RadOnc Is Still The Best Field in Medicine

[Cyberrad]

I am an ABR item writer, test aggregator (meaning I have participated in the Angoff process) and oral examiner on multiple occasions over the past 2 decades. I will not comment on the larger question but wanted to correct the assumption that item writer's go to tropical islands. Not true.
Most item writers never leave home to volunteer. A subset of these people travel to Tempe (yippee!) to assemble the questions; sometimes other join by conference call. This is a 2-3 day process with about 8 hours a day inside ABR HQ. This is time away from family and work that is not paid for. Travel and accommodations are paid for by the ABR. At oral examinations travel and accomodations are paid for and there is a daily food stipend which is roughly 50$ day. The Board members and trustees do travel to an annual retreat (I know that this is in a nice location) but frequently meet in Tempe as well.

and i agree the tropical retreats should end if they still go on.

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[OTN]

Realities are the APM (which may become mandatory as proposed by Azar - and you probably have no clue what an APM is) will have a bigger impact. However, we're always expanding our armentarium. Hypofractionation has been going on for years - APBI is a prime example - we've been doing that for 15 years. Yet breast cancer volumes actually have expanded....many who refused a 6 week course, especially older patients where benefits are less, have actually pursued this strategy to reduce risk in a short time course. COMET trial will explode SBRT use - proven PFS and OS benefit with IOs....which we have already begun to see materialize. My practice has changed a lot in 15 years, and we are constantly evolving. I expect we'll be part of the core group using SBRT for VTach.....according to my EP folks there is a huge market there, that are poor candidates for ablative procedures.

1. Is this (bolded above) really necessary?
2. Good data from other specialties (ABIM) directly refute your "oral examinations are a much better assessment of skills as its more objective" statement - the data supports the exact opposite conclusion.
3. Old radiobiologic models fall apart with stereotactic dosing, so the calculations you're doing for SBRT are not accurate.
4. You really didn't know we're now graduating 200 residents a year instead of 120? Did you bother reading any other posts on this board before wading in?

 

[medgator]

and you probably have no clue what an APM is)

Stay classy, cyberrad

 

[Mandelin Rain]

I fear that you actually believe the misinformation you throw out into the interweb.

EDIT: OTN had a good list of the glaring alternative facts, but it is hardly comprehensive.

 

[medgator]

We are indeed a small specialty - like 120 grads a year.

you are citing residency graduation numbers from a decade ago, predating the shameless and unnecessary expansion of residency slots in this specialty.

Are you purposely providing misinformation on this forum or are you really that ignorant of the subject matter you are discussing?

 

[thecarbonionangle]

poster is either trolling or is actually a “pd” higher up in ABR who happens to be out of loop about the realities of the field. Scary if you think about it. There are people in academics who are in leadership positions who are behind in literature, techniques etc and get by due to residents younger faculty coverage etc so both scenarios plausible.

Either way, the idea that the ABR had any sort of “dialogue” is laughable. They lectured those in attendance about the supposed low quality of small programs and shut down any reasonable proposals to help those harmed. This is not dialogue. I really would like to know what are the plans moving forward. Rumours that a PD (just one?) stormed out in frustration and that was it? Its over? Will there even be a true study guide released for retakers and 2019 takers? Rumours are highly unlikely... so how is this any dialogue?

The editorial by esteemed “leaders” just simply suggests to take us closer and deeper ties to the ABR and with DR/IR. Will there be any sort of dialogue about this? They are already proceeding with incoorporating more imaging into writtens. Just like they had an article warning of the change to the “biology” exam.

I find it frustrating that we are that powerless as a field at the total mercy of “leaders” who dont have our interests in my opinion despite grandious “decency” and “well meaning” on their part.

With all due repect, does Zietman, Hahn, Wallner actually have the interests in mind of “small programs” or simply just “top places” which are insulated from lots of current significant presient issues in our field?

 

[smith2009]

I lol'ed at this. One of the guys responsible for making questions doesn't even understand the basic concepts.

