Canaries in a Coal Mine

[Gfunk6]

I recently attended the Annual UCSF Rad Onc course. One of the featured speakers was Anthony Zietman. Dr. Zietman has always been a highly engaging speaker and his topic was particularly timely - "the future of RO as a specialty."

Many, many interesting points came out of this talk:

1. He reviewed several specialties which have either died off (Syphilology - last board certified in 1951) or are struggling as they did not evolve including: Nuclear Medicine (too narrow, full of IMGs, redundant as can be done by Diagnostic Rads), Family Medicine (too broad, low compensation, increasingly being delivered by NPs/mid-levels), and Cardiac Surgery (they were blindsided by Interventional Cardiology).

2. He reviewed the history of Rad Onc and pointed out that we have hitched our wagon to a modality rather than an anatomic site. This puts as at considerable risk for future irrelevance. His major proposal is to merge Interventional Radiology (officially separated from Diagnostic Radiology effective 2015) and Radiation Oncology. Obviously, this would be done slowly at first in major institutions with a handful of residents; however it would help both our fields considerably.

3. He said that he periodically reads SDN and has noted a significant amount of disgruntlement from medical students/residents regarding the future of our field. He also touched on the fact that we are pumping out a ton of residents. He showed two tables of RO residency applicants in 2005 and 2015 and noted that the # applicants:# positions ratio was reduced from 1.45 to 1.11. As a benchmark, Radiology is now at 0.95 with about 40% non-US grads.

4. He raised the concept of the "canary in a coal mine." In other words, medical students will weight their future prospects in RO vs. the "toxic smell" of the drawbacks of the field. If fewer med students apply, the field will become less competitive and the # of radiation oncologists will eventually self-regulate.

In the questions session, I asked him if there was anything that could be done to stop pumping out so many residents. His response was both enlightening and satisfying. Since there is a five year lead time from training start to graduation, it is pretty unlikely that anything meaningful would happen even if we cut residency spots today; we are stuck with half-decade of surplus MDs. Also, he noted that cutting residency spots purely due to self interest (economics) is a legally tenuous situation.

Therefore, it falls on medical students to weigh the pros and cons of our field before entering it.

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[thecarbonionangle]

Merging IR and rad onc certainly seems like an interesting proposal. I wonder how it would work out if it were actually done, as some people who do IR don't have any interest in oncology, so you'd need people are are interested in being an oncologist and being consulted to put in a line or do an embolectomy. is there any radiation oncology programs out there that allow residents to learn "interventional oncology"? Having the skill to do biopsies would help the field a lot. I also wonder how much interest the IR guys would have in combining the disciplines as a whole. Perhaps a compromise could be reached to expand our field but not totally combining it with IR?

Also, It annoys me to think people think im training to be a radiologist when we are training to be oncologists. Maybe it would make our lives easier to just make us radiologists, so we have to stop explaining this to people.

 

[medgator]

Some of the less scrupulous IRs I've seen in the community could benefit from some oncology training. I've personally seen IRs do "consults" when getting referrals for CT-guided lung biopsies and then bringing pts back to offer RFA upfront either for de novo clinical stage I cancer, or in situations where there are clearly widespread mets and systemic therapy rather than local therapy, let alone something ridiculous like RFA, is indicated. One guy brands himself as an "interventional oncologist" despite the clear lack of oncology training in the current IR track.

There could be advantages to it, but imo, I think a better route would be to do a push to "clinical oncology" like what is seen in the UK. We already have a good base of oncology knowledge and maybe we need to move more in the direction of being able to give targeted therapy, sensitizing iv/oral therapy etc.

I'm not as nihilistic on our future as Zietman, but the current lack of control over the supply/demand issue is probably one of the bigger issues we face.

Derm has regulated its number of spots for years afaik without legal ramifications

 

[Krukenberg]

Not to sound selfish but if rad onc is merged with IR what happens to all the rad oncs who are then a truly one-trick pony? That would include young attendings with many years ahead of them in their careers.


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[medgator]

Not to sound selfish but if rad onc is merged with IR what happens to all the rad oncs who are then a truly one-trick pony? That would include young attendings with many years ahead of them in their careers.


Sent from my iPhone using SDN mobile app

Definitely something to think about.

