Thoughts from a PGY-5

[RickyScott]

I keep saying this, but the problem with these kinds of analyses is that they assume new grads will enter the market and be employed. You can't "hang a shingle" as a radonc as we all know, so those of us in practice are not necessarily going to see a drop in income (APM/CMS/etc aside). I'm not going to hire someone just to dilute my practice, and a hospital isn't going to hire another MD just because they're around. I don't think the crisis is going to be salary/income of practicing radoncs, I think the crisis is going to be what the hell to do with all the graduated radoncs who can't find jobs.

totally agree . I think the analysis is illustrative and shows how upside down we are. As you say, in reality the field will be separated into haves and havenots.

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[w00tz]

Medonc salaries arent related to drug prices as far as I understand, because markup is legally capped at small margins of 4% and one denial will put you in the red for a month. An expensive injectable drug would be a negative in terms of how much they are worth to a practice/hospital. 340B is over. It is an issue of supply and demand.
This specialty just wont acknowledge supply and demand.

I'm not exactly sure how it works, either. I have heard from our CFO something to the effect of med oncs doing well because of immunotherapy. There are more indications, like you stated, but I also think the mark up is related. You may be right about the 4% mark up. But 4% of a chemo drug ($) vs 4% of immunotherapy ($$$$) will make a huge difference.

The 75 %ile rad onc salary I saw in 2010 is now the 90 %ile as of 2018. U.S. rad onc spending is flat-to-mild-decreased over the last 5y with no indications it will suddenly upswing (ie no sudden increase in rad onc demand, no sudden appearance of new lucrative rad onc codes, etc.) to "feed" ever-growing numbers of new rad onc MD mouths. Leaves one a bit wistful because the best and highest number I've seen of annual XRT patients is ~1 million which evenly divided by ~5000 rad oncs is 200 XRT patients per rad onc annually—I know personally I could see 400 a year. I don't now, but I have. And if we all had that level of "busy-ness" we'd need half the number of rad oncs. If you use the maybe "more in touch with reality" number of about ~550K new XRT patients this year, it's an even more stark realization: there just aren't enough new XRT patients to go around, nationally, for all the new rad oncs. (Especially if cancer incidence continues its drop, rad onc utilization continues its drop, hypofractionation gets more "penetrance," etc.) So it's not "hard to predict long-term salaries" per se. It's only hard to predict whether rad oncs are making equal, or more, now versus what they will in 10 years (of course maybe that's just modern American life).

True. Now that you mention it, I think it's probably 2018 since I last saw a MM patient. (Obviously wouldn't be a big loss of XRT business for anybody but still.)

I guess what I meant was in comparison to med onc. I know rad onc salaries have tremendous downward pressure for the reasons you stated. But medical oncology is riding the gravy train right now, and I don't think it will last. And if it does:
- more NPs are going to start giving chemo to get their piece of the pie (see derm and anesthesia)
- maybe rad onc residencies need to start training their residents how to give chemo/immunotherapy

 

[RickyScott]

I'm not exactly sure how it works, either. I have heard from our CFO something to the effect of med oncs doing well because of immunotherapy. There are more indications, like you stated, but I also think the mark up is related. You may be right about the 4% mark up. But 4% of a chemo drug ($) vs 4% of immunotherapy ($$$$) will make a huge difference.



I guess what I meant was in comparison to med onc. I know rad onc salaries have tremendous downward pressure for the reasons you stated. But medical oncology is riding the gravy train right now, and I don't think it will last. And if it does:
- more NPs are going to start giving chemo to get their piece of the pie (see derm and anesthesia)
- maybe rad onc residencies need to start training their residents how to give chemo/immunotherapy

can only speak for my hospital, but am told we dont earn profit from drugs and sometimes take huge hits when something expensive is given to inpatient or as charity, or there is a denial. I could see a scenario where medoncs create tremendous value for themselves in certain managed care situations where they are financially incentivized to use less expensive drugs as costs skyrocket. Have also seen a large increase in NPs in medonc- over last several years it seems that every medonc now has 1 or 2 np/pa as opposed to just a nurse and this was not case historically. I also believe that only way out for our field is training residents in chemo..

 

[Tigerstang]

I keep saying this, but the problem with these kinds of analyses is that they assume new grads will enter the market and be employed. You can't "hang a shingle" as a radonc as we all know, so those of us in practice are not necessarily going to see a drop in income (APM/CMS/etc aside). I'm not going to hire someone just to dilute my practice, and a hospital isn't going to hire another MD just because they're around. I don't think the crisis is going to be salary/income of practicing radoncs, I think the crisis is going to be what the hell to do with all the graduated radoncs who can't find jobs.

The hospital will term you at the end of your contract and higher the new guy who's willing to work for less than you

 

[scarbrtj]

I guess what I meant was in comparison to med onc. I know rad onc salaries have tremendous downward pressure for the reasons you stated. But medical oncology is riding the gravy train right now, and I don't think it will last.

can only speak for my hospital, but am told we dont earn profit from drugs and sometimes take huge hits when something expensive is given to inpatient or as charity, or there is a denial.

As additional "anecdote time," though, I know med oncs with in-house pharmacies that are making 1 million plus by these unavailable-to-rad-onc avenues of reimbursement on "drugs." The orals are changing the narrative (back to the 'ol days IMHO) of "med oncs don't make money on drugs."

 

[OTN]

can only speak for my hospital, but am told we dont earn profit from drugs and sometimes take huge hits when something expensive is given to inpatient or as charity, or there is a denial. I could see a scenario where medoncs create tremendous value for themselves in certain managed care situations where they are financially incentivized to use less expensive drugs as costs skyrocket. Have also seen a large increase in NPs in medonc- over last several years it seems that every medonc now has 1 or 2 np/pa as opposed to just a nurse and this was not case historically. I also believe that only way out for our field is training residents in chemo..

