Rad Onc Twitter

[communitydoc13]

I would love to hear strategies to how you think radonc can improve as a field. I dont believing shrink residency programs solves the whole problem. I think we need innovation and transformation to get with the times. If we keep doing the same thing as we have done for decades, we will get phased out and I think that is what many of you are seeing. Change though must come from us. No one will do it for us. I promise.

The biggest part of the problem is intrinsic. To the outside world, we are by definition purveyors of a single drug, radiation. In an ever expanding therapeutic space with ever more nuanced ways of determining therapeutic need, we will of course become more and more marginalized. Combine this with the appropriate concern that we overtreat localized cancers that may or may not pose a significant risk to survival or QOL, and all meaningful pressures on radiation utilization in cancer are downward.

Unfortunately, I think that the best way that radonc can improve as a field may be devastating to early-to-mid career community doctors like myself and may also undermine the relative prominence of academic radoncs within their respective work space. That is, while focusing on the intrinsic strengths of traditional radiation oncology training (effectively administering radiation to fight cancer, understanding of sectional anatomy, patterns of failure, the relative importance of local control and consideration of competing risks when considering therapeutic escalation), find a way to integrate radonc into a more holistic national model for solid cancer oncology that includes training in systemic therapeutics.

This may require clear eyed restructuring of academic departments. It would require radical changes in training paradigm.

It would also be nice if academic leadership considered accreditation and practical training models for established community or clinical academic radiation oncologists to expand the scope of their practice into non-radio therapies and general outpatient management of low acuity, solid tumor patients. (This in and of itself could be a huge, short interval win for the main reason we are ranked low in health care metrics despite exceptional high-end technical care. Our distribution of care is poor.

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[seper]

As CWR geographic area is not underserved by radiotherapy, your growth can only come at the expense of other radiation oncologists... I also work for a large group with multiple sites and see exactly how that type of growth works. Discussed ad nauseam on SDN. Sorry

 

[RickyScott]

The biggest part of the problem is intrinsic. To the outside world, we are by definition purveyors of a single drug, radiation. In an ever expanding therapeutic space with ever more nuanced ways of determining therapeutic need, we will of course become more and more marginalized. Combine this with the appropriate concern that we overtreat localized cancers that may or may not pose a significant risk to survival or QOL, and all meaningful pressures on radiation utilization in cancer are downward.

Unfortunately, I think that the best way that radonc can improve as a field may be devastating to early-to-mid career community doctors like myself and may also undermine the relative prominence of academic radoncs within their respective work space. That is, while focusing on the intrinsic strengths of traditional radiation oncology training (effectively administering radiation to fight cancer, understanding of sectional anatomy, patterns of failure, the relative importance of local control and consideration of competing risks when considering therapeutic escalation), find a way to integrate radonc into a more holistic national model for solid cancer oncology that includes training in systemic therapeutics.

This may require clear eyed restructuring of academic departments. It would require radical changes in training paradigm.

It would also be nice if academic leadership considered accreditation and practical training models for established community or clinical academic radiation oncologists to expand the scope of their practice into non-radio therapies and general outpatient management of low acuity, solid tumor patients. (This in and of itself could be a huge, short interval win for the main reason we are ranked low in health care metrics despite exceptional high-end technical care. Our distribution of care is poor.

spot on. There is no getting around the fact that radonc will fade without integration. Years ago, I remember one of the founders of gyn onc Phil Di Saia stating that there is no way they would ever let medonc control chemo.

 

[RickyScott]

As CWR geographic area is not underserved by radiotherapy, your growth can only come at the expense of other radiation oncologists... I also work for a large group with multiple sites and see exactly how that type of growth works. Discussed ad nauseam on SDN. Sorry

there is no getting around the fact that if Dan does a great job and grows/expands CWR, it is still a zero sum game. Jobs he creates would have to come from someone else's losses.

 

[seper]

there is no getting around the fact that if Dan does a great job and grows/expands CWR, it is still a zero sum game. Jobs he creates would have to come from someone else's losses.

I wish it was a zero-sum game. I see troubling instances in my area, when an established solo doc gets pushed out of his / her small-hospital contract and University takes over. While the old doc used to take home close to 7 figures, a new University hire works for 350-450K. The difference goes on the University balance sheet and Chair gets a bonus (I presume he does).

 

[medgator]

I wish it was a zero-sum game. I see troubling instances in my area, when an establish solo doc gets pushed out of his / her small hospital contract and University takes over. While the old doc used to take home close to 7 figures, a new University hire works for 350-450K. The difference goes on the University balance sheet and Chair gets a bonus (I presume he does).

Would've done better in a urorads setup, but we all know how ASTRO felt about that...

 

[deleted941485]

there is no getting around the fact that if Dan does a great job and grows/expands CWR, it is still a zero sum game. Jobs he creates would have to come from someone else's losses.

ive been out that way a few times. Its amazing to see. You drive and oh there a CC satellite 10 miles from a UH satellite and both want to take over the PP thats another 20miles down the road. Both are literally gobbling up everything they possibly can. Its disgusting.

 

[thecarbonionangle]

I wish it was a zero-sum game. I see troubling instances in my area, when an establish solo doc gets pushed out of his / her small hospital contract and University takes over. While the old doc used to take home close to 7 figures, a new University hire works for 350-450K. The difference goes on the University balance sheet and Chair gets a bonus (I presume he does).

this is very true. Trash systems have taken over many former pp in many states doing just that. This has had significant impact in the market for graduating residents. This essentially evaporated these opportunities where you could make a lot of money as partner and now take a “well compensated” job For 300-500k.
The Hallahan letter is the smoking gun.
Now trash places like Kansas/UPMC/UCLA and similar places continue to do this (there are many). Only way it can be stopped is refusing to sell instead of cashing out and screwing everyone (aka the Mike Steinberg way). If you are an old guy reading please do not sell your practice!!!

 

[deleted941485]

this is very true. Trash systems have taken over many former pp in many states doing just that. This has had significant impact in the market for graduating residents. This essentially evaporated these opportunities where you could make a lot of money as partner and now take a “well compensated” job For 300-500k.
The Hallahan letter is the smoking gun.
Now trash places like Kansas/UPMC/UCLA and similar places continue to do this (there are many). Only way it can be stopped is refusing to sell instead of cashing out and screwing everyone (aka the Mike Steinberg way). If you are an old guy reading please do not sell your practice!!!

Its basically the only bussiness model they have to rely on. Just getting bigger and monopolizing services.

