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RickyScott said:
It does in the sense that everyone is basically salaried and that salary is going to be deteremined by what the next person would take for the same job. Rvus /cms reimbursement are just post facto manipulated to justify paying market rate.
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yes I agree.

I dont think expansion led to increased corporitization of medicine though.
 
jondunn said:
yes I agree.

I dont think expansion led to increased corporitization of medicine though.
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Commoditization of physicians didn't help.

Had the professional societies just said "No, we will not be training more docs to drive our individual value down," we wouldn't have lost leverage and control of medicine. Alas, there were perverse incentives to all this that the boomers reaped (as with so many things).
 
RickyScott said:
I work for a corporatized community hospital. The urologists walk on water.
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You can get corporatized and valued, or corporatized and devalued. Easier to devalue when your corporatizable professional labor is easy for the corporation to come by.
 
Mandelin Rain said:
Commoditization of physicians didn't help.

Had the professional societies just said "No, we will not be training more docs to drive our individual value down," we wouldn't have lost leverage and control of medicine. Alas, there were perverse incentives to all this that the boomers reaped (as with so many things).
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but there were pervasive incentives for optho/uro/ent to do the same, and they didn't- that is the most important question. What does this say abt our leadership/Astro.
 
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TheWallnerus said:
You can get corporatized and valued, or corporatized and devalued. Easier to devalue when your corporatizable professional labor is easy for the corporation to come by.
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Very basic concept, yet some on this forum can't seem to grasp this, or have a vested interest in not grasping it?
 
TheWallnerus said:
You can get corporatized and valued, or corporatized and devalued. Easier to devalue when your corporatizable professional labor is easy for the corporation to come by.
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look there are multiple things here. i don't know why you can't get past repeating the same thing over and over again.

1) you talked about doing your own billing. no longer possible when forced to be hired to an integrated system
2) you talked about corportization being brought to you by oversupply. this is so silly and you know it. of course oversupply makes it worse. but that is different from what you said.
 
jondunn said:
look there are multiple things here. i don't know why you can't get past repeating the same thing over and over again.

1) you talked about doing your own billing. no longer possible when forced to be hired to an integrated system
2) you talked about corportization being brought to you by oversupply. this is so silly and you know it. of course oversupply makes it worse. but that is different from what you said.
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Made worse yes

By “brought” I didn’t mean wholly responsible; that is silly and you don’t know it

queen omg GIF by VH1s Daytime Divas
 
I would argue that corporatization (and the financialization of everything by The Boomers) of our academic medical infrastructure was a root cause of residency oversupply. The allegiance of academic chairs, over decades, shifted from their specialty to their academic medical center, with predictable results for the specialty.
 
medgator said:
Very basic concept, yet some on this forum can't seem to grasp this, or have a vested interest in not grasping it?
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OTN said:
I would argue that corporatization (and the financialization of everything by The Boomers) of our academic medical infrastructure was a root cause of residency oversupply. The allegiance of academic chairs, over decades, shifted from their specialty to their academic medical center, with predictable results for the specialty.
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Sure, but why did this not occurr for uro, optho, ent. Our guys are greedier.
 
RickyScott said:
Sure, but why did this not occurr for uro, optho, ent. Our guys are greedier.
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Oh I'm with you on this, JD can't seem to grasp it. Hallahan even said the quiet part out loud.

Then again, while the specialty was overtraining and expanding, research was basically about reducing fractions and the footprint of the specialty outside of stereotactic and protons
 
RickyScott said:
Sure, but why did this not occurr for uro, optho, ent. Our guys are greedier.
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Never underestimate the greed of Boomers- that way you'll never be disappointed.

It did occur for Emergency Medicine, dermatology, pathology, and surgical oncology (their job woes are very real). Additionally, urology, ophthalmology, ENT, plastics, neurosugery, etc never went through a period of time where it was dramatically easy to enter into their specialty. I'll let you make your own conclusions about what repercussions that might have down the road for a field.
 
RickyScott said:
Sure, but why did this not occurr for uro, optho, ent. Our guys are greedier.
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Uro/optho/ortho/ENT/NS (especially NS) have a huuuge self selection aspect in terms of residency interest. Lots of medstuds don't have what it takes to make it through these residencies and don't have an interest in committing to a surgical lifestyle.

