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The department chair answering to a meme account.
Clint Eastwood Nod GIF by GritTV
 
elementaryschooleconomics said:
"10 fraction SBRT"

"Alex, I'll take 'signs this study was not done in America' for $500, please."
Click to expand...

I like the 10 fractions. Might give me numerically better coverage than 5 fraction regimens in cases with a lot of epidural disease plus I can complain about the US healthcare system while I do it. Win win.
 
Ray D. Ayshun said:
Any thoughts on this? Just noticed it recently in the context of a relevant case.

SS 25: CNS 1 - 2023 ASTRO Annual Meeting - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

Radiotherapy for Metastatic Spinal Cord Compression with Increased Doses: Final Results of the RAMSES-01 Trial
www.astro.org www.astro.org
Click to expand...
I'd like to see the full data on this.
My main concern is that this may be a self-fulfilling prophecy.

The endpoint of the trial is local control and we all know that systemic treatment has also made significant advancements in the past decades. This trial tested dose escalation and compared the results of it to those of a historic series of patients.

Rades is cool, but many of the scores he has established are based on patients who were treated 20-30 years ago.
pubmed.ncbi.nlm.nih.gov

Evaluation of five radiation schedules and prognostic factors for metastatic spinal cord compression - PubMed

The five RT schedules provided similar functional outcome. The three more protracted schedules seemed to result in fewer in-field recurrences. To minimize treatment time, the following two schedules are recommended: 1 x 8 Gy for patients with poor predicted survival and 10 x 3 Gy for other...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

A patient with multiple myeloma and spinal cord compression presenting in 2005 had a totally different prognosis than one presenting today, and RT may not be crucial component here.
 
Ray D. Ayshun said:
Any thoughts on this? Just noticed it recently in the context of a relevant case.

SS 25: CNS 1 - 2023 ASTRO Annual Meeting - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

Radiotherapy for Metastatic Spinal Cord Compression with Increased Doses: Final Results of the RAMSES-01 Trial
www.astro.org www.astro.org
Click to expand...

A PhII in bone mets w/ 50 patients is cool and I appreciate Dr. Rades and his input to metastatic disease management, but as Palex noted, comparison to historical controls in terms of both LC and OS are not super relevant in the contemporary era. We have much better evidence for dose escalation (primarily with SBRT, but maybe even '10Fx SBRT' as per Guckenberger paper noted above)
 
The evicore dbag doesn’t care and will tell you there is conflicting data because of RTOG 0631. Not only tell you, but give you a lecture. Anyone else gotten that lecture?
 
MidwestRadOnc said:
The evicore dbag doesn’t care and will tell you there is conflicting data because of RTOG 0631. Not only tell you, but give you a lecture. Anyone else gotten that lecture?
Click to expand...

I can’t wait to run across an academic doing evicore on the side
 
medgator said:
Very odd behavior from RD though... Retweeting his own posts constantly while being a heavy ion/proton shill etc.
Click to expand...
Looking at Ron's behavior in a vacuum, independent of Jordan:

Jesus Christ I've never seen anyone violently run back and forth so quickly between positions and ideas that are clearly meant to help him make the most amount of money.

For those who don't know, and I'm not exaggerating slightly with this - Ron has found a way to be the main character of basically everything controversial in RadOnc for the last 20 years. He's made a significantly larger amount of money than any actual Radiation Oncologist in doing so.

Ron, Wallner, Dosoretz, Mantz.

The Four Horsemen of the Radioactive Apocalypse.
 
This is about medicine in general rather than rad onc specifically, but we all see it in our tiny little niche of the medical world too obviously. Corporate takeover of medicine is the root of 99.9% of what we complain about, to my eye. Longer thread of tweets that I didn't bring all of it over, you can go read further if interested.




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the youngest boomer is 60 (ends in 1964). there are def some chairs that are still boomers (oldest one is Ralph who is probably bordering on the greatest generation rather than boomer) but I think a lot of chairs these days are Gen X
 
Whew it's a good thing they put this on page 2 of the SCAROP/ASTRO salary survey:

"These data, contained in the report, may not be used to limit competition, restrain trade, or reduce or stabilize salary or benefit levels. Such improper use is prohibited by federal antitrust laws."

They were totally innocent all along. Sorry about that SCAROP and ASTRO overlords.

