Canaries in a Coal Mine

[BobbyHeenan]

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.

1. I don't mean to besmirch Ben Smith. I'm just saying that his initial projection was wrong. We can no longer use that article as justification for residency expansion. In fact, his new publication suggests expansion could continue to shift the supply/demand curves in the wrong direction.

2. I know your shtick is hyperbole and toupee bashing, but the "market correction" phenomena you speak of is very likely. If groups (or academic centers or hospital admins) know they can find a desperate rad onc due to market issues, you better believe those contracts are going to get worse.

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[Damn_Daniel]

Totally. The amount of works to treat in 8 Gy in 1 fx for the doctor is the same amount as 30 Gy in 10, except for one extra OTV and some more acute toxicity to manage. Yet, the pay is less. But, consults are going up - the treadmill goes faster and faster, less patients on board, less RVUs generated. The people that are bit more cost effective have less patients on treatment and a lower ADT, and if in a business oriented group or one with outside corporate pressures or ownership that has a specific target revenue in mind, it gets to be a bit tricky. You do want to treat more patients, but you want to do it responsibly and cost effectively.

I have some percentage of my patients that are capitated, and I get a flat amount no matter what I do. The opposite pressure starts happening. If you want to do an IMRT plan with CBCT daily, now it's starting to cost you money instead of produce more revenue. Then, you get to the world of ACOs. When that penetrates oncology, since we are not usually the "oncologist" we likely won't be heading those groups, and when the clinical leadership is trying to figure out how to spend the budget, suddenly RT becomes less and less appealing for lymphoma, breast, prostate, and other diseases. If it costs the medical oncologists and the surgeons money, they aren't going to be referring all that much any more.

I wonder what is used to predict how many FTEs are needed for a given practice or department. If you go by straight numbers of ADTs, then the people that do straight prostate and breast can handle probably 25-30, maybe more, patients. If you're a head and neck specialist, 15 can be challenging. If you go by consults, then places that see but don't treat are going to have more FTEs than places that treat almost everyone that walks in the door. And brachy, both seeds and HDR take a lot of time/energy. And covering multiple sites. I'm not sure how they come up with these numbers. ACR Practice Parameters comes up with some "back off the napkin" numbers which I just don't where they came from, it seems based on population. But, to average it out like that isn't great math, and leads to maldistribution.

In addition, "academic" clinical machines like MSKCC, UPMC, Beaumont, and others routinely have attendings with 25-30 patients, and try to do some research, and try to teach, while true academic places truly allow the attendings to function in research and medicine, limiting their patient loads to the low teens. The mindset used to be the community and freestanding centers would do the "heavy lifting" of treating patients while academic centers functioned to teach and find truth. The distinction is blurred, and these academic centers are marketing for patients, getting them, and then needing more faculty and residents to get the work done.

I don't think derm is the right model to follow. Although challenging to get into and possibly cerebral during residency, the real world of it isn't quite as important as what we do. I think we need to have an appropriate number, but skewing the other way to protect ourselves could be dangerous. Some countries in Europe and Canada had a very long wait for initiation of RT in the 1980s and 1990s, and I don't think that's a situation we want to head towards.

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."

 

[BobbyHeenan]

I don't think derm is the right model to follow. Although challenging to get into and possibly cerebral during residency, the real world of it isn't quite as important as what we do. I think we need to have an appropriate number, but skewing the other way to protect ourselves could be dangerous. Some countries in Europe and Canada had a very long wait for initiation of RT in the 1980s and 1990s, and I don't think that's a situation we want to head towards.

I agree with what you're saying here. The derm issue is to see what kind of precedent is there and if any legal action has ever been taken.

What I think we all want is a measured, proactive approach to all of this. If we're staring down a tunnel that looks like radiology, then why can't we take a step back and evaluate this all before we just continue to tread forward?

What people have called for at minimum is a temporary freeze to allow ASTRO and SCAROP to study this in depth, allow public comment, and take the time to figure out where this train is all headed before its too late. I think that is very reasonable but no one in the decision-making bodies seem to even consider this. Having "an appropriate number" like you say is going to take some kind of foresight and input about the supply/demand from SCAROP/ASTRO, not just this "let's just see what happens" approach they're taking now where the ONLY thing limiting expansion is meeting ACGME minimums.

