Columbia

[TheWallnerus]

I’m not one to hide behind pseudonyms or anonymity, so let me be up front about who I am. I’m David Horowitz, the program director for the Columbia University radiation oncology residency. I’ve been in this position for the past year. I’m not here to defend the department against people’s perceptions about what it was in the distant past, or even to try to change anyone’s mind, but I do want to talk about who we are as a program and our vision for the future.

I’m doing this job because I care about our residents; I want to help them to develop into the physicians and people that they want to be. We talk a lot at Columbia about training the next generation of leaders, but to be frank it’s about working with residents to recognize within themselves what they’re truly passionate about, and supporting them as they develop those passions. Those interests go in many directions--whether it’s lab research that we’re supporting with the Holman pathway, NIH-funded work like the intersection of FLASH and immuno-oncology, pursuing a master’s degree in bioethics during their research year, or pursuing a commitment to diversity, equity and inclusion with local, regional and national leadership roles, just to name a few. I think that recognizing and supporting the diverse interests of residents as they develop their true passions have unquestionably paid dividends, with Columbia rad onc residents awarded over $200,000 in grants last year, garnering leadership roles in ARRO, as well as having multiple oral presentations at the upcoming ASTRO meeting.

To be honest, though, I’ve been most influenced by the experience of a resident who instead of pursuing grants and academic plaudits, was truly passionate about being the best damn doctor at treating prostate cancer. Through his incredible devotion and focus, he chose to do additional rotations in prostate brachytherapy, and finished residency training with more than 100 implants. The commitment and leadership that he demonstrated is no less worthy than another resident who received an NIH grant; it just helps to demonstrate the need for genuine support of whatever really makes that resident tick. I feel like it’s my job to try to think differently about what it means to excel in a radiation oncology residency, and make sure that future residents have the support that they need. It’s also about enabling people to take risks, to try new things, without fear of failure causing paralysis.

My commitment to the people who come through the Columbia rad onc residency is that I will work with them as they develop their interests into passions, which will naturally help them become leaders not just as radiation oncologists, but as oncologists who have a seat in the larger medical and scientific community. Because of the diversity of interests we want to continue to foster, we’ve had to completely rethink our mentorship program to be more comprehensive and intentional. Good mentorship is hard, but our associate program director, Fred Wu, has been incredible in developing a mentorship program that takes a holistic view of the residents and works to create a network of both local and national mentors that helps to develop the potential of each individual resident.

We’ve been getting hate for expanding the residency program, and here’s what I’ve got to say about that. While the decision to expand the program predates my tenure as program director, I own it. I think that we provide our residents training that we can be proud of, and I don’t think that we should cede that to other programs just because they decided to expand earlier. But what I won’t do is take residents who aren’t committed to radiation oncology, and that means no SOAPing. If that means we don’t match, so be it. I also think that it speaks to our interest in expanding radiation oncology’s seat at many tables, not just trying to cram more seats into our small table.

Maybe some of you have opinions about my chair, Lisa Kachnic. She doesn’t need to me to defend her or explain her actions. All I’m going to say is this: it is clear to me that she cares deeply about the success of the residents and faculty in her department, and works to bring about that success. More than that, what I’ve seen from her during the worst of the early COVID pandemic in New York City made it 100% clear to me that she cares even more deeply about who we are as people, not just as staff.

I have to admit that it bothers me when the Columbia haters come out on SDN. I don’t care if you mockingly put up a photo of me out with my colleagues (if you want to know which one is me, I’m the good looking one), but I do care about the environment created for residents and students whose “colleagues” disdain them and their place of work. So please, consider having a little empathy.

I’ll be the first to say that we’re far from perfect at Columbia--I certainly have made and will continue to make plenty of mistakes. But there’s room to try new things within radiation oncology training without totally abandoning the successes of the past. So I want to listen to what you have to say. I’m not really one for message board debates, so I’d like to invite anyone who is interested in talking about the good, bad, and ugly of rad onc training (at Columbia or in general) to join me for a zoom chat on Friday, 9/3/21 from 4-5 p.m EDT.

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I’m also always happy to chat at 212-305-7077 or by email at [email protected]



David

This is accountability. It's an order of magnitude greater than what we appear to get from a lot of other leaders in RO.

At least you're willing to talk and appear to have an open mind.

People are not willing to change until they're at the precipice. The precipice is coming/is here. I take a shamelessly "MD rad oncs first" view and selfishly want all ROs to do well because I know it will help me do well. ROs do not do well in over-supply. It decreases salaries. It leads to over-spending at the societal level. It may even lead to poorer cancer survival at the societal level (less patient volume, and experience, per MD... the resident case load experience is declining due to residency over-expansion).

You could be the greatest RO program in America, but it wouldn't change the fact that America needs less programs.

Admitting that it needs less programs and residents is the first step. In that regard, we are farther along than we were 5 years ago.

---

Members don't see this ad.

 

[deleted1111261]

David-

I assure you - I have no direct knowledge of your training program and I personally have not posted memes or opined on its quality. If I have commented about actual quality of your program in a negative way, I humbly apologize. I simply don’t have information to say anything about it.

There are more positions than applicants. There is no need for more positions. Manhattan is a fun place to live and you’ll be able to match someone double applying to ENT/Derm because he/she wants to couple match and live in the city. I know the strategy as I have friends that are PD - interview everyone - even people you’d never consider 3 years ago, don’t worry about their commitment / interest in RO and rank everyone that applies. Then you promise not to SOAP. And then during the cover of night, take someone that didn’t get a position elsewhere and put your finger in your ears when called out. I get it.

As mentioned above, MDACC and Harvard are excellent programs, and if anyone should expand, they should (I mean, where should HMS students go other than Harvard … but I digress). But, they contracted. And of course you can say “I can’t speak for other programs”, but if we are being open and honest - we can presume that they have spoken to their faculty and residents, and made a sacrifice for the good of the field.

One thing I will ask and I hope you can answer without hemming and hawing: do you believe applicant quality has gone down, as your Chairperson believes and has never backed down from? Do you believe what Dr. Wallner says - that the quality of residents is why the board failure rate went down, but suddenly recovered and has stayed high. I’ve co-authored a paper that shows that there is zero evidence of this, in fact quality had been steadily and consistently increasing.

