On the role of known and anonymous forums in Radiation Oncology

[elementaryschooleconomics]

I’ve been following the Google Spreadsheet this year and have refrained from commenting because I do actually believe that it should be a space reserved for current M4s discussing the match. However, there are many instances of people saying “ignore the SDN trolls and listen to your mentor/advisor” and I felt the need to clarify a few things.

Just to get it out of the way - there are definitely a few folks on here who seem to exist only to stir the pot. I’m not entirely sure what the motivation is for those people, as their existence is a true enigma to me. However, they are in the minority, and they usually end up censored or banned.

What was not apparent to me as a medical student, or even as a junior resident, is the fact that Radiation Oncology is so small that it essentially creates High School Drama on a national, professional level. High School Drama, known in these circles as “Academic Politics”, is extraordinarily vicious. There’s actually a formulation for this - Sayre’s Law, which states that “in any dispute the intensity of feeling is inversely proportional to the value of the issues at stake”.

Obviously, this happens in every field in every department across America (and, likely, the planet). However, with RadOnc being one of the smallest specialties with one of the tightest (and worsening) job markets, this issue becomes particularly salient. All these “big names” we discuss on SDN and Twitter - I have personally met and interacted with many of these people in real life over the years. Face-to-face (with a notable exception here and there) they’re all wonderful, personable, and I genuinely enjoy(ed) my time with them.

I guess my thesis with this post: the reason you see such vitriol on SDN, obsequiousness on Twitter, and nebulous platitudes in real life, is that we’re all mired in this game of High School Drama and each of these venues provides a particular outlet for certain energies. However, you should not be quick to ignore any of them out of hand, because they all provide valuable information.

As you approach and absorb these different venues, I would encourage you to keep the following in mind:

SDN: As far as I know, SDN is the only large and anonymous platform where Radiation Oncology is discussed. As such, this will attract mostly negative comments, because it’s probably the only safe space to bring them right now. If you say “I regret going into RadOnc” in real life to colleagues, you will be shunned. You cannot do this. However, SDN is a tremendous resource to actually see the cracks in the shining armor you’re presented as a medical student. It will skew negative, sometimes very negative, but these are real issues. Ignore SDN at your own risk.

Twitter: I actually saw this brought up on the Spreadsheet - Twitter is used in our specialty like how it’s used by the general public. People love attention. Yes, these people REALLY DO want to be considered “influencers”. Thought leaders are a big thing in academics, previously a position attained through traditional means like publishing papers and speaking at conferences. However, for better or for worse, Twitter now presents a way for people to gain influence from the comfort of their cell phones in their offices. Twitter is going to skew very positively. As a side note, that’s why you should REALLY perk up about the job market if the Twitterati are acknowledging issues such as the CMS supervision change. Twitter is where hot-button social issues exist, and where you can learn about what topics you shouldn’t disagree with in real life (i.e. “URMs and women in medicine are a zero sum game, perhaps they should pick other specialties with fewer restrictions than what RadOnc is facing right now”). Ignore Twitter at your own risk.

Real Life: The issue with real life (other than the existential horror), especially as a medical student in an academic setting, is that you’re surrounded by people who have immersed themselves in a particular topic/point of view/etc. I also exist in real life and will frequently broach the issues I see on Twitter and SDN in very non-threatening ways, basically “hey Dr Vice Chair of my Department, I heard about this particular issue, do you have an opinion, I’d like to partake in your esteemed opinion”. Many of these people have no idea what I’m asking about, and just respond with “everything will be fine, you’ll be fine”. Are these people intentionally ignorant? Absolutely not. They’re well established individuals with deep and impressive knowledge about their particular subjects, often tasked with running sections of departments/whole departments/entire cancer centers, etc. As such, there’s really no need for a tenured Professor of Radiation Oncology to concern themselves with issues such as APM or direct vs general supervision. Really, who you should be asking are the people who run the billing section of your department, but I digress. The people who advise medical students are the cream who rise to the top. Through certain events, publications, timing, etc each of them have a story and can teach you very valuable lessons and you SHOULD LISTEN TO THESE PEOPLE. However, few of them have their fingers on the pulse of Healthcare in America, and will default to thinking “everything worked out fine for me, therefore, it will work out fine for you”. Real life mentors provide tremendous value in many areas, ignore them at your own risk.

