Would you advise M3/M4s to go into this field?

[bronx43]

Embrace BFE. It's the last bastion of hope for this generation of young physicians. After that, we are all cooked...

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[Reaganite]

If you don't have a specific job ad to offer to be helpful, please just stop posting about how there are opportunities out there. Maybe you like your job that you've had. Good for you. Please hire me. Oh, I already know that you're not hiring. Any good practice is already full since the market isn't expanding and everyone is too concerned about the future of our specialty.

The job market died and needs a eulogy, not a posthumous attempt at Weekend at Bernie's.

I feel for you, man. Part of the problem with posting opportunities is that you run the risk of losing your anonymity on this board. I watch the job market in my area closely for a variety of reasons. There really have been a lot of new hires with decent pay/hours, but I will stress (and I've said this many times), very few were ever posted. They were almost all filled internally by grads of the program or people with close affiliation (i.e. some guy who had been doing locums for the program for years). Even if it was advertised...you probably never had a shot. Many programs are required to post ads, but they often already know who they are going to hire before that ad goes up. On the PP side, I've personally hired several people over the last few years (and I have friends who have hired), but we never advertised our spots. I only hire people I know or people who my friends can vouch for. I don't think cold-calling or a good CV is enough for many jobs. You really need to be a known commodity. Of course, I'm not saying this is true for ALL cases. Just like I never said there aren't jobs paying 500k+ or that everyone is going to be stuck in a satellite making 250k. What I post are my observations and experiences working in a very busy private practice in a particularly saturated geography where I have many friends and where there are many practices (i.e. competitors) I have to keep a close eye on.

 

[RickyScott]

Embrace BFE. It's the last bastion of hope for this generation of young physicians. After that, we are all cooked...

1) At some point BFE will be saturated. Good read- how some may make statements like "supply does not affect demand, or ignore that pre hypofractionation 100,000 population supported around 15-20 pts on beam)

How an 18th-century priest gave us the tools to make better decisions

2) There is no doubt that there will be some high paying jobs out there for some time, (pathology boards report this as well) and there will always be some of us lucky enough to snag something really good. I am concerned about the "bottom 1/3." This is too competitive a specialty right now that by some happenstance, following a fellowship, a significant proportion of future graduates will at some point get stuck in some dead end 250K/year spot with little chance of professional advancement and close to zero mobility. Like with the recent boards, it is simply inappropriate for a significant portion of such a highly qualified field to be put in this position.

 

[scarbrtj]

How an 18th-century priest gave us the tools to make better decisions

It's heartening you brought this up. Radiation oncology is in need of a Bayesian revolution. If I had the time, will, money, and biostatistical colleagues, I would re-analyse some of the recent practice-changing trials in radiation oncology from a Bayesian vs frequentist (frequentism: what all tests/trials in radiation oncology have used for the past five decades, and you didn't even know you were a frequentist!) interpretation. This would be a rather large undertaking. I have a hunch that many hypofractionation results would not have been accepted as new standards of care were the oncology world Bayesian instead of frequentist. I'm a wannabe philosopher, and this thought process gets into pretty deep subjects (what is one's viewpoint of the world) which might be best alluded to in the fiction piece "The Story of Your Life" by Ted Chiang.
Anyhoo, pardon the interruption. Carry on.

 

[Chartreuse Wombat]

You state "I have a hunch that many hypofractionation results would not have been accepted as new standards of care were the oncology world Bayesian instead of frequentist".

Do you think this applies to hypofractionation studies more than other studies? If so, why?

 

[scarbrtj]

You state "I have a hunch that many hypofractionation results would not have been accepted as new standards of care were the oncology world Bayesian instead of frequentist".

Do you think this applies to hypofractionation studies more than other studies? If so, why?

