Rad Onc Twitter

[scarbrtj]

Suddenly, antitrust is no more a worry than supervision.

With your permission I'm going to start just randomly replying this phrase no matter the post.

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[Ray D. Ayshun]

No truer words. And so the next generation of gaslighters begins, for a whole next generation to come...

Wouldn't say she's gaslighting. She did mention the high rate of "patients" entering rad onc through SOAP. that's a pretty low bar for entry...

 

[2014XRT]

 

[2014XRT]

 

[deleted774703]

Wouldn't say she's gaslighting. She did mention the high rate of "patients" entering rad onc through SOAP. that's a pretty low bar for entry...

Considering her multiple prior posts of saying we need more applicants in RO, I think she is

I appreciate her for making Econtour

But she either needs to stay out of residency information or given her status speak up against it

 

[2014XRT]

It’s fine to want or encourage more applicants in my opinion.

what we need is less spots.

If 1000 people apply and compete for 100 slots a year, great.

 

[deleted774703]

It’s fine to want or encourage more applicants in my opinion.

what we need is less spots.

If 1000 people apply and compete for 100 slots a year, great.

I like the latter part of that and agree mathematically

But in reality we know that academics will either

1) deny any problem if there are enough number of applicants

2) expand more bc of the “high demand”

 

[DebtRising]

Thinking about this further... who wins in this scenario? How can we present ourselves as field with a stat of 'up to 15% of this graduating class is here because they couldn't do something else'?

Who wins?
People in that class lose, at both ends of the spectrum. There are undoubtedly residents in that class who have much better board scores and research than even the heady days, including smashing my own stats, and they will get branded. And so will the people who soaped in, and just happened to be in a year where this number was significantly above average. And neither side deserves it.

People who came before, who worked extremely hard to match and do research etc,, the immediate preceding generation - we sure don't win. We get put in the same boat, and people like Dr. Oliver make snide comments on twitter insinuating we weren't as dedicated. OK.

Medicare / Tax payers do not win. Not all slots are medicare funded - but how is 1 drop of taxpayer money justified in a field with more trainees than jobs? And trend lines in supply and demand (as visits, fractions, indications, reimbursement etc) continue to point in opposite directions? Projections are projections, but is there a single projection or piece of information suggesting the opposite (even pre-COVID)?

Patients don't win - society doesn't need more of us, in a national situation where health care resources are scarce and stretched, spending any additional resources training more rad oncs does not help them.

Does ACGME and ASTRO really win here? 15% SOAP rate? That's a reflection of the rigorous standards of certifying a residency program and reflecting how important the field is? Can't be.

Unless you are end career with 3-5 year window until retirement, it seems every single stakeholder loses, with the biggest losses to be felt by incoming classes and all of the younger physicians in practice. You know, the future of the field.

It's nuts. and we can't even get decent training standards enforced on case numbers, brachytherapy cases, proton exposure (which for prostate or not is a valuable part of our field's future), etc.

I don't even have a point anymore, I am so disappointed in myself in choosing this field, but also so disappointed to work so hard and invest in something and see my 'leadership' running out the clock on their careers without earnest efforts to help ours, now years into multiple pieces of data showing that's exactly what we need

 

[2014XRT]

I disagree with needing proton exposure during training.

 

[2014XRT]

 

[KHE88]

"We observed that Black and Asian patients receive hypofractionated RT less often than Whites, despite more frequent treatment at teaching centers. Multilevel modeling eliminated this disparity, suggesting that differences in facility-specific HF use appear to have contributed. Further inquiry is needed to determine if reduction of facility-level variation may reduce disparities in accessing HF treatment. "

Of course this flaming piece of incendiary race-baiting horse excrement is a red journal publication. Of course it is.

So the preposition here was that non-teaching centers are racist? Naturally.
Looks like that one didn't turn out the way they hoped. Solid red journal publication anyway.

