Rad Onc Twitter

[medgator]

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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.

Huge points i had forgotten about, but very valid as rural jobs become a bigger source of jobs for graduating residents. Physics/dosimetrist support is paramount and i have definitely seen sketchy situations before (dosi/physicist comes in on weekends to work on your plans, check plans etc as a per diem since they can't find anyone willing to work there FT).

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[RadSki]

This is like a Twilight Zone version of a Rad Onc Reddit AMA...

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

I'm not moral policing. Expecting to be treated with the same respect and dignity I treat you is called being polite. I refuse to accept that "Professionalism/civility are ultimately constructs to keep younger attendings, minorities, women etc down." There is a difference between a small group of men deciding wearing a bikini is unprofessional and society as a whole accepting basic tenets of civility and professionalism - don't yell, don't insult, don't treat others in a way you wouldn't want to be treated. If we can't solve problems in radiation oncology, medicine, or the country with civil discourse and debate, we are in serious trouble... and maybe we are... only time will tell. Social media and web forums such as SDN thrive on which post/thread gets the most attention... and unfortunately that is often the most inflammatory, incendiary, or insulting message. Here is some light reading on this topic: The Dark Psychology of Social Networks.

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.

The analogy to a penny stock is hyperbole. Sure, maybe rad onc was in a bubble 10 or 15 years ago when it was IMRT full steam ahead for 44 fractions, take no prisoners, but I reject the analogy that we are trading at <$1 currently. Also, I do not "tell" students to go into radiation oncology. I advise them on the potential pros and cons and encourage them to take time to carefully reflect on their personal and professional priorities before making a specialty decision. I also encourage them to speak to docs in other specialties and consider lots of options before settling on rad onc if it's right for them.

The use of the terms "downside and upside potential" are euphemisms for "likelihood of earning less, not more, in the long run." I guess we just have different perceptions of what is "enough" to live on. If you went to medical school expecting to make no less than $600k/year when you finished residency, I would argue you didn't go to medical school for the right reason. If you went to medical school because you were passionate about medicine and would be willing to choose a specialty because you loved the clinical milieu, patient care, and underlying basic science, regardless of salary, you probably went for the right reasons.

Yes - major metropolitan areas are highly competitive job markets in radiation oncology. As I stated in a prior post, academic faculty need to work to recruit a diverse cadre of trainees that will fill the jobs in urban centers but also the jobs in more rural/less "desirable" locations. If there are enough people living somewhere that they need a radiation oncologist, I am confident there are "desirable" attributes to that location. Iw as born and raised in Oakland/Berkeley, CA. The way many of my family and friends that still live in California see it, if it's not California, the weather or location must be miserable. Well, I've learned that 90% of the country lives outside California and guess what - they're happy and enjoy where they live. This gets back to my point that when counseling students considering the specialty, mentors need to emphasize the low geographic determinability of rad onc and to accept that they may need to move around the country to find "the right job." This might be a reason some students choose another specialty - and I'm OK with that.

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.

I view that article in a different light. To me it says that this is not a new problem, we're just more acutely aware of it because Twitter and SDN allow the aggrieved few to congregate and perseverate. See my story of my brother's friend's mom in ~1995 (same era as that survey). The job market was "tight" or "competitive" or "difficult" back then too. Every radiation oncologist I know in academics or private practice seems very content with their job. Maybe one of you is a friend, and you just haven't told me you believe your job is equal to a penny stock, but if that's the case, you're doing a great job hiding it. The problem on SDN is I have no way to verify who any of you truly are. I'm sure most of you are legit, but it just takes one or two Russian bots or colleagues who enjoy causing problems to stir the whole crowd into a frenzy. I will continue to argue that the best way to effect change is come out of the shadows and engage in open dialogue and advocacy. If ASTRO and ACRO don't do it for you, start your own organization to effect change (see ROECSG). There are many more effective ways to effect change than anonymous rants and insults directed at our colleagues.

OK - I'm going to check how my penny stock performed today and review films and fill out my billing docs.

 

[scarbrtj]

Can you share the data/evidence that "things have gotten a lot worse" in the past seven years?

Like the Eagles on their Hell Freezes Over Tour, here are my greatest hits from the last 10 or so years:
1) Resident numbers are up 60-70%
2) Incidence of residents entering fellowships, and fellowship numbers, are up substantially, a sign of less attainable “regular” jobs and IMHO less well-trained residents upon residency completion (else why seek non-ACGME "fellowships"?)
3) Un/Under-employment was ~8% in 2014 in our specialty (think it's better/worse/same now?)
4) Fraction numbers and thus patients on treatment have fallen; rad onc utilization on a per diagnosis basis has fallen slightly. Think of a rad onc seeing his/her "share" of American breast CA cases 10y ago when tx times were ~6 weeks. That meant ~3 patients per day under beam. Now with 1 week schedules on horizon, it means 0.5 patients per day under beam, or 1 per day one week and 0 per day the next week. This is a clear mathematical exercise, or gedankenexperiment as you say, that shows we can have the same diagnosis rate but literally need zero rad oncs in the clinic on occasion due to hypofractionation.
5) Resident case numbers have fallen overall (as much as 10-25%, relatively, in lung/lymphoma/GU) so residents are getting less case experience now
6) Cancer incidence is falling: by ~7% since 2010. Prevalence only up ~15%.
7) Private practice is declining, academics has been increasing (but the PP people are closed off to academic job opportunities)... so please advise rural job-takers there's no return to nearly half of the available job market.
8) A big “prop up” to the job market, supervision, is getting gradually chipped away—by govt mandate, and by COVID

TL;DR
Rad onc production rate up 60-70% last 10 years, and growing, while all metrics together suggest a flat or negative growth workforce need

However as you demonstrate, there still exists the luxury to some extent to say “I don’t see that things are a lot worse.” I don’t think we will have to wait 20 years to see if the train will go off track though. We have about 5000-5200 rad oncs in America right now. Over the next 5 years, ie by 2025, we will see if an extra 1000 or so can be painlessly added to the workforce. I foresee that on the low side 20 or more residents per year, out of 200, will go jobless. Doubters should refer to the 2014 employment analysis I linked to above when things were ostensibly better.

So that's my metric for no longer being able to deny there's a problem, and people who do so are immoral: if/when we get to >10% unemployment rate in a graduating class. We've been there before, e.g. ~17% unemployment in 1995. That's what we are all trying to avoid. (And not for nothin', high unemployment at the recently graduated level has to have some effect on the out-an-already-practicing-who-want-a-job too. I also think that will affect change.)

 

[deleted774703]

This is like a Twilight Zone version of a Rad Onc Reddit AMA...



I'm not moral policing. Expecting to be treated with the same respect and dignity I treat you is called being polite. I refuse to accept that "Professionalism/civility are ultimately constructs to keep younger attendings, minorities, women etc down." There is a difference between a small group of men deciding wearing a bikini is unprofessional and society as a whole accepting basic tenets of civility and professionalism - don't yell, don't insult, don't treat others in a way you wouldn't want to be treated. If we can't solve problems in radiation oncology, medicine, or the country with civil discourse and debate, we are in serious trouble... and maybe we are... only time will tell. Social media and web forums such as SDN thrive on which post/thread gets the most attention... and unfortunately that is often the most inflammatory, incendiary, or insulting message. Here is some light reading on this topic: The Dark Psychology of Social Networks.



The analogy to a penny stock is hyperbole. Sure, maybe rad onc was in a bubble 10 or 15 years ago when it was IMRT full steam ahead for 44 fractions, take no prisoners, but I reject the analogy that we are trading at <$1 currently. Also, I do not "tell" students to go into radiation oncology. I advise them on the potential pros and cons and encourage them to take time to carefully reflect on their personal and professional priorities before making a specialty decision. I also encourage them to speak to docs in other specialties and consider lots of options before settling on rad onc if it's right for them.

