Virtual Supervision

[deleted1111261]

The problem is that a small minority of the "voluntary" APM reduced costs.

1) CMS looks at the equation Value=Quality/Costs

2) By all accounts Quality is hard to measure.

3) Forcing down costs guarantees increased value.

4) Many will claim that Quality suffers but refer to #2 above

Our leaders thought that they could partner with CMS.

It is telling that the person who is charged with the pricing methodology of the RO APM has a PhD in International Studies and Comparative Politics-no degrees in Economics

Our elites are horrible

Who?

---

Members don't see this ad.

 

[fiji128]

I am fortunate enough to not be affected by the APM. Putting aside the issue of everyone trying to get the job done in one fraction... I think another major concern is less access for patients. There will be clinics who simply cannot afford to treat a second uncompensated course within 90 days, or cannot afford to take APM medicare patients, doctors retiring and not being replaced... and even clinic closures. I worry a lot of places are going to go out of business and a lot of people will decide it isn't worth it anymore. Maybe those big hospitals decide to refocus their resources in non-APM zips. As you know, it's not just an issue of cuts to reimbursement, but there is also requirements for EMR utilization and upgrades... and this will hit those rural clinics the hardest... leaving those patients SOL.

If CMS was smart, they would have made this optional (and a little less spartan). That way, the only places who signed on would be ones who are likely able to survive. CMS would then be able to point to their successes and say "see, it's doable!"

If clinics start closing and we start hearing stories of grandpa having to drive 300 miles to get his cancer treated... the whole APM thing may be done.

Where I'm located one of the systems rural clinics ended up in an APM zip code. Doc working there is old and is definitely of retiring age. Clinic is not that busy but currently enough so to keep the doors open. I've wonder if he leaves would the system just close the clinic rather then deal with all the additional APM headaches. Its a real possibility.

 

[RSAOaky]

First they came for the residents, and I did not speak out, because I was not a resident.
Then they came for the freestanding centers, and I did not speak out, because I am not a freestanding center.
Then they came for the academic centers, and I did not speak out, because I am not an academic center.
Then they came for ASTRO, and there was no one left to speak for them...

 

[evilbooyaa]

Where I'm located one of the systems rural clinics ended up in an APM zip code. Doc working there is old and is definitely of retiring age. Clinic is not that busy but currently enough so to keep the doors open. I've wonder if he leaves would the system just close the clinic rather then deal with all the additional APM headaches. Its a real possibility.

This should be a datapoint that either CMS or private researchers should monitor.

How many RO clinics close as a result of 1-3 years of APM nonsense within APM zip codes, and is that statistically significant compared to RO clinic closures in non-APM zip codes.

There needs to be a quantification to this claim of "reduced patient access" spurred on by APM preferentially affecting rural zip codes.

 

[RSAOaky]

Edit: I deleted this post because it was a diatribe on APM and then I realized the thread was about direct supervision. It was a gem though.

 

[GI_RadOnc]

Because occasionally there are issues with alignment, setup, etc, where I'm at the machine moving the couch with physics/therapy. That can't be done remotely.

Although I guess I could use Facetime!

edit: yup, exactly. Doesn't mean we should encourage activity like that. I'd say it's similar to a surgeon running multiple rooms at once. Although, on second thought, what percent does a whistleblower get again?

Depending on the system; you can move the couch and realign remotely. One of our units allows me to remote into the treatment console where I can directly make shifts, edit contours and approve plans.

I have anywhere between 3-5 SBRT patients per day over two sites. If I didn't maximize remote access; I could never see any new patients... which I need to all the time because my median fraction number is 8!

It is an interesting cultural change though; and after some initial apprehension; our physics/therapy like it BETTER than physical presence. Physical presence took longer to get there, and our physical presence always included a 'floor physician' who would be called... so you could end up with the breast specialist covering the lung SBRT! So, quicker response and better expertise = happier team.

And it's not akin to a surgeon running two rooms... no one is anesthetized, no one is bleeding, there are no hands inside cavities, you are not going to have to run and bag-mask someone. That's why it's under general supervision.

 

[Chartreuse Wombat]

Who?

I don't know this person. Her resume argues for scholarly expertise in the International Relations.

This is not meant to speak ill of her only to note that she has no training in healthcare economics.

