ASTRO Actively Working Against Member's Interest

[deleted1111261]

https://x.com/ParikhSimul/status/1722972663667175879?s=20

These people...

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[drowsy12]

this is a tricky one. Virtual supervision is bad for the collective, good for the individual, in my view

 

[NotMattSpraker]

this is a tricky one. Virtual supervision is bad for the collective, good for the individual, in my view

Sounds like a great topic to discuss openly with members and the field. The secrecy is so damaging.

 

[BobbyHeenan]

this is a tricky one. Virtual supervision is bad for the collective, good for the individual, in my view

I tend to agree.

I think it can very much be a mixed bag for patients too. I do think some patient care is inferior via virtual. But it may also improve access...so mixed bag.

 

[Mandelin Rain]

Yeah. I'm not sure that a site should be open if a doctor isn't available to see each patient on treatment once per week.

Jordan Johnson wants it that way because it (now) suits his business model (as opposed to previously when he'd be screaming fraud and fear mongering people into buying his services).

 

[NotMattSpraker]

I tend to agree.

I think it can very much be a mixed bag for patients too. I do think some patient care is inferior via virtual. But it may also improve access...so mixed bag.

Agree, it's a great tool but in my opinion should be used sparingly.

I've thought about making OTV #1 for most patients virtual to help with clinic bandwidth and patient convenience.

I just find it really hard to have a well timed "hybrid" clinic with virtual and in-person visits in the same day. Im often late to virtual visits and that kind of unfair to the patient. That's been the main reason for me to avoid it thus far.

 

[deleted1111261]

100%

Agree that there are extreme examples where this could get messy.

But, to actually argue against something like this without having a dialogue with members is unfortunate.

I do not subscribe to full APP model. A good RO should be present. But, to say that you can't do a 77427 on the first few weeks of prostate / breast / whatever treatment via telemed/video is not patient/physician friendly. What is the value of restricting?

I don't subscribe to the idea that we should create artificial constraints to prop up the job market. If we have a market problem, we produce less physicians, we push back against consolidation / employment, we try to bring back ownership.

 

[Mandelin Rain]

Counterpoint: an OTV in the first couple weeks of treatment typically takes 13 seconds whether it's on telemed or in person. The telemed is actually likely more cumbersome to get set up and no vitals/non-verbal communication/miscellaneous doctoring, etc...

It's just worse all around.

Once we become full on technicians, the game is over.

 

[deleted1111261]

Counterpoint: an OTV in the first couple weeks of treatment typically takes 13 seconds whether it's on telemed or in person. The telemed is actually likely more cumbersome to get set up and no vitals/non-verbal communication/miscellaneous doctoring, etc...

It's just worse all around.

Once we become full on technicians, the game is over.

What's the rationale against having the option?

 

[Mandelin Rain]

What's the rationale against having the option?

Because Bridge Oncology will put an NP in a site and have a doctor fly in twice a month to see 8 consults/Sims in a day and then fly out.

I don't think it's in the patients' or specialty's best interest (or really, many individual doctors' best interest) to go this route.

If it's an option for rare occurrences, it's an option for every occurrence. It will be abused if it makes a dollar for someone. Likely immediately and wantonly.

 

[NotMattSpraker]

Counterpoint: an OTV in the first couple weeks of treatment typically takes 13 seconds whether it's on telemed or in person. The telemed is actually likely more cumbersome to get set up and no vitals/non-verbal communication/miscellaneous doctoring, etc...

It's just worse all around.

Once we become full on technicians, the game is over.

Really reasonable view to be discussed among physicians.

I don't need some ASTRO staffer or boomer with questionable clinical skills deciding this for me. No thanks.

 

[drowsy12]

What's the rationale against having the option?

It further marginalizes our role.

if we can never be around, why do the med onc or cancer center even need us?

slippery slope

 

[drowsy12]

Because Bridge Oncology will put an NP in a site and have a doctor fly in twice a month to see 8 consults/Sims in a day and then fly out.

