The High Number of Unfilled Positions in the 2019 Radiation Oncology Residency Match: Temporary Variation or Indicator of Important Change?

[deleted941485]

if you are afraid of pissing med oncs off then you’re dead in the water. Besides what are you protecting anyway? When med Onc decides you are no longer useful poof you’re done evidence or no evidence. It doesn’t get much worse than that.

If they Dont want to send you brain Mets cases because they think the next ALK inhibitor will be better so be it. they are already pulling this crap at my place. Might as well take the gamble.

If they are so pissed they won’t even send for cases that require RT as the standard of care then you’ve got a real bunch of crooks on your hand that need to be exposed.

Referring patterns don’t techically start with Med Onc. They start with a PCP or a surgeon. Which goes to one of your points getting to them first. If you can get your pcps on key disease sites to see you first then you are in a much better position.

Everything else has pretty much been **** down at this point.

Limiting spots - no way

Interventional - told it will never work despite the fact that literally everyone is trying to get into the catheter/wire guide procedures

Industry - how many people do they realistically think they need for this sort of work?

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[Gfunk6]

A few counter-points I'd like to raise:

1. In California, when you have a medical license it legally lets you do anything within the scope of medicine and surgery. Therefore, a pediatrician could perform adult neurosurgery. Of course, no hospital in their right mind would offer to credential a pediatrician to do brain surgery. Therefore, just because you CAN do something, it doesn't mean you SHOULD.

2. If you were a Rad Onc who wants to prescribe any systemic agent or oral chemotherapy, it is not so simple as to write a prescription to CVS. Just like "prescribing" a dose of radiation is not so simple as writing it into MOSAIQ/Aria. You need to have a firm handle on chemotherapy infrastructure including: chemotherapy infusion hardware, infusion room operations, hiring certified chemo RNs who know what they are doing, using a third party (e.g. McKesson/Cardinal) to buy your drugs, have appropriate infrastructure to mix drugs, and know how much drug to purchase so that it doesn't go to waste. The average RO knows precisely jack about all the above and it would be next to impossible to learn in America's hyper-specialized environment.

3. You keep saying that Gyn Oncs Rx platinum so why can't we? The simple reason is that they learn to do this in fellowship. Doses, side effects, toxicity management, etc. ROs don't learn any of this.

4. You keep saying we shouldn't be afraid to "piss off Med Oncs." This statement belies a fundamental misunderstanding of where medicine is/has headed in the United States. There are fewer and fewer independent RO and independent MO groups - they will be wholly extinct within 10 years except in rural areas. Many groups are consolidated either through academics, a closed insurance system (Kaiser), or a mega-conglomerate of private practice docs. In all three scenarios you have MO/RO/Surgery working in tandem. Why the hell would I risk my license and engage in legally risky behavior for something I can send down the hallway?

The bottom line is that systemic/oral chemotherapy administration in the US will ALWAYS be held by MOs - that ship has sailed. The only small exceptions will be things like ADT or perhaps oral hormonal agents. The rest is a pipe dream. There is no logic to do it yourself: you need expensive infrastructure, you were not trained to do it, and there are others who can do it better. If you try to do it anyway, you are just setting yourself up for an exorbitant lawsuit.

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Consider for example, the simple scenario where a patient receives IV cisplatin and ends up going deaf. The patient hires a med mal lawyer and sues his treating physician. Imagine going to court in the following scenarios:

Lawyer: Dr. Smith, is it true that your prescription of platinum caused Ms. Jones to go deaf?
MO/RO: Yes.
Lawyer: And did you inform her that this was a possible complication?
MO/RO Yes.
Lawyer: And, Dr. Smith, could you please tell me your experience with this drug?

MO: Well, I completed a three year Heme Onc fellowship and have prescribed this medication 100s of times in practice and training. I am board-certified in Oncology so I am well aware of the side effects. I explained to Ms. Jones that while going deaf was a small risk, it was worth the risk for the greater survival benefit it offered in treating her cancer.

RO: Well, I never prescribed cisplatin in residency but I did talk to my Med Onc colleagues about it. I started prescribing it myself in my practice because I figured any ***** could do it.

 

[medgator]

if you are afraid of pissing med oncs off then you’re dead in the water. Besides what are you protecting anyway? When med Onc decides you are no longer useful poof you’re done evidence or no evidence. It doesn’t get much worse than that.

If they Dont want to send you brain Mets cases because they think the next ALK inhibitor will be better so be it. they are already pulling this crap at my place. Might as well take the gamble.

If they are so pissed they won’t even send for cases that require RT as the standard of care then you’ve got a real bunch of crooks on your hand that need to be exposed.

Referring patterns don’t techically start with Med Onc. They start with a PCP or a surgeon. Which goes to one of your points getting to them first. If you can get your pcps on key disease sites to see you first then you are in a much better position.

Everything else has pretty much been **** down at this point.

Limiting spots - no way

Interventional - told it will never work despite the fact that literally everyone is trying to get into the catheter/wire guide procedures

Industry - how many people do they realistically think they need for this sort of work?

Completely agree with all the above, but a combined training path will only be viable for future grads coming out, not those of us already in existing practice.

I reverse refer a decent amount of my lung/h&n and occasional locally advanced skin pts out for concurrent therapy. I'm too busy to even consider doing anything outside of lupron for my prostate pts.

The key to saving our specialty is embracing our strengths and cutting supply to meet demand via holding our leadership responsible and calling out the ASTRO gaslighting for what it is.

Everything else is window dressing/blowing smoke. It would be political suicide to start competing with MO, not to mention a huge liability as gfunk alluded to. Imo only weak ROs depend on med onc exclusively for definitive patients, so if you're a strong RO, this is not a solution that will help.

 

[deleted774703]

Thank you @Gfunk6

That’s exactly what I am thinking as well.

It’s not about being “scared” of med Onc. It’s about being savvy politically.