Rad Onc Twitter

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medgator said:
Who started the fraction and IMRT shaming years ago, again? Where has ASTRO been during shameless proton expansion? Divisions started somewhere and it wasn't the guy out in Timbuktu trying to virtue signal to the academic centers
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I am not claiming there is no reason for a feud… but we all share a common enemy. We stand nothing to gain by eating our own on this one.

APM is bad for cancer care. United front.
 
Lamount said:
I am not claiming there is no reason for a feud… but we all share a common enemy. We stand nothing to gain by eating our own on this one.

APM is bad for cancer care. United front.
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Except some places aren't taking the pain, even in APM zip codes. Some have been eating the rest of us for years, continuing on with APM.

You still don't get it
 
medgator said:
Except some places aren't taking the pain, even in APM zip codes. Some have been eating the rest of us for years, continuing on with APM.

You still don't get it
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I get it.
They’ve got an advantage for 5 years… followed by zero guarantees and a bunch of insurance companies looking to renegotiate rates… and if APM succeeds, most suspect it is just the beginning.

The PPS folks I know aren’t spiking the football.
 
Lamount said:
I get it.
They’ve got an advantage for 5 years… followed by zero guarantees and a bunch of insurance companies looking to renegotiate rates… and if APM succeeds, most suspect it is just the beginning.

The PPS folks I know aren’t spiking the football.
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What about the 10-20+ years of advantage they've had so far? Again no consistency
 
medgator said:
What about the 10-20+ years of advantage they've had so far? Again no consistency
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regardless of apm, ultimately what matters is supply and demand. Medoncs take home 90-100-+ dollars per rvu and generally produce 6-7 k rvus. Similar story for psych and neuro. What kind of greedy —-s would increase residency spots knowing that apm/hypofract was coming?
 
medgator said:
What about the 10-20+ years of advantage they've had so far? Again no consistency
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Which do you think is a more productive argument for the field?
1) APM would cut cancer care, forcing clinics to close and threatening the supply of services for those who need it most
2) It’s not fair that PPS-exempt hospitals are getting screwed less than their neighbors for a few years. They should get screwed just as hard.
 
Lamount said:
Which do you think is a more productive argument for the field?
1) APM would cut cancer care, forcing clinics to close and threatening the supply of services for those who need it most
2) It’s not fair that PPS-exempt hospitals are getting screwed less than their neighbors for a few years. They should get screwed just as hard.
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False dichotomy. Some of us actually have been fans of bundled payments for awhile to give payment certainty, dealing with massive CMS cuts for years while PPS exempt were carrying on as normal.

Just because the current iteration of it as APM is terrible in some ways doesn't mean the concept lacks merit.
 
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Lamount said:
Which do you think is a more productive argument for the field?
1) APM would cut cancer care, forcing clinics to close and threatening the supply of services for those who need it most
2) It’s not fair that PPS-exempt hospitals are getting screwed less than their neighbors for a few years. They should get screwed just as hard.
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I think the concern is not over fairness as much as competitive advantage. They can buy out their competing centers as well as shiny new toys, shifting pts into high cost care.
 
For once, agree with La Mount (the Mount).
Division will only hurt us.

If you ever get a chance, reach out to Dave Adler, who can give more context to many of the decisions.

I’m as against PPS exempt status as anyone out there and always have been. Two separate issues. RO-APM is terrible for anyone selected, but they should have not exempted those centers. I’d rather have no one “win the lottery”.
 