 

[medgator]

I don't think derm is the right model to follow. Although challenging to get into and possibly cerebral during residency, the real world of it isn't quite as important as what we do. I think we need to have an appropriate number, but skewing the other way to protect ourselves could be dangerous. Some countries in Europe and Canada had a very long wait for initiation of RT in the 1980s and 1990s, and I don't think that's a situation we want to head towards.

What makes you think that was driven by a doctor, rather than a Linac, shortage?

 

[Damn_Daniel]

FWIW, it's not the toupee I bash. The bashing is directed typically towards the wearer of the hairpiece. I meant no offense to toupees or toupee makers, but if any was taken, I sincerely apologize for my prior rant on it.

Well, I don't know for sure what happened in Europe, but in the 1980s and 1990s, Canadian rad oncs were in short supply. They graduated only 10 or so a year, and because of (at that time) lower salaries, many immigrated to the US. The situation has changed, and they make about the same amount as us, now, so most want to stay. However, it's gotten dense there, too. Many have to come for a fellowship if they want to work in a decent city, and not in, for example, Kelowna or Thunder Bay.

 

[canadianoutlaw]

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

Interesting thought, but not sure I agree. Surgery, for example, is very clearly tied to a "modality" (cutting people) rather than an anatomic site. And besides, there are many radiation oncologists and surgeons who are then tied to a specific anatomic site. If anything, radiation is less tied to its modality than surgery is, as we have significantly decreased the normal tissue toxicity with new techniques. Surgery has also done this, but seems like to a lesser degree.

 

[medgator]

Interesting thought, but not sure I agree. Surgery, for example, is very clearly tied to a "modality" (cutting people) rather than an anatomic site. And besides, there are many radiation oncologists and surgeons who are then tied to a specific anatomic site. If anything, radiation is less tied to its modality than surgery is, as we have significantly decreased the normal tissue toxicity with new techniques. Surgery has also done this, but seems like to a lesser degree.

Agree completely. Radiation and surgery are very analagous and neither is likely to be supplanted any time soon. Pundits were forecasting the death of radiation therapy back in the 70s IIRC (Nixon's war on cancer?).

 

[Krukenberg]

From the ASTRO session on labor market issues, it seems to me that reimbursement models that put Med oncs in the driver's seat and incentivize them to reduce RT are a bigger threat to the specialty. They both reduce demand for services and reduce autonomy. I think we should be fighting for a seat at the table in those reimbursement models too.


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[CaesarRO]

I'm far from employment issues, but fwiw on the interview trail I heard a number of chairs talk about plans to expand their programs.

Most commonly, it was at hospital systems that recently expanded and are seeing a large increase in patient volume and in the number of attendings recently hired.

Could there be larger market changes at play that are causing a larger proportion of patients to be seen at rad onc departments with residency programs?

 

[BobbyHeenan]

From the ASTRO session on labor market issues, it seems to me that reimbursement models that put Med oncs in the driver's seat and incentivize them to reduce RT are a bigger threat to the specialty. They both reduce demand for services and reduce autonomy. I think we should be fighting for a seat at the table in those reimbursement models too.


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Agree completely.

But the one thing that our specialty and our specialty alone has complete control of is how many residents we graduate per year. Yes, we should be trying to have a seat at the multi-disciplinary table, but when another variable that greatly impacts our field is within our control, then at least be proactive about managing that variable. You can do both at once.

 

[BobbyHeenan]

I'm far from employment issues, but fwiw on the interview trail I heard a number of chairs talk about plans to expand their programs.

Most commonly, it was at hospital systems that recently expanded and are seeing a large increase in patient volume and in the number of attendings recently hired.

Could there be larger market changes at play that are causing a larger proportion of patients to be seen at rad onc departments with residency programs?

I don't know for sure how you could figure this out, but in my opinion (and in my experience with first hand or second hand knowledge of a handful of academic centers) the short answer is yes - when academic programs merge or buy up local hospitals/linacs then they need to take more rad oncs under their wing(s). When a rad onc is now an "academic," he/she often expects resident coverage. Therefore, the program has incentive to expand and now meets ACGME requirements for patient load because they took on a new clinic and their numbers went up.

The concern is that just because the academic center has a bigger peice of the local market pie, it did not change the overall size of that pie. So by graduating more residents to fit some intra-department needs, it may be doing the field as a whole some harm as demand for radiation services is not increasing (or is even decreasing) while the rate of graduating new residents is rapidly increasing. Does not seem like a good recipe, especially for the young docs.

