Consolidation in Rad Onc Practices

[Neuronix]

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Most ended up competing with and taking jobs from us simple folk who just wanted to treat patients out in the community

I wasn't Holman, but in their defense there aren't enough research jobs out there for them.

 

[metallica81788]

I wasn't Holman, but in their defense there aren't enough research jobs out there for them.

That's fine and a valid point - but you can see how that grinds the gears of someone like me who had to completely bust my @$$ to get into the specialty at all with a true passion to treat patients in the community to end up competing for jobs with some MD/PhD that just treated few patients for a few years in a coddled residency (compared to my crappy balls to wall clinical only scut-based residency) mostly spent in a lab talking up their research and future academic pursuits for 5-6 years only to double back to find some decently paying 100% clinical job. This isn't speaking badly of those types - they were falsely led into this field and promised the world. They probably didn't have great research based job options but still were in a better position to steal what the others had wanted all along. Guess that's the way the world works.

Goes back to the interview process where everyone when asked about future career goals just lied about "oh yeah, I want to do research and work at an academic center" because that's what those in power wanted to hear even though 60%+ ended up in the community. This field in the "golden age" was just based off of lies and horse manure.

 

[medgator]

Most ended up competing with and taking jobs from us simple folk who just wanted to treat patients out in the community

With less clinical training

 

[radiation]

Most ended up competing with and taking jobs from us simple folk who just wanted to treat patients out in the community

DEFINE_ME

~25% over 10 years took non-academic jobs

 

[medgator]

DEFINE_ME

~25% over 10 years took non-academic jobs

Not even clear what that means anymore, considering how many "academic" places have essentially taking over community/PP sites over the years. An "academic" doc covering what is essentially a satellite formerly staffed by a PP or community employed doc isn't practicing academic rad onc at the of the day @Neuronix is absolutely correct

 

[Ray D. Ayshun]

DEFINE_ME

~25% over 10 years took non-academic jobs

~25% took nonacademic nonacademic jobs. 50% of the other 75% are in or run a lab. Are the other 37.5% in nonacademic academic jobs? Many of my coresidents took academic in name only jobs.

 

[metallica81788]

DEFINE_ME

~25% over 10 years took non-academic jobs

That is Holman pathway only - 25 residency programs as mentioned. Lots of MD/Phd "big research people" went to places without Holman in the golden days. They wouldn't be included in that data and most probably fit my description of probably taking a community job as well as those who may/may not meet the "definition" of an academic place nowadays.

 

[elementaryschooleconomics]

Goes back to the interview process where everyone when asked about future career goals just lied about "oh yeah, I want to do research and work at an academic center" because that's what those in power wanted to hear even though 60%+ ended up in the community. This field in the "golden age" was just based off of lies and horse manure.

This was definitely me. When I was interviewing for residency, I wasn't sure I really wanted to try to run my own lab after my excruciating PhD experience, though I was pretty sure I wanted to stay in academia because I loved the educational aspect. Could I say that? Absolutely not. I had to sing a song and dance about my dreams of being a big-time PI or I knew that I had absolutely zero chance of Matching at the programs I was interested in if I told the truth. Fast forward a half decade later, looking for jobs that didn't exist in a global pandemic, and I find myself in a community private practice in the mountains. I'm thinking about getting some camo scrubs!

Perhaps one of the upsides of this specialty burning in front of our eyes is that kids no longer have to lie. Now, of course, that doesn't mean they have anything more than a slim chance of ultimately practicing the way they want...but at least they can be honest from the start?

 

[SubserviantToABR]

This was definitely me. When I was interviewing for residency, I wasn't sure I really wanted to try to run my own lab after my excruciating PhD experience, though I was pretty sure I wanted to stay in academia because I loved the educational aspect. Could I say that? Absolutely not. I had to sing a song and dance about my dreams of being a big-time PI or I knew that I had absolutely zero chance of Matching at the programs I was interested in if I told the truth. Fast forward a half decade later, looking for jobs that didn't exist in a global pandemic, and I find myself in a community private practice in the mountains. I'm thinking about getting some camo scrubs!

