Guessing # unmatched spots

[TDDro]

Mandate that attendings are not allowed to have 24/7 resident coverage. Shrink programs accordingly to fit this mantra.
Mandate a maximum number of separate facilities residents can be sent to (I propose 2-3) during residency for residents to meet their numbers.
Increase educational requirements across the board, including for all brachy and peds. Mandate requirements for definitive EBRT compared to palliative.

So much this. I've heard of programs where residents are kicked around 5 different sites, and they're the only resident at that site. That's ridiculous and an abuse of the resident. How the hell is that a good learning environment?? That's "they're cheaper than paying an NP to support the doc at a privademic site".

Agree that palliative shouldn't count for EBRT. The brachy/peds numbers are tough. Peds, like someone else said, is specialized enough that I don't think it should be a requirement. Maybe keep a low case # just to ensure grads are aware of how it's done or have some exposure so they can decide if they want to specialize in it? I dunno, that's a tough one, I could leave it thew way it is. Brachy in the dawning era of SBRT is going to be tough I think. Should definitely have case #s for cervical. For prostate though, we've already seen our LDR volume (we don't do HDR) cut in half since we started SBRT. I could see that requirement dissolving in 5-10 years.

I'd also suggest that reporting should incorporate the patient MRN (just as a unique identifier) so it injects some honesty into the case system. Would be easy to write a code that flags any duplicate MRNs from a single institution. Would also make an audit easy. There are a couple programs where I have no idea how they meet their numbers when my peers have told me they see an average of 2-3 consults per week and plan 2 of them.

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Members don't see this ad.

 

[evilbooyaa]

Peds numbers should go to nil and it should be a required fellowship IMO. It is sufficiently different enough from adult rad onc that treating even twice the current number of random peds cases over 4 years is nearly useless. If you want peds as a large part of your practice, you should do a fellowship IMO.

I don't fully disagree with you. I know if I am in practice after residency treating a peds I am either going to treat based on a protocol, after discussion with a well-versed peds doc, or simply referring the patient out. Not the case for literally everything else in Rad Onc (except unique brachy situations probably, like brachy for fossa recurrence after salvage RT).

However, if there are going to be ANY requirements then the numbers should go up substantially.

 

[PointA]

There are a couple programs where I have no idea how they meet their numbers when my peers have told me they see an average of 2-3 consults per week and plan 2 of them.

Yep, I know this to be true. Some programs where residents are consistently seeing >10 consults per week and others that are around 2-3 per week. The difference in training volume between programs is staggering and needs looking into.

 

[evilbooyaa]

I'd also suggest that reporting should incorporate the patient MRN (just as a unique identifier) so it injects some honesty into the case system. Would be easy to write a code that flags any duplicate MRNs from a single institution. Would also make an audit easy. There are a couple programs where I have no idea how they meet their numbers when my peers have told me they see an average of 2-3 consults per week and plan 2 of them.

While I do think that including MRNs is not a bad idea, I believe it becomes an issue of identifiable HIPAA information on somethng that is not HIPAA compliant. I think the amount of 'double booking' being done in Rad Onc is likely incredibly low. I have no desire to substantially break the 450 EBRT case log number as I think having a single number without site specific requirements is silly. I'll probably only log curative cases going forward and not every bone met that takes 5-10 minutes to contour/plan.

That being said, if I treat a definitive lung and when the patient comes back, my co-resident does the brain SRS, should we get dinged? I suppose if they're both logged the same day that'd be a workaround, but just playing devil's advocate.

 

[TDDro]

While I do think that including MRNs is not a bad idea, I believe it becomes an issue of identifiable HIPAA information on somethng that is not HIPAA compliant. I think the amount of 'double booking' being done in Rad Onc is likely incredibly low....
That being said, if I treat a definitive lung and when the patient comes back, my co-resident does the brain SRS, should we get dinged? I suppose if they're both logged the same day that'd be a workaround, but just playing devil's advocate.

MRNs are acceptable, so long as there is nothing else that can be used to identify the patient (e.g. a name). I'd imagine double-booking becomes an issue on low-occurrence events such as brachytherapy. I could also see residents trying to get around this by creating 'random' MRNs, but that exposes you to being flagged if you unknowingly used a random MRN twice. Using the same MRN for two different sites or times (e.g. lung and brain, or brain 2 weeks apart) shouldn't be a problem. But if 3 people from the same institution log an MRN on a particular day, or an MRN gets logged 40 times for a brachy...then that's an issue.