I think IR would benefit more from the merger than we would. We've definitely been a more clinically-based specialty, where we work up and manage our own patients. IR struggled with that for years until they finally started setting up their own specialty track in training and their own service line/practice in the community

 

[Ray D. Ayshun]

it seems to me that many of those attracted to ir are attracted to things you don't get in radonc, and somewhat turned off by things you do, and vice versa.

 

[Burt Radnolds]

While you found his reply enlightening and satisfying, I find it depressing and repugnant. To suggest that the best solution will be to pretty much just let it work itself out is unacceptable. Think about it, what he suggested was to let our specialty collect such a toxic stench that it becomes unpalatable to most medical students. What will that be like for those in practice? Unemployment for new grads? Plummeting salary? This sounds like another academic preaching from his pulpit high above the fray. With the latest published analysis confirming the overestimation of need, the bare minimum action should be a freeze on all further expansion. This nonsense regarding the ethics of limiting residency spots is pure and utter hogwash. Dermatology has a dramatic undersupply, yet they have their collective s*** together and I believe they actually have had a recent decline in available residency spots, a situation much more ethically dubious . I don't see the FBI busting down their door. Rant over.

 

[Fpg1245]

Perhaps we could justify a reduction in residency slots. An increasing reluctance for med oncs to refer patients for radiation, Hypo fractionation, targeted therapies. It should certainly cut down on the overall rad onc workload. extrapolating upon those trends, it should give a more realistic picture of demand and serve as a counterpoint to the overly optimistic 2010 jco article.

 

[ReOxygenation]

He's been using and recycling this same thing for at least 4 years now. He needs new material. He prophesied the quality of med students had peaked half a decade ago. Wrong.

I've personally heard the speech twice over the previous 4 years.

 

[mpdoc2]

I recently attended the Annual UCSF Rad Onc course. One of the featured speakers was Anthony Zietman. Dr. Zietman has always been a highly engaging speaker and his topic was particularly timely - "the future of RO as a specialty."

Many, many interesting points came out of this talk:

1. He reviewed several specialties which have either died off (Syphilology - last board certified in 1951) or are struggling as they did not evolve including: Nuclear Medicine (too narrow, full of IMGs, redundant as can be done by Diagnostic Rads), Family Medicine (too broad, low compensation, increasingly being delivered by NPs/mid-levels), and Cardiac Surgery (they were blindsided by Interventional Cardiology).

2. He reviewed the history of Rad Onc and pointed out that we have hitched our wagon to a modality rather than an anatomic site. This puts as at considerable risk for future irrelevance. His major proposal is to merge Interventional Radiology (officially separated from Diagnostic Radiology effective 2015) and Radiation Oncology. Obviously, this would be done slowly at first in major institutions with a handful of residents; however it would help both our fields considerably.

3. He said that he periodically reads SDN and has noted a significant amount of disgruntlement from medical students/residents regarding the future of our field. He also touched on the fact that we are pumping out a ton of residents. He showed two tables of RO residency applicants in 2005 and 2015 and noted that the # applicants:# positions ratio was reduced from 1.45 to 1.11. As a benchmark, Radiology is now at 0.95 with about 40% non-US grads.

4. He raised the concept of the "canary in a coal mine." In other words, medical students will weight their future prospects in RO vs. the "toxic smell" of the drawbacks of the field. If fewer med students apply, the field will become less competitive and the # of radiation oncologists will eventually self-regulate.

In the questions session, I asked him if there was anything that could be done to stop pumping out so many residents. His response was both enlightening and satisfying. Since there is a five year lead time from training start to graduation, it is pretty unlikely that anything meaningful would happen even if we cut residency spots today; we are stuck with half-decade of surplus MDs. Also, he noted that cutting residency spots purely due to self interest (economics) is a legally tenuous situation.

Therefore, it falls on medical students to weigh the pros and cons of our field before entering it.

This is such a ******ed answer (medical students will weight the pros and cons). It shows how little seniors in the field know about residency and the application to residency. Here's a newsflash for you Zietman. Even if you make it an extremely undesirable field you'll always have IMGs coming from abroad who would rather match in a horrible field than not match at all and be sent back to whatever god forsaken place they came from. It's unfortunate when institutions like MGH are screwing up the field by pumping out more and more applicants every year and you have their directors saying (oh you can't base how many we pump out based on economics). Such hogwash really angers me.

