Rad Onc Twitter

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Obv hyperbolic, but it's not a bug, it's feature.
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sure you can say we give 60 Gy, but to where exactly? They don't exactly define where the nurse puts the IV. If we miss, we can't go back. In turn, juggling a bunch of responsibilities seems more problematic for us, sdn posting notwithstanding. imho.

I think systemic management of stage IV lung cancer has gotten incredibly complex. Look at all the category 1 options. What do you do with mutation information in PDL1 positive patients?

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Obv hyperbolic, but it's not a bug, it's feature.
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sure you can say we give 60 Gy, but to where exactly? They don't exactly define where the nurse puts the IV. If we miss, we can't go back. In turn, juggling a bunch of responsibilities seems more problematic for us, sdn posting notwithstanding. imho.

This is like equating the entire field of medical oncology to treating an early stage breast patient with hypofx WBI.

If one only looked at whole breast RT (no RNI) they'd suggest it was 'virtually no brain space' too.

Yeah sure, giving concurrent chemotherapy isn't hard, but that's a small fraction of what med-oncs see and do on a daily basis. If you imagine a rad onc consult practice as being (generously) 50% palliative, then a med oncs has to be even higher than that given that they see ALL the metastatic patients.
 
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If you imagine a rad onc consult practice as being (generously) 50% palliative, then a med oncs has to be even higher than that given that they see ALL the metastatic patients.
Sorry to be Donny but whereas the rad oncs are treating a lot of their metastatic patients via a single day, or few days at most, treatment, the med oncs are treating their metastatic patients over year/multi-year timeframes. Quite $different$!
 
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I think systemic management of stage IV lung cancer has gotten incredibly complex. Look at all the category 1 options. What do you do with mutation information in PDL1 positive patients?

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Give targeted therapy first. And if you're wrong, switch. What happens if you miss a node you should've treated? You've permanently missed a node you should've treated. My point was not that there aren't decisions. When you're the medonc studying mutation positive lung cancer, it's pretty straightforward. When you're the radonc studying ddr and you gotta contour something complex, treating and sparing maximally, it seems like a whole different set of circumstances, which can be tougher if you're seeing consults one day a week. Great to have resident coverage if that's the case... obviously, it's not black and white, but there's a whole lot more agonizing over the where and not the how much. I'm not sure I'm seeing the medonc analogy of "where?"

Edit:. I accept this is an argument I won't win
 
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I think systemic management of stage IV lung cancer has gotten incredibly complex. Look at all the category 1 options. What do you do with mutation information in PDL1 positive patients?

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Or trying to figure out upfront metastatic and CR prostate ca management.... The options over the last few years have just proliferated
 
The fractions are not low enough yet.

We can go lower. We have the technology.

The 5-5-5 thing is totally arbitrary. There is nothing magic about 5, except to eke the maximum $ out of SBRT billing. For example, in breast, if you start out with 50/25 as being the standard, sure something like 42.5/16 etc etc is equivalent if breast ca α/β is about 3.5 and nl tissue about 3. But... three fractions of 7.85 Gy apiece is also equivalent to 50/25. (Calculable.) Three should be the new 5... Yes, I'm saying whole breast 23.55Gy/3fx should work. Since everything else bio-equivalent to it has worked, it's also got high odds of working. When the tumor and nl tissue α/β are equal, or very close, all rad onc fractionation number prescriptions are on a sliding scale of integers which in theory can rationally start at one. And when α/β tumor<tissue, one fraction is theoretically "optimal."

I predict the next decade will see a surge of trials seeking to go lower than 5 fractions... after everyone gets real cozy with 5. The patients deserve as few fractions as we can safely offer.


Hahahaha I agree. Our hands are no longer forced to fractionate.

For those interested in limitations of H&N SBRT, check out this paper. It looks like it was published around 9 days after this discussion.

Gotta be super careful with laryngeal re-RT (SBRT typically re-RT setting only for H&N.. and we like to see 35-50/5 doses, generally speaking). Either way, modern RT techniques are fascinating!

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1) I had no idea there was a soap emoticon. Nice.

