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For those that have been following this stuff for years the RRC moving the core faculty requirements as above is huge. Probably the most significant change in favor of increasing program quality in the past 10 years. This will prevent places from opening/expanding. I'm sure these changes were very hard to get approved and were meet with considerable resistance. This represents a sea change in thinking being done at the very top of the specialty's leadership.

Strange how this news just devolved into pointless attacks on the U of Miami program. This type of stuff does not help the forum's creditability.
 
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fiji128 said:
For those that have been following this stuff for years the RRC moving the core faculty requirements as above is huge. Probably the most significant change in favor of increasing program quality in the past 10 years. This will prevent places from opening/expanding. I'm sure these changes were very hard to get approved and were meet with considerable resistance. This represents a sea change in thinking being done at the very top of the specialty's leadership.

Strange how this news just devolved into pointless attacks on the U of Miami program. This type of stuff does not help the forums creditability.
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It's a start. Key limiting added requirements were the additional residency/fellowship co-location, 75% at main site or 90% at main +1 (believe this also means that the individual case numbers for each disease site have to be there), minimum tech requirements (not sure this is a big deal? Low bar), and minimum of 4 core faculty and a 1.5:1 ratio of attending:residents.

Not sure how many sites this would close down (guessing few to none?), but may be a barrier to expansion.
 
temujim said:
It's a start. Key limiting added requirements were the additional residency/fellowship co-location, 75% at main site or 90% at main +1 (believe this also means that the individual case numbers for each disease site have to be there), minimum tech requirements (not sure this is a big deal? Low bar), and minimum of 4 core faculty and a 1.5:1 ratio of attending:residents.

Not sure how many sites this would close down (guessing few to none?), but may be a barrier to expansion.
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I'm not saying its perfect or an answer to all the issues facing the specialty. But the move is a significant step in the right direction and not something I've seen the RRC do before. It would've been great to see brachy and peds requirements go up as well but this is still a big win.
 
Which programs will get hit w/ a 1.5:1 ratio requirement? I can’t think of any right now.

EDIT: I really don’t put it past certain programs to have residents rotate to distant satellites now in order to make previously non-resident “attendings” now be resident attendings if you get what I’m saying.
 
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jondunn said:
What did I say about Kansas?

You have me confused

The people I know graduated in the last 4 years, multiple

Really not sure why people are not even a little bit suspicious of an Assistant PD’s post
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Oops my bad. You're not confused, I'm confused. Totally mixed up you and carbonion. I was thinking of this post

thecarbonionangle said:
Speaking of Kansas i have heard nothing but good things recently. This program went from half of grads failing boards and worst program in country to a decent place. There is hope for improvement in places who care. The issue is many hellpits like the status quo just fine. Sometimes institutional MO is precicesily what it was designed to be! Dont get it confused!

Some hellpits have been around since 1980s and yet zero improvement. Many places need to be shut down.
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It just stands out to me because the general theme at "SDN" has been that Kansas is a hellpit and I had heard whispers to the contrary, but was never sure because of the SDN insistence. This was the first time "SDN" confirmed that they've turned it around.

That's the power of the forum -- when there is so much info asymmetry out there it gets tricky to figure out what's true insider knowledge, what's outdated insider knowledge, and what's just hearsay
 
CaesarRO said:
Oops my bad. You're not confused, I'm confused. Totally mixed up you and carbonion. I was thinking of this post




It just stands out to me because the general theme at "SDN" has been that Kansas is a hellpit and I had heard whispers to the contrary, but was never sure because of the SDN insistence. This was the first time "SDN" confirmed that they've turned it around.

That's the power of the forum -- when there is so much info asymmetry out there it gets tricky to figure out what's true insider knowledge, what's outdated insider knowledge, and what's just hearsay
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multiple posts in past stating kansas was turning around. They have grown significantly, hired multiple physician scientists, new leadership, good institutional backing with proton centre. It is way away from the hellpit roots where it was the worst program in country 10 years ago.
 
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fiji128 said:
It would've been great to see brachy and peds requirements go up
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I'm on board with brachy requirements going up. I was undertrained in brachy. (Where I ended up, brachy not a winner, and I don't do it. You need the right volume and physics staff numbers for brachy to make sense or you need to be a loooong way away from a place that does a fair bit of brachy for it to make sense. Admins looking at bottom dollar don't emphasize brachy.)

