More and more programs using SOAP to fill

[RadsRocks!]

Rad Onc programs deciding to SOAP

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[DireMoose]

This is true. People who end up in that situation won't speak up about it.

"Wait..... so you scored 260 on Step 1, Honored all your clinical rotations, were inducted into AOA..... and now you're unemployed?"

Not so smart are ya.....

They won't speak up because its embarrassing.

We should have a separate thread anonymously reporting these cases.... if you know of two individuals that can't find jobs it means there are many, many more out there.

I came here to say this and you nailed it. The old posts of "anonymous interview reviews" were a gold mine when getting a flavor of programs. What if we had a thread on Tales from the Job Hunt? Could be sent to @Neuronix and posted anonymously. I personally know of 3 people from this year who got quite far in the interview process only to have a job vaporize. Doesn't do much good with me reporting that, we need the firsthand accounts. @radonc17 already shared a bit about the RadOnc vs MedOnc job hunt. Would love to hear more like that. Cities and regions could be changed to protect the innocent.

The surveys are being done and there are real benefits to publishing these, but we all know the drawbacks when your preferred geographic region is inclusive of CA and Idaho. This could be the next best thing, a case series. I think getting something like this going before the intriguing April 1st Existential Threat Zoom Summit would be useful.

 

[Neuronix]

The following was sent to me to post anonymously. This is not from the program where I work.

Inside perspective from an anonymous (I hope) faculty at an unfilled program:

1. Overall applicant pool: worse than last year, which was down from the year prior. Still feels like a bimodal distribution where there are great applicants or eyebrow-raising applicants without much in the middle. Nothing like 5-10 years ago where 90% of the applicants would be a boon to any program, 9.9% were bordering on that, and 0.1% were living on a prayer. This years applicants would have been unheard of (taking step 1 three times, no LOR, a PS that was more of a bulleted list...).
2. Interviews extended: admittedly very hard this year with everything going virtual (no time/$ cost on the applicant side to interview, so nothing to regulate how many invites an applicant accepts and thus no intrinsic 'interest' value to an applicant accepting your invite). I think we offered ~25% more interview spots with this in mind.
3. Interviews themselves: surprisingly kinda a wash. Hard on both sides to compare to prev years given it was all virtual but I think there was less 'failing' the interview
4. Rank/Match: I think we didn't rank ~10% of interviewees, in line with previous years. Monday came, didn't fill.
5. Initial response: a little bit of shock/shame in the dept from the older members but a shrug from the younger members. Reflexively looked at SOAP pool.
6. SOAP pool: didn't see the whole pool, just a few names the PD picked out. Basically good students who failed to match into more competitive specialties. No prior rad onc exposure. We declined to consider anyone, withdrew from SOAP.
7. Matched: dunno who they are yet but not worried about them. We only ranked people that showed good interest, had the skills to do the job, and would be a good fit for the dept.

Overall I think our dept took the right approach: extended more interviews than normal given covid but maintained some (admittedly looser) standards in who we did interview, didn't rank people that weren't a good fit, then didn't SOAP. We'll be down a spot which as caused an ego bruise with the older faculty but is seen as honorable within the younger faculty. Not sure if that causes a greater problem within GME ("you have an unfilled spot! you must be doing something wrong!").

 

[elementaryschooleconomics]

We'll be down a spot which as caused an ego bruise with the older faculty but is seen as honorable within the younger faculty.

Boomer vs Millennial in a nutshell - "what's good for me" vs "what's good for the group"

 

[Mandelin Rain]

Just as a warning to potential future applicant: If you fail USMLE Part 1 several times, you're going to have a hell of a hard time passing our board gauntlet. Worth a consideration, if you eventually want to work.

 

[Mandelin Rain]

Wonder how next year might go assuming departments go back to in person interviews.

It's really easy for an applicant to schedule 40 zoom interviews with any program they're remotely interested in. Much tougher to pay and find time for travel to lower tiered programs. My guess is, the hellpits will have trouble finding people to even willing to interview unless they throw cash at them.

Other thought is, perhaps when departments get a taste of SOAP, they will stop using it. That will start in earnest next year as last year's class finishes their intern year and is trying to figure out what an isocenter is.

 

[elementaryschooleconomics]

Just as a warning to potential future applicant: If you fail USMLE Part 1 several times, you're going to have a hell of a hard time passing our board gauntlet. Worth a consideration, if you eventually want to work.

Conversely, if you thought the Biochemistry minutiae of Step 1 was totally warranted and thought "I wish I could answer more trivia questions like my career depended on it", RadOnc is for you!

 

[TheWallnerus]

Just as a warning to potential future applicant: If you fail USMLE Part 1 several times, you're going to have a hell of a hard time passing our board gauntlet. Worth a consideration, if you eventually want to work.

I have both “3 writtens become just one written” and “no more oral boards” on my 2020s Bingo card.

 

[Mandelin Rain]

I have both “3 writtens become just one written” and “no more oral boards” on my 2020s Bingo card.

If the pool is indeed as cited above, something will have to give.

