Radiation Oncology is not the best field in medicine.

[evilbooyaa]

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

No but I have spent 2 hours getting a bolus and immobilization for scalp IMRT put together... or 2 hours on a medial thigh sarcoma immobilization that will be reproducible enough for IMRT so as to avoid treating entire circumference of bone, or 2 hours coordinating sim for anything complex in terms of IMRT.

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[Mandelin Rain]

As a guy who treats a lot of H&N, taking a wax marker and drawing about 11 straight/slightly curved lines to obvious bony anatomy on three radiographs seems easier than a full IMRT. But that laryngeal block....

 

[RadOncG]

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).

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.

No but I have spent 2 hours getting a bolus and immobilization for scalp IMRT put together... or 2 hours on a medial thigh sarcoma immobilization that will be reproducible enough for IMRT so as to avoid treating entire circumference of bone, or 2 hours coordinating sim for anything complex in terms of IMRT.

As a guy who treats a lot of H&N, taking a wax marker and drawing about 11 straight/slightly curved lines to obvious bony anatomy on three radiographs seems easier than a full IMRT. But that laryngeal block....

Honestly I am not impressed with the complexity, skill required, or stress level associated with any of these basic functions of a radiation oncologist. Anyone that has spent the night covering an ICU would call this "cute." People love to be the one that has the hardest job, the one that had it the worst in residency, the one that has accomplished the most, the one that has to know the most. This inferiority complex that is so common in our field has lead to forced mindless memorization of historical clinical trial minutiae, useless radiation biology trivia, and non-applicable physics concepts. If we know the most trivia we aren't inferior. This is a coping mechanism that has been forced upon this field by the fossilized founders and current leaders (most of whom are also fossilized).

We have recently learned that the laws of supply and demand apply to us. It is as sure as the law of gravity. Despite some of Lisa Kachnic and Paul Wallner's friends that have been posting here thinking they were grandfathered from gravity. These laws of economics do not work like the ABR- unfortunately for them. We will continue to see that these basic radiation oncology skills are easily replaceable. There is a flood of new graduates that will be willing and forced to work for much lower salaries to just have the privilege of having a job.

 

[Gfunk6]

Assays never covered in hall. Taq man.

Everybody fails Radbio one way or the other
So check out Wallner’s message to you
As a matter of fact, I don't let nothin' hold you back
If Kachnic can do it, so can you
Everybody's sayin' that the taq man is irrelevant
But doesn't ever study these things
But what you don't know I'm gonna tell you right now
That the taq man and the scat is the same thing to you
I'm the Taq man
Where's the Taq man?
I'm the taq man

Why should we be pleasin' in the ABR heathens
Who would try to change the seasons if they could?
The state of the condition insults my intuitions
And it only makes me crazy and a heart like wood
Everybody fails radbio one way or the other
So check out my message to you
As a matter of fact, don't let nothin' hold you back
If the Taq man can do it, brother, so can you
I'm the Taq man

Ba-da-ba-da-ba-be bop bop bodda bope
Bop ba bodda bope
Be bop ba bodda bope
Bop ba bodda
Ba-da-ba-da-ba-be bop ba bodda bope
Bop ba bodda bope
Be bop ba bodda bope
Bop ba bodda bope





Sent from my iPhone using SDN

 

[medgator]

Honestly I am not impressed with the complexity, skill required, or stress level associated with any of these basic functions of a radiation oncologist. Anyone that has spent the night covering an ICU would call this "cute." People love to be the one that has the hardest job, the one that had it the worst in residency, the one that has accomplished the most, the one that has to know the most.

I don't think anyone was trying to compare it to other fields, rather to where it was decades ago, as some believe it is easier now.

I think many of us know examples of people who trained in the pre 3D era who struggle with contouring planning CTs now

 

[deleted18755]

No but I have spent 2 hours getting a bolus and immobilization for scalp IMRT put together... or 2 hours on a medial thigh sarcoma immobilization that will be reproducible enough for IMRT so as to avoid treating entire circumference of bone, or 2 hours coordinating sim for anything complex in terms of IMRT.

