Rad onc supervision, the epilogue

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TheWallnerus

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Was looking at SDN year-end stuff, favorite threads, etc, and this 4 year old post from @elementaryschooleconomics… the smartest poster on SDN… struck me:

I would place a footnote on this - CMS hit us totally randomly with the supervision rule change on November 1st, with uncertain but almost without question negative effects for most of us.

Blame CMS for the mid-interview season timing.

Let us harken back in our collective minds to what a sea change moment this seemed poised to be. CMS was preparing to make a blanket change to supervision levels in all hospital outpatient departments in America come Jan 1, 2020. I also would have written this was going to result in “without question negative effects for most of us.”

However I think 2019 is calling and wants its negative effects back.

I think this is an important discussion to have if only because I can remember how sky-is-falling we all were at the time. But the sky didn’t fall. What happened? Several things in my opinion…

1) ASTRO immediately discovered that image guided radiation therapy was not a therapy but a diagnostic test (and hence why ASTRO no longer calls IGRT “IGRT” anymore but instead “image guidance”).
2) Much of rad onc seemed to have ignored the potential permissiveness of blanket general supervision.
3) The change didn’t affect freestanding (yet in the meantime we have virtual supervision, yada yada).
4) A hodgepodge of varying state laws and restrictive LCDs have helped to make the Supervision Change a dog with more bark than bite?

Suffice it to say I don’t think there have been ANY negative effects from the several supervision changes in rad onc since 2019. No negative patient effects, most importantly, and no negative job market effects. This is my hypothesis… prove me wrong.

Let us learn from history.

Discuss.

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Was looking at SDN year-end stuff, favorite threads, etc, and this 4 year old post from @elementaryschooleconomics… the smartest poster on SDN… struck me:



Let us harken back in our collective minds to what a sea change moment this seemed poised to be. CMS was preparing to make a blanket change to supervision levels in all hospital outpatient departments in America come Jan 1, 2020. I also would have written this was going to result in “without question negative effects for most of us.”

However I think 2019 is calling and wants its negative effects back.

I think this is an important discussion to have if only because I can remember how sky-is-falling we all were at the time. But the sky didn’t fall. What happened? Several things in my opinion…

1) ASTRO immediately discovered that image guided radiation therapy was not a therapy but a diagnostic test (and hence why ASTRO no longer calls IGRT “IGRT” anymore but instead “image guidance”).
2) Much of rad onc seemed to have ignored the potential permissiveness of blanket general supervision.
3) The change didn’t affect freestanding (yet in the meantime we have virtual supervision, yada yada).
4) A hodgepodge of varying state laws and restrictive LCDs have helped to make the Supervision Change a dog with more bark than bite?

Suffice it to say I don’t think there have been ANY negative effects from the several supervision changes in rad onc since 2019. No negative patient effects, most importantly, and no negative job market effects. This is my hypothesis… prove me wrong.

Let us learn from history.

Discuss.
*struts around, adjusts Fedora*

In all seriousness -

I've seen zero negative data, but that's also an artifact of limited data in general. I know a crew at Sloan is shopping around a manuscript on their experience and I'm told it confirms no safety issues, but I'm waiting for the actual paper like Christmas morning.

In the meantime, I've gone looking at...basically all of the telemedicine literature, ever. Most of it centers around patient perception and experience, or trainee education, etc. But I've been unable to find like...any threat to any form of safety in any field of medicine.

I would love to hear people's experiences and opinions on this, though.
 
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Just to also go find what Past Me wrote for Current Me to read:


1704384828929.png


God, those were the days eh?

On November 11th, 2019, I hadn't heard the word "coronavirus" since I took USMLE Step 1 in 2010.

While, obviously, the pandemic was the most Black Swan event ever, the Black Swan of Black Swans, it's hard to overstate how much it shifted the course of Radiation Oncology.

Reading my own post today, in 2024: I completely agree with myself at the time, given the information I had.

And this is the reason I basically refuse to make predictions more than 6 months in the future.
 
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any threat to any form of safety in any field of medicine
This will never come.

Safety is incredibly hard to measure in reference to rare events (clinically significant XRT misadministration or commercial airline disasters). I have no doubt that the safety protocols employed in the recent Japan airlines crash were "unproven".

One would need to use proxy measures, like clinically insignificant XRT misadministration or number of safety tracking tools used (a terrible measure).
 
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*struts around, adjusts Fedora*

In all seriousness -

I've seen zero negative data, but that's also an artifact of limited data in general. I know a crew at Sloan is shopping around a manuscript on their experience and I'm told it confirms no safety issues, but I'm waiting for the actual paper like Christmas morning.

In the meantime, I've gone looking at...basically all of the telemedicine literature, ever. Most of it centers around patient perception and experience, or trainee education, etc. But I've been unable to find like...any threat to any form of safety in any field of medicine.

I would love to hear people's experiences and opinions on this, though.

I am assuming we are now talking both about supervision and telemedicine in clinic. I believe the Sloan paper is about OTVs.

I have thought about this a lot as a user of remote coverage of SBRT and adaptive (published) and doing a fair bit of telemedicine in a lot of settings in the clinic.

The papers I am on suggest that remote coverage of complex procedures is "the same" as being at the machine. I do not agree. That said, people probably vary a lot in their comfort. I like to go to the machine if the case is not straight forward, so that could be comfort over "safety".

If you look at the literature on incident learning in radiation oncology and add in the new Cherenkov imaging data, radiotherapy is exceptionally safe. The risk of an error that reaches the patient has to be less than 5% (could be as low as 1%) and I would guess the vast majority of these cases are only marginally clinically relevant at best.

