Private practice case load

[firewicket]

So I'm looking at a single person private practice with a steady stream of 35-40 patients on treat between 2 linacs. Is this considered a doable number of patients for a single person? I'm coming out of residency and this is a contracted position for all professional fees from the hospital. It is clearly financially lucrative. But... I am worried about quality of life given my family. Can anyone speak to the predicted hours needed for this type of patient load? Feel free to PM me if you do not want to post here.

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[Bequerel]

So I'm looking at a single person private practice with a steady stream of 35-40 patients on treat between 2 linacs. Is this considered a doable number of patients for a single person? I'm coming out of residency and this is a contracted position for all professional fees from the hospital. It is clearly financially lucrative. But... I am worried about quality of life given my family. Can anyone speak to the predicted hours needed for this type of patient load? Feel free to PM me if you do not want to post here.

With 2 machines the treating hours are not going to be the issue. I have similar set-up and 40 patients on 2 machines should be easy 8-4. The issue is vacation coverage and support staff. An amazing support staff of therapists and dosimetrists who have been working together for years can make your life much easier.

That is a lot of patients to cover directly out of residency. Would be much easier if it was mostly breast or prostate. Is there a pier review process or someone you could call with a difficult case?

 

[Gfunk6]

Agree with above. At minimum you will need one good physician extender (NP/PA) and one good RN. However if your patient load goes even a little bit over what you stipulated here, you will be overwhelmed and in need of a second physician partner.

Though two linacs will let you comfortably treat a lot of patients within business hours don't forget all of the OTVs, follow ups and consults you need to do. Not to mention the exhaustive documentation which will require nights and weekends plus on-call responsibilities.


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[Reaganite]

Depends on the type of patients. If all prostate and breast and you are working in an area of high socioeconomic status with lots of early stage disease, it's gonna be very lucrative and if it were me personally, I'd take a shot at it. That being said, I don't have a family, and I am willing to work like a medicine intern if I'm getting paid 7 figures. If you are working in a low income area with advanced head and neck, cervix, etc. it won't be possible. I was thrown into the fire after residency treating a high volume of very advanced disease in low SES area, so I feel like I'm as battle tested as anyone, but even now, the most I can handle is 40-50 myself in a practice that's sort of split between high and low income patients. That volume translates to about 40 hours a week in the office and 10-20 hours working remotely.

 

[Gfunk6]

As a frame of reference, if you have ownership in the equipment and commiserate receipt of tech fees, you can profit at a 2:1 ratio (at least) compared to a pure pro relationsnip. In other words 15 pts on beam with tech fees = 30 pts on beam with pro only


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[BobbyHeenan]

Agree with everything stated above. Having good therapists that can align patients well (or adjust a CBCT well and then get you after adjustment) and don't need you at the machine often and an experience dosimetrist that is meticulous and cares before showing you a plan will go a long way. You get lazy staff that you have to double check everything and that eats into your efficiency. You'll need a very good social worker as well.

A lot will depend on patient mix as well, as stated. Prostate and breast you can do that all day. Start throwing in lungs, head and neck, and gyn and things get hectic...especially if there are social issues.

When I get up into the mid 30's it can be very hectic, especially if you throw in cervix HDR, prostate brachy, and some sick head/neck patients. It's then that I (or the group) think about taking on another partner or NP/PA, then things inevitably slow down. I average probably 30 under treat with HDR, SBRT, Gamma Knife cases thrown in there too. At that number it's busy but doable IMO with a family.

I go to a lot of tumor boards (Thoracic, General, CNS, Breast), so that makes the days longer. I'd say I work about 6:45 AM to 5:30 PM on average...but hospital inpatient consults after a busy clinic can be the death of me. If you get two inpatient consults on a busy day then you've got no choice but to see them later in the evening or very early the next morning.

 

[medgator]

...but hospital inpatient consults after a busy clinic can be the death of me. If you get two inpatient consults on a busy day then you've got no choice but to see them later in the evening or very early the next morning.