RadsWFA1900 said:
Lol. When I rotated as a Med student I was lucky if a resident even acknowledged my existence let alone an attending. But then again times were different
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If I had a time machine, and went back to 2015, and told my past self about 2021: about the pandemic, about politics, about Chairs of RadOnc departments taking to Twitter to sing the praises of rotating DO students because RadOnc has become the least desirable specialty in American medicine...I honestly can't imagine what my reaction would be.
 
elementaryschooleconomics said:
If I had a time machine, and went back to 2015, and told my past self about 2021: about the pandemic, about politics, about Chairs of RadOnc departments taking to Twitter to sing the praises of rotating DO students because RadOnc has become the least desirable specialty in American medicine...I honestly can't imagine what my reaction would be.
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Reality can truly be stranger than fiction. Can't count the number of times I've read news headlines that sounded like they should have been in the onion but weren't
 
elementaryschooleconomics said:
If I had a time machine, and went back to 2015, and told my past self about 2021: about the pandemic, about politics, about Chairs of RadOnc departments taking to Twitter to sing the praises of rotating DO students because RadOnc has become the least desirable specialty in American medicine...I honestly can't imagine what my reaction would be.
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If I had someone tell my pre-med 2007 self what it would be to be practicing now...I think my brain would have melted.
 
medgator said:
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Ralph Sided with RT? LOL. I hope he stashed enough away to live in one of those nice nursing homes where they don't sexually assault you and steal your possessions that is if you still have any left after forking over virtually everything you have.
 
RadsWFA1900 said:
Ralph Sided with RT? LOL. I hope he stashed enough away to live in one of those nice nursing homes where they don't sexually assault you and steal your possessions that is if you still have any left after forking over virtually everything you have.
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I'm CERTAIN Ralph has stashed his doubloons and emeralds in a Trust managed by his family so he can qualify for Medicaid and get into one of the good homes.

Then, from his $7,000 a month room with his round-the-clock nurses, he'll Tweet about how lazy Millennials expect the government to care for them in their old age, unlike how he pulled himself up by his bootstraps and paid for everything himself.
 
elementaryschooleconomics said:
I'm CERTAIN Ralph has stashed his doubloons and emeralds in a Trust managed by his family so he can qualify for Medicaid and get into one of the good homes.

Then, from his $7,000 a month room with his round-the-clock nurses, he'll Tweet about how lazy Millennials expect the government to care for them in their old age, unlike how he pulled himself up by his bootstraps and paid for everything himself.
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If there's one thing this so called intellectual doesn't lack, its the uncanny ability of self preservation unfortunately at someones expense.
 
medgator said:
False dichotomy. Some of us actually have been fans of bundled payments for awhile to give payment certainty, dealing with massive CMS cuts for years while PPS exempt were carrying on as normal.

Just because the current iteration of it as APM is terrible in some ways doesn't mean the concept lacks merit.
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The current iteration is the only relevant iteration… and I don’t think bundled payments are a terrible idea either. The fewer clicks/notes, the better. I don’t think that we actually disagree about any of the substance.

I just don’t think a PP vs. academic war helps either of us when we have bigger external enemies. Perhaps wait until the avalanche abates before throwing stones at us
 
RealSimulD said:
For once, agree with La Mount (the Mount).
Division will only hurt us.

If you ever get a chance, reach out to Dave Adler, who can give more context to many of the decisions.

I’m as against PPS exempt status as anyone out there and always have been. Two separate issues. RO-APM is terrible for anyone selected, but they should have not exempted those centers. I’d rather have no one “win the lottery”.
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For once? That one hurts, brotha. Lol

FWIW… although I may not always agree with you, I respect the hell out of you for calling out BS on Twitter like you do. I am only on Twitter these days to promote research. One day I hope to have the cojones to speak my mind like you do.
 
Lamount said:
For once? That one hurts, brotha. Lol

FWIW… although I may not always agree with you, I respect the hell out of you for calling out BS on Twitter like you do. I am only on Twitter these days to promote research. One day I hope to have the cojones to speak my mind like you do.
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1632100044947.png

This is SimulD in real life.
 
Lamount said:
The current iteration is the only relevant iteration… and I don’t think bundled payments are a terrible idea either. The fewer clicks/notes, the better. I don’t think that we actually disagree about any of the substance.

I just don’t think a PP vs. academic war helps either of us when we have bigger external enemies. Perhaps wait until the avalanche abates before throwing stones at us
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Spoiler alert. APM is more clicks, more notes, more peer review, more bureaucracy. Less QOL and less pay.