 

[canadianoutlaw]

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.

I think SCAROP is the answer to regulating the number of residents. And I agree with what people are saying, I do not it would violate anti-trust issues if done correctly. Not sure if this is true but my impression is that most of the expansion is happening at smaller programs as their departments grow. And this is happening at many programs across the country, not isolated to a few. For example, I looked at the Harvard residency website and the number of residents they have produced has fluctuated but certainly no more than the 1980s.

 

[Mr RADical]

I think SCAROP is the answer to regulating the number of residents. And I agree with what people are saying, I do not it would violate anti-trust issues if done correctly. Not sure if this is true but my impression is that most of the expansion is happening at smaller programs as their departments grow. And this is happening at many programs across the country, not isolated to a few. For example, I looked at the Harvard residency website and the number of residents they have produced has fluctuated but certainly no more than the 1980s.

Not sure if thats 100% true. Most of what I hear about out there is medium to larger size programs expanding. Even if a small program expands, its likely to add a spot, not 1-2 spots a year like some of the bigger programs are doing. I talked to a lot of residents at ASTRO and it seemed like most programs had at least some plans to expand (some by over 4 residents).

 

[canadianoutlaw]

Not sure if thats 100% true. Most of what I hear about out there is medium to larger size programs expanding. Even if a small program expands, its likely to add a spot, not 1-2 spots a year like some of the bigger programs are doing. I talked to a lot of residents at ASTRO and it seemed like most programs had at least some plans to expand (some by over 4 residents).

yea, i think you are probably right

 

[FindMeOnTheLinks]

Just a 1st year med student here, but i have a strong interest in radonc. In the discussion here, do you all make a distinction between private practice and academic radonc with respect to the looming prospect of saturation of the field? Is one more in danger than the other? This might be a dumb question, but I'd be interested in hearing the answer...

 

[RadOncDoc21]

Just a 1st year med student here, but i have a strong interest in radonc. In the discussion here, do you all make a distinction between private practice and academic radonc with respect to the looming prospect of saturation of the field? Is one more in danger than the other? This might be a dumb question, but I'd be interested in hearing the answer...

Private groups would feel the pressure first but eventually it will come back around for everyone to feel the effects.

 

[medgator]

Just a 1st year med student here, but i have a strong interest in radonc. In the discussion here, do you all make a distinction between private practice and academic radonc with respect to the looming prospect of saturation of the field? Is one more in danger than the other? This might be a dumb question, but I'd be interested in hearing the answer...

Private more than academic, but geography more than either of those IMO.

 

[Neuronix]

distinction between private practice and academic radonc

What's the difference?

Just kidding. Sort of. Med students don't understand how similar they've become and how linked they are. See Damn Daniel's post #52.

 

[Chartreuse Wombat]

Red line is resident FTE. Green line is number of programs.
ACGME data. The number of positions and programs are increasing dramatically

 

[mpdoc2]

View attachment 202399
Red line is resident FTE. Green line is number of programs.
ACGME data. The number of positions and programs are increasing dramatically

It seems like the number of residents per program are increasing as opposed to the number of programs. What's happening is that the the private practices are being bought up by academic centers. The academic centers now have an excuse to expand their residency program as they have an increase in the number of patients and an increase in the number of attendings. (While the total number of patients are stagnant or declining). Of course the academic attendings are lazy and love to have more residents (as cheap labor) despite those same residents not having a job in the future. So disgusting. Thanks Chairmen for driving our field to the ground.

 

[Damn_Daniel]

The amount of money that is paid to attendings at "academic" centers is staggering. I know more than a few that make a mill. Not even just chairman, but regular faculty. But you can see UCLA salaries, for example, online and their chair makes a million at a state supported institution. Discussed salary at another "academic" place, and the base was higher than the MGMA median for the region. They get the good hospital rates, grab all the patients from the community, take care of them with help from residents and extenders, and create an underclass of new grads that are screwed. It's going to be The Hunger Games (without a chance at Katniss, except for looking at pictures from the Fappening, because of the rest of us losers won't make that much money. Sad.). The applicants to my sad sack, third rate academic center are more qualified in terms of CV then our Vice Chair, but if they get a job, they will be clawing with the other staff for every last RVU. And they will never reach that RVU level for the bonus.

We were never the doom and gloom crowd that anesthesia went through, and path, and radiology. We are graduating! Yaaay!

