Rad Onc Twitter

[medgator]

look up adz in the dictionary and you'll see a pic of Ralph

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[hbosch]

MY GOODNESS! THERE IS NO END TO THE STUPIDITY OF OUR FIELD. Just when I feel that we have plummeted to the bottom, this comes up. Which specialty walks around saying, "Hey guys we get paid too much!" Are you kidding? And I want that idiot to donate 70% of his savings RIGHT NOW before he walks around speaking dumb ****. Take the clothes off your children's backs (if you have them), downsize to a smaller house, get rid of your assets, and then you DARE say to the younger generation that we get paid too much. Can you IMAGINE a plastic surgeon or dermatologist being "FACT IS, universe, we get paid too much- all of you people not in our specialty, make sure to flay our specialty for making too much money- oh as long as it's not me." Go ahead dummy, go ahead and donate 70% of your current assets Including whatever you have stashed in retirement and then you walk around saying dumb **** like that. Because if you're not bleeding donations right now, you need to shut up. And yes, I am talking into the internet void. I regret that I share the same occupation as THAT man. I regret it so much. I deserve better.

 

[hbosch]

Also, go ahead and retire Ralph. Don't you have too much money? Or better yet, now that you have stuffed yourself with money, just work for free. It's your passion right? So do it as a hobby and do it for free. Ralph, Ralph, Ralph. I just don't have the words Ralph.

 

[domestique]

He's trash pure and simple. I interviewed there a long time ago and even then he was half out of his mind. ****ing guy sucks. Would be surprised if anyone from UC pops their head up here to defend him.

 

[hbosch]

He's trash pure and simple. I interviewed there a long time ago and even then he was half out of his mind. ****ing guy sucks. Would be surprised if anyone from UC pops their head up here to defend him.

How do these people keep their jobs? I’ve noticed a trend in both academic and private practice of pure idiots keeping there jobs meanwhile competent people are pushed out or mistreated? What is happening? Is it really just politics? WTF? I hope UChicago cuts his salary and only his.

 

[deleted774703]

How the f does anyone like Ralph’s we are overpaid tweets

sycophants or idiots???

thanks to all the ppl speaking against him online

 

[elementaryschooleconomics]

look up adz in the dictionary and you'll see a pic of Ralph

I found him once Googling ICD-10 codes, "G31.1".

 

[scarbrtj]

I found him once Googling ICD-10 codes, "G31.1".

Wish he were senile. More like puerile. The vascular surgeons should write a professionalism journal article about RW. He gets on twitter and calls colleagues absurd and embarrassing. Calls fellow MDs overpaid. Is a rad onc, but writes editorials about how 1 Gy of radiation to chest causes an extra 4 people in 100 to get lung cancers, and an extra 7 people in 100 to die from heart disease.

 

[DebtRising]

There is nothing more noble than a gentleman (or woman) who has made millions of dollars and practiced in an era of unmatched physician autonomy and research funding then directing scowl and criticisms at those of us who have hundreds of thousands of debt, the autonomy of what the evicore sheet tells us, and shrinking research time and dollars. But it is much easier to insult us as junior colleagues instead of fighting the system for change.

I admit though, the new “we will match compassionate people now” AD and Dr O push comes close as those same departments exploit the over supply by offering more fellowships and worse positions. I guess their compassion has limits.

 

[hbosch]

Wish he were senile. More like puerile. The vascular surgeons should write a professionalism journal article about RW. He gets on twitter and calls colleagues absurd and embarrassing. Calls fellow MDs overpaid. Is a rad onc, but writes editorials about how 1 Gy of radiation to chest causes extra 4 people in 100 to get lung cancers, and an extra 7 people in 100 to die from heart disease.

This makes me lose respect for UChicago- why are they not firing him or at least pushing him into retirement? What kind of iron clad contract could he possibly have?

 

[elementaryschooleconomics]

This makes me lose respect for UChicago- why are they not firing him or at least pushing him into retirement? What kind of iron clad contract could he possibly have?

Though I recognize my cynicism in saying this - I'll be honest with you, I assume many (if not most) of the Chairs/folks in RadOnc leadership positions feel similar to Ralph and agree with his statements.

Ralph is brash and throws his opinions out, unfiltered and unpolished, on Twitter - but is he really an outlier? Perhaps he should be more refined like the Chair of WashU, and hide it in a letter to the editor?

 

[RickyScott]

Though I recognize my cynicism in saying this - I'll be honest with you, I assume many (if not most) of the Chairs/folks in RadOnc leadership positions feel similar to Ralph and agree with his statements.

Ralph is brash and throws his opinions out, unfiltered and unpolished, on Twitter - but is he really an outlier? Perhaps he should be more refined like the Chair of WashU, and hide it in a letter to the editor?

View attachment 313982

Exactly. Important that he keeps expressing his opinions honestly.

 

[deleted941485]

Though I recognize my cynicism in saying this - I'll be honest with you, I assume many (if not most) of the Chairs/folks in RadOnc leadership positions feel similar to Ralph and agree with his statements.

Ralph is brash and throws his opinions out, unfiltered and unpolished, on Twitter - but is he really an outlier? Perhaps he should be more refined like the Chair of WashU, and hide it in a letter to the editor?

View attachment 313982

I hate Ralph but at the same time no one should be letting the dinguses at WashU and other academic authorizes off the hook for their self serving ends.

Honestly we should be exposing and expressing even more outrage for those who try to slip these purely self serving opinions into journals and forums

 

[deleted774703]

I hate Ralph but at the same time no one should be letting the dinguses at WashU and other academic authorizes off the hook for their self serving ends.

Honestly we should be exposing and expressing even more outrage for those who try to slip these purely self serving opinions into journals and forums

it’s so tough. Residents can do only so much bc they need jobs

Academic attendings need to kiss ass or agree with BS radoncrocks

PP most happy counting their checks lol jk but they have less to gain speaking up

We need more ppl like Simul to be honest. Ideally on every level particularly chair

Or at least a ton of MROGA and lemmiwinks on Twitter

 

[elementaryschooleconomics]

Can't do that if we can't get a job.

This guy runs Chicago RadOnc and can't figure out how to block Tweets? Cool.

 

[hbosch]

View attachment 313987

Can't do that if we can't get a job.

View attachment 313988

This guy runs Chicago RadOnc and can't figure out how to block Tweets? Cool.

The man is nonsensical. If you are so morally superior than just volunteer abroad permanently in underserved countries or even underserved US and request to not get paid. Why should a physician not make a good income? We already sacrificed our youth, 200K+ Debt, and now we should just walk around saying we get paid too much? I’m a sweet angel who doesn’t need to pay bills? It’s ok for my loans to go in default, I don’t actually need a house, I don’t actually have to worry about retirement, I don’t need a car, I don’t need disability insurance, I don’t need to maintain my house, my family also is happy that I work a lot and I don’t bring much money home as long as I’m treating cancer patients? Well this is what happens when the specialty becomes a joke- which is where we are. I’m sure Fannie Mae will understand that we treat cancer and therefore don’t have to pay them back. She’s so understanding, that Fannie.

 

[theradiator]

There is nothing more noble than a gentleman (or woman) who has made millions of dollars and practiced in an era of unmatched physician autonomy and research funding then directing scowl and criticisms at those of us who have hundreds of thousands of debt, the autonomy of what the evicore sheet tells us, and shrinking research time and dollars. But it is much easier to insult us as junior colleagues instead of fighting the system for change.

I admit though, the new “we will match compassionate people now” AD and Dr O push comes close as those same departments exploit the over supply by offering more fellowships and worse positions. I guess their compassion has limits.

Not to mention the pharmaceutical companies, device manufacturers, insurance companies, hospital executes, etc. that are seemingly never subject to the circular firing squad.

 

[Haybrant]

Not to mention the pharmaceutical companies, device manufacturers, insurance companies, hospital executes, etc. that are seemingly never subject to the circular firing squad.

People really need to get at him on twitter so he knows not to keep spreading such absurd opinions. He should give up his high pay but we know hypocrites like him don’t listen to reason, all the problems are somebody else’s fault

 

[elementaryschooleconomics]

Ralph on Twitter:

 

[deleted941485]

People really need to get at him on twitter so he knows not to keep spreading such absurd opinions. He should give up his high pay but we know hypocrites like him don’t listen to reason, all the problems are somebody else’s fault

View attachment 313987

Can't do that if we can't get a job.

View attachment 313988

This guy runs Chicago RadOnc and can't figure out how to block Tweets? Cool.

His career should have been done yesterday. Apparently telling people your job ain’t worth **** isn’t enough. The only way he gets booted is if he somehow makes a racist statement on Twitter.

 

[deleted941485]

Ralph on Twitter:

View attachment 313995

Try every academic RO In the last 10 years

 

[thecarbonionangle]

The boomers are some of the absolutely worst people in rad onc. We have a grave existential crisis of culture and leadership. The field consistently elevates bad people while pushing aside good people. I have seen this phenomenon again and again in this field. I agree, someone asked what is happening to our field?
Look at many “leaders” and they are just corrupt thieves. Really disgusting stuff.
We have a guy who is involved with one of the most fradulent companies in oncology heading our boards and all kiss his ring. The field is rotten to the core, the sewer is draining right into the swamp.

 

[RadSki]

These people just totally miss the point. It's possible for a single person to believe all of the following:

1) RadOnc is the greatest specialty of all time
2) The day-to-day work is amazing, the patients are amazing
3) Decreasing fractions, increasing surveillance, and any/all cost/toxicity reduction is amazing for patients and should be intensely researched and implemented
4) Medical students should not touch this field for 10-20 years because of a 127% increase in residents in light of point #3

Woke Twitterati love to invoke this "if you tell students to avoid RadOnc because of hypofrac you hate patients" strawman, WHICH IS RIDICULOUS.

Walking and chewing gum...look it up, guys.

Wow, I feel like I've really made it into the upper echelon of academic radiation oncology now that I've been called out on SDN! I am compelled to address some of the comments made on here triggered by a couple of my recent tweets. I respect the sentiments raised both on Twitter and in this forum, but disagree with hyperbolic "sky is falling" posts that make blanket statements advising all students to stay away from radiation oncology. Many of these posts imply that we should have 0 residents per year. I really don't know what the right number is - maybe it's 100? maybe it's 200? This is beyond my expertise and I cannot effect change in the national residency numbers in my current position. Unfortunately, a 280 character tweet (or even of a few of them - ThreadReader unroll!) doesn't allow nuanced debate and discussion. I'll address a couple of the comments made on here with regards to my tweets and my current job. This is as much for the students/residents that follow these threads and don't comment as it is for the active users that kindly called me out.

First, I do realize that you can believe rad onc is (?was the way many of you talk) the greatest specialty of all time, the day-to-day work is amazing, and the changes we're seeing with hypofrac, surveillance, etc are beneficial to patients while believing "medical students should not touch this field for 10-20 years." I just have a different viewpoint on #4 - medical students should be well informed about the evolution of our specialty and decide if, for the individual student, points #1-2 outweigh the potential risk to income/job availability implicit in point #3. When I talk to students from my institution or rotating through my department about how to approach specialty selection, I make two recommendations:

1. Talk to lots of people - I'm just one opinion. The student needs get multiple opinions to triangulate what the right specialty for them is based on their personal and professional priorities.
2. Do a thought experiment - assume that in 20 years you are making the same salary as all of your medical school classmates. Would you still select X specialty? If the answer is "Yes," then it's the right specialty for you. If the answer is "No, I'd really rather be doing Y or Q or P, but they make less money," the student should carefully consider why they are leaning towards specialty X.

With regards to radiation oncology, I tell students the pros/cons of the specialty. Pros are well laid out in other posts here and on Twitter. Cons IMO are:

1. Small specialty = tight job market for specific disease sites or specific geographic locations. Be prepared to compromise for a job in a particular geographic location or with a particular disease focus. Yes, some residents hit the jackpot, but many choose to compromise on something when selecting their first job. If a students ultimate goal is to live in X or Y geographic location, rad onc may not be the best specialty (but that goes for many small specialties). Students with this priority might want to consider larger specialties with more jobs turning over in a region.
2. Radiation oncologists are often far downstream from the initial diagnosis and work-up of patients. However, this doesn't mean we are just "technicians." A good radiation oncologist is constantly running differential diagnoses in their heads when seeing weekly on-treatment visits (thoracic RT with chest pain - esophagitis, PE, or MI?; Pelvic RT with dysuria - radiation cystitis or UTI?) We are doctors first, radiation oncologists second.
3. There are existential threats to radiation oncology as a specialty - "Curing cancer," "Severe hypofrac," "Urorads," etc. In the 1970s when the "war on cancer" was declared optimists thought cancer would be simple to conquer. Hey - we'd just landed on the moon, how hard could "one disease" like cancer be? Hasn't turned out that way. We continue to make amazing, but incremental, advances with systemic therapy, new surgical techniques, and - yes - new radiation techniques (SBRT!). Nobody can predict the future. If a student is passionate about treating patients with cancer and loves the clinical milieu and science of radiation oncology, go for it (as long as they understand points 1&2)! If/when we "cure cancer" there will be major upheavals in other specialties as well. PCPs prescribe many of the antibiotics used to treat infection. How do we know med oncs will be left unscathed by a major scientific advance that actually "cures cancer?" Maybe PCPs will get a liquid biopsy and write a prescription for "the cure for cancer" to be picked up at Walgreens or CVS that evening.