2) Mudit is out here building a very strong foundation with this data. When the bottom falls out, and unemployment eventually shows up on the ARRO survey, there's going to be a lot of people pointing to this stuff saying "we told you so".

Watching medical students apply to this specialty in 2020 and beyond is like watching baby polar bears step onto melting icecaps while the elderly polar bears with fading eyesight cheer them on.

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Mudit’s been hitting nothing but net
 
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The fact that this is happening shows the sickness inside the field. SDN is vindicated multiple times over that's for sure.
 
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WWC would have it no different



Pfft, matching in RadOnc when Fumiko and I did was a cakewalk compared to getting a job in RadOnc. I laugh at the carefree days of the RadOnc Match in 2014/2015/2016! Getting a 270 on Step 1 is a far easier accomplishment than getting a good job in a desirable location. But nowadays these kids use something called the Anki with something else called the Sketchy Micro. The only thing that should be Sketchy is ASTRO's understanding of the free market!
 
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In reply to Mudit's thread about no free market correction due to SOAP:

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I take it KO is referencing Cornell RadOnc closing? If he is, I find his "sacred cow" comment interesting, as I had heard rumors of malignancy in that training program when I first became involved in the field in the late 2000s. Those rumors had to come from somewhere. I have been operating under the assumption that there were basically no consequences for any RadOnc program, anywhere, and this is the first I've seen it happen. I don't recall any other instances in the last 20 years (things like CPMC were internal issues). Does anyone know any other instances where the ACGME shut down a RadOnc program?

I'm very interested to see what happens with boards this year and next year (and probably the year after that). The people currently in the boards cycle (from radbio/physics to orals) are still from the ultra-competitive era. Obviously, COVID has completely obliterated any sort of normalcy, rhythm, and strategy to board preparation. I would hope the ABR grants a little leeway to pass rates in light of everything that has happened. However, given what happened in 2018, I'm not so sure.

If board passing rates start to drop due to "weakness" of the people matching, that's a phenomenon we won't observe until for at least another ~3 years. If board failure rates are higher than average this year, I would expect even more unrest from the people already in the field, which would possibly further discourage US MD applicants.
 
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Survivorship bias is also real.

Also even if KO's path to fixing the specialty actually goes as planned, all of that would move so slowly that you'd still be looking at 20 years of oversupply.
I guess at least we see someone of import acknowledging “I see an iceberg.” Now the discussions are moving into “As we approach and hit this iceberg, here’s what I see playing out...”
 
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In reply to Mudit's thread about no free market correction due to SOAP:

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I take it KO is referencing Cornell RadOnc closing? If he is, I find his "sacred cow" comment interesting, as I had heard rumors of malignancy in that training program when I first became involved in the field in the late 2000s. Those rumors had to come from somewhere. I have been operating under the assumption that there were basically no consequences for any RadOnc program, anywhere, and this is the first I've seen it happen. I don't recall any other instances in the last 20 years (things like CPMC were internal issues). Does anyone know any other instances where the ACGME shut down a RadOnc program?

I'm very interested to see what happens with boards this year and next year (and probably the year after that). The people currently in the boards cycle (from radbio/physics to orals) are still from the ultra-competitive era. Obviously, COVID has completely obliterated any sort of normalcy, rhythm, and strategy to board preparation. I would hope the ABR grants a little leeway to pass rates in light of everything that has happened. However, given what happened in 2018, I'm not so sure.

If board passing rates start to drop due to "weakness" of the people matching, that's a phenomenon we won't observe until for at least another ~3 years. If board failure rates are higher than average this year, I would expect even more unrest from the people already in the field, which would possibly further discourage US MD applicants.
I find myself *gasp* agreeing with KO. The weakest programs are also the most shameless when it comes to cutting spots, not SOAPing etc
 
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I find myself *gasp* agreeing with KO. The weakest programs are also the most shameless when it comes to cutting spots, not SOAPing etc

Agreed, I find his opinion here reasonable. He's obviously a smart guy, placed in a tough position. I think some of the leadership just needed to digest where the field is going before talking about it publically. As always, I think there's a lot of ego/loss of prestige that's going into some of the denial we see.
 
