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CurbYourExpectations

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What are the steps that can be taken towards getting people into leadership position who are more vocal about the health of the field and providing good paths for new residents?

1. We want to have a healthy workforce that provides patients with the best care available.
2. We need more minority physicians in our field, that has become obvious as we are towards the bottom. However, we want them and everyone who enters the field to feel like their energy/time/dedication was worthwhile and not a risk.
3. We need to decrease spots, that much has become obvious. The contrarianism has become less and less prevalent that we are at a healthy number of spots. This is important so that young attendings and residents won't be taken advantage and have confidence that their job is secure. Unfortunately people don't seem to be saying much of anything on Twitter these days, is it happening behind closed doors?

What steps are available towards promoting or advocating for people with these ideals and where do I sign up?
 

RickyScott

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So you think we should entice more minority physicians into radonc from other specialties, and that, moreover, this is "obvious" we need to pull them away from other fields ? Every minority that enters radonc could have gone into primary care or medonc etc. where they would have flourished. zero sum game.
 
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CurbYourExpectations

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So you think we should entice more minority physicians into radonc from other specialties, and that, moreover, this is "obvious" ? Every minority that enters radonc could have gone into primary care or medonc etc. where they would have flourished. zero sum game.
Into a healthy job market radonc. The job market is currently trending towards not healthy and people in leadership aren't vocal enough is my point. I have a genuine investment in not wanting minorities to be taken advantage of in their careers. I also think RadOnc is a great field and would like to see a better ratio of them if RadOnc job market does improve.
 
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RickyScott

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into a healthy job market radonc
I don’t think that cutting spots alone will make the job market healthy, even if we cut every single one of them. Probably this a minority view, but the only action that can truly make job market healthy for trainees would be to combine with medonc or
diagnostic rads. Personally wouldn’t want to be part of that at this point in my career, but would be the only way I could have hope that trainee will have viable career for the next 40 years
 
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CurbYourExpectations

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I would be open to either of those options. Need leaders that are willing to look outside the box if the current route is going to harm the entrants. People who direct the field should be directing it for the people earliest in their career.

Do you find that you are doing less work now than when you started?
 
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CurbYourExpectations

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I have been curious where the decrease comes. I would think that with hypofractionation it would just take away from OTVs? Where is the other time lost?
 

Mandelin Rain

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    Part of it is that 2 new shops academic satellites (different universities) opened within 5-10 miles and they systematically start buying the PCP groups. Mind you, the market was already completely saturated.

    Beyond that, converse to some, I've seen a lot less mets as there are additional lines of systemic therapy. Urologists are AS if not operating. Lymphoma gone. Some upper GI gone (mainly pancreas, but also gastric). Observe more breasts. Hypofractionate everything.

    Boom, your list gets pretty short.
     
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    CurbYourExpectations

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    That is horrible. It is really unfortunate that academics just spread out to other sites and open up shop in order to pay RadOncs less and give more to the Admins. I wish that would be discouraged as well. As a field there is a huge issue between private/community ROs and academic ROs. Either we need to expand our scope and treat with medications more often or we need to significantly cut slots.

    Simul is great (Simul the great?), I would cast a vote for him in our leadership. But, even now I feel that he is less vocal in public (twitter?), maybe saving it for a podcast?

    I have also pointed this out before, there are people on twitter who say there needs to be a change. They keep their same spots and expect others to decrease.. (Ohio and Pennsylvania programs are what I have seen) Do as I say, not as I do?

    Oklahoma, Virginia and Colorado have done right, not just tweeted. Top tier programs have cut from 7 spots to 6 spots (wooo?)
     
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    CurbYourExpectations

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    One very practical step is not to just have leaders in academics like @RealSimulD

    Remember, for our leaders, it's a difficulty to not SOAP!
    Should only SOAP people who have shown interest in RadOnc. Weird how less people show interest when the field is crumbling at the grounds while the leaders are climbing ladders into the clouds.
     