90f.gif


PS: For anyone reading this, if you didn't already know what I'm making fun of--it's that SCAROP and ASTRO have a salary survey among academic rad onc programs that is only released to chairs of rad onc programs. Despite it being an ASTRO supported survey, you are not allowed access to the data as an ASTRO member by paying for it or otherwise.

ASTRO's defense for not even discussing limiting residency expansion is that it would be "anti-trust". Yet, creating a confidential survey only given to department chairs with everyone's salaries is totally not anti-trust according to these same people.

200w.gif
 
Neuronix said:
Whew it's a good thing they put this on page 2 of the SCAROP/ASTRO salary survey:

"These data, contained in the report, may not be used to limit competition, restrain trade, or reduce or stabilize salary or benefit levels. Such improper use is prohibited by federal antitrust laws."

They were totally innocent all along. Sorry about that SCAROP and ASTRO overlords.

View attachment 385695

PS: For anyone reading this, if you didn't already know what I'm making fun of--it's that SCAROP and ASTRO have a salary survey among academic rad onc programs that is only released to chairs of rad onc programs. Despite it being an ASTRO supported survey, you are not allowed access to the data as an ASTRO member by paying for it or otherwise.

ASTRO's defense for not even discussing limiting residency expansion is that it would be "anti-trust". Yet, creating a confidential survey only given to department chairs with everyone's salaries is totally not anti-trust according to these same people.

View attachment 385696
Click to expand...

Look.

You didn't hear it from me.

But the SCAROP report is, in fact, the most obvious case of antitrust that I've seen in medicine.

www.justice.gov

Submit a Healthcare Competition Complaint

www.justice.gov www.justice.gov

The government loves to hear about these things.

(from multiple people)
 
CurbYourExpectations said:
View attachment 385705

When the great unemployment of RadOncs happens I hope it's understood: RadOncs promoted unfettered expansion of residency positions, RadOncs promoted virtual supervision, RadOncs ran bad noninferiority trials, RadOncs thought the business men would let them profit with them, RadOncs did this to ourselves.
Click to expand...
Obviously, I'm 90% with you on this statement...

But Mayo can literally reach into far-flung communities and pull patients into their machine for proton treatments, regardless of supervision laws, they told us themselves:


Mayo and the SCAROP Institutions:

We will use our residents to conduct telehealth consults because you saw our advertisements on the internet, and convince you to fly to Rochester (or elsewhere) because it's sooooooooooooo easy to do our 5 fraction proton treatments! We'll connect you with our travel agents, standing by, RIGHT NOW!

Meanwhile...LOOK OVER THERE! IT'S THE EVILS OF VIRTUAL SUPERVISION! GO GET THAT JORDAN GUY! THE DEVIL!
 
elementaryschooleconomics said:
Obviously, I'm 90% with you on this statement...

But Mayo can literally reach into far-flung communities and pull patients into their machine for proton treatments, regardless of supervision laws, they told us themselves:


Mayo and the SCAROP Institutions:

We will use our residents to conduct telehealth consults because you saw our advertisements on the internet, and convince you to fly to Rochester (or elsewhere) because it's sooooooooooooo easy to do our 5 fraction proton treatments! We'll connect you with our travel agents, standing by, RIGHT NOW!

Meanwhile...LOOK OVER THERE! IT'S THE EVILS OF VIRTUAL SUPERVISION! GO GET THAT JORDAN GUY! THE DEVIL!
Click to expand...
For those who don't want to read the whole paper:

1713580473951.png


IPP = in person patients, VP = virtual patients

(in the context of E&M virtual, not supervision virtual)
 
CurbYourExpectations said:
PS no one cares about that guy. There are real threats out there. Tigers in the tall grass, they aren't the ones being loud replying to every post on twitter 🤣.
Click to expand...
Well

You and I completely agree on that

Unfortunately, and for some absolutely bizarre and insane reason I cannot come close to understanding, many, MANY of the people "inside" ASTRO and ACRO do not agree with us

I can't tell what's happening, honestly. I suspect that SCAROP and peers know a little medicine startup isn't a threat (duh). They can rob the country blind regardless of any of this.

But the people not within the true circle of control/power/whatever you want to call it, starting literally at the next rung down, think Bridge is the harbinger of the apocalypse.

At this point I think it's just a giant, circular game of echo chamber telephone, and they're ramping themselves up more and more and more

I base this on the personal conversations I'm having with these people, and it feels like the tone/tenor of the anxiety over Bridge in particular has stepped up over the last few weeks.

Just...as always: there's a reason that only a half dozen people acting on behalf of ASTRO have weighed in on the topic of ROCR and Supervision.

