RO-APM Podcast Episode (from The Accelerators)

[thecarbonionangle]

Its crazy that some are seeing 3 or less. I have not slowed down. Just this week i have 8 consults. More knocking down door spilling into next week. Very busy folks!

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[jondunn]

I saw 12 consults last week. Idk who these people are that are bored!

 

[RO28]

I saw 12 consults last week. Idk who these people are that are bored!

me. though the last two weeks haven't been as bad.

 

[Lamount]

This is very true too. I was talking to a young rad onc recently saying that he sees at least 300 new patients a year. There was a time that this could get you well into the 12000+ RVU range. Now it only gets you close to 9000 evidently. This revelation actually kind of worried me a little. And this young rad onc, by seeing 300 new patients a year, is definitely upper 25%ile busy.

My personal numbers are a little different than that... would be happy to share in the private forum.

 

[elementaryschooleconomics]

Its crazy that some are seeing 3 or less. I have not slowed down. Just this week i have 8 consults. More knocking down door spilling into next week. Very busy folks!

I saw 12 consults last week. Idk who these people are that are bored!

Comparing what the SDN population admits regarding workload to what I've seen in my day-to-day life, I'm going to go out on a limb and assume people posting here aren't necessarily a representative population.

I do know folks seeing 3 consults a week...or fewer. They are not the type of people to spend free time talking about Radiation Oncology on anonymous message boards. They're off publishing evergreen Tweets with all the vogue hashtags, filling their schedule with corporate buzzword meetings ("Synergizing Q3 Service Line Deliverables"), or don't know how to change the brush size in Eclipse (or whatever software their residents use).

 

[RickyScott]

Comparing what the SDN population admits regarding workload to what I've seen in my day-to-day life, I'm going to go out on a limb and assume people posting here aren't necessarily a representative population.

I do know folks seeing 3 consults a week...or fewer. They are not the type of people to spend free time talking about Radiation Oncology on anonymous message boards. They're off publishing evergreen Tweets with all the vogue hashtags, filling their schedule with corporate buzzword meetings ("Synergizing Q3 Service Line Deliverables"), or don't know how to change the brush size in Eclipse (or whatever software their residents use).

Acr metric for consults pts per doc is about 210 on average. 10 years ago it was about 250. This stuff is easy to look up. Small centers with 10 pts on beam probably don’t get accreditation.

Personnel: Radiation Oncology (Revised 7-18-2023)

Revision History Role Personnel Requirements/Recommendations Medical Director Each program must have a medical director who is a radiation oncologist as described below. He/she is responsible for oversight of the department, includi...

accreditationsupport.acr.org

 

[jondunn]

Comparing what the SDN population admits regarding workload to what I've seen in my day-to-day life, I'm going to go out on a limb and assume people posting here aren't necessarily a representative population.

I do know folks seeing 3 consults a week...or fewer. They are not the type of people to spend free time talking about Radiation Oncology on anonymous message boards. They're off publishing evergreen Tweets with all the vogue hashtags, filling their schedule with corporate buzzword meetings ("Synergizing Q3 Service Line Deliverables"), or don't know how to change the brush size in Eclipse (or whatever software their residents use).

Okay yeah we all did residency, but chairs, other senior leadership, and physician scientists aren’t most people either.

Be real

 

[elementaryschooleconomics]

Okay yeah we all did residency, but chairs, other senior leadership, and physician scientists aren’t most people either.

Be real

Oh sorry I missed the part of my post where I wrote that.

 

[jondunn]

Oh sorry I missed the part of my post where I wrote that.

Okay - even if every single academic faculty at your program was seeing 3 consults or less a week, that would not be most people.

Make sense.

 

[elementaryschooleconomics]

Okay - even if every single academic faculty at your program was seeing 3 consults or less a week, that would not be most people.

Make sense.

Oh sorry I missed the part of my post where I said only at my residency institution.

 

[jondunn]

Oh sorry I missed the part of my post where I said only at my residency institution.

Hope you got some Bitcoin

 

[elementaryschooleconomics]

Bitcoin

 

[jondunn]

View attachment 345516

Dude I don’t know what your issue is. Are you mad because I’m saying your story about some people in academics routinely seeing 3 consults a week or less is not the norm, just as you said that some of us working in busy community PP and seeing 8-12 consults a week isn’t the norm?

