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IonsAreOurFuture said:
Pros: smaller and cheaper than a rotating gantry system
Fits in a big linac vault, in theory but not yet demonstrated

Cons - Mevion systems have a history of going down frequently and needing backup XRAY plans for when that happens.

The upright chair system is unproven in clinic and might not pan out for a while

There is no option to treat patients supine, at least at this point, everyone will be seated or semi-standing. There isn't a lot of know-how for treating upright yet.

The Mevion field size is limited to about 20 cm, so a craniospinal patient requires 6 isocenters and takes an hour to treat, so not very cost effective to do that

The Mevion accelerator in the same room as the patient gives a higher neutron dose than if it were outside the room

The list goes on but less impressively
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WTF, really on the bolded?? That seems.... less than ideal for widespread adoption.

drowsy12 said:

x.com

x.com x.com
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Isn't the first rule of the Rad Bio/Physics physics to.... not talk about Rad Bio/Physics?
Funnyt hat Physics was 'proton heavy'. No biases there!
 
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drowsy12 said:

x.com

x.com x.com
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I mean in Canada it’s turned around quite fast as I have mentioned before. Previously 10 years ago where one might need 2 fellowships, now we’re getting recruiters trying to get in touch with our PGY3s lol. It’s wild how fast things have changed
 
taserlaser said:
I mean in Canada it’s turned around quite fast as I have mentioned before. Previously 10 years ago where one might need 2 fellowships, now we’re getting recruiters trying to get in touch with our PGY3s lol. It’s wild how fast things have changed
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You're saying this is because of demographic changes?
 
drowsy12 said:

x.com

x.com x.com

anyone keep track of their own career stats?
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radiaterMike said:
I dont but I am glad to know that he is alive
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He has had a 28y career. That’s about 170 new prostate cancer patients per year. I once worked in a giant practice and could get direct referrals from 5 in house urologists, and in a “killing it” year I would see 100 new prostate cases per year. A year is a long time… 28 years is even longer.

So I guess AVERAGING 170 a year for 28y is feasible. For a solo guy who does his own professional at a hospital. I guess.

In junior high I had this friend who said his dad had a Ninja motorbike and once had to speed from work to home in 5 minutes. In LA. In the afternoon. And the distance was 50 miles.

Of course this worked out to a 600mph average speed. That wasn’t feasible, so once we reviewed the math my friend eventually adjusted downwards to 15 miles in 15 minutes. But I’m sure if twitter existed back then he would have tweeted “My Dad can go 50 miles in 5 minutes with his Ninja,” “My dad is better than your dad,” etc.
 
CaesarRO said:
You're saying this is because of demographic changes?
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Shaun Loewen’s work probably has the best data on this. But it is probably multifactorial. 10-15 years of not increasing training spots, combined with provincial underfunding in both AB&BC for spots, add on immigration, an aging population, and COVID retirements

I thinks Shaun did a survey in Canada before and after COVID and found the number of Canadian ROs post COVID were just a bit fewer than preCOVID, which was ‘peak RO’ for Canada, which is actually quite concerning in an aging population and how long it takes to train specialists. BC suffered from poor access to oncology care and put a lot of money and investment to hiring, building new centers, etc in the past few years. My perception is I think they probably hired close to an entire Canadian graduating class of rad oncs over an 18 month span which basically sucked all the slack out of the workforce. Add on that our own centre grew in indications 10% year over year 2022-2023, for sure we are seeing increased demand for RO services without a commensurate increase in supply, has lead to the current circumstance.

Our own leadership attributes immigration and population demographic changes for a big portion of our services growth. As for the RO job market, nothing is in its own microcosm but to hire for this demand in the current market has resulted in big changes in a short period of time for our graduating RO residents, as well as mid career ROs. I know of one that had been trying to move to their hometown large centre for 10 years that was only able to do so in the past little bit, which wasn’t possible beforehand. There’s a lot of shuffle and new positions, and a large amount of retirement turnover too. 25% of the RO staff retiring in a 5 year span maybe in ours and our neighbouring centre.
 
taserlaser said:
Shaun Loewen’s work probably has the best data on this. But it is probably multifactorial. 10-15 years of not increasing training spots, combined with provincial underfunding in both AB&BC for spots, add on immigration, an aging population, and COVID retirements

I thinks Shaun did a survey in Canada before and after COVID and found the number of Canadian ROs post COVID were just a bit fewer than preCOVID, which was ‘peak RO’ for Canada, which is actually quite concerning in an aging population and how long it takes to train specialists. BC suffered from poor access to oncology care and put a lot of money and investment to hiring, building new centers, etc in the past few years. My perception is I think they probably hired close to an entire Canadian graduating class of rad oncs over an 18 month span which basically sucked all the slack out of the workforce. Add on that our own centre grew in indications 10% year over year 2022-2023, for sure we are seeing increased demand for RO services without a commensurate increase in supply, has lead to the current circumstance.