The 100 SCAROP organizations don't care about any of this, or know that ROCR and Direct Supervision will force further consolidation and therefore, make them even more money.

You can submit antitrust complaints to the DOJ anonymously.
 
elementaryschooleconomics said:
For those who don't want to read the whole paper:

View attachment 385707

IPP = in person patients, VP = virtual patients

(in the context of E&M virtual, not supervision virtual)
Click to expand...

Ha what a clever paragraph. Like saying “we used this a lot to recruit prostates for protons, but we’re not saying that, understand?”
 
CurbYourExpectations said:
Poach patient studies are effectively being performed by RadOncs.
Click to expand...

Tangential, but it is hilarious to me that both ESTRO and ASTRO are doing the green treatment thing.

Yet, only ESTRO talks about how driving to treatment is a huge contributor to carbon monitor units. Im not sure what they are calling them or whatever.

Caveat I have not read these US groups green papers in a while, so please correct me if that has changed.
 
CurbYourExpectations said:
That publication should be an alarm for everyone here and for any RadOncs that read it. Blue prints are being shown of how to get patients to come get more expensive treatments without proven benefit. It should be worrisome to everyone that VIRTUAL PATIENTS ARE 2.5 AND 2.2 TIMES MORE LIKELY TO GET PROTON THERAPY BECAUSE THEY ARE VIRTUAL VISITS.

Animated GIF
Click to expand...
Correct

And to be clear

THIS IS NOT VIRTUAL SUPERVISION

NOT

VIRTUAL SUPERVISION

THIS IS NOT VIRTUAL SUPERVISION

This is exclusively a telehealth consult. The thing that is already permanent. The thing that ASTRO has never said a word about.

Direct Supervision, the classic edition - it's like a Certificate of Need law. Who has the money and power to get a certificate of need?

An existing incumbent.

Mayo would LOVE for Direct Supervision to come back. It would lock the little community RadOnc into their single little vault.

Want to do a lung cancer screening outreach event?

It better be outside normal business hours!

Want to go have lunch with a referring?

Oh man, hope your therapists and patients are willing to move around the schedule.

Meanwhile, Mayo is spending tens of millions of dollars on advertising to steal your patients right from under your nose.

And publish about it, no less!

This is the literal stayed goal of ROCR too. As in, Jeff Michalski literally said with ROCR and 5 fraction treatments, it's "easier for patients to travel away from their homes".

I would....again...just highlight the anonymous antitrust complaint link posted above...
 
elementaryschooleconomics said:
Correct

And to be clear

THIS IS NOT VIRTUAL SUPERVISION

NOT

VIRTUAL SUPERVISION

THIS IS NOT VIRTUAL SUPERVISION

This is exclusively a telehealth consult. The thing that is already permanent. The thing that ASTRO has never said a word about.

Direct Supervision, the classic edition - it's like a Certificate of Need law. Who has the money and power to get a certificate of need?

An existing incumbent.

Mayo would LOVE for Direct Supervision to come back. It would lock the little community RadOnc into their single little vault.

Want to do a lung cancer screening outreach event?

It better be outside normal business hours!

Want to go have lunch with a referring?

Oh man, hope your therapists and patients are willing to move around the schedule.

Meanwhile, Mayo is spending tens of millions of dollars on advertising to steal your patients right from under your nose.

And publish about it, no less!

This is the literal stayed goal of ROCR too. As in, Jeff Michalski literally said with ROCR and 5 fraction treatments, it's "easier for patients to travel away from their homes".

I would....again...just highlight the anonymous antitrust complaint link posted above...
Click to expand...
I am certain rad oncs as a group are not actually as smart as they think they are because I know a significant proportion have not, and never will, sussed any of the above

I can’t trust you to grasp fully an ITV concept if you can’t grasp the above reality eg
 
elementaryschooleconomics said:
Correct

And to be clear

THIS IS NOT VIRTUAL SUPERVISION

NOT

VIRTUAL SUPERVISION

THIS IS NOT VIRTUAL SUPERVISION

This is exclusively a telehealth consult. The thing that is already permanent. The thing that ASTRO has never said a word about.

Direct Supervision, the classic edition - it's like a Certificate of Need law. Who has the money and power to get a certificate of need?

An existing incumbent.

Mayo would LOVE for Direct Supervision to come back. It would lock the little community RadOnc into their single little vault.

Want to do a lung cancer screening outreach event?

It better be outside normal business hours!