If the moderators think this is inappropriate then please remove

 

[TheWallnerus]

View attachment 343362

View attachment 343363

I don't know this person. Her resume argues for scholarly expertise in the International Relations.

This is not meant to speak ill of her only to note that she has no training in healthcare economics.

If the moderators think this is inappropriate then please remove

I wanna get up in front of her, and her ilk, and give em a good Tom Cruising.

 

[deleted1111261]

Edit: I deleted this post because it was a diatribe on APM and then I realized the thread was about direct supervision. It was a gem though.

I enjoyed the thought of this. I wish you'd re post

 

[deleted1111261]

Depending on the system; you can move the couch and realign remotely. One of our units allows me to remote into the treatment console where I can directly make shifts, edit contours and approve plans.

I have anywhere between 3-5 SBRT patients per day over two sites. If I didn't maximize remote access; I could never see any new patients... which I need to all the time because my median fraction number is 8!

It is an interesting cultural change though; and after some initial apprehension; our physics/therapy like it BETTER than physical presence. Physical presence took longer to get there, and our physical presence always included a 'floor physician' who would be called... so you could end up with the breast specialist covering the lung SBRT! So, quicker response and better expertise = happier team.

And it's not akin to a surgeon running two rooms... no one is anesthetized, no one is bleeding, there are no hands inside cavities, you are not going to have to run and bag-mask someone. That's why it's under general supervision.

There is a lack of imagination of what we can do. You doing this remotely shows innovation and imagination. Far better than pretending that there is some magic about adjusting this on site.

Should we contour on site, too?

 

[deleted1111261]

View attachment 343362

View attachment 343363

I don't know this person. Her resume argues for scholarly expertise in the International Relations.

This is not meant to speak ill of her only to note that she has no training in healthcare economics.

If the moderators think this is inappropriate then please remove

I'm not a moderator, but nothing wrong with your post.
Now, what I want to post - that would probably get deleted.

 

[TheWallnerus]

Spratt attack?

 

[TheWallnerus]

Revenue Cycle, one of America's largest independent RO billing/coding companies, says:

1) Kill telehealth weekly OTV
2) Kill virtual direct supervision

Regulations.gov

www.regulations.gov

 

[TheWallnerus]

AAPM: Kill virtual direct supervision.

Regulations.gov

www.regulations.gov

 

[TheWallnerus]

Philips Healthcare:

 

[TheWallnerus]

Virtual direct playing well in Manhattan:

 

[Gfunk6]

AAPM: Kill virtual direct supervision.

Regulations.gov

www.regulations.gov

I read the document. It sounds like they only want to stop direct supervision temporarily. Once the pandemic restrictions are lifted, they want CMS to re-institute direct supervision.

 

[TheWallnerus]

California Medical Association (I'll stop):

 

[BobbyHeenan]

I'm sorry, but international relations and social sciences research analyst designing a reimbursement for radiation oncology screams IYI...



"What we have been seeing worldwide, from India to the UK to the US, is the rebellion against the inner circle of no-skin-in-the-game policymaking “clerks” and journalists-insiders, that class of paternalistic semi-intellectual experts with some Ivy league, Oxford-Cambridge, or similar label-driven education who are telling the rest of us 1) what to do, 2) what to eat, 3) how to speak, 4) how to think… and 5) who to vote for."

"Indeed one can see that these academico-bureaucrats who feel entitled to run our lives aren’t even rigorous, whether in medical statistics or policymaking. They cant tell science from scientism — in fact in their eyes scientism looks more scientific than real science. (For instance it is trivial to show the following: much of what the Cass-Sunstein-Richard Thaler types — those who want to “nudge” us into some behavior — much of what they would classify as “rational” or “irrational” (or some such categories indicating deviation from a desired or prescribed protocol) comes from their misunderstanding of probability theory and cosmetic use of first-order models.) They are also prone to mistake the ensemble for the linear aggregation of its components as we saw in the chapter extending the minority rule."

The Intellectual Yet Idiot

On Medium, Nassim posts an excerpt from Skin in the Game: What we have been seeing worldwide, from India to the UK to the US, is the rebellion against the

nassimtaleb.org

 

[Chartreuse Wombat]

I'm sorry, but international relations and social sciences research analyst designing a reimbursement for radiation oncology screams IYI...