Our own leadership attributes immigration and population demographic changes for a big portion of our services growth. As for the RO job market, nothing is in its own microcosm but to hire for this demand in the current market has resulted in big changes in a short period of time for our graduating RO residents, as well as mid career ROs. I know of one that had been trying to move to their hometown large centre for 10 years that was only able to do so in the past little bit, which wasn’t possible beforehand. There’s a lot of shuffle and new positions, and a large amount of retirement turnover too. 25% of the RO staff retiring in a 5 year span maybe in ours and our neighbouring centre.
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Sounds better than the US. Used to be the other way around for decades
 
CurbYourExpectations said:
Canadian and US differences are prominent. Props to Canada... and Shaun specifically... Canadian workforce is aspirational. However, I do think there are faults in the Canadian workforce and it should not be compared to the US workforce due to differences in goals. Can go into details about it if people find interesting.

Edit- Right now Canada is producing about as many RadOncs as the US relative to the population and they don't have as wide spread linacs as the US does, so if you think Canada is doing a good job, you think the US is doing a great job. In the US Radoncs are incentivized to treat a higher number of patients and fractions, which is not as often the case in Canada which is a more socialist group.
The biggest issue in Canada is likely the number of linacs. They are treating about as many patients per RadOnc as the US. The biggest issue in the US is that there is a push for virtual supervision and there are groups trying to push for midlevel encroachment. These are the things that will make the workforce bad, not the current number of residents being trained.
If Canada moved towards utilizing more virtual supervision and midlevels doing increasing parts of their jobs while being incentivized to treat more patients, I would be worried about Canada too.
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Canada has had “virtual supervision” from way back when

What has been tough for me to figure out is how often and where the Canadian rad oncs engage in that
 
Insurers Pocketed $50 Billion From Medicare for Diseases No Doctor Treated

I subscribe to WSJ and this article may be behind a paywall for you. But here are some snippets:

Gloria Lee was perplexed when the phone calls started coming in from a representative of her Medicare insurer. Could a nurse stop by her Boston home to give her a quick checkup? It was a helpful perk. No cost. In fact, she’d get a $50 gift card.

After several such calls in 2022, Lee agreed. A nurse showed up, checked her over, asked her questions, then diagnosed her with diabetic cataracts.

The finding was good news for Lee’s insurer, a unit of UnitedHealth Group UNH -0.00%increase; green up pointing triangle. Medicare pays insurers more for sicker patients. In the case of someone like Lee with diabetic cataracts, up to about $2,700 more a year at that time.
But the retired accountant doesn’t have diabetes, her own doctor later said, let alone the cloudy vision sometimes caused by the disease.
Private insurers involved in the government’s Medicare Advantage program made hundreds of thousands of questionable diagnoses that triggered extra taxpayer-funded payments from 2018 to 2021, including outright wrong ones like Lee’s, a Wall Street Journal analysis of billions of Medicare records found.
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United health care/optum are pulling the okey doke on many unsuspecting physicians. Wait until they pull the rug
 
fiji128 said:
I wonder what the penalty or prison sentence would be for a physician engaging in systematic wrongful overbilling like this?
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You billed a 99214 when it should have been a 99213 10 years ago = the gas chamber

UHC commits fraud - I miss interpreted the rules - oh no problem and they don’t have to give the money back.
 
drowsy12 said:
Welcome to America my friend. Corporations are what matter.
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In third world countries individuals are corrupt in the government, here in the US it's the major leagues with corruption in the all 3 branches of government (drafted/written by the legislature, the courts etc)
 
CurbYourExpectations said:
Y'all are averaging 500k+ a year working 4 days a week and saying we should be able to work less. Complaining about having to be at work at all? What are we even talking about, you need to chill dude.

hold on no GIF by Shalita Grant
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How many days a week do you think a facility should have a rad onc on site, bare minimum?
 
