Rad Onc Twitter

[medgator]

unhappy and negative posts,

The truths of this specialty over the last 5-10 years are what they are.

Many anecdotal experiences of some of the posters here reflect those truths and those experiences are conspicuously absent on #radonc Twitter

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[radoncgrad2019]

You seem to be thinking he was saying hypofrac does not reduce the need for (number of) rad onc(s) when what he said it does not equate to what you think he said.

Sad!

 

[medgator]

You seem to be thinking he was saying hypofrac does not reduce the need for (number of) rad onc(s) when what he said it does not equate to what you think he said.

Sad!

I guess you graduated last year?

You'll figure it out sooner or later.

Hypofx absolutely allows those in practice to see and treat more patients annually and directly affects demand for new graduates.

The fact that logic escapes you/KO is even more sad.

 

[RadOncDoc21]

Nobody is attacking his character, I don’t know the guy but I can see he was wrong. Everything else is just added shade.

 

[radoncgrad2019]

I guess you graduated last year?

You'll figure it out sooner or later.

Hypofx absolutely allows those in practice to see and treat more patients annually, and the fact that logic escapes you/KO is even more sad.

Dude. Do you read?

He said that hypofrac does make Radiation oncology as a field obsolete. He said nothing about number needed to treat/

I’ve said the same thing to you four times.

No one ever said you needed to be sharp to pass boards I guess.

 

[medgator]

Dude. Do you read?

He said that hypofrac does make Radiation oncology as a field obsolete. He said nothing about number needed to treat/

I’ve said the same thing to you four times.

And you still don't get it!

People don't magically stop seeing X pts/year and will in fact see MORE patients as their schedule permits. There is only a FINITE demand for radiation in this country.

Try to use a little logic here, I know it's a Herculean task to ask of you

No one ever said you needed to be sharp to pass boards I guess.

Ok, KO. #radonc Twitter is that way ----->

 

[radoncgrad2019]

also btw, just to put it out there - you have to be pretty intellectually dishonest to think that seeing two extra useless breast OTRs adds any significant amount of work. SCARBTJ been saying this for a while and it's true.

it's the consult/contouring/plan eval/document signs for each plan that take the majority of the work.

i do a TON of SBRT in my practice and if anything that's way more work, it's only 5 fractions each and they come and go quick but each takes a ton of work. That's lots of sims coming through.

One 30 fraction breast patient in NO way equals 6 Five-fraction SBRT cases (say two lung, one liver, one pancreas, one head and neck, one prostate)

people who hold on to 'on beam' as any sort of reflection of productivity rather than number of consults and sims a month are doomed to be on the wrong side of history.

 

[medgator]

*EDITED by mods*

Something about idiots and experience comes to mind here.

No one was question the role of radonc to begin with (duh!), the original Twitter post was in regards to job market and labor perceptions.

Assuming you aren't banned by tomorrow, and can still read this, maybe you should pass your boards first, practice for a few years and come back here and try to post intelligently. Unless you're just SDN-hating for life in Rochester, MN

 

[medgator]

One 30 fraction breast patient in NO way equals 6 Five-fraction SBRT cases (say two lung, one liver, one pancreas, one head and neck, one prostate)

people who hold on to 'on beam' as any sort of reflection of productivity rather than number of consults and sims a month are doomed to be on the wrong side of history.

Non-sequitur, those aren't even the same diagnoses or indications.

But yes, a 4-5fx early stage lung sbrt pt absolutely does require less RO labor in the clinic than a concurrent chemo-rt Stage IIIB pt if you want to go down that road

 

[radoncgrad2019]

Non-sequitur, those aren't even the same diagnoses or indications.

But yes, a 5fx lung sbrt pt does require less clinical labor than concurrent chemo-rt pt

It's not a non-sequitur.

It's showing how 30 fractions does not equal 30 fractions. (6 x 5 is 30 btw if you didn't catch that).

Again, number of fractions is obsolete.

you're pretty one track minded.

 

[radoncgrad2019]

also speaking of non-sequiturs, would LOVE to know what class of concurrent chemo-RT patients are being hypofractionated in routine clinical practice!

please try to stay involved.

