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radiation said:
while we can talk about the issues with rad onc, i think its a fallacy to give med students this false dichotomy between rad onc and med onc. The current compensation for med onc is likely unsustainable and is more likely than not to decrease in the 7 years when they finish their training. The footprint of current med onc salary will likely come under scrutiny - its not a matter of if, but when
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Medonc compensation is not based on high cost of drugs but supply and demand, just like psychiatry. Demand for medonc will probably increase with time as indications expand and pts live longer. All those 70 year olds getting io went to hospice 5 -10
years ago. Lastly a medonc under no circumstances will ever face unemployment.
 
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LostResident1 said:
Remember that you are lucky to be making anything equal to or greater than a pediatrician's salary despite your training and despite that the powers that be live in $8M homes.
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If radoncs could take home a pediatricians salary in a decent location, field would still be quite competitive.
 
medgator said:
Sometimes it is.... And all the ancillaries they order etc. They can do very well in those cases
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And the have-your-own-little-in-house-pharmacy as a revenue center is coming on strong. I work with med oncs who do this and they are making serious bank. They can make $500 a pop by prescribing certain nausea drugs e.g. It's hit or miss. Some drugs have almost no profit margin. But some of the "PO anti-neoplastics" have really big margins.
 
medgator said:
Sometimes it is.... And all the ancillaries they order etc. They can do very well in those cases
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If they work for
TheWallnerus said:
And the have-your-own-little-in-house-pharmacy as a revenue center is coming on strong. I work with med oncs who do this and they are making serious bank. They can make $500 a pop by prescribing certain nausea drugs e.g. It's hit or miss. Some drugs have almost no profit margin. But some of the "PO anti-neoplastics" have really big margins.
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this is true, but as legacy of 340b prices, something like 80% of medoncs work for hospitals on an rvu basis.
 
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I'm going to set up a Tamoxifen and anastrozole only pharmacy in my clinic. May compound magic mouthwash too.

See yall on the beach.
 
medgator said:
Medical Mary Jane gig too.
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Rick Ross Agree GIF

Every day I'm (side) hustling.
 
medgator said:


Nepotism only way to really guarantee a job these days
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Former ASTRO president just matched his own son. Many chairs have placed their sons and daughters into jobs and priviledge. Country club culture has been rad onc culture for some time. Will this ever change? Probably will be even worst as people use their power to place loved ones in a crumbling job market. The bread lines are officially here.
 
thecarbonionangle said:
Former ASTRO president just matched his own son. Many chairs have placed their sons and daughters into jobs and priviledge. Country club culture has been rad onc culture for some time. Will this ever change? Probably will be even worst as people use their power to place loved ones in a crumbling job market. The bread lines are officially here.
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idk if thats an act of love lol
 
RickyScott said:
Medonc compensation is not based on high cost of drugs but supply and demand, just like psychiatry. Demand for medonc will probably increase with time as indications expand and pts live longer. All those 70 year olds getting io went to hospice 5 -10
years ago. Lastly a medonc under no circumstances will ever face unemployment.
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Lets not forget med onc is about 50% IMG and DO - they have had their bad times too. If targeted therapies get easy enough to be managed by mid-levels you think the med onc salary is going to perpetually increase? Look at what is happening to peds heme onc, their numbers are starting to get into rad onc territory

Recent trends in Pediatric Hematology Oncology fellowship match and the workforce impact - PMC

www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

1629939323117.png


1629939349395.png
 
radiation said:
Lets not forget med onc is about 50% IMG and DO - they have had their bad times too. If targeted therapies get easy enough to be managed by mid-levels you think the med onc salary is going to perpetually increase? Look at what is happening to peds heme onc, their numbers are starting to get into rad onc territory

Recent trends in Pediatric Hematology Oncology fellowship match and the workforce impact - PMC

www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

View attachment 342619

View attachment 342620
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Not quite the same though as these fellows have to pass through Peds residency first. These programs can’t just soap in people with no other options for advanced training so it’s more of a true supply and demand based market for training positions. However as we all know and have witnessed, in rad onc any residency position can be filled if the criteria for applicants is keep open/low enough.
 
fiji128 said:
Not quite the same though as these fellows have to pass through Peds residency first. These programs can’t just soap in people with no other options for advanced training so it’s more of a true supply and demand based market for training positions. However as we all know and have witnessed, in rad onc any residency position can be filled if the criteria for applicants is keep open/low enough.
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About 10 years ago, job market was not great in medonc, but unemployment was unthinkable.
 
