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RadOnc Is Still The Best Field in Medicine

Discussion in 'Radiation Oncology' started by RO2019, Oct 3, 2018.

  1. Cyberrad

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    There seems to be some disconnect in your logic. For private practices, how does an increase in candidates drive salaries down. A private practice hires what it needs. They don't overstaff. Just because there might be a market oversupply, doesn't mean I have to hire. And it's unlikely someone will come in a plop down a center in 2018 next to an existing one if you don't have the referral base which we have built through hands on personal relationships and high quality care.
    Our reimbursement and hence salary are controlled by two things - Medicare and commercial payors. Medicare we have no control over, but there is no clear indication of a fiscal cliff, though it will tend down based on how the medicare pot works. Commercial payors we negotiate with and have dialogues.

    As for satellites, you should be aware, that ever since the ACA passed, many are going into hospital employed models. Pretty analogous to satellites (which actually do pay more than their academic counterparts in many scenarios, or have 3-4 day work weeks). This is a trend in all of medicine currently, and most prevalent in desirable regions of the country - ie california, Northeast, major cities.
     
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  3. Neuronix

    Neuronix Total nerd
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    You're assuming that practices treat their new hires equitably and fairly. Sure, some do. But there are plenty that are happy to take advantage of desperate new grads, paying them less than they could and pocketing the difference.

    I have heard exactly these words used to justify why they pay someone so much less than what they make with no opportunity to ever grow into it.

    Satellites are where the vast majority of the jobs are. Personally, I haven't seen them pay better or have 3-4 day work weeks.
     
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  4. medgator

    medgator Senior Member
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    When you do finally need to though, what do you think excess supply will do to your employment offer? Or locums rates?

    Think logically here. And if that logic is too complicated for you, pose your question in the pathology subforum which has been dealing with excess residency supply and decreased demand for years now.
     
    #253 medgator, Nov 7, 2018
    Last edited: Nov 7, 2018
  5. RickyScott

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    Dont want to be insulting, but this is like asking why the world is round. It is easily the silliest statement I have read on these boards. This is really, really basic and taught to my six grader. Supply and Demand/scarcity. Because when you have a lot of candidates for the job, you can chose who will take it for the least amount of pay/accept the worst conditions to the point where fellowships fill in desirable locations even though they offer very little "training:" palliative care in Boston or NY, lung stereo- Stanford.

    Why do you think rural jobs in our field pay many times more than jobs in Manhattan? Why is a diamond expensive and water cheap. Like gravity, these concepts were formalized hundreds of years ago.

    I am going to doxx you as academic chair you probably are.
     
    #254 RickyScott, Nov 7, 2018
    Last edited: Nov 7, 2018
  6. Cyberrad

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    Well, I am not assuming. I hire for my practice. Most practices are pretty fair....yes there are bad apples.....most do not take advantage of new grads. I have many friends in some of the major private groups across the country, and none of us try to take advantage of anyone. Why would they do that when they expect them to become full partners and colleagues. Why would you treat someone poorly just to score a few bucks when the bigger picture is the lifetime relationship as a colleague.

    I was initially offered a position by one of the top 3 academic centers satellites years ago. The job was a 4 day week, with 1 day of 'academics' that most in the office took as a day off. Salary was 20% higher than the main in town site.
     
  7. Cyberrad

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    ummm....nothing. oversupply doesn't affect us. we hire for what we need. oversupply just means we have better choice of candidates. smart businesses don't overhire.
    it is not my practices responsibility to increase hiring just because there are more candidates. we hire for our clinical needs.

    our hiring package does not change based on more or less people. we pay commensurate with market rate for our geography, on a track towards partnership.

    Not sure what pathology did.

    Locums rates are too high anyway......but that's because the companies take half the dollars.
     
  8. Cyberrad

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    well....radiation oncology is not necessarily a free market. I don't pay less just because I have more candidates. We are fair. We ultimately want to hire someone to be a long term colleague and partner. We don't have an auction and see who will come to us for the least amount of money. That would only give us poor quality on our investment in the person we are hiring. We have a package we use and we fill the spot with the best candidate.
     
  9. Cyberrad

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    As for Manhattan, remember most jobs there are hospital based. There are very few private practices in Manhattan - for my friends who used to be in the city, their practices were bought out by Mt. Sinai and MSKCC.