"What we have been seeing worldwide, from India to the UK to the US, is the rebellion against the inner circle of no-skin-in-the-game policymaking “clerks” and journalists-insiders, that class of paternalistic semi-intellectual experts with some Ivy league, Oxford-Cambridge, or similar label-driven education who are telling the rest of us 1) what to do, 2) what to eat, 3) how to speak, 4) how to think… and 5) who to vote for."

"Indeed one can see that these academico-bureaucrats who feel entitled to run our lives aren’t even rigorous, whether in medical statistics or policymaking. They cant tell science from scientism — in fact in their eyes scientism looks more scientific than real science. (For instance it is trivial to show the following: much of what the Cass-Sunstein-Richard Thaler types — those who want to “nudge” us into some behavior — much of what they would classify as “rational” or “irrational” (or some such categories indicating deviation from a desired or prescribed protocol) comes from their misunderstanding of probability theory and cosmetic use of first-order models.) They are also prone to mistake the ensemble for the linear aggregation of its components as we saw in the chapter extending the minority rule."

The Intellectual Yet Idiot

On Medium, Nassim posts an excerpt from Skin in the Game: What we have been seeing worldwide, from India to the UK to the US, is the rebellion against the

nassimtaleb.org

Taleb...just Taleb. Great book. Much more approachable than his earlier works

 

[BobbyHeenan]

Taleb...just Taleb. Great book. Much more approachable than his earlier works

Skin in the Game is my favorite. So accessible. And when reading it in light of all the radiation problems (residency expansion, APM), it just hits you like a ton of bricks.

 

[RickyScott]

So many iyi in this field…

 

[TheWallnerus]

I'm sorry, but international relations and social sciences research analyst designing a reimbursement for radiation oncology screams IYI...



"What we have been seeing worldwide, from India to the UK to the US, is the rebellion against the inner circle of no-skin-in-the-game policymaking “clerks” and journalists-insiders, that class of paternalistic semi-intellectual experts with some Ivy league, Oxford-Cambridge, or similar label-driven education who are telling the rest of us 1) what to do, 2) what to eat, 3) how to speak, 4) how to think… and 5) who to vote for."

"Indeed one can see that these academico-bureaucrats who feel entitled to run our lives aren’t even rigorous, whether in medical statistics or policymaking. They cant tell science from scientism — in fact in their eyes scientism looks more scientific than real science. (For instance it is trivial to show the following: much of what the Cass-Sunstein-Richard Thaler types — those who want to “nudge” us into some behavior — much of what they would classify as “rational” or “irrational” (or some such categories indicating deviation from a desired or prescribed protocol) comes from their misunderstanding of probability theory and cosmetic use of first-order models.) They are also prone to mistake the ensemble for the linear aggregation of its components as we saw in the chapter extending the minority rule."

The Intellectual Yet Idiot

On Medium, Nassim posts an excerpt from Skin in the Game: What we have been seeing worldwide, from India to the UK to the US, is the rebellion against the

nassimtaleb.org

Intelligence : IYI :: science : scientism :: truth : truthiness

 

[communitydoc13]

That was loss of credibility (LoC) part one.

LoC part deux was COVID. With the PHE, instead of physicians running headlong into proper clinical care and keeping things as safe as possible for patients, those in the ASTRO Ivory Tower said “You know what? Staying home a day or two sounds great. The patients are fine.” When every other MD was being asked to step up, ASTRO said it’s ok to step back. Which was sensible. But totally hypocritical.

LoC part 3 is ASTRO saying that safety is back at the forefront and doctors need to be present. Except maybe at hospitals where CMS has already said they don’t need to be present. So, at the end of the day, ASTRO is picking on supervision flexibility against one group only:

Not a member or fan of ASTRO but all of ASTRO's positions on this pretty rational IMO. All based on basic risk/benefit analysis.

First, that direct supervision would have a statistical impact on patient outcomes is silly and should not be the standard for implementation. Airlines are not graded on safety by number of crashes, because that number is so low that it is meaningless. In 2001 American and United were undoubtedly the worst US carriers. You have to use proxy measures (like safety tracking tools) when dealing with rare events that you want to minimize. I am unaware of analysis regarding trackable safety incidents in unsupervised vs supervised clinics and I am not sure that I would trust them regardless. (Not sure how level of doctor engagement with therapy impacts their tendency to appropriately use things like safety tracking tools).

