ASTRO panel session on US rad onc labor market

[firewicket]

I contacted our ARRO representatives asking what was being done and what we (residents) could do to help make a change. I will keep everyone updated on their response.

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[thesauce]

I contacted our ARRO representatives asking what was being done and what we (residents) could do to help make a change. I will keep everyone updated on their response.

Excellent. Please let us know what they say and if we can be of help.

 

[subatomicdoc]

I took away from this:

1. Supply has outpaced demand for at least the past 5 years.

2. Future demand is very uncertain with very significant threats to our field. Demand has been flat over the past 5 hears.

3. Thus, I would propose a moratorium on growth of residency positions for at least the next 5 years to reassess whether demand has begun to grow again. This would avoid the job market disasters as in Canada and in radiology.

4. Given the current likely oversupply based on surveys and increasing number of fellowships, and the ability to improve productivity for mild undersupply, there would be minimal risk in slowing growth at this time. There seems to be no willpower to make that happen.

I was one of the commenters from the audience at the session, which was excellent. I have interviewed ~150-200 people for my private practice and it is definitely harder for people finishing training. Not only are we training too many people, I think we're training residents the wrong way which only makes it worse.

Radiation oncology programs select people with heavy research backgrounds and among the lowest levels of volunteering except for neurology, neurosurgery and vascular surgery (see NRMP data). When you have 23% of matriculating residents with a PhD and 45% with some advanced degree for a field that only has 25-30% of positions in academics, it's a setup for a mismatch at the end of training.

Residency makes it worse; you're then fed the false sense you have to do research to succeed. More publications, less focus on clinical acumen, communication skills than there should be. Once we choose the remarkably talented pool of people to be trained, it's physician-scientist tracks that are highlighted. Where are the programs aiming to train physician-humanists that excel at patient care?

The goal should be to train people well for successful careers they enjoy. My suggestion: any residency program director should be required to visit at least two community practice settings annually. Department chairs should do it once annually. Get out of the ivory tower. Community-based radiation oncology are 70+% of the jobs that you are trying to prepare trainees to fill.

 

[RadOncDoc21]

Just curious as to why so many people didn't qualify for the position? I know there are some candidates who may not be a great fit for a private group, but 150 people... Wow!

 

[subatomicdoc]

Just curious as to why so many people didn't qualify for the position? I know there are some candidates who may not be a great fit for a private group, but 150 people... Wow!

Caveat lector - those numbers are over a period of years, not a single year. And keep in mind, it wasn't all one-sided. Private practice isn't the right fit for everyone and some candidates ended up not interested in us. Key is a good long-term fit. But it's a good sample size to ask questions about interest, concerns with the job market, feel for clinical medicine etc. And the trend has definitely been more stress about job availability, needs to balance often with a spouse with a career, and increasing amounts of debt.

 

[RadOncDoc21]

I definitely do feel a disconnect with residency training and "the real world" when it comes to being more practical. I agree that ASTRO needs to do more to look after private groups and not strictly focus on academics.

 

[medgator]

I definitely do feel a disconnect with residency training and "the real world" when it comes to being more practical. I agree that ASTRO needs to do more to look after private groups and not strictly focus on academics.

One only need to look at how badly freestanding centers have absorbed Medicare cuts vs hospital-based centers over the last several years to see that ASTRO and its PAC are totally out of touch with the freestanding pp community

 

[RadOncDoc21]

One only need to look at how badly freestanding centers have absorbed Medicare cuts vs hospital-based centers over the last several years to see that ASTRO and its PAC are totally out of touch with the freestanding pp community

Once these hospitals start buying out the smaller groups and start driving down salaries with an expected increase in production. I bet you then, ASTRO will start changing their tune. Hopefully by then, it will not be too late.

 

[medgator]

Once these hospitals start buying out the smaller groups and start driving down salaries with an expected increase in production. I bet you then, ASTRO will start changing their tune. Hopefully by then, it will not be too late.

It probably will be. Astro pushed through changes to imrt next year to bundle in igrt charges and split out prostate and breast into a "simple" code that pays less. They wanted to stick it to freestanding "urorads" centers but there is no reason why Medicare can't expand these changes to hospitals once they take effect in the freestanding centers.

Once you've thrown the freestanding centers under the bus, there will be no one left except the hospitals when CMS starts looking for the next round of cuts.

 

[radiaterMike]

My understanding is that these changes are in effect now, not limited to freestanding centers and were an effort by ASTRO to limit insurer denials of breast IMRT and acknowledge that IMRT for other sites is more complex. I don't think that this was an effort to undermine urorads or freestanding centers but rather a means to have some control over inevitable reimbursement cuts. IMRT simulation was also bundled with IMRT planning presumably with the understanding that IMRT will always require simulation - so IMRT planning bundled with simulation and IMRT delivery bundled with IGRT. CMS will want more bundled services and perhaps eventually diagnosis based reimbursement. ASTRO will have to negotiate with these constraints.

 

[medgator]

My understanding is that these changes are in effect now, not limited to freestanding centers and were an effort by ASTRO to limit insurer denials of breast IMRT and acknowledge that IMRT for other sites is more complex. I don't think that this was an effort to undermine urorads or freestanding centers but rather a means to have some control over inevitable reimbursement cuts. IMRT simulation was also bundled with IMRT planning presumably with the understanding that IMRT will always require simulation - so IMRT planning bundled with simulation and IMRT delivery bundled with IGRT. CMS will want more bundled services and perhaps eventually diagnosis based reimbursement. ASTRO will have to negotiate with these constraints.

As far as I know, the payment differences in the simple/complex IMRT codes only apply in the freestanding setting, just like current IGRT technical billing only occurs in the freestanding setting.

