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MROGA pushing the Hallahan smoking gun. Keep going. Let ‘em know, we know.
This is the way.
This is the way.
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The anti-Beriwal
That's the key. We are (presumably) radiation oncologists. We have some expertise even if only very few of us would be considered "experts within our field". Anonymity can be used as a tool for group decision making. It changes the amount of critical input. It encourages the promotion of other people's ideas.
Anonymity can be toxic of course, but truth filters through. That this same forum was overrun ten years ago with "what are my chances" posts from people with outstanding credentials and is now overrun with what it's overrun with undoubtedly reflects the truth.
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Many years ago, under a different account, I made a "what are my chances" post.
I'm still asking that same question today:
"What are my chances [of staying employed]"?
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expectations are a huge influence.
I applied to rad onc to match in 2012 (graduated in 2017). When I was rotating/applying, it was around the same time Chirag was hearing stuff from his grads about the market being tight in regards to location (leading to the blood bath article), so that was the same stuff I was hearing, same knowledge base with which I went into rad onc. I knew it would be very hard to get a job in a city or cities I was interested in and that I would have to compromise.
Given that I went in knowing this (which I think everyone who matched in the last 15 years knew this to some extent), when I had to compromise (not a lot luckily but a little), I was 'satisfied'
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Can anyone plot the % employed (specifically academic employed) rad oncs vs training positions each year for the past 2 decades?
It seems so obvious that there was a concerted effort to overtrain rad oncs in a high salary moment to drive down compensation and allow for easier/more profitable consolidation of practices.
Obviously, Hallahan was the smoking gun, but my impression is this started years before that.
It seems so obvious that there was a concerted effort to overtrain rad oncs in a high salary moment to drive down compensation and allow for easier/more profitable consolidation of practices.
Obviously, Hallahan was the smoking gun, but my impression is this started years before that.
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hallahan sucks, but im not sure I agree.
I think this is giving a lot more credit to people for being organized than they deserve. We don't EVEN know how many rad oncs there are, as Wallnernus likes to point out. we aren't that organized or cunning as a field
It seems much more likely to me that different programs individually saw opportunities to expand given that they could, were not thinking about the collective, and this had unforseen cirumstances. I truly don't think there was some cabal meeting at ASTRO in 2010 where they all decided to simultaneously expand to drive down salaries. that seems really silly.
The Hallahan comments are the most overblown thing on this board. He was clearly was wrong and dumb about his comments, but thinking there was some concerted effort by chairs to systemically decrease salaries by increasing training slots is truly some tin foil thinking. First of all, academic salaries have clearly risen since his comments, so whatever grandiose plan you think he had clearly backfired. See Terry Wall data
Overtraining is clearly a situation of "tragedy of the commons", where no one intentionally took the field to where we were today, just poor oversight of expansion.
en.wikipedia.org
Overtraining is clearly a situation of "tragedy of the commons", where no one intentionally took the field to where we were today, just poor oversight of expansion.
Tragedy of the commons - Wikipedia
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Mostly tragedy of the commons I agree. However, oversupply, I am sure, was something of a "secondary gain" in the back of some folks' minds. My opinion of what drove residency expansion is that after decades of being a third-rate specialty chugging along in hospital basements, and rad oncs in general being a very weird (and maybe couldn't-cut-it-in-rads) group, all of a sudden with the IMRT Golden Era that struck full force ~2003-2009 rad onc departments were flush with cash and prestige that had to go somewhere. (A lot of departments got all this cash with software upgrades, not infrastructure upgrades.) The dawning of IGRT billing on Jan 1, 2006, also helped a lot. The first place all the money went: hiring new faculty. You can't have such "rich" programs with such small numbers of faculty; it makes the dean suspicious. And then right after all the attendings were getting added, residency expansion followed. It was mostly expansion based on reimbursement, less so on growing societal need (as we all can now see).The Hallahan comments are the most overblown thing on this board. He was clearly was wrong and dumb about his comments, but thinking there was some concerted effort by chairs to systemically decrease salaries by increasing training slots is truly some tin foil thinking. First of all, academic salaries have clearly risen since his comments, so whatever grandiose plan you think he had clearly backfired. See Terry Wall data
View attachment 352418
Overtraining is clearly a situation of "tragedy of the commons", where no one intentionally took the field to where we were today, just poor oversight of expansion.