 

[medgator]

It's not a non-sequitur.

It's showing how 30 fractions does not equal 30 fractions. (6 x 5 is 30 btw if you didn't catch that).

Again, number of fractions is obsolete.

Those fractions don't come to your clinic in same proportion or with the same diagnosis. Bottom line is the cumulative number of fractions treated per doc have nearly been cut in half (scarbtj chart somewhere around here) over the last decade while slots have doubled.

That absolutely does affect labor. Period. It creates a situation where existing docs see more patients per year to maintain the same level of productivity, something that seems to be lost on you/KO

 

[RadOncDoc21]

It's not a non-sequitur.

It's showing how 30 fractions does not equal 30 fractions. (6 x 5 is 30 btw if you didn't catch that).

Again, number of fractions is obsolete.

I don’t believe that’s his argument. Every plan is different and we all can agree an SBRT lung is simple to plan, so is a hypofx/standard tangent breast plan but with different fractionations. I agree, we shouldn’t measure the amount of work based on the number of patients on a machine. The argument isn’t the planning or even the care needed for OTV’s. It’s the fact that hypofx and more residents hurts the job market.

 

[medgator]

also speaking of non-sequiturs, would LOVE to know what class of concurrent chemo-RT patients are being hypofractionated in routine clinical practice!

please try to stay involved.

The ones that can't get chemo?

- American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

www.astro.org

 

[RickyScott]

it seems so clear that while hypofractionation is good for pts and society, it clearly has an adverse impact on the job market, by reducing labor and allowing docs to see more pts.How is this not obvious?
last year, had countless back and forth with posters who denied that doubling residency numbers did not increase supply or affect the job market.

 

[radoncgrad2019]

The ones that can't get chemo?

- American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

www.astro.org

so they're not concurrent chemoRT patients.

WOW. you're really making a fool of yourself.

 

[medgator]

it seems so clear that while hypofractionation is good for pts and society, it clearly has an adverse impact on the job market, by reducing labor and allowing docs to see more pts.How is this not obvious?

last year, had countless back and forth with posters who denied that doubling residency numbers did not increase supply or affect the job market.

Seems like some of those posters still haven't learned. Eventually they'll come around too I would imagine once reality smacks them in the face.

 

[deleted1002574]

We get you’re providing a contrarian voice. I do that, too.

Have you actually read, Dr. Oliver’s posts? The one about hypofx, distinctly makes a snide comment about reimbursement rather than how it affects the field. Which it does.

If there is more work (more fractions), you need more doctors. The converse is true. Less work, less doctors. We have said that for years,

I’m skeptical because of the way he says it. Nobody needs hysteria. Tendulkar without anonymity can admit. Others can, as well.

Again - what is wrong with this?

Hypofrac has not made Radiation obsolete.

 

[Mandelin Rain]

I mean, this is just stupid.

Less fractions = less OTV visits = less physician time = less physician need.

how is that not patently obvious to anyone with a shred of intelligence?

Sure, it’s only 3 less breast and 5 less prostate OTVs per treatment course. But multiply each * 10 minutes needed to see/document the visit *however many breast and prostate patients are treated in America each year. That’s (hundreds of?) thousands of hours of decreased demand for a rad oncs each year.

Stop being intentionally obtuse.

 

[radiaterMike]

I guess what is lost on some ... while most OTVs are not that time consuming, the reimbursement for weekly management (which requires an OTV) is not negligible. Therefore more new states are needed in order to make up for fewer patients on beam. This means less demand for new doctors unless indications for radiation increase.

 

[Mandelin Rain]

I guess what is lost on some ... while most OTVs are not that time consuming, the reimbursement for weekly management (which requires an OTV) is not negligible. Therefore more new states are needed in order to make up for fewer patients on beam. This means less demand for new doctors unless indications for radiation increase.

Of course. Physicians almost always will try to maintain salary in the face of downward pressure by simply seeing more patients. Hypofraction is both downward pressure while simultaneously making it easier to see more patients.