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    temujim

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    Into a healthy job market radonc. The job market is currently trending towards not healthy and people in leadership aren't vocal enough is my point. I have a genuine investment in not wanting minorities to be taken advantage of in their careers. I also think RadOnc is a great field and would like to see a better ratio of them if RadOnc job market does improve.
    Shouldn't minorities look out for their own interest? Why do they need your help?
     
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    Gfunk6

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    I hate to be a nay-sayer and I love Radiation Oncology, but we are done. If the ship is going down, it doesn't matter who is at the helm. Even if we bring in practical and far-seeing leaders like SImul, nobody has the ability to bend reality. I would hate for quality leaders to face the blame for the collapse of a building built with a decrepit foundation.

    What will happen is that the house will collapse and (as usual) the non-boomers will be left to pick up the pieces.

    Also, if you care about URMs tell them to stay far, far away from our field.
     
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    CurbYourExpectations

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    Shouldn't minorities look out for their own interest? Why do they need your help?
    Yes? never said they did, the whole point of this thread was how to get leaders into the field to make it appealing to everyone, especially minorities. I don't understand how people read into it like this?

    "Clearly haven't seen the disingenuous outreach to URMs from ASTRO and the radoncrocks gaalighters on Twitter. It needs to be counteracted with facts"- MedGator

    Agreed, I think twitter is horrible and self serving. "Let's just call each other rising stars and put a bunch of random hash tags!"
    So much more respect for people who speak out against the paradigm non anonymously, but I notice those people get less likes so probably feel discouraged from it. Likes are king.
     
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    RealSimulD

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    That is horrible. It is really unfortunate that academics just spread out to other sites and open up shop in order to pay RadOncs less and give more to the Admins. I wish that would be discouraged as well. As a field there is a huge issue between private/community ROs and academic ROs. Either we need to expand our scope and treat with medications more often or we need to significantly cut slots.

    Simul is great (Simul the great?), I would cast a vote for him in our leadership. But, even now I feel that he is less vocal in public (twitter?), maybe saving it for a podcast?

    I have also pointed this out before, there are people on twitter who say there needs to be a change. They keep their same spots and expect others to decrease.. (Ohio and Pennsylvania programs are what I have seen) Do as I say, not as I do?

    Oklahoma, Virginia and Colorado have done right, not just tweeted. Top tier programs have cut from 7 spots to 6 spots (wooo?)
    Thanks for thinking of me.

    It’s not that I’m saving anything. When there is an issue, I will breathe 🔥. Like right now, my focus is on RO-APM. We all want answers from CMS and Astro and we are working on that. This is (another) true existential threat to our specialty.

    I have nothing to say about the match, because the applications are out and we have to wait and see how program behave. If more and more stop SOAPing (it is going to be iterative progress). The problem with some - and I am on your side - is that demanding 0 new residents or a drop of 50% is just not going to happen. If you want to be that extreme, your voice will not be heard until the Overton Window slides over, some. It is shifting ever slow slowly, with people that said there was no issue in the past coming to terms with the reality.

    I’m not going to quit. I still have a lot to say.

    I would love more non sock puppets backing me up. There is a collective fingers in ears happening. Keep those accounts, but open a real one and help us!

    Thanks again - hope to see many of you at Astro!
     
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    CurbYourExpectations

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    Thanks for thinking of me.

    It’s not that I’m saving anything. When there is an issue, I will breathe 🔥. Like right now, my focus is on RO-APM. We all want answers from CMS and Astro and we are working on that. This is (another) true existential threat to our specialty.

    I have nothing to say about the match, because the applications are out and we have to wait and see how program behave. If more and more stop SOAPing (it is going to be iterative progress). The problem with some - and I am on your side - is that demanding 0 new residents or a drop of 50% is just not going to happen. If you want to be that extreme, your voice will not be heard until the Overton Window slides over, some. It is shifting ever slow slowly, with people that said there was no issue in the past coming to terms with the reality.

    I’m not going to quit. I still have a lot to say.

    I would love more non sock puppets backing me up. There is a collective fingers in ears happening. Keep those accounts, but open a real one and help us!

    Thanks again - hope to see many of you at Astro!
    Believe me, the days I check social media and see people speaking (like you often do), it helps morale. Would back up more if I knew it was safe for young RadOncs to do so.