As an aside did you guys read the new APM posts. Something caught my attention. They said they are going to be looking at enough centers, and their culled data, to detect a 3% or greater savings at an alpha of 0.05 with a 0.8 power.

We. Are. An. Experiment. All of rad onc has just been entered into a trial without its consent. (Who says the government doesn’t experiment on people.)

EDIT: In the initial iterations they were going to declare success at 3.75% or greater savings. They have lowered the bar to 3%.

NMEN2fe.png
 
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TheWallnerus said:
Spoiler alert. APM is more clicks, more notes, more peer review, more bureaucracy. Less QOL and less pay.

As an aside did you guys read the new APM posts. Something caught my attention. They said they are going to be looking at enough centers, and their culled data, to detect a 3% or greater savings at an alpha of 0.05 with a 0.8 power.

We. Are. An. Experiment. All of rad onc has just been entered into a trial without its consent. (Who says the government doesn’t experiment on people.)

EDIT: In the initial iterations they were going to declare success at 3.75% or greater savings. They have lowered the bar to 3%.

NMEN2fe.png
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Glad to see the government approaches studying radiation therapy for cancer with the same rigorous statistical methods - and understanding of informed consent - as a sophomore in undergrad.
 
theradiator said:
How about a SDN lawsuit against CMS?
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I got a loud laugh out of that one. SDN's organizational mission is not helping students AND suing the government. 😆

I guess the question is who would have standing to sue. In my market there's a large hospital system with satellites firmly within APM and their main competition with their satellites are PPS-exempt (and thus excluded from APM). Therefore, the PPS-exempt system has a competitive advantage within the same community.

I wonder if a situation like that would do it. I'm not a lawyer, and I'm sure the legal situation is very complex so this is just idle speculation.
 
theradiator said:
How about a SDN lawsuit against CMS?
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The gov't has been the dominant payor for cancer care since the institution of Medicare (which the AMA initially opposed). They can assign value however they want. They could just do a cost analysis, assign a standard of "reasonableness" to compensation and cut massively (see cataract surgery).

The only rationale for a suit IMO would be the anti-competitiveness angle but I'm not sure there is any precedent for suing the gov't for picking winners like this? They do it all the time and getting specific contracts for things like defense have historically been very biased.

The cynic in me thinks that the APM was "the best that ASTRO could do" in their eyes to protect the interests of big radonc. Alternative would have been a the much fairer across the board cut.
 
elementaryschooleconomics said:
Glad to see the government approaches studying radiation therapy for cancer with the same rigorous statistical methods - and understanding of informed consent - as a sophomore in undergrad.
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I was actually thinking a lawsuit based on performing human experimentation on cancer patients without obtaining the necessary regulatory or ethical approvals.
 
If you ended PPS exemption for 1 year, it would pay for the 5 years of projected "savings" of the APM experiment.

Just end the ****ing exemption for those handful of arbitrarily chosen hospitals, level the playing field for all, and save the rest of us this current hell.

This is what ASTRO would have offered if it had any integrity as an organization.
 
Mandelin Rain said:
If you ended PPS exemption for 1 year, it would pay for the 5 years of projected "savings" of the APM experiment.

Just end the ****ing exemption for those handful of arbitrarily chosen hospitals, level the playing field for all, and save the rest of us this current hell.

This is what ASTRO would have offered if it had any integrity as an organization.
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ASTRO's always been about the "Integrity for thee but not for me."*

* citations available upon request
 
Mandelin Rain said:
If you ended PPS exemption for 1 year, it would pay for the 5 years of projected "savings" of the APM experiment.

Just end the ****ing exemption for those handful of arbitrarily chosen hospitals, level the playing field for all, and save the rest of us this current hell.

This is what ASTRO would have offered if it had any integrity as an organization.
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This is 100% correct. If ASTRO had any integrity this would be the plan.

