Rad Onc Twitter

[elementaryschooleconomics]

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Oh man, entering the DEI space as a white guy in an academic position of power on Twitter? That's quite the needle to thread.

Some say it's impossible to do successfully, while others say -

 

[jondunn]

 

[temujim]

Greatly disappointed, but figured since becoming a chair at a Univ. You gotta bend the knee to the DEI crowd. He’s learned all the right buzzwords too. Wait till he missteps and all his fealty will be worth nothing to the DIE crowd. Good luck. I understand the tremendous pressure you are under. You do good work otherwise.
View attachment 347461

Maybe he believes, maybe not, but a tell that he is aiming higher.

 

[jondunn]

sorry to all you patients who get treated at community sites and VA where you are not getting the SPRATT guarantee and STATE OF THE ART CARE - used car salesman Spratt

guy is gonna flame out

 

[jondunn]

Why don’t you guys PUMP

 

[medgator]

Why don’t you guys PUMP

quantity > quality

 

[jondunn]

 

[jondunn]

 

[temujim]

Social studies with foregone conclusions.

 

[Ray D. Ayshun]

Wonder what proportion of men are considering leaving. How can you make the statement that something needs to change based on 20% of women considering leaving when you have no data on the proportion of men considering leaving? My question seems to recognize this would be a worthwhile undertaking to start, but pretty much any proportion could be problematic when there's no comparison.

 

[RadOncMegatron]

Wonder what proportion of men are considering leaving. How can you make the statement that something needs to change based on 20% of women considering leaving when you have no data on the proportion of men considering leaving? My question seems to recognize this would be a worthwhile undertaking to start, but pretty much any proportion could be problematic when there's no comparison.

After the AHA Dr. Wang debacle who the heck is 1) going to stick their neck out to be chopped 2)
Find a journal who will publish It (besides Peter Singer’s journal where they allow anonymous authors ship to avoid backlash)?

Mean while Reshma strikes again in the NEJM. https://www.nejm.org/doi/full/10.1056/NEJMp2114955

 

[communitydoc13]

Wonder what proportion of men are considering leaving. How can you make the statement that something needs to change based on 20% of women considering leaving when you have no data on the proportion of men considering leaving? My question seems to recognize this would be a worthwhile undertaking to start, but pretty much any proportion could be problematic when there's no comparison.

I agree with this take. Expectations of young men are much different than for generations prior. Our spouses are more likely to be professional and it is almost universally a difficult problem to figure out professional compromise among couples. I doubt there is gender parity here, but definitely not gender specific.

I would not consider the paper helpful.

What is known is that picking geography is very hard for radiation oncologists, and this will force difficult compromises for trainees who have partners with geographic constraints, whether that be due to career or family.

 

[medgator]

Wonder what proportion of men are considering leaving. How can you make the statement that something needs to change based on 20% of women considering leaving when you have no data on the proportion of men considering leaving? My question seems to recognize this would be a worthwhile undertaking to start, but pretty much any proportion could be problematic when there's no comparison.

Yep. Times are a changing...

A Generation of American Men Give Up on College: ‘I Just Feel Lost’

The number of men enrolled at two- and four-year colleges has fallen behind women by record levels, in a widening education gap across the U.S.

www.wsj.com

 

[deleted941485]

Yep. Times are a changing...

A Generation of American Men Give Up on College: ‘I Just Feel Lost’

The number of men enrolled at two- and four-year colleges has fallen behind women by record levels, in a widening education gap across the U.S.

www.wsj.com

It’s social payback for being “dominant” all these years. Just neglect him and focus more on her. Thankfully my son identifies as an ethnic minority so it’s not a total loss. If all he was was white and male…I feel like this would be his destiny.

 

[deleted1111261]

It’s social payback for being “dominant” all these years. Just neglect him and focus more on her. Thankfully my son identifies as an ethnic minority so it’s not a total loss. If all he was was white and male…I feel like this would be his destiny.

“Is” or “identifies” as one ?

 

[deleted941485]

“Is” or “identifies” as one ?

