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[elementaryschooleconomics]

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We already have one of the lowest in person patient care obligations of any other specialist. No nights. No weekends. No inpatient service. Minimal call. And people refuse to see that they are pursuing a marginal near term benefit (don’t have to show up in clinic when your clinical obligations are already so much less onerous than nearly any other physician) while in the medium to long term an ever dwindling number of profiteers can soak up more and more billing for themselves?

But I know our kin: there are numerous sickos out there who would not think twice about virtually supervising 300 patients under the beam

I think the problem with this debate is how many of us either only consider our current situation or take a hypothetical situation to the extreme.

"We already have one of the lowest in-person patient care obligations of any other specialist" is an extremely institution-dependent statement. It is DEFINITELY not true for me. And while some people may have a gig where they only work during "normal business hours" while physically on site, many of us do not. When we say "no nights and weekends", we're broadcasting that no RadOnc does any work on nights and weekends at all.

How many RadOncs spend their nights and weekends contouring, catching up on notes, or doing research/1,000 other admin tasks? I would guess the vast majority of us.

The amount of under-recognized and unpaid work in medicine is out of control, and RadOnc is no different.

Again, for those of you who have secured a job like that - good! I hope it's yours till retirement.

But re: "300 patients under beam if this happens" -

1) This has already happened. We've had General Supervision since January 1st 2020, and Virtual Direct not long after. Talking about the end of Direct Supervision as if it's something that could change in the future...it already changed. Four years ago.

2) Even before that, the entire issue was the policy of "non-enforcement" by the government on the supervision issue. Urban hospitals were bound by direct, rural hospitals could do whatever they needed/wanted to.

For those that don't know: there has been, for many, many years, linacs in rural or underserved locations that rarely have a doc on site. This is not in the national conversation because I don't think any of these places are associated with the institutions that have residency programs.

3) There has ALWAYS been psychopaths exploiting the system. Go pull up the Medicare billing database that's publicly available. Filter by "77263", sort by most to least. Look at the numbers put up by the top 10 docs. Remember that this is ONLY their Medicare patients, which is usually about 33% of the patient mix. So multiply that number by 3.

Direct Supervision never helped with safety. Direct Supervision never prevented psychos from seeing unsafe numbers of patients. Direct Supervision never helped the job market.

The ONLY thing Direct Supervision has done is make a handful of whistleblowers a lot of money, and made us the only doctors who have to punch a clock.

It didn't save us before. It can't save us now.

 

[communitydoc13]

It didn't save us before. It can't save us now.

the entire issue was the policy of "non-enforcement" by the government on the supervision issue

What I want is a policy that requires that the doc is "usually there" and "always available", including a relatively short time to physical availability.

This would allow enough flexibility for truly rural docs. It would put a limit on abuses of large systems with grotesque patient volumes per remote doc and consolidation. It would be a bulwark against APP encroachment, and it would allow us to pick up kids, go to lunch, go to the dentist and go to the doctor ourselves.

Remote work is not the same for physicians. These things are more cultural than easily measurable. I am convinced that a remote doc will not be valued to the same degree as an on-site doc because we are actually effing human beings.

 

[BobbyHeenan]

What I want is a policy that requires that the doc is "usually there" and "always available", including a relatively short time to physical availability.

This would allow enough flexibility for truly rural docs. It would put a limit on abuses of large systems with grotesque patient volumes per remote doc and consolidation. It would be a bulwark against APP encroachment, and it would allow us to pick up kids, go to lunch, go to the dentist and go to the doctor ourselves.

Remote work is not the same for physicians. These things are more cultural than easily measurable. I am convinced that a remote doc will not be valued to the same degree as an on-site doc because we are actually effing human beings.

YES.

It should be the norm IMO that more often than not the doc is in the building but not mandated while the linac is on to be there 100% of the time.

 

[RadOncMegatron]

I think the problem with this debate is how many of us either only consider our current situation or take a hypothetical situation to the extreme.

"We already have one of the lowest in-person patient care obligations of any other specialist" is an extremely institution-dependent statement. It is DEFINITELY not true for me. And while some people may have a gig where they only work during "normal business hours" while physically on site, many of us do not. When we say "no nights and weekends", we're broadcasting that no RadOnc does any work on nights and weekends at all.

How many RadOncs spend their nights and weekends contouring, catching up on notes, or doing research/1,000 other admin tasks? I would guess the vast majority of us.

The amount of under-recognized and unpaid work in medicine is out of control, and RadOnc is no different.

Again, for those of you who have secured a job like that - good! I hope it's yours till retirement.

But re: "300 patients under beam if this happens" -

1) This has already happened. We've had General Supervision since January 1st 2020, and Virtual Direct not long after. Talking about the end of Direct Supervision as if it's something that could change in the future...it already changed. Four years ago.

2) Even before that, the entire issue was the policy of "non-enforcement" by the government on the supervision issue. Urban hospitals were bound by direct, rural hospitals could do whatever they needed/wanted to.