Would then put protons for breast and prostate under a special designation capping reimbursement to medicare IMRT rates (off trial) and funding massive randomized trial here. If patient enrolled in randomized trial (none of this registry BS) you get the old higher rate.

The money saved here with the above (simple) plan would be more than APM hell I'd bet.
 
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...and Ralph goes on in typical Ralph fashion.

Thought experiment: how would 2021 Ralph react if the oligometastatic state was a new hypothesis put forth by someone else? I suspect he would thoroughly trash it.

There are few things in life I look forward to with as much enthusiasm as the day this guy retires.
 
elementaryschooleconomics said:
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...and Ralph goes on in typical Ralph fashion.

Thought experiment: how would 2021 Ralph react if the oligometastatic state was a new hypothesis put forth by someone else? I suspect he would thoroughly trash it.

There are few things in life I look forward to with as much enthusiasm as the day this guy retires.
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He’s been trashing the GARD work thoroughly, which is the only research tying RT response to biology that is making it anywhere close to the clinic.
 
GARD is all hype, very little there in reality if you actually look at the paper. they are master hype men.

don't bring that up in relation to the incredible WashU work.
 
jondunn said:
GARD is all hype, very little there in reality if you actually look at the paper. they are master hype men.

don't bring that up in relation to the incredible WashU work.
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They’ve published a bunch of papers in solid journals, including one in lancet oncology. Tough to call that hype. My read is the validation they’ve done is no worse quality than what’s been done with Decipher
 
I greatly appreciate Dr. Weichselbaum's views, regardless if I agree with them. We need more physicians who are willing to question the dogma, IMO.

An oldie from 2003, but relevant, "The Return of the Snake Oil Salesmen" by Eli Glatstein: DEFINE_ME

"Perhaps patients would balk if they knew they were part of dose escalation treatments for which long-term follow-up data do not exist."

"In the nineteenth century, snake oil salesmen did the selling directly to the public from the back of wagons. Today, it’s smoothly pitched over mass media, as the twenty-first century threatens to become the century of hucksters."
 
Krukenberg said:
They’ve published a bunch of papers in solid journals, including one in lancet oncology. Tough to call that hype. My read is the validation they’ve done is no worse quality than what’s been done with Decipher
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Would be easier to believe GARD if they had few trials on clinical trials.gov
 
SneakyBooger said:
I greatly appreciate Dr. Weichselbaum's views, regardless if I agree with them. We need more physicians who are willing to question the dogma, IMO.

An oldie from 2003, but relevant, "The Return of the Snake Oil Salesmen" by Eli Glatstein: DEFINE_ME

"Perhaps patients would balk if they knew they were part of dose escalation treatments for which long-term follow-up data do not exist."

"In the nineteenth century, snake oil salesmen did the selling directly to the public from the back of wagons. Today, it’s smoothly pitched over mass media, as the twenty-first century threatens to become the century of hucksters."
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I obviously agree that dogma should always be questioned. However, I don't think that's what Ralph is doing most of the time. Dogma, for us, is sticking with classic indications for radiation (cancer), and "progress" in this dogma is reducing or omitting radiation therapy.

Exploring XRT for cardiac ablation (or arthritis, or keloids, or plantar fasciitis, etc) is the opposite of dogma in American RadOnc.

Ralph just strikes me as reactionary in these Tweets, in an "old man yells at clouds" sort of way. It's different from what he knows, and is therefore bad.

Science moves forward one funeral at a time, as the saying goes.
 


This captures it well for me. I like this answer
 
medgator said:
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*sigh*

One more time, for the folks in the back: the actual job of Radiation Oncology is incredible. It's the getting of the job that's the problem.

Might has well have Bezos get on Twitter being like "tell me what you love about being the CEO of a multi-billion dollar company" or Jay-Z Tweeting "tell me what you love about being a multi-platinum world-renowned artist".

I wish #RaRaRadOnc would stop trying to spin this like the "angst" is about the actual work.
 
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