M4 thinking strongly about applying to Rad Onc: Why is there so much dissonance between opinions real life and the internet?

[medgator]

Yes by definition you will see a few more OTRs and a few more films to check for a longer fractionated course,

I rest my case

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[medgator]

Unfortunately we already know the answer when it comes to 38 fraction IMRT vs. 15 fraction IMRT, for example. Pays less and less work. That means less need for physicians.

Exactly my point. Those of us who are incentivized are simply going to see more patients per year. Not a great thing if you're a new grad coming out looking for a job

 

[xrthopeful]

I rest my case

Listen, if you really want to die on the ‘My 40 fraction prostate case is 8 times more work than your 5 fx SBRT case’ then go ahead. You’re on the wrong side of this.

 

[xrthopeful]

Exactly my point. Those of us who are incentivized are simply going to see more patients per year. Not a great thing if you're a new grad coming out looking for a job

No you’re making my point.

Patients/year is a more reasonable way to look at productivity. Not fractions/whatever time point one picks. This was what started this discussion?

 

[medgator]

Listen, if you really want to die on the ‘My 40 fraction prostate case is 8 times more work than your 5 fx SBRT case’ then go ahead. You’re on the wrong side of this.

Putting words in my mouth and misrepresentating my argument won't deflect from my point

 

[medgator]

Patients/year is a more reasonable way to look at productivity.

Which is what I said to begin with. Existing ROs will simply see and treat more patients to counteract APM /hypofx etc

 

[deleted941485]

The future is number of patients per year rather than number of fx treated. The new model is treat them as quickly as possible with as little cost as possible...but still treat them. 8x1 palliatives. 5fx prostate. 5fx breast if it comes to it.

If existing attendings play their cards right it could be very lucrative for them...but for new graduates it means the market is gonna get even tighter. The only way you’ll get a job now is if you literally offer services at a significant discount and even then they probably won’t feel all that comfortable about offering you a job.

 

[taserlaser]

Sounds more like the Canadian model where most provinces are salaried... Ontario and Quebec are fee for service I think. But the rest are generally salaried, and in a resource constrained system, that’s what tends to happen.

 

[PleaseRemainCalm]

I don’t know, I think maybe the easier way to quantify it is new Consults or new starts per week or per month? Because that’s where most of the work is right? I mean a five fraction Prostate SBRT case shouldn’t be counted as one eighth the work (to the physician) of a standard 40 frac prostate case should it? I don’t think it bills one eighth either. I feel like measuring productivity of a rad onc in number of fractions a week doesn’t necessarily capture everything. This is hard stuff to figure out

We get paid the same for the consult, we get paid similarly per sim, but then we a absolutely do get paid differently for the treatment course which is based on the number of fractions and the complexity of the plan. And the RVUs you generate for seeing someone in clinic does not compare to the treatment.

 

[deleted18755]

The future is number of patients per year rather than number of fx treated. The new model is treat them as quickly as possible with as little cost as possible...but still treat them. 8x1 palliatives. 5fx prostate. 5fx breast if it comes to it.

If existing attendings play their cards right it could be very lucrative for them...but for new graduates it means the market is gonna get even tighter. The only way you’ll get a job now is if you literally offer services at a significant discount and even then they probably won’t feel all that comfortable about offering you a job.

This is exactly the conclusion that my (admittedly few) close radiation oncology friends and I have come to if/when payment per case replaces fee for service (assuming the payment per case is greater then it’s proportional number of fractions ... in other words a 5 fraction case pays more then 1/8th of the current 40 fraction course or whatever).

In this likely situation I would imagine that experienced radiation oncologists who are young enough to have trained in the “hypo-fractionated era” will continue hypo-fractionating and increasingly delve into SBRT and more aggressive short courses as they become more comfortable with it and while their new consults/sims/starts will certainly increase their salary will stay the same or perhaps increase as well.

I don’t see the guys who in the year 2019 can count on one hand every time they have hypofractionated a stage I breast cancer (we all knowplenty like this)suddenly knocking out 5 fraction SBRT prostate so I bet it’ll drive some to retire.

In any event no doubt that regardless of compensation decreases, within reason the the vast majority of radiation oncologists will simply increase their workload to make up for the decrease in pay per patient (and sure it’ll push some over the edge to retirement but I think may push some to really increase their efficiency and “throughput” and maybe overall compensation).