1. Is this (bolded above) really necessary?
2. Good data from other specialties (ABIM) directly refute your "oral examinations are a much better assessment of skills as its more objective" statement - the data supports the exact opposite conclusion.
3. Old radiobiologic models fall apart with stereotactic dosing, so the calculations you're doing for SBRT are not accurate.
4. You really didn't know we're now graduating 200 residents a year instead of 120? Did you bother reading any other posts on this board before wading in?

 

[radiaterMike]

perhaps he or she meant to say "like 120 grads a year that can take their oral boards after the written qualifying exam."

4. You really didn't know we're now graduating 200 residents a year instead of 120? Did you bother reading any other posts on this board before wading in?

 

[smith2009]

30% of this year's prisoners.

An adult and physician talking about professionalism.

Smh

But please, continue writing radbio questions for that well oiled, cost-effective, juggernaut of an organization. It's clear that your grasp of the material is far superior to 30% of this year's class.

 

[rymd]

'd encourage you to volunteer as well - you will see you have more power to influence from within, that from out here on this message board. You will also see there are many dedicated people at the ABR and in the volunteers who want to make this process better and practical. You can NOT fix the problem if you are not engaged.

I would echo this sentiment too: Please get involved! The AMA just put out a request for an ABR representative for radiation oncology. The folks posting here are certainly passionate enough to make a difference, and volunteering for ABR, ASTRO etc is probably the best way to do that.

 

[medgator]

This is the first I'm hearing of a job in Irvine, CA. Salina KS and Rhinelander WI are the mainstays. What's the Irvine job that's so not wanted it is falling into RadOnc lore?

It's baaaaack

'radiation OR oncologistfreesting OR clinic OR STATECODE:"CA"' Jobs | ASTRO Radiation Oncology Career Center

2,598 'radiation OR oncologistfreesting OR clinic OR STATECODE:

careers.astro.org

 

[Haybrant]

It's baaaaack

'radiation OR oncologistfreesting OR clinic OR STATECODE:"CA"' Jobs | ASTRO Radiation Oncology Career Center

2,598 'radiation OR oncologistfreesting OR clinic OR STATECODE:

careers.astro.org

Gosh i spoke w that guy a few years ago place seems like a total disaster run by a clueless dude who gets off on recruiting every year pretending he is going to hire someone. He literally does this to talk to people

 

[Reaganite]

Gosh i spoke w that guy a few years ago place seems like a total disaster run by a clueless dude who gets off on recruiting every year pretending he is going to hire someone. He literally does this to talk to people

Run. Do not look back. I know people who know people...

 

[thecarbonionangle]

Another really great thing i found out at ASTRO, is that there are 3+ more brand new residency programmes in the works. Really great stuff coming. You go rad onc!!

 

[Sheldor]

Guys, I had an amazing day at work the other day: I got to see multiple patients in follow up who were brain met free because of what we do. I got to see new patients and tell them confidently that I was going to make their single site of metastatic disease go away. I got to see a Stage I lung patient and tell them they'd most likely be cured with little to no side effects. All the while I contoured/planned multiple patients. It was a busy, amazing day. Reminder: We do AMAZING things. We literally harness the power of radiation, and in <5 treatments make cancer go away with out cutting into a patient. It's easy to lose sight of how incredible that is. Remember, just like how other fields don't hesitate to tell us how great their __Insert new minorly improved drug/surgery__ is, we get to do the same.

 

[Krukenberg]

Guys, I had an amazing day at work the other day: I got to see multiple patients in follow up who were brain met free because of what we do. I got to see new patients and tell them confidently that I was going to make their single site of metastatic disease go away. I got to see a Stage I lung patient and tell them they'd most likely be cured with little to no side effects. All the while I contoured/planned multiple patients. It was a busy, amazing day. Reminder: We do AMAZING things. We literally harness the power of radiation, and in <5 treatments make cancer go away with out cutting into a patient. It's easy to lose sight of how incredible that is. Remember, just like how other fields don't hesitate to tell us how great their __Insert new minorly improved drug/surgery__ is, we get to do the same.