I honestly don’t think I’ve ever done either but definitely no denying that computers have gotten better and faster more quickly than plans have gotten complicated ... I definitely remember the days when we ran an IMRT plan before leaving for the day and it was still calculating when we came in the following morning!

 

[RadOncG]

I don't think anyone was trying to compare it to other fields, rather to where it was decades ago, as some believe it is easier now.

I think many of us know examples of people who trained in the pre 3D era who struggle with contouring planning CTs now

Makes sense. I agree with others that it has always been relatively easy.

It is without question way over-complicated by many for self-aggrandizement purposes.

 

[RickyScott]

I honestly don’t think I’ve ever done either but definitely no denying that computers have gotten better and faster more quickly than plans have gotten complicated ... I definitely remember the days when we ran an IMRT plan before leaving for the day and it was still calculating when we came in the following morning!

This brings out an important historical point: when IMRT entered the clinic, it demanded a tremendous amount of resources and provided justification for huge technical fees by CMS. Those fees never "normalized" despite the fact that IMRT became so much more streamlined, and this is one of the dirty secrets of our field. Hospitals discovered the gold mine in the basements and began investing heavily in their programs (and equipment, which previously had been neglected, even in some of the best departments). There was significant expansion/satellite facilities beyond the main campus (and of course, additional residents). Meanwhile, median salaries have been stagnant, or declined, throughout this period because salaries are set by supply and demand not technical fees (just ask the patholgists, who apparently can also generate high professional and technical fees.).

When I started residency, the chairman complained the Dean did not know who he was, but by the end senior hospital admin had taken a really strong interest in our department.

 

[thecarbonionangle]

Clearly if you dont understand or fully know taqman RTPCr you have no business in a rad onc dept!

 

[Mandelin Rain]

Clearly if you dont understand or fully know taqman RTPCr you have no business in a rad onc dept!

Is this a low level French soccer club?

 

[deleted18755]

This brings out an important historical point: when IMRT entered the clinic, it demanded a tremendous amount of resources and provided justification for huge technical fees by CMS. Those fees never "normalized" despite the fact that IMRT became so much more streamlined, and this is one of the dirty secrets of our field. Hospitals discovered the gold mine in the basements and began investing heavily in their programs (and equipment, which previously had been neglected, even in some of the best departments). There was significant expansion/satellite facilities beyond the main campus (and of course, additional residents). Meanwhile, median salaries have been stagnant, or declined, throughout this period because salaries are set by supply and demand not technical fees (just ask the patholgists, who apparently can also generate high professional and technical fees.).

When I started residency, the chairman complained the Dean did not know who he was, but by the end senior hospital admin had taken a really strong interest in our department.

IMRT planning and of course the amount of time and skills that is required to check IGRT, especially a CBCT. When this gets "normalized" many centers will be at risk of losing at least 20-30% of their revenue overnight. It's no secret but sshhh!!!

 

[evilbooyaa]

Honestly I am not impressed with the complexity, skill required, or stress level associated with any of these basic functions of a radiation oncologist. Anyone that has spent the night covering an ICU would call this "cute." People love to be the one that has the hardest job, the one that had it the worst in residency, the one that has accomplished the most, the one that has to know the most. This inferiority complex that is so common in our field has lead to forced mindless memorization of historical clinical trial minutiae, useless radiation biology trivia, and non-applicable physics concepts. If we know the most trivia we aren't inferior. This is a coping mechanism that has been forced upon this field by the fossilized founders and current leaders (most of whom are also fossilized).

We have recently learned that the laws of supply and demand apply to us. It is as sure as the law of gravity. Despite some of Lisa Kachnic and Paul Wallner's friends that have been posting here thinking they were grandfathered from gravity. These laws of economics do not work like the ABR- unfortunately for them. We will continue to see that these basic radiation oncology skills are easily replaceable. There is a flood of new graduates that will be willing and forced to work for much lower salaries to just have the privilege of having a job.