So, to go through my interpretation of ASTRO's stances.

You need to relax the direct supervision standard in rural clinics for access, continuity of treatment and maybe even risk of driving hundreds of miles a day. These competing risks are only present in rural clinics.

During COVID, competing risk is COVID, exacerbated by indoor population density and in-person visits in poorly ventilated examination rooms. So, relax the standard.

Maybe I'm naive, but I believe that a big part of the standard of direct supervision is to ensure that "there's a doc in the house" for any medical contingency. This is clearly not a problem in a hospital based practice (although if medonc has to come over for every giddy, tachycardic or in-pain patient during the course of the week, they will be pissed), and thus the disparity in application between free-standing (where a doc really might not be in the house) and hospital based practices.

It is telling that the person who is charged with the pricing methodology of the RO APM has a PhD in International Studies and Comparative Politics-no degrees in Economics

Has our pricing ever been rational? Serious question. The difference in compensation between 25 fractions of adjuvant 3D XRT to the groin dwarfs the compensation for that groin dissection.

Is anybody else out there lookin at the MPFS vs APM compensation for bone, brain, breast and prostate and thinking that it won't be that big a hit financially in the short term, but the 90 day rule is unfair and somewhat financially painful and implementing the data reporting for quality measures in a place without good IT will be the real hassle. Cause that's how I'm looking at APM right now.


"

 

[medgator]

Not a member or fan of ASTRO but all of ASTRO's positions on this pretty rationale IMO. All based on basic risk/benefit analysis.

So then why the dichotomy between freestanding and hospitals? Why let "qualified" NPs supervise in the hospital setting only? Why was the "general supervision" rollback only given to hospital-based?

 

[communitydoc13]

So then why the dichotomy between freestanding and hospitals? Why let "qualified" NPs supervise in the hospital setting only? Why was the "general supervision" rollback only given to hospital-based?

Good point. I'm thinking that they're thinking (for what that's worth) that the baseline level of physician coverage is much higher in the hospital setting (always an attached ER or adjacent medonc practice) so final MD level supervision readily available in an acute situation.

 

[medgator]

Good point. I'm thinking that they're thinking (for what that's worth) that the baseline level of physician coverage is much higher in the hospital setting (always an attached ER or adjacent medonc practice) so final MD level supervision readily available in an acute situation.

You know what they say when you assume.... Fwiw chemo supervision in the freestanding setting is allowed with an NP, also many "freestanding" radiation centers are multispecialty in nature, often with med onc attached to or in the same building.

ASTRO isn't in tune with the private practice/freestanding crowd so it wouldn't shock me if many of these facts escaped them, but it definitely creates apathy from many of us towards our specialty's main advocacy organization

 

[communitydoc13]

ASTRO isn't in tune with the private practice/freestanding crowd so it wouldn't shock me if many of these facts escaped them, but it definitely creates apathy from many of us towards our specialty's main advocacy organization

Agree and agree that modification for NP/PA would make sense. In a fairly rural, hospital based place that I covered, I would routinely cover chemo for a few hours. The nurses knew what to give with a sensitivity reaction.

 

[DebtRising]

Depending on the system; you can move the couch and realign remotely. One of our units allows me to remote into the treatment console where I can directly make shifts, edit contours and approve plans.

I have anywhere between 3-5 SBRT patients per day over two sites. If I didn't maximize remote access; I could never see any new patients... which I need to all the time because my median fraction number is 8!

It is an interesting cultural change though; and after some initial apprehension; our physics/therapy like it BETTER than physical presence. Physical presence took longer to get there, and our physical presence always included a 'floor physician' who would be called... so you could end up with the breast specialist covering the lung SBRT! So, quicker response and better expertise = happier team.

And it's not akin to a surgeon running two rooms... no one is anesthetized, no one is bleeding, there are no hands inside cavities, you are not going to have to run and bag-mask someone. That's why it's under general supervision.

How are you able to remote into the treatment unit and what security do you have to keep the treatment unit from being hacked? Honest question. I thought they were supposed to be walled off from general network access for security purposes, though this may be more institutional policy than law.

