Off-Topic Discards

[Mandelin Rain]

It would probably help reduce the number of candidates matching into the specialty if they understand how much work is being supported by the supervision requirements.

I think information symmetry would be a good thing here

Agreed. Demand for rad oncs is probably buoyed by about 25% just based on the abundance of caution that most exercise with the supervision rule. If the CMS rule was ever fully clarified (I honestly don't think it's altogether unclear as is currently) it could decimate the job market overnight. It's hard to say if bundled payments would lead to more hospitals trying to find alternative supervision options. I think IGRT is probably the most uncertain portion of having a non-rad onc physician or non-physician provider supervise daily treatments in the hospital setting, but if that's all bundled into a single, static reimbursement, what then?

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[RTx]

Most of my medicine colleagues including oncology rarely review actual images... just the report.
Can't imagine your average NP/PA is going to feel comfortable..

 

[Mandelin Rain]

Most of my medicine colleagues including oncology rarely review actual images... just the report.
Can't imagine your average NP/PA is going to feel comfortable..

A few points:
1. We all trust RTTs who have *gasp* even less schooling than NPs to line up IGRT every single day.
2. No one is talking about taking an “average” NP off the street. They specialize. The learn the field they work in.
3. All you need to know to supervise is to not treat if something looks grossly incorrect.
4. Physician offline review exists.
5. I’m pretty sure I could teach a monkey to review a kVkV match in 10 minutes (hint: When overlaid, the bones line up to the same bones) and a CBCT in 10 days.
6. At any point during your residency did an attending physician sit down with you for hours or days or weeks to “teach” you how to review IGRT images? Or did you just kind of pick it up naturally because it’s not too hard and you’re a reasonably intelligent person?

 

[RTx]

A few points:
1. We all trust RTTs who have *gasp* even less schooling than NPs to line up IGRT every single day.
2. No one is talking about taking an “average” NP off the street. They specialize. The learn the field they work in.
3. All you need to know to supervise is to not treat if something looks grossly incorrect.
4. Physician offline review exists.
5. I’m pretty sure I could teach a monkey to review a kVkV match in 10 minutes (hint: When overlaid, the bones line up to the same bones) and a CBCT in 10 days.
6. At any point during your residency did an attending physician sit down with you for hours or days or weeks to “teach” you how to review IGRT images? Or did you just kind of pick it up naturally because it’s not too hard and you’re a reasonably intelligent person?

Good points and well-taken. Though RTTs come out of school ready to perform this task. Who is going to decide when a midlevel is ready to do that. Further RTTs come to you when there is an issue outside of their comfort- in other words... you’re still available.

I would argue the issue is when things don’t line up perfectly... oh the CBCT is off because the patient lost some weight... let’s postpone their fraction for HNSCC today.... yikes.

If you were the patient, who would you want verifying your images everyday you got ionizing radiation.

 

[medgator]

Arguments on both sides. At the end of the day, how are you going to feel if you and your np end up in the courtroom? It's probably fine, but it is going to be one of those things where we won't really know until we see a legal case.

There have been plenty of hospital/hospital groups and freestanding groups that have had to settle qui tam lawsuits in the multiple million dollar range. Full stop.

 

[Mandelin Rain]

Good points and well-taken. Though RTTs come out of school ready to perform this task. Who is going to decide when a midlevel is ready to do that. Further RTTs come to you when there is an issue outside of their comfort- in other words... you’re still available.

I would argue the issue is when things don’t line up perfectly... oh the CBCT is off because the patient lost some weight... let’s postpone their fraction for HNSCC today.... yikes.

If you were the patient, who would you want verifying your images everyday you got ionizing radiation.

You decide when someone is ready to do the task you delegate to them. When I started, I watched CBCTs like a hawk at the linac initially until I gained a comfort level with my RTTs. I assume I’d do the same with a resident or NP or PA or whatever if I asked them to do that.

if I were a patient, I’d probably want my doc approving my images (after treatment, mind you), but would I really care if they were doing it at their desk in my clinic after hours or at a desk in another clinic after hours? Probably not.

 

[Mandelin Rain]

Arguments on both sides. At the end of the day, how are you going to feel if you and your np end up in the courtroom? It's probably fine, but it is going to be one of those things where we won't really know until we see a legal case.

There have been plenty of hospital/hospital groups and freestanding groups that have had to settle multi-million dollar qui tam lawsuits. Full stop.

Sure. Without knowing the Full details of those cases, it’s hard to comment. my guess is obvious and blatant fraud was taking place in all of them.

But if it ever were the case, I’d probably submit the CMS rule allowing physician or non-physician providers to supervise treatments. More likely, the case would never be heard in the absence of other offenses because that rule exists.

 

[medgator]

Sure. Without knowing the Full details of those cases, it’s hard to comment. my guess is obvious and blatant fraud was taking place in all of them.

But if it ever were the case, I’d probably submit the CMS rule allowing physician or non-physician providers to supervise treatments. More likely, the case would never be heard in the absence of other offenses because that rule exists.

Nearly all of them have a component of supervision thrown in there, even the hospital based ones. I have yet to see a NP case, but using a med onc next door seems to be considered not kosher

Target tumors, not yourself: A review of False Claims Act allegations against radiation oncologists | Applied Radiation Oncology

appliedradiationoncology.com

 

[MegaVoltagePhoton]

It would probably help reduce the number of candidates matching into the specialty if they understand how much work is being supported by the supervision requirements.

I think information symmetry would be a good thing here.

Supervision reqs, APM, hypofx, SBRT, increasing surveillance in prostate and some breast etc are all indications for reduced RO labor. We should be screaming this at the top of our lungs to anyone who will listen, because no one on #radonc Twitter likely will

Well, don't misunderstand me. I agree about everything you said and others have said, except the ones where some random administrator or other specialist could stumble upon it and look into it. Meaning, the more rad oncs publically talk about ceding supervisions recs or SRS brain, the more others will pick up on it. The same is not true for APM (driven by goverment) or hypofx (horse is out of the barn already).

Just saying be careful.