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communitydoc13 said:
This is an absurd amount of work and I will admit that I am incapable of this volume. I see 4-11 consults a week in a diverse community practice with a fair bit of head and neck, lung, gyn, GI and complicated palliative cases (low volume recurrences) and after years of practice have problems culling my follow-ups down to less than 20/week. I try to write good notes. I'm not efficient and probably push 50 hour weeks. Probably 15-20 on beam at a time.

Wondering what follow-up schedule becomes with this level of volume?
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I dump most of the followsup onto medical oncology, which is the only way its doable. But most clinic days are 30-40 patients. It's nuts. My notes are garbage, but they bill.
 
OTN said:
I know some radoncs do very little follow-up at all. Personally, following up with my patients is a critical part of my practice, both for me and the patients, so I would never let that go.
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Depends on the scenario... Definitely feel stronger about it in lung, h&n, anal etc, but if early stage breast for example, and MO seeing them and doing an exam while checking labs while on AI therapy, i don't feel strongly i need to follow them up often, if at all
 
What could possibly go wrong with the politicization of medicine? Both sides, yes Trump and his hard handed tactics on the FDA, COVID drugs, vaccine, Fauci pressure etc. BAD BAD BAD.

But liberal leaning science and medical groups aligning with the Democratic party and some even endorsing Biden as president, I'm sure will have ZERO adverse consequences. This will be a pyrrhic victory. Main concern is more scientific and medical issues will be partisan (masks, vaccines, are just the beginning). God forbid IORT for breast being discussed by a politician as a good "money saving" policy...

Even if right, I think another approach should be taken. Politics takes things out of the realm of discussion and straight into all the nastiness we see. These editors will regret deciding to steer the ship into this hyper-polarized place. Thoughts?

 
RadOncMegatron said:
What could possibly go wrong with the politicization of medicine? Both sides, yes Trump and his hard handed tactics on the FDA, COVID drugs, vaccine, Fauci pressure etc. BAD BAD BAD.

But liberal leaning science and medical groups aligning with the Democratic party and some even endorsing Biden as president, I'm sure will have ZERO adverse consequences. This will be a pyrrhic victory. Main concern is more scientific and medical issues will be partisan (masks, vaccines, are just the beginning). God forbid IORT for breast being discussed by a politician as a good "money saving" policy...

Even if right, I think another approach should be taken. Politics takes things out of the realm of discussion and straight into all the nastiness we see. These editors will regret deciding to steer the ship into this hyper-polarized place. Thoughts?

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Someone started it first.... And made a conscience decision to ignore the scientists etc (almost sounds like the beginning of a bad hollywood suspense movies).
 
medgator said:
Someone started it first....
Click to expand...

No I completely agree. I don't like the way this was handled. I don't want to defend. Just wondering if using the editorial of all the major scientific journals for this was wise? Unlikely, this will foster more confidence in science b/c we all know this won't cause people to say "The NEJM physicians are right."
 
RadOncMegatron said:
No I completely agree. I don't like the way this was handled. I don't want to defend. Just wondering if using the editorial of all the major scientific journals for this was wise? Unlikely, this will foster more confidence in science b/c we all know this won't cause people to say "The NEJM physicians are right."
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For every action, there will be a reaction. 45 wanted everything politicized, so now every damn thing is, all the way down to masks and science journal editorials
 
medgator said:
For every action, there will be a reaction. 45 wanted everything politicized, so now every damn thing is, all the way down to masks and science journal editorials
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You got me on that one. I actually agree with you on those issues. (Yes, I say that to my conservative friends too). Your anger is justified. Again, not going to defend, but join you on your criticism.

Do you agree with editorials though? Do two wrongs make a right?
 
RadOncMegatron said:
No I completely agree. I don't like the way this was handled. I don't want to defend. Just wondering if using the editorial of all the major scientific journals for this was wise? Unlikely, this will foster more confidence in science b/c we all know this won't cause people to say "The NEJM physicians are right."
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This is pretty much what Vinay Prassad mentions in podcast. It doesnt change minds and they cowardly dont mention trumps name. It is just something the authors write to make them feel good.
 
RadOncMegatron said:
You got me on that one. I actually agree with you on those issues. (Yes, I say that to my conservative friends too). Your anger is justified. Again, not going to defend, but join you on your criticism.

Do you agree with editorials though? Do two wrongs make a right?
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Facts matter. Truth matters, and for me, that transcends which team I'm on (haven't been team blue until the current admin).