Tragedy of the commons - Wikipedia
The Hallahan comments are the most overblown thing on this board. He was clearly was wrong and dumb about his comments, but thinking there was some concerted effort by chairs to systemically decrease salaries by increasing training slots is truly some tin foil thinking. First of all, academic salaries have clearly risen since his comments, so whatever grandiose plan you think he had clearly backfired. See Terry Wall data
View attachment 352418
Overtraining is clearly a situation of "tragedy of the commons", where no one intentionally took the field to where we were today, just poor oversight of expansion.
Tragedy of the commons - Wikipedia
Strongly disagree. His comments represent a rare view into the thoughts of a chair and explains how residency expansion decisions were taken with the implicit intent of decreasing the bargaining power of radiation oncologists in the workforce.
You can believe this, as I do, while also believing there was NOT a concerted effort by all chairs working together, which I also believe. However, their incentives were all aligned in the same direction, so they, being rational actors, all expanded residencies inappropriately, with at least some of them admitting it was to gain more power over the junior faculty they were hiring. Hallahan's comments confirm they knew the effect their actions would have.
"Academic salaries have clearly risen since his comments..." - would they have risen more were it not for residency expansion? Is the growth greater than inflation? Doesn't look like it to me, given that the average salary didn't change for three years running.
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I agree there was no concerted effort regarding residency expansion. Concerted efforts are damn near impossible anyway (as we are seeing now). Residents have always been a good deal for departments, whether federally subsidized or not.
I think the most important factors were the cash on hand (as per @TheWallnerus) and the supply of highly qualified med students. This was undoubtedly prompted by the advent of IMRT, big money jobs and med student awareness of the field, which likely was a result of the internet (maybe even SDN) as a single MS2 lecture had never been effective at raising the profile of radonc prior to the 2000s.
Leadership responded to market forces as though the market had wisdom (a prevailing behavior among the leadership class in our society). Of course sometimes the market has wisdom and sometimes it does not.
I'm pretty sure that the demand for radonc residency positions in the late 2000s and 2010s did not reflect demand for radiation oncologists.
I'm also pretty sure that the lack of demand for residency positions now very much reflects the lack of demand for radiation oncologists.
If there was ever a time to listen to the market, it would be now.
I think the most important factors were the cash on hand (as per @TheWallnerus) and the supply of highly qualified med students. This was undoubtedly prompted by the advent of IMRT, big money jobs and med student awareness of the field, which likely was a result of the internet (maybe even SDN) as a single MS2 lecture had never been effective at raising the profile of radonc prior to the 2000s.
Leadership responded to market forces as though the market had wisdom (a prevailing behavior among the leadership class in our society). Of course sometimes the market has wisdom and sometimes it does not.
I'm pretty sure that the demand for radonc residency positions in the late 2000s and 2010s did not reflect demand for radiation oncologists.
I'm also pretty sure that the lack of demand for residency positions now very much reflects the lack of demand for radiation oncologists.
If there was ever a time to listen to the market, it would be now.
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"Academic" salaries also include those out at the satellite that isn't even in the same time zone as the mother ship, which used to employ a pp doc making twice as much.The Hallahan comments are the most overblown thing on this board. He was clearly was wrong and dumb about his comments, but thinking there was some concerted effort by chairs to systemically decrease salaries by increasing training slots is truly some tin foil thinking. First of all, academic salaries have clearly risen since his comments, so whatever grandiose plan you think he had clearly backfired. See Terry Wall data
View attachment 352418
Overtraining is clearly a situation of "tragedy of the commons", where no one intentionally took the field to where we were today, just poor oversight of expansion.