If you're being told your hospital isn't making money from chemo- or immunotherapeutics, the hospital is either:
- lying to you
or
- grossly mismanaged

 

[scarbrtj]

Have also seen a large increase in NPs in medonc- over last several years it seems that every medonc now has 1 or 2 np/pa as opposed to just a nurse and this was not case historically. I also believe that only way out for our field is training residents in chemo..

Keeping in the Ricky Scott vein, "[Florida's Speaker of the House] made it abundantly clear that, in his view, nurse practitioners and physicians are interchangeable." Everyone knows that NPs can supervise chemo in the outpatient freestanding setting, right? And everyone knows only physicians (MDs, DOs, DPMs, DCs, etc.) can supervise XRT in the freestanding setting though? But everyone also knows that chemo is MUCH more dangerous and has higher rates of in-office complications than XRT, so this is a little bit weird that NPs can supervise chemo but not XRT? And everyone knows that NPs can supervise XRT in hospitals, right? Scratch that. Everyone knows the hospital custodian can supervise XRT in the hospital, right? So does anyone really NOT know that one day NPs will also be able to supervise XRT in the freestanding centers?

 

[RickyScott]

As additional "anecdote time," though, I know med oncs with in-house pharmacies that are making 1 million plus by these unavailable-to-rad-onc avenues of reimbursement on "drugs." The orals are changing the narrative (back to the 'ol days IMHO) of "med oncs don't make money on drugs."

I'm not exactly sure how it works, either. I have heard from our CFO something to the effect of med oncs doing well because of immunotherapy. There are more indications, like you stated, but I also think the mark up is related. You may be right about the 4% mark up. But 4% of a chemo drug ($) vs 4% of immunotherapy ($$$$) will make a huge difference.



I guess what I meant was in comparison to med onc. I know rad onc salaries have tremendous downward pressure for the reasons you stated. But medical oncology is riding the gravy train right now, and I don't think it will last. And if it does:
- more NPs are going to start giving chemo to get their piece of the pie (see derm and anesthesia)
- maybe rad onc residencies need to start training their residents how to give chemo/immunotherapy

I was told there are no procedural fees for employed medoncs , just e an m codes, but hospitals will routinely offer 80$+ per RVU.

 

[Mandelin Rain]

I think there is money to be ma

I was told there are no procedural fees for employed medoncs , just e an m codes, but hospitals will routinely offer 80$+ per RVU.

our guys get $90+

 

[FrostyHammer]

Keeping in the Ricky Scott vein, "[Florida's Speaker of the House] made it abundantly clear that, in his view, nurse practitioners and physicians are interchangeable." Everyone knows that NPs can supervise chemo in the outpatient freestanding setting, right? And everyone knows only physicians (MDs, DOs, DPMs, DCs, etc.) can supervise XRT in the freestanding setting though? But everyone also knows that chemo is MUCH more dangerous and has higher rates of in-office complications than XRT, so this is a little bit weird that NPs can supervise chemo but not XRT? And everyone knows that NPs can supervise XRT in hospitals, right? Scratch that. Everyone knows the hospital custodian can supervise XRT in the hospital, right? So does anyone really NOT know that one day NPs will also be able to supervise XRT in the freestanding centers?

Wow I can't believe he said something ridiculous like that. I found out more about him as a politician and then it made more sense that he'd say dumb stuff like that. What a world it is...

 

[20181121]

med onc fellows are killing it this year. all above 350k starting with partnership double that. locations in desirable cities. they all found jobs very easily. i'm amazed at how quickly their field has taken off.

I am glad to hear it - my view is that Med Oncs have been relatively underpaid for their hard work! I hope the next few years' MGMA, AGMA, and AAMC data show that this is true, though, and not just a collection of anecdotes. All of that said, I hope oncology-related fields - ours included - do not attract medical students whose main interest is compensation.

Now that you mention it, I think it's probably 2018 since I last saw a MM patient.

I am surprised to hear that - we treat a ton of multiple myeloma patients at my center. Do you think they are migrating to academic settings (i.e. they are treated by academic Med Oncs and referred to their centers' Rad Oncs)?

On a related note, thinking about future demand for radiation: why do people think so many centers are outlaying so much capital for proton units, MR linacs, and even newer conventional linacs? Do you think their financial models are inaccurately predicting future demand, even with the lessons learned by private equity backers of large proton centers over the past decade? My impression is that future demand would have to be predicted to be substantial before dropping $40mm. Maybe they will just turn out to be wrong again, even though they have so much skin in the game? Maybe they expect a short-term rather than long-term payoff? I am asking these as true, not rhetorical, questions and am interested in people's thoughts.

 

[deleted941485]

Wow I can't believe he said something ridiculous like that. I found out more about him as a politician and then it made more sense that he'd say dumb stuff like that. What a world it is...

Dude just look at a candid photo of the men and women in congress today. It’s a bad joke just the dumb looks in their faces, portly bodies. Well dressed idiots parroting whatever they heard

I am glad to hear it - my view is that Med Oncs have been relatively underpaid for their hard work! I hope the next few years' MGMA, AGMA, and AAMC data show that this is true, though, and not just a collection of anecdotes. All of that said, I hope oncology-related fields - ours included - do not attract medical students whose main interest is compensation.



I am surprised to hear that - we treat a ton of multiple myeloma patients at my center. Do you think they are migrating to academic settings (i.e. they are treated by academic Med Oncs and referred to their centers' Rad Oncs)?

On a related note, thinking about future demand for radiation: why do people think so many centers are outlaying so much capital for proton units, MR linacs, and even newer conventional linacs? Do you think their financial models are inaccurately predicting future demand, even with the lessons learned by private equity backers of large proton centers over the past decade? My impression is that future demand would have to be predicted to be substantial before dropping $40mm. Maybe they will just turn out to be wrong again, even though they have so much skin in the game? Maybe they expect a short-term rather than long-term payoff? I am asking these as true, not rhetorical, questions and am interested in people's thoughts.

MR guided linacs are experimental and likely will not yield survival benefits. May reduce toxicity but not proven. Financial outlays have largely been research grants and goodwill with the hope that perhaps it will show a benefit. I don’t think it’ll be even a fraction of what we experienced with IMRT. But if the hospitals wanna dump money into it go right ahead.