 

[thecarbonionangle]

Just as a warning to potential future applicant: If you fail USMLE Part 1 several times, you're going to have a hell of a hard time passing our board gauntlet. Worth a consideration, if you eventually want to work.

this. We have arguably one of the most burdensome board process compared to other specialties. Four board exams. Totally ridiculous and unnecessary. Wait until these people who barely passed their classes and failed step multiple times try to pass our boards, coming out of a low education culture hellpit. Total disaster.

 

[thecarbonionangle]

Boomer vs Millennial in a nutshell - "what's good for me" vs "what's good for the group"

anybody who looks at curren situation, so called “older” (boomer) faculty, and is just butt hurt and annoyed about being down a resident and not having someone to do scut, should maybe retire. They have had a good run and their time has passed.

departments who have young and old faculty who cannot function without a resident is not uncommon.

 

[Ray D. Ayshun]

So is there a thought that the unfilled number would've been higher if not for covid and virtual interviews? Anonymous poster said they interviewed 25% more than last year and didn't rank 10%. Iow, they went partially matched while ranking more.

 

[medgator]

I have both “3 writtens become just one written” and “no more oral boards” on my 2020s Bingo card.

Was thinking more of switching to matching instead of sticking with multiple choice....

 

[Dan Spratt]

Argument was BS from the get go b/c of SOAPing. I believe I made comments stating the same in that thread four years ago. I really don't understand why anyone puts any faith in our "leadership" weather its Zietman, a newly woke KO, D. Spratt, the no SOAPing in this program pledgers or anyone else. Literally the only thing that is relevant is reducing complaint and or closing programs. When they start doing that they maybe be worth listening to.

Finally I am woke 😁. I have no clue what happened here at U of M (assume they matched), and when I start at UH/Case in a few months I think the caliber of any hire/recruit/match is of critical importance. Residents included and will be a major focus for the coming year.

SOAP is a problem, but ignores the bigger picture and bigger problem. As so many of you have said, the quality of applicants/standards have simply been lowered. That has happened even at good programs. The SOAP is an easy target to blame, but there are likely another 60+ applicants with similar or even worse applications who actually matched.

It is funny to read that ppl associate good programs with those that fully match, when that is totally based on standards of who to interview and how many you interview. Standards have been massively lowered to the point I have been in shock the past few years. So much more I could say on this.

We have over expanded our field and solutions won’t come from simply PDs or Chairs or IJROBP/PRO editorials. They will come from ASTRO/ABR rules to strongly encourage = mandate Chairs/PDs follow. I had great training in NYC, but remember that MDACC, MSKCC, and HROP have ~25 slots. That means a massive percentage of our field is trained at three programs. This always blew my mind.

Programs with 1 slot each year for 4 years need to be looked at closely to why they exist. From purely an education standpoint I think 1 resident per year is too few and programs should really have 2-3 per year. Important for residents to have co residents. More than 3-4 per year I don’t see why they need more slots.

There are programs without protons, gamma knife, good brachy volume, and MR linac, etc. Ideally training programs should train residents in diverse and broad aspects of radonc.

So don’t let SOAP distract you from an increasingly saturated field that is lowering standards, and a field that needs innovation to expand RT indications.

I would have no issue with ppl filling SOAP slots if they were strong and qualified, the training program could train them in many things, and they would get a good job. Many programs are not taking strong applicants, have training programs that solely offer photon LINAC RT, and struggle for their residents to get jobs. Don’t let SOAP distract you from what is actually happening, which many of you are well aware of.

I love radonc and still believe it is an incredible field with a bright future. I am optimistic change will come, but I also understand the reality of what has and is happening and why ppl have lost hope. I am super excited to try to make change, even in a microcosm! Will work my tail off to make Case/UH a great place to train and work and not to contribute to the problem.

best

 

[radonc17]

Finally I am woke 😁. I have no clue what happened here at U of M (assume they matched), and when I start at UH/Case in a few months I think the caliber of any hire/recruit/match is of critical importance. Residents included and will be a major focus for the coming year.

SOAP is a problem, but ignores the bigger picture and bigger problem. As so many of you have said, the quality of applicants/standards have simply been lowered. That has happened even at good programs. The SOAP is an easy target to blame, but there are likely another 60+ applicants with similar or even worse applications who actually matched.

It is funny to read that ppl associate good programs with those that fully match, when that is totally based on standards of who to interview and how many you interview. Standards have been massively lowered to the point I have been in shock the past few years. So much more I could say on this.

We have over expanded our field and solutions won’t come from simply PDs or Chairs or IJROBP/PRO editorials. They will come from ASTRO/ABR rules to strongly encourage = mandate Chairs/PDs follow. I had great training in NYC, but remember that MDACC, MSKCC, and HROP have ~25 slots. That means a massive percentage of our field is trained at three programs. This always blew my mind.

Programs with 1 slot each year for 4 years need to be looked at closely to why they exist. From purely an education standpoint I think 1 resident per year is too few and programs should really have 2-3 per year. Important for residents to have co residents. More than 3-4 per year I don’t see why they need more slots.

