Voluntary residency contraction and the development of IMRT saved the field in the early 2000s: an analysis of the past 30 years

elementaryschooleconomics

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As an upfront warning: this might be the longest post in the history of Student Doctor Network (probably not true - but this is a dissertation).

Something I’ve heard a lot in both real life and online is the sentiment that the “sky has always been falling in Radiation Oncology”. Indeed, there have been concerns over the job market for as long as I can remember. When I was first looking at the field in the late 2000s, it was widely known and freely shared with me that there were tremendous geographic restrictions. I believe that has always been the case.

However, over the years (and especially recently), folks on SDN have referenced the job market and what happened in the field in the 1990s. In a version of history repeating itself, there was some sort of expansion of RadOnc in the 1980s which culminated in job market concerns in the 90s.

So what happened? Clearly we survived that period and the field massively expanded starting in the mid-2000s. This fact - that people believed the field was facing some sort of crisis and survived/thrived - is being used now by the leadership to avoid contracting residency spots and programs.

This has been discussed in other posts on the forum, but I felt the need to have a singular, cohesive post telling this history as best as I can understand it. To summarize my hypothesis:

In the mid-1990s there was a growing concern regarding oversupply of Radiation Oncologists in America, leading to a poor job market. In response, the leadership of the time manually and voluntarily contracted spots and programs. In the early 2000s, IMRT was introduced, generating significantly more revenue and balancing the “demand” side of the economic equation.

I’ll have a “too long, didn’t read” conclusion at the end. I’ll let the reader decide if my argument makes sense.

(As an aside - I can and probably will do more research into this, however, I can’t exactly add this to my CV and I have but only so much free time in the day. Please let me know if you find gaps or have other evidence I overlooked)

The 1990s: Pre-Golden Era

One of the earliest publications from the 1990s discussing the specialty is “The Case for a Three Year Residency Program in Radiation Oncology” by Thomas W. Griffin from the University of Washington, published in The Red Journal in 1993. In the beginning of the 90s, Radiation Oncology was, in general, a three year residency program, though some (all?) programs apparently had an optional fourth year. In the early 90s, the idea of making the fourth year mandatory was proposed. The article by Dr Griffin pushes back against the mandatory fourth year, arguing that the specialty of Radiation Oncology was learned to competency in three years. Interestingly, he makes similar points we’ve heard recently, that all institutions are not created equal and not every program would be able to provide quality education in the extra year, whether it was a year of bench research or subspecialty training (in areas like heavy particle radiation therapy, for example). It sounds like fellowship training in a particular area of interest was more common/accepted in this time (Dr Griffin states that making a fourth year mandatory would delay allowing residents to attain fellowship training at an institution of their choice).

According to SDN Lore, making RadOnc a mandatory four year program was an underground strategy by programs to address job market concerns (delaying an influx of graduates, thus addressing the “supply side” of the equation). I do not currently have a reputable source for this claim and am unsure if one exists, outside of oral history and speculation.

There is currently an article on The Red Journal’s website, published in 1996 by William D. Bloomer of The Radiation Medicine Institute and the Evanston Hospital Corporation, entitled “On manpower needs and solutions”. However, the linked PDF seems to be uploaded in error, and only the final page of the document is available. The available page contains the following paragraph:

“Not surprisingly, dispersion of radiation oncology services within the historical catchment areas of many academic medical centers accompanied the increased output of radiation oncologists in the 1980s. A boon to patients and their families, these expanded services, nonetheless, adversely affected both the quality and quantity of resident teaching case material at many academic centers. Although it will not solve any current manpower problems, a critical reappraisal of residency accreditation criteria is clearly in order.”

Apparently, that Issue of The Red Journal (Volume 35, Issue 4) had a report on the training and education of RadOnc residents which Dr Bloomer disagreed with. He calls for the development of “objective accreditation criteria to be applied to U.S. programs”. Very interestingly, he notes:

“Implementation of the recommendations from such a process is likely to withstand any antitrust or restraint of trade challenge.”

He ends with:

“In conclusion, we face a very painful decade ahead. Unlike medical and surgical subspecialists who can fall back onto general medicine and surgery if their specialty practices falter, radiation oncologists have no realistic career options without major retraining. We have a collective responsibility to warn prospective residents of the hard times ahead.”

However, the claims by Dr Bloomer did not go unchallenged. In the same issue of The Red Journal, Jonathan H. Sunshine of the ACR published “Too many radiation oncologists? An empirical report.'' Within the manuscript, Dr Sunshine states that, in 1994, the unemployment rate for Radiation Oncologists averaged 0.2%, which was lower than the 0.4% rate for all physicians that year. Surveys were also collected in 1994 and 1995. The results:

“In 1995, none of the graduates of responding programs (who totaled 149 residents and 26 fellows) were reported unemployed as of December, although 11% of residents and 27% of fellows had not had commitments for positions as of April-May, and a survey we conducted for ASTRO showed that 6% (SE = 3%) of residency graduates experienced some unemployment shortly after graduating. The same pattern characterized the relatively small sample (24 residents) in the 1994 survey. (Note that we used the standard definition of “unemployed” - namely, not having work when one is seeking it. In 1995, there were two residency graduates not in the labor force - that is, not working because they had not wanted to be working. This situation typically involves a woman with very young children.)”

[Author’s note: you can tell that paper was written in the 90s because of the women quip]

“In 1995, program directors said that 90% of residents and 85% of fellows had jobs that reasonably matched the individual graduate’s training and employment goals. The percentage of graduating residents who had a position of this type did not differ (by the usual test of statistical significance -- p<0.05) between 1994 and 1995. However, the percentage of residency program directors who reported the difficulty of finding jobs was greater than typical of recent years increased from 29% in 1994 to 63% in 1995.”

[Author’s note: it is unclear to me what Sunshine means when he states that the jobs “reasonably matched the individual graduate’s training and employment goals”]

Dr Sunshine goes on to express astonishment of what he considers positive findings, “particularly given common perceptions that ‘there are no jobs out there’ and the growing pessimism of training program directors". In trying to ascertain the pessimism, he offers the following:

“...when program faculty told us of an unemployed radiation oncologist, the story often involved someone who could look for work only where he or she trained, due to a spouse. Straightforward probability calculations show that if a physician has only a 10% chance of finding work in any one locality, he or she, nonetheless, has a 99.5% probability of finding work if he or she is willing to consider any of 50 localities. And there are literally hundreds of localities in the United States.”

He also notes:

“Long term projections point to a future surplus of radiation oncologists, primarily because the radiation oncologist workforce is growing by at least 4% annually while the number of cancer patients treated by radiation oncology is likely to increase by at most 3% annually. Thus, a surplus of radiation oncologists of at least 1% a year, or at least 10% in a decade, seems likely to emerge.”

He concludes by stating that “there are strong indications that [the job market] is likely to deteriorate in the future”.

In 1999, a report was published in The Red Journal from the Radiation Oncology Resident Training Working Group (organized by SCAROP). Ostensibly, this group sought to study and propose methods to enhance the training of RadOnc residents in America. Subcommittees were formed sometime before May 1998 (unclear when), and the findings of their work was discussed at the May 1998 SCAROP meeting.

The first subsection of the manuscript results explicitly studied the “surplus of radiation oncologists”:

“A variety of studies have indicated that there is a surplus of radiation oncologists in the United States [Author’s note: they reference only two papers for this claim]. The ASTRO Committee on Human Resources found that 165 radiation oncologists are entering practice each year, and only 45 radiation oncologists are leaving through death or retirement. This is reflected in the active membership of ASTRO, which increased from 2,318 in 1990 to 3,539 in 1998. This is an average increase of 150 members per year, or 5.5% per year. On the other hand, the number of patients being treated with radiation therapy in the United States is increasing at a rate of only 2.7% per year. Using these data, it appears that equilibrium would be maintained if the nation produced 130 radiation oncologists per year (45 FTEs to replace radiation oncologists who are leaving practice and 85 FTEs to take positions that become available because of the increased utilization of radiation therapy sources). The 1995 and 1997 ARRO surveys (J. Kresl, personal communication) indicate that some residents are having difficulty finding jobs. The 1997 ARRO graduate employment survey showed that 9% of the graduates were unable to find employment as a radiation oncologist, and 34% took positions which did not meet their first choice as a career option. Only 74% were in full-time practice (32% in academic positions and 42% in private practice). The remaining graduates were either in fellowships, doing locum tenens, employed in other fields, or unemployed.”