 

[RickyScott]

Its basically the only bussiness model they have to rely on. Just getting bigger and monopolizing services.

Yup, if your practice is worth 1 million, to someone who can bill/recover 3x your prices, it is worth 3 million, so they pay you 2 and you are both happy. Penn has been using this strategy with community hospitals to buy/long term lease radiation departments. Great for patients/population to be transferred from low cost to high cost providers.

 

[Reaganite]

this is very true. Trash systems have taken over many former pp in many states doing just that. This has had significant impact in the market for graduating residents. This essentially evaporated these opportunities where you could make a lot of money as partner and now take a “well compensated” job For 300-500k.
The Hallahan letter is the smoking gun.
Now trash places like Kansas/UPMC/UCLA and similar places continue to do this (there are many). Only way it can be stopped is refusing to sell instead of cashing out and screwing everyone (aka the Mike Steinberg way). If you are an old guy reading please do not sell your practice!!!

It was when I watched UCLA take over practices, lose 80% of the existing business, and still stay open that I realized how rigged the game was for these academic centers.

 

[yesmaster]

Wow, @Dan Spratt is a popular guy! I don't know him but he seems intellectually honest, innovative, and energetic. An advocate for trainees and junior faculty.

However, my sense is that an individual chair's success or failure is unrelated to the job market woes of the specialty. Sure, I'm excited to see what comes out of CWRU and UH. It must be fun to launch trials, pioneer indications for radiotherapy using cutting-edge technology, and collaborate across disciplines and institutions. Of course, there are also opportunities for advocacy at the national level, and institution-building at the local level to round out the workday.

I just don't see how a chair's potential successes, like, solidifying the role of SBRT for oligometastatic prostate cancer, can compete with macro forces like US policy, HMO consolidation, and academic center expansion. I get it, I'm a Luddite community practice guy, seeing what is, rather than what could be. Academics get together at conferences and working groups. You're pushing the frontiers of radiation oncology. You're doing the heavy lifting today, for potential benefits tomorrow that community practice docs will also share in. I'm just a free rider, right?

The problem, from my standpoint, is that academics has cannibalized community practice. Certain empire builders, mostly administrators and CEO's and the like, but a few senior radiation oncology chairs, use the idea of academics as an "innovator" as a Trojan horse to justify satellite expansion and anti-competitive practices. Lack of pay parity, all the propaganda and intellectual contortions surrounding proton therapy, and yes, rampant residency expansion fueled by SOAP. Radiation oncology uses SOAP so much we could be an advertisement for Irish Spring. Don't get me wrong, academic centers are just playing the game of corporate healthcare, and I'd rather work for a well-run academic satellite than a bloodsucking system like HCA.

Still, academics isn't all it's cracked up to be. What have we gotten in exchange for academic takeover of radiation oncology? Not much. Okay, we got oligomets SBRT from the Canadians. And believe me, I am rooting for the abscopal guys & gals and the cardiac SBRT team. Mostly, we've gotten fewer fractions, or omissions of radiotherapy. That's great for patients, but hey SCAROP innovators, can you put 2 and 2 together and stop training so many residents if we no longer need 9 OTV's for definitive prostates, and your autocontouring AI buddy is helping me out? With 50% or 2500 radiation oncologists employed by academic centers, you'd think we'd have a few hundred @Dan Spratt's. I'd estimate that a third of academic rad onc's are disillusioned and non-participatory in game-changing innovation, a third are gung-ho about the wrong sorts of innovation, and a third are doing good work. I just can't understand why anybody thinks we need to train 200 radiation oncologists per year for two-thirds to go into the grinder.

Lastly, many SDN doomsayers, including myself, don't believe radiotherapy is dying. That's a straw man argument. We believe that the job of a radiation oncologist is becoming more unattractive, both relative to our jobs in the 2000's and early 2010's, and relative to other specialties of medicine. I'd agree that residency overexpansion is only one of many reasons for our erosion of autonomy, but it certainly hasn't helped.

This is all a roundabout way of saying that I feel confident UH is in good hands, but I don't think it's realistic to expect one person to fix rad onc's job market problems.

 

[elementaryschooleconomics]

Lastly, many SDN doomsayers, including myself, don't believe radiotherapy is dying. That's a straw man argument. We believe that the job of a radiation oncologist is becoming more unattractive, both relative to our jobs in the 2000's and early 2010's, and relative to other specialties of medicine. I'd agree that residency overexpansion is only one of many reasons for our erosion of autonomy, but it certainly hasn't helped.

Preach.

Radiation isn't going anywhere.

There will always be jobs.

There just aren't 200 jobs a year for 200 new grads a year.

And good luck if you want to move laterally.

 

[medgator]

Preach.

Radiation isn't going anywhere.

There will always be jobs.

There just aren't 200 jobs a year for 200 new grads a year.

And good luck if you want to move laterally.

Bingo....i wish the academic gaslighters and those that sympathize with them would stop making this false equivalence argument

 

[deleted969641]

Preach.

Radiation isn't going anywhere.

There will always be jobs.

There just aren't 200 jobs a year for 200 new grads a year.

And good luck if you want to move laterally.

I disagree. I think moving laterally will be the only way to get jobs in the future. I'm already seeing an increase in ads looking for candidates with 5+ years experience or at least 2. I think new grads will be increasingly screwed. "New grads welcome!" in a job ad probably means an exploitative job bargain hunting for someone just trying to avoid the breadlines.

And to the topic, yes I think it is extremely obvious the number one thing that can be done right now is to cut residency spots in half (not just a couple of programs cutting a couple of spots, which would be meaningless theatrics) combined with a focus on recruiting residents who actually have a passion for the field. A lot of what people are complaining about here is the result of a decade of programs trying to pick applicants based on Step 1 scores and prestige of medical school alone to try and make chairs and PDs look good. As a result you ended up with people who worked their whole life so far just looking for the best lifestyle for the best pay (not that there's anything wrong with this). But it should come as no surprise when they pump out fluff research, take cushy academic positions with low clinical load, and continue to push out a bunch of crap. These students have all now moved back over to derm or whatever the other lifestyle specialty is these days.

 

[Dan Spratt]

I disagree. I think moving laterally will be the only way to get jobs in the future. I'm already seeing an increase in ads looking for candidates with 5+ years experience or at least 2. I think new grads will be increasingly screwed. "New grads welcome!" in a job ad probably means an exploitative job bargain hunting for someone just trying to avoid the breadlines.