Radonc has essentially zero self-selection. At some point the market dictated that you be a very good medstud, but radonc does not have long hours or long call or high acuity. Once the secret was out, market forces took over and supply of talent itself drove demand.

I've mentioned this before. Say's Law.

Say's law - Wikipedia

en.wikipedia.org en.wikipedia.org
 
TheWallnerus said:
You can get corporatized and valued, or corporatized and devalued. Easier to devalue when your corporatizable professional labor is easy for the corporation to come by.
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Agree with this... and it may be hard to put the genie back in the bottle with the number of rad oncs...

One other avenue toward improving value (for some, at least) is to find a public metric that assesses how good of a doctor you are. Not Press Ganey ratings, not #pubs on google scholar... something that tells whether you are actually a good doctor -i.e. the sort of person to whom people want to refer their patients. Lawyers can point to their record in court. Fund manages can point to the ROI. We need something that we can point to... and something our corporate overlords can point to to justify why pts should go to their hospital network.

If we can find THAT metric, it doesn't matter how many of us there are so long as you are one of the better ones.
 
OTN said:
Additionally, urology, ophthalmology, ENT, plastics, neurosugery, etc never went through a period of time where it was dramatically easy to enter into their specialty. I'll let you make your own conclusions about what repercussions that might have down the road for a field.
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Can't be overstated enough.... We are just coming full circle back to where this specialty was pre IMRT coming off a bad job market in the 90s
 
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Lamount said:
Agree with this... and it may be hard to put the genie back in the bottle with the number of rad oncs...

One other avenue toward improving value (for some, at least) is to find a public metric that assesses how good of a doctor you are. Not Press Ganey ratings, not #pubs on google scholar... something that tells whether you are actually a good doctor -i.e. the sort of person to whom people want to refer their patients. Lawyers can point to their record in court. Fund manages can point to the ROI. We need something that we can point to... and something our corporate overlords can point to to justify why pts should go to their hospital network.

If we can find THAT metric, it doesn't matter how many of us there are so long as you are one of the better ones.
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Is there a doctor in the world that takes Press Ganey seriously? Such an unbelievable fraud.
 
communitydoc13 said:
Many admins take seriously.
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Let's have 35 meetings to discuss why the surveys didn't come back with perfect scores from patients about answering questions about meds they take unrelated to cancer treatment. Then come up with a process to have the nurse spend 20 minutes with the patient going over every single med on the med list and asking if they have any questions. So the department manager has better survey numbers to report.

Really good use of time.
 
Moonbeams said:
Let's have 35 meetings to discuss why the surveys didn't come back with perfect scores from patients about answering questions about meds they take unrelated to cancer treatment. Then come up with a process to have the nurse spend 20 minutes with the patient going over every single med on the med list and asking if they have any questions. So the department manager has better survey numbers to report.

Really good use of time.
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Not even the half of it
The scoring system is bizarre and nonsensical
 
Do you all have access to the scoring system? I was informed that the actual scoring rubric was proprietary. We get scores, break down and percentiles but not details about questions asked.
 
Lamount said:
Agree with this... and it may be hard to put the genie back in the bottle with the number of rad oncs...

One other avenue toward improving value (for some, at least) is to find a public metric that assesses how good of a doctor you are. Not Press Ganey ratings, not #pubs on google scholar... something that tells whether you are actually a good doctor -i.e. the sort of person to whom people want to refer their patients. Lawyers can point to their record in court. Fund manages can point to the ROI. We need something that we can point to... and something our corporate overlords can point to to justify why pts should go to their hospital network.

If we can find THAT metric, it doesn't matter how many of us there are so long as you are one of the better ones.
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I doubt that such a metric exists. Even if it did beware of Goodhart's Law

"When a measure becomes a target, it ceases to be a good measure"

Goodhart's law - Wikipedia

en.wikipedia.org en.wikipedia.org

The examples are everywhere from gaming USNWR rankings of hospitals, colleges, etc.

Things that are important are heard to measure.

Frequently admins make important those things that we can measure.
 