CurbYourExpectations said:
I have a new appreciation for you MRO and I would move you to the more neutral good region hearing more from you haha.

I think if I never got more pay than I did as a resident (like 40k a year) I would continue to do the same amount of work I currently do. I am always available on treatment and for my patients and their spouses at times when they're dealing with hospice and have questions about radiation, when they discuss hospice (even on phone calls, I sometimes give them my numbers/call them on my phone when they're very sick) I give pros and cons about stopping, and I help them make the decision that is best for them.

I hate what is going on in this forum and want to discuss it more.
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I could be considered biased because I commute a very long way (much farther than what 95% would consider) to cover rural facilities. I am confident these facilities could not get the level of care I provide if they required someone on site 5 days a week and had to call Weatherby to make that happen. Like not even close. That’s where I’m coming from and why ASTRO was so so out of touch
 
CurbYourExpectations said:
Yeah, I go through sperts of paying no attention and paying close attention. And I believe you and want you to continue doing what you're doing. I do not believe @medgator and @TheWallnerus are on our team. Every time I get on here I see posts defending "why would you need a radonc there? you wouldn't, ASTRO Sucks!" I'm not talking about ASTRO, why does it feel like y'all are anti radonc? Or am I wrong?
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Well I can’t speak for them or why they preach what they do. Does politics make for strange bedfellows? Maybe. But if I want to make the argument you can deliver excellent care being on site 3 days a week in a rural facility, which I absolutely am, and in fact I would argue you perhaps deliver superior care this way compared to the practical alternative, then it’s hard to say oh well it’s different for rich suburban centers because even on their worst day they’re doing better than I could ever hope to… because I don’t believe that.
 
CurbYourExpectations said:
Y'all are averaging 500k+ a year working 4 days a week and saying we should be able to work less. Complaining about having to be at work at all? What are we even talking about, you need to chill dude.

hold on no GIF by Shalita Grant
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My comment was in response to the UHC/Optum shenanigans?

Not sure what your beef is with me. I've made my position clear regarding supervision and it sounds like ASTRO is finally getting the message as well with their recent update from their working group. I can't endorse being chained to a linac from start to finish outside of stereo cases or new starts etc, esp when I've got Microsoft teams on my phone and can be reached anywhere anytime
 
CurbYourExpectations said:
I do not believe @medgator and @TheWallnerus are on our team.
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Someone above mentioned that telehealth OTVs are "bad care." I am not on that team, as that is obviously false (as a blanket statement, and it appeared to be a blanket statement). It's important in these discussions to separate hyperbole and "You're either with us or against us" and malpracticing... versus reality and nuance and physician autonomy.
 
TheWallnerus said:
Someone above mentioned that telehealth OTVs are "bad care." I am not on that team, as that is obviously false (as a blanket statement, and it appeared to be a blanket statement). It's important in these discussions to separate hyperbole and "You're either with us or against us" and malpracticing... versus reality and nuance and physician autonomy.
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Ok so, the proposed rule dropped. Let's assess good and bad. Got this screenshot from SDN's favorite RO businessman.

I just want to make sure I have this right. ASTRO's president is a Mayo executive. Not just any executive, a director of a lucrative proton center. Mayo just published a paper about how they use telemedicine to recruit patients for proton therapy. Most were prostate cancer, some were foreign nationals.

That is cool.

The data argues that tele OTVs are perfectly safe. But wait! ASTRO, the same one with the Mayo exec as president, has weighed in and says no no wait, video OTVs are unsafe. They have no data but they are concerned. Think of the mucous membranes.

I dont blame CMS here. At work, if someone says "this might be unsafe!" one is a fool to blow them off. That part I get.

So.

Sameer Keole... good or bad? @CurbYourExpectations or anyone else let us know your thoughts.

This is exactly what I am talking about. Feel free to go listen to my podcast on why I quit ASTRO again, I put it all out there. They are not your friend.

Ill repeat again that I do not do video visits basically ever. This really doesn't impact me. I just want honest people to be leading our field.

1720649138758.png
 
NotMattSpraker said:
Ok so, the proposed rule dropped. Let's assess good and bad. Got this screenshot from SDN's favorite RO businessman.

I just want to make sure I have this right. ASTRO's president is a Mayo executive. Not just any executive, a director of a lucrative proton center. Mayo just published a paper about how they use telemedicine to recruit patients for proton therapy. Most were prostate cancer, some were foreign nationals.

