Will the rad onc job market correct itself within the next 10 years?

[TheWallnerus]

At this point, about half of my practice is definitive hypofractionated RT for oligoprogressive disease in the chest. When you are giving someone the best IO money can buy and a large mass is pinching off their LMSB… who are you gonna call??

Shouldn't about half your practice be single fraction RT for oligoprogressive dz

Convenience ftw.

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[Lamount]

Shouldn't about half your practice be single fraction RT for oligoprogressive dz

Convenience ftw.

I’ve got a IIT for anyone with small peripheral mets (or stage 1). For central disease or cannon balls, I do 15 fx, trying to get as much of tumor as possible >75 Gy, will keeping bronchus, esophagus etc… in tolerance.

I think that 1 fx stuff has a place, but only when travel is a huge concern. I frequently end up treating these folks with multiple courses so I try to leave some un-fibrosed lung left 1-3 fx leaves some nasty scars

 

[TheWallnerus]

"The recommended number of radiation oncologists in the developed world is around 4 per million population."

In the US as of 2022 the number of ROs is ~17-18 per million.

Global Radiation Oncology Markets, 2021-2028 - Increasing Application Of Radiopharmaceuticals, Rising Prevalence Of Cancer, & Rising Adoption Of Radiotherapy

DUBLIN, Oct. 22, 2021 /PRNewswire/ -- The "Global Radiation Oncology Market Size, Share & Trends Analysis Report by Type (External Beam Radiation Therapy, Internal Beam Radiation Therapy), by Application, by

www.benzinga.com

 

[DebtRising]

I don't agree with this take. With SBRT for oligomets and an aging Boomer population, although we have seen some decrease in demand over the last decade, I don't think it's been quite as dramatic as this suggests. It hasn't in my practice at least, and it's not as if we hired a ton of medoncs/surgeons which led to the demand- those inputs for my practice are more or less the same. Obviously if you're a single-site radonc, and your site is lymphoma or GI...well that would be different. Yet another reason it's nonsensical to tie yourself to a single disease site if you can help it. Hypofractionation is big, sure, but again with a well-rounded patient base it wouldn't be world-ending.

The increase in supply has been THE issue. If we still had the same number of residents now we did 10-15 years ago, we'd still be fielding "can I make it into the field??" questions, rather than "should I go into this dumpster fire?"

I respectfully disagree and sorry for the delay, but very hard to prove. Also want to stress respectfully. The sheer drop in number per fractions in prostate (say 11 or 28% percent of conven fraction), and to 15 from 25 (40%) in breast, as well as differences in who even gets radiation ( no more tx of low risk prostate which was 10% of volume 8 years ago let’s say ), and omission of breast RT in 10% (another change from 8 years prior), lead to a calculation of about 30% less RT fractions compared to 8 years ago. We have not had 30% increase in age appropriate consults to make up for this.

Caveats - not a lot of oligomet penetration here. And obligatory - it’s good to treat less people shorter if it’s good for society. But makes no sense to graduate record residency classes.

Your points about supply and the “soft” demand destruction of people working harder to make up for the above totally valid.

 

[GapCalc]

Another possible outcome is that we have a glut of under-utilized but "fully employed" radiation oncologists, working at satellites, making salaries at or below the current level, with 7-12 patients on treatment. This could soak up 40-60 grads/year, at least for a while. RO graduate surveys would continue to have high employment rates/low fellowship and no-job-contract responses. The recent grads are 'happy' to have a job (the doom-and-gloom didn't come to pass). And, perhaps worst of all, the Misanthropes of SDN would be *gasp* wrong.

I don't particularly believe this will happen, but it could satisfy a lot of the aims of Big Rad Onc, including (1) expanding the satellite network which are financially viable due to 3x-5x (or more) of Medicare rates; (2) drive out PP competition (who cannot command said rates), thus allowing further price increases; (3) depress MD wages because docs are 'only' treating 7-12 patients (e.g. the Dennis Hallahans of the world are happy); (4) give a reason to keep this unreasonable supply of RO grads coming down the pipeline.

This would be, of course, a disaster for those who like to practice in the community, like being busy, and like to earn a good income.

 

[RickyScott]

Another possible outcome is that we have a glut of under-utilized but "fully employed" radiation oncologists, working at satellites, making salaries at or below the current level, with 7-12 patients on treatment. This could soak up 40-60 grads/year, at least for a while. RO graduate surveys would continue to have high employment rates/low fellowship and no-job-contract responses.. The recent grads are 'happy' to have a job (the doom-and-gloom didn't come to pass). And, perhaps worst of all, the Misanthropes of SDN would be *gasp* wrong.

