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I have no problem with hypofractionation to improve oncological outcomes or major savings in price or convenience. But then the field needs to contract, not expand! Also, the institutions researching and spearheading it, charge significantly more! (and tout it as competitive advantage for pts to travel there,)
 
Haybrant said:
why is it such a big scientific breakthrough anyway to reduce the number of fractions of treatment. Lifting it up on major platforms as plenary sessions, giving it major press, high impact factor pubs - but scientifically what’s impressive about it at all? Is it some triumph of alpha beta biology? Or is it just a triumph of insurers using physicians as their proxies as pharma does to med oncs with Reckless abandon
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Insures don’t really care. For most plans, High prices benefits them as they are middlemen and profits capped at 10-20% by law. The employer pays and insurances make profit on transaction. As VP said on podcast the other day, if you are limited to 20% of the pizza, you want the biggest pizza possible!
 
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Haybrant said:
why is it such a big scientific breakthrough anyway to reduce the number of fractions of treatment. Lifting it up on major platforms as plenary sessions, giving it major press, high impact factor pubs - but scientifically what’s impressive about it at all? Is it some triumph of alpha beta biology? Or is it just a triumph of insurers using physicians as their proxies as pharma does to med oncs with Reckless abandon
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I think there’s legitimate science here. The UK trials have been successful at using radiobiology and (don’t forget) better technology to make treatments isotoxic and isoeffective while also more convenient and cheaper for patients and society. Recall that hypofractionation was tried long ago and was way too toxic because the technology was too rudimentary.
 
RickyScott said:
Insures don’t really care. For most plans, High prices benefits them as they are middlemen and profits capped at 10-20% by law. The employer pays and insurances make profit on transaction. As VP said on podcast the other day, if you are limited to 20% of the pizza, you want the biggest pizza possible!
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That was a good segment. Commercial insurers care more that the revenues, profits, and costs fit within their calculated projections. And as long as it is, everything is gravy. Don’t let the prior auths fool you wrt their intentions.

Insurers use ‘medical loss ratios’ to cheat us - PNHP

NBER Working Paper No. 23353; Cost of Service Regulation in U.S. Health Care: Minimum Medical Loss RatiosBy Steve Cicala, Ethan M.J. Lieber, and Victoria MaroneNational Bureau of Economic Research, April 2017AbstractPaying for health care is a loss for insurers. They get to keep for their...
pnhp.org pnhp.org

“An extremely important unintended consequence of fixed medical loss ratios has been mentioned here before, but seems to have escaped the mainstream media, so it is being repeated: Once the MLR rules are established, the primary method by which insurers can increase the services they sell us, while increasing their profits, is by increasing gross revenues, since they are guaranteed a fixed percentage of those revenues. The most effective way to increase gross revenues is to increase the amount of health care services authorized and paid for.

If the insurers change provider incentives to double the amount of health care that is being delivered, they can double their own total revenues, keeping even more as profit because of the smaller marginal administrative costs of paying for more care. This incentive of the insurers to increase total health care spending is the exact opposite of the reform goal of slowing future health care cost increases.

All of this is good business. But that’s the problem.

In previous messages it was pointed out that the more the insurers pay out in health benefits, the more they can expand their administrative expenses and especially their profits. They get to keep 15 to 20 percent of the premiums.

How do you pay out more in health benefits? Simple. Negotiate higher prices with physicians and hospitals. Maximize benefits covered. Authorize more care; be very conservative with rejecting prior authorization requests. Avoid adjusting claims and avoid claim denials. Do not investigate over-utilization or frank health care fraud. Then have your actuaries calculate the premiums to include 15 to 20 percent over the inflated health care spending. Make that a little bit over 15 to 20 percent which will then have to be refunded but will ensure that the full padded margin is received.

As with so many policy flaws of the Affordable Care Act that we have reported here, there is some disbelief that the insurers would do that. But isn’t that the way markets work? Maximize revenues and profits? There is nothing illegal here.“
 
sloh said:
That was a good segment. Commercial insurers care more that the revenues, profits, and costs fit within their calculated projections. And as long as it is, everything is gravy. Don’t let the prior auths fool you wrt their intentions.

Insurers use ‘medical loss ratios’ to cheat us - PNHP

NBER Working Paper No. 23353; Cost of Service Regulation in U.S. Health Care: Minimum Medical Loss RatiosBy Steve Cicala, Ethan M.J. Lieber, and Victoria MaroneNational Bureau of Economic Research, April 2017AbstractPaying for health care is a loss for insurers. They get to keep for their...
pnhp.org pnhp.org

“An extremely important unintended consequence of fixed medical loss ratios has been mentioned here before, but seems to have escaped the mainstream media, so it is being repeated: Once the MLR rules are established, the primary method by which insurers can increase the services they sell us, while increasing their profits, is by increasing gross revenues, since they are guaranteed a fixed percentage of those revenues. The most effective way to increase gross revenues is to increase the amount of health care services authorized and paid for.