The use of the terms "downside and upside potential" are euphemisms for "likelihood of earning less, not more, in the long run." I guess we just have different perceptions of what is "enough" to live on. If you went to medical school expecting to make no less than $600k/year when you finished residency, I would argue you didn't go to medical school for the right reason. If you went to medical school because you were passionate about medicine and would be willing to choose a specialty because you loved the clinical milieu, patient care, and underlying basic science, regardless of salary, you probably went for the right reasons.

Yes - major metropolitan areas are highly competitive job markets in radiation oncology. As I stated in a prior post, academic faculty need to work to recruit a diverse cadre of trainees that will fill the jobs in urban centers but also the jobs in more rural/less "desirable" locations. If there are enough people living somewhere that they need a radiation oncologist, I am confident there are "desirable" attributes to that location. Iw as born and raised in Oakland/Berkeley, CA. The way many of my family and friends that still live in California see it, if it's not California, the weather or location must be miserable. Well, I've learned that 90% of the country lives outside California and guess what - they're happy and enjoy where they live. This gets back to my point that when counseling students considering the specialty, mentors need to emphasize the low geographic determinability of rad onc and to accept that they may need to move around the country to find "the right job." This might be a reason some students choose another specialty - and I'm OK with that.



I view that article in a different light. To me it says that this is not a new problem, we're just more acutely aware of it because Twitter and SDN allow the aggrieved few to congregate and perseverate. See my story of my brother's friend's mom in ~1995 (same era as that survey). The job market was "tight" or "competitive" or "difficult" back then too. Every radiation oncologist I know in academics or private practice seems very content with their job. Maybe one of you is a friend, and you just haven't told me you believe your job is equal to a penny stock, but if that's the case, you're doing a great job hiding it. The problem on SDN is I have no way to verify who any of you truly are. I'm sure most of you are legit, but it just takes one or two Russian bots or colleagues who enjoy causing problems to stir the whole crowd into a frenzy. I will continue to argue that the best way to effect change is come out of the shadows and engage in open dialogue and advocacy. If ASTRO and ACRO don't do it for you, start your own organization to effect change (see ROECSG). There are many more effective ways to effect change than anonymous rants and insults directed at our colleagues.

OK - I'm going to check how my penny stock performed today and review films and fill out my billing docs.

View attachment 314184

Dan, I have to disagree with you AGAIN...

Your focus on politeness over discourse is an attempt to distract

Why do you think BLM is happening in this country? It's because ppl have been pushed to the brink due to the failure of "polite discussions or civil discourse, etc"

While RO is not BLM, many of us feel that we are at the brink and have been pushed aside, not listened to, or cared about by the leaders of this field.

If you do not understand that, then you are completely missing the point and by all means pursue civility over action

Second, you continue to morally police us by saying we went to medical school for the wrong reason if we want 600K

I'm sorry, but there is only one "wrong reason" and that is not caring about/hurting patients. It's not just helping people. Guess what, my trash man helps me too.

You can care about money AND provide world class care to another human at the same time. Not that hard to understand.

BTW, low geographic determinability is going to be a problem for the vast majority of the class. That is reason #1 why everyone is so angry...

 

[Chartreuse Wombat]

This is like a Twilight Zone version of a Rad Onc Reddit AMA...



I'm not moral policing. Expecting to be treated with the same respect and dignity I treat you is called being polite. I refuse to accept that "Professionalism/civility are ultimately constructs to keep younger attendings, minorities, women etc down." There is a difference between a small group of men deciding wearing a bikini is unprofessional and society as a whole accepting basic tenets of civility and professionalism - don't yell, don't insult, don't treat others in a way you wouldn't want to be treated. If we can't solve problems in radiation oncology, medicine, or the country with civil discourse and debate, we are in serious trouble... and maybe we are... only time will tell. Social media and web forums such as SDN thrive on which post/thread gets the most attention... and unfortunately that is often the most inflammatory, incendiary, or insulting message. Here is some light reading on this topic: The Dark Psychology of Social Networks.



The analogy to a penny stock is hyperbole. Sure, maybe rad onc was in a bubble 10 or 15 years ago when it was IMRT full steam ahead for 44 fractions, take no prisoners, but I reject the analogy that we are trading at <$1 currently. Also, I do not "tell" students to go into radiation oncology. I advise them on the potential pros and cons and encourage them to take time to carefully reflect on their personal and professional priorities before making a specialty decision. I also encourage them to speak to docs in other specialties and consider lots of options before settling on rad onc if it's right for them.

The use of the terms "downside and upside potential" are euphemisms for "likelihood of earning less, not more, in the long run." I guess we just have different perceptions of what is "enough" to live on. If you went to medical school expecting to make no less than $600k/year when you finished residency, I would argue you didn't go to medical school for the right reason. If you went to medical school because you were passionate about medicine and would be willing to choose a specialty because you loved the clinical milieu, patient care, and underlying basic science, regardless of salary, you probably went for the right reasons.

Yes - major metropolitan areas are highly competitive job markets in radiation oncology. As I stated in a prior post, academic faculty need to work to recruit a diverse cadre of trainees that will fill the jobs in urban centers but also the jobs in more rural/less "desirable" locations. If there are enough people living somewhere that they need a radiation oncologist, I am confident there are "desirable" attributes to that location. Iw as born and raised in Oakland/Berkeley, CA. The way many of my family and friends that still live in California see it, if it's not California, the weather or location must be miserable. Well, I've learned that 90% of the country lives outside California and guess what - they're happy and enjoy where they live. This gets back to my point that when counseling students considering the specialty, mentors need to emphasize the low geographic determinability of rad onc and to accept that they may need to move around the country to find "the right job." This might be a reason some students choose another specialty - and I'm OK with that.



I view that article in a different light. To me it says that this is not a new problem, we're just more acutely aware of it because Twitter and SDN allow the aggrieved few to congregate and perseverate. See my story of my brother's friend's mom in ~1995 (same era as that survey). The job market was "tight" or "competitive" or "difficult" back then too. Every radiation oncologist I know in academics or private practice seems very content with their job. Maybe one of you is a friend, and you just haven't told me you believe your job is equal to a penny stock, but if that's the case, you're doing a great job hiding it. The problem on SDN is I have no way to verify who any of you truly are. I'm sure most of you are legit, but it just takes one or two Russian bots or colleagues who enjoy causing problems to stir the whole crowd into a frenzy. I will continue to argue that the best way to effect change is come out of the shadows and engage in open dialogue and advocacy. If ASTRO and ACRO don't do it for you, start your own organization to effect change (see ROECSG). There are many more effective ways to effect change than anonymous rants and insults directed at our colleagues.

OK - I'm going to check how my penny stock performed today and review films and fill out my billing docs.

View attachment 314184

Simple supply and demand. You got yours. Just wait until the health system tells you that you are too expensive and they have a competent candidate who will work for 60%. they may not write papers on curricula but who cares.

 

[RadSki]

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.

To clarify, I sent my CV to ~40 chairs of departments at numerous academic medical centers in mid to large size cities across the country. The vast majority never responded. My spouse was willing to move out of Chicago/NYV/Philly, but I knew it would significantly impact their career. Thus, Chicago had a leg up already. I had exactly one phone interview from an institution in NYC - never heard back, interviewed at ASTRO with a the aforementioned east coast "academic" satellite job with no protected time. I interviewed at one large department in a mid-to-large midwest city, didn't get an offer, and then interviewed with a west coast department. I had an offer there for a main campus position and at UChicago for the job I currently hold. It was an easy decision because of my spouse's career and I had a sense of the "academic freedom" I'd have by not being in a main campus job. I fully understand the stress and anxiety the job search causes and as I've said before, I'm lucky this job became available when I was graduating.

I am sorry that you regret going into radiation oncology. I hope current trainees hear your story and consider it carefully when making their specialty decision.

