"The Biryani Wars"

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When you look at this history of this specific forum ..

Early era: "What do rad oncs do? What are competitive programs? Is it hard to get into?" .. many general posts

Middle era: "Rad onc is super competitive. How do I get in?" .. mostly posts about how do I get in/here are my stats

Post-Middle era: Clinical cases and beginning of "state of the field" concerns .. my favorite, learned a lot.

Modern era: "The Biryani Wars" - the field is doomed vs the field is in transition but okay, freestanding vs hospitals, academics vs private, SDN vs Twitter, site neutral vs HOPPS + PPS exempt, fractionation is bad vs high total cost is bad, rural life vs city/suburb life, '96 Bulls vs '17 Warriors, PC vs the IDW.

And, the cleavages are cross cutting. Very rarely can you find a pattern - some academics feel that everything is collapsing, and some privates feel like everything is okay, some people like rural areas and biryani. Interestingly, no one that favors the modern style of the NBA with it's spacing and heavy emphasis on 3 pointers while agreeing with what happened in season 8 of GoT while being supportive of site neutral payments. There are no liberals vs conservatives. It's more parliamentary with many factions, with Alligator saying we need 0 spots and other favoring a freeze, with The Duke with his tales of woe and $125k salary for 70 hours a week and KHE whose shoulders are so tired from wheelbarrowing in many stacks of high society, daily. With clearly analytical (and logorrheic) Scarb and, well, the rest of us that write normally.

Seems like we are becoming a convoluted, rabble rousing bunch, with very strong feelings about many issues, but nothing really orderly about them. Even if there was a new association or a new leader, it seems like some significant proportion of radoncs would disagree with their main tenets.

The point of this is ... with the current power structure in place that has an organized platform (i.e. - supporters of the status quo - think ASTRO and the cheerleaders on Twitter), how will there ever be a movement if everyone disagrees about everything? The closest thing to a "victory" is PDs saying that they won't SOAP someone without interest in the field. No contraction or actual reduction in positions. No "real" changes in RRC requirements that would fundamentally change the number of grads or the training of the residents. Nothing suggested was taken up. We still get oral examined about rhabdomyosarcoma! We still can do interstitial vaginal cases legally with a frighteningly low number of cases, while pushing a button for Xofigo takes heaps of paperwork and "80 hours of didactics".

There has a to be organizing principles that people can agree with and have to define the fundamentals of who we are and what we want for radiation oncology in 2020s and beyond. We also need true leadership that is respected and can foment change. We should work on that.

That's all.
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RadsWFA1900 said:
I always thought that law was lame. If a conversation is allowed to continue indefinitely almost any word or topic possibility would be inevitable.
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I think the point is that discourse degrades over time on social media and related platforms. Other technologies that facilitate discourse don't always degrade. People write things that they would never say in a face to face conversation.
 
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Chana masala and aloo gobi
Veggie pakoras
Samosas
Garlic naan
So much mint and tamarind chutney
 
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I don't think any significant changes in the field will take place unless they are inevitable and reach a tipping point; i.e., there's no way to fill unmatched spots via SOAP if there aren't enough SOAP applicants to fill said spots. Whether the Rad Onc "powers that be" (as much as I hate using that phrase) like it or not, such a situation would have to change something about the field, for better or worse, especially if this excess number of unfilled spots became a recurring pattern from year to subsequent year. The question is: are we at that tipping point right now...or is this present situation just barely sustainable enough to keep things more or less the same?

Status quo reins supreme in life, unless something forces it otherwise. I hope things improve for the better, but I think people are kidding themselves when they think they can read the tea leaves and predict exactly where and what this specialty will (or will not) be in the future.
 
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bergonieandtribondeau said:
I don't think any significant changes in the field will take place unless they are inevitable and reach a tipping point; i.e., there's no way to fill unmatched spots via SOAP if there aren't enough SOAP applicants to fill said spots. Whether the Rad Onc "powers that be" (as much as I hate using that phrase) like it or not, such a situation would have to change something about the field, for better or worse, especially if this excess number of unfilled spots became a recurring pattern from year to subsequent year. The question is: are we at that tipping point right now...or is this present situation just barely sustainable enough to keep things more or less the same?