There are programs without protons, gamma knife, good brachy volume, and MR linac, etc. Ideally training programs should train residents in diverse and broad aspects of radonc.

So don’t let SOAP distract you from an increasingly saturated field that is lowering standards, and a field that needs innovation to expand RT indications.

I would have no issue with ppl filling SOAP slots if they were strong and qualified, the training program could train them in many things, and they would get a good job. Many programs are not taking strong applicants, have training programs that solely offer photon LINAC RT, and struggle for their residents to get jobs. Don’t let SOAP distract you from what is actually happening, which many of you are well aware of.

I love radonc and still believe it is an incredible field with a bright future. I am optimistic change will come, but I also understand the reality of what has and is happening and why ppl have lost hope. I am super excited to try to make change, even in a microcosm! Will work my tail off to make Case/UH a great place to train and work and not to contribute to the problem.

best

thanks @Dan Spratt

it’s nice to see at least 1 chair listen to us after all these years

progress...?? Lol

 

[elementaryschooleconomics]

Finally I am woke 😁. I have no clue what happened here at U of M (assume they matched), and when I start at UH/Case in a few months I think the caliber of any hire/recruit/match is of critical importance. Residents included and will be a major focus for the coming year.

SOAP is a problem, but ignores the bigger picture and bigger problem. As so many of you have said, the quality of applicants/standards have simply been lowered. That has happened even at good programs. The SOAP is an easy target to blame, but there are likely another 60+ applicants with similar or even worse applications who actually matched.

It is funny to read that ppl associate good programs with those that fully match, when that is totally based on standards of who to interview and how many you interview. Standards have been massively lowered to the point I have been in shock the past few years. So much more I could say on this.

We have over expanded our field and solutions won’t come from simply PDs or Chairs or IJROBP/PRO editorials. They will come from ASTRO/ABR rules to strongly encourage = mandate Chairs/PDs follow. I had great training in NYC, but remember that MDACC, MSKCC, and HROP have ~25 slots. That means a massive percentage of our field is trained at three programs. This always blew my mind.

Programs with 1 slot each year for 4 years need to be looked at closely to why they exist. From purely an education standpoint I think 1 resident per year is too few and programs should really have 2-3 per year. Important for residents to have co residents. More than 3-4 per year I don’t see why they need more slots.

There are programs without protons, gamma knife, good brachy volume, and MR linac, etc. Ideally training programs should train residents in diverse and broad aspects of radonc.

So don’t let SOAP distract you from an increasingly saturated field that is lowering standards, and a field that needs innovation to expand RT indications.

I would have no issue with ppl filling SOAP slots if they were strong and qualified, the training program could train them in many things, and they would get a good job. Many programs are not taking strong applicants, have training programs that solely offer photon LINAC RT, and struggle for their residents to get jobs. Don’t let SOAP distract you from what is actually happening, which many of you are well aware of.

I love radonc and still believe it is an incredible field with a bright future. I am optimistic change will come, but I also understand the reality of what has and is happening and why ppl have lost hope. I am super excited to try to make change, even in a microcosm! Will work my tail off to make Case/UH a great place to train and work and not to contribute to the problem.

best

Dan, I hope when they hand you the Golden Chalice Encrusted with Diamonds filled with the Essence of the Innocent at your inaugural SCAROP meeting, that you remember these opinions.

 

[thecarbonionangle]

Let’s only allow programs with protons. No peasant protons (do you even proton bro?!) . IMPT only actually (no good passive scatter not allowed) with image guidance and breath hold capabilities. Strict spot size requirements and gamma passing rates above 98%. I actually think this is genius. Raise requirements to demand a high number of proton cases even site specific proton cases. Shut them, bottomless hellpits of doom, all down and give out some spots to “good programs” (the proton ones!!). Damn we good. Holla!

 

[Grubbe-a-dub-dub]

Here we go with the same old "small program" blame game. That has nothing to do with it.

I came from a small program that had one of the best physics departments in the country and had all the bells and whistles in terms of tech. My education and depth of training were fantastic and I feel I am pretty competent when it comes to providing good oncology care to the community. Were there some deficiencies in my training, sure, but nothing that a prep course or working closely with some experienced providers in the modality wouldn't solve.

The problem is when I came to my last year to search for a job. Everyone ran for the hills and I was left to fend for myself. Even years later, the chair acts like he doesn't know me and like I didn't spend 4 years in his department supporting his clinical and research programs.

The reason quality applicants don't apply anymore is that they can read between the lines and see this lack of support.

They can see the board certification process becoming too burdensome of a gauntlet to traverse (ie 4 difficult tests, some of which the bar arbitrarily gets set even higher to pass).

They can see the lack of support practicing clinicians get with new reimbursement models that will make it hard for many clinics to survive, let alone all the new prior authorization companies private payers are using to deny payment and make even standard treatments hard to get approval.

They see an end of the line specialty that needs to grovel at the feet of others to support their clinics, without any real ownership of any disease site.

