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Rad Onc - Supply & Demand

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Gfunk6

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Supply and Demand for Radiation Oncology in the United States: A Resident Perspective

Editorial just published in Red Journal 2/1/17.

Link: http://www.redjournal.org/article/S0360-3016(16)33385-5/fulltext

Intro:
The recent study by Pan et al has raised concerns within the American radiation oncology (RO) trainee community. The authors update supply and demand projections for RO in the United States. Whereas projections several years ago forecasted an undersupply of radiation oncologists (ROs), the study cites updated data for the proposition that supply will outpace demand over the next decade, resulting in an excess of ROs.
This excess would be driven, in part, by residency expansion, creating a 27% predicted increase in practicing ROs, with only a 19% predicted increase in radiation therapy (RT) demand. This study parallels the current perception held by many graduating residents who have encountered a seemingly increasingly competitive job market and is in concert with previously published concerns that we are training too many providers.

Some relevant points:

1. The same oversupply issue reared its head between 1989 -1993. After research, the leaders of the field felt the answer was "limit # of residents + increase time from 3 to 4 years."

2. Authors recommend a subcommittee in ASTRO to look at this and make recommendations as has been done by Plastic Surgery.

3. Recruit residents who are likely to practice in maldistributed areas

But conclusions weak in my opinion:

Despite these new projections for the RO job market, we do see optimism in the future of our field. We survived oversupply issues in the 1990s and will do so again. Abundant data support the efficacy of RT, and our talented physicians are certain to continue to bring forth ingenuity and innovation with novel applications of radiation and expand our scope of practice. However, that alone is not enough. We must take a conscientious, data-driven approach to the workforce needs and continue to advocate for our specialty and patients, from the clinic to Capitol Hill.

This problem (overproduction of residents) can only be solved internally - through ASTRO/SCAROP/Illuminati. Feds are more than happy to have more physicians with ever lower reimbursement.
 

Chartreuse Wombat

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Thanks for posting. I will admit to holding the position of Program Director in a well-known academic center. I was in training during the last oversupply event and the response at that time has proven to be wise. I am reluctant to post as I don't want to be accused of virtual signalling that is so prevalent but I think my comments may provide some perspective.

As part of the required annual survey that residents complete I have included a question on whether the resident complement should increase, decrease or stay the same. For the last 6 years the (vast) majority of residents have answered "Increase resident complement". Despite this, I have held the number of positions constant for the last 5 years despite increase in faculty FTE. We have reworked the schedule so that more faculty are working independently (although most still work with residents) and we are using advanced practice providers with some success.

I share the concerns of many on this site that we are training too many people. Yes, we have managed oversupply in the past but that was when reimbursement levels allowed people to see patients 2-3 days a week. Those days are long gone. Health care reform is driving consolidation and many community hospitals are partnering with an academic center. Unfortunately in many places the residents are being used to provide assistance in centers with limited academic infrastructure. Further complicating things narrowing of networks is making it harder and harder for "centers of excellence" to be paid a premium to provide similar care so that faculty must do more clinical work (which for them is easier with a resident).

I don't share the resident authors enthusiasm that ingenuity and innovation will solve the problem. "Data-driven"? As has been pointed out on several other strings. We have the data!

The solution to the problem lies with the chairs of academic departments-they must stop increasing positions and cease from opening new programs. Every academic center has a different financial structure and I will not guess the motivations of the chairs but this has to stop. This is a classic case of the Tragedy of the Commons. Each department is acting in their own self-interest to the detriment of the specialty (and future trainees). As GFunk suggests an oversupplied labor force leads directly to lower wages and less autonomy and control.
 
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evilbooyaa

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I think it's unfortunate that residents are suggesting to increase resident complement. Is this because attendings have mandatory resident coverage, and therefore a resident covering 2 attendings (on 2 services for example) is routine?

To me, suggesting to increase resident complement likely means that either 1) the residents are blissfully unaware of the job market situation in Rad Onc, or 2) they hope that infusing more residents into the program means that they won't have to double cover attendings in the future.

Even at an academic facility, is it absolutely necessary for every attending to have resident coverage for every single day/week/month of every single year?

I know this is easy to say as a resident, but if I were a PD, I would ensure 1:1 resident to attending coverage without cross-covering. Down time (such as attending vacations or at conferences or in meetings) should be spent pursuing research opportunities or reading. Despite my belief that there is a functional way to make cross covering work to the benefit of the resident's education (as most who support this practice insist upon), I doubt that a resident covering two attendings seeing follow-ups, consults, OTVs, and CT Sims (including contours for both) is an educational use of time.
 