Keep up the good work, rad onc woke-scolds!
Lets keep throwing more gasoline on the raging inferno dumpster full of rabid-racoons on fire that our specialty has become by focusing our efforts on crap like this. I guarantee these people are moonlighting for Evicore on their "academic" days while gleefully splitting the producivity pot with the racist community rad oncs at their satellites.

 

[2014XRT]

I don’t think patterns of practice analysis is race-baiting.

 

[KHE88]

I don’t think patterns of practice analysis is race-baiting.

Then what about all the obvious racial overtones in that awful publication?

The presupposition behind all of this, whether we/they want to admit it or not, is that the old school rad onc majority is systemically oppressing anybody who is not white and male. They publish this crap over and over and over and over again. In this case, they went on a fishing expedition to determine if rad oncs are intentionally over-treating dark-skinned people with inferior fractionation schemes to make more money off of them while giving whites the cheaper and better treatments. And this hypothesis was based off of ???????? Exactly. Not that such a study could have possibly answered such a question.

If you want to make that argument that there is some serious rotten practice patterns, fine. If that's really going on, then lets expose it and burn it to the ground. I'm with you 100%. But the burden on you is to provide very good evidence to base that hypothesis on and prove it, rather than just going on a fishing expedition based off your hunch that America is systematically racist (1619 project anyone?) and community rad oncs are Satan, and hoping some p-value lines up in a mess of confounders.

 

[2014XRT]

The King Speaks

 

[thecarbonionangle]

The King Speaks

Rumours are CS is finally sticking head out of shell, once again. BIG if true.

 

[RickyScott]

Then what about all the obvious racial overtones in that awful publication?

The presupposition behind all of this, whether we/they want to admit it or not, is that the old school rad onc majority is systemically oppressing anybody who is not white and male. They publish this crap over and over and over and over again. In this case, they went on a fishing expedition to determine if rad oncs are intentionally over-treating dark-skinned people with inferior fractionation schemes to make more money off of them while giving whites the cheaper and better treatments. And this hypothesis was based off of ???????? Exactly. Not that such a study could have possibly answered such a question.

If you want to make that argument that there is some serious rotten practice patterns, fine. If that's really going on, then lets expose it and burn it to the ground. I'm with you 100%. But the burden on you is to provide very good evidence to base that hypothesis on and prove it, rather than just going on a fishing expedition based off your hunch that America is systematically racist (1619 project anyone?) and community rad oncs are Satan, and hoping some p-value lines up in a mess of confounders.

Did they adjust for stage and chemo? Black women may be more likely to have triple negative or aggressive cancers and there was hesitation 3-5 years ago to perform hypofract with chemo?
Know of project that was shelved looking at outcome of poor blacks with lung ca, because they actually seemed to have small increase in OS.

 

[2014XRT]

 

[GapCalc]

Behold, The Evolution of Ben Smith:

2010: "The size of residency training classes for the years 2014 to 2019 would have to double to 280 residents per year in order for growth in supply of radiation oncologists to equal expected growth in demand."

2016: "The supply of radiation oncologists is expected to grow more quickly than the demand for radiation therapy from 2015 to 2025. Further research is needed to determine whether this is an appropriate correction or will result in excess capacity."

Also 2016: "There are practical concerns associated with a market-based solution in which medical students self-regulate according to job availability, but antitrust law would likely forbid collaborative self-regulation that purports to restrict supply."

2020: lol jk what antitrust implications? let's go to 150 per year

 

[2014XRT]

The future is more interesting than the past.

 

[elementaryschooleconomics]

Behold, The Evolution of Ben Smith:

2010: "The size of residency training classes for the years 2014 to 2019 would have to double to 280 residents per year in order for growth in supply of radiation oncologists to equal expected growth in demand."

2016: "The supply of radiation oncologists is expected to grow more quickly than the demand for radiation therapy from 2015 to 2025. Further research is needed to determine whether this is an appropriate correction or will result in excess capacity."

Also 2016: "There are practical concerns associated with a market-based solution in which medical students self-regulate according to job availability, but antitrust law would likely forbid collaborative self-regulation that purports to restrict supply."