 

[US_MD_Applicant]

Another thing we need to be doing is increase the awareness of what radiation oncology is, does, etc in the general medical community.

For example, we receive more oncological training than Heme/Onc physicians, yet they are the ones that receive consults. This is because IM residents/attendings generally don't even know about our speciality.

It is our responsibility as current/future residents to try and give a lecture during prelim year regarding the utilities and benefits of radiation in hopes that IM can potentially refer patients to us as well as med oncs if we want a seat at the table rather than letting med oncs make decisions for us in the future.

 

[Mandelin Rain]

He can't just come out and say that as academic centers expand and become glorified private practices, these same academic centers require an ever expanding base of employees willing to accept low pay positions to protect the salaries of the old guy "professors" at the top.

But that's the truth. It's entirely self serving. Much like the over billing, by these same old guys that have placed our field as a target for reimbursement decreases.

Baby boomers...

 

[seper]

Michael Steinberg made $ 975,031.00 in 2014. Wow.

 

[RadOncDoc21]

Michael Steinberg made $ 975,031.00 in 2014. Wow.

No wonder I'm not at the median salary... he skewed me to the left of that DVH plan!

 

[mpdoc2]

Michael Steinberg made $ 975,031.00 in 2014. Wow.

That doesn't include bonuses which bump his salary to well into 7 figures.

 

[seper]

God bless America.

 

[BobbyHeenan]

What is more "legally tenuous" - expanding residency slots to help cover your satellite clinics and/or help your work flow and department economics. Or stopping residency expansion (at least temporarily) to study the result of a graph like you see above where graduates are rising but the demand is steady or declining?

These are hard decisions, and either one will be "legally tenuous." It's why chairman and administrators get paid the good money, because they're supposed to make these hard decisions where gray areas exist. If they're at all concerned about the well being of prospective med students or young residents then that decision seems obvious to me. If they're only beholden to their own department and want to hide behind what I feel is a weak "legal argument," then that is disappointing.

 

[mpdoc2]

What is more "legally tenuous" - expanding residency slots to help cover your satellite clinics and/or help your work flow and department economics. Or stopping residency expansion (at least temporarily) to study the result of a graph like you see above where graduates are rising but the demand is steady or declining?

These are hard decisions, and either one will be "legally tenuous." It's why chairman and administrators get paid the good money, because they're supposed to make these hard decisions where gray areas exist. If they're at all concerned about the well being of prospective med students or young residents then that decision seems obvious to me. If they're only beholden to their own department and want to hide behind what I feel is a weak "legal argument," then that is disappointing.

Out of the several chairmen I've been acquainted with, I guarantee you their priority aren't the lowly residents. Quite sad.

 

[Damn_Daniel]

There are many other places that publish salaries. Eye popping numbers.

These hospital admin lackeys love rad oncs because they bring in money and subsidize other departments in academia. You're welcome rheumatology! You're welcome, benign heme!

But, it's at the expensive of academic rad oncs not really seeking truth, elevating the craft, and passing on their knowledge. Not very many Fletchers,, Perezes, and Hellmans in the bunch.

The irony is we became one of the most educated, passionate about research, and highly qualified doctors, yet the majority of people are just giving expensive haircuts every day.

 

[mpdoc2]

There are many other places that publish salaries. Eye popping numbers.

These hospital admin lackeys love rad oncs because they bring in money and subsidize other departments in academia. You're welcome rheumatology! You're welcome, benign heme!

But, it's at the expensive of academic rad oncs not really seeking truth, elevating the craft, and passing on their knowledge. Not very many Fletchers,, Perezes, and Hellmans in the bunch.

The irony is we became one of the most educated, passionate about research, and highly qualified doctors, yet the majority of people are just giving expensive haircuts every day.

LOL are you talking about Wbrt?

 

[Damn_Daniel]

Hahaha... No, but that would make some sense, too. It's a phrase a friend of mine that is a physician used about his job. He was super well trained, had research knowledge and great at his job. But, it was very easy/routine. So, he basically said he's doing a mindless job but getting paid a lot of money. Sorry, I think it sounded a lot better with context.

LOL are you talking about Wbrt?

 

[RadOncDoc21]

Hahaha... No, but that would make some sense, too. It's a phrase a friend of mine that is a physician used about his job. He was super well trained, had research knowledge and great at his job. But, it was very easy/routine. So, he basically said he's doing a mindless job but getting paid a lot of money. Sorry, I think it sounded a lot better with context.