If the insurers change provider incentives to double the amount of health care that is being delivered, they can double their own total revenues, keeping even more as profit because of the smaller marginal administrative costs of paying for more care. This incentive of the insurers to increase total health care spending is the exact opposite of the reform goal of slowing future health care cost increases.

All of this is good business. But that’s the problem.

In previous messages it was pointed out that the more the insurers pay out in health benefits, the more they can expand their administrative expenses and especially their profits. They get to keep 15 to 20 percent of the premiums.

How do you pay out more in health benefits? Simple. Negotiate higher prices with physicians and hospitals. Maximize benefits covered. Authorize more care; be very conservative with rejecting prior authorization requests. Avoid adjusting claims and avoid claim denials. Do not investigate over-utilization or frank health care fraud. Then have your actuaries calculate the premiums to include 15 to 20 percent over the inflated health care spending. Make that a little bit over 15 to 20 percent which will then have to be refunded but will ensure that the full padded margin is received.

As with so many policy flaws of the Affordable Care Act that we have reported here, there is some disbelief that the insurers would do that. But isn’t that the way markets work? Maximize revenues and profits? There is nothing illegal here.“
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took me 10 years in practice before understanding this! Most insurance products are about making a commission managing the transaction. Higher price of transaction, higher commisssion. The employer pays the actual health care expense. The products that involve taking on a risk- like some Medicare advantage- restrict access to mskcc etc.

This is also why the insurance industry and hospitals are united in opposing price transparency.
 
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Well, Dr Beyer, perhaps you have missed out on what's been going on with the training pipeline over the last several years? In his defense, it looks like he graduated residency in 1985...so I'm sure he'll only continue to practice for another 10 or 20 years.
 
I was a bad example but refused to pay for a virtual meeting at the in-person price; I have been told that i must go to a corner and tell myself that i am not worthy of #radonc.

I have a simple question. Did any of the abstracts report a previously unreported survival difference in a randomized trial? Updates and presenting previously reported information doesn't count.
 
elementaryschooleconomics said:
View attachment 322046

Well, Dr Beyer, perhaps you have missed out on what's been going on with the training pipeline over the last several years? In his defense, it looks like he graduated residency in 1985...so I'm sure he'll only continue to practice for another 10 or 20 years.
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Didn’t this guy string a long a lot of junior docs, promising them partnership and then sell out his practices to 21c or us oncology? Someone in Phoenix screwed over a bunch of juniors a few years back and am pretty sure it is him?
 
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Chartreuse Wombat said:
I have a simple question. Did any of the abstracts report a previously unreported survival difference in a randomized trial? Updates and presenting previously reported information doesn't count.
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Pain control and the convenience of a few days' less treatment can be just as important as survival improvements.
 
Chartreuse Wombat said:
I was a bad example but refused to pay for a virtual meeting at the in-person price; I have been told that i must go to a corner and tell myself that i am not worthy of #radonc.

I have a simple question. Did any of the abstracts report a previously unreported survival difference in a randomized trial? Updates and presenting previously reported information doesn't count.
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Doubtful. Anything important in rad Onc will probably get reported at asco
 
sloh said:
In previous messages it was pointed out that the more the insurers pay out in health benefits, the more they can expand their administrative expenses and especially their profits. They get to keep 15 to 20 percent of the premiums.
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These margins are sick compared to other insurance markets. (well at least property and casualty). Health insurance never been more profitable.
 
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communitydoc13 said:
These margins are sick compared to other insurance markets. (well at least property and casualty). Health insurance never been more profitable.
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It’s profitable, but what it is unique is the misaligned incentives. for Storm insurance, the co is not hoping/trying to cause a more expensive hurricane!
 
I get the angst. Easy to do fractionation trials. But reading this forum and all the issues with insurance... who is going to pay for the research to do radiation for a new indication? De facto that would be not standard of care and not reimbursed. Who is going to support those trials? Who is going to pay for the unreimbursed radiation? Varian? Viewray? Accuray? Elekta? Not really seeing it... maybe just don't know.

And with all the issues with academic places... when is the last time a large RT practice (US Oncology, 21C, etc) ran a trial for a new radiation indication? Or any RT trial outside a co-operative group (I know a grand total of 1). Educate me if I am getting it wrong.

RickyScott said:
Technically, you are right, but it reveals the bizzare mindset/psychology of those hellbent on reducing the footprint of xrt in oncology (while expanding residencies) . Who would even think this is worthy of putting forth the research effort- going from 4 fractions to one fraction? What if medoncs started asking questions like- can we give cisplatin every 25 days instead of 21 during head and neck cancer treatment?
Edit: pi is Gregory Videtic who is smart and a good guy but wtf?
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temujim said:
I get the angst. Easy to do fractionation trials. But reading this forum and all the issues with insurance... who is going to pay for the research to do radiation for a new indication? De facto that would be not standard of care and not reimbursed. Who is going to support those trials? Who is going to pay for the unreimbursed radiation? Varian? Viewray? Accuray? Elekta? Not really seeing it... maybe just don't know.