Interestingly, the next section is called “declining numbers in training”:

“There are indications that the number of applicants to radiation oncology residency programs may be declining, and if this is true, it should help ameliorate the problem of oversupply. The number of residency positions offered in the match has declined 29% from 1995 to 1998, and the number of positions filled in the match decreased from 90% in 1995 to 70% in 1998. Although this decrease may be partially offset by an increased number of resident positions that fill outside the match, the general impression is that the number of residents entering training is diminishing.”

They end this section by drawing virtually the same conclusion being drawn now - the decline in residency applications will naturally balance out the looming oversupply.

In 2003, Lynn D. Wilson and Bruce G. Hafty from Yale published (in The Red Journal) “Evaluation of the National Resident Matching Program (NRMP) radiation oncology data (1993–2003)”. They summarize Radiation Oncology in the 1990s as such:

“In the mid-1990s, programs were downsized and focus was directed on continued development of high-quality training programs that could meet appropriate accreditation standards. In 1998, training programs moved from the required 3 years (after PGY-1) to 4 years. The report on “The Status of Radiation Oncology Training Programs and Their Graduates” was published in 2001 and was a critical appraisal of the “market” and employment situation. The data were generated by responses of radiation oncology program directors to a survey. This report was hopeful, as it unfurled a message (as specified by the program directors) that residency training programs were decreasing in size, and that the applicant pool appeared to be improving in terms of overall quality. Also, evaluation of the employment market was performed through the perspective of 1997 graduates. This study revealed no compelling information provoking cause for concern over unemployment, nor did the data differ significantly from those reported from the graduating class of 1996. So, as evidenced at least by a survey of directors and graduates, the manpower supply situation seemed relatively stable as of the late 1990s. Much of the data generated on the subject of supply, demand, and subjective satisfaction has been provided via survey format and American College of Radiology data.”

Per Dr Wilson and Dr Hafty, it appeared that SCAROP’s assertion that decreasing the number of programs and applicants was indeed balancing out the concerns of an oversupply. The following table was published [Author’s note: I modified it to just see the latter half of the decade]:



As demonstrated by the data, the number of training positions fell from 99 in 1997 to a nadir of 81 in 2001, a drop of about 18%.

To summarize, by the mid-1990s there did indeed seem to be concern by the leadership over the job market of Radiation Oncology based on the growth of the specialty in the 80s, and supply was outpacing demand. This was clearly trickling down to medical students, as, in the absence of SDN and Twitter, applications were naturally and drastically falling (by published accounts). This was compounded by an acknowledgement of the issue by programs who voluntarily contracted, and increased the time of training from three to four years. In the span of 5-7 years, these actions at least stabilized the profession.

But, between 2001 and 2003, positions jumped from 81 to 107. Why?

The 2000s: The Golden Era

IMRT happened, of course!

If you search for the “history of IMRT”, there are many reviews talking about the technology itself. However, it is difficult to ascertain when IMRT was widely adopted. On the AAPM website, there is a PPT Presentation from June 2003 by Steve Webb entitled “Historical perspective on IMRT”. Webb provides the following slide:


These times are important. By 2000, “all major companies [are] offering products”, and by 2003 (when this PPT was created) “everyone wants IMRT”.

This lines up well with the sudden jump in RadOnc positions (word-of-mouth between medical students was also a factor, which I will discuss below)

Webb also has the following slide, which includes a very important point:



“Is the reimbursement dollar driving the science”?

As we all know, IMRT subsequently became the workhorse of Radiation Oncology. While it undeniably produces many benefits for patients, a side effect is that it produces many benefits for the bottom line of physicians, departments, and institutions across the country.

In 2005, Andre Konski published “Cost–effectiveness of intensity-modulated radiation therapy”. The following was presented (studying prostate cancer specifically):

“The mean Medicare reimbursement to the Fox Chase Cancer Center for 14 men undergoing IMRT was $24,953, normally distributed, with a standard deviation of $2039. The mean Medicare reimbursement to the Fox Chase Cancer Center for seven men undergoing 3DCRT was $13,900, log-normally distributed, with a standard deviation of $2547. Costs were adjusted to 2004 US dollars”.

Innumerable analysis of the costs of IMRT have been published and I won’t belabor the point. The take-home is that significantly more revenue could be generated from radiation therapy. This balanced and bolstered the “demand” side of the economic equation for our specialty.

In 2001, programs had contracted to their nadir, with 81 spots in 48 programs. Concurrently, applications to RadOnc exploded, with 214 applicants, more than double the number of applicants in 1998.

So, what happened? This is somewhat unclear to me. Did ASTRO run some sort of awareness campaign? Was there some push to recruit students? I’m still investigating.

However, we’re now at the beginning of the Student Doctor Network forums. SDN RadOnc was launched on August 4th, 2002. Prior to that, there were three threads discussing Radiation Oncology, which Lee (SDN admin) merged into the nascent forum.

In trying to piece together what was going on in RadOnc at the time, there are some interesting posts, which are eerily similar to what we see today. I would encourage you to go back and read some of the threads from 2001-2003, just for entertainment value alone.

In 2003, people were trying to figure out why RadOnc suddenly became popular:

Pic 1.jpg

Pic 2.jpg

I believe the post by AlexanderJ summarized what was happening well:
  1. There was an increase in “buzz” about RadOnc
  2. Students were becoming increasingly concerned with not having their work/life balance destroyed
  3. IMRT was all the rage
What does this look like from the leadership side of things? One can only imagine. Whereas a few short years prior there was concern over declining applications and a tough job market, now your department is flooded with amazing residency applicants and you’re generating far more revenue with IMRT. What’s the only logical thing to do? Expand, of course, which is what they did:

Residency Expansion.jpg

The expansion started around 2003 and continued from there.

I would consider the decade of 2000-2010 to be the true “Golden Era”. Because of the efforts of the leadership in the late 90s, there was a dip in the supply of new Radiation Oncologists for several years. Concurrently, the development of IMRT significantly increased revenue, and residency applications were numerous and amazing. Therefore, the expansion which took place was logical, given the milieu.

2010-present: The Gilded Bubble

I won’t explore this in depth, but in 2010 Ben Smith’s infamous paper predicting a massive shortage of Radiation Oncologists was published. While there was likely a “greed” component, I do believe that most departments expanded out of good faith, at least in the beginning. And why not? The predicted collapse of the job market never happened, the best and the brightest are clamoring for a place in the field, reimbursements were amazing, and now there was published evidence of a looming shortage.

The final piece I’ll touch on is the oft-argued point that may of the new or expanded residency programs are “bad” in that they don’t offer robust education or training. If all these expansion spots offer sub-par training, how do they continue to exist? How do they not collapse naturally? Obviously, whether a program is "good" or "bad" is a soft assertion and difficult to measure. I would posit the following: given the extreme competitiveness of Radiation Oncology, only the “best” students apply and match (even at “low tier” programs). How are you considered the “best” in medical school, or at least competitive for Radiation Oncology? Through board scores, course grades, and research. To do well on the boards (and in your courses), you need to have strong self-study habits. To succeed in research, you need to have tenacity and cunning to find and insert yourself into projects. Medical students are, by their nature, type-A people who have done well in school their entire lives. You then enrich this population for the best of the best. Everything you need to pass the boards and become a board-certified Radiation Oncologist is available through books, papers, audio lectures, regional courses, etc. You could have the “worst” training in this country but as long as you’re motivated enough, you can find study resources adequate to pass the boards. Therefore, these tremendous students/residents “make up” for the poor training by the virtue of the characteristics which got them into the field in the first place.

Alright, time for the “too long, didn’t read” summary of my argument.

I’ll let you decide if my interpretation of the past is reasonable or not:
  • There was a growing concern in the mid-1990s that there was an oversupply of Radiation Oncologists in America.