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scarbrtj

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our talented physicians are certain to continue to bring forth ingenuity and innovation with novel applications of radiation

Said it once, I'll say it again. I do not think the overall number of cancer patients and indications for RT are dramatically changing over time. However, treatment time and fraction number are. Let's say a rad onc sees 6 new patient/week. In 2000, you could assume an average across all patients of 5 weeks (25 fraction) treatment time. That would translate into 6*5=30 patient/day on average under treatment. Fast forward to 2017. I do 16 fractions for most breast patients. Single fraction bony met. Most previous whole brain patients have gone from 10 fractions to a single SRS. Definitive lung RT patients from 7 weeks to 3-4 fractions. So now the math is more like 3 weeks of treatment on average. So those 6 new patients a week equals 6*3=18 patients on treatment every day. HUGE difference in man power necessary there. And IMRT has become much easier. SBRT is very easy. Radiation I think has become much less toxic and "medically fidgety" in the last 20 years. My reimbursement is much less now versus 15 years ago--and that is "my fault" and I'm sort of proud of it.

We have "downsized" our own selves, and appropriately so, clinically, as I mentioned. It's now time for us to realize this as a specialty and respond accordingly. We may have a few more indications for radiation nowadays versus 20 years ago (but we may have lost as many as gained, IDK), and we may gather a few more here and there over the ensuing decades. But we need to deliver A LOT less daily treatments than we were 20 years ago. It's just a different specialty. It's tough to keep up. See the OODA Loop. We're outside the loop!
 
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Chartreuse Wombat

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I think it's unfortunate that residents are suggesting to increase resident complement. Is this because attendings have mandatory resident coverage, and therefore a resident covering 2 attendings (on 2 services for example) is routine?

To me, suggesting to increase resident complement likely means that either 1) the residents are blissfully unaware of the job market situation in Rad Onc, or 2) they hope that infusing more residents into the program means that they won't have to double cover attendings in the future.

Even at an academic facility, is it absolutely necessary for every attending to have resident coverage for every single day/week/month of every single year?

I know this is easy to say as a resident, but if I were a PD, I would ensure 1:1 resident to attending coverage without cross-covering. Down time (such as attending vacations or at conferences or in meetings) should be spent pursuing research opportunities or reading. Despite my belief that there is a functional way to make cross covering work to the benefit of the resident's education (as most who support this practice insist upon), I doubt that a resident covering two attendings seeing follow-ups, consults, OTVs, and CT Sims (including contours for both) is an educational use of time.

I think that you are making some assumptions about our practice that are not true. In our model most of our faculty rotate to other practices (where they generally have no resident coverage). To pair a resident 1:1 with these attendings while at the main center will not result in residents meeting case load minimums (parenthetically, in my estimation-450 cases over four years which is the ACGME minimum is not sufficient with the complexity of XRT today). Most of the rotations are shared with 2 faculty to 1 resident. Residents are in clinic 3-4 days a week and finish with about 650 cases (right around the national median) when they are finished and duty hour violations are rare. Some applicants view shared services as a negative-in my view it requires residents to be efficient and prioritize-skills that will serve them well when they begin their own practice. To keep them in a bubble during training does not prepare them for the real world. Of course many will say that I am "using residents to do scut work". Many of us see patients on our own on a routine basis and contour, approve plans etc on our own.
 

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A third possibility is that this residency program is well-known enough that its grads have no trouble finding jobs regardless of the market.
When your preferred geographic locale is saturated, doesn't matter where you trained....

As has been said before on this forum, program prestige really doesn't master as much for pp, except that larger programs tend to have better networking opportunities through a more expensive alumni network
 

thecarbonionangle

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the main reasons why residents would consistently respond they want an increase in size of a program despite evidence that the growth programs will hurt them in the long term is that they are responding to pressures within their program and acting in self-interest in the short term. I don't think these responses would be unique to one program. I would bet many residents in programs, especially in busy 2-3 residents a year ones, would want an increase in their residents. Many programs have dealt with growth and increase in patient loads by delegating more to the residents, double coverage and in some rare cases triple coverage. Some of this is patient care but a good amount non-patient care related. Residents are spending more time doing these duties and see an extra resident as a way to free up their hands, perhaps they may be able to get an extra academic day, or increase their allowed research months or get some research months in programs that don't even have them, or keep the status quo. It's a self-perpetuating cycle when the general culture of chairs is to use residents as cheap labour. They are the least represented people in an institution. When a hospital administration wants to make a big change to a hospital's nursing schedule or duties, they meet with the nursing leaders, perhaps a union, discussions go back and forth, they negotiate their contracts. When a a department changes something for the residents, what are they to do? talk to their chief? you mean the person who is looking for jobs soon and can't ruffle the feathers of the chair too much? good luck with that.
 