And with all the issues with academic places... when is the last time a large RT practice (US Oncology, 21C, etc) ran a trial for a new radiation indication? Or any RT trial outside a co-operative group (I know a grand total of 1). Educate me if I am getting it wrong.
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Varian Receives Investigational Device Exemption (IDE) and Prepares for First Ever Clinical Trial of FLASH Therapy

/PRNewswire/ -- Varian (NYSE: VAR) today announced the company has received an Investigational Device Exemption (IDE) from the Food and Drug Administration...
www.prnewswire.com www.prnewswire.com
 
temujim said:
I get the angst. Easy to do fractionation trials. But reading this forum and all the issues with insurance... who is going to pay for the research to do radiation for a new indication? De facto that would be not standard of care and not reimbursed. Who is going to support those trials? Who is going to pay for the unreimbursed radiation? Varian? Viewray? Accuray? Elekta? Not really seeing it... maybe just don't know.

And with all the issues with academic places... when is the last time a large RT practice (US Oncology, 21C, etc) ran a trial for a new radiation indication? Or any RT trial outside a co-operative group (I know a grand total of 1). Educate me if I am getting it wrong.
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1) Extrapolating from what happens in the MedOnc world, yes, it would be amazing if companies funded the trials.

2) ...which is exactly what @radiation just posted above me!

3) You're kind of making the point. Who's going to run these trials, if not the large academic centers? But what kind of trials are the academic centers running?

I can't speak for all of us, but I know my complaining/misanthropy on this forum is entirely driven by wasted potential. I know what we're doing right now (in whatever topic, expansion, trials, etc) but I also know what we COULD BE doing. The people in this field are some of the smartest I have ever met. The technology is amazing, it feels like a half step from Star Trek sometimes.

And what are we doing with all this? Collecting med students like we're rounding up cattle for slaughter, putting time and resources comparing 1 fractions to 3. That's where my angst comes from. We should be doing better!

Edit: That being said, I love Videtic and his work and I do think it's convenient for patients if we could do things in a single day. But Videtic and his peers are smart and accomplished enough that I expect more from them, this isn't worth a press release even though that's how the game is played these days.
 
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New indication -- not protons for bone mets. Pharma companies are awash in money. And lots of companies. On trials the drugs are provided, AND the trial is paid for (handsome profit for the institution often!), etc. If it all works out --> new drug/new indication.

Making the research finances work for radiation for a totally new indication (ie radiation is NOT standard of care and NOT covered by insurance??) is difficult/impossible. I have not seen a device company cover that kind of cost -- even the big proton companies -- they are funding replacement (proton > photon) for a known indication -- but not even covering the differential cost of the proton treatment.

Anyway the point is that radiation research isn't as easy as it seems. Lots of hurdles to overcome.

elementaryschooleconomics said:
1) Extrapolating from what happens in the MedOnc world, yes, it would be amazing if companies funded the trials.

2) ...which is exactly what @radiation just posted above me!

3) You're kind of making the point. Who's going to run these trials, if not the large academic centers? But what kind of trials are the academic centers running?

I can't speak for all of us, but I know my complaining/misanthropy on this forum is entirely driven by wasted potential. I know what we're doing right now (in whatever topic, expansion, trials, etc) but I also know what we COULD BE doing. The people in this field are some of the smartest I have ever met. The technology is amazing, it feels like a half step from Star Trek sometimes.

And what are we doing with all this? Collecting med students like we're rounding up cattle for slaughter, putting time and resources comparing 1 fractions to 3. That's where my angst comes from. We should be doing better!

Edit: That being said, I love Videtic and his work and I do think it's convenient for patients if we could do things in a single day. But Videtic and his peers are smart and accomplished enough that I expect more from them, this isn't worth a press release even though that's how the game is played these days.
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radiation said:

Varian Receives Investigational Device Exemption (IDE) and Prepares for First Ever Clinical Trial of FLASH Therapy

/PRNewswire/ -- Varian (NYSE: VAR) today announced the company has received an Investigational Device Exemption (IDE) from the Food and Drug Administration...
www.prnewswire.com www.prnewswire.com
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Med oncs new indications are a product of a better understanding of certain important signalling pathways in certain cancers and creating drugs that target those pathways with few off Target effects. Iow, increasing the therapeutic ratio. We've done that to a degree with improved imaging, etc, which has allowed us to shrink ptv margins, and maybe flash. For us to alter the therapeutic ratio, it seems we need to find selective radioenhancers or protectors, and I'm not sure pharma labs would be interested in that until all the pathway specific small mol inhibitors, etc, are done being created. Iow, never. Otherwise, I can't see how finding new indications is a valid goal, especially when the secondary goal of the targeted med oncs stuff is to reduce the indication.
 
elementaryschooleconomics said:
1) Oh my God, I agree with Ralph.

