Leadership

[CurbYourExpectations]

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[RickyScott]

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.

 

[RickyScott]

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

 

[Mandelin Rain]

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

WAYYYYYYYYY less for mine.

 

[Mandelin Rain]

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.

 

[RadOncMegatron]

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!

 

[temujim]

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?

 

[medgator]

Shouldn't minorities look out for their own interest? Why do they need your help?

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

 

[Gfunk6]

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.

 

[deleted1111261]

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!

 

[TheWallnerus]

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:

Jobs, patients, and trends: not good

(updated the figure) Sources 1. Supply and Demand for Radiation Oncology in the United States: Updated Projections for 2015 to 2025. "In comparison with prior projections, the new projected demand for radiation therapy in 2020 dropped by 24,000 cases (a 4% relative decline). This decrease is...

forums.studentdoctor.net

Temporal Trends of Resident Experience in External Beam Radiation Therapy Cases: Analysis of ACGME Case Logs from 2007 to 2018 - PubMed

We report a longitudinal summary of resident-reported experience in EBRT cases. These findings have implications for future efforts to optimize residency training programs and requirements.

pubmed.ncbi.nlm.nih.gov

@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.

 

[RadOncDoc21]

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.

 

[RadOncDoc21]

For starters:

Jobs, patients, and trends: not good

(updated the figure) Sources 1. Supply and Demand for Radiation Oncology in the United States: Updated Projections for 2015 to 2025. "In comparison with prior projections, the new projected demand for radiation therapy in 2020 dropped by 24,000 cases (a 4% relative decline). This decrease is...

forums.studentdoctor.net

Temporal Trends of Resident Experience in External Beam Radiation Therapy Cases: Analysis of ACGME Case Logs from 2007 to 2018 - PubMed

We report a longitudinal summary of resident-reported experience in EBRT cases. These findings have implications for future efforts to optimize residency training programs and requirements.

pubmed.ncbi.nlm.nih.gov

@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.”

 

[elementaryschooleconomics]

For starters:

Jobs, patients, and trends: not good

(updated the figure) Sources 1. Supply and Demand for Radiation Oncology in the United States: Updated Projections for 2015 to 2025. "In comparison with prior projections, the new projected demand for radiation therapy in 2020 dropped by 24,000 cases (a 4% relative decline). This decrease is...

forums.studentdoctor.net

Temporal Trends of Resident Experience in External Beam Radiation Therapy Cases: Analysis of ACGME Case Logs from 2007 to 2018 - PubMed

We report a longitudinal summary of resident-reported experience in EBRT cases. These findings have implications for future efforts to optimize residency training programs and requirements.

pubmed.ncbi.nlm.nih.gov

@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.

 

[medgator]

For starters:

Jobs, patients, and trends: not good

(updated the figure) Sources 1. Supply and Demand for Radiation Oncology in the United States: Updated Projections for 2015 to 2025. "In comparison with prior projections, the new projected demand for radiation therapy in 2020 dropped by 24,000 cases (a 4% relative decline). This decrease is...

forums.studentdoctor.net

Temporal Trends of Resident Experience in External Beam Radiation Therapy Cases: Analysis of ACGME Case Logs from 2007 to 2018 - PubMed

We report a longitudinal summary of resident-reported experience in EBRT cases. These findings have implications for future efforts to optimize residency training programs and requirements.

pubmed.ncbi.nlm.nih.gov

@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

 

[OTN]

For starters:

Jobs, patients, and trends: not good

(updated the figure) Sources 1. Supply and Demand for Radiation Oncology in the United States: Updated Projections for 2015 to 2025. "In comparison with prior projections, the new projected demand for radiation therapy in 2020 dropped by 24,000 cases (a 4% relative decline). This decrease is...

forums.studentdoctor.net

Temporal Trends of Resident Experience in External Beam Radiation Therapy Cases: Analysis of ACGME Case Logs from 2007 to 2018 - PubMed

We report a longitudinal summary of resident-reported experience in EBRT cases. These findings have implications for future efforts to optimize residency training programs and requirements.

pubmed.ncbi.nlm.nih.gov

@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.

 

[TheWallnerus]

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.

 

[Mandelin Rain]

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

 

[elementaryschooleconomics]

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

Minor correction: "the ability to enroll on a single arm clinical trial comparing adipose tissue sparing with protons compared to photon historical controls" coming to an academic center near you!

 

[Mandelin Rain]

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.

 

[communitydoc13]

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.

 

[RickyScott]

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

 

[elementaryschooleconomics]

My exact situation

Wow, yeah, this is incredibly accurate.

 

[ROforbetterorworse]

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)

 

[thecarbonionangle]

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.

 

[Mandelin Rain]

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]

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.