Even if you do an extreme thought experiment where you do a geographic miss on the majority of early stage NSCLC SBRT fractions in your clinic, you likely will not observe a very high rate of toxicity or treatment failure. Bad radiotherapy is very hard to detect.

So, I do not think the absence of errors in the literature proves that loosening supervision is "safe". I don't think anyone will be able to show it's unsafe. Its going to be all about experience and comfort, as you said.

I can't resist being pedantic here, I have to point out we don't even have an outcomes based definition of safe or good radiotherapy delivery! Our entire quality/safety paradigm hinges on peer review of clinical decision making/target design and technical QA of beam quality.
 
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Suffice it to say I don’t think there have been ANY negative effects from the several supervision changes in rad onc since 2019. No negative patient effects, most importantly, and no negative job market effects. This is my hypothesis… prove me wrong.

Let us learn from history.

Discuss.
There will never be a quantifiable detriment to supervision changes. We can't even 'prove' that people are Bad rad oncs in terms of EBRT, let alone something as minor as supervision changes.

Most jobs that hire are employed. Most employed jobs are not willing to pull the trigger on general supervision despite the rules changes. Those who were doing general a few days a week were likely CAH and were exempted even prior to the rule. Thus, there will be no effect on the job market unless hospitals, en masse, start allowing slower departments to go to a general supervision rule. There are likely anecdotes out there already, but it would have to become main stream.

And you'd probably need to see an academic institution do it first (or perhaps multiple) before the floodgates opened.

*struts around, adjusts Fedora*

In all seriousness -

I've seen zero negative data, but that's also an artifact of limited data in general. I know a crew at Sloan is shopping around a manuscript on their experience and I'm told it confirms no safety issues, but I'm waiting for the actual paper like Christmas morning.

In the meantime, I've gone looking at...basically all of the telemedicine literature, ever. Most of it centers around patient perception and experience, or trainee education, etc. But I've been unable to find like...any threat to any form of safety in any field of medicine.

I would love to hear people's experiences and opinions on this, though.

In regards to bolded: Do you really think Sloan would publish a paper suggesting that something that they do is NOT the best thing ever? If there were a single safety issue identified, the entire project would be buried and never see the light of dead. I can predict the conclusion of the paper right now:

"Telemedicine for OTVs is safe, effective, and convenient for patients to have as an option for their OTVs."

+/- some hedging on only doing it for breast/prostate/whatever disease sites they did, +/- them stating that this is only safe and effective at SLOAN not at some dinky community practice.

But man, can't believe 2019 was only 4ish years ago. Feels a hell of a lot longer than that.
 
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This will never come.

Safety is incredibly hard to measure in reference to rare events (clinically significant XRT misadministration or commercial airline disasters). I have no doubt that the safety protocols employed in the recent Japan airlines crash were "unproven".

One would need to use proxy measures, like clinically insignificant XRT misadministration or number of safety tracking tools used (a terrible measure).
Well...

It will "never come" in the form of evidence we can all universally agree upon, sure.

I guess, as @NotMattSpraker pointed out, we have to be very precise in what we're talking about here in the first place.

We basically have, over the last ~25 years, three distinct "eras" of supervision:

2000-2009 was the transition/bizarro era. You had the development and widespread adoption of both IMRT and routine OBI (with CBCT). From 2006-2009 you had this murky "personal vs direct" supervision debate, which is where the infamous MIMA/NY Times whistleblower case was born.

From 2010-2020, you had the direct supervision era.

From 2020-2024, we're in the general and direct virtual era.

I would argue we can ignore the pre-2010 events because it was too tumultuous.

But it's at least plausible we could build a database with:

Cohort A: January 1st, 2017 - December 31st, 2019 patients
Cohort B: April 1st, 2020 - January 1st, 2024 patients

In the short term, we could compare safety events, whistleblower complaints/claims, disciplinary actions related to radiotherapy (for anyone involved, not just the doctor), etc.

In a few years we could compare outcomes, or we could at least compare outcomes for patients treated March-December 2019 with March-December 2021 (2020 is probably a year with a lot of confounding).

At this point I might just start building this study myself, because to do it well would require data from hospitals and medical boards etc not immediately available to the public.

In regards to bolded: Do you really think Sloan would publish a paper suggesting that something that they do is NOT the best thing ever? If there were a single safety issue identified, the entire project would be buried and never see the light of dead. I can predict the conclusion of the paper right now:

"Telemedicine for OTVs is safe, effective, and convenient for patients to have as an option for their OTVs."

Oh yeah I mean...I already know that's the conclusion of the paper bahahaha, but I'm hopeful that the methods can be even marginally generalized for the rest of us!
 
In the short term, we could compare safety events, whistleblower complaints/claims, disciplinary actions related to radiotherapy (for anyone involved, not just the doctor), etc.
It'll be something, just not something I would take seriously.

Safety events may be higher in a good clinic with a low barrier to reporting such events and a robust reporting system than in a bad clinic with none of the above.

Whistleblower complaints always go down when the regulatory environment becomes more lax (less to blow about)…same with disciplinary actions.

I agree with you to keep the years as close together as possible. It is a worthwhile project if an imperfect one.
 
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It'll be something, just not something I would take seriously.

Safety events may be higher in a good clinic with a low barrier to reporting such events and a robust reporting system than in a bad clinic with none of the above.

Whistleblower complaints always go down when the regulatory environment becomes more lax (less to blow about)…same with disciplinary actions.

I agree with you to keep the years as close together as possible. It is a worthwhile project if an imperfect one.
I keep hoping someone who isn't me does it

(I suspect it will be me)
 
I keep hoping someone who isn't me does it

(I suspect it will be me)

All super low volume with unclear connections to the health of the patient. That said, I guess you don't need to compare statistically. You could just go by like vibes or dreams or whatever, it all seems publishable these days.