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KO has been talking about tightening program requirements for years. Nothing significant has happened.

Any time a real proposal gets made it ends up so watered down that basically anyone can get over the tiny raise in the bar.

I doubt this is going to change in any significant way. I hope I'm wrong.
 
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KO has been talking about tightening program requirements for years. Nothing significant has happened.

Any time a real proposal gets made it ends up so watered down that basically anyone can get over the tiny raise in the bar.

I doubt this is going to change in any significant way. I hope I'm wrong.
At least he isn't gaslighting us about how the current crop of 200 matching in is better than we are because they are more passionate about doing rad Onc
 
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At least he isn't gaslighting us about how the current crop of 200 matching in is better than we are because they are more passionate about doing rad Onc

Baby steps! First, med students do basic math, realize this field is in trouble, run away in droves.

This happens for a few years.

THEN, one or two people in leadership positions say "should we pay attention to this"?

By 2027 I'm sure there will be some action items on the table!
 
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The problem is KO just kind of floats around and hypes whatever direction the wind seems to be blowing in that moment. Typically with about a 1-2 week lag time. #radoncrocks #miscreants #metoo #BLM........

Like two months ago, the residency class were "more dedicated" because they had worse metrics. Now they're "less dedicated" because some SOAPed.

It's cool that he falls on the correct side of history about 50% of the time, but it doesn't seem that proactive original thoughts are a priority.
 
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The problem is KO just kind of floats around and hypes whatever direction the wind seems to be blowing in that moment. Typically with about a 1-2 week lag time. #radoncrocks #miscreants #metoo #BLM........

Like two months ago, the residency class were "more dedicated" because they had worse metrics. Now they're "less dedicated" because some SOAPed.

It's cool that he falls on the correct side of history about 50% of the time, but it doesn't seem that proactive original thoughts are a priority.

EXACTLY. You nailed it. He actively fought against us until it was obvious the tide was changing. That may be something, but it's not leadership.

At the same time, given what happened to our guy Simul on Twitter once the ASTRO Ministry of Truth had enough, it's hard to blame anyone in academia for trying to keep their head down.
 
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EXACTLY. You nailed it. He actively fought against us until it was obvious the tide was changing. That may be something, but it's not leadership.

At the same time, given what happened to our guy Simul on Twitter once the ASTRO Ministry of Truth had enough, it's hard to blame anyone in academia for trying to keep their head down.

Simul being kicked off still burns me...
 
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Waiting for MROGA to show up in the comments - "should cut 125 residents/year instead!"

So...Ohio went RED when the vote count was completed.
I assume Rahul is BLUE because his mask says VOTE (The "O" letter is blue).
Now, either Rahul "privatized" his tweets or deleted it bc I cannot see it now lol...
Maybe bc he was embarrassed that his state of Ohio went RED?

 
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So...Ohio went RED when the vote count was completed.
I assume Rahul is BLUE because his mask says VOTE (The "O" letter is blue).
Now, either Rahul "privatized" his tweets or deleted it bc I cannot see it now lol...
Maybe bc he was embarrassed that his state of Ohio went RED?



It’s private, not deleted. Huge props to him for going beyond his civic duty and helping run a smooth election (trump denialism notwithstanding)
 
It’s private, not deleted. Huge props to him for going beyond his civic duty and helping run a smooth election (trump denialism notwithstanding)

Agreed - taking time out of your day job of being a doctor to work the polls? That's some American spirit right there. Meanwhile, on election day, I think I had to talk some dude off the ledge because his post-RT PSA went up 0.03...
 
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It’s clear that the oversupply problem is not going to be fixed anytime soon by focusing on the number of residency spots. The wheels are moving too slowly and any rules changes will not effect the pool for many years. Not to mention the cognitive dissonance of programs who will resistance change the whole way through.