Want to go have lunch with a referring?

Oh man, hope your therapists and patients are willing to move around the schedule.

Meanwhile, Mayo is spending tens of millions of dollars on advertising to steal your patients right from under your nose.

And publish about it, no less!

This is the literal stayed goal of ROCR too. As in, Jeff Michalski literally said with ROCR and 5 fraction treatments, it's "easier for patients to travel away from their homes".

I would....again...just highlight the anonymous antitrust complaint link posted above...
Click to expand...
i watched the town hall.
Dr. Michalski thinks that physicians should be in clinic nearly all the time (maybe have an exemption 1 day every 2 weeks).
In my experience more senior faculty at my residency training institution were in clinic like 2 days a week. The rest of the days were academic and post-COVID, many were at home.
I highly doubt that the ASTRO chair is in clinic 9 days out of 10. But maybe some from WashU can correct me.
 
radoncftw said:
i watched the town hall.
Dr. Michalski thinks that physicians should be in clinic nearly all the time (maybe have an exemption 1 day every 2 weeks).
In my experience more senior faculty at my residency training institution were in clinic like 2 days a week. The rest of the days were academic and post-COVID, many were at home.
I highly doubt that the ASTRO chair is in clinic 9 days out of 10. But maybe some from WashU can correct me.
Click to expand...
For those chairs to be off, somebody else has to be present to see patients.
 
radoncftw said:
i watched the town hall.
Dr. Michalski thinks that physicians should be in clinic nearly all the time (maybe have an exemption 1 day every 2 weeks).
In my experience more senior faculty at my residency training institution were in clinic like 2 days a week. The rest of the days were academic and post-COVID, many were at home.
I highly doubt that the ASTRO chair is in clinic 9 days out of 10. But maybe some from WashU can correct me.
Click to expand...
Of course

This is do as I say not as I do

It’s really not far off from a well fed person telling the hungry they should eat more food, an employed person telling an unemployed person they should have a job, or a person who can walk telling a paraplegic they need to get their legs moving
 
TheWallnerus said:
Of course

This is do as I say not as I do

It’s really not far off from a well fed person telling the hungry they should eat more food, an employed person telling an unemployed person they should have a job, or a person who can walk telling a paraplegic they need to get their legs moving
Click to expand...
So many other specialties have real leadership (think gu, rads, derm, plastics).

They don't overtrain, they don't create a long-standing civil war between the private and academic folks within their respective specialties, and some of them are smart enough to create professional/lobbying groups that absolutely blow organizations like ASTRO out of the water when the rubber hits the road (urorads 1, ASTRO PAC 0)

Instead we get folks like Dennis hallahan, L Potters, Jeff Michalski, Steinberg etc. that managed to bring Rad Onc from first to worst in a decade in terms of preference by US medical students

 
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elementaryschooleconomics said:
Correct

And to be clear

THIS IS NOT VIRTUAL SUPERVISION

NOT

VIRTUAL SUPERVISION

THIS IS NOT VIRTUAL SUPERVISION

This is exclusively a telehealth consult. The thing that is already permanent. The thing that ASTRO has never said a word about.

Direct Supervision, the classic edition - it's like a Certificate of Need law. Who has the money and power to get a certificate of need?

An existing incumbent.

Mayo would LOVE for Direct Supervision to come back. It would lock the little community RadOnc into their single little vault.

Want to do a lung cancer screening outreach event?

It better be outside normal business hours!

Want to go have lunch with a referring?

Oh man, hope your therapists and patients are willing to move around the schedule.

Meanwhile, Mayo is spending tens of millions of dollars on advertising to steal your patients right from under your nose.

And publish about it, no less!

This is the literal stayed goal of ROCR too. As in, Jeff Michalski literally said with ROCR and 5 fraction treatments, it's "easier for patients to travel away from their homes".

I would....again...just highlight the anonymous antitrust complaint link posted above...
Click to expand...
One of your all time great posts...and there are a lot. Make no mistake-the attack on virtual supervision is an attack on private practice. The salary scale is already tipped towards employed positions, but these arrogant pricks like Sameer and Jeff could never humble themselves to allow their docs to run clinics on their own terms. Yes, there are shady private practices, but there are still some good ones that offer their docs tremendous flexibility and autonomy...and the academics still can't compete with that. This is all about imposing burdensome regulations on private docs to squeeze them out of practice.
 
elementaryschooleconomics said:
Mayo would LOVE for Direct Supervision to come back. It would lock the little community RadOnc into their single little vault.
Click to expand...
I'm not sure here. There is no doubt that any supervision requirements at present mean nothing for places like MAYO. Their scale and staffing make the most stringent requirements moot.