And to the topic, yes I think it is extremely obvious the number one thing that can be done right now is to cut residency spots in half (not just a couple of programs cutting a couple of spots, which would be meaningless theatrics) combined with a focus on recruiting residents who actually have a passion for the field. A lot of what people are complaining about here is the result of a decade of programs trying to pick applicants based on Step 1 scores and prestige of medical school alone to try and make chairs and PDs look good. As a result you ended up with people who worked their whole life so far just looking for the best lifestyle for the best pay (not that there's anything wrong with this). But it should come as no surprise when they pump out fluff research, take cushy academic positions with low clinical load, and continue to push out a bunch of crap. These students have all now moved back over to derm or whatever the other lifestyle specialty is these days.

Many of you make excellent points, some of which a Department Chair can impact, some of which are massive macro level factors that need majority buy in to make an impact (which we all can help move the needle).

Point 1. Growth of 1 department means hurting another. This at a glance must be true, but is not necessarily true.
-A few examples; salvage RT for PSA recurrence is used by only ~30% of men who recur post-surgery. ~45,000 patients a year in the USA have PSA recurrence post-RP, and thus there is ~30,000 patients in the USA per year that are potentially amenable to receive salvage RT (lets say 20,000 once you remove ppl that dont need it). In Michigan, after working with MUSIC, a statewide quality consortium of >90% of all urologists in the state, we have added in a quality metric for practices to increase the use of salvage RT, which is going very well.
There are other examples of bone mets, oligomets, etc. Depending on the practice 40-60% of practices volume is metastatic patients, and as I have written before about, our spine program created an entire new cFTE position, created 2-3 at MSKCC as they are huge, etc without eating into other practices. Even use of definitive RT for prostate, is under utilized and the increased use of RP in high risk disease or use of focal therapy in favorable intermediate risk disease, has a greater impact on radonc volume than one center growing. There are thousands and thousands of patients that have true indications today for RT that dont get RT. Start there. Then work on innovative ways to have RT be a key treatment for patients, especially advanced disease, which each patient often will need 3+ courses, creates a large need. Of course centers of excellence will naturally draw patients to them, but that doesnt mean growth MUST hurt other practices. If you make your center so strong and provide the ability to give exceptional care, that is only market forces at play, like in any business, of where the market goes.

Point 2. We must reduce residency slots. While this makes total sense and may in fact be true (I dont know), I need to get better up to speed as to how many grads do not find a job or is it they dont find the job they want. 2 very different things. I didnt get interviews at many places I applied, and I got hired to be a CNS attending even though I wanted to do GU. I have a long list of many very well known attendings who started out at places that weren't their top choice, were more remote satellites they were not necessarily looking to go to, did a fellowship as they didnt get the job they wanted, did a post-doc or instructorship, or treated different diseases than they wanted. I was very fortunate to work hard to shape and make my dream job, but I realize I am very lucky.
I do think our field made the mistake of expanding residency programs that largely did this to provide good attending coverage. Some though I am sure did this to provide exposure to trainings to things (SBRT, SRS, peds, lymphoma, protons, brachy, etc), however it is clear this was not ubiquitous.

Although I clearly dont know the answers to many things, I do know that complaints without action will change nothing. I have before and I will say it again, I encourage you all to be part of the change. This can be to do what was done in Australia recently to mandate all prostate patients be seen by a radonc and urologist, it could be what we did in Michigan to get urology buy in to refer all patients with BCR to radonc for discussion, to think of innovative methods to improve reimbursement for hypofrac, etc. Please dont think there is some group sitting in an ivory tower making solutions to all of these things. These things come from people like you and me. The Iphone, Amazon prime, etc did not come from the Government looking out for society, they came from incredibly ambitious people wanting to solve a problem and most of you have used these services.

Has radonc made mistakes. ABSOLUTELY. Has it done a lot of good things. Definitely. Can it change? Of course.

 

[kimplera]

Dan - congrats on the job - looking forward to see the changes coming for UH. That is quite the network to use to do some of the things you talk about. Chances for D&I research - how can we translate what we have innovated at academic centers to community practice.

I encourage you (actually not specifically you but all here) to not equate a postdoc with an instructorship - good rationale for physician scientists to pursue a postdoc - build a scientific program that will compete with PhD scientists. Most instructorships are not taken because the applicant needs more training (with the possible exception of brachytherapy and/or peds for those with limited residency experience). These positions are almost certainly a sign of oversupply or the willingness of some to take advantage of the current job market.

 

[Neuronix]

Huh? Instructor vs. post-doc? Please educate me on the difference here. I'm a physician-scientist wannabe and the only difference I can think of is that instructor pays better than post-doc. Exactly how much clinical time you have as an instructor vs. post-doc is negotiable.

By odd coincidence, I ran into someone today who used to work with Dan Spratt. He mentioned that Dan always dressed sharp in a suit and never a hair out of place every single day. I thought he only looked like that at ASTRO. I guess it's true--you dress for the job you want!

 

[drewdog1973]

Do people other than @Dan Spratt think that there is any question that there needs to be less residents? Because, though everyone appreciates the virtual hand pleasure going around, I feel like that seems like an odd thing to say...

 

[RadOncDoc21]

Do people other than @Dan Spratt think that there is any question that there needs to be less residents? Because, though everyone appreciates the virtual hand pleasure going around, I feel like that seems like an odd thing to say...

It’s safe to say it ain’t going to happen anytime soon.

 

[medgator]

. We must reduce residency slots. While this makes total sense and may in fact be true (I dont know)

Really Dan?

Did you know if we needed to increase slots since the turn of the century?

Might want to confer with your soon to be colleague/chair at WUSTL on that one

DEFINE_ME

 

[Dan Spratt]

Huh? Instructor vs. post-doc? Please educate me on the difference here. I'm a physician-scientist wannabe and the only difference I can think of is that instructor pays better than post-doc. Exactly how much clinical time you have as an instructor vs. post-doc is negotiable.

By odd coincidence, I ran into someone today who used to work with Dan Spratt. He mentioned that Dan always dressed sharp in a suit and never a hair out of place every single day. I thought he only looked like that at ASTRO. I guess it's true--you dress for the job you want!

Good point. It could be semantics, but I think they are viewed differently. I know of multiple very successful instructors who are now attendings at MSKCC and Dana Farber, and many would consider them some of the top young physician scientists in the country. There are others out there that went straight to an attending job and were incredible physician scientists, however this is less common. Data published on the success of the Holman pathway has shown that even with those extra months in general our current models for physician scientists are ineffective and many never gain true independence. Shockingly low numbers get independent R01 funding in radonc. Thus, I have seen the argument from both sides that an instructorship provides multiple years to test the waters and try to get enough science going with almost no clinical responsibilities, so when you start your assistant prof job you hit the ground running. Likely depends on the individual, the program, etc.

