Rad onc is the only specialty in medicine I could see myself doing, what should I do?

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inomed said:
Compared to heme onc, is the lifestyle and emotional burden definitely better?
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yes, thats why the field was so popular before residency expansion/xrt ommission
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inomed said:
Compared to heme onc, is the lifestyle and emotional burden definitely better?
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Intra-specialty differences will dwarf inter-specialty differences.

Subspecialty academic hem onc at a well staffed facility will look very different than private practice generalist rad onc and vice versa.

See a bunch of prostate patients, emotional burden probably low regardless.
See a bunch of lung/CNS/palliative it's gonna be high regardless.
 
I can speak to private practice. We don't have the inpatient burden medoncs do, which is nice. Clinic responsibilities can be greater, however, due to the need to cover SBRT/SRS, HDR, etc. Radoncs in pp do have to hustle for patients more, primarily due to residency expansion, however the tendency for academic centers to try harder to keep radiation "in house" due to profitability compared with chemotherapy also plays a role. Urorads also a factor.

Emotional heavy lifting is similar I would guess, and lower than what the neuro-oncologists have to deal with. I genuinely don't know how they can practice long-term seeing GBMs all day.
 
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Fierce competition with the academic and hospital-based places around us

Med onc’s can to some degree build up a patient panel and then they’re set since they just continue systemic therapy maintenance
 
yesmaster said:
Fierce competition with the academic and hospital-based places around us

Med onc’s can to some degree build up a patient panel and then they’re set since they just continue systemic therapy maintenance
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Is it stressful maintaining your referral base?
 
yesmaster said:
Fierce competition with the academic and hospital-based places around us

Med onc’s can to some degree build up a patient panel and then they’re set since they just continue systemic therapy maintenance
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I don’t think any med oncs would put it as simply as you are making it out to be.
 
inomed said:
Compared to heme onc, is the lifestyle and emotional burden definitely better?
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It is an apples to oranges comparison in terms of the job and YMMV for both. You should try to spend some time in these clinics, academic and non-academic if possible.

I also cant see myself doing anything else in medicine, so I would be unhappy as a med onc.
 
Wrong that trainees and students should ignore what I say, or wrong about the ad hominem
 
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yesmaster said:
Wrong that trainees and students should ignore what I say, or wrong about the ad hominem
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Great questions. I would not recommend anyone makes a decision about their life based upon what you said, cuz you sometimes say outrageous things with absolutely no evidence. Am I against you as a person? No, sorry it came like that, I think you're probably a pretty cool person IRL.

My opinion is that things will probably be fine for most med students. Great job, doing good things for people, etc.
 
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CurbYourExpectations said:
This you?
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Opinions are like @$$holes, bro

the dude your opinion GIF
 
Also the global south brachytherapy thing was a joke. Consistent with some red journal FASTRO nonsense article about global health and rad onc workforce, however
 
yesmaster said:
Also the global south brachytherapy thing was a joke. Consistent with some red journal FASTRO nonsense article about global health and rad onc workforce, however
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I'm genuinely curious how some academic gyn brachy faculty do it. Being good at brachy involves having a decent volume of locally advanced patients, and from my time spent on the UES or Back Bay, I'm not so sure.
 
inomed said:
What would you recommend then? There is no other specialty I could see myself wanting to do. But I don’t want to end up in rural Iowa. The current class of graduates seems to be doing fine with jobs, is there a bubble that is about to burst?
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The last few years were good. I think if you're somewhat flexible, you will be able to get a job near a major city on a coast or central US and not be technically rural, if that is what worries you. I do not think the job market will remain to be as good as it is right now. Most people I know that have been looking for jobs over the last few years have gotten ones in areas they wanted, maybe not the disease site they were hoping for or maybe with a longer time to partnership than they were hoping for, etc. Most older docs I know that have been looking for jobs have been able to move to other states, with relatively little issue from what I've heard. But again, this probably won't be this good for a long time, maybe not even when you graduate in the 2030s after the steep decline in growth rate of medicare patients.