 

[mpdoc2]

Not to sound selfish but if rad onc is merged with IR what happens to all the rad oncs who are then a truly one-trick pony? That would include young attendings with many years ahead of them in their careers.


Sent from my iPhone using SDN mobile app

We'd suffer the same fate of nuclear medicine. (ie not have a job).

 

[mpdoc2]

.

 

[Fpg1245]

Well assuming he is not dumb or lazy. It might be safe to assume that not much has really changed in the last 4 years. The challenges the field faces are largely the same if not worse. The question remains: what will we do about it? Based on Dr. Zeitman's answer, not much. It would be a shame if this field degenerated into a nuc med or even pathology because it's leaders thought it best to sit idle.

 

[medgator]

This is such a ******ed answer (medical students will weight the pros and cons). It shows how little seniors in the field know about residency and the application to residency. Here's a newsflash for you Zietman. Even if you make it an extremely undesirable field you'll always have IMGs coming from abroad who would rather match in a horrible field than not match at all and be sent back to whatever god forsaken place they came from. It's unfortunate when institutions like MGH are screwing up the field by pumping out more and more applicants every year and you have their directors saying (oh you can't base how many we pump out based on economics). Such hogwash really angers me.

They pretty much how rad onc used to be once upon a time (IMG heavy). It wasn't that long ago really.... I think the horrible job market peaked in the early-to-mid 90s and iirc, that's in part what prompted an extension in the residency from 3 to 4 years in length.

Unfortunately, seems like we may be heading back in that direction

 

[RadOncDoc21]

I didn't like his response either. More needs to be done versus allowing the field to become garbage. For all I know, he represents the driving force that put us where we are now.

My opinion is that we are too dependent on referrals and all it takes is for someone upstream to intervene on a patient. We may "know" what is best for our patients, but what does that mean when there are Urologists who are operating on all high risk patients, IR doing ablative procedures just because they can or med oncs using induction chemotherapy or delaying treatment just to "avoid radiation."

Maybe SBRT is the a game changer in our field. Unfortunately, I can imagine a scenario where surgeons will start using it simply because we were too afraid or unwilling to challenge tradition.

 

[BobbyHeenan]

I still have seen ZERO reason why we can't at minimum freeze the expansion. You've now got new data/publications to back you up (ie there will be an oversupply soon) when/if you get in a "legally tenuous" situation.

This "let the med student demand" sort it out is the biggest Milquetoast stance and it's on such the opposite end of the spectrum of a proactive approach that to me it is far from encouraging. By the time medical students are avoiding our specialty, then we're already at the radiology/family med level....so why should we not set our goal at preventing that, not just waiting around to see what happens?

The IR/Rad onc thing is at least interesting, but there are a lot of pitfalls. It's not the answer. Maybe a special combined residency for a handful of places, but I agree with those above - it helps IR more than it helps us.

 

[BobbyHeenan]

Also...let's all take a minute to remember how little we knew as a third year medical student. It's very hard to gauge your own interest, what exactly happens as an attending in X field, etc. And you really want to just sit idly by and wait on the confused 3rd year medical student to determine the fate of your residency (and field) competitiveness?

This is not a canary in the coalmine situation. You sent the canary in to test the air...we already know we have a coal mine that is taking on more and more carbon monoxide...but rather than shutting down the carbon monoxide so that we can figure out where it is coming from, how long we can take so much of it in, whether our own coal mine can handle all of it....we're not going to do anything and just going to see how long that canary lasts for now.

 

[Sheldor]

Also...let's all take a minute to remember how little we knew as a third year medical student. It's very hard to gauge your own interest, what exactly happens as an attending in X field, etc. And you really want to just sit idly by and wait on the confused 3rd year medical student to determine the fate of your residency (and field) competitiveness?

This is not a canary in the coalmine situation. You sent the canary in to test the air...we already know we have a coal mine that is taking on more and more carbon monoxide...but rather than shutting down the carbon monoxide so that we can figure out where it is coming from, how long we can take so much of it in, whether our own coal mine can handle all of it....we're not going to do anything and just going to see how long that canary lasts for now.

Also, when I was a med student I like to think I was ahead of my time being seriously concerned about these issues. I came here and asked some version of, "Should I go into Rad Onc given the issues with falling reimbursements and rising residency spots?" I was universally reassured that I was better off pursuing my passion. As long as we here keep talking about what a great field it is, people will keep coming, for better or worse.