For those that don't know: there has been, for many, many years, linacs in rural or underserved locations that rarely have a doc on site. This is not in the national conversation because I don't think any of these places are associated with the institutions that have residency programs.

3) There has ALWAYS been psychopaths exploiting the system. Go pull up the Medicare billing database that's publicly available. Filter by "77263", sort by most to least. Look at the numbers put up by the top 10 docs. Remember that this is ONLY their Medicare patients, which is usually about 33% of the patient mix. So multiply that number by 3.

Direct Supervision never helped with safety. Direct Supervision never prevented psychos from seeing unsafe numbers of patients. Direct Supervision never helped the job market.

The ONLY thing Direct Supervision has done is make a handful of whistleblowers a lot of money, and made us the only doctors who have to punch a clock.

It didn't save us before. It can't save us now.

@elementaryschooleconomics I always love everything you have to say, so would like some clarificaiton. I am speaking out of ignorance and I think like others, are confused why direct supervision is so bad?

Doesn't it make sense we have to be there? I've seen some questionable IGRT matches and just emergencies in the clinic to justify our presence. From the patient's POV, I'd like to know a physician is there if I was a patient.

What are the main benefits of us not being needing to be there?

I also have the concerns @pikachu and @seper have brought up.

I think there can be a middle ground where you have to be there, as some have noted 80% of the time, and just not screw over all rural patients and relax it for those sites. Our patients consent to 70 Gy with concurrent chemoradiation, they can certainly take the risk of the doctor being out of the office for some of their treatments.

 

[medgator]

Honestly some comments in that twitter thread convinced me that rad onc just doesn’t get how good we have it. Like how hard is it to set parameters around practice supervision, on site 80% of beam on hours and available within 30 minutes the remainder. Or something. Just set a guideline then pay people to do their got-dam job like we’ve done the last 50 years. We already have one of the lowest in person patient care obligations of any other specialist. No nights. No weekends. No inpatient service. Minimal call. And people refuse to see that they are pursuing a marginal near term benefit (don’t have to show up in clinic when your clinical obligations are already so much less onerous than nearly any other physician) while in the medium to long term an ever dwindling number of profiteers can soak up more and more billing for themselves? No freaking thank you. We deserve better than this. I mean i’m lazy af and EVEN I recognize this as a bridge too far. I hope we all will enjoy the process of self elimination as a specialty because that’s where it will end up if the supervision guidelines are too lax.

*i edited this post after i got a little less mad*

Yet here is ASTRO letting us use APPs and trying to create the idea of an advanced RTT to replace physician supervision.

ASTROs move here isn't evidence-based, isn't rooted in safety, and certainly isn't meant to protect physician jobs or autonomy

 

[fiji128]

I think the problem with this debate is how many of us either only consider our current situation or take a hypothetical situation to the extreme.

"We already have one of the lowest in-person patient care obligations of any other specialist" is an extremely institution-dependent statement. It is DEFINITELY not true for me. And while some people may have a gig where they only work during "normal business hours" while physically on site, many of us do not. When we say "no nights and weekends", we're broadcasting that no RadOnc does any work on nights and weekends at all.

How many RadOncs spend their nights and weekends contouring, catching up on notes, or doing research/1,000 other admin tasks? I would guess the vast majority of us.

The amount of under-recognized and unpaid work in medicine is out of control, and RadOnc is no different.

Again, for those of you who have secured a job like that - good! I hope it's yours till retirement.

But re: "300 patients under beam if this happens" -

1) This has already happened. We've had General Supervision since January 1st 2020, and Virtual Direct not long after. Talking about the end of Direct Supervision as if it's something that could change in the future...it already changed. Four years ago.

2) Even before that, the entire issue was the policy of "non-enforcement" by the government on the supervision issue. Urban hospitals were bound by direct, rural hospitals could do whatever they needed/wanted to.

For those that don't know: there has been, for many, many years, linacs in rural or underserved locations that rarely have a doc on site. This is not in the national conversation because I don't think any of these places are associated with the institutions that have residency programs.

3) There has ALWAYS been psychopaths exploiting the system. Go pull up the Medicare billing database that's publicly available. Filter by "77263", sort by most to least. Look at the numbers put up by the top 10 docs. Remember that this is ONLY their Medicare patients, which is usually about 33% of the patient mix. So multiply that number by 3.

Direct Supervision never helped with safety. Direct Supervision never prevented psychos from seeing unsafe numbers of patients. Direct Supervision never helped the job market.

The ONLY thing Direct Supervision has done is make a handful of whistleblowers a lot of money, and made us the only doctors who have to punch a clock.

It didn't save us before. It can't save us now.