Perhaps one of the upsides of this specialty burning in front of our eyes is that kids no longer have to lie. Now, of course, that doesn't mean they have anything more than a slim chance of ultimately practicing the way they want...but at least they can be honest from the start?

I too had an extensive basic science background with PhD and was told by program after program that my research acumen would be embraced by the field. I was too damn naïve and fell for the sales pitch. On the interview trail and in the beginning of my residency, I quickly found out that lab-based jobs were basically non-existent and that most people ended up in a primarily clinical positions.

Now, for me, it is a moot point because I love taking care of patients and can't imagine being anything else but a clinician. But, this also illustrates the discordance between the number of trainees over the years with significant research backgrounds and the number of people who end up jobs with a lab. Looking at that paper cited above, out of the 10 years of Holman graduates, 39 have a lab now, or stated differently, 3.9 people per year end up with a lab. We simply do not need that many people with research-based backgrounds, but yet, we continuously emphasize the need for research (over DOs, IMGs, women, minorities...but let's blame SDN, amirite? 😉), only to piss those talents down the drain.

 

[deleted898021]

I too had an extensive basic science background with PhD and was told by program after program that my research acumen would be embraced by the field. I was too damn naïve and fell for the sales pitch. On the interview trail and in the beginning of my residency, I quickly found out that lab-based jobs were basically non-existent and that most people ended up in a primarily clinical positions.

Now, for me, it is a moot point because I love taking care of patients and can't imagine being anything else but a clinician. But, this also illustrates the discordance between the number of trainees over the years with significant research backgrounds and the number of people who end up jobs with a lab. Looking at that paper cited above, out of the 10 years of Holman graduates, 39 have a lab now, or stated differently, 3.9 people per year end up with a lab. We simply do not need that many people with research-based backgrounds, but yet, we continuously emphasize the need for research (over DOs, IMGs, women, minorities...but let's blame SDN, amirite? 😉), only to piss those talents down the drain.

Lol it was not only DO’s and IMG’s apparently, it was also stellar USMD’s who just wanted to take care of patients who were passed up by MD phd’s with not as good “stats” because of their research background.

 

[sueyom]

I'm going through the above cited Red Journal paper on this, DEFINE_ME and the separate paper published in PRO on the same topic, DEFINE_ME.

Both papers cite widely different statics regarding the number of practicing rad oncs.

From the Red Journal paper 4,948 MDs in 2013 and 5,415 MDs in 2017 (increase of 9.4%).
From the PRO paper paper 4,300 MDs in 2012 and 4,679 MDs in 2020 (increase of 9.0%).

Why are these figures so different and why is this such a hard thing to nail down?

From Red Journal paper's Methods section: "We utilized the Medicare Provider Enrollment, Chain, and Ownership System and Physician Compare databases to identify practices with radiation oncologists in 2013 and again in 2017. Individual practices were identified via unique individual or group practice tax identification numbers (TINs). Using this database, we were also able to obtain information on the location of each practice, as well as a listing of the National Provider Identifier (NPI) numbers of all radiation oncologists providing physician services within the practice. With these NPI numbers, we were able to link individual radiation oncologists at each practice to their billing records in the 2013 and 2017 Medicare Claims Carrier Files, which enumerates all physician service charges among a random subset of 20% of all Medicare beneficiaries. We further used NPI numbers to link to the Medicare Data on Provider Practice and Specialty database to obtain each radiation oncologist’s basic demographic information. We aggregated each practice’s zip code into specific Hospital Referral Regions (HRRs) as defined by the Dartmouth Atlas and extracted pertinent community characteristics as generated by the U.S. Census Bureau between the years 2011 and 2015.20 Table E1 provides further information on the specific datasets used and the linkages between each."