  • This was addressed in three ways
    1) As the poor job market news trickled down to medical students, there was a decrease in the number of residency applicants
    - the peak was in 1995 with 168 applicants
    - the nadir was in 1998 with 96 applicants

    2) As the poor job market was acknowledged by departments, there was a decrease in the number of positions and open programs
    - the peak was in 1995, with 127 spots in 65 programs
    - the nadir was in 2001, with 81 spots in 48 programs

    3) Additionally, Radiation Oncology residency training was turned into a mandatory four year program in 1998, whereas only three years were mandatory previously

  • These three factors significantly reduced the supply side of the job market for many years

  • In an almost unbelievably timed fashion, IMRT was released and widely adopted in the early 2000s, a technique which generated far more revenue than 3D-CRT, thus significantly increasing the demand side of the job market

  • The exclusive nature of the RadOnc, as well as the advent of IMRT, made Radiation Oncology a well-paying specialty with an extremely attractive work/life balance, and residency applications skyrocketed as medical students sought more reasonable careers

  • This occurred almost simultaneously with the nadir of voluntary contraction
    - in 2001 (with 81 spots in 48 programs), there were 214 applicants, more than double the number of applicants in 1998

  • Thus, Radiation Oncology - historically competitive due to the small number of training spots - was transformed into an incredibly competitive specialty in a short amount of time

  • Given the high potential of IMRT reimbursements coupled with the increased number of stellar applicants, departments and programs almost immediately began to expand (2005 saw 137 positions offered among 75 programs)

  • This expansion was supported, in part, by how competitive Radiation Oncology was to match into. “Competitive medical students” almost invariably means high USMLE Step exam scores, which means excellent test takers. Programs which may not offer the best training are buoyed by residents who will be able to pass the boards with self-directed study. If residents are becoming board certified, there is no other objective way to indicate “good” vs “bad” training.

  • This expansion was bolstered in 2010 with the infamous Ben Smith paper stating that “demand for radiation therapy is expected to grow 10 times faster than supply between 2010 and 2020”
More recent history (the past 10 years) has and continues to be discussed frequently on the boards.

My belief:

In the early 2000s, IMRT arrived in time to “save” the field. Given it’s unbelievably fortunate timing, people now look back on the history of the specialty with rose-colored glasses - remembering a time when there were significant concerns over the job market, but knowing that it “all just worked out”. It didn’t just “all work out” - a paradigm-shifting tool was introduced to Radiation Oncology at literally the time it was most needed.

There is no apparent version of IMRT today. Regardless, APM is poised to be “technology agnostic” and a “slam-dunk” technological innovation will not and cannot have the same impact now as 20 years ago. Additionally, the CMS direct-to-general supervision change will place further downward pressure on the specialty (regardless of the statements by ASTRO or the AMA).

The only way to preserve the health of the specialty is to significantly reduce the number of residency spots and balance out the supply side of the economic equation.
 
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RickyScott

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dead on. Was part of a class of under 1OO residents and job search was not a cakewalk. Still remember all issues prostate pts would go through and how things changed with ct sim and imrt and igrt and how xrt became so much more widely used in prostate ca.
 
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RickyScott

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Thanks for posting. One of my favorite articles about that era. Referring to financial effect of imrt;
“Many communities have five radiation centers that should have one or two,””


 
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"History repeats itself, but in such cunning disguise that we never detect the resemblance until the damage is done."
 
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thecarbonionangle

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You have had some very good informative posts. I'm thankful for your knowledge and insight and the SDN community is lucky to have you.
 
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thecarbonionangle

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What a fantastic post. A long read but highly insightful and worth the time investment. However, not something that can be crammed into a 280 character limit with a "rah rah" hashtag . . .

wouldn't it be great if someone established would write/publish an objective compendium like one above and just frame it as a starting point for real substantive discussion?
 
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scarbrtj

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It is really not possible today to estimate the impact IMRT had on the field. I know of no reasonable analogue in any other medical specialty. Steve Webb had no impact in the US re: IMRT. The match that lit the fire was a 2001 ASTRO Varian-sponsored presentation by Jerome Landry and Joe Ting. It was a packed room with at least 2000 people. That's what really kicked IMRT into high gear. And until about 2003 or so IMRT was reimbursing at about $1000 per fraction in hospitals. Here are Ting and Landry hyping up breast IMRT in 2000. Emory was a Varian beta site for Eclipse and sliding window IMRT.

 
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elementaryschooleconomics

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It is really not possible today to estimate the impact IMRT had on the field. I know of no reasonable analogue in any other medical specialty. Steve Webb had no impact in the US re: IMRT. The match that lit the fire was a 2001 ASTRO Varian-sponsored presentation by Jerome Landry and Joe Ting. It was a packed room with at least 2000 people. That's what really kicked IMRT into high gear. And until about 2003 or so IMRT was reimbursing at about $1000 per fraction in hospitals. Here are Ting and Landry hyping up breast IMRT in 2000. Emory was a Varian beta site for Eclipse and sliding window IMRT.


This post is EXACTLY what I was looking for.

THANK YOU. This was killing me.
 
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scarbrtj

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This post is EXACTLY what I was looking for.

THANK YOU. This was killing me.
And when I said $1000 per fraction for IMRT I might be underestimating. It was wildly lucrative when it started as G-code only. Once it became a CPT code and could be done in freestanding it was still very high, about $650/fraction depending on geography. This persisted until about 2010 or so.
 
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elementaryschooleconomics

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And when I said $1000 per fraction for IMRT I might be underestimating. It was wildly lucrative when it started as G-code only. Once it became a CPT code and could be done in freestanding it was still very high, about $650/fraction depending on geography. This persisted until about 2010 or so.

So then that begs the question - was it the 2001 ASTRO meeting which spiked applications? I know back then the timing of residency applications and interviews was a little different compared to now, and I could see the hype of IMRT quickly trickling down to students if it generated that much buzz at ASTRO (if ASTRO was held in September of that year like it is now).
 
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scarbrtj

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So then that begs the question - was it the 2001 ASTRO meeting which spiked applications? I know back then the timing of residency applications and interviews was a little different compared to now, and I could see the hype of IMRT quickly trickling down to students if it generated that much buzz at ASTRO (if ASTRO was held in September of that year like it is now).
I don’t think so least not as an isolated event. Not many true rad onc residencies til the 70s. Then it took the 80s for Departments of Radiation Oncology to appear that were previously Divisions in the radiology department; also cobalt teletherapy would’ve been completely disappearing by then and high MV beams have less skin effects. The 90’s saw less people getting horrible RT side effects overall with 3DCRT. It was all a linear line of legitimacy. When other academic departments heard that Emory was the most profitable academic dept in the country along about 2001, it certainly piqued interest in IMRT. This required new MLC capable machines most with new MV imagers. Now rad onc was super profitable (IMRT) and really easy to deliver (no blocks to cut and no port films to constantly develop). Think how a rad onc dept looked in 1995 (china markers, plain films, blocks, simulator suites with C-arms) vs 2005 (fancy looking machines, CT scanners, computers out the wazoo) to a med student’s eyes. And almost everyone got 1.8 or 2.0 Gy per fraction no matter what. Also recall the 90’s were the advent of PSA and widespread adoption of screening mammography.
Add all this up and 2001, or a year very near it, was high time for rad onc to become super popular.
 
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MegaVoltagePhoton

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One of the major problems with our field honestly is the self-hatred. Academics may be "rah rah rah" on twitter, but they certainly ain't "rah rah rah" when it comes to reviewing/critiquing things like for example the MRI-LINAC. And though MRI-LINACS may not pan out I think it will be either online adaptive therapy and or oligomets/oligoprogression panning out that save the specialty. Think about it this way if online adaptive works but a rad onc is required in person to review before the fraction is delivered that will immediately improve the job market and may also improve toxicity and effectiveness. but rad oncs will attack MRI-LINAC etc and we had a whole astro debate about whether treating oligomets where the "naysayers" won. do you think they have "use immunotherapy or not" debates at med onc conferences where the naysayers win?
 
