SDN Rad Onc mentioned in ASTROnews

[Gfunk6]

There was an editorial in the latest ASTROnews written by the current Chief Resident at Harvard.

The quote in question, ". . . disgruntled residents are actively discouraging medical students from joining our specialty due to perceived grim employment prospects." The thread that he quotes is here: Rad Onc - Supply & Demand

The gist of the article is that "everything is fine, move along people, nothing to see here." It casts doubt on any individuals deviating from this idea by branding them as bunch of ill-informed malcontents.

He then closes with a lovely anecdote about how has a singed job contract. Let me tell you things have to get REALLY, REALLY bad before the folks at Harvard have a hard time placing their residents . . .

Also in a later article co-authored by Paul Wallner, Lynn Wilson, and Kaled Alektiar is this gem of a quote:

Medical students are well aware of changes in career opportunities in various practice models and regions, and they share this information freely with their peers . . . These data suggest that, while radiation oncology continues to draw from among the best and brightest of American medical school graduates, the number of applications in relation to available training slots is falling, suggesting that medical students may be concerned about future opportunities. As should be the case, young people are making career decisions based on their own practice preferences and projections and not on artificial determinations by others.

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[medgator]

A signed job contract lol.

No one is complaining about not being able to find a job or sign a contract.

The issue is where, for how much and for what kind of working conditions.

I saw that article and thought it was equally ridiculous

 

[Ray D. Ayshun]

Am also curious to know about the veracity of the statement that residents were doing it. I think it was mostly attendings. Also, not sure about the veracity of “disgruntled.” Guess disgruntled means honest about things that are problematic. Hope he’s not going into a profession where he has to deliver bad news...

 

[evilbooyaa]

Anyone have a link to the editorial itself?

 

[Ray D. Ayshun]

Anyone have a link to the editorial itself?

https://www.astro.org/uploadedFiles...gazine_(ASTROnews)/Volumes/winter17_issue.pdf

Buried in there.

 

[evilbooyaa]

So, read the article, I don't think he's meaning to be antagonistic. He's feeding the same lines that Zeitman posted in IJROBP, which isn't surprising since they're both good ol' Harvard boys. The thought that medical students will self-select out of this field doesn't mean that the numbers will go down - simply that lower quality candidates will take those residency spots. The issues of the job market won't be dealt by that crude strategy.

Collaborate workplace regulation is NOT against the law, as other medical specialties have societies and committees dedicated to it. Radiation Oncology is no different in that matter. The difference is that the Rad Onc leadership continues the trend of physicians looking to maximize their gains in life regardless of the damage that it does to future generations within this field.

I look forward to seeing if Dr. Royce ends up at a satellite facility within the UNC system, or if he is actually at the UNC main campus, down the hall from Tepper and Marks. If someone remembers this in mid 2018 after new hires make it onto the websites, please update this thread.

 

[medgator]

So, read the article, I don't think he's meaning to be antagonistic. He's feeding the same lines that Zeitman posted in IJROBP

Which is antagonistic that mentality is detrimental to the field

 

[Röntgen]

Thanks for your interest in the article; I’m the author of the piece being referenced. Thanks also for everything this site has done to connect our radiation oncology community. Particularly, I know I found this site to be incredibly informative as an applicant to the field and I appreciate that.

I’ve spent the last several years trying to bring awareness to this issue on behalf of the residents, primarily as an ARRO representative, and have tried to give a somewhat vulnerable population (the “trainee”) a voice. This is a delicate topic that only a few years ago was somewhat taboo (see: Bloodbath in the Red Journal thread). My motivation is because I am concerned about the future employment prospects in our field. It is fair to say that many residents are disgruntled (meaning “dissatisfied”) about this issue, myself included.

I respectfully disagree with GFunk (side note: thanks for all the time and energy you put into this community as moderator) that the message is “everything is fine”. Clearly people are concerned about this: “Potentiating this angst, which would be natural in any job market, is the current majority perception that there is a looming oversupply of radiation oncologists. In the 2017 ASTRO Workforce Study, 53 percent of respondents were concerned about a future oversupply of radiation oncologists; the prevalence of this sentiment is likely higher among residents. This perception is fueled by the rapid rise in the number of radiation oncology residency positions, going from a nadir of 93 in 2001 to 200 in 2015, and workforce projections cautioning that supply is outpacing demand”

Everything is not fine, which is why the resident perspective needs to be heard. I’m thankful the editor recognized that residents deserve a voice in this conversation and I tried my best to communicate to the broader community that there is very real unease over this. I feel very fortunate to have been hired, a relief which I tried to portray in the article with my own story. I also realize that as a trainee I’m not in a position to make policy on this issue, but felt I could continue to increase awareness. I simply tried my best to do that with this piece in a way that was approachable to abroad audience.

 

[maruchan]

Thanks for your interest in the article; I’m the author of the piece being referenced. Thanks also for everything this site has done to connect our radiation oncology community. Particularly, I know I found this site to be incredibly informative as an applicant to the field and I appreciate that.

I’ve spent the last several years trying to bring awareness to this issue on behalf of the residents, primarily as an ARRO representative, and have tried to give a somewhat vulnerable population (the “trainee”) a voice. This is a delicate topic that only a few years ago was somewhat taboo (see: Bloodbath in the Red Journal thread). My motivation is because I am concerned about the future employment prospects in our field. It is fair to say that many residents are disgruntled (meaning “dissatisfied”) about this issue, myself included.