I could care less about peds requirement going up and am fine with the rotate at St. Jude's model. I am also fine with peds-onc being consolidated. IMO, a peds cancer diagnosis should buy you full coverage and transportation cost to a dedicated center. It is a vanishingly small portion of total oncology care.
 
TheWallnerus said:
Which programs will get hit w/ a 1.5:1 ratio requirement? I can’t think of any right now.

EDIT: I really don’t put it past certain programs to have residents rotate to distant satellites now in order to make previously non-resident “attendings” now be resident attendings if you get what I’m saying.
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Not sure what situations are like now but in the past plenty of smaller or lower tier programs had 8 faculty for 6 residents. That doesn't fly, especially if one of those faculty are only part time in clinic.
 
communitydoc13 said:
I'm on board with brachy requirements going up. I was undertrained in brachy. (Where I ended up, brachy not a winner, and I don't do it. You need the right volume and physics staff numbers for brachy to make sense or you need to be a loooong way away from a place that does a fair bit of brachy for it to make sense. Admins looking at bottom dollar don't emphasize brachy.)

I could care less about peds requirement going up and am fine with the rotate at St. Jude's model. I am also fine with peds-onc being consolidated. IMO, a peds cancer diagnosis should buy you full coverage and transportation cost to a dedicated center. It is a vanishingly small portion of total oncology care.
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It’s not so much about wanting more training in peds as it is about being a larger barrier to entry or expansion
 
TheWallnerus said:
Which programs will get hit w/ a 1.5:1 ratio requirement? I can’t think of any right now.

EDIT: I really don’t put it past certain programs to have residents rotate to distant satellites now in order to make previously non-resident “attendings” now be resident attendings if you get what I’m saying.
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Agree hundred percent. This will happen.
 
metallica81788 said:
Not sure what situations are like now but in the past plenty of smaller or lower tier programs had 8 faculty for 6 residents. That doesn't fly, especially if one of those faculty are only part time in clinic.
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If that's the case, couldn't they just drop a resident position to skirt over the new ratio rather than lose then entire program?
 
CptCrunch said:
If that's the case, couldn't they just drop a resident position to skirt over the new ratio rather than lose then entire program?
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Sure - or they just wouldn't match one year because their program is not good. Could have already been solved in the past few years with the recent matches.
Or hire one more faculty. Unfortunately some programs that shouldn't exist will get by this new rule without much fanfare.
Would really show where some priorities lie to see what happens there.
 
jondunn said:
It’s not so much about wanting more training in peds as it is about being a larger barrier to entry or expansion
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Yeah, I get it. I just don't think it's a reasonable rationale for eliminating a program. Lots of fairly large cities have multiple academic places with one place seeing the vast majority of peds. This is an ok model from a societal standpoint IMO. Total volume of cases, faculty to resident ratio all make sense to me.
 
metallica81788 said:
Not sure what situations are like now but in the past plenty of smaller or lower tier programs had 8 faculty for 6 residents. That doesn't fly, especially if one of those faculty are only part time in clinic.
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In the meantime vs “the past” the number of academic rad oncs is up ~225% (2019 vs 2004) whilst residents are up only about 170% in that timeframe. (PP rad onc went up <140%.) So I think many lower tiers may have benefited from the explosion of academic rad onc employment.
 
TheWallnerus said:
In the meantime vs “the past” the number of academic rad oncs is up ~225% (2019 vs 2004) whilst residents are up only about 170% in that timeframe. (PP rad onc went up <140%.) So I think many lower tiers may have benefited from the explosion of academic rad onc employment.
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No doubt they have. Cheap labor. A cornered referral pattern. And a bad job market. Ofcourse they benefited.
 
TheWallnerus said:
In the meantime vs “the past” the number of academic rad oncs is up ~225% (2019 vs 2004) whilst residents are up only about 170% in that timeframe. (PP rad onc went up <140%.) So I think many lower tiers may have benefited from the explosion of academic rad onc employment.
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So many more academic attendings are uncovered as opposed to in the past. I guess that’s a good thing , that part of it
 
Mandelin Rain said:
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Haha, I was wondering when this one would come up.

Surely you evidence based rad-oncs wouldn't make any assumptions about relative efficacy based on retrospective data!. Where is Dan Spratt raking this person over the coals! Think of the Biases!. That would be preposterous!