    In rural locations, there are less hospital based practices. Many of the rural facilities are freestanding, where physicians collect the technical revenue. The professional fees are also often higher due to Medicare geographic modifiers that pay more in rural communities. That's the real reason those jobs pay far more. Supply and demand are only a very small piece of it. The larger piece is freestanding vs. hospital based practices.
     
  10. RickyScott

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    I just dont have the time, but pretty much everything you said is flat out wrong.
     
  11. Cyberrad

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    lol....pretty funny that you think I'm an academic chair. I'm about as far from that as you can imagine.
    But just proves you have no idea who you are talking to......
     
  12. Cyberrad

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    Really....I've been in this business for 15 plus years. I know reimbursement and markets....you just don't realize. just remember hospital based employed physicians are based on professional services. freestanding are based on collecting prof and tech. remember the tech fees outweigh the prof 7:1.
    Why don't you name all the private practices in manhattan for me. 10 million people. let's hear them.
    then compare to the rural communities of <500K people and name all the large hospital based practices in those communities.

    If you're right, let's see what you come up with. Why don't you pick Iowa for the rural communities. Fair challenge.
     
  13. medgator

    medgator Senior Member
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    Ding, ding, ding. So what do you logically expect to happen to "market" rates with a long term supply/demand imbalance at the residency level?

    Again, we have the luxury of seeing what can happen in that scenario by looking at our pathology colleagues
     
  14. Cyberrad

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    maybe people who need to retrain if they can't find jobs. legal market is well over-saturated. and still many high paying good jobs. salaries haven't declined at major firms.

    just many grads do other things other than law. there are many rad oncs who work outside of clinical medicine.

    pathology had some substantial reimbursement cuts, similar to what anesthesia had in the early 2000s
     
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  15. OTN

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    Whoops:
    Lawyers' salaries slipping compared to other professions, data indicates
     
  16. Neuronix

    Neuronix Total nerd
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    I'm more junior in this game, but I can tell you that some of the others posting in this thread are quite senior.

    I will simply post that Cyberrad I don't think you realize how bad the job market has become. This is common among many rad oncs in secure positions. Things have really nose dived over the past few years.

    The idea that we're going to train rad oncs who then need to retrain again to find jobs is misguided given the waste of resources that would entail.
     
  17. Mandelin Rain

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  18. medgator

    medgator Senior Member
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    I never interviewed for academic jobs out of training and went straight into pp...kinda glad in retrospect considering what the leadership has done to the job market in just the last few years, making it much more difficult to switch jobs now.

    I don't think I've heard of anyone I know taking an academic job like that in awhile though and I'm sure many would jump at the chance.

    It just shows you how things have changed since you finished training
     
  19. Mandelin Rain

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    I got a similar offer 7-8 years ago. But the 4 days were split between 2 satellites and the 5th day you were expected to teach rad bio (>6 resident program, btw).
     
  20. Mandelin Rain

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    I'm thinking by "retrain" he may have meant fellowship(s). As if 4 years wasn't long enough to figure how to draw serial circles, add another year or two. Eclipse is as difficult to master as cutting into someone's brain, removing something, and then sealing them back up, IMO.
     
  21. thecarbonionangle

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    The idea of “retraining” if you mean do another residency is ridiculous and impractical. I would love it if our field allowed more opportunities to grow spectrum with legit fellowships like learning how to give some systemic therapy. There is no such effort. If one if us wanted to “retrain” this would be a collosal waste of resources.
     
  22. evilbooyaa

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    Cyberrad, I think you are somebody who is likely a good person who is holding onto their experience from actively pursuing a job from years (if not decades) ago. The concept of 'years ago, I was offered a satellite job that paid well and was a 3-4 day work week' is mostly antithetical to most current satellite jobs offered.

    While YOU may be the bastion of good conscience and ensure that all people you hire get the same terms, buy-in, etc. that previous partners got in regards to initial contract, there are likely many employers (across PP, academics, and hospital based) that see an oversupply of rad oncs and can justify paying them less or decreasing RVU bonuses. It is impossible to 'prove' this in a scientific manner because it would require cooperation of every place that hires rad oncs in the entire country. However, the basic market forces of supply and demand do not magically not apply to rad onc as a field.

