ASTRO Blog Post from Dr. Harari

[deleted18755]

Nope those jobs will always remained unfilled haha

Hopefully for the patients in those areas there’s someone from those areas that wants to go back home. Or someone who wants to make bank decides to go live there.

I mean obviously there are multiple urologists, ENTs, breast surgeons etc who choose to work there otherwise there wouldn’t be a need for one rad onc

Good point. With 200 radiation oncology residents graduating a year I find it hard to believe that not a single one is from anywhere near those locations or isn’t willing to work there for 3-5 years or whatever and make bank (heck doctors go overseas to developing and/or war torn countries all the time to provide services ... is providing needed care to patients and living in a small town in Kansas while making who knows how much money worse than providing needed care to patients and living in a third world and/or dangerous country and making no money?) obviously at least a few medical oncologists, pulmonologists, ENT, surgeons and whoever else are referring to the center are doing so (it’s not like the towns just have a lonely family medicine doctor and a random linac).

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[xrthopeful]

I think in MANY fields there are FMGs who frankly are ready to live anywhere to maximize their earning potential. That's happened for years and years. it could do rad onc some good tbh to let some strong FMGs in who will do the same and help take care of cancer patients in underserved areas.

Clearly the American grad Rad Oncs - we have a bit of a selection bias. Many of us chose the field with lifestyle and technology in mind and many of us who think that way have certain places we want to live. Not all, but many, clearly. This particular generation of grads especially I believe (including myself in this).

Rad Oncs are a special breed also. Obviously there are many many ER docs and surgeons etc. (American born and trained) who live and work in every nook and cranny of this country, in far more places than there are linacs, places where there is no need for a Rad Onc. Doesn't seem to be an issue in other fields.

 

[medgator]

I think in MANY fields there are FMGs who frankly are ready to live anywhere to maximize their earning potential. That's happened for years and years. it could do rad onc some good tbh to let some strong FMGs in who will do the same and help take care of cancer patients in underserved areas.

Clearly the American grad Rad Oncs - we have a bit of a selection bias. Many of us chose the field with lifestyle and technology in mind and many of us who think that way have certain places we want to live. Not all, but many, clearly. This particular generation of grads especially I believe (including myself in this).

Rad Oncs are a special breed also. Obviously there are many many ER docs and surgeons etc. (American born and trained) who live and work in every nook and cranny of this country, in far more places than there are linacs, places where there is no need for a Rad Onc. Doesn't seem to be an issue in other fields.

We like to enjoy our weekends more?

 

[Gfunk6]

Pe the Google Doc - a number of the people who ended up SOAP-ing into open spots were ENT and Derm applicants who didn't match

 

[xrthopeful]

Personally I’d take being a rad onc any day over those two other fields. Congrats to them on their match.

 

[deleted947887]

Personally I’d take being a rad onc any day over those two other fields. Congrats to them on their match.

Agree. Congrats. Welcome to Radonc. As you can see, we're having some problems. But don't worry, it'll all be fixed within 7 years. How, you ask? We don't know. No one does. That's why our field is so cool! There are lots of questions that need answering. Maybe you guys can solve this problem!

 

[emt409]

Are you really trying to imply that the decreases in radiation indications/schedule for breast and prostate are made up for a recent phase II abstract presented at ASTRO this past year for SBRTing oligomets?

I think what the other poster was trying to get at is where was RO leadership when med onc tried to make AI the preferred adjuvant tx in early stage breast in older patients? For the record, I've treated a handful of patients where they refused or didn't tolerate AI therapy.

Why does the NCCN talk about omitting rt but not AI therapy in that population? I get referrals directly from surgery, and the general sense I get is pts are less compliant with 5 years of ai and complain about it a lot more when I see them in fu (I follow many of my definitive pts long term). These pts have to get prolia in some cases because the AI is so bad for their bones

We also have RT to primary for low burden M1 prostate now. Indications wax and wane as the evidence gets better. Get used to it. Rads is still drastically underutilized for its indications. You want more patients? Make your clinic more appealing. There are plenty to go around. If you're still dragging men in for 9 weeks of RT for their low-int risk prostate cancer, you deserve your fossilization.

 

[scarbrtj]

You want more patients? Make your clinic more appealing. There are plenty to go around. If you're still dragging men in for 9 weeks of RT for their low-int risk prostate cancer, you deserve your fossilization.