The second point to address is the criticism of my current job. Yes, I practice at a "satellite" University of Chicago clinic (although I argue we are at least a moon since my clinic treats ~50% of the volume as the main campus). Also, I refer to my practice as part of the UChicago network. We have 3 clinics in the southwest suburbs and do prospective planning rounds twice weekly across all sites. I did not "drink the kool aid." I made a conscious decision to take this job understanding full well that many external observers would turn their nose up at it. So let me explain my rationale and tell you how it's turned out after 7 years. As a senior resident I had three priorities in the following order for whatever job I took:

1. My spouse would be able to continue in their non-medical job which is not very mobile. Easy locations for them were NYC, Philly, or staying in Chicago. Neither of us were particularly interested in NYC or Philly (no family), and I didn't get any serious interviews there, so moot point.
2. I wanted to be in a position to teach and work with residents and students and pursue my academic interest in medical education - i.e., a faculty appointment at a medial school
3. I wanted to work in a clinic where I would enjoy the patient care and co-workers

I realized during my PGY4 year my academic interest was not writing clinical protocols or working in a lab - it was, and has remained, medical education. I interviewed for "main site" jobs at a couple other large institutions and what I realized was even though the department leadership said, "Education is important," what they really wanted if I took a main campus job was someone to build and/or maintain a clinical program in X disease site. My medical education academic interest would have to compete with my chair's expectations to open investigator-initiated protocols and make a national/international name for myself in X disease site. I was lucky enough that the position I currently hold become available during my job search. I was offered a full faculty appointment and one protected academic day per week at the main campus. My clinic is an easy 40 minute reverse commute from where I live by the main campus to a suburb. I would not have considered the position if it was a "clinical associate" position (i.e. non-faculty) or there was no protected time (one "satellite" job at another institution during an ASTRO interview said, "You don't get any protected time initially, but if you're academically productive, after 3 years we'll discuss it." I e-mailed them almost immediately following the interview to withdraw my application.).

When considering my current position, I realized opportunities for traditional rad onc academic pursuits (e.g., writing protocols for disease sites) would be limited, but on the flip side, I would have the freedom to pursue my interest in medical education, work with medical students, and residents, and treat all disease sites. My service currently has patients on-treatment with breast, lung, prostate, esophageal, pancreas, rectal, anal, CNS, head/neck, skin, and gyn malignancies. I work with an outstanding clinical partner, nurses, MA, therapists, dosimetrists, physicists, social worker, and other clinic staff. We have a great UChicago med onc group at my clinic. I refer patients to other specialties at the UChicago mothership or to the outstanding private practice physicians and surgeons at the hospital my clinic adjoins. I can "phone a friend" at another UChicago network site or the main campus to discuss challenging/unusual cases. I love my clinical environment - I get to treat all disease sites (anatomy was my favorite pre-clinical course - I use all of it all the time) and I am faculty at UChicago where I am the rad onc clerkship director, APD, and am active in the medical school developing new oncology curricula (I'm co-investigator on a NIH grant for a cancer research education program for students between M1/M2 year), serve on the med school Curriculum Steering Committee, and am taking over as the AOA Councilor. Academically I developed a collaboration with the IIT Institute of Design developing patient education materials that use graphic narrative and received a ROI grant for this work. I help run the Radiation Oncology Education Collaborative Study Group (ROECSG) that has developed foundational curricula for medical students, IROC which is an onboarding course for PGY2s, hosts the annual ROECSG symposium, and is actively working to develop a national consensus curriculum. I have had the opportunity to mentor numerous medical students and residents - some of them work with me, others I help connect to other faculty for research opportunities I can't offer. Sure, I don't "have a resident" to write my notes, but that isn't what defines an academic radiation oncologist - at least for me. I'm proud of what I've accomplished thus far both caring for my patients and academically. Most importantly - my spouse is still at their same job and is happy. We love the neighborhood we live in and plan to stay here for a long time. Taking this job was one of the best professional and personal decisions I've made.

So for those of you that view my job as the worst of both worlds - "Private practice work at an academic salary," I would turn it around and say I have the best of both worlds - "I get to treat all disease sites like I'm in private practice (so fun!), and I am UChicago faculty and can pursue my academic passion in medical education." My salary is more than adequate, so no complaints there.

I expect the usual jeering and berating by a few vocal members of this forum, but that's OK. I'd be more than happy to discuss any of my comments above with anyone on this forum via e-mail. You can look me up in the ASTRO member directory or find my e-mail on PubMed under any of the papers on which I'm corresponding author. I'll also gladly reply to any serious and meaningful comments here. I will not engage with insulting or incendiary comments. For those of you that truly feel the sky is falling, please e-mail me and lets discuss ideas for constructive ways to effect change. Unfortunately, the insulting and incendiary comments on Twitter and this forum by anonymous accounts weakens, not strengthens, your arguments with the powers that be. If you're truly serious about effecting change, volunteer for an ASTRO or ACRO committee, attend the ROECSG symposium, or write an editorial/opinion piece for one of our journals that lays out your argument with evidence to back it up, thus starting a civil discussion and debate.

Off to bed. I have a busy clinic tomorrow with a HNSCC consult and I need to review sarcoma because am seeing a case in consult later this week. Also have a conference call with my colleagues at IIT Institute of Design to finalize our CEBRE discussion guides for Breast, Lung, and Prostate caner. I love my job!

Sincerely,

Dan Golden, MD, MHPE
Assistant Professor
Department of Radiation and Cellular Oncology
The University of Chicago

or

Dan Golden, MD, MHPE
Radiation Oncologist
University of Chicago Comprehensive Cancer Center at Silver Cross Hospital

Take your pick - I'm proud of them both!

 

[Neuronix]

I'm a moderator here and I have no idea who is on Twitter posting. Are they even SDN posters? What posts are you referring to on SDN that are attacking you directly?

You graduated seven years ago into a job you like. I'm happy for you. What would have happened if you couldn't get a job in or anywhere near one of the three cities you listed? What would have happened if the only offers you got outside those cities were those five days a week clinical satellite jobs without academic opportunities (or "we'll talk about it") that you didn't want? Maybe you'd be singing a different tune now. Who knows.

But this is what I'm seeing for a lot of new grads. Some of them are really struggling, underemployed, or unemployed. To shrug off oversupply as you don't know how many residents there should be and that's not within your expertise anyway, but continuing to post about how great rad onc is anyway misses the point. This is what the SDNers are referring to as "gaslighting".

Things have gotten a lot worse in the seven years since you graduated, and it continues to worsen every year with the continued oversupply. If you're a med student planning on starting a career five years from now, rad onc is a really dicey proposition.

It doesn't help that Ralph is out there saying we're all paid too much. Would you personally like a pay cut? You can deny and ignore him as much as you like, but it makes it awkward having someone very senior at your own institution basically telling you and all of us that we're overpaid. That written, he does reflect a certain group of entrenched rad oncs who are salivating to get cheap labor and pay us less while making several times more than new grads.

I personally don't believe that the "powers that be" will ever listen to us, no matter what is written on SDN. They will gaslight, ignore, and continue to expand. The "canaries" listen though. Significantly decreased medical student interest due to a bad job market is finally bringing this issue to the discussion with the "powers that be." It's about time.

 

[scarbrtj]

this is what I'm seeing for a lot of new grads. Some of them are really struggling, underemployed, or unemployed. To shrug off oversupply as you don't know how many residents there should be and that's not within your expertise anyway, but continuing to post about how great rad onc is anyway misses the point.

Many of these posts imply that we should have 0 residents per year. I really don't know what the right number is - maybe it's 100? maybe it's 200?

Dan,

Do you tell medical students/the twitterverse that you "don't know what the right number is - maybe it's 100? maybe it's 200?" In other words, go about openly proclaiming that perhaps rad onc is training twice or more residents per year than it should be? If people would start widely admitting this, it might go a long way. "Admitting what?" Admitting that 1) radiation oncologists are disinterested and/or obtuse re: supply of rad oncs in America, or they're 2) willing to start discussions about the ramifications of cutting training slots to the 0-100 range.

The remainder of your post is good, but it's this passingly-mentioned tidbit that is its sockdolager and makes everything afterward seem like an apologia: "Do I want to go into a field of 200+ residents per year when these guys posit the number ought really be 100 or less?" is what a rad onc hopeful thinks after reading it. "Maybe it's 100? maybe it's 200?" Maybe your sarcoma patient this week needs 5 fractions. Maybe they need 35. But there's an intelligent way, based on tangible facts and figures and outcomes (and yes, even feeble attempts at future-prediction), to discuss this and not just leave it at "maybe." That we can't have a discussion—heaven forfend having a plan—about the rad onc workforce needs if our number one XRT indication sees treatment times cut from 6 weeks to 1 week marks us as having a brittle spirit.

How do we know med oncs will be left unscathed by a major scientific advance that actually "cures cancer?" Maybe PCPs will get a liquid biopsy and write a prescription for "the cure for cancer" to be picked up at Walgreens or CVS that evening.

If there were that pill, we'd need a hell of a lot less medical, and radiation, oncologists, yes? Taking XRT schedules from many, many weeks down to 1 week or less gets us closer to that hypothetical pill scenario than evidently we'd care to admit.

Ralph W is arguing for growing the rad onc supply; he broaches no possibility that trainee number could be 100 (or less). His argument seems to be that more rad oncs equals more chance for disruptive change. We need no longer discuss the disruptive. It's time to begin discussing the irruptive.

 

[elementaryschooleconomics]

Wow, I feel like I've really made it into the upper echelon of academic radiation oncology now that I've been called out on SDN! I am compelled to address some of the comments made on here triggered by a couple of my recent tweets. I respect the sentiments raised both on Twitter and in this forum, but disagree with hyperbolic "sky is falling" posts that make blanket statements advising all students to stay away from radiation oncology. Many of these posts imply that we should have 0 residents per year. I really don't know what the right number is - maybe it's 100? maybe it's 200? This is beyond my expertise and I cannot effect change in the national residency numbers in my current position. Unfortunately, a 280 character tweet (or even of a few of them - ThreadReader unroll!) doesn't allow nuanced debate and discussion. I'll address a couple of the comments made on here with regards to my tweets and my current job. This is as much for the students/residents that follow these threads and don't comment as it is for the active users that kindly called me out.

First, I do realize that you can believe rad onc is (?was the way many of you talk) the greatest specialty of all time, the day-to-day work is amazing, and the changes we're seeing with hypofrac, surveillance, etc are beneficial to patients while believing "medical students should not touch this field for 10-20 years." I just have a different viewpoint on #4 - medical students should be well informed about the evolution of our specialty and decide if, for the individual student, points #1-2 outweigh the potential risk to income/job availability implicit in point #3. When I talk to students from my institution or rotating through my department about how to approach specialty selection, I make two recommendations:

1. Talk to lots of people - I'm just one opinion. The student needs get multiple opinions to triangulate what the right specialty for them is based on their personal and professional priorities.
2. Do a thought experiment - assume that in 20 years you are making the same salary as all of your medical school classmates. Would you still select X specialty? If the answer is "Yes," then it's the right specialty for you. If the answer is "No, I'd really rather be doing Y or Q or P, but they make less money," the student should carefully consider why they are leaning towards specialty X.

With regards to radiation oncology, I tell students the pros/cons of the specialty. Pros are well laid out in other posts here and on Twitter. Cons IMO are:

1. Small specialty = tight job market for specific disease sites or specific geographic locations. Be prepared to compromise for a job in a particular geographic location or with a particular disease focus. Yes, some residents hit the jackpot, but many choose to compromise on something when selecting their first job. If a students ultimate goal is to live in X or Y geographic location, rad onc may not be the best specialty (but that goes for many small specialties). Students with this priority might want to consider larger specialties with more jobs turning over in a region.
2. Radiation oncologists are often far downstream from the initial diagnosis and work-up of patients. However, this doesn't mean we are just "technicians." A good radiation oncologist is constantly running differential diagnoses in their heads when seeing weekly on-treatment visits (thoracic RT with chest pain - esophagitis, PE, or MI?; Pelvic RT with dysuria - radiation cystitis or UTI?) We are doctors first, radiation oncologists second.
3. There are existential threats to radiation oncology as a specialty - "Curing cancer," "Severe hypofrac," "Urorads," etc. In the 1970s when the "war on cancer" was declared optimists thought cancer would be simple to conquer. Hey - we'd just landed on the moon, how hard could "one disease" like cancer be? Hasn't turned out that way. We continue to make amazing, but incremental, advances with systemic therapy, new surgical techniques, and - yes - new radiation techniques (SBRT!). Nobody can predict the future. If a student is passionate about treating patients with cancer and loves the clinical milieu and science of radiation oncology, go for it (as long as they understand points 1&2)! If/when we "cure cancer" there will be major upheavals in other specialties as well. PCPs prescribe many of the antibiotics used to treat infection. How do we know med oncs will be left unscathed by a major scientific advance that actually "cures cancer?" Maybe PCPs will get a liquid biopsy and write a prescription for "the cure for cancer" to be picked up at Walgreens or CVS that evening.

The second point to address is the criticism of my current job. Yes, I practice at a "satellite" University of Chicago clinic (although I argue we are at least a moon since my clinic treats ~50% of the volume as the main campus). Also, I refer to my practice as part of the UChicago network. We have 3 clinics in the southwest suburbs and do prospective planning rounds twice weekly across all sites. I did not "drink the kool aid." I made a conscious decision to take this job understanding full well that many external observers would turn their nose up at it. So let me explain my rationale and tell you how it's turned out after 7 years. As a senior resident I had three priorities in the following order for whatever job I took:

1. My spouse would be able to continue in their non-medical job which is not very mobile. Easy locations for them were NYC, Philly, or staying in Chicago. Neither of us were particularly interested in NYC or Philly (no family), and I didn't get any serious interviews there, so moot point.
2. I wanted to be in a position to teach and work with residents and students and pursue my academic interest in medical education - i.e., a faculty appointment at a medial school
3. I wanted to work in a clinic where I would enjoy the patient care and co-workers

I realized during my PGY4 year my academic interest was not writing clinical protocols or working in a lab - it was, and has remained, medical education. I interviewed for "main site" jobs at a couple other large institutions and what I realized was even though the department leadership said, "Education is important," what they really wanted if I took a main campus job was someone to build and/or maintain a clinical program in X disease site. My medical education academic interest would have to compete with my chair's expectations to open investigator-initiated protocols and make a national/international name for myself in X disease site. I was lucky enough that the position I currently hold become available during my job search. I was offered a full faculty appointment and one protected academic day per week at the main campus. My clinic is an easy 40 minute reverse commute from where I live by the main campus to a suburb. I would not have considered the position if it was a "clinical associate" position (i.e. non-faculty) or there was no protected time (one "satellite" job at another institution during an ASTRO interview said, "You don't get any protected time initially, but if you're academically productive, after 3 years we'll discuss it." I e-mailed them almost immediately following the interview to withdraw my application.).