Need to focus more on demand - if you are community shop with a trials program and not actively accruing on trials like lu002 or any of the dozens of RT immuno studies you are not doing yourself or the field any favors. Most of the trials will be negative and I’m sure many here will find something to nitpick about them, but at the end of the day any datapoint to increase the use of RT needed to counter the oversupply
 
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Agreed - taking time out of your day job of being a doctor to work the polls? That's some American spirit right there. Meanwhile, on election day, I think I had to talk some dude off the ledge because his post-RT PSA went up 0.03...
Funny thing is, he was still able to run a "full" clinic that day...

In all seriousness, kudos to him.
 
So...Ohio went RED when the vote count was completed.
I assume Rahul is BLUE because his mask says VOTE (The "O" letter is blue).
Now, either Rahul "privatized" his tweets or deleted it bc I cannot see it now lol...
Maybe bc he was embarrassed that his state of Ohio went RED?



He made it private. Probably because there were THOUSANDS of likes and hundreds if not thousands of comments from people who saw BO's re-tweet of it. He probably was getting sick of notifications and not ready for that level of twitter fandom. Also people started then arguing about COVID-19 in the comments, so..... I prob would have done the same as him, TBH.

But no qualms about it, Tendulkar is a good dude all around.
 
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It’s clear that the oversupply problem is not going to be fixed anytime soon by focusing on the number of residency spots. The wheels are moving too slowly and any rules changes will not effect the pool for many years. Not to mention the cognitive dissonance of programs who will resistance change the whole way through.

i agree nothing is going to change, for now. I would argue that we are worst off when an excellent program contracts while terrible no good places maintain their same numbers, you will have to pry these spots from their cold bloodied bodies. The fact is many of these places depend heavily on the residents, “the residents are very important in the running of the clinic” and would simply fall apart without them (lazy attendings who demand coverage and “cannot” handle the “heavy” load of 15 patients). These terrible places are in market for ANY warm body, just like they have always done. A successful match year is “we matched our spots”, at these places, guaranteed warm bodies. There is nothing i would like to see more than these places be shut down as they simply could not meet strict significant increases in standards (unless they straight up lie which is unfortunately not uncommon), and the people in these programs who promote bad teaching and lack of involvement in residency education should be shunned and pushed aside. This is their Scarlett letter folks. The breaking point will be reached eventually.

if you are an applicant be very aware this year, as many are pulling the wool over your eyes. The corrupt swindler dotards who “lead” this field and their enablers are heavily incentivised to lie to you, avoid inconvenient truths and embellish reality. Residents are scared to say much in many cases, but you will often be able to read in between the lines. The truth is out there my young aspiring rad oncs, will you find it?
 
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Wasn’t one of the first “orders of business” at a recently shut down program when the new chair started to cut down the research time or make it harder to actually get it? This is a very interesting approach from a “leader” who supposedly values research. This is the perfect example of the dried up pyramid ponzi scheme current academic rad onc is based on. You are told to “pay your dues” and you will one day have a chance to enjoy your benefits. Your sole job is to write notes and help pump put useless papers to guarantee promotion to your attendings (so they can get a raise) at many of these places;maybe if you are lucky the attendings will pick up phone and shower you with lukewarm praise and you get a job SOMEWHERE.
And while some may be shocked this program was recently shut down, it had been known for a while, many people were saying it, that this was a very bad no good program. There are many bad places out there and this information is generally known. Paul Wallner admitted he knew that there are MANY bad places out there from his time at the ACGME. Yet nothing is done...
 
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It’s clear that the oversupply problem is not going to be fixed anytime soon by focusing on the number of residency spots. The wheels are moving too slowly and any rules changes will not effect the pool for many years. Not to mention the cognitive dissonance of programs who will resistance change the whole way through.

