Rad Onc Twitter

[Krukenberg]

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Uh since that's been the hot button topic that Simul has been tweeting about and we have been talking about for years?

🙄 🙄

Not even the most rosy colored glasses people talk about a “market” supporting residency expansion. When you bring up a market, you’re clearly talking about enterprise expansion.

also, I don’t get the sense spratt is mired in the weeds of residency expansion battles. When he hears “expansion” it means department growth. For all of us we automatically think residency expansion

 

[drewdog1973]

Not even the most rosy colored glasses people talk about a “market” supporting residency expansion. When you bring up a market, you’re clearly talking about enterprise expansion.

also, I don’t get the sense spratt is mired in the weeds of residency expansion battles. When he hears “expansion” it means department growth. For all of us we automatically think residency expansion

Incorrect. Duke, COH, and others have expanded. This year.

 

[RickyScott]

City of hope expanded?

 

[Radonc90]

What’s JC? And what rumors

I think he meant the previous Editor-in-Chief of RedJ.
He passed away, we should leave him alone out of respect for him, RIP.
I know all the rumors, but again we should respect the deceased.

 

[medgator]

 

[dieABRdie]

This is true.... we would most certainly not be here today if it weren't for them....

 

[thecarbonionangle]

I think he meant the previous Editor-in-Chief of RedJ.
He passed away, we should leave him alone out of respect for him, RIP.
I know all the rumors, but again we should respect the deceased.

Dead or alive the truth us out there brotha!!! A reckoning of these “leaders” is coming.

 

[RickyScott]

I think he meant the previous Editor-in-Chief of RedJ.
He passed away, we should leave him alone out of respect for him, RIP.
I know all the rumors, but again we should respect the deceased.

Dead or alive the truth us out there brotha!!! A reckoning of these “leaders” is coming.

They were not rumors. I remember reading an article that he had to step aside after a young Asian female undergrad with no connection to Mdacc was found wandering the proton center with his coat and badge.

 

[thecarbonionangle]

They were not rumors. I remember reading an article that he had to step aside after a young Asian female undergrad with no connection to Mdacc was found wandering the proton center with his coat and badge.

I like the gymnastic analogy. The old guard in our field were not just people who walked in when all we needed was a pulse (our new present again). With this came weirdos, pathologic personalities and straight up CREEPS. No i do not respect them one bit. Screw their patriarchy and privilege.

we need to burn down all these fake statues and elevate true leaders to save our field from the bottomless hellpit that is coming.

 

[evilbooyaa]

""

 

[evilbooyaa]

Incorrect. Duke, COH, and others have expanded. This year.

Source? Don't think any programs have actually expanded this year? Duke looks like it has 13 which is inline with the 13 they had in 2019, and 14 in 2021 as per @fiji128 other thread. City of Hope has had 6 spots since 2019, I only see 5 residents listed on their website currently.

 

[Radonc90]

@thecarbonionangle,

If you read the subsequent tweet by Dr Thomas, then he took a stab at Wallner et al.
So I agree with Dr Thomas on that, Wallner does not represent us.
Somehow he is allowed to stay on ABR.
He is NOT a leader, it is not a definition of a leader to act like Wallner did.

Out of respect for "old timers", not all are bad, the vast majority of "old timer leaders"contributed greatly to this field:
- Maurice Tubiana
- Fletcher
- Suit
- Ang
- Lester Peters
etc. etc.

This list is very long, this is why when Dr Thomas sent the first tweet with an opening statement inferring "ABR-radoncs old timers are slow and stupid" using the gymnastics analogy: it was stupid for him to do that bc he put all the old timers in the same basket, when in reality, he just wanted to take a stab at Wallner (which I agree). So the "opening move" was bad, but the "subsequent move" was better, to paraphrase a chess game..
And I agree with Dr Siker, who was very composed...

 

[RickyScott]

@thecarbonionangle,

If you read the subsequent tweet by Dr Thomas, then he took a stab at Wallner et al.
So I agree with Dr Thomas on that, Wallner does not represent us.
Somehow he is allowed to stay on ABR.
He is NOT a leader, it is not a definition of a leader to act like Wallner did.

Out of respect for "old timers", not all are bad, the vast majority of "old timer leaders"contributed greatly to this field:
- Maurice Tubiana
- Fletcher
- Suit
- Ang
- Lester Peters
etc. etc.

This list is very long, this is why when Dr Thomas sent the first tweet with an opening statement inferring "ABR-radoncs old timers are slow and stupid" using the gymnastics analogy: it was stupid for him to do that bc he put all the old timers in the same basket, when in reality, he just wanted to take a stab at Wallner (which I agree). So the "opening move" was bad, but the "subsequent move" was better, to paraphrase a chess game..
And I agree with Dr Siker, who was very composed...

They did solve the problem when faced with an oversupply in the early 1990s

 

[medgator]

They did solve the problem when faced with an oversupply in the early 1990s

Prob not the same group of people now which are mainly composed of self-entitled boomers like Ralph W, M Randall, Steinberg, Hallahan etc. Unless they managed to stay at the top for 20-25 years?

 

[fiji128]

Source? Don't think any programs have actually expanded this year? Duke looks like it has 13 which is inline with the 13 they had in 2019, and 14 in 2021 as per @fiji128 other thread. City of Hope has had 6 spots since 2019, I only see 5 residents listed on their website currently.

Per the ACGME site as of right now, COH is approved for 6 residents and currently has 5 enrolled.