So i agree with the editorial boards of Nature, nejm and scientific American
 
I think most people will pay as much attention to this as they do the incessant editorials in many of these same journals about abortion and government health care. The headline validates your point of view or it doesn't. Very few actually read them.

But who knows... maybe they will push enough people over the edge we elect Biden/Harris and we get a "Green New Deal". So much science we get California style rolling blackouts for the rest of the country. Who will power the science or the LINACs then?

RadOncMegatron said:
What could possibly go wrong with the politicization of medicine? Both sides, yes Trump and his hard handed tactics on the FDA, COVID drugs, vaccine, Fauci pressure etc. BAD BAD BAD.

But liberal leaning science and medical groups aligning with the Democratic party and some even endorsing Biden as president, I'm sure will have ZERO adverse consequences. This will be a pyrrhic victory. Main concern is more scientific and medical issues will be partisan (masks, vaccines, are just the beginning). God forbid IORT for breast being discussed by a politician as a good "money saving" policy...

Even if right, I think another approach should be taken. Politics takes things out of the realm of discussion and straight into all the nastiness we see. These editors will regret deciding to steer the ship into this hyper-polarized place. Thoughts?

Click to expand...
 
Tigerstang said:
I dump most of the followsup onto medical oncology, which is the only way its doable. But most clinic days are 30-40 patients. It's nuts. My notes are garbage, but they bill.
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How many patients do you typically have on treatment at a time?
 
Politicization of science began long ago. I am old enough to remember when JAMA published a (weak) survey during impeachment that "agreed with Bill Clinton that oral sex wasn't sex".

AMA releases old survey on oral sex just in time for President's trial

junksciencearchive.com

Many other examples

pubmed.ncbi.nlm.nih.gov

Politicizing science: the case of the Bush administration's influence on the lead advisory panel at the Centers for Disease Control - PubMed

Since the 1970s, the CDC has depended upon independent scientists and policy consultants, who are experts in the field to gather information and provide advice to the CDC regarding policy initiatives for a variety of toxic materials. One of the most important safeguards of the scientific...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

AAAS

science.sciencemag.org science.sciencemag.org


Many blame Vannevar Bush for politicizing the scientific enterprise following WWII

I must say that I only read the NEJM piece.

The authors did not name themselves and didn't even name Trump.

Not my definition of moral courage.

More virtue signalling
 
scarbrtj said:
Randomized Trial of Long-Term Follow-Up for Early-Stage Breast Cancer: A Comparison of Family Physician Versus Specialist Care
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There is a lot to this paper. On the one hand, it demonstrates a very functional medical system. Family docs were given instructions for appropriate breast cancer follow up. Follow-up was standardized. This is better than us.

On the other hand, this is a perfect example of the dangers of non-inferiority trials and trying to infer things from rare events. Look at the total patient numbers, the total number of evaluable patients at 5 years f/u, and their outcomes of interest (cord compression, hypercalemia, progression to KPS<70?). One could have a trial of appropriately scheduled follow-up in ER+ breast cancer for 5 years on endocrine therapy, vs f/u at 2 year intervals and probably demonstrate non-inferiority. The entire difference between good and bad practitioners, which we know is real from experience, lives in the space of statistical non-inferiority.

The raw data tells us that the cancer centers found 20% more recurrences.
 
communitydoc13 said:
There is a lot to this paper. On the one hand, it demonstrates a very functional medical system. Family docs were given instructions for appropriate breast cancer follow up. Follow-up was standardized. This is better than us.

On the other hand, this is a perfect example of the dangers of non-inferiority trials and trying to infer things from rare events. Look at the total patient numbers, the total number of evaluable patients at 5 years f/u, and their outcomes of interest (cord compression, hypercalemia, progression to KPS<70?). One could have a trial of appropriately scheduled follow-up in ER+ breast cancer for 5 years on endocrine therapy, vs f/u at 2 year intervals and probably demonstrate non-inferiority. The entire difference between good and bad practitioners, which we know is real from experience, lives in the space of statistical non-inferiority.

The raw data tells us that the cancer centers found 20% more recurrences.
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I will admit that I have first-hand experience with NI trials and I recommend that anyone run away when given the opportunity to participate. NI trials used to be rare but now are ubiquitous (unfortunately)

From the paper-

The calculated sample size of 1,045 women was based on the assumption that the SCE proportion would be 4% in both arms, with an upper level of tolerance of 5.5% in the FP arm (ie, a noninferiority margin of 1.5%).