In all honesty I am interested to see the paper because the devil will be in the details. Most of the high volume TMT centers (MGH comes to mind) had specific protocols of patients who were single focus of T2 disease < 3cm completely resected without CIS in the appropriate part of the bladder, namely highly selected. If you do a matching cohort study where you control for T stage, that can be "matched" to a multifocal large T2 + CIS patient who was unresectable and who got a cystectomy. We also need the rates of salvage cystectomy, etc etc etc.

That being said, data like this will contribute to the equipoise necessary to run a real trial. Unlike ralps, where I can honestly say most outcomes are excellent, cystectomies kind of suck and are fraught with issues. Most urologists are not performing cystectomies, and will not have a huge dog in this fight. If anything, your regular private urologist might prefer to send out their T2 patient to get TMT then follow them with q3 month surveillance cysto's forever and ever. On the other hand, trying to salvage patients after failed TMT is the definition of misery (ureteroenteric strictures from cystectomy are already a problem, add in radiation and its a BIG problem), and my experience has been the TMT successes oncologically are often in rough shape symtpomatically/from a bladder QOL standpoint.
 
DoctwoB said:
. Most urologists are not performing cystectomies, and will not have a huge dog in this fight. If anything, your regular private urologist might prefer to send out their T2 patient to get TMT then follow them with q3 month surveillance cysto's forever and ever.
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Definitely feel like i get a decent number of these pts who aren't candidates for travel out for radical surgery for any number of reasons since no one locally is really doing them. Pdl1 therapy has been pretty good for salvage in these pts when they recur/met out
 
DoctwoB said:
Haha, I was wondering when this one would come up.

Surely you evidence based rad-oncs wouldn't make any assumptions about relative efficacy based on retrospective data!. Where is Dan Spratt raking this person over the coals! Think of the Biases!. That would be preposterous!

In all honesty I am interested to see the paper because the devil will be in the details. Most of the high volume TMT centers (MGH comes to mind) had specific protocols of patients who were single focus of T2 disease < 3cm completely resected without CIS in the appropriate part of the bladder, namely highly selected. If you do a matching cohort study where you control for T stage, that can be "matched" to a multifocal large T2 + CIS patient who was unresectable and who got a cystectomy. We also need the rates of salvage cystectomy, etc etc etc.

That being said, data like this will contribute to the equipoise necessary to run a real trial. Unlike ralps, where I can honestly say most outcomes are excellent, cystectomies kind of suck and are fraught with issues. Most urologists are not performing cystectomies, and will not have a huge dog in this fight. If anything, your regular private urologist might prefer to send out their T2 patient to get TMT then follow them with q3 month surveillance cysto's forever and ever. On the other hand, trying to salvage patients after failed TMT is the definition of misery (ureteroenteric strictures from cystectomy are already a problem, add in radiation and its a BIG problem), and my experience has been the TMT successes oncologically are often in rough shape symtpomatically/from a bladder QOL standpoint.
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Only referrals most of us get are 85+ or that have done their own research about combined modality treatment. Why do you think that is?
 
DoctwoB said:
Haha, I was wondering when this one would come up.

Surely you evidence based rad-oncs wouldn't make any assumptions about relative efficacy based on retrospective data!. Where is Dan Spratt raking this person over the coals! Think of the Biases!. That would be preposterous!

In all honesty I am interested to see the paper because the devil will be in the details. Most of the high volume TMT centers (MGH comes to mind) had specific protocols of patients who were single focus of T2 disease < 3cm completely resected without CIS in the appropriate part of the bladder, namely highly selected. If you do a matching cohort study where you control for T stage, that can be "matched" to a multifocal large T2 + CIS patient who was unresectable and who got a cystectomy. We also need the rates of salvage cystectomy, etc etc etc.

That being said, data like this will contribute to the equipoise necessary to run a real trial. Unlike ralps, where I can honestly say most outcomes are excellent, cystectomies kind of suck and are fraught with issues. Most urologists are not performing cystectomies, and will not have a huge dog in this fight. If anything, your regular private urologist might prefer to send out their T2 patient to get TMT then follow them with q3 month surveillance cysto's forever and ever. On the other hand, trying to salvage patients after failed TMT is the definition of misery (ureteroenteric strictures from cystectomy are already a problem, add in radiation and its a BIG problem), and my experience has been the TMT successes oncologically are often in rough shape symtpomatically/from a bladder QOL standpoint.
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'we talked to them about radiation and all options. they preferred surgery!'
 
jondunn said:
'we talked to them about radiation and all options. they preferred surgery!'
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Urologists always tell the patients that they will become urinary cripples despite no literature or any of our experience supporting that. Same true for another urban legend- salvage cystectomies for radiation cystitis after prostate treatment.
 