The current system is set up for cheating. How does surgery manage their op logs, do they have the same problems?

 

[evilbooyaa]

The current system is set up for cheating. How does surgery manage their op logs, do they have the same problems?

Yes, they do, even though they use MRN. I'm sure it's institution dependent, but even when people were double scrubbed they would do MRN and MRN-2 and would simply just discuss who was going to take credit. Of course one person would be the 'chief' and other would be 'junior assist' so not the same binary status of 'observed' and 'performed' that we have in RO. I'm not sure that the issue is that people are overlogging or double-logging cases. Hopefully residents themselves has some iota of self-realization that that is insane.

 

[Mandelin Rain]

I would have to stop logging in October to not go over the maximum.

 

[Chartreuse Wombat]

ROHub morphs into SDN

As seen on ROHub

Post-
Well as the dust on the 2019 Match settles, it does seem a major shift has occurred in RO.

The rampant expansion of residency positions was not met by an equal number of US grads applying , leading to record number of unfilled positions this year ~30+ in total AFAIK.

Maybe the SDN echo chamber was on to something

Response-
I suspect that the top medical school graduates have gotten a whiff of the necrotic stench emanating from the dying corpse our field has become and would elect to go into specialties that retain their autonomy and have a MUCH more aggressive PR and governmental lobby. Had I known that the Radiation Oncology professional societies would allow our profession to be essentially enslaved by the Big Pharma industry (with all their fake studies and statistical lies and governmental bribes) I would have chosen an alternate career.

 

[medgator]

Sure. However, often these programs will also then take outside rotators from near by programs without a Childrens Hospital, thus diluting the numbers for everyone.

If you need (EDIT: looked it up) 450 beam cases for graduation, and we agree even that is not enough, .

150 sims a year is like 3 per week with 2 weeks vacation. That's part time practice IRL imo

 

[Chartreuse Wombat]

150 sins a year is like 3 per week with 2 weeks vacation. That's part time practice IRL imo

I bet it is a typo but as is quite funny.

 

[Gfunk6]

Response-
I suspect that the top medical school graduates have gotten a whiff of the necrotic stench emanating from the dying corpse our field has become and would elect to go into specialties that retain their autonomy and have a MUCH more aggressive PR and governmental lobby. Had I known that the Radiation Oncology professional societies would allow our profession to be essentially enslaved by the Big Pharma industry (with all their fake studies and statistical lies and governmental bribes) I would have chosen an alternate career.

You have to admire the backbone of the poster who typed the above in a non-anonymous manner.

 

[Church of Radiontology]

Does anyone have any deets/money facts for ABR, esp. in light of this lawsuit?
View attachment 253959

The ABR's tax filings are available online through Charity Navigator. (Think Consumer Reports for non-profits. You have to create an account, but it's free.)
Charity Navigator - Unrated Profile for AMERICAN BOARD OF RADIOLOGY INCORPORATED

 

[medgator]

You have to admire the backbone of the poster who typed the above in a non-anonymous manner.

Definitely a straight shooter

Las Vegas job ad

 

[scarbrtj]

ROHub morphs into SDN

As seen on ROHub

Post-
Well as the dust on the 2019 Match settles, it does seem a major shift has occurred in RO.

The rampant expansion of residency positions was not met by an equal number of US grads applying , leading to record number of unfilled positions this year ~30+ in total AFAIK.

Maybe the SDN echo chamber was on to something

Response-
I suspect that the top medical school graduates have gotten a whiff of the necrotic stench emanating from the dying corpse our field has become and would elect to go into specialties that retain their autonomy and have a MUCH more aggressive PR and governmental lobby. Had I known that the Radiation Oncology professional societies would allow our profession to be essentially enslaved by the Big Pharma industry (with all their fake studies and statistical lies and governmental bribes) I would have chosen an alternate career.

Is this guy saying Big Pharma’s shadiness/aggressiveness has improperly displaced rad onc as a cancer therapy or that Big Pharma somehow owns/is in bed with rad onc. Can’t tell which.