Well giving whole brain RT is one good way of not having to shave your head everyday. Logistically with the price of razor blades, it may not be more expensive in the long run, you may just forget where you placed your keys ("which I do now").

 

[Damn_Daniel]

The person that discovers how to give WBRT without hair loss is going to be as famous and well rewarded as the Pet Rock guy.

 

[Mr RADical]

The person that discovers how to give WBRT without hair loss is going to be as famous and well rewarded as the Pet Rock guy.

Almost...
http://www.ncbi.nlm.nih.gov/pubmed/24750002

 

[Damn_Daniel]

Almost...
http://www.ncbi.nlm.nih.gov/pubmed/24750002

Interesting. The problematic part is going to be the patchiness / Bozo The Clown effect. Maybe less hair loss, but not optimal. I'd rather we spend $50 million on this rather than yet another proton facility. Maybe some combination of a radio protectant shampoo, maybe something with MnSOD that gets into the follicles.

 

[DebtRising]

This field is dead man walking for trainees over the next 10-15 years [includes PGY4/5s].

It is unconscionable that SCAROP would neglect its duties to regulate the field in some way, hiding behind a blanket and hard to believe anti-trust concern. In reality though this is not surprising - most chairs, at least in casual conversation (I do not claim to have insights into their mind) are completely clueless about many practical matters. I have met more than a few that seem completely oblivious (again, could be a function of conversation with someone who is not in their inner circle or level) about the budgetary needs of their own department, or how they determine compensation for different faculty. Or how bundled payments may effect their department. It's an unbelievable level of vapidity from people who are essentially business managers! If you hear some of their talks to residents, this view point is only enforced. In reality this should not be surprising- seldom is a chair someone who has demonstrated leadership or business skills, but rather research and grant prowess. These arenas of excellence do not overlap - the grant world is a world unto itself.

The new proposed payment models also will destroy us. Can you imagine if the new medical home for oncology model gets widespread adoption? Can you imagine many of your medical oncology colleagues thinking twice before offering another cycle of Opdivo (costing what? $40,000 or so conservatively) versus referral to radiation for SBRT to shrink a hilar mass, or treat a solitary liver lesion? Immunotherapy is so easy to administer, it's like writing for synthroid and educating your NP or PA which side effect to check on the next visit. And it has the implicit backing of multibillion dollar corporations. Is immunotherapy bad? No! It is amazing and may be a lifeline for many patients, but it is also very early, with very limited evidence, and on a cost-benefit ratio makes IMRT look economical.

This is the message I would impart to people thinking about entering this field, and those who just matched; Work hard, work very, very hard. You will very likely have to complete a fellowship before landing a job, (with the sad reality that your debt on average is higher each successive year as a function of tuition increases - even before interest) you are effectively 1.5-2 years further away from being able to start your life [does not apply if you have no debt]. Outside a few institutions whose brands are essentially a page of resume, you will not be offered partnership (at the dwindling number of private practices), or your buy-in will be in the 7-figure range. Your academic job will be academic in name only, where you will be covering satellites recently acquired by the 'flagship' institution to their heart's content. If you have secured funding, your job will likely not compensate you for being able to publish and secure more grants which was a mainstay of compensation just 5-8 years prior. Rather that will be expected, and if it does not occur, good bye. Once you do have a job expect to fight every year against the increasing numbers of newer, even more desperate graduates, which will keep you in a quagmire of quasi-advancement / checked seniority until you either have 10 years of experience or our field is obsolete. At this point you will likely be so burned out in this 'life style' specialty, either dancing for referrals to offer patients a modality that likely has the highest level of evidence for efficacy, or practicing at so many sites and being paid like a academic without the ability to do real research, that your regret for your decision will be firmly apparent and entrenched.

I know my post is fatalistic - but that's how I feel looking at our field and the lack of any leadership direction, at any level, to help the incoming physicians of this specialty.
But please, keep expanding residencies. I am sure we are all on here, posting our worries and insecurities about the direction and job market for the past 4 years solely because we are miserable people.

 

[Damn_Daniel]

Same thing I said.

Maybe the residents should organize a one day walk out, so that their demands can be heard. If every resident walked out for a day, can you imagine the whining from the attendings having to check ports and see inpatients? I'd actually pay a little money to watch them scramble.