Protons are equally ridiculous. Limited evidence for their use and yet they proliferate mostly because large health systems do t want to lose patients to other systems that have them even if they have to take a loss on it. They reimburse no better than IMRT and the machine costs are dropping so it lowers the threshold but does not eliminate the fact that from a RO perspective t loses money.

Hospitals economic projections are challenging even more so in this environment where everybody and heir Medicare eligible mother is worried about costs. They have miscalculated spectacularly in the past and you will most likely suffer the most from it.

 

[scarbrtj]

On a related note, thinking about future demand for radiation: why do people think so many centers are outlaying so much capital for proton units, MR linacs, and even newer conventional linacs? Do you think their financial models are inaccurately predicting future demand, even with the lessons learned by private equity backers of large proton centers over the past decade? My impression is that future demand would have to be predicted to be substantial before dropping $40mm. Maybe they will just turn out to be wrong again, even though they have so much skin in the game? Maybe they expect a short-term rather than long-term payoff? I am asking these as true, not rhetorical, questions and am interested in people's thoughts.

Well as you probably know there have been some bad miscalculations. I also have friends who are proton center directors and a few are more trepidatious than I expected about the future of protons (not clinically per se but financially). And yes, fwiw, I see major things which tell me demand for radiation therapy is not going on a huge upswing. First, there are only about 20,000 new additional cancer patients, year-on-year, in the US now occurring/happening. (And if we divide that by ~5000 rad oncs, that's only ~4 new addt'l cancer patients/year/rad onc.) Second, these are TOTAL cancer patients (ie melanoma, renal, leukemia, etc.). Third, of these relatively paltry few new cancer patients every year, only maybe 1/3 to one-half are XRT (or possible proton or MR-linac) patients. Fourth, can we really predict that the therapeutic ratio of these two new techs will drive CPT reimbursements so high as to spur the whole of the rad onc market to abandon photons, IMRT, linac SRS/SBRT, or machines capable of electrons and cost-effective, simple palliation (which is 25-33% of most rad oncs' business "in the wild")?

 

[radoncgrad2019]

'First, there are only about 20,000 new additional cancer patients, year-on-year, in the US now occurring/happening. (And if we divide that by ~5000 rad oncs, that's only ~4 new addt'l cancer patients/year/rad onc.)'

so obviously this should have been the first clue that somewhere your numbers are incorrect.

 

[radiation]

Well as you probably know there have been some bad miscalculations. I also have friends who are proton center directors and a few are more trepidatious than I expected about the future of protons (not clinically per se but financially). And yes, fwiw, I see major things which tell me demand for radiation therapy is not going on a huge upswing. First, there are only about 20,000 new additional cancer patients, year-on-year, in the US now occurring/happening. (And if we divide that by ~5000 rad oncs, that's only ~4 new addt'l cancer patients/year/rad onc.) Second, these are TOTAL cancer patients (ie melanoma, renal, leukemia, etc.). Third, of these relatively paltry few new cancer patients every year, only maybe 1/3 to one-half are XRT (or possible proton or MR-linac) patients. Fourth, can we really predict that the therapeutic ratio of these two new techs will drive CPT reimbursements so high as to spur the whole of the rad onc market to abandon photons, IMRT, linac SRS/SBRT, or machines capable of electrons and cost-effective, simple palliation (which is 25-33% of most rad oncs' business "in the wild")?

The other data point to consider is that the two largest radiation oncology vendors are doing well financially. How do we explain this growth? Mostly Europe?

 

[scarbrtj]

'First, there are only about 20,000 new additional cancer patients, year-on-year, in the US now occurring/happening. (And if we divide that by ~5000 rad oncs, that's only ~4 new addt'l cancer patients/year/rad onc.)'

so obviously this should have been the first clue that somewhere your numbers are incorrect.

They're correct. Within margins of error, 1.762 million new cases in 2019, and 1.735 million in 2018, ~27,000 new cases in that one year, and there were ~1.64 million in 2012, so over 8 years (1.76-1.64 million)/8 = ~15,000/year on average, so again let's just round to ~20,000 new additional cases per year which is ~4 (AT MOST! and probably only 1-2 patients factoring in utilization) new additional patients per rad onc in the U.S. very year. Now project out to 2030 with ~6000+ rad oncs and so on and so forth. The ever-decreasing cancer incidence, and decreasing rad onc utilization, and increasing rad onc numbers (and increasing rad oncs per fraction given too) are looming storm clouds IMHO. The math is quite unbelievable/scary though, you're right.

 

[radoncgrad2019]

They're correct.

so 4 new patients a year per rad onc makes sense.

got it, you cray!

 

[RickyScott]

The other data point to consider is that the two largest radiation oncology vendors are doing well financially. How do we explain this growth? Mostly Europe?

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so 4 new patients a year per rad onc makes sense.

got it, you cray!

Additional pts year over year is what he is saying. And regarding vendors, they are switching models to relying on software and service contracts. Varian even bought d3 and wants to offer planning. Machine comes with 200,0000 yearly service contract and eclipse/aria similar amount.

 

[scarbrtj]

so 4 new ADDITIONAL patients a year per rad onc makes sense.

got it, you cray!

where's the error in your opinion?

 

[RickyScott]

scarbtj has methodically shown the small growth (But in my opinion possible decrease for radonc as opposed to medonc ) in expected new cancers/pts and reimbursement (Also in my opinion likely decrease) is tremendously outpaced by growth in docs. Kudos to him for putting out the numbers, but this is something that should be blatantly obvious to anyone in practice.

Perchance, Are you of the opinion that doubling of resident numbers over past 15-20 yrs may not have increased number of docs in practice or we need a trial to establish this?

his whole point is that if docs double (assuming no hypofractionation) pt numbers should double and reimbursement should double.

if pt growth is an anemic 1-2% but doc growth is many x this, there is an obvious problem.