Doesn’t matter especially in 2021. Come on man.

 

[jondunn]

Doesn’t matter especially in 2021. Come on man.

you lost the plot

 

[deleted1111261]

Doesn’t matter especially in 2021. Come on man.

😂
Sure doesn’t

 

[medgator]

 

[elementaryschooleconomics]

What an excellent, data-driven argument.

Sadly, the narrative is dominated by the actions of a handful of greedy folks from 15 years ago, and pesky things like "data" and "evidence" can't save us from the machinations of the government and private insurance companies.

 

[TheWallnerus]

What an excellent, data-driven argument.

Sadly, the narrative is dominated by the actions of a handful of greedy folks from 15 years ago, and pesky things like "data" and "evidence" can't save us from the machinations of the government and private insurance companies.

X * Y = Z

X = amt each rad onc "costs" CMS on avg
Y = No. of rad oncs
Z = total rad onc cost to CMS

X is going down...
But Y is going up more than X is going down

So Z still goes up

So CMS still has a somewhat legitimate bone to pick w/ RO.

 

[communitydoc13]

X * Y = Z

X = amt each rad onc "costs" CMS on avg


X is going down...
But Y is going up more than X is going down

Usually arguments from TheWallnerus are excellent but this is just bogus.

X * Y= Z

X= amt each case "costs" CMS on avg
Y = No. of cases
Z = total rad onc cost to CMS

The relationship of numbers of radoncs to costs is not obvious but probably favors fewer radoncs for cost savings for both good and bad reasons.

Bad reason: Fewer radoncs could "in theory" limit access and thus number of cases. (This is not happening in locales that I am aware of). CMS definitely not (nor should they) going to support a "decrease access to decrease cost" strategy.

Good reason: Fewer radoncs equals busier and better compensated docs with less incentive to maximize cost of each case.

the narrative is dominated by the actions of a handful of greedy folks from 15 years ago

I agree, there is no greater archetype of evil to the CMS bureaucrat or their well connected elite academic advisors than the overly compensated private practice doc. No amount of low value academic expenditure in the name of innovation or very overpaid academic leadership is going to compare.

 

[RickyScott]

Usually arguments from TheWallnerus are excellent but this is just bogus.

X * Y= Z

X= amt each case "costs" CMS on avg
Y = No. of cases
Z = total rad onc cost to CMS

The relationship of numbers of radoncs to costs is not obvious but probably favors fewer radoncs for cost savings for both good and bad reasons.

Bad reason: Fewer radoncs could "in theory" limit access and thus number of cases. (This is not happening in locales that I am aware of). CMS definitely not (nor should they) going to support a "decrease access to decrease cost" strategy.

Good reason: Fewer radoncs equals busier and better compensated docs with less incentive to maximize cost of each case.



I agree, there is no greater archetype of evil to the CMS bureaucrat or their well connected elite academic advisors than the overly compensated private practice doc. No amount of low value academic expenditure in the name of innovation or very overpaid academic leadership is going to compare.

Except today, the overcompensated are the Ben smiths at 1 mill and Lou potters at 2 mill/year

 

[jondunn]

 

[jondunn]

Except today, the overcompensated are the Ben smiths at 1 mill and Lou potters at 2 mill/year

Weird angle to take that hospital corporations should make hundred of millions as well as C suite leadership but that MDs and/or MDs in leadership shouldn’t make these relatively paltry sums?

 

[RickyScott]

Weird angle to take that hospital corporations should make hundred of millions as well as C suite leadership but that MDs and/or MDs in leadership shouldn’t make these relatively paltry sums?

Both these guys have criticized non academic docs for making too much money.

 

[elementaryschooleconomics]

Well THIS should be interesting.

This will go one of two ways:

1) ASTRO or some other professional society/coalition hired real economists to do a workforce study. I feel like rumors of this would have trickled out if it happened, and I haven't heard anything - has anyone else? I think Vapiwala said somewhere recently that they were looking into doing it, but February 2022 seems too soon. I can't for the life of me remember where I read that statement, but I remember thinking maybe we'd have something by the end of 2022 at the earliest.