However, radonc did a major disservice by making the ideal candidate in many centers rank lists the MD/PhD wanting to do basic science. While these people are vitally important in appropriate numbers to the advancement of a field, we did not focus on attracting top clinicians or clinical researchers, which is what >95% of our field is composed of. There are many centers who literally give bonus points in rank lists for a PhD, more bonus points for doing research, etc...well of course a PhD has research...that was their job! They should be judged if they did exceptional research. Most people with 3-7 years can publish research. I am far more impressed by an MD who did amazing clinically who happened to do a tiny bit of research that a PhD who did the average amount of research. What we ended up with is massive numbers of exceptionally talented physician scientists with no place to go do science and they ended up often going to private practice...a loss for all parties as they spent years gaining a skill set they arent using. In my eyes this was one of the biggest mistakes in radonc as there are countless aftereffects of these decisions that we are seeing today. A paper just came out in ARO (Trudy et al) that showed the top reasons people arent going into radonc is concern for too much research and too much physics. We all know day to day there is very little physics and you dont need to do research to be a great radonc.

That same paper showed that what attracted people to radonc was salary/life style. We must not forget what has happened to radonc is happening to most specialties and Medicine as a whole. My wife is a dermatologist and we were shocked that in NYC most of her dermatologist friends made <300k per year (I am not exaggerating) unless they see >50 patients a day (that is NYC!). I had radiology friends who cleared 800k 20 years ago and now make <400k. Healthcare is an expensive mess, and I have friends in Canada, Europe, and Asia in radonc and we still are compensated well. My best friend growing up his Dad was a general surgeon and made ~1 million per year. That was 25 years ago, where that was a lot more back then. He retired a few years ago and was making closer to 300k. I know neurosurgeons who make <500k, today and that is crazy to some of my early mentors where 7 figure salaries were normal. There are of course tons of exceptions to everything, but as many of you know cutting physician salaries and hiring more administrators has likely had a far more massive impact on our field than many other things. Call me a socialist but 300-500k are incredible salaries to me for the number of hours most radoncs work (<60 hrs). They are lower, but they are still great for medicine.

Clearly there are many issues at play and perhaps I am an optimist. I feel that change can always occur. I went from a C/D student who dropped out of college to become a doctor. Change though is not singular moment. It is thousands of daily decisions and consistent actions that culminate into a result. I promise that even if we waved a wand and residency slots were cut to 140 (or whatever you think it should be) there would still be upset people and many unresolved problems.

I believe that any of us can make an impact.

Best,
Dan

 

[RadOncMegatron]

Good point. It could be semantics, but I think they are viewed differently. I know of multiple very successful instructors who are now attendings at MSKCC and Dana Farber, and many would consider them some of the top young physician scientists in the country. There are others out there that went straight to an attending job and were incredible physician scientists, however this is less common. Data published on the success of the Holman pathway has shown that even with those extra months in general our current models for physician scientists are ineffective and many never gain true independence. Shockingly low numbers get independent R01 funding in radonc. Thus, I have seen the argument from both sides that an instructorship provides multiple years to test the waters and try to get enough science going with almost no clinical responsibilities, so when you start your assistant prof job you hit the ground running. Likely depends on the individual, the program, etc.

However, radonc did a major disservice by making the ideal candidate in many centers rank lists the MD/PhD wanting to do basic science. While these people are vitally important in appropriate numbers to the advancement of a field, we did not focus on attracting top clinicians or clinical researchers, which is what >95% of our field is composed of. There are many centers who literally give bonus points in rank lists for a PhD, more bonus points for doing research, etc...well of course a PhD has research...that was their job! They should be judged if they did exceptional research. Most people with 3-7 years can publish research. I am far more impressed by an MD who did amazing clinically who happened to do a tiny bit of research that a PhD who did the average amount of research. What we ended up with is massive numbers of exceptionally talented physician scientists with no place to go do science and they ended up often going to private practice...a loss for all parties as they spent years gaining a skill set they arent using. In my eyes this was one of the biggest mistakes in radonc as there are countless aftereffects of these decisions that we are seeing today. A paper just came out in ARO (Trudy et al) that showed the top reasons people arent going into radonc is concern for too much research and too much physics. We all know day to day there is very little physics and you dont need to do research to be a great radonc.

That same paper showed that what attracted people to radonc was salary/life style. We must not forget what has happened to radonc is happening to most specialties and Medicine as a whole. My wife is a dermatologist and we were shocked that in NYC most of her dermatologist friends made <300k per year (I am not exaggerating) unless they see >50 patients a day (that is NYC!). I had radiology friends who cleared 800k 20 years ago and now make <400k. Healthcare is an expensive mess, and I have friends in Canada, Europe, and Asia in radonc and we still are compensated well. My best friend growing up his Dad was a general surgeon and made ~1 million per year. That was 25 years ago, where that was a lot more back then. He retired a few years ago and was making closer to 300k. I know neurosurgeons who make <500k, today and that is crazy to some of my early mentors where 7 figure salaries were normal. There are of course tons of exceptions to everything, but as many of you know cutting physician salaries and hiring more administrators has likely had a far more massive impact on our field than many other things. Call me a socialist but 300-500k are incredible salaries to me for the number of hours most radoncs work (<60 hrs). They are lower, but they are still great for medicine.

Clearly there are many issues at play and perhaps I am an optimist. I feel that change can always occur. I went from a C/D student who dropped out of college to become a doctor. Change though is not singular moment. It is thousands of daily decisions and consistent actions that culminate into a result. I promise that even if we waved a wand and residency slots were cut to 140 (or whatever you think it should be) there would still be upset people and many unresolved problems.

I believe that any of us can make an impact.

Best,
Dan

@Dan Spratt The people's chair?

Thanks for your well thought out and civil posts.

 

[RadOncDoc21]

Good point. It could be semantics, but I think they are viewed differently. I know of multiple very successful instructors who are now attendings at MSKCC and Dana Farber, and many would consider them some of the top young physician scientists in the country. There are others out there that went straight to an attending job and were incredible physician scientists, however this is less common. Data published on the success of the Holman pathway has shown that even with those extra months in general our current models for physician scientists are ineffective and many never gain true independence. Shockingly low numbers get independent R01 funding in radonc. Thus, I have seen the argument from both sides that an instructorship provides multiple years to test the waters and try to get enough science going with almost no clinical responsibilities, so when you start your assistant prof job you hit the ground running. Likely depends on the individual, the program, etc.