My interpretation-

1.5% NI margin with 4% base rate means that if the rate of SCE in one arm was 37.5% HIGHER (1.49/4.0=.375) then you would conclude that this arm arm was non-inferior. That is a mighty big NI margin.

Again from the paper-

In the FP group, 17 patients (3.5%) experienced an SCE compared with 18 patients (3.7%) in the CC group (0.19% difference; 95% CI, −2.26% to 2.65%). The lower bound of the 95% CI was beyond the noninferiority tolerance of 1.5%.

Completely unsupported by the data provided the authors somehow claim

Breast cancer patients can be offered follow-up by their family physician without concern that important recurrence-related SCEs will occur more frequently

My interpretation-

The study is underpowered to make any inference whatsoever. The 95% CI includes -2.26 or 56.5% WORSE (2.26/4.0=.565). Complete trash. Reviewers should be ashamed. Another example of underpowered study-more egregious in that it is an NI study
 
I hope most of us would feel uncomfortable offering treatment that while "not statistically different" is objectively worse / had numerically worse outcomes. There's lies, damned lies, and statistics.... and when financial/career interests are at stake, my trust does not exist without without unequivocal and transparent evidence of efficacy. The burden of proof is overwhelmingly on the data & authors to be convincing, and NI trials mostly fail in this regard. Even more so when using questionable tactics.
 
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Statistics aside, what kind of bugged me about this trial is I think that followup standards are somewhat a state of flux. As we get better at identifying and treating oligometastatic disease, and if we assume that the data will play out that it will impact one’s disease trajectory, then a reasonable (but yet to be proven as far as I know) assumption is that closer surveillance to try and identify an oligometastatic state may also confer benefits.

Now, last I heard NRG BR 002 was on hold, so no idea if things will truly play out as one might hope in breast. But data is always evolving, and in the future, family medicine surveillance may not reach what is the new standard. Not to start a discussion on primary care NPs, but as they get more prevalent too, that is also something that may also differ from this study.
 
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1602857087911.png
 
elementaryschooleconomics said:
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The reason there could be such an upswing in resident numbers the last decade is that the academic side was absorbing the great majority of them into the fold upon matriculation. From ~2005 to now PP numbers grew ~25% (or less) and academic attendings grew >200%.* Thus why the most recent ASTRO workforce data shows—for the first time—that academic rad onc practitioners make up the biggest proportion of rad onc practitioners in America. Rad onc is very "brittle" because it is small, which makes it sensitive... hence what would be tiny perturbations in other fields hit hard in rad onc. (That's why ASTRO's losing its s**t over APM... they can do math too.) Messing with the "academic hiring rate" just a little is going to be bad for everyone. It may... may... actually begin to shock the consciences of PDs and chairmen. People only make changes when at the precipice. Maybe that'll be the precipice. Or a precipice.

*there was also more PP->academic crossover vs academic->PP crossover in those time periods.
 
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They are trying to steal active residents from other residencies while recruiting another during this cycle. They are probably willing to toss some extra dough at the existing residents to get them to move to Kansas. Obviously, they are willing to do this despite "residents slow us down".
 
Mandelin Rain said:
They are trying to steal active residents from other residencies while recruiting another during this cycle. They are probably willing to toss some extra dough at the existing residents to get them to move to Kansas. Obviously, they are willing to do this despite "residents slow us down".
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Still cheaper than paying a full APP with benefits
 
evilbooyaa said:
LMAO.
Is this:
1) Just a typo
2) Dr. Chera is losing it and thinks ABRO is a real thing
3) He is like Bruce Wayne - oncologist by day, ABRO account by night?
4) None of the above, but he wants ABRO to be a real thing
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This is how I dream of the anonymous Twitter accounts:

MROGA? Malika Siker.

Lemmiwinks? Joel Tepper.

ABRO? Chris Crane.
 
evilbooyaa said:
LMAO.
Is this:
1) Just a typo
2) Dr. Chera is losing it and thinks ABRO is a real thing
3) He is like Bruce Wayne - oncologist by day, ABRO account by night?
4) None of the above, but he wants ABRO to be a real thing
Click to expand...