 

[scarbrtj]

The other data point to consider is that the two largest radiation oncology vendors are doing well financially. How do we explain this growth? Mostly Europe?

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Yes, most of Varian's growth now coming from outside the U.S.

The U.S. market is very mature and, relative to the rest of the world, the most saturated not only in terms of linacs but also radiation oncologists. For example, we have 1 rad onc for every ~60,000 people in the U.S., 1 for every 80,000-100,000 in Europe, and something ridiculous like 1 for every 500,000 in Asia. (Some might quibble with such a low ratio but we gotta remember some smart people in the past have said one rad onc per 500,000 people is OK.) Thus with U.S. being so saturated, their growth market is now not the U.S. anymore. But their revenue from U.S. can rise depending on how they set service contracts, etc., 'cause they clearly have a lot of equipment to service in America.

 

[scarbrtj]

his whole point is that if docs double (assuming no hypofractionation) pt numbers should double and reimbursement should double.,

"If you build it, they will come." And if you graduate them, they will make ~half a million a year. Maybe! One offshoot of loading up rad onc numbers and not increasing patients (and fractions etc) may possibly be an attendant increase in rad onc's overall cost to society. Because if rad onc doesn't start costing more in total, rad onc salaries will go down. Although the market as a whole may "react" and and keep everyone--the ever-increasing everyone--at the same salary level. But without actually delivering more care to the population as a whole; just more MDs to do so. Perhaps a very perverse not-choosing-wisely by us as a specialty.

 

[deleted18755]

OTN: I see what you are saying, and agree that will be the case in the short term, but sooner than later isn't this the more likely scenario:

• #55

OTN said:
I keep saying this, but the problem with these kinds of analyses is that they assume new grads will enter the market and be employed. You can't "hang a shingle" as a radonc as we all know, so those of us in practice are not necessarily going to see a drop in income (APM/CMS/etc aside). I'm not going to hire someone just to dilute my practice, and a hospital isn't going to hire another MD just because they're around. I don't think the crisis is going to be salary/income of practicing radoncs, I think the crisis is going to be what the hell to do with all the graduated radoncs who can't find jobs.

The hospital will term you at the end of your contract and higher the new guy who's willing to work for less than you

 

[RickyScott]

"If you build it, they will come." And if you graduate them, they will make ~half a million a year. Maybe! One offshoot of loading up rad onc numbers and not increasing patients (and fractions etc) may possibly be an attendant increase in rad onc's overall cost to society. Because if rad onc doesn't start costing more in total, rad onc salaries will go down. Although the market as a whole may "react" and and keep everyone--the ever-increasing everyone--at the same salary level. But without actually delivering more care to the population as a whole; just more MDs to do so. Perhaps a very perverse not-choosing-wisely by us as a specialty.

OTN: I see what you are saying, and agree that will be the case in the short term, but sooner than later isn't this the more likely scenario:

• #55

The hospital will term you at the end of your contract and higher the new guy who's willing to work for less than you

yes in long run, there will be downward pressure on all salaries of employed docs by excess supply. This is Just like gravity.

The burden lies with programs to prove that after they doubled resident nunbers, pt numbers and reimbursement subsequently doubled.(if they want to justify course and attract ms4) Of course they can’t so they rely on anecdotes like op. Scarbtj is actually too generous in assumptions which don’t even address hypofractionation.

 

[Pointless]

To present a contrarian argument: what if expanding indications for radiation therapy in metastatic disease offset the declining fractions in prostate and breast? What if we end up ablating mets in every single stage IV patient to potentiate immunotherapy? Everybody on this board seems to be racing to figure out where all the badness is going to come from, while forgetting to account for unexpected (actually, probably expected) positives may come from.

Another thing that I would posit is that if we start to feel true labor pressure, people WILL start to take those jobs in rural areas (biryani be damned) and this will result in increased utilization of radiation services in those areas. There's a name for this, Jevon's paradox or something like that, where increased availability results in increased utilization. Do you think all the women with early stage breast cancer/DCIS in rural areas are getting adjuvant RT after lumpectomy? You think the prostate guys are all getting irradiated with the same frequency that they are in larger metro areas? What do you think happens if there is a motivated rad onc all of a sudden dropped into one of those areas? You think utilization stays the same?

Listen, I agree that we are overtraining and that the current crop of Boomers in charge are not doing us any favors. But I also think it is hyperbolic, and perhaps a bit irresponsible, to consider only the negatives when discussing the future of our specialty.

I've said it before, and I'll say it again: I am very happily and gainfully employed doing a job that I love every single day. If I'm being completely realistic, I don't see any way that my hospital is going to come and tell me tomorrow that they are canning me in favor of some dude who's willing to work for cheaper. Many of my friends who are practicing are in very similar or even better situations than mine, so it's not as if I am some mystical unicorn.

Provide good service, ingratiate yourself with your coworkers and admin, make yourself invaluable and you might be surprised at how secure your job may be. After all, the professional component is peanuts to a hospital system compared with the technical revenue. Why risk disrupting something that works well to save a few hundred thousand a year when the overall rad onc budget is in the 10's of millions??

Rad onc is still the best field in medicine, IMO.

 

[eggeggeggegg]

To present a contrarian argument: what if expanding indications for radiation therapy in metastatic disease offset the declining fractions in prostate and breast? What if we end up ablating mets in every single stage IV patient to potentiate immunotherapy? Everybody on this board seems to be racing to figure out where all the badness is going to come from, while forgetting to account for unexpected (actually, probably expected) positives may come from.

Another thing that I would posit is that if we start to feel true labor pressure, people WILL start to take those jobs in rural areas (biryani be damned) and this will result in increased utilization of radiation services in those areas. There's a name for this, Jevon's paradox or something like that, where increased availability results in increased utilization. Do you think all the women with early stage breast cancer/DCIS in rural areas are getting adjuvant RT after lumpectomy? You think the prostate guys are all getting irradiated with the same frequency that they are in larger metro areas? What do you think happens if there is a motivated rad onc all of a sudden dropped into one of those areas? You think utilization stays the same?

