of reasons, including protecting us from certain aspects of market driven consolidation.

Where I live, it's 6-8 months for a GI, GU or Derm consult, 8+ months for certain orthos. PET can take many weeks (I have some leverage here). 8 days for a radonc consult.

So...yes, maldistribution, but a saturated radonc market has provided a correction of a particular, very downstream specialty.
 
Palex80 said:
Click to expand...
www.nytimes.com

The Growing Private-Sector Involvement in Canadian Public Health Care Systems (Published 2024)

Ontario announced plans this week to further expand services offered through privately owned clinics under its health plan.
www.nytimes.com www.nytimes.com

www.freedomworks.org

NYTimes: Canadian Healthcare "Breaking Down" - FreedomWorks

As the Canadian socialized medicine system breaks down, patients are turning to the free market for medical relief. See this link. Or read below the fold.
www.freedomworks.org www.freedomworks.org


They are trying to get private guys to salvage this. They have been for awhile.
 
Last edited:
TheWallnerus said:
The same??? Something like 98% of all Americans live within 50 miles of a linac, 90% within 25 miles, 80% within 12.5 miles.
Click to expand...

not maldistribution of linacs, but of rad oncs, yes. is this news? tons of areas where lots of people want to be and work, and others where they can't get someone to come out to.
 
drowsy12 said:
not maldistribution of linacs, but of rad oncs, yes. is this news? tons of areas where lots of people want to be and work, and others where they can't get someone to come out to.
Click to expand...
Same reason why Minot and Toledo had trouble recruiting and Palo Alto and beantown didn't paying far less
 
drowsy12 said:
drowsy12 said:
not maldistribution of linacs, but of rad oncs, yes. is this news? tons of areas where lots of people want to be and work, and others where they can't get someone to come out to.
Click to expand...
Click to expand...
In general, where there’s a linac, there’s 1.25 rad oncs. Or, at least a rad onc (a rad onc who locumses, etc etc). So the rad oncs are even slightly more homogenously and better distributed geographically than their machinery. This is based on workforce analyses and IAEA linac database. The story of a geography that has a perm job available and literally sits empty with no rad onc ever darkening the door to treat people… is a really really rare thing. “Can’t get someone to come out to…” I know what you’re saying, but this is not necessarily equal to “no rad onc works at a center that has a linac.”
 
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