Tragedy of the commons - Wikipedia
I would add that while starting Asst. Prof salaries have gone up some (good), overall compensation to RadOncs working in the vicinity of universities have fallen.
In my region (which may be one of the egregious examples, perhaps) small hospitals used to pay out 7 figures
Now these are academic satellites with pretty fixed contracts paying around 430-450K
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I should have mentioned above, but it is a fact worth repeating (a real fact, not an alternative fact): academic attending expansion started before resident expansion. And in fact academic attending expansion has been slightly higher percentage wise than resident expansion.
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I believe it. I got a job at a medium size hospital for $650K in 2010, with full benefits and retirement matching that probably added extra ~$100K a year, with no problem. At first they acted like they were going to buy me a house lol (never pushed for it). And admin said it was all in line with MGMA 75%ile. I had heard I was making more than the hospital's employed CT surgeon. (And when I left, they gave me $100K for being a nice guy.) Try and find that nowadays.
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This is what I was getting at. As the academic centers started needing more docs (largely via consolidation of nearby practices) they responding by training more residents.
Maybe not a “concerted” collusion of chairs (though I’m rather suspect it was), the the goal was obviously a ready supply of docs to choose from.
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To me - The biggest Impact on job types and job salaries available has clearly without a doubt hospital consolidation and continued corporate takeover of medicine
there are still a good amount of employed hospital based jobs where people can make more than 600k+ like Wallnernu is referring to, but every year there are fewer and fewer, as they become centralized, whether an academic satellite or a big health takeover.
there are still a good amount of employed hospital based jobs where people can make more than 600k+ like Wallnernu is referring to, but every year there are fewer and fewer, as they become centralized, whether an academic satellite or a big health takeover.
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or to build off of Wallnernus' 'money came first' argument, which I agree with:
1) IMRT and IGRT became widespread,leading to very high technical and professional revenues - freestanding PP did very well, hospital admins noticed the increased money coming into their rad onc coffers and thought 'how do we get more?!'
2) hospital systems started buying out smaller centers and growing. In academic hospital systems that led to the proliferation of satellites as well as larger main hub academic departments. In private health systems this also led to buyout of smaller hospitals, free standing centers.
3) larger departments and more patients being treated in academic depts led to an increased desire to have more residents. The ACGME says you have enough patients and docs to have more residents - why wouldn't you???
4) rinse and repeat over 10 years.
5) Profit (aka the present)
1) IMRT and IGRT became widespread,leading to very high technical and professional revenues - freestanding PP did very well, hospital admins noticed the increased money coming into their rad onc coffers and thought 'how do we get more?!'
2) hospital systems started buying out smaller centers and growing. In academic hospital systems that led to the proliferation of satellites as well as larger main hub academic departments. In private health systems this also led to buyout of smaller hospitals, free standing centers.
3) larger departments and more patients being treated in academic depts led to an increased desire to have more residents. The ACGME says you have enough patients and docs to have more residents - why wouldn't you???
4) rinse and repeat over 10 years.
5) Profit (aka the present)
Faculty can generate more revenue when they aren’t spending so much time writing notes, putting in orders, calling patients, and coordinating care, and residents are cheaper than NPs…
No conspiracy, just easier.
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Residents are the best rad onc labor. You get paid over 100k per year for a doctor who can write all of your notes, do all of the contours, write prescriptions on their own, can take call and see consults, and is willing to work up to 80 hrs per week if necessary. Such a scenario is perfect for expansion. An NP can write your notes, but they can't do much else. They also cost about 100k per year.
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A nefarious plot where a dossier was prepared laying out a step-by-step plan to create oversupply and drive down salary? Definitely not.
Many years of the same crew meeting up at ASTRO, going out for drinks, casually talking about budgets and overhead of their respective institutions, occasionally bringing up that residents are the best bargain around, and more residents could benefit the individual institution's bottom line?
Yeah...I think that happened. It's why that letter was published. No one batted an eye because it was oft-discussed in casual conversations. Why would anyone have a problem with it?