If you agree with your chairwoman, wouldn’t you agree that expansion makes even less sense? If you disagree with her and Dr. Wallner, have you convinced her that the quality of the residents remained high up until 2019-2020?

Anyway, I would love to have this conversation, but I don’t feel compelled to debate the actual quality of the program (someone else can do that). I think a public debate about the wisdom of expansion is sorely needed and I am happy to participate.

Simul

Hi Simul,

I really appreciate the response, and would love to talk with you about the effect of residency expansion and contraction. I think it's debatable about the effect of individual residency expansion at the margin on the overall rad onc job market, but something that I'm glad we're getting more data about and can have collegial discussion. I'm also not saying that "if I didn't train residents, someone else would have." I'm saying that given a finite supply of radiation oncology applicants, there are good reasons why people would want to do their training at Columbia compared to another program. It's supporting our residents as they decide what is right for them to be doing with their careers--connecting them with alumni in private practice across the country to learn what that's actually all about, mentoring them as they write grant applications if their passions are in academic medicine, supporting efforts to improve their abilities as educators, etc.

I've got to push back on your comment that this has always been about residency expansion, though. Just look higher up in the thread to see real vitriol about Columbia. Or look at the picture of three human skulls and then a Neanderthal skull labeled "Columbia," and think about the dehumanizing effect it might have.

As much as I'd like to talk about the merits of residency expansion, I'd also really like to listen to people who think that our training is lacking, because what I really care about is the quality of the training that our program provides for our residents. No lie, I'd honestly appreciate hearing from our critics, because while I've got a bunch of ideas for ways to change the way we approach residency training, I definitely don't have a monopoly on them.

So if you and any of our colleagues in rad onc are able to, I'd love to talk with you on Zoom on Friday. Or let's find another time to talk. I'd appreciate hearing more of your perspective. And please, call me David. My colleagues at CU all do that, and we’re all colleagues here hoping to improve rad onc as a field.

Thanks,

Dav

 

[ROforbetterorworse]

PD in office

Open Excel -> Change filter to interview anyone with Step 1 score >160

PD in public

I vow to never SOAP!

 

[CurbYourExpectations]

Correcting residency spots would rebuild trust in the field from those outside the innermost circle and help residents. By having a bad job market you are probably pushing people who are interested in RadOnc into other fields while taking people who aren't as interested in RadOnc.

 

[thecarbonionangle]

The lowering of standards is already here. I have reviewed applications for past few years. There were people brought in by my “leadership” over past few years with multiple failed boards, criminal records, inability to speak fluent english who i legitimally tried to block and they ended up matching at supposedly “good” places. Some of these people will graduate in next few years. I know who some of them are…..The lowering of quality is coming soon. The breadlines are here.

 

[deleted1111261]

The lowering of standards is already here. I have reviewed applications for past few years. There were people brought in my “leadership” over past few years with multiple failed boards, criminal records, inability to speak fluent english who i legitimally tried to block and they ended up matching at supposedly “good” places. Some of these people will graduate in next few years. I know who some of them are…..The lowering of quality is coming soon. The breadlines are here.

You guys do background checks ?
(Probably a good idea)

 

[seper]

This thread is so sad. If even Columbia cannot acknowledge the need to them no to expand spots, we are doomed for some painful time ahead. Smaller programs in undesirable locales will not fill for years and wind up closing

 

[medgator]

This thread is so sad. If even Columbia cannot acknowledge the need to them no to expand spots, we are doomed for some painful time ahead. Smaller programs in undesirable locales will not fill for years and wind up closing

They'll try to fill with whatever they can get their hands on sadly, possibly by pulling their spots out of the match altogether

 

[RickyScott]

This thread is so sad. If even Columbia cannot acknowledge the need to them no to expand spots, we are doomed for some painful time ahead. Smaller programs in undesirable locales will not fill for years and wind up closing

Columbia was a small program historically in terms of number of pts treated at their main site when I interviewed years ago. Had around 40 on treatment. Not sure if that is the case today?

 

[evilbooyaa]

PD in office

Open Excel -> Change filter to interview anyone with Step 1 score >160

PD in public

I vow to never SOAP!

What filter? All the filters have been removed for interviewing. Better look at each individual application and offer 30-40 applicants an interview per spot offered. Remember when programs could interview like 10-20 people per spot and still match just fine?

@DHorowitz I met you in person, years ago. I liked you as a person at that time and my opinion of you has not changed. I appreciate you coming to SDN to have a discourse and provide an opposite opinion. I agree with a large portion of your post. I do believe that you, as do most PDs, have a modicum of power to actually make any effective changes when it comes to the resident complement at Columbia. We generally know these decisions are made at the department chair/vice-chair level, especially given that you are now PD (after the decision to expand was made). You may actually believe that Columbia deserves to expand, or you may be simply parroting the 'unspoken/private institutional message' that many in academics (especially those not happy with their position in academics) are very well aware of. I won't speculate on whether LK has specifically asked you to post on SDN to defend Columbia (because we at least know she reads it, or did read it).

All that being said, as others have said, the concept of "our training is so awesome how can we NOT expand" rings hollow and tone deaf. Especially when MDACC/Harvard have contracted. The concept of "well we didn't expand when every other program did and so we're making up for it now" is not something I can agree with. Every program should #AlwaysBeContracting at this point. At minimum, standing pat on the total number of spots. Expanding in the current climate of the job market is an affront by the leadership of the institution. I am not blaming your residents. It is those in power that have made this poorly timed move.

The ire against LK is real and people will always hold a grudge, even now as I imagine the class of 2019 has likely (mostly) fully recovered from the ABR fiasco, including doubling down on "residents r stupid!!111" as a response to the collective "WTF" that every RO PD had in response to physics/rad bio that year.

In regards to criticism of Columbia as a program, a revolving door at PD is a really bad look (in addition to everything else). Again, this is not the fault of the poor residents, but an issue of leadership at the departmental level.

 

[OTN]

@DHorowitz thanks for coming in and tackling this head-on. You seem like a PD who always has his residents' interests in mind and is very supportive regardless of what those future interests entail. That's great!

What was not great, however, was Columbia's insistence in expanding last year (!), and now Columbia's reticence to contract. Without immediate and significant residency contraction, unfortunately Columbia's residency program cannot be said to be acting in its residents best interests- quite the opposite, in fact. The quality of training provided is immaterial. Until the Columbia Department of Radiation Oncology contracts its residency complement, it simply cannot be argued with a straight face that the department itself cares about the futures of those who it trains.