They see the lack of any real funding to support their research endeavors and lack of any protected time to get meaningful research done.

They see a field that is simply not worth their time.

 

[medgator]

At this point I'm good with shutting all the small ones down... Cut the fat somewhere, just cut it dammit, even if it means leaving nothing left but PPS exempt financially toxic nci centers as training sites

 

[RickyScott]

Finally I am woke 😁. I have no clue what happened here at U of M (assume they matched), and when I start at UH/Case in a few months I think the caliber of any hire/recruit/match is of critical importance. Residents included and will be a major focus for the coming year.

SOAP is a problem, but ignores the bigger picture and bigger problem. As so many of you have said, the quality of applicants/standards have simply been lowered. That has happened even at good programs. The SOAP is an easy target to blame, but there are likely another 60+ applicants with similar or even worse applications who actually matched.

It is funny to read that ppl associate good programs with those that fully match, when that is totally based on standards of who to interview and how many you interview. Standards have been massively lowered to the point I have been in shock the past few years. So much more I could say on this.

We have over expanded our field and solutions won’t come from simply PDs or Chairs or IJROBP/PRO editorials. They will come from ASTRO/ABR rules to strongly encourage = mandate Chairs/PDs follow. I had great training in NYC, but remember that MDACC, MSKCC, and HROP have ~25 slots. That means a massive percentage of our field is trained at three programs. This always blew my mind.

Programs with 1 slot each year for 4 years need to be looked at closely to why they exist. From purely an education standpoint I think 1 resident per year is too few and programs should really have 2-3 per year. Important for residents to have co residents. More than 3-4 per year I don’t see why they need more slots.

There are programs without protons, gamma knife, good brachy volume, and MR linac, etc. Ideally training programs should train residents in diverse and broad aspects of radonc.

So don’t let SOAP distract you from an increasingly saturated field that is lowering standards, and a field that needs innovation to expand RT indications.

I would have no issue with ppl filling SOAP slots if they were strong and qualified, the training program could train them in many things, and they would get a good job. Many programs are not taking strong applicants, have training programs that solely offer photon LINAC RT, and struggle for their residents to get jobs. Don’t let SOAP distract you from what is actually happening, which many of you are well aware of.

I love radonc and still believe it is an incredible field with a bright future. I am optimistic change will come, but I also understand the reality of what has and is happening and why ppl have lost hope. I am super excited to try to make change, even in a microcosm! Will work my tail off to make Case/UH a great place to train and work and not to contribute to the problem.

best

Thank you.

 

[deleted941485]

Here we go with the same old "small program" blame game. That has nothing to do with it.

I came from a small program that had one of the best physics departments in the country and had all the bells and whistles in terms of tech. My education and depth of training were fantastic and I feel I am pretty competent when it comes to providing good oncology care to the community. Were there some deficiencies in my training, sure, but nothing that a prep course or working closely with some experienced providers in the modality wouldn't solve.

The problem is when I came to my last year to search for a job. Everyone ran for the hills and I was left to fend for myself. Even years later, the chair acts like he doesn't know me and like I didn't spend 4 years in his department supporting his clinical and research programs.

The reason quality applicants don't apply anymore is that they can read between the lines and see this lack of support.

They can see the board certification process becoming too burdensome of a gauntlet to traverse (ie 4 difficult tests, some of which the bar arbitrarily gets set even higher to pass).

They can see the lack of support practicing clinicians get with new reimbursement models that will make it hard for many clinics to survive, let alone all the new prior authorization companies private payers are using to deny payment and make even standard treatments hard to get approval.

They see an end of the line specialty that needs to grovel at the feet of others to support their clinics, without any real ownership of any disease site.

They see the lack of any real funding to support their research endeavors and lack of any protected time to get meaningful research done.

They see a field that is simply not worth their time.

Someones program has gotta die and the ones with the small footprint will be first...sorry

 

[BobbyHeenan]

Well, I guess Cleveland now houses another rad onc with some stones to tell the truth.

I swore I wouldn’t do it, but if Spratt goes shirtless, face painted, with bull horns on head and storms the ASTRO plenary stage I will faithfully join him.

 

[deleted941485]

Well, I guess Cleveland now houses another rad onc with some stones to tell the truth.

I swore I wouldn’t do it, but if Spratt goes shirtless, face painted, with bull horns on head and storms the ASTRO plenary stage I will faithfully join him.

I just hope he doesnt turn into some side show chair that SDN supports but really nobody else listens to in the rest of the world. But yeah I like him

 

[BobbyHeenan]

I just hope he doesnt turn into some side show chair that SDN supports but really nobody else listens to in the rest of the world. But yeah I like him

Im just kidding, obviously , but I’m a fan. He’s been a good voice for our specialty and isn’t afraid to say unpopular things.

* note: This is not a Dan Spratt alt account.

 

[Dan Spratt]

I just hope he doesnt turn into some side show chair that SDN supports but really nobody else listens to in the rest of the world. But yeah I like him

We shall see. Rarely looking to sit on the sidelines. Try to pop on here now and then as diversity of opinions valuable. Leaders who lose touch are flying blind. Plus it keeps me humble when I read ppl hating on me 😁. No one is perfect.