The frisson of sanctimony one feels from shaming others has and always will be seductive to the human nature. But over and above the physical plant and staff of your center, the physician will always be the most important part of the clinic. "Mak(ing) your clinic more appealing" equals making yourself more appealing; there is a disconnect between your advice and your delivery of the advice. And, yes, an irony in my saying something about it. Peace & love, peace & love.

 

[Pointless]

The frisson of sanctimony one feels from shaming others has and always will be seductive to the human nature. But over and above the physical plant and staff of your center, the physician will always be the most important part of the clinic. "Mak(ing) your clinic more appealing" equals making yourself more appealing; there is a disconnect between your advice and your delivery of the advice. And, yes, an irony in my saying something about it. Peace & love, peace & love.

I learned a new word today! Frisson - a sudden strong feeling of excitement or fear; a thrill. It might be possible that you are the first person in history to coin the term "frisson of sanctimony". Congratulations!

 

[emt409]

The frisson of sanctimony one feels from shaming others has and always will be seductive to the human nature. But over and above the physical plant and staff of your center, the physician will always be the most important part of the clinic. "Mak(ing) your clinic more appealing" equals making yourself more appealing; there is a disconnect between your advice and your delivery of the advice. And, yes, an irony in my saying something about it. Peace & love, peace & love.

What's more appealing? Being done with an isoeffective course of RT in 1 week or 9 weeks? Not a hard choice. Patients travel from a long way for high quality treatment.

 

[medgator]

What's more appealing? Being done with an isoeffective course of RT in 1 week or 9 weeks? Not a hard choice. Patients travel from a long way for high quality treatment.

If treatment is unnecessary in the first place, better treatment does not represent an advance

 

[emt409]

If treatment is unnecessary in the first place, better treatment does not represent an advance

I said low-int. You can put them on AS, but I've not had any patient's agree to it when offered, and I wouldn't either if I were in their situation.

 

[evilbooyaa]

I'm confused why you guys are confused?

We already know that some unfilled programs took people in the SOAP and some decided to go and remain unfilled.

All I posted was looks like some of the spots ended up being taken by 'competitive applicants' and it wasn't all just bottom of the barrel US applicants who didn't match to non-competitive fields and FMGs (who also would have been outsiders to rad onc)

calm down.

I think the point being made is that, as a field, I would prefer people who rotated in rad onc and showed interest but were DOs, IMGs, and/or had poor stats rather than people who last minute decided a cush outpatient specialty was a good back-up plan. Obviously certain departments disagree and went chasing Step scores.

Match day is a distant memory for some of us and I think the process changed anyway.

Can one of you guys clarify: so on Monday programs and applicants know if they matched (but not where) or not, and if not the list of all unmatched programs an applicants are known just to them? In most (all?) cases other than Rad Onc this year there are more applicants then positions so the programs fill with those who applied to Rad Onc (maybe even their program) but this year some medical student from California who applied to derm and on Monday finds out he doesn’t match 48 hours later signs up for radiation oncology in a program in Pennsylvania?

Do they try to fly out for a quick interview or just walk into the department for the first time on the first day of residency?

On Monday programs and applicants find out IF they matched.
On Monday or Tuesday, applicants apply to an additional number of programs (capped).
By Tuesday and/or Wednesday, programs have reviewed apps and done phone interviews (mostly on phone, some on Skype, never heard of an in-person one).
I believe Thursday applicants begin receiving offers, in rounds, from programs. I believe there are 3 rounds total, where applicants check their offers, decide if they want to accept them (if they received any) and if they can't/don't accept, wait for the next round.

 

[radbioistheworst]

I think the point being made is that, as a field, I would prefer people who rotated in rad onc and showed interest but were DOs, IMGs, and/or had poor stats rather than people who last minute decided a cush outpatient specialty was a good back-up plan. Obviously certain departments disagree and went chasing Step scores.

Yes switching into rad onc isn’t like going from ortho to gen surg or radiology to medicine. What we do is pretty unique and students likely would not have been exposed to it unless they actively sought out a rotation. Although it’s kind of a moot point this year since all but one who applied to rad onc ended up matching. Would love to know how many students did rad onc rotations vs how many actually applied.