Hospitals and freestanding centers are reimbursed in very disparate ways, something bundled payments might actually solve, which is probably why ASTRO remains very silently opposed to bundles

https://www.astro.org/uploadedFiles...bursement/Medicare/News/2015/MPFSComments.pdf

Check out this little gem from a recent ASTRO letter:

"CMS includes “Radiation Therapy Centers” in the impact table produced annually in the proposed and final MPFS. The impact table is often the first place that individuals go to when the rule is produced. However, by including “Radiation Therapy Centers” in the impact table, CMS may inadvertently confuse and mislead the radiation oncology community and the public about the actual impact of the proposed policies. Radiation Therapy Centers are a small and limited number of freestanding centers that are not representative of the larger specialty. ASTRO urges CMS to omit the reference to “Radiation Therapy Centers” in future rulemaking."

Here's another thread on this: http://forums.studentdoctor.net/thr...n-hospital-and-free-standing-centers.1073032/

 

[Reaganite]

I was one of the commenters from the audience at the session, which was excellent. I have interviewed ~150-200 people for my private practice and it is definitely harder for people finishing training. Not only are we training too many people, I think we're training residents the wrong way which only makes it worse.

Radiation oncology programs select people with heavy research backgrounds and among the lowest levels of volunteering except for neurology, neurosurgery and vascular surgery (see NRMP data). When you have 23% of matriculating residents with a PhD and 45% with some advanced degree for a field that only has 25-30% of positions in academics, it's a setup for a mismatch at the end of training.

Residency makes it worse; you're then fed the false sense you have to do research to succeed. More publications, less focus on clinical acumen, communication skills than there should be. Once we choose the remarkably talented pool of people to be trained, it's physician-scientist tracks that are highlighted. Where are the programs aiming to train physician-humanists that excel at patient care?

The goal should be to train people well for successful careers they enjoy. My suggestion: any residency program director should be required to visit at least two community practice settings annually. Department chairs should do it once annually. Get out of the ivory tower. Community-based radiation oncology are 70+% of the jobs that you are trying to prepare trainees to fill.

Very solid post and mirrors my own experiences interviewing new graduates. Way too much emphasis on candidates with PhDs and research experience, and I don't think those skills translate well to private practice. So much of private practice is about building personal relationships with referring doctors (dinners, drinks, etc.) and getting your patients to like you and speak highly of you to the referring doctors...I just didn't see that in the people I was interviewing. Solid CVs, but my referring docs could care less about that. Granted, you want people who excel academically, but 90% of my practice is bread-and-butter cases (breast, prostate, lung) that don't require a PhD to treat.

 

[Becquerel]

I am very happy to see how much discussion the panel has generated. I have some bias here since I helped to put the panel together and served as the first speaker. There are no easy answers.

It is important to take a step back and view the problem through a neutral, patient-centric lens. An undersupply of radiation oncologists is a genuine concern for society and arguably presents a much more serious problem for patients than an oversupply. Declining salaries, longer partnership tracks and tight metropolitan markets are not, by themselves, reasons to alter our course.

On the flip side, we have to acknowledge that program directors face significant perverse incentives to increase residency spots without regard to societal need. Residency expansion restrained only by whether there are sufficient resources to provide acceptable training, does not serve our needs or those of our patients. And as subatomicdoc rightly points out, it is worthwhile to consider whether our residencies are optimally selecting and training medical students for clinical practice.

We are currently at a crossroads in terms of payment policy for oncology services. The payment disparity between freestanding centers and hospitals is widening substantially, making acquisitions and joint ventures inevitable. In spring 2016 Medicare will roll out the Oncology Care Model, which allows medical oncologists to save money by reducing spending on radiation therapy (among other things). Unless our specialty brings forward some viable alternatives, payers are likely to remain focused on payment models that make it difficult for radiation oncologists to share in the savings associated with a transition to value-based care. In my mind, how our specialty handles these challenges will have a larger impact on the job market than anything discussed in this thread, including residency expansion.

ASTRO has been working hard on this issue, and has done an excellent job putting together some preliminary proposals. However, there is a fine balance between advancing models in which payers will have interest and minimizing the economic risk to providers. Hospitals and freestanding centers undoubtedly have disparate interests, but ALL of our specialty societies (ASCO, ASTRO, RTA, etc) have tread very gingerly with payment reform to avoid short-term economic disruption.

I believe that this conservatism will change, but I expect much of the future payment innovation in radiation oncology to occur outside our specialty societies, at the hospital level. MDACC has been a leader in this regard, and I expect the next 5 years to bring a diverse array of payment pilots from a number of oncology systems, many of which will give radiation oncologists a seat at the table and a chance to share the value that's created. It is important that radiation oncology departments participate in these models and mold them in ways that are best for our specialty and our patients. Participation is especially important for private groups that wish to remain independent, since collaboration with the hospitals (and the downstream contracting) will solidify relationships and discourage proliferation of an employment model. Physician groups that sit on the sidelines while the hospitals they staff figure out how to bear financial risk and prove value run a significant risk of being displaced. If we can protect our revenues through meaningful involvement in payment reform and maintain the independence of private practice, it will go a long way to stabilizing the radiation oncology job market.

 

[Sheldor]

I was one of the commenters from the audience at the session, which was excellent. I have interviewed ~150-200 people for my private practice and it is definitely harder for people finishing training. Not only are we training too many people, I think we're training residents the wrong way which only makes it worse.

Radiation oncology programs select people with heavy research backgrounds and among the lowest levels of volunteering except for neurology, neurosurgery and vascular surgery (see NRMP data). When you have 23% of matriculating residents with a PhD and 45% with some advanced degree for a field that only has 25-30% of positions in academics, it's a setup for a mismatch at the end of training.

Residency makes it worse; you're then fed the false sense you have to do research to succeed. More publications, less focus on clinical acumen, communication skills than there should be. Once we choose the remarkably talented pool of people to be trained, it's physician-scientist tracks that are highlighted. Where are the programs aiming to train physician-humanists that excel at patient care?

