Rad Onc chances

[bletkqru]

MS3 finishing up my core rotations at a low tier/unranked MD program on the east coast. Will be taking my Step 1 at the end of February. I understand it’s a bit premature to ask for my chances without that score, but would greatly appreciate any input on how competitive I am for any of the programs in major cities on the East and West coast given what’s set on paper already.

Research
2x ASTRO poster presentations – drafting a manuscript for one of these projects.
2x other Rad Onc-related poster presentations.
1x oral abstract presentation, 2x poster presentations, and 3x publications (1x 1st author) from Radiology-related projects started before medical school – additional manuscript in the works.
1x basic science research from undergrad (middle author).

Clinical Grades
1H, 2HP, 2P so far. Likely to be ranked either 1st or 2nd quartile. Have been receiving great clinical evaluations but haven’t doing well on shelves (80%ile required for honors). Can’t attribute all the scores to not having Step 1 under the belt, but not having the background from studying for the test has cost me a few questions here and there.

At a minimum, I'd need to score as high as I can on Step 1, wrap up my rad onc-related manuscript, and excel at my aways. Ideally I'd love to go home to California or be in a major city on the east coast, but I know that's hard to guarantee even if my application was immaculate. Would just like to get an idea how well I’d need to do on Step 1/2 to make up for the weakness in my application (clinical grades, school’s lack of name recognition and lack of rad onc residency program) and have a realistic chance at matching at any program in these areas.

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[scarbrtj]

I might be misreading or mis-hearing things but I don't think rad onc is that competitive anymore. I think the most competitive is ENT. I think the application-to-position ratio for rad onc is around 1.2:1, for ENT it's nearly 3:1. About 100 people who listed ortho as their only choice went unmatched in 2017. How many US students who listed rad onc as their only choice went unmatched in 2017?

Three people. 3. Statistically, an American is 30 times more likely to die by bee sting or be unmatched in orthopedic surgery than they are to be unmatched in radiation oncology.

You have far more research/pubs under your belt than the average bear. You ought to be fine, Yogi. Let me be the first to welcome to an oversupplied specialty whose oncological effectiveness in relation to non-radiation therapies progressively wanes as the years tick by. Browsing the internet for cat videos for hours on end while you provide a physical presence at a satellite center for an academic department is almost certainly in your future. That element of the job is depressing, I ain't gonna lie.

 

[medgator]

oncological effectiveness in relation to non-radiation therapies progressively wanes as the years tick by.

What a nihilist....don't worry immunotherapy isn't going to make radiation obsolete.

The rest of your post regarding training to become a satellite academic center linac babysitter is spot on

 

[scarbrtj]

What a nihilist....don't worry immunotherapy isn't going to make radiation obsolete.

The rest of your post regarding training to become a satellite academic center linac babysitter is spot on

I'm not a nihilist. It may or may not be "immunotherapy." Yes, the pie will not disappear. But it will harbor fewer calories as the years go by. Protons or ViewRay won't be to oncology what immuno (or future-drugs) will be to oncology is what I'm saying. In my brief career so far, I have seen MUCH more innovation and growth of indications on the "drug" side whilst here on our side, the indications (and fractions) have dwindled. This is my only point that there has been a trend, and trends usually carry on through time.

 

[Palex80]

I'm not a nihilist. It may or may not be "immunotherapy." Yes, the pie will not disappear. But it will harbor fewer calories as the years go by. Protons or ViewRay won't be to oncology what immuno (or future-drugs) will be to oncology is what I'm saying. In my brief career so far, I have seen MUCH more innovation and growth of indications on the "drug" side whilst here on our side, the indications (and fractions) have dwindled. This is my only point that there has been a trend, and trends usually carry on through time.

Perhaps.
But "innovation" in medical oncology has also shrunk demand / need for treatment as well in some cases. Don't look at it only one-sided.
When I entered training every breast cancer patient with a positive lyamph node or Ki67 of 20% got chemo after BCS or mastectomy. Nowadays they get oncotype and roughly half of them, get chemo in the end.
In the 90s hundreds of breast cancer patients were sent to high-dose chemotherapy and stem-cell rescue until the concept was proven wrong.

I saw a patient last week where I prescribed radiation for his 20th volume. I have been treating his myeloma for 7 years now. When I entered training these patients died after 2-3 years usually. They now live a lot longer and we need to treat them a lot more frequently.

The oversupply in radiation oncology is not a matter of shrinking indications / fractions / patient numbers. Its a matter of too many radiation oncologists "produced" by residency programs, too many treatment centers set up and pretty bad PR on our side.