I don't think it's in the patients' or specialty's best interest (or really, many individual doctors' best interest) to go this route.

If it's an option for rare occurrences, it's an option for every occurrence. It will be abused if it makes a dollar for someone. Likely immediately and wantonly.

exactly

 

[deleted1111261]

Because Bridge Oncology will put an NP in a site and have a doctor fly in twice a month to see consults/Sim and then fly out.

I don't think it's in the patients' or specialty's best interest (or really many individual doctors' best interest) to go this route.

If it's an option for rare occurrences, it's an option for every occurrence. It will be abused if it makes a dollar for someone. Likely immediately and wantonly.

My hospital does general supervision, not direct (we follow Medicare). I take a WFH day maybe once a quarter.

I would never have a sim occur without me on site, we don't treat higher than 4 Gy / Fx without me here.

You want rules to enforce bad behavior, good luck. People are sh*tty, that's the world we live in.

But, for me to not be able to go off site for half a day on OTV day .. this is the height of absurdity.

I understand what you're saying - I'm definitely do. Have not seen people abuse at multiple centers I know that do general supervision.

 

[deleted1111261]

exactly

If you were allowed to be off site, would you do it every day?
NPs are at infusion centers. Medoncs still are working. Not marginalized.

 

[pikachu]

Because Bridge Oncology will put an NP in a site and have a doctor fly in twice a month to see consults/Sim and then fly out.

I don't think it's in the patients' or specialty's best interest (or really many individual doctors' best interest) to go this route.

If it's an option for rare occurrences, it's an option for every occurrence. It will be abused if it makes a dollar for someone. Likely immediately and wantonly.

Precisely this. Remember, "it's fine until it's not". Are the rules going to be different for higher risk patients, eg the H&N who has already lost 30# before starting treatment and is refusing a feeding tube? What about people getting concurrent chemo? Despite frequently grousing about having to stop whatever I'm doing to go check in with the person who just started and has no complaints, or the person who has the same questions every week like groundhog day, seeing on treatment patients in person for a weekly check is non-negotiable as far as I'm concerned. Employment questions aside the patients need it. Leaving even acute RT toxicity management aside I can't tell you how many times I have caught drug reactions, DVTs, dehydration/renal failure, infections...all kinds of serious stuff...just by getting a set of vitals and checking in with the patient. It's not like the med oncs are doing it. We are just going to roll over and sign away our professional obligations to extenders because we can't be bothered? Whoever upthread said that a center that can't staff a weekly OTV with an MD shouldn't be open is 100% correct. Same with AI. Who does all this benefit? not the MDs and certainly not the patients I assure you.

 

[metallica81788]

I just want options - usually I'm working the entire day 5 days a week
If I've completed my contours for the week and my clinic is done, would love to go home early on those days and approve images there
Or see a few patients virtually on a half day when I have something going on
Or run a 4 day clinic, knowing I can go in if there is a problem or we need to do a sim, etc
Part of this is my problem that I chose to work in a relatively undesirable area but I live an hour away, so the commute plays into it

 

[Mandelin Rain]

My hospital does general supervision, not direct (we follow Medicare). I take a WFH day maybe once a quarter.

I would never have a sim occur without me on site, we don't treat higher than 4 Gy / Fx without me here.

You want rules to enforce bad behavior, good luck. People are sh*tty, that's the world we live in.

But, for me to not be able to go off site for half a day on OTV day .. this is the height of absurdity.

I understand what you're saying - I'm definitely do. Have not seen people abuse at multiple centers I know that do general supervision.

By your own admission here, don't you treat like 10-12 patients? You really can't find time in the week to spent 5 minutes with each of them?

 

[Mandelin Rain]

I will say, that if any point, you find yourself agreeing with Jordan Johnson... some deep reflection and introspection is indicated.

He is not here to help.

 

[drowsy12]

Sounds like a great topic to discuss openly with members and the field. The secrecy is so damaging.