The goal should be to train people well for successful careers they enjoy. My suggestion: any residency program director should be required to visit at least two community practice settings annually. Department chairs should do it once annually. Get out of the ivory tower. Community-based radiation oncology are 70+% of the jobs that you are trying to prepare trainees to fill.

This really hit home for me. I've always wanted to be a community physician as I enjoy small to mid-town life, and want to really be a part of the community in a unique way. Unfortunately, every step of the way I've had to both do things I wasn't interested in (research on nights and weekends in medical school) to get into residency, and then use hyperbole during residency interviews to convince people that I want to do a ton of research. Only a couple years left of residency, but I am counting down the days until I can be in a small practice and actually TAKE CARE OF PEOPLE.

Could you imagine if I had been honest with people up front about my goals? "I want to be an oncologist because I love patients and want to serve them in underserved communities in the middle of the country." I likely wouldn't have matched, or I would have matched at a "bad" program. Although in hind site, those "bad" programs focused on clinical care and likely would have prepared me quite well for my goals.

 

[Sheldor]

I am very happy to see how much discussion the panel has generated. I have some bias here since I helped to put the panel together and served as the first speaker. There are no easy answers.

It is important to take a step back and view the problem through a neutral, patient-centric lens. An undersupply of radiation oncologists is a genuine concern for society and arguably presents a much more serious problem for patients than an oversupply. Declining salaries, longer partnership tracks and tight metropolitan markets are not, by themselves, reasons to alter our course.

On the flip side, we have to acknowledge that program directors face significant perverse incentives to increase residency spots without regard to societal need. Residency expansion restrained only by whether there are sufficient resources to provide acceptable training, does not serve our needs or those of our patients. And as subatomicdoc rightly points out, it is worthwhile to consider whether our residencies are optimally selecting and training medical students for clinical practice.

We are currently at a crossroads in terms of payment policy for oncology services. The payment disparity between freestanding centers and hospitals is widening substantially, making acquisitions and joint ventures inevitable. In spring 2016 Medicare will roll out the Oncology Care Model, which allows medical oncologists to save money by reducing spending on radiation therapy (among other things). Unless our specialty brings forward some viable alternatives, payers are likely to remain focused on payment models that make it difficult for radiation oncologists to share in the savings associated with a transition to value-based care. In my mind, how our specialty handles these challenges will have a larger impact on the job market than anything discussed in this thread, including residency expansion.

ASTRO has been working hard on this issue, and has done an excellent job putting together some preliminary proposals. However, there is a fine balance between advancing models in which payers will have interest and minimizing the economic risk to providers. Hospitals and freestanding centers undoubtedly have disparate interests, but ALL of our specialty societies (ASCO, ASTRO, RTA, etc) have tread very gingerly with payment reform to avoid short-term economic disruption.

I believe that this conservatism will change, but I expect much of the future payment innovation in radiation oncology to occur outside our specialty societies, at the hospital level. MDACC has been a leader in this regard, and I expect the next 5 years to bring a diverse array of payment pilots from a number of oncology systems, many of which will give radiation oncologists a seat at the table and a chance to share the value that's created. It is important that radiation oncology departments participate in these models and mold them in ways that are best for our specialty and our patients. Participation is especially important for private groups that wish to remain independent, since collaboration with the hospitals (and the downstream contracting) will solidify relationships and discourage proliferation of an employment model. Physician groups that sit on the sidelines while the hospitals they staff figure out how to bear financial risk and prove value run a significant risk of being displaced. If we can protect our revenues through meaningful involvement in payment reform and maintain the independence of private practice, it will go a long way to stabilizing the radiation oncology job market.

Thank you for arranging this panel. Payment reform measures and jobs are very closely connected and it is difficult to talk about one without the other. I am thankful you addressed both sides of the coins, as I think it will be important to try and deal with this from both angles. Anyway, keep fighting the good fight and let us know of any opportunities there are to help!

 

[medgator]

Considering the costs vs efficacy of systemic therapy in solid tumors, it seems silly imo to have med onc as the gatekeepers, esp over radiation therapy usage.

We are our own specialty for a reason. It's good to hear that places like MDACC are making sure we have a seat at the table

 

[RadOncDoc21]

It's the old social belief that Med Onc is the "Oncologist," even though we have 2 more years of Oncologic training. There's going to be a lot more induction and chemo given up front for sure.

I bet our role will be used more for palliation and less for cure in the future.

 

[BobbyHeenan]

I am very happy to see how much discussion the panel has generated. I have some bias here since I helped to put the panel together and served as the first speaker. There are no easy answers.

It is important to take a step back and view the problem through a neutral, patient-centric lens. An undersupply of radiation oncologists is a genuine concern for society and arguably presents a much more serious problem for patients than an oversupply. Declining salaries, longer partnership tracks and tight metropolitan markets are not, by themselves, reasons to alter our course.

On the flip side, we have to acknowledge that program directors face significant perverse incentives to increase residency spots without regard to societal need. Residency expansion restrained only by whether there are sufficient resources to provide acceptable training, does not serve our needs or those of our patients. And as subatomicdoc rightly points out, it is worthwhile to consider whether our residencies are optimally selecting and training medical students for clinical practice.

We are currently at a crossroads in terms of payment policy for oncology services. The payment disparity between freestanding centers and hospitals is widening substantially, making acquisitions and joint ventures inevitable. In spring 2016 Medicare will roll out the Oncology Care Model, which allows medical oncologists to save money by reducing spending on radiation therapy (among other things). Unless our specialty brings forward some viable alternatives, payers are likely to remain focused on payment models that make it difficult for radiation oncologists to share in the savings associated with a transition to value-based care. In my mind, how our specialty handles these challenges will have a larger impact on the job market than anything discussed in this thread, including residency expansion.