Thought this was interesting. A blog about the telemedicine experience of Dr. Shaffer for dupuytrens. 5% had the wrong diagnosis! I have no idea how referrals work or anything, but if 5% of my consults had the wrong diagnosis Id probably have a talk with my admins.
 
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All super low volume with unclear connections to the health of the patient. That said, I guess you don't need to compare statistically. You could just go by like vibes or dreams or whatever, it all seems publishable these days.


Thought this was interesting. A blog about the telemedicine experience of Dr. Shaffer for dupuytrens. 5% had the wrong diagnosis! I have no idea how referrals work or anything, but if 5% of my consults had the wrong diagnosis Id probably have a talk with my admins.
...

...

...

I'd consider only 5% of my consults with the wrong diagnosis a 5-year goal for my neck of the woods.
 
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ASTRO released an update from their supervision working group:


At first glance, this seems a lot like the plan advocated by ACRO. Seems pretty reasonable to me. Most notably, it requires a lot of 'hands on' time with MDs including OTVs. This prevents clinics from being gutted by PE firms enticed by over-zealous radiation therapists ...
 
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ASTRO released an update from their supervision working group:


At first glance, this seems a lot like the plan advocated by ACRO. Seems pretty reasonable to me. Most notably, it requires a lot of 'hands on' time with MDs including OTVs. This prevents clinics from being gutted by PE firms enticed by over-zealous radiation therapists ...
Meeting direct supervision requirements is one of the most challenging problems faced by rural and small radiation oncology practices across the country, and there is little evidence of benefit to the patient. Onerous direct supervision requirements have resulted in access to care issues for patients living in remote areas. Adopting general supervision for those procedures that do not require face-to-face interaction between the patient and the radiation oncologist strikes a balance between patient safety and the practicality of supervision requirements in real-world practice settings. Additionally, the application of general supervision policies will make radiation therapy more accessible to remote patient populations.

Common sense prevails? I mean, they could have just said this to begin with and not caused the giant s***storm they instead did. It sounds like they have realized general supervision is not going away and are moving into the bargaining phase.
 
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In the instance when the radiation oncologist cannot be on site to provide an in-person OTV, the work group recommends not billing the management code. This protects patients, the involved practices and the specialty.

So it's better to not do an otv at all than to check in on a patient remotely?
 
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In the instance when the radiation oncologist cannot be on site to provide an in-person OTV, the work group recommends not billing the management code. This protects patients, the involved practices and the specialty.

So it's better to not do an otv at all than to check in on a patient remotely?
No no no silly

Do the virtual OTV, just don’t bill it

If the President does it, it’s not illegal… said Nixon (a Reaganite)

If ASTRO recommends it, it’s also not illegal

Just ask ROCR Ambassador C Mantz
 
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In the instance when the radiation oncologist cannot be on site to provide an in-person OTV, the work group recommends not billing the management code. This protects patients, the involved practices and the specialty.

So it's better to not do an otv at all than to check in on a patient remotely?

If a remote OTV is never billed, did it even happen?

I'm very over doing work that I'm not compensated for - regardless whether I'm on site or not.
 
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If a remote OTV is never billed, did it even happen?

I'm very over doing work that I'm not compensated for - regardless whether I'm on site or not.
Lawyers have charged for phone calls forever. I guess during the pandemic some of us found out we can charge for them as well. But the amount is apparently such a pittance
 
If a remote OTV is never billed, did it even happen?

I'm very over doing work that I'm not compensated for - regardless whether I'm on site or not.
Imagine an OTV that could be unburdened by what has been.

Hello and welcome to the 77427 Campaign Headquarters...
 
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Gaslighting me on this one. Shortsightedness. Whenever I see RadOncs diminishing their worth and acting like they barely even have to be a part of anything, I imagine a business person who understands that undercutting the physicians can make them money warming their hands.

ASTRO tried to protect the field, lets be honest. I obviously do not agree with everything ASTRO does, but some of the things you're harping on are false narratives.1. Keeping RadOncs necessary on site does protect the majority of RadOncs, that is a fact. 2/3. Yeah, rightfully so, if it was widely employed and when progressed to the "end game" such as virtual supervision, it would ruin the career of many people who went into community radiation oncology. Thought you were on their side?

You are acting like the world should change in a mere 2-3 years of supervision changes, changes that people don't even now fully comprehend on a general level. "No negative patient effects". I feel like this is extremely disingenuous. Are people collecting any data towards that? What the **** is this voodoo misdirection technique? Send me the treatment plans, for the lols and face palms.

Progression of supervision changes to become fully realized will kill the radonc market.

The unironic approach people are taking that built up their popularity on this site by defending the future of RadOnc to now be doing the complete opposite and trying to attack the field of RadOnc is outrageous to me.

While you think these things will end up helping you in the short term, I want everyone to think about the long term. The future of the field will be big name centers slapping the name of their cancer care center on sites and seeing patients virtually. This is what you think is best for patients?
Bad take. Sorry. But it is.

Supervision regulations should be evidence-based and patient/practice-centered, NOT a tool to prop up an oversupplied job market, full stop, secondary to too many residents graduating (ASTRO member institutions at fault).

Direct supervision didn't exist before 2009, didn't exist for decades and certainly doesn't exist in other countries or for any insured pts outside of CMS.

A common sense and reasonable approach needs to be taken, esp when we are talking community and rural places staffed by a single doc. Are you trying to tell me a doc needs to be on site 5 days a week at a rural hospital treating 15-20 a day?

Even ASTRO eventually figured out the absurdity of their statement/letter from Feb 2024 earlier this month... How do you see inpatients, or go to tumor board, or do an HDR at a solo doc practice?