 

[RTx]

On a shred of optimism, I’m curious to know what people thinking of adaptive planning going forward? Watched the Varian hype session about dynamic prescriptions and the ability to re-plan daily or weekly even at the treatment console by simple sliders covering differing objectives and with machines like the halcyon giving you high quality daily CTs in treatment position. Obviously not needed for all dz sites. But for head and neck and prostates for example if there was reimbursement for the physician work for adaptive planning and accounting for the time needed it could really help increase the physician need in the treatment workflow while providing better care for patients.

 

[MegaVoltagePhoton]

People on twitter are actively going on about how we need to look at DOs and FMGs as they might be willing to go into rural practice. Same old ****.

Complete garbage.

 

[radoncgrad2019]

Neither what this private practice Doc Katz says or the replies say that

Yes a reasonable discussion is complete garbage.


Jesus Christ.

 

[MegaVoltagePhoton]

Neither what this private practice Doc Katz says or the replies say that

Yes a reasonable discussion is complete garbage.


Jesus Christ.

Try clicking on the link, genius. Maybe i'll spoonfeed it to you!




Thought it might help to give readers context to source the beginning of the discussion but happy to link to the actual posts for those who are lazy.

 

[radoncgrad2019]

Do you understand context? He’s correcting his own statement. He’s saying NON MD/PHDs. IE lessening the importance of research that Became such a huge part of this field when it was uber competitive.

I swear none of you cracked a 700 on the verbal section of the SAT

 

[RadOncDoc21]

So accepting more “MD’s or DO’s” with more “Volunteer services” will solve the problem? Am I reading this correctly? Not the 200 residency positions a year?

I don’t think a 700 verbal on the SAT will help solve any of this either.

 

[Doctorer]

On a shred of optimism, I’m curious to know what people thinking of adaptive planning going forward? Watched the Varian hype session about dynamic prescriptions and the ability to re-plan daily or weekly even at the treatment console by simple sliders covering differing objectives and with machines like the halcyon giving you high quality daily CTs in treatment position. Obviously not needed for all dz sites. But for head and neck and prostates for example if there was reimbursement for the physician work for adaptive planning and accounting for the time needed it could really help increase the physician need in the treatment workflow while providing better care for patients.

Unfortunately, adaptive planning will likely be included as part of bundled payments.

 

[KHE88]

I swear none of you cracked a 700 on the verbal section of the SAT

How you have not been banned yet is beyond me.
Sphinx was a much more entertaining troll.

 

[deleted947887]

I think we should all collectively ignore people who continue to derail the discussion with nonsense. Anyone with half a brain can see what is being said here. “Lower standards and get warm bodies into those residencies. Maybe they’ll go practice in rural areas! Do I have evidence for this? No way! Won’t prevent me from saying it!”

Doesn’t take a PhD to understand that.

The Memorial Sloan mantra: "Bleed the field anyway you can. We'll think of reasons and rationale after the fact."
Ask them why they still offer fellowships to US grads that lead to nothing, if they're so concerned about maldistribution. Wouldn't it make more sense to send that fellow to Kansas?
Ask them how they manage to accommodate all of the underserved in NYC that MSK treats. I hear they're all flocking to midtown Manhattan for cancer care.
Then, when that's all done ask them to show you their COIs. I hear they have problems with that.

 

[medgator]

I want to respond to the bulgogi comment. But I just can’t even... what a mess. Twitter has sent us a very nasty present. It’s like the dead fish that Rahm Emanuel sent to a political enemy. Except instead of just stinking, this gift also spews vile nonsense.

You would think they'd actually want to use their real Twitter handle here, but no such luck.

 

[Mandelin Rain]

There is an ignore feature that I just found. The problem is that the back and forth over nonsense only buries the actual story. Trump has been highly successful in getting people to get caught up in what are ultimately meaningless words while they ignore the meaningful issues. It's almost a brilliant strategy, because it always works. Rise above, and click ignore.

 

[radoncgrad2019]

Sigh. Forget it. I’ve been posting here for months, many of you have liked my posts multiple times. Im not some new person from twitter you weirdo.

Medgator agreed with me so that back and forth was for naught.