Nobody is comparing it to an overnight shift in the ICU. Historical versus current comparisons. Lots more uncertainty back in the old days for sure, and a lot more toxic treatments, and less ability to push the envelope in terms of what we can safely treat.

 

[Mandelin Rain]

Nobody is comparing it to an overnight shift in the ICU. Historical versus current comparisons. Lots more uncertainty back in the old days for sure, and a lot more toxic treatments, and less ability to push the envelope in terms of what we can safely treat.

When you do something day in and day out for years, difficulty is lost. After an Intensivist fellowship and 5 years of practice, I'm sure altering vent settings and cardizem drips isn't too challenging either. You get patterns down and develop algorithms like anything else.

 

[OTN]

IMRT planning and of course the amount of time and skills that is required to check IGRT, especially a CBCT. When this gets "normalized" many centers will be at risk of losing at least 20-30% of their revenue overnight. It's no secret but sshhh!!!

IGRT with CBCT or other modalities needs expensive hardware and takes both staff and MD time to accomplish. MD CBCT review does take time when done correctly. It's not accurate to say centers are at risk of losing 20-30% of their revenue.

 

[deleted18755]

IGRT with CBCT or other modalities needs expensive hardware and takes both staff and MD time to accomplish. MD CBCT review does take time when done correctly. It's not accurate to say centers are at risk of losing 20-30% of their revenue.

I don't pay attention to things like this anymore so I certainly could be mistaken, but isn't just the physician's RVU (not technical) something like 0.8 RVU? An administrator told me not too long ago that we get paid more for checking a CBCT than a PCP gets for a 15 minute follow-up.

I've never spent anywhere near that amount of time on one and we all know radiation oncologist's who spend less than 10-15 seconds per scan.

 

[medgator]

I don't pay attention to things like this anymore so I certainly could be mistaken, but isn't just the physician's RVU (not technical) something like 0.8 RVU? An administrator told me not too long ago that we get paid more for checking a CBCT than a PCP gets for a 15 minute follow-up.

I've never spent anywhere near that amount of time on one and we all know radiation oncologist's who spend less than 10-15 seconds per scan.

How hard is to give keytruda or opdivo, certainly there is e&m for managing patients in on, but should med oncs be making thousands for ordering an infusion?

 

[evilbooyaa]

I don't pay attention to things like this anymore so I certainly could be mistaken, but isn't just the physician's RVU (not technical) something like 0.8 RVU? An administrator told me not too long ago that we get paid more for checking a CBCT than a PCP gets for a 15 minute follow-up.

I've never spent anywhere near that amount of time on one and we all know radiation oncologist's who spend less than 10-15 seconds per scan.

Again, only in radiation oncology, do we as a specialty try to provide evidence for why we should not be paid for what we do. Seriously, it's like a sickness of our field. Reviewing a CBCT may not take long because you're good at radiographical anatomy. You're also taking on the liability of saying that the CBCT looks good. If CBCTs don't look good and patient has a poor outcome, guess who is getting sued?

A PCP should get paid more for a 15 minute follow-up than they currently do, but that doesn't mean we should make less.

 

[deleted18755]

Again, only in radiation oncology, do we as a specialty try to provide evidence for why we should not be paid for what we do. Seriously, it's like a sickness of our field. Reviewing a CBCT may not take long because you're good at radiographical anatomy. You're also taking on the liability of saying that the CBCT looks good. If CBCTs don't look good and patient has a poor outcome, guess who is getting sued?

A PCP should get paid more for a 15 minute follow-up than they currently do, but that doesn't mean we should make less.

Oh yes, I agree. I think my initial statement was misinterpreted because it was in response to another post I didn't quote.

I'm speaking from the viewpoint of whoever it is that periodically adjust RVU's and payment across the board. I think if anything the PCP should be paid way more but from their viewpoint they will obviously "normalize" us down not the PCP up sometime very soon and/or just bundle everything and just like that the reimbursement is done (and the IGRT checks are a huge reimbursement for most practices).