    I always remember that most people are greedy, and doctors are people. Senior partners in PP, chairs in academics, all have motivation (more money for them) and ability (more applicants per job) to pay their junior faculty less or make partner requirements more stringent (longer years, sweat equity, larger buy-in, etc.)
     
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  23. scarbrtj

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    On a scale of one to ten it's about a turd.
     
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  24. Cyberrad

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    Not really rural. But that is the starting community size where freestanding centers are more dominant. Probably more suburban.
     
  25. medgator

    medgator Senior Member
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    Wrong. I know of dominant freestanding centers in several large metros throughout Florida and California
     
  26. Old rad onc

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    I passed my boards in 1995. The first year a time limited certificate was issued. I have taken the recertification exam 2 times, the last in 2015. Now I am told that no credit is given for taking the exam and I must do all MOC requirements every year. I find this to be utter BS as I’m pretty sure very few have taken the exam twice!

    To make this even more enjoyable, my competitor never passed his written exams and no one in my community even knows he has not been board certified for over 20 years. It is not posted anywhere and his insurance is not restricted in any way.

    The fact that Rad Oncs boarded in 1994 do not have to do MOC is even more ridiculous. No wonder why docs in other fields and ours have attacked the MOC as the Sham that it is!
     
  27. radiaterMike

    radiaterMike Junior Member
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    Having been issued a lifetime certification is not unique to radiation oncology and not something the ABR or any other board could change.
     
    #276 radiaterMike, Nov 8, 2018 at 4:39 AM
    Last edited: Nov 8, 2018 at 6:49 AM
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  28. KHE88

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    This nonsense from the ABR about unprofessional personal attacks on Kachnic and Wallner is absurd. It's yet another classic bully tactic they are employing. First of all, what's a personal attack? A personal attack is when you make an incendiary remark about someone's person without providing evidence to back up a claim. An ad hominem. When you suggest that someone may be corrupt or dishonest and then you provide evidence to support such claims, that is not a personal attack. If you call someone It is honest and genuine inquiry. Corrupt and dishonest people tend not to like such things and use terms like "unprofessional" to try and shut down dialogue and demands for transparency that threaten their power. This is what dictators do.

    I do not know Kachnic or Wallner. I had never really heard Kachnic's name before this mess. However, I think the way that this has been handled is disgraceful, dishonest, and cruel. That's not a personal attack. That's not unprofessional. The fact is that the current PGY-5s in small programs were attacked with an unfair exam and treatment from our certifying body who has conspired to stack the cards against us evidenced by multiple incendiary publications and statements. We are, and should be, defending ourselves.

    It is not news to anyone that these forums are widely read, and no doubt closely followed by the ABR. A number of recent posters that have popped up appear to be posting party line ABR dogma using suspicious oft-repeated phrases like "criterion referenced," and it makes me wonder who is driving these avatars.
     
  29. Old rad onc

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    While that is true, how the MOC is run is up to the ABR.I took a day off to take the test again in 2015, plus some prep time. Taking a recert test that we are told will take care of the cognitive portion of MOC for 10 years, passing it and then being told it does not matter anymore. No more tests and no credit for the test you took. ACR could give the 10 year credit they promised for the test. Then I would do the rest of the MOC stuff happily.
     
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  30. radiaterMike

    radiaterMike Junior Member
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    The MOC exam was actually to apply to the 10 year window in which you took the exam. For the next 10 year window, instead of needing to take an exam at some point in that time frame, we will have to answer questions on a regular basis. If we get them wrong, we will get feedback, and be asked the same or similar questions again. I like this system better as it not only tests concepts, but aims to provide useful feedback. As someone in a similar situation (took the exam shortly before it was eliminated) I am happy with the change.
     
  31. Old rad onc

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    When I took my boards in 1995, I got a 10 year certificate until 2005. The next test in 2005 was to cover the next 10 years. So you are saying the test I took in 2005, covered the years in which my Boards had covered which was a 10 year certificate.

    Does not make sense. By your logic a test taken in 2018 was to cover the window from 2008-18. So if you did not take the test, you would have to do 9 more years of modules.

