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.