Unfortunately, the story in the advice column is not unique to rad onc. Medicine is notoriously hard on relationships during training - this isn't how it should be, and my impression is it's better than it used to be - but it's still how it is. I remember a PBS documentary series called "Doctors' Diaries" that was being released through the 1990s when I was considering a career in medicine. Over half of the documentary subjects got divorced. I still remember being asked "Why would you want to be a doctor when it will destroy your personal life?" I was willing to take the risk because being a doctor was worth it. I knew rad onc had risks with regards to geographic determinability. If my priority was living in the Bay Area where I grew up, I should have chosen IM, Peds, or another general specialty. I decided rad onc was worth the risk.

 

[RadSki]

Keep smoking that crack RadSki. Simple supply and demand. You got yours. Just wait until the health system tells you that you are too expensive and they have a competent candidate who will work for 60%. they may not write papers on curricula but who cares.

I was wondering when @Chartreuse Wombat would come out of hiding with a well reasoned and thoughtful response. Glad I didn't have to wait too long.

 

[elementaryschooleconomics]

To clarify, I sent my CV to ~40 chairs of departments at numerous academic medical centers in mid to large size cities across the country. The vast majority never responded. My spouse was willing to move out of Chicago/NYV/Philly, but I knew it would significantly impact their career. Thus, Chicago had a leg up already. I had exactly one phone interview from an institution in NYC - never heard back, interviewed at ASTRO with a the aforementioned east coast "academic" satellite job with no protected time. I interviewed at one large department in a mid-to-large midwest city, didn't get an offer, and then interviewed with a west coast department. I had an offer there for a main campus position and at UChicago for the job I currently hold. It was an easy decision because of my spouse's career and I had a sense of the "academic freedom" I'd have by not being in a main campus job. I fully understand the stress and anxiety the job search causes and as I've said before, I'm lucky this job became available when I was graduating.

I am sorry that you regret going into radiation oncology. I hope current trainees hear your story and consider it carefully when making their specialty decision.

Unfortunately, the story in the advice column is not unique to rad onc. Medicine is notoriously hard on relationships during training - this isn't how it should be, and my impression is it's better than it used to be - but it's still how it is. I remember a PBS documentary series called "Doctors' Diaries" that was being released through the 1990s when I was considering a career in medicine. Over half of the documentary subjects got divorced. I still remember being asked "Why would you want to be a doctor when it will destroy your personal life?" I was willing to take the risk because being a doctor was worth it. I knew rad onc had risks with regards to geographic determinability. If my priority was living in the Bay Area where I grew up, I should have chosen IM, Peds, or another general specialty. I decided rad onc was worth the risk.

"I earned my pink Cadillac, and so can you"?

 

[Chartreuse Wombat]

I was wondering when @Chartreuse Wombat would come out of hiding with a well reasoned and thoughtful response. Glad I didn't have to wait too long.

Begin your refutation most illustrious one.

Supply has increased this in inarguable. Refute with data please. I got plenty but simple to just look at ACGME.

Demand has decreased. Refute with data please. Please reference scarb

It is simple math. Is that in your curricula?

 

[Chartreuse Wombat]

I was wondering when @Chartreuse Wombat would come out of hiding with a well reasoned and thoughtful response. Glad I didn't have to wait too long.

Please refute the following most illustrious ONE

Supply is increased. I will translate. The number of trainees has increased over the last decade by something like >50%.

Demand has decreased. Google hypofractionation, RO APM, Medicare limits physical presence. Oligomets aint't the savior (sorry Ralph)

Labor economics. Supply/demand. I know that is not in your educational curriculum but perhaps it should be.

 

[deleted774703]

To clarify, I sent my CV to ~40 chairs of departments at numerous academic medical centers in mid to large size cities across the country. The vast majority never responded. My spouse was willing to move out of Chicago/NYV/Philly, but I knew it would significantly impact their career. Thus, Chicago had a leg up already. I had exactly one phone interview from an institution in NYC - never heard back, interviewed at ASTRO with a the aforementioned east coast "academic" satellite job with no protected time. I interviewed at one large department in a mid-to-large midwest city, didn't get an offer, and then interviewed with a west coast department. I had an offer there for a main campus position and at UChicago for the job I currently hold. It was an easy decision because of my spouse's career and I had a sense of the "academic freedom" I'd have by not being in a main campus job. I fully understand the stress and anxiety the job search causes and as I've said before, I'm lucky this job became available when I was graduating.

I am sorry that you regret going into radiation oncology. I hope current trainees hear your story and consider it carefully when making their specialty decision.

Unfortunately, the story in the advice column is not unique to rad onc. Medicine is notoriously hard on relationships during training - this isn't how it should be, and my impression is it's better than it used to be - but it's still how it is. I remember a PBS documentary series called "Doctors' Diaries" that was being released through the 1990s when I was considering a career in medicine. Over half of the documentary subjects got divorced. I still remember being asked "Why would you want to be a doctor when it will destroy your personal life?" I was willing to take the risk because being a doctor was worth it. I knew rad onc had risks with regards to geographic determinability. If my priority was living in the Bay Area where I grew up, I should have chosen IM, Peds, or another general specialty. I decided rad onc was worth the risk.

I find it ironic that you cling to show me the data that the sky is falling but then regale us with your individual experience

 

[medgator]

I was wondering when @Chartreuse Wombat would come out of hiding with a well reasoned and thoughtful response. Glad I didn't have to wait too long.

Honest question, are you actually going to address the argument or keep making it personal? We have employment surveys from 1995 and 2014 published in the IJROBP showing real issues with the job market. You got lucky a chi-town job opened up your year... What would have happened if it didn't? Realistically, either one of us could have been forced into Salina, or Rhinelander or Joplin MO.

 

[hbosch]

Dan, I have to disagree with you AGAIN

Your focus on politeness over discourse is an attempt to distract

Why do you think BLM is happening in this country? It's because ppl have been pushed to the brink due to the failure of "polite discussions or civil discourse, etc"

While RO is not BLM, many of us feel that we are at the brink and have been pushed aside, not listened to, or cared about by the leaders of this field.

If you do not understand that, then you are completely missing the point and by all means pursue civility over action

Second, you continue to morally police us by saying we went to medical school for the wrong reason if we want 600K

I'm sorry, but there is only one "wrong reason" and that is not caring about/hurting patients. It's not just helping people. Guess what, my trash man helps me too.

You can care about money AND provide world class care to another human at the same time. Not that hard to understand.

BTW, low geographic determinability is going to be a problem for the vast majority of the class. That is reason #1 why everyone is so angry...

Yes, and I’m sure this poster is not attempting to say we have suffered as much as black people have in this country as he did state it’s not the same as BLM.

We definitely are affected with a bad job market. And you want us to try to have a civil discourse showing our identi? So what, my prior employers can flip out that I implied they were toxic, support staff was dangerous? And who will fill out my credentialing forms for any future jobs. The chairman fills it out. It is easy to say what you say without worrying about repercussions. It is impossible to say what we say without facing retaliation and even more difficult time getting another job. Essentially we would be destroying our futures (what little we have). This is exactly why a poor job market is dangerous. It makes us mute.

I still need you figure out who is going to convince a smart and reliable dosimetrist or physicist to go to the rural jobs you want to fill. Whoever goes to those jobs needs to deal with the following as well: possibly bad pathology, surgeons who are general or even if they aren’t- they may not be good. I’ve seen thoracic surgeons, ENT surgeons consistently get 2 nodes and then blame pathology for not finding the nodes. I’ve seen general surgeons do blunt dissections with TME or just not do a TME. I’ve seen bad med oncs who don’t order the proper work up or give the wrong chemo. You think the admin cares how well those surgeons do surgery? Or they just care that A surgery is being done. You think the patient pop knows the surgery was bad? You think it’s easy for the person at the end of the referral process who might be 30 years younger to get into an argument with some guy practicing in the community for 2 or 3 decades? Who will the admin listen to? Me the new person or that guy who has already made the hospital a **** ton of money with his bad surgeries?