I was in a curious mood yesterday and considering congress' BS move to lower Medicare eligibility I started reading articles about the fate of RO and various medical subs in Canada. Apparently if you are an RO or a Med/Surg Subspecialist you basically cannot get a job anywhere. I found this article about NSX from 2006 a bigwig NSX in Canada and I was struck by his take on the Saturation problem facing his own field in Canada. Many of the points he made resemble the same gaslighting BS I have heard in RO over the years.

In the face of oversaturation increasing trainees, he claims

- We should continue to expand slots to keep other specialties from taking our procedures
- Sub specialization will keep us in demand - (This is even more problematic in RO than NSX)
- The "Private" Sector will Employ Us
- Market Forces will dictate Med Student Interest
- Do More Research

www.researchgate.net

(PDF) Canadian Neurosurgical Manpower: Need for Self-Determination

PDF | On Jun 1, 2006, Brian D Toyota published Canadian Neurosurgical Manpower: Need for Self-Determination | Find, read and cite all the research you need on ResearchGate
www.researchgate.net www.researchgate.net

Fast Forward to 2021 - The NSX market is still poor and not much has changed. Only jobs available are academic jobs (Sound Familiar?), Fellowships abound, and yet 26% of their trainees end up in the US. If they didn't have that option, they'd probably be underemployed.


pubmed.ncbi.nlm.nih.gov

Recent Trends in Neurosurgery Career Outcomes in Canada - PubMed

Underemployment in neurosurgery has become a significant issue in Canada for various reasons. Pursuit of in-folded research, but not fellowship training, was associated with obtaining full employment.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
Disclosure: have not yet listened to Simul’s podcast, will do so this weekend

Ortho and NSx are notorious for being bad In Canada. Ortho a few years ago iirc decreased their intake at a few centres, but due to increased demand from med students, and not by a significant amount relatively speaking. There are a lot of Ortho’s!

Rad onc on the other hand, I think is a success story, or at least is in the process of turning itself around in Canada. A dozen years or so after spots were slashed, the job market continues to improve. It’s not great by any means still, but compared to two years of fellowship, and a third of the trainees bailing to the US, it’s in a position where either everyone has a job after one year of fellowship, very few people going to the US now (still one or two), and maybe 10-15% of folks are getting offers in PGY-4. Some places have directly hired without fellowships too. Not great, but even compared to the state of things 5 years ago while I was a resident, it’s a huge difference. The momentum is such that we are taking another resident this year in my program, but it’s taken a long time to get here.

The difference between us and path/ortho/etc are that RO is quite small. It took a lot of sustained effort from all programs over a decade to change the situation. And even then, some might say it’s not great, even though it’s effect relatively speaking, is dramatically different (one year of ‘training’ less, even).
 
taserlaser said:
Disclosure: have not yet listened to Simul’s podcast, will do so this weekend

Ortho and NSx are notorious for being bad In Canada. Ortho a few years ago iirc decreased their intake at a few centres, but due to increased demand from med students, and not by a significant amount relatively speaking. There are a lot of Ortho’s!

Rad onc on the other hand, I think is a success story, or at least is in the process of turning itself around in Canada. A dozen years or so after spots were slashed, the job market continues to improve. It’s not great by any means still, but compared to two years of fellowship, and a third of the trainees bailing to the US, it’s in a position where either everyone has a job after one year of fellowship, very few people going to the US now (still one or two), and maybe 10-15% of folks are getting offers in PGY-4. Some places have directly hired without fellowships too. Not great, but even compared to the state of things 5 years ago while I was a resident, it’s a huge difference. The momentum is such that we are taking another resident this year in my program, but it’s taken a long time to get here.

The difference between us and path/ortho/etc are that RO is quite small. It took a lot of sustained effort from all programs over a decade to change the situation. And even then, some might say it’s not great, even though it’s effect relatively speaking, is dramatically different (one year of ‘training’ less, even).
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Difference between US and Canada 1) US MD take on hundreds thousands in debt- no job means you and your family are totally f--d 2) No escape outlet to canada when our job market sours.
 
RickyScott said:
Difference between US and Canada 1) US MD take on hundreds thousands in debt- no job means you and your family are totally f--d 2) No escape outlet to canada when our job market sours.
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Agree on number 1. My med tuition total was 45k CAD less 5k in stipends.