2020: lol jk what antitrust implications? let's go to 150 per year

I'm glad Ben et al seem to be coming around. But these are just the first steps towards improvement. Openly acknowledging and discussing the oversupply issue is wonderful but no one (especially medical students) should feel relief until actions are actually taken.

Medical students should still be avoiding the field for the indefinite future until things start to change. Making decisions now based on Ben, Rahul, etc talking about addressing the issue would be the same thing as getting a 2AM phone call from an intern who says there's a patient with no cancer history and lower back pain with ?CT findings of a mass, no MRI, no tissue - could we deliver urgent XRT?

Don't treat that patient!

 

[deleted774703]

Behold, The Evolution of Ben Smith:

2010: "The size of residency training classes for the years 2014 to 2019 would have to double to 280 residents per year in order for growth in supply of radiation oncologists to equal expected growth in demand."

2016: "The supply of radiation oncologists is expected to grow more quickly than the demand for radiation therapy from 2015 to 2025. Further research is needed to determine whether this is an appropriate correction or will result in excess capacity."

Also 2016: "There are practical concerns associated with a market-based solution in which medical students self-regulate according to job availability, but antitrust law would likely forbid collaborative self-regulation that purports to restrict supply."

2020: lol jk what antitrust implications? let's go to 150 per year

Can I love this multiple times

Someone needs to call him out on Twitter ASAP

Probably in his basement trying to pad his stats with more BS publications

 

[GapCalc]

I'm glad Ben et al seem to be coming around. But these are just the first steps towards improvement. Openly acknowledging and discussing the oversupply issue is wonderful but no one (especially medical students) should feel relief until actions are actually taken.

As much as I poke fun, I am very, very happy that this conversation is happening. It's a shame it took this long, but I applaud anyone who (finally) sees the writing on the wall.

 

[scarbrtj]

Behold, The Evolution of Ben Smith:

2010: "The size of residency training classes for the years 2014 to 2019 would have to double to 280 residents per year in order for growth in supply of radiation oncologists to equal expected growth in demand."

2016: "The supply of radiation oncologists is expected to grow more quickly than the demand for radiation therapy from 2015 to 2025. Further research is needed to determine whether this is an appropriate correction or will result in excess capacity."

Also 2016: "There are practical concerns associated with a market-based solution in which medical students self-regulate according to job availability, but antitrust law would likely forbid collaborative self-regulation that purports to restrict supply."

2020: lol jk what antitrust implications? let's go to 150 per year

I've got a shockingly shocking shocker: residency numbers need to be zero for a few years. And how many times have I used Ben Smith data to refute Ben Smith? Now that Ben Smith is refuting Ben Smith maybe people should at least begin to question their so-called reality.

For many moons I've felt like one of those guys in movies like 'The Core' or 'Deep Impact' looking at future data... that asteroid coming or ELE coming... and saying to myself "That can't be right; no way man." But then keep looking at the data and thinking "We're screwed."

To put in perspective, let's say best case for years 2020-25 there's ~600K new XRT patients per year on average. Now say we held steady at 5000 rad oncs in the U.S... ie didn't generate a single new rad onc during that time (and no rad oncs retired or died). Now also imagine we transition to 5 fraction radiotherapy for the vast majority of patients...

600,000 new pts per 5,000 rad oncs = 120 new pts per rad onc per year = ~2 to 3 new patients per rad onc per week =
only 1 to 2 de novo new patients on the linac, per day, per rad onc

So, yeah, granted, this is worst case (doesn't account for retreats etc). "But cancer cases will increase..." Will they double? They've never doubled in 5 years but even if they double we're still screwed using the most optimistic of outlooks. We must think worst case. Look at this world we live in and how bad not thinking worst case has been. And don't factor COVID decreases in rad onc workforce projections right now. It'll make your eyes water.

 

[medgator]

 

[RadOncDoc21]

Took a pandemic for people to finally come around believing the crazy people on SDN.

 

[2014XRT]

 

[RadOncDoc21]

I would just ask him to quit his current job and apply for a new one. Can’t get more objective than that.