For a job like rad Onc rural medicine is not just hard it puts you at massive risk!!

it is so easy for someone in Chicago to act like Lubbock TX has something desirable about it- you and you’re family won’t be the ones searching for that something.

as someone stated already nobody is born to be a rad onc. so why not do another specialty?

and yes trash men, janitors, grocery store workers are as essential as we are. We see that’s very clearly now. It’s not just about helping people.

 

[Chartreuse Wombat]

SInce I am guessing you think you know who I am let me quote back your profound insight.

"Great minds discuss ideas; average minds discuss events; small minds discuss people."

Engage with the idea that supply has increased

Engage with the idea that demand has decreased

No need to go ad hominem on the person

amirite

 

[RadSki]

Dan, I have to disagree with you AGAIN

Your focus on politeness over discourse is an attempt to distract

Why do you think BLM is happening in this country? It's because ppl have been pushed to the brink due to the failure of "polite discussions or civil discourse, etc"

While RO is not BLM, many of us feel that we are at the brink and have been pushed aside, not listened to, or cared about by the leaders of this field.

If you do not understand that, then you are completely missing the point and by all means pursue civility over action

Second, you continue to morally police us by saying we went to medical school for the wrong reason if we want 600K

I'm sorry, but there is only one "wrong reason" and that is not caring about/hurting patients. It's not just helping people. Guess what, my trash man helps me too.

You can care about money AND provide world class care to another human at the same time. Not that hard to understand.

BTW, low geographic determinability is going to be a problem for the vast majority of the class. That is reason #1 why everyone is so angry...

Politeness and discourse are not mutually exclusive @radoncdoc16. I'm not distracting anyone. "Distracting" is trying to twist my primary point that radiation oncology is still a wonderful field that medical students can consider (with aforementioned caveats) into some sort of referendum on BLM and #MedBikini. Equating the "struggle" of rad onc residents and junior attendings (the vast majority of whom will make millions of dollars of income over their careers whether they are in NYC or the rural Midwest) to hundreds of years of systemic oppression, racism, and police brutality is a non-starter. This diminishes the importance of BLM, which is utterly wrong. This analogy was used on Twitter a month or two ago and I called it out then, and I'll do it again now. You really should be ashamed of yourself. As a Jew I would never use the holocaust as an analogy in an argument about the radiation oncology workforce, job market, or future prospects of our specialty. The magnitude and gravity of the two topics are so far apart that it's laughable. Using BLM in this context is similarly uncalled for.

I think my time here has unfortunately come to an end in the way I figured it would. All I asked was not to be personally insulted (see @Chartreuse Wombat). I encourage everyone here to discuss ideas, not people... but I won't hold my breath. I wish you all well and I hope your life journeys (personal and professional) lead you to happiness in one form or another. Maybe I can come back again and visit in another 7 years and let you know how things are going on my end? Someone put it on their calendar. We can reflect on whether radiation oncology has truly become a penny stock or not... I'm confident in my professional "investment." It won't make me a gazillionaire, but I'm not worried that my professional investment is going to zero anytime soon either.

 

[Chartreuse Wombat]

Politeness and discourse are not mutually exclusive @radoncdoc16. I'm not distracting anyone. "Distracting" is trying to twist my primary point that radiation oncology is still a wonderful field that medical students can consider (with aforementioned caveats) into some sort of referendum on BLM and #MedBikini. Equating the "struggle" of rad onc residents and junior attendings (the vast majority of whom will make millions of dollars of income over their careers whether they are in NYC or the rural Midwest) to hundreds of years of systemic oppression, racism, and police brutality is a non-starter. This diminishes the importance of BLM, which is utterly wrong. This analogy was used on Twitter a month or two ago and I called it out then, and I'll do it again now. You really should be ashamed of yourself. As a Jew I would never use the holocaust as an analogy in an argument about the radiation oncology workforce, job market, or future prospects of our specialty. The magnitude and gravity of the two topics are so far apart that it's laughable. Using BLM in this context is similarly uncalled for.

I think my time here has unfortunately come to an end in the way I figured it would. All I asked was not to be personally insulted (see @Chartreuse Wombat). I encourage everyone here to discuss ideas, not people... but I won't hold my breath. I wish you all well and I hope your life journeys (personal and professional) lead you to happiness in one form or another. Maybe I can come back again and visit in another 7 years and let you know how things are going on my end? Someone put it on their calendar. We can reflect on whether radiation oncology has truly become a penny stock or not... I'm confident in my professional "investment." It won't make me a gazillionaire, but I'm not worried that my professional investment is going to zero anytime soon either.

שהשלום יהיה עימך

 

[deleted774703]

Politeness and discourse are not mutually exclusive @radoncdoc16. I'm not distracting anyone. "Distracting" is trying to twist my primary point that radiation oncology is still a wonderful field that medical students can consider (with aforementioned caveats) into some sort of referendum on BLM and #MedBikini. Equating the "struggle" of rad onc residents and junior attendings (the vast majority of whom will make millions of dollars of income over their careers whether they are in NYC or the rural Midwest) to hundreds of years of systemic oppression, racism, and police brutality is a non-starter. This diminishes the importance of BLM, which is utterly wrong. This analogy was used on Twitter a month or two ago and I called it out then, and I'll do it again now. You really should be ashamed of yourself. As a Jew I would never use the holocaust as an analogy in an argument about the radiation oncology workforce, job market, or future prospects of our specialty. The magnitude and gravity of the two topics are so far apart that it's laughable. Using BLM in this context is similarly uncalled for.

I think my time here has unfortunately come to an end in the way I figured it would. All I asked was not to be personally insulted (see @Chartreuse Wombat). I encourage everyone here to discuss ideas, not people... but I won't hold my breath. I wish you all well and I hope your life journeys (personal and professional) lead you to happiness in one form or another. Maybe I can come back again and visit in another 7 years and let you know how things are going on my end? Someone put it on their calendar. We can reflect on whether radiation oncology has truly become a penny stock or not... I'm confident in my professional "investment." It won't make me a gazillionaire, but I'm not worried that my professional investment is going to zero anytime soon either.

Apparently analogies are inappropriate when they are inconvenient to your truth Dan

Everyone, civil discourse is the only way to make change

My god this was lot of condescension

Be well

 

[hbosch]

To clarify, I sent my CV to ~40 chairs of departments at numerous academic medical centers in mid to large size cities across the country. The vast majority never responded. My spouse was willing to move out of Chicago/NYV/Philly, but I knew it would significantly impact their career. Thus, Chicago had a leg up already. I had exactly one phone interview from an institution in NYC - never heard back, interviewed at ASTRO with a the aforementioned east coast "academic" satellite job with no protected time. I interviewed at one large department in a mid-to-large midwest city, didn't get an offer, and then interviewed with a west coast department. I had an offer there for a main campus position and at UChicago for the job I currently hold. It was an easy decision because of my spouse's career and I had a sense of the "academic freedom" I'd have by not being in a main campus job. I fully understand the stress and anxiety the job search causes and as I've said before, I'm lucky this job became available when I was graduating.

I am sorry that you regret going into radiation oncology. I hope current trainees hear your story and consider it carefully when making their specialty decision.

Unfortunately, the story in the advice column is not unique to rad onc. Medicine is notoriously hard on relationships during training - this isn't how it should be, and my impression is it's better than it used to be - but it's still how it is. I remember a PBS documentary series called "Doctors' Diaries" that was being released through the 1990s when I was considering a career in medicine. Over half of the documentary subjects got divorced. I still remember being asked "Why would you want to be a doctor when it will destroy your personal life?" I was willing to take the risk because being a doctor was worth it. I knew rad onc had risks with regards to geographic determinability. If my priority was living in the Bay Area where I grew up, I should have chosen IM, Peds, or another general specialty. I decided rad onc was worth the risk.

I do appreciate you saying that med students need to hear my story. And I see that it was not easy for you either to get your current job.
And yes certain people are looking for very specific areas- those people should definitely not apply to rad Onc.