 

[BobbyHeenan]

Also, when I was a med student I like to think I was ahead of my time being seriously concerned about these issues. I came here and asked some version of, "Should I go into Rad Onc given the issues with falling reimbursements and rising residency spots?" I was universally reassured that I was better off pursuing my passion. As long as we here keep talking about what a great field it is, people will keep coming, for better or worse.

It absolutely is a great field.

But there are some challenges up ahead and in order to keep it a great field we need to be proactive. The last thing you want is the synergy between a major oversupply and hospitals mergers/huge academic centers buying up every linac around town...then administrators get a sense that they have an endless supply of rad oncs. It ceases to become a great field when it's difficult to find a job, questionably necessary fellowships become more standard due to said job issue, reimbursement continues to decline, and you're beholden to an administrator(s) that knows if you don't do what he/she says they'll just go out and find someone else.

 

[seper]

I utterly hate IR attendings in my institution. They destroy patient bodies in relentless pursuit of "lesions", completely disregarding patient as the whole. Our hospital pays them nearly double that it pays us. If we were to merge with IR, I'll quit to teach gross anatomy.

 

[mpdoc2]

I utterly hate IR attendings in my institution. They destroy patient bodies in relentless pursuit of "lesions", completely disregarding patient as the whole. Our hospital pays them nearly double that it pays us. If we were to merge with IR, I'll quit to teach gross anatomy.

In most of the country radonc is paid more than IR. You're in the wrong hospital my friend.

 

[seper]

: ( true

 

[Chartreuse Wombat]

As I have posted on other threads, the only organization that can change the number of radiation oncology resident positions is SCAROP. This is where your ire should be directed and I would encourage you to attempt to persuade them. This is not a situation that ASTRO can fix (they want more members and have no jurisdiction), ACGME cannot fix either as it is specifically forbidden to discuss workforce issues as it relates to training programs or positions (restriction of trade and so forth). Do something constructive and gather a group of like-minded individuals and appeal to SCAROP.

 

[mpdoc2]

As I have posted on other threads, the only organization that can change the number of radiation oncology resident positions is SCAROP. This is where your ire should be directed and I would encourage you to attempt to persuade them. This is not a situation that ASTRO can fix (they want more members and have no jurisdiction), ACGME cannot fix either as it is specifically forbidden to discuss workforce issues as it relates to training programs or positions (restriction of trade and so forth). Do something constructive and gather a group of like-minded individuals and appeal to SCAROP.

I agree with you, though we have to make people like Zeitman (who are closer to the chairs than we are) to understand the problem will not fix itself. I encourage all of the residents to be vocal in their training programs to describe the problems that they are seeing in getting hired. Maybe that'll make some programs think twice before selfishly expanding. I know I was successful with that at my former program after me and my fellow residents voiced their concerns.

 

[Ray D. Ayshun]

I didn't like his response either. More needs to be done versus allowing the field to become garbage. For all I know, he represents the driving force that put us where we are now.

My opinion is that we are too dependent on referrals and all it takes is for someone upstream to intervene on a patient. We may "know" what is best for our patients, but what does that mean when there are Urologists who are operating on all high risk patients, IR doing ablative procedures just because they can or med oncs using induction chemotherapy or delaying treatment just to "avoid radiation."

Maybe SBRT is the a game changer in our field. Unfortunately, I can imagine a scenario where surgeons will start using it simply because we were too afraid or unwilling to challenge tradition.

I'm admittedly naive, but it also makes sense to me to consider what integrating medonc might look like rather than ir. One day we might have lung oncs, breast oncs, etc., that do chemo and xrt. Id love it, and I could argue easily it's better for the pt.

 

[mpdoc2]

I'm admittedly naive, but it also makes sense to me to consider what integrating medonc might look like rather than ir. One day we might have lung oncs, breast oncs, etc., that do chemo and xrt. Id love it, and I could argue easily it's better for the pt.

I agree that this is probably a better approach and what's done in most of the world.