To boil down my personal experience after nearly two decades in academics:

SDN will skew negative, Twitter will skew positive, and real life will skew based on that person’s life experience and tactfulness.

Nothing should be ignored.

Ignorantia juris non excusat.

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[medgator]

Great post, should be stickied

 

[deleted18755]

I agree . . . excellent post.

The only thing that I would add, or rather emphasize, is that I am sure that for everybody on twitter who is knowingly falsely voicing very positive opinions and people on here or elsewhere who are knowingly expressing false negative opinions, there are probably ten people who are genuine but providing medical students horrible advise based on their experiences 5-10 or maybe even 15-20 years ago (I fear sometimes that I am one of them!) without realizing how much has changed outside of one's bubble.

I have no idea how medical students are supposed to figure things out but perhaps try to speak with people in different settings and at different points in their career.

 

[elementaryschooleconomics]

I agree . . . excellent post.

The only thing that I would add, or rather emphasize, is that I am sure that for everybody on twitter who is knowingly falsely voicing very positive opinions and people on here or elsewhere who are knowingly expressing false negative opinions, there are probably ten people who are genuine but providing medical students horrible advise based on their experiences 5-10 or maybe even 15-20 years ago (I fear sometimes that I am one of them!) without realizing how much has changed outside of one's bubble.

I have no idea how medical students are supposed to figure things out but perhaps try to speak with people in different settings and at different points in their career.

Ah I strongly agree with this, but only because I have time and experience to have attained this perspective. This is not intuitive or apparent to students, because medicine grooms you to give deference to authority at all times.

It would indeed be best to speak to people in different settings at different stages. However, then you're faced with the challenge of synthesizing what information is good and relevant, which is extraordinarily difficult as a student (or a resident, or an attending, or a chair, or a...).

I guess a well-informed student is basically faced with the personal calculus: "Knowing the difficulty of the job market of Radiation Oncology [or some other aspect in a negative column], do I love this field to a degree such that I am OK with accepting this downside?"

If the answer is "Yes", I'll see you at ASTRO!

 

[Krukenberg]

Ah I strongly agree with this, but only because I have time and experience to have attained this perspective. This is not intuitive or apparent to students, because medicine grooms you to give deference to authority at all times.

It would indeed be best to speak to people in different settings at different stages. However, then you're faced with the challenge of synthesizing what information is good and relevant, which is extraordinarily difficult as a student (or a resident, or an attending, or a chair, or a...).

I guess a well-informed student is basically faced with the personal calculus: "Knowing the difficulty of the job market of Radiation Oncology [or some other aspect in a negative column], do I love this field to a degree such that I am OK with accepting this downside?"

If the answer is "Yes", I'll see you at ASTRO!

agree. The key here is that any applicant who has read this forum knows the risks and has decided they love the field and are ok with not having the geographic flexibility of family med or psych. Further scaremongering to persuade these applicants to switch fields mid-interview season is not fair to them.

 

[elementaryschooleconomics]

agree. The key here is that any applicant who has read this forum knows the risks and has decided they love the field and are ok with not having the geographic flexibility of family med or psych. Further scaremongering to persuade these applicants to switch fields mid-interview season is not fair to them.

I would place a footnote on this - CMS hit us totally randomly with the supervision rule change on November 1st, with uncertain but almost without question negative effects for most of us.

Blame CMS for the mid-interview season timing.

 

[medgator]

agree. The key here is that any applicant who has read this forum knows the risks and has decided they love the field and are ok with not having the geographic flexibility of family med or psych. Further scaremongering to persuade these applicants to switch fields mid-interview season is not fair to them.