 

[medgator]

Is this guy saying Big Pharma’s shadiness/aggressiveness has improperly displaced rad onc as a cancer therapy or that Big Pharma somehow owns/is in bed with rad onc. Can’t tell which.

I think he's saying that MO is steering the ship thanks to big pharmas influence and dollars at the federal level.

Probably true when you look at the possible direction of oncology bundles.

Academic RO is probably expanding residency positions faster than MO/HO, I'd wager though

 

[RANDO_Phantom]

I think he's saying that MO is steering the ship thanks to big pharmas influence and dollars at the federal level.

Probably true when you look at the possible direction of oncology bundles.

Academic RO is probably expanding residency positions faster than MO/HO, I'd wager though

You are probably right, even though there are 10+ advertised HO jobs in.any.given.state. at any.given.time. Fresh out of fellowship, starting at 500-600K. Contrast to RO state of affairs ...

 

[jupiterianvibe]

This is a good list. I would go so far to say patient numbers from satellite clinics should not be allowed to count towards residency expansion. As academic departments are gobbling up more and more satellites, this is becoming a bigger issue. Many of these clinics are essentially private practices with the university name on the door so it's questionable whether it is really part of the traditional "teaching hospital."

The case log requirements are a total disaster. The requirement for SBRT cases is 10, which is less than the requirement for pediatrics! All radiation oncologists will perform SBRT but probably less than 5% actually treat peds. Brachy and SRS numbers are way too low also. When was the last time these case requirements were adjusted? Leadership asleep at the wheel... and then they why wonder why so many of us are upset and medical students are running for the exits.

Get your house in order about this.

Pathology is in its sorry state because the only prerequisite for a program to open is if a resident can do 50 autopsies. If real criteria were required such as specimen volumes, types and complexity, I wager half of our FMG mills would be shuttered

 

[multitudes]

Hot of the (Twitter) press:

New proposed ACGME guidelines for accrediting a residency program:
- Six or more residents
- On-site rad bio/cancer biologist and physicist staff (I thought this was already a requirement?)
- Minimum of 7 interstitial cases (up from 5)
- Minimum of 15 intracavitary cases, with minimum of 5 tandem and max of 5 cylinders
- Required rotations (GI, GU, GYN, CNS, H&N, Breast, Lung) (this is new?)
- Required conferences in palliative care, patient-centered care, finance

These will apparently be published in early April, and will be open for comment for 45 days.

Source: @KenOlivierMD (Twitter)

 

[evilbooyaa]

Can you post the actual tweet? I can't find it in the insane amount of stuff that is tweeted by that source.
I wish the focus wasn't some arbitrary number of residents, but I guess something is better than nothing. Will old programs be grand-fathered in?
I had heard that interstitial was going to go up to 9. No distinction for gyn vs prostate still.
I'm glad a max of 5 tandem (1 patient) and 5 cylinders (2-3 patients) is felt to be clinically sufficient for independent brachy practice. /s
Required conferences in palliative care (god, seriously???), patient-centered care (what???) and finance (as long as they include billing practice for residents, I'm all for this).

First two "required" conferences seem like additional wastes of time to most residents going through their training. I wish we learned more about billing than we currently do, but I imagine most departments aren't even doing it well enough to "teach" it to the residents.

What a joke. The numbers should be like 15 interstitials, with at least 5 prostate and 5 gyn. Intracavitary should be upwards of 50 performed, with at least 25 tandems. SRS should be like 75, SBRT should be 50. I shouldn't be able to hit all of my non-EBRT requirements to graduate radiation oncology residency in the first year of residency!

 

[levels]

I bet they grandfather programs in. If possible, they should consider having a requirement on attending to resident ratio and make sure that is > 1:1. Maybe at least 3:2, if not more? For a minimum program of 6 residents, they'd need 9 attendings. This would keep PDs/chairs from expanding simply to ensure attending coverage.

 

[seper]

Many programs with 4 or 5 residents will struggle to quickly expand, and therefore will be shut down.

 

[medgator]

I bet they grandfather programs in.

They may let the current crop of residents graduate but not let them match any new ones

 

[multitudes]

Can you post the actual tweet?