 

[thecarbonionangle]

Man they really must be selling some good stuff in those Chicago dispensaries. Perhaps Ralph should make some people pee in a cup even though he prob wouldnt pass the piss test himself considering recent tweets. I think the department is definitely smoking some good stuff. The implication that because people dont self dox, “i cant verify who you are”, so therefore we are not “legit” and must be some russian bots stirring the pot really is laughable. You gotta be in some hotboxing bubble to believe that. Keep smoking that good stuff, brother.

 

[hbosch]

Politeness and discourse are not mutually exclusive @radoncdoc16. I'm not distracting anyone. "Distracting" is trying to twist my primary point that radiation oncology is still a wonderful field that medical students can consider (with aforementioned caveats) into some sort of referendum on BLM and #MedBikini. Equating the "struggle" of rad onc residents and junior attendings (the vast majority of whom will make millions of dollars of income over their careers whether they are in NYC or the rural Midwest) to hundreds of years of systemic oppression, racism, and police brutality is a non-starter. This diminishes the importance of BLM, which is utterly wrong. This analogy was used on Twitter a month or two ago and I called it out then, and I'll do it again now. You really should be ashamed of yourself. As a Jew I would never use the holocaust as an analogy in an argument about the radiation oncology workforce, job market, or future prospects of our specialty. The magnitude and gravity of the two topics are so far apart that it's laughable. Using BLM in this context is similarly uncalled for.

I think my time here has unfortunately come to an end in the way I figured it would. All I asked was not to be personally insulted (see @Chartreuse Wombat). I encourage everyone here to discuss ideas, not people... but I won't hold my breath. I wish you all well and I hope your life journeys (personal and professional) lead you to happiness in one form or another. Maybe I can come back again and visit in another 7 years and let you know how things are going on my end? Someone put it on their calendar. We can reflect on whether radiation oncology has truly become a penny stock or not... I'm confident in my professional "investment." It won't make me a gazillionaire, but I'm not worried that my professional investment is going to zero anytime soon either.

While I do understand how you might interpret it that way, I didn’t think the analogy implied equivalency. He was simply stating that arguing about lack of politeness and not hearing the message because of lack of politeness is a distraction method used by people to shut down an argument be it about something horrible like centuries of oppression or something on a far smaller scale with far less history that is nowhere near as bad. Analogies are not equivalencies.
I have heard doctors use all sorts of non medical analogies to describe cancer to their patients. in no way were they trying to say some non medical issue is equivalent to their physical and emotional pain and the possible end of their lives.

when you Shut down an argument over someone expressing anger you are implying that their anger is worse than the act causing the anger. It’s how those in power (whether it’s society at large or medical hierarchy) shut down the opposition.

the issue Dan is that radonc16 is experiencing real pain and fear from not being able to find a job or getting a job in rural area (because beyond location rural medicine has an array of problems that severely affect your daily work life, including the issue of safety/medicolegal risk). If you can’t find a job but you have loans And a family- do you know how ****ing scary that is?!! And if you sucked as a doctor that would be fine with me for you to suffer, but if you don’t?

Just as there are rural people who would almost rather die than live in Chicago or Manhattan, there is also the opposite. You can’t just tell someone to change their entire mindset (growing up in a densely populated area in the east or west coast gives you a completely different mentality than growing up in a rural area)- so yeah we should be skewing towards med students passionate about rural medicine, instead of someone like me or radinc16. I can tell you that my life is 100% different than the lives of 95% of my high school, college classmates all of whom live on the east or west coast in large cities, and I am the only person in my family (including all my cousins who live in a metropolitan area with less than 1 million people. For me it’s isolating. I get envious talking to them. In fact, I’ve stopped talking to most of them because I don’t want to hear how much better their life is outside of work. And I have worked harder than almost all of them to be where I am. It’s painful and hard. it’s extremely painful. It’s not easy either admitting that your life is so far from what you expected even anonymously but I’m writing it because med students need to hear it.

So please tell UChicago to only accept people interested in rural medicine because in 5 years you don’t want your residents to be me or radocn16. And I don’t want your residents to be me.

 

[RickyScott]

I do appreciate you saying that med students need to hear my story. And I see that it was not easy for you either to get your current job.
And yes certain people are looking for very specific areas- those people should definitely not apply to rad Onc.

1) if it was not easy for Dan 7 years ago (and his type of job had no takers when I graduated)hate to think what is like today.
2) what is going to happen when rural jobs are taken. No one is stupid enough to believe we are in an equilibrium?

 

[RadSki]

SInce I am guessing you think you know who I am let me quote back your profound insight.

"Great minds discuss ideas; average minds discuss events; small minds discuss people."

Engage with the idea that supply has increased

Engage with the idea that demand has decreased

No need to go ad hominem on the person

amirite

One for the road

I have no idea who you are @Chartreuse Wombat. If I did, I'd just send you an e-mail or call you and we could chat like normal grown-ups. I just know you enjoy some good old-fashioned anonymous web forum mud slinging.

As I've said before, I am not a health economics or workforce expert. I joined in the fray on SDN to clarify mischaracterizations of my job situation and to argue that students passionate about radiation oncology should still consider it as long as they are appropriately informed about the specialty's pros/cons. With regards to the ideas you raise above, here are my brief thoughts.

Yes - the supply of radiation oncologists has increased (i.e., more residents in training). I believe this has swung too far in the oversupply direction driven by departments looking for residents to manage services, and we are seeing a market correction currently. I would like to see more departments decouple the education and service missions. This would mean hiring midlevels to support the attendings rather than relying solely on residents. This would reduce the temptation to increase resident numbers to fill clinic staffing shortages. Unfortunately, in the US we do not have a centralized organization that can mandate programs contract. I've heard through the grapevine the ACGME is scrutinizing existing programs closer and will carefully scrutinize any new program applications. This may slowly shrink numbers and we may also see some programs unable to match.

I'm not as convinced demand has or will decrease as much as some on this forum project. Baby boomers are aging and cardiac disease is better managed. There are expanding indications that are overlooked or ignored - SBRT for lung, liver, oligomets, etc. More use of SRS than WBRT. Etc. This may not balance out the drop in treatment volume from breast and prostate hypofrac, but we won't be out on the streets any time soon. Additionally, much of the clinical work is the consult, contouring, etc. If consult numbers stay flat and treatment volume decreases we may see decreasing average salaries, but we'll need to the same number of docs. Personally, I wouldn't be able to see 15 new consults a week - so overall salaries may drop, but the number of docs needed may stay the same or increase. I know a drop in salary is hard to stomach, but this isn't a reason to tell students not to even consider rad onc. But that was all speculation, and we all know how speculation is viewed on this forum. So I retract my prior speculations and will leave it at "nobody knows what the future holds."

Lastly, to tie this into my original point - medical students need to understand the concerns re: above. They should also understand that increased supply and decreased demand does not mean the specialty is a penny stock.

Anyone on here that wants to discuss this IRL, feel free to e-mail me.

Over and out.

Dan

 

[elementaryschooleconomics]

To clarify, I sent my CV to ~40 chairs of departments at numerous academic medical centers in mid to large size cities across the country. The vast majority never responded. My spouse was willing to move out of Chicago/NYV/Philly, but I knew it would significantly impact their career. Thus, Chicago had a leg up already. I had exactly one phone interview from an institution in NYC - never heard back, interviewed at ASTRO with a the aforementioned east coast "academic" satellite job with no protected time. I interviewed at one large department in a mid-to-large midwest city, didn't get an offer, and then interviewed with a west coast department. I had an offer there for a main campus position and at UChicago for the job I currently hold. It was an easy decision because of my spouse's career and I had a sense of the "academic freedom" I'd have by not being in a main campus job. I fully understand the stress and anxiety the job search causes and as I've said before, I'm lucky this job became available when I was graduating.

I think this is really the take home point of this exchange:

7 years ago, reached out to ~40 academic departments.

One phone interview, one ASTRO interview, one midwest interview (no offer), an offer from a West Coast department and UChicago.

2 offers on 40 attempts, and this was 1,400 graduates ago. Even if the other downward pressures didn't exist (APM, hypofrac, general supervision, COVID)...those are tremendous odds.