 

[xrthopeful]

I mean I don’t think there were people that applied rad onc that didn’t match that were left in the dust for derm applicants. There weren’t enough applicants. Kind of a straw man argument.

 

[scarbrtj]

If you're still dragging men in for 9 weeks of RT for their low-int risk prostate cancer, you deserve your fossilization.

What's more appealing? Being done with an isoeffective course of RT in 1 week or 9 weeks? Not a hard choice. Patients travel from a long way for high quality treatment.

That's just, like, your opinion, man. Per the NCCN, 9 weeks of treatment is a medical standard and an acceptable XRT treatment option for all CaP presentations; thus, purely in terms of "quality," there is no XRT treatment which is of a demonstrably higher quality. More convenient, maybe, and I could debate isoeffective too, although all this would be decided between patient and physician. To disparage a practitioner for "dragging" men in for an NCCN-recommended treatment, and that whoever would do so should "deserve fossilization," says more about who would say such things than it does about whom such things are said. Which is, like, my—and the NCCN's—opinion.

I learned a new word today! Frisson - a sudden strong feeling of excitement or fear; a thrill. It might be possible that you are the first person in history to coin the term "frisson of sanctimony". Congratulations!

That is the flexibility of language.

 

[evilbooyaa]

I mean I don’t think there were people that applied rad onc that didn’t match that were left in the dust for derm applicants. There weren’t enough applicants. Kind of a straw man argument.

Perhaps. Or the counter argument - there are too many spots now?

That being said, this certainly won't be the case next year as the number of low score or DO or IMG grads applying Rad Onc will skyrocket.

 

[thecarbonionangle]

It is much personal bias but i’d take a surgical person over Derm any day. Some of the derm interns i worked with were just bad/lazy. Left a lasting impression in my mind. Some of the IMGs have very strong resumes but they would have been unlikely to get in a few years ago. In some, language barrier is a worry in a field where communication is so important. The field will change for sure if current pattern holds. We’ll be back to our roots. Ive heard from older attendings that back in day rad onc was mostly IMGs.

 

[xrthopeful]

Perhaps. Or the counter argument - there are too many spots now?

That being said, this certainly won't be the case next year as the number of low score or DO or IMG grads applying Rad Onc will skyrocket.

Will be interesting to see if they do. I'm curious to see If more of them do rotations this year

 

[radoncradonc]

Our esteemed ASTRO president, Dr. Harari, has decided to lead the charge in residency expansion. The University of Wisconsin is now looking for a PGY2 note writer scut monkey to start this July. I can't believe he is expanding his residency program only one week after writing an article stating that there's too many residency positions in rad onc. Our field is lead by hypocritical self serving people who have no regard to the plight of us trainees. I am already accepting the fact that I will be doing locums and insurance authorizations when I graduate this summer. I swear I will make life hell if I get insurance authorization requests from any big name academics. You've ruined my future and I will make your life hell too.

 

[xrthopeful]

Whoa get a hold of yourself.

Anyways - is that posting indicative of expansion? I thought it was perhaps more that someone left their program and transferred somewhere else? That’s often the case with these postings

 

[FindMeOnTheLinks]

If I remember correctly, Wisconsin didn’t fill in the 2018 match due to an nrmp snafu - resulting in the open pgy2 spot they have been advertising

 

[xrthopeful]

If I remember correctly, Wisconsin didn’t fill in the 2018 match due to an nrmp snafu - resulting in the open pgy2 spot they have been advertising

Oh yeah that’s right

 

[CCJW]

Our esteemed ASTRO president, Dr. Harari, has decided to lead the charge in residency expansion. The University of Wisconsin is now looking for a PGY2 note writer scut monkey to start this July. I can't believe he is expanding his residency program only one week after writing an article stating that there's too many residency positions in rad onc. Our field is lead by hypocritical self serving people who have no regard to the plight of us trainees. I am already accepting the fact that I will be doing locums and insurance authorizations when I graduate this summer. I swear I will make life hell if I get insurance authorization requests from any big name academics. You've ruined my future and I will make your life hell too.

We are not expanding. This is filling an open PGY-2 slot.