2) As someone who has a PhD, Brian NAILS IT for me here. I fit into most of those boxes (burned out, slow project, want to focus on clinical learning). That being said...I can still play the game, and have managed to author or co-author over a dozen manuscripts in residency. Are any of them good? Eh...
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I was at one of the institutions on the top list for training and I was on the high end of those numbers for first author publications. All my first authors in residency were retrospective series.

Was this what I wanted to do? Absolutely not. When I went to interview for residency, I was very upfront with everyone about the basic/translational stuff I wanted to do that directly extended my PhD. Most institutions were not impressed, and overall I would say that my interviews at maybe 1 or 2 institutions went very well. The chair where I matched was interested, so that's how I ended up there. When I arrived for residency training a year and half or so after matching, the chair wasn't the chair any more. I told the new people in charge what research I wanted to do, and I was flatly told that I wasn't allowed to do that work there.

With nothing else to do, I wrote a whole bunch of retrospective reviews and worked on my basic/translational work elsewhere. The retrospective reviews were easily published, and the basic/translational science stuff I'm still struggling to get established with as faculty and publish. I mean, you can publish a survey with a 5% response rate in the red journal, and meanwhile I struggle to publish novel basic/translational stuff that takes years of work and hundreds of thousands in funding.

What I take from all this is: if you focus on basic research with your PhD in residency, you should expect maybe one first author publication. This is the nature of the game. This is what I would expect in one year or 1.5 years (Holman) in a new lab for a post-doc. You won't be making any top lists with your one paper. You will be lucky to even get an academic attending job with that one paper.

So I do agree with Ralph from the standpoint of... What's the point of counting retrospective reviews? Well, that's how you get a job in academics, unfortunately. Chairs may not care to think enough to evaluate you and the value of your work, but they know how to count (publications and grants).
 
Another example of making what we can measure important, rather than measuring what is important.

In another context known as the McNamara fallacy


The first step is to measure whatever can be easily measured. This is OK as far as it goes. The second step is to disregard that which can't be easily measured or to give it an arbitrary quantitative value. This is artificial and misleading. The third step is to presume that what can't be measured easily really isn't important. This is blindness. The fourth step is to say that what can't be easily measured really doesn't exist. This is suicide.

— Daniel Yankelovich, "Corporate Priorities: A continuing study of the new demands on business" (1972).
 
Chairs want publications for publicity/departmental visibility, their own career advancement. Numbers more important than quality as no one outside of radonc really knows what we are doing. It seems like md/phd today would be much better off in medonc from a research standpoint (not just gainful employment)
 
I think a lot of the people crapping on rad onc research are right in that there is a what appears to be a large number of fluffy studies.

However I think in many cases the criticism is also very superficial and seems like a discount Howard Sandler or someone’s critique.

First, med onc/Uro certainly has tons of fluff research. This Is not unique to rad onc (though I do agree that the social justice stuff is disproportionately high in rad onc)

Second, think about the diseases you treat and about the outcome you are going for. Improving overall survival when patients have a median OS of 12 months? Very easy to accrue to that trial, very easy to complete that trial, and...still, the bar has not moved that much for most cancers.
Improving overall survival in localized breast or prostate? You’ll need 20 years. The survival is very good so you also need a huge sample size.
ok, what about rt plus immunotherapy in metastatic disease? Yea, what about it? So far the trials have been disappointing. But also, how many patients are you referred for treatment with something like this, or for sbrt in general for oligomets? Will the patientsagree to randomization? Will the referring?

third, not all retrospective studies are inherently bad. Given that our decisions are often made by taking into account minute pathological details, it is impractical to expect a prospective study to evaluate nuances of treatment. Further no one would support, intellectually or otherwise, a study with no basis, and the Basis is often retrospective. For many rare or uncommon cancers, given the lack of portabilityand difficulty to standardize radiation, it is impractical to design and execute a proper study. It’s not “give xx drug a 3 weeks”, there are other logistical issues like transportation for daily treatment, lodging, remote qa, etc that are required.

fourth,how many here(or who critique retrospective studies in general) have actually run a trial or attempted to?How much does that cost? Is there a big funding source for rad onc? The government and patient philanthropy groups will certainly fund hypofractionation trials. Will industry?

I could go on, but it’s a whole lot more complicated than portrayed here, or on Twitter.
 
Ray D. Ayshun said:
Med oncs new indications are a product of a better understanding of certain important signalling pathways in certain cancers and creating drugs that target those pathways with few off Target effects. Iow, increasing the therapeutic ratio. We've done that to a degree with improved imaging, etc, which has allowed us to shrink ptv margins, and maybe flash. For us to alter the therapeutic ratio, it seems we need to find selective radioenhancers or protectors, and I'm not sure pharma labs would be interested in that until all the pathway specific small mol inhibitors, etc, are done being created. Iow, never. Otherwise, I can't see how finding new indications is a valid goal, especially when the secondary goal of the targeted med oncs stuff is to reduce the indication.
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Totally agree, the base reality may be that there just are not many/any remaining “new” indications for xrt. Akin to trying to find indications for antibiotics outside of infectious disease. Also, new indications for xrt should not be driven by residency expansion.
 