One could argue p ≤ 0.05, statistically significant odds.

 

[medgator]

I'm not as convinced demand has or will decrease as much as some on this forum project. Baby boomers are aging and cardiac disease is better managed. There are expanding indications that are overlooked or ignored - SBRT for lung, liver, oligomets, etc. More use of SRS than WBRT. Etc. This may not balance out the drop in treatment volume from breast and prostate hypofrac, but we won't be out on the streets any time soon. Additionally, much of the clinical work is the consult, contouring, etc. If consult numbers stay flat and treatment volume decreases we may see decreasing average salaries, but we'll need to the same number of docs. Personally, I wouldn't be able to see 15 new consults a week - so overall salaries may drop, but the number of docs needed may stay the same or increase. I know a drop in salary is hard to stomach, but this isn't a reason to tell students not to even consider rad onc. But that was all speculation, and we all know how speculation is viewed on this forum. So I retract my prior speculations and will leave it at "nobody knows what the future holds."

You keep it way too focused on pay when that is truly a secondary concern for most. I'm sure most on here aren't looking to make anywhere close to 600k vs obtaining employment in their preferred geographic location which is why we still have all these rural jobs open and places in cal can still start people at 200k/year. @elementaryschooleconomics just nailed it

 

[DebtRising]

It’s awesome to come on and engage, but to the sidestep all the data or arguments with “well I think the drop in prostate and breast will be offset etc” with literally no data to support that, nor an engagement on payment discrepancies or acceptance of SBRT by insurance companies, is not a counter argument. Rad onc is a penny stock until that is proven to be false. But thank you for coming, I sincerely hope you use your position in the system to study this.

If you or anyone else at ASTRO actually does want to examine this, I’ll offer my labor in a heartbeat. Feel free to pm me.

 

[Haybrant]

Too much to read through at one time but do appreciate the engagement Dan. I’m just seriously curious why Ralph doesn’t give up his extra pay and come down to the level of a new attending or better yet a new med onc? It’s a utterly fair question to be posed to him and if he puts his money where his mouth is respect to him. Unlikely he will though, he just loves talking nonsense without backing it up and claiming that’s what other people do.

 

[medgator]

. Rad onc is a penny stock until that is proven to be false.

Denial isn't just a river in Egypt. I'm sure Dan was one of those that was shocked to see the nrmp outcomes in 2019/2020.... That's just the beginning i imagine once the job woes during covid really get out

 

[Mandelin Rain]

Disclaimer: I have interviewed (whether phone, ASTRO, in-person) 15-20 graduating residents per year for probably 8 of the past 10 years or so. So give or take about 10% of the graduating class. No experience with this year's cohort though.

I simultaneous hold these beliefs...
1. The job market the past few years has been better than as portrayed by most here.
2. The future job market (really, future of the specialty) will be worse than portrayed by most here.

 

[RickyScott]

You keep it way too focused on pay when that is truly a secondary concern for most. I'm sure most on here aren't looking to make anywhere close to 600k vs obtaining employment in their preferred geographic location which is why we still have all these rural jobs open and places in cal can still start people at 200k/year. @elementaryschooleconomics just nailed it

I am sure would love to deligitimize as “greedy” complainers who all want to live in middle of manhattan or sf, when most would take primary care/er salaries in suburb of any large city.

 

[medgator]

Disclaimer: I have interviewed (whether phone, ASTRO, in-person) 15-20 graduating residents per year for probably 8 of the past 10 years or so. So give or take about 10% of the graduating class. No experience with this year's cohort though.

I simultaneous hold these beliefs...
1. The job market the past few years has been better than as portrayed by most here.
2. The future job market (really, future of the specialty) will be worse than portrayed by most here.

Like real estate or anything else... Location, location, location. Has always been tough in certain large metros and parts of the South and West.

 

[scarbrtj]

I simultaneous hold these beliefs...
1. The job market the past few years has been better than as portrayed by most here.
2. The future job market (really, future of the specialty) will be worse than portrayed by most here.

I can't say much about the job market last ~10y. Like Dan gave his N=1 experience on the job hunt, I'll try to extrapolate my job experience to the job market: I make a few less dollars, and I'm less busy overall now than 10y ago. So I've witnessed some declines. Medicare is reimbursing rad onc as a whole about 1/7th less now than it did 10 years ago... and there are more rad oncs now than 10y ago. So do the math. There's less money going around to all of us. And there's more "all of us." But in general I very much agree with you. Sometimes extrapolation gives almost unbelievable results. About 100 years ago this one guy this one time looked at his math and he saw that if you took his math and ran it backward in time it meant the whole dang universe started as a single point. A kind of "big bang" if you will. "How preposterous," some thought. When I run some of my calculations forward in time for supply and demand and case numbers, it shows our whole rad onc universe could essentially collapse. A kind of "big crunch" if you will. Preposterous! Preposterous?

 

[Mandelin Rain]

Like real estate or anything else... Location, location, location. Has always been tough in certain large metros and parts of the South and West.

Definitely. But I've seen people turn down [what I think is] a great job for positions on either coast, Florida, their home town, whatever. Overall, I think the placement of most of the people I've interviewed has been decent for them. Can't say what happens after Day #1 though.

 

[medgator]

Definitely. But I've seen people turn down [what I think is] a great job for positions on either coast, Florida, their home town, whatever. Overall, I think the placement of most of the people I've interviewed has been decent for them. Can't say what happens after Day #1 though.

Lots of mill practices in ca, tx, fl, ATL etc from what I've heard and seen over the years. I think those practices still exist and are probably loving it now

 

[PointA]

Dr. Golden, how do you plan to increase the acceptance of applicants who will practice in rural areas? If you ask applicants whether they are interested in research, they will say yes. If you ask applicants if they are interested in rural medicine, they will say yes. Applicants will always tell you what you want to hear.

Even those who grew up in small towns often complete medical school or residency in large cities and become accustomed to the lifestyle or meet their spouse in the large city, who cannot or refuses to move to the small town. The only real way to get people to go rural IMHO is to throw large sums of money at them, but for many young millennials even that is not enough.

As I have posted before, women and minorities are less likely to go rural than white men and women are more likely to have professional spouses with their own geographic limitations. These facts have all been well documented in the literature yet there is literally no discussion of this conundrum among academics in the push to increase diversity when urban markets are saturated.

 

[scarbrtj]

Dr. Golden, how do you plan to increase the acceptance of applicants who will practice in rural areas? If you ask applicants whether they are interested in research, they will say yes. If you ask applicants if they are interested in rural medicine, they will say yes. Applicants will always tell you what you want to hear.

Even those who grew up in small towns often complete medical school or residency in large cities and become accustomed to the lifestyle or meet their spouse in the large city, who cannot or refuses to move to the small town. The only real way to get people to go rural IMHO is to throw large sums of money at them, but for many young millennials even that is not enough.

As I have posted before, women and minorities are less likely to go rural than white men and women are more likely to have professional spouses with their own geographic limitations. These facts have all been well documented in the literature yet there is literally no discussion of this conundrum among academic elites in their push to increase diversity in a speciality with over saturated urban markets.

"I want to go practice in my hometown rural area."

State Law: No, you may not practice here.

Dan Golden... ASTRO... lobby to remove CONs.

 

[fiji128]

To clarify my post.

It is unethical to tell any med student at this point to do anything but run from this field.

The field is in seriously bad long term shape with "leadership" abdicating any responsibility for the mess they have created with decreased utilization and over supply of physicians. To paraphrase the UK chair M. Randall post on RO Hub, "I want to see enough lives ruined to generate a p value before I'll believe any oversupply exist."

Adults have to make decisions based on a cost/benefit analysis. This happens with any career. Currently in rad onc the downside potential is significant including, landing a job where you do not want to live, losing out on friends and family because of the physical distance, finding no permanent job, having zero negotiating power, exploitative positions with poor support, situations where your salary may make it very difficult to pay back your medical school student loans, board certification issues, no ability to transfer to a new/better positions, no realistic avenue out of the specialty if you can't deal with any of the above, ect... The downside potential for this specialty is real, significant and increasing. The upside potential is hard to see beyond maybe one can get lucky and avoid some of these pressures.