ASTRO has been working hard on this issue, and has done an excellent job putting together some preliminary proposals. However, there is a fine balance between advancing models in which payers will have interest and minimizing the economic risk to providers. Hospitals and freestanding centers undoubtedly have disparate interests, but ALL of our specialty societies (ASCO, ASTRO, RTA, etc) have tread very gingerly with payment reform to avoid short-term economic disruption.

I believe that this conservatism will change, but I expect much of the future payment innovation in radiation oncology to occur outside our specialty societies, at the hospital level. MDACC has been a leader in this regard, and I expect the next 5 years to bring a diverse array of payment pilots from a number of oncology systems, many of which will give radiation oncologists a seat at the table and a chance to share the value that's created. It is important that radiation oncology departments participate in these models and mold them in ways that are best for our specialty and our patients. Participation is especially important for private groups that wish to remain independent, since collaboration with the hospitals (and the downstream contracting) will solidify relationships and discourage proliferation of an employment model. Physician groups that sit on the sidelines while the hospitals they staff figure out how to bear financial risk and prove value run a significant risk of being displaced. If we can protect our revenues through meaningful involvement in payment reform and maintain the independence of private practice, it will go a long way to stabilizing the radiation oncology job market.

Thank you for your work, input, and involvement.

I too agree that payment models will have the biggest impact. However, with regard to this variable we as a specialty will only have partial say about that outcome.

We will have 100% say about rad Onc residency expansion. So given the current uncertainty (with many signs pointing toward unfavorable variables/outcomes being possible), I still feel that we need to be proactive with the one issue we can fully control. A 24-36 month freeze on expansion to allow for more study and clarity on the market and payment reform seems very reasonable.

 

[subatomicdoc]

Could you imagine if I had been honest with people up front about my goals? "I want to be an oncologist because I love patients and want to serve them in underserved communities in the middle of the country." I likely wouldn't have matched, or I would have matched at a "bad" program. Although in hind site, those "bad" programs focused on clinical care and likely would have prepared me quite well for my goals.

Thanks for pointing that out, Sheldor. Becquerel correctly pointed out the problem is more than just the number of residency positions. It's the degree to which we present ourselves as doctors, not technicians. It's time to stop patting ourselves on the back for having such smart people enter the field and start being more patient-centered, both in our training and practice.

We also increasingly have the opportunity to explain our value to patients and the public at large. Whether it's face-to-face or online, patients want to know what to expect with treatment. We let medical oncologists, surgeons and others taint opinions on what we offer. Rather than waiting hat in hand for referrals, we can explain how valuable radiotherapy is for cancer treatment. Did you know in some parts of Spain only one of seven men get surgery, most get radiation? It's because in Spain radiation oncologists see part of their responsibility being communication and outreach.

Maybe if we valued communication more in residency, we could be better advocates for patients, expand our value and influence. We need to be proactive, not reactive. Otherwise it's back to the basement.

 

[RadOncDoc21]

Thanks for pointing that out, Sheldor. Becquerel correctly pointed out the problem is more than just the number of residency positions. It's the degree to which we present ourselves as doctors, not technicians. It's time to stop patting ourselves on the back for having such smart people enter the field and start being more patient-centered, both in our training and practice.

We also increasingly have the opportunity to explain our value to patients and the public at large. Whether it's face-to-face or online, patients want to know what to expect with treatment. We let medical oncologists, surgeons and others taint opinions on what we offer. Rather than waiting hat in hand for referrals, we can explain how valuable radiotherapy is for cancer treatment. Did you know in some parts of Spain only one of seven men get surgery, most get radiation? It's because in Spain radiation oncologists see part of their responsibility being communication and outreach.

Maybe if we valued communication more in residency, we could be better advocates for patients, expand our value and influence. We need to be proactive, not reactive. Otherwise it's back to the basement.

Great post!

This is why I ask to see consult charts in advance and attend all tumor boards to put my input on the care of patients at the beginning of their treatment plan. I would get so tired of seeing patients not properly staged or worked up with the plan to recieve radiation therapy with the plan and dose already established by either the med oncs or the surgeons.

"Why do you need mediastinal staging if the PET/CT is negative?"

"I wanted to spare the limited stage small cell lung cancer whole brain."

"Plan is for RT" no workup done when I see the patient- not even a biopsy because the med onc believes it's cancer.

"Gamma knife to lung mass"

 

[Chartreuse Wombat]

"While I appreciate your setting up the panel, I think that the real issue is that this issue was brought up over 2 years ago and nothing has changed, programs continue to expand and no controls have been put in place. The powers that be can't even seem to settle who is responsible to start making changes."

This is the problem. Who is responsible for making changes? The answer is SCAROP..the group of chair(wo)men directing programs..Unless they decide to limit production there will be no changes. ACGME cannot use workforce issues to determine whether expansion is appropriate (ACGME lawyers specifically instruct RRC members in this regard). ASTRO is conflicted as more ROs means more dues and most membership organizations are striving for growth.

SCAROP is the organization that needs to be the target of advocacy efforts. You know who these people are and you should make your concerns known directly to them. I am skeptical that they will heed the call but calling on ASTRO or ACGME will not work.

 

[Phantom1]

I wonder if there is also some feed forward effect or unfortunate self-fullfilling prophecy... for example.. with more residents now in faculty positions, program directors and chairs are getting pressured to find "coverage" for the new faculty and thus requesting more residency slots... ? This is not good, and the unbridled expansion has to stop. There needs to be a governing body with this charge, SCAROP may have the influence, but do they have authority to block requested program expansions? Who regulates residency positions in Derm or Plastics?

I wonder if new attending would be happier with cheaper Scribes, just to finish notes.. queue things up etc? Could also be more efficient if no need to train/teach residents on service?

 

[canadianoutlaw]

Who regulates residency positions in Derm or Plastics?

Agree, would be interesting to hear more about how other specialties have successfully regulated this and achieved an optimal balance. Can anyone speak to this?