 

[PhotonBomb]

Our esteemed ASTRO president, Dr. Harari, has decided to lead the charge in residency expansion. The University of Wisconsin is now looking for a PGY2 note writer scut monkey to start this July. I can't believe he is expanding his residency program only one week after writing an article stating that there's too many residency positions in rad onc. Our field is lead by hypocritical self serving people who have no regard to the plight of us trainees. I am already accepting the fact that I will be doing locums and insurance authorizations when I graduate this summer. I swear I will make life hell if I get insurance authorization requests from any big name academics. You've ruined my future and I will make your life hell too.

you're either trolling or going through a hard time/suffering from depression. I'm going to give you the benefit of the doubt. Talk to someone in real life, get some help. Everyone needs help sometimes. Nothing wrong with it. Wish you the best, feel free to PM me at any time.

 

[thecarbonionangle]

Our esteemed ASTRO president, Dr. Harari, has decided to lead the charge in residency expansion. The University of Wisconsin is now looking for a PGY2 note writer scut monkey to start this July. I can't believe he is expanding his residency program only one week after writing an article stating that there's too many residency positions in rad onc. Our field is lead by hypocritical self serving people who have no regard to the plight of us trainees. I am already accepting the fact that I will be doing locums and insurance authorizations when I graduate this summer. I swear I will make life hell if I get insurance authorization requests from any big name academics. You've ruined my future and I will make your life hell too.

What will you gain from that? Not aprooving IMRT for N2 lung? For esophagus? you’re harming patients. You’re harming the poor resident who has to deal with it. You sure showed Paul and Lisa!

your situation sucks. I sympathize, no job and/or failed boards is terrible. Try to see if you can snap out of it and do something positive. Don’t harm those that are on your side or need your help. Doing locums can only help you and things will hopefully improve.

 

[scarbrtj]

If treatment is unnecessary in the first place, better treatment does not represent an advance

With all due respect to Dr. Z and his brilliance (I say non-facetiously). It's not merely the act of being diagnosed with CaP that makes men with early prostate cancer live longer than men who don't have cancer. It's getting diagnosed and treated.

 

[emt409]

That's just, like, your opinion, man. Per the NCCN, 9 weeks of treatment is a medical standard and an acceptable XRT treatment option for all CaP presentations; thus, purely in terms of "quality," there is no XRT treatment which is of a demonstrably higher quality. More convenient, maybe, and I could debate isoeffective too, although all this would be decided between patient and physician. To disparage a practitioner for "dragging" men in for an NCCN-recommended treatment, and that whoever would do so should "deserve fossilization," says more about who would say such things than it does about whom such things are said. Which is, like, my—and the NCCN's—opinion.


That is the flexibility of language.

Oh yes, I'm SURE you give all your patients the full array of NCCN options as choices for their fractionation scheme. Practitioners like you are the reason our system is being forced into bundled payments.

 

[medgator]

Oh yes, I'm SURE you give all your patients the full array of NCCN options as choices for their fractionation scheme. Practitioners like you are the reason our system is being forced into bundled payments.

Yes,, I'm sure it has nothing to do with the the cost differential for the same treatment between freestanding and academic/hospital based centers.

ASTRO actually opposed bundles for awhile until they came around..... The freestanding community was the one who pushed that concept (you were probably in med school at that point, when groups like RTA and Vantage were discussing bundles and working with payors to try and test the waters with them).

AFAIK,, ASTRO still opposes site neutral payments, which would cut costs significantly, to the detriment of hospitals /NCI designated centers though

 

[OTN]

Given the relative lack of long-term toxicity data and worse acute toxicity with hypofractionated courses, I have zero problem with anyone offering 79.2 Gy in 1.8 Gy fractions for PCa. Zero.

Hospital vs freestanding prices are the biggest pricing issue in radiation oncology. All academicians and ASTRO have zero credibility when it comes to pricing/cost control until this is dealt with and have no right to lecture anyone.

 

[Gfunk6]

Given the relative lack of long-term toxicity data and worse acute toxicity with hypofractionated courses, I have zero problem with anyone offering 79.2 Gy in 1.8 Gy fractions for PCa. Zero.

Hospital vs freestanding prices are the biggest pricing issue in radiation oncology. All academicians and ASTRO have zero credibility when it comes to pricing/cost control until this is dealt with and have no right to lecture anyone.

Exactly, once site neutral payments become a reality academicians/ASTRO will be dancing to a different tune.

 

[emt409]

Yes,, I'm sure it has nothing to do with the the same treatment cost differential between freestanding and academic/hospital based centers.