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BobbyHeenan

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Supply and Demand for Radiation Oncology in the United States: A Resident Perspective

Editorial just published in Red Journal 2/1/17.

Link: http://www.redjournal.org/article/S0360-3016(16)33385-5/fulltext

Intro:

Some relevant points:

1. The same oversupply issue reared its head between 1989 -1993. After research, the leaders of the field felt the answer was "limit # of residents + increase time from 3 to 4 years."

2. Authors recommend a subcommittee in ASTRO to look at this and make recommendations as has been done by Plastic Surgery.

3. Recruit residents who are likely to practice in maldistributed areas

But conclusions weak in my opinion:



This problem (overproduction of residents) can only be solved internally - through ASTRO/SCAROP/Illuminati. Feds are more than happy to have more physicians with ever lower reimbursement.

Regarding # 3 - there's really no way to do this with reliable results unless you tether a commitment to pay/loan forgiveness or something based upon eventual practice location. Otherwise, you're going to get the same lines at interviews about enthusiasm about practicing in Rhinelander, WI the same way everyone at all my interviews was just so enthusiastic about going into the lab for a year because they couldn't wait to go into academics...then end up in private practice.

Agree about solving it...I think we just keep holding feet to the fire. Ultimately I think you're going to need someone with power or a "name" (or a coalition of a few institutions that make a pact not to continue to expand) come out and get really brave and step up at ASTRO or theMedNet or some public forum and basically call a spade a spade - there is perverse incentive for all of these chairmen/women to keep churning out residents and new programs and you're doing a major disservice to a whole generation of physicians in our specialty.

Ultimately, I think it's going to take the Chair of ASTRO to make a statement about this in a concrete manner condemning further expansion. Not statements like "we'll look into it" or let's look outside the box (rad onc/IR combined residency), just cut and dry "we must stop expansion right now and re-evaluate at a later date, because right now the data is clear the trend is alarming." Is it not his/her job to have the best interest of the field as a whole and to stand up for the entirety of the field, irrespective of the financial considerations of individual departments?
 

OTN

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In the current environment, I do think strong private practices take training pedigree into account. While research isn't all that important, exposure to a wide variety of treatment techniques and technologies is important, and if you've trained with some well-known names it certainly doesn't hurt. I'd certainly take someone from a big name program over a smaller program, all other things being equal (big caveat there). Why not? Now, some of these big name programs have better clinical training than others, which is also an important consideration, but we all generally know which programs have well-trained residents.

I strongly agree that medical students will lie through their teeth about wanting to be in a rural/undesirable practice after graduation. I lied voraciously, multiple times over, when talking about loving research, wanting to go into academics, etc. I really do wish I didn't have to, but that's the game that was played 11-12 years ago when I applied.

I'm glad to see this issue continue to get addressed by ASTRO. It's very clear the # of residency spots needs to be dramatically reduced- let's hope it happens much sooner than later.
 
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Okazaki Frag Grenade

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(M1 here) I recognize that nobody here is a fortune teller and that many factors play a role in the supply/demand of the field. With that said, should this climate give a med student pause about pursuing this field?
 

medgator

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(M1 here) I recognize that nobody here is a fortune teller and that many factors play a role in the supply/demand of the field. With that said, should this climate give a med student pause about pursuing this field?
Do you care about where you will practicing geographically when you're all finished?
 

Okazaki Frag Grenade

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Do you care about where you will practicing geographically when you're all finished?

To some extent. I'd prefer the southeast if possible and would probably pick a smaller city over a huge metropolis. I wouldn't want to be in a Boston/NYC/LA.
 

medgator

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To some extent. I'd prefer the southeast if possible and would probably pick a smaller city over a huge metropolis. I wouldn't want to be in a Boston/NYC/LA.
Regions are probably safe, wouldn't bank on a specific city in any given year esp if more desirable, closer to the coasts etc
 
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thecarbonionangle

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NPs and PAs cost a significant amount of money compared to residents, especially a well seasoned one. A rad onc NP or a PA who has experience in the field, can easily cost a program 100K+ and they demand more benefits like a matching 401k and they do not take call. Some of these advanced practioners can contour and that makes them even more valuable. These advanced practitioners tend to be more protective of their schedule and are not necessarily subservient to the chairs. It becomes a lot easier to hire people who don't get to negotiate their contacts and who need a contract renewal every year from you, have an MD, and work for 50k without much benefits. This is overall a problem with the way medical residencies are set up in the US. To make things worst, ask the general public and most would have little sympathy because they already believe we get paid too much.
 