 

[medgator]

I'm not a nihilist. It may or may not be "immunotherapy." Yes, the pie will not disappear. But it will harbor fewer calories as the years go by. Protons or ViewRay won't be to oncology what immuno (or future-drugs) will be to oncology is what I'm saying. In my brief career so far, I have seen MUCH more innovation and growth of indications on the "drug" side whilst here on our side, the indications (and fractions) have dwindled. This is my only point that there has been a trend, and trends usually carry on through time.

With the move towards value-based care, $ for $, photons and protons are much cost effective than the latest targeted or pd-l1 agent, and, hopefully, will be recognized as such. If bundles hit med onc the way they may hit rad onc, you can kiss many of those 5-6 figure targeted treatments good bye

 

[nkmiami]

With the move towards value-based care, $ for $, photons and protons are much cost effective than the latest targeted or pd-l1 agent, and, hopefully, will be recognized as such. If bundles hit med onc the way they may hit rad onc, you can kiss many of those 5-6 figure targeted treatments good bye

Bundles in medonc is a whole different ball game. Pharm- the industry with the highest profit margins- has so much influence in certain states like NJ/Penn, that is not coming anytime soon. That would be like asking the gov to stop taxing those who work on wall streeet at 15%.

 

[nkmiami]

Perhaps.
But "innovation" in medical oncology has also shrunk demand / need for treatment as well in some cases. Don't look at it only one-sided.
When I entered training every breast cancer patient with a positive lyamph node or Ki67 of 20% got chemo after BCS or mastectomy. Nowadays they get oncotype and roughly half of them, get chemo in the end.
In the 90s hundreds of breast cancer patients were sent to high-dose chemotherapy and stem-cell rescue until the concept was proven wrong.

I saw a patient last week where I prescribed radiation for his 20th volume. I have been treating his myeloma for 7 years now. When I entered training these patients died after 2-3 years usually. They now live a lot longer and we need to treat them a lot more frequently.

The oversupply in radiation oncology is not a matter of shrinking indications / fractions / patient numbers. Its a matter of too many radiation oncologists "produced" by residency programs, too many treatment centers set up and pretty bad PR on our side.

I am not sure that innovation in medonc has shrunk demand- we are seeing a lot of pts staying on treatment in lung and melanoma that previously gone to hospice, or would have been too elderly to treat. I am starting to think there should actually be a fellowship in radiation that would allow grads to give chemo (just thinking out loud) Graduates of the NCI program I think used to be certified in both?

 

[kristofer]

MS3 finishing up my core rotations at a low tier/unranked MD program on the east coast. Will be taking my Step 1 at the end of February. I understand it’s a bit premature to ask for my chances without that score, but would greatly appreciate any input on how competitive I am for any of the programs in major cities on the East and West coast given what’s set on paper already.

You are competitive based on the information you provided. The troubling part is your need to both train and find permanent work on the coast. Depending on how important that is to you, this may not be the best subspecialty for you. There is a huge oversupply of radoncs who. unfortunately and often ignorantly, shun the Midwest and rural areas due to the run-up in competitiveness over the prior decade and rapid program expansion resulting in people entering it for lifestyle reasons only and programs cherry picking applicants based on astronomical board scores and ivy league educational backgrounds.

Would just like to get an idea how well I’d need to do on Step 1/2 to make up for the weakness in my application (clinical grades, school’s lack of name recognition and lack of rad onc residency program) and have a realistic chance at matching at any program in these areas.

You don't really have any weaknesses at this point. Minimum step score is around 220 as it is a common hard cutoff for screening, although people match with less. For your goals, I would shoot for 250. IMO the difference on a rank list between a candidate with a 245 and a 265 is going to come down to things other than the step 1 score, such as research, references, interview performance, and medical school name. However, IMO if you are absolutely unwilling to consider a Midwestern or community-focused program, then you should think really hard about another field because there is a realistic chance you may have to spend some time, either temporarily or permanently, as an attending in those places to find work.

 

[scarbrtj]

Rad onc was always a specialty where a person's geographic preferences were likely to be unfulfilled. This was the case in ~1998 and even more so now. The just-out-of-training radiation oncologist is the most like Blanche DuBois versus any other MD: he or she must always rely on the kindness of strangers.

 

[bletkqru]

Thank you for the responses everyone. I appreciate the debate as its all relevant for me to consider.