With virtual supervision being the next battleground to lose, I truly remain amazed Astro and academic leaders continue to keep near record residency slots. It is nonsensical and greedy.

 

[deleted941485]

Not a member or fan of ASTRO but all of ASTRO's positions on this pretty rationale IMO. All based on basic risk/benefit analysis.

First, that direct supervision would have a statistical impact on patient outcomes is silly and should not be the standard for implementation. Airlines are not graded on safety by number of crashes, because that number is so low that it is meaningless. In 2001 American and United were undoubtedly the worst US carriers. You have to use proxy measures (like safety tracking tools) when dealing with rare events that you want to minimize. I am unaware of analysis regarding trackable safety incidents in unsupervised vs supervised clinics and I am not sure that I would trust them regardless. (Not sure how level of doctor engagement with therapy impacts their tendency to appropriately use things like safety tracking tools).

So, to go through my interpretation of ASTRO's stances.

You need to relax the direct supervision standard in rural clinics for access, continuity of treatment and maybe even risk of driving hundreds of miles a day. These competing risks are only present in rural clinics.

During COVID, competing risk is COVID, exacerbated by indoor population density and in-person visits in poorly ventilated examination rooms. So, relax the standard.

Maybe I'm naive, but I believe that a big part of the standard of direct supervision is to ensure that "there's a doc in the house" for any medical contingency. This is clearly not a problem in a hospital based practice (although if medonc has to come over for every giddy, tachycardic or in-pain patient during the course of the week, they will be pissed), and thus the disparity in application between free-standing (where a doc really might not be in the house) and hospital based practices.


Has our pricing ever been rational? Serious question. The difference in compensation between 25 fractions of adjuvant 3D XRT to the groin dwarfs the compensation for that groin dissection.

Is anybody else out there lookin at the MPFS vs APM compensation for bone, brain, breast and prostate and thinking that it won't be that big a hit financially in the short term, but the 90 day rule is unfair and somewhat financially painful and implementing the data reporting for quality measures in a place without good IT will be the real hassle. Cause that's how I'm looking at APM right now.


"

I already got word from my dept email about contracts. Corporate bean counters at the community hospital already has the lube out. Talking about major "updates" to compensation. Meanwhile my place is hiring 3 new med oncs...and gasp one went to Caribbean school and has no publications!! oh the humanity how could they possibly be a good oncologist!

 

[TheWallnerus]

You need to relax the direct supervision standard in rural clinics for access, continuity of treatment and maybe even risk of driving hundreds of miles a day. These competing risks are only present in rural clinics.

Would be nice to relax this in rural clinics.
1) Rural clinics NEVER were able to. Only rural hospitals. Big difference.
2) Re: rural, ASTRO never once voiced support for rural freestanding, or rural hospitals, having supervision flexibility.
3) By coming out against virtual direct supervision, ASTRO is singling out one entity: freestanding centers.

Not a member or fan of ASTRO but all of ASTRO's positions on this pretty rational IMO. All based on basic risk/benefit analysis.

Under COVID...

If general supervision is really unsafe, you don't do it. You're a doctor. You don't put patients' lives at risk even if it means by going in to work you are putting yourself, you the MD, at risk. However, if deep down inside you know that you aren't putting patients at risk by not going into work... you don't go into work.

ASTRO was both rational and completely hypocritical, and they couldn't be the former without showing the latter. Before COVID, they were purely irrational. But guileless.

Maybe I'm naive, but I believe that a big part of the standard of direct supervision is to ensure that "there's a doc in the house" for any medical contingency.

Radiologists in freestanding radiology centers whilst (solely) "irradiating" patients do not nor have ever been expected to meet this contingency by Medicare or the ACR. Furthermore, Medicare has allowed "there's a nurse practitioner in the house" for chemotherapy, in freestanding, for decades.

 

[communitydoc13]

Radiologists in freestanding radiology centers whilst (solely) "irradiating" patients do not nor have ever been expected to meet this contingency by Medicare or the ACR.

They need to be there for multiple aspects of care, including administration of contrast agents.

Whistleblower could get $2.9M reward in Medicare fraud case

Orthopaedic and Neuro Imaging LLC submitted false claims for Medicare reimbursement, the Department of Justice announced.

www.delawareonline.com

 

[TheWallnerus]

They need to be there for multiple aspects of care, including administration of contrast agents.

