To Medical Students Considering Rad Onc - Perspectives on the Future by an Optimist

[fiji128]

I know of 4 rad onc locums in my tinny part of one state so noway there are just 24 throughout out the entire country.

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[OTN]

I know of 4 rad onc locums in my tinny part of one state so noway there are just 24 throughout out the entire country.

I know of 4 in my relatively small area as well. 24 is an order of magnitude too small of a number.

 

[seper]

there are locums that also have part time or full time permanent jobs

 

[medgator]

there are locums that also have part time or full time permanent jobs

Yup.. "locums to perm"

 

[deleted18755]

A recent thread stated, “the demand for rad onc just died,” after discussion that CMS is modifying the supervision level required in hospital-associated practices. This view could not be more pessimistic and in my opinion, wrong. While some of the concerns are valid, I am skeptical this will have the catastrophic effect so confidently predicted. Perhaps there will be a decrease in demand/staffing in rural practices - it is just too early to know. However, I suspect many practices will not be interested in the increased liability or operational troubles associated with leaving facilities un-supervised, particularly for SBRTs. I predict this rule is ultimately amended in the future but we will see. Regardless, for many already in established practices, this will be a welcome change due to the increased flexibility.

You make some very good points but on this one I think your lack of real world experience is showing...

Many of these "rural practices" treat something like 10-15 patients a day (oftentimes falling into single digits . . . and even that is without hypofractionation of breast let alone prostate). I've worked in these centers and while some days get very busy many days it is mind numbling boring with literally nothing to do but sit there because we (had) to do so. They don't do SBRT, or maybe they do infrequently, but in any event why not just do SBRT every other day and staff the place 2 or 3 days per week. A lot of these centers don't have any competition so it's not like the referring physician will send a patient 50 miles away to the next closest center on Thursday since the local center is only staffed M, W, F by a physician.

As is, any average rad onc can easily manage that volume in 2-3 days/week onsite plus once the bundled payments come through and they hypofractionate all their breast and prostate I'm not sure there is even 2-3 days worth of work for the physician and staff. I have no sympathy for centers that are staying open in the year 2019 just because they refuse to hypofractionate even the most appropriate cases but the reality is that a lot of such centers exist and when they close there will be even less jobs.

Most (or at least many) of these changes are good for society and patients*, and won't change the fact that radiation oncology is the best field in all of medicine, but it will obviously change the demand for practicing radiation oncologists.

* Addendum: and practicing radiation oncologists . . . now I can come into a rural center that provides literally life saving therapies and knock out 2-3 days worth of work in 2-3 days (vs 5), which makes me more money while improving my job satisfaction since I'm more satisfied at work since I'm more productive and less bored. Most of us on here have been appropriately hypofractionating for many years so bundled payments won't kill us.

In many ways all of this is a win/win/win for patients, society, and physicians . . . we just have to be realistic and acknowledge that we simply don't need 200 graduating radiation oncologists every year and just make the supply of physicians match the demand and literally everybody wins and is happy!

 

[Lamount]

It's remarkable how angry some people become when you tell them you are happy...

 

[RSAOaky]

You quoted a survey with a 25% response rate as evidence that graduating residents are happy with their jobs...

You can love a field and still be pessimistic about the future. I think I've made this point in most of my posts and I'd venture to guest that even SDN's biggest malcontents still love what they do. As far as the labor market goes, I didn't find it to be particularly strong 2 years ago when I applied. Perhaps you can comment in a year when you do.

We may be going through a period of job expansion as large hospital systems build satellites to treat 10-15 patients so that they can grab a foothold in competitive markets. My institution is doing that right now. These are not high quality jobs. You will earn an entry level salary with little advancement from there. You quote a $500k MGMA median salary but you will be lucky to top out at $350-400k in these jobs and as the supply of radonc increases, thes salaries will drop. Up until recently, these jobs had to be staffed by a radonc, hence some jobs opening up. Recent CMS rulings mean this will no longer be the case. I can tell you right now that the conversations my partners and I had 6 months ago about the potential need to add a radonc for coverage when we add another fancy satellite next year has become a non-starter. This is great for us. We have a job. We can treat more patients and not worry about coverage. We can potentially convince hospital administration to give us a raise when that does happen. However, this is bad for you and this is bad for everyone that comes after you because that's a potential job that is not going to exist anymore.

I think that we are really at a tipping point. I don't want to belabor the point about residency expansion but there will be 800 new radiation oncologists over the next 4 years. The job market now may seem reasonable to new grads because they are looking for entry level positions and are not thinking about future prospects. Additionally, older radoncs that delayed retirement over the last decade may finally be retiring at a time when hospital expansion is adding new low quality satellite jobs.

In 2015 There were 5000 radiation oncologists in the United States. We've added about 800 since and will add 1600 more over the next 8 years. In a 12 year period, the supply of radiation oncologists will have risen by almost 50%. Sure we will lose some to retirement, death, and dismemberment, but I'd venture to guess that the attrition isn't that high and the attrition rates are going to drop further and further as we keep increasing the supply of YOUNG radoncs.

So lets say you are an MS3 thinking about applying to radonc, with 7 years until your first job and 12 years until your peak earning potential. In that period of time, the supply of labor will have increased by almost 50% with a majority of those people wanting to be in places that you probably want to be as well. The field is great. The state of the field is not. If you are optimistic about the state of the field then you are being naive.

 

[medgator]

You can love a field and still be pessimistic about the future. I think I've made this point in most of my posts and I'd venture to guest that even SDN's biggest malcontents still love what they do.