That is cool.

The data argues that tele OTVs are perfectly safe. But wait! ASTRO, the same one with the Mayo exec as president, has weighed in and says no no wait, video OTVs are unsafe. They have no data but they are concerned. Think of the mucous membranes.

I dont blame CMS here. At work, if someone says "this might be unsafe!" one is a fool to blow them off. That part I get.

So.

Sameer Keole... good or bad? @CurbYourExpectations or anyone else let us know your thoughts.

This is exactly what I am talking about. Feel free to go listen to my podcast on why I quit ASTRO again, I put it all out there. They are not your friend.

Ill repeat again that I do not do video visits basically ever. This really doesn't impact me. I just want honest people to be leading our field.

View attachment 389062
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Same mayo prez who used to lead ASTRO PAC telling everyone it was bad for rad oncs to own their own equipment or partner with urologists or MOs to own equipment together by trying to kill the in office ancillary exemption.

All the while telling all of us he used to be in "private practice" and he "gets it."
 
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medgator said:
Same mayo prez who used to lead ASTRO PAC telling everyone it was bad for rad oncs to own their own equipment or partner with urologists or MOs to own equipment together by trying to kill the in office ancillary exemption.

All the while telling all of us he used to be in "private practice" and he "gets it."
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I guess people are too busy worrying about Bridge to weigh in.

I cant get over that in person physical examination is vital for OTVs but not for consults.
 
NotMattSpraker said:
I guess people are too busy worrying about Bridge to weigh in.

I cant get over that in person physical examination is vital for OTVs but not for consults.
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Doing the first full physical exam on a patient after the first fractions of radiation have already been prescribed/given being “good” and safe care? So rad onc.

Doing the physical exam on the patient after the single fraction of palliative radiation has been prescribed and given, and the treatment is now over and complete, being “good” and safe care?SO, so rad onc.
 
NotMattSpraker said:
I guess people are too busy worrying about Bridge to weigh in.

I cant get over that in person physical examination is vital for OTVs but not for consults.
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Makes no sense but maybe a bone just to shut up our annoying little society. ASTRO very abruptly gave up on pursuing in person direct. Maybe this was the behind-the-scenes compromise with cms? Haven't done a Virtual OTV in years, so won't miss it. But very happy to see I can continue to attend my tumor boards and dental appointments in peace.
 
Reaganite said:
Makes no sense but maybe a bone just to shut up our annoying little society. ASTRO very abruptly gave up on pursuing in person direct. Maybe this was the behind-the-scenes compromise with cms? Haven't done a Virtual OTV in years, so won't miss it. But very happy to see I can continue to attend my tumor boards and dental appointments in peace.
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I could see that. They view a couple of codes as "very important" because they make a relatively large proportion of RVUs for the average RO (77427 is one).

These RO leadership types just cannot seem to understand how meaningless a single code is to the average employed RO. IF that RO understands the system, they know the converted RVU dollar value of an OTV essentially set by the hospital contract, not CMS.

Now, one would think that these same leaders would be freaking out about ROCR, because no one has said what will happen to the RVU system that drives the many hospital contracts out there in RO.

Maybe that bit is in Connie's patented billing software.
 
NotMattSpraker said:
I guess people are too busy worrying about Bridge to weigh in.

I cant get over that in person physical examination is vital for OTVs but not for consults.
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Haven't caused any toxicity yet? I definitely do skin checks on some of my patients at both ends.... Lot of gi and h&n
 
medgator said:
Haven't caused any toxicity yet? I definitely do skin checks on some of my patients at both ends.... Lot of gi and h&n
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Agree. People are grossly misunderstanding or mis-stating the "safety" related findings of the MSKCC paper.

If you read the methods closely, you'll also see its a highly selected cohort, potentially self-selected. Have fun deploying their system in a no-name hospital in a town where no one over the age of 40 uses video calling.

Take a step back though. There is no new technology that is without new operational challenges and new types of risk. Where would you anchor your expectation for the video OTV? If you take them seriously (which you should not), ASTRO has at best shown us that they have anchored in catastrophic hypotheticals. That is an unhealthy way of thinking.

How safe is the "in person" OTV? I'd argue we don't even know. I have worked with ROs that don't really seem to understand how to identify and treat dermatitis.