Old rad onc

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NPs and PAs cost a significant amount of money compared to residents, especially a well seasoned one. A rad onc NP or a PA who has experience in the field, can easily cost a program 100K+ and they demand more benefits like a matching 401k and they do not take call. Some of these advanced practioners can contour and that makes them even more valuable. These advanced practitioners tend to be more protective of their schedule and are not necessarily subservient to the chairs. It becomes a lot easier to hire people who don't get to negotiate their contacts and who need a contract renewal every year from you, have an MD, and work for 50k without much benefits. This is overall a problem with the way medical residencies are set up in the US. To make things worst, ask the general public and most would have little sympathy because they already believe we get paid too much.

Hey everyone,
I have been in pp for 22 years. I have never seen our field more uncertain. The decrease in reimbursement has been extreme the last few years. Now MACRA and threat of bundling, threaten to make either Med oncs or hospitals the gate keepers. Meanwhile my longtime friends and colleagues are planning on retiring in 2 years. I honestly believe that after 2 years there will be some practices that will need to close. University programs will get more aggressive. As a student, you had better love this field as I don't think it will be getting better for a while. Good jobs with honest partners will be getting fewer to come by.

I am an optimist and eventually things will get better. But too late for me I am afraid. I will be 55 soon and although I love what I do, I see the writing on the wall. Be good to your staff and your patients and you will always find work. I have been a big fan of your site and I must say that reading your commitment to patients, the great field of Rad Onc, and to helping those who need it most..... the young docs, makes me proud to be one of you. I wear 2 hats, owner and doctor. Getting harder, but the doctor hat is always the most important!
 
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XRT_doc

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Hey everyone,
I have been in pp for 22 years. I have never seen our field more uncertain. The decrease in reimbursement has been extreme the last few years. Now MACRA and threat of bundling, threaten to make either Med oncs or hospitals the gate keepers. Meanwhile my longtime friends and colleagues are planning on retiring in 2 years. I honestly believe that after 2 years there will be some practices that will need to close. University programs will get more aggressive. As a student, you had better love this field as I don't think it will be getting better for a while. Good jobs with honest partners will be getting fewer to come by.

I am an optimist and eventually things will get better. But too late for me I am afraid. I will be 55 soon and although I love what I do, I see the writing on the wall. Be good to your staff and your patients and you will always find work. I have been a big fan of your site and I must say that reading your commitment to patients, the great field of Rad Onc, and to helping those who need it most..... the young docs, makes me proud to be one of you. I wear 2 hats, owner and doctor. Getting harder, but the doctor hat is always the most important!

Unfortunately the abundance of the labor pool and the decreasing reimbursements have made most private practice partnerships pretty ruthless towards the young. I would be far more careful in joining a private practice in this day and age than joining a hospital which would probably be more honest about what they'll pay you at the end of the day.
 
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Gfunk6

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Unfortunately the abundance of the labor pool and the decreasing reimbursements have made most private practice partnerships pretty ruthless towards the young. I would be far more careful in joining a private practice in this day and age than joining a hospital which would probably be more honest about what they'll pay you at the end of the day.


I would replace hospitals being "more honest" than PP to "less dishonest" and than PP.


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DebtRising

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Supply and Demand for Radiation Oncology in the United States: A Resident Perspective

This problem (overproduction of residents) can only be solved internally - through ASTRO/SCAROP/Illuminati. Feds are more than happy to have more physicians with ever lower reimbursement.

Awesome post. This is where you may be mistaken however.
CMS (since you reference feds) actually are not happy with increased physicians. Yes, reimbursement is based on a mostly static formula with some regional variation based on supply relating to workforce however one of the biggest drivers of health care costs is utilization (you can google and see so many reports on this, some from the CDC, that I will not link. It is also self evident, more use = more costs; also there is only very limited cost reduction with scale - a hospital doing 100 hip surgeries versus 20, both still need OR investment, infection protocols, anesthesiologists, in patient beds, etc. It's not like a manufacturing center where if you start doing 10000 of something you can replace part of the work force with automated machines for parts... but I digress).

What then are the potential drivers of health care utilization? Well there are many, but one of the biggest factors is increased supply of services.
https://www.google.com/url?sa=t&rct...ePcnCRXbYNlmeZOECICSHg&bvm=bv.143423383,d.amc

This is a report from the CDC, see chart 2.