QFT..... it can get even worse when you cover multiple hospitals

 

[Mandelin Rain]

If you're getting 100% of the pro on 35-40 patients, you're probably looking at about a million-ish dollars in collections with an average payor mix. You don't get to keep all that. 40% goes off the top. A good family health insurance policy on marketplace... maybe $1,200 per month. Malpratice insurance depends on the state. Regardless, you'd still be taking home >550K. If you got sick of it, you could hire a really good NP for $150k and still be making a lot of money. You'd have to talk to the hospital system, but you may be able to use the NP for linac coverage on days off, etc...

Those numbers just off the top of my head, so highly prone to error.

On your own, 40 patients would yield a lot of 12 hour days.

 

[deleted18755]

I agree 100% with everything others have said above but would also like to add that a lot of it depends on your referring physicians too. I have some who are excellent physicians whose insight I highly value and highly organized communicators that thoroughly work up patients then refer to me at the appropriate time while others want a patient seen asap before a biopsy (I've literally had patients show up without even a single consult note from the referring provider and the patient doesn't even know they have cancer!). As above it's all about patient mix, support staff, and the other physicians. I can easily imagine a situation where 15-20 patients is more difficult and time consuming than 35-40 especially in underserved areas.

 

[OTN]

My partner and I are treating ~70-75 currently on 2 linacs, with SRS/SBRT/HDR thrown in as well. Very large private practice. I don't have an NP/PA or a scribe, but do have a good RN and MA to help. I'm able to get all the work done, and for us the hours have become an issue only when we have a lot of SBRT/SRS treatments in a particular week, which can extend hours. Going until 7:30-8:00 pm two nights this week for example, but I only have 4 clinic days/week, which really is huge. It's not too common that we treat past 6 pm. I'm usually home by 6:30 or earlier during my 4 clinic days, with the days starting at either 7 am or 9 am, depending on tumor boards, of which there are a ton.

40 patients on 2 linacs should be doable. It will be important to get systems in place which maximize your efficiency, and make sure the staff work with those in mind. You'll feel overwhelmed at first no doubt, but that's a function of going from residency to being an attending, and likely would happen no matter what the setting (boards studying during the first year certainly adds to it). Once you get going, however, if you're like me you'll be happy to be busy.

 

[RadOncDoc21]

Pretty soon breast and eventually prostate patients will be hard to keep for too long on the machine... I know we need longer follow up data but still.

http://www.redjournal.org/article/S0360-3016(17)30274-2/fulltext?rss=yes

 

[medgator]

Don't worry, medgator gonna be long retired by the time there's enough follow up from that study.

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[fiji128]

And there is this from this week's JCO about hypofx prostate. Not that I every see definitive prostate patients where I am b/c of urorads but to quote one line from this, "In the United States, the move to moderate hypofractionation is estimated to result in a reduction of technical reimbursement by approximately $9,000 per patient, which could lead to a total reduction of $678,070 for the average radiation oncology department." I'm not against this from a patient stand point but it is one more thing that will make the economics of our practices more difficult moving forward.

Editorial Response:
http://ascopubs.org/doi/full/10.1200/JCO.2017.72.7016

The Papers:
78Gy/39fx/2Gy vs 60Gy/20fx/3Gy
http://ascopubs.org/doi/full/10.1200/JCO.2016.71.7397
High risk patients 80Gy/40fx/2Gy vs 62Gy/20fx/3.1Gy to prostate and SV.
http://ascopubs.org/doi/full/10.1200/JCO.2016.70.4189

 

[OTN]

The moderate prostate hypofractionation stuff drives me a bit crazy. Table 1 in the editorial you attached (thanks for all that btw) shows that most trials showed an increase in toxicity with hypofractionation. Isn't that worse? Sure, biochemical control is the same, but isn't worsening toxicity moving in the wrong direction? Wouldn't some patients be happier being treated for longer, but with less toxicity? Will there be an increase in late toxicity (especially GU) like some are whispering? Aren't these differences in toxicity (albeit not huge) what academic centers use to push proton therapy?

