With great power comes great responsibility right?
I agree.
If I were to ascribe a reason for academics leveraging their power in such a sh%$ty way, it is their inability to see what the field really is. This has been compounded by the fact that external beam radiation is an enormous financial winner for academic centers and that radonc was able to recruit incredibly accomplished residents for a period of roughly 15 years. Incredibly accomplished residents don't become humble over time. They were sold on the narrative that they were going to be the docs who change the standard of care in oncology. The fact that the only way radonc is doing this is by eliminating or reducing radiation as a treatment modality is not as important as the fact that they are fulfilling their academic destiny. Other avenues to academic prominence also do nothing for the practicing radiation clinician. (Disparity research, fundamental molecular oncology, becoming a chair somewhere (a chair needs residents)).
I like to think of it as an ambition/opportunity mismatch. Sort of like a V/Q mismatch. It results in an agonal existence and ultimately death.
So what is radonc? It is the good lifestyle oncology field that gives
one drug (XRT). It is a device oriented field and not a pharmaceutical oriented one. It is highly technical but almost certainly not as vulnerable, in terms of outcomes, to personal expertise as surgery.
The consequences of clinical incompetence typically become evident late and often not at all. As it is a one trick pony, outcomes are improved incrementally through technical innovation. Although ion therapy has been sold as a paradigm change (a new drug?), it is not. FLASH could be, but likely won't be. As a recent abstract noted, the toxicity of 3D, standard fractionation prostate XRT is pretty
reasonable.
Radonc, in the global oncologic world, where the pharmaceutical management of cancer is improving and indications for adjuvant treatment are becoming more refined, will become less. It is becoming less. We in the community know it.
Academic radonc has responded by making itself a larger portion of the smaller pie, by marketing regionally or nationally, by subsuming regional community practices, by believing that their one drug, fundamentally the same as the community doc's one drug, is somehow better, and by pursuing high cost and at best very marginal value innovations to distinguish themselves from the community.
It's just not a healthy field, and won't be until it becomes a different field.
In a healthy field, most of the work is done in the community and academics are there to explore experimental care or take on the toughest cases.
Academic medoncs never want to keep a patient from local care unless on protocol or receiving transplant level care. They have essentially infinite opportunities for progressive clinical trials at this point.
A routine patient takes away from their academic mission.
Academic neurosurgeons are fine when their academic colleagues take $$$ PP jobs. These jobs help preserve their own market value.
What would a healthy radonc academic culture do? Cut spots and look for a strategy to expand the clinical scope of radiation oncology.