Most institutions are still doing direct supervision for whatever reason(s) at this point. I think if the requirement was permanently and unequivocally done away with institutions would start taking advantage of the new policy. Satellite clinics with 10 undertreatment would start to staff the site with a MD 3 days a week (like med onc already does) or whatever variation of that. Giving how over supplied the specialty currently is I don't really understand why people are so gun ho on going down that path. It's the same but this might really help me personally so I don't care about anything else attitude.

 

[NotMattSpraker]

Honestly some comments in that twitter thread convinced me that rad onc just doesn’t get how good we have it.

You know what's funny is I have it really great, but Id love for things to be better for all the people that reach out to discuss their concerns with their job.

If only our leaders acted that way...

 

[elementaryschooleconomics]

@elementaryschooleconomics I always love everything you have to say, so would like some clarificaiton. I am speaking out of ignorance and I think like others, are confused why direct supervision is so bad?

Doesn't it make sense we have to be there? I've seen some questionable IGRT matches and just emergencies in the clinic to justify our presence. From the patient's POV, I'd like to know a physician is there if I was a patient.

What are the main benefits of us not being needing to be there?

I also have the concerns @pikachu and @seper have brought up.

I think there can be a middle ground where you have to be there, as some have noted 80% of the time, and just not screw over all rural patients and relax it for those sites. Our patients consent to 70 Gy with concurrent chemoradiation, they can certainly take the risk of the doctor being out of the office for some of their treatments.

I assume you work at a place with at least one other RadOnc?

I don't. It's just me and the linac. Direct Supervision for those in my position is essentially house arrest. Forget dentist appointments - I couldn't even do outreach events to improve the health of the community.

Hospital wants to do skin cancer screenings at a local nursing home at 11AM on a Wednesday? Sorry, can't make it, Direct Supervision.

Town is hosting a lung cancer screening event at the VFW on Tuesday at 2PM? Sorry, can't make it, Direct Supervision.

The medical staff are planning a trip to the State Capitol to meet with representatives about a proposed bill that would harm patient access? What time does the bus leave? Thursday at 8AM? Sorry, can't make it, Direct Supervision.

But my opinion on this was crafted long before I had this job, it's just that I've discovered new issues as the years roll on.

Even though I'm a solo doc with a solo linac, I am still physically in clinic 5 days a week, during treatment hours and more, always.

I usually prefer to show up at 8:15AM and treatments technically start at 8AM, so I'm technically generally supervising for ~10 minutes a day.

I have a busy but normal number of patients on beam. I support virtual OTVs but have never done it.

Therapists concerned about IGRT match and I'm not there? If we can't figure it out over the phone or via FaceTime: just don't treat. That should be the answer even if you're physically there. The option to hold treatment for a day is always available.

There IS already a middle ground. We're living it. That's the crazy thing: we already live in the world people are nervous about. We've been living it for years.

The middle ground is me choosing to engage in direct supervision the majority of the time because I think it's important for patient care.

The middle ground is a department/hospital deciding to have a local policy of direct supervision because they think it's important for patient care.

The middle ground is hospital attorneys expressing concern about potential litigation without direct supervision, and a local policy to engage in direct supervision is created.

My argument is...change nothing. Literally just keep things the way they are now.

The change would be bringing back Direct Supervision.

 

[RadOncMegatron]

I assume you work at a place with at least one other RadOnc?

I don't. It's just me and the linac. Direct Supervision for those in my position is essentially house arrest. Forget dentist appointments - I couldn't even do outreach events to improve the health of the community.

Hospital wants to do skin cancer screenings at a local nursing home at 11AM on a Wednesday? Sorry, can't make it, Direct Supervision.

Town is hosting a lung cancer screening event at the VFW on Tuesday at 2PM? Sorry, can't make it, Direct Supervision.

The medical staff are planning a trip to the State Capitol to meet with representatives about a proposed bill that would harm patient access? What time does the bus leave? Thursday at 8AM? Sorry, can't make it, Direct Supervision.

But my opinion on this was crafted long before I had this job, it's just that I've discovered new issues as the years roll on.

Even though I'm a solo doc with a solo linac, I am still physically in clinic 5 days a week, during treatment hours and more, always.

I usually prefer to show up at 8:15AM and treatments technically start at 8AM, so I'm technically generally supervising for ~10 minutes a day.

I have a busy but normal number of patients on beam. I support virtual OTVs but have never done it.

Therapists concerned about IGRT match and I'm not there? If we can't figure it out over the phone or via FaceTime: just don't treat. That should be the answer even if you're physically there. The option to hold treatment for a day is always available.

There IS already a middle ground. We're living it. That's the crazy thing: we already live in the world people are nervous about. We've been living it for years.

The middle ground is me choosing to engage in direct supervision the majority of the time because I think it's important for patient care.

The middle ground is a department/hospital deciding to have a local policy of direct supervision because they think it's important for patient care.

The middle ground is hospital attorneys expressing concern about potential litigation without direct supervision, and a local policy to engage in direct supervision is created.

My argument is...change nothing. Literally just keep things the way they are now.