When considering my current position, I realized opportunities for traditional rad onc academic pursuits (e.g., writing protocols for disease sites) would be limited, but on the flip side, I would have the freedom to pursue my interest in medical education, work with medical students, and residents, and treat all disease sites. My service currently has patients on-treatment with breast, lung, prostate, esophageal, pancreas, rectal, anal, CNS, head/neck, skin, and gyn malignancies. I work with an outstanding clinical partner, nurses, MA, therapists, dosimetrists, physicists, social worker, and other clinic staff. We have a great UChicago med onc group at my clinic. I refer patients to other specialties at the UChicago mothership or to the outstanding private practice physicians and surgeons at the hospital my clinic adjoins. I can "phone a friend" at another UChicago network site or the main campus to discuss challenging/unusual cases. I love my clinical environment - I get to treat all disease sites (anatomy was my favorite pre-clinical course - I use all of it all the time) and I am faculty at UChicago where I am the rad onc clerkship director, APD, and am active in the medical school developing new oncology curricula (I'm co-investigator on a NIH grant for a cancer research education program for students between M1/M2 year), serve on the med school Curriculum Steering Committee, and am taking over as the AOA Councilor. Academically I developed a collaboration with the IIT Institute of Design developing patient education materials that use graphic narrative and received a ROI grant for this work. I help run the Radiation Oncology Education Collaborative Study Group (ROECSG) that has developed foundational curricula for medical students, IROC which is an onboarding course for PGY2s, hosts the annual ROECSG symposium, and is actively working to develop a national consensus curriculum. I have had the opportunity to mentor numerous medical students and residents - some of them work with me, others I help connect to other faculty for research opportunities I can't offer. Sure, I don't "have a resident" to write my notes, but that isn't what defines an academic radiation oncologist - at least for me. I'm proud of what I've accomplished thus far both caring for my patients and academically. Most importantly - my spouse is still at their same job and is happy. We love the neighborhood we live in and plan to stay here for a long time. Taking this job was one of the best professional and personal decisions I've made.

So for those of you that view my job as the worst of both worlds - "Private practice work at an academic salary," I would turn it around and say I have the best of both worlds - "I get to treat all disease sites like I'm in private practice (so fun!), and I am UChicago faculty and can pursue my academic passion in medical education." My salary is more than adequate, so no complaints there.

I expect the usual jeering and berating by a few vocal members of this forum, but that's OK. I'd be more than happy to discuss any of my comments above with anyone on this forum via e-mail. You can look me up in the ASTRO member directory or find my e-mail on PubMed under any of the papers on which I'm corresponding author. I'll also gladly reply to any serious and meaningful comments here. I will not engage with insulting or incendiary comments. For those of you that truly feel the sky is falling, please e-mail me and lets discuss ideas for constructive ways to effect change. Unfortunately, the insulting and incendiary comments on Twitter and this forum by anonymous accounts weakens, not strengthens, your arguments with the powers that be. If you're truly serious about effecting change, volunteer for an ASTRO or ACRO committee, attend the ROECSG symposium, or write an editorial/opinion piece for one of our journals that lays out your argument with evidence to back it up, thus starting a civil discussion and debate.

Off to bed. I have a busy clinic tomorrow with a HNSCC consult and I need to review sarcoma because am seeing a case in consult later this week. Also have a conference call with my colleagues at IIT Institute of Design to finalize our CEBRE discussion guides for Breast, Lung, and Prostate caner. I love my job!

Sincerely,

Dan Golden, MD, MHPE
Assistant Professor
Department of Radiation and Cellular Oncology
The University of Chicago

or

Dan Golden, MD, MHPE
Radiation Oncologist
University of Chicago Comprehensive Cancer Center at Silver Cross Hospital

Take your pick - I'm proud of them both!

1) This is awesome for you to come on here and engage - bring your friends! Bring Ralph!

2) Sadly, your post isn't relevant to many of our arguments. I'll be honest with you - I want your job. It sounds great. Sadly, senior residents in 2020 can't get your job. It would have been hard to get your job last year - let alone in the year of COVID. I know Chicago isn't even hiring its own residents this year - let alone anyone else.

3) So what does that mean? Many of us who will be forced into rural PP jobs 1,000 miles away from our families will be coming for the jobs normally taken by new grads in 2022. Except we'll (probably) be board certified and have experience. We'll get those jobs. New grads in 2022, like 2021, will be hung out to dry.

4) The cycle repeats.

5) I agree with Neuronix - you got your job SEVEN YEARS AGO. Your experience and choices are no longer relevant. In my current job search strategy I spoke with a friend of mine who graduated more recently, 3-5 years ago. They wanted to stay in academics. They contacted over 50 places and were offered 2-3 interviews. They were offered no contract (ended up in rural PP). Now we have someone on Twitter who graduated last year saying they contacted over 100 places for maybe 10 interviews to stay in academics. This isn't the case in any other specialty I'm aware of.

6) The only way to help our field remain great for both patients and doctors is to drastically reduce the number of graduating residents. This involves cutting spots, which the great minds of ASTRO claim is "violating anti-trust laws". So the next best thing is to speak directly to students and tell them - please, stay away.

 

[scarbrtj]

The only way to help our field remain great for both patients and doctors is to drastically reduce the number of graduating residents. This involves cutting spots, which the great minds of ASTRO claim is "violating anti-trust laws". So the next best thing is to speak directly to students and tell them - please, stay away.

I love data, numbers, comparisons. After coming across that article in the Red Journal where it showed mean resident EBRT case numbers dropped from ~520 to ~480 from 2007 to 2018, it seemed pretty obvious to me certain things:
1) We are diluting the workload amongst too many rad oncs: this means less cases per rad onc in the US. This has always seemed an obvious (math is obvious) outcome. It's good to have that data.
2) You can extrapolate and predict ("Nobody can predict the future" , I hope this is true) that by 2030, especially if rad onc resident numbers continue the current trajectory, that residents will struggle to meet the 450 minimum. The data show that the proportion of metastatic cases rose from 0.3 to 0.37 over that time period; it also means residents will be seeing, and getting trained in, less curative cases going forward. This is bad for the specialty...
3) Not getting a lot of experience is bad. To graduate rad onc residency, you need 450 EBRT cases. You know how many cases you have to have in general surgey to graduate (and their program is as long as ours)?

850.

 

[pgy5radonc]

Long time lurker, recently made an account.

along with what the above responses have so eloquently stated, there is also a MAJOR conflict of interest at play here that needs to be addressed:

Dr Golden and his ilk stand to benefit from more residents (and fellows!). Cutting residency spots makes his job (which sounds amazing btw - congrats on finishing residency at the right time) on the chopping blocks to get cut. Decreased medical student interest makes his role in the medical school not as important. He has a vested financial interest in bringing more rats onto the ship before it sinks. Reminds me of a pyramid scheme...

 

[theradiator]

Wow, I feel like I've really made it into the upper echelon of academic radiation oncology now that I've been called out on SDN! I am compelled to address some of the comments made on here triggered by a couple of my recent tweets. I respect the sentiments raised both on Twitter and in this forum, but disagree with hyperbolic "sky is falling" posts that make blanket statements advising all students to stay away from radiation oncology. Many of these posts imply that we should have 0 residents per year. I really don't know what the right number is - maybe it's 100? maybe it's 200? This is beyond my expertise and I cannot effect change in the national residency numbers in my current position. Unfortunately, a 280 character tweet (or even of a few of them - ThreadReader unroll!) doesn't allow nuanced debate and discussion. I'll address a couple of the comments made on here with regards to my tweets and my current job. This is as much for the students/residents that follow these threads and don't comment as it is for the active users that kindly called me out.

First, I do realize that you can believe rad onc is (?was the way many of you talk) the greatest specialty of all time, the day-to-day work is amazing, and the changes we're seeing with hypofrac, surveillance, etc are beneficial to patients while believing "medical students should not touch this field for 10-20 years." I just have a different viewpoint on #4 - medical students should be well informed about the evolution of our specialty and decide if, for the individual student, points #1-2 outweigh the potential risk to income/job availability implicit in point #3. When I talk to students from my institution or rotating through my department about how to approach specialty selection, I make two recommendations:

1. Talk to lots of people - I'm just one opinion. The student needs get multiple opinions to triangulate what the right specialty for them is based on their personal and professional priorities.
2. Do a thought experiment - assume that in 20 years you are making the same salary as all of your medical school classmates. Would you still select X specialty? If the answer is "Yes," then it's the right specialty for you. If the answer is "No, I'd really rather be doing Y or Q or P, but they make less money," the student should carefully consider why they are leaning towards specialty X.

With regards to radiation oncology, I tell students the pros/cons of the specialty. Pros are well laid out in other posts here and on Twitter. Cons IMO are:

1. Small specialty = tight job market for specific disease sites or specific geographic locations. Be prepared to compromise for a job in a particular geographic location or with a particular disease focus. Yes, some residents hit the jackpot, but many choose to compromise on something when selecting their first job. If a students ultimate goal is to live in X or Y geographic location, rad onc may not be the best specialty (but that goes for many small specialties). Students with this priority might want to consider larger specialties with more jobs turning over in a region.
2. Radiation oncologists are often far downstream from the initial diagnosis and work-up of patients. However, this doesn't mean we are just "technicians." A good radiation oncologist is constantly running differential diagnoses in their heads when seeing weekly on-treatment visits (thoracic RT with chest pain - esophagitis, PE, or MI?; Pelvic RT with dysuria - radiation cystitis or UTI?) We are doctors first, radiation oncologists second.
3. There are existential threats to radiation oncology as a specialty - "Curing cancer," "Severe hypofrac," "Urorads," etc. In the 1970s when the "war on cancer" was declared optimists thought cancer would be simple to conquer. Hey - we'd just landed on the moon, how hard could "one disease" like cancer be? Hasn't turned out that way. We continue to make amazing, but incremental, advances with systemic therapy, new surgical techniques, and - yes - new radiation techniques (SBRT!). Nobody can predict the future. If a student is passionate about treating patients with cancer and loves the clinical milieu and science of radiation oncology, go for it (as long as they understand points 1&2)! If/when we "cure cancer" there will be major upheavals in other specialties as well. PCPs prescribe many of the antibiotics used to treat infection. How do we know med oncs will be left unscathed by a major scientific advance that actually "cures cancer?" Maybe PCPs will get a liquid biopsy and write a prescription for "the cure for cancer" to be picked up at Walgreens or CVS that evening.

The second point to address is the criticism of my current job. Yes, I practice at a "satellite" University of Chicago clinic (although I argue we are at least a moon since my clinic treats ~50% of the volume as the main campus). Also, I refer to my practice as part of the UChicago network. We have 3 clinics in the southwest suburbs and do prospective planning rounds twice weekly across all sites. I did not "drink the kool aid." I made a conscious decision to take this job understanding full well that many external observers would turn their nose up at it. So let me explain my rationale and tell you how it's turned out after 7 years. As a senior resident I had three priorities in the following order for whatever job I took:

1. My spouse would be able to continue in their non-medical job which is not very mobile. Easy locations for them were NYC, Philly, or staying in Chicago. Neither of us were particularly interested in NYC or Philly (no family), and I didn't get any serious interviews there, so moot point.
2. I wanted to be in a position to teach and work with residents and students and pursue my academic interest in medical education - i.e., a faculty appointment at a medial school
3. I wanted to work in a clinic where I would enjoy the patient care and co-workers

I realized during my PGY4 year my academic interest was not writing clinical protocols or working in a lab - it was, and has remained, medical education. I interviewed for "main site" jobs at a couple other large institutions and what I realized was even though the department leadership said, "Education is important," what they really wanted if I took a main campus job was someone to build and/or maintain a clinical program in X disease site. My medical education academic interest would have to compete with my chair's expectations to open investigator-initiated protocols and make a national/international name for myself in X disease site. I was lucky enough that the position I currently hold become available during my job search. I was offered a full faculty appointment and one protected academic day per week at the main campus. My clinic is an easy 40 minute reverse commute from where I live by the main campus to a suburb. I would not have considered the position if it was a "clinical associate" position (i.e. non-faculty) or there was no protected time (one "satellite" job at another institution during an ASTRO interview said, "You don't get any protected time initially, but if you're academically productive, after 3 years we'll discuss it." I e-mailed them almost immediately following the interview to withdraw my application.).

When considering my current position, I realized opportunities for traditional rad onc academic pursuits (e.g., writing protocols for disease sites) would be limited, but on the flip side, I would have the freedom to pursue my interest in medical education, work with medical students, and residents, and treat all disease sites. My service currently has patients on-treatment with breast, lung, prostate, esophageal, pancreas, rectal, anal, CNS, head/neck, skin, and gyn malignancies. I work with an outstanding clinical partner, nurses, MA, therapists, dosimetrists, physicists, social worker, and other clinic staff. We have a great UChicago med onc group at my clinic. I refer patients to other specialties at the UChicago mothership or to the outstanding private practice physicians and surgeons at the hospital my clinic adjoins. I can "phone a friend" at another UChicago network site or the main campus to discuss challenging/unusual cases. I love my clinical environment - I get to treat all disease sites (anatomy was my favorite pre-clinical course - I use all of it all the time) and I am faculty at UChicago where I am the rad onc clerkship director, APD, and am active in the medical school developing new oncology curricula (I'm co-investigator on a NIH grant for a cancer research education program for students between M1/M2 year), serve on the med school Curriculum Steering Committee, and am taking over as the AOA Councilor. Academically I developed a collaboration with the IIT Institute of Design developing patient education materials that use graphic narrative and received a ROI grant for this work. I help run the Radiation Oncology Education Collaborative Study Group (ROECSG) that has developed foundational curricula for medical students, IROC which is an onboarding course for PGY2s, hosts the annual ROECSG symposium, and is actively working to develop a national consensus curriculum. I have had the opportunity to mentor numerous medical students and residents - some of them work with me, others I help connect to other faculty for research opportunities I can't offer. Sure, I don't "have a resident" to write my notes, but that isn't what defines an academic radiation oncologist - at least for me. I'm proud of what I've accomplished thus far both caring for my patients and academically. Most importantly - my spouse is still at their same job and is happy. We love the neighborhood we live in and plan to stay here for a long time. Taking this job was one of the best professional and personal decisions I've made.

So for those of you that view my job as the worst of both worlds - "Private practice work at an academic salary," I would turn it around and say I have the best of both worlds - "I get to treat all disease sites like I'm in private practice (so fun!), and I am UChicago faculty and can pursue my academic passion in medical education." My salary is more than adequate, so no complaints there.