 

[Fpg1245]

Again, only in radiation oncology, do we as a specialty try to provide evidence for why we should not be paid for what we do. Seriously, it's like a sickness of our field. Reviewing a CBCT may not take long because you're good at radiographical anatomy. You're also taking on the liability of saying that the CBCT looks good. If CBCTs don't look good and patient has a poor outcome, guess who is getting sued?

A PCP should get paid more for a 15 minute follow-up than they currently do, but that doesn't mean we should make less.

Cue the circular firing squad and self flagellation.

 

[evilbooyaa]

Oh yes, I agree. I think my initial statement was misinterpreted because it was in response to another post I didn't quote.

I'm speaking from the viewpoint of whoever it is that periodically adjust RVU's and payment across the board. I think if anything the PCP should be paid way more but from their viewpoint they will obviously "normalize" us down not the PCP up sometime very soon (and the IGRT checks are a huge reimbursement for most practices).

Fair enough. I still think that doing CT-based IGRT properly takes longer than 10-15 seconds.

Fortunately for us (and unfortunately for PCPs) in the fee for service model procedures always get paid more than talking to a patient

 

[thecarbonionangle]

Peter Orio Writes in recent ABS newsletter:

"Also featured this month is a highlight by Sushil Beriwal, MD on a highly debated question on the horizon for our specialty. Dr. Beriwal outlines for us the current training guidelines of our radiation oncology residents and debates enhancing the minimum number of brachytherapy cases that must be performed by residents in an ACGME accredited training program in his article entitled Is it time for us to revisit ACGME requirements for brachytherapy caseloads during residency? This is a topic I am passionate about and is a conversation I will work to ensure we continue to discuss with our sister societies and the ACGME. I believe ABS has a responsibility to the entire profession of radiation oncology to ensure that high quality and safe brachytherapy is available to our patients now and well into the future. If we do not hold others accountable, then who will? We must continue to be the voice that educates and motivates others to choose what is right. We must fight to allow our surgically minded residents the opportunity to emerge proficient in performing brachytherapy and educate all our residents on the merits of brachytherapy so appropriate referrals can be made rather than not offering a patient “all their options.”


looks like discussion is ongoing

 

[seper]

Not sure what the situation at Harvard is (they used to have 16 residents), but SB oversaw doubling of his program size recently. If he still needs more residents assisting on his BCT cases, it's easier for him to email his Chair rather than publishing nonsense opinion letters.

Peter Orio Writes in recent ABS newsletter:

"Also featured this month is a highlight by Sushil Beriwal, MD on a highly debated question on the horizon for our specialty. Dr. Beriwal outlines for us the current training guidelines of our radiation oncology residents and debates enhancing the minimum number of brachytherapy cases that must be performed by residents in an ACGME accredited training program in his article entitled Is it time for us to revisit ACGME requirements for brachytherapy caseloads during residency? This is a topic I am passionate about and is a conversation I will work to ensure we continue to discuss with our sister societies and the ACGME. I believe ABS has a responsibility to the entire profession of radiation oncology to ensure that high quality and safe brachytherapy is available to our patients now and well into the future. If we do not hold others accountable, then who will? We must continue to be the voice that educates and motivates others to choose what is right. We must fight to allow our surgically minded residents the opportunity to emerge proficient in performing brachytherapy and educate all our residents on the merits of brachytherapy so appropriate referrals can be made rather than not offering a patient “all their options.”


looks like discussion is ongoing

 

[thecarbonionangle]

Not sure what the situation at Harvard is (they used to have 16 residents), but SB oversaw doubling of his program size recently. If he still needs more residents assisting on his BCT cases, it's easier for him to email his Chair rather than publishing nonsense opinion letters.

Lol you’re always welcome to write a countereditorial and add to discussion

 

[lhl]

Not sure what the situation at Harvard is (they used to have 16 residents), but SB oversaw doubling of his program size recently. If he still needs more residents assisting on his BCT cases, it's easier for him to email his Chair rather than publishing nonsense opinion letters.