    There are less Twitter voices pretending everything is okay, which is great. I wish more people would stir up conversations about it.
     

    TheWallnerus

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    I have been curious where the decrease comes. I would think that with hypofractionation it would just take away from OTVs? Where is the other time lost?
    For starters:



    @Gfunk6 just recently said it: more workers, less work. "Work" encompasses everything: fractions, number of patients, incidence of the cancers we tx, RT utilization, alternatives to RT, etc.

    As just a total aside, whole brain RT e.g. used to be a mainstay treatment. Did it all the time. Now, for me, it's rare. Good for pts, bad for us. One day, there's going to be "The Last Whole Brain Irradiation Patient Ever Treated." I wonder when the last total skin electron for mycosis fungoides patient was.
     
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    RadOncDoc21

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    Should only SOAP people who have shown interest in RadOnc. Weird how less people show interest when the field is crumbling at the grounds while the leaders are climbing ladders into the clouds.
    I’m at a place where transitional year residents do rotations on my service and all of them tell me the same story that they likely would have gone into rad onc if it wasn’t for the job market. I even had a few years where there were no rad onc residents when I used to see at least 3-4 a year. I know I’m preaching to the choir but the word is out.
     
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    RadOncDoc21

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    For starters:



    @Gfunk6 just recently said it: more workers, less work. "Work" encompasses everything: fractions, number of patients, incidence of the cancers we tx, RT utilization, alternatives to RT, etc.

    As just a total aside, whole brain RT e.g. used to be a mainstay treatment. Did it all the time. Now, for me, it's rare. Good for pts, bad for us. One day, there's going to be "The Last Whole Brain Irradiation Patient Ever Treated." I wonder when the last total skin electron for mycosis fungoides patient was.
    I had a patient with painful bone mets demand she see a radiation oncologist because all the med onc wanted to do was “observe.”
     
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    elementaryschooleconomics

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    For starters:



    @Gfunk6 just recently said it: more workers, less work. "Work" encompasses everything: fractions, number of patients, incidence of the cancers we tx, RT utilization, alternatives to RT, etc.

    As just a total aside, whole brain RT e.g. used to be a mainstay treatment. Did it all the time. Now, for me, it's rare. Good for pts, bad for us. One day, there's going to be "The Last Whole Brain Irradiation Patient Ever Treated." I wonder when the last total skin electron for mycosis fungoides patient was.
    The WBRT thing has been the weirdest for me to observe, but maybe because that's one I witnessed personally. At least in my neck of the woods, my referring docs love SRS so I still see these patients - or at least that's my perception. I don't know how many patients I don't even hear about which are put on a different path.
     
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    medgator

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    For starters:



    @Gfunk6 just recently said it: more workers, less work. "Work" encompasses everything: fractions, number of patients, incidence of the cancers we tx, RT utilization, alternatives to RT, etc.

    As just a total aside, whole brain RT e.g. used to be a mainstay treatment. Did it all the time. Now, for me, it's rare. Good for pts, bad for us. One day, there's going to be "The Last Whole Brain Irradiation Patient Ever Treated." I wonder when the last total skin electron for mycosis fungoides patient was.
    TSE cases still exist. There are just less places offering it these days. We stopped several years ago. Too much of a labor and time suck for the reimbursement... Stop me if you think youve heard that one before
     
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    OTN

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    For starters:



    @Gfunk6 just recently said it: more workers, less work. "Work" encompasses everything: fractions, number of patients, incidence of the cancers we tx, RT utilization, alternatives to RT, etc.

    As just a total aside, whole brain RT e.g. used to be a mainstay treatment. Did it all the time. Now, for me, it's rare. Good for pts, bad for us. One day, there's going to be "The Last Whole Brain Irradiation Patient Ever Treated." I wonder when the last total skin electron for mycosis fungoides patient was.
    In our pp we do TSET for MF. I’ve treated two this year. I see it more as a “we do it all here, so just send patients to us no matter what” than a money maker. Patients are also super happy to be able to receive it, and it’s satisfying to be able to physically watch the disease get cured.
     