I respectfully disagree with GFunk (side note: thanks for all the time and energy you put into this community as moderator) that the message is “everything is fine”. Clearly people are concerned about this: “Potentiating this angst, which would be natural in any job market, is the current majority perception that there is a looming oversupply of radiation oncologists. In the 2017 ASTRO Workforce Study, 53 percent of respondents were concerned about a future oversupply of radiation oncologists; the prevalence of this sentiment is likely higher among residents. This perception is fueled by the rapid rise in the number of radiation oncology residency positions, going from a nadir of 93 in 2001 to 200 in 2015, and workforce projections cautioning that supply is outpacing demand”

Everything is not fine, which is why the resident perspective needs to be heard. I’m thankful the editor recognized that residents deserve a voice in this conversation and I tried my best to communicate to the broader community that there is very real unease over this. I feel very fortunate to have been hired, a relief which I tried to portray in the article with my own story. I also realize that as a trainee I’m not in a position to make policy on this issue, but felt I could continue to increase awareness. I simply tried my best to do that with this piece in a way that was approachable to abroad audience.

I read the article and I didn't find it antagonistic and overall I thought the vibe of the article was voicing that there was an issue. I was however, extremely disappointed to see Zeitman's point about self-regulation repeated and it greatly weakened the article for me. This is a factually incorrect perspective. The residency market is not a free market, the number of residency slots is artificially fixed by the ACGME. If US MDs don't fill the positions, then IMGs will. There is no chance that the market will ever self regulate. Holding up this perspective as valid is dangerous; it will get repeated (and already is being repeated) as a counterargument by those who don't want any reform.

 

[evilbooyaa]

@Röntgen I certainly appreciate you coming here to discuss your editorial in greater detail. Like I said, I didn't think the article came off as antagonistic. However, I do completely agree with the above that parroting the Zeitman line is the one part of the article that most of us here have an issue with. I certainly understand it's hard to refute one of your most well known attendings when you're < 6 months away from graduating, however, even if you have a job locked in.

 

[Gfunk6]

@Röntgen I too will give you credit for coming online and defending your views in a constructive manner. While I agree with all of the political caveats stated above (e.g. you are still technically in training and are therefore beholden to your superiors), I don't think your article (the second to last paragraph in particular) helps the overall situation. While I think first 2/3ths or so were helpful in summarizing the situation, expressing the angst, and citing the data, things went down hill when you use the word "disgruntled" and then repeated the stance of our "leadership" (sit tight, we need more data, do nothing now).

My two cents.

 

[RickyScott]

(outsiders view): circa 2003- Harvard/Partners/BI offered starting salaries of around 90-120, and there was a lot of turnover with junior faculty and it was reportedly not the easiest place to work. There were almost no satellites. Salaries improved; the work environment really improved, from what I hear, and now there is less turnover. The number of satellites/affiliates must have tripled at the very least. They were doing a lot of hiring for a while, but they are probably at capacity and no longer able to absorb all their residents. In the past many of these centers may have needed 2 docs for 1.-1.5 FTE/positions for redundancy/coverage etc, but can now be more efficiently staffed by a network. If one center were to close, because of payment reform, hypofractionation, bundled payment, patients could easily be diverted/scaled to another.

 

[evilbooyaa]

@Röntgen I too will give you credit for coming online and defending your views in a constructive manner. While I agree with all of the political caveats stated above (e.g. you are still technically in training and are therefore beholden to your superiors), I don't think your article (the second to last paragraph in particular) helps the overall situation. While I think first 2/3ths or so were helpful in summarizing the situation, expressing the angst, and citing the data, things went down hill when you use the word "disgruntled" and then repeated the stance of our "leadership" (sit tight, we need more data, do nothing now).

My two cents.

I mean, I know "disgruntled" has a negative connotation (as in a "disgruntled" person is a problem, not the system that they are complaining about) , but I don't think it's entirely inaccurate given the vitriol that's thrown about these forums.

 

[thecarbonionangle]

I share the general feelings expressed by others. In one hand, I understand the constraints that a current resident and soon to be UNC faculty would have to truly speak his mind being under the supervision of those who may disagree with him (and stand to benefit from continuing this trend) and also having seen what happened to Dr. Shah when he spoke his mind in the infamous "blood-bath" article. However, I do find the last paragraph unhelpful, and counter-productive to your stated purpose, even if you did not mean it like that ( you are in an ivory tower bubble, and people are sensitive to this true reality). I think people are generally annoyed by the parroting group think (from anyone who does it), the general idea that more data is needed, more research on the subject is needed, little can be done, and the market "self-correction" will take care of it. Its a euphemism for a very painful thing in our field . The current residents will and are being screwed in jobs and compensation, and then the quality of medical students will decrease, which will really hurt our field. IMGs will still fill these spots even if US grads don't want to take them.

The "leadership" in our field is non-existent and actively working against our interests. People are tired of the elitism and arrogance toward the PP physician from academics. Programs continue to expand, fellowships also expanding and people are rightfully annoyed by this (see the closed down Stanford expansion thread). The pitchforks are gathering and people are unhappy. From my perspective, one of the things we can do is to speak with our pocket book. I never plan to donate to ASTRO or any similar crony organizations. Feel free to call me DISGRUNTLED if you wish.

 

[Fpg1245]

I remember bringing the topic up to my program director a few years back and got a similar type of response. They might have pulled the “Market Correction” argument on me but I knew better. Granted at the time, they had just said their goal was to expand the residency. That being said, I actively discourage med students that are on the fence about what to pursue. I always conclude that discussion with “If you come into rad onc, just know that NOBODY in the leadership has your best interests at heart and nobody cares if you spend the better part of your life doing attending level work for resident pay”. Ofcourse, I can’t stop everyone but if I could get just a few to see the light.