In the actual piece by Beriwal (did you even read the actual piece or just Orio’s summary?), he is suggesting that brachytherapy case minimums be re-visited for an increase in the case volume requirements. The goal of this would be to promote more thorough training and competency in practice, as most residents don’t feel well prepared to practice brachytherapy independently (recent survey published in red journal). An increase in case minimums could help curtail additional expansion of programs/positions as programs without sufficient case volume would not expand/exist. He alludes to this in his piece. Most people on this board are in favor of stopping expansion or perhaps even a contraction. I’m not sure if that’s where you stand or not, but to those that believe our field is oversaturated with trainees, Berwial’s piece should be viewed as a step in the right direction. The ACGME, through strengthening of program requirements, is likely the most practical route.

 

[Mandelin Rain]

To be fair, it doesn't necessarily imply curtailing residency expansion. Just limiting expansion to those programs with a heavy brachy tilt. Coincidentally, like the one he is part of.

I do agree with the overall message and am one who did/does not feel well prepared to perform brachy.

 

[evilbooyaa]

I mean what if brachytherapy was only part of the equation? Increasing requirements for SRS, SBRT, and Peds? Requiring a certain number of definitive cancer treatments instead of potentially 450 palliative cases?

Might not massively affect numbers, but would some programs that are borderline on stuff like that have to consider contracting?

 

[evilbooyaa]

To be fair, it doesn't necessarily imply curtailing residency expansion. Just limiting expansion to those programs with a heavy brachy tilt. Coincidentally, like the one he is part of.

I do agree with the overall message and am one who did/does not feel well prepared to perform brachy.

I mean, do you feel adequately trained to do everything else out of residency, like SRS/SBRT? Why is brachytherapy 'OK' to not feel comfortable doing for rad onc graduates? This is how doing SBRT/IMRT boosts for cervical cancer becomes more prevalent, leading to worse oncologic outcome in patients.

 

[medgator]

To be fair, it doesn't necessarily imply curtailing residency expansion. Just limiting expansion to those programs with a heavy brachy tilt. Coincidentally, like the one he is part of.

I do agree with the overall message and am one who did/does not feel well prepared to perform brachy.

Net effect is still the same. And he has a point...why should we let programs get away with so little? As EB alluded to, it's still integral to cervix and maybe to high risk prostate one day

Also, brachy may come back with a vengeance once we go to bundles in low risk prostate

 

[RadOncG]

Programs will always have different strengths and weaknesses. Picking brachytherapy as the standard by which all other programs should be judged seems a bit silly. What percent of radiation oncologists do any brachytherapy?

Obviously Sushil Beriwal thinks it is the most important aspect of clinical radiation oncology since that is his life. There may be a different sentiment outside of the ivory tower.

 

[scarbrtj]

Every time someone talks brachy it's always mentioned that no one is doing enough (there is an American Brachytherapy Society after all), it's a dying art, it should be a standard tool in the rad onc's toolbox, etc. And when brachy is mentioned, so is cervix. There are about 8000-10000 brachytherapy-able cervical CA cases per year in the US. There are about 5500 radiation oncologists in the US. Thus, there are about 1-2 cervical cancer brachy cases per year, per rad onc, in the US. And we need be "experts" in brachy? All trainees need be? Remuneratively speaking, pretty low yield. Just food for thought... and perhaps another evidence of our specialty's neuroses. Won't really need more brachytherapists in future quite likely.

 

[Bequerel]

I often try to envision the future and wonder what people 50 years from now will look back and say “wow, I can’t believe that you all actually used to do that!?!” As technology continues to improve, I can’t help but think that brachytherapy will be on that list.

 

[Radiated_GuineaPig]

Every time someone talks brachy it's always mentioned that no one is doing enough (there is an American Brachytherapy Society after all), it's a dying art, it should be a standard tool in the rad onc's toolbox, etc. And when brachy is mentioned, so is cervix. There are about 8000-10000 brachytherapy-able cervical CA cases per year in the US. There are about 5500 radiation oncologists in the US. Thus, there are about 1-2 cervical cancer brachy cases per year, per rad onc, in the US. And we need be "experts" in brachy? All trainees need be? Remuneratively speaking, pretty low yield. Just food for thought... and perhaps another evidence of our specialty's neuroses. Won't really need more brachytherapists in future quite likely.