Either way there is definitely a lot of unaccounted for “oversupply” of physician’s already if one factors in the linacs and otv schedules that are currently filled only because of non fractionated cases at many centers AND in addition lot of potential for existing physicians to work more to maintain compensation (if compensation decreases 10-25% most 3-4 physician groups, and certainly larger ones, will simply see more patients to keep compensation steady vs hire).

 

[xrthopeful]

 

[PleaseRemainCalm]

I hope that the title is a typo as something like only 4% of rad onc positions are pgy1. And we didn't match a single DO last year? Seems unlikely.

 

[xrthopeful]

Yeah not sure. Definitely remember it seeming like there were more IMGs than normal last year when scanning the google doc post match, but don’t remember seeing more the standard 2-3 DO per/year that we have seen match Rad Onc forever.

I was more posting out of interest regarding other specialities for comparison.

Probably have to wait for the Charting Outcomes to see more specific data like Step scores etc

 

[scarbrtj]

I don’t know, I think maybe the easier way to quantify it is new Consults or new starts per week or per month? Because that’s where most of the work is right? I mean a five fraction Prostate SBRT case shouldn’t be counted as one eighth the work (to the physician) of a standard 40 frac prostate case should it? I don’t think it bills one eighth either. I feel like measuring productivity of a rad onc in number of fractions a week doesn’t necessarily capture everything. This is hard stuff to figure out

Listen, if you really want to die on the ‘My 40 fraction prostate case is 8 times more work than your 5 fx SBRT case’ then go ahead. You’re on the wrong side of this.

Remember there is more work than just MD work in this. Look at it from the global view. You will require about 8 times as much man hours from the therapists whom you have to pay. More work from the physicist especially if you factor in “cone downs” and more QAs in the longer course. More physician work in contouring and plan approvals. More OTVs. More chance for side effects during the treatment (just because they aren’t out the door after 5 fractions). More films to check, yes. More wear and tear on the machine. So actually way more departmental man hours and overhead expended with 40 fractions. And more MD work for sure. Eight times more work overall? No. But that’s I guess why 40 fractions only pays (globally) about 3 or 4 times as much as SBRT. However on the professional side this is one of those situations where the multiple is more than 3 or 4 I believe.

There is no website forum for rad onc administrators. I bet if there were one they’d be complaining about decreasing rad onc reimbursement. I would wager they don’t know it’s been self imposed versus the random winds of change. Would be interested to see if they’ve felt any pain.

 

[xrthopeful]

I would wager that the vast majority of admins know about it. Certainly the ones I know at my current place, place where I trained, and other ones I’ve talked to are well aware and planning for it.

 

[xrthopeful]

Interesting thread to read

From a rad onc resident: Derm specialty's experience with over-training?

Rad onc resident here. In the rad onc world, academic leaders have expanded the # of residency slots to the point that the number of graduating rad onc residents each year doubled over a decade for no good reason other than probably to provide their faculty with resident coverage so they can...

forums.studentdoctor.net

 

[taserlaser]

Interesting thread to read

From a rad onc resident: Derm specialty's experience with over-training?

Rad onc resident here. In the rad onc world, academic leaders have expanded the # of residency slots to the point that the number of graduating rad onc residents each year doubled over a decade for no good reason other than probably to provide their faculty with resident coverage so they can...

forums.studentdoctor.net

I can’t help but notice that it got locked fairly quickly.

 

[xrthopeful]

I can’t help but notice that it got locked fairly quickly.

yeah seems like the mods didnt like it when it got to the 'IMG's are not being the 'brightest minds' part....
I made it clear here before I don't feel that way about IMGs necessarily, but shouldn't have gotten locked for that

 

[medgator]

yeah seems like the mods didnt like it when it got to the 'IMG's are not being the 'brightest minds' part....
I made it clear here before I don't feel that way about IMGs necessarily, but shouldn't have gotten locked for that

As has been posted earlier, there really are two sets of IMGs, the truly international ones that have gone to great schools abroad and possibly have already done full residencies and then the AMGs that couldn't cut it for getting into a US allo school, but didn't want the DO moniker etc. Very different groups and capabilities

 

[deleted1002574]

I can’t help but notice that it got locked fairly quickly.

Yup. And the posts stay directed, informative, instead of devolving into name calling, picking on other docs, and bringing up the same three facts over and over. Good thread management. Wild wild west over here, tho.