This. When I watched Chernobyl one of my first thoughts was how cool it was that I could harness this pure energy to cure cancer and palliative symptoms.

 

[medgator]

Guys, I had an amazing day at work the other day: I got to see multiple patients in follow up who were brain met free because of what we do. I got to see new patients and tell them confidently that I was going to make their single site of metastatic disease go away. I got to see a Stage I lung patient and tell them they'd most likely be cured with little to no side effects. All the while I contoured/planned multiple patients. It was a busy, amazing day. Reminder: We do AMAZING things. We literally harness the power of radiation, and in <5 treatments make cancer go away with out cutting into a patient. It's easy to lose sight of how incredible that is. Remember, just like how other fields don't hesitate to tell us how great their __Insert new minorly improved drug/surgery__ is, we get to do the same.

Completely agree. I feel like I hit the life lottery with what I do. I'm very happy with my job compromise regarding the big "3". Most of us hope that can continue, but trends are unfavorable and have been for years.

Thanks to issues raised, in part, at SDN, leadership is finally looking at this issue to bring the specialty back to near perfection again (hopefully)

 

[RickyScott]

Another really great thing i found out at ASTRO, is that there are 3+ more brand new residency programmes in the works. Really great stuff coming. You go rad onc!!

going to get flamed for this but, consider boycott hiring anyone from those programs. As there are so many open spots, us medstudents can match into an existing program if they wish. Why choose a new program that was so irresponsible as to open at this time? It would be hard for me to believe that any of these programs care about residents and their education and future if they are willing to open in this market.

 

[OTN]

going to get flamed for this but, consider boycott hiring anyone from those programs. As there are so many open spots, us medstudents can match into an existing program if they wish. Why choose a new program that was so irresponsible as to open at this time? It would be hard for me to believe that any of these programs care about residents and their education and future if they are willing to open in this market.

Our practice wouldn't hire from a new residency anyway, given the unknowns about their quality of training. Just reprehensible that these programs continue to grow, and instead of addressing it directly, radonc twitter (the cringiest place in the universe) just tells prospective medical students to not engage with us "doctors" (their quotes not mine) on here. For shame.

 

[deleted774703]

Another really great thing i found out at ASTRO, is that there are 3+ more brand new residency programmes in the works. Really great stuff coming. You go rad onc!!

I'm surprised b/c we heard at ARRO that RRC is being extremely strict towards allowing new programs to start.

Do you know the names of the programs in the works?

 

[Mandelin Rain]

There are truly predatory programs out there. Anyone who was at the ARRO session could see this acknowledged openly - not by “internet malcontents” but leaders in the field.

Denying it in public at this point is to be an accessory to the crime. All these sycophant twitter folks are culpable IMO

What was said at the ARRO session?

 

[medgator]

I heard it second hand from one of my residents but was told Vapiwala and Lee were very clear that standards had been far too lax and many subpar programs had been allowed to open.

Vapiwala intends to raise RRC standards and Lee made a point to encourage her to stick to her guns despite the inevitable blowback she’ll receive.

The only way one can offer bogus non accredited fellowships is by residents graduate from all these subpar programs. Win, win for them at both levels

 

[scarbrtj]

The only way one can offer bogus non accredited fellowships is by residents graduate from all these subpar programs. Win, win for them at both levels

Yes but cantfindajobitis is a real and growing condition; can cause a horrible rash, force one to take what one can get, etc.

 

[medgator]

Yes but cantfindajobitis is a real and growing condition; can cause a horrible rash, force one to take what one can get, etc.

Yup, definitely knew a couple of AMGs who matched into decent programs who did a fellowship year to wait out the job market a few years ago, hoping something would open up

 

[Krukenberg]

I'm surprised b/c we heard at ARRO that RRC is being extremely strict towards allowing new programs to start.

Do you know the names of the programs in the works?

Vapiwala only just became chair and these new programs were probably approved a while ago. Takes time to boot up.