However, radonc did a major disservice by making the ideal candidate in many centers rank lists the MD/PhD wanting to do basic science. While these people are vitally important in appropriate numbers to the advancement of a field, we did not focus on attracting top clinicians or clinical researchers, which is what >95% of our field is composed of. There are many centers who literally give bonus points in rank lists for a PhD, more bonus points for doing research, etc...well of course a PhD has research...that was their job! They should be judged if they did exceptional research. Most people with 3-7 years can publish research. I am far more impressed by an MD who did amazing clinically who happened to do a tiny bit of research that a PhD who did the average amount of research. What we ended up with is massive numbers of exceptionally talented physician scientists with no place to go do science and they ended up often going to private practice...a loss for all parties as they spent years gaining a skill set they arent using. In my eyes this was one of the biggest mistakes in radonc as there are countless aftereffects of these decisions that we are seeing today. A paper just came out in ARO (Trudy et al) that showed the top reasons people arent going into radonc is concern for too much research and too much physics. We all know day to day there is very little physics and you dont need to do research to be a great radonc.

That same paper showed that what attracted people to radonc was salary/life style. We must not forget what has happened to radonc is happening to most specialties and Medicine as a whole. My wife is a dermatologist and we were shocked that in NYC most of her dermatologist friends made <300k per year (I am not exaggerating) unless they see >50 patients a day (that is NYC!). I had radiology friends who cleared 800k 20 years ago and now make <400k. Healthcare is an expensive mess, and I have friends in Canada, Europe, and Asia in radonc and we still are compensated well. My best friend growing up his Dad was a general surgeon and made ~1 million per year. That was 25 years ago, where that was a lot more back then. He retired a few years ago and was making closer to 300k. I know neurosurgeons who make <500k, today and that is crazy to some of my early mentors where 7 figure salaries were normal. There are of course tons of exceptions to everything, but as many of you know cutting physician salaries and hiring more administrators has likely had a far more massive impact on our field than many other things. Call me a socialist but 300-500k are incredible salaries to me for the number of hours most radoncs work (<60 hrs). They are lower, but they are still great for medicine.

Clearly there are many issues at play and perhaps I am an optimist. I feel that change can always occur. I went from a C/D student who dropped out of college to become a doctor. Change though is not singular moment. It is thousands of daily decisions and consistent actions that culminate into a result. I promise that even if we waved a wand and residency slots were cut to 140 (or whatever you think it should be) there would still be upset people and many unresolved problems.

I believe that any of us can make an impact.

Best,
Dan

140 would be a good start and we can go from there. It’s hard to imagine how the supply/demand ratio isn’t an obvious first step to consider making first.

 

[medgator]

I'm shocked, the article by "Graypeace" made it into today's Quadshot:

View attachment 324803

While we can guess the author(s) based on writing style/graphics I honestly have no idea, but I presume they're reading this post so - thank you.

 

[RickyScott]

"Call me a socialist but 300-500k are incredible salaries to me for the number of hours most radoncs work (<60 hrs). They are lower, but they are still great for medicine." It is the geographic limitation due to oversupply, not the salary.

 

[Chartreuse Wombat]

Do people other than @Dan Spratt think that there is any question that there needs to be less residents? Because, though everyone appreciates the virtual hand pleasure going around, I feel like that seems like an odd thing to say...

Dan plans to recruit faculty and most "need" residents. That will be the benchmark for me. Can he grow faculty without increasing resident complement? If anyone can do it he can but i will await the reality on the ground in a few years.

 

[yesmaster]

This isn't addressing anybody in particular, but the problem with socialism is that while it espouses social or public ownership of the means of production, nothing could be further from the truth. The state and typically a dictator & his cronies live as hedonistic kings while the populace lives at or below the subsistence level.

The problem with radiation oncology is similar in kind, in which ownership of our means of production, including machines, referral patterns, various forms of prestige and branding, payor contracts, even the legal rights to work in certain locales, shifted from radiation oncologists and physician colleagues to administrators and institutions. In my experience, the folks that decry greed and urge altruism, have their hands in others' wallets and plan to grow rich from the labor of their comrades.

America, over the decades, has used its institutions to undermine "greedy" (i.e. capitalist) doctors and physician-owned hospitals, for instance, but seems to accept the capitalist ethos of administrators, CEO's, private equity, insurance companies, and others in healthcare.

All this isn't to say that I wouldn't work with administrators and such, but parties have to come to the table with an understanding of the value each party brings. It makes no sense to abase oneself or anchor low in negotiations.

 

[Old rad onc]

140 would be a good start and we can go from there. It’s hard to imagine how the supply/demand ratio isn’t an obvious first step to consider making first.

Dan,
Congrats and particular thanks for coming to our turf as a good will gesture to promoting the kind of debate that will be productive in Rad Onc as a field.

I graduated from CWRU and grew up in Ohio. I live in California now but am glad to see someone of your talents taking over. Not only that you are the first Chairman to publicly state that Rad Onc needs changes to not only survive but thrive.

We who have been apart of SDN have seen the problems coming for 10 years or more. It will take that many years to solve just the residency numbers and so the outcry to do something now is great but nothing can be done overnight , nor can one program change the field.

I will say thanks for being a part of our discussion and so here are my thoughts as a private practice guy with 30 years in the field.

1) All of us are swayed in bias by our own interests and situation. We are not different in that regard than any doctor in any field. As a new Chair, you will wear many hats , but keeping your program strong is your first priority . We do wish all programs would look at the oversupply issue and not SOAP, lesser candidates to fill spots but it is a business so I get why it’s done. I just ultimately feel it will not help the field or that candidate get a job 5 years from now. Having said that, a chairman who is brave enough to even shine light on this someone we can support. Think Robert the Bruce! By the way, I’m an optimist so I think you will find a way to lead!

2) I have survived in this field by being creative. Carving out niches where others have not. No doubt we are a tertiary specialty but that does not mean we have to rely on Med Onc or Urology or Breast surgeons. The old thinking must give way to thinking outside the Box. An example is not surrendering the possible benefit of Radiation in Lymphoma. I do see patients that have failed all chemo but Rads were never considered. Newer Med oncs have frankly never considered its use.

3) Hypofraction unfortunately is here to stay. Once Pandora has been opened the box cannot be closed. Europe and Canada drive it , but for the love of God, 1 fraction and even 5 are not enough for some things. If academics can push protons, then certainly studies that promote QOL can show a benefit even in oligomets.