 

[mpdoc2]

There's actually a conflict of interest for chairs to decide the number of residency positions. The greater the number of residency positions, the cheaper attendings will be 5 years down the line ( on top of the fewer the PAs the department needs to hire now). Since chair's salary and job are dependent on how the department is doing financially, hiring cheaper attendings will significantly benefit the chair's position. Thank you chairs for screwing over our field. It's quite sad how difficult it was to get into this field and having it goto trash by the very people who got into this field by merely graduating from any medschool. I understand how a Radiology fellowship can possibly help a radiologist learn a newer technique but Radiation Oncology absolutely does not need a fellowship (maybe except for peds) and fellows are just more cheap labor.

 

[Sheldor]

This field is dead man walking for trainees over the next 10-15 years [includes PGY4/5s].

It is unconscionable that SCAROP would neglect its duties to regulate the field in some way, hiding behind a blanket and hard to believe anti-trust concern. In reality though this is not surprising - most chairs, at least in casual conversation (I do not claim to have insights into their mind) are completely clueless about many practical matters. I have met more than a few that seem completely oblivious (again, could be a function of conversation with someone who is not in their inner circle or level) about the budgetary needs of their own department, or how they determine compensation for different faculty. Or how bundled payments may effect their department. It's an unbelievable level of vapidity from people who are essentially business managers! If you hear some of their talks to residents, this view point is only enforced. In reality this should not be surprising- seldom is a chair someone who has demonstrated leadership or business skills, but rather research and grant prowess. These arenas of excellence do not overlap - the grant world is a world unto itself.

The new proposed payment models also will destroy us. Can you imagine if the new medical home for oncology model gets widespread adoption? Can you imagine many of your medical oncology colleagues thinking twice before offering another cycle of Opdivo (costing what? $40,000 or so conservatively) versus referral to radiation for SBRT to shrink a hilar mass, or treat a solitary liver lesion? Immunotherapy is so easy to administer, it's like writing for synthroid and educating your NP or PA which side effect to check on the next visit. And it has the implicit backing of multibillion dollar corporations. Is immunotherapy bad? No! It is amazing and may be a lifeline for many patients, but it is also very early, with very limited evidence, and on a cost-benefit ratio makes IMRT look economical.

This is the message I would impart to people thinking about entering this field, and those who just matched; Work hard, work very, very hard. You will very likely have to complete a fellowship before landing a job, (with the sad reality that your debt on average is higher each successive year as a function of tuition increases - even before interest) you are effectively 1.5-2 years further away from being able to start your life [does not apply if you have no debt]. Outside a few institutions whose brands are essentially a page of resume, you will not be offered partnership (at the dwindling number of private practices), or your buy-in will be in the 7-figure range. Your academic job will be academic in name only, where you will be covering satellites recently acquired by the 'flagship' institution to their heart's content. If you have secured funding, your job will likely not compensate you for being able to publish and secure more grants which was a mainstay of compensation just 5-8 years prior. Rather that will be expected, and if it does not occur, good bye. Once you do have a job expect to fight every year against the increasing numbers of newer, even more desperate graduates, which will keep you in a quagmire of quasi-advancement / checked seniority until you either have 10 years of experience or our field is obsolete. At this point you will likely be so burned out in this 'life style' specialty, either dancing for referrals to offer patients a modality that likely has the highest level of evidence for efficacy, or practicing at so many sites and being paid like a academic without the ability to do real research, that your regret for your decision will be firmly apparent and entrenched.

I know my post is fatalistic - but that's how I feel looking at our field and the lack of any leadership direction, at any level, to help the incoming physicians of this specialty.
But please, keep expanding residencies. I am sure we are all on here, posting our worries and insecurities about the direction and job market for the past 4 years solely because we are miserable people.

This seems overly fatalistic and like the "Fox news" presentation on our field. Don't get me wrong, I think you are right about a lot of things but I don't think its fair to say that it is dead man walking on such a short time table. Remember, there are still a ton of jobs out there right now AND we are are on the cusp of a ton of rad oncs retiring now that the stock market has recovered. I think you paint a good picture for anyone who wants to live or work in any of the top 10-15 cities in the country, but not the country at large. I Feel like it is not too late and if we can some how do something, anything we can still prevent this from going the way of radiology!

 

[seper]

Nice piece. Very depressing. I have to start using the word "vapidity" more often.
I'd disagree on "Opdivo is easy to use". It frequently causes severe pneumonitis. If it occurs, pt is a nightmare to manage. I saw a man that died of it.