Need to focus more on demand - if you are community shop with a trials program and not actively accruing on trials like lu002 or any of the dozens of RT immuno studies you are not doing yourself or the field any favors. Most of the trials will be negative and I’m sure many here will find something to nitpick about them, but at the end of the day any datapoint to increase the use of RT needed to counter the oversupply
Disagree, need to shame the bottom 50% of programs by getting the word out. Programs will contract if they keep ending up in the SOAP matching no/terrible candidates
 
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Disagree, need to shame the bottom 50% of programs by getting the word out. Programs will contract if they keep ending up in the SOAP matching no/terrible candidates

If they completely shut down any new applicants this cycle we would still have oversupply problems for the 5-10 years. Addressing the supply issue without attempting to increase demand is losing proposition both short and long term
 
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Here's a wild idea... ACGME could make a new rule that if a program SOAPs at least one of their positions for a reasonable number of years (i.e. 2-3), then they are barred from recruiting new residents for a period of time.

Seems like a way to "let the market decide"...
 
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Wasn’t one of the first “orders of business” at a recently shut down program when the new chair started to cut down the research time or make it harder to actually get it? This is a very interesting approach from a “leader” who supposedly values research. This is the perfect example of the dried up pyramid ponzi scheme current academic rad onc is based on. You are told to “pay your dues” and you will one day have a chance to enjoy your benefits. Your sole job is to write notes and help pump put useless papers to guarantee promotion to your attendings (so they can get a raise) at many of these places;maybe if you are lucky the attendings will pick up phone and shower you with lukewarm praise and you get a job SOMEWHERE.
And while some may be shocked this program was recently shut down, it had been known for a while, many people were saying it, that this was a very bad no good program. There are many bad places out there and this information is generally known. Paul Wallner admitted he knew that there are MANY bad places out there from his time at the ACGME. Yet nothing is done...
said program has 16 attendings, yet can not have more than 100 pts at main campus and 50 at satellite.
 
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I just got an email from a locums company that said the following:

"Good Afternoon Dr. XXX,

I'm hoping this message finds you safe and at the right time to consider helping in a new area. Radiation Oncology is a specialty that I enjoy working with but lately the opportunities in your field have been scare. This client is looking for ..... "

I've been on here for the past four years talking about how terrible the market is, especially when compared to just about every other specialty in medicine. The thing about economics is you don't need studies and cooked up data and all this nonsense to know whats going on. The market will tell you immediately what the market is doing and it has been very clear that good jobs with good practices and good opportunities have been increasingly harder to find to the point where now even high paying and stable rural jobs are no longer even a given as a last resort. Basically, rather then dealing with the obvious reality, as seen in the above email, "leadership" has basically been saying we just need to lower expectations to the point any job, any practice type that is anywhere should be considered a win.

To me, with all the information that is out there its just incredible that there are even 100 US MD applicants out there applying to a specialty that has a possibility of providing no real future once there are done with training. KO's four tweets are a joke. This guy has been gaslighting med students for years telling everyone that posters on SDN are fake or just don't understand whats going on and that everything is great. There is no will for ASTRO to do anything about this, as the current president is the poster child for these problems. Opening a program that is not needed and then just SOAPing in residents because the program is just that bad. People like that should be shunned and not made president of ASTRO. That alone just tells you everything you need to know about the total rot at the top of our specialty. There are numerous other examples of this rot like members of ASTRO not being allowed to tweet their own opinions and don't even try to say anything on RO Hub. The over training of residents problem is super easy to fix at least in therory if the problem is acknowledged. All training programs must have an employed radiation biologist working in that field and all residents must be clinically competent in brachytherapy as shown by having 80 cases or whatever during training. That alone would force the closure of many of these not great programs.

The locums recruiter at "Staff Care" gets it, wonder why so many chairs don't.
 
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If they completely shut down any new applicants this cycle we would still have oversupply problems for the 5-10 years. Addressing the supply issue without attempting to increase demand is losing proposition both short and long term
Agree except for the zero summiness of some of this. Eg to increase demand for prostate RT have to have urologists buy in to decreasing demand for RP. Increasing demand for SBRT lung requires pulms to demand less surgery from the surgeons. However that said if we were to look at the total pantheon of RT utility in all of medicine, RT may have a 5% utilization rate of what might be possible/proper. Think benign diseases which are tens of millions people per year, skin cancers which number 5 million a year or so; and RT only has ~30% utilization rate in cancer proper for the 1.8 million cases diagnosed per year. As a modality and field, we are VASTLY underutilized. The increasing underutilization has been correlated with much smarter people and higher quality applicants entering the field and rad onc becoming more competitive; I don’t know if that’s ironic or not. In many other specialties demand grows organically with growth of the specialty workforce. This has not happened in rad onc.
 