Exactly how I feel. There used to be decent jobs when I left training. Certainly barely enough to support the 120-130 of us that were graduating every year, but they were still out there

 

[elementaryschooleconomics]

It's remarkable how angry some people become when you tell them you are happy...

Can you expand on what you mean in the context of this thread? I can interpret this a few ways, haha.

I feel like the gestalt of 2019 SDN is often misinterpreted. One of my colleagues, after reading one of the (many) job-related threads, said (direct quote) - "man, those people really hate Radiation Oncology". I feel like that's demonstrably untrue. Overall, everyone here seems to have positive (optimistic) opinions about using radiation to treat and cure cancer - there have been amazing advances over the previous few decades.

The negativity/anger stems mostly from the concern that we're training too many radiation oncologists - the supply is vastly outpacing demand.

The negativity/anger is rarely phrased as "man do I hate curing cancer with fewer side effects".

 

[RickyScott]

e jobs.

In 2015 There were 5000 radiation oncologists in the United States. We've added about 800 since and will add 1600 more over the next 8 years. In a 12 year period, the supply of radiation oncologists will have risen by almost 50%. Sure we will lose some to retirement, death, and dismemberment, but I'd venture to guess that the attrition isn't that high and the attrition rates are going to drop further and further as we keep increasing the supply of YOUNG radoncs.

SCAROP editorial said there are 4000 radoncs? and we are adding 1000 over next 5 years.

 

[RSAOaky]

SCAROP editorial said there are 4000 radoncs? and we are adding 1000 over next 5 years.

Honestly, I just googled how many radoncs in the united states and the first thing that popped up was that there were 5000 in 2015.

 

[scarbrtj]

Exactly how I feel. There used to be decent jobs when I left training. Certainly barely enough to support the 120-130 of us that were graduating every year, but they were still out there

~50 years ago, this was the rad onc landscape per Paul Wallner DO:

"...jobs were plentiful, and we were seeing an explosive growth in training programs."

I'll take "Things Future Rad Oncs Will Never Say in the Next 50 Years " for $1000, Alex.

SCAROP editorial said there are 4000 radoncs? and we are adding 1000 over next 5 years.

See here. It is likely 5000. at least.

 

[Old rad onc]

No. However, you are open to having your own (real) optimism about the field.

I am optimistic that the field will correct with strong action on the residency landscape based on the results of the match this year.

I'm optimistic that the things SDN is saying will continue to make their way into mainstream rad onc thoughts. I'm optimistic because I know people of relative power (RRC, ARRO, etc.) read SDN and are able to take anonymous frustrations and convert them into real 'data' (as much as surveys can be data) for consumption by the remainder of the rad onc community. And at the end of the day, I think we as a field pull out of this, eventually. The day is darkest before the dawn, etc. etc.

I'm optimistic that with site-neutral payments as part of the APM, formation of private practice groups will rebound, and while the technical reimbursement unicorn is likely lost forever, high-quality physician owned private
practice can continue to exist.

As part of the apparent small number of malcontents, I do need to reply but I am a bit torn by the whole optimist/pessimist view of rad onc. I am by nature an optimist which is how I survived all the shenanigans I went through for my first 10 years in the field starting in the 1990’s. I went into the field and loved it and money was not even an issue for why I became an oncologist. I was shocked when I learned the average doc made 270000.My starting salary was 125k and I was happy with that compared to 40k as chief resident. I have felt for some time that while money and happiness are not necessarily linked, not finding a job after many years of sacrifice due to shark infested waters is a crime. I love my work and feel I have been amongst the luckiest men alive to have been in the greatest field and have had 3/3 of pay, location, and lifestyle.

I will say that the docs that have picked derm, rad onc, ortho, rads, etc are overachieving, wanting certainty that comes from wanting to go to Harvard, medicine , Silicon Valley, business school. So I say to everyone, life is uncertain, those that succeed learn to navigate the difficulties of life that are certainly coming whether the job market is golden are sucks. I am not for talking med students out of our field as it will fill with either AOA geniuses or less gifted ones. But being a genius rad onc does not mean a better doctor. So being a young rad onc with great knowledge about the latest trials and skills does not automatically make for a superior one compared to an old one with experience

Now having said my optimistic side, I am also with the group that thinks the academics are selling out the future for their own personal gain today. By having cheap labor of residents and fellows now, little plan of the future will create what should be avoidable problems of the future. Those complaining really have no particular stake as we all already have good jobs. And in fact will likely make some money off the cheap labor that is likely coming. They are emotionally involved for the future of the field and for the younglings. But you do have the right to think for yourselves and the truth will come in time. The match Armageddon is in small part due to us, but applicants see it too because they want their sure thing. But no field is guaranteed. Not derm, not even being a doctor. So do what you love and the money may follow. And if it doesn’t hopefully you will still like what you do. But don’t blame people in SDN. Every month we get a med student who wants to know about the job market and the future.

We cannot help but give our perspective that too many residents, not enough work. But who really knows. They promised more cancer and more work 10 years ago so we expanded. No one predicted hypofrac and SBRT or Obamacare or bundled payments or supervision. But I guess we ask why are we still expanding? I am curious which programs are cutting as claimed....... so yes I’m an optimist and I will keep working until I don’t want to. So don’t try to kick me out!

 

[thaddeus]

I don’t think you understand how capitalism or the USA works

I can provide a cancer patient with world class care while being empathetic and simultaneously be well compensated for it

I would much rather lose ppl like you from our field who would let CMS and admins walk all over them for the “love of the game”

Yikes. I won't take the bait on that first bit of asinine rhetoric. We can have a debate on a separate thread about how well our ostensibly capitalist health care system has served our fellow citizens.