 

[Burt Radnolds]

As others have said, I think being cautious as to avoid the dreaded undersupply is posturing and very far from reality at this point. The current tightening of the market is very real. Secondly, there are many many people that would not move to the middle of nowhere, regardless of the circumstances. Driving up numbers until total desperation sets in and essentially forcing people out into these fringe jobs sounds insane. Every single time I see a newly stamped and approved residency position I cringe. The writing is currently on the wall as far as our future as a specialty. Unchecked increases in residency numbers, tightening job market, decreasing compensation overall, and potential systemic changes in oncology management will create an untenable situation faster than many realize.

However, it is not all doom and gloom. Counteracting the forces at play will take a coordinated proactive response. Luckily, we are a group of highly qualified intelligent physicians. I think this talk about touting our value and being very active as true oncologists is spot on. This is a major part of the solution. However, one of the only things we have direct control over as a specialty is how many additional rad oncs we produce. If this is under our direct influence, wouldn't it be an easy place to start as we address all these issues head on?

 

[seper]

There is absolutely no RaOnc undersupply. As pointed out, the problem with unfilled jobs is related to maldistribution (rural hospitals managers' greed, to be exact).

 

[thecarbonionangle]

This seems like the most straightforward solution.



How can radiation oncologists be more involved in overall oncology care, formally? It's interesting to me that in some European countries and China, rad/onc and med/onc are one specialty. Med/onc is only 1 year of training (or less, if you remove hematologic malignancies). Instead of 1 year of research, can radiation oncology programs include some formal med/onc training? I know there are roadblocks to this, but recently an int'l oncologist trained to give both systemic therapy and RT was telling me about the advantages of this for patient care.

The problem as summarized by an above poster is the following: "We let medical oncologists, surgeons and others taint opinions on what we offer".
I don't really know how to to fix this "bottom feeding" problem of the specialty. Medical oncology is thought of as the "real oncologists" and they are almost always consulted before radiation oncology gets a chance to see the patient. Med oncs (or a surgeon) ultimately "taint" the options for the patients or ultimately decide if radiation is necessary, then radiation is consulted at that point. I think the problem begins with medical education. Think back to when you were a medical student how many radiation oncologists lectured you? the answer for me was zero, all oncology lectures were taught by surgeons and medical oncologists. Medical students go on to become physicians without any clue whatsoever about the value the specialty offers and its role in cancer care. The level of ignorance in other specialties, even at the attending level, of what radiation oncologists do and offer for patients is incredibly astounding. I can't tell you how many times as a medical student I listened to an attending surgeon, med onc, dermatologist, or internist tell a patient to avoid radiation because it is "bad", when so many of them have no idea what they are talking about. The field needs to be active and vocal about the value it offers beginning at the medical education level and beyond. Even then we will still find ourselves as "bottom dwellers", but how do we fix that? can we even fix that?

 

[thecarbonionangle]

Very solid post and mirrors my own experiences interviewing new graduates. Way too much emphasis on candidates with PhDs and research experience, and I don't think those skills translate well to private practice. So much of private practice is about building personal relationships with referring doctors (dinners, drinks, etc.) and getting your patients to like you and speak highly of you to the referring doctors...I just didn't see that in the people I was interviewing. Solid CVs, but my referring docs could care less about that. Granted, you want people who excel academically, but 90% of my practice is bread-and-butter cases (breast, prostate, lung) that don't require a PhD to treat.

I have a questions for you and perhaps others in this forum who are in the PP setting. Let's say, as a young resident, I am very disillusioned with the academics world already and find myself strongly leaning PP. How much does research really matter during my time as a resident to land a PP job, and how much does it play in your decision to interview an applicant if all you are seeing is their CV? will you think less of an applicant with less research or will you give them a fair shot and actually meet them? Clearly, based on what you are saying, some of the highly published applicants may not actually have what it takes to be in the PP setting per you, where having a personality actually matters, yet I would think these candidates get lots of interviews based on their pedigree....

 

[Krukenberg]

The problem as summarized by an above poster is the following: "We let medical oncologists, surgeons and others taint opinions on what we offer".
I don't really know how to to fix this "bottom feeding" problem of the specialty. Medical oncology is thought of as the "real oncologists" and they are almost always consulted before radiation oncology gets a chance to see the patient. Med oncs (or a surgeon) ultimately "taint" the options for the patients or ultimately decide if radiation is necessary, then radiation is consulted at that point. I think the problem begins with medical education. Think back to when you were a medical student how many radiation oncologists lectured you? the answer for me was zero, all oncology lectures were taught by surgeons and medical oncologists. Medical students go on to become physicians without any clue whatsoever about the value the specialty offers and its role in cancer care. The level of ignorance in other specialties, even at the attending level, of what radiation oncologists do and offer for patients is incredibly astounding. I can't tell you how many times as a medical student I listened to an attending surgeon, med onc, dermatologist, or internist tell a patient to avoid radiation because it is "bad", when so many of them have no idea what they are talking about. The field needs to be active and vocal about the value it offers beginning at the medical education level and beyond. Even then we will still find ourselves as "bottom dwellers", but how do we fix that? can we even fix that?

I think that your point is an important one; that all of oncology in the preclinical years is taught by Med oncs and surg oncs. It establishes them as the onc experts both among students and other attendings who are involved in medical education. I think that eventually bleeds through to other specialties and the referrals that are made when the students become attendings themselves.

I can honestly say that the vast majority of my classmates do not know what radiation oncologists do, and many of them think that it is an integrated radiology residency.