RickyScott said:
Totally agree, the base reality may be that there just are not many/any remaining “new” indications for xrt. Akin to trying to find indications for antibiotics outside of infectious disease. Also, new indications for xrt should not be driven by residency expansion.
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It’s very obvious but of course the indications for XRT are almost overwhelmingly: another doctor in another specialty thinks the patient needs XRT--instead of what they offer, in addition to what they offer, or because they have nothing to offer--so the patient is sent to Rad onc for XRT. But the raw number of XRT patients has fallen by ~10% over the last 20y. Which means indications are slowly dropping. Why? Probably because the incidence of "another doctor in another specialty thinks the patient needs XRT," aka the true indication for XRT, has slowly dropped over that time. This is upon which residency expansion, surveys, retrospective reviews, fascinating basic science research, shorter treatment schedules, novel molecules, Star Trek tech, and diversity have had no effect.
 
scarbrtj said:
It’s very obvious but of course the indications for XRT are almost overwhelmingly: another doctor in another specialty thinks the patient needs XRT--instead of what they offer, in addition to what they offer, or because they have nothing to offer--so the patient is sent to Rad onc for XRT. But the raw number of XRT patients has fallen by ~10% over the last 20y. Which means indications are slowly dropping. Why? Probably because the incidence of "another doctor in another specialty thinks the patient needs XRT," aka the true indication for XRT, has slowly dropped over that time. This is upon which residency expansion, surveys, retrospective reviews, fascinating basic science research, shorter treatment schedules, novel molecules, Star Trek tech, and diversity have had no effect.
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Exactly! I’m seeing yet another patient who was being managed with immunotherapy for known brain mets. Let’s not even mention the borderline pancreatic cancers not even being considered for neoadj RT or the early stage lungs and prostates that are being managed by med oncs. The lymphomas receiving 6-8 cycles of chemo, etc.

We have continued to make our presence less and less for some bizarre reason. I have surgeons claiming one fraction of standard dose of radiation is “harmful” to patients. Of course I’m educating the docs but this baseline ignorance has to have come from somewhere!
 
RadOncDoc21 said:
We have continued to make our presence less and less for some bizarre reason.
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Dilution of any substance, gas, solution, medicine, etc., makes it less potent. There are, roughly, the same number of XRT patients today as 20y ago but 50+% more rad oncs. And those rad oncs are giving patients 25-33+% less treatments. So: less patients per doctor spending less time in the doctors' clinics and seeing those doctors less often. The indications for rad onc, as much as we want to be scientific, come from extra-specialty perception (ESP!) as I alluded to prior. How's our perception now vs 20y ago? As you and I are both alluding to... it's not better (where it counts). Whose fault? "We?" Maybe so.
 
Neuronix said:
I was at one of the institutions on the top list for training and I was on the high end of those numbers for first author publications. All my first authors in residency were retrospective series.

Was this what I wanted to do? Absolutely not. When I went to interview for residency, I was very upfront with everyone about the basic/translational stuff I wanted to do that directly extended my PhD. Most institutions were not impressed, and overall I would say that my interviews at maybe 1 or 2 institutions went very well. The chair where I matched was interested, so that's how I ended up there. When I arrived for residency training a year and half or so after matching, the chair wasn't the chair any more. I told the new people in charge what research I wanted to do, and I was flatly told that I wasn't allowed to do that work there.

With nothing else to do, I wrote a whole bunch of retrospective reviews and worked on my basic/translational work elsewhere. The retrospective reviews were easily published, and the basic/translational science stuff I'm still struggling to get established with as faculty and publish. I mean, you can publish a survey with a 5% response rate in the red journal, and meanwhile I struggle to publish novel basic/translational stuff that takes years of work and hundreds of thousands in funding.

What I take from all this is: if you focus on basic research with your PhD in residency, you should expect maybe one first author publication. This is the nature of the game. This is what I would expect in one year or 1.5 years (Holman) in a new lab for a post-doc. You won't be making any top lists with your one paper. You will be lucky to even get an academic attending job with that one paper.

So I do agree with Ralph from the standpoint of... What's the point of counting retrospective reviews? Well, that's how you get a job in academics, unfortunately. Chairs may not care to think enough to evaluate you and the value of your work, but they know how to count (publications and grants).
Click to expand...

Yup I learned this early on. Started doing bench work and got one paper in several years of undergrad/medschool. Switched to chart review and got about a paper/year in late medschool and early residency. Switched to modeling studies and cranked out a bunch of studies with (comparatively) little work). Switched to private practice and am blissfully free of all that and haven't looked back.
 