My point here was pretty simple, and I think blown way out of proportion by the swarming malcontents. Traditionally there have been many excellent reasons to go into rad onc, including intellectual stimulation, rewarding patient population, reasonable hours and lifestyle, and high pay. We all have our reasons for making personal and career choices, and I'm not judging anyone else's reasons. For a variety of factors that have been amply described, the last reason is no longer as compelling as it used to be. I am not saying this change is a good thing, its just a fact. So if your primary motivation for looking into rad onc is to make lots of money, I would encourage you to look elsewhere, as you will likely be unsatisfied in our field. I don't see how this is at all controversial. If your primary motivation is one of the other wonderful things about the field, and you would be happy with a comfortable-but-not-extravagant salary in the 300-400k range, come on in, the water's fine.

This is supposed to be a thread about optimism, but any optimistic statement gets instantly crushed by a barrage of insults and regugitation of the same tired memes that infect every thread on sdn. I agree its important for med students to hear some different perspectives.

 

[deleted774703]

would you be OK if 10 years out from training you were making ~350k instead of ~550k? If the answer is no, then you should look for another speciality. And, honestly, our field will be better off if you do. Cancer patients deserve doctors who care more about treating cancer patients than their portfolio balance. If we lose some bright-but-financially-motivated med students because of current changes I'm good with that.

It’s totally fine to be optimistic. What’s irritating is ppl like you telling us

1) we should be happy go lucky about our compensation going down or
2) not trying to reach your full earning potential based on the ridiculous money we have made for hospitals with our sweat labor
3) or as you stated we are better off if we lose ppl who want to make more money

The day you start to become complacent about ppl taking away your cash or privileges is when admins start taking away more

Also stop acting all high and mighty. We all care about cancer pts. Of course They deserve good doctors. Stop acting like this fact is exclusive to cancer patients.

Finally You can be a good doctor while wanting to be paid appropriately

 

[Mandelin Rain]

The path to demonstrating that you care about patients in rad onc reminds me of the trials that Indiana Jones went through in Last Crusade.

1. Graduate top of your medical school class with excellent cancer related references and research.
2. Spend 5 year residency in some city neither you, nor your spouse likely have any desire to be in.
3. Pass rigorous 4 step boarding process, where any year they could decide to cut the head off the non-penitent.
4. Take a leap of faith in a job knowing that there are many "free fall" and "poorly chosen" options out there.
5. Arrive at the reward for hard work and realize there's only 60% of a Grail and it doesn't hold any water. The rest is being shared by the hospital admins down the hall. Blindly be okay with this.

Only in this journey will you prove your worth.

EDIT: On second thought, we also need you to leave a pound of flesh over there, or else the field will be better without you.

 

[Lamount]

Can you expand on what you mean in the context of this thread? I can interpret this a few ways, haha.

I feel like the gestalt of 2019 SDN is often misinterpreted. One of my colleagues, after reading one of the (many) job-related threads, said (direct quote) - "man, those people really hate Radiation Oncology". I feel like that's demonstrably untrue. Overall, everyone here seems to have positive (optimistic) opinions about using radiation to treat and cure cancer - there have been amazing advances over the previous few decades.

The negativity/anger stems mostly from the concern that we're training too many radiation oncologists - the supply is vastly outpacing demand.

The negativity/anger is rarely phrased as "man do I hate curing cancer with fewer side effects".

Consider that this forum is to discuss the entirety of our field ("curing cancer with few side effects", inclusive), yet 90% of the posts seem to imply (or outright state) that we are in the end-times.

Do you spend 90% of your day in clinic worrying about the job market?

 

[medgator]

Do you spend 90% of your day in clinic worrying about the job market?

Not at all. Do you think it's fair to current applicants and prospective ones to ignore the elephant in the room, esp given recent developments?

 

[evilbooyaa]

Consider that this forum is to discuss the entirety of our field ("curing cancer with few side effects", inclusive), yet 90% of the posts seem to imply (or outright state) that we are in the end-times.

Do you spend 90% of your day in clinic worrying about the job market?

Of course not (although it's maybe 25-50% of my time as a current PGY-5), but most of what we do is relatively standard with some variations in practice. People discuss tough cases (although I will admit that Mednet likely does that better than SDN since it's not 'anonymous' and you can tell who is actually recommending x,y,z), but I don't expect people to have long discussions on how to treat stage I breast cancer.

But I see your point - let me think of some exampels of how people treat and we can maybe spark some discussion about that.

 

[elementaryschooleconomics]

Consider that this forum is to discuss the entirety of our field ("curing cancer with few side effects", inclusive), yet 90% of the posts seem to imply (or outright state) that we are in the end-times.

Do you spend 90% of your day in clinic worrying about the job market?

Ah, OK, now I can understand the "SDN malcontent" phenotype better if that's how you (and presumably others) approach this.

I use different platforms for different reasons.

As @evilbooyaa mentioned above, I use Mednet for discussion of actual cases.

I use Twitter to stay up to date on potentially impactful new literature (both clinical and bench-based), as well as to stay current on whatever Virtue Signaling is hot this week (is it gender-based, perhaps Step 1 scores?).

I use SDN to engage in gloves-off debates about things that would be potentially harmful to my career if I discussed them openly elsewhere.

But to summarize, I love the field of Radiation Oncology, I love the patients and the treatments and the advances. I abhor the job market/economics of Radiation Oncology, and spend a huge amount of time thinking about it as a senior resident about to try to find a job.

 

[Lamount]

Sure, but that's all theoretical assuming you get a decent job in a decent location.

We all know it's a great field and no one on SDN has ever questioned that. I love my job. I really do. Unfortunately jobs like mine are like unicorns these days.