 

[OTN]

I'll jump in, too- better late than never. I'm not as pessimistic on the field as a whole, as I have seen a substantial uptick in patients referred with metastatic melanoma/lung/renal cell etc who need radiation who wouldn't ever have had a chance to have seen me before the recent advances in systemic therapeutics. We're still vital in lung, head and neck, GI (minus colon), early-stage lymphomas, prostate, sarcoma, some skin cancers, CNS, and breast cancers, and I don't see that changing anytime soon. Stereotactic radiation has been a great advance over the last decade and really shouldn't be dismissed, and I'd be willing to bet we'll be involved in immunotherapy soon to try and capture the synergy that clearly exists between immunotx and XRT. Sure, hypofractionation has/will impact the field, but every field has its unique challenges, and hypofractionation is what we're all debating/dealing with at the moment.

The main thing to keep in mind, as others have appropriately mentioned, is geography. Even in "good" times when the job market isn't as tight, there's just no guarantee you'll end up in a particular region of the country. Just too small of a field, requiring too much capital to set up shop, for that to happen. If you're geographically restricted and don't see that changing, be sure to keep that in mind when thinking about radonc.

 

[scarbrtj]

I do think existential threats abound in rad onc as compared to other specialties. But, this may be because I'm heavily invested. And, I trend toward pessimism. Caveat emptor for all important life decisions.

 

[nkmiami]

I do think existential threats abound in rad onc as compared to other specialties. But, this may be because I'm heavily invested. And, I trend toward pessimism. Caveat emptor for all important life decisions.

Do you think it possible that semi-automation could lead to simplifying xrt so that it becomes part medical oncology?

 

[evilbooyaa]

Do you think it possible that semi-automation could lead to simplifying xrt so that it becomes part medical oncology?

Lol. No. No way, absolutely not. Medical oncologists do not know 5% of what radiation oncologists know in regards to radiation.

 

[medgator]

Lol. No. No way, absolutely not. Medical oncologists do not know 5% of what radiation oncologists know in regards to radiation.

Yet we often know much more than 5% of what med onc knows wrt chemo

 

[DebtRising]

How can start clerkship without step 1? Wasn't that mandatory?

"Ideally I'd love to go home to California or be in a major city on the east coast"

Can't speak for residency. Best estimate, 200 already grad rad oncs or their spouses waiting for position in those locations, by time you graduate that number will increase greatly. Better than even chance you would not get a job in that location to start, or for years after graduation. Also many people in big med schools on coasts may have inside track if they can turn that into residency at same big name coast program. Anything possible, but if that location important to you very uphill climb in this field today. In 5-6 years will be worse.

*Unless the 'less desirable' parts of CA work for you, that different, but those are different worlds than southern cal / big coastal cities

 

[scarbrtj]

Do you think it possible that semi-automation could lead to simplifying xrt so that it becomes part medical oncology?

Is it so hard to imagine that:
1) a computer could contour and design a prostate radiation plan using AI/machine learning/image analysis that when tested in a randomized trial (years of followup, PSA metrics, side effects, etc) against humans' plans would have equal or better clinical outcomes?
2) The radiation side effects from prostate radiation therapy (which are minor-to-zero) can be managed by other docs... like e.g. a urologist
3) Given #1 and #2, use your imagination

 

[OTN]

Is it so hard to imagine that:
1) a computer could contour and design a prostate radiation plan using AI/machine learning/image analysis that when tested in a randomized trial (years of followup, PSA metrics, side effects, etc) against humans' plans would have equal or better clinical outcomes?
2) The radiation side effects from prostate radiation therapy (which are minor-to-zero) can be managed by other docs... like e.g. a urologist
3) Given #1 and #2, use your imagination

Prostate MAYBE could be done via deep learning way in the future, but that's really the only one, and contouring is only one small part of treating someone with radiation. The contours generated by the deep learning algorithm in that paper you posted were complete garbage as shown in the figures, so I think in reality we are a very long way off. Brainlab's iPlan can't even get the chiasm right at the present. Not even close.

 

[medgator]

Is it so hard to imagine that:
1) a computer could contour and design a prostate radiation plan using AI/machine learning/image analysis that when tested in a randomized trial (years of followup, PSA metrics, side effects, etc) against humans' plans would have equal or better clinical outcomes?
2) The radiation side effects from prostate radiation therapy (which are minor-to-zero) can be managed by other docs... like e.g. a urologist
3) Given #1 and #2, use your imagination

Yup, a risk for those rad oncs who decided to go the urorads road exclusively during their career. I feel like you probably can't do anything else if you work at one of those centers long enough....

But a nasopharynx? Node-positive anal cancer?

 

[nkmiami]

Lol. No. No way, absolutely not. Medical oncologists do not know 5% of what radiation oncologists know in regards to radiation.

