Radiation Oncology is not the best field in medicine.

[Chaoseater]

The field is sick. Many in our leadership refuse to admit it, but those of us who look - We see.

I’ll try to be brief. I’m another recent grad. I did not have a job lined up until I was within 1 month of graduation. I did everything I was supposed to do: networking, several publications, following up with postings on the ASTRO site (many of which were jobs that had already been taken by an internal candidate). I graduated from a competitive residency program. This process – beginning in medical school, continuing to residency recruitment, and then including several aspects of our training and our boards (see Cyberrad’s postings)– is little more than a circus. The position I’ve taken is highly undesirable, and in discussing potential job contracts, I have had very little room to negotiate. Put simply, if I do not take the job, it would be easy to find someone else who will. It is a simple step of induction to realize that I am not alone in my experience.

To the M3s – read the other posts in this forum (hbosch and others) and ask: is this what you want? Suppose you work hard, and do well on Step 1, in third year, perhaps get AOA, maybe you even have a PhD (like ~25% of our applicants each year). The experience of the recent grads who are both on this forum, and likely at your home departments will tell you that this is not enough. The voices of the old guard would tell you otherwise. But there are others who will be more honest with you. And I certainly appreciate their honest input and open discussion of worsening trends in our field.

This is not an exaggeration, and I encourage prospective applicants to read some of the other postings in this forum.

And to see how things have deteriorated even within this forum lends more force to the argument against becoming part of this group (recent doxxing of a previous long-standing member prompting a plea for professionalism). Becoming a new grad in a field where the old guard are comfortable in their positions, and have no real incentive to dissuade new membership, or to even consider that the state of the field is deteriorating, is to me, ill advised.

It hurts me to say this, but I would not choose this field again. I have love for my patients, and for the science, but our community is not well, and the actions of our leadership reek primarily of self-interest. We as new grads are poorly supported, and easily taken advantage of. With increasing residency slots, and an, at best, static (if not diving) job market – I could not, in good conscience, recommend that anyone join this field now.

Radiation Oncology is not the best field in medicine. To say that it is, and to say it so emphatically as many have, evokes a desperation to convince others (and perhaps oneself) that this was a good decision. And perhaps, for some, at the time – it was a good decision. But now, this statement rings hollow, as little more than opinion and self-protection masquerading and being trumpeted as fact. Put another way: "Full of sound and fury. Signifying nothing."

M3s, please be judicious, and consider that there are many other specialties to choose from, and that you can find happiness and fulfillment in more than one place. Even if you have been building your resume to make a run at Rad Onc - and even if you land in a reasonably strong residency program, please consider that 5 years of training are small in comparison to the rest of your life and career.

Be well. I sincerely wish you all luck.

---

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[Shufflin]

I third the above poster, and I'm not even in Rad Onc. I'm impressed by his eloquent plea.

 

[smith2009]

I third the above poster, and I'm not even in Rad Onc. I'm impressed by his eloquent plea.

Oh what I would give to be a psychiatrist.

 

[Shufflin]

Oh what I would give to be a psychiatrist.

Very funny. I agree it's definitely not for everyone. But let's not detract from this thread. Very impressed by the OP. As someone who studies ancient Roman and Greek history I am reminded of Cicero.

 

[clue_cells]

I second the poster above. I am a PGY5 looking for jobs, and there aren't many out there. Our leadership is sick, and they do not have our best interest in mind. If given the choice, I would absolutely not choose radiation oncology again. I would choose med onc, but I've lost 5 years of my life already.

And you would have lost three of those years to an IM residency.

 

[KHE88]

I was fairly optimistic, neutral at worst, at Rad Onc's prospects until the ABR threw half of us under the bus with a ridiculous exam testing minimal competence, lied to us, hid data, patronized us, called us unprofessional, and basically told us they didn't care about us or care that residents in more elite coastal programs had a leg up through recall/cheating methods.

Couple that with neverending program expansion, a dwindling job market, changes in employment in large health systems with downward pressure on compensation and upward pressure on take-it-or-leave-it scenarios with garbage benefits and 40+ county non-compete agreements, yeah this field sucks. The work is great, the hours are good, it's the right field for me. But be real, the negatives have finally tipped the scale that was once about as awesome as it could be.

 

[Fpg1245]

The field is sick. Many in our leadership refuse to admit it, but those of us who look - We see.

I’ll try to be brief. I’m another recent grad. I did not have a job lined up until I was within 1 month of graduation. I did everything I was supposed to do: networking, several publications, following up with postings on the ASTRO site (many of which were jobs that had already been taken by an internal candidate). I graduated from a competitive residency program. This process – beginning in medical school, continuing to residency recruitment, and then including several aspects of our training and our boards (see Cyberrad’s postings)– is little more than a circus. The position I’ve taken is highly undesirable, and in discussing potential job contracts, I have had very little room to negotiate. Put simply, if I do not take the job, it would be easy to find someone else who will. It is a simple step of induction to realize that I am not alone in my experience.

To the M3s – read the other posts in this forum (hbosch and others) and ask: is this what you want? Suppose you work hard, and do well on Step 1, in third year, perhaps get AOA, maybe you even have a PhD (like ~25% of our applicants each year). The experience of the recent grads who are both on this forum, and likely at your home departments will tell you that this is not enough. The voices of the old guard would tell you otherwise. But there are others who will be more honest with you. And I certainly appreciate their honest input and open discussion of worsening trends in our field.

This is not an exaggeration, and I encourage prospective applicants to read some of the other postings in this forum.

And to see how things have deteriorated even within this forum lends more force to the argument against becoming part of this group (recent doxxing of a previous long-standing member prompting a plea for professionalism). Becoming a new grad in a field where the old guard are comfortable in their positions, and have no real incentive to dissuade new membership, or to even consider that the state of the field is deteriorating, is to me, ill advised.

It hurts me to say this, but I would not choose this field again. I have love for my patients, and for the science, but our community is not well, and the actions of our leadership reek primarily of self-interest. We as new grads are poorly supported, and easily taken advantage of. With increasing residency slots, and an, at best, static (if not diving) job market – I could not, in good conscience, recommend that anyone join this field now.

