Meeting Derm’s Rad Onc Needs... w/o Rad Oncs

[scarbrtj]

The therapists are essentially the radiation oncologists (because the derms can’t be bothered with the XRT physics-y stuff). These centers are on average much busier than “average” PP rad onc clinic. Imho. As Zeitman says (?) better to own a disease site than a modality. Especially since it seems we don’t own either?

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[RickyScott]

Couldn’t agree more. Only way radonc rights itself is offering fellowships/training (for those who want it) in delivery of some systemic treatments for cancer.

 

[elementaryschooleconomics]

The therapists are essentially the radiation oncologists (because the derms can’t be bothered with the XRT physics-y stuff). These centers are on average much busier than “average” PP rad onc clinic. Imho. As Zeitman says (?) better to own a disease site than a modality. Especially since it seems we don’t own either?

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SkinCure Oncology is changing the face of non-melanoma skin cancer treatment forever with Image-Guided SRT, an Image-Guided Superficial Radiotherapy solution. Image-Guided SRT provides a painless, effective alternative to Mohs surgery as well as an additional treatment option for your...

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Good Lord this is terrifying

 

[Reaganite]

Couple of guys in my neck of the woods doing it. 30-40 on treat even for a small derm practice. One of my old therapists staffs and says she basically does everything.

 

[scarbrtj]

don't hold me to it, but some practices using a handheld ultrasound to "measure depth" daily and billing some IGRTs... again w/ no rad oncs anywhere to be found. ASTRO... you totally whiffed.

 

[medgator]

don't hold me to it, but some practices using a handheld ultrasound to "measure depth" daily and billing some IGRTs... again w/ no rad oncs anywhere to be found. ASTRO... you totally whiffed.

Until they treat things deeper than they should be treating. I see at least 1-2 srt recurrences/f-ups every quarter. Seeing one this week.

Thank God for libtayo

 

[scarbrtj]

Until they treat things deeper than they should be treating. I see at least 1-2 srt recurrences/f-ups every quarter. Seeing one this week.

Thank God for libtayo

What do you call a radiation oncologist who never took physics or rad bio boards and treats more patients and has a higher LF than any other rad onc in town? A dermatologist.

 

[Reaganite]

don't hold me to it, but some practices using a handheld ultrasound to "measure depth" daily and billing some IGRTs... again w/ no rad oncs anywhere to be found. ASTRO... you totally whiffed.

They are definitely doing that. A proforma I saw maybe 2 years ago also had you billing simple sim DAILY and some even proposed a daily established patient charge. The actual treatment code pays crap. It requires big volume and questionable charges to make it work.

 

[radiation]

Its just so strange to me how we have a million posts about how negative the impact of residency expansion is and all the different things that need to be done to fight the chairs that allowed this etc...

and here we have probably a pool of million of pts to treat with a modality that belongs to us and the general sentiment is "oh well I guess we'll just let the dermatologists have it since it doesnt reimburse as much as imrt"

 

[RickyScott]

Its just so strange to me how we have a million posts about how negative the impact of residency expansion is and all the different things that need to be done to fight the chairs that allowed this etc...

and here we have probably a pool of million of pts to treat with a modality that belongs to us and the general sentiment is "oh well I guess we'll just let the dermatologists have it since it doesnt reimburse as much as imrt"

That’s certainly not the sentiment.1) Post abt very low reimbursement was referring to kv treatments (not electrons) which few radoncs utilize. Since reimbursement for kv is virtually nothing dermatologists have to manibpulate codes- ultrasound and plan every day etc 2) it’s not like we can pass laws prohibiting dermatologists from delivering kv treatments, and if we did, they would just turn to mohs 3) greedy chairs did ruin this field! Skin cancer, cardiac ablation or oligomets, not going to save xrt.

 

[elementaryschooleconomics]

Its just so strange to me how we have a million posts about how negative the impact of residency expansion is and all the different things that need to be done to fight the chairs that allowed this etc...

and here we have probably a pool of million of pts to treat with a modality that belongs to us and the general sentiment is "oh well I guess we'll just let the dermatologists have it since it doesnt reimburse as much as imrt"

It's more about what we perceive we can control. The number of residency spots can basically be altered by a group of ~100 people (Chairs) deciding to take fewer residents in the Match. That's it. A small intervention with a potential large benefit.