Are you suggesting that 0-3 consults a week is common amongst you and most of your rad onc colleagues around the country?

What is your point, exactly

 

[RickyScott]

Dude I don’t know what your issue is. Are you mad because I’m saying your story about some people in academics routinely seeing 3 consults a week or less is not the norm, just as you said that some of us working in busy community PP and seeing 8-12 consults a week isn’t the norm?

Are you suggesting that 0-3 consults a week is common amongst you and most of your rad onc colleagues around the country?

What is your point, exactly

math doesn’t lie. On average most radonc see somewhere between 3 and 4 new pts per week and should be closer to 3 in a few years.

 

[thecarbonionangle]

The future is definitely mega centres with protons and carbon ions seeing 12+ consults per rad onc in 5 fx. These people will do well. The rest will be unemployed. We all need to have a plan when time comes!

 

[elementaryschooleconomics]

Dude I don’t know what your issue is. Are you mad because I’m saying your story about some people in academics routinely seeing 3 consults a week or less is not the norm, just as you said that some of us working in busy community PP and seeing 8-12 consults a week isn’t the norm?

Are you suggesting that 0-3 consults a week is common amongst you and most of your rad onc colleagues around the country?

What is your point, exactly

Ah, to alleviate your confusion - none of the above. I do think you and @thecarbonionangle really are seeing 8-12 consults a week. My perception, at least, is that the majority of people who post here regularly are early-to-mid career and in jobs/environments which are busier than average.

Just like the pre-med forums, the people who are apt to not only frequent SDN but also post here are not a representative sample. The historical joke being that going by the "SDN averages", the only people who get into medical school have a 4.0 GPA and a 99th percentile MCAT with 4,000 hours of shadowing.

To help build your understanding, my post also did not comment on 3 consults a week being "routine" or "common". Instead, I stated:

I do know folks seeing 3 consults a week...or fewer.

Your inferences here are your own.

Are you mad

I'm not mad, just disappointed.

 

[jondunn]

Are they common in academics? In my experience they are not.

Of course we all know or know of rad oncs with 0-3. I guess I don’t see the importance of that fact.

I do think business is booming for many I know these days, many who have no clue what SDN is.

 

[TheWallnerus]

Are you suggesting that 0-3 consults a week is common amongst you and most of your rad onc colleagues around the country?

Exceedingly common. In the first graph, it's a histogram (y-axis is number of ROs and x-axis is dollars; each bin is $100K) of per rad onc CMS reimbursement; 40-50% (about 2500) of ROs get <$150K per year from Medicare. In the second graph, 58% of rad onc *centers* are seeing less than 2 new breast cancer patients (pink dots) per week. And as you can see, breast is by far the most common RT indication in the U.S. This would suggest, since it's per center, that the majority of U.S. rad oncs (again, as this is *per center data*) are seeing <150 new patients per year.

 

[jondunn]

So many assumptions.

I wish someone would publish this real data, for working clinical rad oncs. Lot of dirt in that data, though I know you’re trying to make the best of the flawed data

 

[TheWallnerus]

So many assumptions.

I wish someone would publish this real data, for working clinical rad oncs. Lot of dirt in that data, though I know you’re trying to make the best of the flawed data

Well there are no assumptions per se. Just the data as published. Re: "working clinical rad oncs," from the viewpoint of the maw of radiation oncologist production (aka the number of new grads per year) it doesn't matter.

 

[RickyScott]

Are they common in academics? In my experience they are not.

Of course we all know or know of rad oncs with 0-3. I guess I don’t see the importance of that fact.

I do think business is booming for many I know these days, many who have no clue what SDN is.

The acr publishes on average 200 new pts per academic doc per year- that’s slightly less than 4 per week. It also means that a significant portion of academics see ess than average. No assumptions.

 

[TheWallnerus]

The acr publishes on average 200 new pts per academic doc per year- that’s slightly less than 4 per week.

And keep in mind that "average" is very misleading in rad onc because, as the data above show, we are very Pareto in rad onc... in money, salary, and work.

Based on the data, one can reasonably guess that if the ACR says the average is 200, the median is 100-150. (I would pick 125.) That is to say, 50% of *all* rad oncs seeing less than ~125 per year.