 

[deleted774703]

Vapiwala only just became chair and these new programs were probably approved a while ago. Takes time to boot up.

No new or pending programs listed on ACGME websites

Dartmouth, UTenn opened within last 2 yrs and shouldn’t have been allowed

 

[DukeNukem]

The cycle of radonc:
1. Acquire satellite clinic from pp docs
2. Hire new academic docs to staff clinic. Pay them 1/2 of what the pp docs made, but that’s okay because you’ll be provided resident coverage!
3. Expand residency program, acquire free labor to provide coverage to new satellite attendings.
4. Job market tanks and wages fall.
5. Pay your satellite docs less.
6. $$$$

My experience has been:
1. Build satellite wherever convenient, even if across the street from PP group.
2. Hire desperate new grad to staff it. What other choice does the new grad have?
3. No residents. Residents essentially only at main center. Maybe you'll get one if they keep expanding the residency program, so be sure to push for that.
4. Pay at academic levels ~$300k, small bonus, work you like a dog, and turn over docs quickly until someone doesn't leave due to family and huge non-compete, visa issues, or can't find a job due to collapsing job market.
5. Threaten constantly that the PP world is collapsing, that you're essentially a worthless bad doc for every mistake, and you're lucky to be employed at all given the 100 applications from other desperate new grads received for your job.

 

[xrthopeful]

As always has been said Duke - you need to leave your job if you're being that harassed. Either clean up your act (it's a YOU problem) or it's a THEM problem, which means you need to leave.

 

[medgator]

which means you need to leave.

If only it were that easy for some....

 

[thecarbonionangle]

No new or pending programs listed on ACGME websites

Dartmouth, UTenn opened within last 2 yrs and shouldn’t have been allowed

You ain’t seen nothing yet baaaaby

 

[metallica81788]

You ain’t seen nothing yet baaaaby

Have West Virginia and Arkansas opened yet? They were in the works recently.

 

[seper]

WVU is open.

 

[thecarbonionangle]

Have West Virginia and Arkansas opened yet? They were in the works recently.

Both have since started residency programs. WV has multiple satellites they can't fill, constantly posted on ASTRO site. Arkansas is growing.

 

[thecarbonionangle]

I’d be terrified to open a new program in the current environment. There are going to be dozens of empty spots this year. The days of applying to 40 programs and interviewing everywhere are over, much less flying out at your expense to a TTT residency in the middle of nowhere. And now that the stink is on this field it will likely continue to decline for several years until medical students get a signal that something is being done about the oversupply crisis, which doesn’t appear forthcoming for at least a decade.

Welcome to the radonc dark ages.

What an embarrassment if you opened a new program and had nobody apply...

plenty of thirsty FMGs and DOs. many warm bodies with a pulse. BTW idk of anybody who applied to only 40 programs recently and inteviewed all over lol. If those are your days, they been gone for a while, brotha!

 

[deleted956486]

Have West Virginia and Arkansas opened yet? They were in the works recently.

I know 10 programs that expanded by 1-2 residents in the last year. These same programs are expanding satellites...i guess they're killing the field both ways, bleeding the specialty slowly. In a few years, rad once will be nothing more than technicians-it's already the case at some academic centers.

 

[scarbrtj]

Getting more of these types emails. I like posting the actual emails, 'cause data... reality... informational symmetry, etc.
"Young and energetic." "Responsive to paperwork."
Med students if you want a field where your responsiveness to paperwork is valued, and you wanna clamor for a locums job, choose rad onc. Yeesh.

 

[medgator]

plenty of thirsty FMGs and DOs. many warm bodies with a pulse. BTW idk of anybody who applied to only 40 programs recently and inteviewed all over lol. If those are your days, they been gone for a while, brotha!

That was our life a decade ago.

Many of us didn't match with 5-10+ interviews.

At this rate, the low tier programs better be flying you to interview

 

[medgator]

I know 10 programs that expanded by 1-2 residents in the last year. These same programs are expanding satellites...i guess they're killing the field both ways, bleeding the specialty slowly. In a few years, rad once will be nothing more than technicians-it's already the case at some academic centers.