Meanwhile, to essentially go to war with Dermatology over a modality would require intense resources, likely legislation, and referral/practice patterns would then need to change for existing RadOncs to absorb these patients. A large benefit for us to be sure, but the path to get to that point is long and tortuous.

In an ideal world both would happen, but since we can't even get people to agree increasing residents by 127% was not a good idea...I have low optimism for either.

 

[Mandelin Rain]

No specialty holds the right to practice medicine.

If you want, you could start chopping out appendices. No cabal of surgeons will stop you. You should, however, have a good explanation for the judge if something goes wrong. Dermatologist's explanation, "You see, my expertise is solely skin disorders, including malignant skin disorders. I have extensive training to manage them surgically and non-surgically." Judge: "That checks out. Next."

 

[OTN]

No specialty holds the right to practice medicine.

If you want, you could start chopping out appendices. No cabal of surgeons will stop you. You should, however, have a good explanation for the judge if something goes wrong. Dermatologist's explanation, "You see, my expertise is solely skin disorders, including malignant skin disorders. I have extensive training to manage them surgically and non-surgically." Judge: "That checks out. Next."

Given how terribly ASTRO’s fight went with urorads, I don’t think they would be successful in the least trying to eliminate “dermorads”. What they should do is work with CMS to help reveal the shady billing practices that go on. That would both build political capital with CMS and mess with the pro formas of all those derm offices.

 

[RickyScott]

No specialty holds the right to practice medicine.

If you want, you could start chopping out appendices. No cabal of surgeons will stop you. You should, however, have a good explanation for the judge if something goes wrong. Dermatologist's explanation, "You see, my expertise is solely skin disorders, including malignant skin disorders. I have extensive training to manage them surgically and non-surgically." Judge: "That checks out. Next."

Totally agree. And in truth, dermatologist who sticks to accepted fractionation will manage 99% skin cancers with kv correctly. (Stay away from high grade advanced disease- same true for mohs). As scarbtj states, we need to own disease not modality. A dermatologist would make a more convincing argument to a judge than a radiation oncologist!

What passes for logic and common sense in our world doesn’t fly in the real one: same true for cms/general supervision.

 

[medgator]

No specialty holds the right to practice medicine.

If you want, you could start chopping out appendices. No cabal of surgeons will stop you. You should, however, have a good explanation for the judge if something goes wrong. Dermatologist's explanation, "You see, my expertise is solely skin disorders, including malignant skin disorders. I have extensive training to manage them surgically and non-surgically." Judge: "That checks out. Next."

I see way too many recurrences/under treated lesions, some of these derms just don't know what they are doing, quite frankly

 

[evilbooyaa]

I see way too many recurrences/under treated lesions, some of these derms just don't know what they are doing, quite frankly

The issue is that even when cancer is treated ****tily with radiation (regardless of whether it is a derm or a rad onc) and the patient develops a recurrence there is NEVER real QA on an institutional level to say "could something have been done differently to potentially prevent this"? > 10 patients I saw treated during residency where contours were wrong, regions were massively underdosed (like in breast, at the junction line, leading to an in-breast 'recurrence' of visible LNs at time of initial treatment), or PTVs were too tight (seen an attending do 0 margin in certain areas for lung SBRT) and then those patients recurred.

Everyone wrung their hands and said "man cancer is really a bitch" but if you look at the original plan, it was a garbage treatment as is. I'd estimate, outside of GBM, that at least 10-20% of post-radiation recurrences are due to ****ty radiation rather than 'bad biology', but unless you have an inherent drive to be better, you'll just accept it because "cancer recurs".

 

[Radonc90]

Can someone educate me, I thought radiation can only be delivered by "authorized radiation user" per NRC guidelines?

In this case, the Derm people probably get away because it is kV machine (instead of MV machine)...

Best is to pass regulation like the Canadians did "Therapeutic ionizing radiation can only be given by a board-certified radiation oncologist..." This way, no matter what machine (kV, electrons or MV), therapeutic radiation can only be delivered by radonc.