This field is dead man walking for trainees over the next 10-15 years [includes PGY4/5s].

It is unconscionable that SCAROP would neglect its duties to regulate the field in some way, hiding behind a blanket and hard to believe anti-trust concern. In reality though this is not surprising - most chairs, at least in casual conversation (I do not claim to have insights into their mind) are completely clueless about many practical matters. I have met more than a few that seem completely oblivious (again, could be a function of conversation with someone who is not in their inner circle or level) about the budgetary needs of their own department, or how they determine compensation for different faculty. Or how bundled payments may effect their department. It's an unbelievable level of vapidity from people who are essentially business managers! If you hear some of their talks to residents, this view point is only enforced. In reality this should not be surprising- seldom is a chair someone who has demonstrated leadership or business skills, but rather research and grant prowess. These arenas of excellence do not overlap - the grant world is a world unto itself.

The new proposed payment models also will destroy us. Can you imagine if the new medical home for oncology model gets widespread adoption? Can you imagine many of your medical oncology colleagues thinking twice before offering another cycle of Opdivo (costing what? $40,000 or so conservatively) versus referral to radiation for SBRT to shrink a hilar mass, or treat a solitary liver lesion? Immunotherapy is so easy to administer, it's like writing for synthroid and educating your NP or PA which side effect to check on the next visit. And it has the implicit backing of multibillion dollar corporations. Is immunotherapy bad? No! It is amazing and may be a lifeline for many patients, but it is also very early, with very limited evidence, and on a cost-benefit ratio makes IMRT look economical.

This is the message I would impart to people thinking about entering this field, and those who just matched; Work hard, work very, very hard. You will very likely have to complete a fellowship before landing a job, (with the sad reality that your debt on average is higher each successive year as a function of tuition increases - even before interest) you are effectively 1.5-2 years further away from being able to start your life [does not apply if you have no debt]. Outside a few institutions whose brands are essentially a page of resume, you will not be offered partnership (at the dwindling number of private practices), or your buy-in will be in the 7-figure range. Your academic job will be academic in name only, where you will be covering satellites recently acquired by the 'flagship' institution to their heart's content. If you have secured funding, your job will likely not compensate you for being able to publish and secure more grants which was a mainstay of compensation just 5-8 years prior. Rather that will be expected, and if it does not occur, good bye. Once you do have a job expect to fight every year against the increasing numbers of newer, even more desperate graduates, which will keep you in a quagmire of quasi-advancement / checked seniority until you either have 10 years of experience or our field is obsolete. At this point you will likely be so burned out in this 'life style' specialty, either dancing for referrals to offer patients a modality that likely has the highest level of evidence for efficacy, or practicing at so many sites and being paid like a academic without the ability to do real research, that your regret for your decision will be firmly apparent and entrenched.

I know my post is fatalistic - but that's how I feel looking at our field and the lack of any leadership direction, at any level, to help the incoming physicians of this specialty.
But please, keep expanding residencies. I am sure we are all on here, posting our worries and insecurities about the direction and job market for the past 4 years solely because we are miserable people.

 

[Damn_Daniel]

This seems overly fatalistic and like the "Fox news" presentation on our field. Don't get me wrong, I think you are right about a lot of things but I don't think its fair to say that it is dead man walking on such a short time table. Remember, there are still a ton of jobs out there right now AND we are are on the cusp of a ton of rad oncs retiring now that the stock market has recovered. I think you paint a good picture for anyone who wants to live or work in any of the top 10-15 cities in the country, but not the country at large. I Feel like it is not too late and if we can some how do something, anything we can still prevent this from going the way of radiology!

It's not the Fox News presentation, unfortunately. Not being able to find partnership track jobs, not being to have autonomy at freestanding centers, academic jobs being more or less private practice jobs with less pay, consistently dropping reimbursements (refer to the last 3 years of MGMA salary surveys) - this is the new normal. I'm not saying that the field is not worthwhile to go into, has lost any of it's cerebral nature, or that it's on the outs in terms of oncology. It's just that the pecuniary advantages are diminishing, compared to other fields.