If it's really the only thing in medicine you want to do, then I think that kind of settles things, but keep an open mind when you're rotating on other specialties. I recommend living below your means, saving up money, in pretty much any specialty you choose. The Emergency Medicine forum used to have some good discussions on that. AI could drastically impact any market in the next 20 years. Choose the specialty that would make you the happiest, unless you have to be in a certain city, then maybe choose a larger specialty that has many jobs open in a location at any time of the year, RadOnc may have 0-1 jobs open in a major city at a given time. I don't know if the field has ever been good enough in the job department that you may be fielding multiple job offers in the state you want as a PGY3, like what happens in other fields.
 
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The one thing that makes me nervous that you said OP is that you don’t want to live in rural Iowa. The two most common categories of jobs in rad onc are:

- rural jobs in towns of 25k to 250k paying roughly mgma median typically employed by academic satellite or hospital system
- academic jobs in which you’re underpaid and you have to lick somebody’s boots, usually the chair and disease site director, these include VA jobs, the ARRO survey numbers are fairly accurate

If you’re not willing to work somewhere rural then you’re ruling out a big category of jobs.

Metro employed job at mgma median with a 30 minute commute is doable if you’re willing to go to any big city but may not be your first job out of residency. Anything better than that is sheer luck. Like the Tennessee Oncology job opening a few months ago was highly desirable but you’re probably competing with 50 other PGY-5’s plus 25 board-certified rad onc’s with a few years of experience after residency. If you have to be in a particular big city, you might be waiting 10+ years, and even then, the hiring group may already have a short list of people in mind.

I can’t imagine things will get better because we are losing indications faster than we are gaining them, and it takes time for practice patterns to change. US academic rad onc, which is supposed to be this engine of progress (that’s why they get the big PPSE bucks), is simply not innovative and even worse, only advocates for their narrow self interest (protons, etc.)

Academic chairs generally do not care about your job placement unless you’re staying within their academic circle, that is you’ll be working for them or their chair buddy at a peer institution. Stagnant or declining PP/community comp doesn’t matter to the people in charge of residency spots, frankly we do well compared to most people including almost all the non-MD staff at academic programs. Problem is we compare ourselves against our peers and for us, that’s heme/onc, rads, IM specialties, surgery and in terms of job availability, geographic flexibility, comp, opportunities for ownership or self employment, we do worse. That’s just a fact.

To steel man the other side, would I dissuade students from pursuing rad onc so there’s fewer rad onc’s competing for patients with me in 7 years? Yeah, probably. I’m far enough out however from being a PGY-5 and well established enough that I don’t think more or less graduating rad onc residents would affect me. What matters is PPSE billing and other anti-competitive nonsense perpetuated by the big academic hospitals.

Anyways I do think that overtraining rad oncs creates incentives to give radiation when the benefit isn’t apparent, and I also think we need more heme onc’s and other specialties. So yeah, if OP wants to train as a heme onc, message me as a PGY-5/6 oncology fellow, assuming you’re clinically sound and come with good references, we will pay you more than most rad onc chairs make. Because like most metro areas, we need heme onc’s. Diagnostic rads I wouldn’t do because of AI, but for most specialties that work adjacent to rad onc, or rather we work adjacent to them, there’s just more demand.
 
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Doctorer said:
I'm genuinely curious how some academic gyn brachy faculty do it. Being good at brachy involves having a decent volume of locally advanced patients, and from my time spent on the UES or Back Bay, I'm not so sure.
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The best gyn brachytherapists practice at the county or similar environment with a lot of cervix cancer patients.
 
How easy is it to find jobs 20-30 min from tier 2-3 cities like Dallas, Cincinnati, Charlotte or desirable suburban areas like northern Virginia?
 
inomed said:
How easy is it to find jobs 20-30 min from tier 2-3 cities like Dallas, Cincinnati, Charlotte or desirable suburban areas like northern Virginia?
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Hard imo. Very luck of the draw.

