SDN Rad Onc mentioned in ASTROnews

[evilbooyaa]

@Becquerel, I see your point about that it wasn't exclusively for workplace regulation. And that's fine, but let's increase the requirements and see programs contract their residency numbers as they struggle to meet the new numbers. Just like with what happened in 1997.

To me the matter of increasing minimum requirements of case numbers for residents needs to be driven by the utilization of radiation in the current setting.

Pediatrics is not common, and I don't feel has to be changed significantly. Radiating children with solid tumors is NOT something I would feel comfortable doing in a community setting as an attending and would refer to my local children's hospital. I have no doubt that somebody who sees high volume of pediatrics would be able to care for a Medullo better than me as an attending.

However, SRS/SBRT indications are growing significantly, and this increase in usage means that residents need to be able to graduate residency with good competency to be able to do SRS/SBRT. 20 and 10 cases, respectively, are painfully low in this matter. The diminished usage of brachytherapy is actively hurting patients (at least those with cervical cancer, and likely those with prostate cancer per ASCENDE-RT), and I think a program that cannot provide a robust enough brachytherapy experience for each and everyone of their residents needs to be really scrutinized.

The CORE issue of this, however, is the fact that the leadership at the top has ZERO motivation to enact any changes that increase the minimum requirements for graduation for a resident. I really hope that I'm not the first person who has thought of this as a solution (albeit an indirect one) to the residency expansion issue, as this exact thing was essentially done 20 years ago.

Finally: Some are saying that academic facilities can use satellites to supplant their 'case volume' numbers. Unless residents are going to those satellites for rotations, that is an absolute mockery of what case volume is supposed to represent. If a place has 7 satellites but residents only rotate at 2 or 3, then those 2 or 3 should be included in the case numbers.

I sarcastically look forward to the day that a program has 4 residents per year, and residents rotate at one of 7 satellites throughout the course of their 4 year residency.

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[Irradi8or]

To me the matter of increasing minimum requirements of case numbers for residents needs to be driven by the utilization of radiation in the current setting.

Another challenge with changing (increasing) minimum programmatic requirements for Rad Onc programs is the constituency of the ACGME Rad Onc RRC itself (see link and image below). It consists of (not surprisingly) a highly academic group with physicians from relatively large programs that have expanded in recent years.

 

[RickyScott]

Another challenge with changing (increasing) minimum programmatic requirements for Rad Onc programs is the constituency of the ACGME Rad Onc RRC itself (see link and image below). It consists of (not surprisingly) a highly academic group with physicians from relatively large programs that have expanded in recent years.


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... of course... thats why if you want your voice ultimately heard- it would be through ACRO not astro. ASTRO is negatively affecting the livelihood of the majority of radiation oncologists, and its true economic interests (ultra high prices/rates/exemptions at these large academic hospital systems) is also not aligned with the societal good... and a drop in resident/new attending in membership/enrollment will be noticed. (by the way, there are many internal reasons why these programs prefer residents over np/pa's.)
Dont give them legitimacy.

I would also point out that if you are a junior/midlevel attending at one of these large institutions, having no lateral mobility or leverage due to the job situation is very damaging to your career.

 

[Haybrant]

free market? ha. this is a centralized system 100% through and through and you simply will not be let into the room to make any useful decisions or have your voice heard. Havent had a chance to read the whole article but truthfully it doesn't matter what it says. If you are a medical student right now, and you want to make an informed decision you can discuss the market with your academic advisors (who have no clue what is going on beyond the walls of their box, literally 0 clue) or you come here where you will learn what the masses know. There is no journal or article written that will give you the understanding that we provide you with here. And many of us have said it before, rad onc is a great clinical field probably the best in medicine. But there is a lot of good in a lot of fields that will not have the same pressures of job restriction, diminishing supply, no authority for young physicians that rad onc has

The boomers are not going anywhere, many of them will try to weasel you over for pennies (what else are these **** fellowships they keep throwing out there) and truthfully they are scared that information like this is so easily accessible now (the chair and vice chairs who treat no patients will be making >650-700k a year while you will slave for 200-250 at many academic places and beg for a rvu bonus) - This really isn't a field you want to go into right now so choose wisely and take w a grain of salt what centralized sources of information are telling you.

 

[Irradi8or]

There should seriously be a Choosing Wisely campaign aimed at medical students who are choosing their careers.

it would be through ACRO not astro

RickyScott - for those of us who haven't spent as much time with ACRO, can you send some links to point us to getting more info on ACRO initiatives in this area?

 

[Mandelin Rain]

Choosing Wisely - Medical Student Edition

Lesson 1: How to not buy Whole Life Insurance.

 

[nkmiami]

Choosing Wisely - Medical Student Edition

Lesson 1: How to not buy Whole Life Insurance.

that was first piece of advice I got in residency.

 

[medgator]

There should seriously be a Choosing Wisely campaign aimed at medical students who are choosing their careers.




RickyScott - for those of us who haven't spent as much time with ACRO, can you send some links to point us to getting more info on ACRO initiatives in this area?

Should be an interesting annual meeting in a couple of weeks for those of you in in the Midwest and east coast that need to warm up....