The change would be bringing back Direct Supervision.

Well, you are right that the regulation would be terrible for clinics like yours. As in all regulations, they should be scapels and not hammers, but alas...

You and your patients would be screwed by this I acknowledge that... need to think about this some more as the regulations will likely not have the exceptions that are needed.

 

[elementaryschooleconomics]

Well, you are right that the regulation would be terrible for clinics like yours. As in all regulations, they should be scapels and not hammers, but alas...

You and your patients would be screwed by this I acknowledge that... need to think about this some more as the regulations will likely not have the exceptions that are needed.

Yeah, to be clear I'm obviously not against the concept of supervision, haha

But there appears to be two main "boogeymen" of no more Direct Supervision - which again, neither of which have happened in the years since it went away:

1) Psychos are gonna do crazy stuff without guardrails

This...already happens. It will always happen. They let that Mantz guy treat the wrong breast!

2) There will be 50 Radiation Oncologists staffing 2,000 ghost linacs and the rest of us will be unemployed

There is NO WAY that's happening. First, I'm not alone in my own opinion of what being a good Radiation Oncologist looks like. Many of us will continue on practicing in a similar manner to Direct Supervision.

But most importantly: good luck getting existing, entrenched hospitals to sign off on completely virtual/ghost linacs at scale. I know for an absolute fact that even though my hospital knows and supports general supervision, if I were to suggest routinely not coming in 1-2 days per week from now on...that would...that would not go over well.

Maybe new entities (like the dreaded Bridge!) could have a fleet of ghost linacs because they're not fighting inertia.

Well...then they're up against state regulations. The majority of states have CON laws, and the majority of those CON laws are crazy.

But let's say some ghost linacs are installed somewhere. There are two options really:

1) They're in an area that lacked a linac because of geography/it didn't make financial sense. As long as they're practicing cookbook/NCCN medicine, I would argue that's a tremendous benefit for the community. Everyone wins!

2) They dropped a ghost linac in an area with competition. Let's say they dropped one next to me.

Will I lose some patients? Sure, probably. But not many. The ad campaign writes itself - "hometown touch".

Really just to emphasize: we left Direct Supervision behind in the pre-pandemic days. The long long ago.

It was enforced for a decade, 2009-2019.

The decade the job market steadily deteriorated and the specialty's competitiveness collapsed. Safety events still happened. Sketchy doctors treated too many patients.

We ran the trial with 10 years of follow-up. The results were negative.

Direct Supervision is not recommend by the evidence.

 

[communitydoc13]

The middle ground is hospital attorneys expressing concern about potential litigation without direct supervision

But most importantly: good luck getting existing, entrenched hospitals to sign off on completely virtual/ghost linacs at scale. I know for an absolute fact that even though my hospital knows and supports general supervision, if I were to suggest routinely not coming in 1-2 days per week from now on...that would...that would not go over well.

This is a moving target. This is based on the value they can get from you presently compared to the alternative as well as the existing regulatory environment. You just don't have that much leverage long term.

Hospitals will move to remote services for almost anything if they are assuaged regarding legal risk. Remote is commonly employed for CVA management in the community. The remote services entities (whether corporate start-ups or academic entities) will engage the most desperate community hospitals first, but their scope will inexorably increase.

I am confident that you provide exceptional value personally...this is where you are protected regarding the downside of more permissive regulation regarding supervision...it is also why a stringent surveillance regulation is not ideal for you.

But, I do think the bogeymen are coming in this lax regulatory environment. I see the cultural slide every day. APPs in house. Docs providing outpatient and some emergency specialty care. Outsourcing wherever possible for economies of scale.

Direct Supervision is not recommend by the evidence.

How many redundancies in airplane design are supported by evidence? I am certain that a doc on site at the right time has helped in innumerable (while rare day to day...weird how large numbers work) clinical scenarios.

 

[elementaryschooleconomics]

But, I do think the bogeymen are coming in this lax regulatory environment. I see the cultural slide every day. APPs in house. Docs providing outpatient and some emergency specialty care. Outsourcing wherever possible for economies of scale.

Oh. Yeah.

The wolves are everywhere in the tall grass. I can smell them. I can see them.

Which is why we shouldn't waste our efforts on silly battles like this!

In your "innumerable scenarios" where the on-site doc helped: what about their physical presence saved the day that a phone call couldn't?

 

[communitydoc13]

In your "innumerable scenarios" where the on-site doc helped: what about their physical presence saved the day that a phone call couldn't?

First, I believe that physical presence usually helps a patient in distress...if only for relief of anxiety and comfort reasons. Nearly every patient who wants to quit concurrent treatment because of acute toxicity on a Friday is going to perceive better care when the doc comes in person to talk with them and assess them. Some fraction of them will continue treatment based on the immediate service they receive at the time of their distress.