Some of them pop up from time to time but it's not like every city/metro, every year is having a job in every applicant cycle straight out of training.

Could be a job in the city/metro you're looking at. Or not.
 
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inomed said:
How easy is it to find jobs 20-30 min from tier 2-3 cities like Dallas, Cincinnati, Charlotte or desirable suburban areas like northern Virginia?
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Currently, very doable. 2030s it might be tougher again, I recommend trying to get into residency in the general area you want to live in. If you're okay with living near any city in the US, probably will be fine and find a job in/near a city, but if you specifically want to live in Cinci or Charlotte, it might not be your first job if the job market gets bad again, which is a possibility. Even when things were bad in the 2015-2019 times, I still think the majority of people eventually ended up somewhere they were happy, even if it was a year or two after their initial end date. I know people that in the 1990s took jobs in the middle of no where, because they had to and there were legit unemployment possibilities, some ended up having very solid careers in well desired areas afterwards.

Of course those possibilities are not ideal for anyone who is applying to a five year residency after doing years of schooling. Unfortunately, the job market in the US can get very tight and it can take a while to correct. Like others have said, some things are getting omitted, faster than new indications are taking off (demand down), population growth rate is shrinking (demand slowing), etc.
 
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inomed said:
How easy is it to find jobs 20-30 min from tier 2-3 cities like Dallas, Cincinnati, Charlotte or desirable suburban areas like northern Virginia?
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Before I answer, I need to say that it apparels to me that you are looking for reassurance that none of us can give you. I am as optimistic as it gets on this board. I think you would be fine and that if you are flexible and you love the job that much that you should do it.

As of now, all of our residents from a mid tier Midwest program who have wanted the jobs you described have gotten them. So I’d say it’s typically not that hard if you are open to most such jobs available and not geographically restricted.

But the elephants in the room are real. We are a small field and more vulnerable to major shifts than most. We were already facing significant headwinds. Now we have a new government and like them or love them, they are pushing for major changes in spending that have strong potential to affect our job market in innumerable ways. Time will tell what happens and I am keeping this discussion entirely neutral because I don’t want to see a political argument here. But again, the point is we are quite vulnerable to significant swings because of our small size. All anyone can say is as of now, doable. Even predicting 5 years ahead is basically impossible at this point.
 
CurbYourExpectations said:
Currently, very doable. 2030s it might be tougher again, I recommend trying to get into residency in the general area you want to live in. If you're okay with living near any city in the US, probably will be fine and find a job in/near a city, but if you specifically want to live in Cinci or Charlotte, it might not be your first job if the job market gets bad again, which is a possibility. Even when things were bad in the 2015-2019 times, I still think the majority of people eventually ended up somewhere they were happy, even if it was a year or two after their initial end date. I know people that in the 1990s took jobs in the middle of no where, because they had to and there were legit unemployment possibilities, some ended up having very solid careers in well desired areas afterwards.

Of course those possibilities are not ideal for anyone who is applying to a five year residency after doing years of schooling. Unfortunately, the job market in the US can get very tight and it can take a while to correct. Like others have said, some things are getting omitted, faster than new indications are taking off (demand down), population growth it shrinking (demand slowing), etc.
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Isn’t demand going up with an aging population, increasing incidence of cancer, expansion into oligometastatic disease, and benign conditions?
 
inomed said:
Isn’t demand going up with an aging population, increasing incidence of cancer, expansion into oligometastatic disease, and benign conditions?
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Yes, most of those aging population and incidence increases will be within the next few years. The largest growth of older people is due to the baby boomer population, which by the time you start, all of them will already be over 65 years old. Even with the demand rising overall, it's going to start slowing (I think this is discussed in the ASTRO workforce paper, but haven't read it in a while), most importantly, it needs to result in more jobs for it to be beneficial.