 
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It is pathetic that we are having to result to defending making a profession a literal racket to make sure we retain our fees for service without a middleman scalping it by taking advantage of certificates of need and an excess of skilled labor.

Maybe the govt should pass a law that the plumber has to come once a week and inspect your toilets because there are too many licensed plumbers, and that’s just a coincidence it’s really about toilet safety.

wtf
 
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Even ASTRO eventually figured out the absurdity earlier this month... How do you see inpatients, or go to tumor board, or do an HDR at a solo doc practice?
Further, how do you RECRUIT and RETAIN a full time doc to a rural place? The only way this is going to happen is:

1. Pay (well) over 1M

OR

2. Let him commute in 3 days a week then go back to his family and do the rest of the treatment planning and image checks from home.

The third option is to use a revolving door of locums.

(There’s also actually a 4th option… it’s called let him own the linac LOL)

The first option is financially non viable for the hospital.
The third option results in very poor patient care and referrals sent out.
 
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Private equity is trying to take control of plumbing and other services, luckily for plumbers they still need to be on site to do the work, so they will still have jobs. I think #2 would be great as well, solo docs have gotten hosed from supervision, which ASTRo is thankfully pulling back on their initial requests. If there is a complete stripping of supervision and RadOncs don't even need to have ever set foot in a hospital they are treating patients in, people will take notice of that and the outcome won't be good for RadOncs.
ASTRO’s follow-up was entirely reasonable.

77427, 77435, 77432, 77290 and sim codes and sbrt/SRS delivery need direct supervision to bill, agree. Telehealth otvs are bad care and an existential threat. There’s a middle ground between that and 5 day a week incident to linac babysitting.

The business model here was managing low volume rural centers with virtual doctors. That model rightfully needed to be killed with fire.
 
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ASTRO obviously tries to protect the specialty.

The key word is "try" - they're just bad at it.

They have this mix of reactive/myopic/hierarchical behavior that just...has not been effective.

One could argue that ROCR is "proactive", however, they recycled the 21C/Humana plan from 2012, sought no outside input, and rushed into it because there were faint whispers of rumors last year that CMS was thinking about RO-APM again. Thus...reactive.

Clinging to direct supervision while the world shifts around us might slow "the badness" down...maybe? The problem with these conversations is that it assumes we're operating in a free market.

We're not.

The combination of consolidation and employment means supply and demand are not directly correlated.

It would actually be quite surprising to me, at this point, if there was ever a significant percentage of unemployed RadOncs. Maybe if the pendulum of consolidation swings the other way and private practices come roaring back, or the health insurance cartel system collapses, or something along those lines.

I think the underemployment of RadOncs will be devastating and hard to measure/easy to hide.

Clinging to direct supervision in this transition period isn't an actual solution. The only solution I really see is expanding the scope of RadOnc (into Radiation Medicine). But that's a whole separate discussion, and whenever I bring it up I uncover just how many people dreamed of a career of 3-4 clinic days per week exclusively drawing circles on their computer.

So - yeah. ASTRO tried. They continue to try. We're living the results.
 
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The future of the field will be big name centers slapping the name of their cancer care center on sites and seeing patients virtually. This is what you think is best for patients?

*The present of this field.

The weirdest part about this whole thing is that ASTRO leadership does not seem to understand the status quo of the US healthcare system.

Keeping RadOncs necessary on site does protect the majority of RadOncs, that is a fact.

You are right. However, the fact is that it's an employment issue and they are pretending it's a safety issue. Anyone with a brain sees that and people don't like liars. I know rank-and-file ROs that are very neutral on ASTRO and the letter really pissed them off.

If you are a Rad Onc engaged in this space, you probably also see several other things ASTRO could do to help the employment issue. Yet, they don't.

And didn't the MSKCC virtual paper have significantly more errors from their virtual management? Seems like there is definitely room to grow for virtual issues, but I don't think a lot of things ever actually get reported.

This is my favorite part of this whole thing. There is a conversation to be had about how virtual impacts operations and safety. No one is having it, though, because... it's about employment.

They should just stop. This is a distraction from more important conversations.
 
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Telehealth otvs are bad care and an existential threat.
Why did ASTRO and every rad onc I know support the ability for rad oncs to deliver bad care during COVID? To save/spare the rad oncs' health at the expense of their patients? How absolutely cowardly and unethical of us to have done that.
 
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Why did ASTRO and every rad onc I know support the ability for rad oncs to deliver bad care during COVID? To save/spare the rad oncs' health at the expense of their patients? How absolutely cowardly and unethical of us to have done that.

Well, it was because it was felt (for years, apparently) that the detrimental care resulting from not seeing your patients face-to-face weekly was outweighed by the risk that Covid could be spread in clinic. You know, the insanely infectious airborne virus that was mostly spread in the household and everyone eventually got anyway no matter what was done or not done to try and prevent it? The one we're not allowed to talk about?

FWIW, putting my money where my mouth is, I refused to do telehealth consults and OTVs.
 
Well, it was because it was felt (for years, apparently) that the detrimental care resulting from not seeing your patients face-to-face weekly was outweighed by the risk that Covid could be spread in clinic. You know, the insanely infectious airborne virus that was mostly spread in the household and everyone eventually got anyway no matter what was done or not done to try and prevent it? The one we're not allowed to talk about?

FWIW, putting my money where my mouth is, I refused to do telehealth consults and OTVs.
Oh. Telehealth OTVs weren't engaged in to protect the doctor's health; they were in fact still purely for the benefit of the patients.

Riiiiiiight.