4) The battle between University and privates will continue to mount just as insurance companies and the government will be involved. You cannot blame old guys for selling their practice, just as you cannot blame young guys for wanting to make more money. My advice, be happy with your situation for now and that no matter what life WILL change. If you want something different then you have to plan for it or just get lucky. The smartest do both.....

5) Dan welcome to SDN and we could sure use your help. But do what you need to do ( But still help us fix Rad Onc!) and don’t take any crap from your friends here!

 

[Neuronix]

Good point. It could be semantics, but I think they are viewed differently. I know of multiple very successful instructors who are now attendings at MSKCC and Dana Farber, and many would consider them some of the top young physician scientists in the country. There are others out there that went straight to an attending job and were incredible physician scientists, however this is less common. Data published on the success of the Holman pathway has shown that even with those extra months in general our current models for physician scientists are ineffective and many never gain true independence. Shockingly low numbers get independent R01 funding in radonc. Thus, I have seen the argument from both sides that an instructorship provides multiple years to test the waters and try to get enough science going with almost no clinical responsibilities, so when you start your assistant prof job you hit the ground running. Likely depends on the individual, the program, etc.

I'm with you on this. I just don't understand the difference between post-doc and instructor in this context. Maybe kimplera will enlighten us.

However, radonc did a major disservice by making the ideal candidate in many centers rank lists the MD/PhD wanting to do basic science. While these people are vitally important in appropriate numbers to the advancement of a field, we did not focus on attracting top clinicians or clinical researchers, which is what >95% of our field is composed of. There are many centers who literally give bonus points in rank lists for a PhD, more bonus points for doing research, etc...well of course a PhD has research...that was their job! They should be judged if they did exceptional research. Most people with 3-7 years can publish research. I am far more impressed by an MD who did amazing clinically who happened to do a tiny bit of research that a PhD who did the average amount of research. What we ended up with is massive numbers of exceptionally talented physician scientists with no place to go do science and they ended up often going to private practice...a loss for all parties as they spent years gaining a skill set they arent using. In my eyes this was one of the biggest mistakes in radonc as there are countless aftereffects of these decisions that we are seeing today. A paper just came out in ARO (Trudy et al) that showed the top reasons people arent going into radonc is concern for too much research and too much physics. We all know day to day there is very little physics and you dont need to do research to be a great radonc.

The reason why people aren't going into rad onc is because the job market is terrible. The last sentence of the results of the abstract you cited states: "In the subgroup of students who were interested in RO but ultimately applied to another specialty, the job market was the most salient concern."

Concerns about too much research, too much physics, etc has not changed in decades. When I applied during the peak of rad onc competitiveness, attendings used to talk about "medical students don't have exposure to rad onc and they are afraid of the physics and research." Meanwhile, happy rad onc attendings used to say on here and elsewhere, "don't worry about it, it's not that bad, etc." Now they say, "do you have any preference where you want to live?"

That same paper showed that what attracted people to radonc was salary/life style. We must not forget what has happened to radonc is happening to most specialties and Medicine as a whole. My wife is a dermatologist and we were shocked that in NYC most of her dermatologist friends made <300k per year (I am not exaggerating) unless they see >50 patients a day (that is NYC!). I had radiology friends who cleared 800k 20 years ago and now make <400k. Healthcare is an expensive mess, and I have friends in Canada, Europe, and Asia in radonc and we still are compensated well. My best friend growing up his Dad was a general surgeon and made ~1 million per year. That was 25 years ago, where that was a lot more back then. He retired a few years ago and was making closer to 300k. I know neurosurgeons who make <500k, today and that is crazy to some of my early mentors where 7 figure salaries were normal. There are of course tons of exceptions to everything, but as many of you know cutting physician salaries and hiring more administrators has likely had a far more massive impact on our field than many other things. Call me a socialist but 300-500k are incredible salaries to me for the number of hours most radoncs work (<60 hrs). They are lower, but they are still great for medicine.

You are giving examples of specialties in the worst job market in the country (NYC) compared to rad onc anywhere.

My experience when I finished residency training a few years ago was as follows. I applied to jobs all over the country with few limitations as to where I'd work. I had a preference, but couldn't find any job in that region. I was willing to do a primarily research post-doc/instructorship and applied to several, but was rejected to all (and my CV was and is very strong for level). I ended up with two offers in two wildly different parts of the country, both of which were 100% clinical within "academics" and were non-negotiable. I had to practically beg for the second offer. Salaries were shockingly the same in all positions discussed, PP or academics ($300k). This was true even in "undesirable" locations.

One of my co-residents needed to be in a particular large city--not usually mentioned by people as a desirable city. So they moved there jobless despite applying to everything in the area, and went unemployed for awhile with some locums work. This went on for years before finally finding a full-time job in that city. I know several rad oncs who are similarly unemployed or underemployed. We had a few fellowship programs where I trained, and it was painful watching those fellows end up not using their fellowship at all or also ending up unemployed or underemployed.

Contrast this with the med onc and radiology fellows where I trained. They were getting phone calls, dinners, and interview offers from their first year of fellowship from all over the state trying to recruit them with starting offers at $600k and higher bonus potential with their choice of location. More general specialties like hospitalists couldn't get their phone to stop ringing from recruiters, and their salaries are also $300k ish though they're getting one week on, one week off offers. The fellowship programs were desperately trying to lock their fellows in to stay on as faculty since they were, and still are, critically short of faculty.

Sure, maybe NYC is tight for every specialty. I'm not talking about NYC. I'm talking about a different large state with several urban centers where I watched other specialties have their pick with significantly more pay. You are lucky to get a job anywhere as a rad onc in this state. People literally apply to every job in the state and often don't get one or end up with something very predatory. Where I work now the med oncs are being hired to make at least 50% more than I do, and they have all the lateral mobility they want. If they're unhappy, they just pick up and leave. I know several who have left for PP and make 7 figures or close to it. Where am I going to go? People who leave the department either no longer work as clinical rad oncs or are in very rural areas (not their choice). The residents have it similarly. I watch them struggle to find jobs at all, some of whom don't have jobs until the moment before they graduate or go months or longer after graduation without finding permanent employment despite broad area searches.

Meanwhile you are on twitter posting "ABR: Always Be Recruiting". No. It doesn't work that way. Create the demand, and then recruit. You don't keep oversupplying in a time of critical oversupply and hope that you or someone else will be able to fix it some day. You react to reality as it is, not how you want it to be. If we manage to create significantly more demand for radiation oncology in the future, that would be great. We can always turn up the residency programs again at a later date and create those trainees. A 5 year delay would be just fine to unwind all the oversupply in the current market.