 

[xrthopeful]

As has been posted earlier, there really are two sets of IMGs, the truly international ones that have gone to great schools abroad and possibly have already done full residencies and then the AMGs that couldn't cut it for getting into a US allo school, but didn't want the DO moniker etc. Very different groups and capabilities

You’re repeating my own post back to me, but yeah. The latter aren’t in rad onc as of now.

 

[medgator]

The latter aren’t in rad onc as of now.

Quite a chunk that got in during the 90s and turn of the century though

 

[Neuronix]

Yup. And the posts stay directed, informative, instead of devolving into name calling, picking on other docs, and bringing up the same three facts over and over. Good thread management. Wild wild west over here, tho.

Well, I can either cut the whole discussion short when it gets off track or let the discussion play out and selectively moderate. I personally prefer the latter.

I can see why the derm mods cut that one off though. Talking about rad onc in a derm forum is off topic at baseline.

I do think the derm thread provides a good answer though. I don't think that rad onc chairs are necessarily more greedy, more conspiratorial, or whatever else than non-rad onc chairs. The pressures rad onc chairs feel to get more residents are the same as any other chairs. It's just that some specialties are growing faster than others relative to the training pathway. There is a decoupling of supply of residents and demand for physicians in that specialty in this way. Nobody is paying attention in any specialty to my knowledge in any meaningful way about whether the number of residency positions is commiserate with societal need. This seems like something CMS should be looking at IMO.

From a working physician's point of view, some specialties like pathology feel supply-demand mismatch in a very bad way (very bad oversupply), others feel it in a good way (undersupply of physicians). Rad onc is swinging from undersupply to oversupply, hence all the discussion. Radiology went from undersupply to oversupply and back in the past few decades.

 

[deleted941485]

Well, I can either cut the whole discussion short when it gets off track or let the discussion play out and selectively moderate. I personally prefer the latter.

I can see why the derm mods cut that one off though. Talking about rad onc in a derm forum is off topic at baseline.

I do think the derm thread provides a good answer though. I don't think that rad onc chairs are necessarily more greedy, more conspiratorial, or whatever else than non-rad onc chairs. The pressures rad onc chairs feel to get more residents are the same as any other chairs. It's just that some specialties are growing faster than others relative to the training pathway. There is a decoupling of supply of residents and demand for physicians in that specialty in this way. Nobody is paying attention in any specialty to my knowledge in any meaningful way about whether the number of residency positions is commiserate with societal need. This seems like something CMS should be looking at IMO.

From a working physician's point of view, some specialties like pathology feel supply-demand mismatch in a very bad way (very bad oversupply), others feel it in a good way (undersupply of physicians). Rad onc is swinging from undersupply to oversupply, hence all the discussion. Radiology went from undersupply to oversupply and back in the past few decades.

I think larger specialties with higher levels of demand like gas and rads swing from over/under supply pretty rapidly. But smaller fields like ours where the damage can be felt for years if not decades

 

[deleted573262]

Just a note that there were a few DOs matching rad onc this year based on the spreadsheet.

 

[medgator]

I think larger specialties with higher levels of demand like gas and rads swing from over/under supply pretty rapidly. But smaller fields like ours where the damage can be felt for years if not decades

Imagine if a scan was developed in rads that cut the amount of imaging needed in half. That's pretty much what we've faced

 

[taserlaser]

Imagine if a scan was developed in rads that cut the amount of imaging needed in half. That's pretty much what we've faced

As an aside, if FLASH RT plays out as people speculate in the other thread, there might be an argument to convert diagnostic scanners to high dose rate to minimize second cancer risk on a population level. And with that, there might be a desire to up the dose delivered for increased scan quality. But still no magic scan on their end on the horizon as far as I know.

Auto segmentation and planning is also significantly closer than AI diagnostic reads. I doubt that will effect our workflow, but I can also imagine it might spur further downward pressure on compensation yet again. Ooph.

 

[scarbrtj]

Interesting thread to read

From a rad onc resident: Derm specialty's experience with over-training?