 

[OliveTree]

The article by Dr. Royce is well written; it conveys the idea that there is concern about the job market, and it ends with Dr. Royce's relief at having found a job and a hope that other residents will do the same. The use of the world "disgruntled" in the context of the entire article doesn't seem to my eye to be antagonist at all. Nor should it be held again the author that he is supposedly at Harvard in an ivory tower; there's no reason to believe he hasn't thought about resident issues more than most as an ARRO rep. That's my 2 cents.

 

[MegaVoltagePhoton]

The article by Dr. Royce is well written; it conveys the idea that there is concern about the job market, and it ends with Dr. Royce's relief at having found a job and a hope that other residents will do the same. The use of the world "disgruntled" in the context of the entire article doesn't seem to my eye to be antagonist at all. Nor should it be held again the author that he is supposedly at Harvard in an ivory tower; there's no reason to believe he hasn't thought about resident issues more than most as an ARRO rep. That's my 2 cents.

I didn't know you read SDN, Dr. Zietman!

 

[Ray D. Ayshun]

The article by Dr. Royce is well written; it conveys the idea that there is concern about the job market, and it ends with Dr. Royce's relief at having found a job and a hope that other residents will do the same. The use of the world "disgruntled" in the context of the entire article doesn't seem to my eye to be antagonist at all. Nor should it be held again the author that he is supposedly at Harvard in an ivory tower; there's no reason to believe he hasn't thought about resident issues more than most as an ARRO rep. That's my 2 cents.

The premise of this article “tails from the trail,” suggests it will be stories about finding a job after residency, the trials and tribulations and such, to which most can relate. With that premise in mind, does it seem reasonable to have the chief at Harvard write it? I don’t hold it against him, but it’s not quite reality, yet represented as such. Further, the thread which is cited in his article is not as he described. There’s some angst, mostly by longstanding attendings, and I’m not sure I saw really good examples of residents actively discouraging medical students from applying.

 

[OliveTree]

I didn't know you read SDN, Dr. Zietman!

Haha! I'm a resident with no Zietman-like aspirations. Sorry to disappoint.

 

[OliveTree]

The premise of this article “tails from the trail,” suggests it will be stories about finding a job after residency, the trials and tribulations and such, to which most can relate. With that premise in mind, does it seem reasonable to have the chief at Harvard write it? I don’t hold it against him, but it’s not quite reality, yet represented as such. Further, the thread which is cited in his article is not as he described. There’s some angst, mostly by longstanding attendings, and I’m not sure I saw really good examples of residents actively discouraging medical students from applying.

I know I didn't go out of way trying to write something in ASTRO news... I don't mind if someone from Harvard or elsewhere took the time to do it.

 

[Gfunk6]

There’s some angst, mostly by longstanding attendings, and I’m not sure I saw really good examples of residents actively discouraging medical students from applying.

I think people see Student Doctor Network and simply assume all members must be trainees.

 

[Becquerel]

I am a friend and former colleague of Dr. Royce. I thought his article was well-written and neutral. It reads more like a factual account of the issues at hand, rather than an opinion piece, which makes sense for an ASTRO News article.

The criticism that he is "parroting the Zietman line"(regarding market-based correction as a reasonable solution to oversupply) is unjustified IMO. He dedicates a mere 2-3 sentences to describing the fact that self-correction has been proposed as a solution and even describes this approach as "crude." The article also mentions the rise in fellowships as a dangerous trend, suggesting that the purported need for further specialization is "disingenuous." Also, FWIW, I do not think it's accurate that Dr. Zietman advocates for pure market-based correction as the optimal solution.

I personally don't have a problem with the word "disgruntled" since it doesn't necessarily signify that the affected individual was in the wrong or inappropriately discontent. From what I've read on SDN, I think it's accurate that residents (and attendings) are often discouraging medical students from applying in radiation oncology by voicing their concerns about the job market. IMO, including the statement about residents actively discourage medical student applications shows that Dr. Royce is sensitive to the general concern about worsening career prospects in our field.

The second to last paragraph, which speaks to the limited data on the market for current gradates, is accurate and reported factually. The article states that collecting more data could help inform policy (which is true), but it does not espouse the view that additional data is required to implement a solution.

I also find the last paragraph to be in good taste. Dr. Royce tells us that he was "fortunate" to get a position and that he felt "great relief" that he could start to pay down a "daunting student loan burden." In no way does this come across as boastful and he is in no way saying that his experience (as a Harvard chief resident) is representative of the larger resident community.

Again, the article seems more like a factual rendition of the issues and purposefully avoids talking a stance on what should be done to correct any perceived imbalance. For an invited piece in the ASTRO News, I think this very appropriate.

 

[maruchan]

I am a friend and former colleague of Dr. Royce. I thought his article was well-written and neutral. It reads more like a factual account of the issues at hand, rather than an opinion piece, which makes sense for an ASTRO News article.

The criticism that he is "parroting the Zietman line"(regarding market-based correction as a reasonable solution to oversupply) is unjustified IMO. He dedicates a mere 2-3 sentences to describing the fact that self-correction has been proposed as a solution and even describes this approach as "crude." The article also mentions the rise in fellowships as a dangerous trend, suggesting that the purported need for further specialization is "disingenuous." Also, FWIW, I do not think it's accurate that Dr. Zietman advocates for pure market-based correction as the optimal solution.