It seems to me that academic departments love to do this research, probably because it's really, really easy. Why explore a new avenue of research and treatment like what XRT can do with the Abscopal effect and immunotx when you can come up with yet another moderate hypofractionation trial? Why try to improve outcomes when you can just try to match them? Then, once your results show the biochemical outcomes are similar, even though it was more toxic, you can apparently just ignore that worsening toxicity and use your data as a club to beat clinical radocs to death, claiming they only choose treatments based on reimbursement. Easy peasy, tenure here I come.

I'm not against hypofractionation when the data looks good: I hypofractionate 90+% of my breast patients (all who make the < 107% criteria, more or less), and we have a huge urorads group in town, so I don't treat many prostates at all and don't have as much of a dog in this particular fight. However, I just cannot understand the disconnect I'm seeing on the prostate data. The toxicity is somewhat worse in the acute setting, and we'll have to see what longer follow-up shows. If the situation were explained to patients clearly ("We're going to treat you with hypofractionation, which is somewhat more toxic, but you can get it done more quickly and it saves society money"), I can't imagine 100% of patients would choose hypofractionation. If we're saying "the increase in toxicity is small and patients would accept that for a shorter treatment course", is that true? Has anyone asked patients that question?

My ultimate standard for every patient is "what would I want"? Were I to be diagnosed with prostate cancer, and I elected EBRT (which I likely would, to be honest), I would not chose hypofractionation for myself, but rather standard fractionation.

 

[Mandelin Rain]

I agree.

Ideally, we'd aim for better outcomes and less toxic. We've settled for, more toxic but outcomes are no worse and it's cheaper.

Academic radiation oncology in 2017.

 

[seper]

For those who could not read the papers, 60Gy/20fx/3Gy has actually better toxicity profile compared to standard fractionation.

 

[OTN]

While that one trial didn't show an increase in toxicity, the weight of the data in total appears to show worsening toxicity with hypofractionation:

 

[evilbooyaa]

The moderate prostate hypofractionation stuff drives me a bit crazy. Table 1 in the editorial you attached (thanks for all that btw) shows that most trials showed an increase in toxicity with hypofractionation. Isn't that worse? Sure, biochemical control is the same, but isn't worsening toxicity moving in the wrong direction? Wouldn't some patients be happier being treated for longer, but with less toxicity? Will there be an increase in late toxicity (especially GU) like some are whispering? Aren't these differences in toxicity (albeit not huge) what academic centers use to push proton therapy?

It seems to me that academic departments love to do this research, probably because it's really, really easy. Why explore a new avenue of research and treatment like what XRT can do with the Abscopal effect and immunotx when you can come up with yet another moderate hypofractionation trial? Why try to improve outcomes when you can just try to match them? Then, once your results show the biochemical outcomes are similar, even though it was more toxic, you can apparently just ignore that worsening toxicity and use your data as a club to beat clinical radocs to death, claiming they only choose treatments based on reimbursement. Easy peasy, tenure here I come.

I'm not against hypofractionation when the data looks good: I hypofractionate 90+% of my breast patients (all who make the < 107% criteria, more or less), and we have a huge urorads group in town, so I don't treat many prostates at all and don't have as much of a dog in this particular fight. However, I just cannot understand the disconnect I'm seeing on the prostate data. The toxicity is somewhat worse in the acute setting, and we'll have to see what longer follow-up shows. If the situation were explained to patients clearly ("We're going to treat you with hypofractionation, which is somewhat more toxic, but you can get it done more quickly and it saves society money"), I can't imagine 100% of patients would choose hypofractionation. If we're saying "the increase in toxicity is small and patients would accept that for a shorter treatment course", is that true? Has anyone asked patients that question?

My ultimate standard for every patient is "what would I want"? Were I to be diagnosed with prostate cancer, and I elected EBRT (which I likely would, to be honest), I would not chose hypofractionation for myself, but rather standard fractionation.