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FrostyHammer

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As an upfront warning: this might be the longest post in the history of Student Doctor Network (probably not true - but this is a dissertation).

Something I’ve heard a lot in both real life and online is the sentiment that the “sky has always been falling in Radiation Oncology”. Indeed, there have been concerns over the job market for as long as I can remember. When I was first looking at the field in the late 2000s, it was widely known and freely shared with me that there were tremendous geographic restrictions. I believe that has always been the case.

However, over the years (and especially recently), folks on SDN have referenced the job market and what happened in the field in the 1990s. In a version of history repeating itself, there was some sort of expansion of RadOnc in the 1980s which culminated in job market concerns in the 90s.

So what happened? Clearly we survived that period and the field massively expanded starting in the mid-2000s. This fact - that people believed the field was facing some sort of crisis and survived/thrived - is being used now by the leadership to avoid contracting residency spots and programs.

This has been discussed in other posts on the forum, but I felt the need to have a singular, cohesive post telling this history as best as I can understand it. To summarize my hypothesis:

In the mid-1990s there was a growing concern regarding oversupply of Radiation Oncologists in America, leading to a poor job market. In response, the leadership of the time manually and voluntarily contracted spots and programs. In the early 2000s, IMRT was introduced, generating significantly more revenue and balancing the “demand” side of the economic equation.

I’ll have a “too long, didn’t read” conclusion at the end. I’ll let the reader decide if my argument makes sense.

(As an aside - I can and probably will do more research into this, however, I can’t exactly add this to my CV and I have but only so much free time in the day. Please let me know if you find gaps or have other evidence I overlooked)

The 1990s: Pre-Golden Era

One of the earliest publications from the 1990s discussing the specialty is “The Case for a Three Year Residency Program in Radiation Oncology” by Thomas W. Griffin from the University of Washington, published in The Red Journal in 1993. In the beginning of the 90s, Radiation Oncology was, in general, a three year residency program, though some (all?) programs apparently had an optional fourth year. In the early 90s, the idea of making the fourth year mandatory was proposed. The article by Dr Griffin pushes back against the mandatory fourth year, arguing that the specialty of Radiation Oncology was learned to competency in three years. Interestingly, he makes similar points we’ve heard recently, that all institutions are not created equal and not every program would be able to provide quality education in the extra year, whether it was a year of bench research or subspecialty training (in areas like heavy particle radiation therapy, for example). It sounds like fellowship training in a particular area of interest was more common/accepted in this time (Dr Griffin states that making a fourth year mandatory would delay allowing residents to attain fellowship training at an institution of their choice).

According to SDN Lore, making RadOnc a mandatory four year program was an underground strategy by programs to address job market concerns (delaying an influx of graduates, thus addressing the “supply side” of the equation). I do not currently have a reputable source for this claim and am unsure if one exists, outside of oral history and speculation.

There is currently an article on The Red Journal’s website, published in 1996 by William D. Bloomer of The Radiation Medicine Institute and the Evanston Hospital Corporation, entitled “On manpower needs and solutions”. However, the linked PDF seems to be uploaded in error, and only the final page of the document is available. The available page contains the following paragraph:

“Not surprisingly, dispersion of radiation oncology services within the historical catchment areas of many academic medical centers accompanied the increased output of radiation oncologists in the 1980s. A boon to patients and their families, these expanded services, nonetheless, adversely affected both the quality and quantity of resident teaching case material at many academic centers. Although it will not solve any current manpower problems, a critical reappraisal of residency accreditation criteria is clearly in order.”

Apparently, that Issue of The Red Journal (Volume 35, Issue 4) had a report on the training and education of RadOnc residents which Dr Bloomer disagreed with. He calls for the development of “objective accreditation criteria to be applied to U.S. programs”. Very interestingly, he notes:

“Implementation of the recommendations from such a process is likely to withstand any antitrust or restraint of trade challenge.”

He ends with:

“In conclusion, we face a very painful decade ahead. Unlike medical and surgical subspecialists who can fall back onto general medicine and surgery if their specialty practices falter, radiation oncologists have no realistic career options without major retraining. We have a collective responsibility to warn prospective residents of the hard times ahead.”

However, the claims by Dr Bloomer did not go unchallenged. In the same issue of The Red Journal, Jonathan H. Sunshine of the ACR published “Too many radiation oncologists? An empirical report.'' Within the manuscript, Dr Sunshine states that, in 1994, the unemployment rate for Radiation Oncologists averaged 0.2%, which was lower than the 0.4% rate for all physicians that year. Surveys were also collected in 1994 and 1995. The results:

“In 1995, none of the graduates of responding programs (who totaled 149 residents and 26 fellows) were reported unemployed as of December, although 11% of residents and 27% of fellows had not had commitments for positions as of April-May, and a survey we conducted for ASTRO showed that 6% (SE = 3%) of residency graduates experienced some unemployment shortly after graduating. The same pattern characterized the relatively small sample (24 residents) in the 1994 survey. (Note that we used the standard definition of “unemployed” - namely, not having work when one is seeking it. In 1995, there were two residency graduates not in the labor force - that is, not working because they had not wanted to be working. This situation typically involves a woman with very young children.)”

[Author’s note: you can tell that paper was written in the 90s because of the women quip]

“In 1995, program directors said that 90% of residents and 85% of fellows had jobs that reasonably matched the individual graduate’s training and employment goals. The percentage of graduating residents who had a position of this type did not differ (by the usual test of statistical significance -- p<0.05) between 1994 and 1995. However, the percentage of residency program directors who reported the difficulty of finding jobs was greater than typical of recent years increased from 29% in 1994 to 63% in 1995.”

[Author’s note: it is unclear to me what Sunshine means when he states that the jobs “reasonably matched the individual graduate’s training and employment goals”]

Dr Sunshine goes on to express astonishment of what he considers positive findings, “particularly given common perceptions that ‘there are no jobs out there’ and the growing pessimism of training program directors". In trying to ascertain the pessimism, he offers the following:

“...when program faculty told us of an unemployed radiation oncologist, the story often involved someone who could look for work only where he or she trained, due to a spouse. Straightforward probability calculations show that if a physician has only a 10% chance of finding work in any one locality, he or she, nonetheless, has a 99.5% probability of finding work if he or she is willing to consider any of 50 localities. And there are literally hundreds of localities in the United States.”

He also notes:

“Long term projections point to a future surplus of radiation oncologists, primarily because the radiation oncologist workforce is growing by at least 4% annually while the number of cancer patients treated by radiation oncology is likely to increase by at most 3% annually. Thus, a surplus of radiation oncologists of at least 1% a year, or at least 10% in a decade, seems likely to emerge.”

He concludes by stating that “there are strong indications that [the job market] is likely to deteriorate in the future”.

In 1999, a report was published in The Red Journal from the Radiation Oncology Resident Training Working Group (organized by SCAROP). Ostensibly, this group sought to study and propose methods to enhance the training of RadOnc residents in America. Subcommittees were formed sometime before May 1998 (unclear when), and the findings of their work was discussed at the May 1998 SCAROP meeting.

The first subsection of the manuscript results explicitly studied the “surplus of radiation oncologists”:

“A variety of studies have indicated that there is a surplus of radiation oncologists in the United States [Author’s note: they reference only two papers for this claim]. The ASTRO Committee on Human Resources found that 165 radiation oncologists are entering practice each year, and only 45 radiation oncologists are leaving through death or retirement. This is reflected in the active membership of ASTRO, which increased from 2,318 in 1990 to 3,539 in 1998. This is an average increase of 150 members per year, or 5.5% per year. On the other hand, the number of patients being treated with radiation therapy in the United States is increasing at a rate of only 2.7% per year. Using these data, it appears that equilibrium would be maintained if the nation produced 130 radiation oncologists per year (45 FTEs to replace radiation oncologists who are leaving practice and 85 FTEs to take positions that become available because of the increased utilization of radiation therapy sources). The 1995 and 1997 ARRO surveys (J. Kresl, personal communication) indicate that some residents are having difficulty finding jobs. The 1997 ARRO graduate employment survey showed that 9% of the graduates were unable to find employment as a radiation oncologist, and 34% took positions which did not meet their first choice as a career option. Only 74% were in full-time practice (32% in academic positions and 42% in private practice). The remaining graduates were either in fellowships, doing locum tenens, employed in other fields, or unemployed.”