Radiation Oncology is not the best field in medicine. To say that it is, and to say it so emphatically as many have, evokes a desperation to convince others (and perhaps oneself) that this was a good decision. And perhaps, for some, at the time – it was a good decision. But now, this statement rings hollow, as little more than opinion and self-protection masquerading and being trumpeted as fact. Put another way: "Full of sound and fury. Signifying nothing."

M3s, please be judicious, and consider that there are many other specialties to choose from, and that you can find happiness and fulfillment in more than one place. Even if you have been building your resume to make a run at Rad Onc - and even if you land in a reasonably strong residency program, please consider that 5 years of training are small in comparison to the rest of your life and career.

Be well. I sincerely wish you all luck.

Even our attendings job advice in residency was if somebody offers you a job don’t bother negotiating with them because they likely have a handful of candidates to choose from. I pity the delusional/ignorant med student that pursues this field.

 

[Fpg1245]

Also, we need to stop pretending people have choices. Location, salary, lifestyle - Pick None in RO. 5 years baby and you’re not even qualified to give chemo! Lol.

 

[medgator]

Also, we need to stop pretending people have choices. Location, salary, lifestyle - Pick None in RO. 5 years baby and you’re not even qualified to give chemo! Lol.

To be fair, based on recent hearsay, it sounds like you can still pick one if you look hard enough...Maybe not location but certainly one of the other two. It used to be 2/3.

 

[Fpg1245]

Med students need to be concerned about not where we are currently but where it’s going 1/3 is bad but 0/3 is a definite possibility. And honestly for the time commitment of training, how many in demand skills are we really bringing to the table? Not many. The certfication process has become sort of a hodgepodge of rote memorization rad bio, physics, and historical irrelevant nonsense that simply papers over the fact that there really isn’t much to learn. It’s really just a paid waiting game

 

[smith2009]

Very funny. I agree it's definitely not for everyone. But let's not detract from this thread. Very impressed by the OP. As someone who studies ancient Roman and Greek history I am reminded of Cicero.

I was not joking.

 

[smith2009]

Med students need to be concerned about not where we are currently but where it’s going 1/3 is bad but 0/3 is a definite possibility. And honestly for the time commitment of training, how many in demand skills are we really bringing to the table? Not many. The certfication process has become sort of a hodgepodge of rote memorization rad bio, physics, and historical irrelevant nonsense that simply papers over the fact that there really isn’t much to learn. It’s really just a paid waiting game

Truth.

 

[RadOncDoc21]

I guess we’re going to continue to keep these threads going.

The field of medicine sucks as a whole but radiation oncology is definitely not the worst field. Is it the best? Maybe not but I couldn’t see myself doing anything else.

If I could go back in time, I would have probably gone into becoming a hospital administrator.

 

[deleted18755]

Med students need to be concerned about not where we are currently but where it’s going 1/3 is bad but 0/3 is a definite possibility. And honestly for the time commitment of training, how many in demand skills are we really bringing to the table? Not many. The certfication process has become sort of a hodgepodge of rote memorization rad bio, physics, and historical irrelevant nonsense that simply papers over the fact that there really isn’t much to learn. It’s really just a paid waiting game

I got rid of my radiobiology and physics books a long time ago but just out of curiosity scanned through the select pages available online. As somebody who honestly clearly recalls enjoying learning and studying the material in the depth but hadn’t reviewed it seriously in a very time (all the while running a successful practice and arguably being an excellent or at least competent clinician) I have to agree. So much of it is still interesting to me but as noted above mainly from a historic context ... it’s certainly not clinically relevant or at least not to the degree that we have a separate physics and radiobiology textbook each hundreds of pages and much of it reference/memorize type i formation.

Just so those of us who have been practicing for years but haven’t studied for the exam in ages are aware, can you provide a link to sample or study questions? I’m really curious to what depth the exam administrators think one needs to understand physics and radiobiology to competently practice clinical radiation oncology (especially since you could always reference the text vs memorize trivial details).

 

[Fpg1245]

Anybody else want to share?

Physics

- QA for protons
- troubleshooting IMRT SRS failures
- nuances of imrt algorithms
- memorize exposure rate constants for isotopes not radium

Rad bio

Signaling pathways nobody outside of a mol bio lab has heard of and then how RT might affect them.

Assays never covered in hall. Taq man. Tunnel. RT-Pcr

Clinical

I really dont care if RO used to radiate people with suspected CNS germinomas with out tissue dx.

 

[DukeNukem]

I'll add my experience. The big 3: Location, lifestyle, pay. Right... I got zero of those.

I graduated a few years ago from a large residency program. I did a bunch of academic stuff, worked really hard in residency, was well liked, blah blah blah. Home program offered me a clinical fellowship. Leadership refused to make phone calls to help me get jobs elsewhere. Eventually they did offer me a non-fellowship position once I got a real offer somewhere else. I was pretty mad at them by that point so I left. Also, faculty there had pretty high turnover and low morale anyway.

I couldn't find a single job in the entire region where I wanted to live. We're talking hundreds of miles area. I had connections there. I contacted all of them--nobody was hiring except one University there who for whatever reason never interviewed me.

So I figured ok, I'll go into academics right? Nobody said rad onc was good for people who were picky about location. So I applied to every academic job in the entire country that I could find. I had mostly done research as a resident in one area of rad onc, but there were no jobs out there hiring for that area of research. So I had to switch my area no matter what.

I ended up with a few interviews and eventually two job offers. They were both lousy offers frankly (100% clinical, low pay, no clinic support, etc etc etc). Neither was willing to negotiate in any way. I took the better location of the two. What I didn't realize is that the location was available because the turnover was very very high. My position turned over every 1-2 years for 4 different people before I started. Even since I started we lose people every year.

Ok so I get to my new job. I thought it was a main center job. NOPE. They put me in three satellites immediately on different days. The clinic director is completely insane. Half day here, half day there, overbook clinic schedule all the time, etc. Inpatient coverage galore at various hospitals. First few months dumped on constantly by seniors, working 60-80 hours a week, less than 25th percentile AAMC pay with over 75th percentile RVUs. Minimal opportunity to do research. Mild clinic support--different nurse every day (who will tell me they aren't allowed to do anything I ask), occasional residents (who can do whatever they want, show up whenever they want, etc), no midlevel. I received virtually no orientation to my job, but any screw up--no matter if it's minor or isn't even my fault--is harshly reprimanded. I am immediately thrown under the bus for any perceived slight, and they are very clear that they will not help me change anything to help me in any way. It's not just me--all of my colleagues have low morale but any voiced dissent will bring down the wrath of the leadership. It's just a culture of misery. The only way to get anywhere is to take everything with a smile and kiss up to the leadership.