 

[RickyScott]

Try clicking on the link, genius. Maybe i'll spoonfeed it to you!




Thought it might help to give readers context to source the beginning of the discussion but happy to link to the actual posts for those who are lazy.

This guy is a real gem. Where is the evidence that radoncs are maldistributed. virtually every metro with 100,000 has linac, best in the world- slide at Astro. When you get smaller than that, it is not profitable to have linac, even if someone willing to go there.
Ironically what can increase care in rural America are the new cms regulations that are freeing up docs to take care of pts, now that they don’t need to worry abt babysitting home centers...but someone still have donate equipment and staff/service for small metros.
Now Katz can fly out to North Dakota (btw which doesn’t need a radonc) one day a week and not worry abt babysitting his linac.

In my experience, a lot of rural places don’t pay well because of lack of volume.They are the last jobs to fill. it is a misconception that all rural places pay large salaries. (Or they will have one year guaranteed) these jobs keep appearing often because of turnover, not because of shortage!

 

[deleted1002574]

Seems like there are two people pushing back hard against the “party line” on radonc twitter. MROGA and lemmiwinks. Follow them, retweet them, join them !!

 

[CaesarRO]

I mean, this is just stupid.

Less fractions = less OTV visits = less physician time = less physician need.

how is that not patently obvious to anyone with a shred of intelligence?

Sure, it’s only 3 less breast and 5 less prostate OTVs per treatment course. But multiply each * 10 minutes needed to see/document the visit *however many breast and prostate patients are treated in America each year. That’s (hundreds of?) thousands of hours of decreased demand for a rad oncs each year.

Stop being intentionally obtuse.

I think something lost in the discussion is that with the coming changes with APM, reimbursement will _not_ be tied to OTVs or number on beam anymore, but directly to the number of new consults/new starts.

It may actually even things out so that those with a lot of SBRT/Hypofrac in their practice don't have to kill themselves to see more patients to compensate for lack of fractions/on treats.

It all comes down to where they peg the actual reimbursement per treatment course. It seems to me there is a fine line between rad oncs breaking even with APM and losing money based on where they set that level. In my view, the whole point of the APM is to save CMS money, so I imagine it's not going to be favorable by design.

Bottom line, though, linking individual rad onc busy-ness to the old way of reimbursement may not make sense in the new the system. In a way they are responding to your complaint by compensating for the real work instead of the easy stuff.

Sent from my Pixel 2 XL using Tapatalk

 

[radoncgrad2019]

I think something lost in the discussion is that with the coming changes with APM, reimbursement will _not_ be tied to OTVs or number on beam anymore, but directly to the number of new consults/new starts.

It may actually even things out so that those with a lot of SBRT/Hypofrac in their practice don't have to kill themselves to see more patients to compensate for lack of fractions/on treats.

It all comes down to where they peg the actual reimbursement per treatment course. It seems to me there is a fine line between rad oncs breaking even with APM and losing money based on where they set that level. In my view, the whole point of the APM is to save CMS money, so I imagine it's not going to be favorable by design.

Bottom line, though, linking individual rad onc busy-ness to the old way of reimbursement may not make sense in the new the system. In a way they are responding to your complaint by compensating for the real work instead of the easy stuff.

Sent from my Pixel 2 XL using Tapatalk

Yes.

 

[BobbyHeenan]

====

"It's still not clear why can't get people in rural clinics...."

It's pretty clear to me - you spend 4 years in a med school (typically located in an urban area), then 5 years in residency (typically in an urban area). In your residency you get used to "fancy" things like high end linacs, maybe protons, sub specialists everywhere, craft beer and coffee, arts, ethnic food, pro sports and other amenities that aren't in rural America. So the draw to go live somewhere like you haven't lived in 9 years just isn't there unless you're going to make a bunch of money. It doesn't seem like rocket science or cardiac SBRT to me.

I encourage everyone to go back and read the 2013 "Bloodbath in the Red Journal" thread. Those on SDN and the author of that original paper in the red journal were beating ourselves over the head "screaming" that you don't fix a maldistribution problem by just pumping out more and more residents. We saw this coming more than a half decade ago. All this talk of "canary in coal mine" and "market forces" were laughed at because unless the ONE thing happened (residency contraction), then the field was in peril.