Annual Meeting - American College of Radiation Oncology

 

[RickyScott]

There should seriously be a Choosing Wisely campaign aimed at medical students who are choosing their careers.




RickyScott - for those of us who haven't spent as much time with ACRO, can you send some links to point us to getting more info on ACRO initiatives in this area?

Honestly, I am not renewing my ASTRO membership, and have just joined ACRO. I dont see how the group's interest is so divergent from my own, as with ASTRO. Being a smaller organization, I would think, it would be easier to get involved and have your voice heard.

 

[scarbrtj]

Expand residency to eight years (rationale: current residency training is inadequate). It will solve a lot problems:
1) Residents will get an adequate case load/experience across all modalities (think of the amount of research that could be done!); fellowship would be a moot point
2) The academic programs will have a cheap labor boon
3) Those of us in the post-residency world will get a very nice labor force correction
Pie in the sky? Maybe. But if you don't think of a solution that shows all the academic programs some major teat, it's gonna be a no-go.

 

[Röntgen]

I’m glad the article catalyzed this discussion some, which is its intent for the broader audience (although admittedly could have done without the ad hominem jabs). It is meant to be a portrayal of the issues at hand from the resident perspective with a personal twist, not an endorsement of any “solution”; I agree with the free-market criticisms articulated by Maruchan and have criticized this approach previously, but to leave this idea out entirely would be error by omission, as evidenced by the Wallner article. I stand by the use of the word disgruntled, which in all sincerity was not used in the pejorative (and I apologize if it was interpreted as such) but as an accurate adjective of the prevailing sentiment. There are many examples on this site where attendings and trainees alike discourage the pursuit of this specialty; I have no issue with that. But clearly the message could have been better delivered.

Becquerel and Wombat are correct that ASTRO, ACGME or any accrediting body will not take overt collective action to reduce the number of residents. Off the record, I have spoken to ASTRO’s legal counsel about this and their interpretation of the law is very clear: that it is illegal. Interestingly, nearly every ASTRO committee meeting opens with something similar to the following pledge, “to carefully observe antitrust principles and refrain from any discussion that could be viewed as encouraging collective market action”. The rise and fall and rise of resident positions is well documented as posted above. Its hard to say what exactly happened now 20 years ago and in other specialties behind closed doors but clearly other specialties have these same issues.

At 2017 ASTRO we presented that the majority of constituents (53%, up 20% from 2012) are concerned about oversupply. In a desperate attempt to find a silver lining, we may have hit a plateau in residency expansion for the first time in a decade (also presented, 2014-2017 the number of spots have hovered between 185-200). It is plausible that the table banging and shouting has been heard by some and individual action (opposed to collective) is being taken to stem the tide, but of course this may be wishful thinking judging by some anecdotes and we will see with the next charting outcomes of the match coming out in this spring.

Again, speaking against as a resident, I can tell you that increasing the length of residency as suggested above sounds even “less palatable” and “crude”.

 

[RickyScott]

If ASTRO leadership (through their day jobs as chairs and program directors) created this problem (because of short term selfish motivation/tragedy of the commons), and they wont take overt action, how can residents and medstudents be expected to join or support the organization? Again, this is a unique situation not faced by other fields. Hypofractionation and disease management have a big role here, and its not like ASTRO isnt pushing something called "choose wisely"

 

[OTN]

So let's say ASTRO/whomever finds a reason to restrict residency positions, maybe quality, maybe inadequate brachy/SRS, who knows. Who is going to care? Who is going to sue? Residency funding is severely restricted and has been the bottleneck for MDs for some time now. Fewer government spending training radonc residents means more money for family practice/primary care, which is desperately needed. Is the federal government really going to care about a tiny specialty freeing up some money to be used in other fields? Is a medical student or resident really going to alienate the entire field they're trying to join by suing? No and no. Of COURSE when you ask one of ASTRO's lawyers what they recommend they're going to dive into CYA mode- no skin off their back to do so. At this point the damage done to the field far outweighs any potential problems from restricting residency #s, as I truly believe the odds that anything would happen are very, very close to zero, especially if ASTRO uses quality/case load to determine which programs need to contract. The bottom line is that the "leaders" in our field are weak, ineffective, and have done nothing to address what a majority of radoncs think is a very important issue in our field.

 

[nkmiami]

Previous antitrust lawsuit re resident wages (which failed) against ACGME was class action, so lawyers had strong financial incentive to pursue it. I also doubt someone is going to devote hundreds of thousands to challenging this. I actually ran this by antitrust lawyer (at home), who stated that it would be surprising if a challenge was ultimately successful. Courts inherently tend to defer (as they have in the past to ACGME) and are also heavily going to consider "public good/interest" since government subsidizes medical education, and residency slots, and having underemployed doctors is not in the public interest and could (encourage overutilization), especially when more funding and spots are needed in primary care.



wiki."..along with those of Richard Posner and other law and economics thinkers, were heavily influential in causing a shift in the U.S. Supreme Court's approach to antitrust laws since the 1970s, to be focused solely on what is best for the consumer rather than the company's practices.[44]


Ironically, monopolistic pricing by large health organizations, well I am sure ASTRO does not think that is anti-trust, and certainly in the public interest.