Many years of the same crew meeting up at ASTRO, going out for drinks, casually talking about budgets and overhead of their respective institutions, occasionally bringing up that residents are the best bargain around, and more residents could benefit the individual institution's bottom line?
Yeah...I think that happened. It's why that letter was published. No one batted an eye because it was oft-discussed in casual conversations. Why would anyone have a problem with it?
Spot on.
I think an NP would cost more than 100k if you include benefits.
I also think some attendings actually pay for NP coverage, depending on the institution. They don't pay for resident coverage.
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Bingo.
I’m not saying there was a structured grand plan. More so conversations at the chairs’ meeting like
“I can’t find anyone to staff a satellite in Jefferson city. And if I do, I have to pay them 700k to keep them happy and it’s pissing off the main site docs. Wish there was a greater supply so they couldn’t be so picky.”
“Same with me a Dubuque.”
Have that conversation x25 each year for a decade and it’s normalized, and people just kind of understand why it’s happening while they benefit in multiple ways from it.
I can't exclude this but I think it gives our leadership too much credit. I think the reality was that it was a bit of a perfect storm. Reimbursements spiked, the complexity of what we do increased, universities saw prestige and cheap labor in having residency programs, satellites got absorbed, departments got bigger, need/capacity for resident coverage went up, etc. etc. Med students heard radoncs made boatloads of money working office hours 4 days a week and flocked to the specialty, the number and quality of the applicants increased, awkward old basement dwellers would felate one another over jobs well done at our annual conferences and all was right in the world. It was an embarrassment of riches and when the party is bumpin' nobody wants to be the guy who cuts off the music.
We have no practical leadership because for 20 years this field could do no wrong. There were no difficult decisions to be made and we made so much money that any mistakes were just blips on the radar. For the last 10 years as residents and young graduates have voiced job market concerns and clamored for leadership to pump the breaks, we were ignored, gaslit, or even worse maligned. When the ABR debacle happened, rather than issuing a mea culpa leadership doubled down and said the residents are just getting dumber. Bad programs were able to expand, worse programs were able to form, and there was no accountability because the quality of your program is irrelevant when med school studs are banging at the doors to let them in.
Now every concern that people have had for the last decade has come to fruition. It's harder to get a job, jobs pay less, average program quality has gone down, and now average resident quality is going down. People like KO think that all is right in the world because the average new grad salary has gone up a bit, but coinciding with a small bump in the floor is a large collapse of the ceiling. Small practices with docs making 600k+ are either getting pinched or bought out by hospital systems. They're getting staffed by new grads making 300-350k who may top off at 400k. I have spoken to multiple new grads recently who took academic satellite jobs where they're overworked and underpaid or appropriately paid but underutilized. Their bonuses don't come to fruition or the bonus structure changes on a whim, no one is willing to give them their RVU data, they're on the same contract 2-3 years out making new grad dollars for mid career volumes, and no one cares because if they leave they'll just be replaced by one of the 200 other new grads that wants to take the job. It's the calm before the storm right now. Covid initially halted some expansion plans that have since gone on as planned and the stock market accelerated some retirement plans creating a brief reprieve for the job market, but we're all competing harder and harder for a pie that's shrinking and eventually something has to give.
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Sticky??
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Looks like 6 from Yale matched rad onc. Most of any T20 from what I’ve seen
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I would be absolutely terrified as a patient if I knew my doctor was there solely based on what they look like. US seems to have gone completely mad.
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Never mind. It was 2 who matched from Yale. Somebody posted the list from 2010 by accident on the threat and it was 6 in that year.
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Again, that was the problematic era. I think Yale has about 100 grads/year (correct me if I'm wrong). 6% into radonc as it approached peak-peak.
Those peak Yalies are still young and will presumably be working at least another 20 years. No need for more.
0-2% interest is appropriate.
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Random question for my colleagues who prefer reading studies to cutting people open that I was trying to answer;
In men with prostate cancer getting ADT with their XRT, is there any evidence of the time of ADT being associated with a shorter time to development of castrate resistance when resuming ADT for metastatic disease?