I personally don't have a problem with the word "disgruntled" since it doesn't necessarily signify that the affected individual was in the wrong or inappropriately discontent. From what I've read on SDN, I think it's accurate that residents (and attendings) are often discouraging medical students from applying in radiation oncology by voicing their concerns about the job market. IMO, including the statement about residents actively discourage medical student applications shows that Dr. Royce is sensitive to the general concern about worsening career prospects in our field.

The second to last paragraph, which speaks to the limited data on the market for current gradates, is accurate and reported factually. The article states that collecting more data could help inform policy (which is true), but it does not espouse the view that additional data is required to implement a solution.

I also find the last paragraph to be in good taste. Dr. Royce tells us that he was "fortunate" to get a position and that he felt "great relief" that he could start to pay down a "daunting student loan burden." In no way does this come across as boastful and he is in no way saying that his experience (as a Harvard chief resident) is representative of the larger resident community.

Again, the article seems more like a factual rendition of the issues and purposefully avoids talking a stance on what should be done to correct any perceived imbalance. For an invited piece in the ASTRO News, I think this very appropriate.

I actually agree with most everything here. I don't mean to cast any negative light on Dr. Royce and think that he was well intentioned.

I want to emphasize again the sheer fallacy of "market-based correction" though. This is not just a crude approach. It is a nonexistent approach. It is not just a suboptimal solution. It is NOT a solution, and there is no scenario in which it could become even a partial solution. It is literally just a rationalization for inaction. Again, the number of residents is completely fixed by the ACGME and no amount of self-selection will make even 0.00000000001% difference in the supply of residents.

I just already know that "market-based correction" will continue to be used as a justification for postponing intervention and that really bothers me.

 

[OTN]

I am a friend and former colleague of Dr. Royce. I thought his article was well-written and neutral. It reads more like a factual account of the issues at hand, rather than an opinion piece, which makes sense for an ASTRO News article.

The criticism that he is "parroting the Zietman line"(regarding market-based correction as a reasonable solution to oversupply) is unjustified IMO. He dedicates a mere 2-3 sentences to describing the fact that self-correction has been proposed as a solution and even describes this approach as "crude." The article also mentions the rise in fellowships as a dangerous trend, suggesting that the purported need for further specialization is "disingenuous." Also, FWIW, I do not think it's accurate that Dr. Zietman advocates for pure market-based correction as the optimal solution.

I personally don't have a problem with the word "disgruntled" since it doesn't necessarily signify that the affected individual was in the wrong or inappropriately discontent. From what I've read on SDN, I think it's accurate that residents (and attendings) are often discouraging medical students from applying in radiation oncology by voicing their concerns about the job market. IMO, including the statement about residents actively discourage medical student applications shows that Dr. Royce is sensitive to the general concern about worsening career prospects in our field.

The second to last paragraph, which speaks to the limited data on the market for current gradates, is accurate and reported factually. The article states that collecting more data could help inform policy (which is true), but it does not espouse the view that additional data is required to implement a solution.

I also find the last paragraph to be in good taste. Dr. Royce tells us that he was "fortunate" to get a position and that he felt "great relief" that he could start to pay down a "daunting student loan burden." In no way does this come across as boastful and he is in no way saying that his experience (as a Harvard chief resident) is representative of the larger resident community.

Again, the article seems more like a factual rendition of the issues and purposefully avoids talking a stance on what should be done to correct any perceived imbalance. For an invited piece in the ASTRO News, I think this very appropriate.

Is this what we want? We want the Chief Resident from Harvard to feel "fortunate" to get a position and "great relief" that he can now pay down his debt? I really can't get on board with describing his editorial as "neutral" when all it did was parrot the B.S. line that we can't restrict residency positions due to market forces. Simply not true, and if you remember, several years ago market forces were used to JUSTIFY residency expansion to make sure rural areas had radiation oncologists.

 

[Becquerel]

I really can't get on board with describing his editorial as "neutral" when all it did was parrot the B.S. line that we can't restrict residency positions due to market forces. Simply not true, and if you remember, several years ago market forces were used to JUSTIFY residency expansion to make sure rural areas had radiation oncologists.

He is not "parroting a B.S. line". Dr. Royce makes a factual statement with an appropriate citation. This was researched and addressed in the 2016 Red J article that he cites. Antitrust case law is clear that collaborative self-regulation that purports to restrict (rather than expand) the supply of physicians, even if based on sound empirical evidence of a surplus, would be forbidden by antitrust laws. Your accusation that this is some type of conspiracy theory is not based on any sort of legitimate legal analysis, and is counter to bringing forth real solutions to correct what appears to be a growing over-supply of physicians. I agree with you that some top-down regulation is ideal, but just pounding the table and saying that the antitrust concerns are unfounded does not make it so. If you have a reference to a paper that supports your point, or know an antitrust attorney or professor that shares your sentiments, making that public would be productive.

 

[seper]

What's your source for illegality of regulating the number of residency positions?

He is not "parroting a B.S. line". Dr. Royce makes a factual statement with an appropriate citation. This was researched and addressed in the 2016 Red J article that he cites. Antitrust case law is clear that collaborative self-regulation that purports to restrict (rather than expand) the supply of physicians, even if based on sound empirical evidence of a surplus, would be forbidden by antitrust laws. Your accusation that this is some type of conspiracy theory is not based on any sort of legitimate legal analysis, and is counter to bringing forth real solutions to correct what appears to be a growing over-supply of physicians. I agree with you that some top-down regulation is ideal, but just pounding the table and saying that the antitrust concerns are unfounded does not make it so. If you have a reference to a paper that supports your point, or know an antitrust attorney or professor that shares your sentiments, making that public would be productive.