Listen, I agree that we are overtraining and that the current crop of Boomers in charge are not doing us any favors. But I also think it is hyperbolic, and perhaps a bit irresponsible, to consider only the negatives when discussing the future of our specialty.

I've said it before, and I'll say it again: I am very happily and gainfully employed doing a job that I love every single day. If I'm being completely realistic, I don't see any way that my hospital is going to come and tell me tomorrow that they are canning me in favor of some dude who's willing to work for cheaper. Many of my friends who are practicing are in very similar or even better situations than mine, so it's not as if I am some mystical unicorn.

Provide good service, ingratiate yourself with your coworkers and admin, make yourself invaluable and you might be surprised at how secure your job may be. After all, the professional component is peanuts to a hospital system compared with the technical revenue. Why risk disrupting something that works well to save a few hundred thousand a year when the overall rad onc budget is in the 10's of millions??

Rad onc is still the best field in medicine, IMO.

Best for who? Key points I took from your reply:
- Job market is becoming bad enough you're forced to take jobs in rural areas away from family/friends (expected) but now also benefits of living in a large center. Is this meant to be a positive?? At least you might find a job after 4+4+1+4 years of training
- Valid positive points regarding utilization
- You like the job that you already have and probably won't be replaced. What about the new grads?

Rad onc is definitely amazing, but hard to rationalize it being the "best" field when it has this many drawbacks.

 

[Pointless]

Best for who? Key points I took from your reply:
- Job market is becoming bad enough you're forced to take jobs in rural areas away from family/friends (expected) but now also benefits of living in a large center. Is this meant to be a positive?? At least you might find a job after 4+4+1+4 years of training
- Valid positive points regarding utilization
- You like the job that you already have and probably won't be replaced. What about the new grads?

Rad onc is definitely amazing, but hard to rationalize it being the "best" field when it has this many drawbacks.

I was responding the prevailing "worst case" scenario being posited all over this board, where there will be a massive surplus compared to jobs available. Yes, in that instance, people will likely have to decide between location vs unemployment (or crappy employment). I should add a couple points about my situation:

1) I am relatively new to my current position (<5 years), so its not as if I have been entrenched for 20 years.

2) I took a job outside a major metro area (GASP, the horror!). This, after having been in a large metro area, and I couldn't be happier for it.

If geographic flexibility was a major/primary factor for job satisfaction for someone, then they already made an awful decision of pursuing a niche field like radiation oncology. This has always been true and probably will be more so than ever in the future.

When I said rad onc is the "best", what I meant is this: when I go to work every day, and I see what others doctors do for their living, I thank my lucky stars every day that I don't do that. An adjective like "best" is obviously subjective.

I grow increasingly concerned when people who express alternative views (such as a generally favorable view of rad onc) get shouted down. There should be room on this board, and in life in general, for both sides to be explored and discussed. The discussions on this message board have been instrumental in generating increased awareness of the problems in our field and I think it important that we continue to support our credibility by promoting rational discourse.

 

[evilbooyaa]

I was responding the prevailing "worst case" scenario being posited all over this board, where there will be a massive surplus compared to jobs available. Yes, in that instance, people will likely have to decide between location vs unemployment (or crappy employment). I should add a couple points about my situation:

1) I am relatively new to my current position (<5 years), so its not as if I have been entrenched for 20 years.

2) I took a job outside a major metro area (GASP, the horror!). This, after having been in a large metro area, and I couldn't be happier for it.

If geographic flexibility was a major/primary factor for job satisfaction for someone, then they already made an awful decision of pursuing a niche field like radiation oncology. This has always been true and probably will be more so than ever in the future.

When I said rad onc is the "best", what I meant is this: when I go to work every day, and I see what others doctors do for their living, I thank my lucky stars every day that I don't do that. An adjective like "best" is obviously subjective.

I grow increasingly concerned when people who express alternative views (such as a generally favorable view of rad onc) get shouted down. There should be room on this board, and in life in general, for both sides to be explored and discussed. The discussions on this message board have been instrumental in generating increased awareness of the problems in our field and I think it important that we continue to support our credibility by promoting rational discourse.

As always, all opinions are welcome, including both optimistic and pessimistic. Those who have optimism are welcome to have their opinions here.

 

[scarbrtj]

...To present a contrarian argument: what if expanding indications for radiation therapy in metastatic disease offset the declining fractions in prostate and breast? What if we end up ablating mets in every single stage IV patient to potentiate immunotherapy?...
...There's a name for this, Jevon's paradox or something like that, where increased availability results in increased utilization...
...I also think it is hyperbolic, and perhaps a bit irresponsible, to consider only the negatives when discussing the future of our specialty...
...you might be surprised at how secure your job may be. After all, the professional component is peanuts to a hospital system compared with the technical revenue. Why risk disrupting something that works well to save a few hundred thousand a year when the overall rad onc budget is in the 10's of millions??
...If geographic flexibility was a major/primary factor for job satisfaction for someone, then they already made an awful decision of pursuing a niche field like radiation oncology...
...I think it important that we continue to support our credibility by promoting rational discourse...

For my part, I try to avoid hyperbole and keep it factual when/if I pen negative missives. Granted, it's a fact of human nature that there's a tendency to over-react. Is that ever justifiable? The future of our specialty is a thousand times more existential to anyone reading this than a couple degree rise in planetary temperatures 50 years from now (people sure seem to get hyperbolic over that). Thus there are going to be some rad onc observations that boil down (pardon the pun) to "You have stolen my dreams and my childhood with your empty words!"

And re: "10's of millions" budgets, that won't be the case for a solo, rural rad onc practice which you seem to suggest will (or must?) become more of a thing. (~90% or more of these solo dept tech collections will be $5-9 million a year btw.) As you know, there has been a steady and ever-increasing trend of 1) migration of American rad onc care from private practice to academics, and 2) migration of American rad onc care from rural to urban. So to "be happy" about the State of Radiation Oncology not only must one cover the vectors of labor oversupply, decreasing cancer incidence, increasing rad onc class sizes, decreasing salary upper %iles, increasing geographic inflexibility, rising fellowship numbers, and decreasing reimbursement (switch to SBRT from multi-fx, hypofx, etc.), and decreased utilization, we must also invoke a thaumaturgical surge (no hyperbole here... it would have to be a surge) in radiation oncologists' care of Stage IV patients and repeat patient irradiations. Plus a good 'ol Jevon's paradox.