Interestingly, the next section is called “declining numbers in training”:

“There are indications that the number of applicants to radiation oncology residency programs may be declining, and if this is true, it should help ameliorate the problem of oversupply. The number of residency positions offered in the match has declined 29% from 1995 to 1998, and the number of positions filled in the match decreased from 90% in 1995 to 70% in 1998. Although this decrease may be partially offset by an increased number of resident positions that fill outside the match, the general impression is that the number of residents entering training is diminishing.”

They end this section by drawing virtually the same conclusion being drawn now - the decline in residency applications will naturally balance out the looming oversupply.

In 2003, Lynn D. Wilson and Bruce G. Hafty from Yale published (in The Red Journal) “Evaluation of the National Resident Matching Program (NRMP) radiation oncology data (1993–2003)”. They summarize Radiation Oncology in the 1990s as such:

“In the mid-1990s, programs were downsized and focus was directed on continued development of high-quality training programs that could meet appropriate accreditation standards. In 1998, training programs moved from the required 3 years (after PGY-1) to 4 years. The report on “The Status of Radiation Oncology Training Programs and Their Graduates” was published in 2001 and was a critical appraisal of the “market” and employment situation. The data were generated by responses of radiation oncology program directors to a survey. This report was hopeful, as it unfurled a message (as specified by the program directors) that residency training programs were decreasing in size, and that the applicant pool appeared to be improving in terms of overall quality. Also, evaluation of the employment market was performed through the perspective of 1997 graduates. This study revealed no compelling information provoking cause for concern over unemployment, nor did the data differ significantly from those reported from the graduating class of 1996. So, as evidenced at least by a survey of directors and graduates, the manpower supply situation seemed relatively stable as of the late 1990s. Much of the data generated on the subject of supply, demand, and subjective satisfaction has been provided via survey format and American College of Radiology data.”

Per Dr Wilson and Dr Hafty, it appeared that SCAROP’s assertion that decreasing the number of programs and applicants was indeed balancing out the concerns of an oversupply. The following table was published [Author’s note: I modified it to just see the latter half of the decade]:



As demonstrated by the data, the number of training positions fell from 99 in 1997 to a nadir of 81 in 2001, a drop of about 18%.

To summarize, by the mid-1990s there did indeed seem to be concern by the leadership over the job market of Radiation Oncology based on the growth of the specialty in the 80s, and supply was outpacing demand. This was clearly trickling down to medical students, as, in the absence of SDN and Twitter, applications were naturally and drastically falling (by published accounts). This was compounded by an acknowledgement of the issue by programs who voluntarily contracted, and increased the time of training from three to four years. In the span of 5-7 years, these actions at least stabilized the profession.

But, between 2001 and 2003, positions jumped from 81 to 107. Why?

The 2000s: The Golden Era

IMRT happened, of course!

If you search for the “history of IMRT”, there are many reviews talking about the technology itself. However, it is difficult to ascertain when IMRT was widely adopted. On the AAPM website, there is a PPT Presentation from June 2003 by Steve Webb entitled “Historical perspective on IMRT”. Webb provides the following slide:


These times are important. By 2000, “all major companies [are] offering products”, and by 2003 (when this PPT was created) “everyone wants IMRT”.

This lines up well with the sudden jump in RadOnc positions (word-of-mouth between medical students was also a factor, which I will discuss below)

Webb also has the following slide, which includes a very important point:



“Is the reimbursement dollar driving the science”?

As we all know, IMRT subsequently became the workhorse of Radiation Oncology. While it undeniably produces many benefits for patients, a side effect is that it produces many benefits for the bottom line of physicians, departments, and institutions across the country.

In 2005, Andre Konski published “Cost–effectiveness of intensity-modulated radiation therapy”. The following was presented (studying prostate cancer specifically):

“The mean Medicare reimbursement to the Fox Chase Cancer Center for 14 men undergoing IMRT was $24,953, normally distributed, with a standard deviation of $2039. The mean Medicare reimbursement to the Fox Chase Cancer Center for seven men undergoing 3DCRT was $13,900, log-normally distributed, with a standard deviation of $2547. Costs were adjusted to 2004 US dollars”.

Innumerable analysis of the costs of IMRT have been published and I won’t belabor the point. The take-home is that significantly more revenue could be generated from radiation therapy. This balanced and bolstered the “demand” side of the economic equation for our specialty.

In 2001, programs had contracted to their nadir, with 81 spots in 48 programs. Concurrently, applications to RadOnc exploded, with 214 applicants, more than double the number of applicants in 1998.

So, what happened? This is somewhat unclear to me. Did ASTRO run some sort of awareness campaign? Was there some push to recruit students? I’m still investigating.

However, we’re now at the beginning of the Student Doctor Network forums. SDN RadOnc was launched on August 4th, 2002. Prior to that, there were three threads discussing Radiation Oncology, which Lee (SDN admin) merged into the nascent forum.

In trying to piece together what was going on in RadOnc at the time, there are some interesting posts, which are eerily similar to what we see today. I would encourage you to go back and read some of the threads from 2001-2003, just for entertainment value alone.

In 2003, people were trying to figure out why RadOnc suddenly became popular:

View attachment 287257

View attachment 287258

I believe the post by AlexanderJ summarized what was happening well:
  1. There was an increase in “buzz” about RadOnc
  2. Students were becoming increasingly concerned with not having their work/life balance destroyed
  3. IMRT was all the rage
What does this look like from the leadership side of things? One can only imagine. Whereas a few short years prior there was concern over declining applications and a tough job market, now your department is flooded with amazing residency applicants and you’re generating far more revenue with IMRT. What’s the only logical thing to do? Expand, of course, which is what they did:

View attachment 287259

The expansion started around 2003 and continued from there.

I would consider the decade of 2000-2010 to be the true “Golden Era”. Because of the efforts of the leadership in the late 90s, there was a dip in the supply of new Radiation Oncologists for several years. Concurrently, the development of IMRT significantly increased revenue, and residency applications were numerous and amazing. Therefore, the expansion which took place was logical, given the milieu.

2010-present: The Gilded Bubble

I won’t explore this in depth, but in 2010 Ben Smith’s infamous paper predicting a massive shortage of Radiation Oncologists was published. While there was likely a “greed” component, I do believe that most departments expanded out of good faith, at least in the beginning. And why not? The predicted collapse of the job market never happened, the best and the brightest are clamoring for a place in the field, reimbursements were amazing, and now there was published evidence of a looming shortage.

The final piece I’ll touch on is the oft-argued point that may of the new or expanded residency programs are “bad” in that they don’t offer robust education or training. If all these expansion spots offer sub-par training, how do they continue to exist? How do they not collapse naturally? Obviously, whether a program is "good" or "bad" is a soft assertion and difficult to measure. I would posit the following: given the extreme competitiveness of Radiation Oncology, only the “best” students apply and match (even at “low tier” programs). How are you considered the “best” in medical school, or at least competitive for Radiation Oncology? Through board scores, course grades, and research. To do well on the boards (and in your courses), you need to have strong self-study habits. To succeed in research, you need to have tenacity and cunning to find and insert yourself into projects. Medical students are, by their nature, type-A people who have done well in school their entire lives. You then enrich this population for the best of the best. Everything you need to pass the boards and become a board-certified Radiation Oncologist is available through books, papers, audio lectures, regional courses, etc. You could have the “worst” training in this country but as long as you’re motivated enough, you can find study resources adequate to pass the boards. Therefore, these tremendous students/residents “make up” for the poor training by the virtue of the characteristics which got them into the field in the first place.

Alright, time for the “too long, didn’t read” summary of my argument.

I’ll let you decide if my interpretation of the past is reasonable or not:
  • There was a growing concern in the mid-1990s that there was an oversupply of Radiation Oncologists in America.