 

[Becquerel]

What's your source for illegality of regulating the number of residency positions?

The 2016 Red J paper relies on antitrust case law and an article that analyzed similar issues related to restricting radiology resident slots. I am an author on the Red J piece and we researched this Q extensively. We discussed the issue with a few antitrust experts, all of whom said that restriction of residency slots to correct a perceived oversupply would raise very serious antitrust concerns. I know it's not what we want to hear, but this is the reality.

 

[seper]

Thanks. Then, positions should be restricted on an explicitly different basis: dearth of available Peds cases or Gyn implants for education, for example.

The 2016 Red J paper relies on antitrust case law and an article that analyzed similar issues related to restricting radiology resident slots. I am an author on the Red J piece and we researched this Q extensively. We discussed the issue with a few antitrust experts, all of whom said that restriction of residency slots to correct a perceived oversupply would raise very serious antitrust concerns. I know it's not what we want to hear, but this is the reality.

 

[nkmiami]

The 2016 Red J paper relies on antitrust case law and an article that analyzed similar issues related to restricting radiology resident slots. I am an author on the Red J piece and we researched this Q extensively. We discussed the issue with a few antitrust experts, all of whom said that restriction of residency slots to correct a perceived oversupply would raise very serious antitrust concerns. I know it's not what we want to hear, but this is the reality.

At least for the match, acgme is exempt from antitrust... where is the case law on radiology? I would really expect courts to broadly defer in this kind of situation. I am not sure why saturated xrt slots should be funded when their ate bottlenecks in primary care.

Whether there is a top down solution available or not, ASTRO leadership (in their other role as department chair/program director) created the problem?

 

[MegaVoltagePhoton]

The 2016 Red J paper relies on antitrust case law and an article that analyzed similar issues related to restricting radiology resident slots. I am an author on the Red J piece and we researched this Q extensively. We discussed the issue with a few antitrust experts, all of whom said that restriction of residency slots to correct a perceived oversupply would raise very serious antitrust concerns. I know it's not what we want to hear, but this is the reality.

So how have derm, plastics, and neurosurg maintained a stable # of spots?

ACGME does not have to be the organization to make the edict anyway. If programs didn't file for expansion, expansions wouldn't be granted. Is the any incentive not to expand? Any recommendation from the top down not to expand?

 

[mheat3]

would raise very serious antitrust concerns.

...I'm pretty sure this does not equal breaking the law nor is it something that could be upheld in the court of law. This is lawyer speak for extreme caution and possible worst case scenario.

 

[nkmiami]

here is the case that was not succesful

Challenging the Medical Residency Matching System through Antitrust Litigation, Feb 15 - American Medical Association Journal of Ethics (formerly Virtual Mentor)

The second component of the alleged conspiracy focused on the ACGME accreditation system. The plaintiffs asserted that the ACGME, in working with institutional defendants, did the following: (1) regulated the number of available residency positions; (2) made the NRMP match result permanent by imposing “substantial obstacles to the ability of a resident to transfer employment from one employer to another during the period of a residency” [9]; (3) encouraged and/or required medical institutions to participate in the match as a condition for receiving accreditation; and (4) directly reviewed “compensation and other terms of employment with the purposes of fixing and depressing” them

 

[medgator]

Is this what we want? We want the Chief Resident from Harvard to feel "fortunate" to get a position and "great relief" that he can now pay down his debt? I really can't get on board with describing his editorial as "neutral" when all it did was parrot the B.S. line that we can't restrict residency positions due to market forces. Simply not true, and if you remember, several years ago market forces were used to JUSTIFY residency expansion to make sure rural areas had radiation oncologists.

He is not "parroting a B.S. line". Dr. Royce makes a factual statement with an appropriate citation. This was researched and addressed in the 2016 Red J article that he cites. Antitrust case law is clear that collaborative self-regulation that purports to restrict (rather than expand) the supply of physicians, even if based on sound empirical evidence of a surplus, would be forbidden by antitrust laws. Your accusation that this is some type of conspiracy theory is not based on any sort of legitimate legal analysis, and is counter to bringing forth real solutions to correct what appears to be a growing over-supply of physicians. I agree with you that some top-down regulation is ideal, but just pounding the table and saying that the antitrust concerns are unfounded does not make it so. If you have a reference to a paper that supports your point, or know an antitrust attorney or professor that shares your sentiments, making that public would be productive.

The 2016 Red J paper relies on antitrust case law and an article that analyzed similar issues related to restricting radiology resident slots. I am an author on the Red J piece and we researched this Q extensively. We discussed the issue with a few antitrust experts, all of whom said that restriction of residency slots to correct a perceived oversupply would raise very serious antitrust concerns. I know it's not what we want to hear, but this is the reality.

I distinctly remember an article from the 90s regarding the bad job market, and how programs were in fact shut down, spots were reduced, and the length of RO training was increased from 3 to 4 years post-internship. Care to tell me how that came about?

 

[maruchan]

I am similarly confused by this notion of residency contraction as a legal issue. Here is an article published in red journal that explicitly describes action taken by the ACR to decrease residency slots in response to employment concerns. Thus there is a clear precedent and antitrust concerns were never an issue in the past. There is furthermore precedent by both dermatology and neurosurgery of regulating residency slots. Of course though law is quite complex and I am no lawyer. I am genuinely curious -- did you discuss these precedents with the antitrust experts that you consulted with?