Maybe mixing COH up with Loma Linda, which has increased by one spot since 2019 and is currently approved for 6 residents?

 

[elementaryschooleconomics]

They did solve the problem when faced with an oversupply in the early 1990s

Prob not the same group of people now which are mainly composed of self-entitled boomers like Ralph W, M Randall, Steinberg, Hallahan etc. Unless they managed to stay at the top for 20-25 years?

I'm obviously fascinated by what happened to RadOnc in the 90's, and have spent a disturbing amount of time reading Red Journal articles from back then (I uh, probably should get like, an actual hobby, at least according to my family).

Specifically, one of the things I'm interested in (and why I read stuff from the 90s) is how RadOnc went from a mix of 3- and 4-year residencies to a mandated 4-year program. Can you imagine that happening today? With social media (and 10,000 different journals to publish in), there would be a ridiculous amount of backlash if the ABR came out and said: "RadOnc will now be a 5-year residency".

I have to think that there was a decent amount of backlash against the move, and the prevailing notion is a big part of why that was done was to use increasing educational standard to decrease supply and help out the job market. The people in charge who made that decision were probably the same/similar group of people who willingly cut their residency spots and programs - thus, showing actual leadership and caretaking of the field, making uncomfortable moves for the long-term greater good.

All that is to say - the names that I see popping up in journal articles at the time are NOT Ralph or Hallahan. In RadOnc, the lifespan of an academician's career is gigantic, as we all know people still bumbling along 30-40 years (or more) after graduating residency. It seems that many people start to join the real ranks of leadership 15-20 years after graduating residency. If we apply that observation to what was happening in the 90s (the people in charge are probably 20 years out from residency), that would put almost everyone as part of the original crew of non-Radiology residency-trained Radiation Oncologists, as the earliest programs opened up in the late 1960s/early 1970s.

This is obviously a gross sweeping generalization, but my impression is that we had the initial generation of Radiation Oncologists (after breaking off from Radiology) occupying the era of 1970-2000, and each generation's peak presence is roughly 25-30 years long. Thus, many of the people in power today graduated residency from 1990-2000...when RadOnc was basically a walk on sport.

 

[TheWallnerus]

I'm obviously fascinated by what happened to RadOnc in the 90's, and have spent a disturbing amount of time reading Red Journal articles from back then (I uh, probably should get like, an actual hobby, at least according to my family).

Specifically, one of the things I'm interested in (and why I read stuff from the 90s) is how RadOnc went from a mix of 3- and 4-year residencies to a mandated 4-year program. Can you imagine that happening today? With social media (and 10,000 different journals to publish in), there would be a ridiculous amount of backlash if the ABR came out and said: "RadOnc will now be a 5-year residency".

I have to think that there was a decent amount of backlash against the move, and the prevailing notion is a big part of why that was done was to use increasing educational standard to decrease supply and help out the job market. The people in charge who made that decision were probably the same/similar group of people who willingly cut their residency spots and programs - thus, showing actual leadership and caretaking of the field, making uncomfortable moves for the long-term greater good.

All that is to say - the names that I see popping up in journal articles at the time are NOT Ralph or Hallahan. In RadOnc, the lifespan of an academician's career is gigantic, as we all know people still bumbling along 30-40 years (or more) after graduating residency. It seems that many people start to join the real ranks of leadership 15-20 years after graduating residency. If we apply that observation to what was happening in the 90s (the people in charge are probably 20 years out from residency), that would put almost everyone as part of the original crew of non-Radiology residency-trained Radiation Oncologists, as the earliest programs opened up in the late 1960s/early 1970s.

This is obviously a gross sweeping generalization, but my impression is that we had the initial generation of Radiation Oncologists (after breaking off from Radiology) occupying the era of 1970-2000, and each generation's peak presence is roughly 25-30 years long. Thus, many of the people in power today graduated residency from 1990-2000...when RadOnc was basically a walk on sport.

Someone mentioned JC above. Say what you will about JC and all those notorious peccadilloes of his, guys of that (Moss e.g.) generation were pragmatic toward RO and issues like supply and demand. They realized that the primary purpose of a RO residency was to train a great RO who could practice as an excellent general RO in all disease sites, and the second most important purpose of RO residency was to set people up for good jobs.*

* (substitute RO for any other specialty and this holds true for all residencies of all types)

 

[Neuronix]

I'm obviously fascinated by what happened to RadOnc in the 90's, and have spent a disturbing amount of time reading Red Journal articles from back then (I uh, probably should get like, an actual hobby, at least according to my family).

Specifically, one of the things I'm interested in (and why I read stuff from the 90s) is how RadOnc went from a mix of 3- and 4-year residencies to a mandated 4-year program.

I have to think that there was a decent amount of backlash against the move, and the prevailing notion is a big part of why that was done was to use increasing educational standard to decrease supply and help out the job market. The people in charge who made that decision were probably the same/similar group of people who willingly cut their residency spots and programs - thus, showing actual leadership and caretaking of the field, making uncomfortable moves for the long-term greater good.

I don't see it this way. Increasing the length of residency is a great compromise so that nobody loses except trainees who have to spend an extra year in training.

Programs only want to expand or keep their current residency complement. By increasing the length of training, they get to keep the same number of residents in their program, while graduating less per year.

To put it simply, if you have 6 residents in a 3 year program, going to a 4 year program and keeping 6 residents decreases from 2 grads per year to 1.5 grads per year (decreasing overall supply), but the program still has the same number of residents so they have given up nothing. There is no sacrifice here on the part of the residency program.