But they could still take advantage of direct virtual (which could create an enhanced market for their existing remote services) …also, I doubt they are considering the little community radonc at all.

The deeply ingrained assumption of many academic radoncs is that they provide a differential value over the community, to the point where they advertise their proton treatment as "standard of care for patients under 40" directly to patient's far, far away from their facility. They believe that the diminution of community radonc is in fact ethical.

Meanwhile, this is hardly supported by data ...and it is of course just rationalizing how one should best serve an institution when what you do is both very profitable and, except in rare occasions, equivalently and more affordably provided by the community.

If radonc were a loss leader, nobody would believe in their differential value in most circumstances, protons would remain scarcely disseminated and we would be training roughly 60% of the docs that we are presently.

Reaganite said:
Sameer and Jeff could never humble themselves to allow their docs to run clinics on their own terms
Click to expand...
Is there a notable training program out there that takes pride in producing community docs? Serious question. Mine sure as hell didn't.

Reaganite said:
to squeeze them out of practice.
Click to expand...
Could work either way. Consolidation will come at the hospital level (although history shows that radonc departments may be among the first integrated in a merger). Owning or at least having a very lucrative PSA with a distant community hospital, which you staff remotely regarding multiple specialty services, is happening now and will benefit from virtual direct in terms of staffing radonc and institutional bottom line.
 
elementaryschooleconomics said:
Obviously, I'm 90% with you on this statement...

But Mayo can literally reach into far-flung communities and pull patients into their machine for proton treatments, regardless of supervision laws, they told us themselves:


Mayo and the SCAROP Institutions:

We will use our residents to conduct telehealth consults because you saw our advertisements on the internet, and convince you to fly to Rochester (or elsewhere) because it's sooooooooooooo easy to do our 5 fraction proton treatments! We'll connect you with our travel agents, standing by, RIGHT NOW!

Meanwhile...LOOK OVER THERE! IT'S THE EVILS OF VIRTUAL SUPERVISION! GO GET THAT JORDAN GUY! THE DEVIL!
Click to expand...

Mayo trainees are basically telemarketers
 
drowsy12 said:
View attachment 385755
Click to expand...
Interesting take. Of course IMGs have been the backbone of much of community medicine for 40 years. They are certainly the backbone of medical oncology in the community presently.

Per the rural health information hub, "J-1 visa waivers allow rural facilities in or near Health Professional Shortage Areas (HPSAs) or Medically Underserved Areas (MUAs) to recruit IMGs for vacancies which have been difficult to fill."

This could be DEI, or it could be anti-DEI.

J-1 is one of the best tools that underserved places have to get docs. Is academia underserved?
 
Academia is not underserved

But many locations are underserved (and really when I say underserved, what I really mean is 'hard to recruit US MDs to'.). Some of these locations have 'academic' name hospitals, some standard non-academic name hospitals, and rarer, free-standing. in rad onc and med onc. they go hand in hand.
 
drowsy12 said:
Academia is not underserved

But many locations are underserved (and really when I say underserved, what I really mean is 'hard to recruit US MDs to'.). Some of these locations have 'academic' name hospitals, some standard non-academic name hospitals, and rarer, free-standing. in rad onc and med onc. they go hand in hand.
Click to expand...
Yeah...I can only speak from my point of view.

I have no problem with facilitating the most academically ambitious IMGs getting real academic positions.

However, if really what is going on is a push to hire J1 candidates at satellite facilities, this is another example of the scale of consolidation likely hurting access (and value).

J1 candidates have one overwhelming concern....the effectual processing of their visa. This makes total sense, as the consequences of not getting the proper processing are profound. It will be difficult for smaller community places to offer the same assurances as a large center with a large legal team.

I have seen the change in availability of J1 candidates in real time.

Also, certainly hoping that these docs are not getting leveraged into bad contracts.
 
Agree there is no doubt that visa concerns drive people into certain kinds of jobs and locations. The one I am aware of recently is someone signing a job more than a year in advance to secure their protected status. It wasn’t an academic name hospital, but we should not think that academic names have a monopoly on large systems. There are many non academic corporations that benefit from the same advantages.

My posting of that wasn’t necessarily an endorsement of course, just found it interesting how this is being framed by ASCO
 
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