This sounds pedantic, but it is the conversation I wish we were having.

Imagine if Rad Onc had to implement something like cardiac telemetry lol. I can think of a few academics that would anxiety themselves into their own acute chest 🤣

Should we roll back the EMR to paper charts? We might get hacked! (Oh no.)

No one should be arguing... or expecting... that a new medical technology offers a 0% chance of toxicity. The only group I've seen even trying to compare the new and old way is MSKCC, and they showed the new way is reasonable.
 
MidwestRadOnc said:
Somebody please show me where you have to document a physical exam to bill 77427.
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No one can show you that. But CMS just strongly implied you need an in person physical exam to make an OTV “safe.” (This actually creates some weird liabilities for rad oncs if we stop too long to think about this.) Iirc you also said telehealth OTVs were “bad care,” presumably because there is no exam of the patient? Can we bill for “bad care” OTVs? I mean… if zero physical exam OTVs *are* safe… how can a telehealth OTV be bad care?
 
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TheWallnerus said:
No one can show you that. But CMS just strongly implied you need an in person physical exam to make an OTV “safe.” (This actually creates some weird liabilities for rad oncs if we stop too long to think about this.) Iirc you also said telehealth OTVs were “bad care,” presumably because there is no exam of the patient? Can we bill for “bad care” OTVs?
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Let me be clear, I believe tele health in general is bad care. Watch the move “Up in the Air” where they get the idea to fire people over an iPad. Do we want to be the rad onc version of that? Do you want to see your doctor via a screen on a robotic arm for anything serious?

Plus we can’t even use FaceTime and non-HIPPA compliant solutions since last August to do it anyway so how exactly are we implementing this (betting everyone is still using FaceTime anyway).

But yes, we don’t have to document a physical exam on our OTV notes. If there is a pertinent exam finding, I note it “with care”
 
MidwestRadOnc said:
Let me be clear, I believe tele health in general is bad care. Watch the move “Up in the Air” where they get the idea to fire people over an iPad. Do we want to be the rad onc version of that? Do you want to see your doctor via a screen on a robotic arm for anything serious?
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BobbyHeenan said:
I think it’s fear of slippery slope - a hospital system admin will think rather than paying a higher rate for an in person doc they can start skimping and pay a remote-ish doc.
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"I believe telehealth in general is bad care." "I think it’s fear of slippery slope."

"Do we want to be the rad onc version of that?" With all the data that is out there, with all the possibilities that this expands access to care and improves human beings' satisfaction... a "yes" answer to this question has to be considered. It doesn't matter what we, the docs, think or believe... if there is data to refute what we think or believe.

  1. "[D]esignating virtual days on which employees have all of their virtual [radiation oncology] appointments on 1 day of the week and allowing for those with academic days to complete them remotely can decrease commute time, allow for more personalization of one’s schedule, and increase efficiency."
  2. "In this study, radiation oncology care provided by fully remote clinicians was safe and feasible, with no serious patient events. High patient satisfaction, substantial cost savings, and decreased environmental consequences were observed. These findings support the continuation of a fully remote management option for select patients in the post–COVID-19 era."
  3. "Integration of telemedicine within a radiation oncology clinic reduces the environmental impact of patient care. Advocacy efforts should support telemedicine where feasible and clinically appropriate to decrease carbon emissions associated with the practice of radiation oncology, as well as to establish and promote environmentally sustainable behaviors within the field."
  4. "During the COVID-19 pandemic patients have found telemedicine a beneficial tool for consulting healthcare providers. A high level of satisfaction with telehealth was observed in each study across every medical specialty [emphasis added]."

1. Adapting to the Virtual World: An Analysis of Remote Work Policies in Academic Radiation Oncology. Adapting to the Virtual World: An Analysis of Remote Work Policies in Academic Radiation Oncology | Applied Radiation Oncology.
2. Patient Safety and Satisfaction With Fully Remote Management of Radiation Oncology Care. Patient Safety and Satisfaction With Fully Remote Management of Radiation Oncology Care.
3. Travel-Related Environmental Impact of Telemedicine in a Radiation Oncology Clinic. Travel-Related Environmental Impact of Telemedicine in a Radiation Oncology Clinic | Applied Radiation Oncology.
4. Patient Satisfaction with Telemedicine during the COVID-19 Pandemic—A Systematic Review. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9140408/pdf/ijerph-19-06113.pdf.
 
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