I disagree about brachytherapy. Its true brachytherapy is being more concentrated and that's a shame. For example lets talk about prostate. The lack of brachy use is driven in large part by hospital admins looking at the money they lose from not doing 44 fractions IMRT. However when the noose tightens and we get something close to bundle payments the hospital admins may be singing a different tune. Free up alot of machine time and get the patient out of there in 1 hour is a win-win. Then we'll end up training more. Or we get a bunch of Canadians.

 

[scarbrtj]

disagree about brachytherapy. Its true brachytherapy is being more concentrated and that's a shame. For example lets talk about prostate. The lack of brachy use is driven in large part by hospital admins looking at the money they lose from not doing 44 fractions IMRT. However when the noose tightens and we get something close to bundle payments the hospital admins may be singing a different tune. Free up alot of machine time and get the patient out of there in 1 hour is a win-win. Then we'll end up training more.

We could go way off the thread reservation on this one but for a whole host of reasons we shouldn't rely on prostate brachy to be a "win-win" for us. I've run the whole gamut in my own career. One could cite literally an orgy of data to argue brachy's superiority over EBRT (though we all could admit no one would win the argument either way). Personally, anecdotally, patients are happier with EBRT. There's a good 5-10% or more of brachy patients who have post-tx "drama" and need catheters etc. You never have that with EBRT. Plus, we are the captains of the ship with EBRT. Not so much with brachy. Out in the real world it's still a urologist and rad onc tag team with rad onc being more XO than captain. Again, part of that being the acute toxicity risks are much higher with brachy than EBRT and more need for a non-rad onc/urologist to help manage the patient postop. (Managing post-brachy toxicities is billable for about zero dollars I think for a rad onc.) When "noose tightens" as you say I foresee more prostate SBRT happening than brachy. (If we really get back to brachy with prostate ASTRO should allow urorad-ish arrangements instead of attacking them.)

 

[Mandelin Rain]

I am in total agreement. I can also say that in my region there is very little hypofractionation, apart from a smattering of stereo. I just cant see how some of the smaller facilities treating 15 pts will be able to survive.

They won't. Which makes graduating 200 rad oncs per year a very scary proposition.

 

[seper]

Increasing brachy requirements would probably not work to decrease residency spots. Most RadOnc programs, located usually in large centers, see brachy patients already and residents log enough cases.
Unfortunately very few people actually bother to train residents to become brachytherapists. There is no incentive for Beriwal to train his potential replacements. That's why residents report lack of preparedness to do implants on their own.

To be fair, it doesn't necessarily imply curtailing residency expansion. Just limiting expansion to those programs with a heavy brachy tilt. Coincidentally, like the one he is part of.

I do agree with the overall message and am one who did/does not feel well prepared to perform brachy.

 

[scarbrtj]

We must fight to allow our surgically minded residents the opportunity to emerge proficient in performing brachytherapy

A funny thing to ponder: how many surgery educators are thinking "We must fight to allow our radiation-minded surgery residents the opportunity to emerge proficient in assisting in SBRT?" or some such.

 

[RickyScott]

I am in total agreement. I can also say that in my region there is very little hypofractionation (prostate and breast), apart from a smattering of stereo. I just cant see how some of the smaller facilities treating 15 pts will be able to survive.

ASTRO has already released response on mandatory participation in bundling as put forth by the Secretary of Health. Maybe they can co-opt/modify it, but that is unlikely. Then everything will be in place for perfect - category 5 s---storm in the job market in several years.

Response to HHS Secretary Azar's comments on a radiation oncology alternative payment model

 

[lhl]

Programs will always have different strengths and weaknesses. Picking brachytherapy as the standard by which all other programs should be judged seems a bit silly. What percent of radiation oncologists do any brachytherapy?