Did anyone actually contract their programs back in those days?

Analogous to today's problem, we could increase our training from 4 years to 5 years. We will see this whether we like it or not with the rise of fellowships.

Selfish chairs and other "leadership" wouldn't mind this at all. They still get to keep the same number of trainees, and the seniors/fellows are even better trained. Most programs just don't want to contract outside of maybe a token gesture. I.e. We were thinking about one less this year for various reasons (you all know how numbers fluctuate from year to year at individual programs), so we'll take one less this year but probably add it back in a future year. For now let's make it seem like we're contracting for PR.

It's a bit of a diminishing returns issue however. If you take 8 residents in a 4 year program and go to 5 years, you've gone from 2 per year to 1.6 per year. That is, a 33% reduction going from 3 years to 4 years becomes a 25% reduction going from 4 years to 5 years.

 

[TheWallnerus]

Dead or alive the truth us out there brotha!!! A reckoning of these “leaders” is coming.

Is it coming? Titillating to think so, but we'll never be granted that schadenfreude. The only option is like the one outlined in "The Sociopath Next Door." How do you deal with the sociopath next door? You can't. There's one winning move: total avoidance. Rad onc is the specialty next door. But the shame is, it wasn't born that way. It was beat over the head too much by its parents and got a traumatic encephalopathy.

Did anyone actually contract their programs back in those days?

That is a hazy time. Vandy e.g. completely shut down in the mid-90's, didn't produce a new grad until about 2003.

 

[theradiator]

I don't see it this way. Increasing the length of residency is a great compromise so that nobody loses except trainees who have to spend an extra year in training.

Programs only want to expand or keep their current residency complement. By increasing the length of training, they get to keep the same number of residents in their program, while graduating less per year.

To put it simply, if you have 6 residents in a 3 year program, going to a 4 year program and keeping 6 residents decreases from 2 grads per year to 1.5 grads per year (decreasing overall supply), but the program still has the same number of residents so they have given up nothing. There is no sacrifice here on the part of the residency program.

Did anyone actually contract their programs back in those days?

Great points.

In terms of contraction, several programs actually were shut down. University of Oklahoma, Beth Israel, University of Illinois are a few that come to mind. So yes, real leadership.

 

[OTN]

Someone mentioned JC above. Say what you will about JC and all those notorious peccadilloes of his, guys of that (Moss e.g.) generation were pragmatic toward RO and issues like supply and demand. They realized that the primary purpose of a RO residency was to train a great RO who could practice as an excellent general RO in all disease sites, and the second most important purpose of RO residency was to set people up for good jobs.*

* (substitute RO for any other specialty and this holds true for all residencies of all types)

True for some in his generation, but it was well-known that one became “dead to him” if you went into private practice.

 

[RickyScott]

I don't see it this way. Increasing the length of residency is a great compromise so that nobody loses except trainees who have to spend an extra year in training.

Programs only want to expand or keep their current residency complement. By increasing the length of training, they get to keep the same number of residents in their program, while graduating less per year.

To put it simply, if you have 6 residents in a 3 year program, going to a 4 year program and keeping 6 residents decreases from 2 grads per year to 1.5 grads per year (decreasing overall supply), but the program still has the same number of residents so they have given up nothing. There is no sacrifice here on the part of the residency program.

Did anyone actually contract their programs back in those days?

Analogous to today's problem, we could increase our training from 4 years to 5 years. We will see this whether we like it or not with the rise of fellowships.

Selfish chairs and other "leadership" wouldn't mind this at all. They still get to keep the same number of trainees, and the seniors/fellows are even better trained. Most programs just don't want to contract outside of maybe a token gesture. I.e. We were thinking about one less this year for various reasons (you all know how numbers fluctuate from year to year at individual programs), so we'll take one less this year but probably add it back in a future year. For now let's make it seem like we're contracting for PR.

It's a bit of a diminishing returns issue however. If you take 8 residents in a 4 year program and go to 5 years, you've gone from 2 per year to 1.6 per year. That is, a 33% reduction going from 3 years to 4 years becomes a 25% reduction going from 4 years to 5 years.

A lot of programs closed down at the time. Someone should call up Dan Flynn if he is still around.

 

[Neuronix]

Ok I will stand corrected then on my earlier post.

I think it will take a crisis for more than 10% of spots to close today. The crisis will be: nobody is willing to fill the spots at all, including FMGs.

Was this the case in the 1990s? I can't believe that chairs have changed since the 1990s. Why would they willingly contract then and not now? There has to be more to it than just "our leaders are selfish" today compared to the 1990s.

We certainly have not reached a crisis point yet.

We're still at about 190 residents per year. I think we have levelled off there, though it's still way too many. If we get down to 140 I will be pleasantly shocked. When counting, please remember that just because a program doesn't fill in SOAP doesn't mean that they won't find someone outside of the match entirely. This is still happening.

 

[Mandelin Rain]

Was this the case in the 1990s? I can't believe that chairs have changed since the 1990s. Why would they willingly contract then and not now? There has to be more to it than just "our leaders are selfish" today compared to the 1990s.

Not unique to rad onc, I think much of "academic medicine" has largely abandoned the academic mission in favor of enriching admins, etc... with "not-for-profit" profits.

If we don't have to hire an NP AND can hire our next doc cheaper, it's a win-win!

Medicine has become a corporate game. This is something we all need to get comfortable with or abandon the profression.