    I want to know why the acr did not give people that took the test and passed credit going forward for it. I payed extra for the test and most in MOC did not have to do it a second time. Seems unfair.....I will happily go through the extra hoops but if they knew they wanted to do this, why make some of us take and pay for a second test, basically for those of us that tested in 1995-1997. 1994 and before never test, and 1998-2007 take the test once. If I have to study for a test, take a day off to take it, pay $1500 for it, then please give me some credit for it! Only fair considering most of those in charge of this whole process are Radiation Oncologists who never had to deal with MOC except making it up.


    n I
     
  32. evilbooyaa

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    While I don't have a suitable answer for you, this is something that changed like 3 years ago, right? Seems unfair to have the test go from 10 years of "you're good" to then falling into the same role as everybody else and I sympathize, but I don't think anything is going to happen about it going forward. I agree that, in general, MOC, across specialties, is mostly to make the ABMS money. I do wish even those that are grandfathered into MOC still have to do yearly CME to maintain certification - I don't know whether they have to or not.
     
  33. medgator

    medgator Senior Member
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    Most have to do yearly cme to keep up their medical licensure I would imagine, independent of the abr/moc requirements
     
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  34. Chartreuse Wombat

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    Diplomates with time unlimited certificates do not pay the ABR anything unless they voluntarily enroll in MOC. Paying for CME is separate.
     
  35. Phantom1

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    RickyScott, I think this is a great example of difference between a junior person and a senior community/private practice person. Cyberrad clearly has much more experience and is likely actually hiring people into his practice. Everything he said makes alot of sense, if you are hiring someone for a long term partner track in a good firm do you not think you will want to take the best person and compensate them accordingly? Sure there are bad firms, and people get taken advantage of all the time, but that happens in any field. I dont know why people think that a new grad should walk in making just as much as a senior partner who likely helped build the practice. Should an assistant professor make as much as a full professor with tenure?

    Yes, supply and demand are critical, its rediculus to think that Cyberrad doesn’t know that or its some new concept you are introducing to us. Evilbooya, you have some pretty strong/inflammatory opinions for a moderator. The job market this year is not as bad as you all are saying. Yes I am in complete agreement that more spots than applicants is bad, and residency expansions should be stopped, but again this constant end of the Rad Onc world talk is too much and counterproductive. If I were a med student I would apply to Rad onc today. Work hard, distinguish youself and you can have a great life.

    Rickyscott, also the question of why the world is round is actually fairly complex. If I recall it has to do with swirling gasses and interaction between gravity and conservation of angular momentum. I think gravity was “formalized” a little longer than “hundrends of years ago”. Also water is not cheap, bottles of water sell for $3-4 now. More than a gallon of gas.. I would suggest you comment on things you have more personal experience with.
     
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  36. RickyScott

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    Believe whatever you want. Since supply and demand apparently dont affect the job market, you must be relieved that bundled payments are coming ...
     
  37. smq123

    smq123 John William Waterhouse
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    As a somewhat neutral person in this debate, it's ok for a moderator to have strong opinions. Being a moderator on SDN does not necessarily mean that you need to shut down all of your own private opinions; it just means that you need to help present ideas and topics in a fair manner that does not devolve into personal insults. So far @evilbooyaa has done so, and the SDN moderator staff is just asking that you all do that as well.

    I will admit that I am puzzled by the disconnect. On one hand, people who are going through the job search, or have recently gone through it, have said that there are not very many jobs left; the ones that are being advertised aren't real, and the ones that ARE real aren't very good - too many hours, less pay, no partnership track, etc. On the other hand, people who haven't gone through the job search, but have close experience with those who have, are saying that the job market is fine. Why the wide disconnect? Is it geographic dependent? Is there any objective way to look at this that will convince both sides?
     
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  38. evilbooyaa

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    Since you're going after me directly, I'm curious as to what you feel is an inflammatory opinion. Strong opinions, sure, I'm an opinionated person. What is your data that the job market this year is not as bad as we're saying? People have posted the resident reported outcomes on the job hunt in recent history. I don't feel that I'm even the strongest opinion on my side of the 'status of the job market' debate - I see places like UCSF, Yale, etc. that at least have jobs posted to the ASTRO website. Not going to comment on whether those are really available, or if they already have a candidate in mind, etc. There are academic jobs out there, but it's in low numbers. The number of PGY-5s is at an all time high. There's not going to magically be more jobs than there were 5 years ago. Supply and Demand kinetics.