I think so. Because in regards to long-term accepted standards of care, it's hypofractionation vs. standard which has in my opinion most supplanted previously accepted standards of care in radiation oncology. I can think of other situations where other trials produced disruption in the standard of care (Smalley's trial, Calais' trial leap to mind) in rad onc. Still, seems like there has been a bit more disruption in the fractionation arena, and that disruption has been against previous very robust data. My opinion only. It's at best a wild guess on my part. I have pointed out previously that there is a crisis in reproducibility and that there's a p-value war: taken together, previous trials which have changed the standard of care wouldn't have done so if the standards for significance were different (and/or we were all more skeptical I suppose). Feel free to ignore me 'bout all that. Although when I read this thing recently, I thought "pretty Bayesian."

 

[RickyScott]

Protons and the proton/academic complex are really going to damage this field. At some point, I hope there will be a critical mass of outrage among us. Reimbursement of protons is bad for society and hurts us all. I honestly dont expect the abr to continue with such high board failure rates, but will these proton/academic centers keep churning out 200 residents/year- of course.

 

[20181121]

I am dismayed by some of these recent posts, really for a good many reasons:
- I am sorry to hear from people who regret going into this field, since so many of us feel that it is a fantastic field of medicine: we have the privilege to treat patients with a modality that in many cases can cure, in others can prolong survival, and in others can really improve quality of life; we get to spend time with our patients and develop long-term relationships both with them and with our colleagues in other specialties; and our work is frankly really interesting and intellectually stimulating.

- White I appreciate that people have geographic preferences, it is worth remembering that many of our patients do not live near a major coastal city. All of our patients deserve top-quality cancer care, and these patients need well-trained, clinically strong radiation oncologists.

- It is discouraging to see so much discusssion around hours, workweek, compensation, jobs, and other matters along these lines. We are well-compensated and can sit down for dinner with our families. Some fields of medicine can say the same; others cannot. Many residents accept job offers in the fall of PGY-5 year or earlier; others sign contracts later in the year. Students should go into Radiation Oncology because they want to help cancer patients and find radiotherapy more interesting than systemic therapy or surgery.

- Professional disagreements are healthy, but unprofessional comments are unhelpful. Specifically in reference to the posts above, proton therapy has pros and cons, and heated arguments about protons vs. photons will likely be moot at some point in the future when the costs of protons and photons are more similar. At that point, clinical decision-making and comparison plans (we will never have level 1 data for everything!) can figure out which is better for a given scenario. Proton therapy is a technology that deserves continuing research, as do carbon ion therapy, novel photon delivery techniques, etc.

This being an Internet forum, there is plenty of venting and arguing, and the more positive comments are diluted out. But in the real world, the vast majority of radiation oncologists I know are collegial, highly professional, and a pleasure to work with, are excellent doctors, and love what they do.

 

[deleted947887]

My sincere advice to you is do derm. If you like cancer patients, do heme/onc. Radonc is not where you want to be.

I am curious to hear what you end up doing.

Hi all,

I appreciate everyone's time as I am trying to figure out what to do with my life. We are now getting to the end of M3 and I haven't really liked much and am starting to panic because I don't know what to do. My priorities are lifestyle, enjoying the work, and pay in that order.

I am a third year, going to be starting M4 around April/May and have been set on Rad Onc since the beginning of medical school and have made myself somewhat competitive for it (i.e. step 1 >260; ~8ish publications). However, given the posts I see around here and what I hear about the job market I am very reluctant to apply to this field. From what I have seen shadowing and doing research I like the work but I don't think I would enjoy living in the middle of nowhere working a high volume job for declining compensation (considering i have ~300k in loans).

Would you advise someone like me to apply to this field? Why or why not?

For those who regret entering this field, what would you have applied to instead?

Thank you so much,

Cremaster Reflex

 

[deleted18755]

This being an Internet forum, there is plenty of venting and arguing, and the more positive comments are diluted out. But in the real world, the vast majority of radiation oncologists I know are collegial, highly professional, and a pleasure to work with, are excellent doctors, and love what they do.