I don't particularly believe this will happen, but it could satisfy a lot of the aims of Big Rad Onc, including (1) expanding the satellite network which are financially viable due to 3x-5x (or more) of Medicare rates; (2) drive out PP competition (who cannot command said rates), thus allowing further price increases; (3) depress MD wages because docs are 'only' treating 7-12 patients (e.g. the Dennis Hallahans of the word are happy); (4) give a reason to keep this unreasonable supply of RO grads coming down the pipeline.

This would be, of course, a disaster for those who like to practice in the community, like being busy, and like to earn a good income.

I think this is exactly what’s happening. Divide pts on beam by attendings ar many places and this is what you find. It also can’t last.

 

[elementaryschooleconomics]

Another possible outcome is that we have a glut of under-utilized but "fully employed" radiation oncologists, working at satellites, making salaries at or below the current level, with 7-12 patients on treatment. This could soak up 40-60 grads/year, at least for a while. RO graduate surveys would continue to have high employment rates/low fellowship and no-job-contract responses.. The recent grads are 'happy' to have a job (the doom-and-gloom didn't come to pass). And, perhaps worst of all, the Misanthropes of SDN would be *gasp* wrong.

I don't particularly believe this will happen, but it could satisfy a lot of the aims of Big Rad Onc, including (1) expanding the satellite network which are financially viable due to 3x-5x (or more) of Medicare rates; (2) drive out PP competition (who cannot command said rates), thus allowing further price increases; (3) depress MD wages because docs are 'only' treating 7-12 patients (e.g. the Dennis Hallahans of the word are happy); (4) give a reason to keep this unreasonable supply of RO grads coming down the pipeline.

This would be, of course, a disaster for those who like to practice in the community, like being busy, and like to earn a good income.

As long as technical fees remain significantly higher than professional fees, this is a very real dystopian future.

If you have an army of docs spread across a large geographic footprint, each of them with 7-12 on beam, and you pay them all $300k a year (with a production bonus to make them want to work harder), you've won the game for the institution. Even with inflation, given the growing economic divide in America, an individual making $300k a year puts them in the top 1%. The average American will have no pity on a doctor "only" making a flat $300k per year for all of their career.

There will be no leverage for the average "boots on the ground" Radiation Oncologist. At the end of the referral chain, they can't just "work harder" to make more money. With an oversupply, if they're unhappy and threaten to quit...no worry, they can be replaced. The "new grad unemployment" number will always remain low, which has been established as the only number the folks in power are willing to consider as a barometer of the market.

This doesn't even consider the looming AI autocontouring and planning...

 

[RickyScott]

As long as technical fees remain significantly higher than professional fees, this is a very real dystopian future.

If you have an army of docs spread across a large geographic footprint, each of them with 7-12 on beam, and you pay them all $300k a year (with a production bonus to make them want to work harder), you've won the game for the institution. Even with inflation, given the growing economic divide in America, an individual making $300k a year puts them in the top 1%. The average American will have no pity on a doctor "only" making a flat $300k per year for all of their career.

There will be no leverage for the average "boots on the ground" Radiation Oncologist. At the end of the referral chain, they can't just "work harder" to make more money. With an oversupply, if they're unhappy and threaten to quit...no worry, they can be replaced. The "new grad unemployment" number will always remain low, which has been established as the only number the folks in power are willing to consider as a barometer of the market.

This doesn't even consider the looming AI autocontouring and planning...

View attachment 344942

Also demand that they turnout garbage pubs (especially on DEI/disparity) to make your department look productive. 0 lateral movement.

 

[Palex80]

Shouldn't about half your practice be single fraction RT for oligoprogressive dz

Convenience ftw.

This is probably the future. Perhaps a one-appointment service, where you have planing and treatment within one day. A bit like what our colleagues are doing in intervention radiology (with the exception of the consultation), or what some of us used to do (and some still do) with rigid stereotactic frames for SRS.

 

[Baws]

Between ABRs abuse of residents, APM, hypofx, residency expansion, job market issues, lack of leadership there are several reasons why radiation oncology is the least desirable specialist in medicine for current medical students as we have seen by ERAS data. I sometimes do wonder the singular impact this article made (dated 2018 where radiation oncology was still going strong for the most part)

FUTURE RESIDENT, DO NOT BECOME A RADIATION ONCOLOGIST!!!

UNLESS YOU CAN MATCH INTO A TOP 3 PROGRAM. I will share my experience of job finding so that prospective applicants and medical students have a clear understanding of “job opportunities” in radiation oncology when you graduate from a mediocre/nobody program. I graduated from a small program...

forums.studentdoctor.net

 

[TheWallnerus]

Between ABRs abuse of residents, APM, hypofx, residency expansion, job market issues, lack of leadership there are several reasons why radiation oncology is the least desirable specialist in medicine for current medical students as we have seen by ERAS data. I sometimes do wonder the singular impact this article made (dated 2018 where radiation oncology was still going strong for the most part)

FUTURE RESIDENT, DO NOT BECOME A RADIATION ONCOLOGIST!!!