Whistleblower could get $2.9M reward in Medicare fraud case

Orthopaedic and Neuro Imaging LLC submitted false claims for Medicare reimbursement, the Department of Justice announced.

www.delawareonline.com

Why I said solely irradiating. CT/MRI sans contrast, or plain film X-ray, all general supervision.

For radiation oncologists OTOH, from 2006-08, plain film X-raying required personal supervision.

 

[Reaganite]

Good point. I'm thinking that they're thinking (for what that's worth) that the baseline level of physician coverage is much higher in the hospital setting (always an attached ER or adjacent medonc practice) so final MD level supervision readily available in an acute situation.

I just cannot take any argument regarding physician supervision for possible acute situations in the XRT setting seriously when NPs are allowed to supervise chemotherapy. It's a joke. Similarly, there are practices in all specialties all across America where NPs are running clinics and the doc is definitely not in 5 days a week. There are NPs all over Rxing meds far more likely to kill a patient than a radiation treatment not personally supervised by a board certified radiation oncologist. So the idea that a board certified radiation oncologist needs to be on site in the event some acute issue occurs makes 0 sense in the context of the practice of medicine elsewhere in the U.S. If the argument is a board certified radonc is needed to specifically supervise radiation to "ensure proper set-up," then the standard should be uniformly applied to all settings.

 

[communitydoc13]

I just cannot take any argument regarding physician supervision for possible acute situations in the XRT setting seriously when NPs are allowed to supervise chemotherapy. It's a joke. Similarly, there are practices in all specialties all across America where NPs are running clinics and the doc is definitely not in 5 days a week. There are NPs all over Rxing meds far more likely to kill a patient than a radiation treatment not personally supervised by a board certified radiation oncologist. So the idea that a board certified radiation oncologist needs to be on site in the event some acute issue occurs makes 0 sense in the context of the practice of medicine elsewhere in the U.S. If the argument is a board certified radonc is needed to specifically supervise radiation to "ensure proper set-up," then the standard should be uniformly applied to all settings.

Agree modification for NP/PA reasonable in today's environment.

I would like to think that radonc is peculiar and presents real clinical challenges in real time that the average NP may be less equipped to handle than say prescribing anti-emetics, pain meds or steroids. I would like to think that the availability of the consulting MD to reassure patients thinking of quitting mid-week or assessing for futility dynamically during treatment is an MDs job.

I certainly don't think that the potential for medical catastrophe is the same in the therapeutic vs diagnostic radiology setting.

I admit, I am biased against the transfer of medicine as a whole to remote care. I think the wrong statistical tools will be used to show equivalence and that the performative aspect of medicine is damn critical. I have personally seen significant delay of diagnosis cases during COVID due to remote medicine supplanting in-patient examination. I also am not in a situation where relaxation of supervision standards is going to be a QOL or financial boon, but rather likely another step in the devaluation of my specialty within my community. My response to the marginalization of radonc has been a maximalist one, with more engagement with multi-disciplinary care, palliative care and pt ownership.

Again, I'm in the minority that thinks we should be giving cancer drugs.

 

[Krukenberg]

Agree modification for NP/PA reasonable in today's environment.

I would like to think that radonc is peculiar and presents real clinical challenges in real time that the average NP may be less equipped to handle than say prescribing anti-emetics, pain meds or steroids. I would like to think that the availability of the consulting MD to reassure patients thinking of quitting mid-week or assessing for futility dynamically during treatment is an MDs job.

I certainly don't think that the potential for medical catastrophe is the same in the therapeutic vs diagnostic radiology setting.

I admit, I am biased against the transfer of medicine as a whole to remote care. I think the wrong statistical tools will be used to show equivalence and that the performative aspect of medicine is damn critical. I have personally seen significant delay of diagnosis cases during COVID due to remote medicine supplanting in-patient examination. I also am not in a situation where relaxation of supervision standards is going to be a QOL or financial boon, but rather likely another step in the devaluation of my specialty within my community. My response to the marginalization of radonc has been a maximalist one, with more engagement with multi-disciplinary care, palliative care and pt ownership.

Again, I'm in the minority that thinks we should be giving cancer drugs.