Are you kidding? 11/1/20 will live in infamy thanks to CMS

 

[RickyScott]

Are you kidding? 11/1/20 will live in infamy thanks to CMS

the cms ruling will not be as devastating as the apm and 1000 new residents in the next 5 years.

 

[deleted774703]

I give honest advice on the field when students ask me including residency expansion and how to put yourself in position to still get the best job possible

With the new APM and HOPPS ruling, I honestly don't know what to say that wouldn't at best be worded as "overly optimistic"

Choose the field if you really love it and nothing else can make you happy. There are going to be ridiculous challanges awaiting you.

Otherwise, GTFO while you can lol

 

[medgator]

the cms ruling will not be as devastating as the apm and 1000 new residents in the next 5 years.

It is certainly significant enough to be mentioned as yet another risk factor in applying to the specialty, contrary to what @Krukenberg s post would suggest

 

[elementaryschooleconomics]

the cms ruling will not be as devastating as the apm and 1000 new residents in the next 5 years.

This is true, but these were issues known to us 6, 12, 18 months ago (APM was first proposed years ago, I believe 2015 and 2017 were landmark years for the proposal ).

However, I definitely appreciate what @Krukenberg is trying to advocate for. Anyone who read these forums over the past year doesn't deserve to be beat over the head with APM/Residency expansion, they should know - if they've done their homework. If they didn't, that's on them.

The CMS ruling and its timing could not have come at a worse time for these applicants, because it REALLY ratcheted up the rhetoric and fear. Love it or hate it, "linac babysitting" was a huge job security blanket for the field for 10-15 years. Taking that need away throws things into turmoil.

As I've said elsewhere, I want to be wrong about my sad view of the job market. But what's happening on SDN and Twitter right now is sort of "real time processing" for people as we try to understand what this means for those of us locked into the profession. I have tried (and will continue to try) to have these conversations in real life with my department and colleagues, but there's very few of them who are even aware of what the APM is, let alone direct vs general supervision (I imagine this will change in the coming months).

I think my goal with posting is to dissuade future (even current) applicants who are on the fence. Again, if you cannot see yourself doing anything else, I will welcome you with open arms. In real life, few things make me happier than working with genuinely interested/passionate students, whether in the clinic or research arenas. I will continue to do so. I will also be very honest during interview season this year, however, I will do so with the utmost tact. So, lurkers reading this post, I'm sure some of us will meet in real life without knowing it - I promise to be honest with you about my feelings, within the constraints imposed on me by Radiation High School™ . Then you can have a "real life" example in your personal consideration of the field. However, I will continue to play the game and show up in photographs with popular Twitter tags. I sure as hell didn't make it this far being tone deaf to politics.

 

[Chartreuse Wombat]

In a few years someone will write a paper examining the relative contribution of hypofractionation, residency expansion, APM and decreased supervision to the bad job market. At this point it should be inarguable that all of these move the job market in a direction that is good for existing employers and bad for people looking to be employed (winners and losers there will always be). Who cares which is more important?

 

[RadOncMegatron]

I’ve been following the Google Spreadsheet this year and have refrained from commenting because I do actually believe that it should be a space reserved for current M4s discussing the match. However, there are many instances of people saying “ignore the SDN trolls and listen to your mentor/advisor” and I felt the need to clarify a few things.

Just to get it out of the way - there are definitely a few folks on here who seem to exist only to stir the pot. I’m not entirely sure what the motivation is for those people, as their existence is a true enigma to me. However, they are in the minority, and they usually end up censored or banned.

What was not apparent to me as a medical student, or even as a junior resident, is the fact that Radiation Oncology is so small that it essentially creates High School Drama on a national, professional level. High School Drama, known in these circles as “Academic Politics”, is extraordinarily vicious. There’s actually a formulation for this - Sayre’s Law, which states that “in any dispute the intensity of feeling is inversely proportional to the value of the issues at stake”.