 

[DHorowitz]

I appreciate hearing everyone’s feedback. It certainly does seem clear that there’s an imbalance in the number of residents and jobs (though there seems to be significant geographic variability in the data that I’ve seen). I agree that something needs to be done by leadership nationally to address this. However, my worry is that permanently contracting our field does a disservice to the long-term future of radiation oncology and overall cancer care by shrinking our sphere of influence in terms of how oncologic care is being developed. We are a small field already and contraction without direction is a big risk.

There must be a plan to develop future leaders in rad onc such that when the balance is achieved, brighter minds than I will be in position to help our field. To date, I haven’t seen any debate on that and to Simul’s point, I think that should be the bigger topic of debate and discussion as opposed to just expansion/contraction. But given the realities of the situation, what I can do is have a discussion of the Columbia program in this climate and how we can help.

Look, the last thing I want to be doing is training residents who can’t get jobs, or are unhappy in the jobs they get. I don’t want to get too much into self-help, but we have to begin with the end in mind. It’s important that those of us in residency programs are always mindful that residency is not the be-all and end-all. It is a stepping stone to prepare people for the careers that they ultimately want to have. I think that we need to be thinking more broadly about those careers, rather than narrowly. As there is natural progression from 2D to 3D to IMRT and SBRT, we need to make sure the brightest minds are encouraged to join our field to further expand what rad onc has to offer.

The days of 45-fraction prostate treatment or 30-fraction breast treatment are numbered (if not already gone). But just look at all the data coming out for SBRT/SRS for metastatic disease—many of these patients would not have been referred before, and the data is only getting stronger. As a PD I think we need to train the next generation to work with government, economists, and counterparts from medical and surgical oncology to make sure our value for oncology care is recognized. We also need to develop new tools and explore new indications to help improve patient care. We need leadership from the field to help develop the vision of next steps as we get through this phase.

So what can I do as PD at Columbia? What I can do is to develop a creative and innovative training track that doesn't fit within the traditional confines of residency training. To help new talents explore ways to adapt their knowledge to the field of radiation oncology.

One example of this is our APD, Fred Wu. His background was in cardiovascular research and became interested in focused ultrasound usage to open the blood brain barrier. He had support to do this work as a resident and signed on at Columbia to continue this work as a physician scientist. His group has a Phase I study open and they are treating patients with ultrasound as outpatients in the Department of Radiation Oncology and he's developing workflow processes to allow for intensity modulated treatment planning and clinical modeling that can be adapted to outpatient rad onc.

In addition, our residents are working on projects to help advance technology in the realm of adaptive RT. Many of the residents have been sent to clinical trials training workshops to foster their skills to become trialists, and the cooperative groups are a setting where we need as many seats at the table as possible. Others have had interests in bioethics or diversity and are working to apply that not just within rad onc, but to overall patient care.

Are all of these things going to work out? Of course not, but we need to be thinking about creating the environment to train residents to lead and advocate effectively as the field of radiation oncology changes.

Radiation oncology training has a history of innovative training through the Holman pathway. The Holman pathway has done an impressive job of preparing residents who want to have careers in basic and translational research. What I don’t think that we’ve done a good job with is aligning academic and community practices in a way that ensures that residents going into community practice are optimally prepared. The graduation standards established by the ACGME create a floor, and ROECSG is working to define entrustable professional activities for residents, but we need to be doing something that truly develops and celebrates residents who “just” want to be damn good doctors. This alternate pathway (called Namloh by our APD), aims to do exactly that.

I'm on the forum not to just defend the residency, but really hope that we can have a discussion about what people think is important to their practice today that they didn’t learn in residency, or something non-required that they did learn in residency that has been particularly impactful in practice. Or maybe most importantly, what did people spend a lot of time on in residency that turned out to be a total waste of time when they got to practice? We need more creative pathways to train next level leaders and it would be naive of me to believe that I have all of the answers. The SDN community has been an advocate for private practice and this is the type of cross collaboration I think is needed to help our field.

Lastly, as someone pointed out, yes the process of expansion was started long before my appointment, but I'm not dogmatic about it and I am open to withholding expansion for the right cause. If we as a community have a plan and create a solid path forward and these unique training programs need time to develop, we can reach a happy medium. We want to work to not just preserve our field temporarily but help develop it for the future.

(Oh, and we haven’t had a fellow for several years. I’m not a fan of fellowships outside of very specific circumstances, and we got rid of it a few years ago. If there is any misinformation out there, please let me know! I would be glad to remove it from any listing).

Thanks,

David

 

[radOresident]

Lmao how tone deaf can you get. Contracting our field represents a risk? Are you joking? How about we also stop treating locally advanced head and neck cancers because of the risk of hearing loss.

"Look, the last thing I want to be doing is training residents who can’t get jobs, or are unhappy in the jobs they get."

And yet, here you are contributing to literally this. Don't just maintain numbers. Contract. It's for the greater good and deep down you KNOW that. But, you and every other academic is unwilling to make even the slightest sacrifice to your own career to keep our field healthy.

"So what can I do as PD at Columbia? What I can do is to develop a creative and innovative training track that doesn't fit within the traditional confines of residency training. To help new talents explore ways to adapt their knowledge to the field of radiation oncology."

No, what you can do is follow the data and do the right thing. Close the entire residency program. It's not the 100 spot decrease that we need, but it's a start.

Everything you've said so far comes across as pure, unadulterated pseudo-academic drivel. How are you any different than LK, Hallahan, Wallner, Randall, or the rest of the lot that got our field into this mess with their own selfishness.

 

[SubserviantToABR]

I appreciate hearing everyone’s feedback. It certainly does seem clear that there’s an imbalance in the number of residents and jobs (though there seems to be significant geographic variability in the data that I’ve seen). I agree that something needs to be done by leadership nationally to address this. However, my worry is that permanently contracting our field does a disservice to the long-term future of radiation oncology and overall cancer care by shrinking our sphere of influence in terms of how oncologic care is being developed. We are a small field already and contraction without direction is a big risk.