Pretty much like "a commercial airlines can ONLY be flown by licensed certified pilots" for the sake of safety. Sorry Microsoft Flight Sim kids...

 

[elementaryschooleconomics]

Can someone educate me, I thought radiation can only be delivered by "authorized radiation user" per NRC guidelines?

In this case, the Derm people probably get away because it is kV machine (instead of MV machine)...

Best is to pass regulation like the Canadians did "Therapeutic ionizing radiation can only be given by a board-certified radiation oncologist..." This way, no matter what machine (kV, electrons or MV), therapeutic radiation can only be delivered by radonc.

Pretty much like "a commercial airlines can ONLY be flown by licensed certified pilots" for the sake of safety. Sorry Microsoft Flight Sim kids...

NRC guidelines are for radioactive sources, the FDA controls machines like linear accelerators. (This is "walking around knowledge" I can access right from my brain because of the extra 6 months of studying for radbio/physics I've been given this year, thanks COVID/ABR!)

Currently, the only possible legislation the Derm crew would come up against would be "Certificate of Need" laws, so they might have issues in say, New York, but be totally fine in Florida. I don't know the specifics of kV machines though (I might fail physics, crap).

It would be great if we could pass legislation for this, but especially now that Derm has a large VC presence...our lobbying power is nothing compared to theirs.

 

[scarbrtj]

NRC guidelines are for radioactive sources, the FDA controls machines like linear accelerators. (This is "walking around knowledge" I can access right from my brain because of the extra 6 months of studying for radbio/physics I've been given this year, thanks COVID/ABR!)

Currently, the only possible legislation the Derm crew would come up against would be "Certificate of Need" laws, so they might have issues in say, New York, but be totally fine in Florida. I don't know the specifics of kV machines though (I might fail physics, crap).

It would be great if we could pass legislation for this, but especially now that Derm has a large VC presence...our lobbying power is nothing compared to theirs.

You are right. Amazingly, a derm has never bought a linac in Florida. But they could. Just like e.g. a NSG can buy a Zap-X in Florida. And cardiologists can buy a linac if they wanted to get into SBRT, but I don't think cardiac SBRT for V-tach is reimburseable by anyone yet. Urologists demonstrably bought linacs, but they have "always" hired a rad onc to oversee it....... except when that rad onc was sick, or had a family emergency, or took a vacation..... then the urologist on site, who had bought the linac, "oversaw." CONs have only applied to linacs in America, never kV X-ray machines.

 

[OTN]

You are right. Amazingly, a derm has never bought a linac in Florida. But they could. Just like e.g. a NSG can buy a Zap-X in Florida. And cardiologists can buy a linac if they wanted to get into SBRT, but I don't think cardiac SBRT for V-tach is reimburseable by anyone yet. Urologists demonstrably bought linacs, but they have "always" hired a rad onc to oversee it....... except when that rad onc was sick, or had a family emergency, or took a vacation..... then the urologist on site, who had bought the linac, "oversaw." CONs have only applied to linacs in America, never kV X-ray machines.

Sure, a derm could buy a linac and offer more advanced treatments, but can you imagine how a malpractice lawyer's eyes would light up if a patient had a complication?

"So, Dr. Mohs, you did not train in radiation oncology, but rather dermatology, correct? You were never formally trained in radiation oncology? You're not a board-certified radiation oncologist?"

Medicolegal barriers to linac purchasing by non-radoncs are far, FAR higher than worthless board exams ever will be.

 

[RickyScott]

Sure, a derm could buy a linac and offer more advanced treatments, but can you imagine how a malpractice lawyer's eyes would light up if a patient had a complication?

"So, Dr. Mohs, you did not train in radiation oncology, but rather dermatology, correct? You were never formally trained in radiation oncology? You're not a board-certified radiation oncologist?"

Medicolegal barriers to linac purchasing by non-radoncs are far, FAR higher than worthless board exams ever will be.

Just going to play devils advocate here:
Dr. mohs- “I have treated more skin cancers with radiation than any radiation oncologist in the United States. I also have more training in mananagement of skin cancer by thousands of hours.”
I treat about one skin cancer a month. I know of dermatologists who have over 15 on treatment at any one time.