So let's take radiation oncology from the perspective of medicare, who pays for some of these trainees.
1. The federal government is paying money to educate physicians in a specialty whose labor model projects a large oversupply over the next decade
2. The more radiation oncologists, the more utilization. More providers will find the extra bone met, the extra borderline DCIS, low risk prostate (and maybe correctly so). This will lead to more health costs and divert dollars away from needed programs.
3. Even with slightly lower reimbursement per provider, you cannot overcome 2 because as reimbursement goes down then there is an inverse response of trying to increase volume to make up the difference, which is a pan specialty response


I think you are correct in that ASTRO could care less about us. Senior attendings may care about job prospects only in so much as it affects reputation, and will often act in a protective manner if they are challenged by the hiring of younger faculty (because in some payment models, that would be money out of their pocket). So will private practice docs. The ARRO paper is a nice nod but this field needs to go down to 80 residents by next year. Remember that the labor forecast projects a 27% increased in work force and a 19% increase in demand. There is no way this environment supports a 19% increase in demand. Even since 2015 there has been decreased reimbursement, decreased referrals under new payment models, decreased indications, and increasing hypofractionation. So while the 27% work force is a number based on facts, the demand % is an estimate and it is going downwards. Who is going to bear the brunt of that? The guy who loaded up 200-300K debt and will never have a chance at the caliber of career most of these senior physicians have had.

So back to my point, the argument needs to be taken to CMS directly. I am crafting a letter to Dr. Price and to CMS that builds on this data and highlights how in this forgotten corner of medicine, radiation oncology may be abusing the system with willful expansion of slots in the face of evidence there is already an oversupply projected for 10 years and may be a ripe area to cut education funds without damage to society. Will it matter? Who knows - but it is a reasonable position to lobby CMS to cut off all medicare funding for a field that DOES NOT REQUIRE even close to the number of graduates they produce based on the fields' own published labor model. Let the programs self fund using the resident as a poor man's PA / physician extender and antiquated case log requirement roster as proof of 'education'.

The next step is to publish a paper examining in all the programs that expanded, the number of either new positions or new faculty track candidates they have taken. If the demand for radiation has grown so much, and the biggest centers have been absorbing satelites and thus patient loads, then there should be a concordant increase in positions year by year, and this could be retrieved by googling rosters and a bit of doximity digging. If there is not, and we then pair that with the evidence that private practice is now being absorbed into these centers at alarming rates, then how can any program director or chair justify the expansions? If the jobs aren't at those centers, they aren't out there in numbers proportional to how much this field expanded regardless of the smattering of jobs in remote areas that need targeting recruiting.

The bottom line is that with such obvious abuse of the residency system, thinking ASTRO will protect us does not appear to be realistic. But highlighting the data to education payers directly may have some merit. Or the field might go down in flames and get a real ugly and nasty divide between the older and younger generations. Hopefully you are all being honest with the medical students you come in contact with.
 
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Old rad onc

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I would replace hospitals being "more honest" than PP to "less dishonest" and than PP.





Response by old rad onc:
I agree that hospitals should be lumped together with pp as far as honesty. I have seen rad oncs left high and dry by hospitals. As I learned from Terry Wall, the new hires must always research an employer for their track record of churning. As the oversupply in our field gets worse, buyer beware. We are a small field. My advice is to research the job as much as possible. But even then it can be unavoidable. I was an employee for 6 years, and had been promised partnership after 3. I was so po'ed I started my own center. The research shows many rad oncs don't stay with the first job. But it all works out in the end.

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bluebubbles

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CMS (since you reference feds) actually are not happy with increased physicians.

So back to my point, the argument needs to be taken to CMS directly.

This is really smart, much better than waiting for SCAROP. Agree that senior rad onc's and "big names" of academia are nice to your face but are predatory when it comes to issues of employment and resident expansion.
 

radiaterMike

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This is really smart, much better than waiting for SCAROP. Agree that senior rad onc's and "big names" of academia are nice to your face but are predatory when it comes to issues of employment and resident expansion.

CMS funds hospitals for a specified allotment of residents. Most hospitals exceed that and are funded from the hospital budget. I may be wrong but I don't think CMS dictates what specialities it pays for but rather only the total number of residents. Unless you think there is an overall excess across all specialities not sure this is the best avenue.


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fiji128

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Awesome post. This is where you may be mistaken however.
CMS (since you reference feds) actually are not happy with increased physicians. Yes, reimbursement is based on a mostly static formula with some regional variation based on supply relating to workforce however one of the biggest drivers of health care costs is utilization (you can google and see so many reports on this, some from the CDC, that I will not link. It is also self evident, more use = more costs; also there is only very limited cost reduction with scale - a hospital doing 100 hip surgeries versus 20, both still need OR investment, infection protocols, anesthesiologists, in patient beds, etc. It's not like a manufacturing center where if you start doing 10000 of something you can replace part of the work force with automated machines for parts... but I digress).

What then are the potential drivers of health care utilization? Well there are many, but one of the biggest factors is increased supply of services.
https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwihjqHqmLnRAhUE7oMKHTQPC4oQFggaMAA&url=https://www.cdc.gov/nchs/data/misc/healthcare.pdf&usg=AFQjCNHZR9kjrp-0cSrNXQDuh0dyXMTirA&sig2=ePcnCRXbYNlmeZOECICSHg&bvm=bv.143423383,d.amc

This is a report from the CDC, see chart 2.