 

[2014XRT]

 

[deleted941485]

Can I love this multiple times

Someone needs to call him out on Twitter ASAP

Probably in his basement trying to pad his stats with more BS publications

What’s that saying

A wise man speaks because he has something to say

A foolish man speaks because he has to say something

 

[elementaryschooleconomics]

This is an EXCELLENT point - where is the data about the job market?

What the RaRaRadOnc crowd don't understand: there now exists a preponderance of objective data demonstrating a huge increase in resident numbers over the last 20 years. Even if you want to just ignore everything else - hypofrac, APM, whatever - from 2000-2020, RadOnc resident graduates per year have doubled.

No one, NO ONE, has presented any data that the demand side of the equation has increased. That JACR survey doesn't count as evidence.

I would happily log off SDN and block it from my browser forever if a single, well-designed study came out saying "look, here is the reason it's OK to have X amount of new RadOncs produced per year".

 

[2014XRT]

 

[deleted774703]

This is an EXCELLENT point - where is the data about the job market?

What the RaRaRadOnc crowd don't understand: there now exists a preponderance of objective data demonstrating a huge increase in resident numbers over the last 20 years. Even if you want to just ignore everything else - hypofrac, APM, whatever - from 2000-2020, RadOnc resident graduates per year have doubled.

No one, NO ONE, has presented any data that the demand side of the equation has increased. That JACR survey doesn't count as evidence.

I would happily log off SDN and block it from my browser forever if a single, well-designed study came out saying "look, here is the reason it's OK to have X amount of new RadOncs produced per year".

Could this Jeff brower character be any more ignorant about job market?

 

[2014XRT]

 

[dieABRdie]

As scarbtj mentioned above... he has previously collected his own publicly available data and presented them in a nice and eye pleasing format. These weren't hard numbers demonstrating that an alarming proportion of residents were actively unemployed.... but rather about demonstrating the trends in practice environment which will eventually lead to a large number of residents unemployed in the not too distant future. So I guess we can take a deep breath and relax now.

The unfortunate thing about this reasoning is that if we wait to have hard data showing too many residents are going to be unemployed.... IT. IS. TOO. F*CKING LATE!

 

[elementaryschooleconomics]

I think something people forget when we talk about the job market is the timescale we're working with.

Not to be overly pedantic but - only once a year are new graduates released into the wild, though we're able to see and measure a new cohort 5 years out.

SDN, Twitter...these things are available 24 hours a day, 365 days a year. There is a HUGE time lag in what actually happens vs our conversations about what happened/will happen. We're observing current trends and making predictions about the future. Just because the job market was OK last year does not mean it'll be OK next year - past trends do not predict future performance.

I usually think about the RadOnc job market as similar to climate science and the difference between climate and weather. Actually, the better analogy here is that we're talking about the job market as...Radiation Oncologists. If a patient comes to me with early stage, hormone receptor positive breast cancer s/p lumpectomy with clean margins and no nodes, am I offering her adjuvant XRT to "cure" her cancer? No, ostensibly, she has been "cured". I am reducing her risk of local recurrence. If I'm making noise about the job market now, I'm trying to make sure the field stays strong, and things don't go completely sideways for the whole field in the near future.

Attain local control...cut residency spots.

 

[RadOncDoc21]

My simple explanation is the fact that we have to talk about it means something. Why should we have to “prove” something we know is there. I feel like I’m taking a BS philosophy class again.

 

[RickyScott]

I think something people forget when we talk about the job market is the timescale we're working with.

Not to be overly pedantic but - only once a year are new graduates released into the wild, though we're able to see and measure a new cohort 5 years out.

SDN, Twitter...these things are available 24 hours a day, 365 days a year. There is a HUGE time lag in what actually happens vs our conversations about what happened/will happen. We're observing current trends and making predictions about the future. Just because the job market was OK last year does not mean it'll be OK next year - past trends do not predict future performance.