There must be a very subtle dividing line from when the telehealth OTV switches from "bad care" to good care. Probably need daily CDC updates to determine that precisely. Dr. Fauci (not a rad onc!) makes the call if telehealth OTVs are bad or good, I guess. I likely wouldn't know, I am just a rad onc, but I think it was October 7, 2022,1:33PM CST, when COVID was sufficiently low threat enough that telehealth OTVs risk/benefit flipped back to normal (i.e. they once again became bad care). That's the moment I ceased continuing doing the telehealth OTV.

"I refused to do telehealth consults and OTVs." This is surprising, as your rationale seems to posit that telehealth OTVs during COVID were good care. But I kind of read between the lines you didn't throw in with all that protect-the-patients-from-COVID stuff.

(Thank you for indulging my snarky facetiousness :) )
 
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Oh. Telehealth OTVs weren't engaged in to protect the doctor's health; they were in fact still purely for the benefit of the patients.

Riiiiiiight.

There must be a very subtle dividing line from when the telehealth OTV switches from "bad care" to good care. Probably need daily CDC updates to determine that precisely. Dr. Fauci (not a rad onc!) makes the call if telehealth OTVs are bad or good, I guess. I likely wouldn't know, I am just a rad onc, but I think it was October 7, 2022,1:33PM CST, when COVID was sufficiently low threat enough that telehealth OTVs risk/benefit flipped back to normal (i.e. they once again became bad care). That's the moment I ceased continuing doing the telehealth OTV.

"I refused to do telehealth consults and OTVs." This is surprising, as your rationale seems to posit that telehealth OTVs during COVID were good care. But I kind of read between the lines you didn't throw in with all that protect-the-patients-from-COVID stuff.

(Thank you for indulging my snarky facetiousness :) )
Oh, we're on the same side with the covid stuff. I was not worried about contracting it myself, at any point. My concern was getting my patients the same level of cancer care. Having all of my staff out at once because they all got Covid and couldn't come in, yes, I thought about that early on. Was I worried they were all going to go on the ventilator and drop dead because I didn't switch all my prostate patients to 5 fractions or just give them Lupron instead? No. There are rad oncs and other MDs that are still wrapping masks around themselves and their healthy (although "allergic" to everything) children in airports. I think we all know these people (Hint: they're the same ones that refuse to go through the non-ionizing millimeter wave body scanners because they are worried about radiation exposure). At this point, it's somewhat helpful to have people wear what is essentially a sign around their neck that says "I am a self-absorbed crazy person."

We should be able to see our patients in person once a week. That's not a lot to ask. If you're dying on this hill, I uhhh...think something else is going on. Being physically present in the building for every routine LINAC treatments you're not at the machine for in the building? GTFO.
 
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We should be able to see our patients in person once a week. That's not a lot to ask. If you're dying on this hill, I uhhh...think something else is going on. Being physically present in the building for every routine LINAC treatments you're not at the machine for in the building? GTFO.
💯💯
 
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We should be able to see our patients in person once a week. That's not a lot to ask. If you're dying on this hill, I uhhh...think something else is going on. Being physically present in the building for every routine LINAC treatments you're not at the machine for in the building? GTFO.

Does anyone else notice how this quietly moved from a supervision issue to a weekly management issue? Haha. Sadly, I dont think this was intentional as the people driving this discussion don't seem to know the difference.

If we do nothing, the world is "pro-tele", not sure what else to call it here. I think ASTRO is the one dying on a hill trying to change the current policy, seemingly literally. Most doctors do not care about this very much.

I do agree there is something else going on.

You can continue to see your patients of course. I will do that too.
 
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What do you think a physician should be required to do? Sounds like you're a virtual guy.

So I think me and MedGator and MRO agree on that physicians should be on site at least a lot of times, but direct supervision is dumb, virtual supervision is dumb. Should just be a good doctor taking care of their patients.

Edit- For everyone here, let's get the Anesthesiology or Emergency Medicine SDN crew to discuss it and have them give their take on these conversations. Should we give up our "power" for private equity and encroachment? Just let them do it? Equal care who needs a RadOnc, RadOncs don't even need to be on site, no data is kept to monitor this stuff. Invite the other SDN crews in, they have a lot of thoughts about this.

More Edits- Eh maybe I'll get it started cuz I love those guys and enjoy their thoughts

You know there are radiation oncology practices owned by private equity firms right now. Today. They might even be in your state prescribing 44 fractions for prostate right now as we speak!

Today on the X I saw people arguing about whether large hospital networks or PE firms are the true villain. LOL

Bring the radiologists too. They write about PE. I have no power to give or anything, but Im excited for the discussion.
 
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Oh, yeah there are. I know there are PEs that own linacs and have a RadOnc there making them money. I'm not asking should we stop a single one of them from happening, but I'm asking if we should try to protect our field for physicians.

Just because there are PEs that own some Urorads groups doesn't mean that we should be trying to give up power for RadOncs. What is this discussion?

I don’t know. I guess my joke was too vague.

I work for a giant hospital network, not sure what power you think I have to give up.

Jokes aside, I am curious why you think ASTROs supervision opinions are preventing an otherwise inevitable PE take over…

I don’t get it.
 
Yeah I see your point, but from my point of view you're a valued member of RadOnc and your thoughts do have meaning and sway (maybe you don't think that way).

No joking, I think having RadOncs work together and doing all they can to avoid PE is the best chance we have.

Reminds me of one of my favorite poems:
Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.

Though wise men at their end know dark is right,
Because their words had forked no lightning they
Do not go gentle into that good night.

Good men, the last wave by, crying how bright
Their frail deeds might have danced in a green bay,
Rage, rage against the dying of the light.

Wild men who caught and sang the sun in flight,
And learn, too late, they grieved it on its way,
Do not go gentle into that good night.

Grave men, near death, who see with blinding sight
Blind eyes could blaze like meteors and be gay,
Rage, rage against the dying of the light.