 

[RickyScott]

Academic/Comprehensive Cancer Center/Main Teaching Hospital of a Med School​

200​

Personnel: Radiation Oncology (Revised 7-18-2023)

Revision History Role Personnel Requirements/Recommendations Medical Director Each program must have a medical director who is a radiation oncologist as described below. He/she is responsible for oversight of the department, includi...

accreditationsupport.acr.org

 

[TheWallnerus]

Acr metric for consults pts per doc is about 210 on average. 10 years ago it was about 250. This stuff is easy to look up. Small centers with 10 pts on beam probably don’t get accreditation.

Personnel: Radiation Oncology (Revised 7-18-2023)

Revision History Role Personnel Requirements/Recommendations Medical Director Each program must have a medical director who is a radiation oncologist as described below. He/she is responsible for oversight of the department, includi...

accreditationsupport.acr.org

I wish someone would publish this real data,

The acr publishes on average 200 new pts per academic doc per year- that’s slightly less than 4 per week. It also means that a significant portion of academics see ess than average. No assumptions.

Using the ACR link from RickyScott, if you look there is a table (in the first column for "600 or more patients" that's facility workload stratum and "275" is number of new patients per rad onc per year on average in that facility), and we can use the Zaorsky data to infer:

@jondunn this data is published...

 

[deleted1111261]

This is an extremely challenging question and I still don’t know how to answer it.

“How many new patients should a busy RO see in a week / month / year?”

The way we decide that tends to be based on RVU targets (last few places I worked). They pick a number, and when everyone is above a certain number, they tend to hire, or they project out and over - hire. But, RVUs are based on consults and fractions. Modern ROs treat with fewer fractions and thus fewer RVUs. So, if they see the 200-230 new patients number that is floating around, they may not even get close to the target. So, they end up seeing more to get closer and find themselves exhausted, when the c-suite is like - “they only got 10k RVUs”.

It’s a funny game to play. To get more RVUs, you can slow down, give 44 fx to prostates (which is fine 🐊, I’m not getting into that) and 10 fx for all bone Mets and just manufacture enough RVUs to get a new hire … all while seeing LESS patients. The whole thing is so confusing to me, especially now when I’m supposed to try to figure out our needs.

In my head, I think a generalist should be able to see 6-8 consults a week of a good mix of patients - breast, prostate, lung, mets and the occasional tougher stuff. With modern fractionation, is that going to get you to your target? I don’t know, depends on a lot.

What a field - we decided to pay ourselves in a way that punishes us if we see more patients, have the same outcomes and do it more efficiently. Bizarre to say the least.

 

[RickyScott]

This is an extremely challenging question and I still don’t know how to answer it.

“How many new patients should a busy RO see in a week / month / year?”

The way we decide that tends to be based on RVU targets (last few places I worked). They pick a number, and when everyone is above a certain number, they tend to hire, or they project out and over - hire. But, RVUs are based on consults and fractions. Modern ROs treat with fewer fractions and thus fewer RVUs. So, if they see the 200-230 new patients number that is floating around, they may not even get close to the target. So, they end up seeing more to get closer and find themselves exhausted, when the c-suite is like - “they only got 10k RVUs”.

It’s a funny game to play. To get more RVUs, you can slow down, give 44 fx to prostates (which is fine 🐊, I’m not getting into that) and 10 fx for all bone Mets and just manufacture enough RVUs to get a new hire … all while seeing LESS patients. The whole thing is so confusing to me, especially now when I’m supposed to try to figure out our needs.

In my head, I think a generalist should be able to see 6-8 consults a week of a good mix of patients - breast, prostate, lung, mets and the occasional tougher stuff. With modern fractionation, is that going to get you to your target? I don’t know, depends on a lot.

What a field - we decided to pay ourselves in a way that punishes us if we see more patients, have the same outcomes and do it more efficiently. Bizarre to say the least.

6-8 pts on average is a good number, 300-400 pts per year, but very few radoncs are so fortunate.

 

[TheWallnerus]

“How many new patients should a busy RO see in a week / month / year?” ... In my head, I think a generalist should be able to see 6-8 consults a week of a good mix of patients - breast, prostate, lung, mets and the occasional tougher stuff. With modern fractionation, is that going to get you to your target? I don’t know, depends on a lot.