Regarding bolded, it does make me laugh that the general body pushing protons for prostate, even when the benefits are only in dosimetric considerations without affecting clinical outcomes, do push for this when the editorial IN SUPPORT of hypofrac shows worse toxicity. I completely agree with OTN. I'm not overtly familiar with the hypofrac prostate data, but the graph posted above (from the editorial) would make me LESS likely to offer hypofrac than to offer it.

 

[seper]

For those who did not read the papers, 60Gy/20fx/3Gy has BETTER toxicity profile compared to standard fractionation (late GI, GU). See tables in original paper and don't listen to experts

 

[OTN]

For those who did not read the papers, 60Gy/20fx/3Gy has BETTER toxicity profile compared to standard fractionation (see tables).

I read the paper. You are correct. That one trial showed better toxicity with hypofractionation. Many other trials do not (see table).

 

[seper]

I admit that I have not read all of them, but 78 vs. 60 Gy is the comparison that made the most sense to me, personally.

I read the paper. You are correct. That one trial showed better toxicity with hypofractionation. Many other trials do not (see table).

 

[Chartreuse Wombat]

Haters gonna hate

PROFIT-Late GI toxicity better with hypo; PRO no difference
CHHIP-No difference in late toxicity; PRO no difference
RTOG-More Grade 2 toxicity; no difference Grade 3 and PROs no different
HYPRO-No one is advocating this regimen
Fox Chase- No difference in overall toxicity; unplanned subgroup shows excess GU with high IPSS
Italian-No difference in overall toxicity; macroscopic hematuria is a subgroup of a subgroup...possible Type I error
MD Anderson-No difference in late toxicity.

The three largest studies with >5000 patients find that patients cannot tell the difference (PRO). One shows late GI better with hypo, one shows late GI/GU Grade 2 is better with conventional; the largest shows no difference.

The weight of the evidence is that there is no excess toxicity. If you fish around enough and do subgroups of subgroups; multiplicity demands that there will be differences in some of the multiple comparisons.

Of course all of this is meaningless since brachytherapy is the best option for patients

 

[medgator]

Of course all of this is meaningless since brachytherapy is the best option for patients

You mean active surveillance?

From the Zietman editorial:

"It is possible that many of these men would have fared just as well with prostate brachytherapy, the greatest therapeutic bargain currently available in the United States, or even on a program of active surveillance. If treatment is unnecessary in the first place, better treatment does not represent an advance."

 

[seper]

Whenever you hear senior radiation oncologists denigrating a new treatment approach, remember this paper:

Rosenthal DI, Glatstein E. We've Got a Treatment, but What's the Disease? Or A
Brief History of Hypofractionation and Its Relationship to Stereotactic
Radiosurgery. Oncologist. 1996;1(1 & 2):1-7. PubMed PMID: 10387962.

We've Got a Treatment, but What's the Disease? Or A Brief History of Hypofractionation and Its Relationship to Stereotactic Radiosurgery. - PubMed - NCBI

http://theoncologist.alphamedpress.org/content/1/1/1.1.full.pdf

 

[OTN]

Well, believe it or not, I just recommended hypofractionated prostate RT for a patient who lives pretty far away from...well...damn near everything. I did counsel him that he could have a slight increase in toxicity, but we weren't sure. Wanted to hedge for you guys and all.

 

[evilbooyaa]

Whenever you hear senior radiation oncologists denigrating a new treatment approach, remember this paper:

Rosenthal DI, Glatstein E. We've Got a Treatment, but What's the Disease? Or A
Brief History of Hypofractionation and Its Relationship to Stereotactic
Radiosurgery. Oncologist. 1996;1(1 & 2):1-7. PubMed PMID: 10387962.

We've Got a Treatment, but What's the Disease? Or A Brief History of Hypofractionation and Its Relationship to Stereotactic Radiosurgery. - PubMed - NCBI

http://theoncologist.alphamedpress.org/content/1/1/1.1.full.pdf

I mean, I read the abstract (although not the full article), and they recommended fractionated SRS instead of single shot SRS. For most places without a gamma knife, this is a reasonable practice, especially for anything of significant size. SRS mantra shouldn't be 'single fraction or bust', which is the point they make here. Sure, they're probably misinformed and it's not 100% accurate, but I don't see the parallels you're trying to draw between these two scenarios.