Qft. Our ACR re accreditation reviewer said as much at a site visit lol. Many in academics can only treat their 1-2 sites after subspecializing for a few years and that's it. Quite pathetic imo, and being in the community, I see my success and failures first hand in fu.

I love the variety in my practice and feel sad that autonomous full scope pp in radiation oncology is going the way of the dodo bird

 

[seper]

2-3 weeks/month availability is a sign of unemployment, agree

Getting more of these types emails. I like posting the actual emails, 'cause data... reality... informational symmetry, etc.
"Young and energetic." "Responsive to paperwork."
Med students if you want a field where your responsiveness to paperwork is valued, and you wanna clamor for a locums job, choose rad onc. Yeesh.

 

[evilbooyaa]

Have West Virginia and Arkansas opened yet? They were in the works recently.

Both have opened and have residents.

 

[GapCalc]

I know 10 programs that expanded by 1-2 residents in the last year

Care to name names?

I think it's fair to let future applicants know which programs are expanding despite these job market concerns and the poor match.

What could be more telling about the culture of a program and it's care/concern for it's future alumni, than expanding during these times?

 

[deleted956486]

https://www.astro.org/uploadedFiles/_MAIN_SITE/Affiliate/ARRO/Resident_Resources/Certification_Resources/Content_Pieces/FellowshipDirectory.pdf

The ten programs I know of are listed there. Maximizing profits by expanding residency slots and creating fellowships to ease the burden on faculty. Plus Emory. Lord knows how difficult being an attending is. We need an IGRT and oligomet fellowship. I suggest adding a vaginal cylinder or eye plaque fellowship.

Care to name names?

I think it's fair to let future applicants know which programs are expanding despite these job market concerns and the poor match.

What could be more telling about the culture of a program and it's care/concern for it's future alumni, than expanding during these times?

 

[xrthopeful]

I have a major problem with continued residency expansion.

but I gotta be honest, I have never understood the anger surrounding these fellowships. The majority are taken up by FMGs who come here for 1-2 years, and then go back. A small minority of them end up going for the ABR backwards path certification and end up thus impacting the job market, but this is seriously a minority.

I have met and trained with a number of these people. Some are super smart and genuinely want to learn here and go back home and take stuff back. I have even met some that paid a lot of money out of their own pocket just to come observe for 1-2 months before going back, so in comparison a 1 year fellowship where you actually get PAID is a sweet deal for some. (one guy told me he was literally doing it for the money - 60k US salary for a year is a ton in South Asian terms). Some are not so smart or well trained and need the extra year of education before going back. and yes, some are exceptional, are motivated to stay in the US, and get sponsored by the department to enter the 5 year ABR Pathway for certification.

Yes, it's 'cheap labor' for departments that is cheaper than hiring an NP. But it ultimately did not bother me one bit during residency, and I learned a lot from some of the fellows earlier in my training.

I would much rather a department open a 1 year fellowship than try to expand resident slots.

 

[PleaseRemainCalm]

I have a major problem with continued residency expansion.

but I gotta be honest, I have never understood the anger surrounding these fellowships. The majority are taken up by FMGs who come here for 1-2 years, and then go back. A small minority of them end up going for the ABR backwards path certification and end up thus impacting the job market, but this is seriously a minority.

I have met and trained with a number of these people. Some are super smart and genuinely want to learn here and go back home and take stuff back. I have even met some that paid a lot of money out of their own pocket just to come observe for 1-2 months before going back, so in comparison a 1 year fellowship where you actually get PAID is a sweet deal for some. (one guy told me he was literally doing it for the money - 60k US salary for a year is a ton in South Asian terms). Some are not so smart or well trained and need the extra year of education before going back. and yes, some are exceptional, are motivated to stay in the US, and get sponsored by the department to enter the 5 year ABR Pathway for certification.

Yes, it's 'cheap labor' for departments that is cheaper than hiring an NP. But it ultimately did not bother me one bit during residency, and I learned a lot from some of the fellows earlier in my training.

