Rad Onc at risk for losing its turf?

[oncology2020]

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In the academic setting, I noticed neurosurgeons, gyn oncs, urologists, etc tend to oversee the rad onc therapy for the cancers in their respective fields and the radiation oncologist is relegated to the role of a token technician. Some of the brightest med students enter rad onc so why aren't rad oncs leading the way and taking sole leadership of these services especially since rad onc is already at risk for being a "one trick pony." Why do rad onc departments even allow neurosurgeons, urologists and gyn onc to be medical directors of rad onc services?

I understand treating cancer is a multidisciplinary approach and physicians, surgeons, pathologists, radiologists, etc are all involved in providing their input. I understand the need and importance of collaboration and seeking input from a colleague regarding his/her patient or discussing cases during tumor boards but I noticed that the surgeon is ultimately in charge of the operative note for radiosurgery for example. Do you need a urologist to be present and overseeing brachytherapy for example in the OR? Is there a reason why this happens? Are rad oncs setting up the field to be taken over by other more aggressive fields? I know currently rad oncs must be present when radiation is being provided but seems like other fields are aggressively taking over the oversight of the services leaving rad oncs to become technicians which is essentially the underlying issue with urorads. There are even fellowships being develop for neurosurgeons in stereotactic radiosurgery (http://neurosurgery.ucla.edu/body.cfm?id=61). If one day the rules change to allow for fellowship-trained neurosurgeons/urologists to oversee radiation with the help of dosimeterists, physicists, therapists, etc. seems like rad oncologists are setting themselves for failure by not being more protective of their turf and allowing other fields to be co-leaders in their domain (look at most stereotactic radiosurgery programs there is always a neurosurgeon as a Co-director of rad onc services).

This would be similar to fellowship-trained cardiologists wanting to be in charge of everything related to the heart and taking over radiological services (ECHO from radiologists) and interventional services from IR..thereby destroying the fields of both cardiothoracic surgery and vascular IR in the process just by essentially doing a 2-3 year "fellowship in IR" without the need for doing a 5-year radiology residency. What is stopping neurosurgeons/urologists/gyn oncs/etc from eventually doing the same with rad onc? There has to be a reason why neurosurgeons are investing another 1-2 years of fellowship in radiosurgery after a grueling 7-8 year residency...

Basically point of this thread is am I completely off track? Does any of this actually pose a legitimate threat to the field?

 

[oncology2020]

and also another issue: with the on-going recession in the health care industry and the push towards a hospital employee-model seems like hospitals can ultimately just hire only a few rad oncs to meet the legal requirements and to help with contouring/treatment plans and hire NPs/PAs instead to see the follow-ups and have their neurosurgeons/urologists (who are much bigger assets to the hospital since they bring in more $$) help over-see the radiation services to minimize their overall costs...medical physicists have also been trying for years to get provider status and the recession might finally serve as a catalyst for that to happen..the government and hospitals may agree to provide midlevel providers with greater autonomy since it'll be much cheaper for hospitals/government to pay/reimburse their salary than a rad onc..

are these realistic threats to the field? and if so, what can be done about them?

 

[Scatter]

Unfortunately, we're downstream of all the "feeders," i.e., urologists, neurosurgeons, oncologists, more recently dermatologists, etc., which sucks. On top of that, Rad Oncs have sold/are prostituting their souls to hospitals and anyone with equipment (the old guard made their gazillions in the 80's and 90's, have sold their practices to hospitals, so what do they care for the "Best and the Brightest" of our age). How did so many and so myopically give up the technical fees?!? Diagnostics would never do that. That'd be like surgeons giving up their technical expertise and only settling for professional fees. It's pretty ridiculous and makes me upset (because ***WE*** have the longest and most onc-centric training of all!), not to mention worried about being sidelined. I wouldn't be surprised if the "sharks" from the aforementioned fields become "first among equals" when it comes to a lot of our latest and greatest technology, treatments, etc.