2) Barring a real economic analysis, everyone has access to the same data. You can try to spin it positive like Potters keeps trying to do ("I surveyed my friends at SCAROP and they might hire over the next three years! Word of mouth is hiring is OK this year! All is well!"), or you could just have a frank discussion of all the different forces involved, which are overwhelming and go beyond simple supply/demand.

The fact that this is happening in the RJ is a good sign. As we all know, the last time any meaningful contraction took place in an attempt to curb oversupply was in the late 1990s. I was reading (very) old issues of the Red Journal, and rediscovered this gem, "The Manpower Crisis Facing Radiation Oncology" from April 1986:

Again, in advance of whatever happens in February, I feel the need to point out this timeline:

1) As early as the mid-1980s there were concerns about oversupply
2) It took ten years for things to be done about it (extending training by a year, cutting back spots - late 90s)
3) Almost as soon as these changes took place, IMRT became widely available and a ton of money came into the specialty
4) So now, all the "old timers" remember how people were warning of oversupply but it "didn't happen"

I will keep repeating myself about this, because the gray haired people in charge who say "the sky is always falling in Radiation Oncology" DO NOT seem to appreciate the crazy timing of IMRT, and I'm tired of them dismissing workforce concerns because they can't view their experience through a wider historical lens.

 

[RickyScott]

View attachment 347677

Well THIS should be interesting.

This will go one of two ways:

1) ASTRO or some other professional society/coalition hired real economists to do a workforce study. I feel like rumors of this would have trickled out if it happened, and I haven't heard anything - has anyone else? I think Vapiwala said somewhere recently that they were looking into doing it, but February 2022 seems too soon. I can't for the life of me remember where I read that statement, but I remember thinking maybe we'd have something by the end of 2022 at the earliest.

2) Barring a real economic analysis, everyone has access to the same data. You can try to spin it positive like Potters keeps trying to do ("I surveyed my friends at SCAROP and they might hire over the next three years! Word of mouth is hiring is OK this year! All is well!"), or you could just have a frank discussion of all the different forces involved, which are overwhelming and go beyond simple supply/demand.

The fact that this is happening in the RJ is a good sign. As we all know, the last time any meaningful contraction took place in an attempt to curb oversupply was in the late 1990s. I was reading (very) old issues of the Red Journal, and rediscovered this gem, "The Manpower Crisis Facing Radiation Oncology" from April 1986:

View attachment 347678

Again, in advance of whatever happens in February, I feel the need to point out this timeline:

1) As early as the mid-1980s there were concerns about oversupply
2) It took ten years for things to be done about it (extending training by a year, cutting back spots - late 90s)
3) Almost as soon as these changes took place, IMRT became widely available and a ton of money came into the specialty
4) So now, all the "old timers" remember how people were warning of oversupply but it "didn't happen"

I will keep repeating myself about this, because the gray haired people in charge who say "the sky is always falling in Radiation Oncology" DO NOT seem to appreciate the crazy timing of IMRT, and I'm tired of them dismissing workforce concerns because they can't view their experience through a wider historical lens.

Yip. Prostate exploded while in medschool

 

[TheWallnerus]

Usually arguments from TheWallnerus are excellent but this is just bogus.

X * Y= Z

X= amt each case "costs" CMS on avg
Y = No. of cases
Z = total rad onc cost to CMS

The relationship of numbers of radoncs to costs is not obvious but probably favors fewer radoncs for cost savings for both good and bad reasons.

Bad reason: Fewer radoncs could "in theory" limit access and thus number of cases. (This is not happening in locales that I am aware of). CMS definitely not (nor should they) going to support a "decrease access to decrease cost" strategy.

Good reason: Fewer radoncs equals busier and better compensated docs with less incentive to maximize cost of each case.