I voiced some of my frustrations to my boss recently. The response (I'm paraphrasing) was: "If you don't like it we'll replace you with a new grad." So recently I applied to almost every job I could find online. I talked to all my connections before ASTRO and during ASTRO. I didn't get a single interview. I had a couple offered to me that ended up rescinded because they filled before I could even interview.

I have a lot of regrets. I try not to just spiral down into a pit of depression. So I'll tell myself that I like rad onc, the patients like me, the referring docs like me, I give excellent care, I take advantage of whatever opportunities I'm given, etc...

I agree with the op. This field is sick. The leaders are just looking to take advantage of you. Things have swung too far in favor of academics and big hospital systems that are looking to prop up one million dollar or more chair and C-level salaries off your hard work.

I'm surprised there aren't more negative posts on SDN. I know people forced into multiple years of "fellowships" in various ways. I know people forced into part-time positions. I even know people who have left the field entirely. It's not a bad idea to get out while you can. I'm too far gone--all I can do is try to provide for my family and hope for an early retirement.

 

[medgator]

Basic supply and demand....

RO was in an equilibrium from the mid-90s (coming off a horrible job market addressed through increasing training length from 3 to 4 years, and shutting down a bunch of programs) through around 2010-2012 or so at ~100-110 spots.

Several of us (me included) went on 10+ interviews and could not match in the 2000-2010 decade, eventually getting spots outside of the match or going through the match again. However, most people could get 1-2/3 when it came time to the job search.

Around that time (~2010 or so), IIRC, leadership in the field found it necessary to expand residency slots based on false/bad data, which has continued unabated into the current environment, running head first into the perfect storm/proliferation of SBRT/hypo-fractionation, and practice consolidation by hospitals/corporations.

RO leadership doesn't care. The last decade is proof. Facts matter, regardless of what some out-of-touch PDs/volunteer ABR question writers may say (many of whom are out of touch with the job market as well).

Until RO gets back to 100-110/spots a year (and honestly, probably less in the current SBRT/hypo-fx environment), stories like the above will only get more frequent.

 

[RickyScott]

I guess we’re going to continue to keep these threads going.

The field of medicine sucks as a whole but radiation oncology is definitely not the worst field. Is it the best? Maybe not but I couldn’t see myself doing anything else.

If I could go back in time, I would have probably gone into becoming a hospital administrator.

Almost no one is complaining about the practice of radiation oncology. Everyone seems to agree the science/patient care/ etc is tremendous and like you, I would not want to do something else. However, given the residency expansion/hospital consolidation/hypofractionation, I cant see how this fields future is anything but untenable for medstudents, who have plenty of other great choices. No matter how interesting I find the field, I would rather be an optho/med onc/gi if a career in radonc meant an undesirable location, exploitation of hours/pay, lack of job mobility, bs fellowship, possibly practicing for some sketchy practice with 20 year old machines and pressure to overutilize xrt etc.

What continues to shock me are posters who feel everything is fine and that there are zero consequences to going from 90 to 200 residents (2005-2018) during a perfect storm of hypofractionation and hospital consolidations. And we are not done expanding - I know of several large programs that are adding residency spots.

 

[RO28]

I agree with the op and several others who followed with the same sentiment. As a new grad who is stuck having to retake the physics exam yet again I have severe anxiety about my ability to pass and actually become board certified because I don’t believe the ABR when they say there will be better guides for next year. I have a great job actually that I’m pretty happy with and I love working with patients, but I absolutely would not choose this field again. It makes me really sad to know I just finished residency and am already looking towards retirement.

 

[Fpg1245]

I agree with the op and several others who followed with the same sentiment. As a new grad who is stuck having to retake the physics exam yet again I have severe anxiety about my ability to pass and actually become board certified because I don’t believe the ABR when they say there will be better guides for next year. I have a great job actually that I’m pretty happy with and I love working with patients, but I absolutely would not choose this field again. It makes me really sad to know I just finished residency and am already looking towards retirement.

Its one of several reasons I think the Physician on FIRE thing is catching on among some younger physicians. It’s not a ringing endorsement of the future of medicine but rather an exit strategy borne out of bad specialty choices and destruction of medicine in general.

 

[w00tz]

Currently a PGY-5 on the job search and I've been thinking about alternative careers for the past year. Seriously considering doing part-time, so I can help myself segue into something else. I feel like it's only a matter of time before the field gets to a point where I will feel like a resident again - more getting dumped on (by insurance companies, vulture-like administrators or big hospitals, etc) and less pay. It seems unlikely I will be able to sustain 30 years in rad onc with the way things are going...

I got rid of my radiobiology and physics books a long time ago but just out of curiosity scanned through the select pages available online. As somebody who honestly clearly recalls enjoying learning and studying the material in the depth but hadn’t reviewed it seriously in a very time (all the while running a successful practice and arguably being an excellent or at least competent clinician) I have to agree. So much of it is still interesting to me but as noted above mainly from a historic context ... it’s certainly not clinically relevant or at least not to the degree that we have a separate physics and radiobiology textbook each hundreds of pages and much of it reference/memorize type i formation.

Just so those of us who have been practicing for years but haven’t studied for the exam in ages are aware, can you provide a link to sample or study questions? I’m really curious to what depth the exam administrators think one needs to understand physics and radiobiology to competently practice clinical radiation oncology (especially since you could always reference the text vs memorize trivial details).

The "recommended" texts have not changed in a long time - it's still Hall for rad bio and Khan or Caggiano for physics. The problem with the last administration of the radbio exam is that they started to include material from outside of Hall.

In-service exam: https://www.acr.org/-/media/ACR/Files/DXIT-TXIT/TXIT-Exam.pdf?la=en
ASTRO rad bio study guide: https://www.astro.org/uploadedFiles...ources/Content_Pieces/2017ASTRORadBioPrac.pdf

I would say the in-service exam radbio and physics exam questions are not representative of the board questions, because they mostly reference Hall and Khan. However, a lot of the questions on the board exams cannot be found from these texts. Physic questions on the board exam included several minutiae on the different task groups, instead of general concepts.