So let's take radiation oncology from the perspective of medicare, who pays for some of these trainees.
1. The federal government is paying money to educate physicians in a specialty whose labor model projects a large oversupply over the next decade
2. The more radiation oncologists, the more utilization. More providers will find the extra bone met, the extra borderline DCIS, low risk prostate (and maybe correctly so). This will lead to more health costs and divert dollars away from needed programs.
3. Even with slightly lower reimbursement per provider, you cannot overcome 2 because as reimbursement goes down then there is an inverse response of trying to increase volume to make up the difference, which is a pan specialty response


I think you are correct in that ASTRO could care less about us. Senior attendings may care about job prospects only in so much as it affects reputation, and will often act in a protective manner if they are challenged by the hiring of younger faculty (because in some payment models, that would be money out of their pocket). So will private practice docs. The ARRO paper is a nice nod but this field needs to go down to 80 residents by next year. Remember that the labor forecast projects a 27% increased in work force and a 19% increase in demand. There is no way this environment supports a 19% increase in demand. Even since 2015 there has been decreased reimbursement, decreased referrals under new payment models, decreased indications, and increasing hypofractionation. So while the 27% work force is a number based on facts, the demand % is an estimate and it is going downwards. Who is going to bear the brunt of that? The guy who loaded up 200-300K debt and will never have a chance at the caliber of career most of these senior physicians have had.

So back to my point, the argument needs to be taken to CMS directly. I am crafting a letter to Dr. Price and to CMS that builds on this data and highlights how in this forgotten corner of medicine, radiation oncology may be abusing the system with willful expansion of slots in the face of evidence there is already an oversupply projected for 10 years and may be a ripe area to cut education funds without damage to society. Will it matter? Who knows - but it is a reasonable position to lobby CMS to cut off all medicare funding for a field that DOES NOT REQUIRE even close to the number of graduates they produce based on the fields' own published labor model. Let the programs self fund using the resident as a poor man's PA / physician extender and antiquated case log requirement roster as proof of 'education'.

The next step is to publish a paper examining in all the programs that expanded, the number of either new positions or new faculty track candidates they have taken. If the demand for radiation has grown so much, and the biggest centers have been absorbing satelites and thus patient loads, then there should be a concordant increase in positions year by year, and this could be retrieved by googling rosters and a bit of doximity digging. If there is not, and we then pair that with the evidence that private practice is now being absorbed into these centers at alarming rates, then how can any program director or chair justify the expansions? If the jobs aren't at those centers, they aren't out there in numbers proportional to how much this field expanded regardless of the smattering of jobs in remote areas that need targeting recruiting.

The bottom line is that with such obvious abuse of the residency system, thinking ASTRO will protect us does not appear to be realistic. But highlighting the data to education payers directly may have some merit. Or the field might go down in flames and get a real ugly and nasty divide between the older and younger generations. Hopefully you are all being honest with the medical students you come in contact with.
 

fiji128

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Overall agree with DebtRising's post, it feels like there is something that is starting to go deeply wrong with the field because of the oversupply of MDs issue and other external factors. I just got my first email today regarding the MARCHA stuff telling me how I have to treat bone mets (dose and number of fractions) to meet CMS performance measures, too bad if you are a 55 year old with a breast/prostate cancer with only a single spine met, can't do any better then 30 Gy in 10 fx per the government. I can imagine that soon this will involve all commonly treated diseases and sites with the overall goal taking clinical judgement out of the picture so as to decrease utilization of our services and with an over supply of MDs there will be no way to push back. Esh.
 
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Overall agree with DebtRising's post, it feels like there is something that is starting to go deeply wrong with the field because of the oversupply of MDs issue and other external factors. I just got my first email today regarding the MARCHA stuff telling me how I have to treat bone mets (dose and number of fractions) to meet CMS performance measures, too bad if you are a 55 year old with a breast/prostate cancer with only a single spine met, can't do any better then 30 Gy in 10 fx per the government. I can imagine that soon this will involve all commonly treated diseases and sites with the overall goal taking clinical judgement out of the picture so as to decrease utilization of our services and with an over supply of MDs there will be no way to push back. Esh.
Macra? Haven't heard anything about that in terms of clinical recs. Care to share more?
 

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Macra? Haven't heard anything about that in terms of clinical recs. Care to share more?