    I'm less interested in year to year variation (so fine, I'll agree with you, that maybe this year is better than last year), than general trends. Current MS-4s have to think about what the reality of the situation is FIVE years from now. I know when I was a MS4, ~4-5 years ago, the job market was not as bad as it is now. Hopefully that isn't a discussion point either. With no programs planning on decreasing their number of residency positions, do I think that the job market is going to bounce back to be any better 4-5 years from now?

    As to the bolded - ah yes, work hard(er than all the other residents), distinguish yourself (from all of the rest of the residents in the rat race trying to do the same thing through retrospective chart reviews and database analyses) and have a great life.

    To clarify my position - I still think this is the best field in all of medicine. I know others may not agree with me, but that's my opinion. If I was a MS4 I would go into this again as well because this field made me more interested in going to work than literally any other field in medicine. Not to say I would rather not be a doctor than a radiation oncologist, but the love I have for this field was not similar to anything else when I was a medical student, and despite all of these non-clinical issues as a resident, the clinical work still gets me up in the morning without dread. It's not a chore for me to read the (newly published) important articles in this field.

    That's not to say that all medical students considering applying for Rad Onc have that mentality. There are some that have a 250-260+ Step 1, like a couple of fields relatively equally, and are weighing lifestyle, job market, location, etc. If I was a medical student who was genuinely 50-50 between say Urology (just an example) and Rad Onc (and despite the lifestyle differences, I'm sure there are a decent number of "Surgery vs RadOnc/Radiology" medical students out there), I would go into Urology in a heart-beat given that I would likely have a better pick of where I wanted to work, with greater ease, when I got out of residency.

    I think the concept of anybody making a blanket statement like "DO NOT BECOME A RADIATION ONCOLOGIST" is hyperbole, because it ignores people's preferences, their wants, their desires. But not everything about this field is roses and doves, and I honestly think that despite all of the things going for most rad oncs (lifestyle, no call, salary, etc.) there are negatives that medical students have a right to know about.
     
    #287 evilbooyaa, Nov 8, 2018 at 4:25 PM
    Last edited: Nov 8, 2018 at 4:43 PM
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  39. Phantom1

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    Hey, I agree with you. Strong opinions are good, didn’t mean to say you were inflammatory. Sorry ☺️. Thanks for all your help and time moderating this forum.
     
  40. radiaterMike

    radiaterMike Junior Member
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    My 'logic' is not logic, but simply how the ABR set up MOC. After your initial certification, you entered a 10 year window in which you needed to take the MOC exam. It would have been OK to have taken it in 1996 or 2004 or 2005 or any time in between (though taking it in 1996 would have necessitated that you take it again in 2006 since there was a 10 year look back as well - with a little wiggle room)

     
  41. Mandelin Rain

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    Partnership track positions in PP are likely to be fair and equitable deals, less subject to market forces than group precedence. The issue is, how many of these jobs are going to be available: PP is no longer a majority of this field. Hospital employed positions (and that really does include include many/most academic positions) are different. They are much more likely to see you as a commodity and therefore supply and demand are of utmost importance.

    Again, even if 2018 is a good year to find a job (and it may be), this is about projecting a trend. Is 2018 an exception? Did the guys who deferred retirement after losing 50% in 2008 now feel comfortable to retire after a decade long bull run? Did others retire earlier than expected after a 25% portfolio swell last year? These are one off events. The trend is shorter courses of XRT and greater consolidation of practices, i.e. less demand for rad oncs and greater number of residency positions, i.e. more supply of rad oncs. This equation is easy to predict the outcome.
     
    #290 Mandelin Rain, Nov 9, 2018 at 8:29 AM
    Last edited: Nov 9, 2018 at 8:37 AM
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  42. scarbrtj

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    Radiation oncologists rarely agree on anything. Like for example there's been a historically fraught argument in the field as to whether or not radiation-induced carcinogenesis is deterministic (there's a threshold dose) or stochastic (linear/no threshold). The "winners" in this argument have been on the side of stochastic in the past, but times are changing and maybe determinism will win the day eventually. Yet it's kind of like this re: the job market and supply/demand in rad onc. Clearly everyone can agree that a million radiation oncologists would be too many. Is there a threshold? Have we passed it? Or are we just traveling a stochastic highway to hell? Time will tell! There's evidence on both sides. There's been a very large drop in private rad onc practices in the US over last 5 years: one-half of all rad oncs were in private practice 5 years ago and now only 1/3 are... over half in private practice saw a decrease in pay over that time period, but hospital and academic practitioners have held steady. To me these metrics do not bode well for us. But I'm a stochastic kind of guy.
     