I expect the usual jeering and berating by a few vocal members of this forum, but that's OK. I'd be more than happy to discuss any of my comments above with anyone on this forum via e-mail. You can look me up in the ASTRO member directory or find my e-mail on PubMed under any of the papers on which I'm corresponding author. I'll also gladly reply to any serious and meaningful comments here. I will not engage with insulting or incendiary comments. For those of you that truly feel the sky is falling, please e-mail me and lets discuss ideas for constructive ways to effect change. Unfortunately, the insulting and incendiary comments on Twitter and this forum by anonymous accounts weakens, not strengthens, your arguments with the powers that be. If you're truly serious about effecting change, volunteer for an ASTRO or ACRO committee, attend the ROECSG symposium, or write an editorial/opinion piece for one of our journals that lays out your argument with evidence to back it up, thus starting a civil discussion and debate.

Off to bed. I have a busy clinic tomorrow with a HNSCC consult and I need to review sarcoma because am seeing a case in consult later this week. Also have a conference call with my colleagues at IIT Institute of Design to finalize our CEBRE discussion guides for Breast, Lung, and Prostate caner. I love my job!

Sincerely,

Dan Golden, MD, MHPE
Assistant Professor
Department of Radiation and Cellular Oncology
The University of Chicago

or

Dan Golden, MD, MHPE
Radiation Oncologist
University of Chicago Comprehensive Cancer Center at Silver Cross Hospital

Take your pick - I'm proud of them both!

Dan,

God bless you for engaging. Other posters have highlighted many of the salient points and I will try add to the discussion, albeit in an anonymous fashion.

1) As a thought leader in radiation oncology education, I do not think you can responsibly be agnostic to the question of optimal number of residents. I understand that a future decrease in radiation oncology residents would devalue your academic contributions but you can pivot your work to medical education as a whole and still make a meaningful contribution. This is the concept of taking a principled rather than self-serving position.

2) Medical oncologists (in contrast to hematologists) are equally downstream from diagnosis as radiation oncologists. This is actually a pro-radiation oncology point.

3) If you and your partner treat 50% of the volume of the main campus and presumably there are more than 4 attendings at the main campus, didn't you make the point of the SDN critique on satellites? You are maintaining a private practice volume and are presumably not making a private practice salary. Also, one can infer that your position displaced a community-based radiation oncologist.

4) Given the level of violence currently occurring in the city of Chicago, working in the suburbs could arguably be more desirable.

5) Based on your significant accomplishments, why is someone 7 years out still an Assistant Professor rather than Associate Professor?

6) What is your opinion on your chair's incendiary rhetoric on Twitter?

 

[scarbrtj]

I love data, numbers, comparisons. After coming across that article in the Red Journal where it showed mean resident EBRT case numbers dropped from ~520 to ~480 from 2007 to 2018, it seemed pretty obvious to me certain things:

I'll also gladly reply to any serious and meaningful comments here.

I think it's worthwhile to go back for veracity checks: about 7 mos ago I calculated the "average" rad onc was seeing ~105-~120 de novo new patients/year in 2018. And with the report that the average resident sees ~480 EBRT cases in 4 years, this works out to the "average" resident seeing ~120 EBRT cases/year. To point out the obvious: ~120/yr is not different from ~105-~120/yr. So far, my hypotheses haven't been disproven per se. I don't know if this is a "true" number (clearly the resident number is a true number), or just a metric of rad onc "busy-ness" over time. Probably more the latter than the former. Yet I feel like I'm making a reasonable case that the trends are concerning. This kind of "future predicting" is where I have put the bulk of any serious, meaningful comments I make on SDN. (I do try to be serious and meaningful, believe it or not.)

 

[RickyScott]

1)Hate the argument that we can’t predict the future, because if you truly believe that, you sure as hell should not have doubled residency numbers.
2) something very juvenile about suggesting that doubling/flooding market with radoncs (who would then be unhappy) could some how magically innovate our way to more utilization. Command approach to economics don’t work (Chicago school of economics/Milton Friedman)

 

[Chartreuse Wombat]

Evergreen-

“It is difficult to get a man to understand something, when his salary depends on his not understanding it.”

-Upton Sinclair

 

[RadOncMegatron]

Wow, I feel like I've really made it into the upper echelon of academic radiation oncology now that I've been called out on SDN! I am compelled to address some of the comments made on here triggered by a couple of my recent tweets. I respect the sentiments raised both on Twitter and in this forum, but disagree with hyperbolic "sky is falling" posts that make blanket statements advising all students to stay away from radiation oncology. Many of these posts imply that we should have 0 residents per year. I really don't know what the right number is - maybe it's 100? maybe it's 200? This is beyond my expertise and I cannot effect change in the national residency numbers in my current position. Unfortunately, a 280 character tweet (or even of a few of them - ThreadReader unroll!) doesn't allow nuanced debate and discussion. I'll address a couple of the comments made on here with regards to my tweets and my current job. This is as much for the students/residents that follow these threads and don't comment as it is for the active users that kindly called me out.

First, I do realize that you can believe rad onc is (?was the way many of you talk) the greatest specialty of all time, the day-to-day work is amazing, and the changes we're seeing with hypofrac, surveillance, etc are beneficial to patients while believing "medical students should not touch this field for 10-20 years." I just have a different viewpoint on #4 - medical students should be well informed about the evolution of our specialty and decide if, for the individual student, points #1-2 outweigh the potential risk to income/job availability implicit in point #3. When I talk to students from my institution or rotating through my department about how to approach specialty selection, I make two recommendations:

1. Talk to lots of people - I'm just one opinion. The student needs get multiple opinions to triangulate what the right specialty for them is based on their personal and professional priorities.
2. Do a thought experiment - assume that in 20 years you are making the same salary as all of your medical school classmates. Would you still select X specialty? If the answer is "Yes," then it's the right specialty for you. If the answer is "No, I'd really rather be doing Y or Q or P, but they make less money," the student should carefully consider why they are leaning towards specialty X.

With regards to radiation oncology, I tell students the pros/cons of the specialty. Pros are well laid out in other posts here and on Twitter. Cons IMO are:

1. Small specialty = tight job market for specific disease sites or specific geographic locations. Be prepared to compromise for a job in a particular geographic location or with a particular disease focus. Yes, some residents hit the jackpot, but many choose to compromise on something when selecting their first job. If a students ultimate goal is to live in X or Y geographic location, rad onc may not be the best specialty (but that goes for many small specialties). Students with this priority might want to consider larger specialties with more jobs turning over in a region.
2. Radiation oncologists are often far downstream from the initial diagnosis and work-up of patients. However, this doesn't mean we are just "technicians." A good radiation oncologist is constantly running differential diagnoses in their heads when seeing weekly on-treatment visits (thoracic RT with chest pain - esophagitis, PE, or MI?; Pelvic RT with dysuria - radiation cystitis or UTI?) We are doctors first, radiation oncologists second.
3. There are existential threats to radiation oncology as a specialty - "Curing cancer," "Severe hypofrac," "Urorads," etc. In the 1970s when the "war on cancer" was declared optimists thought cancer would be simple to conquer. Hey - we'd just landed on the moon, how hard could "one disease" like cancer be? Hasn't turned out that way. We continue to make amazing, but incremental, advances with systemic therapy, new surgical techniques, and - yes - new radiation techniques (SBRT!). Nobody can predict the future. If a student is passionate about treating patients with cancer and loves the clinical milieu and science of radiation oncology, go for it (as long as they understand points 1&2)! If/when we "cure cancer" there will be major upheavals in other specialties as well. PCPs prescribe many of the antibiotics used to treat infection. How do we know med oncs will be left unscathed by a major scientific advance that actually "cures cancer?" Maybe PCPs will get a liquid biopsy and write a prescription for "the cure for cancer" to be picked up at Walgreens or CVS that evening.

The second point to address is the criticism of my current job. Yes, I practice at a "satellite" University of Chicago clinic (although I argue we are at least a moon since my clinic treats ~50% of the volume as the main campus). Also, I refer to my practice as part of the UChicago network. We have 3 clinics in the southwest suburbs and do prospective planning rounds twice weekly across all sites. I did not "drink the kool aid." I made a conscious decision to take this job understanding full well that many external observers would turn their nose up at it. So let me explain my rationale and tell you how it's turned out after 7 years. As a senior resident I had three priorities in the following order for whatever job I took:

1. My spouse would be able to continue in their non-medical job which is not very mobile. Easy locations for them were NYC, Philly, or staying in Chicago. Neither of us were particularly interested in NYC or Philly (no family), and I didn't get any serious interviews there, so moot point.
2. I wanted to be in a position to teach and work with residents and students and pursue my academic interest in medical education - i.e., a faculty appointment at a medial school
3. I wanted to work in a clinic where I would enjoy the patient care and co-workers

I realized during my PGY4 year my academic interest was not writing clinical protocols or working in a lab - it was, and has remained, medical education. I interviewed for "main site" jobs at a couple other large institutions and what I realized was even though the department leadership said, "Education is important," what they really wanted if I took a main campus job was someone to build and/or maintain a clinical program in X disease site. My medical education academic interest would have to compete with my chair's expectations to open investigator-initiated protocols and make a national/international name for myself in X disease site. I was lucky enough that the position I currently hold become available during my job search. I was offered a full faculty appointment and one protected academic day per week at the main campus. My clinic is an easy 40 minute reverse commute from where I live by the main campus to a suburb. I would not have considered the position if it was a "clinical associate" position (i.e. non-faculty) or there was no protected time (one "satellite" job at another institution during an ASTRO interview said, "You don't get any protected time initially, but if you're academically productive, after 3 years we'll discuss it." I e-mailed them almost immediately following the interview to withdraw my application.).

When considering my current position, I realized opportunities for traditional rad onc academic pursuits (e.g., writing protocols for disease sites) would be limited, but on the flip side, I would have the freedom to pursue my interest in medical education, work with medical students, and residents, and treat all disease sites. My service currently has patients on-treatment with breast, lung, prostate, esophageal, pancreas, rectal, anal, CNS, head/neck, skin, and gyn malignancies. I work with an outstanding clinical partner, nurses, MA, therapists, dosimetrists, physicists, social worker, and other clinic staff. We have a great UChicago med onc group at my clinic. I refer patients to other specialties at the UChicago mothership or to the outstanding private practice physicians and surgeons at the hospital my clinic adjoins. I can "phone a friend" at another UChicago network site or the main campus to discuss challenging/unusual cases. I love my clinical environment - I get to treat all disease sites (anatomy was my favorite pre-clinical course - I use all of it all the time) and I am faculty at UChicago where I am the rad onc clerkship director, APD, and am active in the medical school developing new oncology curricula (I'm co-investigator on a NIH grant for a cancer research education program for students between M1/M2 year), serve on the med school Curriculum Steering Committee, and am taking over as the AOA Councilor. Academically I developed a collaboration with the IIT Institute of Design developing patient education materials that use graphic narrative and received a ROI grant for this work. I help run the Radiation Oncology Education Collaborative Study Group (ROECSG) that has developed foundational curricula for medical students, IROC which is an onboarding course for PGY2s, hosts the annual ROECSG symposium, and is actively working to develop a national consensus curriculum. I have had the opportunity to mentor numerous medical students and residents - some of them work with me, others I help connect to other faculty for research opportunities I can't offer. Sure, I don't "have a resident" to write my notes, but that isn't what defines an academic radiation oncologist - at least for me. I'm proud of what I've accomplished thus far both caring for my patients and academically. Most importantly - my spouse is still at their same job and is happy. We love the neighborhood we live in and plan to stay here for a long time. Taking this job was one of the best professional and personal decisions I've made.

So for those of you that view my job as the worst of both worlds - "Private practice work at an academic salary," I would turn it around and say I have the best of both worlds - "I get to treat all disease sites like I'm in private practice (so fun!), and I am UChicago faculty and can pursue my academic passion in medical education." My salary is more than adequate, so no complaints there.

I expect the usual jeering and berating by a few vocal members of this forum, but that's OK. I'd be more than happy to discuss any of my comments above with anyone on this forum via e-mail. You can look me up in the ASTRO member directory or find my e-mail on PubMed under any of the papers on which I'm corresponding author. I'll also gladly reply to any serious and meaningful comments here. I will not engage with insulting or incendiary comments. For those of you that truly feel the sky is falling, please e-mail me and lets discuss ideas for constructive ways to effect change. Unfortunately, the insulting and incendiary comments on Twitter and this forum by anonymous accounts weakens, not strengthens, your arguments with the powers that be. If you're truly serious about effecting change, volunteer for an ASTRO or ACRO committee, attend the ROECSG symposium, or write an editorial/opinion piece for one of our journals that lays out your argument with evidence to back it up, thus starting a civil discussion and debate.

Off to bed. I have a busy clinic tomorrow with a HNSCC consult and I need to review sarcoma because am seeing a case in consult later this week. Also have a conference call with my colleagues at IIT Institute of Design to finalize our CEBRE discussion guides for Breast, Lung, and Prostate caner. I love my job!

Sincerely,

Dan Golden, MD, MHPE
Assistant Professor
Department of Radiation and Cellular Oncology
The University of Chicago

or

Dan Golden, MD, MHPE
Radiation Oncologist
University of Chicago Comprehensive Cancer Center at Silver Cross Hospital

Take your pick - I'm proud of them both!

Really appreciate your discourse and encourage more participation here. I think many of us said it's possible to get a great job, but we have noted that if you have a risk of 25% to be unemployed, forced to do a fellowship, or be limited geographically (sounds like you and your family was in this situation), is it really worth it? Let's also be frank, very few people will be accomplished as you, so their choice of jobs will be far less than what you can accomplish.

Also, please do not try to say anonymous forums weakens the cause. Simul Parikh got kicked off ROHubs about job market issues and you know very well that dissent against the diversity movement is NOT welcome by ASTRO, ASCO, and almost all Universities (*Univ. of Chicago does have my respect for their free speech stance). See your articles below. We cannot have a reasonable debate about them in the open without fear of retribution.

Taking a Step in the Right Direction for Radiation Oncology

Visiting Professorship in Academic Radiation Oncology

Visiting professorship is an enjoyable activity that is also influential in academic promotional processes as evidence of the invitee’s national reput…

www.sciencedirect.com

 

[yesmaster]

I'm doing my best to stay quiet as my cohort of residents applies to jobs but I'll throw in my 2 cents.