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    TheWallnerus

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    In our pp we do TSET for MF. I’ve treated two this year. I see it more as a “we do it all here, so just send patients to us no matter what” than a money maker. Patients are also super happy to be able to receive it, and it’s satisfying to be able to physically watch the disease get cured.
    That’s good. In reality you deserve probably 250K per patient. You know, proton prices.
     
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    Mandelin Rain

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    “Adipose sparing Total Skin Proton Therapy” coming to an academic center near you.
     
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    Mandelin Rain

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    I’m old enough to remember when the PP docs were the greedy bastards for doing 20 fraction bone mets and charging IMRT for breast.

    All that pales to what’s currently happening behind the academic veil of greed. Proton breast boosts… smh.
     
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    communitydoc13

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    Do you find that you are doing less work now than when you started?
    Less than 10 years into community job. Demographics of my area props me up. Oldest boomer is 75, youngest is ~61 and my area's population increasing so still lots of cancer coming our way, but:

    All fractionation shorter and much more observation for breast/prostate. Pretty much never adjuvant RT prostate. Only going to get worse. This is the bulk of radonc volume.

    Lymphoma essentially gone. (But was essentially gone when I got here).

    Almost never whole brain.

    H&N stable. I think very few people over 40 vaccinated, so not expecting dramatic drop in this over next 15 years.

    GI limited to anal, rectal and esophagus for most part. Will have to adapt 5 fraction rectal soon and will probably enroll on protocol. Treat less rectal than used to but have moved to TNT with observation for some. Waiting for medonc to argue against triple modality therapy in esophagus.

    More of my patients are truly marginal very old folks. Fair bit of locally advanced skin in this population. Some medoncs believe locally advanced skin (as in regional nodal disease) should be managed with Libtayo first. Haven't treated a melanoma outside of brain for years.

    In past year, had a Merkel of the face referred to academic center where they opted for upfront immunotherapy followed by planned resection based on a single arm trial demonstrating 50% response. Thing grew through IT to point where it encroached on orbit and was non-resectable. I did ultimately get rid of this with harsh, wide field (what you have to do in Merkel) RT with toxicity far exceeding what would have been there if I got the patient first.

    RP sarcoma gone. In past year had local surgeon (quite good with sarcoma expertise) close up after ex-lap and request pre-op RT. We discussed Strass trial in TB and agreed that reasonable in this circumstance to do pre-op RT due to surgeon's concern for getting clear margin. Pt got second opinion at academic place where their paradigm is now surgery alone with definitive RT for unresectable only. They never pre-op RT. Confirmed that this is the common new paradigm at academic places.

    Still treating stage III endometrial but don't know for how long. Rationale is local control and don't treat all patients.

    Lung will decrease and is a function of surgical environment. A good thoracic surgeon will do segmental resections on very early stage disease even for frail patients and eat into your volume. Very old patients with lung nodules will likely make up a stable group of my patients (but this is somewhat unsatisfying, in era of incidentalomas we overtreat lung).

    Oligomets are a part of my practice, but all oligometastatic disease will be contextualized to the systemic therapy of the time. IMO lymphoma represented the first oligometastatic disease, with a stage III hematologic malignancy curable by XRT. See where our role there is now.

    My ratio of consults to treatment has gone up significantly. I am aware of my tenuous value and do everything to project value to the hospital, including admin stuff, every tumor board, will curbside on everything, will see anyone. Because of this, I don't do less work. But I do generate less revenue.

    Going forward, zero expectation to ever make more money than I am today.

    Some academic places can claim growth because they are growing. They are moving into markets hours away from main hospital and taking over. Patients ask about protons all the time. Despite this, many academic docs would be happy to get out if there was a good private option.

    All community hospitals very vulnerable to consolidation. We know what this means for physician satisfaction.
     
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    RickyScott

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    Less than 10 years into community job. Demographics of my area props me up. Oldest boomer is 75, youngest is ~61 and my area's population increasing so still lots of cancer coming our way, but:

    All fractionation shorter and much more observation for breast/prostate. Pretty much never adjuvant RT prostate. Only going to get worse. This is the bulk of radonc volume.