No one should be making a specialty choice based on some short of "right reasons" argument given the above. It is immature. The "clinical milieu, patient care, and underlying basic science, regardless of salary" is irrelevant in the face of above. The personal consequences are too grave for the applicant. Medical students are not able to fully understand/appreciate all of this due to their lack of experience in the medical field. This is how I equate rad onc to a penny stock. There is very serious downside risk and it is not wise to bet all your human capital assets on it. There are too many other great medical fields that do not require the applicant to take on this type of risk for rad onc to even be consider an reasonable option.

Therefore, it is unethical to tell any med student at this point to do anything but run from this field.

I saw the above play out the other day in real life. A mid career rad onc was working at urorads that was bought out by a large monopolistic academic mega center type place. They kept it open for a few years but decided not to upgrad the linac and gave the rad onc the boot. There are no rad onc jobs within 100 miles where he set up his life with wife and kids. Now he going along begging for locums type positions. This is why the "right reasons" argument is nonsense for this field. This could happen to anyone of us.


From above:
"The analogy to a penny stock is hyperbole. Sure, maybe rad onc was in a bubble 10 or 15 years ago when it was IMRT full steam ahead for 44 fractions, take no prisoners, but I reject the analogy that we are trading at <$1 currently. Also, I do not "tell" students to go into radiation oncology. I advise them on the potential pros and cons and encourage them to take time to carefully reflect on their personal and professional priorities before making a specialty decision. I also encourage them to speak to docs in other specialties and consider lots of options before settling on rad onc if it's right for them.

The use of the terms "downside and upside potential" are euphemisms for "likelihood of earning less, not more, in the long run." I guess we just have different perceptions of what is "enough" to live on. If you went to medical school expecting to make no less than $600k/year when you finished residency, I would argue you didn't go to medical school for the right reason. If you went to medical school because you were passionate about medicine and would be willing to choose a specialty because you loved the clinical milieu, patient care, and underlying basic science, regardless of salary, you probably went for the right reasons.

Yes - major metropolitan areas are highly competitive job markets in radiation oncology. As I stated in a prior post, academic faculty need to work to recruit a diverse cadre of trainees that will fill the jobs in urban centers but also the jobs in more rural/less "desirable" locations. If there are enough people living somewhere that they need a radiation oncologist, I am confident there are "desirable" attributes to that location. Iw as born and raised in Oakland/Berkeley, CA. The way many of my family and friends that still live in California see it, if it's not California, the weather or location must be miserable. Well, I've learned that 90% of the country lives outside California and guess what - they're happy and enjoy where they live. This gets back to my point that when counseling students considering the specialty, mentors need to emphasize the low geographic determinability of rad onc and to accept that they may need to move around the country to find "the right job." This might be a reason some students choose another specialty - and I'm OK with that. "

 

[GapCalc]

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.

I guess we just have different perceptions of what is "enough" to live on. If you went to medical school expecting to make no less than $600k/year when you finished residency, I would argue you didn't go to medical school for the right reason.

Dan: I'm not sure if you're still reading, but I appreciate you coming in. I have admired your work in resident education. That being said, I have a bone to pick re: salaries. One of the most frustrating parts of the conversation regarding physician compensation is that someone else can play (an indirect) role to decide what is "appropriate" compensation. If a doc questions that number (or the underlying premise), the only real conclusion is that they have Bad Motivations and may even be (*gasp*) a bad doctor!

Please follow me on a trip down memory lane...
When I was a premed student, I thought that all healthcare should be "not-for-profit" because that would remove perverse incentives, and I would "make enough." The private school loans would sort themselves out, I told myself. It would be fine. Then as medical student I clerked in a local all-consuming "community health system" that was a 501c3, and witnessed how it decimated physician leadership and morale. Physicians were paid pretty well, but I couldn't help but notice that the C-suite folks sponsored the local Major League Team and had a box at the stadium. Guess it pays to work hard, right?

So then I thought as I applied for rad onc residencies I told my faculty interviewers that my career goal would be to work in an academic center, those shining beacons of knowledge and advanced care. But as a resident, I saw that despite the research and educational missions, there was also a strong focus on "incentives" and "productivity" and "RVU targets." When resident unions were discussed among residents, the hospital suddenly found money to hire "union consultants" and even offered a housing stipend! So the academic center wasn't too much different from the community 501c3 in many ways.

What I realized is, there is always someone who is going to make a buck off my work. It might be Mega Hospital Corp, or it might be Feel Good Community Clinic System, or may be Legendary University Medical Center. But the fact is, I put in the time, I took out the loans, I see the patients, I assume the risk for complications and outcomes. Who are you or Ralph or anyone else to suggest that what I generate in income is 'enough', or that if I expect a salary in line with historical standards that I am somehow not providing excellent, patient-oriented care? By expanding the labor pool, those in charge of training (i.e. academicians) dilute my ability to earn the income I had hoped for/anticipated/desire (and will use to pay off my handsome loan balance), but if I question it, I am reflexively assumed to be greedy, or a physician with ulterior motives.

Anyway, thanks for coming to my Ted Talk.

 

[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.

This is outdated advice from a better job market. A large number of people are simply stuck in their jobs now. A few years as an attending does not necessarily mean you can move to greener pastures if it doesn't work out.

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.

That's fair. Here's the twitter post from the "expert" on this topic whose papers were used to justify (over)expansion.

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).

I tell medical students that if you are willing to take any job (location, salary, and hours) and are willing to do a fellowship to be a rad onc, go for it. I am watching this with our graduating residents every year. Some graduate unemployed, some go part-time against their will, and some look across the country to get a single job offer and take something they would have never wanted when they started. It's interesting to see the majority of employed residents come out after years of "networking" and angling for a job, only to immediately start looking again for a new job.

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.

This is the typical chair argument. No data was necessary to expand, just a model that more rad oncs would be needed in the future, which has now been refuted even by the author of that paper. Now that people are screaming on numerous surveys that the job market is terrible, individual experience doesn't matter.

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.

This story straight up makes no sense. She was commuting from a top-5 most competitive market to another top-5 most competitive market? I'm sorry but I don't believe it. Things were a lot different 25 years ago. I know someone who works in Miami area who told me when they finished training (around that time), they wanted to be in South Florida, had 8 interviews, and just wanted to pick "academics versus private". That WILL NOT HAPPEN today. You are lucky to get 1 interview in the entire state of Florida, likely at an exploitative practice. Your story more than likely reflects a past shortage of radiation oncologists at the time drawing your "brother's best friend's mom" to cover a GK across the country for some reason (part-time work, good pay, some reason to be in South FL, etc). There are no such positions in Miami nowadays, I can assure you.

I did know someone more recently who was otherwise unemployed but flexible and commuting every week to cover a small clinic in the middle of nowhere (3 hours from the nearest small city), but that job was eliminated by the elimination of supervision requirements.

The vast majority of physics "make enough" money to be happy.

Much less training, less liability, and a wide open job market. The physicists I know also work fewer hours on average than the MDs I know. This is a false comparison.

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.

Indeed. If you have no choice of location, your practice type, and you make similar money to a generalist, would you still do rad onc? Some people still will. Like you, I am happy to mentor them, and I do.

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 know several rad onc attendings who recently have left clinical medicine entirely. Not for dislike of rad onc, but because of a malignant employer and no other options. So yes, your first job may just be your last, unless you count working for Evicore or doing something outside of rad onc another job.

But the problem here isn't JUST continued overexpansion. The specialty needs to contract before we hit a wall. Will this be the year where a large number of residents come out unemployed?

