I'm not sure I would call what we are in a "mismanaged decline." As we have seen from Dr. Dennis Hallahan's missive in The Red Journal, increasing residency spots in order to decrease bargaining power of physicians and decrease reimbursement was a feature, not a bug, of residency expansion.
It's sobering reading how RadOnc's well-intentioned focus on evidence based care and clinical endpoints that matter (e.g. overall survival) end up detracting from their own employment/careers/earning potential while MedOnc chugs along with their "game changer" drugs that at best usually only improve surrogate markers (e.g. PFS).
I tend to agree that things have been managed perfectly.
Radonc is not a synthetic field. Even paradigm changing technological advancements will only replace existing practices, not augment them. If FLASH works, its replacing standard XRT. Elite centers actively try to convince the public and the radonc community that protons should replace standard XRT. What are "brilliant minds" going to study when there is no synthesis? De-escalation, value based care and disparities research. (All valuable BTW)
I got to interview the best medical students in the country in the relatively early 2010s. I would not have gotten an interview at the place that I matched 5 years earlier (still peak radonc and significantly fewer spots). At that time radonc had widely entered medical students consciousness and had accomplished a triumvirate of sorts (money, lifestyle and cachet). The third pillar being the most important. A little like derm, which has been the repository of brilliant med students who will contribute very little to medicine as a whole for decades, radonc became "the place to go" for really exceptional students who were interested in lifestyle. Many of the candidates had been goal directed to the field since before med school. It didn't matter that you didn't work as hard as medicine or surgery, people knew you were smart if you went into the field.
I can only speak of my own program, but when confronted with this glut of talent, the powers that be (high profile academics, chairs) didn't blanch at all. They did however drop any pretense of selecting candidates who would "make good doctors". They expanded their spots and selected for academic ambition. I literally watched as the chair and another physician scientist culled the list strictly based on commitment to academic medicine. The absolutely best candidate that I have ever seen (based on grades, boards, pedigree, LORs, meaningful research output and interview) was ranked low as there was an inkling that they might not do academics. The mission of the department was clear, to produce academics. And, they were going to expand their residency numbers to produce more.
Unlike a big field or synthetic field, where most of the docs are by definition in the community doing the hard work of providing clinical care, radonc can and has effectively consolidated care over time. Whereas new pharmaceuticals are generally quickly adapted by the community and are priced in a way that there is very little barrier to community administration, new radonc tech is prohibitively expensive and compensation is disparate with remarkable institutional leverage regarding payment. The academics have no interest in a healthy community radonc market. They have an interest in consolidating care and maintaining advantageous payment to themselves in order to continue their de-escalation, value based care, disparities and basic science research, almost none of which will result in new XRT indications and much of which will result in less radiation administration.
I'm sure that the academic leadership also knew during peak-peak radonc that most of those applicants just wanted a good job, liked taking care of cancer patients and eventually would want to spend a reasonable amount of time with their family. They knew that those applicants might suffer but were not sympathetic. They would be able to get them on the cheap at their ever expanding satellite practices. They also knew that med students would respond as they have.
Radiation oncology has enough academic talent from the last 10 years to see the field into it's total demise roughly 30 years from now. In my opinion, it will become an increasingly niche and academic field with fewer indications for treatment. New indications will go the way of brain SRS with academic collaboration with outside departments that will become the high volume practitioners. Eventually the academics will function as thought leaders for integrating the field into medical oncology or radiology. Thousands of papers will be written on this. Their unfortunate contemporaries in the community will be rushing to retire.
Is radonc still a good opportunity for some? Sure. If you have an established onc research background and are elite, you can make a run at a rare physician scientist job. It may be a better opportunity for elite candidates only interested in academics now than 7-10 years ago as the meritocracy is less brutal and all those comparable candidates who thought they might like to live close to their family are gone.