 

[napoleondynamite]

As I have posted on other threads, the only organization that can change the number of radiation oncology resident positions is SCAROP. This is where your ire should be directed and I would encourage you to attempt to persuade them. This is not a situation that ASTRO can fix (they want more members and have no jurisdiction), ACGME cannot fix either as it is specifically forbidden to discuss workforce issues as it relates to training programs or positions (restriction of trade and so forth). Do something constructive and gather a group of like-minded individuals and appeal to SCAROP.

SCAROP Executive Committee
President
Stephen M. Hahn, MD, FASTRO
University of Texas MD Anderson Cancer Center
Houston

Vice-president
Charles R. Thomas Jr., MD
Oregon Health and Sciences University
Portland, Oregon

Secretary/Treasurer
Benjamin Movsas, MD, FASTRO
Henry Ford Hospital/Wayne State University
Detroit

Immediate Past-president
Silvia Chiara Formenti, MD, FASTRO
New York-Presbyterian/Weill Cornell Medical Center
New York

 

[napoleondynamite]

I have sent an email to Emily Wilson to ask about who in their organization would accept a petition.

Has anyone ever started a petition before? What would be the best way to circulate this? If we had an electronic petition that we could all sign, then it would just be a matter of spreading the word to sign it and then forward to SCAROP.

We could at least maybe gain a podium at their annual meeting that way..?

 

[medgator]

I have sent an email to Emily Wilson to ask about who in their organization would accept a petition.

Has anyone ever started a petition before? What would be the best way to circulate this? If we had an electronic petition that we could all sign, then it would just be a matter of spreading the word to sign it and then forward to SCAROP.

We could at least maybe gain a podium at their annual meeting that way..?

https://www.change.org/petition

 

[XRT_doc]

I have sent an email to Emily Wilson to ask about who in their organization would accept a petition.

Has anyone ever started a petition before? What would be the best way to circulate this? If we had an electronic petition that we could all sign, then it would just be a matter of spreading the word to sign it and then forward to SCAROP.

We could at least maybe gain a podium at their annual meeting that way..?

I think this is excellent. We really should be connecting together and voicing our opinions en-mass so that they are heard.

 

[canadianoutlaw]

https://www.astro.org/SCAROP/Annual-Meeting/Index.aspx

Annual Meeting
The SCAROP Meeting is held yearly in conjunction with ASTRO's Advocacy Day.

2016 SCAROP Meeting
The 2016 SCAROP Meeting will be held in Washington on Sunday, May 22, 2016. The meeting will commence with networking lunch at 12:00 p.m., and will conclude at 5:30 p.m. Eastern time. The meeting agenda will be released to the SCAROP membership when it becomes available. Please contact Emily Wilson with any questions.

 

[napoleondynamite]

I had an interesting discussion with Emily Wilson today.

SCAROP sees limitation of residency expansion as a violation of anti-trust law.

Over the years, I have seen it pointed out on this forum that other fields (e.g. Derm) has been able to successfully regulate the expansion of residency programs. Does anyone have a detailed understanding about this? Like, is that really true? Because anti-trust laws should apply to everyone the same.

I would be happy to lead the charge on a petition - but we need to craft it in an evidence-based approach and provide real-world solutions that have been effective in other fields. Also, if someone has any or all of the workforce radonc publications at their fingertips, can you PM them to me?

 

[medgator]

I had an interesting discussion with Emily Wilson today.

SCAROP sees limitation of residency expansion as a violation of anti-trust law.

Over the years, I have seen it pointed out on this forum that other fields (e.g. Derm) has been able to successfully regulate the expansion of residency programs. Does anyone have a detailed understanding about this? Like, is that really true? Because anti-trust laws should apply to everyone the same.

I would be happy to lead the charge on a petition - but we need to craft it in an evidence-based approach and provide real-world solutions that have been effective in other fields. Also, if someone has any or all of the workforce radonc publications at their fingertips, can you PM them to me?

What about what happened in the mid 90s? Anecdotally, I've heard that programs were closed (leading to less spots in the match) and the residency length was extended because of the bad job market. Maybe someone more senior can chime in

 

[napoleondynamite]

Yes, apparently there are legal approaches..in a roundabout way..to regulate spots, with one solution being increasing the number of years of training that other specialties have done. I think I understood that closure of residencies may have been more of a demand thing or an accreditation thing than a regulation of workforce thing..