 

[scarbrtj]

Sure, a derm could buy a linac and offer more advanced treatments, but can you imagine how a malpractice lawyer's eyes would light up if a patient had a complication?

"So, Dr. Mohs, you did not train in radiation oncology, but rather dermatology, correct? You were never formally trained in radiation oncology? You're not a board-certified radiation oncologist?"

Medicolegal barriers to linac purchasing by non-radoncs are far, FAR higher than worthless board exams ever will be.

Certainly in theory this is correct. But when you look at the massive differences in absorbed dose between bone and soft tissue with orthovoltage vs MV electrons honestly I think orthovoltage dosing is trickier. As long as you had a “turnkey linac overseer” hand holding the derms linacs would as safe for them as us. Small 3cm 9 MeV electron fields have low risks as long as the MUs are reasonable.

 

[OTN]

Certainly in theory this is correct. But when you look at the massive differences in absorbed dose between bone and soft tissue with orthovoltage vs MV electrons honestly I think orthovoltage dosing is trickier. As long as you had a “turnkey linac overseer” hand holding the derms linacs would as safe for them as us. Small 3cm 9 MeV electron fields have low risks as long as the MUs are reasonable.

Sure, we know that, and a radonc certainly could testify in a dermatologist's behalf. I just don't think it would matter one bit to a jury.

 

[BobbyHeenan]

Certainly in theory this is correct. But when you look at the massive differences in absorbed dose between bone and soft tissue with orthovoltage vs MV electrons honestly I think orthovoltage dosing is trickier. As long as you had a “turnkey linac overseer” hand holding the derms linacs would as safe for them as us. Small 3cm 9 MeV electron fields have low risks as long as the MUs are reasonable.

Had Moh's surgeon call me about a case he operated on after the patient failed their orthovoltage (done by a different derm) treatment. Moh's surgeon said something akin to "there was something seriously weird about the patients bone" as he was down on calvarium.

He got negative margins but was concerned about recurrence risk. I declined more radiation, fearing bone necrosis.

 

[medgator]

Sounds like dermatologists have become aware of a niche....

Seeking Radiation Oncologists for part time continuous positions treating skin cancer exclusively with electronic brachytherapy in several Western states.

These are ideal positions for retired or semi-retired Radiation Oncologists or new graduates in the process of seeking full time employment. Full time physicians can usually fit in one or two days a month of work into their usual schedule.

Radiation Oncologists can work as few or as many days a month as they like, and can be scheduled on consecutive days so as to maximized their time and compensation.

'part OR time OR continuous OR electronic OR brachytherapy OR positions OR STATECODE:"CA"' Jobs | ASTRO Radiation Oncology Career Center

3,152 'part OR time OR continuous OR electronic OR brachytherapy OR positions OR STATECODE:

careers.astro.org

 

[mheat3]

Sounds like dermatologists have become aware of a niche....

'part OR time OR continuous OR electronic OR brachytherapy OR positions OR STATECODE:"CA"' Jobs | ASTRO Radiation Oncology Career Center

3,152 'part OR time OR continuous OR electronic OR brachytherapy OR positions OR STATECODE:

careers.astro.org

Of all the things that truly signal the end this might be the most damning yet. #radoncrocs

 

[Mandelin Rain]

Best part is, ASTRO dutifully took the money for the "Dermrads" job to be posted.

These are ideal positions for retired or semi-retired Radiation Oncologists or new graduates in the process of seeking full time employment.

Getting dunked on by pimple poppers is a really bad look.

 

[Bequerel]

Per diem compensation?!? They’re going to pay me like a locum, while I generate God knows how much revenue for them! Better be >5k/day per diem, but I’m guessing it’s under 2k!

 

[Reaganite]

Per diem compensation?!? They’re going to pay me like a locum, while I generate God knows how much revenue for them! Better be >5k/day per diem, but I’m guessing it’s under 2k!

Hah, good luck getting even 1K in newport beach. Also, the rad onc definitely isn't present every treatment. That's why they are so flexible with their days. They are usually just asking the rad oncs to help with the initial set up then it's mostly therapist-directed.