 

[thecarbonionangle]

Someone mentioned JC above. Say what you will about JC and all those notorious peccadilloes of his, guys of that (Moss e.g.) generation were pragmatic toward RO and issues like supply and demand. They realized that the primary purpose of a RO residency was to train a great RO who could practice as an excellent general RO in all disease sites, and the second most important purpose of RO residency was to set people up for good jobs.*

* (substitute RO for any other specialty and this holds true for all residencies of all types)

JC wrote an infamous proton editorial as well. You agree with that surely.

 

[RickyScott]

he was not very smart, but quite eloquent.

 

[CaesarRO]

Not unique to rad onc, I think much of "academic medicine" has largely abandoned the academic mission in favor of enriching admins, etc... with "not-for-profit" profits.

If we don't have to hire an NP AND can hire our next doc cheaper, it's a win-win!

Medicine has become a corporate game. This is something we all need to get comfortable with or abandon the profression.

Agree this is the overriding trend in Healthcare. In my opinion it is clearly the root of a lot of the problems we complain about.

Is there any hope to fight against the tide and regain physician autonomy?

 

[medgator]

Is it coming? Titillating to think so, but we'll never be granted that schadenfreude. The only option is like the one outlined in "The Sociopath Next Door." How do you deal with the sociopath next door? You can't. There's one winning move: total avoidance. Rad onc is the specialty next door. But the shame is, it wasn't born that way. It was beat over the head too much by its parents and got a traumatic encephalopathy.


That is a hazy time. Vandy e.g. completely shut down in the mid-90's, didn't produce a new grad until about 2003.

A few other programs shut down... I know st Barnabas in NJ did also

 

[RickyScott]

A few other programs shut down... I know st Barnabas in NJ did also

And let’s not forget Paul wallners (he was chair at time) program- cooper in Camden, NJ was shut down.

 

[deleted969641]

If you are familiar with the politics in the city of Chicago, here you go circa 2010...

The 537 letters were in response to UC building a cancer center in New Lenox IL just east of Joliet IL (SW suburb of Chicago).
UC somehow got the approval to build it anyway.

Scroll down and read letters on pages #4 , #6...

https://www2.illinois.gov/sites/hfsrb/Projects/OlderApplicationDocuments/2010/10-049%20OPPOSITION%20LETTERS%20updated%2010-19-10.pdf

 

[Gfunk6]

Twitter always gravitates to extremes and hyperbolic positions. Two true statements are:

1. Many lifetime board certified Radiation Oncologists have no business practicing clinical medicine let alone dictating the future of the specialty.
2. Much of the success and critical foundations of Radiation Oncology are the result of pioneering "old timers" and we would not enjoy our current position without their hard work and dedication.

While true, the above statements won't generate likes or re-tweets.

 

[Haybrant]

To be fair, Dartmouth started their new residency a couple years ago now, has nothing to do with Dr. Thomas taking the helm.

i remember all these people coming to our residency program for their 'away' peds rotations and not really thinking what that meant until years later. Would be really interesting to find out how that all went down initially when programs were applying to acgme with no brachy, no peds, no SRS training but still being given 8 residency spots. Pretty sure dartmouth does not or did not have peds on site

 

[medgator]

Quite a thread going on about the well known PW/LK op-ed from a few years ago

 

[ROforbetterorworse]

Quite a thread going on about the well known PW/LK op-ed from a few years ago

I tried to read this thread just now and got a headache

 

[Radonky]

Quite a thread going on about the well known PW/LK op-ed from a few years ago

contort into a verbal pretzel. I might have to use that one in the future. Thanks Dr.Parikh!

 

[Ray D. Ayshun]

I tried to read this thread just now and got a headache

Can we please not turn SDN into #radonc Twitter?

 

[elementaryschooleconomics]

I would actually have joined this conversation under my real-name account, but these thoughts and questions aren't well suited for the character restrictions of Twitter (and I know @Dan Spratt comes here).

Obviously, I'm not going to defend the ridiculous things eviCore does and how it often negatively affects patient care. However, this is another symptom of the terrible job market in Radiation Oncology.

MANY of my colleagues, senior residents are junior faculty alike, keep eviCore in their back pocket as a potential career option. I include myself in those ranks - it's definitely on my radar, as abhorrent as it sounds.

Why?

In my opinion, Simul and Khang are spot on. My hometown is relatively small - not truly rural, but not metropolitan by any standards. There is a single linear accelerator in my hometown. It is the only linear accelerator for an hour in any direction (I know this because I cold-called every spot with a linear accelerator in a 4-hour radius). My hometown linac has been staffed by the same RadOnc for decades.

If I EVER want to go back home in my career, I need to wait for that single RadOnc to retire, throw my name in the hat at the perfect time, and hope that the institution hires me over all the other people looking for a job. If I miss that window, or the institution hires someone else - that's it. Unless their new hire leaves in a reasonable time frame, I will never get another chance (and even if I did, if the institution didn't like me the first time, why would they like me the second time?).

Almost all of my family lives in that town. I have tried to make it clear why I can never come back home, and I think they mostly accept it. It's fine now, but this means I can't take care of my parents as they age without uprooting them, too. I think I've made my peace with that - have they? It's not a problem now, but what about in 10 or 20 years, when they can no longer care for themselves? Will everyone feel the same way?

Dan goes on:

Alright Dan, so let's say life throws me a curveball in 10 years and I really need to be back in my hometown. Even if I sell my house (an incredibly stressful process, as many people know), how will I support myself and my family? There are no industry or educational jobs in my hometown, or in the surrounding region for at least an hour drive in any direction. What do I do then?