 

[Mr RADical]

This just simply isn't the case at many institutions. At our institution the radiation oncologists deliver SRS without neurosurgery input (sometimes there is a neurosurgeon who is present as a courtesy if they have already treated the patient). We do prostate brachytherapy without a urologist present or involved in the planning. We do interstitial implants and T&Os without GYN-ONC involved. We give all our unsealed sources without nuclear medicine too.

On very complex cases we will sometimes get input from a surgeon/neurosurgeon but to me this just seems smart. Why try to be a cowboy when there is someone with more training and experience in a particular difficult case readily available?

 

[Gfunk6]

I'm sorry to start my post off with a confrontational tone but the OP's post contains a lot of misinformation.

Why do rad onc departments even allow neurosurgeons, urologists and gyn onc to be medical directors of rad onc services?

I would like you to quote me a single example of this. Seriously.

. . . but I noticed that the surgeon is ultimately in charge of the operative note for radiosurgery for example

At some institutions, the neurosurgeon is responsible for dictating the SRS procedure note. So what?

I think this OP comment regarding neurosurgery participation in SRS requires some background. FACT: Gamma Knife SRS was invented by a Neurosurgeon (Lars Leksell). FACT: Cyberknife SRS was invented by a Neurosurgeon (John Adler). Therefore, there is an indelible contribution that the field of Neurosurgery made (and continues to make). Second, Neurosurgeons have billing codes for professional services rendered in SRS planning. They may carry out their responsibility by actually sitting down the Rad Onc and co-contouring target volumes/critical structures or simply give a cursory nod in the OR while a staff member holds up a hard copy of the plan PDF. Third, Neurosurgeons (as a general rule) know MRI-based neuro anatomy better than Rad Oncs - so it would be in your best interests to have them at least review your volumes.

The extent of Neurosurgery involvement in SRS varies strongly by institution and practice setting. However, regardless of this, Rad Oncs should (at the least) be considered a co-attending and (at the most) be the primary attending the Neurosurgery serving in an advisory role.

Do you need a urologist to be present and overseeing brachytherapy for example in the OR? Is there a reason why this happens? Are rad oncs setting up the field to be taken over by other more aggressive fields?

Again, it depends on the institution and practice setting. For GU Onc, ideally you would want a Urologist present for the same reasons as above. A Urologist's primary job is to operate on the GU tract - why the hell wouldn't you want their expertise? You can either be co-attendings or Urology can serve an advisory role as above. Without a Urologist what would you do if you accidentally perforate the bladder with a brachytherapy needle? What if the patient starts to bleed uncontrollably? Personally, I would always want a surgeon in the OR - as a backup if nothing else.

This would be similar to fellowship-trained cardiologists wanting to be in charge of everything related to the heart and taking over radiological services (ECHO from radiologists) and interventional services from IR..thereby destroying the fields of both cardiothoracic surgery and vascular IR in the process just by essentially doing a 2-3 year "fellowship in IR" without the need for doing a 5-year radiology residency. What is stopping neurosurgeons/urologists/gyn oncs/etc from eventually doing the same with rad onc?

If you haven't completed a Rad Onc residency, then it is very difficult to explain this. Trust me when I say that there is ABSOLUTELY ZERO chance that we will be removed the SRS/Brachytherapy equation.

with the on-going recession in the health care industry and the push towards a hospital employee-model seems like hospitals can ultimately just hire only a few rad oncs to meet the legal requirements and to help with contouring/treatment plans and hire NPs/PAs instead to see the follow-ups and have their neurosurgeons/urologists (who are much bigger assets to the hospital since they bring in more $$) help over-see the radiation services to minimize their overall costs...medical physicists have also been trying for years to get provider status and the recession might finally serve as a catalyst for that to happen..the government and hospitals may agree to provide midlevel providers with greater autonomy since it'll be much cheaper for hospitals/government to pay/reimburse their salary than a rad onc..

are these realistic threats to the field? and if so, what can be done about them?