From the PRO paper's Methods section: "All data were obtained from the Physician Compare (PC) database. Given that this data set is publicly available and does not include patient-specific information, the study did not require institutional review board (IRB) approval. The PC database was created by the Centers for Medicare & Medicaid Services (CMS) in 2010 and is based on Medicare’s Provider Enrollment, Chain, and Ownership System (PECOS), a more comprehensive data set.22 The PC database contains information for health care providers who have either (1) newly registered in the PECOS system in the past 6 months, or (2) billed Medicare for at least 1 feefor-service reimbursement in the past 12 months; thus, all providers analyzed in our study meet these criteria. CMS uses billing claims to ensure that practice addresses are correct. The PC database is updated twice a month.23 In our study, we used data from the PC archive for 201224 (posted in September 2014) and April 2020.25 To identify RO physicians, the National Provider Identifier (NPI) was used. Those whose primary specialty was listed as RO were selected. The total number of individual practicing radiation oncologists and unique practices employing radiation oncologists were calculated for 2012 and 2020. A physician selection flowchart is provided in Fig. 1. Individual radiation oncologists were then categorized into bins based on their respective practice size (sizes 1-2, 3-9, 10-24, 25-49, 50-99, 100-499, and ≥500) using the same groupings as previous studies examining practice size consolidation.8,11 The number of individual radiation oncologists in each practice size category was determined for 2012 and 2020 using NPI (physician-level analysis). The number of unique practices in each practice size category for 2012 and 2020 was performed using a group’s Taxpayer Identification Number, or (TIN) (practice-level analysis). A Cochran-Armitage test for linear trend was used to determine whether the proportion of individual radiation oncologists or unique practices in each size category increased significantly between 2012 and 2020 for this test and tests in all subcategories. Nationwide data were divided into 4 US geographic census regions (Northeast, Midwest, South, and West), and the previously mentioned analysis was repeated for each. ....."

Just trying to be helpful here although I'm sure you already figured it out. PECOS is the larger dataset. Thank you for reading the RJ!

 

[SubserviantToABR]

Lol it was not only DO’s and IMG’s apparently, it was also stellar USMD’s who just wanted to take care of patients who were passed up by MD phd’s with not as good “stats” because of their research background.

You're absolutely right. I remember on the interview trail, meeting a couple of people who had a tough time getting interviews because they did not have significant research. They all seemed to have a great application overall, with a clear dedication to patient care, but did note how difficult it was to get an interview at a "top" rad onc program.

 

[jondunn]

That’s still how it is in all the other super competitive fields, don’t get it twisted.

We used to be them, now we ain’t

 

[elementaryschooleconomics]

That’s still how it is in all the other super competitive fields, don’t get it twisted.

We used to be them, now we ain’t

Academic Medicine: the ultimate multi-level marketing scheme.

But yeah, let's just dress it up so the ambition to chase brass rings, to be Chairs and Deans and wield power over not just patients but also other doctors isn't super obvious.

 

[medgator]

That’s still how it is in all the other super competitive fields, don’t get it twisted.

We used to be them, now we ain’t

Derm and Ortho have always cared way more about stats and other intangibles during the interview process, NOT research/whether you had a PhD degree. They still do now while many rad onc are SOAPing in whatever they can find lately, research and stats be damned.

The old adage used to be that to match Ortho your step 1 + your bench press had to ≥ 500

 

[deleted898021]

That’s still how it is in all the other super competitive fields, don’t get it twisted.

We used to be them, now we ain’t

No it’s really not, in derm, ortho, uro, IR, etc the better clinical applicant with some research and a well rounded app will beat out a MD PhD that’s not good clinically.

 

[deleted898021]

Derm and Ortho have always cared way more about stats and other intangibles during the interview process, NOT research/whether you had a PhD degree. They still do now while many rad onc are SOAPing in whatever they can find lately, research and stats be damned.

The old adage used to be that to match Ortho your step 1 + your bench press had to ≥ 500

Yea rad onc is essentially an IMG field now. No decent USMD or DO will touch it

 

[medgator]

Yea rad onc is essentially an IMG field now. No decent USMD or DO will touch it

The truth is radonc has been here before @jondunn probably too millennial to remember the ****ty graduates who came out in the 70s and 90s when they would literally take anyone. We are just in another bust cycle for rad onc

Derm, ortho, plastics have been super competitive consistently for many decades otoh

 

[jondunn]

The truth is radonc has been here before @jondunn probably too millennial to remember the ****ty graduates who came out in the 70s and 90s when they would literally take anyone. We are just in another bust cycle for rad onc

Derm, ortho, plastics have been super competitive consistently for many decades otoh

.... what the hell?

a) this is a non-sequiter if I ever saw one
b) everyone knows this. you are not special.