A University of Chicago satellite job sounds AWESOME. Major props. NYC, Philly, and Chicago are Tier 1 cities, easily in the top 10 of US cities in terms of professional, cultural, entertainment, educational, culinary, and social offerings. I would literally do ANYTHING within the bounds of the law and civil society to work within an hour of a top 10 US city, not just for myself, but for the well-being of my family, spouse, and children.

Seeing as how these jobs are RARE and highly COVETED, I'd gladly toe the party line and defend the old guard to get or keep such a job.

 

[medgator]

I'm doing my best to stay quiet as my cohort of residents applies to jobs but I'll throw in my 2 cents.

A University of Chicago satellite job sounds AWESOME. Major props. NYC, Philly, and Chicago are Tier 1 cities, easily in the top 10 of US cities in terms of professional, cultural, entertainment, educational, culinary, and social offerings. I would literally do ANYTHING within the bounds of the law and civil society to work within an hour of a top 10 US city, not just for myself, but for the well-being of my family, spouse, and children.

Seeing as how these jobs are RARE and highly COVETED, I'd gladly toe the party line and defend the old guard to get or keep such a job.

I'm sure UC koolaid tastes great and RW hands it out in crystal goblets

 

[deleted774703]

Wow, I feel like I've really made it into the upper echelon of academic radiation oncology now that I've been called out on SDN! I am compelled to address some of the comments made on here triggered by a couple of my recent tweets. I respect the sentiments raised both on Twitter and in this forum, but disagree with hyperbolic "sky is falling" posts that make blanket statements advising all students to stay away from radiation oncology. Many of these posts imply that we should have 0 residents per year. I really don't know what the right number is - maybe it's 100? maybe it's 200? This is beyond my expertise and I cannot effect change in the national residency numbers in my current position. Unfortunately, a 280 character tweet (or even of a few of them - ThreadReader unroll!) doesn't allow nuanced debate and discussion. I'll address a couple of the comments made on here with regards to my tweets and my current job. This is as much for the students/residents that follow these threads and don't comment as it is for the active users that kindly called me out.

First, I do realize that you can believe rad onc is (?was the way many of you talk) the greatest specialty of all time, the day-to-day work is amazing, and the changes we're seeing with hypofrac, surveillance, etc are beneficial to patients while believing "medical students should not touch this field for 10-20 years." I just have a different viewpoint on #4 - medical students should be well informed about the evolution of our specialty and decide if, for the individual student, points #1-2 outweigh the potential risk to income/job availability implicit in point #3. When I talk to students from my institution or rotating through my department about how to approach specialty selection, I make two recommendations:

1. Talk to lots of people - I'm just one opinion. The student needs get multiple opinions to triangulate what the right specialty for them is based on their personal and professional priorities.
2. Do a thought experiment - assume that in 20 years you are making the same salary as all of your medical school classmates. Would you still select X specialty? If the answer is "Yes," then it's the right specialty for you. If the answer is "No, I'd really rather be doing Y or Q or P, but they make less money," the student should carefully consider why they are leaning towards specialty X.

With regards to radiation oncology, I tell students the pros/cons of the specialty. Pros are well laid out in other posts here and on Twitter. Cons IMO are:

1. Small specialty = tight job market for specific disease sites or specific geographic locations. Be prepared to compromise for a job in a particular geographic location or with a particular disease focus. Yes, some residents hit the jackpot, but many choose to compromise on something when selecting their first job. If a students ultimate goal is to live in X or Y geographic location, rad onc may not be the best specialty (but that goes for many small specialties). Students with this priority might want to consider larger specialties with more jobs turning over in a region.
2. Radiation oncologists are often far downstream from the initial diagnosis and work-up of patients. However, this doesn't mean we are just "technicians." A good radiation oncologist is constantly running differential diagnoses in their heads when seeing weekly on-treatment visits (thoracic RT with chest pain - esophagitis, PE, or MI?; Pelvic RT with dysuria - radiation cystitis or UTI?) We are doctors first, radiation oncologists second.
3. There are existential threats to radiation oncology as a specialty - "Curing cancer," "Severe hypofrac," "Urorads," etc. In the 1970s when the "war on cancer" was declared optimists thought cancer would be simple to conquer. Hey - we'd just landed on the moon, how hard could "one disease" like cancer be? Hasn't turned out that way. We continue to make amazing, but incremental, advances with systemic therapy, new surgical techniques, and - yes - new radiation techniques (SBRT!). Nobody can predict the future. If a student is passionate about treating patients with cancer and loves the clinical milieu and science of radiation oncology, go for it (as long as they understand points 1&2)! If/when we "cure cancer" there will be major upheavals in other specialties as well. PCPs prescribe many of the antibiotics used to treat infection. How do we know med oncs will be left unscathed by a major scientific advance that actually "cures cancer?" Maybe PCPs will get a liquid biopsy and write a prescription for "the cure for cancer" to be picked up at Walgreens or CVS that evening.

The second point to address is the criticism of my current job. Yes, I practice at a "satellite" University of Chicago clinic (although I argue we are at least a moon since my clinic treats ~50% of the volume as the main campus). Also, I refer to my practice as part of the UChicago network. We have 3 clinics in the southwest suburbs and do prospective planning rounds twice weekly across all sites. I did not "drink the kool aid." I made a conscious decision to take this job understanding full well that many external observers would turn their nose up at it. So let me explain my rationale and tell you how it's turned out after 7 years. As a senior resident I had three priorities in the following order for whatever job I took:

1. My spouse would be able to continue in their non-medical job which is not very mobile. Easy locations for them were NYC, Philly, or staying in Chicago. Neither of us were particularly interested in NYC or Philly (no family), and I didn't get any serious interviews there, so moot point.
2. I wanted to be in a position to teach and work with residents and students and pursue my academic interest in medical education - i.e., a faculty appointment at a medial school
3. I wanted to work in a clinic where I would enjoy the patient care and co-workers

I realized during my PGY4 year my academic interest was not writing clinical protocols or working in a lab - it was, and has remained, medical education. I interviewed for "main site" jobs at a couple other large institutions and what I realized was even though the department leadership said, "Education is important," what they really wanted if I took a main campus job was someone to build and/or maintain a clinical program in X disease site. My medical education academic interest would have to compete with my chair's expectations to open investigator-initiated protocols and make a national/international name for myself in X disease site. I was lucky enough that the position I currently hold become available during my job search. I was offered a full faculty appointment and one protected academic day per week at the main campus. My clinic is an easy 40 minute reverse commute from where I live by the main campus to a suburb. I would not have considered the position if it was a "clinical associate" position (i.e. non-faculty) or there was no protected time (one "satellite" job at another institution during an ASTRO interview said, "You don't get any protected time initially, but if you're academically productive, after 3 years we'll discuss it." I e-mailed them almost immediately following the interview to withdraw my application.).

When considering my current position, I realized opportunities for traditional rad onc academic pursuits (e.g., writing protocols for disease sites) would be limited, but on the flip side, I would have the freedom to pursue my interest in medical education, work with medical students, and residents, and treat all disease sites. My service currently has patients on-treatment with breast, lung, prostate, esophageal, pancreas, rectal, anal, CNS, head/neck, skin, and gyn malignancies. I work with an outstanding clinical partner, nurses, MA, therapists, dosimetrists, physicists, social worker, and other clinic staff. We have a great UChicago med onc group at my clinic. I refer patients to other specialties at the UChicago mothership or to the outstanding private practice physicians and surgeons at the hospital my clinic adjoins. I can "phone a friend" at another UChicago network site or the main campus to discuss challenging/unusual cases. I love my clinical environment - I get to treat all disease sites (anatomy was my favorite pre-clinical course - I use all of it all the time) and I am faculty at UChicago where I am the rad onc clerkship director, APD, and am active in the medical school developing new oncology curricula (I'm co-investigator on a NIH grant for a cancer research education program for students between M1/M2 year), serve on the med school Curriculum Steering Committee, and am taking over as the AOA Councilor. Academically I developed a collaboration with the IIT Institute of Design developing patient education materials that use graphic narrative and received a ROI grant for this work. I help run the Radiation Oncology Education Collaborative Study Group (ROECSG) that has developed foundational curricula for medical students, IROC which is an onboarding course for PGY2s, hosts the annual ROECSG symposium, and is actively working to develop a national consensus curriculum. I have had the opportunity to mentor numerous medical students and residents - some of them work with me, others I help connect to other faculty for research opportunities I can't offer. Sure, I don't "have a resident" to write my notes, but that isn't what defines an academic radiation oncologist - at least for me. I'm proud of what I've accomplished thus far both caring for my patients and academically. Most importantly - my spouse is still at their same job and is happy. We love the neighborhood we live in and plan to stay here for a long time. Taking this job was one of the best professional and personal decisions I've made.

So for those of you that view my job as the worst of both worlds - "Private practice work at an academic salary," I would turn it around and say I have the best of both worlds - "I get to treat all disease sites like I'm in private practice (so fun!), and I am UChicago faculty and can pursue my academic passion in medical education." My salary is more than adequate, so no complaints there.

I expect the usual jeering and berating by a few vocal members of this forum, but that's OK. I'd be more than happy to discuss any of my comments above with anyone on this forum via e-mail. You can look me up in the ASTRO member directory or find my e-mail on PubMed under any of the papers on which I'm corresponding author. I'll also gladly reply to any serious and meaningful comments here. I will not engage with insulting or incendiary comments. For those of you that truly feel the sky is falling, please e-mail me and lets discuss ideas for constructive ways to effect change. Unfortunately, the insulting and incendiary comments on Twitter and this forum by anonymous accounts weakens, not strengthens, your arguments with the powers that be. If you're truly serious about effecting change, volunteer for an ASTRO or ACRO committee, attend the ROECSG symposium, or write an editorial/opinion piece for one of our journals that lays out your argument with evidence to back it up, thus starting a civil discussion and debate.

Off to bed. I have a busy clinic tomorrow with a HNSCC consult and I need to review sarcoma because am seeing a case in consult later this week. Also have a conference call with my colleagues at IIT Institute of Design to finalize our CEBRE discussion guides for Breast, Lung, and Prostate caner. I love my job!

Sincerely,

Dan Golden, MD, MHPE
Assistant Professor
Department of Radiation and Cellular Oncology
The University of Chicago

or

Dan Golden, MD, MHPE
Radiation Oncologist
University of Chicago Comprehensive Cancer Center at Silver Cross Hospital

Take your pick - I'm proud of them both!

Dan,

Thank you for coming on here and discussing your viewpoints. I respect that and won't discuss your specific job anymore seeing how it was truly a personal choice and it doesn't sound terrible (I would probably disagree on salary but thats okay). However, I have several issues at hand

1. You assume that b/c you were successful that current and future residents will be ->
   1. not true
2. You mention you needed to be in only a few big cities, guess what so do many of us!
   1. And unlike you, we CANNOT find spots there. It is totally booked. So what do you want us to do?
      1. Be temporarily unemployed while our student loans increase?
         1. Divorce our spouse? Or do long distance as >30 year old adults with possibly children?
3. You feel that your moral obligation stops at "disclosing the problems of the field" ->
   1. that means literally nothing to a resident who cannot find the job they desire down the road
4. You omit the discussion of your chairman (probably for your own safety) and the detriment it plays for all of us ->
   1. Yet you expect us to email you to discuss with you and openly reveal who we are?
      1. BTW, if you are so eager, then share your damn email on here. You want us to look you up on PubMed to contact you? That is very condescending and uncivil behavior
5. You talk about phoning a friend? ->
   1. Do you think that you are exclusive in asking for help b/c you are in an "academic satellite"?
6. You assume that none of us are on ASTRO or ARRO committees ->
   1. Perhaps we are and we feel unsafe there due to our past experiences. Or we need multiple avenues to make our points
7. You talk about civil discussion/discourse ->
   1. It's interesting you require a level of civility just to engage considering everything that is going on in USA today

 

[RO28]

I think something lost in the consideration of how great hypofx is for the patient, is how I ungreat it is for us, and I don't mean financially. An initial attraction for me to this specialty was not only the cool tech, but the potential to get to know people and be with them through hard times. Otherwise, I would have just gone into rads or something. It's becoming that to an extent, with less and less meaningful patient contact. Figuring a way to double board in hpm would allow for that, and residency is already 12 months, minimum, longer than it needs to be.

I completely agree. I think hypofx is fantastic for patients. I did not go into this for $, but also life costs $. I did actually consider a palliative care fellowship when I was a pgy-3/4, but I am not in a one person partnership and I think it is important to consider your partner when making training decisions.

 

[RadSki]

Someone needs to tell dan golden to STFU

Guy writes all these papers like hes a real academic doc while in reality he is an underpaid private practice guy (drank the kool aid with satellite UChicago)

Here you go @Neuronix. I am happy to have collegial discussions with peers about the challenges facing our specialty. I value differences of opinion and look forward to vigorous debate. However, I will not stand idly by and have insults lobbed at me by anonymous posters on this forum.

 

[Neuronix]

Here you go @Neuronix. I am happy to have collegial discussions with peers about the challenges facing our specialty. I value differences of opinion and look forward to vigorous debate. However, I will not stand idly by and have insults lobbed at me by anonymous posters on this forum.

That's fair. SDN protects members from personal attacks. We have permitted posts criticizing "public figures", including Twitter posters.

That written, since you're here and engaging the members here personally, SDN posters need to be professional towards you as any other SDN member. So this serves as a public warning to everyone to be professional.

You'll find that we recently had a very nice discussion with Dan Spratt here as well.

However, I do hope you'll stay and engage our users on the significant concerns they have regarding oversupply.

 

[scarbrtj]

Here you go @Neuronix. I am happy to have collegial discussions with peers about the challenges facing our specialty. I value differences of opinion and look forward to vigorous debate. However, I will not stand idly by and have insults lobbed at me by anonymous posters on this forum.

Know how many times I’ve been insulted on SDN? Like the radiologist sometimes says when looking at a brain met MRI: too numerous to count. Unlike the brain met patient though, it always wound up with me (and my ego) surviving. We still want to hear from you. Non-anonymous, you carry ten times more water than everyone else. Anyone “lobbing insults” now will just look silly. Factual retorts silence unserious folks eventually.

 

[deleted774703]

Here you go @Neuronix. I am happy to have collegial discussions with peers about the challenges facing our specialty. I value differences of opinion and look forward to vigorous debate. However, I will not stand idly by and have insults lobbed at me by anonymous posters on this forum.