Neuronix said:
I was at one of the institutions on the top list for training and I was on the high end of those numbers for first author publications. All my first authors in residency were retrospective series.

Was this what I wanted to do? Absolutely not. When I went to interview for residency, I was very upfront with everyone about the basic/translational stuff I wanted to do that directly extended my PhD. Most institutions were not impressed, and overall I would say that my interviews at maybe 1 or 2 institutions went very well. The chair where I matched was interested, so that's how I ended up there. When I arrived for residency training a year and half or so after matching, the chair wasn't the chair any more. I told the new people in charge what research I wanted to do, and I was flatly told that I wasn't allowed to do that work there.

With nothing else to do, I wrote a whole bunch of retrospective reviews and worked on my basic/translational work elsewhere. The retrospective reviews were easily published, and the basic/translational science stuff I'm still struggling to get established with as faculty and publish. I mean, you can publish a survey with a 5% response rate in the red journal, and meanwhile I struggle to publish novel basic/translational stuff that takes years of work and hundreds of thousands in funding.

What I take from all this is: if you focus on basic research with your PhD in residency, you should expect maybe one first author publication. This is the nature of the game. This is what I would expect in one year or 1.5 years (Holman) in a new lab for a post-doc. You won't be making any top lists with your one paper. You will be lucky to even get an academic attending job with that one paper.

So I do agree with Ralph from the standpoint of... What's the point of counting retrospective reviews? Well, that's how you get a job in academics, unfortunately. Chairs may not care to think enough to evaluate you and the value of your work, but they know how to count (publications and grants).
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i feel your pain on the time to publish good biology. Unless you single cell sequence 10 tumors - then you can publish in a high impact journal without anything else... 😛
 
temujim said:
New indication -- not protons for bone mets. Pharma companies are awash in money. And lots of companies. On trials the drugs are provided, AND the trial is paid for (handsome profit for the institution often!), etc. If it all works out --> new drug/new indication.

Making the research finances work for radiation for a totally new indication (ie radiation is NOT standard of care and NOT covered by insurance??) is difficult/impossible. I have not seen a device company cover that kind of cost -- even the big proton companies -- they are funding replacement (proton > photon) for a known indication -- but not even covering the differential cost of the proton treatment.

Anyway the point is that radiation research isn't as easy as it seems. Lots of hurdles to overcome.
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GOOD Radiation research is not as easy as it seems. Bad research, on the other hand, is quite easy. Anyone who spends any time looking at abstracts at any radiation conference can see that. As the last few years of ASTRO has shown us, with this year being the most egregious example, we have hit a brick wall in terms of advancement. Despite this, over the last decade we have seen academic departments growing in size, justifying their "academic" titles via mostly worthless retrospective studies, and expanding resident complements to fill the growing need for physician coverage.

The traditional physician/trainee paradigm has been that academic physicians accept fewer clinical responsibilities in exchange for more educational and research responsibilities. Speak to residents at any program and ask them how much their attendings actually teach them. Not all academic physicians are good teachers, not all academic physicians care about teaching, and the number of academic physicians that are BOTH good at teaching AND care to teach becomes the exception rather than the rule.

So how do we continue to justify academic titles for physicians that do not do meaningful research and do not teach? These physicians are glorified hospital employees who are overpaid for their clinical work and oversupported with "protected research time" and "resident coverage" despite a lack of academic production in either.

If the research finances for a new treatment indication don't work, then lets start concentrating the limited research resources on institutions that actually produce meaningful work. While we're at it, we can concentrate our residents at institutions that actually provide meaningful education. Make academic physicians EARN the support that they get and give the few remaining qualified residents that still have an interest in this dumpster fire of a field the quality education that they deserve.
 
elementaryschooleconomics said:
Let's be real - what has the siren song of Radiation Oncology been for the last 20 years?

Great money.

Great lifestyle.

That's what made it competitive.

Obviously, a lot of people went into it for a lot more than that. But there's many people who look amazing on paper who feel like they "made it" and just rest on laurels thereafter. It's really no mystery as to why the quality of RadOnc studies seems inversely correlated with the quality of the CV of its practitioners. It's no mystery why expansion went unchecked while reimbursements were great. If we're honest with ourselves, nothing that has happened has been surprising.

Now RadOnc got punched in the mouth. Students can do basic math and see that there are way too many people coming out of the pipeline and the government has turned its glare on everything we do.

Yes, we need less research quantity - we need better research quality.

Yes, we need fewer "smart" med students looking for a payday - we need more "smart" med students who have something to prove.

To imply that studies do not have anything to do with financial gain is equally disingenuous.
Click to expand...

