There is not a simple narrative regarding disgruntled PP docs. (I would argue that PP is a bit of a misnomer at this point, as the vast majority of community docs are employed or on a PSA with one or more community hospitals).
Very few of us on this board ever experienced PP life as it was 20 years ago or compensation commensurate to what many of those docs had. Very few of us have ever had technical buy in.
Nearly all of us are grateful for our jobs, the relative control we have over our hours and our income. Many of us, who have been in practice a decade or more, have seen real income decrease year over year and very few of us in the community are looking at meaningful increases in income for the rest of our careers.
Some of us do not have the pro fee collections to constitute a good salary, even by academic standards. Some of this is because of low volumes at community centers. Some of this is because of payor mix. (A practice in certain states with overwhelming Medicare coverage is much different than a typical payor mix/remuneration per patient at a large academic place). In my case, I am propped up by a favorable location and see more patients with less professional revenue. If fractionation SOC had remained stable relative to 2013, we would likely have 40-50+ patients on beam per doc.
I believe that the number of folks out there adamantly opposed to case based payment is small. (We have to do our own appeals and deal with our own payment rejections in the community). Admin in the community often overemphasizes rejections while underemphasizing total revenue. Most of us want to pick to technique, fractionation and imaging that we think best serves the patient. Again, the technical owning crowd is small.
I am going to provide a hypothetical career (take the word hypothetical as you wish) that I believe likely represents to some degree a lot of folks out there (or here).
You match into radonc in the late 2000s or early 2010s and your residency cohort is absolutely baller. Standards of research productivity during and progressively even before residency become absurd. You and most of your colleagues have some intrinsic and authentic interest in academic medicine and significant past research productivity.
During residency you notice the following:
1. Emergence of a revolution in systemic therapy (starts with the ipi melanoma trial and the grab bag single agent anti-PD1 drug trials).
2. Your residency getting bigger (depending on exact timing). Goes from 2 to 3-4 residents per year.
3. Cohorts of residents get stronger (on paper at least) or remaining very strong year after year.
4. Satellite docs are busy and relatively small in number. They are typically really good and also a bit disrespected by the system and sometimes main site docs. It's not the aspirational career that the main site is selling.
During your job search you notice:
1. It's competitive out there, and the market has definitely softened from 5-10 years earlier, when many grads were offered spots at the home site and there was even an opportunity to get back into academics from PP. Maybe you were chief or considered good clinically, but for academic jobs, number one is having your chair in your pocket and number two is number of pubs or funding history. If you are limiting yourself geographically for family, you have to get damn lucky. You are competing with folks who already had funding history and a research trajectory established before they ever set foot in residency.
You take the community job you get that is best for family based on location. You would have probably taken an offer from your home institution or any regional academic place, but none was offered. You were smart enough not to pursue satellite academics (or maybe not).
**You may have peaked at your ascendant chair's CV and realized that they had one publication in total a year after residency.
During your career to date you notice:
1. Indications and fractionation keep dropping and dropping and dropping. You were a fairly early adopter of moderately hypo breast and succumb to cultural pressure to hypo prostate. You offer SBRT for everything but liver and pancreas in the community. There is some uptick in SBRT volume during your career, but everything else is decreasing on a per capita basis. You enroll in collaborative group clinical trials and some of these are radiation exclusion trials. You are now treating 5 fraction breast APBI often. Your enthusiasm for oligometastatic treatment is getting more refined (and treatment less reflexive) as data emerges. Oligoprogressive lung...yes. Oligoprogressive breast....maybe not. While there have some technical advances in your practice (RA almost everything, Filter Free tx, GEUD planning at times), you have no delusions that any of these advances are impacting survival. Doing some TNT for rectal is the most progressive thing you have done in the past 10 years.
2. Systemic therapy has gone bonkers. SOC for locally advanced breast cancer has changed 5+ times and by molecular type in the past several years. IO is used for everything. There are multiple targeted agents for many solid tumor sites. With the aging population, blood dyscrasias and other volume becomes overwhelming for medonc. Your medonc partner practice has doubled in size, while your practice has stayed the same.
3. Your regional medonc colleagues at major academic places respect you and view you as interchangeable for their patients relative to in-house radonc. Your regional radonc academic colleagues try to retain patients unnecessarily and tout their preferential value even for routine cases (palliative brain and bone).
4. You may have had to hire once. You had a glut of interest and excellent applicants. No problem hiring an excellent doc from a name brand place. Plenty of early career academic folks considering a change.
5. If you are involved in admin, you may have to help recruit for medonc. You are now offering J-1 visa candidates straight from a community medonc fellowship more than you or your radonc partners are making. They are not biting. They are able to get jobs in fairly large metros.
6. Your personal lateral mobility is very, very poor. No hopes at hometown. Would have to be a national search (or at least a very large regional search) for anyone. This is unique to your field.
7. Your colleagues a few years after you had it worse. Asked to do a fellow-ship to get an academic track job. Took an underworked satellite job.
So you take stock:
You have no problems getting out the door for work and you are grateful for your life. But....you would not recommend the field to anyone young. You are not excited about the new things that you are going to be doing for the rest of your career or the active learning you are going to have to do to stay up-to-date. (We could all answer all those OLA questions out of residency). You know some of the leadership in the field and you view them as careerists at this point. Loyal to their institutions and interests and not terribly interested in taking an honest look at the field. You find it preposterous that there was ever residency expansion like in circa 2010 and that there has not been a correction since.
You quit ASTRO, you put your head down and work, you try to do your part to help keep your community hospital afloat and you occasionally bitch, talk about clinical cases, science and culture on SDN!
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