Status quo reins supreme in life, unless something forces it otherwise. I hope things improve for the better, but I think people are kidding themselves when they think they can read the tea leaves and predict exactly where and what this specialty will (or will not) be in the future.
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That’s why its helpful to look at path. 30% American applicants, 2 fellowships commonplace and the CAP does not think they have a problem.
 
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Eradicating arthritis like crazy.
 
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bergonieandtribondeau said:
I don't think any significant changes in the field will take place unless they are inevitable and reach a tipping point; i.e., there's no way to fill unmatched spots via SOAP if there aren't enough SOAP applicants to fill said spots. Whether the Rad Onc "powers that be" (as much as I hate using that phrase) like it or not, such a situation would have to change something about the field, for better or worse, especially if this excess number of unfilled spots became a recurring pattern from year to subsequent year. The question is: are we at that tipping point right now...or is this present situation just barely sustainable enough to keep things more or less the same?

Status quo reins supreme in life, unless something forces it otherwise. I hope things improve for the better, but I think people are kidding themselves when they think they can read the tea leaves and predict exactly where and what this specialty will (or will not) be in the future.
Click to expand...
I don't think people realize the huge capacity that exists in radiation oncology. I'm using the word "capacity" here in a very specific sense, and I may be misusing the word, but I can't think of a better one. Radiation oncologists don't realize the capacity, and people outside of rad onc SURE don't realize it. If they did, that would be a tipping point really. It would be big come to Jesus moment.

Yesterday, I saw 4 new patients. I simulated all of them and had their plans done by end of day, plus got a plan done on a cervical patient I'd seen prior. I was thinking: what if I did that level of work every day? I could. It would be a little tiring after a time, but totally doable. If one used the "old metrics" and saw ~5 new patients a day 5 times/week, this would equate to ~125 patients under treatment. No surprise that I'm not treating that many. I average 20-25 total. I'm therefore running at ~20% of my personal capacity. I mean I'm kind of like Cordarelle Patterson sprinting to haul in a pass at 4 mph. We all are!

Primary care doctors will easily see 20 or more patients a day. Med oncs do it too. Radiologists are reading much more than 20 scans a day. But radiation oncologists are medicine's tortoises. It's cultural though. I remember a young poster on here way back when talking about all the committee meetings he has per day, has an academic day, attends many hospital meetings, etc etc. That stuff doesn't pay the bills. Only doing clinical work and taking care of patients pays the bills. At least for most of medicine this is how it works. (Despite our better intentions, medicine is a business. Even for the academic rad onc chairmen... especially for the rad onc chairmen.)

So nobody is working at capacity in rad onc. A vast many of us could easily handle 3 or 4 times as many patients, and therefore handle more work. But there are so few patients to go around in America, and radiation oncologists have this culture and perception (it's a false one) that we're all busy and there's so much cancer in the world that we are adding residents and new rad oncs at a pace much faster than increasing work demands. There *is* no increasing work in reality, certainly no vast untapped cache of cancer patients out there, and every rad onc in America is performing far below his or her capacity! I'll not bore you with any calculations although @ROFallingDown I do love analysis :)

When you ask: "is this present situation just barely sustainable enough to keep things more or less the same?" Yes. Yes it is. I can predict this because this is how we have operated now for more than a decade. There is enough profit margin in rad onc, and med students still interested in rad onc, and it is a small enough and niche enough field that our indignities will be suffered in dribs and drabs, that things will never change. We can pack new rad oncs in as far as the eye can see I think. This is how things are and how they will be for a long time coming. Rad onc won't change in a Big Crunch. It'll be a heat death.
 
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I've had 55-60 patients under treatment myself, consistently, for 4-6 weeks before. I think that's about my limit without an NP.

"A vast many of us could easily handle 3 or 4 times as many patients" - I don't agree with this. You might be able to, but given my clinical experience with higher patient numbers, I don't think that statement is true for the vast many of us. I also don't think it wise to put that statement on a public forum which is read by public policy experts.

Edit: While my number of 60 is 3x 20, my partner is not able to handle a load much above 30 or so patients. I work very efficiently and think I'm pretty dialed-in. Doing a lot of brachy can also limit your ability to get to higher numbers as well.
 