Obviously, this happens in every field in every department across America (and, likely, the planet). However, with RadOnc being one of the smallest specialties with one of the tightest (and worsening) job markets, this issue becomes particularly salient. All these “big names” we discuss on SDN and Twitter - I have personally met and interacted with many of these people in real life over the years. Face-to-face (with a notable exception here and there) they’re all wonderful, personable, and I genuinely enjoy(ed) my time with them.

I guess my thesis with this post: the reason you see such vitriol on SDN, obsequiousness on Twitter, and nebulous platitudes in real life, is that we’re all mired in this game of High School Drama and each of these venues provides a particular outlet for certain energies. However, you should not be quick to ignore any of them out of hand, because they all provide valuable information.

As you approach and absorb these different venues, I would encourage you to keep the following in mind:

SDN: As far as I know, SDN is the only large and anonymous platform where Radiation Oncology is discussed. As such, this will attract mostly negative comments, because it’s probably the only safe space to bring them right now. If you say “I regret going into RadOnc” in real life to colleagues, you will be shunned. You cannot do this. However, SDN is a tremendous resource to actually see the cracks in the shining armor you’re presented as a medical student. It will skew negative, sometimes very negative, but these are real issues. Ignore SDN at your own risk.

Twitter: I actually saw this brought up on the Spreadsheet - Twitter is used in our specialty like how it’s used by the general public. People love attention. Yes, these people REALLY DO want to be considered “influencers”. Thought leaders are a big thing in academics, previously a position attained through traditional means like publishing papers and speaking at conferences. However, for better or for worse, Twitter now presents a way for people to gain influence from the comfort of their cell phones in their offices. Twitter is going to skew very positively. As a side note, that’s why you should REALLY perk up about the job market if the Twitterati are acknowledging issues such as the CMS supervision change. Twitter is where hot-button social issues exist, and where you can learn about what topics you shouldn’t disagree with in real life (i.e. “URMs and women in medicine are a zero sum game, perhaps they should pick other specialties with fewer restrictions than what RadOnc is facing right now”). Ignore Twitter at your own risk.

Real Life: The issue with real life (other than the existential horror), especially as a medical student in an academic setting, is that you’re surrounded by people who have immersed themselves in a particular topic/point of view/etc. I also exist in real life and will frequently broach the issues I see on Twitter and SDN in very non-threatening ways, basically “hey Dr Vice Chair of my Department, I heard about this particular issue, do you have an opinion, I’d like to partake in your esteemed opinion”. Many of these people have no idea what I’m asking about, and just respond with “everything will be fine, you’ll be fine”. Are these people intentionally ignorant? Absolutely not. They’re well established individuals with deep and impressive knowledge about their particular subjects, often tasked with running sections of departments/whole departments/entire cancer centers, etc. As such, there’s really no need for a tenured Professor of Radiation Oncology to concern themselves with issues such as APM or direct vs general supervision. Really, who you should be asking are the people who run the billing section of your department, but I digress. The people who advise medical students are the cream who rise to the top. Through certain events, publications, timing, etc each of them have a story and can teach you very valuable lessons and you SHOULD LISTEN TO THESE PEOPLE. However, few of them have their fingers on the pulse of Healthcare in America, and will default to thinking “everything worked out fine for me, therefore, it will work out fine for you”. Real life mentors provide tremendous value in many areas, ignore them at your own risk.

To boil down my personal experience after nearly two decades in academics:

SDN will skew negative, Twitter will skew positive, and real life will skew based on that person’s life experience and tactfulness.

Nothing should be ignored.

Ignorantia juris non excusat.

Agree with this post. I would note one thing that 10 years ago (am I really that old now?) this place was uniformly positive with the only sarcastic comments here are there when someone posted "I am a AOA MD PhD with a step I of 250 - can I make it?!?!?" It's crazy that was the topic a decade ago and now its time to flee for med students.