Dan, I apologize for that especially after seeing your message as I hope you stay and address the other concerns with your post as seen above

I do disagree with your moral policing however. That is one of the lasting message of medbikini on twitter this weekend and seen on SDN.

Professionalism/civility are ultimately constructs to keep younger attendings, minorities, women etc down.

This is especially ironic that we care so much about civility when our entire country is engaged in BLM, protests, etc

 

[fiji128]

It's always good to have more view points but still.....

The fact of the matter it is unethical/immoral to tell anyone to go into this field at this point given the giant downside potential and minimal upside potential. This is a fact. Not even debatable anymore. It's like advising someone to bet their life saving's on a penny stock hoping it will pop. Ya some will get lucky but most won't. Understand the risk you are taking and know once you start traing there are no good exit strategies.

Med students, if whomever you are talking to can't reasonably explain why it makes sense to bet your whole future on something where yesterday's 35 patient's under treatment are today's 20 and will likely be tomorrow's 10, that is the biggest of red flags. All the oligomets and cardiac ablation in the world will never replace prior breast and prostate fractions, just a fact.

Also I know the chicago rad onc market well. It is beyond terrible. Staturated with MDs that have been practing for 10, 20 and 30 years. The landscape for private practaces fighting for contracts to provided coverage to various centers is ultra competitive and this drives down salaries. The salary for new grad hires, if you get that far, are about the same as IM. Tons of abusive jobs where you are esentially a technician. This will not change in the near term. Don't like it? Well there are 50 people in line willing to take the position.

 

[RickyScott]

Lack of moral qualms over Hyping a penny stock Is very apt analogy.

 

[thecarbonionangle]

Wow, I feel like I've really made it into the upper echelon of academic radiation oncology now that I've been called out on SDN! I am compelled to address some of the comments made on here triggered by a couple of my recent tweets. I respect the sentiments raised both on Twitter and in this forum, but disagree with hyperbolic "sky is falling" posts that make blanket statements advising all students to stay away from radiation oncology. Many of these posts imply that we should have 0 residents per year. I really don't know what the right number is - maybe it's 100? maybe it's 200? This is beyond my expertise and I cannot effect change in the national residency numbers in my current position. Unfortunately, a 280 character tweet (or even of a few of them - ThreadReader unroll!) doesn't allow nuanced debate and discussion. I'll address a couple of the comments made on here with regards to my tweets and my current job. This is as much for the students/residents that follow these threads and don't comment as it is for the active users that kindly called me out.

First, I do realize that you can believe rad onc is (?was the way many of you talk) the greatest specialty of all time, the day-to-day work is amazing, and the changes we're seeing with hypofrac, surveillance, etc are beneficial to patients while believing "medical students should not touch this field for 10-20 years." I just have a different viewpoint on #4 - medical students should be well informed about the evolution of our specialty and decide if, for the individual student, points #1-2 outweigh the potential risk to income/job availability implicit in point #3. When I talk to students from my institution or rotating through my department about how to approach specialty selection, I make two recommendations:

1. Talk to lots of people - I'm just one opinion. The student needs get multiple opinions to triangulate what the right specialty for them is based on their personal and professional priorities.
2. Do a thought experiment - assume that in 20 years you are making the same salary as all of your medical school classmates. Would you still select X specialty? If the answer is "Yes," then it's the right specialty for you. If the answer is "No, I'd really rather be doing Y or Q or P, but they make less money," the student should carefully consider why they are leaning towards specialty X.

With regards to radiation oncology, I tell students the pros/cons of the specialty. Pros are well laid out in other posts here and on Twitter. Cons IMO are:

1. Small specialty = tight job market for specific disease sites or specific geographic locations. Be prepared to compromise for a job in a particular geographic location or with a particular disease focus. Yes, some residents hit the jackpot, but many choose to compromise on something when selecting their first job. If a students ultimate goal is to live in X or Y geographic location, rad onc may not be the best specialty (but that goes for many small specialties). Students with this priority might want to consider larger specialties with more jobs turning over in a region.
2. Radiation oncologists are often far downstream from the initial diagnosis and work-up of patients. However, this doesn't mean we are just "technicians." A good radiation oncologist is constantly running differential diagnoses in their heads when seeing weekly on-treatment visits (thoracic RT with chest pain - esophagitis, PE, or MI?; Pelvic RT with dysuria - radiation cystitis or UTI?) We are doctors first, radiation oncologists second.
3. There are existential threats to radiation oncology as a specialty - "Curing cancer," "Severe hypofrac," "Urorads," etc. In the 1970s when the "war on cancer" was declared optimists thought cancer would be simple to conquer. Hey - we'd just landed on the moon, how hard could "one disease" like cancer be? Hasn't turned out that way. We continue to make amazing, but incremental, advances with systemic therapy, new surgical techniques, and - yes - new radiation techniques (SBRT!). Nobody can predict the future. If a student is passionate about treating patients with cancer and loves the clinical milieu and science of radiation oncology, go for it (as long as they understand points 1&2)! If/when we "cure cancer" there will be major upheavals in other specialties as well. PCPs prescribe many of the antibiotics used to treat infection. How do we know med oncs will be left unscathed by a major scientific advance that actually "cures cancer?" Maybe PCPs will get a liquid biopsy and write a prescription for "the cure for cancer" to be picked up at Walgreens or CVS that evening.

The second point to address is the criticism of my current job. Yes, I practice at a "satellite" University of Chicago clinic (although I argue we are at least a moon since my clinic treats ~50% of the volume as the main campus). Also, I refer to my practice as part of the UChicago network. We have 3 clinics in the southwest suburbs and do prospective planning rounds twice weekly across all sites. I did not "drink the kool aid." I made a conscious decision to take this job understanding full well that many external observers would turn their nose up at it. So let me explain my rationale and tell you how it's turned out after 7 years. As a senior resident I had three priorities in the following order for whatever job I took:

1. My spouse would be able to continue in their non-medical job which is not very mobile. Easy locations for them were NYC, Philly, or staying in Chicago. Neither of us were particularly interested in NYC or Philly (no family), and I didn't get any serious interviews there, so moot point.
2. I wanted to be in a position to teach and work with residents and students and pursue my academic interest in medical education - i.e., a faculty appointment at a medial school
3. I wanted to work in a clinic where I would enjoy the patient care and co-workers

I realized during my PGY4 year my academic interest was not writing clinical protocols or working in a lab - it was, and has remained, medical education. I interviewed for "main site" jobs at a couple other large institutions and what I realized was even though the department leadership said, "Education is important," what they really wanted if I took a main campus job was someone to build and/or maintain a clinical program in X disease site. My medical education academic interest would have to compete with my chair's expectations to open investigator-initiated protocols and make a national/international name for myself in X disease site. I was lucky enough that the position I currently hold become available during my job search. I was offered a full faculty appointment and one protected academic day per week at the main campus. My clinic is an easy 40 minute reverse commute from where I live by the main campus to a suburb. I would not have considered the position if it was a "clinical associate" position (i.e. non-faculty) or there was no protected time (one "satellite" job at another institution during an ASTRO interview said, "You don't get any protected time initially, but if you're academically productive, after 3 years we'll discuss it." I e-mailed them almost immediately following the interview to withdraw my application.).

When considering my current position, I realized opportunities for traditional rad onc academic pursuits (e.g., writing protocols for disease sites) would be limited, but on the flip side, I would have the freedom to pursue my interest in medical education, work with medical students, and residents, and treat all disease sites. My service currently has patients on-treatment with breast, lung, prostate, esophageal, pancreas, rectal, anal, CNS, head/neck, skin, and gyn malignancies. I work with an outstanding clinical partner, nurses, MA, therapists, dosimetrists, physicists, social worker, and other clinic staff. We have a great UChicago med onc group at my clinic. I refer patients to other specialties at the UChicago mothership or to the outstanding private practice physicians and surgeons at the hospital my clinic adjoins. I can "phone a friend" at another UChicago network site or the main campus to discuss challenging/unusual cases. I love my clinical environment - I get to treat all disease sites (anatomy was my favorite pre-clinical course - I use all of it all the time) and I am faculty at UChicago where I am the rad onc clerkship director, APD, and am active in the medical school developing new oncology curricula (I'm co-investigator on a NIH grant for a cancer research education program for students between M1/M2 year), serve on the med school Curriculum Steering Committee, and am taking over as the AOA Councilor. Academically I developed a collaboration with the IIT Institute of Design developing patient education materials that use graphic narrative and received a ROI grant for this work. I help run the Radiation Oncology Education Collaborative Study Group (ROECSG) that has developed foundational curricula for medical students, IROC which is an onboarding course for PGY2s, hosts the annual ROECSG symposium, and is actively working to develop a national consensus curriculum. I have had the opportunity to mentor numerous medical students and residents - some of them work with me, others I help connect to other faculty for research opportunities I can't offer. Sure, I don't "have a resident" to write my notes, but that isn't what defines an academic radiation oncologist - at least for me. I'm proud of what I've accomplished thus far both caring for my patients and academically. Most importantly - my spouse is still at their same job and is happy. We love the neighborhood we live in and plan to stay here for a long time. Taking this job was one of the best professional and personal decisions I've made.

So for those of you that view my job as the worst of both worlds - "Private practice work at an academic salary," I would turn it around and say I have the best of both worlds - "I get to treat all disease sites like I'm in private practice (so fun!), and I am UChicago faculty and can pursue my academic passion in medical education." My salary is more than adequate, so no complaints there.

I expect the usual jeering and berating by a few vocal members of this forum, but that's OK. I'd be more than happy to discuss any of my comments above with anyone on this forum via e-mail. You can look me up in the ASTRO member directory or find my e-mail on PubMed under any of the papers on which I'm corresponding author. I'll also gladly reply to any serious and meaningful comments here. I will not engage with insulting or incendiary comments. For those of you that truly feel the sky is falling, please e-mail me and lets discuss ideas for constructive ways to effect change. Unfortunately, the insulting and incendiary comments on Twitter and this forum by anonymous accounts weakens, not strengthens, your arguments with the powers that be. If you're truly serious about effecting change, volunteer for an ASTRO or ACRO committee, attend the ROECSG symposium, or write an editorial/opinion piece for one of our journals that lays out your argument with evidence to back it up, thus starting a civil discussion and debate.

Off to bed. I have a busy clinic tomorrow with a HNSCC consult and I need to review sarcoma because am seeing a case in consult later this week. Also have a conference call with my colleagues at IIT Institute of Design to finalize our CEBRE discussion guides for Breast, Lung, and Prostate caner. I love my job!

Sincerely,

Dan Golden, MD, MHPE
Assistant Professor
Department of Radiation and Cellular Oncology
The University of Chicago

or

Dan Golden, MD, MHPE
Radiation Oncologist
University of Chicago Comprehensive Cancer Center at Silver Cross Hospital

Take your pick - I'm proud of them both!

nobody really knows what the right number is. Many people are saying it should be 100? Or 200? Nobody really knows! We may never know but MANY people are looking at it. We’ll see what happens! MROGA!

 

[thecarbonionangle]

Long time lurker, recently made an account.

along with what the above responses have so eloquently stated, there is also a MAJOR conflict of interest at play here that needs to be addressed:

Dr Golden and his ilk stand to benefit from more residents (and fellows!). Cutting residency spots makes his job (which sounds amazing btw - congrats on finishing residency at the right time) on the chopping blocks to get cut. Decreased medical student interest makes his role in the medical school not as important. He has a vested financial interest in bringing more rats onto the ship before it sinks. Reminds me of a pyramid scheme...

rad onc is the herbalife of medicine. I sell you some snake oil supplement. You sell it to your gullible buddy. We both make money. Pyramid scheme. Someone is getting screwed!

 

[RadSki]

I'm happy to have a civil discussion. I have the same concerns as everyone on here, I just don't believe it's as dire as some of you make it out to be. Maybe I'll be proved wrong in 20 years and we can have another discussion here about how you were all correct and the sky really was falling in 2020. With regards to my chair, he is entitled to his opinions which he expresses openly. He has not gotten to where he is by mincing words. I encourage you all to read about Radical Candor. When I read it I said, "Ah hah - Dr. Weichselbaum is the king of radical candor." He calls it how he sees it and you might not like it, but he's being honest. I will keep this subsequent discussion focused on the critique of my post above and my personal tweets.