I would much rather a department open a 1 year fellowship than try to expand resident slots.

At many institutions most fellows are American residency grads. Brigham as am example stands out as a place where many are foreigners, but don't dismiss the fact that there are more than a few Americans who take these fellowships or quasi fellowships

 

[medgator]

I have a major problem with continued residency expansion.

but I gotta be honest, I have never understood the anger surrounding these fellowships. The majority are taken up by FMGs who come here for 1-2 years, and then go back. A small minority of them end up going for the ABR backwards path certification and end up thus impacting the job market, but this is seriously a minority.

I have met and trained with a number of these people. Some are super smart and genuinely want to learn here and go back home and take stuff back. I have even met some that paid a lot of money out of their own pocket just to come observe for 1-2 months before going back, so in comparison a 1 year fellowship where you actually get PAID is a sweet deal for some. (one guy told me he was literally doing it for the money - 60k US salary for a year is a ton in South Asian terms). Some are not so smart or well trained and need the extra year of education before going back. and yes, some are exceptional, are motivated to stay in the US, and get sponsored by the department to enter the 5 year ABR Pathway for certification.

Yes, it's 'cheap labor' for departments that is cheaper than hiring an NP. But it ultimately did not bother me one bit during residency, and I learned a lot from some of the fellows earlier in my training.

I would much rather a department open a 1 year fellowship than try to expand resident slots.

Just because you never met an amg from a decent program who couldn't get a job in a certain geographic area and used the fellowship to wait it out doesn't meant that it doesn't happen with some frequency.

The increase of BS "advanced" and palliative/met fellowships in places like Columbia, Stanford etc in recent years speaks to that exploitation

 

[medgator]

At many institutions most fellows are American residency grads. Brigham as am example stands out as a place where many are foreigners, but don't dismiss the fact that there are more than a few Americans who take these fellowships or quasi fellowships

Traditionally they had respectable fellowships like protons and brachy, but even Harvard is taking advantage of residency expansion with advanced/igrt/palliative fellowships

 

[xrthopeful]

I know of current and previous AMGs who did fellowships - not many, but they were from lower tier programs and also did legit fellowships (proton or brachy) at one of the big three programs.

I have not known any AMGs who did one of these 'SBRT' or 'Advanced Radiation' fellowships - all of the ones I have met or have known about (roughly 7-8 over the past 6-7 years) have been FMGs. (correction, I actually did know of one AMG who did one of these fake fellowships some 5-6 years ago. He needed the help and has been changing jobs every year since starting practice. Some people can't be helped lol).

I've said before that for AMGs who are from lower tier programs and want to find a way to leapfrog up into a good job, a 1 year proton fellowship at MDACC, Sloan, or MGH is a reasonable investment. WIsh it wasn't the case for them, but I can see why people choose it if they want to do something in academics and their current CV is not helping them.

 

[medgator]

I know current and previous AMGs who did fellowships - they were from lower tier programs and also did legit fellowships (proton or brachy) at one of the big three programs.

Did they use said legit fellowship training in their eventual practice or was it just an extra year to wait things out until their preferred job opened up?

Most AMGs I know have taken fellowships mainly for that expressed purpose.

 

[xrthopeful]

Did they use said legit fellowship training in their eventual practice or was it just an extra year to wait things out until their preferred job opened up?

Most AMGs I know have taken fellowships mainly for that expressed purpose.

some got proton jobs at either one of the big three institutions (or moved on later to one of the PP proton centers)

One person I know did use it as a year in a big/nice city to figure his/her life out before moving on to a job in which they did not ever use proton. This was a few years ago.

 

[medgator]

some got proton jobs at either one of the big three institutions (or moved on later to one of the PP proton centers)

One person I know did use it as a year in a big/nice city to figure his/her life out before moving on to a job in which they did not ever use proton. This was a few years ago.

Did the fmgs who took those fellowships feel more comfortable figuring out 30/10, 20/5 or 8/1 afterwards?