For those curious, the history of the prior residency contraction is well-chronicled in this red journal commentary, co-authored by our own Dr. Royce. I feel a little bad about the flak he's getting on this thread as it seems to me he does ultimately see things from the same perspective as most of us and he's been trying to raise awareness of the issue -- it just didn't totally come through in the astronews piece.

 

[Skindoc83]

So how have derm, plastics, and neurosurg maintained a stable # of spots?

ACGME does not have to be the organization to make the edict anyway. If programs didn't file for expansion, expansions wouldn't be granted. Is the any incentive not to expand? Any recommendation from the top down not to expand?

I can’t speak to plastics and neurosurgery but they have been expanding the number of derm spots and it’s starting to impact us negatively

 

[evilbooyaa]

The 2016 Red J paper relies on antitrust case law and an article that analyzed similar issues related to restricting radiology resident slots. I am an author on the Red J piece and we researched this Q extensively. We discussed the issue with a few antitrust experts, all of whom said that restriction of residency slots to correct a perceived oversupply would raise very serious antitrust concerns. I know it's not what we want to hear, but this is the reality.

So that's complete nonsense, IMO. Here's what we did back in the late 1980s to prepare for the 1990 oversupply (leading to the 1997 contraction and extension of residencies):

Quote from this article: The manpower crisis facing radiation oncology - ScienceDirect

External control of residency programs lies solely with
the Residency Review Committee (RRC) for Radiology,
a committee of the AMA Accreditation Council for
Graduate Medical Education. The RRC assesses the
quality of training programs with respect to accreditation
status, and insofar as it sets educational standards, the
RRC has an impact on the number of trainees. The new
set of “Essentials and Guidelines” for training programs3
approved at the Program Director’s meeting in 1984 is
being integrated into the existing AMA guidelines (Special
Requirements for Residency Training in Therapeutic Radiology)
and was designed to improve standards for training
programs. This may be a factor in terminating a number
of marginal programs and will decrease the number
of training positions available. Because most of these programs
are small, the overall impact is unclear. However,
if the new guidelines assuring quality resident education
are implemented, more programs may be closed. On the
other hand, new programs meeting all of these standards
may be approved.


Maybe 20 SRS and 10 SBRT cases per resident, over a 4-year residency career, isn't enough to be sufficiently trained given the existence of SRS/SBRT fellowships? Maybe 450 EBRT cases, at least half of which are likely palliative AP/PA or 3D-CRT set-ups at best, and whole brains at worst, isn't enough? Maybe the requirements to completing a Rad Onc residency isn't something that could be theoretically done in a 12 month period (outside the 450 EBRT cases)? Maybe required numbers for all this stuff should go up so that programs won't be able to show volume to expand sufficiently? Is 5 interstitial cases really all that's required before you're primed and ready to start doing Syed templates? What if all of your interstitial brachy was PSI or HDR? What about vice-versa?

 

[Chartreuse Wombat]

I spent six years with the ACGME RRC. At the risk of being vilified I can tell you that one of the first things that you did when joining the committee was to be oriented by the ACGME. In this process their lawyers made very clear that any discussion of workforce issues at it relates to residency spots was verboten. I can tell you that the ACGME made decisions based on educational potential alone. If a program wanted to increase the complement and had sufficient patient resources, faculty, good board pass rates, sufficient case logs, etc then the position was approved. Similarly for new programs.

I was not present at the table in the 1990s when some programs were shut down but the "wisdom" passed along was that these programs were unacceptable from an educational standpoint. Poor board pass rates, history of documented resident harassment, etc. In my time with ACGME 2-3 programs were closed for educational reasons (but more were opened and many increased in size).

Now perhaps someone will push back on the ACGME lawyer's guidance and sue the ACGME but efforts to date have not succeeded to my knowledge.

The question raised above about what constitutes a minimum number of cases for procedures is something that the committee wrestles with every year as the practice patterns change. SBRT and SRS requirements are new additions and it would not surprise if the required numbers increase in the next few years as they have in the last decade starting at zero to 5-10 cases to the current requirements.

Brachytherapy requirements is a very difficult problem. As has been documented the utilization of brachytherapy is falling in the US and the resident experience is decreasing as well. There are many reasons for this which are beyond the scope of this post.

Bottom line is that the ACGME is not going to solve this problem (and I believe there is a problem). I am an older academic whose practice is very similar to many in private practice in that I don't have resident coverage and rely on a nurse to help me with clinical care of 20-25 patients on treatment. If asked I warn medical students that the specialty is overtraining and if they are able to get into a top 20 training program (whatever that means) then they should find a reasonable job. If a student is geographically restricted (especially large coastal cities) or is trained at a lesser program then the job market is poor.

 

[DebtRising]

The article by the resident isn't bad overall, but the ASTRO response is horribly cruel.

Market solutions require free and [mostly] honest information.

How can medical student's possibly know the information about the job market? ASTRO sending the most recent employment projection (oversupply) to all applicants? Is it free article? Are advisory deans being sent this?
Is ASTRO or ACGME publishing the fellowship expansion numbers? ASTRO or ACGME reviewing why uncertified 'fellowship' popping up for bread and butter aspects of field? Does ACGME allow surgical residency only teach open prostatectomy, so other program can use labor for 'laproscopic fellowship'?

ASTRO official article disingenuous and cruel. It's sending patient to Florida who gets 50 fractions for bone met and then saying 'hey, patient, why didn't you know 50 fractions was too many???'