...and that's where eviCore comes in. I would say that many people are not pursuing these jobs under the most ideal of circumstances. It's incredibly elitist to assume they "aren't good enough to keep a clinical job". Maybe that's true, but that's a grossly insulting, sweeping statement. Life is cold, chaotic, and bad things happen to good people routinely. At the end of the day, the only person who you can truly count on is yourself, and you'll do what you need to do to survive. Dan, you're pretty open about your struggles when you were younger, so I know you know these truths better than most.

I don't use these words lightly in the modern era, but an attitude of "the only people who take [insert X] jobs do so because they're terrible clinically" is an overwhelming privileged and elitist opinion. While I am often furious at eviCore and the decisions they make, and perhaps I have literally yelled through the phone at them on occasion, I would caution folks from making assumptions about the people on the other end of the P2P line and how they found themselves in that position. In all likelihood, their life isn't playing out the way they planned.

Which brings me back to my central hypothesis: if you have any sort of geographic aspirations, RadOnc is not the specialty for you. It wasn't 10 years ago, it's not now, and it definitely won't be in 10 years. For any medical students who would consider joining this field, go look at how many linear accelerators are near your parents, or any family you care about. It's great if your family lives in an area where there are potential industry or educational positions to fall back on. If not...well, save yourself from that fate, and pick a different specialty.

 

[RickyScott]

View attachment 338276
View attachment 338277

I would actually have joined this conversation under my real-name account, but these thoughts and questions aren't well suited for the character restrictions of Twitter (and I know @Dan Spratt comes here).

Obviously, I'm not going to defend the ridiculous things eviCore does and how it often negatively affects patient care. However, this is another symptom of the terrible job market in Radiation Oncology.

MANY of my colleagues, senior residents are junior faculty alike, keep eviCore in their back pocket as a potential career option. I include myself in those ranks - it's definitely on my radar, as abhorrent as it sounds.

Why?

In my opinion, Simul and Khang are spot on. My hometown is relatively small - not truly rural, but not metropolitan by any standards. There is a single linear accelerator in my hometown. It is the only linear accelerator for an hour in any direction (I know this because I cold-called every spot with a linear accelerator in a 4-hour radius). My hometown linac has been staffed by the same RadOnc for decades.

If I EVER want to go back home in my career, I need to wait for that single RadOnc to retire, throw my name in the hat at the perfect time, and hope that the institution hires me over all the other people looking for a job. If I miss that window, or the institution hires someone else - that's it. Unless their new hire leaves in a reasonable time frame, I will never get another chance (and even if I did, if the institution didn't like me the first time, why would they like me the second time?).

Almost all of my family lives in that town. I have tried to make it clear why I can never come back home, and I think they mostly accept it. It's fine now, but this means I can't take care of my parents as they age without uprooting them, too. I think I've made my peace with that - have they? It's not a problem now, but what about in 10 or 20 years, when they can no longer care for themselves? Will everyone feel the same way?

Dan goes on:

View attachment 338278

Alright Dan, so let's say life throws me a curveball in 10 years and I really need to be back in my hometown. Even if I sell my house (an incredibly stressful process, as many people know), how will I support myself and my family? There are no industry or educational jobs in my hometown, or in the surrounding region for at least an hour drive in any direction. What do I do then?

...and that's where eviCore comes in. I would say that many people are not pursuing these jobs under the most ideal of circumstances. It's incredibly elitist to assume they "aren't good enough to keep a clinical job". Maybe that's true, but that's a grossly insulting, sweeping statement. Life is cold, chaotic, and bad things happen to good people routinely. At the end of the day, the only person who you can truly count on is yourself, and you'll do what you need to do to survive. Dan, you're pretty open about your struggles when you were younger, so I know you know these truths better than most.

I don't use these words lightly in the modern era, but an attitude of "the only people who take [insert X] jobs do so because they're terrible clinically" is an overwhelming privileged and elitist opinion. While I am often furious at eviCore and the decisions they make, and perhaps I have literally yelled through the phone at them on occasion, I would caution folks from making assumptions about the people on the other end of the P2P line and how they found themselves in that position. In all likelihood, their life isn't playing out the way they planned.

Which brings me back to my central hypothesis: if you have any sort of geographic aspirations, RadOnc is not the specialty for you. It wasn't 10 years ago, it's not now, and it definitely won't be in 10 years. For any medical students who would consider joining this field, go look at how many linear accelerators are near your parents, or any family you care about. It's great if your family lives in an area where there are potential industry or educational positions to fall back on. If not...well, save yourself from that fate, and pick a different specialty.

In my very large (4 pro sports metro), group lost contract with hospital who hired their own radonc. After looking for a while, 2 docs had no choice but to join evercore. (Kids in high school; elderly parents that kind of ****) In this town, would not have happened in any other speciality.

 

[medgator]

In my very large (4 pro sports metro), group lost contract with hospital who hired their own radonc. After looking for a while, 2 docs had no choice but to join evercore. (Kids in high school; elderly parents that kind of ****) In this town, would not have happened in any other speciality.

Knew a few docs last year who joined for similar reasons as the pandemic dried up volumes

 

[Palex80]

Certainly, prior approval by insurance companies in the US are not as strict as what we experience in Europe.
However, I do think that looking at all physicians working for insurance companies as people who ONLY deny patients standard of care treatment is a bit one-sided, wouldn't you agree?