There must be a plan to develop future leaders in rad onc such that when the balance is achieved, brighter minds than I will be in position to help our field. To date, I haven’t seen any debate on that and to Simul’s point, I think that should be the bigger topic of debate and discussion as opposed to just expansion/contraction. But given the realities of the situation, what I can do is have a discussion of the Columbia program in this climate and how we can help.

Look, the last thing I want to be doing is training residents who can’t get jobs, or are unhappy in the jobs they get. I don’t want to get too much into self-help, but we have to begin with the end in mind. It’s important that those of us in residency programs are always mindful that residency is not the be-all and end-all. It is a stepping stone to prepare people for the careers that they ultimately want to have. I think that we need to be thinking more broadly about those careers, rather than narrowly. As there is natural progression from 2D to 3D to IMRT and SBRT, we need to make sure the brightest minds are encouraged to join our field to further expand what rad onc has to offer.

The days of 45-fraction prostate treatment or 30-fraction breast treatment are numbered (if not already gone). But just look at all the data coming out for SBRT/SRS for metastatic disease—many of these patients would not have been referred before, and the data is only getting stronger. As a PD I think we need to train the next generation to work with government, economists, and counterparts from medical and surgical oncology to make sure our value for oncology care is recognized. We also need to develop new tools and explore new indications to help improve patient care. We need leadership from the field to help develop the vision of next steps as we get through this phase.

So what can I do as PD at Columbia? What I can do is to develop a creative and innovative training track that doesn't fit within the traditional confines of residency training. To help new talents explore ways to adapt their knowledge to the field of radiation oncology.

One example of this is our APD, Fred Wu. His background was in cardiovascular research and became interested in focused ultrasound usage to open the blood brain barrier. He had support to do this work as a resident and signed on at Columbia to continue this work as a physician scientist. His group has a Phase I study open and they are treating patients with ultrasound as outpatients in the Department of Radiation Oncology and he's developing workflow processes to allow for intensity modulated treatment planning and clinical modeling that can be adapted to outpatient rad onc.

In addition, our residents are working on projects to help advance technology in the realm of adaptive RT. Many of the residents have been sent to clinical trials training workshops to foster their skills to become trialists, and the cooperative groups are a setting where we need as many seats at the table as possible. Others have had interests in bioethics or diversity and are working to apply that not just within rad onc, but to overall patient care.

Are all of these things going to work out? Of course not, but we need to be thinking about creating the environment to train residents to lead and advocate effectively as the field of radiation oncology changes.

Radiation oncology training has a history of innovative training through the Holman pathway. The Holman pathway has done an impressive job of preparing residents who want to have careers in basic and translational research. What I don’t think that we’ve done a good job with is aligning academic and community practices in a way that ensures that residents going into community practice are optimally prepared. The graduation standards established by the ACGME create a floor, and ROECSG is working to define entrustable professional activities for residents, but we need to be doing something that truly develops and celebrates residents who “just” want to be damn good doctors. This alternate pathway (called Namloh by our APD), aims to do exactly that.

I'm on the forum not to just defend the residency, but really hope that we can have a discussion about what people think is important to their practice today that they didn’t learn in residency, or something non-required that they did learn in residency that has been particularly impactful in practice. Or maybe most importantly, what did people spend a lot of time on in residency that turned out to be a total waste of time when they got to practice? We need more creative pathways to train next level leaders and it would be naive of me to believe that I have all of the answers. The SDN community has been an advocate for private practice and this is the type of cross collaboration I think is needed to help our field.

Lastly, as someone pointed out, yes the process of expansion was started long before my appointment, but I'm not dogmatic about it and I am open to withholding expansion for the right cause. If we as a community have a plan and create a solid path forward and these unique training programs need time to develop, we can reach a happy medium. We want to work to not just preserve our field temporarily but help develop it for the future.

(Oh, and we haven’t had a fellow for several years. I’m not a fan of fellowships outside of very specific circumstances, and we got rid of it a few years ago. If there is any misinformation out there, please let me know! I would be glad to remove it from any listing).

Thanks,

David

Thank you for your thoughtful response. It sounds like you are a very proactive PD, and your residents are fortunate to have you at the helm.

However, the point is that, regardless of Columbia, Harvard, or world's worst rad onc program, we just don't need that many rad oncs right now. Maybe in the future, there will be an expansion of rad onc indications, and we need the brightest to help lead the charge. But fact of the matter is that we just don't need that many. The types of jobs that are out there are purely clinical and as stated in another thread: 2/3rds of RT centers only do a quarter of the RT volume, at this time. And as time goes on, our leaders are finding ways to cut that volume more and more by the day.

In the end, we just don't need that many rad oncs. I'm glad that you have a well-rounded, tailored residency that will provide a unique experience for those 4 years in residency. But if the job market does not support those skills and experience, both clinical and non-clinical, all of your efforts (and your residents time and energy and talents) will go to waste. And that statement applies to any residency, not just Columbia. That is the problem.

 

[OTN]

We're in a Catch-22 here: You say you need to attract good residents to do good research/work and drive the field forward, but good medical students won't look to radonc as long as future employment is in question. Therefore, in order to attract said good students to the field, thus propelling the field forward, contraction is necessary in order to attract those students and develop the field like you wish to do. Contraction doesn't work against innovation, but rather in its favor.

 

[TheWallnerus]

There's a lot to unpack here. Mega kudos to you for continuing the convo.

However, my worry is that permanently contracting our field does a disservice to the long-term future of radiation oncology and overall cancer care by shrinking our sphere of influence in terms of how oncologic care is being developed.

The best rad onc has done in the last 30 years has been the advent of IMRT. That advent came because of medical physicists' innovations and RT vendors. IMRT was well adopted before ANY phIII data showed its benefit. The RO MD bench was a lot lighter then, and rad onc as a field took off. What has happened since then? Since we increased the number of ROs by almost 60% but the number of RT patients has slightly declined? The indications for RT have declined.

The increase of ROs is correlated with a decrease in RT indications and fractions and thus a shrinkage in this "sphere of influence" of which you speak. I vote we shrink our numbers and see if it doesn't grow our sphere of influence back to previous levels.

But just look at all the data coming out for SBRT/SRS for metastatic disease—many of these patients would not have been referred before, and the data is only getting stronger

... yes there are more indications for metastatic disease.