  • This was addressed in three ways
    1) As the poor job market news trickled down to medical students, there was a decrease in the number of residency applicants
    - the peak was in 1995 with 168 applicants
    - the nadir was in 1998 with 96 applicants

    2) As the poor job market was acknowledged by departments, there was a decrease in the number of positions and open programs
    - the peak was in 1995, with 127 spots in 65 programs
    - the nadir was in 2001, with 81 spots in 48 programs

    3) Additionally, Radiation Oncology residency training was turned into a mandatory four year program in 1998, whereas only three years were mandatory previously

  • These three factors significantly reduced the supply side of the job market for many years

  • In an almost unbelievably timed fashion, IMRT was released and widely adopted in the early 2000s, a technique which generated far more revenue than 3D-CRT, thus significantly increasing the demand side of the job market

  • The exclusive nature of the RadOnc, as well as the advent of IMRT, made Radiation Oncology a well-paying specialty with an extremely attractive work/life balance, and residency applications skyrocketed as medical students sought more reasonable careers

  • This occurred almost simultaneously with the nadir of voluntary contraction
    - in 2001 (with 81 spots in 48 programs), there were 214 applicants, more than double the number of applicants in 1998

  • Thus, Radiation Oncology - historically competitive due to the small number of training spots - was transformed into an incredibly competitive specialty in a short amount of time

  • Given the high potential of IMRT reimbursements coupled with the increased number of stellar applicants, departments and programs almost immediately began to expand (2005 saw 137 positions offered among 75 programs)

  • This expansion was supported, in part, by how competitive Radiation Oncology was to match into. “Competitive medical students” almost invariably means high USMLE Step exam scores, which means excellent test takers. Programs which may not offer the best training are buoyed by residents who will be able to pass the boards with self-directed study. If residents are becoming board certified, there is no other objective way to indicate “good” vs “bad” training.

  • This expansion was bolstered in 2010 with the infamous Ben Smith paper stating that “demand for radiation therapy is expected to grow 10 times faster than supply between 2010 and 2020”
More recent history (the past 10 years) has and continues to be discussed frequently on the boards.

My belief:

In the early 2000s, IMRT arrived in time to “save” the field. Given it’s unbelievably fortunate timing, people now look back on the history of the specialty with rose-colored glasses - remembering a time when there were significant concerns over the job market, but knowing that it “all just worked out”. It didn’t just “all work out” - a paradigm-shifting tool was introduced to Radiation Oncology at literally the time it was most needed.

There is no apparent version of IMRT today. Regardless, APM is poised to be “technology agnostic” and a “slam-dunk” technological innovation will not and cannot have the same impact now as 20 years ago. Additionally, the CMS direct-to-general supervision change will place further downward pressure on the specialty (regardless of the statements by ASTRO or the AMA).

The only way to preserve the health of the specialty is to significantly reduce the number of residency spots and balance out the supply side of the economic equation.
You should write this up formally and publish it in a journal. I would suggest the red journal but its people are too in denial to understand most of that essay...
 
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PointA

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The bottom line now is that this field is at the bottom of the barrel in terms of competitiveness. Pretty much anyone can walk into a residency position. The future looks bleak and we don't have the next IMRT boon coming to save us, especially in the era of APM. Combining downward pressure on salaries with severe geographic uncertainty is simply not appealing. At least hospitalists and pediatricians can pick their practice location without worry. I don't see this field attracting the best and brightest again until there is a large reduction in residency slots and academic leadership takes up this issue with the gravity that it deserves. Your move.
 
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The bottom line now is that this field is at the bottom of the barrel in terms of competitiveness. Pretty much anyone can walk into a residency position. The future looks bleak and we don't have the next IMRT boon coming to save us, especially in the era of APM. Combining downward pressure on salaries with severe geographic uncertainty is simply not appealing. At least hospitalists and pediatricians can pick their practice location without worry. I don't see this field attracting the best and brightest again until there is a large reduction in residency slots and academic leadership takes up this issue with the gravity that it deserves. Your move.

Mostly agree, though last year the applicant pool was still competitive. Not sure if any PDs out there can comment on if the applicant pool has dropped yet as far as quality. What programs do this year post-match will be true litmus test of times to come.
 

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There are less applicants overall but for the most part the stats and research etc for people that are applying are top notch. Basically these are people who have put multiple years into building a rad onc resume.

It’s not the case yet that subpar people are attracted to rad onc
 
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bluebubbles

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I’d attribute the steady quality of applicants to the hysteresis effect. That is, systems have inertia; the quality applicants have been mentored by mskcc/MDA-type faculty since early on in med school, and are committed in some sense. The decline in applicant numbers is likely due to the margin effect, where students on the fence decided to go with other fields.

That is to say, in the absence of big structural change, applicant quality and numbers will continue to drop, if we ignore the potential countervailing effect of the #radoncrocks PR campaign on twitter and IRL.
 
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I’d attribute the steady quality of applicants to the hysteresis effect. That is, systems have inertia; the quality applicants have been mentored by mskcc/MDA-type faculty since early on in med school, and are committed in some sense. The decline in applicant numbers is likely due to the margin effect, where students on the fence decided to go with other fields.

That is to say, in the absence of big structural change, applicant quality and numbers will continue to drop, if we ignore the potential countervailing effect of the #radoncrocks PR campaign on twitter and IRL.

Yes exactly. There will be downstream effects of decline in quality and number in future years, there is a lag effect
 

RickyScott

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I’d attribute the steady quality of applicants to the hysteresis effect. That is, systems have inertia; the quality applicants have been mentored by mskcc/MDA-type faculty since early on in med school, and are committed in some sense. The decline in applicant numbers is likely due to the margin effect, where students on the fence decided to go with other fields.

That is to say, in the absence of big structural change, applicant quality and numbers will continue to drop, if we ignore the potential countervailing effect of the #radoncrocks PR campaign on twitter and IRL.
Exactly, sunk cost effects. We used to call it shi- sandwich effect in high school when someone would eat something shi—y at restaurant solely because they paid for it. Can’t cut losses.
 
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medgator

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Exactly, sunk cost effects. We used to call it shi- sandwich effect in high school when someone would eat something shi—y at restaurant solely because they paid for it. Can’t cut losses.
Seems like a risky game at this point, with 1000 or so residents hitting the market in the next 5 years before they do
 

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The star applicants this year to the top 3/top 10 programs will be graduating in 2025. They’ll be competing not just with their own cohort, but with 1000 graduates with 1-5 years of post-residency job experience. Some of these 1000 graduates won’t be at their “dream job”, and they’ll be clamoring for a job with a better mix of location, income, autonomy, prestige, etc.

Also, the OP touched on this, but some programs are buoyed up by the high quality of self-directed, motivated residents who can essentially succeed and become competent radiation oncologists as long as they care for enough patients with a breadth and depth of disease pathology. The reliance of some subpar attendings on resident “coverage” is an addiction that will lead to painful withdrawal, if applicant numbers and quality continue to decline. Voluntary program contraction is like proper rehab.

One thing that we can do to combat unchecked residency expansion. As many of us residents graduate and take up academic jobs, it’d be good if we never or rarely accept resident coverage. That may be incredibly unrealistic on many levels, but it would reduce the “demand” for cheap resident labor.
 
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aspiring rapper

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The star applicants this year to the top 3/top 10 programs will be graduating in 2025. They’ll be competing not just with their own cohort, but with 1000 graduates with 1-5 years of post-residency job experience. Some of these 1000 graduates won’t be at their “dream job”, and they’ll be clamoring for a job with a better mix of location, income, autonomy, prestige, etc.

Also, the OP touched on this, but some programs are buoyed up by the high quality of self-directed, motivated residents who can essentially succeed and become competent radiation oncologists as long as they care for enough patients with a breadth and depth of disease pathology. The reliance of some subpar attendings on resident “coverage” is an addiction that will lead to painful withdrawal, if applicant numbers and quality continue to decline. Voluntary program contraction is like proper rehab.