2. My escape outlet is still either lucky to get a job in another province or retrain.
 
I had a chance to listen to the podcast. Perhaps due to time constraints of the format (it’s not the Firing Line). I found it to be a missed opportunity. Some points that I thought were certainly up for debate

- it’s better to have a gentle excess of doctors than a shortage - this is highly debatable especially since workloads are falling and so are reimbursements coupled with AI increasing productivity

- The Ortho job market issues seem to stem from a lack of willingness to fund MSK care in general and the lack of a private sector to meet demand (given the long wait times). There’s probably plenty of demand - contrasted with RO where demand is falling and govt is cutting back

- geographic distribution issues should be addressed somehow - Unless the govt takes a more command and control approach to where new grads practice and perhaps even what they practice this problem isn’t getting solved. To suggest that we simply pump out grads and make the situation even ****tier for the money in an effort to force them into rural areas is absurd which the speakers rightly point out.

- Cheap Labor is king - regardless of what your national health system looks like the system runs on lowly grunts (the residents) who go along to get along because they know this is only a temporary state. But what if it wasn’t a temporary state? What if you ended up going from fruitless fellowship to fellowship? There was a remark about dealing with the onerous work hours of residents and the idiotic solution to that problems seems to have been increase the number of residents so attendings can still get work done and residents don’t feel overworked. They just couldn’t hire MLPs which would have been a perfect role for them.

- Long Term Labor projections continue to be a waste of time - too many unconsidered variables.

- Excess doctors leads to bad behavior - I agree. At the end of the day medical training teaches you how to be one thing and you cannot easily retrain. You have to justify your job and salary and you do what you need to survive. it’s hard to justify an excess of doctors (you know just in case) when it can actually end up harming patients.

Voluntarism is Bull**** - token acknowledgement and reduction of spots is not enough. Programs need to close en masses d new requirements need to be put in place to prevent them from gaming the system.

The effects of excess capacity are long lived and detrimental.


I think Simuls cynicism is entirely justified. There is no easy solution but if we can rid ourselves of any illusions that our collective suffering in RO is for the greater good of patients and realize that it’s simple economic gain that drives these decisions I think we would all be better off.

Also this isn’t helping matters

www.medscape.com

CMS' Proposed 22% Cut to Radiation Oncology Is 'Tone Deaf'

A mandatory new model that would see a 22% reduction in payments for some radiation oncology treatments has received strong pushback from the medical community.
www.medscape.com www.medscape.com
 


This is an interesting conversation, besides being called out for my "inexpertness".

Thought experiment - what if every radiation facility stopped seeing RTOG9804/CALGB/PRIME II eligible patients based on pathology and went straight to omission? Didn't send consult. In fact, surgeon wrote the Tam prescription, skipped the OncoType, didn't send to MO or RO. Would this be good or bad for patient care? They are talking about this 9804 update as if something new has been gleaned from it. Any board certified radiation oncologist knows that this data has been around for several years and the update shows the same thing the 2015 paper showed. We have known for decades that radiation does not improve survival in DCIS patients. It's very curious.
 
RealSimulD said:


This is an interesting conversation, besides being called out for my "inexpertness".

Thought experiment - what if every radiation facility stopped seeing RTOG9804/CALGB/PRIME II eligible patients based on pathology and went straight to omission? Didn't send consult. In fact, surgeon wrote the Tam prescription, skipped the OncoType, didn't send to MO or RO. Would this be good or bad for patient care? They are talking about this 9804 update as if something new has been gleaned from it. Any board certified radiation oncologist knows that this data has been around for several years and the update shows the same thing the 2015 paper showed. We have known for decades that radiation does not improve survival in DCIS patients. It's very curious.
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Not sure if @Dan Spratt has considered the alternative of long term endocrine therapy in these patients which is probably far worse.


We really are our own worst enemy sometimes
 
RealSimulD said:


This is an interesting conversation, besides being called out for my "inexpertness".