I usually think about the RadOnc job market as similar to climate science and the difference between climate and weather. Actually, the better analogy here is that we're talking about the job market as...Radiation Oncologists. If a patient comes to me with early stage, hormone receptor positive breast cancer s/p lumpectomy with clean margins and no nodes, am I offering her adjuvant XRT to "cure" her cancer? No, ostensibly, she has been "cured". I am reducing her risk of local recurrence. If I'm making noise about the job market now, I'm trying to make sure the field stays strong, and things don't go completely sideways for the whole field in the near future.

Attain local control...cut residency spots.

I am very pessimistic and share scarbtj’s view that even with 0 graduating residents, we are still in for a lot of hurt.

 

[DebtRising]

It’s very reasonable to want data on the job market. The problem is the nature of the data. If you wait until there is 25% unemployment, with a 5 year training cycle, then your field “owns” that problem for a decade. It happened in the 1990s. If you wait too long to take action, the consequences are pretty severe. Thus timing of making decisions needs to be done upstream before it is catastrophic - and while not perfect the timing of covid lockdowns is a great analogy; wait too long, and the damage is great.

But it is unreasonable for some of these people to ignore everything out there and say “prove it” , as if we have no idea what is going on. We published over supply back in 2015. 2015!! Yes, it’s a model. But the methodology behind said modeling was so well believed by the field that the previous model 5 years prior showing under supply was linked and featured on the ASTRO site and used to justify program expansion. Oh and how much did programs expand? 50% then? OK

since then, fractions are down, indications are down (and the two biggest disease sites, prostate cancer and breast, are great examples with significantly less treatment of low risk prostate cancer, and less and less breast), and reimbursement is down. CMS has changed supervision guidelines, which did justify some positions. A forced bundled payment is coming - that’s not to improve reimbursement. These are multiple, verifiable pieces of data there that show demand is going to keep going down and down . I welcome someone to show data that any of the above will lead to a demand increase. I shake my head when they are dismissed as irrelevant to the discussion.

Also, all the indicators from the field show the job market is rough. Fellowships are up pretty dramatically, a training “mechanism” even the ABR called out as being falsely labeled - because most fellowships provide new billable skills (pulm, cards, t Surg etc) and a rad onc “fellowship” does not. If the average medical school debt is 160k, please show me evidence that the increase in these offerings and fillings of 70k per year temp positions is not a sign of a poor job market. Every single survey done shows respondents are overwhelmingly concerned about the job market. prove to me that, even accepting surveys are flawed, such data points are so disposable in the assessment of the job market.

 

[ProtonElectronNeutron]

1) There was a lot of blaming SDN behind the scenes during this talk, rest assured.

2) ARRO and Shauna Campbell really seem to be swinging for the fences in terms of advocating for the health of the specialty. I'm so impressed with what they're willing to do, non-anonymously. I sit here and complain behind a silly internet forum moniker and this crew is out there trying to make changes for the better.

ARRO - you have my sincere gratitude.

I second that!!

 

[Chartreuse Wombat]

Thinking about this further... who wins in this scenario? How can we present ourselves as field with a stat of 'up to 15% of this graduating class is here because they couldn't do something else'?

Who wins?
People in that class lose, at both ends of the spectrum. There are undoubtedly residents in that class who have much better board scores and research than even the heady days, including smashing my own stats, and they will get branded. And so will the people who soaped in, and just happened to be in a year where this number was significantly above average. And neither side deserves it.

People who came before, who worked extremely hard to match and do research etc,, the immediate preceding generation - we sure don't win. We get put in the same boat, and people like Dr. Oliver make snide comments on twitter insinuating we weren't as dedicated. OK.

Medicare / Tax payers do not win. Not all slots are medicare funded - but how is 1 drop of taxpayer money justified in a field with more trainees than jobs? And trend lines in supply and demand (as visits, fractions, indications, reimbursement etc) continue to point in opposite directions? Projections are projections, but is there a single projection or piece of information suggesting the opposite (even pre-COVID)?