To look past all these signs... well, it's almost diagnosable. And the necessary amount and magnitude of the positives in order to offset the negatives will be an as unlikely path for our specialty as Oswald's magic bullet. Wait. Now that actually could be hyperbolic. But as booya more or less says, to each her own. And regarding "rational discourse." Brothers and sisters, these are irrational times for our specialty. It is being propped up on flimsy stilts over bubbly waters. If they give way... look out.

 

[deleted18755]

2) I took a job outside a major metro area (GASP, the horror!). This, after having been in a large metro area, and I couldn't be happier for it.

If geographic flexibility was a major/primary factor for job satisfaction for someone, then they already made an awful decision of pursuing a niche field like radiation oncology. This has always been true and probably will be more so than ever in the future.

I would encourage everybody, even an "ultra liberal coastal elite snowflake" type person (I'm not sure if such people even exist in real life . . . seems like they're a sizable proportion of the younger population according to the intern and some of my patients and even family and friends) to spend some serious time outside of major metro areas. Who knows maybe like the poster above you'd actually be very happy in such a place and radiation oncology or another small field would work for you.

Alternatively, maybe you would know for certain that you would be miserable, in which case you should seriously reconsider radiation oncology or ANY small/niche field of medicine or job in general, since even in the best of the best of times securing such a position in a specific location in a specific year was and will continue to be challenging.

 

[MegaVoltagePhoton]

One thing I find interesting as mostly someone on the sidelines for these arguments...when someone comes to the board and talks about how they know new grads getting good jobs, etc., it's all anecdote. But when someone talks about how a job offer was pulled because of APM supervision changes (really?)...that's not anecdote? At least be consistent.

 

[deleted950463]

I would encourage everybody, even an "ultra liberal coastal elite snowflake" type person (I'm not sure if such people even exist in real life . . . seems like they're a sizable proportion of the younger population according to the intern and some of my patients and even family and friends) to spend some serious time outside of major metro areas. Who knows maybe like the poster above you'd actually be very happy in such a place and radiation oncology or another small field would work for you.

Alternatively, maybe you would know for certain that you would be miserable, in which case you should seriously reconsider radiation oncology or ANY small/niche field of medicine or job in general, since even in the best of the best of times securing such a position in a specific location in a specific year was and will continue to be challenging.

priorities in life change. One may not know how badly they miss the competitive region until later in life.

 

[RickyScott]

Worst

priorities in life change. One may not know how badly they miss the competitive region until later in life.

worsf case scenario, and why I post here, is that rural jobs fill up and there is unemployment.

 

[xrthopeful]

If you want to live on the east coast
But are okay not being in a major city - job in Salisbury MD was just posted. I know it to be a good practice

 

[KHE88]

Worst

worsf case scenario, and why I post here, is that rural jobs fill up and there is unemployment.

Never going to happen. If there's one thing that's been demonstrated over and over here it's that people have no idea what "rural" means when it comes to "rural" jobs. We have people saying they will take any job, even rural jobs, complaining about the job market, then it turns out Lexington, KY or something is considered rural in their eyes.

Very few people in this field are willing to go to truly rural areas. And interestingly, the demographic more likely to take these jobs (white males) is being diluted out of fields in general these days by the so-called social justice movement. So there's that also.

Minot-type jobs will always be there. I had been worried about that as a truly worst-case scenario previously too, but there's just no realistic way I can see that happening when you take a closer look at the demographics of our field and how people end up training in radiation oncology (all the hoops that have to be jumped through from an early age).

 

[RickyScott]

Never going to happen. If there's one thing that's been demonstrated over and over here it's that people have no idea what "rural" means when it comes to "rural" jobs. We have people saying they will take any job, even rural jobs, complaining about the job market, then it turns out Lexington, KY or something is considered rural in their eyes.

Very few people in this field are willing to go to truly rural areas. And interestingly, the demographic more likely to take these jobs (white males) is being diluted out of fields in general these days by the so-called social justice movement. So there's that also.

Minot-type jobs will always be there. I had been worried about that as a truly worst-case scenario previously too, but there's just no realistic way I can see that happening when you take a closer look at the demographics of our field and how people end up training in radiation oncology (all the hoops that have to be jumped through from an early age).

It happened here in the past, early 90s, and it recently happened in Canada.
There are not many truly rural jobs because they are in fact truly rural! 1) not many people by definition live there
2) can’t support linac physics erc
Pre hypof era needed catchment 100,000 to support linac.

“ Ruralness” is a magical hand waving to save specialty. “We don’t have job problem just maldistribution” - BK; or we can just put all the excess new grads in rural America if we have a supply issue, and of course this amorphous huge reservoir that contains huge number of pts despite its name and definition will never fill up.

And let’s not forget doc doesn’t even have to be present anymore- can come in one day a week.
Also Since a lot of twitter all stars passionately care about the issue Like subatomicdoc and the guy from cedars, and they work 4 days a week, well I am sure they are making arrangements now to fly out on their off day to cover all the places in need...

 

[deleted18755]

priorities in life change. One may not know how badly they miss the competitive region until later in life.

If this potential is a serious concern than one shouldn’t pick any specialty with limited numbers regardless of the job market prospects

 

[KHE88]

It happened here in the past, early 90s, and it recently happened in Canada.
There are not many truly rural jobs because they are in fact truly rural! 1) not many people by definition live there
2) can’t support linac physics erc
Pre hypof era needed catchment 100,000 to support linac.

“ Ruralness” is a magical hand waving to save specialty. “We don’t have job problem just maldistribution” - BK; or we can just put all the excess new grads in rural America if we have a supply issue, and of course this amorphous huge reservoir that contains huge number of pts despite its name and definition will never fill up.