What's the point of being optimistic if you don't find a job during senior year and get forced into some unaccredited fellowship or exploitative job situation?

This is reality:

It's worth noting that not everyone who does a fellowship was "forced" into it. For me, I had reasonable job offers but lacked clinical training in an area that I wanted to do research... and wasn't receiving many offers from places that would have allowed me to continue this research. A fellowship opened the door for me to get a "unicorn" job that afforded me the necessary opportunities, time, resources, and financial support ... and I couldn't be happier with my choice.

This is my unique perspective -equally valid as any other FIRST HAND account.

 

[Lamount]

Regarding the survey data from Kahn et al., while it certainly is compelling that 91% of residents are concerned about the job market and 72% rank it among their top 3 concerns, there are no data quantifying HOW CONCERNED the residents are. After all, they were given a list of 14 issues and asked to rank them in order of how "concerning" they find these issues... e.g. "if I had to pick something that was concerning me, I would choose __________". (just like 90% of Americans are in favor of background checks for firearm purchases, but only a sliver would admit that this issue will impact their vote) Supporting this notion is the finding (further down in the article) that 47% of those surveyed (numbers getting small) said that they perceived the 2018 job market to be equally or less competitive compared to 2016... which is also consistent with the a similar number of ASTRO postings between these two years.

Any person who publicly expresses the smallest shred of optimism vis a vis radiation oncology is portrayed by some here to be either naive or nefarious. It's not that most optimists deny the significant structural issues facing our field (i.e. out-of-control residency expansion, changing payment models, increased use of hypoFrac), it's just that we think going into rad onc is STILL worth it. Consider that there likely more of us than you think. Many simply have more common sense than me and acknowledge the futility in arguing with people dead-set on remaining pessimists.

 

[medgator]

It's worth noting that not everyone who does a fellowship was "forced" into it. For me, I had reasonable job offers but lacked clinical training in an area that I wanted to do research... and wasn't receiving many offers from places that would have allowed me to continue this research. A fellowship opened the door for me to get a "unicorn" job that afforded me the necessary opportunities, time, resources, and financial support ... and I couldn't be happier with my choice.

This is my unique perspective -equally valid as any other FIRST HAND account.

I also have first hand experience from 2 people that took fellowships to wait out the job market for a year.

Bottom line is that fellowships are increasing in number despite the fact that none of them are accredited by the acgme.

The bigger question is why your residency program lacked the training, unless we are talking protons or something. Upping requirements would fix a lot of these problems and reduce the number of unnecessary/questionable fellowships in things like igrt/sbrt etc

 

[Lamount]

Ah, OK, now I can understand the "SDN malcontent" phenotype better if that's how you (and presumably others) approach this.

I use different platforms for different reasons.

As @evilbooyaa mentioned above, I use Mednet for discussion of actual cases.

I use Twitter to stay up to date on potentially impactful new literature (both clinical and bench-based), as well as to stay current on whatever Virtue Signaling is hot this week (is it gender-based, perhaps Step 1 scores?).

I use SDN to engage in gloves-off debates about things that would be potentially harmful to my career if I discussed them openly elsewhere.

But to summarize, I love the field of Radiation Oncology, I love the patients and the treatments and the advances. I abhor the job market/economics of Radiation Oncology, and spend a huge amount of time thinking about it as a senior resident about to try to find a job.

That's fair. For what it's worth, SDN used to involve more discussions of cases and interesting new directions in our field... perhaps SDN is now 'sub-specialized' in debates about how much we are all doomed haha

 

[Lamount]

I also have first hand experience from 2 people that took fellowships to wait out the job market for a year.

Bottom line is that fellowships are increasing in number despite the fact that none of them are accredited by the acgme.

The bigger question is why your residency program lacked the training, unless we are talking protons or something. Upping requirements would fix a lot of these problems and reduce the number of unnecessary/questionable fellowships in things like igrt/sbrt etc

I don't want to get into specifics publicly on a heated topic like this, but suffice to say, it wasn't IGRT/SBRT. If you are curious, PM me and I would be happy to share.

 

[elementaryschooleconomics]

Any person who publicly expresses the smallest shred of optimism vis a vis radiation oncology is portrayed by some here to be either naive or nefarious. It's not that most optimists deny the significant structural issues facing our field (i.e. out-of-control residency expansion, changing payment models, increased use of hypoFrac), it's just that we think going into rad onc is STILL worth it. Consider that there likely more of us than you think. Many simply have more common sense than me and acknowledge the futility in arguing with people dead-set on remaining pessimists.

I actually think there are many people who believe going into RadOnc is "still worth it".

What concerns me is that these people don't understand or pay attention to the real market forces facing and shaping our field.

So if you, @Lamount, in a hypothetical future situation, tell a medical student there are "significant structural issues facing our field (i.e. out-of-control residency expansion, changing payment models, increased use of hypoFrac)", and tell that medical student that in light of these issues matching into RadOnc in 2019/2020 is still worth it, I can't argue with that. That's your opinion and importantly, you are letting that student know things are not great like if they were matching in 2009/2010.

However, that's not what I'm seeing. What I'm seeing is "ra-ra-RadOnc, the economic concerns are overblown, there are no issues, SDN is full of angry people who hate Radiation Oncology".

That's what concerns me.

 

[deleted18755]

It's worth noting that not everyone who does a fellowship was "forced" into it. For me, I had reasonable job offers but lacked clinical training in an area that I wanted to do research... and wasn't receiving many offers from places that would have allowed me to continue this research. A fellowship opened the door for me to get a "unicorn" job that afforded me the necessary opportunities, time, resources, and financial support ... and I couldn't be happier with my choice.