I couldn't agree with you more, but the issue is not how things are now for the majority of radiation oncologists: awesome (almost unbelievable) I agree for those of us in mid-career who have had the privilege of working with cancer patients in this field for 15-20 years, paid off our loans with VERY nice nest eggs, and can continue along regardless of what the future may hold, whether it's 5-7 more years like this or 20+ more. If my pay dropped 25% today I'd be at work tomorrow and if it dropped 33% over the next 5 years I'd still love my job.

The problem is for new graduates who simply cannot a find a job that suites them (I agree that at this moment there are very good jobs and patients who need doctors in places where most graduates don't want to live) or more importantly the original poster who right now has many options and is trying to do his best to estimate what the job market in radiation oncology will be like 8-10 years from now (especially relative to other specialties).

Nobody can tell the future but demand is simply not going to keep up with supply (come on . . . residencies spots are over 200/year . . . literally double!?! . . . and there are apparently residency programs opening in medical schools that I've never even hear of!).

The ABR issue is really unfortunate . . . I would definitely still tell somebody who is concerned about the job market but happy to work in rural areas to apply now because this field is so incredible and I'd bet there will still be jobs in rural areas in the future, but I can't image applying to a specialty where 25-50% or whatever of an entire residency class failed an exam with what appears to be an unsatisfactory explanation (and even more uncertainty for the future in that regard too).

 

[OTN]

Our med onc colleagues are routinely publishing trials that shows improved overall survival while our rad onc leaders are pushing protons that have never shown an overall survival benefit. If you enjoy being a snake oil salesman, choose rad onc. Rad oncs emphasizes "perceived" quality when we choose our residents or who to dole out jobs to while the med oncs are focusing on NIH funding and pushing out clinical trials that show real improvements in survival. My med onc friends are getting offers of $350-450K in major metro areas like Atlanta and Chicago while I am not even getting a single interview.

If you are a med student, the very least you can do at this moment is to rank prelim medicine over transition year because you might just want that additional year of medicine training when you decide to bail on rad onc in the near future. Hell, I would not have chosen rad onc if I can get my 5 years of life back, but I am too old and lazy to retrain now. Our leaders are money hungry and disgusting. They are liars who will enslave you.

Just wait until this July when the ABR fails another 40% of the graduating PGY5 class on our clinical boards, and you'll understand why not to choose rad onc.

Choosing rad onc has been the biggest mistake of my life.

We're still seeing survival advances from RT trials. The COMET results were huge- RT for oligomets led to a doubling (!) of overall survival at 5 years.

 

[RickyScott]

We're still seeing survival advances from RT trials. The COMET results were huge- RT for oligomets led to a doubling (!) of overall survival at 5 years.

While those trials are promising, most positive randomized phase II trials in oncology do not translate into the phase III setting! This was mentioned in one of the lung sessions at ASTRO. (For investors, you can loose big money in biotech stock by betting on a randomized phase II) I wouldnt advise a medstudent to bank on this kind of thing, when historitcal odds are that it will not hold up. Anyway, increasing hypofractionation will more than offset oligomets, so much so, that I am advising our hospital to go down to one machine, when our second one enters "end of life" in several years.

The hazards of randomized phase II trials
"This is somewhat borne out of historical experience: the likelihood of a positive phase II combination chemotherapy trial resulting in a subsequently positive phase III trial within 5 years was reported to be just 0.038 [3]. The randomized phase II design was supposed to rescue us from this rather dismal yield. Unfortunately, for all its promises and advantages, we must recognize its many limitations and pitfalls"

 

[thecarbonionangle]

This has been written about extensively but the fact is the majority of “evidence” out there in unreplicable and unconfirmed. Many studies, clinical, basic science cannot be replicated and there is a lot of fraud out there.

 

[nkmiami]

While those trials are promising, most positive randomized phase II trials in oncology do not translate into the phase III setting! This was mentioned in one of the lung sessions at ASTRO. (For investors, you can loose big money in biotech stock by betting on a randomized phase II) I wouldnt advise a medstudent to bank on this kind of thing, when historitcal odds are that it will not hold up. Anyway, increasing hypofractionation will more than offset oligomets, so much so, that I am advising our hospital to go down to one machine, when our second one enters "end of life" in several years.