One thing that we can do to combat unchecked residency expansion. As many of us residents graduate and take up academic jobs, it’d be good if we never or rarely accept resident coverage. That may be incredibly unrealistic on many levels, but it would reduce the “demand” for cheap resident labor.
Would you take an academic job with residents knowing that you will not have resident coverage while the other attendings benefit from year-round coverage?
 

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Would you take an academic job with residents knowing that you will not have resident coverage while the other attendings benefit from year-round coverage?

Right that isn’t good for anyone. Residents also deserve to have variety in who they work with.

It’s pretty simple really - all attendings need to have months where they go uncovered
 
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Would you take an academic job with residents knowing that you will not have resident coverage while the other attendings benefit from year-round coverage?

I wouldn't mind if I was an academic rad onc. We have 1 attending who pays for their own scribe out of pocket so doesn't care at all if resident present. Now, to finagle having the dept to pay for a scribe is another story...
 
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Mandelin Rain

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Reading this, one thing becomes clear... as wax pencils went away, faculty needed a kid to spend time “contouring” the small bowel with something called a “mouse”.
 
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bluebubbles

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Would you take an academic job with residents knowing that you will not have resident coverage while the other attendings benefit from year-round coverage?

Absolutely. I'd prefer it, independent of job market issues (I'm a control freak).

In the setting of proper RN's, schedulers, etc., a resident or even an NP/PA isn't necessary. Without proper support staff, the best solution isn't to get a resident to do scut; it's to get proper support staff, or implement efficient workflows, or use IT tools (e.g. auto-contouring).

Residents also deserve to have variety in who they work with.

There are many ways of teaching residents without having them do a full clinical rotation with me.

The OP describes the demand & supply of the job market for (primarily) new attending labor. However, the primary concern of PD's and academic attendings is the market for resident labor. The supply side for these markets is identical (graduating US and international med students). However, the demand side is radically different; even as the demand for new attending labor drops, the demand for resident labor is holding steady or even increasing as academic departments gobble up private practices. The PD's and academic attendings do not see eye-to-eye with us not because they're ignorant (in fact, they're incredibly intelligent). It's because they live in a different marketplace with different incentives.

In addition to growing demand for new attending labor @radiation (e.g. radiopharmaceuticals), reducing supply for new attending labor @elementaryschooleconomics (e.g. contracting residency slots), we can also reduce demand for resident labor by weaning ourselves from the crème liqueur that is resident coverage, or never succumbing to its siren call in the first place.

Yes, residents are a great help to attendings. But resident coverage is a Faustian bargain. In exchange for preserving the status quo for the resident labor market, we will continue to degrade the market for new attending labor.
 
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There is no way to deny the fact that residents help speed things up with notes and normal OAR contours.

They do potentially slow you down in clinic (if like me you spend a lot of time with consults and would likely repeat discussions a resident has already had) and with fixing target volumes for complex stuff (if you are particular in how you draw).
 
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As a very naïve observer, and based on some great posts in this thread, it seems that a very loosely regulated market has overcorrected to the detriment of students, future physicians, their patients, and perhaps the healthcare system (more layers of inefficiency?).

I wonder if something like the Flexner report, and the diversity of experience (including funding) that put it into action, may help. We do have regulatory bodies such as the ACGME. I wonder if they could be inclined to revisit board-eligibility, increase costs by mandating educational quality such that only programs capable of "high-value" training persist, and improve patient trust to further elevate our field.

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It’s often said that rad onc in the 90s was very non competitive and anyone matched, but looking at those numbers you posted, in 1995, 168 applied for 127 spots. Then 2000 and 2001 were uber competitive
 

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A PGY-2 will slow an attending down a lot. The attending waits around for the resident to see the patient. Then the attending still sees the patient for consult/OTV/follow-up, present at sim, review/fix the contours and the plan and at each step of the way needs to explain what is being done and should try to discuss relevant literature. They may save a little time with notes, but notes shouldn't take that long with good templates and EMR. Imagine a T&O that could be done in 15 mins, but with a PGY-2 may take 2-3 times as long. Then add time needed to prepare for or being a didactics instead of working on your grant, notes, contours,plans.

As a PGY-5, the resident should be able to save the attending at least a little bit of time. Contours take minimal time to evaluate. Crappy plans already reviewed by resident and attending gets to see the final or close to final version. Notes are also better, so attending may not have to add as much.
 
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“The 1997 ARRO graduate employment survey showed that 9% of the graduates were unable to find employment as a radiation oncologist, and 34% took positions which did not meet their first choice as a career option. Only 74% were in full-time practice (32% in academic positions and 42% in private practice). The remaining graduates were either in fellowships, doing locum tenens, employed in other fields, or unemployed.”

that is scary and a result solely of program expansion. Now we have program expansion and hypofractionation and payment reform and regulatory presence changes all occurring together.
 
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“The 1997 ARRO graduate employment survey showed that 9% of the graduates were unable to find employment as a radiation oncologist, and 34% took positions which did not meet their first choice as a career option. Only 74% were in full-time practice (32% in academic positions and 42% in private practice). The remaining graduates were either in fellowships, doing locum tenens, employed in other fields, or unemployed.”

that is scary and a result solely of program expansion. Now we have program expansion and hypofractionation and payment reform and regulatory presence changes all occurring together.
And no IMRT to save us
 
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RickyScott

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It is really not possible today to estimate the impact IMRT had on the field. I know of no reasonable analogue in any other medical specialty. Steve Webb had no impact in the US re: IMRT. The match that lit the fire was a 2001 ASTRO Varian-sponsored presentation by Jerome Landry and Joe Ting. It was a packed room with at least 2000 people. That's what really kicked IMRT into high gear. And until about 2003 or so IMRT was reimbursing at about $1000 per fraction in hospitals. Here are Ting and Landry hyping up breast IMRT in 2000. Emory was a Varian beta site for Eclipse and sliding window IMRT.


to put into context,initial implementation of imrt was very labor intensive which justified reimbursement.Computers were left on for hours to do one iteration, a lot of qa etc, burning pts skin etc ,but within a few years it was less labor intense than 3D in many cases.
Also, about 2006, I started to see radiation technology advertised on billboards...(and one now prominent chairman very upset about that)
 
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BobbyHeenan

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That Ben Smith paper was so bad.

Two fatal flaws: Zero accounting for both hypofractionation or mid level use.

In 2010 our department was using hypofrac in many breast and prostate cases. Hell, Smith himself was the first author on the 2010 ASTRO breast fractionation guidelines basically saying most should get it. Well before the CMS ruling I was seeing busy departments replace outgoing docs with mid levels.

Both of these variables should have been seen by authors/reviewers ...because both were discussed on here as I recall and certainly in discussions I had with colleagues toward the end of residency when this came out.
 
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scarbrtj

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ElementarySchool... I wrote this here about 6 months ago. I don’t know if it adds any nuance to your insight but it might. In keeping with the demand/supply theme, the demand for academic radiation oncologists shot up first. Then resident slots shot up. The demand for more academic rad oncs was (and is) being met by increasing resident supply. The “academic market” has been more robust in rad onc than the overall free market the last 15 years. Two theories: the academic market is so out of whack with the free market, the academic market will eventually contract... or, the free market is simply becoming the academic market in rad onc (no longer a major distinction). But to summarize, academic attending growth has outpaced residency growth which has outpaced rad onc growth overall. (This explains why recently for the first time the majority of rad oncs are no longer in private practice.)

—————

An expansion factor (EF) for radiation oncologists was calculated in various scenarios using the following criteria. From ten Internet Archive-sampleable academic programs (Stanford, UTHSCA, Emory, WUSTL, UCLA, UCSF, MGH, OSU, IU, UNC) the number of active clinical MD attendings in radiation oncology were recorded from the years 2004 and 2019 respectively. An EF was calculated for each program. (E.g., Emory had 11 attendings in 2004 and 26 attendings in 2019 for an EF of 26/11 or 2.36). In 2004, there were 96 attendings in these 10 programs and 208 now for an average EF of 2.17 (range 0.83, 4.5).

Using NRMP match data, 128 radiation oncology residency spots were offered in 2004 and 207 in 2019 for an EF of 1.62. Using available workforce data and ASTRO data, there were 3997 active practicing radiation oncologists in the United States in 2004 and 5000 in 2019 for an EF of 1.25.