This is my unique perspective -equally valid as any other FIRST HAND account.

That's great. This is exactly why there should be such opportunities available (or just make sure all residency programs provide adequate clinical training in the first place . . . unless it's peds or something like that).

 

[thaddeus]

Many simply have more common sense than me and acknowledge the futility in arguing with people dead-set on remaining pessimists.

I seem to share your lack of common sense here, but the recent vitriol may have changed that. Enjoy your fecal throwing contest, SDNers. I'll see you on Mednet when you want to focus on patient care.

 

[evilbooyaa]

Any person who publicly expresses the smallest shred of optimism vis a vis radiation oncology is portrayed by some here to be either naive or nefarious. It's not that most optimists deny the significant structural issues facing our field (i.e. out-of-control residency expansion, changing payment models, increased use of hypoFrac), it's just that we think going into rad onc is STILL worth it. Consider that there likely more of us than you think. Many simply have more common sense than me and acknowledge the futility in arguing with people dead-set on remaining pessimists.

I agree with this.

So if you, Lamount, in a hypothetical future situation, tell a medical student there are "significant structural issues facing our field (i.e. out-of-control residency expansion, changing payment models, increased use of hypoFrac)", and tell that medical student that in light of these issues matching into RadOnc in 2019/2020 is still worth it, I can't argue with that. That's your opinion and importantly, you are letting that student know things are not great like if they were matching in 2009/2010.

However, that's not what I'm seeing. What I'm seeing is "ra-ra-RadOnc, the economic concerns are overblown, there are no issues, SDN is full of angry people who hate Radiation Oncology".

That's what concerns me.

But I more agree with this.

Twitterverse thinks SDN folks all hate their job and/or the field of radiation oncology, which is absolutely not true.

I seem to share your lack of common sense here, but the recent vitriol may have changed that. Enjoy your fecal throwing contest, SDNers. I'll see you on Mednet when you want to focus on patient care.

Here's the thing. You're welcome to your opinion. But if you say things that other people feel are untrue, they are going to tell you as such. That's not vitriol... that's discussion. Nobody is calling you an idiot (and if they are, report it and I will take action as I have against multiple members, including long-time ones, in the past few months). I can't take action on somebody calling you naive or an optimist.

However, If you throw feces on SDNers (not enough to be actionable) by saying those who care about compensation should just be left out of the field entirely and we should all be happy with whatever compensation we get regardless of what that number is, then don't complain when there's some feces that make it back your way.

At the end of the day we're (mostly) all a bunch of nerds who want to correct each other and make you agree with us. This is a place where that can be attempted to be done safely without negative reprecussions on one's career.

I'm not surprised that twitter is 95% positive, nor am I surprised that SDN is 95% negative (about the job market in some way, because right now what else is there to be negative about?). As always, people who complain about something have more to say than people that are happy with it, doubly-so when they can do so anonymously.

 

[Mandelin Rain]

Should probably craft a SDN concern manifesto to sticky for passersby.

The negativity here is born out of academia's ongoing exploitation of their role as gatekeeper of resident physician supply to ensure a ready army of cheap labor to expand their departmental footprints, solely to reap reimbursement rewards. This was done in the face of obvious downward market pressures impacting demand for radiation oncology services (and by extension doctors) and reimbursement for all of us; even those 59% of us beyond their sphere of influence. They have sold us (and you) out, and we're mad. This issue has been raised for the past half decade on this board, but it wasn't until they were directly impacted via the match this year that they began any dialogue. They won't even acknowledge that resident concerns are actually a "concern". No solutions have been proposed, and we the dissenters have been patronized, even as continued downward pressures are applied. Many of us find this situation to be completely out of our control, except for the ability to inform medical students about the situation on this board.

TL/DR: The fox guarding the hen house ate the hens. We're really mad at the fox, not ready to burn down the farm. We don't want uninformed chickens (canaries?) to wander back into the hen house until the fox changes his ways.

 

[thaddeus]

I agree with this.



But I more agree with this.

Twitterverse thinks SDN folks all hate their job and/or the field of radiation oncology, which is absolutely not true.



Here's the thing. You're welcome to your opinion. But if you say things that other people feel are untrue, they are going to tell you as such. That's not vitriol... that's discussion. Nobody is calling you an idiot (and if they are, report it and I will take action as I have against multiple members, including long-time ones, in the past few months). I can't take action on somebody calling you naive or an optimist.

However, If you throw feces on SDNers (not enough to be actionable) by saying those who care about compensation should just be left out of the field entirely and we should all be happy with whatever compensation we get regardless of what that number is, then don't complain when there's some feces that make it back your way.

At the end of the day we're (mostly) all a bunch of nerds who want to correct each other and make you agree with us. This is a place where that can be attempted to be done safely without negative reprecussions on one's career.

I'm not surprised that twitter is 95% positive, nor am I surprised that SDN is 95% negative (about the job market in some way, because right now what else is there to be negative about?). As always, people who complain about something have more to say than people that are happy with it, doubly-so when they can do so anonymously.

Fair points. In point of fact I was called an idiot by one poster, which you appropriately edited. I also care about compensation, and believe we should all continue to fight for what we view to be fair compensation for our field. I don't mean to minimize anyones current concerns about the financial state of our field - they are real and things will change for the worse moving forward even if we continue to fight. My point is simply that medical students who care PRIMARILY about compensation as their main reason for being interested in rad onc (over other considerations) will not be happy in our field and will not feel fulfilled going into it. Unfulfilled doctors do not provide good patient care. I personally would rather see more slightly-less-brilliant applicants who really care about treating cancer patients and fewer AOA superstars who are primarily in it for the money, but I suppose reasonable people can disagree on this point.