    Lymphoma essentially gone. (But was essentially gone when I got here).

    Almost never whole brain.

    H&N stable. I think very few people over 40 vaccinated, so not expecting dramatic drop in this over next 15 years.

    GI limited to anal, rectal and esophagus for most part. Will have to adapt 5 fraction rectal soon and will probably enroll on protocol. Treat less rectal than used to but have moved to TNT with observation for some. Waiting for medonc to argue against triple modality therapy in esophagus.

    More of my patients are truly marginal very old folks. Fair bit of locally advanced skin in this population. Some medoncs believe locally advanced skin (as in regional nodal disease) should be managed with Libtayo first. Haven't treated a melanoma outside of brain for years.

    In past year, had a Merkel of the face referred to academic center where they opted for upfront immunotherapy followed by planned resection based on a single arm trial demonstrating 50% response. Thing grew through IT to point where it encroached on orbit and was non-resectable. I did ultimately get rid of this with harsh, wide field (what you have to do in Merkel) RT with toxicity far exceeding what would have been there if I got the patient first.

    RP sarcoma gone. In past year had local surgeon (quite good with sarcoma expertise) close up after ex-lap and request pre-op RT. We discussed Strass trial in TB and agreed that reasonable in this circumstance to do pre-op RT due to surgeon's concern for getting clear margin. Pt got second opinion at academic place where their paradigm is now surgery alone with definitive RT for unresectable only. They never pre-op RT. Confirmed that this is the common new paradigm at academic places.

    Still treating stage III endometrial but don't know for how long. Rationale is local control and don't treat all patients.

    Lung will decrease and is a function of surgical environment. A good thoracic surgeon will do segmental resections on very early stage disease even for frail patients and eat into your volume. Very old patients with lung nodules will likely make up a stable group of my patients (but this is somewhat unsatisfying, in era of incidentalomas we overtreat lung).

    Oligomets are a part of my practice, but all oligometastatic disease will be contextualized to the systemic therapy of the time. IMO lymphoma represented the first oligometastatic disease, with a stage III hematologic malignancy curable by XRT. See where our role there is now.

    My ratio of consults to treatment has gone up significantly. I am aware of my tenuous value and do everything to project value to the hospital, including admin stuff, every tumor board, will curbside on everything, will see anyone. Because of this, I don't do less work. But I do generate less revenue.

    Going forward, zero expectation to ever make more money than I am today.

    Some academic places can claim growth because they are growing. They are moving into markets hours away from main hospital and taking over. Patients ask about protons all the time. Despite this, many academic docs would be happy to get out if there was a good private option.

    All community hospitals very vulnerable to consolidation. We know what this means for physician satisfaction.
    My exact situation
     
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    ROforbetterorworse

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    Less than 10 years into community job. Demographics of my area props me up. Oldest boomer is 75, youngest is ~61 and my area's population increasing so still lots of cancer coming our way, but:

    All fractionation shorter and much more observation for breast/prostate. Pretty much never adjuvant RT prostate. Only going to get worse. This is the bulk of radonc volume.

    Lymphoma essentially gone. (But was essentially gone when I got here).

    Almost never whole brain.

    H&N stable. I think very few people over 40 vaccinated, so not expecting dramatic drop in this over next 15 years.

    GI limited to anal, rectal and esophagus for most part. Will have to adapt 5 fraction rectal soon and will probably enroll on protocol. Treat less rectal than used to but have moved to TNT with observation for some. Waiting for medonc to argue against triple modality therapy in esophagus.

    More of my patients are truly marginal very old folks. Fair bit of locally advanced skin in this population. Some medoncs believe locally advanced skin (as in regional nodal disease) should be managed with Libtayo first. Haven't treated a melanoma outside of brain for years.

    In past year, had a Merkel of the face referred to academic center where they opted for upfront immunotherapy followed by planned resection based on a single arm trial demonstrating 50% response. Thing grew through IT to point where it encroached on orbit and was non-resectable. I did ultimately get rid of this with harsh, wide field (what you have to do in Merkel) RT with toxicity far exceeding what would have been there if I got the patient first.