Dan,

Thank you for coming on here and discussing your viewpoints. I respect that and won't discuss your specific job anymore seeing how it was truly a personal choice and it doesn't sound terrible (I would probably disagree on salary but thats okay). However, I have several issues at hand

1. You assume that b/c you were successful that current and future residents will be ->
   1. not true
2. You mention you needed to be in only a few big cities, guess what so do many of us!
   1. And unlike you, we CANNOT find spots there. It is totally booked. So what do you want us to do?
      1. Be temporarily unemployed while our student loans increase?
         1. Divorce our spouse? Or do long distance as >30 year old adults with possibly children?
3. You feel that your moral obligation stops at "disclosing the problems of the field" ->
   1. that means literally nothing to a resident who cannot find the job they desire down the road
4. You omit the discussion of your chairman (probably for your own safety) and the detriment it plays for all of us ->
   1. Yet you expect us to email you to discuss with you and openly reveal who we are?
      1. BTW, if you are so eager, then share your damn email on here. You want us to look you up on PubMed to contact you? That is very condescending and uncivil behavior
5. You talk about phoning a friend? ->
   1. Do you think that you are exclusive in asking for help b/c you are in an "academic satellite"?
6. You assume that none of us are on ASTRO or ARRO committees ->
   1. Perhaps we are and we feel unsafe there due to our past experiences. Or we need multiple avenues to make our points
7. You talk about civil discussion/discourse ->
   1. It's interesting you require a level of civility just to engage considering everything that is going on in USA today

1. My point is if a resident is interested in academic work (research, education, teaching, etc.) there might be certain advantages to having a job at a network site. If your passion is informatics or health economics or education, maybe you don't need to be a disease site guru at a main campus. I have the utmost respect for my colleagues that are world renowned disease site experts, write novel clinical protocols (both adding or removing RT), or run a lab. That wasn't for me and I was lucky to have this job become available. I do not "assume" that because I've been successful (at least by my own measure, maybe not by others), current/future residents will be. However, I do believe that if current/future residents can be given other yardsticks by which to measure "success" they may consider themselves successful in unconventional positions.
2. I took a job with a 40 minute commute so my spouse could stay at their job. I gambled that I would be given the academic freedom I was hoping for, and it worked out. I always bring up this risk (i.e., low geographic determinability) with medical students when counseling about career choice. I've had two stellar mentees in the past 2 years that decided to pursue other specialties for this reason. One chose diagnostic radiology because they wanted to be in one of three major metropolitan areas and felt it was more flexible for them and their significant other. The other chose internal medicine because their significant other wants to do a competitive specialty and so this student wanted to be support them and be able to have a more flexible job location (in this case it was a male mentee choosing a "less competitive" specialty for their female partner - some good #HeForShe there). I was not sad these students chose not to pursue rad onc - I was happy that they made informed decisions and decided rad onc wasn't for them due to the tight job market. My job is not to blindly recruit students into the specialty. It's to counsel students about the pros/cons of different specialties and help them do affective forecasting so 5 or 10 or 20 years later they aren't angry about their job. I'm sorry that some of you weren't counseled about this aspect of choosing a small specialty (rad onc isn't unique) and when I give talks to ADROP or ASTRO I always bring this up as a critical aspect of counseling students.
3. I have a finite amount of time/energy. I choose to direct my energy at UGME and developing educational curricula. My personal interest is in how we educate our trainees, patients, and colleagues. Workforce research requires a different expertise (economics, supply/demand, reimbursement, etc, etc) that I don't have. If a resident is having trouble finding a position, I would be happy to talk to them and help strategize. One piece of advice I got when applying for jobs was "Your first job usually isn't your last." I have numerous colleagues who took jobs initially that worked for them but after some time transferred to a different position - some moved across the country, some left academics, some went back to academics. Point is, you might have to compromise initially, but keep your eyes open and head up and if you feel the need, consider moving positions.
4. I initially posted my e-mail. Wasn't sure if that was safe/appropriate to put a direct link to my e-mail on this forum - I come here once in a blue moon. I decided to let you know how to contact me. My point was my e-mail is easy to access (ASTRO, PubMed). You can also search the UChicago directory. Sure, the PubMed comment was a little snippy, but it was a visceral response to the OP that implied I was somehow "not academic." And to this point, there are plenty of PP docs that are super academic (have R01s, write national protocols, etc) and plenty of "academic" docs that aren't academic. "Academic" to me implies working to advance the field, teaching, and publishing scholarship. This can be done in any job - it's just facilitated more at "academic" medical centers where it is part of the institutional mission.
5. I'm sure most of you can "phone a friend." My point was I'm not sitting solo at some clinic in the cornfields (it is in cornfields, but I'm not solo) "babyistting" linacs with no support. Some of you have an amazing ability to assume every comment on Twitter or this site is directed at you. It's usually not.
6. Maybe you are on ASTRO/ARRO committees. Great - these are avenues to effect change. Incendiary posts on Twitter or SDN worsen the divide between what you espouse you want and what you'll be able to get. I don't agree with the psychology of your approach.
7. I'm not sure what this comment is trying to get at. Just because others in society choose to use incendiary/inflammatory rhetoric in an attempt to get their point across doesn't mean it's OK or a good tactic. I refuse to conflate the challenges our specialty faces with the social, cultural, and political challenges currently facing our country.

I'm a moderator here and I have no idea who is on Twitter posting. Are they even SDN posters? What posts are you referring to on SDN that are attacking you directly?

You graduated seven years ago into a job you like. I'm happy for you. What would have happened if you couldn't get a job in or anywhere near one of the three cities you listed? What would have happened if the only offers you got outside those cities were those five days a week clinical satellite jobs without academic opportunities (or "we'll talk about it") that you didn't want? Maybe you'd be singing a different tune now. Who knows.

But this is what I'm seeing for a lot of new grads. Some of them are really struggling, underemployed, or unemployed. To shrug off oversupply as you don't know how many residents there should be and that's not within your expertise anyway, but continuing to post about how great rad onc is anyway misses the point. This is what the SDNers are referring to as "gaslighting".

Things have gotten a lot worse in the seven years since you graduated, and it continues to worsen every year with the continued oversupply. If you're a med student planning on starting a career five years from now, rad onc is a really dicey proposition.

It doesn't help that Ralph is out there saying we're all paid too much. Would you personally like a pay cut? You can deny and ignore him as much as you like, but it makes it awkward having someone very senior at your own institution basically telling you and all of us that we're overpaid. That written, he does reflect a certain group of entrenched rad oncs who are salivating to get cheap labor and pay us less while making several times more than new grads.

I personally don't believe that the "powers that be" will ever listen to us, no matter what is written on SDN. They will gaslight, ignore, and continue to expand. The "canaries" listen though. Significantly decreased medical student interest due to a bad job market is finally bringing this issue to the discussion with the "powers that be." It's about time.

Thanks @Neuronix. It would have been a challenge if I didn't find a job in one of those three locations. My spouse was willing to move and look for other work, although their job description would have likely changed significantly. I do consider myself lucky that this particular job came about the year I was graduating. I was prepared to take a different job and was already telling myself, "Your first job usually isn't your last job." I have friends/colleagues in other small niche specialties (ophtho, neurosurg, etc) that have to move around to find a job that works. Again, this is something med school advisors need to counsel students about what they are discussing specialty selection.

Gaslighting is "a form of psychological manipulation in which a person or a group covertly sows seeds of doubt in a targeted individual or group, making them question their own memory, perception, or judgment, often evoking in them cognitive dissonance and other changes including low self-esteem." I'm not shrugging off oversupply or gaslighting anyone. I don't tell students "Rad onc is the greatest thing ever and there are no potential downsides." I'm saying I don't have the data or expertise to properly comment on the workforce supply issue. Anything I say would be speculation. I've seen how this forum treats speculation about the future of our specialty (workforce or treatment volumes) and therefore will refrain from speculating. I routinely tell students that it is currently a tight job market and they need to carefully consider this. To paraphrase one of the other posts "It's possible to say 1) rad onc is a great field, 2) students that are passionate about it should consider it, and 3) there is a tight job market especially in "desirable" geographic locations." I don't agree that I'm "shrugging off" the workforce/job supply issue. Similar to how I settled on my current job, it is more of a conscious decision that you imply. As stated above, I've chosen to direct my energy at improving our rad onc educational system. I assume (although you know what they say about "assuming") everyone on here agrees we have to keep training some radiation oncologists (25, 50, 200 - that's what I don't know), and that we should ensure these trainees come out of training able to offer the highest quality clinical care possible. If me as an individual choosing to focus my efforts somewhere other than workforce issues is morally wrong, then by this argument all labs and clinical research should stop and we all should endlessly discuss workforce issues. There are smart, dedicated, and well-intentioned ASTRO members with trainees' and the specialty's interests at heart looking closely at this, clearly SDN and Twitter have plenty of energy poured into them about this, and there are many other individuals looking at this. Just like I've chosen to acknowledge that many of my colleagues are more adept at writing protocols or conducting bench research than I am, I've chosen to trust that my more qualified colleagues focused on workforce issues are working in our field's and trainees' best interests and therefore I won't expend my personal energy on it.

We're all entitled to opinions. As I've stated in multiple places, if students understand the pros/cons to the specialty and feel it is the best fit for them, I would not tell them, "Well, I know you love the clinic, science, and personal interactions of rad onc, but there is no way I would do rad onc now." I would say, "If you feel you're well informed about the potential upside and downside and this is the best fit for you, go for it!" And then I work my hardest to help them match well and I continue to work with them during residency to offer any guidance I can (with the caveat I am only one opinion).

Can you share the data/evidence that "things have gotten a lot worse" in the past seven years? This isn't meant as an attack (since it's so hard in these forums to get "tone" across). I really am just curious to see the data/evidence. Hearsay doesn't count. 25 years ago we didn't have social networking to bring everyone together. My first awareness that rad onc even existed as a specialty - long before I had any idea I would end up a radiation oncologist - was my brother's best friend's mom (Bueller? Bueller? Bueller?) commuting every week from Berkeley CA to Miami FL to work at a practice with a Gamma Knife. I didn't understand why she was doing that... until I got into the specialty. It was hard to find jobs in specific geographic locations 25 years ago.

With regards to a pay cut, nobody "wants" a pay cut. If rad onc salaries decline, that would be a tough pill to swallow, but if you would have chosen peds or EM if the pay was equal, maybe rad onc wasn't the right choice. The vast majority of physicians "make enough" money to be happy. Mo money doesn't necessarily equal mo happiness. This is why I ask my mentees to play the aforementioned thought experiment - "If your entire med school class is making the same amount of money in 20 years, would you still choose this specialty?" A few of my colleagues at UChicago published a great paper looking at intrinsic (sense of calling, perception of rewarding work, etc) vs. extrinsic (annual income, workload and composition, etc) motivating factors and burnout. My goal with this question is to get the student to think about whether they would be intrinsically motivated by rad onc if the salary differential were equal. Who knows - maybe we'll have Medicare-for-all and all physicians will make a set annual salary regardless of specialty. I don't predict this, but the future has a funny way of throws us curveballs (I certainly didn't see coronavirus coming last year).

Maybe I'm just an optimist, but the "powers that be" are listening. The ACGME is taking a closer look at training programs and from my understanding is requiring more than just "case volumes" to justify increasing a resident complement. Academic radiation oncology faculty are working to counsel students better so they make informed decisions about potential challenges facing the specialty. I don't have easy answers for current residents or attendings that aren't happy with their job prospects/job... but remember, "Your first job usually isn't your last."

Know how many times I’ve been insulted on SDN? Like the radiologist sometimes says when looking at a brain met MRI: too numerous to count. Unlike the brain met patient though, it always wound up with me (and my ego) surviving. We still want to hear from you. Non-anonymous, you carry ten times more water than everyone else. Anyone “lobbing insults” now will just look silly. Factual retorts silence unserious folks eventually.

I can take an insult. I just want to be able to fling an insult back. If you're going to attack me personally, at least have the courage to tell me who you are so I can belittle your career path in return. Or as my mom always said, "If you don't have something nice to say about someone, don't say anything at all." Perhaps a better quote is "Great minds discuss ideas; average minds discuss events; small minds discuss people." I know everyone on this forum has a great mind. So consider restraining yourself from attacking individuals, and focus on ideas.

Here are a few of my ideas about the workforce for further discussion:
1) Residency programs should not continue to expand purely based on volumes. They need to justify high quality educational experiences. My understanding is the ACGME is taking a much closer look at program metrics and training quality. We may see more programs shrink or close in the near future. Being in academics doesn't mean "having a resident." Programs need to decouple the education component of training from the service component and ensure academic attendings have adequate clinical support whether or not they have a resident on their service. This may help to reduce the rate of expansion, although when Medicare will pay for a resident I can imagine it's hard to turn that down.
2) We don't need to train more radiation oncologists that want to practice in NYC or SF. We need to train future physician scientists (yes, I am a product of UChicago and agree with Dr. Weichselbaum on this) but we also need to train future radiation oncologists that want to practice in rural or at least non metropolitan areas. I get plenty of head hunter e-mails for more rural/non-metro locations - so how do we attract medical students that want to practice in these locations and will find a sense of calling/intrinsic motivation by practicing there?

 

[medgator]

.

Gaslighting is "a form of psychological manipulation in which a person or a group covertly sows seeds of doubt in a targeted individual or group, making them question their own memory, perception, or judgment, often evoking in them cognitive dissonance and other changes including low self-esteem." I'm not shrugging off oversupply or gaslighting anyone. I don't tell students "Rad onc is the greatest thing ever and there are no potential downsides." I'm saying I don't have the data or expertise to properly comment on the workforce supply issue. Anything I say would be speculation. I've seen how this forum treats speculation about the future of our specialty (workforce or treatment volumes) and therefore will refrain from speculating. I routinely tell students that it is currently a tight job market and they need to carefully consider this. To paraphrase one of the other posts "It's possible to say 1) rad onc is a great field, 2) students that are passionate about it should consider it, and 3) there is a tight job market especially in "desirable" geographic locations." I don't agree that I'm "shrugging off" the workforce/job supply issue. Similar to how I settled on my current job, it is more of a conscious decision that you imply. As stated above, I've chosen to direct my energy at improving our rad onc educational system. I assume (although you know what they say about "assuming") everyone on here agrees we have to keep training some radiation oncologists (25, 50, 200 - that's what I don't know), and that we should ensure these trainees come out of training able to offer the highest quality clinical care possible. If me as an individual choosing to focus my efforts somewhere other than workforce issues is morally wrong, then by this argument all labs and clinical research should stop and we all should endlessly discuss workforce issues. There are smart, dedicated, and well-intentioned ASTRO members with trainees' and the specialty's interests at heart looking closely at this, clearly SDN and Twitter have plenty of energy poured into them about this, and there are many other individuals looking at this. Just like I've chosen to acknowledge that many of my colleagues are more adept at writing protocols or conducting bench research than I am, I've chosen to trust that my more qualified colleagues focused on workforce issues are working in our field's and trainees' best interests and therefore I won't expend my personal energy on it.

We're all entitled to opinions. As I've stated in multiple places, if students understand the pros/cons to the specialty and feel it is the best fit for them, I would not tell them, "Well, I know you love the clinic, science, and personal interactions of rad onc, but there is no way I would do rad onc now." I would say, "If you feel you're well informed about the potential upside and downside and this is the best fit for you, go for it!" And then I work my hardest to help them match well and I continue to work with them during residency to offer any guidance I can (with the caveat I am only one opinion).

Can you share the data/evidence that "things have gotten a lot worse" in the past seven years? This isn't meant as an attack (since it's so hard in these forums to get "tone" across). I really am just curious to see the data/evidence. Hearsay doesn't count. 25 years ago we didn't have social networking to bring everyone together. My first awareness that rad onc even existed as a specialty - long before I had any idea I would end up a radiation oncologist - was my brother's best friend's mom (Bueller? Bueller? Bueller?) commuting every week from Berkeley CA to Miami FL to work at a practice with a Gamma Knife. I didn't understand why she was doing that... until I got into the specialty. It was hard to find jobs in specific geographic locations 25 years ago.

Because we've been here before Dan. Those that forget the past are doomed to repeat it.