The ASTRO rad bio study guide is closer to the real test.

 

[KHE88]

Med students need to be concerned about not where we are currently but where it’s going 1/3 is bad but 0/3 is a definite possibility. And honestly for the time commitment of training, how many in demand skills are we really bringing to the table? Not many. The certfication process has become sort of a hodgepodge of rote memorization rad bio, physics, and historical irrelevant nonsense that simply papers over the fact that there really isn’t much to learn. It’s really just a paid waiting game

Its one of several reasons I think the Physician on FIRE thing is catching on among some younger physicians. It’s not a ringing endorsement of the future of medicine but rather an exit strategy borne out of bad specialty choices and destruction of medicine in general.

I got a solid 1.5/3, however took a massive hit on the last one. Had some buyer's remorse at first but now realizing how lucky I am -- we'll see how it goes. My fear is that even these undesirable jobs will become very competitive in the next 10 years. I'm surprised more of my peers aren't interested in the middle of nowhere jobs and willing to make literally a third or even a quarter of the same income to be in a big city where you have absolutely zero say in anything as you can be replaced tomorrow. With aggressive saving, I think I can secure retirement in about 10 years and can bail to something else if I need to. Working in a "desirable" area? Forget about it. You'd be lucky to even buy a decent house in 10 years, let alone FIRE. One of those poor souls with 300k+ in loans? I can't even...

For med students stupid enough to go into this field, a piece of advice if you're single. Start hanging out around the dental school and marry a dental student. Your dentist spouse can go anywhere with you and will probably make more money than you will ever make even while you are still a resident. Just don't marry another radiation oncologist. I've already seen that go extremely poorly twice.

Just so those of us who have been practicing for years but haven’t studied for the exam in ages are aware, can you provide a link to sample or study questions? I’m really curious to what depth the exam administrators think one needs to understand physics and radiobiology to competently practice clinical radiation oncology (especially since you could always reference the text vs memorize trivial details).

Just ask one of the residents at the large elite programs to share their recalls. Good luck though. Nobody wants to talk about the cheating problem in our field.

The "recommended" texts have not changed in a long time - it's still Hall for rad bio and Khan or Caggiano for physics. The problem with the last administration of the radbio exam is that they started to include material from outside of Hall.

In-service exam: https://www.acr.org/-/media/ACR/Files/DXIT-TXIT/TXIT-Exam.pdf?la=en
ASTRO rad bio study guide: https://www.astro.org/uploadedFiles...ources/Content_Pieces/2017ASTRORadBioPrac.pdf

I would say the in-service exam radbio and physics exam questions are not representative of the board questions, because they mostly reference Hall and Khan. However, a lot of the questions on the board exams cannot be found from these texts. Physic questions on the board exam included several minutiae on the different task groups, instead of general concepts.

The ASTRO rad bio study guide is closer to the real test.

Hall and Giaccia is a terrible textbook. Despite Giaccia being on the ABR rad bio committee, it is insufficient standalone for the exam and the updates to the new editions are minimal and not helpful. When I started residency, I thought it was the most poorly organized textbook I've ever read, terrible at explaining basic rad bio concepts, and terrible to digest in a manner conducive for study. And it is completely lacking in the advanced molecular and cancer biology topics/memorization contest that have become about a third of the test suddenly. I thought there has to be a better way, and there is. The Joiner and Van der Kogel book is infinitely better.

The ASTRO study guides were notoriously inaccurate in terms of covering tested content this year. It's like the test writers went over them and purposely made sure that all of the questions they asked were not covered on any previous ASTRO study guide. I place zero faith in using these as study resources and will not be using them for my retake next year.

The ABR has openly criticized the ACR and its in-service exams multiple times making a point of saying how they think the ACR in-service is awful and basically turn their nose up at it. While the clinical questions on the in service can be nitpicky in terms of trial data recall, the rad bio and physics questions appropriately test fundamental knowledge, and as you mentioned reference common textbooks. Again, it's like the ABR went out of their way to make sure they were testing stuff that was not in Hall, Khan, Raphex, or on the inservice. And as a result you get this random crap that you either know because the previous residents gave you a list of remembered questions or you have a PhD background. For the rest of us, the only option is to severely overstudy and waste months memorizing low yield factoids. Yay.

 

[thecarbonionangle]

I'll add my experience. The big 3: Location, lifestyle, pay. Right... I got zero of those.

I graduated a few years ago from a large residency program. I did a bunch of academic stuff, worked really hard in residency, was well liked, blah blah blah. Home program offered me a clinical fellowship. Leadership refused to make phone calls to help me get jobs elsewhere. Eventually they did offer me a non-fellowship position once I got a real offer somewhere else. I was pretty mad at them by that point so I left. Also, faculty there had pretty high turnover and low morale anyway.

I couldn't find a single job in the entire region where I wanted to live. We're talking hundreds of miles area. I had connections there. I contacted all of them--nobody was hiring except one University there who for whatever reason never interviewed me.

So I figured ok, I'll go into academics right? Nobody said rad onc was good for people who were picky about location. So I applied to every academic job in the entire country that I could find. I had mostly done research as a resident in one area of rad onc, but there were no jobs out there hiring for that area of research. So I had to switch my area no matter what.

I ended up with a few interviews and eventually two job offers. They were both lousy offers frankly (100% clinical, low pay, no clinic support, etc etc etc). Neither was willing to negotiate in any way. I took the better location of the two. What I didn't realize is that the location was available because the turnover was very very high. My position turned over every 1-2 years for 4 different people before I started. Even since I started we lose people every year.

Ok so I get to my new job. I thought it was a main center job. NOPE. They put me in three satellites immediately on different days. The clinic director is completely insane. Half day here, half day there, overbook clinic schedule all the time, etc. Inpatient coverage galore at various hospitals. First few months dumped on constantly by seniors, working 60-80 hours a week, less than 25th percentile AAMC pay with over 75th percentile RVUs. Minimal opportunity to do research. Mild clinic support--different nurse every day (who will tell me they aren't allowed to do anything I ask), occasional residents (who can do whatever they want, show up whenever they want, etc), no midlevel. I received virtually no orientation to my job, but any screw up--no matter if it's minor or isn't even my fault--is harshly reprimanded. I am immediately thrown under the bus for any perceived slight, and they are very clear that they will not help me change anything to help me in any way. It's not just me--all of my colleagues have low morale but any voiced dissent will bring down the wrath of the leadership. It's just a culture of misery. The only way to get anywhere is to take everything with a smile and kiss up to the leadership.