Lots of competing forces, but progress can be made. Starts somewhere, others follow, etc.

 

[Radonc90]

My 2 cents:

1- Proton: leave it the way it was in 1990s and 2000s. Highly specialized technology that is best left with a few facilities in the country. No need for every program to own a proton machine. Every time I had a pt with base-of-skull chordoma, I sent to Boston, no problems. This is what proton is for.
Proton is not for anatomic sites with big volumes (lung, breast).
The dosimetry might look better with proton but 2 important questions (let's say lung, and breast and I will NOT get into prostate debate):
1. Is outcome better (cancer-free survival)?
2. Cost to society, who is paying for these, now with RO-APM coming...
This country is going bankrupt with significant debt ~ $28 Trillions heading to $30T soon.

Also, one cannot use technology (let's say Proton) to beat biology (nasty lung cancer that is IIIB)...to quote Dr Lester J. Peters...

2- Gamma Knife: many places I know are decommissioning GF bc the majority of the depts in the US can offer SRS or SRT (with or without mask). GF had its days, it is going the way of cassette tapes and VHS tapes.
So the SRS training is basically standard in any program now. Basically treating most mets with SRS or SRT.

3- Brachy: yes some programs don't have good brachy volumes, simply bc technology such as IMRT sadly replaces good brachy.
Prostate brachy will go the wayside soon bc EBRT is as good as brachy without the anesthesia and risks involved with brachy. I have done over 1000 prostate brachy procedures in my life, I enjoyed it, but now with data from IMRT so good, why should I "torture" my patients? The last time I did prostate brachy was some 6-7 yrs ago.
The "real" brachy gurus have slowly retired (Syed, Goffinet, L. Harrison), there are few gurus remaining.
How many people really know how to do a proper oral tongue implant or a good vaginal interstitial, very few...
How many people know how to do soft tissue sarcoma brachy, very few...

4- MRI-Linac: of course on paper, it looks better. But on the long run, it will not affect the ultimate outcome, which is cure of cancer.
MRI-Linac, to me, is a just a Nintendo...Will see how long the Nitendo lasts...
The cost to society is significant, and yet there is no data to support its use.
Who is paying for this: the pt or society?
This is where the field is heading in the wrong direction: significant investment for doubtful outcome.
Again, technology cannot beat the biology.

I have to agree with RW that we need smart physician-scientists, not so much for radonc itself, but for discovery of new cancer treatments, whether it is IO or some other modalities. But my guess is that out of 100 radoncs, only 5% or so should be in the labs, the rest 95% still have to to do the "dirty job", providing safe/effective/outstanding/compassionate care for our cancer pts at as-low-as-reasonably-achieved (ALARA) cost.

We need to advance basic science bc there is where the future is...but only 5% of us need to be in the labs....

5- Program size: I have seen outstanding radonc from small programs with 1 to 1.5 residents/yr.
I have seen horrible radonc from one of the big three you mentioned above: terrible bedside manner, not up-to-date etc.
It all depends on the trainee's desire to read/learn/have discipline...
So closing a program bc it is small in size is NOT a good idea.
Why was Cornell closed, it was not a small program?
Just look back at 1990s data and scale program size back down and things will be fine.
This field has not had good leadership in the last 20 years...

 

[thecarbonionangle]

Equipment my practice has: very good

Equipment my practice does not have: expensive, unproven, who will pay for this???

shut down all hellpits without all modalities!!!!

 

[Music Man Stan]

Equipment my practice has: very good

Equipment my practice does not have: expensive, unproven, who will pay for this???

shut down all hellpits without all modalities!!!!

I strongly agree with this. I think in a training environment, diversity is key. It’s like test driving a bunch of cars and then ultimately choosing a car. Everybody has their own opinion about what is their ideal car but an informed decision is best.

Protons, GammaKnife, Brachy, MR-Linac are all designed to have a better ratio of tumor dose to normal tissue dose. If you keep dose to the tumor constant, you will thus have less morbidity to your patients. Keep the dose to the normal tissue constant, and you’ll have higher tumor control.

I find pencil beam scanned protons to be a wonderful technology and I wish I had access to them again. When people commercialize proton-imaging to eliminate the stopping power uncertainty, I think that I myself would want to be treated using protons (or hopefully carbon ions) when I get cancer. Besides breast cases where you can have an easy exit path, and maybe lung where the plans always looked wonky, I think protons (and carbon) can beat photons.

I think GammaKnife‘s workflow forces very high quality care. I don’t have one currently but forcing the MRI to be done on the same day, and using a rigid headframe really gave me confidence that I “got” the tumor even without using a PTV margin.

Brachytherapy and its high heterogeneity and steep falloff gives incredible control rates if you do things right. I also don’t to brachytherapy in my current practice but I recognize its huge advantages. For example with my morbidly obese population, I wouldn’t be able to get even close to the same dose conformity and gradients for cervical or prostate brachy when using external beam.