Rad onc resident here. In the rad onc world, academic leaders have expanded the # of residency slots to the point that the number of graduating rad onc residents each year doubled over a decade for no good reason other than probably to provide their faculty with resident coverage so they can...

forums.studentdoctor.net

That was a good thread. Highlights:
* Derm is a lot different than rad onc ("We are not dependent on expensive equipment, hospitals, and to some extent can still hang a shingle. This blunts the effect of residency expansion to some degree")
* There are some in derm who feel job market to be "excellent" ("The derm job market is definitely still excellent - basically any resident trained at any program can reasonably find *some* job in any geographic location")... whilst in rad onc ~0% would rate job market as "excellent" and/or expect *some* job in "any" location
* Remunerative prospects are voiced as being better in derm ("if you can get a good position you can establish and make 700k-1mill")
* The rad onc "problem" is become known outside rad onc ("I've also heard similar things about rad-onc from med school friends who are current residents - mostly that the job market is incredibly tight (e.g. 0-2 open positions annually in some large, desirable metros) and extremely competitive, especially as most residents are pretty much universally great candidates")
* The rad onc OP came off as elitist/insensitive to the derms: not an easy feat!

 

[medgator]

* The rad onc OP came off as elitist/insensitive to the derms: not an easy feat!

Agree with everything except that

 

[Krukenberg]

I thought the most interesting thing from that thread was there is no concerted effort by derm chairs to constrain residency #s...it’s just that the financials of expansion don’t work out.

The path resident warning derm that PE is their enemy was interesting too. I can’t imagine a worse scenario than your own professional society being controlled by Wall Street. Doesn’t get more “cog in a wheel” than that.

I could have written that last post differently to not conflate best and brightest with IMG/FMG (that’s not what I meant), but the moderator did a good job and closed the thread when things were beginning to go off the rails.

 

[bluebubbles]

I'm not going to post this in the dermatology thread to avoid getting flamed, but yes, dermatology has more elastic demand. That's a polite way of putting it. Their procedures are more innocuous than radiotherapy, and some are performed for marginal/questionable indications and minimal marginal benefit. Also, it wasn't explicit, but I'd bet that radiation oncology with its technical fees generates a lot more money for the institution that dermatology, even though provider salaries are comparable, thus providing perverse incentives for the people in charge to push & fund radiation oncology residency expansion.

If I had a magic wand, it wouldn't be to limit radiation oncology residency slots. It would be pay parity between academics and PP for a given procedure/diagnosis, and amendment of the Stark Law. That way, academic chairs would be afraid that if they trained too many residents, those residents would graduate and compete for market share. Unfortunately, the deck is stacked against PP by dumb, anticompetitive payer laws currently.

That's my resident-level guess. Anyone with actual experience can correct me.

 

[scarbrtj]

Unfortunately, the deck is stacked against PP by dumb, anticompetitive payer laws currently.

I think there's a large nugget of truth to this. Today I read:

There are several for-profit companies that install and operate the [red light] cameras, some of them foreign-owned. In a typical arrangement, a camera company will contract with a local government to pay the capital cost of installing the cameras in exchange for a share of the revenue generated via fines. In short, governments get a new revenue stream without any operating cost, and the camera companies make a tidy profit.

And thought "What if this was done in medicine? It would be illegal!" But yet, legal everywhere else outside medicine (ie teaming up for revenue sharing, creating "profit centers," etc). There's no CON process for red light cameras, only linacs and such

 

[medgator]

I think there's a large nugget of truth to this. Today I read:

There are several for-profit companies that install and operate the [red light] cameras, some of them foreign-owned. In a typical arrangement, a camera company will contract with a local government to pay the capital cost of installing the cameras in exchange for a share of the revenue generated via fines. In short, governments get a new revenue stream without any operating cost, and the camera companies make a tidy profit.

And thought "What if this was done in medicine? It would be illegal!" But yet, legal everywhere else outside medicine (ie teaming up for revenue sharing, creating "profit centers," etc). There's no CON process for red light cameras, only linacs and such

But sometimes, the little guy wins

Texas bans red light cameras

Texas Governor Greg Abbott on Saturday signed into law a bill that prohibits the use of red light cameras by local authorities. House bill 1631, sponsored by state state Rep. Jonathan Stickland, was a...

www.jurist.org

https://www.miamiherald.com/news/local/community/miami-dade/article222298820.html

 

[deleted941485]

Did anyone else get this ACRO alert regarding a restricted grant to research the effects of reimbursement from proposed CMS. I think it’s around 20K to study it. Not sure what they think they’ll uncover.

 

[Neuronix]

I hope that the title is a typo as something like only 4% of rad onc positions are pgy1. And we didn't match a single DO last year? Seems unlikely.

You're right. The twitter post is wrong.