It looks like from '13 to '19:
- There were 6 more patients per RO per year over that time period (increase of ~1 pt per year... per year... per RO).
- But... there were ~180 more "services" per year per RO over that time period (increase of ~25 svcs per yr... per yr... per RO).
- There was net ~$20K less reimbursement per RO per yr.
- The "spread" of reimbursement about the median dramatically shrunk (by about 30%); the median held steady.

I don't think there's an access-to-RO problem. I think there's a too-many-ROs problem. For whatever underlying rationale, I think dialing back the number of ROs would save Medicare money. But unfortunately I think it's also true that ROs are doing too many "services," and the high dollar services are increasing year upon year. However, the one thing that has increased the most in the Medicare spending tables is not high dollar services, high dollar reimbursements, or pure services (per RO)... it's the number of rad oncs. EDIT: And also it seems that while the mean is falling, every new RO we add is added below the ever-falling mean.

 

[communitydoc13]

For whatever underlying rationale, I think dialing back the number of ROs would save Medicare money.

I agree. Among the factors at play costing CMS money with expanding RO workforce are: 1) Percentage of RO docs employed at every expanding large networks associated with PPS exempt systems. 2) Investment at large academic systems in procedures that require more human or technical capital with questionable clinical benefit (MRI linac and protons). This means more docs for the same number of patients.

 

[elementaryschooleconomics]

Yip. Prostate exploded while in medschool

I forgot about that convenient occurrence as well:

There's a sharp rise in diagnosis for a few years starting in 2005.

IMRT likely enjoyed a wide rate of adoption by that point.

What else is interesting about 2005...oh! That's right.

21C filed IPO documents with the SEC.

We continue to pay for the sins of 21C.

(not to lay everything at their feet, because it's far more complicated than that, obviously)

 

[RickyScott]

I forgot about that convenient occurrence as well:

View attachment 347679

There's a sharp rise in diagnosis for a few years starting in 2005.

IMRT likely enjoyed a wide rate of adoption by that point.

What else is interesting about 2005...oh! That's right.

21C filed IPO documents with the SEC.

View attachment 347681

We continue to pay for the sins of 21C.

(not to lay everything at their feet, because it's far more complicated than that, obviously)

Beginning in late 1990s prostate treatment with xrt became very “benign” and an excellent alternative to surgery.

 

[TheWallnerus]

Beginning in late 1990s prostate treatment with xrt became very “benign” and an excellent alternative to surgery.

And the 1990s saw widespread adoption in the house of medicine of breast conserving surgery ALWAYS with radiation. PSA screening and Bernie Fisher were the tee, and IMRT was Tiger swinging the club.

 

[RickyScott]

And the 1990s saw widespread adoption in the house of medicine of breast conserving surgery ALWAYS with radiation. PSA screening and Bernie Fisher were the tee, and IMRT was Tiger swinging the club.

Exactly.

 

[jondunn]

 

[metallica81788]

I guess I don't understand the context because that post is either hilarious or extremely lame depending

 

[elementaryschooleconomics]

I guess I don't understand the context because that post is either hilarious or extremely lame depending

Half the RadOnc Twitter posts over the last 2+ years have been about that bike (unless I'm just following the wrong people), I assume context would be "this is all you guys talk about".

The holidays (and COVID...covidays?) have made things very slow on Twitter and SDN, which means I'm doomscrolling 1) skiing pics, 2) peloton, 3) abysmal COVID stats.

One of y'all has to have something we can debate about. Anything? Anything? Bueller?

 

[Gfunk6]

I avoid Twitter like the plague. However, I am an avid Peolton user. If there are others who are enthusiastic about this, I'm happy to start another thread.

 

[deleted1111261]

GFunk!!!
Then I’ll start posting ski pictures

 

[TheWallnerus]

Half the RadOnc Twitter posts over the last 2+ years have been about that bike (unless I'm just following the wrong people), I assume context would be "this is all you guys talk about".

The holidays (and COVID...covidays?) have made things very slow on Twitter and SDN, which means I'm doomscrolling 1) skiing pics, 2) peloton, 3) abysmal COVID stats.

One of y'all has to have something we can debate about. Anything? Anything? Bueller?