 

[Neuronix]

No it’s really not, in derm, ortho, uro, IR, etc the better clinical applicant with some research and a well rounded app will beat out a MD PhD that’s not good clinically.

That was true for rad onc during the peak of competition as well. It was very rare to get a rad onc spot with a below average step 1 score or any clinical red flags, no matter how good your PhD. The competition on the MD only side was full of 260+ step 1, AOA, and clinical rad onc papers if not a full year out for research.

 

[jondunn]

No it’s really not, in derm, ortho, uro, IR, etc the better clinical applicant with some research and a well rounded app will beat out a MD PhD that’s not good clinically.

being MD/PhD is just one more gem in the wide array of gems that PDs look for in terms of what makes them competitive...in every single field. Yes a disproportionate amount of them pursued rad onc in the last 15 years, but that is large part because many people go through MSTP programs focused on.....you guessed it, cancer. Also, at least at my med school, we were actively told that rad onc was the highest zenith one can reach as an MD/PhD, and so there was a lot of self selection too.

 

[jondunn]

That was true for rad onc during the peak of competition as well. It was very rare to get a rad onc spot with a below average step 1 score or any clinical red flags, no matter how good your PhD. The competition on the MD only side was full of 260+ step 1, AOA, and clinical rad onc papers if not a full year out for research.

yes.

 

[medgator]

That was true for rad onc during the peak of competition as well. It was very rare to get a rad onc spot with a below average step 1 score or any clinical red flags, no matter how good your PhD. The competition on the MD only side was full of 260+ step 1, AOA, and clinical rad onc papers if not a full year out for research.

The point is, consider who is matching this decade vs then compared to Ortho derm plastics where things haven't changed at all because leadership hasn't wrecked their job market through expansion.

Meanwhile, increasing demand for Psych has essentially allowed it to flip flop with rad onc in terms of competitiveness since the turn of the century

 

[communitydoc13]

Above regarding selection all true. MD/PhD helps get into any field. I would not have matched into my residency program without a PhD (in a non-cancer related field).

What I witnessed at a good (but not big 3) program from when I first became aware of radonc (~2005) through a few years after I finished training (~2015).

In the early 2000s, there were already very, very good candidates at good programs with a fair number (but certainly minority) of MD/PhD types. Residents who were good clinically but not necessarily super productive in terms of research were often offered real, clinical academic jobs at the main campus (satellites were around but small). These young faculty not infrequently left after a few years to pursue very lucrative private practice jobs.

In the late 2000s/early 2010s, it was getting increasingly hard to land a job at my home institution and the standards for research productivity during residency were soaring. My training program was now preferentially recruiting from big 3 and their own residents were expected to do a national academic job search. (There was never support for private practice and if you weren't encouraged to do academics out of residency, it was an insult.) The residency program and department were expanding rapidly with plans for large scale consolidation with regional community hospitals. Some very good residents who wanted to stay were asked to do something extra (fellowship or advanced degree) to be considered for a clinical faculty position, even at a satellite.

Around this time, clinical acumen was becoming a very devalued commodity IMO. This impacted even the culture of residency. Careerism very early on was becoming the norm and it was rewarded. The same residents (good clinical reviews, good in-service, good radonc board scores) who 10 years earlier were being offered clinical faculty positions were now not serious candidates for jobs at the program and were even going to be beaten out at purely clinical academic jobs at lower tier places by residents with more research productivity.

The classes that matched into radonc around 2012/2013 were absolutely bonkers. I believe this was true "peak-peak" radonc. Top of class at top med schools with absurd research productivity type applicants. Of course, everyone knew there was not enough room in the field for these folks. I followed the people that I interviewed as a chief resident from this era and some did leave the field early. The meritocracy is brutal and these folks were competing against each other, and as a consequence, a significant number of the best applications ever for residency are now in the hands of PP radiation oncologists or lower tier academic positions. This was the time period where hard working, good personality, 260+ board scores, AOA type med-students who rotated through and did well were often not matching at top ranked programs. They were matching, but often at mid-tier or sometimes lower tier places. The faculty ranking these applicants were now looking strictly for commitment to either translational/basic science research or for future "policy thought leaders".