Just like patients put their trust IN US to help guide them, ACGME, SCAROP, ASTRO have a responsibility to at least GIVE INFORMATION to medical students. This is not 1990, medicine is not great for new grads. If you want to preach market based solutions you put relevant info out there to students with multiple 6 figure debts, the objective PUBLISHED data in journals that must be subscribed too.

None of them chose to do so. They controlled and manipulated market, and now keeping new participants from that information, and discounting those of us who have put that information together as disgruntled. Hypofractionation? Market based.

So, new residents and potential medical students, enjoy your 50 fraction bone mets of a job. Don't like it? Blame the market we didn't have the guts to tell you about. Don't look at our annual survey, the 50%+ of field whose biggest concern with oversupply were all disgruntled internet posters.

 

[Chartreuse Wombat]

Again at the risk of being vilified. Much of the information is available.

The NRMP provides information on applicants in their "Charting Outcomes" which is available online for free. Knoweldgeable medical students know that median Step I is 240 (and rising).

I have personally met with Associate Deans about Radiation Oncology and emphasize the competitiveness of the match and the uncertain future job market. I just sent them the ASTRO News piece with the "more than 50% perceive too many trainees" highlighted.

The ACGME does not accredit fellowships in Radiation Oncology. There are no accredited fellowship programs in Radiation Oncology. Most applicants are choosing fellowships because they are trying to get an inside track on opportunities within a geographic area or are trained outside of the US or at a lower tier program and trying to buff their credentials. I recommend against fellowships unless they are tailored to a subspecialty (e.g. peds) and even then my enthusiasm is tempered.

I reread Dr Royce's piece and dispute the contention that the number of resident applicants is falling. I estimate that >300 applied for about 200 positions (the program at my institution received a similar number of applications as the last several years). Ten percent of Harvard's senior medical school class is attempting to match in RadOnc. The mediocre applicants may be decreasing in numbers (but they have little chance anyway).

 

[RickyScott]

If new grads/residents feel they have negatively been affected by these issues, I would strongly suggest not joining ASTRO.
(even if you decide to go to the meeting.) I think you would have more influence in ACRO anyway. I know someone is going to say this is counterproductive, but I really dont think ASTRO is reformable.

 

[DebtRising]

Again at the risk of being vilified. Much of the information is available.

We are speaking about different pieces of information.
Charting outcomes does not have the publish employment projection, prior to even more hypofractionation push, that we have an oversupply of rad oncs for at least the next ten years due to increased training slots and decreased radiation utilization.

Charting outcomes does not provide information on an explosion of unaccredited fellowships. It does not have the ASTRO sponsored membership survey which showed over half the respondents biggest concern is oversupply.

My position is that ASTRO is at best disingenuous and at worst cruel for endorsing a 'market based' solution to the job market and yet not making that information freely available to medical students or advisory deans. Or highlighting it at all. Their response in the news letter was 'well, there may be some information, but projections can be wrong' in not so many words.

There is no reason to vilify you. There is every reason to vilify leadership. If there is objective, published information, an objective explosion of unaccredited fellowships [only known by ARRO and googling], and you commence a nationwide survey and respond to the top complaint with 'doesn't matter, no plan, get on with it' you should be vilified.

 

[maruchan]

At risk of sounding like a broken record, it is irrelevant whether medical students have all the information about the workforce or not. It is irrelevant whether applications are decreasing.

Decreased applications and decreased medical student interest in radiation oncology will not translate into a decrease in the number of residents. It will translate into a decrease in median step 1 score first, then a decrease in number of US allopathic seniors, and then if things get truly dire an increase in number of spots filled through SOAP.

But the number of residents will remain unchanged, and therefore the present imbalance between supply and demand of workforce will continue.

 

[thecarbonionangle]

Changing the cases requirements is a doable solution, but a difficult one. The number of cases required is likely too little, but as pointed out it's a difficult topic. There are programs out there, even some very well regarded, which barely meet the required number of cases in some of these categories for multiple factors. For peds, many places have to go somewhere else. To increase peds requirements would cause the programs which allow rotators, to likely cut them off as they will need these cases for their own residents (some of them may even have to contract their already bloated number of residents). For brachy, some programs don't have the patient populations to see a good amount of gyn cancer cases. Even if they do, there are programs out there which do not do interstitial brachy for gyn cancers, and are still doing parametrial boosts. Some meet the interstitial requirement through eye plaques. Some would struggle meeting an increased number of T&Os if intracavitary numbers went up. Some programs don't even do any prostate brachy. Bottomline, these difficult decisions were made in the past. Programs did close down. Measures could be taken to protect the residents which would have their programs cut down or contracted. What's going on right now is that there is no leadership in this issue. Some of this is because their own programs would get hurt as a result of directly making some of these hard choices, and some of it is because they stand to benefit BIGLY from continuing this trend. I know for sure that seniors had less options this year and had little bargaining power. People are being told "take it or leave it, there are 50+ people begging for this job". The worst is just beginning. With the growth of "academic" satellites, programs are now able to count these potential cases to continue to expand.

 

[stcl]

I'm curious what people think about this: Even if there is expansion of trainees as has been discussed, isn't it possible that the job market will turn around once older radiation oncologists retire in coming years? The radiology forums here were talking about the demise of the rads job market some years back, and now it's arguably improved since then as more radiologists have retired. People who went into radiology in 2011-12 are probably pretty happy right now.