 

[Tigerstang]

Hot of the (Twitter) press:

New proposed ACGME guidelines for accrediting a residency program:
- Six or more residents
- On-site rad bio/cancer biologist and physicist staff (I thought this was already a requirement?)
- Minimum of 7 interstitial cases (up from 5)
- Minimum of 15 intracavitary cases, with minimum of 5 tandem and max of 5 cylinders
- Required rotations (GI, GU, GYN, CNS, H&N, Breast, Lung) (this is new?)
- Required conferences in palliative care, patient-centered care, finance

These will apparently be published in early April, and will be open for comment for 45 days.

Source: @KenOlivierMD (Twitter)

This will not happen. Olivier's own institution would need to shut down one of their three residency programs, as the southern satellite does not have that many residents nor is there a radiation biologist on site.

 

[xrthopeful]

I mean I’m sure there will be pushback from the program size idea from all
Different sorts of parties - but Olivier is the PD of Mayo Rochester. Not Mayo Jacksonville, so dont think it’s really his concern. But maybe it is.

I think the program size idea is the only potential proposition with MEAT, and any idea with Meat is going to bother someone. We need more ideas that actually move the needle like that. Glad to see it

 

[Irradi8or]

As the SDN group, I wonder if we could consider putting together some of the points discussed in our various threads and submit for comment during the open comment period. It's of course important that the RRC gets this right, and not be too lenient on currently existing programs or "grandfathering" in some of the current programs. We also have a good collective voice regarding community based practices and therefore perhaps what the needs are for community practice. The RRC physician reps are all academics and their perspectives would be broadened with more direct community practice inputs...

 

[medgator]

As the SDN group, I wonder if we could consider putting together some of the points discussed in our various threads and submit for comment during the open comment period. It's of course important that the RRC gets this right, and not be too lenient on currently existing programs or "grandfathering" in some of the current programs. We also have a good collective voice regarding community based practices and therefore perhaps what the needs are for community practice. The RRC physician reps are all academics and their perspectives would be broadened with more direct community practice inputs...

We are the "miscreants" according to the ABR/ASTRO establishment, doubt they care about the collective opinion of SDN even if we called it first

 

[Krukenberg]

We are the "miscreants" according to the ABR/ASTRO establishment, doubt they care about the collective opinion of SDN even if we called it first

They would have to take it seriously if people sign on with their names. Doesn’t have to be connected back to your sdn username

 

[evilbooyaa]

If it's open comment and anonymous, I'm happy to put together a 'best of SDN thoughts' on this and submit. Of course I'm never notified when the 'open comment' session opens and closes. If it's not anonymous, if anybody is willing to post publicly please feel free to let me know.

Unfortunately, they can always hurt you more as a resident.

 

[fiji128]

If you could close down all the programs with 4 to 5 residents you would cut the number of rad onc residency training spots by about 8%. If existing larger programs continue with their expansions it could all just be a wash. It's a start but doubt that in of its self would solve the long term oversupply of MDs and decreasing need for them issues. I think the active clinical faculty to resident ratios need to be address. There are for sure programs out there that have more residents then actual clinically active faculty.

 

[Neuronix]

If you could close down all the programs with 4 to 5 residents you would cut the number of rad onc residency training spots by about 8%. If existing larger programs continue with their expansions it could all just be a wash. It's a start but doubt that in of its self would solve the long term oversupply of MDs and decreasing need for them issues.

100% this. I believe that the current proposal is just a token gesture.

 

[Ray D. Ayshun]

If you could close down all the programs with 4 to 5 residents you would cut the number of rad onc residency training spots by about 8%. If existing larger programs continue with their expansions it could all just be a wash. It's a start but doubt that in of its self would solve the long term oversupply of MDs and decreasing need for them issues. I think the active clinical faculty to resident ratios need to be address. There are for sure programs out there that have more residents then actual clinically active faculty.

I counted up spots based on Doximity program size data. Counting Loma Linda, there are 76 spots affiliated with programs with 5 or less, 56 with programs with 4 or less (of which LL was not one, so 61 spots gone). This is more on the order of 35%. Maybe I'm missing something.

 

[Neuronix]

I counted up spots based on Doximity program size data. Counting Loma Linda, there are 76 spots affiliated with programs with 5 or less, 56 with programs with 4 or less (of which LL was not one, so 61 spots gone). This is more on the order of 35%. Maybe I'm missing something.

Fiji already did a great analysis of this here, and came up with 6%.