Patients don't win - society doesn't need more of us, in a national situation where health care resources are scarce and stretched, spending any additional resources training more rad oncs does not help them.

Does ACGME and ASTRO really win here? 15% SOAP rate? That's a reflection of the rigorous standards of certifying a residency program and reflecting how important the field is? Can't be.

Unless you are end career with 3-5 year window until retirement, it seems every single stakeholder loses, with the biggest losses to be felt by incoming classes and all of the younger physicians in practice. You know, the future of the field.

It's nuts. and we can't even get decent training standards enforced on case numbers, brachytherapy cases, proton exposure (which for prostate or not is a valuable part of our field's future), etc.

I don't even have a point anymore, I am so disappointed in myself in choosing this field, but also so disappointed to work so hard and invest in something and see my 'leadership' running out the clock on their careers without earnest efforts to help ours, now years into multiple pieces of data showing that's exactly what we need

Winners in Overtraining..

Membership organizations (ASTRO, ACRO, etc)...more members more dues

Employers (Hospitals, Academic Department Chairs and Partnered Private Practitioners)..simple supply and demand

 

[deleted573262]

good suggestion on getting to ~145 spots/yr by decreasing resident cohort by 1/yr every other year. we need better data on # practicing rad oncs. assuming an average career of 30 years, likely there are 140 - 150 rad oncs retiring each year. this means, 145 new residents a year will keep the current # practicing rad oncs steady. dr shah's suggestions 100/yr for 10yr sounds better. ultimately, none of this matters if nothing is done.

 

[2014XRT]

good suggestion on getting to ~145 spots/yr by decreasing resident cohort by 1/yr every other year. we need better data on # practicing rad oncs. assuming an average career of 30 years, likely there are 140 - 150 rad oncs retiring each year. this means, 145 new residents a year will keep the current # practicing rad oncs steady. dr shah's suggestions 100/yr for 10yr sounds better. ultimately, none of this matters if nothing is done.

I think everyone can agree that with surveys and data and analysis being done about every single other part of this, an important component will be prospective data on the most important end result - job procurement for graduates. We need this. It will not tell the whole picture and will be flawed, but some data better than none.

Also I agree that the best first step that is fair and easily achievable is every program dropping one. Kudos to MDACC and Harvard for already doing that this past cycle.

Perfection is the enemy of good.

 

[CaesarRO]

Solid thread from Simul leading to some prominent voices deconflating the issues of diversity and # of spots

 

[RickyScott]

Side note, twitter cheerleaders not unique to xrt
'Twitter Cheerleaders': A Megaphone for Bad Science

 

[DebtRising]

Winners in Overtraining..

Membership organizations (ASTRO, ACRO, etc)...more members more dues

Employers (Hospitals, Academic Department Chairs and Partnered Private Practitioners)..simple supply and demand

Your point is sound, but at this level does that still hold when there is such a high level of entrants who have no predilection toward this field, or may even oncology in general? At some level that matters. I do not discount the ability of any individual to make the most out of an opportunity, and cannot rule out that some people who SOAPed in would run circles around me in any endeavor. But are employers really getting a decent crop of labor when there is at least the potential for say 1 in 6 to have no interest in radiation or may even oncology, before entering? Training a successful physician, in any way success is defined, is always dependent on multiple factors. But certainly that mix is harder to get right if say 1 in 6 didn't even consider this field to begin with but then felt pressure post match day to do something.

Similar on ASTRO, ACRO - is it really a win when the data shows those SOAP numbers?

 

[2014XRT]

Counterpoint - there are a phenotype of people who pursued rad onc solely because it was ‘hot’ who are now on to whatever else is ‘hot’ whether that is IR or psych or whatever it may be.

I don’t think there was some innate ‘born to be an oncologist’ that we are now missing out on.

 

[deleted127837]

 

[2014XRT]

 

[medgator]

And we went from that to warm bodies with no interest in the specialty. Rad Onc PDs and depts have 0 shame

 

[2014XRT]

Some people who reply to tweets have no shame. I appreciated this series of posts from Siker