My threshold for referral to ED is higher in person than by phone. If my physical exam assures me that the patient is at low risk, I am less reflexive about ED referral for bad vitals or labs...every avoided, low value ED referral is a win.

Acute DVT...been a few over the years. Patient presents with pleurisy type symptoms and you examine their legs.

Figured out that the electron cutout was aligned wrong.

Appreciated patient motion during or prior to stereotactic treatment (guessing most still subscribe to doc at machine for stereotactic treatment).

Aborted treatment and discussed transition to supportive care in person with acute decline in performance status or abrupt change in patient goals. I'd prefer this be an in person conversation.

Would you advertise remote docs on treatment vs on-site? Of course not.

As an aside, old patients with asymptomatic disease often like their follow-up to be remote.

 

[TheWallnerus]

First, I believe that physical presence usually helps a patient in distress...if only for relief of anxiety and comfort reasons. Nearly every patient who wants to quit concurrent treatment because of acute toxicity on a Friday is going to perceive better care when the doc comes in person to talk with them and assess them. Some fraction of them will continue treatment based on the immediate service they receive at the time of their distress.

Do you think the 75yo locums dude covering for me on vacay is going to do better, in person, in this instance than I would by FaceTime—or phone!—from wherever I'm vacationing? A doctor the patient has never met, versus having met me in consult and on OTVs? Unless we are saying a solo rad onc should never take an out-of-town trip because patients might need immediate in-person conversations, on demand, from their treating physician...

My threshold for referral to ED is higher in person than by phone. If my physical exam assures me that the patient is at low risk, I am less reflexive about ED referral for bad vitals or labs...every avoided, low value ED referral is a win.

Acute DVT...been a few over the years. Patient presents with pleurisy type symptoms and you examine their legs.

Figured out that the electron cutout was aligned wrong.

Appreciated patient motion during or prior to stereotactic treatment (guessing most still subscribe to doc at machine for stereotactic treatment).

Aborted treatment and discussed transition to supportive care in person with acute decline in performance status or abrupt change in patient goals. I'd prefer this be an in person conversation.

Would you advertise remote docs on treatment vs on-site? Of course not.

As an aside, old patients with asymptomatic disease often like their follow-up to be remote.

Again, all of these are either reasons to tell a solo doc never to take vacation, or never to miss a day of work because of diarrhea, or to ignore CDC guidance during the next pandemic, or whatever. Or they're just (admittedly concerning!) hypotheticals that can happen but actually have zero to do (save for the SBRT case) with direct supervision as defined by Medicare.

 

[pikachu]

Oh. Yeah.

The wolves are everywhere in the tall grass. I can smell them. I can see them.

Which is why we shouldn't waste our efforts on silly battles like this!

In your "innumerable scenarios" where the on-site doc helped: what about their physical presence saved the day that a phone call couldn't?

In the question of supervision requirements, why do we have to be beholden to the twin strawmen of the apocalypse: 1) Doc chained to linac 100% of the time vs 2) the Ghost Linac Fleet with one doc covering some very large number of patients. If supervision requirements need to be updated, wouldn't it benefit us to delineate reasonable expectations for coverage/staffing (including but not limited to what duties are delegated to an MD and what to an APP) and reasonable exceptions to same? Don't we want to be out in front of whatever the advanced practice RTT is going to turn out to mean? seems to me that advocating for sensible supervision requirements protects both us and the patients, no?

We can't rely on hospital systems to "just do the right thing" when they see dollars, potentially lots of dollars, up for grabs, as so many above have noted.

Also @NotMattSpraker I think you are 100% correct in not expecting astro to lift a proverbial finger with respect to helping set forth sensible parameters on this. In the points I made above I was certainly not trying to push the 'astro' line, rather noting that good regulations around supervision could help us in many aspects as a specialty.

 

[communitydoc13]

Again, all of these are either reasons to tell a solo doc never to take vacation, or never to miss a day of work because of diarrhea, or to ignore CDC guidance during the next pandemic, or whatever.

They aren't reasons at all. They are examples.

Nothing is perfect and an absolutely failproof medical system would never be sustainable.

They are examples of the value of being there...full stop. The value of being there is of course relative to the nature of the practice.

So, we should usually be there and strategically be there.

The value of being in clinic for the first four patients, all of whom are healthy breast and prostate patients is close to zero.

The value to being there for simulations, new starts, frail concurrent patients and SBRT is much higher.

I was gonna mention strawman but @pikachu beat me to it. A parameterized requirement of presence is reasonable. It could be used as a legal tool to discourage abusers of all sorts, and it will be a bulwark against the complete replacement (or marked reduction) of in person physician services in our field.

 

[TheWallnerus]

So, we should usually be there and strategically be there.

Ever since 2020 when direct supervision has been abolished, it appears everyone is usually and strategically there.

I was gonna mention strawman but @pikachu beat me to it. A parameterized requirement of presence is reasonable. It could be used as a legal tool to discourage abusers of all sorts, and it will be a bulwark against the complete replacement (or marked reduction) of in person physician services in our field.