Well, in all fairness I was in the #2 category when ABRO first debuted on Twitter
 
elementaryschooleconomics said:
This is how I dream of the anonymous Twitter accounts:

MROGA? Malika Siker.

Lemmiwinks? Joel Tepper.

ABRO? Chris Crane.
Click to expand...

It'd be like Dr. Jekyll and Mr. Hyde for Siker at least. Chris Crane I could see as a Bruce Wayne figure. I don't know anything about Joel Tepper besides he's old and white, but he's old and white and doesn't post the other old white men "this is fine, everything is fine" (the oliviers, wallners, steinbergs, randalls of the world) non-sense so maybe, just maybe.
 
We should be praising programs that are permanently contracting spots. There’s too much incentive to try to fill any open spot, and for those who “chose not to fill” a spot, the true story is more likely that they tried but couldn’t find someone (minimally) qualified. If I was in charge of a program I would be trying to fill my allocated positions too, whatever staff position that may be.
 
scarbrtj said:
The reason there could be such an upswing in resident numbers the last decade is that the academic side was absorbing the great majority of them into the fold upon matriculation. From ~2005 to now PP numbers grew ~25% (or less) and academic attendings grew >200%.* Thus why the most recent ASTRO workforce data shows—for the first time—that academic rad onc practitioners make up the biggest proportion of rad onc practitioners in America. Rad onc is very "brittle" because it is small, which makes it sensitive... hence what would be tiny perturbations in other fields hit hard in rad onc. (That's why ASTRO's losing its s**t over APM... they can do math too.) Messing with the "academic hiring rate" just a little is going to be bad for everyone. It may... may... actually begin to shock the consciences of PDs and chairmen. People only make changes when at the precipice. Maybe that'll be the precipice. Or a precipice.

*there was also more PP->academic crossover vs academic->PP crossover in those time periods.
Click to expand...

Not if they are shielded from the ramifications of APM.
 
1603535979270.png


Wally Curran steps down as director at Emory Winship – The Cancer Letter

In the spirit of Paul Wallner (this is the company that bought 21C).

These academics just keep showing their true colors. Spend the bulk of their career espousing the mission of truth and knowledge of academia, casting subtle aspersion on private practice/industry...but as soon as their payday arrives, they eagerly jump ship.

Thanks, Boomers. I'm glad you got yours while you killed this specialty.
 
elementaryschooleconomics said:
View attachment 321242

Wally Curran steps down as director at Emory Winship – The Cancer Letter

In the spirit of Paul Wallner (this is the company that bought 21C).

These academics just keep showing their true colors. Spend the bulk of their career espousing the mission of truth and knowledge of academia, casting subtle aspersion on private practice/industry...but as soon as their payday arrives, they eagerly jump ship.

Thanks, Boomers. I'm glad you got yours while you killed this specialty.
Click to expand...

I think it's about time we had a revolution of sorts. Perhaps with a person like Simul Parikh leading the new generation.

Rather than chopping off heads, we'd mandate that every radiation oncologist who wants to keep board certification take the same oral boards that they make new grads take. I can almost guarantee that 75+% of older academics would fail (good luck remembering the patterns of failure of a forehead squamous cell carcinoma when you've been doing breast tangents for 2 decades) and >25% of private practice rad oncs who don't know how to do MRI-based cervical brachytherapy. This by itself would cut the number of practicing rad oncs by thousands and increase the average quality of rad-onc physician to a level being proud of. We could alternatively create a system in which academic rad oncs could be board certified in specific disease sites. If they want to jump ship to private practice where they see everything, they'll have to take the full battery of oral examinations.

We'd then call for cutting of radiation oncology residents positions down to 65. We'd basically allow 20-30 good programs to keep their programs as-is and close down essentially EVERY other place. Residents get less than 40 interstitial brachy cases a year? Cut. Residents don't get faculty-led didactics at least 3 times a week? Did more than 10% fail a board exam in the past 5 years? Cut. Residents don't get particle therapy training? Cut. Residents need to rotate elsewhere for peds? Cut. Residents don't see at least 750 external beam cases a year? Cut. Residents don't get 12 months of protected research? Cut. Faculty:resident ratio not > 2:1? Cut.

The downside is that rad onc will cease to be known as a "chill" residency and only intense places that train good residents will remain. Furthermore, the bar gets raised as well after you graduate. No more relaxing and making money - you'll have to read and keep up to date constantly for fear that you'll fail your next oral board recertification.

The upside - jobs.
 
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