Obviously Sushil Beriwal thinks it is the most important aspect of clinical radiation oncology since that is his life. There may be a different sentiment outside of the ivory tower.

no one is suggesting picking brachy as the standard. the suggestion is that the current acgme minimums: 5 interstitial across disease sites and 15 intracavitary (with no distinction between cylinder, tandem, etc) is too low. despite what other posters on this thread seem to imply, brachytherapy has been, and still is, an integral part of our field. Now, of course not everyone will go out and perform brachy in practice, but to have a basic level of understand and competency with the techniques shouldn't be too much to ask. If this helps curtail residency expansion then great. If not, it's still in the best interest of resident education.

As evilboya suggests I believe the ACGME should also revisit the minimums for other techniques (SRS/SBRT) and classifications (definitive vs palliative).

 

[Neuronix]

To me one of the biggest problems with this whole residency expansion issue is that every residency program is convinced that their program is the one that should expand (and definitely not contract!!!).

In a big name center? We should expand because we're the best (most brachy or peds or protons or whatever) with the biggest name attendings who can teach the best.

In a rural location? We should expand because our rural area has a shortage of rad oncs due to maldistribution. Our residents get to know the area and are more likely to stay in a rural area. All the programs in more populated places should contract.

In Florida? We should expand because Florida doesn't have enough residency positions compared to the large population. The programs concentrated in the northeast with the highest number of residents per population should contract.

In a small program in a mostly community center? We should expand because we give people the best preparation for busy general practice outside of academics. The big name academic places don't train the residents clinically as well as we do. Those big name academic places should contract.



The reality is that if all of a sudden we require more brachy or SBRT or whatever, the programs will just find ways to do more of it and get the resident numbers up to at least not contract or continue expanding. As Zeitman has said repeatedly, our specialty won't respond to a declining job market. Only when the job market totally collapses then medical students will stop going into the specialty and the situation will correct itself (maybe).

 

[OTN]

The reality is that if all of a sudden we require more brachy or SBRT or whatever, the programs will just find ways to do more of it and get the resident numbers up to at least not contract or continue expanding. As Zeitman has said repeatedly, our specialty won't respond to a declining job market. Only when the job market totally collapses then medical students will stop going into the specialty and the situation will correct itself (maybe).[/QUOTE]

FMGs will prevent that correction from ever occurring.

 

[nkmiami]

ASTRO has already released response on mandatory participation in bundling as put forth by the Secretary of Health. Maybe they can co-opt/modify it, but that is unlikely. Then everything will be in place for perfect - category 5 s---storm in the job market in several years.

Response to HHS Secretary Azar's comments on a radiation oncology alternative payment model

I can say that in community hospitals, a lot of people I know are thinking twice about hiring after this statement.

 

[lhl]

To me one of the biggest problems with this whole residency expansion issue is that every residency program is convinced that their program is the one that should expand (and definitely not contract!!!).

In a big name center? We should expand because we're the best (most brachy or peds or protons or whatever) with the biggest name attendings who can teach the best.

In a rural location? We should expand because our rural area has a shortage of rad oncs due to maldistribution. Our residents get to know the area and are more likely to stay in a rural area. All the programs in more populated places should contract.

In Florida? We should expand because Florida doesn't have enough residency positions compared to the large population. The programs concentrated in the northeast with the highest number of residents per population should contract.

In a small program in a mostly community center? We should expand because we give people the best preparation for busy general practice outside of academics. The big name academic places don't train the residents clinically as well as we do. Those big name academic places should contract.



The reality is that if all of a sudden we require more brachy or SBRT or whatever, the programs will just find ways to do more of it and get the resident numbers up to at least not contract or continue expanding. As Zeitman has said repeatedly, our specialty won't respond to a declining job market. Only when the job market totally collapses then medical students will stop going into the specialty and the situation will correct itself (maybe).

I agree with you. two things to point out though:
1. In the 90's numerous programs/spots were eliminated largely due to increasing ACGME requirements so there is precedent that the concept at least has some chance of being effective
2. A much more pragmatic/even handed approach to the issue of "it shouldn't be me that has to reduce spots" would be this:
if you have 8-14 total spots you give up 2 (one every other year). If you have 16+ spots you give up 4 (one every year). This would have the net effect of decrease spots by about 40 per year across the country which would be reasonable. Although, no one has the power to just make this sort of blanket declaration (or some variation of it) and execute it...thus we are left with less direct strategies like increasing ACGME requirements.