A requirement of presence, including the various completely reasonable requirements thus far bandied about here, cannot be unmoored from a requirement for a punitive outcome if the rule is broken. That's the way laws work. Every action has an equal and opposite reaction, usually. We need to be careful what we wish for insofar as wanting special rad onc rules... and punishments that would come with them.

We can't rely on hospital systems to "just do the right thing" when they see dollars, potentially lots of dollars, up for grabs, as so many above have noted.

Had a friend from large hospital system in the South contact me yesterday....

"I’m in the midst of a supervision fight at my centers, which I am losing by the way. With CMS general and Covid CMS virtual Direct, we hired a PA and things were going great. Then we had an ACR audit in preparation for re-accreditation and they noticed we sometimes had a surrogate supervising the linac. I fought for as long as I could, but ultimately the other groups that have a more defined one doc/ one center model in the 22 Hospital system argued for a return to ACR guidelines to maintain certification."

The hospital refused to risk losing ACR accreditation, even though the doctor who had the professional service contract would have liked to have done that because now he needs more FTEs to staff two (hospital affiliated outpatient) centers treating 5-10 on beam each per day rather than just splitting an FTE between the two.

 

[BobbyHeenan]

Ever since 2020 when direct supervision has been abolished, it appears everyone is usually and strategically there.


A requirement of presence, including the various completely reasonable requirements thus far bandied about here, cannot be unmoored from a requirement for a punitive outcome if the rule is broken. That's the way laws work. Every action has an equal and opposite reaction, usually. We need to be careful what we wish for insofar as wanting special rad onc rules... and punishments that would come with them.

Had a friend from large hospital system in the South contact me yesterday....

"I’m in the midst of a supervision fight at my centers, which I am losing by the way. With CMS general and Covid CMS virtual Direct, we hired a PA and things were going great. Then we had an ACR audit in preparation for re-accreditation and they noticed we sometimes had a surrogate supervising the linac. I fought for as long as I could, but ultimately the other groups that have a more defined one doc/ one center model in the 22 Hospital system argued for a return to ACR guidelines to maintain certification."

The hospital refused to risk losing ACR accreditation, even though the doctor who had the professional service contract would have liked to have done that because now he needs more FTEs to staff two (hospital affiliated outpatient) centers treating 5-10 on beam each per day rather than just splitting an FTE between the two.

I have seen this happen as well.

I was told (second hand) that ACR was considering eliminating that supervision requirement because people were dropping their accreditation because of the supervision standard.

 

[elementaryschooleconomics]

A parameterized requirement of presence is reasonable. It could be used as a legal tool to discourage abusers of all sorts, and it will be a bulwark against the complete replacement (or marked reduction) of in person physician services in our field.

All I can keep pointing out is we had Direct Supervision in all settings from 2009-2019. It didn't really "exist", per se, before then (in the way we define it now), and it hasn't existed in hospital outpatient departments (the majority of RadOnc) for the past four years. That's a pretty good experiment, we don't normally get this amount of data.

In all those years Direct Supervision was in effect, the only thing it appears to have done is enrich some Relators from whistleblower cases. Well, and their attorneys.

Well, and certain people with billing agencies who can sell fear and serve as expert witnesses.

At the end of the day, it's just a question of if you believe you can deploy broad, blunt regulation to achieve a desire effect. Usually not, and, in the case of the RadOnc job market, definitely not based on real-world evidence.

But to go a step further for those who want Direct Supervision to come back:

Should we just "reset" the system to 2019? As in, the two-tiered system of enforcement? No "real time audio/visual communication" - pretend like that never happened?

Because to be clear, I think many of us - myself included - would support some kind of thoughtful regulation. Which is, of course, not ASTRO's stance.

 

[TheWallnerus]

I have seen this happen as well.

I was told (second hand) that ACR was considering eliminating that supervision requirement because people were dropping their accreditation because of the supervision standard.

I have confirmed with ACR as of yesterday that they want a rather thorough presence. Anything less than 90% physician on site they would never accredit. However they are reasonable and not direct supervision Nazis (not sure if they ever were). Contact Brian Monzon at 703-476-1116 at the ACR.

 

[elementaryschooleconomics]

I have confirmed with ACR as of yesterday that they want a rather thorough presence. Anything less than 90% physician on site they would never accredit. However they are reasonable and not direct supervision Nazis (not sure if they ever were). Contact Brian Monzon at 703-476-1116 at the ACR.

Can someone text Dave Adler that number?

ASTRO could learn a thing or two from a real organization.

 

[elementaryschooleconomics]

Re-reading this thread:

I would propose, instead of "Direct Supervision", regulation preventing "Ghost Radiotherapy".

Specifically, you would be unable to receive Medicare reimbursement if any of your treatment sites (regardless of modality) were staffed 100% virtually.