I voiced some of my frustrations to my boss recently. The response (I'm paraphrasing) was: "If you don't like it we'll replace you with a new grad." So recently I applied to almost every job I could find online. I talked to all my connections before ASTRO and during ASTRO. I didn't get a single interview. I had a couple offered to me that ended up rescinded because they filled before I could even interview.

I have a lot of regrets. I try not to just spiral down into a pit of depression. So I'll tell myself that I like rad onc, the patients like me, the referring docs like me, I give excellent care, I take advantage of whatever opportunities I'm given, etc...

I agree with the op. This field is sick. The leaders are just looking to take advantage of you. Things have swung too far in favor of academics and big hospital systems that are looking to prop up one million dollar or more chair and C-level salaries off your hard work.

I'm surprised there aren't more negative posts on SDN. I know people forced into multiple years of "fellowships" in various ways. I know people forced into part-time positions. I even know people who have left the field entirely. It's not a bad idea to get out while you can. I'm too far gone--all I can do is try to provide for my family and hope for an early retirement.

Aweful story. I hate that “best specialty” thread too. So full of bs.

 

[PointA]

We definitely have a problem with the number of graduating residents. Though whenever I discuss the issue with chairs, they either say 1) they don't believe there is a problem (residents are too picky) or 2) it shouldn't be their program that has to contract.

So I'm wondering how residency contraction would actually work in a way that is fair and agreeable to all the chairs/ PDs. Take for instance 3 programs: program A has 4 residents total, program B has 6 residents, and program C has 8 residents. How would contraction actually work in a way that is fair to all parties?

 

[KHE88]

The argument that is typically given is that it's an antitrust violation to try and restrict residency spots at the certifying level and that any program that requests expansion and meets criteria has to be automatically granted approval.

Another way to restrict residency spots would be to simply shut certain programs down. Oh, I don't know how. Perhaps by introducing a new rule that says that first-time pass rate on all 4 board exams (not just orals) must be >60% lest you get put on probation then increasing the difficulty of the exam exponentially. Not that that would ever happen intentionally. And certainly wouldn't affect small programs any more than it would large programs. And those freed up spots by small programs that vanished certainly wouldn't result in requests for further expansion by the academic behemoths, which definitely aren't expanding satellite sites.

 

[Chartreuse Wombat]

Tragedy of the commons comes to Radiation Oncology

 

[thecarbonionangle]

Tragedy of the commons comes to Radiation Oncology

So what are you and your colleagues doing to make things better?

 

[deleted950463]

care that residents in more elite coastal programs had a leg up through recall/cheating methods.

That’s a serious accusation. Do you have proof to back this up?

 

[Mandelin Rain]

Couple things:
1. I don't believe that the Smith "data" had much to do with residency expansion. I think it was a conscious move on behalf of academic center leadership, in a moment of intense consolidation, to create this exact scenario of cheap labor for satellites with few options. Additionally, I think the over-emphasis on "academics" has lead some likely, well-meaning and ambitious people to open residencies where programs aren't needed/shouldn't be to start with.

2. Recalls definitely do exist. It's not a secret, and it's not limited to coastal elite schools. They are very helpful, I'm told. The acting ABR president confirmed it and laughed it off.

3. If, after 4 years of clinical residency my program leadership like me well enough to offer me a job but offered me a clinical fellowship job, it would take every fiber of my being to not start handing out gut punches. Umm... you took 4 years of my life and are either saying that 1. you didn't educate me well enough and/or 2. you don't mind taking advantage of me.

 

[RickyScott]

Couple things:
If, after 4 years of clinical residency my program leadership like me well enough to offer me a job but offered me a clinical fellowship job, it would take every fiber of my being to not start handing out gut punches. Umm... you took 4 years of my life and are either saying that 1. you didn't educate me well enough and/or 2. you don't mind taking advantage of me.

well said.
Prior to hypofractionation, in the early 2000s, conventional wisdom when purchasing a linac was that a population of abt 100,000 catchment was needed for 15-20 pts to support one linac. (us pop = 330 million) Certifying 4000 radoncs every 20 years in an era of hypofractionation can not end well. Fellowships will be required to accommodate excess docs. This is clear to anyone with experience in the field and probably why Hahn and Zeitman are writing red journal editorials about the need for additional training /skills in diagnositc or interventional procedures.

(I am going to keep putting the same facts out there.)

 

[medgator]

1. I don't believe that the Smith "data" had much to do with residency expansion. I think it was a conscious move on behalf of academic center leadership, in a moment of intense consolidation, to create this exact scenario of cheap labor for satellites with few options.

I think they used that data as cover though. Pretty shady.

This article was also the rage in RO when it came out despite it being focused on med/gyn onc:

http://ascopubs.org/doi/abs/10.1200/jop.0723601

 

[Mandelin Rain]

I will say that aligning with diagnostic modalities kills this field as we know it. It then becomes a sub of radiology. We should be actively trying to distance ourselves from being viewed as technicians, and portraying ourselves as the most expert oncology clinicians, that we are.

 

[RickyScott]

I will say that aligning with diagnostic modalities kills this field as we know it. It then becomes a sub of radiology. We should be actively trying to distance ourselves from being viewed as technicians, and portraying ourselves as the most expert oncology clinicians, that we are.

Of course. We should be aligning with medonc, but from a practical standpoint, it may be easier to maneuver within the same board. (medonc fellowship without heme is 2 years and radonc really only requires maximum of 3 years). I am not sure we can expect a perfect solution, but something has to be done. Will it involve pretexts for failing more residents at the boards, additional years of training, additional training in diagnostic or interventions ?

 

[Fpg1245]

Of course. We should be aligning with medonc, but from a practical standpoint, it may be easier to maneuver within the same board. (medonc fellowship without heme is 2 years and radonc really only requires maximum of 3 years). I am not sure we can expect a perfect solution, but something has to be done. Will it involve pretexts for failing more residents at the boards, additional years of training, additional training in diagnostic or interventions ?