But SCAROP as body, their position is that it's really not up to them to take formal action based on market drivers. If that is wrong or has been challenged by other specialties, we should convince them otherwise. But basically I understood that any petition would be forwarded directly to the lawyers of SCAROP who have already made the decision that any action on their part would violate anti-trust law. So we just need evidence as to how it has been successfully managed in other specialties and then petition SCAROP to take those steps.

 

[BobbyHeenan]

I'm not buying the anti-trust line at all.

This anti-trust stance was never discussed by the powers that be in the original Red Journal reply to Dr. Shah when he sounded the first in-print alarm back in 2013. Dating back to that response and up to most recently the commentary by Dr. Zeitman, the "market/3rd year med students will determine demand" party line has been used. The only good in bringing up this anti-trust stance is to just hide behind a fear of a lawsuit that will never come. A Lexus-Nexus search on anti-trust cases for residency spots could possibly help clarify if this is a real legit threat or not. For what it's worth, I asked my wife (attorney, but practices no where near anti-trust stuff), and she said at first glance this looked like just a hand waiving thing to hide behind rather than a real threat.

A few stream of consciousness thoughts:

- Terry Wall that does the ASTRO/ARRO job market stuff I believe is an attorney. May be interesting to get his thoughts on some of this.
- I'm sure the derm chairmen/women will not want to divulge their in house secrets, but knowledge of their process would be helpful.
- It's definitely correlation and not necessarily causation, but isn't it curious that the expansion of academic rad onc departments into outlying clinics and employing more "academic" rad onc satellite doctors has coincided with the rapid residency expansion?

 

[BobbyHeenan]

Yes, apparently there are legal approaches..in a roundabout way..to regulate spots, with one solution being increasing the number of years of training that other specialties have done. I think I understood that closure of residencies may have been more of a demand thing or an accreditation thing than a regulation of workforce thing..

But SCAROP as body, their position is that it's really not up to them to take formal action based on market drivers. If that is wrong or has been challenged by other specialties, we should convince them otherwise. But basically I understood that any petition would be forwarded directly to the lawyers of SCAROP who have already made the decision that any action on their part would violate anti-trust law. So we just need evidence as to how it has been successfully managed in other specialties and then petition SCAROP to take those steps.

This scenario is not entirely out of the question, but that legal advice can go one of three ways; all I've seen happen many times in dealing with a spouse that is an attorney and now sitting on a number of administrative boards for my practice/hospital. Remember, your legal team works for you, they can find you legal justification for many things:

1. SCAROP meets with attorneys, but frames the conversation this way: We aren't really interested in limiting residency spots right now, so Mr. Legal Team Guy, give me a legal reason why we can't do it. Legal Guy: OK, just mention anti-trust.

2. SCAROP is legit interested in possibly limiting spots but wants to be very careful. They make it clear they are wanted to tread lightly. They ask legal counsel to give them some worst case scenarios, so Legal Team Guy mentions anti-trust.

3. SCAROP is legit interested in limiting spots and just does due diligence and asks their legal team. The legal team (without prompting or fear from SCAROP) mention anti-trust.

 

[napoleondynamite]

I agree with everything you are saying..it's a lot of handwaving and excuses by SCAROP to not have to do the real work of taking action.

Just would be nice to have some proof so we can really nail down a solid petition with a solid plan.

Reaching out to Terry Wall is a GREAT idea. Anyone chummy with him want to ask him his thoughts?

Let's really do this! We need all hands on deck to make a difference and be heard. But I think there is enough distaste for this issue that we can unite and make a difference.

 

[Fpg1245]

The cynic in me says Scenario 1 is the most likely sequence of events. A strong heavy hitting evidenced based approach is best with respected RO attendings backing us up. This will be an uphill battle and we need to make our position loud, clear, and constantly. There is so much going on right now in health care to be worried about. Finding a decent job post residency shouldn't be one of them. Of course the word "decent" is open to interpretation.

 

[BobbyHeenan]

I completely agree with the evidence based approach. Input from Terry Wall and Chirag Shah (the original red journal paper author) would be helpful.

It will take some time, but i think with decent research you'll be able to show objectively that our field/residency expansion has risen at a rate higher than that of other fields and/or similar to that of fields that have had major deleterious effects of such an expansion (radiology, pathology, etc).