From ASTRO:

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repealed the Sustainable Growth Rate (SGR) and replaced it with the Quality Payment Program (QPP), which consists of the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Model (APM) programs. Under the QPP, the focus of Medicare payments has shifted from the current volume-based, fee-for-service payment structure, to a more value- and quality-based payment system. MIPS and APMs will go into effect beginning January 1, 2017, and participation in 2017 will be used to determine Part B payments in 2019.

I am no expert on this whatsoever, but overall I think its a different way of calculating reimbursements for services. It moving away from fee for services to some sort of quality-based payment. The letter I got suggest that quality for bone mets will be graded by the following:

All patients, regardless of age, with bone metastases, and no previous radiation to the same anatomic site who receive EBRT [for the treatment of bone metastases] with any of the following recommended fractionation schemes: 30Gy/10fxns, 24Gy/6fxns, 20Gy/5fxns, and 8Gy/1fxn.

Anything outside of this would be counted against the quality of care you are providing in the eyes of CMS (Center of Medicare and Medicaid Services).
 

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Came across this recently....seems to just add more to the pile of evidence that there is a maldistribution problem with headhunters making a killing on supplying rad onc labor to rural areas, while we have underemployment/unemployment on the coasts.....

The Rise of the temp Radiation Oncologist
 
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OTN

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What's the job market in Texas like?
As with anything, depends on the specific location. Austin, Dallas, Houston, San Antonio are very competitive markets, but the market improves a bit in smaller towns, clinics, etc.
 

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update since I wrote an earlier post in this thread. I never received any contact back regarding my post above.

Inarguably is a worthwhile issue... tax dollars in some capacity used to train more radiation oncology residents while our own fields employment model states the country is oversupplied for a decade. That should be illegal or fraudulent, in fact. in time will re attempt via phone, if anything happens will post.

Different issue; there are multiples of new medical student posts trying to assess field. Can a sticky post be constructed of all the objective evidence that exists of the over supply? No emotion, just expansion #s, employment model, job market woes in similar countries when same occurred, basic explanation why not cyclical, the absolutely ridiculous and exploitative, non credited fellowships that exist etc (ok, some emotion).
Needs to be put to bed. Field is a mirage. You enter this field now and expect a decent career(without major changes) you are taking major risk with your future and all decisions by elders thus far have been to enrich themselves at your expense. Except for the fellowship they just opened after expanding their residency program, that one is to further your learning.
 
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fiji128

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For family reasons, I'd like to be able to end up in Houston, ideally. What do I need to be doing to make sure I make this happen?

Getting into MDACC for residency would be a good start.
 
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fiji128

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I just saw this position in my email this morning and I think it does a pretty good job of summarizing the lack of quality positions available out there. Title should read, "Full time job for part time pay at faux academic rad onc department in a third/fourth tier city!"

Job Summary:
  • The Department of Radiation Oncology at the PinnacleHealth Cancer Institute (this is in Harrisburg, PA) is looking for a board-certified or board-eligible part-time (0.6) radiation oncologist to join a growing team of academically oriented oncology providers, with potential for the position to grow to full time effort as our needs expand.
  • Physician will be responsible for practicing radiation oncology in both inpatient and ambulatory care settings.
  • The successful candidate will be part of a multidisciplinary group of physicians, advance care practitioners and allied health professionals.
  • The clinician will be expected to develop an active practice and to actively participate in clinical research and teaching initiatives.
Job Requirements:
  • Qualified applicants must possess an MD degree or equivalent
  • Board certified or board eligible in radiation oncology
  • Eligible for licensure in the state of Pennsylvania
  • Will consider 2017 radiation oncology fellowship graduates for candidacy
 
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arthurdent

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Well, as one of the attendings at Pinnacle, a few things:
- It's a part time job - 3 days a week in clinic. Split very benign call 4 ways. We anticipate that our volumes will continue to expand, and as they do, the position can grow to a full time effort
- It's a great department - our cancer program has grown dramatically in the past 3 years, hiring recent grads from good places.
- Not sure what is meant by "faux academic," but we deliver excellent care with multidisciplinary buy in. We have site specific tumor boards, an active clinical trials program, and strong support from the administration.
- If Harrisburg doesn't check the location box for you, OK. We're 90 minutes from Baltimore, ~2 hours to Philly/DC, ~3 hours to Pittsburgh/NYC. Central PA is a lovely area with a low cost of living.
- For all the discussion of XRT as a "lifestyle specialty" in the other thread, I'm very happy with my situation...
 
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I trained in central PA in another specialty. It's a dying region. Harrisburg is run down and a shell of its former industrial self. Plus race relations in central PA are not the greatest if one is a minority.
 
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The ideal scenario imo is the small to medium sized city an hour away from a major city/metro

Yeah but even Harrisburg is only hiring part-time. That used to be the mantra--suburbs, college towns, good quality of living without the hassle of big city with better pay. Even those locations are saturated nowadays.
 