    RP sarcoma gone. In past year had local surgeon (quite good with sarcoma expertise) close up after ex-lap and request pre-op RT. We discussed Strass trial in TB and agreed that reasonable in this circumstance to do pre-op RT due to surgeon's concern for getting clear margin. Pt got second opinion at academic place where their paradigm is now surgery alone with definitive RT for unresectable only. They never pre-op RT. Confirmed that this is the common new paradigm at academic places.

    Still treating stage III endometrial but don't know for how long. Rationale is local control and don't treat all patients.

    Lung will decrease and is a function of surgical environment. A good thoracic surgeon will do segmental resections on very early stage disease even for frail patients and eat into your volume. Very old patients with lung nodules will likely make up a stable group of my patients (but this is somewhat unsatisfying, in era of incidentalomas we overtreat lung).

    Oligomets are a part of my practice, but all oligometastatic disease will be contextualized to the systemic therapy of the time. IMO lymphoma represented the first oligometastatic disease, with a stage III hematologic malignancy curable by XRT. See where our role there is now.

    My ratio of consults to treatment has gone up significantly. I am aware of my tenuous value and do everything to project value to the hospital, including admin stuff, every tumor board, will curbside on everything, will see anyone. Because of this, I don't do less work. But I do generate less revenue.

    Going forward, zero expectation to ever make more money than I am today.

    Some academic places can claim growth because they are growing. They are moving into markets hours away from main hospital and taking over. Patients ask about protons all the time. Despite this, many academic docs would be happy to get out if there was a good private option.

    All community hospitals very vulnerable to consolidation. We know what this means for physician satisfaction.

    Same. I don’t want to hear any current resident or new attending say things are all good

    They are just not experienced enough to understand (or unwilling)
     
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    thecarbonionangle

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    I am hearing reports of the coming spin as this being a “great” jobs year, to be true. Many are saying it folks! no problems, nothing to fix folks!

    From what im hearing if you want to make cash these days you gotta go to acadmemics! The swamp is switching.
     
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    Mandelin Rain

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    Less than 10 years into community job. Demographics of my area props me up. Oldest boomer is 75, youngest is ~61 and my area's population increasing so still lots of cancer coming our way, but:

    All fractionation shorter and much more observation for breast/prostate. Pretty much never adjuvant RT prostate. Only going to get worse. This is the bulk of radonc volume.

    Lymphoma essentially gone. (But was essentially gone when I got here).

    Almost never whole brain.

    H&N stable. I think very few people over 40 vaccinated, so not expecting dramatic drop in this over next 15 years.

    GI limited to anal, rectal and esophagus for most part. Will have to adapt 5 fraction rectal soon and will probably enroll on protocol. Treat less rectal than used to but have moved to TNT with observation for some. Waiting for medonc to argue against triple modality therapy in esophagus.

    More of my patients are truly marginal very old folks. Fair bit of locally advanced skin in this population. Some medoncs believe locally advanced skin (as in regional nodal disease) should be managed with Libtayo first. Haven't treated a melanoma outside of brain for years.

    In past year, had a Merkel of the face referred to academic center where they opted for upfront immunotherapy followed by planned resection based on a single arm trial demonstrating 50% response. Thing grew through IT to point where it encroached on orbit and was non-resectable. I did ultimately get rid of this with harsh, wide field (what you have to do in Merkel) RT with toxicity far exceeding what would have been there if I got the patient first.

    RP sarcoma gone. In past year had local surgeon (quite good with sarcoma expertise) close up after ex-lap and request pre-op RT. We discussed Strass trial in TB and agreed that reasonable in this circumstance to do pre-op RT due to surgeon's concern for getting clear margin. Pt got second opinion at academic place where their paradigm is now surgery alone with definitive RT for unresectable only. They never pre-op RT. Confirmed that this is the common new paradigm at academic places.

    Still treating stage III endometrial but don't know for how long. Rationale is local control and don't treat all patients.

