Parisian mathematician Jules Henri Poincare is credited with identifying fundamental concepts that established chaos theory, which describes dynamic systems wherein small differences in initial conditions can lead to widely diverging outcomes. The phenomenon is often called the “butterfly effect,” conjuring an image of an insect in China flapping its wings, possibly triggering a cascade of meteorologic events that ultimately cause a tornado in Texas.
1 For the record, we know of no actual Asian lepidopteran that has ever affected Panhandle weather, intentionally or otherwise.
As for the fluttery initial conditions that led eventually to the current chaotic state of affairs in radiation oncology residency applications, we offer a Nymphalidae candidate from the past not considered by Maas et al
2 as they sought to explain the recent drop off in applicants to radiation oncology residency programs. Was it Dr Joseph Gerstein blowing the whistle that alerted authorities to the infamous TAP Pharmaceuticals scandal? For those too young to remember: In the 1990s, many urologists supplemented their incomes by liberally prescribing leuprolide under an arrangement with the manufacturer, TAP Pharmaceutical Products, which supplied the drug to urologists at a steep discount, whereupon the urologists billed Medicare the full price—a fraudulent practice eventually halted via litigation that obliged TAP and other pharma companies to pay over $1 billion in penalties. Carreyrou and Tamman
3 connected the dots between the abrupt loss of this source of revenue and the sudden birth of urologist-owned intensity modulated radiation therapy centers, exploiting a freshly minted well-reimbursed treatment modality
4and ushering in a new era of unbridled entrepreneurialism in the field, coinciding with a steadily upward salary trend for radiation oncologists all around, attracting more and more applicants to the field.
Was it surprising that this bubble would eventually burst? Along the same lines, was it surprising that many rockstar MD PhDs who entered the field—to the chest-thumping delight of those already there, who felt smarter by association—would, upon finally finishing a decade or more of postgraduate education in their late 30s with a heavy burden of accumulated debt and often a young family to support, veer toward substantially higher-paying community jobs rather than toil away as physician-scientists at the mercy of unstable research funding support for a fraction of their potential annual income outside of academia?
The retrospectoscope might also show us other sneaky Pieridae who flittered around and set the maelstrom in motion, but enough nostalgia: Now is the time to plan a better future. We hereby issue a call to action to the American Society for Radiation Oncology (ASTRO), the American Board of Radiology (ABR), academic department chairs, residency program directors and faculty, and everyone in the radiation oncology community.
A Call to Action to ASTRO
ASTRO, interpreting antitrust laws against collective market action, has historically steered clear of acting upon the issue of a potential oversupply of radiation oncologists. Nevertheless, as the leading US professional organization of our specialty, for the benefit of present and future members, ASTRO should initiate a formal objective assessment of the radiation oncology job market in the United States, ideally enlisting an outside consulting agency to perform this service, given the essential need to avoid bias in the analysis.
There is a precedent for this initiative. In the early 1990s, after a perceived deficiency of radiation oncologists in the prior decade, the ASTRO Committee on Human Resources took on this responsibility, stating that it “is certainly appropriate that ASTRO evaluate the manpower issue because it will have significant effect on quality, efficiency, and cost issues.”
5 Ultimately, the Society of Chairs of Academic Radiation Oncology Programs (SCAROP) was charged with operationalizing the information.
6 Informed by public discussions on this issue,
7 we also fear that there is a widening generational divide between more senior members of ASTRO and recent residency graduates entering the workforce. The European Society for Radiotherapy and Oncology (ESTRO) has a Young ESTRO committee to ensure that the “voices of the next generation of researchers and practitioners are heard” and to “secure a high level of relevance of ESTRO for young members.” We call upon ASTRO to establish a similar committee with board of director representation because we believe that it would be a win-win for ASTRO to engage younger members to help guide the society into the future.
A Call to Action to the ABR
In the painful aftermath of the 2018 physics and radiation biology examinations, trainees were increasingly distrustful of the ABR. To its credit, the ABR has since responded to input from many stakeholder groups including Association of Residents in Radiation Oncology, Association for Directors of Radiation Oncology Programs, American Association for Women in Radiology, the AAWR, and others on several important issues. Residents and junior faculty can now sit for their boards remotely, with earlier examination dates for initial certification examinations, and a generous parental leave policy during residency training has been endorsed.
Although these changes are steps in the right direction, radiation oncology residents remain burdened with 3 qualifying examinations, more than all other specialties.
8,
9 Now is the time to condense these examinations into a single one, focusing more on clinically relevant material that will maintain a high level of skill and knowledge in the field.
A Call to Action to Academic Chairs
Programs have steadily added residency positions over the past 10 years. However, now that applicant numbers are down and a large number of programs are unfilled in the primary match (32 in 2020 and 35 in 2021), many programs have elected to fill slots with applicants who were unmatched after applying to another field of medicine via the Supplemental Offer and Acceptance Program (SOAP).
10 A 2020 plea from a number of program directors to avoid using the SOAP and allow a natural market correction to occur
11 had minimal impact.
The result is that 15% of our incoming class in 2021 and 25% in 2022 will be hastily recruited students who found out a day or 2 before signing up for a career in radiation oncology that they had not matched in their preferred specialty. We believe that there is an escalated risk of discontent in this cohort for numerous reasons, notably job opportunity concerns and lack of inherent interest in the subject matter, compounded by the aforementioned complex qualifying examination structure. In 1998, when the supply of radiation oncologists exceeded anticipated demands, SCAROP led the charge to decrease the number of residency positions to decrease the graduating pool each year.
6 We need SCAROP now to cease residency program expansion—indeed, preferably to contract program sizes—and to normalize not using the SOAP to fill unmatched positions.
A Call to Action to Program Directors and Faculty
The Accreditation Council for Graduate Medical Education has proposed new program requirements to ensure that residents are being trained in an atmosphere where they are exposed to multidisciplinary oncologic care, see adequate numbers of patients, and receive appropriate supervision. These new rules will be out for public comment and, if approved, enacted in 2022. The goal is to reduce the number of residents at programs where the residents are employed primarily as clinical workhorses without sufficient learning opportunities. Program directors need to look critically at their programs and evaluate how many residents they should be training, and faculty might have to adjust expectations about the percentage of cases covered by residents.
A Call to Action for Everyone
We believe that the vast majority of practicing radiation oncologists feel privileged to render care to their patients and enjoy their chosen career path in medicine. We also believe that the overwhelming majority of stakeholders in the field are acting in good faith to provide high-quality care now and ensure that in the future patients will continue to have access to an important modality of our cancer-fighting armamentarium. Furthermore, we believe that our field's ongoing success hinges on the intellectual agility to find creative solutions and abandon outmoded dogmas when appropriate. Now is the time for the entire community to come together to optimize trainee numbers and improve the climate in radiation oncology.