And let’s not forget doc doesn’t even have to be present anymore- can come in one day a week.
Also Since a lot of twitter all stars passionately care about the issue Like subatomicdoc and the guy from cedars, and they work 4 days a week, well I am sure they are making arrangements now to fly out on their off day to cover all the places in need...

A couple of points:
1. Freestanding centers in rural areas still need direct physician coverage.
2. A hospital can turn a profit on a linac with 8-10 under beam. Happens all the time and they don't shut down. Keeping patients in the system generates ancillary revenue.
3. It's not just about catchment but geography. Even in remote areas, there needs to be a linac within 2-3 hours driving distance.
4. If they have no other option, many/most rad oncs are not going to suddenly take jobs in BFE where the only moderately high speed internet access is on their hospital computer and the nearest airport with a commercial flight is 3 hours away. Many of these will flee to a different line of work in order to stay in their current area rather than move their family out to BFE.
5. Regarding the docs who work 4 days a week, pfffttt... most of them already have their nights and "academic" day earmarked to work for evicore and to pad their subpar academic salaries (not even half joking -- see it all the time). If I have to stay after work one more goddamned time to wait until the evicore MD is available at 7:30 PM (because that is the only time option I am given or else I get an automatic denial) and hear dinner cooking, dogs barking, and babies wailing in the background. So infuriating.

 

[Ionized]

5. Regarding the docs who work 4 days a week, pfffttt... most of them already have their nights and "academic" day earmarked to work for evicore and to pad their subpar academic salaries (not even half joking -- see it all the time). If I have to stay after work one more goddamned time to wait until the evicore MD is available at 7:30 PM (because that is the only time option I am given or else I get an automatic denial) and hear dinner cooking, dogs barking, and babies wailing in the background. So infuriating.

Your statement about Evicore is hilarious. I remember doing a peer to peer with Evicore and it was this rad onc from the midwest who was denying my IGRT request. He said that IGRT would be denied but an "isocentric setup" of some sort was allowed. I had no idea what the hell he was talking about. I really wanted to ask if he hated his life and why he would want to do this kind of work with an insurance company to deny such a basic thing that 99% of other insurance companies have always approved. I never thought it would be because a rad onc desperately wanted supplemental income... but here we are.

 

[xrthopeful]

Lol why would you possibly be surprised Ionized? Rad onc has a long long long history of people doing stuff for money. If people are going to over fractionate for money, why the **** would they not also try to screw over other rad oncs for money?

(Personally don’t do it and wouldn’t; but this doesn’t surprise me at all).

 

[Ionized]

Lol why would you possibly be surprised Ionized? Rad onc has a long long long history of people doing stuff for money. If people are going to over fractionate for money, why the **** would they not also try to screw over other rad oncs for money?

(Personally don’t do it and wouldn’t; but this doesn’t surprise me at all).

Actually, I remember the discussion now. That rad onc on the peer 2 peer with Evicore was denying my 3D conformal plan for a palliative spine case. I was like are you allowing only a 2D mid-plane calculation type plan?? He replied no, and proceeded to describe an "isocentric setup plan" that still allows for CT simulation and would be covered by the insurance, or something along those lines. I legitimately had no idea what the hell he was talking about. I said "there's nothing between 2D and 3D, I don't understand the treatment planning that you're describing. Either I can use CT based planning with delineated organs at risk or not." He then proceeded to repeat himself several times still making no sense. Eventually, I just did a 3D plan.

 

[RadOncDoc21]

Actually, I remember the discussion now. That rad onc on the peer 2 peer with Evicore was denying my 3D conformal plan for a palliative spine case. I was like are you allowing only a 2D mid-plane calculation type plan?? He replied no, and proceeded to describe an "isocentric setup plan" that still allows for CT simulation and would be covered by the insurance, or something along those lines. I legitimately had no idea what the hell he was talking about. I said "there's nothing between 2D and 3D, I don't understand the treatment planning that you're describing. Either I can use CT based planning with delineated organs at risk or not." He then proceeded to repeat himself several times still making no sense. Eventually, I just did a 3D plan.

How long ago was this? I ask because there have been some changes in billing I’ve been confused about regarding something very similar. I’ve always been taught to do a 3D plan which requires at least two structures and a target, but lately I’ve been told that I also had to specify an IDL and order for 3D calculations in all my treatment planning notes. The use for IGRT has also become even more specific. I feel like all this stuff is new and very confusing.

 

[scarbrtj]

Lol why would you possibly be surprised Ionized? Rad onc has a long long long history of people doing stuff for money. If people are going to over fractionate for money, why the **** would they not also try to screw over other rad oncs for money?

(Personally don’t do it and wouldn’t; but this doesn’t surprise me at all).

The phrase “Over fractionate for money” should go in the straw man argument category. First, I've seen it more in training by my attendings than I have out in practice. Second, never saw a fractionation scheme "out in the wild" that wasn't backed in some way by literature or data or long-standing tradition. Were there shorter alternatives? Yes. There always usually are. But I've never seen any MD use the shortest known fractionation schedules 100% of the time. "Over" in medicine has a particular connotation. Don't strain a gnat to swallow a camel: in rad onc there's much more over-treatment (due to over-diagnosis) than swarthy over-fractionationating boogeymen doing stuff, like, 28 fractions of XRT for all their whole brains. And while, yes, more fractions cost more money, one can never "over-fractionate" enough to match the 10x to 20x attempted over-charging/over-pricing that seems to go on at every NCI designated cancer center in the country.