Inevitably we will step on toes in the process and face resistance. I don’t see med oncs being cool with ROs calling themselves “oncologists” and giving out systemic agents. will we be able to overcome that roadblock?

 

[fiji128]

This is my take on the above.

The problem with our field is that there is a lack of opportunities for many of those completing residency. This is largely due to unchecked residency expansion that was all predicated on this JCO article in 2010.

http://ascopubs.org/doi/10.1200/JCO.2010.31.2520

My first impression on reading this article in 2010 was the number of assumptions needed to reach the conclusion are astounding. This is from the conclusion, " Demand for radiation therapy is expected to grow 10 times faster than supply between 2010 and 2020." At any rate, after this was published, all the expansion stuff really ramped up b/c those in the ivory towers called a shortage before any had actually taken place.

The control of program expansion is governed by the ACGME's Resident Review Committee (this also lists the current committee members).

https://www.acgme.org/Specialties/Program-Requirements-and-FAQs-and-Applications/pfcatid/22/Radiation Oncology

I used to follow this stuff when I was applying for residency and was just taking a look at it now see if any of the main requirements have been changed since about 2010. The big requirements are minimum of four FTE radiation oncologists at the primary clinical site who devote the majority of their professional time to the education of residents (same), at least one full-time radiation biologist or cancer biologist (PhD level or equivalent) who devotes the majority of his or her professional time to laboratory-based cancer research and is at the primary clinical site or at an integrated site to provide a scholarly environment of research and to participate in the teaching of radiation and cancer biology (same), there must be a minimum of 600 patients receiving external beam radiation therapy per year cumulatively at the primary clinical site and any integrated sites (same, I think), each resident must treat at least 450 patients with external beam radiation therapy (same) and at the primary clinical site there must be two or more megavoltage machines (this used to be 3 in 2010 I believe).

One way to reduce unchecked expansion that would be transparent would be increase these requirements, especially the faculty and linac requirements to say something like 10 faculty and 4 linacs or something along those lines. That would be much more transparent then to just say hay, now with have the lowest board past rate of any specialty for some unknown reason.

I never bought the whole "antitrust" argument as here is what the medical establishment actually thinks about it.

The National Resident Matching Program and Antitrust Law

And at any rate there is now signed legislation since 2004 that exempts those participating in a matching program from federal anti-trust laws anyways. I'm not a lawyer but its seems this would shield programs and the ACGME/RCC from any "antitrust" arguments.

JUNG v. ASSOCIATION OF AMERICAN MEDICAL COLLEGES | D.D.C. | Judgment | Law | CaseMine

 

[scarbrtj]

...historical irrelevant nonsense that simply papers over the fact that there really isn’t much to learn. It’s really just a paid waiting game...

This is one of the inconvenient truths in our specialty. Radiation oncology was more complicated in the "old days" (20th century) and it was easier to mistreat and cause harm back then (no 3D planning, no R&V systems, much more need for dosimetrists and physicists, "hand calcs," cesium implants in the hospital... and I could go on). Then, the residency was three years... or 1 year of DR and 2 years of TR (totally antediluvian). Now, clinical radiation oncology is quite streamlined in comparison. You can whip up the most fantastic (and low-toxicity) plans in minutes and "upload" to the machine in seconds. (We could cite multiple examples of this across multiple fields.) The knowledge base of oncology (and physics insofar as IGRT, IMRT, protons, etc.) and radbio has expanded... but the "nuts and bolts" of clinical radiation oncology has arguably gotten easier. But now the residency is 4 (+1=5) years. To be a good clinical radiation oncologist, with a focused curriculum and good patient load, I could get you there in two years easily. Perhaps 18 months. (Heck, even the "best" rad oncs get there in 27 months, correct?) But as I previously mentioned we are in a state of neurosis. Who are we? What should we become? Should we go back into radiology a bit? Should we be great clinicians? Or theoreticians? Both? One more than the other? More than 100 years ago Cushing came up with the notion that a neurosurgeon was a neurologist who operated. That core raison d'être hasn't changed in a century for the neurosurgeons. What's our raison d'être? The theoretical is fantastic... it is intellectually stimulating, etc. However, nowadays, that and two dollars will get you a cup of coffee. Rad oncs, due to multiple factors (allowing themselves to be hospital-employed as well as rad oncs who have decided to work exclusively at insurance companies to set rad onc policy—it is entities like Evicore who control rad onc guidelines nowadays, not ASTRO, NCCN, etc.) are now commoditized. I can speak from experience that is a bit soul-crushing. It has not been good for other specialties.

 

[RickyScott]

This is my take on the above.

The problem with our field is that there is a lack of opportunities for many of those completing residency. This is largely due to unchecked residency expansion that was all predicated on this JCO article in 2010.

http://ascopubs.org/doi/10.1200/JCO.2010.31.2520

My first impression on reading this article in 2010 was the number of assumptions needed to reach the conclusion is astounding. This is from the conclusion, " Demand for radiation therapy is expected to grow 10 times faster than supply between 2010 and 2020." At any rate after this was published all the expansion stuff really ramped up b/c those in the ivory towers called a shortage before any had actually taken place.

The control of program expansion is governed by the ACGME's Resident Review Committee (this also lists the current committee members).

https://www.acgme.org/Specialties/Program-Requirements-and-FAQs-and-Applications/pfcatid/22/Radiation Oncology

I used to follow this stuff when I was applying for residency and was just taking a look at it now see if any of the main requirements have been changed since about 2010. The big requirements are minimum of four FTE radiation oncologists at the primary clinical site who devote the majority of their professional time to the education of residents (same), at least one full-time radiation biologist or cancer biologist (PhD level or equivalent) who devotes the majority of his or her professional time to laboratory-based cancer research and is at the primary clinical site or at an integrated site to provide a scholarly environment of research and to participate in the teaching of radiation and cancer biology (same), there must be a minimum of 600 patients receiving external beam radiation therapy per year cumulatively at the primary clinical site and any integrated sites (same, I think), each resident must treat at least 450 patients with external beam radiation therapy (same) and at the primary clinical site there must be two or more megavoltage machines (this used to be 3 in 2010 I believe).