Using the Mann-Whitney test, EFs were compared between groups. Given that MD numbers only increase over time, a one-sided p-value of <0.05 was assumed to be significant. An EF of 1.62 for residency slots was assumed per program, consistent with historical data mentioned above.

Academic Attendings vs Residency Slots, 2004 vs 2019
EF=2.17 vs 1.62, p=0.24
Academic Attendings vs Practicing Rad Oncs, 2004 vs 2019
EF=2.17 vs 1.25, p<0.05
Residency Slots vs Practicing Rad Oncs, 2004 vs 2019
EF=1.62 vs 1.25, p<0.05

There's been a non-signficant trend of increasing attendings vs residents over time, although the increase in residency slots has generally attempted to keep pace with the increased number of attendings. However, given the author's personal laziness and desire not to waste HUGE amounts of time, only 10 programs were sampled. With more samples, the academic and residency EF discrepancy could likely become significant. That said, there has been a significant increase in attendings, and residency slots, vs practicing rad oncs in the US, over the last 15 years. (On a side note, the EF for residency slots 2000-2003 was exactly 1.0.)
 
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radiation

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That Ben Smith paper was so bad.

Two fatal flaws: Zero accounting for both hypofractionation or mid level use.

In 2010 our department was using hypofrac in many breast and prostate cases. Hell, Smith himself was the first author on the 2010 ASTRO breast fractionation guidelines basically saying most should get it. Well before the CMS ruling I was seeing busy departments replace outgoing docs with mid levels.

Both of these variables should have been seen by authors/reviewers ...because both were discussed on here as I recall and certainly in discussions I had with colleagues toward the end of residency when this came out.

Do we have solid data showing that hypofractionation decreased overall radiation demand? I am asking sincerely, would really like to dig through that data. I understand the argument of if it takes 2 rads oncs to manage 40 pts and 2400 fractions of breast treatment, and then the number of fractions drops to 1200 or less, one conceivably doesn't need the second person.

But there is also a nonsignificant number of prostate patients than wouldn't have gotten standard radiation because of the 8 week commitment but were willing to chose SBRT over surgery. Or breast pts that choose one week of partial breast over 5 years of endocrine therapy. And thus the total number of pts getting radiation is increased, which actually works out favorably in the APM model. Anybody have those numbers?

If we play out the scenario in the first situation where 1 doc can essentially treat twice as many pts in the same amount of time without the second doc, one would expect the total number of patients treated per physician to go up (and maybe even corresponding salary increase). I don't have this info, but would be really interesting to see empiric numbers on what actually happened when hypofrac went into vogue.
 
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medgator

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Do we have solid data showing that hypofractionation decreased overall radiation demand? I am asking sincerely, would really like to dig through that data. I understand the argument of if it takes 2 rads oncs to manage 40 pts and 2400 fractions of breast treatment, and then the number of fractions drops to 1200 or less, one conceivably doesn't need the second person.

But there is also a nonsignificant number of prostate patients than wouldn't have gotten standard radiation because of the 8 week commitment but were willing to chose SBRT over surgery. Or breast pts that choose one week of partial breast over 5 years of endocrine therapy. And thus the total number of pts getting radiation is increased, which actually works out favorably in the APM model. Anybody have those numbers?

If we play out the scenario in the first situation where 1 doc can essentially treat twice as many pts in the same amount of time without the second doc, one would expect the total number of patients treated per physician to go up (and maybe even corresponding salary increase). I don't have this info, but would be really interesting to see empiric numbers on what actually happened when hypofrac went into vogue.
That's what happened in my practice, and many others I'm aware of.

Less otvs equals more clinic time for new patients
 
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BobbyHeenan

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Do we have solid data showing that hypofractionation decreased overall radiation demand? I am asking sincerely, would really like to dig through that data. I understand the argument of if it takes 2 rads oncs to manage 40 pts and 2400 fractions of breast treatment, and then the number of fractions drops to 1200 or less, one conceivably doesn't need the second person.

But there is also a nonsignificant number of prostate patients than wouldn't have gotten standard radiation because of the 8 week commitment but were willing to chose SBRT over surgery. Or breast pts that choose one week of partial breast over 5 years of endocrine therapy. And thus the total number of pts getting radiation is increased, which actually works out favorably in the APM model. Anybody have those numbers?

If we play out the scenario in the first situation where 1 doc can essentially treat twice as many pts in the same amount of time without the second doc, one would expect the total number of patients treated per physician to go up (and maybe even corresponding salary increase). I don't have this info, but would be really interesting to see empiric numbers on what actually happened when hypofrac went into vogue.


It’s hard to quantify it, thus the lack of data.

It reduces overall revenue to the department; if IMRT increased revenue then led to changes, a decrease in revenue will lead to change as well.

In our health system the breast consults and CT Sims stayed constant while the fractions/revenue decreased. Physicians chose to work more (ie not hire when older partners retired) to keep salaries the same.

Of course all anecdotal, but as I recall from that paper there was nary a mention of hypofrac and how it may impact all this. Or at least people propping up the paper as “evidence “ for residency expansion didn’t discuss this omission.

Regarding prostate and SBRT, I think this is a big area for growth. However, depending upon your local friendly urology practice, even the most robust data won’t sway them from “talked about radiation with the patient , he wanted surgery.” Until insurers, Medicare, or nccn mandates a rad onc consult before surgical decision making it’s going to be challenging to move the needle on total new prostate patients.
 
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PhotonBomb

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‘And thus the total number of pts getting radiation is increased, which actually works out favorably in the APM model.’

Yes I have the same question
 

scarbrtj

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Do we have solid data showing that hypofractionation decreased overall radiation demand? I am asking sincerely, would really like to dig through that data. I understand the argument of if it takes 2 rads oncs to manage 40 pts and 2400 fractions of breast treatment, and then the number of fractions drops to 1200 or less, one conceivably doesn't need the second person.

But there is also a nonsignificant number of prostate patients than wouldn't have gotten standard radiation because of the 8 week commitment but were willing to chose SBRT over surgery. Or breast pts that choose one week of partial breast over 5 years of endocrine therapy. And thus the total number of pts getting radiation is increased, which actually works out favorably in the APM model. Anybody have those numbers?

If we play out the scenario in the first situation where 1 doc can essentially treat twice as many pts in the same amount of time without the second doc, one would expect the total number of patients treated per physician to go up (and maybe even corresponding salary increase). I don't have this info, but would be really interesting to see empiric numbers on what actually happened when hypofrac went into vogue.
I would like to think it should.
And it probably would were rad onc just to go "all in" for 15-16fx breast (I was kinda "shocked" recently to discover most breast hypofractionators give ~21 fx's e.g.) or single fraction bone met.
I can say it has in my own practice; I treat about 33% less on beam and collect about 25% less $$$ I reckon than ~5-7y ago.
But let's talk data.
There were about 15 million allowable Part B radiation procedures in 2011; reimbursement about $1.8 billion.
In 2018 there were about 16.5 million radiation services; reimbursement about $1.5 billion.
So to bust one myth/fake news a little... reimbursement is falling in rad onc over time. In 2011 rad oncs were paid about $120 per service, and now we get $90/service. That's a ~25% drop off. Wowie. Matches my own experience lol.
The amount of rad onc services has increased ~10% since 2011. But rad onc MD numbers have probably increased at least ~20+% since that time per OP's nice line graph above.
So to summarize:
1) Rad onc reimbursement down about 25% in 7 years; rate ~3.5%/year.
2) Rad onc services up about 10% over 7 years; rate ~1.4%/year.
3) Rad onc MD numbers up about 20% over 7 years; rate ~2.8%/year.
4) Current data would shift #3 to about 3-4%/year going forward, but looking at #2 this rate increase seems to be slowing over time.

But to your original question: hypofractionation has not put much of a dent in radiation services overall. And thus this is why Medicare is now essentially saying WTF. You CAN NOT blame private practice for this (lack of hypofractionation adoption). There's too many Medicare patients treated in academic centers for this to carry much water.
 
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