The field was expanding like crazy to let the talent in.

Every resident who graduated from my research oriented program in the roughly 5 years after me, who was successful at doing physician/scientist work, emphasized immunotherapy. To my knowledge: every, single, one.

Today, I can recruit top residents or existing faculty to a community practice hours away from a major city. Yippee!!! I am actively involved in trying to recruit other specialties however, because it is very difficult to recruit medical oncology, urology, surgical oncology, thoracic surgery, good PCPs, and everybody else needed to have a healthy community hospital.

We should be happy that the talent has left he building.

 

[TheWallnerus]

non-sequiter

*sequitur 😉

we were actively told that rad onc was the highest zenith one can reach as an MD/PhD, and so there was a lot of self selection too.

That made me very sad for the people who were told that and and very angry at the people who said it. Who said these things had about zero evidence that MD/PhD's make huge medical achievements in rad onc. And I bet most who said that rad onc offered "zeniths" to MD/PhDs were not MD/PhDs themselves. That this was said and went down this way back then, and given where we are now, is such an indictment against the trustworthiness of rad oncs recruiting medical students into radiation oncology.

 

[elementaryschooleconomics]

Above regarding selection all true. MD/PhD helps get into any field. I would not have matched into my residency program without a PhD (in a non-cancer related field).

What I witnessed at a good (but not big 3) program from when I first became aware of radonc (~2005) through a few years after I finished training (~2015).

In the early 2000s, there were already very, very good candidates at good programs with a fair number (but certainly minority) of MD/PhD types. Residents who were good clinically but not necessarily super productive in terms of research were often offered real, clinical academic jobs at the main campus (satellites were around but small). These young faculty not infrequently left after a few years to pursue very lucrative private practice jobs.

In the late 2000s/early 2010s, it was getting increasingly hard to land a job at my home institution and the standards for research productivity during residency were soaring. My training program was now preferentially recruiting from big 3 and their own residents were expected to do a national academic job search. (There was never support for private practice and if you weren't encouraged to do academics out of residency, it was an insult.) The residency program and department were expanding rapidly with plans for large scale consolidation with regional community hospitals. Some very good residents who wanted to stay were asked to do something extra (fellowship or advanced degree) to be considered for a clinical faculty position, even at a satellite.

Around this time, clinical acumen was becoming a very devalued commodity IMO. This impacted even the culture of residency. Careerism very early on was becoming the norm and it was rewarded. The same residents (good clinical reviews, good in-service, good radonc board scores) who 10 years earlier were being offered clinical faculty positions were now not serious candidates for jobs at the program and were even going to be beaten out at purely clinical academic jobs at lower tier places by residents with more research productivity.

The classes that matched into radonc around 2012/2013 were absolutely bonkers. I believe this was true "peak-peak" radonc. Top of class at top med schools with absurd research productivity type applicants. Of course, everyone knew there was not enough room in the field for these folks. I followed the people that I interviewed as a chief resident from this era and some did leave the field early. The meritocracy is brutal and these folks were competing against each other, and as a consequence, a significant number of the best applications ever for residency are now in the hands of PP radiation oncologists or lower tier academic positions. This was the time period where hard working, good personality, 260+ board scores, AOA type med-students who rotated through and did well were often not matching at top ranked programs. They were matching, but often at mid-tier or sometimes lower tier places. The faculty ranking these applicants were now looking strictly for commitment to either translational/basic science research or for future "policy thought leaders".

The field was expanding like crazy to let the talent in.

Every resident who graduated from my research oriented program in the roughly 5 years after me, who was successful at doing physician/scientist work, emphasized immunotherapy. To my knowledge: every, single, one.

Today, I can recruit top residents or existing faculty to a community practice hours away from a major city. Yippee!!! I am actively involved in trying to recruit other specialties however, because it is very difficult to recruit medical oncology, urology, surgical oncology, thoracic surgery, good PCPs, and everybody else needed to have a healthy community hospital.

We should be happy that the talent has left he building.

This is the best summary of the last 20 years that I've seen. I came in from the research side in the late 2000s and witnessed very similar events at the multiple institutions I've been affiliated with.