But, if SBRT single fraction becomes standard of care and/or is mandated (think: APM) we will have to literally wind up increasing the SBRT-for-mets volume 17-fold, for example, to make up for 45-fx to 28-fx prostate.

Many of the residents have been sent to clinical trials training workshops to foster their skills to become trialists

Something like 80% of the phIII trials looking specifically at RT questions the last two decades have been either fraction reducing or RT-eliminating trials. The top 4 RT indications in RO are breast, prostate, lung, and bone mets. Twenty years ago breast got 6.5 weeks, prostate got 8 weeks, lung got 7 weeks, and bone mets got 2-3 weeks. Now we're at 1-3 weeks, 4-5.5 weeks, 1 day-6 weeks, and 1 day, respectively.

Please God let's make no more RT trialists for a while. They're doing to the field what Lorena did to John Bobbitt.

The Holman pathway has done an impressive job of preparing residents who want to have careers in basic and translational research

That's great. What basic or translational research done by a Holman pathway scholar has resulted in changing any RT practice in the last two decades? Do we have great evidence that the Holman pathway is valuable to RO? I know this may be an unpopular question, but did a Holman MD bring us IMRT, IGRT, protons, Tomo, MRgRT, BgRT...

Oh, and we haven’t had a fellow for several years. I’m not a fan of fellowships outside of very specific circumstances, and we got rid of it a few years ago.

I know a lot of people disagree with my above takes.

 

[communitydoc13]

We want to work to not just preserve our field temporarily but help develop it for the future.

David,

Great posts. Way to stand in there.

But you don't need residents to develop the field for the future. PhD physicists and biologists and in between can be hired to work in concert with the present cohort of academic radoncs to push biophysical cancer initiatives. These are things like focused ultrasound, FLASH, alternating electric fields, hyperthermia. They take technical expertise and some decent math and to be truthful are initiatives that very much like IMRT will have the heavy intellectual work done largely by non-physicians.

The big glut of talent from the past ten years is enough to staff the departments for the next thirty.

 

[RadOncDoc21]

Dude is eloquent but if you read between the lines you will see that’s he’s not “hearing us.”

 

[Bequerel]

Looks like no one gets the point!!!

PGY-2 Residency Position Available in Maywood, IL for Loyola University Medical Center

Exciting opportunity in Maywood, IL for Loyola University Medical Center as a PGY-2 Residency Pos...

careers.astro.org

 

[ROforbetterorworse]

Looks like no one gets the point!!!

PGY-2 Residency Position Available in Maywood, IL for Loyola University Medical Center

Exciting opportunity in Maywood, IL for Loyola University Medical Center as a PGY-2 Residency Pos...

careers.astro.org

Looking forward to the standard PD copy and paste on how there is a global radonc problem but their specific program isn’t the one with bad training

PS - id go to Loyola twice before Columbia even once

 

[deleted1111261]

"Lastly, as someone pointed out, yes the process of expansion was started long before my appointment, but I'm not dogmatic about it and I am open to withholding expansion for the right cause. If we as a community have a plan and create a solid path forward and these unique training programs need time to develop, we can reach a happy medium. We want to work to not just preserve our field temporarily but help develop it for the future."


David, I think all of what you are saying can be accomplished without adding to your complement of residents.

If a PD/Chairperson came on here and said, "Hey, we hear you. We want to make training better AND part of our approach will be to cut a position," they would be received heroically. I think trying to justify the additional position AND ask what can we do better makes it hard for us to be too excited. ROECSG, ROVER, eContour, TheMedNet, SDN, RadOncReview, RadOncTables, Dr. Vapiwala, ARRO, ASTRO - they are all doing amazing things. Even though we occasionally gently rib some of the initiatives, Rad Onc training and resources are the best they have ever been. We don't need more positions. We need dedicated teachers like you, DH.

Here is just some basic thoughts. Forget innovations. Let's go back to basics.

- Cut spots.
- Everyone knows who the ****ty teachers are. Stop letting them get away with it. This is on you. If you have terrible teaching faculty, strip them of their resident. If you don't have enough EXCELLENT faculty, then reduce your complement or shut down.
- Focus on training who you currently have rather than worrying about adding residents or the upcoming class or recruiting.
- Spend more time on clinical training. Lean in and really teach - this is not going on enough at a lot of places. For every Beriwal, Holliday, Tendulkar, Henson, there are 10+ attendings that coast by and use residents as cheap labor/scribes.
- Pay for good teachers rather than for RVUs - compensate holistically, not by fractions
- Take resident evaluations of faculty seriously. Don't let it be a decades long running joke about how terrible So and So's rotation is.
- Highlight and shadow good teachers. Surgeons watch other surgeons. So, send faculty to "how to teach" conferences/seminars. It is a skill, not something you're born with.

Anyway - I think we want to debate two different things, so I'm happy to bow out and maybe chat with you some time off line.

-s

 

[thecarbonionangle]

So much of academia is filled with people who can write paragraphs yet say absolutely nothing. They had the brightest minds in medicine for a decade and all we got was less radiation and non-inferiority studies, thousands of retrospective garbage. Now the same people say trust us we got this, we will innovate our way out of this! Just give us more bright minds! People in power have their heads in the sand about what must be done. The canaries have spoken. The decline of this field cannot be stopped until the issues are discussed without equivocating and hand waving. Issues need to be directly addressed and tough decisions must be taken.

i think the holman pathway is one of the biggest scams ever. Can anybody name any practice changing stuff to come out of this? I know multiple of these people who ended up in pp. there are very little ways to end up a physician scientist in current funding environment.

 

[temujim]

"Lastly, as someone pointed out, yes the process of expansion was started long before my appointment, but I'm not dogmatic about it and I am open to withholding expansion for the right cause. If we as a community have a plan and create a solid path forward and these unique training programs need time to develop, we can reach a happy medium. We want to work to not just preserve our field temporarily but help develop it for the future."


David, I think all of what you are saying can be accomplished without adding to your complement of residents.

If a PD/Chairperson came on here and said, "Hey, we hear you. We want to make training better AND part of our approach will be to cut a position," they would be received heroically. I think trying to justify the additional position AND ask what can we do better makes it hard for us to be too excited. ROECSG, ROVER, eContour, TheMedNet, SDN, RadOncReview, RadOncTables, Dr. Vapiwala, ARRO, ASTRO - they are all doing amazing things. Even though we occasionally gently rib some of the initiatives, Rad Onc training and resources are the best they have ever been. We don't need more positions. We need dedicated teachers like you, DH.