Although this is an anonymous forum, it is unique in that it is mostly, if not all, radiation oncologists or those interested in coming into the field, giving it more credibility than a random reddit page. We all know, there are very few non med students, non residents, and non rad oncs here. SDN also has a mix of PP, academics, from all across the spectrum, whereas the vocal Twitter people are predominantly the academic elites.

The pulse of the front line practical issues in rad onc is definitely here and not on Twitter as OP noted.

 

[gmsquid]

As I've said elsewhere, I want to be wrong about my sad view of the job market. But what's happening on SDN and Twitter right now is sort of "real time processing" for people as we try to understand what this means for those of us locked into the profession. I have tried (and will continue to try) to have these conversations in real life with my department and colleagues, but there's very few of them who are even aware of what the APM is, let alone direct vs general supervision (I imagine this will change in the coming months).

Sounds like you may also be in academics. I think you hit the nail on the head with this. Academics is a different world than pp. Our pressures are different, and even though everyone trained in academic sites I don’t know if you grasp these pressures as a resident. I only know about apm because our department modified our salary structure to minimize a potential hit in anticipation of it. To be frank, to tell you how clueless I am, I don’t even know how many rvus I do. It’s hard to discuss things we are so disconnected from but I try to bring these issues up to my colleagues because I care about the people we train.

As an aside, I think it’s a bit disingenuous to characterize people in academics as harming the field, when pp groups refuse to hire with the supervision change, because it means they have to pay less money on salary and can pocket the difference. People from both parties are guilty. Ultimately people tend to do what’s in their best interest and remain aloof to the problems of others.

 

[deleted774703]

Sounds like you may also be in academics. I think you hit the nail on the head with this. Academics is a different world than pp. Our pressures are different, and even though everyone trained in academic sites I don’t know if you grasp these pressures as a resident. I only know about apm because our department modified our salary structure to minimize a potential hit in anticipation of it. To be frank, to tell you how clueless I am, I don’t even know how many rvus I do. It’s hard to discuss things we are so disconnected from but I try to bring these issues up to my colleagues because I care about the people we train.

As an aside, I think it’s a bit disingenuous to characterize people in academics as harming the field, when pp groups refuse to hire with the supervision change, because it means they have to pay less money on salary and can pocket the difference. People from both parties are guilty. Ultimately people tend to do what’s in their best interest and remain aloof to the problems of others.

The PP docs didn't overtrain the field

If a chair or PD has any decency, they will create at minimum temporary 3-yr spots for their PGY 4-5s that can't find a job despite realistically trying

 

[medgator]

As an aside, I think it’s a bit disingenuous to characterize people in academics as harming the field, when pp groups refuse to hire with the supervision change, because it means they have to pay less money on salary and can pocket the difference. People from both parties are guilty. Ultimately people tend to do what’s in their best interest and remain aloof to the problems of others.

Really? Did pp groups hire 20 years ago when it "general supervision" just to employ excess grads during a bad job market?

 

[gmsquid]

The PP docs didn't overtrain the field

If a chair or PD has any decency, they will create at minimum temporary 3-yr spots for their PGY 4-5s that can't find a job despite realistically trying

Really? Did pp groups hire 20 years ago when it "general supervision" just to employ excess grads during a bad job market?

Both points are valid. To medgators point, I’m guessing no.

At the end of the day everybody is about their bottom line. Academics trained more because it was feasible to and there was an abundance of riches with good trainees. There was no pulse on the job market. I don’t think it was collusion that said let’s open 80-90 new spots, I think it was a response to interest in the field. And each program was like hey room for one more and before you knew it the market was flooded.

PP groups are cutting positions because it’s feasible to without supervision requirements and now it’s an abundance of riches as well. It’s not collusion here either, people are looking at their bottom line.

 

[RadOncMegatron]

The PP docs didn't overtrain the field

If a chair or PD has any decency, they will create at minimum temporary 3-yr spots for their PGY 4-5s that can't find a job despite realistically trying

Also, in PP you have much more risk and chance to get hurt from the shift in economics. Not saying that it doesn’t effect academics, but the chairs are likely not effected directly by the over saturation of residents, in fact it looks like they benefit with cheap labor and then ability to hire jr faculty at cheaper rates. Incentives for academics much different than PP.