As I read this i thought about “the odyssey”. Our hero Odysseus puts the earwax, as the beautiful chorus of the sirens begs him to ram the ship into the rocks. The “leaders” are the sirens, rad onc rocks with beautiful hymns trying to steer more people into the rocks and collect more souls. God help us all.
 
scarbrtj said:
It’s very obvious but of course the indications for XRT are almost overwhelmingly: another doctor in another specialty thinks the patient needs XRT--instead of what they offer, in addition to what they offer, or because they have nothing to offer--so the patient is sent to Rad onc for XRT. But the raw number of XRT patients has fallen by ~10% over the last 20y. Which means indications are slowly dropping. Why? Probably because the incidence of "another doctor in another specialty thinks the patient needs XRT," aka the true indication for XRT, has slowly dropped over that time. This is upon which residency expansion, surveys, retrospective reviews, fascinating basic science research, shorter treatment schedules, novel molecules, Star Trek tech, and diversity have had no effect.
Click to expand...


To boil this down, there are vanishingly few people who can describe what radiation oncology is... and most of the ones who can are only able to do so to other radiation


Ask a person on the street:

1) what does a oncologist do?
-Gives chemotherapy

2) what does a neurosurgeon do?
-Brain surgery

3) what does a dermatologist do?
-Checks for skin cancer and gets rid of pimples.

3) what does a radiation oncologist do?
-what?

I give a 5 minute talk to every consult describing what radiation is... and how precisely and effectively it can treat cancer. A good chunk of patients are astonished that such a thing is even possible.

Our entire specialty is a complete mystery because we have never thought to explain it to the public. It’s hard to convince other specialties of our importance when their patients don’t even know that radiation oncology is a thing. That’s our problem...
 
Lamount said:
To boil this down, there are vanishingly few people who can describe what radiation oncology is... and most of the ones who can are only able to do so to other radiation


Ask a person on the street:

1) what does a oncologist do?
-Gives chemotherapy

2) what does a neurosurgeon do?
-Brain surgery

3) what does a dermatologist do?
-Checks for skin cancer and gets rid of pimples.

3) what does a radiation oncologist do?
-what?

I give a 5 minute talk to every consult describing what radiation is... and how precisely and effectively it can treat cancer. A good chunk of patients are astonished that such a thing is even possible.

Our entire specialty is a complete mystery because we have never thought to explain it to the public. It’s hard to convince other specialties of our importance when their patients don’t even know that radiation oncology is a thing. That’s our problem...
Click to expand...

Scene: Third year of medical school, Family Medicine rotation, surrounded by several PCPs who had been in practice for a few decades each:

"Student Doctor Elementary, what specialty are you interested in?"

"Radiation Oncology"

"Oh man, Radiologists are so important to almost everything we do! Why, one time..." *several nod in agreement*

I'm sure we have all experienced this and similar conversations countless times over the years.
 
This is also gaslighting. How many >50% research fellowships are there available for rad onc graduates? A handful at best. I was willing to do a research fellowship when I graduated, and none of the institutions that work in my area were interested. Only 50% or more clinical fellowships were on offer. Even the NIH told me they were only considering medical oncology fellows.

Mudit's analysis already showed this with data. The vast majority of advertised "fellowships" are clinical fellowships.

I actually agree with Paul Wallner on this--they shouldn't even be called fellowships. It is a failure in my opinion, but the failure of our leadership with overtraining.
 
From the Google Spreadsheet, talking about Chicago (I don't like writing there 1) because I do like a place where applicants can talk about applicant mechanics and 2) I hate that anyone can edit anything, if I say something I want it recorded for all time):

1604577093595.png


This is a fascinating statement. Do medical students actually think Ralph being free with his opinion is a good thing? We talk about him openly a lot in my department, residents and faculty. It's done in a joking, "that dude has really gone over the edge" sort of way.

I've said this before but students - this is a super small field and you can alienate a lot of people quickly and easily, which can have negative consequences forever. It's why most of us prefer the relative anonymity of SDN. Ralph was already in a position of power before he started doing this - even if he's been this way his whole life (which I'm sure he has), I have serious doubts he would have climbed the ranks like he did if he was currently a junior faculty member and had to do it all over again in the age of Social Media.

I think Chicago is a good training program. I think that despite Ralph being the chair.
 
Neuronix said:
This is also gaslighting. How many >50% research fellowships are there available for rad onc graduates? A handful at best. I was willing to do a research fellowship when I graduated, and none of the institutions that work in my area were interested. Only 50% or more clinical fellowships were on offer. Even the NIH told me they were only considering medical oncology fellows.
Click to expand...
Just seems like mdphds need to avoid this field in the worst way and go for medonc?
 
RickyScott said:
Just seems like mdphds need to avoid this field in the worst way and go for medonc?
Click to expand...

I try to avoid getting too "grass is greener on the other side". Being an MD/PhD is not an easy road no matter what specialty you pick.

Still, I do try to point out the realities out there in our specialty, since this is the specialty I'm in. There are positions within the specialty for a very small number of junior physician-scientists per year (5? 10?). We were graduating dozens of MD/PhDs per year at one point. So there's obviously a ton of selection pressure there.