Oligomets, seems regional, as you need buy in from your MedOncs and some data is kinda iffy. Benign conditions could help, but haven't really taken off enough to be creating more jobs (I have seen no one expanding jobs based on benign disease yet, maybe someone else has). Some major disease sites are looking at decreasing/omitting radiation, breast, GI, etc. For whatever reason it seems to be faster to decrease our indications than increase them. For example a paper in ASCO can decrease/nearly cut us out of some sites with what seems like over night, but I don't see us picking up new indications quite as fast.
 
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inomed said:
How easy is it to find jobs 20-30 min from tier 2-3 cities like Dallas, Cincinnati, Charlotte or desirable suburban areas like northern Virginia?
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Dallas is hard. It’s not a desirable city to live in for the natural beauty for example, but it has grown very quickly in last decade. Doctors in Dallas generally do well financially, probably to the detriment of working class people. Dallas medical bankruptcy rates are very high.. You can find a job at UTSW but their pay is low, probably under 300k. The 2 large private groups in DFW are both great groups but are challenging to break into. It would help if you went to UTSW or MDA for residency. There’s smaller hospitals and groups but in the last few years the only attainable jobs in DFW seem predatory to me.

Charlotte is dominated by a large private rad onc group that is amongst the most competitive in US to get into. It’s a good gig though.

DC area is easier I believe, they have advertised in recent years, INOVA and another community group in suburbs that seems solid, unsure what it’s like further along job interview pathway.

Cincinnati is not a city I’d be interested in but it seems like there are opportunities that’d pop up at university and in community practice. It doesn’t seem like a hard city to break into.
 
inomed said:
Isn’t demand going up with an aging population, increasing incidence of cancer, expansion into oligometastatic disease, and benign conditions?
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Aging population and increasing incidence of cancer, I’m not sure these are true. You’d need to look at current demographic data. We do see increase in GI cancers but smoking is probably becoming less common and HPV vaccine uptake will probably decrease H&N/cervix but who knows with RFK Jr.

Oligomets and benign conditions and radiopharm are outweighed by loss of newly diagnosed locally advanced cases, esophagus, stomach, lung to IO/surgery in some geographies. Oligomets I do think sabr-comet phase 3 will be positive for at least half of histologies but this is already being done off trial. Get med onc buy-in as others said. Benign, the evidence seems weak to me and better data is needed. A lot of it is just docs or centers talking their book. Others on this forum who have done more arthritis XRT will disagree with me, but my intuition says this is placebo. I hope I am wrong. Or it's a noninvasive intra-articular steroid shot, which is fine but I'm just not that excited by no changes to the natural history of the disease. Regardless it’s only 6 fractions and is a low complexity of treatment so it can’t make up for several weeks of IMRT for cancers.
 
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inomed said:
Isn’t demand going up with an aging population, increasing incidence of cancer, expansion into oligometastatic disease, and benign conditions?
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Cancer incidence is not increasing. But population is increasing so raw cancer cases per year are still increasing. Yet rad onc utilization is decreasing, and “fraction incidence” is really falling. All this points to the rad onc work force most rationally staying the same, or decreasing; but neither are rationally happening. Benign is a wild card.
 
If I were to do another specialty, it would be allergy and immunology through IM, which is also a small / niche field. What would you all recommend between the two?
 
OP, you need to do some soul searching if you have the mindset of: "I can only see myself doing x specialty". Most people can do variety of specialties and live a great/fulfilling life and the more important thing is trying to rule out a specialty you would end up being miserable in.

Choosing a specialty involves some honest self reflection to assess the combination of "what am I good at", "what do I like/find interesting", and "what are the logistics/feasibility of that specialty (either matching or career prospects)". You need to spend more time thinking about the first two things and maybe less time on the latter. You need to spend more time shadowing in clinic of the specialties you are interested in, and talk to real people in all levels of that specialty (residents, new attendings, old attendings, academic, and private)
 
inomed said:
Is the job market so bad, that I should avoid rad onc as I am only competitive for a mid-tier place currently? I cannot see myself practicing any other field of medicine. What is the worst case scenario? An 8-5 job paying 300k? That's still better than being a hospitalist or PCP in my opinion.
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Arthritis isn't going anywhere...
 