The hazards of randomized phase II trials
"This is somewhat borne out of historical experience: the likelihood of a positive phase II combination chemotherapy trial resulting in a subsequently positive phase III trial within 5 years was reported to be just 0.038 [3]. The randomized phase II design was supposed to rescue us from this rather dismal yield. Unfortunately, for all its promises and advantages, we must recognize its many limitations and pitfalls"

Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trial finally, a phase II update to the famous article.

1. 1Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 375 Longwood Avenue, Boston, MA 02215, USA
2. 2David Geffen School of Medicine, University of California, Los Angeles, CA, USA
3. 3Department of Emergency Medicine, University of Michigan and Saint Joseph Hospital, Ann Arbor, MI, USA
4. 4Michigan Integrated Center for Health Analytics and Medical Prediction, Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA

Abstract
Objective To determine if using a parachute prevents death or major traumatic injury when jumping from an aircraft.

Design Randomized controlled trial.

Setting Private or commercial aircraft between September 2017 and August 2018.

Participants 92 aircraft passengers aged 18 and over were screened for participation. 23 agreed to be enrolled and were randomized.

Intervention Jumping from an aircraft (airplane or helicopter) with a parachute versus an empty backpack (unblinded).

Main outcome measures Composite of death or major traumatic injury (defined by an Injury Severity Score over 15) upon impact with the ground measured immediately after landing.

Results Parachute use did not significantly reduce death or major injury (0% for parachute v 0% for control; P>0.9). This finding was consistent across multiple subgroups. Compared with individuals screened but not enrolled, participants included in the study were on aircraft at significantly lower altitude (mean of 0.6 m for participants v mean of 9146 m for non-participants; P<0.001) and lower velocity (mean of 0 km/h v mean of 800 km/h; P<0.001).

Conclusions Parachute use did not reduce death or major traumatic injury when jumping from aircraft in the first randomized evaluation of this intervention. However, the trial was only able to enroll participants on small stationary aircraft on the ground, suggesting cautious extrapolation to high altitude jumps. When beliefs regarding the effectiveness of an intervention exist in the community, randomized trials might selectively enroll individuals with a lower perceived likelihood of benefit, thus diminishing the applicability of the results to clinical practice.

 

[medgator]

We're still seeing survival advances from RT trials. The COMET results were huge- RT for oligomets led to a doubling (!) of overall survival at 5 years.

Not to mention the trial showing a survival benefit to palliative dose consolidative thoracic xrt in extensive stage sclc that was published a few years ago.

A lot cheaper than even a month of pdl1 therapy in some cases. Med onc would go nuts over that

 

[bobloblaw]

Hi all,

I appreciate everyone's time as I am trying to figure out what to do with my life. We are now getting to the end of M3 and I haven't really liked much and am starting to panic because I don't know what to do. My priorities are lifestyle, enjoying the work, and pay in that order.

I am a third year, going to be starting M4 around April/May and have been set on Rad Onc since the beginning of medical school and have made myself somewhat competitive for it (i.e. step 1 >260; ~8ish publications). However, given the posts I see around here and what I hear about the job market I am very reluctant to apply to this field. From what I have seen shadowing and doing research I like the work but I don't think I would enjoy living in the middle of nowhere working a high volume job for declining compensation (considering i have ~300k in loans).

Would you advise someone like me to apply to this field? Why or why not?

For those who regret entering this field, what would you have applied to instead?

Thank you so much,

Cremaster Reflex

Lots of factors go into the choice of a specialty. It sounds like you have already had a chance to explore the specialty so you are familiar with the nature of the work. This is probably the most important factor. Is this work that you will find fulfilling over a career?

Job markets in radiation oncology have historically been cyclical. It is impossible to predict what the job market will be like when you graduate.

With respect to salary - the "ARRO graduating resident survey" from ASTRO 2018 presented some numbers for graduating residents.
For private practice, the average was ~ $353K, median was $330K.
For academic practices, the average was $299K and median was $310K.

best of luck!