A former colleague of mine also left our clinic several years ago because he found working at the clinic stressful and did not want to commute any longer.
He found a job in an insurance company looking into delivered treatments (not only RT), doing something similar to what I've often read in these forums. He told me that sometimes he did feel his hands were tied and he knew that treatment X may have been better, but he wasn't allowed to approve it due to regulations. On the other hand, he also told me that he regularly stopped physicians from delivering ridiculous treatments of not benefit or even with potential harm to patients.

Things are not as black and white as many may think.

 

[RickyScott]

View attachment 338276
View attachment 338277

I would actually have joined this conversation under my real-name account, but these thoughts and questions aren't well suited for the character restrictions of Twitter (and I know @Dan Spratt comes here).

Obviously, I'm not going to defend the ridiculous things eviCore does and how it often negatively affects patient care. However, this is another symptom of the terrible job market in Radiation Oncology.

MANY of my colleagues, senior residents are junior faculty alike, keep eviCore in their back pocket as a potential career option. I include myself in those ranks - it's definitely on my radar, as abhorrent as it sounds.

Why?

In my opinion, Simul and Khang are spot on. My hometown is relatively small - not truly rural, but not metropolitan by any standards. There is a single linear accelerator in my hometown. It is the only linear accelerator for an hour in any direction (I know this because I cold-called every spot with a linear accelerator in a 4-hour radius). My hometown linac has been staffed by the same RadOnc for decades.

If I EVER want to go back home in my career, I need to wait for that single RadOnc to retire, throw my name in the hat at the perfect time, and hope that the institution hires me over all the other people looking for a job. If I miss that window, or the institution hires someone else - that's it. Unless their new hire leaves in a reasonable time frame, I will never get another chance (and even if I did, if the institution didn't like me the first time, why would they like me the second time?).

Almost all of my family lives in that town. I have tried to make it clear why I can never come back home, and I think they mostly accept it. It's fine now, but this means I can't take care of my parents as they age without uprooting them, too. I think I've made my peace with that - have they? It's not a problem now, but what about in 10 or 20 years, when they can no longer care for themselves? Will everyone feel the same way?

Dan goes on:

View attachment 338278

Alright Dan, so let's say life throws me a curveball in 10 years and I really need to be back in my hometown. Even if I sell my house (an incredibly stressful process, as many people know), how will I support myself and my family? There are no industry or educational jobs in my hometown, or in the surrounding region for at least an hour drive in any direction. What do I do then?

...and that's where eviCore comes in. I would say that many people are not pursuing these jobs under the most ideal of circumstances. It's incredibly elitist to assume they "aren't good enough to keep a clinical job". Maybe that's true, but that's a grossly insulting, sweeping statement. Life is cold, chaotic, and bad things happen to good people routinely. At the end of the day, the only person who you can truly count on is yourself, and you'll do what you need to do to survive. Dan, you're pretty open about your struggles when you were younger, so I know you know these truths better than most.

I don't use these words lightly in the modern era, but an attitude of "the only people who take [insert X] jobs do so because they're terrible clinically" is an overwhelming privileged and elitist opinion. While I am often furious at eviCore and the decisions they make, and perhaps I have literally yelled through the phone at them on occasion, I would caution folks from making assumptions about the people on the other end of the P2P line and how they found themselves in that position. In all likelihood, their life isn't playing out the way they planned.

Which brings me back to my central hypothesis: if you have any sort of geographic aspirations, RadOnc is not the specialty for you. It wasn't 10 years ago, it's not now, and it definitely won't be in 10 years. For any medical students who would consider joining this field, go look at how many linear accelerators are near your parents, or any family you care about. It's great if your family lives in an area where there are potential industry or educational positions to fall back on. If not...well, save yourself from that fate, and pick a different specialty.

Exactly. Life throws curveballs and lets not mention if your spouse has geographic restrictions.

 

[Lamount]

I would also point out to Dan…

It’s not the physicians who work for eviCore who deny our patients. It’s the eviCore “guidelines”. There are some cases where the physician has SOME discretion but, most of the time, the docs have no wiggle room. Don’t get me wrong… I have lost my temper with them on the phone, but I usually end up feeling badly for them after I hang up. Having to make a choice between having dignity/professional integrity vs. supporting one’s family must be awful.

 

[Ray D. Ayshun]

Seriously, this is a little off the mark. It's just as easy to argue that by having a board certified rad onc there, we're more likely to get approval than
if it were staffed by (and it will always be staffed by someone) a doc with no cancer experience.

 

[deleted969641]

View attachment 338276
View attachment 338277

I would actually have joined this conversation under my real-name account, but these thoughts and questions aren't well suited for the character restrictions of Twitter (and I know @Dan Spratt comes here).

Obviously, I'm not going to defend the ridiculous things eviCore does and how it often negatively affects patient care. However, this is another symptom of the terrible job market in Radiation Oncology.

MANY of my colleagues, senior residents are junior faculty alike, keep eviCore in their back pocket as a potential career option. I include myself in those ranks - it's definitely on my radar, as abhorrent as it sounds.

Why?

In my opinion, Simul and Khang are spot on. My hometown is relatively small - not truly rural, but not metropolitan by any standards. There is a single linear accelerator in my hometown. It is the only linear accelerator for an hour in any direction (I know this because I cold-called every spot with a linear accelerator in a 4-hour radius). My hometown linac has been staffed by the same RadOnc for decades.