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  43. Cyberrad

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    Florida is itself an unusual market.
     
  44. Cyberrad

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    No one has conspired to stack the deck against you. The scoring system has not changed in decades. It is certainly possible that the program directors who developed the criterion reference this year overestimated how their residents would do. Unfortunately this can’t just be undone. Kachnic and Wallner has no part of this process. The exam is not made by them.

    Take some time to understand how it is composed. I, like many other write items for a specific test section. We write fair questions - some are hard - to assess your knowledge. Each site has a committee and the group reviews all questions and identifies the best of the questions written. We write new questions every year. The chair then takes the questions to the exam committee and they identify how many questions each site has to contribute. These are decided by the disease chairs. Then a separate group evaluates each question using Angoff methokodoly. I criterion reference (pass rate) is determined by a group of experts - usually PDs.

    As you can see Kachnic and Wallner are not as involved as you think on conspiring to harm you. They are honest decent people whom YOU don’t know and are very dedicated to residents. Lisa has done more to help ease MOC. To say you have evidence that she is dishonest or corrupt is opinion, not backed by evidence. Professionalism has nothing to do with stifling dissent. It has to do with acting ina reasonable behavior and having dialogue but it accusing people of being out to get you.

    I certified almost 15 years ago taking physics biology, and clinical at one time, the orals and decertified. I very much support residents and help to write completely fair questions....as do most exam writers.

    It’s unfortunate you clearly didn’t pass. The world doesn’t end. You retry and likely you’ll pass the next time. It won’t stop you from getting a job. Life will move on. But there is no need to say the ABR consoired against small programs. I know of many residents in large program who also failed. And indint see all of them throwing tantrums and rants against specific individuals.
     
  45. Cyberrad

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    It’s not starting for a few years. Rad Onc will be kasybto launch. I am in same situation. But it will take years of participation before they can come up some standards.
     
  46. Cyberrad

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    Two more things. ACR has no role here....assume you meant ABR.
    Not sure where you came up with $1500. I took my recert at no cost. It's included in the MOC fees, and took my exam literally next to my office at Pearson Vue.
     
  47. Cyberrad

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    Well....you should be aware that bundled payments have been here for years. IGRT is a bundled payment to IMRT. SImulation is a bundled payment to IMRT. Nothing new. This is how CMS has cut back. And moving forward, the proposed APM which will likely pay case rates will impact us too.
    In our field, supply and demand wont impact business minded practice who will hire what we need. No one is going to come into a territory and compete when they don't have the referral base. Yes it might mean some people have to go to less desirable areas. But it really doesn't impact us as much as you think, as we're not a true market in the economical sense.
    You may disagree, but as phantom1 said, I'm sure I have more experience here than you. Clearly, you have little experience suggesting bundled payments are coming, when they have been here for years.
     
  48. Cyberrad

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    Fair post. I too could not see myself doing anything else in medicine. Comparing a surgical subspecialy to us is not a comparison. We have much better control of lifestyle and call. My urology friend in private practice work long days, with unpredictable delays in cases, and very busy calls. My lifestyle is far better. Sure I make less, but my income is not something I complain about.
     
  49. Cyberrad

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    Majority of hospital based practice hire for needs. They don't overhire. If they don't have a need, they just don't hire. As for salaries, most hosptial based employeed positions are paid using MGMA data - and these numbers are fairly high and consistent....not as good as private practice, but better than academics. In fact new grads get paid far more than private practice....but you are not buying into something with sweat equity. In the end you don't own the business. But at the same time you have little upward mobility that you may get in private practice.
     
  50. Cyberrad

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    Based on COMET trial, I expect a significant increase in patients getting SBRT. This will drive growth into our specialty.
     
  51. medgator

    medgator Senior Member
    Physician 10+ Year Member

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    Not in the freestanding setting, but you are correct in the move of CMS moving towards bundling more and more codes together
     

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