It would make sense that it would, in that you are applying selective pressure with the ADT, like how in bladder CA high stage disease after neoadjuvant chemo portends poorly when it comes to response to subsequent therapy on progression, but a quick search didn’t show much data to guide this.
In men with prostate cancer getting ADT with their XRT, is there any evidence of the time of ADT being associated with a shorter time to development of castrate resistance when resuming ADT for metastatic disease?
It would make sense that it would, in that you are applying selective pressure with the ADT, like how in bladder CA high stage disease after neoadjuvant chemo portends poorly when it comes to response to subsequent therapy on progression, but a quick search didn’t show much data to guide this.
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This is the best study that I am aware of...it suggests that short-term ADT doesn't compromise salvage ADT
Effect of a short course of neoadjuvant hormonal therapy on the response to subsequent androgen suppression in prostate cancer patients with relapse after radiotherapy: a secondary analysis of the randomized protocol RTOG 86-10 - PubMed
Although a 4-month course of neoadjuvant and concurrent maximum androgen suppression and RT (compared with RT alone) significantly increases the freedom from relapse rate and freedom from receiving salvage HT, it does not compromise the long-term beneficial effect of subsequent salvage HT, if...
pubmed.ncbi.nlm.nih.gov
Yes...boomer here
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Here's your proton therapy center sign
D
deleted1111261
Todd posts this:
This should get a boisterous conversation going. But, collective yawn except from a few people.
The absolute worst part of this field is that WHO has the message >> than the message itself. If Dan or Drew says it, it’s noteworthy. If Todd says it, it’s me and Chang and a couple other folks. Sheesh.
This should get a boisterous conversation going. But, collective yawn except from a few people.
The absolute worst part of this field is that WHO has the message >> than the message itself. If Dan or Drew says it, it’s noteworthy. If Todd says it, it’s me and Chang and a couple other folks. Sheesh.
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nice post but the biggest limitation to me is the continued insistence of looking at fractions or number of patients on beam per day. Certainly important, but agree with Spraker's reply here that we need new ways to think about our work, ESPECIALLY when SBRT is a big part of the discussion here. Agree with Spraker/Shah/Beckta discussing this on the jobs podcast. Fractions are important, but less and less so every year.
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Less fractions mean less reimbursement, pound for pound, and less fractions almost always mean an earlier stage patient is being treated too; that usually means a patient with less side effects and in need of less rad onc on-treat medical management and problems in followup. So how unimportant are fractions really. Fractions really link at the most basic level to much of a rad onc's day to day experiences and workload. In addition, much of Medicare reimbursement (and how Medicare looks at how RT is reimbursed) look at how busy the linac is per day. Less fractions mean less business for the linac on a given per day basis, especially as high dose per fraction delivery gets quicker and quicker and fits in smaller treatment time slots.
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That's how reimbursement works for most places unless you've got a negotiated bundle with insurance companies, work in an HMO/Kaiser Permanente setting etc. In that regard, bundles need to happen and APM was supposed to be that solution before it was completely bastardized
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also to me the upshot of Todd's numerous posts/threads about number of patients on beam/doc just seems to make the argument that there needs to be more centralization of rad oncs and rad onc services? I don't love that as a free standing PP guy, but it seems to be the elephant in the room.
We need less rad oncs and fewer linacs. what that means is these linacs being put in the most central places for highest access, and less in people's neighborhoods.
We need less rad oncs and fewer linacs. what that means is these linacs being put in the most central places for highest access, and less in people's neighborhoods.
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Absolutely, and sbrt lends itself to this. Elephant in the room is that we become like the rest of the world?
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I agree on the pay stuff.