Chartreuse Wombat said:
I doubt that such a metric exists. Even if it did beware of Goodhart's Law

"When a measure becomes a target, it ceases to be a good measure"

Goodhart's law - Wikipedia

en.wikipedia.org en.wikipedia.org

The examples are everywhere from gaming USNWR rankings of hospitals, colleges, etc.

Things that are important are heard to measure.

Frequently admins make important those things that we can measure.
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Do you think there is literally zero quality metrics we could use in RO (or medicine)?
 
RealSimulD said:
Do you think there is literally zero quality metrics we could use in RO (or medicine)?
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No. I am saying but those measures that can be "massaged" will be massaged.

There are some high level metrics (30 day mortality/readmission/etc) that are difficult to "fake" but they can still be manipulated.

To my knowledge there are no outcome measures in RO beyond mortality that cannot be manipulated. Of course one can lie about death but ignoring fraud it is a pretty solid outcome. Of course hard to compare this endpoint given the enormous selection for who gets treated where.

The only other endpoint that comes to mind is the rate of medical events but RO has examples of how medical events can be differently interpreted/defined.

Morbidity scales are unreliable.

PROs are OK but they have problems as well.
 
Chartreuse Wombat said:
I doubt that such a metric exists. Even if it did beware of Goodhart's Law

"When a measure becomes a target, it ceases to be a good measure"

Goodhart's law - Wikipedia

en.wikipedia.org en.wikipedia.org

The examples are everywhere from gaming USNWR rankings of hospitals, colleges, etc.

Things that are important are heard to measure.

Frequently admins make important those things that we can measure.
Click to expand...
Agree. Any good measurement is likely to exist in an unstable equilibrium, easily falling into mediocrity when manipulated

Nonetheless, I think it is instructive to consider -as a thought experiment- why do we respect some clinicians but not others?

We aren’t all interchangeable… we just have to get a little better at explaining why.
 
communitydoc13 said:
Uro/optho/ortho/ENT/NS (especially NS) have a huuuge self selection aspect in terms of residency interest. Lots of medstuds don't have what it takes to make it through these residencies and don't have an interest in committing to a surgical lifestyle.

Radonc has essentially zero self-selection. At some point the market dictated that you be a very good medstud, but radonc does not have long hours or long call or high acuity. Once the secret was out, market forces took over and supply of talent itself drove demand.

I've mentioned this before. Say's Law.

Say's law - Wikipedia

en.wikipedia.org en.wikipedia.org
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Rad onc has the possibility to self select. Just amp up the physics difficulty level and watch applicants flee and programs shut down. But I doubt anyone in charge has the will for this approach.
 
temujim said:
Rad onc has the possibility to self select. Just amp up the physics difficulty level and watch applicants flee and programs shut down. But I doubt anyone in charge has the will for this approach.
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increasing physics boards difficulty is sure to be right up there with 'cut technical reimbursement' in popularity in the 'Grand Plans to Fix Rad Onc' from this crack brain trust.
 
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temujim said:
Rad onc has the possibility to self select. Just amp up the physics difficulty level and watch applicants flee and programs shut down. But I doubt anyone in charge has the will for this approach.
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The ABR would have to actually have the guts to fail to certify and let board eligibility lapse for a large contingent of questionable admits, thereby ruining their careers and dooming them to bottom-of-the-barrel locums gigs forever. I don't think they have the guts to do that. Make a lot of people miserable for an extra year? Sure. Fail them 5 times in a row? No, I don't see that happening.
 
jondunn said:
increasing physics boards difficulty is sure to be right up there with 'cut technical reimbursement' in popularity in the 'Grand Plans to Fix Rad Onc' from this crack brain trust.
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Honest question: if cms doubled the technical reimbursement, do you think the salary of employed radoncs would increase?
 
RickyScott said:
Honest question: if cms doubled the technical reimbursement, do you think the salary of employed radoncs would increase?
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1) Never happen...CMS wants to lower reimbursement
2) Admins will spread the riches...any increase will go to them first and then subsidize the other "loss leaders" like (non-proton) peds cases
 
Future MD Anderson residents in 10 years will look back and ask themselves why their attendings spent a whole week discussing rectal cancer 10 years ago...
Rectal cancer will have joined gastric cancer and pancreatic cancer in the Hall of Fame of Obsolete Indications for Radiation Therapy by then.
 