 

[20181121]

Well as you probably know there have been some bad miscalculations. I also have friends who are proton center directors and a few are more trepidatious than I expected about the future of protons (not clinically per se but financially). And yes, fwiw, I see major things which tell me demand for radiation therapy is not going on a huge upswing. First, there are only about 20,000 new additional cancer patients, year-on-year, in the US now occurring/happening. (And if we divide that by ~5000 rad oncs, that's only ~4 new addt'l cancer patients/year/rad onc.) Second, these are TOTAL cancer patients (ie melanoma, renal, leukemia, etc.). Third, of these relatively paltry few new cancer patients every year, only maybe 1/3 to one-half are XRT (or possible proton or MR-linac) patients. Fourth, can we really predict that the therapeutic ratio of these two new techs will drive CPT reimbursements so high as to spur the whole of the rad onc market to abandon photons, IMRT, linac SRS/SBRT, or machines capable of electrons and cost-effective, simple palliation (which is 25-33% of most rad oncs' business "in the wild")?

Based on your numbers, what do you think the long-term equilibrium number of residents produced per year should be going forward?

 

[deleted1002574]

Isodose complex plans. Evicore is huge on this. The guidelines say something about how if it’s a certain size, close to something important, or close to a treated area, can use 3D instead of isodose complex which is:

CT simulation, no DVH, no CTV / PTV. Just a few beams, MLCs, but no segments.

It’s not 3D, but it’s not 2D
It’s what the French call “Le ****ty Palliative Plan”

They even suggest it for whole brain sometimes.

How long ago was this? I ask because there have been some changes in billing I’ve been confused about regarding something very similar. I’ve always been taught to do a 3D plan which requires at least two structures and a target, but lately I’ve been told that I also had to specify an IDL and order for 3D calculations in all my treatment planning notes. The use for IGRT has also become even more specific. I feel like all this stuff is new and very confusing.

 

[scarbrtj]

Based on your numbers, what do you think the long-term equilibrium number of residents produced per year should be going forward?

That's just it. We should be in equilibrium which by definition would be replacing rad oncs lost per year (retirement... death... new jobs outside rad onc) with new rad oncs. And that would be ~125/year. Since the number of new rad onc patients/year is essentially not growing, this would be reasonable. (And keep in mind, wild as it sounds, the number of new pts/rad onc is not just not growing... it's declining. Why? Very little new pts, but ever more rad oncs.) More controversial is the idea that since we are so over-supplied and new rad oncs in the next 1-10 years are (theoretically/potentially) facing employment difficulty: a 1-2y moratorium on any new residents at some point in the next 5 years. I would say if there's any objective data that a class hits 10+% unemployment (and I consider a fellowship rad onc to be unemployed at being a practicing rad onc), this would be essential. That'd be a huge red flag that we have gone from theoretical problems to real problems. But a moratorium would cause an absolute renaissance in rad onc, free up geographic brittleness, and so forth. The best thing rad onc will ever have going for it: exclusivity. It should have been guarded not discarded.

 

[scarbrtj]

Isodose complex plans. Evicore is huge on this. The guidelines say something about how if it’s a certain size, close to something important, or close to a treated area, can use 3D instead of isodose complex which is:

CT simulation, no DVH, no CTV / PTV. Just a few beams, MLCs, but no segments.

It’s not 3D, but it’s not 2D
It’s what the French call “Le ****ty Palliative Plan”

They even suggest it for whole brain sometimes.

Promise you that a company called Revenue Cycle has blessed this kooky billing kabuki with unassailable legitimacy.

 

[deleted950463]

That's just it. We should be in equilibrium which by definition would be replacing rad oncs lost per year (retirement... death... new jobs outside rad onc) with new rad oncs. And that would be ~125/year. Since the number of new rad onc patients/year is essentially not growing, this would be reasonable. (And keep in mind, wild as it sounds, the number of new pts/rad onc is not just not growing... it's declining. Why? Very little new pts, but ever more rad oncs.) More controversial is the idea that since we are so over-supplied and new rad oncs in the next 1-10 years are (theoretically/potentially) facing employment difficulty: a 1-2y moratorium on any new residents at some point in the next 5 years. I would say if there's any objective data that a class hits 10+% unemployment (and I consider a fellowship rad onc to be unemployed at being a practicing rad onc), this would be essential. That'd be a huge red flag that we have gone from theoretical problems to real problems. But a moratorium would cause an absolute renaissance in rad onc, free up geographic brittleness, and so forth. The best thing rad onc will ever have going for it: exclusivity. It should have been guarded not discarded.

To be fair almost all rads go through a fellowship.

 

[radoncgrad2019]

The phrase “Over fractionate for money” should go in the straw man argument category. First, I've seen it more in training by my attendings than I have out in practice. Second, never saw a fractionation scheme "out in the wild" that wasn't backed in some way by literature or data or long-standing tradition. Were there shorter alternatives? Yes. There always usually are. But I've never seen any MD use the shortest known fractionation schedules 100% of the time. "Over" in medicine has a particular connotation. Don't strain a gnat to swallow a camel: in rad onc there's much more over-treatment (due to over-diagnosis) than swarthy over-fractionationating boogeymen doing stuff, like, 28 fractions of XRT for all their whole brains. And while, yes, more fractions cost more money, one can never "over-fractionate" enough to match the 10x to 20x attempted over-charging/over-pricing that seems to go on at every NCI designated cancer center in the country.

this is the biggest crock of BS.

There is over-fractionation. And it is clearly done for money or RVUs or 'appearing to look busy' depending on what scope of practice you are in. It is certainly not for the patient's sake when you do 20 fractions for a bone met. So stop the blathering.

 

[RickyScott]

this is the biggest crock of BS.

There is over-fractionation. And it is clearly done for money or RVUs or 'appearing to look busy' depending on what scope of practice you are in. It is certainly not for the patient's sake when you do 20 fractions for a bone met. So stop the blathering.

At one point fractionation was clearly a surrogate for money/price. Now it is not, and I care about the unjust/ misappropriation of resources/money.

large academic center often negotiate rates 3-5x price of a community center. You are not a good guy delivering 8gy x 1 if it is still costs more than an extended fractionation in the community!

We have price problem far more than fractionation problem- if one exists. Macroscopically, recent JAMA article that America does not use more health resources than europe, just charges a ton more:”its still the prices stupid.”

the same entities that are expanding residencies are source of financial toxicity