One way to reduce unchecked expansion that would be transparent would be increase these requirements, especially the faculty and linac requirements to say something like 10 faculty and 4 linacs or something along those lines. That would be much more transparent then to just say hay, now with have the lowest board past rate of any specialty for some unknown reason.

I never bought the whole "antitrust" argument as here is what the medical establishment actually thinks about it.

The National Resident Matching Program and Antitrust Law

And at any rate there is now signed legislation since 2004 that exempts those participating in a matching program from federal anti-trust laws anyways. I'm not a lawyer but its seems this would shields programs and the ACGME/RCC from any "antitrust" arguments.

JUNG v. ASSOCIATION OF AMERICAN MEDICAL COLLEGES | D.D.C. | Judgment | Law | CaseMine

I am sure limitations on residency numbers could be challenged, but a good case can be made that limiting residency expansion is aligned with the public good ( which is criterea for anti-trust actions). For example 1) It costs the government a lot of money to train docs in medschool and residency, so public good is being harmed if they are underemployed 2) It can be shown that overutilization of trearment occurs with excess docs which costs medicare. When you think about it, a certificate of need (CON)- is in some ways a similar situation, and that is not unconstituitional because of public good arguments.

Is astro looking at this or does their POLITICAL ACTION COMMITTEE care more about proton reimbursement.


From astro PAC July 2018

Medicare coverage policy on proton beam therapy
The report analyzes selected services, including proton beam therapy (PBT), which the Commission deems “low value” and notes increased Medicare spending on proton therapy for prostate cancer. According to the report, low-value services “have little or no clinical benefit or care in which the risk of harm from the service outweighs the potential benefit.” MedPAC identifies multiple tools to address low-value care, including requiring prior authorization for certain types of services; implementing clinician decision support and provider education; altering beneficiary cost sharing; establishing new payment models that foster delivery of system reform; revisiting coverage determinations on an ongoing basis; and linking fee-for-service coverage and payment to clinical comparative effectiveness and cost-effectiveness information.

While ASTRO agrees with efforts to address inappropriate utilization of services that do not benefit patient care, ASTRO is very concerned with the broad-brush approach that led MedPAC to single out PBT. PBT is an effective, evidence-based treatment for a specific group of clinical indications.
(Indeed, the government has a good argument that protons should not be reimbursed with the exception of pediatric and base of skull unless proof emerges of their benefit - and we all know that is not occurring in common cancers like prostate. It would disgust me if I was a member of ASTRO that some of my dues were being used to lobby against the public good.)

 

[medgator]

. But now the residency is 4 (+1=5) years. To be a good clinical radiation oncologist, with a focused curriculum and good patient load, I could get you there in two years easily. Perhaps 18 months. (Heck, even the "best" rad oncs get there in 27 months, correct?).

I know that's a tongue in cheek comment, but "best" is subjective.

many have questioned whether that's enough clinical training for Holman graduates. I'd imagine it pretty would pretty much make you ready for treating a single subsite in academics and that's it. Good luck if you try to pivot away from that

 

[nkmiami]

This is one of the inconvenient truths in our specialty. Radiation oncology was more complicated in the "old days" (20th century) and it was easier to mistreat and cause harm back then (no 3D planning, no R&V systems, much more need for dosimetrists and physicists, "hand calcs," cesium implants in the hospital... and I could go on). Then, the residency was three years... or 1 year of DR and 2 years of TR (totally antediluvian). Now, clinical radiation oncology is quite streamlined in comparison. You can whip up the most fantastic (and low-toxicity) plans in minutes and "upload" to the machine in seconds. (We could cite multiple examples of this across multiple fields.) The knowledge base of oncology (and physics insofar as IGRT, IMRT, protons, etc.) and radbio has expanded... but the "nuts and bolts" of clinical radiation oncology has arguably gotten easier. But now the residency is 4 (+1=5) years. To be a good clinical radiation oncologist, with a focused curriculum and good patient load, I could get you there in two years easily. Perhaps 18 months. (Heck, even the "best" rad oncs get there in 27 months, correct?) But as I previously mentioned we are in a state of neurosis. Who are we? What should we become? Should we go back into radiology a bit? Should we be great clinicians? Or theoreticians? Both? One more than the other? More than 100 years ago Cushing came up with the notion that a neurosurgeon was a neurologist who operated. That core raison d'être hasn't changed in a century for the neurosurgeons. What's our raison d'être? The theoretical is fantastic... it is intellectually stimulating, etc. However, nowadays, that and two dollars will get you a cup of coffee. Rad oncs, due to multiple factors (allowing themselves to be hospital-employed as well as rad oncs who have decided to work exclusively at insurance companies to set rad onc policy—it is entities like Evicore who control rad onc guidelines nowadays, not ASTRO, NCCN, etc.) are now commoditized. I can speak from experience that is a bit soul-crushing. It has not been good for other specialties.

I am in total agreement. Technically, It was a much more difficult specialty in the era of fluor-sim and more widespread brachy with a lot more "skill" required, and even then residency was 3 years.

 

[scarbrtj]

I really dont care if RO used to radiate people with suspected CNS germinomas with out tissue dx

HA! The infamous "radiation biopsy."

 

[medgator]

I am in total agreement. Technically, It was a much more difficult specialty in the era of fluor-sim and more widespread brachy with a lot more "skill" required, and even then residency was 3 years.

Yet those old timers still may not know cross sectional anatomy to save their lives when it comes to contouring.

Easier, but a different skill set. Drawing fields on a film is a lot different

 

[evilbooyaa]

I agree that the day to day work of clinical rad onc is my favorite. Despite the issues, I wouldn't change what field I went into if I was re-applying now.

I agree that the administrative/job-market/compensation/workload related issues people have is significant and is not trending in the right direction.

I don't believe that every graduating PGY-5 (or new attending) is dealing with these issues - I imagine most of those that are content in their jobs/situations are not routinely posting on SDN, especially not on the weekend.

Just something for prospective medical students to keep in mind. I certainly believe there are issues with this field for a percentage now (as evidenced above), and worry about what the field will be in 5 years (in the context of current medical students applying for attending jobs).

I believe the real answer, as always, is in-between the two extremes (everything is fine, suck it up buttercups vs the sky is falling and nobody can get a job anywhere), and we're going to hear the most from people that are at one of those two extremes.