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If all I ever had to do was see consults, do sims, and contour and then never think about patients again I could probably get to 120 patients on treat.

But that is not reality. I've carried 50 patients for spells. That's enough to me.
 
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scarbrtj said:
I don't think people realize the huge capacity that exists in radiation oncology. I'm using the word "capacity" here in a very specific sense, and I may be misusing the word, but I can't think of a better one. Radiation oncologists don't realize the capacity, and people outside of rad onc SURE don't realize it. If they did, that would be a tipping point really. It would be big come to Jesus moment.

Yesterday, I saw 4 new patients. I simulated all of them and had their plans done by end of day, plus got a plan done on a cervical patient I'd seen prior. I was thinking: what if I did that level of work every day? I could. It would be a little tiring after a time, but totally doable. If one used the "old metrics" and saw ~5 new patients a day 5 times/week, this would equate to ~125 patients under treatment. No surprise that I'm not treating that many. I average 20-25 total. I'm therefore running at ~20% of my personal capacity. I mean I'm kind of like Cordarelle Patterson sprinting to haul in a pass at 4 mph. We all are!

Primary care doctors will easily see 20 or more patients a day. Med oncs do it too. Radiologists are reading much more than 20 scans a day. But radiation oncologists are medicine's tortoises. It's cultural though. I remember a young poster on here way back when talking about all the committee meetings he has per day, has an academic day, attends many hospital meetings, etc etc. That stuff doesn't pay the bills. Only doing clinical work and taking care of patients pays the bills. At least for most of medicine this is how it works. (Despite our better intentions, medicine is a business. Even for the academic rad onc chairmen... especially for the rad onc chairmen.)

So nobody is working at capacity in rad onc. A vast many of us could easily handle 3 or 4 times as many patients, and therefore handle more work. But there are so few patients to go around in America, and radiation oncologists have this culture and perception (it's a false one) that we're all busy and there's so much cancer in the world that we are adding residents and new rad oncs at a pace much faster than increasing work demands. There *is* no increasing work in reality, certainly no vast untapped cache of cancer patients out there, and every rad onc in America is performing far below his or her capacity! I'll not bore you with any calculations although @ROFallingDown I do love analysis :)

When you ask: "is this present situation just barely sustainable enough to keep things more or less the same?" Yes. Yes it is. I can predict this because this is how we have operated now for more than a decade. There is enough profit margin in rad onc, and med students still interested in rad onc, and it is a small enough and niche enough field that our indignities will be suffered in dribs and drabs, that things will never change. We can pack new rad oncs in as far as the eye can see I think. This is how things are and how they will be for a long time coming. Rad onc won't change in a Big Crunch. It'll be a heat death.
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125 patients on treatment per day is not feasible. You would be quickly overwhelmed with OTVs and follow-ups.
 
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BruiservonWillebrand said:
125 patients on treatment per day is not feasible. You would be quickly overwhelmed with OTVs and follow-ups.
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never gotten close, but have always been in hospital departments, which have diff pt mix. I do think it would be doable in a freestanding center with 2 nps and large amount of prostate and early breast. For hospital setting, my experience ( relatively few prostate and breast in places i have worked), max 35-50 with mixed load (including inpts, icu, chemorads) before you start dropping ball, and will need good nursing support or pa. (i have never worked with good nursing support).
 
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Uncle Scar correct as usual

He’s not completely off. 125 is probably a bit high, but part of Rad onc is a construct. The OTV is a billing thing and if it did not exist, we would see on treatment patients PRN. Follow up patients- yeah we’ve debated this, but there are many patients that could be seen by the referrings or PCPs, especially prostate, breast, palliative, and many adjuvant or neoadjuvant patients.

Radoncs also love to tinker with the contours at the margins. Everyone has worked with the attending who is still there at 6.30p shaving slices off a GTV of a bone met case.

Make OTVs PRN, schedule more efficiently, can easily treat 35-40. Relax supervision, and boom, we can end this field in 5 years rather than 10-15!
 
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ROFallingDown said:
Uncle Scar correct as usual

He’s not completely off. 125 is probably a bit high, but part of Rad onc is a construct. The OTV is a billing thing and if it did not exist, we would see on treatment patients PRN. Follow up patients- yeah we’ve debated this, but there are many patients that could be seen by the referrings or PCPs, especially prostate, breast, palliative, and many adjuvant or neoadjuvant patients.