Haters gonna hate

PROFIT-Late GI toxicity better with hypo; PRO no difference
CHHIP-No difference in late toxicity; PRO no difference
RTOG-More Grade 2 toxicity; no difference Grade 3 and PROs no different
HYPRO-No one is advocating this regimen
Fox Chase- No difference in overall toxicity; unplanned subgroup shows excess GU with high IPSS
Italian-No difference in overall toxicity; macroscopic hematuria is a subgroup of a subgroup...possible Type I error
MD Anderson-No difference in late toxicity.

The three largest studies with >5000 patients find that patients cannot tell the difference (PRO). One shows late GI better with hypo, one shows late GI/GU Grade 2 is better with conventional; the largest shows no difference.

The weight of the evidence is that there is no excess toxicity. If you fish around enough and do subgroups of subgroups; multiplicity demands that there will be differences in some of the multiple comparisons.

Of course all of this is meaningless since brachytherapy is the best option for patients

PROFIT is the one trial that showed that late GI toxicity is better than standard. Otherwise, toxicity in all other trials favors that either there is no difference or that hypofrac induces worse toxicity. That is likely the true answer - Either toxicity is worse with hypofrac, or it's similar. I highly doubt that hypofrac toxicity will be ever be LESS than standard fractionation.

Trials that showed similar toxicity (Regina, FCC, MD Anderson) all had < 300 patients. RTOG 0415 had 1115 and showed some worsening of GU/GI late toxicity, even if it wasn't Grade 3. Grade 2 Late GI toxicity is no joke. Only trial that has a significant number of patients is CHHiP, which I'll have to review in detail.

 

[Palex80]

From what I have seen so far, late toxicity was worse in some trials.
It was not astonishingly worse, not that worse that you could not view hypoFx as safe, but it was worse.
For example:
RTOG 0415 had worse toxicity: 18.3% vs. 11% GI- and 26.2% vs. 20.5% GU-toxicity for the hypofractionated and normofractionated arms respectively (G2-toxicity to be precise).

 

[hot sauce]

So I'm looking at a single person private practice with a steady stream of 35-40 patients on treat between 2 linacs. Is this considered a doable number of patients for a single person? I'm coming out of residency and this is a contracted position for all professional fees from the hospital. It is clearly financially lucrative. But... I am worried about quality of life given my family. Can anyone speak to the predicted hours needed for this type of patient load? Feel free to PM me if you do not want to post here.

To respond the original question, 35-40 is doable but busy. However, I think that going straight out of residency into a solo private practice with 35-40 on treat would be stressful. High volume and solo for a brand new attending is a lot to take on; you could easily become overwhelmed. Also, what other duties will you have? Tumor boards? Call? Inpatient consults? Cancer committee?

With no partners to rely on I don't think it sounds like an ideal first job to be honest. (Of course I don't know what else is out there to compare and what other considerations you may have.)

Others have mentioned the importance of support staff which is key. If you want to pursue this job I would make sure that you have great nursing, physics, therapy, and dosimetry. You are getting professional fees so whoever owns the machines should be hiring the staff. Make sure that party is paying the staff competitively and hiring enough staff. You may even want something in the contract about the level of staffing they need to provide. You will want a practice that runs smoothly not one that you are having to troubleshoot on top of taking care of patients. Ask questions about the procedures that physics follows and the required qualifications for the staff. My physics friends helped me evaluate the practice I was joining before I signed. You are ultimately responsible for all of this.

PS Even with good staff you have to be careful. I had a case where the dosimetrist had forgotten to finish contouring the cord (not a bad dosimetrist but anyone can make a mistake). The dose was very high but didn't show on the DVH because that section of cord wasn't contoured. Luckily I caught it when reviewing the plan. You get too busy and that could be missed.