The employment status of 1995 graduates from radiation oncology training programs in the United States - PubMed

This is the only employment survey for any specialty in which a 100% response rate was achieved. Upon graduation, a significant number of residents and fellows were either unemployed or involuntarily underemployed. The job market absorbed only a fraction of them at 6-8 months. Most graduates...

pubmed.ncbi.nlm.nih.gov

Is that what it will take for you to believe there is a problem?

I'm thrilled with my job. I also know jobs like mine are very hard to find these days and i understand the forces behind why that's the case. I also know what the recent arro resident survey showed.

 

[RickyScott]

I'm happy to have a civil discussion. I have the same concerns as everyone on here, I just don't believe it's as dire as some of you make it out to be. Maybe I'll be proved wrong in 20 years and we can have another discussion here about how you were all correct and the sky really was falling in 2020. With regards to my chair, he is entitled to his opinions which he expresses openly. He has not gotten to where he is by mincing words. I encourage you all to read about Radical Candor. When I read it I said, "Ah hah - Dr. Weichselbaum is the king of radical candor." He calls it how he sees it and you might not like it, but he's being honest. I will keep this subsequent discussion focused on the critique of my post above and my personal tweets.

1. My point is if a resident is interested in academic work (research, education, teaching, etc.) there might be certain advantages to having a job at a network site. If your passion is informatics or health economics or education, maybe you don't need to be a disease site guru at a main campus. I have the utmost respect for my colleagues that are world renowned disease site experts, write novel clinical protocols (both adding or removing RT), or run a lab. That wasn't for me and I was lucky to have this job become available. I do not "assume" that because I've been successful (at least by my own measure, maybe not by others), current/future residents will be. However, I do believe that if current/future residents can be given other yardsticks by which to measure "success" they may consider themselves successful in unconventional positions.
2. I took a job with a 40 minute commute so my spouse could stay at their job. I gambled that I would be given the academic freedom I was hoping for, and it worked out. I always bring up this risk (i.e., low geographic determinability) with medical students when counseling about career choice. I've had two stellar mentees in the past 2 years that decided to pursue other specialties for this reason. One chose diagnostic radiology because they wanted to be in one of three major metropolitan areas and felt it was more flexible for them and their significant other. The other chose internal medicine because their significant other wants to do a competitive specialty and so this student wanted to be support them and be able to have a more flexible job location (in this case it was a male mentee choosing a "less competitive" specialty for their female partner - some good #HeForShe there). I was not sad these students chose not to pursue rad onc - I was happy that they made informed decisions and decided rad onc wasn't for them due to the tight job market. My job is not to blindly recruit students into the specialty. It's to counsel students about the pros/cons of different specialties and help them do affective forecasting so 5 or 10 or 20 years later they aren't angry about their job. I'm sorry that some of you weren't counseled about this aspect of choosing a small specialty (rad onc isn't unique) and when I give talks to ADROP or ASTRO I always bring this up as a critical aspect of counseling students.
3. I have a finite amount of time/energy. I choose to direct my energy at UGME and developing educational curricula. My personal interest is in how we educate our trainees, patients, and colleagues. Workforce research requires a different expertise (economics, supply/demand, reimbursement, etc, etc) that I don't have. If a resident is having trouble finding a position, I would be happy to talk to them and help strategize. One piece of advice I got when applying for jobs was "Your first job usually isn't your last." I have numerous colleagues who took jobs initially that worked for them but after some time transferred to a different position - some moved across the country, some left academics, some went back to academics. Point is, you might have to compromise initially, but keep your eyes open and head up and if you feel the need, consider moving positions.
4. I initially posted my e-mail. Wasn't sure if that was safe/appropriate to put a direct link to my e-mail on this forum - I come here once in a blue moon. I decided to let you know how to contact me. My point was my e-mail is easy to access (ASTRO, PubMed). You can also search the UChicago directory. Sure, the PubMed comment was a little snippy, but it was a visceral response to the OP that implied I was somehow "not academic." And to this point, there are plenty of PP docs that are super academic (have R01s, write national protocols, etc) and plenty of "academic" docs that aren't academic. "Academic" to me implies working to advance the field, teaching, and publishing scholarship. This can be done in any job - it's just facilitated more at "academic" medical centers where it is part of the institutional mission.
5. I'm sure most of you can "phone a friend." My point was I'm not sitting solo at some clinic in the cornfields (it is in cornfields, but I'm not solo) "babyistting" linacs with no support. Some of you have an amazing ability to assume every comment on Twitter or this site is directed at you. It's usually not.
6. Maybe you are on ASTRO/ARRO committees. Great - these are avenues to effect change. Incendiary posts on Twitter or SDN worsen the divide between what you espouse you want and what you'll be able to get. I don't agree with the psychology of your approach.
7. I'm not sure what this comment is trying to get at. Just because others in society choose to use incendiary/inflammatory rhetoric in an attempt to get their point across doesn't mean it's OK or a good tactic. I refuse to conflate the challenges our specialty faces with the social, cultural, and political challenges currently facing our country.

Thanks @Neuronix. It would have been a challenge if I didn't find a job in one of those three locations. My spouse was willing to move and look for other work, although their job description would have likely changed significantly. I do consider myself lucky that this particular job came about the year I was graduating. I was prepared to take a different job and was already telling myself, "Your first job usually isn't your last job." I have friends/colleagues in other small niche specialties (ophtho, neurosurg, etc) that have to move around to find a job that works. Again, this is something med school advisors need to counsel students about what they are discussing specialty selection.

Gaslighting is "a form of psychological manipulation in which a person or a group covertly sows seeds of doubt in a targeted individual or group, making them question their own memory, perception, or judgment, often evoking in them cognitive dissonance and other changes including low self-esteem." I'm not shrugging off oversupply or gaslighting anyone. I don't tell students "Rad onc is the greatest thing ever and there are no potential downsides." I'm saying I don't have the data or expertise to properly comment on the workforce supply issue. Anything I say would be speculation. I've seen how this forum treats speculation about the future of our specialty (workforce or treatment volumes) and therefore will refrain from speculating. I routinely tell students that it is currently a tight job market and they need to carefully consider this. To paraphrase one of the other posts "It's possible to say 1) rad onc is a great field, 2) students that are passionate about it should consider it, and 3) there is a tight job market especially in "desirable" geographic locations." I don't agree that I'm "shrugging off" the workforce/job supply issue. Similar to how I settled on my current job, it is more of a conscious decision that you imply. As stated above, I've chosen to direct my energy at improving our rad onc educational system. I assume (although you know what they say about "assuming") everyone on here agrees we have to keep training some radiation oncologists (25, 50, 200 - that's what I don't know), and that we should ensure these trainees come out of training able to offer the highest quality clinical care possible. If me as an individual choosing to focus my efforts somewhere other than workforce issues is morally wrong, then by this argument all labs and clinical research should stop and we all should endlessly discuss workforce issues. There are smart, dedicated, and well-intentioned ASTRO members with trainees' and the specialty's interests at heart looking closely at this, clearly SDN and Twitter have plenty of energy poured into them about this, and there are many other individuals looking at this. Just like I've chosen to acknowledge that many of my colleagues are more adept at writing protocols or conducting bench research than I am, I've chosen to trust that my more qualified colleagues focused on workforce issues are working in our field's and trainees' best interests and therefore I won't expend my personal energy on it.

We're all entitled to opinions. As I've stated in multiple places, if students understand the pros/cons to the specialty and feel it is the best fit for them, I would not tell them, "Well, I know you love the clinic, science, and personal interactions of rad onc, but there is no way I would do rad onc now." I would say, "If you feel you're well informed about the potential upside and downside and this is the best fit for you, go for it!" And then I work my hardest to help them match well and I continue to work with them during residency to offer any guidance I can (with the caveat I am only one opinion).

Can you share the data/evidence that "things have gotten a lot worse" in the past seven years? This isn't meant as an attack (since it's so hard in these forums to get "tone" across). I really am just curious to see the data/evidence. Hearsay doesn't count. 25 years ago we didn't have social networking to bring everyone together. My first awareness that rad onc even existed as a specialty - long before I had any idea I would end up a radiation oncologist - was my brother's best friend's mom (Bueller? Bueller? Bueller?) commuting every week from Berkeley CA to Miami FL to work at a practice with a Gamma Knife. I didn't understand why she was doing that... until I got into the specialty. It was hard to find jobs in specific geographic locations 25 years ago.

With regards to a pay cut, nobody "wants" a pay cut. If rad onc salaries decline, that would be a tough pill to swallow, but if you would have chosen peds or EM if the pay was equal, maybe rad onc wasn't the right choice. The vast majority of physics "make enough" money to be happy. Mo money doesn't necessarily equal mo happiness. This is why I ask my mentees to play the aforementioned thought experiment - "If your entire med school class is making the same amount of money in 20 years, would you still choose this specialty?" A few of my colleagues at UChicago published a great paper looking at intrinsic (sense of calling, perception of rewarding work, etc) vs. extrinsic (annual income, workload and composition, etc) motivating factors and burnout. My goal with this question is to get the student to think about whether they would be intrinsically motivated by rad onc if the salary differential were equal. Who knows - maybe we'll have Medicare-for-all and all physicians will make a set annual salary regardless of specialty. I don't predict this, but the future has a funny way of throws us curveballs (I certainly didn't see coronavirus coming last year).

Maybe I'm just an optimist, but the "powers that be" are listening. The ACGME is taking a closer look at training programs and from my understanding is requiring more than just "case volumes" to justify increasing a resident complement. Academic radiation oncology faculty are working to counsel students better so they make informed decisions about potential challenges facing the specialty. I don't have easy answers for current residents or attendings that aren't happy with their job prospects/job... but remember, "Your first job usually isn't your last."



I can take an insult. I just want to be able to fling an insult back. If you're going to attack me personally, at least have the courage to tell me who you are so I can belittle your career path in return. Or as my mom always said, "If you don't have something nice to say about someone, don't say anything at all." Perhaps a better quote is "Great minds discuss ideas; average minds discuss events; small minds discuss people." I know everyone on this forum has a great mind. So consider restraining yourself from attacking individuals, and focus on ideas.

Here are a few of my ideas about the workforce for further discussion:
1) Residency programs should not continue to expand purely based on volumes. They need to justify high quality educational experiences. My understanding is the ACGME is taking a much closer look at program metrics and training quality. We may see more programs shrink or close in the near future. Being in academics doesn't mean "having a resident." Programs need to decouple the education component of training from the service component and ensure academic attendings have adequate clinical support whether or not they have a resident on their service. This may help to reduce the rate of expansion, although when Medicare will pay for a resident I can imagine it's hard to turn that down.
2) We don't need to train more radiation oncologists that want to practice in NYC or SF. We need to train future physician scientists (yes, I am a product of UChicago and agree with Dr. Weichselbaum on this) but we also need to train future radiation oncologists that want to practice in rural or at least non metropolitan areas. I get plenty of head hunter e-mails for more rural/non-metro locations - so how do we attract medical students that want to practice in these locations and will find a sense of calling/intrinsic motivation by practicing there?

Appreciate coming on here, but would add 2 points. 1) geography much bigger factor for most of us vs salaries and therefore rural jobs are the least desirable. Consequently, they are the last too fill, but this does not mean shortage of xrt in rural areas, just that they are the most undesirable jobs. we will still see that this is the case in several years when unemployment and fellowships abound.
2) we all agree that radiation is very interesting field, but psychological research on passion and careers show that most people would be engaged in a number of fields. Nobody was born to be a radiation oncologist and almost all of us would have had equally fulfilling career in a number of specialties. Many great specialties in medicine so why choose one with such significant limitations.

 

[hbosch]

Dan,

I’m repeating what many have already stated eloquently and nicely. You graduated 7 years ago and got a job in Chicago that you enjoy. You limited your search to 3 cities. For anyone looking for a job now is laughable to possibly mentally ill (as in not acknowledging reality). I am not calling you mentally ill to be clear.

Also, I have seen that a bad job market leads to people such as your senior Ralph to getting away with harassment, underpaying, poor leadership, toxic work culture and accepting (this is the worst part) dangerously bad physics with the possibility of hurting your patients and putting yourself at medicolegal risk. (I’m not saying this happening at your institution but it is happening at many community facilities). And you can’t ask your toxic leadership for help because they might just not care and if you complain they will make your life miserable. The people in these jobs (and it’s far more prevalent than you think) can’t just get up and find another job - even if they do it requires relocating far away from the life they have made for themselves with their families enduring yet another move. We’re not where you were 7 years ago. I wish I had started looking for a job that long ago. And yes, if you don’t know what the right residency number is than stop expanding.

And I will post this from an advice column- don’t know the specialty of the doctor but many of the criticizers seem to think young rad Oncs live in a vacuum without a life outside their job.

I absolutely fully regret going into radiation oncology because I can’t find a job near a large city and in small cities the support staff can be dangerous because talented and reliable people don’t want to live there. Otherwise I adore our field and what we do every day. I love being in a room with a patient. I love contouring. One of my favorite parts of a job to this day is opening up a follow up image. None of it makes up for feeling unsafe in your job. And it can’t make up for giving your family a stifling life or negatively affecting the career of your spouse. We are full formed humans not one dimensional contouring machines. And even if we were contour machines we are machines that rely on having adequate support staff.

 

[DebtRising]

Thanks for your post Dr Golden.
Appreciate you’re engagement.

Both Astro and Scarop abdicated all responsibility in studying the labor market, which they have the power to do more effectively than anyone else. When the field told them they were worried in the workplace survey, their response was “We don’t care” (and read that astrogram if you think that is a blithe oversimplification).

So when you ask questions (what is the right number of residents) and then ask for data (but do not seem to object to the content of the oversupply paper, the decreased utilization disease site papers, the increase in resident compliments, or the obvious aspect that we don’t treat low risk prostate and breast fractions went from 25 to 0-15), while also seeking to represent the organizations that can logistically collect this data and study it, to me it comes across as intellectually dishonest. If I am an incorrect internet troll, or the data I have posted number times is wrong - either cite the fallacies in the data, or take the responsibility of representing the societies that can study this seriously and do so. I would be thrilled to be proven wrong, heck I would be thrilled to be proven right just to be done with it. But to cast aspersions on us, without bothering to actually investigate (while having the best and maybe only true resources and connections to do so) is not a valid argument, wether anonymous or not.