And you, my father, there on the sad height,
Curse, bless, me now with your fierce tears, I pray.
Do not go gentle into that good night.
Rage, rage against the dying of the light.
I've always felt like, in terms of poetry, Invictus was peak RadOnc:

Beyond this place of wrath and tears
Looms but the Horror of the shade,
And yet the menace of the years
Finds and shall find me unafraid.


I would change "unafraid" with "trapped till retirement" though.
 
That is sad bro/broette,

I think this is the best job in the world, I would even do it 6 (6!!!) days a week if other people would be willing to come in to work. Can't do that, would have to move mountains, drain oceans(even with evidence behind it...). But if I can at least help people who entered this field to try to keep it afloat, I guess that is good enough.
Oh I'm divorcing the mechanics of the day-to-day "medicine" with the meta components of the job, namely, the severe geographic limitations that restrict bargaining power on both a micro- and macro-level in an overall social, economic, and political landscape where the entire industry of healthcare is producing severe issues for everyone who isn't an insurance executive.

Yes, I completely agree that wielding the beam itself is great!

It's just, like, the rest of it.
 
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RadOncs don't know what hardship is to be honest, y'all got put into a cush job and now are asking for getting rid of physician protection and inviting in mid levels. CRNAs would have ate the RadOnc field alive.

"The moment you let them in, and especially the moment you start being 'available' rather than present, is the moment that the Noctors are going to think they don't need you, and start making decisions they're not qualified to make. They start thinking they know better and decide they don't need to call you. In fact, they'll just call their other Noctor friend for their opinion.

Ask me how I know...

Never never never let this happen. Huge mistake. Keep showing up for your cush 4-5 days/week job with minimal to no call."
- From the Anesthesiology forum
Just to help me contextualize your posts: is it safe to assume your primary practice experience has been at an urban academic medical center?

I don't disagree that we need to be concerned about PE/encroachment of course. More that out all the "wolves in the tall grass" I've personally seen/been concerned about (in Radiation Oncology), this hasn't been high on the list.

If I was in an urban academic setting, especially one with residents and less than 5 days a week of clinic time for most/all attendings, I could see this being a bigger concern though.

(for many of us, the biggest threat is...the expansion of the urban academic medical center, haha)
 
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You're going to find considerable resistance from those of us in private practice who lived through the heyday of supervision hysteria. Maybe it's self-serving, but don't burden me with BS rules because chairmen refuse to cut residency spots and medical students are stupid enough to keep applying to the field. That being said, I think ROCR type proposals are a far more existential threat to jobs. I know ASTRO talks about rate stabilization, but utilization will inevitably fall. I've been part of these pilots...staffing needs drop in half.
 
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What do you think a physician should be required to do? Sounds like you're a virtual guy.

So I think me and MedGator and MRO agree on that physicians should be on site at least a lot of times, but direct supervision is dumb, virtual supervision is dumb. Should just be a good doctor taking care of their patients.

Edit- For everyone here, let's get the Anesthesiology or Emergency Medicine SDN crew to discuss it and have them give their take on these conversations. Should we give up our "power" for private equity and encroachment? Just let them do it? Equal care who needs a RadOnc, RadOncs don't even need to be on site, no data is kept to monitor this stuff. Invite the other SDN crews in, they have a lot of thoughts about this.

More Edits- Eh maybe I'll get it started cuz I love those guys and enjoy their thoughts

I’ll bite.

I’m a rheumatologist. I have worked in both hospital systems and large multispecialty private practices. I’ll address the “issues” discussed here as follows:

- Telehealth: it’s garbage. I did video visits as a rheumatologist for a few months at the height of the pandemic. I have seldom done them ever since (in fact, most recently I basically have laid down the law that I will do no telehealth visits whatsoever). When I got a lot of these telehealth patients back in the office months later, suddenly a lot of things clicked that I wasn’t able to see through the camera. I lived in a city with a lot of patients driving in from rural areas, and let me tell you…judging who does and doesn’t have inflammatory arthritis through a webcam is bad enough. Judging it through a pixelated phone camera from 2011 on a choppy 3G connection in the middle of nowhere was frankly impossible. I couldn’t wait until these people got back in the clinic. Telehealth is maybe one thing for psych or something, but if you have to actually examine your patient, it is not ok.

- Private equity: it’s a cancer on our profession. It’s bad for patients. It’s bad for doctors. It exists just to make rich Harvard douchebag MBA types richer. How is this even a discussion? Next question.

- Masks: guess what. I hardly ever got sick for years wearing masks during the pandemic. Against my better judgment, I stopped masking during this cold/flu season and spent 4 months hacking my brains out with one cold after another. I really, really don’t relish getting sick - and being a PP doc I lost some productivity one of the months when I was out for 4 consecutive days because I completely lost my voice during the nastiest cold I’ve had in a decade. I’ll wear a mask to prevent that next year, and I don’t care what anyone else has to say about it (thank you very much).

Now for me to say some things that perhaps folks here don’t want to hear.

- Radiation Oncology: I’ve been reading the posts here with interest for some time. It’s interesting. I get that you guys were top notch, super competitive medical students and you were sold a bill of goods that goes something like this: you match this top flight, super competitive residency => you get a good lifestyle and good money. You all saw that as the prize for busting your ass in medical school. And for a long time, you got both. And I get that things changed, and now a confluence of factors has come together from CMS, hospitals, PE, etc etc and now there’s fewer jobs out there and the money isn’t as good (but objectively, as far as I can tell, it still looks pretty good compared to a lot of medical specialties!). And you guys are bitter, because now this specialty isn’t delivering on this bill of goods you were sold. Someone pissed in your Cheerios.