 

[radiation]

Interesting they buried this in the supplement of the Red journal paper. Which size practices charge the most per pt?
Practice Consolidation Among U.S. Radiation Oncologists Over Time

 

[TheWallnerus]

Interesting they buried this in the supplement of the Red journal paper. Which size practices charge the most per pt?
Practice Consolidation Among U.S. Radiation Oncologists Over Time

View attachment 344486

A few things from this interesting study, and this supplemental material (it's mentioned in the text)...

1) I would think "service charges" would include only consults, followups, that sort of thing. The average RO physician professional charges are going to be much greater than $1000, so something's wonky about these numbers re "service charges per patient." By wonky, I don't mean wrong... I just mean (as usual) not the whole picture. (Would be almost impossible for ~$1000 per pt to include all the average weekly OTVs eg.)
2) As defined in the study, keep in mind a solo practice could be a DermRads with 8 derms and 1 RO, or a UroRads with multiple urologists and 1 RO. I started my career in a group of 100 physicians... surgeons, radiology, med onc, int med, urology, derm, ENT, etc... and I was the only RO. That would be a solo practice in this study.
3) Although not graphed this way in the paper, this data (below) is in the paper, and I think it once again shows that we have more ROs than RO work in the U.S.

 

[radiation]

A few things from this interesting study, and this supplemental material (it's mentioned in the text)...

1) I would think "service charges" would include only consults, followups, that sort of thing. The average RO physician professional charges are going to be much greater than $1000, so something's wonky about these numbers re "service charges per patient." By wonky, I don't mean wrong... I just mean (as usual) not the whole picture. (Would be almost impossible for ~$1000 per pt to include all the average weekly OTVs eg.)
2) As defined in the study, keep in mind a solo practice could be a DermRads with 8 derms and 1 RO, or a UroRads with multiple urologists and 1 RO. I started my career in a group of 100 physicians... surgeons, radiology, med onc, int med, urology, derm, ENT, etc... and I was the only RO. That would be a solo practice in this study.
3) Although not graphed this way in the paper, this data (below) is in the paper, and I think it once again shows that we have more ROs than RO work in the U.S.

Agree with limitations of paper. Hard to get the raw data unfortunately. But lets talk through the following math and let me know if my logic is off
- Rad onc spending is roughly stable over last decade ( or perhaps going down per capita)
- More rad oncs are going to large practices (consolidation)
- There are more rad onc being produced than ever before (by a large amount)

Doesn't that have to mean large rad onc practices are charging less?

 

[dieABRdie]

Agree with limitations of paper. Hard to get the raw data unfortunately. But lets talk through the following math and let me know if my logic is off
- Rad onc spending is roughly stable over last decade ( or perhaps going down per capita)
- More rad oncs are going to large practices (consolidation)
- There are more rad onc being produced than ever before (by a large amount)

Doesn't that have to mean large rad onc practices are charging less?

I would imagine that large practices are more likely in more populated areas. More populated area means more competition for reimbursements and likely lower charges. Unless you are one of the "exempted" centers of course...

 

[TheWallnerus]

Doesn't that have to mean large rad onc practices are charging less?

Again I don't know.

If by "charging less" you mean less per physician... I would need to see data for the OTVs, the treatment technical charges, all the G-codes, the CPT codes, etc.

If by "charging less" you mean a large (>10 RO) practice charges Medicare less per year than a solo practice... I would say: no way, doesn't happen, fake news.

 

[Mandelin Rain]

Again I don't know.

If by "charging less" you mean less per physician... I would need to see data for the OTVs, the treatment technical charges, all the G-codes, the CPT codes, etc.

If by "charging less" you mean a large (>10 RO) practice charges Medicare less per year than a solo practice... I would say: no way, doesn't happen, fake news.

Large practices also likely to have the "babysitter's club" of docs who don't do much of anything with patients, which could certainly drive down the "per physician" average.

 

[elementaryschooleconomics]

Large practices also likely to have the "babysitter's club" of docs who don't do much of anything with patients, which could certainly drive down the "per physician" average.

We need that crew though! Otherwise, the therapists might learn that it's OK for patients to wear deodorant on treatment or that the scar doesn't need to be boosted for every PMRT case.