Palex80 said:
Future MD Anderson residents in 10 years will look back and ask themselves why their attendings spent a whole week discussing rectal cancer 10 years ago...
Rectal cancer will have joined gastric cancer and pancreatic cancer in the Hall of Fame of Obsolete Indications for Radiation Therapy by then.
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Does pancreatic rally make the Hall? I'd put rectal in there with HD. Though rectal may be a two sport player, and after it's retirement from neoadjuvant, it may go on to a strong career in definitive.
 
Ray D. Ayshun said:
Does pancreatic rally make the Hall? I'd put rectal in there with HD. Though rectal may be a two sport player, and after it's retirement from neoadjuvant, it may go on to a strong career in definitive.
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pancreatic belongs in the hall much more than rectal IMO

like you say - rectal has two sports. one will continue/rise, one will fall to some extent, but the definitive will stay.
 
jondunn said:
pancreatic belongs in the hall much more than rectal IMO

like you say - rectal has two sports. one will continue/rise, one will fall to some extent, but the definitive will stay.
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Only low lying, apr necessitating rectal would recieve definitive. Otherwise, lar is not very morbid and xrt can be thrown out as it has almost not incremental benefit over neo adjuvant folfox. All of gi is headed for the garbage bin.
The case for bladder is 1000x better than rectum, yet surgery is still the main option.
 
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RickyScott said:
Only low lying, apr necessitating rectal would recieve definitive. Otherwise, lar is not very morbid and xrt can be thrown out as it has almost not incremental benefit over neo adjuvant folfox. All of gi is headed for the garbage bin.
The case for bladder is 1000x better than rectum, yet surgery is still the main option.
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yeah I mean I don't disagree. It's just that at least theres a role in rectal, there really is none in pancreas.

so I would put pancreas in as a first ballot in the hall of fame over rectal
 
jondunn said:
yeah I mean I don't disagree. It's just that at least theres a role in rectal, there really is none in pancreas.

so I would put pancreas in as a first ballot in the hall of fame over rectal
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Esophagus/gi junction just one drug away from getting on the ballot.
 
jondunn said:
yeah I mean I don't disagree. It's just that at least theres a role in rectal, there really is none in pancreas.

so I would put pancreas in as a first ballot in the hall of fame over rectal
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What I'm saying is, was pancreas ever really that good to begin with? Maybe for billing purposes, but that's like putting Ryan leaf in the hall. Sure, he was expensive, and gave the impression he might be great, but his stats never amounted to much and he was quickly benched and put out of the league before he could do any more harm.
 
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I strongly disagree about XRT going away for rectal. There was a recent randomized trial published that for the life of me I can't find right now that was kind of a "prelude to PROSPECT" trial which demonstrated a significant impact of neoadjuvant RT. I'll continue to look today, as it just came out in the last 2 weeks or so. Made me hopeful that we will continue to have a role in most rectal cancers for the time being.

Pancreas is a different story. I will expect to continue to see a pancreatic patient every now and then, but our days of playing a significant role in most patients is over, as the data suggests it should be.

I haven't seen a gastric patient in more than a decade.
 
OTN said:
I strongly disagree about XRT going away for rectal. There was a recent randomized trial published that for the life of me I can't find right now that was kind of a "prelude to PROSPECT" trial which demonstrated a significant impact of neoadjuvant RT. I'll continue to look today, as it just came out in the last 2 weeks or so. Made me hopeful that we will continue to have a role in most rectal cancers for the time being.

Pancreas is a different story. I will expect to continue to see a pancreatic patient every now and then, but our days of playing a significant role in most patients is over, as the data suggests it should be.

I haven't seen a gastric patient in more than a decade.
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Man. Gastric.

How much intellectual effort was put into that.

After the intergroup came out showing a chemoRT benefit 20+y ago, Tepper et al wrote a lengthy how to on gastric cancer ports/volumes and how to treat. Intense amounts of mental masturbation in that Red Journal classic.

And rectal is kind of on the ropes. Not bad, maybe just on one rope. But I have seen the future. UK NICE and recent introduction of term I had never heard before: immunoablation.
 
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