And MR Linac - I really miss it for everything in the abdomen. I recently treated a recurrent esophageal case (which recurred in the stomach) and I wish I could have adapted my plan daily (and seen the actual tumor). Air artifacts on my CBCT limited my confidence on alignment too.

Bottom line: While we will all likely settle into using only a few different tools, we should be exposed to the full armatorium of tools to make an informed decision.

 

[RSAOaky]

Big props to Spratt for entering the arena. I’ve always been appreciative of his ability and willingness to draw pragmatic conclusions from the best available data. We’ve reached a critical mass of leadership that is not reflective of its constituency and thus does not have its constituents’ best interests in mind. Hopefully as more and more boomer chairs trying to hold the line just long enough to retire get replaced by a new guard that actually cares about this field, we will start to see some shifting tides.

With the trend of the old boys club protecting its own though, I don’t anticipate the closure of smaller legacy programs any time soon, even though consolidation is probably the right move both from a contraction and an educational quality standpoint. I’m not sure how many times West Virginia needs to go unmatched before we decide they shouldn’t have a program.

It will be interesting to see the radbio/physics pass rates 4 years from now. While everyone was rightfully up in arms (myself included) about the 2018 boards debacle that was explained away as a decline in resident quality, I wonder what will happen in a few years when a field of objectively poorer quality residents take the test.

 

[Dan Spratt]

Here we go with the same old "small program" blame game. That has nothing to do with it.

I came from a small program that had one of the best physics departments in the country and had all the bells and whistles in terms of tech. My education and depth of training were fantastic and I feel I am pretty competent when it comes to providing good oncology care to the community. Were there some deficiencies in my training, sure, but nothing that a prep course or working closely with some experienced providers in the modality wouldn't solve.

The problem is when I came to my last year to search for a job. Everyone ran for the hills and I was left to fend for myself. Even years later, the chair acts like he doesn't know me and like I didn't spend 4 years in his department supporting his clinical and research programs.

The reason quality applicants don't apply anymore is that they can read between the lines and see this lack of support.

They can see the board certification process becoming too burdensome of a gauntlet to traverse (ie 4 difficult tests, some of which the bar arbitrarily gets set even higher to pass).

They can see the lack of support practicing clinicians get with new reimbursement models that will make it hard for many clinics to survive, let alone all the new prior authorization companies private payers are using to deny payment and make even standard treatments hard to get approval.

They see an end of the line specialty that needs to grovel at the feet of others to support their clinics, without any real ownership of any disease site.

They see the lack of any real funding to support their research endeavors and lack of any protected time to get meaningful research done.

They see a field that is simply not worth their time.

Grubbe-
Excellent points. In no way do small programs mean the people that work or train there are in anyway of lesser caliber. As someone who went to public school and then went to a lower caliber undergrad (George State), I recognize the value in the little guys.

The field generally agrees that we have too many residency spots. The solution will need to be to equitably reduce spots. No program, big or small, will like this. However, if every time someone tries to propose a solution it gets shot down the cycle will continue. I think if the goal of training is to be well versed in ones discipline, there is true educational benefit of having more than 1 resident per year. I learned potentially more from my co-residents than I did many of my attendings in training. I also believe training should be to learn many areas of radonc, not just photon EBRT. Just as in surgical training a urologist will learn cystectomies, however in real practice they may choose to never perform one again and just treat kidney stones. If you dont have exposure you are stuck doing only what you learned. Training should provide experience in peds/protons, GU/GYN/brachy with good volume, ideally both benign and malignant CNS conditions (trigeminal neuralgia most would never treat without a gamma knife), etc. Wash U St Louis is a great example of a program that trainees see protons, photons, MR Linac, brachy, etc. If graduates want to leave and just do photons, great. If they want to go to a place doing brachy or protons or MR linac RT they have the credentials to get a job and will out compete people that just have learned 1 thing.

I by no means have "THE" solution, but people must agree on a few basic points to move forward:
1. What defines an optimal training environment? Given there are 30+ programs with protons and growing throughout the world, and fewer and fewer programs have robust brachy programs, and more and more having adaptive (ethos) and MR Linac, should residency programs have standards of what they can offer?
2. Is there educational benefit to having more than 1 resident per year?
3. Is there educational benefit to having more than 3 residents per year (this may vary for some programs that functionally are multiple hospitals like HROP vs MSKCC)?

If we have ~180 slots per year, and the market supports <130 per year, some equitable standards need to be made. This again has nothing to do with SOAP as many who match now are less qualified than SOAP candidates. It has to do with providing excellent training that allows people to get jobs and contribute meaningfully to our field and help patients.

Perhaps in remote areas of the country the standards should be different than large urban areas. I dont know, but you must start somewhere.