 

[seper]

Here is the problem in nutshell: other specialties restricted slots by gentlemen's agreements. You all would agree, the likes of Regine and Hahn are not gentlemen. They spill the problem into the public and site legal concerns... such a shame.

 

[maruchan]

I agree with the free-market criticisms articulated by Maruchan and have criticized this approach previously, but to leave this idea out entirely would be error by omission, as evidenced by the Wallner article.

It's unfortunate that every post I make is just me going on about this point but: calling the free-market approach "crude" implies something like "this is inelegant, but you know, maybe it could be somewhat valid." In reality, it's completely invalid. I'm not so much "criticizing" this approach as I am pointing out its factual inaccuracy.

I have to say again that the "free-market approach" thing is a very dangerous idea. You can see the seeds of the danger even in this thread. You have otherwise very intelligent people, who are firmly on the side of reform, going on about information asymmetries and choosing wisely for medical students -- these are completely irrelevant to the labor imbalance!

What happens when you go to the other side of the fence, where people are predisposed against reform? It's such a convenient idea to justify inaction. Unless this option is taken completely off the table, leadership can and will just continue telling themselves "let's just wait, the free market will take care of it." When it's a cold, hard fact that it won't.

 

[RickyScott]

It's unfortunate that every post I make is just me going on about this point but: calling the free-market approach "crude" implies something like "this is inelegant, but you know, maybe it could be somewhat valid." In reality, it's completely invalid. I'm not so much "criticizing" this approach as I am pointing out its factual inaccuracy.

I have to say again that the "free-market approach" thing is a very dangerous idea. You can see the seeds of the danger even in this thread. You have otherwise very intelligent people, who are firmly on the side of reform, going on about information asymmetries and choosing wisely for medical students -- these are completely irrelevant to the labor imbalance!

What happens when you go to the other side of the fence, where people are predisposed against reform? It's such a convenient idea to justify inaction. Unless this option is taken completely off the table, leadership can and will just continue telling themselves "let's just wait, the free market will take care of it." When it's a cold, hard fact that it won't.

And they will say this happens in all specialties from time to time, hypofractionation and disease management have nothing to do with the future job market.

 

[thecarbonionangle]

Ok if the general agreement is that our "leadership" is low energy, weak, small handed, what can be done about it? The way I see it is that these "leaders" are not just passively standing by and riding in with the horsemen and beholding the apocalypse, but actually ACTIVELY working against us. A lot of these "leaders" could care less since their program is not affected. They have 5+ residents and are not willing to lead by example by reducing their bloated numbers. Stanford even keeps a good amount of their residents as "fellows" for example, so they eat their young.

I find dubious the suggestion that "experts" opine there is nothing to do because of anti-trust laws. In law, there are never generalized consensus about the interpretation of laws. What these "experts" say is nothing but their opinion. This is why we have courts and disagreements about issues and multiple famous court cases show that consensus can be defeated. In the law, you also have to have STANDING. Who would challenge these moves? Who would actually sue?

 

[nkmiami]

Ok if the general agreement is that our "leadership" is low energy, weak, small handed, what can be done about it? The way I see it is that these "leaders" are not just passively standing by and riding in with the horsemen and beholding the apocalypse, but actually ACTIVELY working against us. A lot of these "leaders" could care less since their program is not affected. They have 5+ residents and are not willing to lead by example by reducing their bloated numbers. Stanford even keeps a good amount of their residents as "fellows" for example, so they eat their young.

I find dubious the suggestion that "experts" opine there is nothing to do because of anti-trust laws. In law, there are never generalized consensus about the interpretation of laws. What these "experts" say is nothing but their opinion. This is why we have courts and disagreements about issues and multiple famous court cases show that consensus can be defeated. In the law, you also have to have STANDING. Who would challenge these moves? Who would actually sue?

Absolutely, please see my above post- I actually spoke with anti-trust lawyer. IT IS NOT ILLEGAL. Obviously, it can be challenged, but the outcome is far from clear, and may need to be litigsated. The whole specialty board ACGME concept can be challenged as antitrust, and in essence was, but the courts consider what is in the publics best interest. The ACGME as a matter of policy may not want to get involved at all. ASTRO, our professional organization should.

One more thing, Can an FMG who is in fellowship/juniot attending for 4 years sit for the boards without having done a residency? I believe the answer is yes.

 

[medgator]

Can an FMG who is in fellowship/juniot attending for 4 years sit for the boards without having done a residency? I believe the answer is yes.

I think that used to happen quite a bit, not sure if that loophole was closed, or we just don't see it as much because there aren't as many IMGs/FMGs in the field...

 

[thecarbonionangle]

The FMG loophole still exists. The rule is the person has to come and stay for 4 years and then be able to take boards. I know of multiple people who had already done rad onc residency in another country, came and did a fellowship and secured academic faculty positions. This is not going away anytime soon. The people I've interacted taking advantage of this loophole are actually excellent physicians and clinitians, many rad onc and med onc trained.