Anyway, I don't envy your position as the moderator of all this. Thank you for trying to keep things civil.

 

[elementaryschooleconomics]

I seem to share your lack of common sense here, but the recent vitriol may have changed that. Enjoy your fecal throwing contest, SDNers. I'll see you on Mednet when you want to focus on patient care.

So because people don't agree with you here you're going to rage-quit SDN? If you're so certain the negative points of view are wrong, craft compelling arguments to the contrary.

To draw a parallel to our actual jobs - to me, the statement "the job market looks bleak because of residency expansion, hypofrac, APM, and general supervision" is the equivalent of saying "we should offer SBRT to this 92 year old woman with a 2cm PET-avid nodule in the LLL who isn't an operable candidate due to her lung function". Those who claim the market isn't bleak sounds like a cowboy surgeon arguing to take that patient to the OR.

I desperately want to be proven wrong. I want someone to come on here and make a strong case for why we're not following in the footsteps of Pathology. I want that more than anything.

 

[evilbooyaa]

Fair points. In point of fact I was called an idiot by one poster, which you appropriately edited. I also care about compensation, and believe we should all continue to fight for what we view to be fair compensation for our field. I don't mean to minimize anyones current concerns about the financial state of our field - they are real and things will change for the worse moving forward even if we continue to fight. My point is simply that medical students who care PRIMARILY about compensation as their main reason for being interested in rad onc (over other considerations) will not be happy in our field and will not feel fulfilled going into it. Unfulfilled doctors do not provide good patient care. I personally would rather see more slightly-less-brilliant applicants who really care about treating cancer patients and fewer AOA superstars who are primarily in it for the money, but I suppose reasonable people can disagree on this point.

Anyway, I don't envy your position as the moderator of all this. Thank you for trying to keep things civil.

As always, I encourage use of the report post to moderator function for posts that you feel are out of line.

I agree with you that people who are PRIMARILY about the money above all else like caring for cancer patients should not be in the field. We all know people who are not hypofraccing all of their stage I breasts or do 20 fraction palliation routinely for a bone met. I agree that people with that mentality should not be in our field.

 

[Mandelin Rain]

Brilliant people who are "all about the money" don't go into medicine.

Mutually exclusive ideas.

 

[metallica81788]

Brilliant people who are "all about the money" don't go into medicine.

Mutually exclusive ideas.

True. However, there are people that once in medicine become "all about the money" and this field definitely has more than a few.

 

[Hippocrates II]

Just my perspective as a 2nd year medical student in response to OP's points:

I did fairly extensive (relatively) cancer research in undergrad with eventual hopes of med or rad onc after medical school. I'm now doing some research with a local oncology dept. I only mention this because it has allowed me to meet several (>10) medical students also interested in oncology and to get a feel for what people are interested in. I have yet to meet a single student interested in radiation oncology purely due to job outlook.

It has nothing to do with reimbursement, job satisfaction, etc. I know for myself and many of my peers, the potential salaries of RO mean very little as long as they are on par with average physician salaries. It's the uncertainty of getting a job, or the idea of having to accept a job in an undesirable place where your spouses' job prospects may be poor, little opportunities for your children exist, etc. that scares people away. After 4 years of medical school, being a relatively-higher achieving medical student, and 5 years of residency, can you really expect anyone to commit to all of that for questionable job prospects? Particularly when there are so many other specialties out there offering similar salaries, similar training, and significant job prospects at the end of it? I realize RO is a small specialty and there will always be geographical consideration because of that, but it appears to have hit a point of being unreasonable in its limitations now.

I think OP's post missed the mark. From my perspective as a student, no one is down on this specialty for much other than job prospects. Until that is rectified, I don't see that changing a whole ton.

 

[w00tz]

Just my perspective as a 2nd year medical student in response to OP's points:

I did fairly extensive (relatively) cancer research in undergrad with eventual hopes of med or rad onc after medical school. I'm now doing some research with a local oncology dept. I only mention this because it has allowed me to meet several (>10) medical students also interested in oncology and to get a feel for what people are interested in. I have yet to meet a single student interested in radiation oncology purely due to job outlook.

It has nothing to do with reimbursement, job satisfaction, etc. I know for myself and many of my peers, the potential salaries of RO mean very little to me as long as they are on par with average physician salaries. It's the uncertainty of getting a job, or the idea of having to accept a job in an undesirable place where your spouses' job prospects may be poor, little opportunities for your children exist, etc. that scares people away. After 4 years of medical school, being a relatively-higher achieving medical student, and 5 years of residency, can you really expect anyone to commit to all of that for questionable job prospects? Particularly when there are so many other specialties out there offering similar salaries, similar training, and significant job prospects at the end of it? I realize RO is a small specialty and there will always be geographical consideration because of that, but it appears to have hit a point of being unreasonable in its limitations now.

I think OP's post missed the mark. From my perspective as a student, no one is down on this specialty for much other than job prospects. Until that is rectified, I don't see that changing a whole ton.

Pretty much in line with this survey report

https://www.merritthawkins.com/uploadedFiles/MerrittHawkins_Final_Year_Medical_Residents_Survey_2019.pdf

Location is #1

 

[RickyScott]

Docs like B kavanaugh and the medical college wisconsin virtue signaller need cultural sensitivity training. They probably assume that all candidates have the geographic flexibility of a white male with stay at home wife. Simply dont understand geographic needs of minorities or men and women married to spouses with graduate degrees who have their own careers.