If I EVER want to go back home in my career, I need to wait for that single RadOnc to retire, throw my name in the hat at the perfect time, and hope that the institution hires me over all the other people looking for a job. If I miss that window, or the institution hires someone else - that's it. Unless their new hire leaves in a reasonable time frame, I will never get another chance (and even if I did, if the institution didn't like me the first time, why would they like me the second time?).

Almost all of my family lives in that town. I have tried to make it clear why I can never come back home, and I think they mostly accept it. It's fine now, but this means I can't take care of my parents as they age without uprooting them, too. I think I've made my peace with that - have they? It's not a problem now, but what about in 10 or 20 years, when they can no longer care for themselves? Will everyone feel the same way?

Dan goes on:

View attachment 338278

Alright Dan, so let's say life throws me a curveball in 10 years and I really need to be back in my hometown. Even if I sell my house (an incredibly stressful process, as many people know), how will I support myself and my family? There are no industry or educational jobs in my hometown, or in the surrounding region for at least an hour drive in any direction. What do I do then?

...and that's where eviCore comes in. I would say that many people are not pursuing these jobs under the most ideal of circumstances. It's incredibly elitist to assume they "aren't good enough to keep a clinical job". Maybe that's true, but that's a grossly insulting, sweeping statement. Life is cold, chaotic, and bad things happen to good people routinely. At the end of the day, the only person who you can truly count on is yourself, and you'll do what you need to do to survive. Dan, you're pretty open about your struggles when you were younger, so I know you know these truths better than most.

I don't use these words lightly in the modern era, but an attitude of "the only people who take [insert X] jobs do so because they're terrible clinically" is an overwhelming privileged and elitist opinion. While I am often furious at eviCore and the decisions they make, and perhaps I have literally yelled through the phone at them on occasion, I would caution folks from making assumptions about the people on the other end of the P2P line and how they found themselves in that position. In all likelihood, their life isn't playing out the way they planned.

Which brings me back to my central hypothesis: if you have any sort of geographic aspirations, RadOnc is not the specialty for you. It wasn't 10 years ago, it's not now, and it definitely won't be in 10 years. For any medical students who would consider joining this field, go look at how many linear accelerators are near your parents, or any family you care about. It's great if your family lives in an area where there are potential industry or educational positions to fall back on. If not...well, save yourself from that fate, and pick a different specialty.

I'm with Dan on this. Working for Evicore to deny care so you can live where you want is peak do-as-i-say-not-as-i-do extra nonsense. Like the politicians who preach fixing social problems by spending your money and shifting other people's problems onto you but not on the politicians themselves who putt about on private jets and shelter their own money.

If you are really interested in going back near your hometown, and it sounds like it may not be totally saturated if there is no other LINAC within an hour, then you might want to investigate the possibility of starting your own center. This is actually do-able in some locations. You may not be able to get in your home town, but there may be enough market share for you to plant a cheap used Tomo or something within a 60-100 mile radius away and get a center going. There are consultants who specialize in this sort of thing and can help you determine if it will be profitable, expected patient load and revenue, how to build and acquire capital equipment, etc.

Something to think about if you're willing to think outside the box. I know a few that have done it. Payoff can be huge.

 

[Neuronix]

What industry or educational positions? These are extremely rare. I can think of 5 rad oncs who work full or part-time in industry, and I used to be one of them. There might be room there to absorb one or two more, but that's about it. This idea that industry can absorb excess rad oncs is a complete farce.

I do know one rad onc a few years ago who went full-time industry, their job was eliminated as part of a merger, and they ended up at Evicore for awhile before finding a clinical rad onc job again.

Education? What is a clinical rad onc going to teach outside of clinical radiation oncology as a faculty member? This is a fairly ridiculous suggestion if you scratch the surface.

There's probably room for one or two more rad oncs in government. These positions are also extremely rare. I had applied for one years ago and was rejected--told they were only interested in med oncs and not rad oncs.

People like @Dan Spratt have survivorship bias. He's been a superstar his whole career, top residency, exceptional research, now chair. Good for him. He has no idea what it's like to be one of the rank and file, in a bad exploitative job or lost their job, and now has the option of moving to the rural Midwest and not seeing their children or working for Evicore.

 

[FrostyHammer]

People like @Dan Spratt have survivorship bias. He's been a superstar his whole career, top residency, exceptional research, now chair. Good for him. He has no idea what it's like to be one of the rank and file, in a bad exploitative job or lost their job, and now has the option of moving to the rural Midwest and not seeing their children or working for Evicore.

Bingo. And yet when he gets on SDN, everyone starts to grovel around him. Thinking that he and his eloquent words would help the "rank and file" is as insane as millions of uneducated/unqualified people thinking a narcissistic billionaire would meaningfully improve their lives as President.

 

[FrostyHammer]

Certainly, prior approval by insurance companies in the US are not as strict as what we experience in Europe.
However, I do think that looking at all physicians working for insurance companies as people who ONLY deny patients standard of care treatment is a bit one-sided, wouldn't you agree?

A former colleague of mine also left our clinic several years ago because he found working at the clinic stressful and did not want to commute any longer.
He found a job in an insurance company looking into delivered treatments (not only RT), doing something similar to what I've often read in these forums. He told me that sometimes he did feel his hands were tied and he knew that treatment X may have been better, but he wasn't allowed to approve it due to regulations. On the other hand, he also told me that he regularly stopped physicians from delivering ridiculous treatments of not benefit or even with potential harm to patients.

Things are not as black and white as many may think.