The raw data is in the Results and Data: 2019 Main Residency Match found here Main Residency Match Data and Reports - The Match, National Resident Matching Program. See pages 8 and 9.

Five of the first round matches were osteopaths.
Seven of the first round matches were non-US IMGs (1 was in the PGY-1 group, the rest were PGY-2)

Other data I found intersting.
211 total rad onc positions last year!
15 were PGY-1
192 were PGY-2
4 were PGY-2 positions only available to those with prior GME training

32 positions went unfilled in the first round of the match (combining all positions above)

 

[xrthopeful]

Based on past reporting, that 211 number likely isn’t completely accurate, it may be more like 207 or 208 or something. I think ACGME publishes some slots as ‘available’ even if not meant to be filled.

 

[medgator]

211 total rad onc positions last year!

Based on past reporting, that 211 number likely isn’t completely accurate, it may be more like 207 or 208 or something.

Def way better

 

[xrthopeful]

Per the google Doc, there were 206 slots open last year, though ultimately some (at least 4 or 5) did not fill even after the SOAP.

Not saying it’s better, Medgator, just looking for accuracy since we trend these numbers.

 

[scarbrtj]

Def way better

Point of order, sir: 211 is different than 208 or 207. We are radiation oncologists, after all, and have traditions and a culture to uphold.

 

[PleaseRemainCalm]

You're right. The twitter post is wrong.

The raw data is in the Results and Data: 2019 Main Residency Match found here Main Residency Match Data and Reports - The Match, National Resident Matching Program. See pages 8 and 9.

Five of the first round matches were osteopaths.
Seven of the first round matches were non-US IMGs (1 was in the PGY-1 group, the rest were PGY-2)

Other data I found intersting.
211 total rad onc positions last year!
15 were PGY-1
192 were PGY-2
4 were PGY-2 positions only available to those with prior GME training

32 positions went unfilled in the first round of the match (combining all positions above)

This mistake has been made before by others. Not sure why it is so hard to remember that some specialties are almost exclusively advanced positions.

 

[evilbooyaa]

This mistake has been made before by others. Not sure why it is so hard to remember that some specialties are almost exclusively advanced positions.

Who cares about being accurate when you can have a tweet worthy picture instead

 

[RickyScott]

Just got a call from locums offering 150$ an hour at large hospital system in northeast. Hows that for discrepancy.

 

[medgator]

Just got a call from locums offering 150$ an hour at large hospital system in northeast. Hows that for discrepancy.

Depends on what they want you to do..... Busy clinic? Nah. IGRT baby sitter? Cha-ching.

 

[xrthopeful]

Just got a call from locums offering 150$ an hour at large hospital system in northeast. Hows that for discrepancy.

Is that lower than normal? I don’t know much about locums rates

 

[Mandelin Rain]

Locums rates I've seen through and agency typically range 1500-2000 per day pending location and expectation. I'd say 1800 is probably the median I've seen.

 

[evilbooyaa]

Just got a call from locums offering 150$ an hour at large hospital system in northeast. Hows that for discrepancy.

That's.... not a lot right? Assume an 8 hour day of machines running (not uncommon for small single practice doc that would require locums) and that's only $1200.

 

[Neuronix]

Offers in my neck of the woods for board certified have been $1000 per day to babysit, $1500 if doing significantly more than that.

For non-board certified (senior residents, others in this boat), maybe 75% of that.

 

[RickyScott]

That's.... not a lot right? Assume an 8 hour day of machines running (not uncommon for small single practice doc that would require locums) and that's only $1200.

As resident in early 2000s used to babysit a methadone inpatient clinic on weekends, and would earn a little bit more than that. Locums physicist that we have hired charges significantly more.

 

[Reaganite]

As resident in early 2000s used to babysit a methadone inpatient clinic on weekends, and would earn a little bit more than that. Locums physicist that we have hired charges significantly more.

Sad but true...there are some geographies where the physicists are making nearly as much as the MDs. Heard from my physics buddy that it's becoming increasingly hard to hire a physicist for <200k. This is just my n=1 in a specific geography...Speaking of physics, I've heard their oral board pass rate is only 50%!

 

[medgator]

As resident in early 2000s used to babysit a methadone inpatient clinic on weekends, and would earn a little bit more than that. Locums physicist that we have hired charges significantly more.

I know for a fact that locums physicists get $2k+/day in some rural locations