There are a lot of errors and misconceptions in the above quoted paragraph. Some Rad Oncs (including self-employed ones in free standing centers) have employed NPs/PAs to do precisely what you stated. They see on-treatments/follow-ups, thereby saving the Rad Onc time and (if the volume is high enough) money. However, just like a scrub tech or a surgical PA won't be able to manage a patient who is bleeding out in the OR without a Surgeon present - a Surgeon won't be able to contribute meaningfully if there is a problem with a radiation patient (e.g. XRT-induced side effects, setup problems on the machine, clinical setups for pt's that don't require CT planning, adaptive planning during treatment, metabolically-guided treatment planning, etc.).

Another misconception is that Rad Oncs are not big-time money makers for the hospital - they are! Surgeons are similarly profitable but only when they are in the OR - seeing follow-ups/consults is a small percentage of total revenue.

Physics will always provide a complementary role to Rad Oncs. Physicists have no formal training in human anatomy/physiology/pharmacology/cancer biology.

 

[seper]

It's not that bad - depends on an individual RadOnc. 's. A lot of us do choose to be sheep, and go with the flow. This is more common in private practice, not academic setting.

 

[medgator]

It's not that bad - depends on an individual RadOnc. 's. A lot of us do choose to be sheep, and go with the flow. This is more common in private practice, not academic setting.

And some of us in private practice recognize these encroachments and make sure we are placed higher up in the food chain 😉 Outside of perhaps lymphoma/leukemia, rad onc can pretty much have direct referrals from any non med onc specialist (whether it's urology, general surgery, pulmonary, ENT, thoracic surgery, derm, etc)

 

[Gfunk6]

A lot of us do choose to be sheep, and go with the flow. This is more common in private practice, not academic setting.

Sounds like someone has been drinking the academic Kool-Aid - reality is much greyer.

 

[OTN]

The experience OP quotes is very, very different from what I've experienced either in an academic setting in training or in private practice. In my experience non-radoncs other than a few select neurosurgeons who really want to be involved know very little about radiation and are not interested in doing so. The one exception I can think of is superficial XRT being delivered by dermatologists. However, in my area the one dermatologist who has purchased a superficial machine is seen as a cowboy by the more reasonable dermatologists in town (we may have helped them come to that conclusion a bit), so it hasn't impacted our referrals at this point.

I've never even heard of a GynOnc or urologist being present for brachytherapy delivery. Never happened to me once during training, and I personally placed more than 100 T+Os during training.

 

[medgator]

I've never even heard of a GynOnc or urologist being present for brachytherapy delivery. Never happened to me once during training, and I personally placed more than 100 T+Os during training.

I think it's all institution/practice dependent. Gyn Oncs would be present during our LDR T+Os in the OR particularly since they actually admitted them to their service (I've heard that rad oncs actually do that at some places). With HDR in private practice, the Gyn Onc simply places the smit sleeve and we place the applicator each time by ourselves.

In terms of brachy, I've seen it done with or without the GU. The GU's can bill for it, so sometimes they like to be there to place the needles under the directions of the rad onc (and sometimes they do a cysto and charges for it afterwards).

 

[medgator]

Sounds like someone has been drinking the academic Kool-Aid - reality is much greyer.

Yup. It's funny how much you don't know during and at the end of training. Rad Onc is really at the end of the food chain in many academic places (from what I've seen), but in practice, part of surviving and making sure the referrals come to you (rather than filter out elsewhere) is to make sure you aren't just a "sheep that goes with the flow" and waits for consults to drop in your front door. In practice, I've routinely fed Med Oncs GI and pulmonary consults that I "worked up/staged" and were sent to me by the primary medical/surgical specialists.

Many people both within and outside of this field fail to realize we have more oncology training than either our surgical or medical oncology colleagues. Med Oncs often do the 3-year fellowship track where half the time is spent in hematology. Surg Onc is a one year fellowship.

Rad Onc is 4 years of pure oncology (with the occasional HO prophylaxis, Acoustic Schwannoma, or keloid thrown in). In my practice's tumor board, a g00d chunk of the time the med oncs don't even remember staging for some less common disease sites 😉

 

[Reaganite]

Yup. It's funny how much you don't know during and at the end of training. Rad Onc is really at the end of the food chain in many academic places (from what I've seen), but in practice, part of surviving and making sure the referrals come to you (rather than filter out elsewhere) is to make sure you aren't just a "sheep that goes with the flow" and waits for consults to drop in your front door. In practice, I've routinely fed Med Oncs GI and pulmonary consults that I "worked up/staged" and were sent to me by the primary medical/surgical specialists.