UNLESS YOU CAN MATCH INTO A TOP 3 PROGRAM. I will share my experience of job finding so that prospective applicants and medical students have a clear understanding of “job opportunities” in radiation oncology when you graduate from a mediocre/nobody program. I graduated from a small program...

forums.studentdoctor.net

And there have been even more worrisome posts than this since then

 

[theradiator]

Statements from a recent breast tumor board:

Rad Onc: The only options I am considering for your elderly patient with early breast cancer/DCIS with poor mobility are 0 fractions or 5 fractions.
Surgeon: Do we even need post-mastectomy RT for a young patient with 2 positive lymph nodes after neoadjuvant chemo?
Med Onc: Let's add Verzenio for a receptor positive patient with 1 to 3 positive lymph nodes and a ki-67 of 20% or poorly differentiated tumor

Not looking good here

 

[theradiator]

Statements from a recent breast tumor board:

Rad Onc: The only options I am considering for your elderly patient with early breast cancer/DCIS with poor mobility are 0 fractions or 5 fractions.
Surgeon: Do we even need post-mastectomy RT for a young patient with 2 positive lymph nodes after neoadjuvant chemo?
Med Onc: Let's add Verzenio for a receptor positive patient with 1 to 3 positive lymph nodes and a ki-67 of 20% or poorly differentiated tumor

Not looking good here

RadOnc: You know, I really feel strongly on giving post-mastectomy RT on triple negative patients with biopsy proven axillary nodes despite a pathological complete response.

Med Onc: That will all change with Keytruda

 

[TheWallnerus]

RadOnc: You know, I really feel strongly on giving post-mastectomy RT on triple negative patients with biopsy proven axillary nodes despite a pathological complete response.

The pCRs in TNBC have really good outcomes. It's like the old days of HER2+: "This is aggressive breast cancer." Now the treatment shifts the biology where it's actually the more favorable breast cancer. "Six years ago, a medical oncologist told me he had never seen a patient with HER2-positive breast cancer develop local recurrence. I set out to find patients who had recurrence in this setting. Approximately 2,000 patients later, I have not seen one, either."

 

[madchemist89]

I Understand that med oncs love chemo but does chemo not have potential deleterious side effects? Aren't adria and herceptin cardiotoxic? My xray beams barely even touch the heart in terms of mean heart dose with modern techniques. There is minor skin toxicity with rt. The toxicities of rt are minimal.

 

[jondunn]

I Understand that med oncs love chemo but does chemo not have potential deleterious side effects? Aren't adria and herceptin cardiotoxic? My xray beams barely even touch the heart in terms of mean heart dose with modern techniques. There is minor skin toxicity with rt. The toxicities of rt are minimal.

Herceptin is a highly active systemic drug. The bang for buck makes breast RT look like play-doh

 

[fiji128]

FUTURE RESIDENT, DO NOT BECOME A RADIATION ONCOLOGIST!!!

UNLESS YOU CAN MATCH INTO A TOP 3 PROGRAM. I will share my experience of job finding so that prospective applicants and medical students have a clear understanding of “job opportunities” in radiation oncology when you graduate from a mediocre/nobody program. I graduated from a small program...

forums.studentdoctor.net

This basically describes me although I'm not as quite as gloom about it as the OP. You can only move forward. In the long run (ie >10 years) ending up in nowherevilles might actually be a huge bonus as you can earn and save enough to financially protect yourself before the floor falls out of the specialty.

 

[TheWallnerus]

Herceptin is a highly active systemic drug. The bang for buck makes breast RT look like play-doh

Harry Connick Jr. played Dennis Slamon. Who will play our most famous rad onc in the rad onc movie? (said sarcastically)

 

[Radonky]

As long as technical fees remain significantly higher than professional fees, this is a very real dystopian future.

If you have an army of docs spread across a large geographic footprint, each of them with 7-12 on beam, and you pay them all $300k a year (with a production bonus to make them want to work harder), you've won the game for the institution. Even with inflation, given the growing economic divide in America, an individual making $300k a year puts them in the top 1%. The average American will have no pity on a doctor "only" making a flat $300k per year for all of their career.

There will be no leverage for the average "boots on the ground" Radiation Oncologist. At the end of the referral chain, they can't just "work harder" to make more money. With an oversupply, if they're unhappy and threaten to quit...no worry, they can be replaced. The "new grad unemployment" number will always remain low, which has been established as the only number the folks in power are willing to consider as a barometer of the market.

This doesn't even consider the looming AI autocontouring and planning...

View attachment 344942

 

[Gfunk6]

View attachment 345121

You missed the last part of that quote, "until you [private practice] are dead."