The field isn’t hard to master. We didn’t need 260s and letters from “famous people” or a bunch of trash research. They just made you think you needed it to be good at this job. You need some bit of dedication and willingness to read on your own and an inherent desire to take care of cancer patients. I don’t know how any of the prior metrics predict for that.
This is, obviously, the truth. I keep thinking about where we went wrong.
There was this thread which was re-Tweeted recently about the rise of the Academic Medical Center over the last 20-30 years, which helps explain some of it, I think.
The way medicine was painted to me - the world I thought I was signing up for - back when I was considering getting into this whole doctor thing:
Medical schools and their associated education/training programs were bastions of truth and knowledge to benefit mankind. They were usually in urban areas serving large populations and also took complicated referrals from far-flung geographies. Because of this, the faculty who chose to work in academia had the ability to specialize in very obscure things (both clinically and at the bench), with financial and cultural support to advance the understanding and treatment of their slice of medicine. Medical students and residents went to these schools and hospitals to study with these people and see these patients, but America is a large country and the population is spread out. The majority of doctors will not (and cannot) be hyper-specialized (either on a particular facet of a disease, or be the physician-scientist ideal, etc).
As always, money twisted everything. Institutions did the math and saw that the revenue possibility from the clinical activities of the faculty were tremendous. Educating medical students generates almost no revenue (other than their tuition), and faculty were not rewarded for it.
Simultaneously, specialties become "competitive" through their perceived money and lifestyle. You have to have measurable differences between people to decide competitiveness, preferably, easy-to-measure metrics. Empathy and thoughtfulness are very difficult to measure; Step 1 scores and number of publications are very easy to measure. Humans are lazy - we picked numbers.
In the early 2000s, these things converged rapidly in Radiation Oncology. This specialty always had the potential for a "better" lifestyle with no inpatient service, and IMRT made the gold rain down (though, as is occasionally mentioned, the true gold was back in the 20 years after Medicare came out, but that's a different story).
We had academic RadOnc faculty, from an era without the internet and, if we're being honest, less medical knowledge overall, who still thought the traditional Flexner ideals were in play, being asked to pick from "top" medical students (as defined by lazy metrics based on test taking ability). These faculty were increasingly rewarded for their ability to generate RVUs, not teach the next generation. However, because the majority of kids entering the specialty were the ones who could memorize books the best, the lack of teaching was glossed over by the sheer skill (and willingness) of residents to teach themselves.
The Boomer RadOncs patted themselves on their back for how elite and hard the specialty was, as this must be a reflection on how elite and special they themselves were. When they trained, "the best" doctors had the most archaic, useless minutiae memorized - aided, in no small part, from an era when academic faculty occasionally remembered to teach. Everyone convinced themselves Radiation Oncology was SO HARD and only THE BRIGHTEST MINDS could handle it, and this was perpetuated with FOUR board exams of primarily trivia which got more and more difficult every year.
Amdur and Lee very succinctly demonstrate the issue with the exams and how we're defining "quality", "competitive", etc:
This data is ridiculous - the mean Step 1 score in 2016 was 247, an almost 20-point improvement compared to 2005 and significantly above the national average, but the board exam rates were virtually unchanged? How does that make sense???
Let's not forget the insane growth of knowledge and treatments in Oncology, as demonstrated by the fact that the NCCN guidelines, from the inception in 1996 to 2019, had a
three-thousand and fifty seven percent increase in the number of references, and a
three hundred and seventy percent increase in the number of decision paths.
Even the "lowest quality" Radiation Oncologist in 2020 (quality lazily defined by test scores), who was able to pass all four board exams, needed to know SIGNIFICANTLY more information than the "highest quality" Radiation Oncologist in 1996.
The TL;DR is this: the hubris in this specialty is ASTOUNDING, but it's obvious how we got here.
There will always be a need for genius-level savants cloistered away in Ivory Towers, advancing medicine for humanity. This is true for every specialty.
The majority of us, however, will be much more general in nature, and have absolutely no need to memorize the proteins involved in the signaling pathway for NHEJ, or the median 5-year OS for Stage III Merkel cell - especially when we carry small devices in our pockets which can literally access the entirety of medical knowledge from anywhere.
We draw circles in MS Paint-level software, and make sure the computer simulation of the theoretically most-likely dose cloud doesn't violate constraints which may or may not be made up, and assume that the computer was mostly right. Sometimes we give Flomax before letting MedOnc follow the patients.
We're a specialty that should absolutely value "soft" skills like compassion and communication over Step 1 scores.
(and before anyone gets upset - yes, I am making simple, broad statements about our day-to-day for comedic effect)
(also, I don't want to hear anyone comparing us to the surgeons. We do everything in a computer. Our contouring comes with an eraser tool, for God's sake. A scalpel doesn't come with an eraser)