But here’s the thing: out here in the rest of “Doctorville”, where IM subspecialists, PCPs, peds, psych etc etc live, these institutions piss in our Cheerios basically every single day. So for us, it’s a little bit harder to see what your fussing is all about, and to be sympathetic to it. As far as I can tell, EM is currently getting shafted 100x harder than you guys ever did. Geographical limitations? Guys, in my specialty (as a reminder, it’s rheum), there are tons of jobs, but most of the jobs in “good locations” are pretty crap compared to the more rural jobs - they don’t pay well, admin treats you like trash, etc. So I live in a town of like 40k in the Midwest which is about 2 hours from bigger cities in either direction. And guess what? It’s great. I made $540k last year and I am treated well by admin. When I worked in an urban area at a hospital (first job out of fellowship), I was paid $250k and treated like ****. I’m not doing that again. I bought a decent house for about $200k (try doing that in most cities in the US). It’s not thaaaat bad.

Basically: welcome to Doctorville. It’s just outside the gilded palace you guys were promised, but it’s still a nice neighborhood and all. We’ve been warming the pool up for you. Come on in, the water’s fine.
 
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Eh it varies I guess. I have always been a fan of reading anesthesiology, radiology, and EM forums, as well as other things. So I "think" I know what the typical right path is for physicians in this field, but of course I am not the smartest person in the world. The issue is when I start to see people who think they're the rightest about things and they have a clear non physician outcome, it really itches me, especially when they're the richest, somewhat oldest physicians on this forum. Makes me itchy.

From your question you ask me about urban status, but I think I am trying to help nonurban docs, so do you disagree with that?
We are both concerned about PE and encroachment, what do you think about @medgator and @TheWallnerus? Are they wolves? Cuz dude/ette, what is going on here? Feels so weird to me over this last year. @TheWallnerus used to be very pro RadOnc

Ill just say that I would have agreed a lot more with your posts 6 years ago when I graduated. My views about medicine have changed a lot. The biggest is just learning that medicine is a (often disgusting) political and economic mess.

I love my job because I actually do help people every day in real tangible ways. I barely ever get to bill 77427 for that. I dont know why you think I can only help people inside the Rad Onc clinic or that Im not working when Im remote.

I have no concerns about expressing my value to my employers, except for the fact that we keep training Rad Oncs with data suggesting we may not need them.

My practice is not going to be virtual for what it's worth, and of course we internally discussed the implications of virtual on our livelihood. Im just not so stupid to believe that I know what is best for our enormous and heterogenous country with a circus of a medical system.
 
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Eh it varies I guess. I have always been a fan of reading anesthesiology, radiology, and EM forums, as well as other things. So I "think" I know what the typical right path is for physicians in this field, but of course I am not the smartest person in the world. The issue is when I start to see people who think they're the rightest about things and they have a clear non physician outcome, it really itches me, especially when they're the richest, somewhat oldest physicians on this forum. Makes me itchy.

From your question you ask me about urban status, but I think I am trying to help nonurban docs, so do you disagree with that?
We are both concerned about PE and encroachment, what do you think about @medgator and @TheWallnerus? Are they wolves? Cuz dude/ette, what is going on here? Feels so weird to me over this last year. @TheWallnerus used to be very pro RadOnc
Hahaha - I take this as a "yes", you're a main campus urban academic RadOnc.

I don't disagree with your concerns. I absolutely think you're interested in the health/integrity of the specialty.

I only disagree with how you're weighting each of the risks we all face. Maybe "disagree" is too strong of a word.

For the other posters in this discussion, I either know them personally or know enough about their practice situations to understand what drives their opinions.

You're going to find considerable resistance from those of us in private practice who lived through the heyday of supervision hysteria. Maybe it's self-serving, but don't burden me with BS rules because chairmen refuse to cut residency spots and medical students are stupid enough to keep applying to the field. That being said, I think ROCR type proposals are a far more existential threat to jobs. I know ASTRO talks about rate stabilization, but utilization will inevitably fall. I've been part of these pilots...staffing needs drop in half.

I'm much more in line with @Reaganite here.

It's just...these supervision arguments are only a piece of the existential threats we all face. All of medicine has already moved into the virtual/general/telehealth world. Fighting it is pointless - accepting and adapting is more conducive to successful survival.
 
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Basically: welcome to Doctorville. It’s just outside the gilded palace you guys were promised, but it’s still a nice neighborhood and all. We’ve been warming the pool up for you. Come on in, the water’s fine.

This is my favorite post and I cant wait to adopt the phrase someone pissed in your cheerios.

I just want to say I am a care giver for someone with lupus and have a ton of respect for rheumatologists. I wish you all were paid more and had better data/biomarkers. I always feel lucky in oncology with what we can offer patients in terms of data, clinical information, and hope.

I am not convinced that telehealth can't work in oncology yet, but agree that it is likely too poor quality to replace an in-person physician completely.
 
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Guys, in my specialty (as a reminder, it’s rheum), there are tons of jobs, but most of the jobs in “good locations” are pretty crap compared to the more rural jobs - they don’t pay well, admin treats you like trash, etc. So I live in a town of like 40k in the Midwest which is about 2 hours from bigger cities in either direction. And guess what? It’s great. I made $540k last year and I am treated well by admin. When I worked in an urban area at a hospital (first job out of fellowship), I was paid and treated like ****. I’m not doing that again. I bought a decent house for about $200k (try doing that in most t cities in the US). It’s not thaaaat bad.
You're making more than many RadOncs I know - I'm super happy you posted, please don't run away.

Can you tell us more about the bad jobs? I think it would be helpful for people to begin to understand why people like me aren't worried about unemployment in RadOnc, I'm worried about underemployment.