That's not to say EVERYBODY is at one of those two extremes, and I personally fall closer to the sky is falling group than being truly in the middle.

This is one of the inconvenient truths in our specialty. Radiation oncology was more complicated in the "old days" (20th century) and it was easier to mistreat and cause harm back then (no 3D planning, no R&V systems, much more need for dosimetrists and physicists, "hand calcs," cesium implants in the hospital... and I could go on). Then, the residency was three years... or 1 year of DR and 2 years of TR (totally antediluvian). Now, clinical radiation oncology is quite streamlined in comparison. You can whip up the most fantastic (and low-toxicity) plans in minutes and "upload" to the machine in seconds.

I think the concept that Rad Onc is less complicated now than it was 20 years ago is laughable. Yeah dosimetrists can do x, y, and z, but you better know how to contour, how to evaluate a 3D or IMRT plan, how to dose paint or evaluate a dose painted plan, evaluate dose constraints, etc. The concept of marginal miss with IMRT is STILL an issue with people who dont understand the concept of appropriate PTV margins (or creation of an ITV, or whatever).

I agree that there needs to be somebody with the responsibility of saying "this residency expansion that you have proposed does not meet the requirements for need, and thus has been denied". The requirements for graduating residents should be doubled or tripled in currently low volume areas (SRS, SBRT, Brachy, Peds) especially as things like SRS and SBRT explode in popularity.

 

[thecarbonionangle]

This is my take on the above.

.

The control of program expansion is governed by the ACGME's Resident Review Committee (this also lists the current committee members).

https://www.acgme.org/Specialties/Program-Requirements-and-FAQs-and-Applications/pfcatid/22/Radiation Oncology

its funny how the institutions represented are UTSW, Upenn, Michigan, MDACC, Maryland, Mt. Sinai. Most of these institutions offer fellowships or have recently expanded. Some both.

For me the solution is to "modernize" the case requirements: increase brachy requirements (require breast, prostate and gyn brachy, etc). It is crazy that there are programs where people don't do a single T&O or Syed. Increase SBRT/SRS requirements by site (require liver, brain, etc etc).

 

[nkmiami]

Is michigan still offering a "bring your own funding" fellowship for us grads and did they fill that position?

 

[OTN]

I agree that the day to day work of clinical rad onc is my favorite. Despite the issues, I wouldn't change what field I went into if I was re-applying now.

I agree that the administrative/job-market/compensation/workload related issues people have is significant and is not trending in the right direction.

I don't believe that every graduating PGY-5 (or new attending) is dealing with these issues - I imagine most of those that are content in their jobs/situations are not routinely posting on SDN, especially not on the weekend.

Just something for prospective medical students to keep in mind. I certainly believe there are issues with this field for a percentage now (as evidenced above), and worry about what the field will be in 5 years (in the context of current medical students applying for attending jobs).

I believe the real answer, as always, is in-between the two extremes (everything is fine, suck it up buttercups vs the sky is falling and nobody can get a job anywhere), and we're going to hear the most from people that are at one of those two extremes.

That's not to say EVERYBODY is at one of those two extremes, and I personally fall closer to the sky is falling group than being truly in the middle.



I think the concept that Rad Onc is less complicated now than it was 20 years ago is laughable. Yeah dosimetrists can do x, y, and z, but you better know how to contour, how to evaluate a 3D or IMRT plan, how to dose paint or evaluate a dose painted plan, evaluate dose constraints, etc. The concept of marginal miss with IMRT is STILL an issue with people who dont understand the concept of appropriate PTV margins (or creation of an ITV, or whatever).

I agree that there needs to be somebody with the responsibility of saying "this residency expansion that you have proposed does not meet the requirements for need, and thus has been denied". The requirements for graduating residents should be doubled or tripled in currently low volume areas (SRS, SBRT, Brachy, Peds) especially as things like SRS and SBRT explode in popularity.

Agree re: complexity of radonc. Sure, some things were more difficult (hand calcs, etc), but some things were far easier. H+N contouring didn't exist, 4d CT data didn't have to be included in contouring, the myriad of BS computer-based clicking requirements hadn't been created, and we didn't have as many imaging modalities to master as we do now.

 

[RickyScott]

its funny how the institutions represented are UTSW, Upenn, Michigan, MDACC, Maryland, Mt. Sinai. Most of these institutions offer fellowships or have recently expanded. Some both.

For me the solution is to "modernize" the case requirements: increase brachy requirements (require breast, prostate and gyn brachy, etc). It is crazy that there are programs where people don't do a single T&O or Syed. Increase SBRT/SRS requirements by site (require liver, brain, etc etc).

I am not sure the solution is to increase case requirements as that just affects the smaller programs and still would allow your MDACC and MSKCC UPENN etc to increase spots as these all have huge networks now.

 

[thecarbonionangle]

I am not sure the solution is to increase case requirements as that just affects the smaller programs and still would allow your MDACC and MSKCC UPENN etc to increase spots as these all have huge networks now.

Not advocating to increase requirements to hurt small programs only to at least gautantee minimal competency. If you cant guarantee your residents know how to do a TO then the program may not add much (assuming they are unwillimg to make adjustments, and i suppose most would be able to). We can all agree the current case requirements are a joke.

 

[Chartreuse Wombat]

So what are you and your colleagues doing to make things better?

If you grant the analogy then there are no easy solutions. Each is acting in their own best interest.

I tell everyone that asks that I think we are training too many people; using the data that has been highlighted on multiple occassions on SDN. The only people that can change this are Department Chairs. I have managed to convince my chief that we shouldn't increase out resident complement and hire APPs for clinical coverage but other departments feel differently.

The economics of the GME system are fubar as highlighted in paper below. Hospitals are exploiting trainees so RadOnc is not alone

NEJM - Error

If you don't want to read the paper the bottom line is that residents bear the cost of their own training.

 

[medgator]

Devil's advocate.... I did a few base of tongue, syed, sarcoma and floor of mouth implants in training. Have done 0 in practice.

I did more t&o and cylinders than that, even then I'm not seeing a ton now because the employed gyn onc works for a competitor.

 

[scarbrtj]

I think the concept that Rad Onc is less complicated now than it was 20 years ago is laughable.

Complication is subjective, but it seems like you have never spent two hours in the fluoro sim suite trying to get a three-field breast just perfect