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said program has 16 attendings, yet can not have more than 100 pts at main campus and 50 at satellite.
several attendings are smart/good guys. How does this place get so malignant? Resident housing in worlds most desirable location, Services w 10 pts on treat, wealthy hospital with a lot of resources. Chair is btsht crazy?
 
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Just seems like mdphds need to avoid this field in the worst way and go for medonc?

I think if you like onc research you’ll have a more fruitful career with med onc. Many more opportunities to be on the cutting edge and do some lab work or even prospective clinical work.
 
In July of 2007 both Sears and Amazon were both worth about $30 billion in total market capitalization. Sears was talking about focusing on increasing revenue by investing in those stores in healthy malls while closing the others and focusing on their Craftsman and Kenmore brands. Amazon, well you know. Rad onc kinda feeling like stagnant/declining Sears to me these days and med onc more like high growth Amazon.
 
In July of 2007 both Sears and Amazon were both worth about $30 billion in total market capitalization. Sears was talking about focusing on increasing revenue by investing in those stores in healthy malls while closing the others and focusing on their Craftsman and Kenmore brands. Amazon, well you know. Rad onc kinda feeling like stagnant/declining Sears to me these days and med onc more like high growth Amazon.

I get the analogy even if I don’t agree with it because I don’t think Sears was figuring out ways to eliminate its own footprint even if that’s ultimately what happened.
 
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In July of 2007 both Sears and Amazon were both worth about $30 billion in total market capitalization. Sears was talking about focusing on increasing revenue by investing in those stores in healthy malls while closing the others and focusing on their Craftsman and Kenmore brands. Amazon, well you know. Rad onc kinda feeling like stagnant/declining Sears to me these days and med onc more like high growth Amazon.

I don't share the pessimism others have about the field in general. We still provide incredible value for cancer patients, and the side effect profiles of our treatments have improved dramatically over the last 15-20 years. We're not going anywhere, unlike Sears.

Those of us who are already in good jobs we enjoy are in good shape- the same couldn't be said about anyone working at a Sears these days. Sure, we're facing headwinds like APM, unfair pricing by monopolistic academic health systems, etc, but all industries and physicians have challenges of their own. NOT all specialties create their own job crisis by needlessly doubling the numbers of highly specialized docs over the course of a decade.

If the ACGME increases the requirements for a residency program, that's a good start, but I'm still pretty pessimistic that will move the needle very much. I hope very much to be proven wrong, but I would guess, after political wrangling (can you imagine the new ASTRO president will allow her unnecessary residency program to close?), the requirement changes will be quite toothless.
 
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The point of the analogy is to generally illustrate what growth versus stagnation/decline looks likes after 15 years.

In no universe is radiation oncology in any sort of growth phase. Doesn’t mean some won’t still continue to do well with their slice of the pie. But I’d still rather take my chances with growth.
 
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The point of the analogy is to generally illustrate what growth versus stagnation/decline looks likes after 15 years.

In no universe is radiation oncology in any sort of growth phase. Doesn’t mean some won’t still continue to do well with their slice of the pie. But I’d still rather take my chances with growth.
We do have growth in supply...not matched by demand. Even those who are presently comfortable are at risk as employers seek value (lower salaries).
 
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What happened to the cornell program?What was KO referring to? Sorry I’m out of the loop

several attendings are smart/good guys. How does this place get so malignant? Resident housing in worlds most desirable location, Services w 10 pts on treat, wealthy hospital with a lot of resources. Chair is btsht crazy?
 
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What happened to the cornell program?What was KO referring to? Sorry I’m out of the loop

Cornell got permanently closed down by the acgme for some reason that hasn’t been publicly stated at this point but rumors on this forum seems to indicate that it had to do with poor resident training experience.
 
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