In retrospect I think the solution all a long was residency contraction coupled with a more liberal definition of a rural center (not as strict as the previous critical access one, ie like the NHS gives certain centers certain designations, a single linac center that can't do SBRT, HDR, etc) .and allow physician coverage at a minimum of 2 days/week). It can be reasonably argued that a part time MD with NP coverage is better than a revolving door of locums and/or no linac at all for rural centers.

 

[medgator]

I think something lost in the discussion is that with the coming changes with APM, reimbursement will _not_ be tied to OTVs or number on beam anymore, but directly to the number of new consults/new starts.

It may actually even things out so that those with a lot of SBRT/Hypofrac in their practice don't have to kill themselves to see more patients to compensate for lack of fractions/on treats.

It all comes down to where they peg the actual reimbursement per treatment course. It seems to me there is a fine line between rad oncs breaking even with APM and losing money based on where they set that level. In my view, the whole point of the APM is to save CMS money, so I imagine it's not going to be favorable by design.

Bottom line, though, linking individual rad onc busy-ness to the old way of reimbursement may not make sense in the new the system. In a way they are responding to your complaint by compensating for the real work instead of the easy stuff.

Sent from my Pixel 2 XL using Tapatalk

All of which is going to be addressed by a given physician seeing more new patients annually. Hypofx ensured that we actually didn't need residency expansion at all, but those in academics acted in self-interest and against any rational thought/logic and opened the spigot the last decade leading to our current predicament, which is only worsened now with a relaxation of supervision requirements

 

[Mandelin Rain]

I think something lost in the discussion is that with the coming changes with APM, reimbursement will _not_ be tied to OTVs or number on beam anymore, but directly to the number of new consults/new starts.

It may actually even things out so that those with a lot of SBRT/Hypofrac in their practice don't have to kill themselves to see more patients to compensate for lack of fractions/on treats.

It all comes down to where they peg the actual reimbursement per treatment course. It seems to me there is a fine line between rad oncs breaking even with APM and losing money based on where they set that level. In my view, the whole point of the APM is to save CMS money, so I imagine it's not going to be favorable by design.

Bottom line, though, linking individual rad onc busy-ness to the old way of reimbursement may not make sense in the new the system. In a way they are responding to your complaint by compensating for the real work instead of the easy stuff.

I completely understand what you're saying.

Still....

Less work = Less work = Less demand for those who do the work

The reimbursement model doesn't matter. Whether we're paid more or less (spoiler: it will be less) for the "less work" doesn't make it any more work. Hell, if anything, the APM will likely simplify the coding which again will make "less work". Maybe we won't have to fill out worthless treatment planning notes or special treatment procedure notes or argue with insurers for IMRT and IGRT = less work.

Auto contouring = less work. Adaptive planning = less work. Less toxicity to manage = less work. Active surveillance = less work. CALGB 9343 = less work. OncotypeDCIS = less work. Hypofractionation = less work. General supervision = less work.

These are NOT bad things. Pretty much all good things. But.... none of them increase the demand for radiation oncologists. Indeed, the opposite is true.

 

[radiaterMike]

^^^ I think Mandelin Rain is correct. While the APM will not be tied to # fractions or OTVs, the diagnosis-specific reimbursement will likely be tied to the reimbursement for what is thought to be most appropriate care for the patient under the current model.

My only disagreement with the above is that adaptive planning is not less work (unless the physician is not involved in this). But currently, adaptive planning is very time consuming since the physician needs tor review planning parameters daily.

 

[Mandelin Rain]

My only disagreement with the above is that adaptive planning is not less work (unless the physician is not involved in this). But currently, adaptive planning is very time consuming since the physician needs tor review planning parameters daily.

This may well be the case as I'm not super familiar with adaptive planning. I remember seeing it on Tomo in the early days and it seemed to be pretty quick. Quicker than Resimming, recountouring, replanning, re QAing.... but I could definitely buy that in aggregate all those daily reviews (if you're doing it daily) add up to more work.