I don't consider myself a pessimist, just a realist. When the market tried to correct itself over the past two years by medical students choosing specialties with better job prospects, programs just SOAPed residents in, often unmatched from other specialties. As long as the residency positions exist, the vast majority will be filled. What I find funny is that now programs are taking residents who they would have turned their noses up at 10 years ago. ACGME is not going to fix this oversupply problem unless they seriously tighten the training requirements, and so far the proposals have been weak at best.

 

[RickyScott]

Dr. Golden, how do you plan to increase the acceptance of applicants who will practice in rural areas? If you ask applicants whether they are interested in research, they will say yes. If you ask applicants if they are interested in rural medicine, they will say yes. Applicants will always tell you what you want to hear.

Even those who grew up in small towns often complete medical school or residency in large cities and become accustomed to the lifestyle or meet their spouse in the large city, who cannot or refuses to move to the small town. The only real way to get people to go rural IMHO is to throw large sums of money at them, but for many young millennials even that is not enough.

As I have posted before, women and minorities are less likely to go rural than white men and women are more likely to have professional spouses with their own geographic limitations. These facts have all been well documented in the literature yet there is literally no discussion of this conundrum among academics in the push to increase diversity when urban markets are saturated.

Who wants to appear "woke" by increasing black representation in Radonc, but doesnt see any problem telling blacks and women that they should be ready to reside in MAGA communities (with their now stay-at-home) spouse?

 

[scarbrtj]

2. The future job market (really, future of the specialty) will be worse than portrayed by most here.

I saw the above play out the other day in real life. A mid career rad onc was working at urorads that was bought out by a large monopolistic academic mega center type place. They kept it open for a few years but decided not to upgrad the linac and gave the rad onc the boot. There are no rad onc jobs within 100 miles where he set up his life with wife and kids. Now he going along begging for locums type positions. This is why the "right reasons" argument is nonsense for this field. This could happen to anyone of us.

Then as medical student I clerked in a local all-consuming "community health system" that was a 501c3, and witnessed how it decimated physician leadership and morale. Physicians were paid pretty well, but I couldn't help but notice that the C-suite folks sponsored the local Major League Team and had a box at the stadium. Guess it pays to work hard, right?

I did know someone more recently who was otherwise unemployed but flexible and commuting every week to cover a small clinic in the middle of nowhere (3 hours from the nearest small city), but that job was eliminated by the elimination of supervision requirements.

I know several rad onc attendings who recently have left clinical medicine entirely. Not for dislike of rad onc, but because of a malignant employer and no other options. So yes, your first job may just be your last, unless you count working for Evicore or doing something outside of rad onc another job.

This is scarier than 'The Exorcist.'

 

[Mandelin Rain]

Physicians shaming physicians for wanting to make more money is a tale as old as time. It allows administrators and corporations and insurers (who do not share such sentiments) to skim and skim and skim and skim....

We need to stop doing this guys.

 

[RickyScott]

Physicians shaming physicians for wanting to make more money is a tale as old as time. It allows administrators and corporations and insurers (who do not share such sentiments) to skim and skim and skim and skim....

We need to stop doing this guys.

It starts with pay and then moves to geographic shaming! You aren’t truly committed because you want to live near a top 20 metro? (Like most the population)

 

[thecarbonionangle]

Generally speaking, Admins and greedy chairs succeed in dividing us and weakening our position by utilizing useful idiots who agree we get paid “too much” and that people should be willing to go anywhere and take any pay “for the right reasons”. Interestingly, quite often, these admins, greedy chairs and useful idiots make good money and/or are located in top cities but want to lecture you on how you make too much money and should take a job for 200k in salina kansas with terrible benefits. I mean, do it for the right reasons bro!
I mean what do we know folks, we are all apparently not legit, unverified Russian bots in a troll farm, so nothing to see here folks.

 

[RollTideRadOnc]

First of all, kudos to Dan for stepping up and coming on here. It takes guts to come onto an anoymous forum, which is not exactly known for its friendliness.

That being said, I think it's really easy to get lost in the weeds and lose sight of the bottom line issues.

- First, if geography matters for you as an applicant *at all* it makes absolutely no sense to go into this field. It's great that things worked out fortuitously for Dan, but no honest assessment of radonc career outlook can overlook its geographic inflexibility as a central feature.

- Second, if you care about reimbursement and life style issues, again it's a no brainer to avoid this field. Decreasing reimbursement, decreasing utilization (overall trend given hypofrac, which is not mitigated by small uptick in oligomet cases), increasing residency supply, consolidation of practices into huge academic or corporate or for profit conglomerates. The field is a disaster in this regard. We will be lucky if in 5 years new attending salaries are above 200k.

- Third, still passionate about cancer care? Well, there are a host of much better fields for you to consider. Want to have geographic flexibility, great money, and be on the cutting edge of science? Try MedOnc. Love anatomy and an surgical approach? Try ENT, Urology, Surg Onc, Neurosurgery, Ortho Onc. Love CNS but don't want to operate? NeurOnc. Want to "do it all" -- surgery and chemo? Try Gyn Onc. Want a field that is a little more hands off but still has intellectual stimulation, good compensation and more flexibility? Try interventional rads.

Each of these fields has a much better financial and geographic outlook than RadOnc.

Don't listen to BS about being committed to cancer care etc. You can be committed to cancer care, research, and whatever other noble value one can imagine. You can do ALL that and STILL have money and geographic flexibility. Just in a number of other fields. In RadOnc, such a total picture is for the lucky few (or for the boomers who got in while the standards were even lower than they are today and have now grandfathered out of any MoC or other quality requirements).

Our field has been betrayed by its leaders.

Stop paying ASTRO dues.

Tune out the Twitterati cheerleaders. (and frankly, screw them for misleading med students).

Things are gonna get a lot worse before they get better. We better hope that FLASH xrt can cure every single cancer and send an astronaut to Mars, because that's what it's going to take to turn this field around. Scientifically and technically, we peaked in the late 90s / early 00's. Other cancer specialists know that, and treat us accordingly.

Good luck everyone.

 

[hbosch]

Who wants to appear "woke" by increasing black representation in Radonc, but doesnt see any problem telling blacks and women that they should be ready to reside in MAGA communities (with their now stay-at-home) spouse?

Yes, this is what happens when people take on a moral stance for selfish purposes. You want to make yourself and your department look good but you don’t give a **** about those people once they walk out of your department. They’re no longer on your current stats and you couldn’t care less if they found a job (or a job they actually wanted). It is unethical to try to convince anyone into this field regardless of race, gender, orientation...

 

[hbosch]

Physicians shaming physicians for wanting to make more money is a tale as old as time. It allows administrators and corporations and insurers (who do not share such sentiments) to skim and skim and skim and skim....

We need to stop doing this guys.

Because doctors are possibly one of the easiest group of people to convince to harm their own kind...it’s exactly how admin controls doctors. How insurance companies do...the other is “well this is best for patient care” when you bring up a concern about your schedule - an automatic shut down implying that you need to sacrifice all of your life for patient care...meanwhile the same doesn’t apply to them. Admin, managers, chairmen and residency directors all use the “patient care” argument. And it’s these same people who aren’t around for their own new start because they are busy hanging out with their best friend somewhere not in the dept...the same people who say don’t put anew start on my lunch hour...the same people who magically cancel patients and dumb those patients on some other doctors schedule ...the same people who hire their incompetent unreliable best friends or family members to fill positions... the same people who bill 1/4 of your RVU month after month but get paid way more than you- what the **** are you people doing for patient care? You are hardly caring for them!!!

 

[Mandelin Rain]

The need to debate the person's name and pedigree rather than their ideas and arguments is also classic academic medicine.

 

[medgator]

It starts with pay and then moves to geographic shaming! You aren’t truly committed because you want to live near a top 20 metro? (Like most the population)

 

[Mandelin Rain]

Things that make you an uncaring doctor per #radonc
1. High board scores
2. Publishing research
3. Financial success

They are looking to graduate ignorant and impoverished docs nowadays; which strangely sounds about right.

 

[Mandelin Rain]

Ha. That escalated quickly.