In the Graypeace article there was data to show that ~20 years ago the *average* RO was seeing 350 new pts a year (so the median was probably ~250-275). In the meantime the average and median have dropped to ~200/150 or less. So the argument is "Well patients are more complex nowadays" so we are seeing less patients.

For the generalist the patients are not really more complex.

The generalist is mostly a breast doc. By mostly I mean that's going to be the most common patient. That and prostate and some lung. The breasts should all be 5-15 fractions mostly and have less side effects than breast patients 20 years ago. Prostates? Easier to treat, less fx's and less side effects than 20 years ago. Lung? Less side effects for sure and if you factor in SABRs way less fractions too. So yeah treatments, technologically speaking, are more complex. "Computering" is more complex. But the clinic? That's easier (for a generalist).

To repeat... So the argument is "Well patients are more complex nowadays so we are seeing less patients." This is just an RO over-supply excuse when people say this.

 

[RickyScott]

In the Graypeace article there was data to show that ~20 years ago the *average* RO was seeing 350 new pts a year (so the median was probably ~250-275). In the meantime the average and median have dropped to ~200/150 or less. So the argument is "Well patients are more complex nowadays" so we are seeing less patients.

For the generalist the patients are not really more complex.

The generalist is mostly a breast doc. By mostly I mean that's going to be the most common patient. That and prostate and some lung. The breasts should all be 5-15 fractions mostly and have less side effects than breast patients 20 years ago. Prostates? Easier to treat, less fx's and less side effects than 20 years ago. Lung? Less side effects for sure and if you factor in SABRs way less fractions too. So yeah treatments, technologically speaking, are more complex. "Computering" is more complex. But the clinic? That's easier (for a generalist).

To repeat... So the argument is "Well patients are more complex nowadays so we are seeing less patients." This is just an RO over-supply excuse when people say this.

I am amazed how some just can’t acknowledge that increasing the number of radoncs means less pts per doc.

 

[medgator]

I am amazed how some just can’t acknowledge that increasing the number of radoncs means less pts per doc.

Some of them can't fathom how hypofractionation means less time seeing patients under treatment and therefore means you have more time to see more patients to stay busy

 

[elementaryschooleconomics]

Are they common in academics? In my experience they are not.

Of course we all know or know of rad oncs with 0-3. I guess I don’t see the importance of that fact.

I do think business is booming for many I know these days, many who have no clue what SDN is.

So many assumptions.

I wish someone would publish this real data, for working clinical rad oncs. Lot of dirt in that data, though I know you’re trying to make the best of the flawed data

So the data which @TheWallnerus and @RickyScott linked, and the Zaorsky published data from that Tweet are "assumptions"?

Yet you - someone who has stated they're in private practice - are referencing your "experience" regarding academic workflow and the "booming business" of "people you know" as a reason you're skeptical?

What data would you consider "real"?

 

[madchemist89]

I think that the extrapolation from breast cases is a stretch. At my center, we treat some breast, but its a minority of our patients on treatment. We have more prostate and lung than breast probably. Practice patterns are different wherever you go.

 

[medgator]

I think that the extrapolation from breast cases is a stretch. At my center, we treat some breast, but its a minority of our patients on treatment. We have more prostate and lung than breast probably. Practice patterns are different wherever you go.

Bingo. One of my clinics skews lungs and h&n/skin. Lots of smoking sun worshippers

 

[jondunn]

I think that the extrapolation from breast cases is a stretch. At my center, we treat some breast, but its a minority of our patients on treatment. We have more prostate and lung than breast probably. Practice patterns are different wherever you go.

yes.

 

[jondunn]

So the data which @TheWallnerus and @RickyScott linked, and the Zaorsky published data from that Tweet are "assumptions"?

Yet you - someone who has stated they're in private practice - are referencing your "experience" regarding academic workflow and the "booming business" of "people you know" as a reason you're skeptical?

What data would you consider "real"?

to be clear - I am not calling anything fake. I have no disagreement that rad oncs are both less busy than in the past, nor that many have capacity for more. many people are in low volume facilities that somehow makes it work for everyone involved. some rad oncs self select for sleepy clinics or sleepy satellites, for example. perfect jobs for parents who want to prioritize their family.

the zarosky data is better. but still, one can dream of published per doc data. maybe a survey. facility volume still has lots of confounders and external factors that affect this. even published per doc would be confusing depending on who replied. where i trained there were 21 attendings. all saw well over 3 consults a week except for 4. the chair and three physician scientists, who probably saw 2 or 3 many weeks. so technically the percent seeing less than 3 consults a week was roughly 20%, though I never would have considered them as part of the equation during residency, they are, tehcnically.