 

[Mandelin Rain]

This dude is killing it.

 

[deleted18755]

^^^ I think Mandelin Rain is correct. While the APM will not be tied to # fractions or OTVs, the diagnosis-specific reimbursement will likely be tied to the reimbursement for what is thought to be most appropriate care for the patient under the current model.

My only disagreement with the above is that adaptive planning is not less work (unless the physician is not involved in this). But currently, adaptive planning is very time consuming since the physician needs tor review planning parameters daily.

I feel like I play the old guy role on her sometimes but two things I may add:

1. Please try to avoid linking or copying and pasting something from twitter and then dissecting and analyzing every word ... as far as I can tell it’s a dumb platform where people hastily throw down thoughts carelessly sometimes within the confines of its limitations not some brilliant classic poem or play written by a literary genius who carefully picked every word. Sure maybe highlight a tweet or two but going back and worth trying to argue the true meaning or intent of a tweet as if it's a college class on Shakespeare when the person who wrote it isn’t providing additional input seems ridiculous to me (sure it would begreat if this same people posted here with their real names but I doubt that’ll happen).

2. Once the payment model and details (I mean exact down to the $ compensated and minute of work) are clear a lot if not most will adjust accordingly to maximize payment per effort/time. I’m not sure if those in training or newer graduates or even those whose bosses keep these things secret realize that RVU’s/payment are not strongly correlated with time/effort. Add up the RVU’s for seeing 25 prostate OTV and CBCT one day (then realize that’s why we have urorads and not [insert any other site] rads) vs one days RVU for anything else (let alone 60-90 minute family meetings for end of life discussion). I know rad oncs who will literally chase down patients in the parking lot to document and bill for an OTV . . . guess why that is and if they would do it if the 3 minute encounter didn't compensate almost as much RVU as a consult. I remember many short lived silly practice that have popped up and died overnight (daily portal images, multiple sims for cone downs vs integrated boosts . . . I could go on and on). My point is when rules change, especially those that have to do with compensation and especially relative to time/effort, it instantly changes clinical practice.

I don’t know exactly what the changes will be but I guarantee that almost all establishes physicians will maintain their income by increasing their workload (bad for new graduates) and the second it becomes clear, no matter what it is, some or many will go all out to take advantage of loopholes or other opportunities to pick the "low hanging fruit" (and of course well established physicians will have a huge advantage).

I’ve said it a million times, radiation oncology is the best thing that every happened to me other than my kids, and I love my job and I’ll show up to work tomorrow if my pay go downs 25-50% overnight. I'd honestly probably be some of the relative few who would just do the exact same thing for less money because of where I am in my finances and life, but I can guarantee that if compensation somehow globally went down 10% most doctors would just work 10% more but it's more likely that it will go down non-uniformly and most practices will then maximize that which compensates relatively more, whatever that may be (with the most obvious being hiring a very good PA to hold down, for 2-3 days per week, a linac/center that sees 4-6 consults a week and has 15-20 patients under treatment vs hiring a full time MD to staff the place 5 days per week). Trust me when the details of the changes are clear everybody is going to adjust somewhat and some will adjust their practices tremendously, but I can't see how any such changes will help new graduates and see ways in which it could be devastating.

 

[medgator]

This dude is killing it.

That whole thread is hysterical.

My personal fave, esp last option:

 

[Mandelin Rain]

May have to add some Three 6 Mafia to the music thread to honor.

 

[Mandelin Rain]

First question; what is ABRO?

 

[deleted774703]

First question; what is ABRO?

Lmao I was thinking the same thing

I Even googled them and couldn’t find a straight answer

Though If we split from ABR. I wouldn’t be upset

 

[medgator]

First question; what is ABRO?

Their website is under construction

The American Board of Radiation Oncology

The American Board of Radiation Oncology – Supporting our candidates and diplomates for the benefit of patients

theabro.org

I wonder if RO is splitting up with the abr?

At one point, ASTRO used to collaborate with the ACR too on inspection

 

[Mandelin Rain]

They stole the ABR's logo.

I imagine it's just a parody account or someone squatting on a domain name or something.