RickyScott said:
Urologists always tell the patients that they will become urinary cripples despite no literature or any of our experience supporting that. Same true for another urban legend- salvage cystectomies for radiation cystitis after prostate treatment.
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Urban legend only for those who don’t see their own complications. That’s urinary diversions btw, not salvage . My friends dad had one a few weeks ago. I performed 4-5 in residency. 4 deaths and counting from bladder perfs from clot retention from xrt. Far more common are the recurrent hematuria, clot retention, in and out of the hospital on CBI, hyperbaric oxygen variety of radiation cystitis.

FWIW I was not trying to restart a flame war about a paper none of us have seen. I would not be shocked to see TMT play a larger role in bladder CA care, there is definitely a lot of room for improvement over the status quo. Was just pointing out the irony of the shoe being on the other foot, with retrospective data showing radiation superiority and suddenly both sides jumping back across the line re:retrospective data. Just know that one of the reasons surgeons and radoncs don’t see eye to eye is you haven’t spent the months on call in the ED (do you cover call?) dealing with the complications.
 
The reason we dont have higher level data is your field refuses to play ball. They ignore PROTECT pointing at their anecdotal “data”, i saw i heard. same reason it has taken so long to get a lobectomy vs SBRT study. Urologists know the SBRT data for RCC is great yet they also will refuse to run a trial.

When i mention urologists to my colleagues even the med oncs get a bit of a smirk. You guys got quite a reputation.
 
DoctwoB said:
Just know that one of the reasons surgeons and radoncs don’t see eye to eye is you haven’t spent the months on call in the ED (do you cover call?) dealing with the complications.
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Very important. I try to keep a very open mind. However when we go looking for non-rare complications from TMT in our own literature using chemoRT for bladder, especially modern adaptive IMrT approaches, we don’t see any. Outside the literature, I also look to my own eyes. And I treat a relative lot of bladder. My urologists complement me on how well the patients do. They seem “astounded.” How they talk about me behind my back I don’t know!
 
I put very little stock into matched pair analysis. Just impossible to eliminate bias associated with decisions to treat.

I'm most interested in TNT in T4 disease, although this is not where it has traditionally been used. While T4 disease historically was considered non-ideal for bladder preservation, the surgical outcomes are not good, competing risk of distant progression is high and it's not clear to me that we don't do just as well with bladder conserving strategies to begin with. T4 included in BC2001 trial. I've seen malignant priapism and other ungodly pelvic toxicity from local progression of surgically managed T4 disease.

I'm not really sure that hydro should really be considered a contraindication to bladder conserving therapy any more. Any thoughts?
 
thecarbonionangle said:
The reason we dont have higher level data is your field refuses to play ball. They ignore PROTECT pointing at their anecdotal “data”, i saw i heard. same reason it has taken so long to get a lobectomy vs SBRT study. Urologists know the SBRT data for RCC is great yet they also will refuse to run a trial.

When i mention urologists to my colleagues even the med oncs get a bit of a smirk. You guys got quite a reputation.
Click to expand...
💯
 
thecarbonionangle said:
The reason we dont have higher level data is your field refuses to play ball. They ignore PROTECT pointing at their anecdotal “data”, i saw i heard. same reason it has taken so long to get a lobectomy vs SBRT study. Urologists know the SBRT data for RCC is great yet they also will refuse to run a trial.

When i mention urologists to my colleagues even the med oncs get a bit of a smirk. You guys got quite a reputation.
Click to expand...

If you think the vitriol is high from radonc towards urology from time to time, wait until they start giving systemic treatment for metastatic prostate cancer like they do in this town. That gives medical oncologists the big mad.
 
OTN said:
If you think the vitriol is high from radonc towards urology from time to time, wait until they start giving systemic treatment for metastatic prostate cancer like they do in this town. That gives medical oncologists the big mad.
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No doubt. Surgeons have balls unlike catfish RO. Thoracic surgeons are toying IO and giving other drugs. Urologists already do intravesical MMC. They could easily start giving abi+pred or enzalutamide and getting bone density and zytiga. We are the ones on sideline waiting for daddy to give us permission.
 