 

[jondunn]

anyone here see less than 200 patients a year, which is the majority of facilities per above?

I guess say you have 8 weeks of vacation, that works out to 4.5 consults a week. that seems pretty believable.

 

[TheWallnerus]

So many assumptions.

I wish someone would publish this real data, for working clinical rad oncs. Lot of dirt in that data, though I know you’re trying to make the best of the flawed data

Data has been published ad nauseum, in reality. Google anything to do with RT utilization e.g., lots of it from Bates and Royce. Consistently they show that there are ~550-600K de novo new RT patients per year in America. Divide that by your best guess number of working clinical rad oncs. Is that number 4000? That's the lowest that's reasonable. That's 550K/4000=138 de novo new RT patients per year per RO. Or you can assume close to 600K per year, the highest ever published. But if there are 5000 working rad oncs, and ASTRO says there is, that's 120 (de novo, ignoring re-tx, ignoring later RT farther along diagnosis course) new RT patients per year per RO.

I think that the extrapolation from breast cases is a stretch.

Time after time, the data shows that breast is the most common RT indication in the US. It is the most common malignancy and has very high RT utilization vs other malignancies. So it is a bellwether for RT "busy-ness," and as the Zaorsky data shows, it's the most common patient in >99% of clinics (again, see the "pink dots"). Visually you can see that they're usually 2:1 all other patients.

the zarosky data is better. but still, one can dream of published per doc data.

Here is published per doc data. Your name is in here... it includes every RO that billed Medicare for RO in a year.

Centers for Medicare & Medicaid Services Data

I won't walk you through all the math, but you can plow through it and determine that the average number of Medicare patients per RO (per year) is:

58 Medicare patients per year per RO (average)
50 Medicare patients per year per RO (median)

There were 318,483 CMS patients who received a weekly tx management or 1-2 tx management EBRT code, or SBRT or SRS, in 2019. As a comparison, derms likely see 10-20x this number of CMS patients per year even though there are only about 3x as many derms as ROs.

Those who are producing ROs for America are being very poor stewards.

 

[jondunn]

Data has been published ad nauseum, in reality. Google anything to do with RT utilization e.g., lots of it from Bates and Royce. Consistently they show that there are ~550-600K de novo new RT patients per year in America. Divide that by your best guess number of working clinical rad oncs. Is that number 4000? That's the lowest that's reasonable. That's 550K/4000=138 de novo new RT patients per year per RO. Or you can assume close to 600K per year, the highest ever published. But if there are 5000 working rad oncs, and ASTRO says there is, that's 120 new RT patients per year per RO.

Time after time, the data shows that breast is the most common RT indication in the US. So it is a bellwether for RT "busy-ness," and as the Zaorsky data shows, it's the most common patient in >99% of clinics (again, see the "pink dots"). Visually you can see that they're usually 2:1 all other patients.

Here is published per doc data. Your name is in here... it includes every RO that billed Medicare for RO in a year.

Centers for Medicare & Medicaid Services Data

I won't walk you through all the math, but you can plow through it and determine that the average number of Medicare patients per RO (per year) is 58 and the median is 50. There were 318,483 CMS patients who received a weekly tx management or 1-2 tx management EBRT code, or SBRT or SRS, in 2019. As a comparison, derms likely see 10-20x this number of CMS patients per year even though there are only about 3x as many derms as ROs.

Those who are producing ROs for America are being very poor stewards.

You will get zero argument from me regarding oversupply

I do stand by my question above about people here and their consult/week numbers. It is true that perhaps SDN may have a non-representative population, but just curious

 

[TheWallnerus]

You will get zero argument from me regarding oversupply

I do stand by my question above about people here and their consult/week numbers. It is true that perhaps SDN may have a non-representative population, but just curious

Even the people that "believe" in over-supply struggle with believing the above numbers and per-RO work.

Imagine how those who don't believe in over-supply struggle.