Guessing # unmatched spots

 

[Irradi8or]

Agreed. I think that the current proposal, as written, could be gamed by existing smaller programs looking to expand from 4 to 6 or the larger programs who would be able to absorb and increase their spots as current smaller programs close. Additionally, those 70-75 spots that could be taken away from smaller programs would still have current residents that need to complete residency at their current program or a future program. I would imagine that should a program be slated to close, even if current residents stay there to finish off, the quality of training, didactics, radbio, physics, etc would dwindle as there's no incentive. It would be worth having us all crowd source our thoughts together for comment submission.

 

[medgator]

Fiji already did a great analysis of this here, and came up with 6%.

Guessing # unmatched spots

That's only programs with 4. Another 18% 5-6

 

[Neuronix]

That's only programs with 4. Another 18% 5-6

I will be very curious how many of the size 5-6 programs will actually shutter, how many of the size 4 programs will expand to meet the new requirements, and how much any closures will be counterbalanced by large programs expanding, either in the immediate or short-term future.

 

[Ray D. Ayshun]

Fiji already did a great analysis of this here, and came up with 6%.

Guessing # unmatched spots

Oops, wrong denominator. 35% sounded good though. Perhaps we should go with that number and do inverse planning.

 

[RadOncG]

I will be very curious how many of the size 5-6 programs will actually shutter, how many of the size 4 programs will expand to meet the new requirements, and how much any closures will be counterbalanced by large programs expanding, either in the immediate or short-term future.

Same. Curious how people are concluding that this is a reasonable solution.

If I am a chair with 4 residents I have two options:
1. Expand to 6
2. Close residency program and hire additional support staff to fill the deficit left by the resident slaves/scribes

Number 1 is cost effective and would benefit the program. Number 2 is the complete opposite. If someone could explain why a program would chose number 2 I am genuinely curious.

The number of cases requirement is a joke. This is not well tracked and can easily be manipulated in ways that others have already mentioned.

 

[PhotonBomb]

Same. Curious how people are concluding that this is a reasonable solution.

If I am a chair with 4 residents I have two options:
1. Expand to 6
2. Close residency program and hire additional support staff to fill the deficit left by the resident slaves/scribes

Number 1 is cost effective and would benefit the program. Number 2 is the complete opposite. If someone could explain why a program would chose number 2 I am genuinely curious.

The number of cases requirement is a joke. This is not well tracked and can easily be manipulated in ways that others have already mentioned.

You are aware that a program can't 'just decide' to expand to 6, right? Like it's not an active choice they can just make one day? It's a loong process to apply and get approval for an expansion, and it's actually not easy to get approval for expansion.

I doubt many programs with 4 even has the volume to meet criteria for expansion to 6, and EVEN if there were on paper, the backbone of these changes seem to be against the idea of further expansion of the residency cohort, so the same people who are proposing these changes (along with the RRC) would be motivated to deny further expansion.

 

[RadOncG]

You are aware that a program can't 'just decide' to expand to 6, right? Like it's not an active choice they can just make one day? It's a loong process to apply and get approval for an expansion, and it's actually not easy to get approval for expansion.

I doubt many programs with 4 even has the volume to meet criteria for expansion to 6, and EVEN if there were on paper, the backbone of these changes seem to be against the idea of further expansion of the residency cohort, so the same people who are proposing these changes (along with the RRC) would be motivated to deny further expansion.

Good points. The prospect of hiring 4 NPs/PAs is similarly a difficult and possibly cost prohibitive endeavor that departments would wish to avoid.

I do think there are better metrics than program size. Academics are just repeating Paul Wallner's thesis from prior to the ABR board fiasco.

 

[xrthopeful]

One of the things it would immediately do is raise the barrier to entry for a new program. There have been probably ten programs open up in the last 8 years or so. I think they all started with approval for (probably many still have) 4 residents. That’s huge in itself if we can prevent the openings of the next (I’ll name names) - Nebraska, WVU, Dartmouth, Arkansas, Tennessee etc etc etc

 

[KHE88]

One of the things it would immediately do is raise the barrier to entry for a new program. There have been probably ten programs open up in the last 8 years or so. I think they all started with approval for (probably many still have) 4 residents. That’s huge in itself if we can prevent the openings of the next (I’ll name names) - Nebraska, WVU, Dartmouth, Arkansas, Tennessee etc etc etc

You forgot MCG. Or whatever their name is now -- they've changed it like 4 times. They recruited I think one person out of the match 5 years ago, never matched after that as far as I know, and their chair left immediately after the program was started.