But is this statement true? to me new starts at the basic level have the most to do with rad onc workload. of course OTVs matter and add some work, but I think the overall 'patient' (workup, consult, sim, contouring, plan sign, communication with referrings, completion summary, followups, ordering imaging) have to do more with each new start and reflect most of the real work
in my opinion - 'New starts really link at the most basic level to much of a rad onc's day to day experiences and workload'
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Well, the bigger issue (speaking for myself, in my personal day-to-day) is not that WE (the physicians) don't understand it's a bad metric, but the admins in our healthcare systems don't understand. "On beam" is very easy to measure, track, and compare to historical numbers - everything admin loves.
On that note - after reading the Todd Lung Tweetorial, I ran the numbers for my own hospital. All of these are true statements:
1) My hospital admin is still using "on beam" to set/track my department's budget.
2) The Lung Math uses an approximate 10-year comparison, 2013 to 2022.
3) 10 years ago, my hospital had one linac and didn't really do SRS/SBRT (small community hospital).
4) Currently, my hospital has two linacs and I frequently do SRS/SBRT.
5) Despite doubling our linear accelerators, our targeted "on beam" number has only increased approximately 30-35%. As we all know, reimbursements in general have been cut over the last 10 years.
6) Running the numbers for patients treated for lung cancer over the last 5 years (I don't have easy access to older data, and I can't drill down on staging easily), it appears my department has treated 33% fewer lung cancer patients, pretty much exactly in line with Todd's estimates. This makes sense, the LDCT recommendations came out in 2014 and needed time to be adopted.
7) I have my hospital's "Standard Charges" list, and I know that SRS and SBRT generate significantly higher reimbursement than conventional fractions. However, as far as I can tell, none of my admins appear to factor this in to their budget math.
8) In terms of total patients simmed per year, we are slightly busier now than 5 years ago, up approximately 12-15%.
9) Like the rest of the country, we have switched from all conventional fractions for breast/prostate to hypofrac for most patients.
10) In a meeting last week, I was told we are several hundred thousand dollars "below our targeted budget".
So we doubled our linacs, but only increased our targeted "on beam" number by 30%, while reimbursements were cut, are seeing less lung patients, using fewer fractions for prostate and breast, started doing a lot of SRS/SBRT which reimburses a lot more, are simming more patients, and being told we're not meeting financial targets, yet there are no tangible consequences for not meeting these targets (no staff have been laid off, no capital expenses denied, etc).
The only conclusion I have: all these numbers are completely invented.
I am incredibly interested to see this ASTRO economics report. Because this is JUST my little community hospital, these are numbers I can personally verify, and none of this makes sense to me.
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also if we are talking about money/fraction - the SBRT is different than standard IMRT. My math has told me that 3 weeks is about equal to one sbrt.
so 30 IMRT fractions (Standard stage III) is equivalent to about two stage 1 SBRT cases.
(posted this before I saw ESE's post!)
so 30 IMRT fractions (Standard stage III) is equivalent to about two stage 1 SBRT cases.
(posted this before I saw ESE's post!)
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Compare for Stage I (up 50+% since 2013) versus Stage III (down 30+% since 2013). For me, Stage I is way easier. YMMV.
That said, even new starts are down non-trivially per RO "on average" since 2013. The number of definitive lung cancer OTVs would be down it looks like 36%. As the incidence of lung cancer itself continues to fall, we will see how this all shakes out by 2030 and later.
We are in a time of change in rad onc folks!
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'yet there are no tangible consequences for not meeting these targets (no staff have been laid off, no capital expenses denied, etc'
this is the key, you nailed it. It's because there is still plenty of money coming in (maybe the same? maybe more?!) despite fraction numbers being down.
the math has changed, the game has changed
the budget story is the same everywhere, and is totally made up based on a natural desire for MBAs to always have numbers rise year to year
this is the key, you nailed it. It's because there is still plenty of money coming in (maybe the same? maybe more?!) despite fraction numbers being down.
the math has changed, the game has changed
the budget story is the same everywhere, and is totally made up based on a natural desire for MBAs to always have numbers rise year to year
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This math is good for Medicare and even private insurance out in most private practices. However, w/ insurance and at the Big Rad Onc places, all bets are off. 5 fraction prostate SBRT can easily out-reimburse 45 IG-IMRTs.