We can argue about minimum presence requirements, but linking Medicare eligibility with a minimum level of MD/DO presence would be an "easy" way to enact some form of "guardrails" without bringing back "Whistleblower House Arrest Bonanza".

 

[radiaterMike]

just to clarify - ACR allows 90% ? meaning they accept that circumstances arise that might preclude 100% direct supervision ?

 

[BobbyHeenan]

I have confirmed with ACR as of yesterday that they want a rather thorough presence. Anything less than 90% physician on site they would never accredit. However they are reasonable and not direct supervision Nazis (not sure if they ever were). Contact Brian Monzon at 703-476-1116 at the ACR.

helpful to know. like I said, second hand info....so there you go.

But 90% is better than 100%....

 

[Mandelin Rain]

We all agree 100% is ridiculous and 0% is ridiculous.

The issue with making further, specific parameters is that every doc and every clinic will think their threshold in between those extremes is completely reasonable. And, honestly, they're probably correct.

 

[RadOncDoc21]

Only rad oncs can find ways to never agree on anything useful!

 

[elementaryschooleconomics]

We all agree 100% is ridiculous and 0% is ridiculous.

The issue with making further, specific parameters is that every doc and every clinic will think their threshold in between those extremes is completely reasonable. And, honestly, they're probably correct.

Only rad oncs can find ways to never agree on anything useful!

Bingo!

I mean it's pretty clear we all agree on the vision for the world we want to live in, it's just the mechanism(s) by which to get there.

 

[NotMattSpraker]

Can someone text Dave Adler that number?

ASTRO could learn a thing or two from a real organization.

I like Brian, he is a nice guy. So please do not burden him with Dave.

 

[TheWallnerus]

just to clarify - ACR allows 90% ? meaning they accept that circumstances arise that might preclude 100% direct supervision ?

Totally.

 

[Palex80]

I am having trouble to understand the rationale.

 

[RadRadRad]

View attachment 383783


I am having trouble to understand the rationale.

Because similar trials have been done? Or because 74 gy dose escalation failed

I think the concept of sbrt boost only to primary makes sense as primary disease harder to control than nodal disease.
Would make me nervous if primary is very central or endobronchial

Sounds like authors hypothesized improved oxygenation with up front sbrt

 

[Ray D. Ayshun]

Because similar trials have been done? Or because 74 gy dose escalation failed

I think the concept of sbrt boost only to primary makes sense as primary disease harder to control than nodal disease.
Would make me nervous if primary is very central or endobronchial

Sounds like authors hypothesized improved oxygenation with up front sbrt

The alternative to this is sib. 60/30 and 66/30 where it's safe. Many of us already do this, and i think standard at mdacc.

 

[thecarbonionangle]

The alternative to this is sib. 60/30 and 66/30 where it's safe. Many of us already do this, and i think standard at mdacc.

Heard Harvard takes it to 70 if it is safe? Joe Chang has posted on mednet about their 66/30 SIb approach

 

[RadOncMegatron]

The alternative to this is sib. 60/30 and 66/30 where it's safe. Many of us already do this, and i think standard at mdacc.

I have thought about this alot and go back and forth between 60 vs 66 Gy, but not sure it makes any difference except to make me feel better b/c I think (with absolutely no proof) that 60 Gy is inadequate. It's funny but I think it really does make us feel better as one of the main reasons. If 74 Gy "hurts" or at best is neutral, what will 70 Gy accomplish? With that said I think if you go to 66 Gy, might as well go to 70 Gy?!?!? Sorry just thinking out loud in my confusion!

 

[thecarbonionangle]

Of note RTOG 1308, which had finished accruing BTW, goes to 70/35 with photons and protons. Will be interesting to see results and compare them to RTOG 0617. There has been more recent negative trials of dose escalation in lung with modern isotoxic techniques, however.

 

[communitydoc13]

View attachment 383783


I am having trouble to understand the rationale.

It's fine. On the innovation thread we discussed the peculiarities of dose kinetics and it's an understudied space. This is a low risk trial. Phase III will probably be negative but would anyone really mind accruing to it out in the community?

There are phase II trials and there are phase II trials. This is a baby phase II trial.

 

[RadOncMegatron]

Of note RTOG 1308, which had finished accruing BTW, goes to 70/35 with photons and protons. Will be interesting to see results and compare them to RTOG 0617. There has been more recent negative trials of dose escalation in lung with modern isotoxic techniques, however.

Do you mind linking some of those studies if you have them? I would love to take a look.

 

[thecarbonionangle]

Do you mind linking some of those studies if you have them? I would love to take a look.