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CurbYourExpectations said:
Think there will be a bigger randomized trial soon?

I guess what I should ask is: if LoRD-KNeA is negative when it's published this year or next year, would people still treat?

pubmed.ncbi.nlm.nih.gov

Low-dose RaDiation therapy for patients with KNee osteoArthritis (LoRD-KNeA): a protocol for a sham-controlled randomised trial - PubMed

NCT05562271.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
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If nothing else, it would be nice to no longer have to explain to patients that they are wrong, their joint isn't actually hurting them less after the radiation.
 
CurbYourExpectations said:
Think there will be a bigger randomized trial soon?

I guess what I should ask is: if LoRD-KNeA is negative when it's published this year or next year, would people still treat?

pubmed.ncbi.nlm.nih.gov

Low-dose RaDiation therapy for patients with KNee osteoArthritis (LoRD-KNeA): a protocol for a sham-controlled randomised trial - PubMed

NCT05562271.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
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Do we really think a RCT of 38 patients per arm is going to tell us ANYTHING about the value of LDRT for OA??? Fixed one problem of the dutch study but didn't address the low sample size

Here is their sample size calculation:
"

Sample size calculation​

For sample size calculation, a randomised, comparative, parallel, three-arm design is used with 80% power and a two-sided alpha of 0.025 considering the comparison of the control group to each of the two types of experimental groups; a total of two tests are planned, and Bonferroni correction is performed. According to the ArthroRad trial, when doses of 0.05 Gy and 0.5 Gy per fraction (similar to this trial) were applied to degenerative arthritis of the hand and knee, the combined response rate of ‘markedly improved’ and ‘improved’ was around 60%.15 In addition, when the results of several retrospective studies were combined, clinical symptom improvement was observed in 63%–90% of cases after LDRT.2 Therefore, the number of samples for this study may be determined by the following hypothesis test: assuming that the proportion of responders is 65% in the experimental groups and 30% in the control group, when the power is 80% and the alpha error is 5%, 34 patients are needed in each group. Considering a 10% dropout rate, each arm requires 38 patients. A total of 114 patients will be enrolled in this study."

Bolded is my emphasis. To assume that LDRT will crease a 35% ABSOLUTE improvement in response compared to sham RT is such an insane improvement. Chemotherapy doesn't help compared to placebo by 35%. This trial is almost guaranteed to be negative. And if so, it will still do nothing because no sensible person (IMO) thinks that a 35% increase in response is a reasonable expectation of 3Gy in 6 fractions.

****ing *****s.
 
LORD
CurbYourExpectations said:
Think there will be a bigger randomized trial soon?

I guess what I should ask is: if LoRD-KNeA is negative when it's published this year or next year, would people still treat?

pubmed.ncbi.nlm.nih.gov

Low-dose RaDiation therapy for patients with KNee osteoArthritis (LoRD-KNeA): a protocol for a sham-controlled randomised trial - PubMed

NCT05562271.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
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LORD - KNEA very well could be negative because the "sham dose" (0.3 Gy/6 fractions) likely is therapeutic.

See Arthropod Trial by DEGRO: https://doi.org/10.1007/s00066-021-01866-2

1739992488629.png
 
SneakyBooger said:
LORD

LORD - KNEA very well could be negative because the "sham dose" (0.3 Gy/6 fractions) likely is therapeutic.

See Arthropod Trial by DEGRO: https://doi.org/10.1007/s00066-021-01866-2

View attachment 399222
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No, the LORD-KNEA trial also has a completely sham 0 Gy RT arm. It is a 1:1:1 trial.
The arguments I can see people making are: "too small to see a real difference, needs a bigger trial" like booya said and I agree with that. Wish it was hundreds per arm. The other is I don't think they allow retreatment of any group, which I am a little bit more questioning of if that would affect showing therapeutic outcome of LDRT for arthritis, maybe if because the size is too small.
 
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