Here is just some basic thoughts. Forget innovations. Let's go back to basics.

- Cut spots.
- Everyone knows who the ****ty teachers are. Stop letting them get away with it. This is on you. If you have terrible teaching faculty, strip them of their resident. If you don't have enough EXCELLENT faculty, then reduce your complement or shut down.
- Focus on training who you currently have rather than worrying about adding residents or the upcoming class or recruiting.
- Spend more time on clinical training. Lean in and really teach - this is not going on enough at a lot of places. For every Beriwal, Holliday, Tendulkar, Henson, there are 10+ attendings that coast by and use residents as cheap labor/scribes.
- Pay for good teachers rather than for RVUs - compensate holistically, not by fractions
- Take resident evaluations of faculty seriously. Don't let it be a decades long running joke about how terrible So and So's rotation is.
- Highlight and shadow good teachers. Surgeons watch other surgeons. So, send faculty to "how to teach" conferences/seminars. It is a skill, not something you're born with.

Anyway - I think we want to debate two different things, so I'm happy to bow out and maybe chat with you some time off line.

-s

Ultimately very few to no programs are going to willingly cut spots, certainly not enough to make a dent in the overall numbers. I think the only way to accomplish the reduction in spots necessary is to close programs through the acgme or close them by changing the minimum standards. If you haven't submitted comments to the acgme (due in like 2 days), and you care about this particular issue, then get on the ball.

 

[CurbYourExpectations]

However, my worry is that permanently contracting our field does a disservice to the long-term future of radiation oncology

It doesn't have to be permanently contracting, just contracting while there is an oversupply. If indications increase and jobs are plentiful and there is a need for more RadOncs then increase thoughtfully. Right now a lot of residents and medical students are worried that correction won't happen.

 

[medgator]

.

i think the holman pathway is one of the biggest scams ever. Can anybody name any practice changing stuff to come out of this? I know multiple of these people who ended up in pp. there are very little ways to end up a physician scientist in current funding environment.

In a robust and busy private full spectrum private practice, would anyone trust a Holman pathway graduate to start practicing? Even less stringent minimums than the existing ones which many of us agree is trash to begin with (not enough criteria in terms of definitive vs palliative, broken down by system etc)

 

[radiation]

So much of academia is filled with people who can write paragraphs yet say absolutely nothing. They had the brightest minds in medicine for a decade and all we got was less radiation and non-inferiority studies, thousands of retrospective garbage. Now the same people say trust us we got this, we will innovate our way out of this! Just give us more bright minds! People in power have their heads in the sand about what must be done. The canaries have spoken. The decline of this field cannot be stopped until the issues are discussed without equivocating and hand waving. Issues need to be directly addressed and tough decisions must be taken.

i think the holman pathway is one of the biggest scams ever. Can anybody name any practice changing stuff to come out of this? I know multiple of these people who ended up in pp. there are very little ways to end up a physician scientist in current funding environment.

An ultrasensitive method for quantitating circulating tumor DNA with broad patient coverage

AM Newman, SV Bratman, J To, JF Wynne, NCW Eclov, LA Modlin, CL Liu, JW Neal, HA Wakelee, RE Merritt…, Nature medicine, 2014 - Cited by 2,204

scholar.google.com

 

[RadOncDoc21]

An ultrasensitive method for quantitating circulating tumor DNA with broad patient coverage

AM Newman, SV Bratman, J To, JF Wynne, NCW Eclov, LA Modlin, CL Liu, JW Neal, HA Wakelee, RE Merritt…, Nature medicine, 2014 - Cited by 2,204

scholar.google.com

How about in normal every day radiation oncology?

 

[RickyScott]

How about in normal every day radiation oncology?

Ctc technology dominated by industry and will one day help eliminate adjuvant radiation.

 

[RadOncDoc21]

Ctc technology dominated by industry and will one day help eliminate adjuvant radiation.

So we basically helped to create Skynet… are we pre John Connor era or is he a teenager at this point?

 

[SubserviantToABR]

In a robust and busy private full spectrum private practice, would anyone trust a Holman pathway graduate to start practicing? Even less stringent minimums than the existing ones which many of us agree is trash to begin with (not enough criteria in terms of definitive vs palliative, broken down by system etc)

At my residency, my PD was so eager to put residents into the Holman pathway, to show that we had broad opportunities for residency applicants. Some (not all of course!) took it as an opportunity to get out of clinic for nearly two years.

 

[SubserviantToABR]

An ultrasensitive method for quantitating circulating tumor DNA with broad patient coverage

AM Newman, SV Bratman, J To, JF Wynne, NCW Eclov, LA Modlin, CL Liu, JW Neal, HA Wakelee, RE Merritt…, Nature medicine, 2014 - Cited by 2,204

scholar.google.com

I've used this exactly ZERO times in my clinical practice. Like protons, would need substantial clinical evidence to implement into routine clinical practice. I know Max Diehn, and I think his work is solid. Just not prime time yet.

 

[radiation]

Ctc technology dominated by industry and will one day help eliminate adjuvant radiation.

Integrating genomic features for non-invasive early lung cancer detection - Nature

Circulating tumour DNA in blood is analysed to identify genomic features that distinguish early-stage lung cancer patients from risk-matched controls, and these are integrated into a machine-learning method for blood-based lung cancer screening.

www.nature.com

Or increase efficiency of lung cancer screening and increase the pool of treatable pts

 

[radiation]

How about in normal every day radiation oncology?

Association of Posttherapy Positron Emission Tomography With Tumor Response and Survival in Cervical Carcinoma

Context Retrospective studies have demonstrated that the use of positron emission tomography (PET) with F-18 fluorodeoxyglucose (FDG) in the posttherapy evaluation of patients with cervical carcinoma is predictive of survival outcome.Objective To validate the association between the metabolic...

jamanetwork.com

how pet scans got into NCCN guidelines for cervical cancer

 

[OTN]

Using anything from Julie Schwarz is cheating- she is an absolute badass radonc.

 

[yesmaster]

WashU and Stanford will produce successful Holman graduates whether residency class sizes are 200 or 100.