ASTRO actually opposed bundles for awhile until they came around..... The freestanding community was the one who pushed that concept (you were probably in med school at that point, when groups like RTA and Vantage were discussing bundles and working with payors to try and test the waters with them).

AFAIK,, ASTRO still opposes site neutral payments, which would cut costs significantly, to the detriment of hospitals /NCI designated centers though

You are ABSOLUTELY right that is not fair that hospital based practices charge more than freestanding facilities; but that has nothing to do with the short vs long course debate.

Also, acute toxicity data for prostate SBRT is excellent. Not sure what @OTN is talking about. Even if you do get grade 2 dysuria with short course, it's still over long before you finish a conv RT fractionation. Late GU numbers look just like historical controls.

 

[medgator]

You are ABSOLUTELY right that is not fair that hospital based practices charge more than freestanding facilities; but that has nothing to do with the short vs long course debate.

You're the one who brought up fractionation as the reason for bundling, rather the extreme differential in cost per fraction that can be seen between freestanding and NCI designated CCs.

Without any evidence I might add. The data on prostate hypofx isn't nearly the slam dunk that it is in breast. And there really is no long term data at all in sbrt. Which is probably why the prostate and breast hypofx guidelines look different.

Fraction shaming is no better than giving a free pass to the big name places charging more than everyone else for the same service

 

[OTN]

You are ABSOLUTELY right that is not fair that hospital based practices charge more than freestanding facilities; but that has nothing to do with the short vs long course debate.

Also, acute toxicity data for prostate SBRT is excellent. Not sure what @OTN is talking about. Even if you do get grade 2 dysuria with short course, it's still over long before you finish a conv RT fractionation. Late GU numbers look just like historical controls.

I agree that acute toxicity is good for SBRT, which I do offer to patients. Some of the "hypofractionated" courses (non-SBRT) did show a slight increase in urinary toxicity, which is what I was referencing.

 

[evilbooyaa]

Guys/gals. I'm not going to repeat myself again (after this post). If you want to discuss the merits/downsides of prostate hypofrac in detail take it to one of the previous threads or start a new thread on it. This has minimal relevance to this thread and is drowning out discussion on topics relevant to what Dr. Harari wrote in his blog post. Tried the carrot, next will be the stick.

Let's try to keep this thread about the blog post, and not a discussion of hypofrac and prices (cue @scarbrtj and his "it's the prices, it's always the prices") and bundled payments and a bunch of stuff that has nothing to do with the blog post.

 

[seper]

Diagnosis can lead to increased personal health monitoring and healthier behaviors post-diagnosis.

With all due respect to Dr. Z and his brilliance (I say non-facetiously). It's not merely the act of being diagnosed with CaP that makes men with early prostate cancer live longer than men who don't have cancer. It's getting diagnosed and treated.

 

[scarbrtj]

Tried the carrot, next will be the stick.

Let's try to keep this thread about the blog post, and not a discussion of hypofrac and prices (cue @scarbrtj and his "it's the prices, it's always the prices")

Aw man I stayed above the pecuniary fray on this thread

 

[Irradi8or]

Exactly, once site neutral payments become a reality academicians/ASTRO will be dancing to a different tune.

Agreed - unfortunately based on the recent transmittal from CMS, looks like we won't be at site neutrality for the CMMI RO-APM, as payments will still be based on historical look backs (probably plus some national blend?) based on MPFS (freestanding centers) or HOPPS (hospital centers). Hopefully we finally get there in a future model.

 

[Carotenoid]

FYI, I posted a response - it was very politely and "appropriately" worded; I GENTLY voiced some of the concerns we all seem to have; and my comment (which would have been #3) - has not been published. Censored out.
Wallner. Kachnic. Harari. And the rest of them. Dishonest, duplicitous individuals. They denounce SDN for being some fringe movement - yet when I attempt to express my opinion at astro.org, I can't. They hold the reins.

Shameless

 

[deleted947887]

#SaveMedicalStudents

FYI, I posted a response - it was very politely and "appropriately" worded; I expressed some of the concerns we all seem to have; and my comment (which would have been #3) - has not been published.
Wallner. Kachnic. Harari. Dishonest, duplicitous individuals. They denounce SDN for being some fringe movement - yet when I attempt to express my opinion at astro.org, I can't. They hold the reins.

Shameless