Clearly there are many issues at play and perhaps I am an optimist. I feel that change can always occur. I went from a C/D student who dropped out of college to become a doctor. Change though is not singular moment. It is thousands of daily decisions and consistent actions that culminate into a result. I promise that even if we waved a wand and residency slots were cut to 140 (or whatever you think it should be) there would still be upset people and many unresolved problems.

I'm an optimist too. I'm a high school dropout who worked hard and eventually graduated from an MSTP. My father was illiterate. I was homeless for awhile just like my mother who spent much of her life in mental hospitals or on the street. Now I'm sitting here with a small team trying to design and run studies to improve lives of cancer patients and expand rad onc indications. Not a single one of my studies are about shortening or eliminating radiation--more about intensification and expanding indications. Will I be successful? Who knows. But, I'm not going to sit here and claim we need more residents just in case I hit gold. That's not optimism--it's foolish.

Let's wave that wand and cut residency slots to 140. There are always problems and issues in life, but I'd call that a good start to fixing the biggest problem facing radiation oncology trainees.

 

[radonc17]

I hate to say it but The paper cited above by @Dan Spratt in Advances in Rad Onc is not good work

look at the author list and see the COI...

don’t buy into the propaganda that online forums is the issue

In a vacuum, not having enough applicants literally means nothing.

There is no study to suggest we need 150-200 students annually applying into radonc

if we have 100 applicants great so what, what’s the big deal if we have a low match rate?

it’s all about prestige chasing and saying we are competitive field nothing else

I don’t think Dan is suggesting there is no problem but I’m writing just to raise awareness so that study does not become "widely quoted"

Anyways, appreciate Dan coming on and having a legit discussion

wish u success

 

[speakeroftruth]

What a great discussion. I just had a thought (PROMISE it was not one of my wonderful lightbulb thoughts) -- imagine how different the conversations could be if chairs and so-called "leaders" engaged like Dan Spratt.

Instead, we have Louis Potters vowing to SOAP if needed into his hell pit program no matter what after ASTRO released a good (it's a start that they acknowledged the issue but could have been more forceful) statement about the concerns of students/trainees on the job market. We have Paul Wallner sending threatening emails to sue to a new junior rad onc attending for libel because she talked about how she wished she had some accommodations during testing as a new mother. We have Lisa Kachnic calling a group residents who matched during peak rad onc "stupid" because they failed an inane test which needs to be completely overhauled.

We can disagree on how to get to the end goal of improving the job market which is the primary concern but these conversations we have here can hopefully begin to heal the pain and horrors of where we are today.

 

[RickyScott]

A paper just came out in ARO (Trudy et al) that showed the top reasons people arent going into radonc is concern for too much research and too much physics. We all know day to day there is very little physics and you dont need to do research to be a great radonc.

Wanted to give some push back re Michael Steinberg paper which somehow comes to conclusion that loss of interest in radonc due to physics phobia, not the very real fear medstudents will be un/under employed or if lucky, land job thousands of miles from family.

 

[radonc17]

Wanted to give some push back re Michael Steinberg paper which somehow comes to conclusion that loss of interest in radonc due to physics phobia, not the very real fear medstudents will be un/under employed or if lucky, land job thousands of miles from family.

ha wonder why ppl have a physics phobia?

because one of the coauthors of the article happened to be in charge when 30% failed unexpectedly?

or after that same coauthor said residents are worse then ever bc they failed? (Hilariously debunked)

or maybe bc we have to take the test in the first place despite universal acknowledgment that we use a bare minimum of med phys in our life as a physician

 

[elementaryschooleconomics]

ha wonder why ppl have a physics phobia?

because one of the coauthors of the article happened to be in charge when 30% failed unexpectedly?

or after that same coauthor said residents are worse then ever bc they failed? (Hilariously debunked)

or maybe bc we have to take the test in the first place despite universal acknowledgment that we use a bare minimum of med phys in our life as a physician

After passing physics boards, I can confirm my "physics phobia" is now "physics PTSD".

Ridiculous exam.

 

[RickyScott]

Also wanted to push back on Dan’s point that growth of one department is not necessarily at the expense of another. It’s the cold truth. Total pie is getting smaller not bigger.

 

[RickyScott]

Just took a zofran.

 

[fiji128]

Just took a zofran.

More garbage research from rad onc "leaders," shocking. Even got a Dan Golden authorship on that, nice. Any med students wondering about the difference between rad onc and med onc currently, find a paper edition of JCO vs the Red Journal and compare.

 

[RickyScott]

More garbage research from rad onc "leaders," shocking. Even got a Dan Golden authorship on that, nice. Any med students wondering about the difference between rad onc and med onc currently, find a paper edition of JCO vs the Red Journal and compare

Weekend journal club on mentoring initiatives in radonc is over the top.

 

[medgator]

Weekend journal club on mentoring initiatives in radonc is over the top.

Id be mentoring on how to GTFO if not in a good job now.... Side gig thread is a good start

something me and Siker have in common

 

[FrostyHammer]

Just took a zofran.

Thanks for the heads-up, I'm not even going to read it. Papers like this offer nothing to the field and get cited about 10 times over the next decade. AKA no one cares except the authors and apparently the red journal editorial staff.

 

[speakeroftruth]

I found actual behind the scenes footage of Marsiglio et al celebrating their groundbreaking oncology research published in rad onc's top journal, the Red Banana. Sorry, I meant the Red Journal.

Turn the sound on.





Edit: My mistake, Katz was not an author. Changed the author name, thanks Sue Yom.