I agree with you. Additionally, I’m surprised that there are PP docs with PSAs on here rallying for relaxation. You’re making yourself replaceable and non-essential to the hospital.

 

[dieABRdie]

I agree with you. Additionally, I’m surprised that there are PP docs with PSAs on here rallying for relaxation. You’re making yourself replaceable and non-essential to the hospital.

Agree. Our most senior partner is always bitching and moaning about all of the requirements for us to supervise procedures and the mountain of documents we have to sign "just because." Not a peep from me.... lol.

 

[TheWallnerus]

I agree with you. Additionally, I’m surprised that there are PP docs with PSAs on here rallying for relaxation. You’re making yourself replaceable and non-essential to the hospital.

Agree. Our most senior partner is always bitching and moaning about all of the requirements for us to supervise procedures and the mountain of documents we have to sign "just because." Not a peep from me.... lol.

If our value was "be physically nearby just because" or sign things "just because" eventually... eventually... someone external and above us would realize the rad onc's argument has no clothes. ASTRO couldn't sit back and write two sentence explanations about the irreversible nature of radiation and that "rad onc presence is critical" forever. ASTRO had no hard data. CMS cites UK and Canadian breast fractionation outcomes now in its policies; one has to think they're also aware of supervision standards in those countries. CMS had its own data re: rad onc presence, and none of it supported the "presence argument."

Rad oncs are not replaceable. They are essential. Why do we need to conflate physical presence with essentialness. Patients still need a consult. They still need a prescription and plan. Every other specialty, best as I can tell, is embracing the telehealth concept. The modernization of rad onc traditions and policies won't change the fact that we are the only doctors willing and able to be legally responsible for beaming potentially lethal amounts of radiation into people's organs. Unfortunately there are so many rad oncs the modernization process is going to hurt many, especially grads-to-be. This is where the leaders let us down. They didn't look into the future and plan what-if. One could've seen virtual and telehealth coming from a mile away on the track, yet all the rad onc leaders preferred the view from the caboose. The meals are great there but the view infaust.

 

[RickyScott]

I agree with you. Additionally, I’m surprised that there are PP docs with PSAs on here rallying for relaxation. You’re making yourself replaceable and non-essential to the hospital.

What truly makes us all replaceable is the unjustified residency expansion.

 

[medgator]

I agree with you. Additionally, I’m surprised that there are PP docs with PSAs on here rallying for relaxation. You’re making yourself replaceable and non-essential to the hospital.

That train left the station prepandemic at the start 2020 with CMS's decision to ride right over ASTRO and expand general supervision outside of rural critical access hospital centers. Residency expansion has been far worse than anything CMS could have done, and we did that to ourselves as a specialty

 

[communitydoc13]

Rad oncs are not replaceable.

I've never practiced in the UK but had a physicist who did. He stated that the docs there are pretty much technicians themselves with much less emphasis on patient interaction and global oncology type thinking. I don't know, maybe he's wrong.

Rad oncs are of course replaceable.... by fewer radoncs. If things got ugly where I am, we would have to shrink the practice, reduce coverage and maximize technical throughput while minimizing patient follow-up. This is not what I'm doing now, which is maximizing my availability and input as an oncologist.

I'm pretty sure we could not train another radonc for 20 years, maximally distribute radoncs for community care (bye-bye 3 consult/week academic jobs), "modernize" the norms of radonc medicine to minimize clinical management, physician presence or global oncology thinking while maximizing treatable consults per doc and treat all radonc patients for the foreseeable future.

Really a shame for all those fairly recent trainees who were taught to think holistically, who understand prognosis, competing risks, when and where and what type of biopsy should be performed and what sort and schedule of restaging imaging should be ordered and can actually read these studies themselves. Heck, they even know the relative response rates of XRT vs other interventions.

Well let medonc have at it.

 

[TheWallnerus]

Rad oncs are of course replaceable.... by fewer radoncs. If things got ugly where I am, we would have to shrink the practice, reduce coverage and maximize technical throughput while minimizing patient follow-up.

Technically this is fungibility not replaceability. I am fully, sadly, painfully aware that virtuality, plus significant oversupply, significantly increases our fungibility. That's what always worried me about oversupply. But in the spirit of Tyler Durden, and maybe Coach Bobby Knight, let's go ahead and "hit rock bottom" because then maybe we can actually get somewhere.