It may also be helpful to find the written mission of SCAROP. Possibly somewhere within their written mission statement or bylaws or whatever may be a statement about the "general welfare" of our field. Clearly, the chairs/powers that be have cited the ACGME bylaws that expressly mention that it is only their role to ensure that programs are training docs adequately, not to take into account the number of graduates. So somewhere someone or some entity surely has to be looking out for the general welfare of our field, correct?

More questions to ponder...

- What is driving this expansion? If it was the erroneous projection Smith published in JCO off of SEER data then that now has been refuted with his updated publication showing much less demand. So while originally the response in the 2013 red journal article cited that Smith data this can no longer be used as rationale for expansion.
- What has changed over the last 10-15 years where now all of the sudden more programs are meeting the ACGME standards or more established programs now meet the requirements to add more slots? Is is just that academic volumes have gone up? Why have more and more new programs opened up at a higher incidence recently than ~10 years ago?
- Finally, if they're' sticking to the anti-trust guns, then they are literally saying: no one has any say over residency expansion. If you meet the minimum ACGME requirements you may have your program/expansion. That's it. The end. Nothing else matters. You meet ACGME miniums and you're good. That's what is being said here.

 

[BobbyHeenan]

Sorry for the rapid repeat posting, this has me intrigued....

I'm seeing only one case, settled in the courts in 2004 (Jung v. Association of Medical Colleges), that upheld the match as not violating anti-trust statutes. Some components appear at minimum tangentially related to the rad onc residency expansion issue at hand.

Here is a good link: http://journalofethics.ama-assn.org/2015/02/hlaw1-1502.html

See below an exerpt from the link. From the case, Jung et al argued a few things, one of them seemingly somewhat related to the issue of how the ACGME and "institutional defendents" (ie the specialties and academic departments) regulate the number of available residency positions.

The second component of the alleged conspiracy focused on the ACGME accreditation system. The plaintiffs asserted that the ACGME, in working with institutional defendants, did the following: (1) regulated the number of available residency positions; (2) made the NRMP match result permanent by imposing “substantial obstacles to the ability of a resident to transfer employment from one employer to another during the period of a residency” [9]; (3) encouraged and/or required medical institutions to participate in the match as a condition for receiving accreditation; and (4) directly reviewed “compensation and other terms of employment with the purposes of fixing and depressing” them [9].

 

[Damn_Daniel]

Don't you talk ill of Ben Smith. He is Taylor and you are Kanye.

That article had the data points it had. I don't think the ACGME ever used that data to make decisions. It was 2013! The residency expansions started way, way before that. And it's slowed comparatively since then.

I'm not sure what the expectation will be from SCAROP. You think those clowns are going to admit wrong doing or that they are going to ask the Tony's at Harvard to stop growing their program? They don't give an F. That's not in their mindset. That's not the point.

Here's what we will do, just like before. We will stop hiring people. People will start not applying. Programs will not fill. Programs will close. That's all we have left. Our "leaders" at ASTRO (let's not put this on ACGME, SCAROP, ABR, ACR, or Ben "Hova" Smith) let us down. Meaning, those that are in academic medicine as chairman and program directors making these decisions. They won't contract without an active market correction. The market correction will be cannibalization of our young (don't make them partners, don't hire unless in dire straits, don't offer them good contracts). Sorry, that's the ballgame. Not only am I viciously ugly, I also don't make bank because of what has happened. And it sucks.

 

[medgator]

I also don't make bank because of what has happened.

Says the hyper-hypofractionator.

 

[Damn_Daniel]

Oh, and I hope you appreciate the irony of people that generally vote the right (medical specialists) asking these things of our national organizations:

1) ignore the fact that the graduating residents, even though are more of them, are as qualified or more qualified than those of the past

2) inviting regulatory capture (those regulating being asked, i.e. told by the regulatees what to do)

3) want the labor supply to be what determine the wages rather than production, or quality, or other measurable factors, and want some national organization to regulate this, rather than the market.

4) want the general good to be secondary to the good of few (letting farm subsidies exist so a few farmers continue to make money, while the whole country pays more for agricultural goods)

5) not excited about low cost, hard working workers to provide good care to people that are in need.

Have you answered yes to any/all those questions ? If so, you probably "Feel The Bern" ... My condolences, I'm sorry to be the one to tell you may be a socialist.

Funny how many people are good with the market until it messes with your game, and limits opportunities with threesomes. It's messed with my game. I'm as protectionist as all of you now. We all feel the Bern. And I don't mean like when I last visited New Orleans.