The other issue is clearly there used to be a much collegial relationship between PP and academics where PP could give deference to the expertise of those individuals who are moving the field without feeling threatened economically very much. Now the threat is very real with satellite expansions, glut of residents (controlled only by academics unilaterally mind you), aggressive ad campaigns claiming superiority against community docs (ok this is an admin problem mostly), so now the collegiality is gone. It will be very hard road to be won back at this point. Kudos to those of you trying - we see you!

 

[evilbooyaa]

Great post, should be stickied

Agreed.

Congrats @elementaryschooleconomics

 

[RickyScott]

This is true, but these were issues known to us 6, 12, 18 months ago (APM was first proposed years ago, I believe 2015 and 2017 were landmark years for the proposal ).

However, I definitely appreciate what @Krukenberg is trying to advocate for. Anyone who read these forums over the past year doesn't deserve to be beat over the head with APM/Residency expansion, they should know - if they've done their homework. If they didn't, that's on them.

But as you said, medicine trains students to defer to and revere authority. And up until recently, many "authorities" were vocally (on twitter) outright misleading students and residents. So while some students may "know" what is on SDN, they ultimately may be inclined to "believe" their academic heroes that really, there is nothing to worry about. (or that all specialties have problems etc) Thats why you probably still have some decent candidates applying. Reality is starting to creep in, as anecdotes about withdrawn offers are posted and the issue becomes increasingly "real.". But large scale supply/demand effects due to APM or 1000 graduates over next 5 years have not taken effect.

 

[elementaryschooleconomics]

But as you said, medicine trains students to defer to and revere authority. And up until recently, many "authorities" were vocally (on twitter) outright misleading students and residents. So while some students may "know" what is on SDN, they ultimately may be inclined to "believe" their academic heroes that really, there is nothing to worry about. (or that all specialties have problems etc) Thats why you probably still have some decent candidates applying. Reality is starting to creep in, as anecdotes about withdrawn offers are posted and the issue becomes increasingly "real.". But large scale supply/demand effects due to APM or 1000 graduates over next 5 years have not taken effect.

Very true. I think SDN was successful, with the continued discussion about residency expansion, in deterring the people who could be deterred. For two cycles now we've seen drastic changes in application numbers/match rate (this cycle, TBD, obviously).

There will always be people who will ignore or not believe what is said online if a counter opinion comes from a strong authority figure, and there's nothing any of us can do about that (except have these discussions in real life).

That's a big factor in why I don't engage on the Google Spreadsheet. Those kids are COMMITTED. Targets acquired, weapons locked.

But, again, I do appreciate when certain people push back about almost every thread turning into a discussion about the job market. I'm hopeful that someday it won't be like this. I don't know when that "someday" is, but I can dream...

However, while I appreciate the sentiment, I will likely be right there with the rest of you, turning every thread into a discussion about residency expansion, APM, CMS rules, Twitter shenanigans, etc.

 

[medgator]

Very true. I think SDN was successful, with the continued discussion about residency expansion, in deterring the people who could be deterred. For two cycles now we've seen drastic changes in application numbers/match rate (this cycle, TBD, obviously).

There will always be people who will ignore or not believe what is said online if a counter opinion comes from a strong authority figure, and there's nothing any of us can do about that (except have these discussions in real life).

That's a big factor in why I don't engage on the Google Spreadsheet. Those kids are COMMITTED. Targets acquired, weapons locked.

But, again, I do appreciate when certain people push back about almost every thread turning into a discussion about the job market. I'm hopeful that someday it won't be like this. I don't know when that "someday" is, but I can dream...

However, while I appreciate the sentiment, I will likely be right there with the rest of you, turning every thread into a discussion about residency expansion, APM, CMS rules, Twitter shenanigans, etc.

Yup. Looking forward to the day when SDN can return to what it was a decade ago or so