Radoncs also love to tinker with the contours at the margins. Everyone has worked with the attending who is still there at 6.30p shaving slices off a GTV of a bone met case.

Make OTVs PRN, schedule more efficiently, can easily treat 35-40. Relax supervision, and boom, we can end this field in 5 years rather than 10-15!
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Thoughts: you really dont need to follow breast and prostate more than once a year if they are asymptomatic, no suspicions of recurrence and followed by other surgeon/uro/medonc.
APM may ultimately decrease notes etc since you will no longer be justifying each charge?
 
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The 125 is a high high end gedankenexperiment. But I stand by ~4 new patients a day is possible if... a lot of other things fell in behind that. (Get NPs, cut down on OTVs eg in APM model, streamlined processes etc etc.) Four new patients a day is prob worth 60 under treatment in the hypofx era. But four a day is 20 new a week, 1000 new a year, per rad onc. If all of America’s 5000 rad oncs saw 1000 a year, you’re talking 5 million new rad onc patients per year. Right now best estimates are there are only 600,000 (at most... out of 1.8 million total new cancer patients per year) new rad onc patients a year. So we can all clearly see America’s rad oncs are functioning nowhere near their theoretical capacity. And yet, we need more?????
 
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RickyScott said:
Thoughts: you really dont need to follow breast and prostate more than once a year if they are asymptomatic, no suspicions of recurrence and followed by other surgeon/uro/medonc.
APM may ultimately decrease notes etc since you will no longer be justifying each charge?
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A lot of early stage breast, I see followed by radonc every 3-4 months in addition to surg onc and medonc (who have them on hormones). No sure the point of that? almost like radonc is insecure that they are not real doc or something.
 
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scarbrtj said:
The 125 is a high high end gedankenexperiment. But I stand by ~4 new patients a day is possible if... a lot of other things fell in behind that. (Get NPs, cut down on OTVs eg in APM model, streamlined processes etc etc.) Four new patients a day is prob worth 60 under treatment in the hypofx era. But four a day is 20 new a week, 1000 new a year, per rad onc. If all of America’s 5000 rad oncs saw 1000 a year, you’re talking 5 million new rad onc patients per year. Right now best estimates are there are only 600,000 (at most... out of 1.8 million total new cancer patients per year) new rad onc patients a year. So we can all clearly see America’s rad oncs are functioning nowhere near their theoretical capacity. And yet, we need more?????
Click to expand...

That's the thing about all these changes - APM, general supervision, the rise of the mid-levels, etc. It has the potential to reduce documentation/billing/OTV requirements, and make a single RadOnc much more efficient. Great for established practices and established, mid-career docs.

Terrible when combined with residency expansion.
 
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My breast follow up is 1 month (with NP for "survivorship"), 4 months, and 12 months for discharge.

This often feels like too much.
 
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elementaryschooleconomics said:
That's the thing about all these changes - APM, general supervision, the rise of the mid-levels, etc. It has the potential to reduce documentation/billing/OTV requirements, and make a single RadOnc much more efficient. Great for established practices and established, mid-career docs.

Terrible when combined with residency expansion.
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Don't forget the decline in reimbursement, which will give all required motivation to increase efficiency and volume.
 
elementaryschooleconomics said:
That's the thing about all these changes - APM, general supervision, the rise of the mid-levels, etc. It has the potential to reduce documentation/billing/OTV requirements, and make a single RadOnc much more efficient. Great for established practices and established, mid-career docs.

Terrible when combined with residency expansion.
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Efficiency, a necessity in most of medicine, has been the mother of inventing the need to work a lot more to make the same amount of money in most other specialties in medicine the last 20y or so. (Rad oncs and their tumor boards and committees and academic days and driving one hour one way to the satellite and so on are notoriously inefficient, which is almost an epithet in medicine nowadays.) When we get there in rad onc, ie “I’d like to work a lot more,” I don’t think that option will be there. I’d love to work more. I just don’t have the patients. They’re too divvied up methinks amongst all my fellow rad oncs. (Thus why the academic places needed to drink everyone else’s milkshake. Or eat their biryani.)
 