 

[sueyom]

Hello all. Just wanted to say I think the "monke" video is funny and has good beats.
I also wanted to clarify that the article in question was published in the RJ but Matt Katz is not a co-author on that article if I am understanding this thread correctly.
On occasion articles from RJ (or other journals) are selected as kickoff points for Rad Nation's Twitter based journal club - RJ provides access to the articles but otherwise is not involved and likewise Matt is not part of the RJ at least at present.
I also wanted to introduce myself as the current Deputy Editor of the RJ and incoming Editor in Chief in 2022.
I am interested in new media in all forms and some of my experiments have succeeded and some have not, but overall I think it's important for RJ to stay current. As part of this I occasionally look at SDN and other social media channels.
I would also like to say, I tend to be a pretty broad minded person and I believe at RJ we reflect that. RJ for me is a reflection of all of our community. We consciously self-monitor for biases - this is part of why we developed the deputy/senior editor structure where we can convene multiple perspectives to check ourselves, all of us including Anthony. That being said, we have to publish the best of what we receive and we cannot create publications or discussions on topics that are never submitted. However, even within those constraints, we strive to provide balance and quality and reasonableness - and I can assure you that I am not someone who shies from presenting multiple views or speaking truth to power.
However the one point on which I will not budge, ever, is that the RJ is, for better or for worse, and taking into account the many challenges confronting the publishing industry, our journal. It brings us together and reflects and expands our community of radiation oncology across many types of boundaries in ways the societies cannot. ASTRO has never to its credit interfered with the editorial independence of the RJ and hence we have relationships that are wide ranging and important to the scientific and social power of our field. The exact specifications of how the journal runs are likely to evolve (and this will be my continued stress point) but the fundamental role of RJ as a community structure must not.
A few last things. I believe we do have to stay concerned about the political strength of our specialty and its turf so to speak. I believe residency should be a high quality experience. I believe that financial health while not everything in life certainly brings powers and opportunities. While I have been an academic my whole life I want to assure you I am interested in strategic and practical concerns.
So I just wanted to introduce that perspective. I hope that you as important voices in the radonc community will support our beloved journal and understand my/our intent as reporters and conveyors of new research and events in our field - and perhaps even participate in that dialogue through whatever venues in our journal might suit you.
With my best regards for your health and well being, Sue Yom

 

[elementaryschooleconomics]

Hello all. Just wanted to say I think the "monke" video is funny and has good beats.
I also wanted to clarify that the article in question was published in the RJ but Matt Katz is not a co-author on that article if I am understanding this thread correctly.
On occasion articles from RJ (or other journals) are selected as kickoff points for Rad Nation's Twitter based journal club - RJ provides access to the articles but otherwise is not involved and likewise Matt is not part of the RJ at least at present.
I also wanted to introduce myself as the current Deputy Editor of the RJ and incoming Editor in Chief in 2022.
I am interested in new media in all forms and some of my experiments have succeeded and some have not, but overall I think it's important for RJ to stay current. As part of this I occasionally look at SDN and other social media channels.
I would also like to say, I tend to be a pretty broad minded person and I believe at RJ we reflect that. RJ for me is a reflection of all of our community. We consciously self-monitor for biases - this is part of why we developed the deputy/senior editor structure where we can convene multiple perspectives to check ourselves, all of us including Anthony. That being said, we have to publish the best of what we receive and we cannot create publications or discussions on topics that are never submitted. However, even within those constraints, we strive to provide balance and quality and reasonableness - and I can assure you that I am not someone who shies from presenting multiple views or speaking truth to power.
However the one point on which I will not budge, ever, is that the RJ is, for better or for worse, and taking into account the many challenges confronting the publishing industry, our journal. It brings us together and reflects and expands our community of radiation oncology across many types of boundaries in ways the societies cannot. ASTRO has never to its credit interfered with the editorial independence of the RJ and hence we have relationships that are wide ranging and important to the scientific and social power of our field. The exact specifications of how the journal runs are likely to evolve (and this will be my continued stress point) but the fundamental role of RJ as a community structure must not.
A few last things. I believe we do have to stay concerned about the political strength of our specialty and its turf so to speak. I believe residency should be a high quality experience. I believe that financial health while not everything in life certainly brings powers and opportunities. While I have been an academic my whole life I want to assure you I am interested in strategic and practical concerns.
So I just wanted to introduce that perspective. I hope that you as important voices in the radonc community will support our beloved journal and understand my/our intent as reporters and conveyors of new research and events in our field - and perhaps even participate in that dialogue through whatever venues in our journal might suit you.
With my best regards for your health and well being, Sue Yom

Dan Spratt, Jillian Tsai, and Sue Yom all came to hang out on SDN in the past week.

I like this new era of communication. It feels like it might, perhaps, MAYBE, be a constructive venture.

Maybe.

 

[scarbrtj]

We consciously self-monitor for biases

I believe that financial health while not everything in life certainly brings powers and opportunities.

As an aside, here are the first names of the top 50 paid-by-CMS rad oncs in the USA. We need more Sue Yoms, not Sues.

JOHN
ALLEN
TIMOTHY
SACHIN
RICHARD
DANIEL
KEITH
HEJAL
ALAN
JASON
RYAN
JACK
MICHAEL
PATRICK
JARED
MARK
MICHAEL
JOSHUA
ANDREW
WILSON
CONSTANTINE
MICHAEL
NEIL
WILLIAM
RIZWAN
DANIEL
THOMAS
PAUL
GREGORY
EDUARD
ERIC
DAVID
KISHORE
MATTHEW
JOHN
JEFFREY
DAVID
JOSEPH
MARK
JAMIE
CHRISTOPHER
ANAND
BRIAN
LARRY
GILBERT
STEPHEN
ALEXANDER
HENRY
RICHARD
GRENVILLE

 

[RadOncG]

Dan Spratt, Jillian Tsai, and Sue Yom all came to hang out on SDN in the past week.

I like this new era of communication. It feels like it might, perhaps, MAYBE, be a constructive venture.

Maybe.

Just need Lisa Kachnic to come on and explain why Columbia needs to expand to 8 residents from current 6.

 

[speakeroftruth]

Just need Lisa Kachnic to come on and explain why Columbia needs to expand to 8 residents from current 6.

Not just Columbia. She expanded Vanderbilt's number of spots as well. No offense to Vanderbilt but it is not a program that should have 10 residents (and growing). And let's not even start on Columbia's rad onc program -- an embarrassingly bad program that is now taking 8 residents? God help those poor students and residents.

Edit: @evilbooyaa thanks for the correction. Number edited.

 

[elementaryschooleconomics]

Just need Lisa Kachnic to come on and explain why Columbia needs to expand to 8 residents from current 6.

Oh man that would be great.

I would love to talk to these folks behind my Elementary moniker...because while they can destroy my career with minimal effort, I'm pretty sure I can't put a dent into Dan Spratt, for example.

And not just because he's at least 14% whey protein on any given day!

(note: I don't actually think Dan/Jillian/Sue are vindictive people, but I come from that DTA background)

 

[medgator]

Not just Columbia. She expanded Vanderbilt's number of spots as well. No offense to Vanderbilt but it is not a program that should have 13 residents (and growing). And let's not even start on Columbia's rad onc program -- an embarrassingly bad program that is now taking 8 residents? God help those poor students and residents.

Not including the inpatient/Palliative radiation "fellows"

 

[medgator]