There hasnt been any new phase 3 studies that i am aware of recently like 0617. There are multiple smaller studies which are restrostepective, phase 1/2 which have looked at question (search for isotoxic dose escalation NSCLC) . Some have used PETCT. I have not seen a newer ph 3 study clearly showing a benefit to dose escalation which is why i don’t believe we have a positive study to fall back on. Some of the conclusions say it is “promising” or possible without increased toxiticy, worthy of study. I agree with you that it seems like more dose would be better but take a look at the negative oesophageal studies again and again. Higher dose for cervical oesophagus is now completely out of NCCN. I’m simply saying it does not necessarily help as far as I know based on best high level data we have. I do take it to 66 in 33 or 30 from time to time but i wonder if it is something I do for myself lol

If someone is aware of anything different please post too!

RTOG 1106

https://ascopubs.org/doi/10.1200/JCO.2021.39.15_suppl.8548

RTOG 1308 is unpublished

 

[medgator]

I have thought about this alot and go back and forth between 60 vs 66 Gy, but not sure it makes any difference except to make me feel better b/c I think (with absolutely no proof) that 60 Gy is inadequate. It's funny but I think it really does make us feel better as one of the main reasons. If 74 Gy "hurts" or at best is neutral, what will 70 Gy accomplish? With that said I think if you go to 66 Gy, might as well go to 70 Gy?!?!? Sorry just thinking out loud in my confusion!

LS sclc should be 70/35 if you treat daily and follow the calgb/nrg intergroup protocol. Less for nsclc. Makes perfect sense

 

[drowsy12]

Dose escalation in conv fractionation in context of chemo doesn’t do jack other than cause more toxicity. How many times and how many solid tumor types do we have to see it in. Harvard is nuts going to 70 for NSCLC

 

[elementaryschooleconomics]

In a thread about Direct Supervision, Ron is, as always, playing the scare tactic cards.

He had the audacity to post this:

Just a reminder, Ron had his therapist licensed revoked by the ASRT:

He managed to get this removed from the website list you can easily search (I believe you can...perhaps offer a "donation" if ~10 years have passed) but you can always call the ASRT to verify a revocation.

Now, who can say WHY his license was revoked. I mean, it sure would be weird if it was like, cheating on continuing education credits or something, right? Like that would be super weird for a guy like this, preaching his scary puritanical interpretation of regulations.

Guess it will remain a mystery!

 

[RickyScott]

In a thread about Direct Supervision, Ron is, as always, playing the scare tactic cards.

He had the audacity to post this:

View attachment 383827

Just a reminder, Ron had his therapist licensed revoked by the ASRT:

View attachment 383828

He managed to get this removed from the website list you can easily search (I believe you can...perhaps offer a "donation" if ~10 years have passed) but you can always call the ASRT to verify a revocation.

Now, who can say WHY his license was revoked. I mean, it sure would be weird if it was like, cheating on continuing education credits or something, right? Like that would be super weird for a guy like this, preaching his scary puritanical interpretation of regulations.

Guess it will remain a mystery!

Types of Sanctions - ARRT

R.T.s can face a range of ARRT sanctions and additional actions as a result of ethics violations. Learn more about each type.

www.arrt.org

Revocation for cheating on cme seems kind of harsh.

 

[elementaryschooleconomics]

Types of Sanctions - ARRT

R.T.s can face a range of ARRT sanctions and additional actions as a result of ethics violations. Learn more about each type.

www.arrt.org

Revocation for cheating on cme seems kind of harsh.

What if it was some sort of...ring? Like a cheating ring?

Just asking questions of course, who knows.

 

[drowsy12]

https://x.com/lauradovermd/status/1767176509943398745?s=46&t=rlNDSubO1Ki87D_HsF0Yvg

 

[TheWallnerus]

Where's Limpy?

 

[RickyScott]

Where's Limpy?

Calling arrt?

 

[Mandelin Rain]

View attachment 383783


I am having trouble to understand the rationale.

Haven't read the paper, but wasn't it hypothesized that moderate doses such as 6-8 Gy have the best immunogenic response?

Shrinking tumor/volume with traditional fx and then boosting residual to potentially increase LC and immunogenicity right before IO starts; I kind of like it.

 

[TheWallnerus]

Haven't read the paper, but wasn't it hypothesized that moderate doses such as 6-8 Gy have the best immunogenic response?

Shrinking tumor/volume with traditional fx and then boosting residual to potentially increase LC and immunogenicity right before IO starts; I kind of like it.

Of course we don’t know if many weeks of traditional fx prior to the large fx kills the possibility of increased immunogenicity from the large fx or not.

 

[evilbooyaa]

Haven't read the paper, but wasn't it hypothesized that moderate doses such as 6-8 Gy have the best immunogenic response?

Shrinking tumor/volume with traditional fx and then boosting residual to potentially increase LC and immunogenicity right before IO starts; I kind of like it.

But doesn't this do the opposite? SBRT to bring in all the immune cells. Then conventional fx RT to kill them all.

 

[Mandelin Rain]

But doesn't this do the opposite? SBRT to bring in all the immune cells. Then conventional fx RT to kill them all.

Whoops. Yes. You're correct. I like that less.