 

[communitydoc13]

I'm just waiting for for an institution or entrepreneurial group with capital to start soliciting comprehensive, virtual radonc services to community hospitals. Docs would do in-person rounds 1-2x/ week or month. The new "satellite job", except now the satellites are nowhere near commuting distance.

Anybody want to go in on this?

 

[TheWallnerus]

I'm just waiting for for an institution or entrepreneurial group with capital to start soliciting comprehensive, virtual radonc services to community hospitals. Docs would do in-person rounds 1-2x/ week or month. The new "satellite job", except now the satellites are nowhere near commuting distance.

Anybody want to go in on this?

There was some job... many years back... was it the Elko, NV job?... and the company was like "The moment we can have a remote rad onc we can put more centers in rural locations, and we won't have to close down smaller centers which we've been forced to in the past." For every action there is an equal and opposite reaction. I know you may be being slightly facetious, but in some markets this kind of approach is going to be highly efficient and sought after.

 

[deleted1111261]

This is Blockbuster all over again.

You can’t stick to old things just because you like them or you can’t wrap your head around it.

It’s coming. Understand it, make sense out if it.

 

[RickyScott]

This is Blockbuster all over again.

You can’t stick to old things just because you like them or you can’t wrap your head around it.

It’s coming. Understand it, make sense out if it.

Smashing sowing machines did not create jobs for the luddites? A reassuring, avuncular 1-2 million dollar a year POS like mike steinberg or Louie potters is not going to save the new grads.

 

[OTN]

I've never practiced in the UK but had a physicist who did. He stated that the docs there are pretty much technicians themselves with much less emphasis on patient interaction and global oncology type thinking. I don't know, maybe he's wrong.

Rad oncs are of course replaceable.... by fewer radoncs. If things got ugly where I am, we would have to shrink the practice, reduce coverage and maximize technical throughput while minimizing patient follow-up. This is not what I'm doing now, which is maximizing my availability and input as an oncologist.

I'm pretty sure we could not train another radonc for 20 years, maximally distribute radoncs for community care (bye-bye 3 consult/week academic jobs), "modernize" the norms of radonc medicine to minimize clinical management, physician presence or global oncology thinking while maximizing treatable consults per doc and treat all radonc patients for the foreseeable future.

Really a shame for all those fairly recent trainees who were taught to think holistically, who understand prognosis, competing risks, when and where and what type of biopsy should be performed and what sort and schedule of restaging imaging should be ordered and can actually read these studies themselves. Heck, they even know the relative response rates of XRT vs other interventions.

Well let medonc have at it.

In my experience newly-minted medoncs don't have nearly the solid tumor training we do. As a result, helping manage these patients through the initial part of their diagnosis can be valuable. In addition, helping to take care of side effects during treatment helps to unload some of the burden from our medonc colleagues.

So, at least in my practice, being an "oncologist who uses radiation" rather than just a technician does have some value. Having said that, I just had a conversation with my partner, and we both agreed that we likely will not be bringing in another doc to our region again, even when our older docs retire. Maybe when our current slate of mid-40s/early-50s docs retire we will need to hire someone else...in 10-20 years.

 

[RickyScott]

In my experience newly-minted medoncs don't have nearly the solid tumor training we do. As a result, helping manage these patients through the initial part of their diagnosis can be valuable. In addition, helping to take care of side effects during treatment helps to unload some of the burden from our medonc colleagues.

hard to separate training from quality of people who went into radonc. very likely that anyone who matches today has glorified technician written all over them.

 

[kimplera]

There is a lack of imagination of what we can do. You doing this remotely shows innovation and imagination. Far better than pretending that there is some magic about adjusting this on site.

Should we contour on site, too?

pretty sure we've been told to contour and sign films on site - but even on site i have to log into citrix to do so and i'm not sure what the difference is...

 

[TheWallnerus]

pretty sure we've been told to contour and sign films on site - but even on site i have to log into citrix to do so and i'm not sure what the difference is...

Which is pretty stupid.

Direct supervision means in the building with the patient.

If the patient is home while you're contouring/signing films, to truly meet direct supervision you need to be at the patient's kitchen table.