To make it sound like an overflow of residency grads can go to research fellowships is naive at best. First, the positions aren't there. Second, research jobs in rad onc are extremely competitive and not going to increase, so increasing the number in that pipeline only makes it even more competitive. Unless you view the year as one to just spend a year trying to generate papers for your future clinical (satellite?) academic job, in which case it does seem like a waste to me.

The research fellowships and faculty positions with start-up package/protected time are very few and far between. Without institutional support, physician-scientists are doomed to failure.
 
Ray D. Ayshun said:
MDs need to avoid PhDs
Click to expand...

MD/PhDs get hate from all sides--PhDs (not a "real PhD"), MDs ("PhD is a waste of time / at least you got free med school / you're not as good a doctor if you're not 100% clinical"), etc. I've heard it all before.

Nevertheless, I am a believer in MD/PhD training and careers. About 40-50% will end up in careers that really use both degrees with significant research and/or admin based on the data.

Still, I try to steer people in the best directions and give them a realistic expectation that nothing will be handed to them. Usually MD/PhDs are highly motivated, high achiever types (they have the highest stats and accomplishments generally coming into med school), so these things are not foreign to them.
 
Neuronix said:
MD/PhDs get hate from all sides--PhDs (not a "real PhD"), MDs ("PhD is a waste of time / at least you got free med school / you're not as good a doctor if you're not 100% clinical"), etc. I've heard it all before.

Nevertheless, I am a believer in MD/PhD training and careers. About 40-50% will end up in careers that really use both degrees with significant research and/or admin based on the data.

Still, I try to steer people in the best directions and give them a realistic expectation that nothing will be handed to them. Usually MD/PhDs are highly motivated, high achiever types (they have the highest stats and accomplishments generally coming into med school), so these things are not foreign to them.
Click to expand...
I'm speaking from experience, and partly kidding. I have much respect for the effort you put in. However, I consider ours more of a surgical subspecialty than anything, and therefore not ideal for bench researchers in the sense that it's easier for us to make big mistakes that can't be undone. That, combined with the fact that there are a lot more steps from bench to linac than to bedside. Med Onc is ideal for MD PhDs as there's virtually no brain space that needs to be used for clinical decision-making.
 
Last edited:
Neuronix said:
Nevertheless, I am a believer in MD/PhD training and careers. About 40-50% will end up in careers that really use both degrees with significant research and/or admin based on the data.
Click to expand...
Ray D. Ayshun said:
I'm speaking from experience, and partly kidding. I have much respect for the effort you put in. However, I consider ours more of a surgical subspecialty than anything, and therefore not ideal for bench researchers in the sense that it's easier for us to make big mistakes. Med Onc is ideal for MD PhDs as there's virtually no brain space that needs to be used for clinical decision-making.
Click to expand...
Respect the heck out of Neuronix and respect anyone who wants to get dual advanced degrees. I at one time was seriously considering getting a PhD on top of the MD. But what do you do with a PhD... in rad onc? Does it lead to more discoveries... in rad onc? (It may lead to a quicker path to career advancement. But even there I'm not convinced.) What have been the clearest punctuated equilibriums in rad onc in the last few decades? IMRT, IGRT, SRS, SBRT? Hypofx? These things didn't come from MD/PhDs, did they? IMRT and IGRT came from our physics/Stefan Vilsmeier/James Dempsey types, SRS and SBRT from non-rad oncs and Gil Lederman (only half joking). Has there been any bench to bedside success in rad onc? Granted, you want the prestige of that Eponymous Lab thing in rad onc, you better have that PhD. I'm still waiting for any of these labs to give me something I use in the clinic on radiation patients. If it's not happened by now, it's not like the "talent pool" entering rad onc from here on out is going to get more stellar is it?
 
Look I did a PhD to do device development and translational work with new devices. Rad onc was the perfect specialty for me to do that, and that's what I'm doing, with all the associated challenges and heartache. Like I wrote before, I've heard all the anti-MD/PhD stuff before, and nothing I write is going to convince people that MD/PhDs are valuable in the specialty or in general if they don't have some belief in that already.

Ray D. Ayshun said:
However, I consider ours more of a surgical subspecialty than anything, and therefore not ideal for bench researchers in the sense that it's easier for us to make big mistakes that can't be undone.
Click to expand...

There are many physician scientists in surgical subspecialties too. Of course the same gets said about them.

That, combined with the fact that there are a lot more steps from bench to linac than to bedside.
Click to expand...

Actually fewer. The regulatory pathway on medical devices is weaker than on drugs.

Med Onc is ideal for MD PhDs as there's virtually no brain space that needs to be used for clinical decision-making.
Click to expand...

That's just straight up insulting to med oncs, IMO.
 
evilbooyaa said:
Yeah, idk about denigrating an entire field of oncology as 'no brain space necessary'.
Click to expand...

Obv hyperbolic, but it's not a bug, it's feature.
1604591722686.png


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.
 
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