 

[evilbooyaa]

To me one of the biggest problems with this whole residency expansion issue is that every residency program is convinced that their program is the one that should expand (and definitely not contract!!!).

In a big name center? We should expand because we're the best (most brachy or peds or protons or whatever) with the biggest name attendings who can teach the best.

In a rural location? We should expand because our rural area has a shortage of rad oncs due to maldistribution. Our residents get to know the area and are more likely to stay in a rural area. All the programs in more populated places should contract.

In Florida? We should expand because Florida doesn't have enough residency positions compared to the large population. The programs concentrated in the northeast with the highest number of residents per population should contract.

In a small program in a mostly community center? We should expand because we give people the best preparation for busy general practice outside of academics. The big name academic places don't train the residents clinically as well as we do. Those big name academic places should contract.



The reality is that if all of a sudden we require more brachy or SBRT or whatever, the programs will just find ways to do more of it and get the resident numbers up to at least not contract or continue expanding. As Zeitman has said repeatedly, our specialty won't respond to a declining job market. Only when the job market totally collapses then medical students will stop going into the specialty and the situation will correct itself (maybe).

Can somebody who was around in the 90s, when there was closure of programs (at least in part due to job market and insufficient training concerns), give details to how it happened? Who was the instigator of programs contracting/closing? Who had that responsibility? Who could have that same responsibility now?

 

[OTN]

I can say that in community hospitals, a lot of people I know are thinking twice about hiring after this statement.

Our large private practice is being very, very cautious with expansion and hiring as well after that statement.

 

[RickyScott]

Our large private practice is being very, very cautious with expansion and hiring as well after that statement.

I am not sure the overall effect right now. A lot of the more exploitative practices, will hire if they need to, and just start firing once bundling starts.

 

[Gfunk6]

I can say that in community hospitals, a lot of people I know are thinking twice about hiring after this statement.

Our large, multi-specialty, physician-owned, independent private practice has stayed on the bleeding edge of payment reform through CMS and private payers. We have been on the Oncology Care Model for years, adhered to every CMS mandate for quality, and have embraced MIPS. We have our own Department of Quality which includes a physician thought leader and an MBA level dyad.

Azar wants to go into capitation? Bring it on - I would love to have the opportunity to compete with hospital-based and academic facilities on cost and quality measures.

 

[nkmiami]

Our large, multi-specialty, physician-owned, independent private practice has stayed on the bleeding edge of payment reform through CMS and private payers. We have been on the Oncology Care Model for years, adhered to every CMS mandate for quality, and have embraced MIPS. We have our own Department of Quality which includes a physician thought leader and an MBA level dyad.

Azar wants to go into capitation? Bring it on - I would love to have the opportunity to compete with hospital-based and academic facilities on cost and quality measures.

Well, would we all be capitated/bundling charges equally?

 

[Fpg1245]

Our large, multi-specialty, physician-owned, independent private practice has stayed on the bleeding edge of payment reform through CMS and private payers. We have been on the Oncology Care Model for years, adhered to every CMS mandate for quality, and have embraced MIPS. We have our own Department of Quality which includes a physician thought leader and an MBA level dyad.

Azar wants to go into capitation? Bring it on - I would love to have the opportunity to compete with hospital-based and academic facilities on cost and quality measures.

So will you be hiring more RO attendings as a result? It just sounds like you’ll be running a lean ship.

 

[Gfunk6]

Well, would we all be capitated/bundling charges equally?

I would think so, but we have to see the proposal first.

 

[Gfunk6]

So will you be hiring more RO attendings as a result? It just sounds like you’ll be running a lean ship.

Yes, we run very lean. We have been hypofractionating everything for years before ASTRO guidelines came out. There is less pressure to churn when you own the machines and can access technical fees. We will hire more RO MDs in future but this is due to geographic expansion.