 

[imhopeful432]

Docs like B kavanaugh and the medical college wisconsin virtue signaller need cultural sensitivity training. They probably assume that all candidates have the geographic flexibility of a white male with stay at home wife. Simply dont understand geographic needs of minorities or men and women married to spouses with graduate degrees who have their own careers.

I have an SO with a professional career and I both want/need to leave in a large metropolitan area.

BUT there is nothing wrong with BK or others talking about the need to recruit folks who want to practice in non-metro areas. Those places do need more rad oncs (relative to large metros). I'm for one glad that academic leaders are talking about that and I just hope that translates into the actual people they match/look for during interviews.

At the same time, I also think we need to increase diversity in rad onc (women and URM). Literature is replete with benefits of this in medicine in general, both for innovation/culture of a field/workplace and for patients.

Yes, the above 2 can (will) be in conflict with one another at times, but I do not agree that talking about both of those are virtue signalling that we should shame.

 

[RickyScott]

I have an SO with a professional career and I both want/need to leave in a large metropolitan area.

BUT there is nothing wrong with BK or others talking about the need to recruit folks who want to practice in non-metro areas. Those places do need more rad oncs (relative to large metros). I'm for one glad that academic leaders are talking about that and I just hope that translates into the actual people they match/look for during interviews.

At the same time, I also think we need to increase diversity in rad onc (women and URM). Literature is replete with benefits of this in medicine in general, both for innovation/culture of a field/workplace and for patients.

Yes, the above 2 can (will) be in conflict with one another at times, but I do not agree that talking about both of those are virtue signalling that we should shame.

I just dont see the evidence that there is significant maldistribution of docs. These places are and will always be the last jobs to fill, because they are the least desirable, but that cant be taken as reflecting a shortage of radoncs in rural places. I feel like this is a spurious point that is trumped up to justify residency expansion. It needs to be emphasized that as a whole, women and minorities, are even more geographically sensitive than other applicants.

 

[medgator]

I just dont see the evidence that there is significant maldistribution of docs. These places are and will always be the last jobs to fill, because they are the least desirable, but that cant be taken as reflecting a shortage of radoncs in rural places. I feel like this is a spurious point that is trumped up to justify residency expansion. It needs to be emphasized that as a whole, women and minorities, are even more geographically sensitive than other applicants.

Dumping plenty of grads into the job market seems to be the way the specialty wanted to fill it

 

[RickyScott]

Dumping plenty of grads into the job market seems to be the way the specialty wanted to fill it

Sure, but they will always still be the last to fill, and then some will point fingers and say we continue to need more grads.

 

[evilbooyaa]

Moved gender/diversity stuff to Dare you to reply!

 

[beamseyeview]

A recent thread stated, “the demand for rad onc just died,” after discussion that CMS is modifying the supervision level required in hospital-associated practices. This view could not be more pessimistic and in my opinion, wrong. While some of the concerns are valid, I am skeptical this will have the catastrophic effect so confidently predicted. Perhaps there will be a decrease in demand/staffing in rural practices - it is just too early to know. However, I suspect many practices will not be interested in the increased liability or operational troubles associated with leaving facilities un-supervised, particularly for SBRTs. I predict this rule is ultimately amended in the future but we will see. Regardless, for many already in established practices, this will be a welcome change due to the increased flexibility.

Here's the thing I really disagree with you on - on the difference that requiring direct vs general supervision will have on the job market - the majority of this country is still treated outside of where most of us do our residencies. The places that pay well now generally do so because of the issues in requiring coverage. I personally think that removing that supervision requirement is bad for the job market in terms of availability of jobs for new grads. Individual practices will now no longer require linac baby-sitters. The majority of the locums market will have dried up overnight.

I'm a data-driven person, as are many of you, so I figured I'd leave this depressing data point here.

I'm a PGY-5 at a well-regarded program. I'm currently interviewing for jobs. I previously received (within the last two weeks) two job offers -- both private practices (professional service) in a large metro area close to family. The people seemed great, compensation was more than fair. I was ecstatic. I was having a hard time deciding, but I knew that I couldn't make a wrong decision because I liked them both.

And then... both practices called me earlier this week after the new CMS guidance came out. They told me that they are no longer hiring. I'm pretty devastated.

If anyone has any counter data points, I'd love to hear. But the market is tightening. That's a fact. I hope that I'll end up OK.

 

[Mandelin Rain]

Yeah. I wouldn’t trust a resident’s take (the guy quoted above who made the opening post in this thread) on the impact the supervision rule will have on the job market. You just have no idea what the real landscape is like out there. The guy who posted that was either completely naive or a plant from Twitter, specifically Mayo.

I’m sorry to hear about your situation though. I’m guessing we may hear a few stories of signed contracts not being honored this year.

 

[medgator]

I'm a data-driven person, as are many of you, so I figured I'd leave this depressing data point here.

I'm a PGY-5 at a well-regarded program. I'm currently interviewing for jobs. I previously received (within the last two weeks) two job offers -- both private practices (professional service) in a large metro area. The people seemed great, compensation was more than fair. I was ecstatic. I was having a hard time deciding, but I knew that I couldn't make a wrong decision because I liked them both.

And then... both practices called me earlier this week after the new CMS guidance came out. They told me that they are no longer hiring. I'm pretty devastated.

If anyone has any counter data points, I'd love to hear. But the market is tightening. That's a fact. I hope that I'll end up OK.

Feel bad for this year's graduating class between the ABR **** sandwich last year and then this. It's not CMS's fault they decided to implement this change and it's not their responsibility to find employment for the excess residents that have been graduating recently and those that will be.

Said it before, said it again.... Goal for all parties in rad onc should be to have 0 slots fill in this year's match.