Best,
Dan

 

[Dan Spratt]

My 2 cents:

1- Proton: leave it the way it was in 1990s and 2000s. Highly specialized technology that is best left with a few facilities in the country. No need for every program to own a proton machine. Every time I had a pt with base-of-skull chordoma, I sent to Boston, no problems. This is what proton is for.
Proton is not for anatomic sites with big volumes (lung, breast).
The dosimetry might look better with proton but 2 important questions (let's say lung, and breast and I will NOT get into prostate debate):
1. Is outcome better (cancer-free survival)?
2. Cost to society, who is paying for these, now with RO-APM coming...
This country is going bankrupt with significant debt ~ $28 Trillions heading to $30T soon.

Also, one cannot use technology (let's say Proton) to beat biology (nasty lung cancer that is IIIB)...to quote Dr Lester J. Peters...

2- Gamma Knife: many places I know are decommissioning GF bc the majority of the depts in the US can offer SRS or SRT (with or without mask). GF had its days, it is going the way of cassette tapes and VHS tapes.
So the SRS training is basically standard in any program now. Basically treating most mets with SRS or SRT.

3- Brachy: yes some programs don't have good brachy volumes, simply bc technology such as IMRT sadly replaces good brachy.
Prostate brachy will go the wayside soon bc EBRT is as good as brachy without the anesthesia and risks involved with brachy. I have done over 1000 prostate brachy procedures in my life, I enjoyed it, but now with data from IMRT so good, why should I "torture" my patients? The last time I did prostate brachy was some 6-7 yrs ago.
The "real" brachy gurus have slowly retired (Syed, Goffinet, L. Harrison), there are few gurus remaining.
How many people really know how to do a proper oral tongue implant or a good vaginal interstitial, very few...
How many people know how to do soft tissue sarcoma brachy, very few...

4- MRI-Linac: of course on paper, it looks better. But on the long run, it will not affect the ultimate outcome, which is cure of cancer.
MRI-Linac, to me, is a just a Nintendo...Will see how long the Nitendo lasts...
The cost to society is significant, and yet there is no data to support its use.
Who is paying for this: the pt or society?
This is where the field is heading in the wrong direction: significant investment for doubtful outcome.
Again, technology cannot beat the biology.

I have to agree with RW that we need smart physician-scientists, not so much for radonc itself, but for discovery of new cancer treatments, whether it is IO or some other modalities. But my guess is that out of 100 radoncs, only 5% or so should be in the labs, the rest 95% still have to to do the "dirty job", providing safe/effective/outstanding/compassionate care for our cancer pts at as-low-as-reasonably-achieved (ALARA) cost.

We need to advance basic science bc there is where the future is...but only 5% of us need to be in the labs....

5- Program size: I have seen outstanding radonc from small programs with 1 to 1.5 residents/yr.
I have seen horrible radonc from one of the big three you mentioned above: terrible bedside manner, not up-to-date etc.
It all depends on the trainee's desire to read/learn/have discipline...
So closing a program bc it is small in size is NOT a good idea.
Why was Cornell closed, it was not a small program?
Just look back at 1990s data and scale program size back down and things will be fine.
This field has not had good leadership in the last 20 years...

I agree with many of these points, but not all. In practice you are spot on that you may need nothing more than a LINAC to treat 90%+ of patients. This is different than training. One can't predict where the field is going, and training should train people in the breadth of radonc as best as possible. Some will love brachy, some protons, some SRS, some adaptive, etc. No different than surgeons learning dozens of different surgical techniques, equipment/tools, etc, and they will decide what and how they treat patients when they get a job. If they only learned to do hernia repairs they will struggle to get a job and stay relevant. Even if they are the best at hernia repairs I wish I had exposure to more than just brachy and photons in training, and that was when there were very few proton centers, no MR Linacs, etc. Now it is even more important for trainees to have this exposure and experience.

 

[TheWallnerus]

I wish I had exposure to more than just brachy and photons in training, and that was when there were very few proton centers, no MR Linacs, etc. Now it is even more important for trainees to have this exposure and experience.

It's been quite a party thus far with academic centers able to efficiently absorb the slack in the market by having obscene profit margins built on the back of private insurance companies. (And thus why most rad oncs working in US are now academic, or "academic.") ASTRO "lost their s**t* over APM because it saw a gravy train ending that those in the community were kind of "meh" to. A proforma for a CMS patient with MRgRT looks incredible right now; it'll look pretty scary to buy a $6+ million dollar machine if that proforma looks the same regardless the machine. If private insurance adopts APM pricing, the "arms race" era of rad onc (oh you got protons? me too! oh you got an MRgRT machine? me too!) will be on the ropes.

 

[Conn Seannery]

As a dosimetrist, I'm disturbed that this place is ACR accredited.

 

[RadsRocks!]

Will you guys/gals be happy for the students who match into your programs?

 

[TheWallnerus]

As a dosimetrist, I'm disturbed that this place is ACR accredited.

Now *this* is choosing violence!

 

[elementaryschooleconomics]

Will you guys/gals be happy for the students who match into your programs?

Fortunately, I've only got a few months left of training, so I can easily just reply to the email my PD will send out with "WELCOME!" or something equivalently cheesy/insignificant, and then never talk to these kids again.