And this program was accredited and remains accredited. It is a community freestanding center with some affiliation to something with the name "university" in it.

Current residents = literally a blank page.
Radiation Oncology Residents

Yeah, stuff like that needs to end. Numerous programs were allowed to start up that never should have seen the light of day.

 

[fiji128]

I counted up spots based on Doximity program size data. Counting Loma Linda, there are 76 spots affiliated with programs with 5 or less, 56 with programs with 4 or less (of which LL was not one, so 61 spots gone). This is more on the order of 35%. Maybe I'm missing something.

I'm guessing you are looking at the total number of residency training slots available for programs with 5 or fewer residency and comparing to the number of residency positions available yearly through the match. Currently from the ACGME, there are 52 (13 programs x 4 resident training slots) + 15 (3 programs x 5 resident training slots) = 67 total available currently approved positions in radiation oncology in programs with 4 to 5 residents. Granted these may not all be actively filled at this time like the Georgia program. Per the ACGME there are 833 total currently approved training positions in radiation oncology and again not all approved positions are currently 100% filled even at larger programs. But if the ACGME closes down the programs with 4 or 5 residents 67/833 or 8% of total residency training positions would be closed. This would likely play out as 67/4 or 17 fewer positions offered in the match each year.

I have a prior post on this thread (post number #132 and #133 on page 3) listing all the programs with their approved residency positions and year of program founding.

If you look at those programs with 6 residents, I don't think the ACGME could easy close those as many of them are older programs with a strong history of resident training.

 

[deleted947887]

Can we guess how many programs went unmatched this year and see who guesses right for a prize?

I'm gonna say 8 programs and 16 spots.

Gonna go 16/32 this year. Let's hear it folks. What do yall think?

 

[evilbooyaa]

25 prog, 30 spots is my guess

*EDIT* - Wait, 30 sopts was last year.

Gonna go bold and say 40 prog, 50 spots go unmatched this year.

 

[RickyScott]

I really don’t think unmatched spots are good metric. Programs will just start interviewing worse candidates/fmgs in future: “academic beer goggles.” Decreasing selectivity and prestige will trigger “status anxiety”

 

[evilbooyaa]

In the future yes, but since this was a surprise the field is still self-selected. Next year I expect a 'rebound' in applications as there will be many more DOs, US-IMGs, and FMGs who apply**.

**This is not a knock against physicians that are in these categories, simply an understanding that a field is inherently considered less competitive the more non US-MDs make up the resident class.

 

[Lamount]

So is everyone hoping for a low number because it means the field is healthier, or a high number so you can say “I told you so”?

I am guessing a lot more of the latter... couched in the Zeitman canary in the coal mine argument, of course (to keep up appearances) - I.e. “a lot of unmatched spots is really good for the field in the long run”, right? What’s wrong a little schadenfreude between colleagues?

Put me down for 15-20% unmatched

 

[deleted947887]

So is everyone hoping for a low number because it means the field is healthier, or a high number so you can say “I told you so”?

I am guessing a lot more of the latter... couched in the Zeitman canary in the coal mine argument, of course (to keep up appearances) - I.e. “a lot of unmatched spots is really good for the field in the long run”, right? What’s wrong a little schadenfreude between colleagues?

Put me down for 15-20% unmatched

This is just for kicks. I've come to terms with the fact that our field is run by imbecils and nothing will change no matter what we say or prove. Strictly for kicks.

 

[RickyScott]

So is everyone hoping for a low number because it means the field is healthier, or a high number so you can say “I told you so”?

I am guessing a lot more of the latter... couched in the Zeitman canary in the coal mine argument, of course (to keep up appearances) - I.e. “a lot of unmatched spots is really good for the field in the long run”, right? What’s wrong a little schadenfreude between colleagues?

Put me down for 15-20% unmatched

I honestly don’t care. If we matched the top 200 medical students, still won’t change the demand for new radoncs and some of this class won’t have a job when they graduate. Filling match with high quality med students may Momentarily assuage “status anxiety” of high achievers already in the field, who haven’t yet come to terms with inhabiting a bottom rung specialty, but in long run Gravity at work here and we are falling to the bottom.