OTN said:
If you think the vitriol is high from radonc towards urology from time to time, wait until they start giving systemic treatment for metastatic prostate cancer like they do in this town. That gives medical oncologists the big mad.
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“The Big Mad”
Love it !!
 
thecarbonionangle said:
No doubt. Surgeons have balls unlike catfish RO. Thoracic surgeons are toying IO and giving other drugs. Urologists already do intravesical MMC. They could easily start giving abi+pred or enzalutamide and getting bone density and zytiga. We are the ones on sideline waiting for daddy to give us permission.
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Daddy’s already left in with his hot new secretary in his blue Maserati moving to Miami while we got left at home with mom in her robe and curlers chain smoking and drinking martinis all day long and yelling “you look just your GD father” in between crying bouts. Dad will send you a card on your birthday though with a 5 dollar bill. FUN LIFE.
 
OTN said:
If you think the vitriol is high from radonc towards urology from time to time, wait until they start giving systemic treatment for metastatic prostate cancer like they do in this town. That gives medical oncologists the big mad.
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Was shocked when i heard about a urologist giving prolia in his office and prescribing second gen anti androgens for his M1 crpc pts on long term ADT.

No different than the gyn oncs around here doing Systemics and pissing MO off
 
medgator said:
Was shocked when i heard about a urologist giving prolia in his office and prescribing second gen anti androgens for his M1 crpc pts on long term ADT.

No different than the gyn oncs around here doing Systemics and pissing MO off
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But Gyn oncs are trained to give chemo right? Is it really no different?
 
RealSimulD said:
But Gyn oncs are trained to give chemo right? Is it really no different?
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Not sure prolia, xtandi and lupron are the same. Many radoncs do give ADT with radiation even though they weren't officially trained in residency. Taxotere wouldn't be the same imo, I've yet to meet a GU giving that
 
medgator said:
Was shocked when i heard about a urologist giving prolia in his office and prescribing second gen anti androgens for his M1 crpc pts on long term ADT.

No different than the gyn oncs around here doing Systemics and pissing MO off
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As far as I can tell, RadOnc residency programs have a hidden curriculum which convinces their graduates they're only allowed to prescribe a certain medicine/perform a treatment if they were "taught" to do it when they were a resident.

Heaven help my generation of RadOncs if FLASH really pans out and in 10 years it's the new IMRT.

"I need to go back for a FLASH fellowship" - 2018 grad in 2031
 
elementaryschooleconomics said:
As far as I can tell, RadOnc residency programs have a hidden curriculum which convinces their graduates they're only allowed to prescribe a certain medicine/perform a treatment if they were "taught" to do it when they were a resident.

Heaven help my generation of RadOncs if FLASH really pans out and in 10 years it's the new IMRT.

"I need to go back for a FLASH fellowship" - 2018 grad in 2031
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Some of us had to start prescribing lupron and placing fiducials out of necessity, without training or exposure in residency. The horror
 
medgator said:
Some of us had to start prescribing lupron and placing fiducials out of necessity, without training or exposure in residency. The horror
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I once wrote a script for tamoxifen. The pharmacist couldn’t read it though because I guess my hand shook too much.
 
medgator said:
Was shocked when i heard about a urologist giving prolia in his office and prescribing second gen anti androgens for his M1 crpc pts on long term ADT.

No different than the gyn oncs around here doing Systemics and pissing MO off
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Urologists just like Gyn Oncs, control the patient flow. They can do whatever they want.
 
TheWallnerus said:
I once wrote a script for tamoxifen. The pharmacist couldn’t read it though because I guess my hand shook too much.
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When I came to my current department I immediately started prescribing ADT for all my prostate patients. While that was not commonly done in my residency program (punters gotta punt), I'm a doctor, and I'm pretty sure managing ADT is something I can handle.

Good Lord. The chaos. My nurses stepped up and handled it professionally and everything went great from my perspective, but several months later I found out my charge/supervising nurse landed on several grenades thrown by therapist-turned-admin pencil pushers about it.

You'd think I started doing in-office lobotomies.
 
jondunn said:


The poor urorads folks took some strays with this tweet
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I like the sentiment with these proposed changes.

I have very little faith they will be enforced.

I want to be proven wrong. I want Neha and team to come back to this post and just absolutely obliterate me in the future. I hope I'm dragged all over the internet for how wrong I am.

#dreams
 
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