And by that, I mean, compared to the shiny bill of goods we all heard about 20 years ago - that's gone. Instead of unemployment we got geographic restrictions and significant wage stagnation/cuts.

My personal impression is that the floor and ceiling of RadOnc jobs (in terms of compensation and lifestyle) have become very compressed. The ceiling has lowered but the floor remains relatively unchanged (to lowered).

Many specialties which were "known" to not be paid well (in comparison to RadOnc) when I was in med school in the 2000s now are in the ballpark (or better) of RadOnc.

I just don't know how "true" my impression is, if that makes sense.
 
Not sure those are entirely unreasonable requests. But maybe docs should know their location before asking for stuff like that 🤷🏾

I’ll bite.

I’m a rheumatologist. I have worked in both hospital systems and large multispecialty private practices. I’ll address the “issues” discussed here as follows:

- Telehealth: it’s garbage. I did video visits as a rheumatologist for a few months at the height of the pandemic. I have seldom done them ever since (in fact, most recently I basically have laid down the law that I will do no telehealth visits whatsoever). When I got a lot of these telehealth patients back in the office months later, suddenly a lot of things clicked that I wasn’t able to see through the camera. I lived in a city with a lot of patients driving in from rural areas, and let me tell you…judging who does and doesn’t have inflammatory arthritis through a webcam is bad enough. Judging it through a pixelated phone camera from 2011 on a choppy 3G connection in the middle of nowhere was frankly impossible. I couldn’t wait until these people got back in the clinic. Telehealth is maybe one thing for psych or something, but if you have to actually examine your patient, it is not ok.

- Private equity: it’s a cancer on our profession. It’s bad for patients. It’s bad for doctors. It exists just to make rich Harvard douchebag MBA types richer. How is this even a discussion? Next question.

- Masks: guess what. I hardly ever got sick for years wearing masks during the pandemic. Against my better judgment, I stopped masking during this cold/flu season and spent 4 months hacking my brains out with one cold after another. I really, really don’t relish getting sick - and being a PP doc I lost some productivity one of the months when I was out for 4 consecutive days because I completely lost my voice during the nastiest cold I’ve had in a decade. I’ll wear a mask to prevent that next year, and I don’t care what anyone else has to say about it (thank you very much).

Now for me to say some things that perhaps folks here don’t want to hear.

- Radiation Oncology: I’ve been reading the posts here with interest for some time. It’s interesting. I get that you guys were top notch, super competitive medical students and you were sold a bill of goods that goes something like this: you match this top flight, super competitive residency => you get a good lifestyle and good money. You all saw that as the prize for busting your ass in medical school. And for a long time, you got both. And I get that things changed, and now a confluence of factors has come together from CMS, hospitals, PE, etc etc and now there’s fewer jobs out there and the money isn’t as good (but objectively, as far as I can tell, it still looks pretty good compared to a lot of medical specialties!). And you guys are bitter, because now this specialty isn’t delivering on this bill of goods you were sold. Someone pissed in your Cheerios.

But here’s the thing: out here in the rest of “Doctorville”, where IM subspecialists, PCPs, peds, psych etc etc live, these institutions piss in our Cheerios basically every single day. So for us, it’s a little bit harder to see what your fussing is all about, and to be sympathetic to it. Geographical limitations? Guys, in my specialty (as a reminder, it’s rheum), there are tons of jobs, but most of the jobs in “good locations” are pretty crap compared to the more rural jobs - they don’t pay well, admin treats you like trash, etc. So I live in a town of like 40k in the Midwest which is about 2 hours from bigger cities in either direction. And guess what? It’s great. I made $540k last year and I am treated well by admin. When I worked in an urban area at a hospital (first job out of fellowship), I was paid $250k and treated like ****. I’m not doing that again. I bought a decent house for about $200k (try doing that in most cities in the US). It’s not thaaaat bad.

Basically: welcome to Doctorville. It’s just outside the gilded palace you guys were promised, but it’s still a nice neighborhood and all. We’ve been warming the pool up for you. Come on in, the water’s fine.
What you don't understand is that when you become a radiation therapist you undergo an internal change in your circadian rhythms wherein you happily wake up at 5AM every day. And you will happily treat Mr. Johnson with prostate cancer at 6AM. And you will tell Dr. SDN Radonc that Mr. Johnson can ONLY come in at 6AM for treatment. And if Dr. SDN isn't in at 6am, you may be staring down a certain selfie-taking ex RTT at your quitam trial.
 
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I agree everyone, I do not think Radiation Oncologists need to make money. Let's get this down. Thank you @elementaryschooleconomics, @medgator, @NotMattSpraker. We barely even work, I clearly want to work more than you guys.

I want to work more than you guys and I'll take less money.
I agree with this. My upper limit of the RVUs I’ll tolerate at my current rate is at least double if not triple. But they’re not there.

I’m in the minority. Plenty are content with 5k wRVU at whatever that pays. And I’ll drive many hours to do it. But centers prefer to fly in incompetent geriatric locums who will do it for half of pro collections because they are bored. And there’s no shortage of those guys.
 
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Jordan Johnson literally posted here last year I believe. I don’t think his business model will work with rad oncs on site minimum three days a week and staffing all OTV, sims, and stereo in person.

Hahahahahaha I dont want to admit what I thought BO meant until I saw this post.
 
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i think a Rheumatologist making 550k in an undesirable location is pretty good especially if you used to make 200s in a hellpit job. You already make more or equivalent than a lot of rad oncs I know. The difference is if you wanted to get back to a big city, you probably could find a job quite easily. For many rad oncs leaving a job, might mean never getting even 300 miles close to family ever again. There are some unique things about our job market. You do touch on a wider issue in medicine which is a lack of solidarity. I care that your cheetos are being pissed on and you should care about mine.
 
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