It's better for everyone if the Holman pathway is limited to 5-10 institutions that have the institutional memory, resources, and mentorship to support rad onc physician-scientist training.

 

[TheWallnerus]

Association of Posttherapy Positron Emission Tomography With Tumor Response and Survival in Cervical Carcinoma

Context Retrospective studies have demonstrated that the use of positron emission tomography (PET) with F-18 fluorodeoxyglucose (FDG) in the posttherapy evaluation of patients with cervical carcinoma is predictive of survival outcome.Objective To validate the association between the metabolic...

jamanetwork.com

how pet scans got into NCCN guidelines for cervical cancer

And this improved the Horowitzian sphere of influence of rad onc? Nah. More of a "cool story bro." Sorry!

 

[SubserviantToABR]

The question is not, can a Holman resident be scientifically successful? Yes, they can be, based on the cherry-picked citations above, but as stated above, that 'success' is only for a very small number of people, requiring significant institutional support and individual persistence and commitment.

The basic science can only support so many basic scientists at this time, because of their own oversupply and funding issues, and radiation oncology can only support so many radiation oncologists (obviously!).

The number of lab-based radiation oncologists that can be supported by our current market is probably 3-4 people per year (39 people with lab jobs from 2010 to 2019, DEFINE_ME). Not every resident needs to do Holman and can be just offered at a handful of programs, again, in order to match the number of lab-based jobs out there. There's a significant oversupply issue in our field, no need to focus on lab-based training and opportunities when the lab-based job market can't support those people either.

 

[communitydoc13]

Thread way off base now in my opinion. Of course there is good research that comes out of radonc. Most of the aforementioned is not specific to radonc or inspired by the clinical specifics of being a radiation oncologist while being a scientist. People like Diehn and Tim Chan were going to be massively successful in any field and I suspect were in that rarified group medical students that all top departments were courting. They could easily have been medoncs and collected a smaller salary while being on call 1-2 months a year while running a lab. They could have gone full Vogelstein and never seen patients. The fundamental aspect of their research is molecular biology with periodic translational radiation aspects thrown in.

This brings up a type that I think a lot of academics think is widely applicable but is really just exceptionalism. Even today, there are probably two or three stellar MD/PhD types with Nature or Cell articles in tow and funding who want to collect a clinicians salary while doing research and for whom radonc is the right place to be. This is not because they are going to further radonc (that's going to take physics initiatives or radical academic restructuring), but because it's a nice place for them to hide while doing good basic oncologic research.

 

[SubserviantToABR]

When I interviewed for residency in 2013 (same year as the publication of Chirag's editorial and Hallahan's absolutely stupid response), I was blown away by the quality of people that I was interviewing with. Everyone with top scores, massive number of publications, and broad life experiences were applying to the field. Everyone was a potential leader in our field.

And what happened since then? Decreased number of fractions, omission of RT, massive increases in the complement of residents, LK telling us that we are all dumb (yep, still angry about that one). In a tight job market, all of us got jobs wherever we are able to. Some of us are happy, and some of us are <25% MGMA.

What makes anyone, Columbia included, think that improving some aspect of their own residency program is going to change the fact that the way our field is now is basically pissing those talents down the drain? We pissed away so much potential, including those in the peak rad onc years. How will that be different during the nadir rad onc years?

#AlwaysBeContracting

 

[RadOncDoc21]

When I interviewed for residency in 2013 (same year as the publication of Chirag's editorial and Hallahan's absolutely stupid response), I was blown away by the quality of people that I was interviewing with. Everyone with top scores, massive number of publications, and broad life experiences were applying to the field. Everyone was a potential leader in our field.

And what happened since then? Decreased number of fractions, omission of RT, massive increases in the complement of residents, LK telling us that we are all dumb (yep, still angry about that one). In a tight job market, all of us got jobs wherever we are able to. Some of us are happy, and some of us are <25% MGMA.

What makes anyone, Columbia included, think that improving some aspect of their own residency program is going to change the fact that the way our field is now is basically pissing those talents down the drain? We pissed away so much potential, including those in the peak rad onc years. How will that be different during the nadir rad onc years?

#AlwaysBeContracting

The Blood Knife (A story of oppression)​

In order to trap and kill wolves, the native Americans use what is called the Blood Knife. They take a blood-soaked knife and stick it into a block of ice with the blade showing. Wolves are instinctively drawn to the smell of the blood. As bloodthirsty animals, they lick the blade of the knife believing they are getting a great meal. In a frenzy, they lick the knife, slicing their tongue to shreds because they can’t distinguish their own blood from the original blood on the knife. Unbeknownst to the wolves, they have just sealed their own fate, slowly bleeding to death. By the time they happen to “wake up” and realize they’ve been duped, it’s too late. They either die from the wounds or the the pack turns on them and rip them to shreds because their own blood lust must be quenched.

 

[Mandelin Rain]

Yawn.

If you purport to care about your residents, do the ultimate good and improve their post-graduate prospects. That's the end game to all this training after all.

Cut a spot, rather than add one.

 

[metview]

Kudos for Columbia PD coming here and engaging but he still misses the point and bring up points that have been thrown out by academic people who are defending expansion/anti-contraction. You don’t need more rad oncs to fuel innovation. In fact, you are hurting innovation by doing what you are doing. Smart med students are avoiding this field and we are now having med students who don’t care about rad onc/other specialty rejects getting in because it’s an easy path to a once prestigious residency. You really think these people are gonna innovate and save our field? Instead you should make rad onc more attractive again by fixing the oversupply. Only then will you have smart passionate med students apply and those are going to be rad oncs who will innovate and change the field. Also, as a senior resident at very good program, I am no longer considering academics given how you guys have botched this entire situation. There’s no sense of being wanted and instead residents have to beg to find a good academic job. And why do I want to work for the people who put us in this situation and aren’t fixing it?

 

[RickyScott]

Yawn.

If you purport to care about your residents, do the ultimate good and improve their post-graduate prospects. That's the end game to all this training after all.

Cut a spot, rather than add one.

Three magic words that will make you forget about jobs: Leadership, Mentorship, Diversity/Inclusion. Who needs jobs when you have so much mentoring and celebration of diverse backgrounds going on?

 

[Mandelin Rain]

Three magic words that will make you forget about jobs: Leadership, Mentorship, Diversity/Inclusion. Who needs jobs when you have so much mentoring and celebration of diverse backgrounds going on?