    Lung will decrease and is a function of surgical environment. A good thoracic surgeon will do segmental resections on very early stage disease even for frail patients and eat into your volume. Very old patients with lung nodules will likely make up a stable group of my patients (but this is somewhat unsatisfying, in era of incidentalomas we overtreat lung).

    Oligomets are a part of my practice, but all oligometastatic disease will be contextualized to the systemic therapy of the time. IMO lymphoma represented the first oligometastatic disease, with a stage III hematologic malignancy curable by XRT. See where our role there is now.

    My ratio of consults to treatment has gone up significantly. I am aware of my tenuous value and do everything to project value to the hospital, including admin stuff, every tumor board, will curbside on everything, will see anyone. Because of this, I don't do less work. But I do generate less revenue.

    Going forward, zero expectation to ever make more money than I am today.

    Some academic places can claim growth because they are growing. They are moving into markets hours away from main hospital and taking over. Patients ask about protons all the time. Despite this, many academic docs would be happy to get out if there was a good private option.

    All community hospitals very vulnerable to consolidation. We know what this means for physician satisfaction.
    Yeah, very accurate.
     

    RO28

    Full Member
    2+ Year Member
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    Less than 10 years into community job. Demographics of my area props me up. Oldest boomer is 75, youngest is ~61 and my area's population increasing so still lots of cancer coming our way, but:

    All fractionation shorter and much more observation for breast/prostate. Pretty much never adjuvant RT prostate. Only going to get worse. This is the bulk of radonc volume.

    Lymphoma essentially gone. (But was essentially gone when I got here).

    Almost never whole brain.

    H&N stable. I think very few people over 40 vaccinated, so not expecting dramatic drop in this over next 15 years.

    GI limited to anal, rectal and esophagus for most part. Will have to adapt 5 fraction rectal soon and will probably enroll on protocol. Treat less rectal than used to but have moved to TNT with observation for some. Waiting for medonc to argue against triple modality therapy in esophagus.

    More of my patients are truly marginal very old folks. Fair bit of locally advanced skin in this population. Some medoncs believe locally advanced skin (as in regional nodal disease) should be managed with Libtayo first. Haven't treated a melanoma outside of brain for years.

    In past year, had a Merkel of the face referred to academic center where they opted for upfront immunotherapy followed by planned resection based on a single arm trial demonstrating 50% response. Thing grew through IT to point where it encroached on orbit and was non-resectable. I did ultimately get rid of this with harsh, wide field (what you have to do in Merkel) RT with toxicity far exceeding what would have been there if I got the patient first.

    RP sarcoma gone. In past year had local surgeon (quite good with sarcoma expertise) close up after ex-lap and request pre-op RT. We discussed Strass trial in TB and agreed that reasonable in this circumstance to do pre-op RT due to surgeon's concern for getting clear margin. Pt got second opinion at academic place where their paradigm is now surgery alone with definitive RT for unresectable only. They never pre-op RT. Confirmed that this is the common new paradigm at academic places.

    Still treating stage III endometrial but don't know for how long. Rationale is local control and don't treat all patients.

    Lung will decrease and is a function of surgical environment. A good thoracic surgeon will do segmental resections on very early stage disease even for frail patients and eat into your volume. Very old patients with lung nodules will likely make up a stable group of my patients (but this is somewhat unsatisfying, in era of incidentalomas we overtreat lung).

    Oligomets are a part of my practice, but all oligometastatic disease will be contextualized to the systemic therapy of the time. IMO lymphoma represented the first oligometastatic disease, with a stage III hematologic malignancy curable by XRT. See where our role there is now.

    My ratio of consults to treatment has gone up significantly. I am aware of my tenuous value and do everything to project value to the hospital, including admin stuff, every tumor board, will curbside on everything, will see anyone. Because of this, I don't do less work. But I do generate less revenue.

    Going forward, zero expectation to ever make more money than I am today.

    Some academic places can claim growth because they are growing. They are moving into markets hours away from main hospital and taking over. Patients ask about protons all the time. Despite this, many academic docs would be happy to get out if there was a good private option.

    All community hospitals very vulnerable to consolidation. We know what this means for physician satisfaction.
    +1 here.
     
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