Look at the latest 10 jobs on ASTRO, in order:

1. Tulsa - Hope you like steak and rodeo
2. UPMC - NW - Erie? If the best thing about your city is that it's 2 hours from Buffalo and Cleveland, you've got problems
3. College Station, TX - see #2, but replace with Austin and Houston
4. Alexandria, MN - over 2 hours from Twin Cities; the average high temperature in January is 19 degrees (F)
5. Greater Phoenix - sucker job with someone that will never make you partner
6. Modesto, CA - if you love Grapes of Wrath, you'll love living in Modesto!!
7. Syracuse - probably the worst city in NY State, but still better than most on the list.
8. St. Cloud, MN - 1.5h from Twin Cities. You could go ice fishing with the guy that takes the Alexandria job
9. Salina, KS - 1.5h from Wichita. And Wichita's major claim to fame is it's less than 3h from Kansas City
10. Fox Cities, WI - 40 minutes from Green Bay

So, basically, out the ten jobs listed (in order), the best location is ... Phoenix, if you don't mind being an indentured servant.

 

[RadOncDoc21]

In my experience coming out, the job market was fiercely competitive in regards to my ideal location. As many have stated, most jobs are not advertised but you will have to do some serious networking during residency if you are focusing on a particular area.

 

[radoncftw]

This thread is unsettling as a rising M4 with a strong interest in Rad Onc.

 

[Gfunk6]

This thread is unsettling as a rising M4 with a strong interest in Rad Onc.

I believe this is the stated goal of Dr. Zietman and other leaders of our field. So . . . mission accomplished?

 

[Damn_Daniel]

And the next posting for a job on ASTRO ... Is it Chicago? Is it Miami? Is it Atlanta? Is it Philadelphia? Is it Orange County? Is it Portland? ... No, ladies and germs ... it's York, PA! Yessiree, a life in a town of B&Bs and the Amish community. On the sign when you drive in: "York, PA: Only 1 hour from Heroin Wracked Baltimore."

 

[deleted18755]

I had many meetings with our two chief residents this year while they were searching for jobs and just had a little get together with my former co-residents.

If you are like my two close friends you can still make partner after three years and by age 35 make $500,000 per year with 4 day workweeks and 8 weeks of vacation and basically live like a 0.01% er but expect to do so in place where your patients consider Macon, Georgia to be a booming metropolis or where you have to drive 20+ miles to the closet Walmart (which apparently was the talk of the town for many months while it was being build but has since decimated the "mom and pop" shops that made the little town quite pleasant and cute).

Like any other job it comes down to the following but to the extreme and increasingly so: location, salary, workload/job satisfaction . . . pick two.

If you (and your family of course) don't care about location I can personally guarantee that for the next few years but for who knows how long after that you can make a ridiculous amount of money working 35-50 hours/week with a lot of vacation helping people who desperately need your help and appreciate it so very much in the best field in medicine (at least for now). I'm not in such a small town and there is no way I would move to Salina, KS so my salary and vacations are not quite as above but my wife and family are happy here and I am so, so lucky I live in a relatively undesirable location because I honestly feel blessed to be able to do what I do and in peace with very fair compensation (the vast majority of people would consider a 1%er to be more than "fair compensation" I know) and most importantly no significant competition for patients and very reasonable referring physicians and PCP's.

If you are a resident with a huge student loan and your wife will leave you if you don't find a job in San Diego then God help you...

 

[seper]

Looks like that columbia place is in a sorry state.

 

[medgator]

Nice piece. Very depressing. I have to start using the word "vapidity" more often.
I'd disagree on "Opdivo is easy to use". It frequently causes severe pneumonitis. If it occurs, pt is a nightmare to manage. I saw a man that died of it.

Not to mention colitis and rupture/peritonitis when it gets really bad.

And the next posting for a job on ASTRO ... Is it Chicago? Is it Miami? Is it Atlanta? Is it Philadelphia? Is it Orange County? Is it Portland? ... No, ladies and germs ... it's York, PA! Yessiree, a life in a town of B&Bs and the Amish community. On the sign when you drive in: "York, PA: Only 1 hour from Heroin Wracked Baltimore."

QFT, DD. The best part about that York job? It's PRN!!

I remember when FL would get a smattering of listings a few years ago, now I can't remember the last time I saw a FL job post. Or cali (meaning the bay area or SoCal, not Modesto or El Centro etc.), Atlanta, Charlotte, Austin, Seattle, Portland OR, etc.

 

[Ray D. Ayshun]

This field is sounding more and more perfect for me as an mdphd. I delayed financial gratification so long I no longer care.