I feel like it's easy for academics to forget that residents are not there to celebrate them/pad their CV/advance their department, but rather to learn to do a job that ideally exists on the backend.

The job is the only mission.

Hire them as faculty if you want the fluff.

 

[elementaryschooleconomics]

I feel like it's easy for academics to forget that residents are not there to celebrate them/pad their CV/advance their department, but rather to learn to do a job that ideally exists on the backend.

The job is the only mission.

Hire them as faculty if you want the fluff.

This is EXACTLY how I perceived my recruitment and subsequent experience as a resident. While there were a couple faculty that seemed to know I needed to be trained to be a competent Radiation Oncologist for the future, most of them viewed my presence as a "what have you done for me lately", what grants did I bring in or help someone else bring in, what papers did I publish, what awards did I win for them to brag about...and if I learned how to do a VSIM in the process, well, that was on me.

 

[Ray D. Ayshun]

This is EXACTLY how I perceived my recruitment and subsequent experience as a resident. While there were a couple faculty that seemed to know I needed to be trained to be a competent Radiation Oncologist for the future, most of them viewed my presence as a "what have you done for me lately", what grants did I bring in or help someone else bring in, what papers did I publish, what awards did I win for them to brag about...and if I learned how to do a VSIM in the process, well, that was on me.

Learning that, too. Also wondering if some of the docs that trained me would pass the boards, in their own body site. There are a lot of discrepancies between recommended volumes in certain disease sites, which means, in turn, I'm trying to forget some things and just use NCCN. This is perhaps all well and good if there were actual conversations re treatment decisions as opposed to deciphering things on my own time.

 

[RadOncDoc21]

Learning that, too. Also wondering if some of the docs that trained me would pass the boards, in their own body site. There are a lot of discrepancies between recommended volumes in certain disease sites, which means, in turn, I'm trying to forget some things and just use NCCN. This is perhaps all well and good if there were actual conversations re treatment decisions as opposed to deciphering things on my own time.

During my residency training there was a lot of do as I say not as I do teaching.

 

[RickyScott]

Dhorowitz, how would you respond to Bk’s red journal editorial. Did he get it all wrong?

 

[DHorowitz]

"Lastly, as someone pointed out, yes the process of expansion was started long before my appointment, but I'm not dogmatic about it and I am open to withholding expansion for the right cause. If we as a community have a plan and create a solid path forward and these unique training programs need time to develop, we can reach a happy medium. We want to work to not just preserve our field temporarily but help develop it for the future."


David, I think all of what you are saying can be accomplished without adding to your complement of residents.

If a PD/Chairperson came on here and said, "Hey, we hear you. We want to make training better AND part of our approach will be to cut a position," they would be received heroically. I think trying to justify the additional position AND ask what can we do better makes it hard for us to be too excited. ROECSG, ROVER, eContour, TheMedNet, SDN, RadOncReview, RadOncTables, Dr. Vapiwala, ARRO, ASTRO - they are all doing amazing things. Even though we occasionally gently rib some of the initiatives, Rad Onc training and resources are the best they have ever been. We don't need more positions. We need dedicated teachers like you, DH.

Here is just some basic thoughts. Forget innovations. Let's go back to basics.

- Cut spots.
- Everyone knows who the ****ty teachers are. Stop letting them get away with it. This is on you. If you have terrible teaching faculty, strip them of their resident. If you don't have enough EXCELLENT faculty, then reduce your complement or shut down.
- Focus on training who you currently have rather than worrying about adding residents or the upcoming class or recruiting.
- Spend more time on clinical training. Lean in and really teach - this is not going on enough at a lot of places. For every Beriwal, Holliday, Tendulkar, Henson, there are 10+ attendings that coast by and use residents as cheap labor/scribes.
- Pay for good teachers rather than for RVUs - compensate holistically, not by fractions
- Take resident evaluations of faculty seriously. Don't let it be a decades long running joke about how terrible So and So's rotation is.
- Highlight and shadow good teachers. Surgeons watch other surgeons. So, send faculty to "how to teach" conferences/seminars. It is a skill, not something you're born with.

Anyway - I think we want to debate two different things, so I'm happy to bow out and maybe chat with you some time off line.

-s

Hi Simul,

Again, I appreciate the thoughtful comments that you and everyone have been bringing. I’m glad that we can have a conversation where we don’t all agree with each other, but still can have an exchange of ideas to help understand each other’s perspective to ultimately help improve our field. Like I said from the beginning, I’m not here to try to change opinions about rad onc or about my program. But I am here to listen and try to work to improve our residency and the training experience for our residents at Columbia.

As you and the SDN community are focused on always be contracting as one approach to help our field, I am focused on creating new training pathways to foster individualized talent and create new types of leaders. This includes developing and celebrating people who “just” want to be great doctors, which is frankly the most important thing we do.

I agree with you that creating new training pathways, developing the next generation of leaders, and expansion do NOT have to go hand in hand. I have actually been working with Dr. Kachnic and the residents at Columbia, and we will contract our residency from 8 to 7 until the current environment improves. Having taken this step, what we do need is help from you and other private practice rad oncs, in addition to chairs and other PDs, to work with us to develop a curriculum or pathway for those who want to go into the community to be the best damn doctors possible. Trainees wanting to be extraordinary in patient care should have a “Namloh” pathway to celebrate and develop their passion, as research scientists have with Holman.

I like your recommendation of going back to the basics and I have already implemented changes that I have control over. The APD and I have reached out to some colleagues in the community and have received helpful recommendations, including developing a practical Physics/Dosi/QA curriculum, a billing/coding and APM literacy program, a practical leadership development series, and building a support network of alumni in the community to help residents. But we need more.

I agree the conversation on the blog is changing so let’s talk offline. I need your help and the help of anyone else who wants to try to be part of the solution. Having the narrow view of someone who has stayed in academia, I know I will need help from the community for broad perspectives if the goal is to improve training for real success in all aspects of post-residency practice. I hope to hear from you in the near future. Feel free to email me at your earliest convenience. And anyone else who wants to join as we work constructively, please email me at [email protected].

Thanks,

David

 

[thecarbonionangle]

isnt contracting from 8 to 7 still a 1 net expansion?