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Yeah but even Harrisburg is only hiring part-time. That used to be the mantra--suburbs, college towns, good quality of living without the hassle of big city with better pay. Even those locations are saturated nowadays.
certainly true in FL, CA, GA etc. It's really sad to have watched the job market turn on a dime in the last few years while the leadership in this field not only pretends it isn't happening, but actively opens up the spigot for more supply.

It almost the same scenario that's been happening in pathology as per their forums.... leadership insists there's a coming undersupply, and they have lots of and lots of positions ready to fill.
 

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I've looked at nrmp reports and spots seemed to be steady over the last few years , right?
 

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After putting in about 10 years into medical training to become BE/BC in rad onc and to see jobs posted that start part time with a chance of working your way up to full time in a city that is 2-3 hours drive from major metro area is probably what few people have in mind when they initially think about pursing rad onc in medical school. I would guess at working 0.6 time most fiscally responsible recent graduates would be living only somewhat better then they did in residency after you account for the $3,000-$4,000 a month student loan payment. I do realize this maybe an ideal position for someone out there but its not like there are a lot of other quality positions being posted on the various job boards for rad oncs these days.
 
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I don't know much about Pinnacle RO, but these 0.6 FTE jobs sometimes wind up being just as busy and annoying as 1.0. People would tend to fill up your schedule with patients that other partner(s) don't want.
 
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Mandelin Rain

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I don't know much about Pinnacle RO, but these 0.6 FTE jobs sometimes wind up being just as busy and annoying as 1.0. People would tend to fill up your schedule with patients that other partner(s) don't want.

Not knowing anything past what was posted, I'd be very leery of a 0.6 position that will "increase as needed." What/who defines the need to add more FTE (i.e. pay)? If the need goes the opposite way, does that 0.6 FTE become 0.4 or 0.0?
 

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Part time jobs are typically for mom with children/or semi-retired doc (I am sure there are exceptions). Anyway, 1)what is the chance that someone would move to Harrisburg in this demographic?
 
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I remember how devastated the radiology match became when the job market issue became wide spread. Some of the most brilliant people I know graduated into the worst of times. I've seen credential of incoming residents going from AOA and 250s to brilliant but much less accomplished caribean grads.

Now days the radiology job market got a bit better and competitiveness is picking up again. I especially like what our field did with the IR/DR residency as we are recruitig some of the best again.

More over, we used 80 slots from DR to create IR/DR (many of those 80 people will not be practicing DR full time, if at all). Our PGY2 spot went from 982 last year to 932 this year. That's the right approach.

I hope rad onc doesn't go the way of radiology. I know brilliant MD/PHDs who busted their ass throughout med school and it would be tragic if they are relegated to small town away from their family due to lack of career options, but this could happen and it's so unfair.
 
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Neuronix

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I know brilliant MD/PHDs who busted their ass throughout med school and it would be tragic if they are relegated to small town away from their family due to lack of career options, but this could happen and it's so unfair.

This is already happening. Rad onc is such a small specialty that location preferences are a chronic problem for us.
 

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Part time jobs are typically for mom with children/or semi-retired doc (I am sure there are exceptions). Anyway, 1)what is the chance that someone would move to Harrisburg in this demographic?

As a non radiation oncologist, the fact that a group in Harrisburg of all places has the temerity to advertise a part time position and probably feel confident that they can hire someone speaks volumes of the current job market. Either the partners are barely scraping by financially and can only offer a part time gig to minimize their costs or they're being greedy as hell. Either way, not great.

Should be a warning for all medical students out there in general that although it is important to choose a field of medicine you can tolerate/enjoy, you must be cognizant of what the job situation is like. Not saying the situation is permanent and things to change, but food for thought.
 

radiaterMike

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As a non radiation oncologist, the fact that a group in Harrisburg of all places has the temerity to advertise a part time position and probably feel confident that they can hire someone speaks volumes of the current job market. Either the partners are barely scraping by financially and can only offer a part time gig to minimize their costs or they're being greedy as hell. Either way, not great.

Should be a warning for all medical students out there in general that although it is important to choose a field of medicine you can tolerate/enjoy, you must be cognizant of what the job situation is like. Not saying the situation is permanent and things to change, but food for thought.

You are making a lot of assumptions. As stated above there are people looking for part time jobs. It can simply be that the practice reviewed their volume, RVUs etc and they can expand their group by less than an FTE. Or a partner wants to go half time and they want to add another to make up for that. Just because it is not the job you want doesn't give you license to be judgmental or derisive. Yes there are people who want to live in Harrisburg. Yes there are people who want a part time job.


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