 

[Damn_Daniel]

Says the hyper-hypofractionator.

Hahahahaha, I should fractionate more to make more money.... Hahahaahaha. My patients don't matter, and money does!!! Hahahaahaha. You're a parody of a 1990s rad onc.

 

[medgator]

Hahahahaha, I should fractionate more to make more money.... Hahahaahaha. My patients don't matter, and money does!!! Hahahaahaha. You're a parody of a 1990s rad onc.

Please, your agenda is very clear through numerous threads. You purposely try to hypofractionate everything you can under the sun, even when there are clear gray zones and a lack of good evidence to do so.

And then you whine about not making bank.

You're not doing your 42 y/o ER- g3 dcis pt or your "bank" account any favors.

Hmmmm, starts with T, ends with L and rhymes with bowl

 

[Damn_Daniel]

So, you want to give 33 fractions to patients with a non invasive disease and get mad when someone dissolves that "truth" with evidence from randomized controlled trials, and then say that it's problematic when there are complaints about lost income due to it? And then ignore thought leaders on the field that say we should do it, "preferred" by national guidelines, like the NCCN and the people that write the trials? When the evidence is strong to do it for all women with stage I to IIA? When a disease is not even considered by some to be worthy of treatment, but you want to treat it more aggressively than invasive disease (no trial said no HF for patients with invasive disease with a non invasive component, and one trial showed a better outcome for that same women you mentioned that's 42 with DCIS)? Be my guest. It makes our field look bad. Who here holds that in high regard? Are you waiting for Whelan and START to re do their trials with DCIS? Are you waiting for NSABP to do a mastectomy vs BCS+RT trial for DCIS? Who here holds that in high regard?

Nope, not treating Stage 0 more aggressively than Stage I-IIA. Goes against all oncologic dogma. Is that we want to be?

Should we be paid by fractions? Should we get paid more to treat DCIS more aggressively than invasive cancer? Is that good medicine? Is that good for health care?

 

[medgator]

The freestanding community, myself included, is pushing for bundled payments that are site neutral with hospital-based rad onc. We all know who opposes it. That model will solve a lot of problems in terms of fractionation incentives, but not our disagreements on how to treat that patient

Anyways, I digress.... It's disappointing that Scarop is punting on this issue. Hate to echo others on this thread, but it looks like we may seeing the beginning of a path/rads job market here

 

[kimplera]

Clearly NOT a lawyer, is this similar to the NBA/NFL age or minimum number of years post high school graduation before entering the draft?
Clearly this has been settled and the leagues can restrict entry to the field....

Sorry for the rapid repeat posting, this has me intrigued....

I'm seeing only one case, settled in the courts in 2004 (Jung v. Association of Medical Colleges), that upheld the match as not violating anti-trust statutes. Some components appear at minimum tangentially related to the rad onc residency expansion issue at hand.

 

[Phantom1]

I completely agree with the evidence based approach. Input from Terry Wall and Chirag Shah (the original red journal paper author) would be helpful.
]
- What has changed over the last 10-15 years where now all of the sudden more programs are meeting the ACGME standards or more established programs now meet the requirements to add more slots? Is is just that academic volumes have gone up? Why have more and more new programs opened up at a higher incidence recently than ~10 years ago?

I honestly think it is a vicious circle, the more academic residents you graduate, the more academic faculty you have who then want/demand resident coverage. I don't think most PD or chairs are just saying "we would love to have more residents to take care of and teach".. I think much of the expansion is driven by wanting to have more resident coverage for faculty..

Another angle to curb expansion would be to increase the requirements for a residency expansion... that being said what are those requirements?? I know that you have to have a specific Rad Bio professor and teaching course, I think you need at least 4 faculty, but what are the actual requirements? Can those be altered so that ACGME is not orchestrating a change, but just enforcing more stringent rules?

 

[RadOncDoc21]

Not going to lie, ever since I came on board with my group with my hypofractionation treatments, I have been getting a lot of heat for not having enough patients under treatment.

I'm still trying to do the right thing but sadly I am constantly being reminded by my administration that it's all about business at the end of the day.

Our consult numbers have actually increased so I am doing more work, treating more patients and making less while getting an earful for not "doing enough."