 

[RadOncDoc21]

Now *this* is choosing violence!

Wow... this can’t be real

 

[w00tz]

Wow... this can’t be real

Lol, definitely a fake account. Joined March 2021, 1 follower.

 

[RickyScott]

Wow... this can’t be real

? The acr accreditation?

 

[Gfunk6]

Some folks'll never eat a skunk but then again some folk'll, like CLETUS the slack jawed yokel!

 

[Radonc 2013]

It looks like 35 unfilled positions for programs offering PGY-2 positions. https://mk0nrmp3oyqui6wqfm.kinstacd...ds/2021/03/Advance-Data-Tables-2021_Final.pdf

 

[Mandelin Rain]

It looks like 35 unfilled positions for programs offering PGY-2 positions. https://mk0nrmp3oyqui6wqfm.kinstacd...ds/2021/03/Advance-Data-Tables-2021_Final.pdf

54% US MD seniors. 5.8% US DO seniors. Rest unfilled or FMG.

Like completely inconceivable a decade ago.

 

[evilbooyaa]

I came here to say this and you nailed it. The old posts of "anonymous interview reviews" were a gold mine when getting a flavor of programs. What if we had a thread on Tales from the Job Hunt? Could be sent to @Neuronix and posted anonymously. I personally know of 3 people from this year who got quite far in the interview process only to have a job vaporize. Doesn't do much good with me reporting that, we need the firsthand accounts. @radonc17 already shared a bit about the RadOnc vs MedOnc job hunt. Would love to hear more like that. Cities and regions could be changed to protect the innocent.

The surveys are being done and there are real benefits to publishing these, but we all know the drawbacks when your preferred geographic region is inclusive of CA and Idaho. This could be the next best thing, a case series. I think getting something like this going before the intriguing April 1st Existential Threat Zoom Summit would be useful.

Happy to help with this as well if desired.

 

[Vandalia]

Since WVU has been mentioned, interesting that no WVU student matched in radiation oncology.

If you have the President-Elect of ASTRO as the department chair and no student this year selected the specialty that is .... interesting.

2021 | School of Medicine | West Virginia University

 

[Radonc90]

54% US MD seniors. 5.8% US DO seniors. Rest unfilled or FMG.

Like completely inconceivable a decade ago.

Interesting...

I am almost sure most of the 35 unfilled spots will eventually be filled anyway.

There are ___ US grads per yr, and there are a finite ____ residency slots (everything from IntMed to Pathology to GenSurg etc.), people who don't match in their chosen specialty may end up in radonc.
I feel bad for these M4s who don't match and have to SOAP. Let's say an M4 is not matched to let's say Derm and decided to SOAP into radonc, we should not blame the student, he/she needs a job, we should blame the programs that SOAP.

NRMP Match in one photo:
- RED = Rad Onc.
- GREEN = I didn't know there are only 2 programs offering Nuc Med in this country. Learning something everyday.

---

 

[thecarbonionangle]

In all seriousness, anybody who matches rad onc is now our eskimo brother/sister , cut bloody handshake brother/sister. I want to say congratulations to anybody who matched and welcome you, hold door open for you. I hope you can join us as we all work together to improve the field we all love. Enjoy the journey.

 

[CurbYourExpectations]

RadOnc with more unmatched spots than every other advanced specialty combined. The only logical explanation is people are not aware of RadOnc, definitely not the worrisome job prospects in the near future.

 

[medgator]

AUC grad matched at CRWU... Amazing how much things are coming full circle. Gonna need the rad oncs who went to caribbean schools 20+years ago maybe to start an orientation group for them coming back to the states....

 

[TheWallnerus]

About 104 U.S. seniors tried to match rad onc, and about 94 succeeded?

Honestly that's Blink-level, market-fully-informed level numbers. U.S. med students showing high levels of insight and intelligence as usual, and if you think about it a few programs tried to be discerning (ie some U.S. MDs unmatched) and also let the market correct itself. If it stopped at these numbers it would be an almost perfect attempt by the market to correct itself. But no! This is not a truly free market, is it. Not only were/are we oversupplied in ROs nationally by twofold, now we're over-correcting the market by twofold, too.

 

[DebtRising]

The best force is to have a whistleblower complaint to CMS that these programs, such as WVU, are committing Medicare fraud by using residency slots for a field with no demand from the population, and adequate staffing for decades. But not all slots are Medicare funded.

Another is to bring to attention the lax requirements of our residency completion by the ACGME and make them a party to a medical malpractice lawsuit. But these are hard to find and personal, and would likely involve judgement.

Otherwise, WVU’s gonna WVU and you can see how much support we get from ASTRO. The amount of programs that SOAP this year and last year shows the “leaders” would rather have people with no draw to cancer care or inability to get in other specialities as up to 25% of our graduating class. And no individual should be made to feel shame here or singled out - but some gal/guy who woke up and was like “man I didn’t get OB, maybe FM or rad onc” should be supported? What was the value of our work? What was the value of screening to see who would be good in cancer care? Or research / physics driven?