The academics that created these newer programs and expanded long-standing ones (or tell us there is zero problem) are screwing everyone collectively. Time to fight back.

 

[elementaryschooleconomics]

I'm a data-driven person, as are many of you, so I figured I'd leave this depressing data point here.

I'm a PGY-5 at a well-regarded program. I'm currently interviewing for jobs. I previously received (within the last two weeks) two job offers -- both private practices (professional service) in a large metro area close to family. The people seemed great, compensation was more than fair. I was ecstatic. I was having a hard time deciding, but I knew that I couldn't make a wrong decision because I liked them both.

And then... both practices called me earlier this week after the new CMS guidance came out. They told me that they are no longer hiring. I'm pretty devastated.

If anyone has any counter data points, I'd love to hear. But the market is tightening. That's a fact. I hope that I'll end up OK.

This is terrible!!

Man, if I was a well established partner in a private practice with a decent geographic footprint who long ago adopted hypofrac/SRS/SBRT...I would be out of my mind with joy right now for APM+general supervision.

One of my docs needs to take some unplanned personal time for a family emergency? Whatever, I don't need to scramble to arrange coverage, don't need a linac babysitter anymore. I'll have one of the mid-levels swing by at some point this week to cover problem issues.

Maybe I'll set up an old/used linac out in the boonies and just treat bone mets. Under APM, I can bill fee-for-service for the initial evaluation and management, then put them on the bone met episode of care and do 8Gy x 1 out in my rural linac satellite staffed only by mid-levels.

Maybe my partners and I have wanted to open up a new satellite for awhile now but were limited by the capital and logistics of bringing in more MDs to staff it. No worries! One of us can just rotate out to that site 1-2 days a week to see consults, we'll hire an NP at $100k/year to RX magic mouthwash and Zofran the other 3-4 days.

I could dream up some more dystopian money-making schemes, but I would rather go to bed and question all of my life choices while I struggle to fall asleep.

 

[elementaryschooleconomics]

This is terrible!!

Man, if I was a well established partner in a private practice with a decent geographic footprint who long ago adopted hypofrac/SRS/SBRT...I would be out of my mind with joy right now for APM+general supervision.

One of my docs needs to take some unplanned personal time for a family emergency? Whatever, I don't need to scramble to arrange coverage, don't need a linac babysitter anymore. I'll have one of the mid-levels swing by at some point this week to cover problem issues.

Maybe I'll set up an old/used linac out in the boonies and just treat bone mets. Under APM, I can bill fee-for-service for the initial evaluation and management, then put them on the bone met episode of care and do 8Gy x 1 out in my rural linac satellite staffed only by mid-levels.

Maybe my partners and I have wanted to open up a new satellite for awhile now but were limited by the capital and logistics of bringing in more MDs to staff it. No worries! One of us can just rotate out to that site 1-2 days a week to see consults, we'll hire an NP at $100k/year to RX magic mouthwash and Zofran the other 3-4 days.

I could dream up some more dystopian money-making schemes, but I would rather go to bed and question all of my life choices while I struggle to fall asleep.

Also, @evilbooyaa, this technically counts as optimism, right? Optimism from the perspective of a mid-late career private practice partner who has already been pulling in $750k+ for one-two decades.

Maybe not so much optimism for us senior residents, though.

 

[thecarbonionangle]

I'm a data-driven person, as are many of you, so I figured I'd leave this depressing data point here.

I'm a PGY-5 at a well-regarded program. I'm currently interviewing for jobs. I previously received (within the last two weeks) two job offers -- both private practices (professional service) in a large metro area close to family. The people seemed great, compensation was more than fair. I was ecstatic. I was having a hard time deciding, but I knew that I couldn't make a wrong decision because I liked them both.

And then... both practices called me earlier this week after the new CMS guidance came out. They told me that they are no longer hiring. I'm pretty devastated.

If anyone has any counter data points, I'd love to hear. But the market is tightening. That's a fact. I hope that I'll end up OK.

People listen up. As i said in another post, we are not as needed or liked as we may think. We are all replaceable in this market. Poster sat and slept on contracts too long and they took it back. This is SAD and the new reality.

again if you are sitting on something reasonable strongly consider locking something down in current environment. you may not know what you have until you lose it!!

 

[scarbrtj]

This is terrible!!

Man, if I was a well established partner in a private practice with a decent geographic footprint who long ago adopted hypofrac/SRS/SBRT...I would be out of my mind with joy right now for APM+general supervision.

One of my docs needs to take some unplanned personal time for a family emergency? Whatever, I don't need to scramble to arrange coverage, don't need a linac babysitter anymore. I'll have one of the mid-levels swing by at some point this week to cover problem issues.

Maybe I'll set up an old/used linac out in the boonies and just treat bone mets. Under APM, I can bill fee-for-service for the initial evaluation and management, then put them on the bone met episode of care and do 8Gy x 1 out in my rural linac satellite staffed only by mid-levels.

Maybe my partners and I have wanted to open up a new satellite for awhile now but were limited by the capital and logistics of bringing in more MDs to staff it. No worries! One of us can just rotate out to that site 1-2 days a week to see consults, we'll hire an NP at $100k/year to RX magic mouthwash and Zofran the other 3-4 days.

I could dream up some more dystopian money-making schemes, but I would rather go to bed and question all of my life choices while I struggle to fall asleep.

This is bad for a lot of “us.” But there is that immutable law of physics that every action has an equal and opposite reaction. This will be good for a lot of “them” (patients who’ve had limited access to nearby convenient care... and “entrepreneurs” who know how to deliver it in the Brave New World).