 

[RickyScott]

I'm curious what people think about this: Even if there is expansion of trainees as has been discussed, isn't it possible that the job market will turn around once older radiation oncologists retire in coming years? The radiology forums here were talking about the demise of the rads job market some years back, and now it's arguably improved since then as more radiologists have retired. People who went into radiology in 2011-12 are probably pretty happy right now.[/QUOTE

hypofractionation and disease management changed

 

[thecarbonionangle]

I'm curious what people think about this: Even if there is expansion of trainees as has been discussed, isn't it possible that the job market will turn around once older radiation oncologists retire in coming years? The radiology forums here were talking about the demise of the rads job market some years back, and now it's arguably improved since then as more radiologists have retired. People who went into radiology in 2011-12 are probably pretty happy right now.

Didn't radiology contract the number of diagnostic spots and turned some of these spots into IR residencies? The baby boomers aren't retiring any time soon. Some of them will be leaving their centres only when they die. They have many years to continue to do damage.

 

[Fpg1245]

Baby boomers aren’t going anywhere. Why would they? They get paid well and from what I’m seeing don’t need to work all that hard while the junior peons get dumped on with train wreck cases for half the salary. A lot of them didn’t save enough when the going was good and they likely have 20 or 30 something year old kids still latched on to them in one form or another. Wouldn’t be surprised to find one slumped over in a desk while checking films.

 

[DrfluffyMD]

Didn't radiology contract the number of diagnostic spots and turned some of these spots into IR residencies? The baby boomers aren't retiring any time soon. Some of them will be leaving their centres only when they die. They have many years to continue to do damage.

Radiology contracted maybe 50 or so spots and turned them into IR.

I am one of the last class of IR fellow and there are around 260 in the current class (250 or so in my class next year). Current fellow is definity having trouble with full IR jobs.

Thankfully, due to the IR fellowship to IR residency switch, the number of integrated IR spots are now down to the hundreds and the clinical training period went from one to two, essentially halfing the pool of IR trainees. I feel fortunate that this is happening in my eary career.

 

[Becquerel]

To the best of my knowledge, no collective body within radiation oncology has ever expressly restricted radiation oncology resident slots because of a concern about poor job prospects. Individual programs may have done this, but this is not illegal because they are not acting collectively. Any collective action taken in the 90s was done (at least ostensibly) for reasons related to the quality of the training and not to reduce the number of graduates. Nothing in the Crewson 1999 article suggests otherwise. Similarly, I am not aware of any collective action to reduce the number of trainees taken by other specialties (derm, neruosurgery, etc.) that was done for the express purpose of mitigating an oversupply. Perhaps there have been gentlemen's agreements not to expand in other specialties, but this is pure conjecture.

Continuing to push the conspiracy theory and arguing that antitrust concerns are not a major and legitimate barrier to collective action is counterproductive. ACGME, ASTRO, ADROP, SCAROP and all other other collective radiation oncology bodies will NEVER reduce the number of residency slots because of a perceived oversupply. Dr. Royce was absolutely correct when he wrote that "collaborative workforce self-regulation by accrediting bodies is prohibited by antitrust and fair-trade law." He was not "parroting a BS line" (as OTN said), but stating a fact with appropriate literature support.

As an aside, I will say that I agree wholeheartedly with the comments on this forum that the market for resident applications is very imperfect, casting serious doubt on the appropriateness and practicality of a market-based solution. The informational asymmetries are substantial and cause medical student applicants to make significant errors, while allowing programs to expand beyond their ability to competently train residents without a market penalty. Training program-specific employment data, including compensation details, would go a long way in this regard.

I also agree that ACGME accreditation standards may be too lenient and that stricter standards are likely necessary to ensure competent graduates. However, this is a separate issue that must be addressed without regard to any perceived oversupply. If changing ACGME requirements happens to mitigate the oversupply, that can be no more than a lucky happenstance. In some sense, training programs are attempting to have their cake and eat it too insofar as they offer residencies that meet purportedly adequate accreditation standards but then offer those same graduates fellowships that are allegedly needed to competently practice radiation oncology. If one argues that the rise in fellowships has been driven by genuine training gaps (a highly doubtful statement but one that is often espoused by training programs), then it seems natural to conclude that ACGME residency accreditation standards have not sufficiently kept pace with the changing demands of radiation oncology.

 

[maruchan]

Thank you Becquerel for the practical, high-quality discussion.

For me, the big takeaway from the combination of your posts and evilbooyah's and Chartreuse Wombat's: there are indeed serious barriers to directly addressing the oversupply issue. Whether it's a real legal issue or only a perceived one probably doesn't matter from a practical perspective.

ACGME accreditation standards on the other hand are a real problem and may be a more actionable issue. Current minimum case numbers are clearly insufficient for modern practice of radiation oncology.

I must though ask you to reconsider your thinking on the following:

As an aside, I will say that I agree wholeheartedly with the comments on this forum that the market for resident applications is very imperfect, casting serious doubt on the appropriateness and practicality of a market-based solution. The informational asymmetries are substantial and cause medical student applicants to make significant errors, while allowing programs to expand beyond their ability to competently train residents without a market penalty. Training program-specific employment data, including compensation details, would go a long way in this regard.

The rad onc residency market is not a free market and is subject to restrictions that make a free-market solution impossible. "Serious doubt" is not a strong enough phrase. Furthermore, informational asymmetries are not the root of the issue or even a contributor at all to the issue.

Hopefully this example helps illustrate the point. If a program openly said "all our graduates require palliative care and SRS fellowships to be fully trained before finding employment with below-median income in the rural Midwest" -- that program would 100% still fill with an IMG who would rather do rad onc than do family medicine or be unemployed. Since the position still fills, the number of graduating radiation oncology residents does not change and the supply does not change.