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I found this post via my google search for "cleavages," and I've never been so disappointed.
 
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RickyScott said:
A lot of early stage breast, I see followed by radonc every 3-4 months in addition to surg onc and medonc (who have them on hormones). No sure the point of that? almost like radonc is insecure that they are not real doc or something.
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Totally agree. It's a pet peeve of mine. Patients need to follow-up with any doc no more than q6 months. That's it. Can't help it if surgeons think they're the only ones that can order mammograms and med oncs think they're the only ones who can order bloodwork for HT...
 
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FrostyHammer said:
Totally agree. It's a pet peeve of mine. Patients need to follow-up with any doc no more than q6 months. That's it. Can't help it if surgeons think they're the only ones that can order mammograms and med oncs think they're the only ones who can order bloodwork for HT...
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Most of these pts have cardiologists etc as well. Spending their life at the doc.
 
Mandelin Rain said:
My breast follow up is 1 month (with NP for "survivorship"), 4 months, and 12 months for discharge.

This often feels like too much.
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I do 1 month, 6 months then yearly x 5 years. Agree this often feels like to much.
 
scarbrtj said:
I ain't mad one bit. But you know how much you get to bill for all that work you do (which I agree, is a lot) during the week? Zero, technically. Can do all that work and the patient has to zip out on OTV and you don't see 'em for a few minutes and no OTV charge for you. So yes the OTV encompasses many, many days' work (in theory). But in practice and reality it's just that single brief face-to-face. Thank God for the OTV though. It floats many boats.

I had a (semi) famous attending that just refused to do the face-to-face most times. All his OTVs still got billed of course. He made the arguments that 1) he did a lot of work during the week (checking their charts, etc., you know the spiel), and 2) when he would walk through the waiting room he would "see" the patients so.... that counted!
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He sounds like an attending I’ve worked with and to be honest I’ve used this myself.
 
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I had Biryani yesterday, thanks to this thread. It was my first time having biryani, and it was damn good, too. SDN should receive a cut of the proceeds.
 
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BRIM- your old photo was a middle aged Indian man. I thought you had biryani chops. Floored that you are a newbie. Welcome to the club, bhaisab!
 
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Anybody had some good vindaloo lately?
Curious to hear about the rad onc lamb vibdaloo rural scene.
 
I just get mine from Trader Joe's which is a paradox in and of itself

Urban enough to have a Trader Joe's yet rural enough to not have any good Indian restaurants...
 
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metallica81788 said:
I just get mine from Trader Joe's which is a paradox in and of itself

Urban enough to have a Trader Joe's yet rural enough to not have any good Indian restaurants...
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interesting i have never had the lamb vindaloo from there. I do love a good 3 buck chuck!
 
thecarbonionangle said:
interesting i have never had the lamb vindaloo from there. I do love a good 3 buck chuck!
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Learn to make your own vindaloo. It’s the only way to not be disappointed if you may need to live in a particularly Caucasian region. Especially during a global pandemic. I mean, what are the chances of that right????
 
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ramsesthenice said:
Learn to make your own vindaloo. It’s the only way to not be disappointed if you may need to live in a particularly Caucasian region. Especially during a global pandemic. I mean, what are the chances of that right????
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When the perfect $h!?storm of oversupply and a bad job market ensure you can't lateral into a place with good/any vindaloo....
 
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Brim said:
I had Biryani yesterday, thanks to this thread. It was my first time having biryani, and it was damn good, too. SDN should receive a cut of the proceeds.
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Folks need to take their Biriyani experience to the next level with Deer, or Elk.
 
RickyScott said:
or roadkill, which is quite the prize in some of these locations with job openings
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“That rotting dead possum is not so bad. Just take a bite. You will be ok. Your first job is not your last. Ain’t nothing some cracker barrel butter can’t fix! ”
 
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thecarbonionangle said:
“That rotting dead possum is not so bad. Just take a bite. You will be ok. Your first job is not your last. Ain’t nothing some cracker barrel butter can’t fix! ”
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Correction: crack barrel never did anything good for hemorrhoids or anal fissures. Food wise, I have to agree with you though.
 
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