Thought experiment - what if every radiation facility stopped seeing RTOG9804/CALGB/PRIME II eligible patients based on pathology and went straight to omission? Didn't send consult. In fact, surgeon wrote the Tam prescription, skipped the OncoType, didn't send to MO or RO. Would this be good or bad for patient care? They are talking about this 9804 update as if something new has been gleaned from it. Any board certified radiation oncologist knows that this data has been around for several years and the update shows the same thing the 2015 paper showed. We have known for decades that radiation does not improve survival in DCIS patients. It's very curious.
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As long as this was brought up, I think this conversation was an absolutely terrible, terrible look for Dr. Daniel Spratt for two main reasons:

1. He completely misses the (should be incredibly obvious) fact that local recurrences of breast cancer are, indeed, very bothersome to women- many of those women, doing their own calculus, make the decision to go with adjuvant XRT, believing the SEs of XRT to be better than an increased chance of LR. If I were a woman with DCIS, I would most likely choose BCS and adjuvant XRT. However, perhaps he doesn't care about what they or I think because we are not...

2. "Experts". The academic lie that one needs to specialize in one disease site to be an "expert" is just that- a complete, total, bold-faced lie. Perhaps the academicians are indeed telling the truth when they say they would be unable to be an expert in more than one disease site, but I consider it downright libelous and incredibly offensive for Dr. Daniel Spratt to say someone like Dr. Simul Parikh is not an expert in radiotherapy for breast cancer. His critique isn't even internally consistent: If one needs to focus on one (maaaaaaaybe two amirite?) disease site to be an "expert", then why is a GU "expert" like himself weighing in on a breast cancer debate?
 
OTN said:
As long as this was brought up, I think this conversation was an absolutely terrible, terrible look for Dr. Daniel Spratt for two main reasons:

1. He completely misses the (should be incredibly obvious) fact that local recurrences of breast cancer are, indeed, very bothersome to women- many of those women, doing their own calculus, make the decision to go with adjuvant XRT, believing the SEs of XRT to be better than an increased chance of LR. If I were a woman with DCIS, I would most likely choose BCS and adjuvant XRT. However, perhaps he doesn't care about what they or I think because we are not...

2. "Experts". The academic lie that one needs to specialize in one disease site to be an "expert" is just that- a complete, total, bold-faced lie. Perhaps the academicians are indeed telling the truth when they say they would be unable to be an expert in more than one disease site, but I consider it downright libelous and incredibly offensive for Dr. Daniel Spratt to say someone like Dr. Simul Parikh is not an expert in radiotherapy for breast cancer. His critique isn't even internally consistent: If one needs to focus on one (maaaaaaaybe two amirite?) disease site to be an "expert", then why is a GU "expert" like himself weighing in on a breast cancer debate?
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I think it is odd that a man is saying what is and what is not important for a woman. I think it should be up to the female patient what happens to her breast, after having a balanced discussion on the pros and cons of the treatment recommendation.
 
I'm sure Dan will be pushing his Case Western breast "experts" to omit XRT in all low-risk patients that come through the doors.
 
SubserviantToABR said:
I think it is odd that a man is saying what is and what is not important for a woman. I think it should be up to the female patient what happens to her breast, after having a balanced discussion on the pros and cons of the treatment recommendation.
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I believe the term is "mansplaining"
 
SubserviantToABR said:
I think it is odd that a man is saying what is and what is not important for a woman. I think it should be up to the female patient what happens to her breast, after having a balanced discussion on the pros and cons of the treatment recommendation.
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3-4% os was benefit of chemo 15 years ago and there was plenty of literature saying that overwhelming majority of women comfortable with this minimum benefit for a very toxic treatment.
 
i like Dan Spratt’s papers and he’s a smart guy, but this is a bad look. I had DCIS (int grade) as a resident and I chose mastectomy somewhat ironically because I didn’t want to deal (and also, ironically, because it was much faster). NNTs sound great and make you look smart (unless you mess up the calculation) but patients may have other fears or concerns. Maybe it is true that it’s the doctors job to set the patient straight but sometimes you should give them space to make the decision that works for them. No woman wants a recurrence even of pre invasive cancer.
 
MegaVoltagePhoton said:
i like Dan Spratt’s papers and he’s a smart guy, but this is a bad look. I had DCIS (int grade) as a resident and I chose mastectomy somewhat ironically because I didn’t want to deal (and also, ironically, because it was much faster). NNTs sound great and make you look smart (unless you mess up the calculation) but patients may have other fears or concerns. Maybe it is true that it’s the doctors job to set the patient straight but sometimes you should give them space to make the decision that works for them. No woman wants a recurrence even of pre invasive cancer.
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Thank you for sharing. Wishing you best of health!!
 