Palex, as usual you are absolutely on point. I don't like insurance MDs either but we have to admit that they play a vital regulatory role in not allowing m0ronic and/or dinosaur radoncs from milking the system for their own benefit. We seem to conveniently forget that if it weren't for insurance MDs, there'd be a hell lot more 15-25 fractions for bone mets, conventional fractionation for WBI, and 40-45 fractions of protons for prostate. I know no one on SDN who would do that sort of nonsense, but I never underestimate other idiot radoncs to do things like that.

 

[RickyScott]

Bingo. And yet when he gets on SDN, everyone starts to grovel around him. Thinking that he and his eloquent words would help the "rank and file" is as insane as millions of uneducated/unqualified people thinking a narcissistic billionaire would meaningfully improve their lives as President.

Agreed. His twitter post about “worthiness” of “fired”docs is off putting. Over my career, know of number good docs forced out for a variety of reasons, including power struggles, dept politics, malignant chairs. Some years ago, the Group north of Boston (roa) was on a tear- using connections to get all the hospital contracts and then firing and replacing the docs with new grads. Fired a bunch of very well respected docs in Lahey, including one who was the Astro gold medalist that year!

 

[elementaryschooleconomics]

I'm with Dan on this. Working for Evicore to deny care so you can live where you want is peak do-as-i-say-not-as-i-do extra nonsense. Like the politicians who preach fixing social problems by spending your money and shifting other people's problems onto you but not on the politicians themselves who putt about on private jets and shelter their own money.

If you are really interested in going back near your hometown, and it sounds like it may not be totally saturated if there is no other LINAC within an hour, then you might want to investigate the possibility of starting your own center. This is actually do-able in some locations. You may not be able to get in your home town, but there may be enough market share for you to plant a cheap used Tomo or something within a 60-100 mile radius away and get a center going. There are consultants who specialize in this sort of thing and can help you determine if it will be profitable, expected patient load and revenue, how to build and acquire capital equipment, etc.

Something to think about if you're willing to think outside the box. I know a few that have done it. Payoff can be huge.

I hear you, and I'm definitely not talking about folks who go to eviCore as "Option A".

@RickyScott's story is a perfect example. Say your group loses the contract with the hospital, hires someone else. Maybe you have a few kids, one's a sophomore in high school, the other is a junior. Your spouse has a career in the city, but their income alone probably won't cut it. Maybe you're an immigrant or a first generation citizen and you have family depending on your support in another country.

Your youngest kid (the sophomore) has 3 years left to go in the school system they've been in their whole life. You have roots in that area, perhaps a large family network as well. Do you just turn everyone's world upside down and immediately to try to get a clinical job elsewhere? Or do you try to stick it out for a couple years for your family? You cast a wide net and try to get outside the box, but you can't find anything that will pay you more than maybe 20% of the income you've been making for years. At that point, I imagine eviCore is an attractive option - but I also imagine you're going to try to not stay in that job forever.

All I'm saying is that life is complicated and it's impossible to understand all the motivations behind someone's actions. If I needed to urgently move back home to help out my dying Mom, and the only way I could financially make that happen is to take a temporary job at eviCore where my decisions might harm someone else's dying Mom...I know which Mom I'm choosing, and I know it's the same choice 90%+ of people would make as well.

The universe is cruel, we try to do the best we can. But the best laid plans of mice and men oft go astray. I think it's wise to not use cheap heuristics that "doc working for eviCore --> lazy, incompetent, only cares about the money". It's tribalism, and is similar to academicians claiming community docs are inferior in both their ability and aspirations.

(and to be clear, I remain a Dan Spratt fan, I just don't agree with this particular Tweet/opinion)

 

[radiation]

I hear you, and I'm definitely not talking about folks who go to eviCore as "Option A".

@RickyScott's story is a perfect example. Say your group loses the contract with the hospital, hires someone else. Maybe you have a few kids, one's a sophomore in high school, the other is a junior. Your spouse has a career in the city, but their income alone probably won't cut it. Maybe you're an immigrant or a first generation citizen and you have family depending on your support in another country.

Your youngest kid (the sophomore) has 3 years left to go in the school system they've been in their whole life. You have roots in that area, perhaps a large family network as well. Do you just turn everyone's world upside down and immediately to try to get a clinical job elsewhere? Or do you try to stick it out for a couple years for your family? You cast a wide net and try to get outside the box, but you can't find anything that will pay you more than maybe 20% of the income you've been making for years. At that point, I imagine eviCore is an attractive option - but I also imagine you're going to try to not stay in that job forever.

All I'm saying is that life is complicated and it's impossible to understand all the motivations behind someone's actions. If I needed to urgently move back home to help out my dying Mom, and the only way I could financially make that happen is to take a temporary job at eviCore where my decisions might harm someone else's dying Mom...I know which Mom I'm choosing, and I know it's the same choice 90%+ of people would make as well.

The universe is cruel, we try to do the best we can. But the best laid plans of mice and men oft go astray. I think it's wise to not use cheap heuristics that "doc working for eviCore --> lazy, incompetent, only cares about the money". It's tribalism, and is similar to academicians claiming community docs are inferior in both their ability and aspirations.

(and to be clear, I remain a Dan Spratt fan, I just don't agree with this particular Tweet/opinion)

The funny thing about this forum is that someone can do the empathy and put themselves in the shoes some hired gun insurance company employee, but when it comes to academic residencies and chairmen, they are automatically greedy/evil/exploitative and any of the choices that have been made are because of their personal character deficiencies