 

[jondunn]

Well it’s clear that things like hospital based reimbursement and stuff like SBRT/SRS which muddy the waters for ‘number of patients’ keep the salaries looking okay. But it’s a house of cards

Also another confounder - Our practice has 6 sites. We are not at 2 of the sites every day, and the volume is low at each site. However because of the deal we have, it’s financially viable to keep those two places as offices facilities we have open.

 

[OTN]

I am amazed how some just can’t acknowledge that increasing the number of radoncs means less pts per doc.

I guess I'm one of those.

Just because a new radonc is minted doesn't mean that radonc will be joining the workforce and diluting patients. Our practice isn't going to hire anyone unless we have the demand, and radonc is one of of those truly "impossible to hang a shingle" specialties. Also, especially now with hospital- and academic-based salaries where they are, it's not as if the radonc's salary is the one thing preventing a cancer center from being built.

 

[TheWallnerus]

Just because a new radonc is minted doesn't mean that radonc will be joining the workforce and diluting patients.

 

[RickyScott]

I guess I'm one of those.

Just because a new radonc is minted doesn't mean that radonc will be joining the workforce and diluting patients. Our practice isn't going to hire anyone unless we have the demand, and radonc is one of of those truly "impossible to hang a shingle" specialties. Also, especially now with hospital- and academic-based salaries where they are, it's not as if the radonc's salary is the one thing preventing a cancer center from being built.

on macroscopic level, if they are minted and not joining the workforce, they are treating 0 patients and bringing down the average.

 

[deleted1111261]

on macroscopic level, if they are minted and not joining the workforce, they are treating 0 patients and bringing down the average.

Tis true

 

[OTN]

on macroscopic level, if they are minted and not joining the workforce, they are treating 0 patients and bringing down the average.

That's a good point. Are we talking about the average among all radoncs who graduated from a training program, or radoncs who are actually working? If we're talking about the former, then I certainly stand corrected.

If we're talking about the latter, then I still think I'm correct, as we can't assume that just because someone graduated from residency they will be employed. Isn't that what breadlines were all about?

 

[RickyScott]

That's a good point. Are we talking about the average among all radoncs who graduated from a training program, or radoncs who are actually working? If we're talking about the former, then I certainly stand corrected.

If we're talking about the latter, then I still think I'm correct, as we can't assume that just because someone graduated from residency they will be employed. Isn't that what breadlines were all about?

thats why pareto distribution. Locums etc will count against the average. nevertheless, the acr averages are falling over time (which dont take it into account locums, unemployed etc, or likely small centers). Am surprised that nobody is writing this up

 

[TheWallnerus]

Am surprised that nobody is writing this up

Because it's on par with us all being in the Freon manufacturing business. And discovering via various lines of evidence that chlorofluorocarbons were slowly destroying the ozone layer. And then having someone in our industry write that up.

as we can't assume that just because someone graduated from residency they will be employed.

Per ARRO's data clinical, taking-care-of-people unemployment after graduation is for all intents and purposes <5%, so it seems to be a reasonable assumption at least just for the sake of making some workforce guesstimates.

 

[Gfunk6]

Don't cross the streams!

 

[RickyScott]

Because it's on par with us all being in the Freon manufacturing business. And discovering via various lines of evidence that chlorofluorocarbons were slowly destroying the ozone layer. And then having someone in our industry write that up.


Per ARRO's data clinical, taking-care-of-people unemployment after graduation is for all intents and purposes <5%, so it seems to be a reasonable assumption at least just for the sake of making some workforce guesstimates.

Regarding the ARRO survey: Several of the MSKCC graduating residents entered fellowship as did several from Stanford. So these 2 programs represent the majority of the 7 fellowships?

 

[TheWallnerus]

Regarding the ARRO survey: Several of the MSKCC graduating residents entered fellowship as did several from Stanford. So these 2 programs represent the majority of the 7 fellowships?

The ARRO fellowship data are as inscrutable as Enron's accounting methods.

 

[jondunn]

Regarding the ARRO survey: Several of the MSKCC graduating residents entered fellowship as did several from Stanford. So these 2 programs represent the majority of the 7 fellowships?

the MSKCC people (at least a few of them) I know for a fact sought out research fellowships on purpose.


there are some people that actually want to do this stuff!