With an extra year of training, could a medonc give xrt, is my question. In a lot of the world, they do both, so it is not inconceivable. (or, instead of choosing 3rd year of heme, why not the option for radonc during that year-?) Moreover, graduates of the NCI program I believe were licensed at one point in both. I dont see computers taking over radiation oncology like self driving cars, but I could see them and metrics/analytics moving it into another specialty (obviously accompanied by some extra training)
When I was in medical school, xrt was a 3 year program, and at least half that time was learning principles of oncology- the radiation part could easily be mastered in a year by someone with a good oncology background.)

 

[seper]

I'm afraid we are underestimating a possibility of a breakthrough in automated treatment planning, i.e. discovery of a completely new, currently unknown process. I'm hedging by specializing in brachy.

Prostate MAYBE could be done via deep learning way in the future, but that's really the only one, and contouring is only one small part of treating someone with radiation. The contours generated by the deep learning algorithm in that paper you posted were complete garbage as shown in the figures, so I think in reality we are a very long way off. Brainlab's iPlan can't even get the chiasm right at the present. Not even close.

 

[nkmiami]

How can start clerkship without step 1? Wasn't that mandatory?

"Ideally I'd love to go home to California or be in a major city on the east coast"

Can't speak for residency. Best estimate, 200 already grad rad oncs or their spouses waiting for position in those locations, by time you graduate that number will increase greatly. Better than even chance you would not get a job in that location to start, or for years after graduation. Also many people in big med schools on coasts may have inside track if they can turn that into residency at same big name coast program. Anything possible, but if that location important to you very uphill climb in this field today. In 5-6 years will be worse.

*Unless the 'less desirable' parts of CA work for you, that different, but those are different worlds than southern cal / big coastal cities

You probably could find a spot in California in which you are in an "exploited" low paying position where you certainly wont be permitted to "choose wisely." In South Flroida, there is always a spot for someone to ride around in a van with HDR unit and hyperfractionate inconsequential basal cells in nursing home residents. I am sure California has the same. If you want to work for Keiser, you probably need to graduate from UCSF or Stanford.

 

[evilbooyaa]

Yet we often know much more than 5% of what med onc knows wrt chemo

Absolutely agreed. 4 years Onc training vs 1.5. They're certainly schooling us in general medicine, however.

With an extra year of training, could a medonc give xrt, is my question. In a lot of the world, they do both, so it is not inconceivable. (or, instead of choosing 3rd year of heme, why not the option for radonc during that year-?) Moreover, graduates of the NCI program I believe were licensed at one point in both. I dont see computers taking over radiation oncology like self driving cars, but I could see them and metrics/analytics moving it into another specialty (obviously accompanied by some extra training)
When I was in medical school, xrt was a 3 year program, and at least half that time was learning principles of oncology- the radiation part could easily be mastered in a year by someone with a good oncology background.)

I can't speak to other countries, but if Rad Onc truly can be learned in 1 year still, what the hell are we doing in 4 years of Rad onc residency???

I'm not familiar with how Rad Onc training works in other countries.

 

[medgator]

Absolutely agreed. 4 years Onc training vs 1.5. They're certainly schooling us in general medicine, however.



I can't speak to other countries, but if Rad Onc truly can be learned in 1 year still, what the hell are we doing in 4 years of Rad onc residency???

I'm not familiar with how Rad Onc training works in other countries.

Not sure I agree that rad onc could be learned in a year, unless we are talking about someone who only treats a single site and doesn't do special procedures/brachy

Sent from my LG-H910 using SDN mobile

 

[nkmiami]

Again, assuming you come in already with a 2 year background in oncology, how much radiation training do you need (and visa verse)? I do think how the rest of the world approaches radiation is very relevant to our specialty.


https://www.rcr.ac.uk/system/files/publication/field_publication_files/bfco145_co_workforce.pdf

"The majority of clinical oncologists deliver both systemic therapy and radiation ..."

 

[ToasterThief]

With an extra year of training, could a medonc give xrt, is my question. In a lot of the world, they do both, so it is not inconceivable. (or, instead of choosing 3rd year of heme, why not the option for radonc during that year-?) Moreover, graduates of the NCI program I believe were licensed at one point in both. I dont see computers taking over radiation oncology like self driving cars, but I could see them and metrics/analytics moving it into another specialty (obviously accompanied by some extra training)
When I was in medical school, xrt was a 3 year program, and at least half that time was learning principles of oncology- the radiation part could easily be mastered in a year by someone with a good oncology background.)

Most hemeonc fellowships include a year of research, some include more. Half of that time is spent learning hematology. I wonder how much time I'd need to learn how to give chemo...

 

[medgator]

Most hemeonc fellowships include a year of research, some include more. Half of that time is spent learning hematology. I wonder how much time I'd need to learn how to give chemo...

Prob not much...most HOs don't even admit anymore IRL outside of academic centers