 

[oncology2020]

let's be real, this isn't about meeting any projected shortages..your "leaders" are brilliant people, nothing is done without reason, everything is a calculated maneuver regardless of the justifications they may give publicly..the only real demand here is $ for hospital administrations

hospital administrators are maximizing their supply of government-subsidized cheap labor (i.e. residents) that bring money to the hospital with complete disregard of job market because ultimately their goal to decrease their expenses and maximize their revenues..one way to do that is to keep operating their clinics and hospitals with cheap labor, and drive salaries down by destroying job markets (hospitals then can pay lower salaries to attendings, making them work harder for less) and by essentially forcing trainees to do (more) fellowships (ie. fellows are also cheap labor)

rad onc is profitable for hospitals--your "leaders" will destroy your field just like the leaders did in their greediness to take advantage of other highly profitable specialities-- radiology, pathology, anesthesiology, and cardiology. The competitiveness of all these specialities in turn got destroyed as many trainees were forced to do multiple fellowships before they could even find a legitimate job due to over-training of cheap labor..imagine for cardiology doing 3 years of IM, 3 years of cardiology, and then two 2-year fellowships (4 years) a total of 10 years post-MD....almost 20 years of education and training before earning an attending salary..ridiculous..this is why cardiology is now increasingly being filled with IMGs just like radiology...this is not how it should be..leaders in medicine do not have the best interests of their trainees in mind unlike nurses who keep fighting to get more and more autonomy with less requirements for their trainees (online Master's and 700 clinical hours allows them to practice medicine independently and make $110,000+/yr in some states, while 8 years of high end education at the highest standards that terminates with a medical doctorate does not even allow us to practice medicine unless we complete at least a 3 year residency at minimum). To put it in perspective, 700 hour clinical hours we get within 9-10 weeks of intern year....

best of luck, hope you guys can fight your leadership to stop expanding as you guys will ultimately lose your bargaining power and ruin your field in the process..this is not a problem specific to your field, hospital administrators are destroying every field without any regard..it's sad

 

[subatomicdoc]

I can honestly say that the vast majority of my classmates do not know what radiation oncologists do, and many of them think that it is an integrated radiology residency.

If we are an unknown to other doctors, imagine how little patients and caregivers understand. And it doesn't help that most mainstream perspectives on radiation are negative. Until we make a coherent, proactive case for the value we add, we'll be left out.

I would suggest people pool resources for best communication tools with primary care, the general public. A small, ethical army of radiation oncologists can accomplish a lot to change the current ignorance of our field.

 

[subatomicdoc]

I have a questions for you and perhaps others in this forum who are in the PP setting. Let's say, as a young resident, I am very disillusioned with the academics world already and find myself strongly leaning PP. How much does research really matter during my time as a resident to land a PP job, and how much does it play in your decision to interview an applicant if all you are seeing is their CV? will you think less of an applicant with less research or will you give them a fair shot and actually meet them? Clearly, based on what you are saying, some of the highly published applicants may not actually have what it takes to be in the PP setting per you, where having a personality actually matters, yet I would think these candidates get lots of interviews based on their pedigree....

I interview in a private practice. I see great value in learning about academic research by direct participation. Doing a research project or two gives you a sense of the work and grit necessary, and a sense of the opportunities to improve care. It also provides direct experience that better allows you to interpret new research once you're in practice. It's an opportunity to be a 'good citizen' in the department committed to training you. It also gave me a sense of appreciation for those who stay on an academic track.

Also, the BS detector works much better when you've done some research and can distinguish thoughtful inquiry from less substantial research. Critical analysis of research is what will keep you current in private practice.

I have not seen large quantities of research make people better private practice candidates beyond that. Excessive amounts raises a flag for me about how much you're really interested in patient care. And if someone can't run through a practical case with clarity and clinical sensibility, pedigree doesn't matter much to me. I have a hierarchy of needs that is helpful for me to assess.

 

[ramsesthenice]

Excessive amounts raises a flag for me about how much you're really interested in patient care.

I really appreciated your post until right here. Completely agree that a productive research track does not translate into exceptional (and critically important) people skills. Lets call it what it is, some people look really good on paper because they are on the spectrum (ASD). We all know its true and we all know those people are not going to do well in a PP setting where bad people skills can destroy your referral base.

But that is not the majority. I don't see how for most residents an exceptionally productive research portfolio and genuine interest in patient care are at odds in any way. Its very easy to see how some people may really enjoy research opportunities while they have them during residency yet still be fully devoted to patient care. I'm a physician scientist and I assure you I'm not willing to work longer hours than my colleagues at a lower pay rate just because of a mild interest in patient care. Its easier to get more grants and data out when you don't have to spend 2 full days a week (plus unscheduled visits and treatment planning time) with those pesky patients

But Im not just talking about physician scientists. Some of our most productive residents (research wise) have also been the most clinically adept and bound for PP from the moment they walked in the door. They are just very curious and exceptionally good with their time, traits which serve them well in any setting. I also know for a fact one of the attendings on this forum completed a very productive Holman residency and is now a very successful member of a PP group in a pretty competitive market.

Excluding the occasional super weird people you can filter out in a few miliseconds, have you really found a correlation between quantity of research and poor clinical/people skills?

 

[subatomicdoc]

Excluding the occasional super weird people you can filter out in a few miliseconds, have you really found a correlation between quantity of research and poor clinical/people skills?

Good points, ramses. I agree that talented people often do multiple things well. I didn't say that there is a correlation, it's just a flag for me because of what I think fits community practice needs best. No research is also a flag for me because it shows lack of engagement in your work environment. Both are reasons to further inquire about a candidate. It's not a bad thing, but when making decisions about who will cover for my patients in what is essentially a professional marriage, I want to ensure that job candidates are the right fit for my practice. I don't have a final say but I do have an opinion.

By no means am I suggesting that people who choose academics aren't committed to patient care. If that's what is coming across, I apologize. My comments do not address academics at all. I am simply giving my opinion on thecarbonionangle's question about how research may be perceived from a private practice perspective. Hopefully that makes sense.

 

[ramsesthenice]

By no means am I suggesting that people who choose academics aren't committed to patient care. If that's what is coming across, I apologize. My comments do not address academics at all. I am simply giving my opinion on thecarbonionangle's question about how research may be perceived from a private practice perspective. Hopefully that makes sense.