Many people both within and outside of this field fail to realize we have more oncology training than either our surgical or medical oncology colleagues. Med Oncs often do the 3-year fellowship track where half the time is spent in hematology. Surg Onc is a one year fellowship.

Rad Onc is 4 years of pure oncology (with the occasional HO prophylaxis, Acoustic Schwannoma, or keloid thrown in). In my practice's tumor board, a g00d chunk of the time the med oncs don't even remember staging for some less common disease sites 😉

Totally agree with you here. I've adopted the same principle of getting to the patients before the med oncs. Of course, I first marketed to the med oncs when I started practicing, but I quickly realized many already had their favorite rad onc, so I had to do something to get the patients. I'm pretty much now thee oncologist for the surgeons in my community, and I'm triaging several cases a month to my med oncs rather than the reverse. Yeah, they're pissed about it, but they weren't sending to me so I did what I had to do. It helps that nobody liked them to begin with. It takes A LOT of work, but it pays off. And by the way, as others have said, we mop the floor with these med oncs and surg oncs when it comes to overall oncology knowledge, so we are actually doing the patients a favor. It f'n pisses me off to no end that med oncs believe they should be the gatekeepers of these patients.

 

[oncology2020]

awesome to hear..im glad i was completely off track with my limited exposure as a med student

thanks for all the input and clearing up the misconceptions and inaccuracies that I had

we should definitely be the gatekeepers of these patients and should be the ones referring to med oncs for chemo and surgery for resection..and educating other fields about the role of rad onc in the treatment of cancer...residency programs and ASTRO should be pushing rad oncs to adopt this approach

 

[medgator]

ASTRO should be pushing rad oncs to adopt this approach

I agree we need to continue to take a more active role in oncologic management of patients particularly once the hand off occurs from the PCP or a specialist once the Dx is made.

I can't find the link to the Op ed at the moment, but it is referenced in this thread: http://forums.studentdoctor.net/threads/rad-onc-and-ir-should-we-get-married.967504/ Anthony Zeitman, one of the big names in the field, alluded to this several years ago. It will be a paradigm shift at many academic places where rad onc started out as the "field relegated to the basement" and where it continues to be at the "end" of the referral food chain. And at many of these places, the medical director of the cancer center is often a surgeon or a med onc.

 

[Gfunk6]

From a reimbursement perspective - keep in mind that things like 'referral hierarchy' and sending the patient among multiple oncology specialists for 'slicing and dicing' will soon become an outmoded concept. If you are an employee in a large health system or a partner in a private practice multi-specialty group, these concepts are vanishing in relevance. Once we get case-based reimbursement, it will officially be over.

For professional satisfaction, however, it is always better to strive for practice autonomy.

 

[seper]

I commend those striving to be primary oncologists. Just realize that means admitting and managing patients for diarrhea, and taking care of end-of-life issues, among otherh things.

 

[medgator]

I commend those striving to be primary oncologists. Just realize that means admitting and managing patients for diarrhea, and taking care of end-of-life issues, among otherh things.

I've ordered Immodium/lomotil and hospice referrals before 😉 I see your point though. That's part of the whole package I guess. It's funny..... I've had med oncs coming out of fellowship that I work with in practice surprised that I know how to put people on decadron (and a PPI while they are on it) for brain mets etc.

 

[medgator]

Once we get case-based reimbursement, it will officially be over.

I know this is something being pushed by various interest groups (esp on the freestanding side), but realistically, how close is this to coming to fruition?

 

[Gfunk6]

I know this is something being pushed by various interest groups (esp on the freestanding side), but realistically, how close is this to coming to fruition?

An excellent question that I dearly wish I had an answer to. Most people I've spoken to "in the know" think that it is > 3 years away. However, as we all know, hospitals/private practices with a lick of foresight are already preparing for this eventuality.