MegaVoltagePhoton said:
i like Dan Spratt’s papers and he’s a smart guy, but this is a bad look. I had DCIS (int grade) as a resident and I chose mastectomy somewhat ironically because I didn’t want to deal (and also, ironically, because it was much faster). NNTs sound great and make you look smart (unless you mess up the calculation) but patients may have other fears or concerns. Maybe it is true that it’s the doctors job to set the patient straight but sometimes you should give them space to make the decision that works for them. No woman wants a recurrence even of pre invasive cancer.
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Absolutely not your job is to robotically rattle off statistics and make a recommendation then promptly leave the room and dismiss any questions and minimize all concerns the patient has as irrelevant might have either way and then tell them to let the nurse know when they make the a decision. Data only...feelings illegal. moving on
 
RadsWFA1900 said:
Absolutely not your job is to robotically rattle off statistics and make a recommendation then promptly leave the room and dismiss any questions and minimize all concerns the patient has as irrelevant might have either way and then tell them to let the nurse know when they make the a decision. Data only...feelings illegal. moving on
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I forget where I read it but someone analyzed Spock’s decisions/plans on Star Trek and he was wrong 80% of the time because he failed to factor in or imagine what the humans would do or choose.
 
SubserviantToABR said:
I think it is odd that a man is saying what is and what is not important for a woman. I think it should be up to the female patient what happens to her breast, after having a balanced discussion on the pros and cons of the treatment recommendation.
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Is it really about gender here? I mean, does it have to be? Is a man allowed to treat breast cancer? By this metric, I'm not sure how I can ever make a rec when a patient asks me what she should do. We could pretty much eliminate breast cancer from earth by performing bilateral mastectomies on all women at 25. I, as a man, would like to say that's a bad idea.
 
Ray D. Ayshun said:
Is it really about gender here? I mean, does it have to be? Is a man allowed to treat breast cancer? By this metric, I'm not sure how I can ever make a rec when a patient asks me what she should do. We could pretty much eliminate breast cancer from earth by performing bilateral mastectomies on all women at 25. I, as a man, would like to say that's a bad idea.
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I think it’s more about the approach to your recommendations then the actual take home points being offered to the patient. Just be Tom Brady and you’re good.
 
Ray D. Ayshun said:
Is it really about gender here? I mean, does it have to be? Is a man allowed to treat breast cancer? By this metric, I'm not sure how I can ever make a rec when a patient asks me what she should do. We could pretty much eliminate breast cancer from earth by performing bilateral mastectomies on all women at 25. I, as a man, would like to say that's a bad idea.
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No, don't misconstrue what I am trying to say. I, as a man, am not offering a penectomy to you, another man, to eliminate your risk of penile cancer...but if your breast cancer patient asks you what they should do, after you discuss the pros and cons, that is fair to offer them what you think is best, regardless of the gender of the physician. However, to categorically say that local recurrence, and its subsequent salvage options, does not matter should be from the patient, not from the physician, as demonstrated by the discussed tweet.

Regardless of the gender of the radiation oncologist, RT offers great control, as RTOG 9804 demonstrated, and can be offered in a variety of convenient ways. I am not a breast cancer expert by any means and I have a 🍆, but I can read and interpret data.
 
SubserviantToABR said:
No, don't misconstrue what I am trying to say. I, as a man, am not offering a penectomy to you, another man, to eliminate your risk of penile cancer...but if your breast cancer patient asks you what they should do, after you discuss the pros and cons, that is fair to offer them what you think is best, regardless of the gender of the physician. However, to categorically say that local recurrence, and its subsequent salvage options, does not matter should be from the patient, not from the physician, as demonstrated by the discussed tweet.

Regardless of the gender of the radiation oncologist, RT offers great control, as RTOG 9804 demonstrated, and can be offered in a variety of convenient ways. I am not a breast cancer expert by any means and I have a 🍆, but I can read and interpret data.
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Thanks, I don't disagree about your summation of how we as a field stop thinking at local control, and generally lose site of the bigger picture. My feeling is that Dr spratts argument is borne of that, an agnostic consideration of nonvital human anatomy, inasmuch as vital anatomy is important for overall survival and not happiness or confidence. This was the same approach taken by the female breast rad oncs that taught me. My issue is that when gender comes up, it becomes a whole thing. Perhaps I made it so,..
 
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