I didn't mean to imply that you were at all. My apologies to you. I guess I just found the answer a little confusing. Try to do some research but not too much. I've never officially been part of a PP, and certainly have not been on the side of finding people to fill those positions. I just felt strongly, at least from the people that we have trained, some of the best suited for success in the community setting have also had exceptionally strong research profiles during residency.

 

[RadOncDoc21]

I personally do not have a problem with people who have an extensive research history. I understand that in order to get into a residency program, research is emphasized a great deal more than other fields. Right or wrong, this is the story for 99.9% of medical students entering the field and I would say maybe 30% of residents leaving the field to launch their careers.

Indeed, my initial goal was be an academic physician-scientist, future department chair, but found out quickly that wasn't my cup of tea. I'm thankful for the research experiences I've had, but as many would probably realize, I'm more comfortable in private practice.

 

[Gfunk6]

I think what subatomicdoc was trying to point out was that if a resident has a major commitment to research, then (s)he deserves increased scrutiny while interviewing for a PP job. My own experience reflects this observation well. I was heavily invested in the physician-scientist track and decided relatively late in my residency that I would prefer PP. My future partners were interested but justifiably skeptical, "how do we know that you won't run to UCSF or Stanford as soon as they have a junior faculty position available?"

If I had not completely satisfied them with my answer, they would have been fully justified in passing on my candidacy.

 

[thecarbonionangle]

Most academic departments require a few projects before graduation. Indeed mine is one of them with a pretty good amount of dedicated research time, I just wanted to get a sense of what was actually important down the line. I will have publications and projects I can tell people about, so that won't be a problem if that is something certain people care about. I just wanted to make sure I didn't need to focus on so much research all through residency, so I certainly appreciate your candid response and your insight. It sounds to me from reading the general opinion (small sample size of course) is do some research but you don't need to pump out so many papers if you're leaning the PP route. Obviously, if a reader who hires in the PP setting has a contrary opinion, that will be nice to hear as well.

 

[PhotonBomb]

You guys are making this overcomplicated.

1) First off - and this is a BIG point - academics jobs and PP jobs are on big spectrum and there can often be a good amount of overlap between the two. Some 'Academic' Jobs are essentially PP jobs. and then there are academic satellites too.

2) No matter what you may think you are leaning towards now, I guarantee you in the end you will end up applying to a broad range of jobs. no job in radiation oncology is like another. So many things ultimately come into play, not the least of which is location. But also support staff, salary, partners, stability etc come into play. I've seen so many examples of people being sure they wanted academics going PP and vice versa. In the end - you pick the best job available, whatever it is classified as. People who say 'I want a PP job' emphatically are being naive.

3) The second point leads to this point - whatever you do in residency, you should be building yourself up to be competitive for any job. Because you just don't know what's out there that particular year. You just want to be well-prepared for it all, and for every person that reads your CV. A lot of the PP job networking is done at ASTRO, for example. Even if you have no interest in academics, it behooves you to go to ASTRO to see people and be seen. You never know who is going to help you get that job.

 

[Reaganite]

I have a questions for you and perhaps others in this forum who are in the PP setting. Let's say, as a young resident, I am very disillusioned with the academics world already and find myself strongly leaning PP. How much does research really matter during my time as a resident to land a PP job, and how much does it play in your decision to interview an applicant if all you are seeing is their CV? will you think less of an applicant with less research or will you give them a fair shot and actually meet them? Clearly, based on what you are saying, some of the highly published applicants may not actually have what it takes to be in the PP setting per you, where having a personality actually matters, yet I would think these candidates get lots of interviews based on their pedigree....

I think it matters to certain people. It really depends on the practice, though. At the very least, I can't see how it would hurt you. If you're joining a large, established group or some sort of urorad/medoncrad, it probably matters more. In these settings, there's already a built-in referral base, and I've noticed these guys tend to favor the Harvard grad with the big CV. You'll probably be an employee in this setting, and you may not be asked to do much marketing. If you're talking about a true private practice (e.g. community hospital where it's you alone or maybe one other guy), I think it matters a lot less. All of my practices are in this setting, and for me, I could care less about research. I certainly don't frown on it, though, or hold it against an applicant. It just carries less weight for me. It would only make a difference to me if I had two equally personable candidates, and I needed some additional measure to distinguish between them. It's very important to me that my referring docs and patients like you, and that you have a marketable personality. I do all interviews in conjunction with my referring docs. I work in a very competitive metropolitan area and none of the solo guys who are doing really well trained at big-name institutions or have outstanding CVs. What they all have in common is amazing personal skills (patients and referring doctors love them) and a good understanding of the business of medicine.

 

[RadOncDoc21]

...good understanding of the business of medicine.

40 Gy in 30 fractions for a bone met.. I kid I kid!

 

[medgator]

40 Gy in 30 fractions for a bone met.. I kid I kid!

There's a line that separates good from bad pp docs.

"It's like pornography...you'll know it when you see it"

 

[Reaganite]

Contract negotiations, how to interact with referring doctors and hospital administrators, how to be politically correct in tumor boards, significance of in-office ancillary services exception, etc. These are the scenarios I discuss when interviewing someone. That being said, it would behoove you NOT to stress hypofractionation, over-use of IMRT, etc. if you want a private practice gig. Don't even joke about it. Rather, stress the legitimate scenarios where you use IMRT where older docs might not use it (endometrial, anal Ca, etc.) and stress newer, high-reimbursing, legitimate modalities like SBRT. It's all a game. Most PP rad oncs practice legitimate medicine, but it's in your best interest to stress the ways you can add to the revenue of a practice rather than discussing ways you're gonna take money away!!