I have a debate. Maybe not a debate but a provocation.

Are MD PhDs disappearing from rad onc?

Holman, over time. Incidentally, 2012-13 was the timeframe of peak Medicare RO spending.

 

[Ray D. Ayshun]

I avoid Twitter like the plague. However, I am an avid Peolton user. If there are others who are enthusiastic about this, I'm happy to start another thread.

Aren't you in NorCal somewhere? I thought most of the footage on the Peloton screen was filmed out there. Too many whisper quiet Tesla's mowing down cyclists?

 

[Gfunk6]

Aren't you in NorCal somewhere? I thought most of the footage on the Peloton screen was filmed out there. Too many whisper quiet Tesla's mowing down cyclists?

Yes, I'm in the Bay Area. Peloton studios are in New York and London - this is where the vast majority of their content is streamed live. Because of the time zones, I tend to not take too many live rides except on weekends or holidays.

 

[Ray D. Ayshun]

I have a debate. Maybe not a debate but a provocation.

Are MD PhDs disappearing from rad onc?

Holman, over time. Incidentally, 2012-13 was the timeframe of peak Medicare RO spending.

Hard to say. I'm MD/PhD and had no interest in Holman as I wanted to be clinically competent when getting the f out of academia.

 

[Ray D. Ayshun]

I have a debate. Maybe not a debate but a provocation.

Are MD PhDs disappearing from rad onc?

Holman, over time. Incidentally, 2012-13 was the timeframe of peak Medicare RO spending.

Where's this chart from anyway?

 

[TheWallnerus]

Where's this chart from anyway?

the numbers are from the ABR Holman page

 

[Ray D. Ayshun]

the numbers are from the ABR Holman page

Ah, ok, maybe I get it now. 18ish per year Holman residents (was thinking that seemed low for all of radonc). Still seems kinda low.

 

[dieABRdie]

I have a debate. Maybe not a debate but a provocation.

Are MD PhDs disappearing from rad onc?

Holman, over time. Incidentally, 2012-13 was the timeframe of peak Medicare RO spending.

Oh no! This is going to decimate rad onc bench research....

 

[deleted1111261]

That is what we in the business call a precipitous drop.

 

[radiation]

I have a debate. Maybe not a debate but a provocation.

Are MD PhDs disappearing from rad onc?

Holman, over time. Incidentally, 2012-13 was the timeframe of peak Medicare RO spending.

Chart shows mixed things. The absolute number of Holman graduates is stable to increased, but less of those Holman grads have PhDs. The lack of MD Phds is probably indicative of rad onc being less competitive combined with trend that you don't necessarily need a phd to do rad onc research. There are still 93 active residents with MD PhDs, so not quite disappeared yet, but numbers definitely going down.

Table B4. MD-PhD Residents, by GME Specialty

MD-PhD Residents, by GME Specialty

www.aamc.org

 

[communitydoc13]

There are still 93 active residents with MD PhDs

The numbers here are very strange. A single first year MD/PhD for 3 years with 93 residual active MD/PhDs as of 2020? This in a residency that is 4-5 years long? Was half the class from 2017 MD/PhD? Just doesn't seem plausible. Are there residual MD/PhDs extending their training through fellowship and counting as active?

Unless the data is somehow wildly misrepresented, this reveals a radical shunning of the field by MD/PhDs. (It should be noted that this table refers to the real deal: Dual degree MD/PhD from US med school, not jokers like me who had a PhD and then went to med school.)

If it does represent a radical shunning, there is likely one reason for this, and it is not SDN. MD/PhD folks are typically very close to their very small cohort and classes ahead of them. I suspect downstream MD/PhDs must have been discouraging their upstream friends based on personal experience.

Edit: I noticed that no specialty without commonly integrated PGY-1 had significant numbers of first year MD/PhD's listed. I suspect this explains the tiny number of listed first year residents.

The trend remains significant but not radical. Nineteen fewer MD/PhDs in 2020 vs 2018, likely with significant frontloading of the duel degree cohort among remaining more senior classes.