 

[punkedoutriffs]

Contract negotiations, how to interact with referring doctors and hospital administrators, how to be politically correct in tumor boards, significance of in-office ancillary services exception, etc. These are the scenarios I discuss when interviewing someone. That being said, it would behoove you NOT to stress hypofractionation, over-use of IMRT, etc. if you want a private practice gig. Don't even joke about it. Rather, stress the legitimate scenarios where you use IMRT where older docs might not use it (endometrial, anal Ca, etc.) and stress newer, high-reimbursing, legitimate modalities like SBRT. It's all a game. Most PP rad oncs practice legitimate medicine, but it's in your best interest to stress the ways you can add to the revenue of a practice rather than discussing ways you're gonna take money away!!

Are these skills something that can be picked up during residency?

 

[subatomicdoc]

I didn't mean to imply that you were at all. My apologies to you. I guess I just found the answer a little confusing. Try to do some research but not too much. I've never officially been part of a PP, and certainly have not been on the side of finding people to fill those positions. I just felt strongly, at least from the people that we have trained, some of the best suited for success in the community setting have also had exceptionally strong research profiles during residency.

No problem at all. I could have been clearer in how I said it. And I want to hire people smarter than me (easy nowadays) with good critical thinking skills. Research experience can help with those skills. I just want to make sure the other essential strengths are there too.

 

[BobbyHeenan]

Are these skills something that can be picked up during residency?

One of the biggest things you can do is go to every tumor board possible in residency. Speak up. Prep for them and act as if every single question will be directed your way. Be prepared and proactive there. Learn how to lobby for your recommendation with data and rationale. Learn how to present your side of the "argument" when there are difficult cases with multiple options. Learn how to delicately but authoritatively call someone out when they've suggested doing something with inferior or little data(ie recommending RCHOP over XRT for stage I follicular lymphoma, or why a patient with Gleason 9 disease should think about radiation/ADT over surgery). There are ways to challenge referring docs without insulting their intelligence to where they will respect you but not feel threatened.

A lot of this comes with experience and simple "people skills," but IMO in residency one of the best ways to learn this is by going to tumor boards and conferences and actually doing your homework and speaking up. Anticipate questions like "what benefit will XRT have here" and be ready to answer. Don't just sit back and let attendings talk. One of the best parts of my training program was that every rad onc question in tumor board was directed to a resident, and I was grateful for that training. If that's not the culture at your residency then work to make it that way.

 

[Carotenoid]

I was one of the commenters from the audience at the session, which was excellent. I have interviewed ~150-200 people for my private practice and it is definitely harder for people finishing training. Not only are we training too many people, I think we're training residents the wrong way which only makes it worse.

Radiation oncology programs select people with heavy research backgrounds and among the lowest levels of volunteering except for neurology, neurosurgery and vascular surgery (see NRMP data). When you have 23% of matriculating residents with a PhD and 45% with some advanced degree for a field that only has 25-30% of positions in academics, it's a setup for a mismatch at the end of training.

Residency makes it worse; you're then fed the false sense you have to do research to succeed. More publications, less focus on clinical acumen, communication skills than there should be. Once we choose the remarkably talented pool of people to be trained, it's physician-scientist tracks that are highlighted. Where are the programs aiming to train physician-humanists that excel at patient care?

The goal should be to train people well for successful careers they enjoy. My suggestion: any residency program director should be required to visit at least two community practice settings annually. Department chairs should do it once annually. Get out of the ivory tower. Community-based radiation oncology are 70+% of the jobs that you are trying to prepare trainees to fill.

It is such a shame. 99% of this "research" is driven not by scientific curiosity or a noble aspiration to "cure cancer", whatever that means, but to pad the CV. Those posters at ASTRO - 99% of them are fantastically ridiculous, and would not be allowed to hang at any self-respecting scientific meeting... But unfortunately, everyone - from med students to the departmental chairs - have been sucked into this delusional chest-thumping race where "simply" being a good clinician (OR researcher!) is not enough, where a graduate's worth is measured by the NUMBER (NOT quality!) of the stuff he published... How many times have you heard "Oh, so and so published 12 papers just during residency!" Is this a hot dog eating competition, where the quantity is all that matters?

How I would love to spend the "research time" being in the clinic OR actually doing lab research (but the latter is out of reach also because those of you who have done bench research know that there is NO way of producing a paper after 6 months in a lab)!

 

[Chartreuse Wombat]

It is such a shame. 99% of this "research" is driven not by scientific curiosity or a noble aspiration to "cure cancer", whatever that means, but to pad the CV. Those posters at ASTRO - 99% of them are fantastically ridiculous, and would not be allowed to hang at any self-respecting scientific meeting... But unfortunately, everyone - from med students to the departmental chairs - have been sucked into this delusional chest-thumping race where "simply" being a good clinician (OR researcher!) is not enough, where a graduate's worth is measured by the NUMBER (NOT quality!) of the stuff he published... How many times have you heard "Oh, so and so published 12 papers just during residency!" Is this a hot dog eating competition, where the quantity is all that matters?

How I would love to spend the "research time" being in the clinic OR actually doing lab research (but the latter is out of reach also because those of you who have done bench research know that there is NO way of producing a paper after 6 months in a lab)!

Let's not be so hard on ourselves. Lots of other "scientific" society meetings are littered with junk posters. All have figured out that accepting nearly everything (ASTRO acceptance is >90%) means lots more registrants which translates into more $$$ for the society.

That said rad onc has a problem.

 

[medgator]

Imo, some of the more relevant data to my everyday practice data gets presented at asco

 

[Carotenoid]

.. with more residents now in faculty positions, program directors and chairs are getting pressured to find "coverage" for the new faculty and thus requesting more residency slots... ?

I think you are right on the money here

 

[Mandelin Rain]

I think you are right on the money here

Yeah, I could see that. Academic hospitals are taking over community satellites like crazy, and need someone to staff them. The old guard faculty isn't going to do it. It falls to the new grad who quickly realizes that they are doing the work of a private practitioner for the pay of a junior academic. Obviously, a bad situation. Need a steady flow of new grads to pump through that ringer.