I realize that ASTRO is the arch enemy of many, and I understand you personal concerns.

on the other hand - the organization exists to do this. It is like the government. We won't agree with all they do, and may not know it all either, but ultimately the big picture stuff is presented, individual people (many of whom we like, including community folks) are on these panels and are decision makers.

if every decision is voted on, that's how we end up like California where every proposition needs to be voted on.


I'm not pro ASTRO - but this is more to say, like this is sort of their job.... so I guess I can understand why 'they' would do things without running every single thing past every member. that's not how organizations like this work, right?

 

[Mandelin Rain]

BTW, I'm all for general supervision. If you're treating 12 patients, show up twice per week. Cool. Two days is plenty of time to manage that. But when you do show up, see the patients.

 

[communitydoc13]

If you were allowed to be off site, would you do it every day?
NPs are at infusion centers. Medoncs still are working. Not marginalized.

I think if by and large we were desperately trying to keep up with volume, you would get a different response.

Medonc is becoming a significantly APP driven service in the community, because it has to be. Because doc leverage is so great and the supply to demand ratio of docs is so low.

These dynamics are not present for us at all, and they will not be for the foreseeable future.

If we have moved from 6 weeks to 1 week to zero treatment for some indications in radonc over the past 15 years, medonc has moved to indefinite adjuvant therapy with poorly defined f/u schedules and markedly improved survival regarding their patients. (Plus the demographic catastrophe that is boomers with blood dyscrasias).

Medoncs are a precious commodity, because there is so much therapy to give. I'm actively working to convert our inpatient medonc service to an APP driven service line with periodic MD supervision...because we have to.

 

[OTN]

Being able to do my final OTV via telemedicine last night allowed me to read to my daughter before bed, instead of not seeing her entirely.

We should be able to choose which patients are appropriate for telemedicine OTVs.

 

[drowsy12]

Bridge oncology is a dangerous thing for the future health of the field

 

[communitydoc13]

Virtual for OTN but mandate in-person for Simul. Let's start there.

 

[deleted1111261]

By your own admission here, don't you treat like 10-12 patients? You really can't find time in the week to spent 5 minutes with each of them?

I do all of mine in person. But the option…

 

[NotMattSpraker]

I realize that ASTRO is the arch enemy of many, and I understand you personal concerns.

on the other hand - the organization exists to do this. It is like the government. We won't agree with all they do, and may not know it all either, but ultimately the big picture stuff is presented, individual people (many of whom we like, including community folks) are on these panels and are decision makers.

if every decision is voted on, that's how we end up like California where every proposition needs to be voted on.


I'm not pro ASTRO - but this is more to say, like this is sort of their job.... so I guess I can understand why 'they' would do things without running every single thing past every member. that's not how organizations like this work, right?

Yea, I think this is a very reasonable take, I just disagree. There is a middle ground between a dictatorship deciding everything for me and California.

Some issues are also very large and impactful, supervision and a legislative approach to remove all of Rad Onc from Medicare are good examples.

This approach is just so unhealthy.... and for what? So some Rad Onc chairs and Connie Mantz get to do what they think is best for the field without having to defend their ideas to their peers?

There is a reason democratic style societies are popular and successful. Asking for discussion and learning the opinions of my peers is not unreasonable.

 

[thecarbonionangle]

The field is so small that it lends itself to an authoritarian culture where the few “leaders” oligarchs “know best”. It has been the MO of the field for a long time. How do we change this?

If these remote companies are such a threat to our field, how do we crush this? Refuse to participate in it

 

[deleted1111261]

Virtual for OTN but mandate in-person for Simul. Let's start there.

COLD, BRO

 

[NotMattSpraker]

The field is so small that it lends itself to an authoritarian culture where the few “leaders” oligarchs “know best”. It has been the MO of the field for a long time. How do we change this?

A nice start would be to stop pretending like people who are just asking for discussion are calling for the "death of ASTRO" or labeling them as misanthropes or negative.

 

[deleted1111261]

I realize that ASTRO is the arch enemy of many, and I understand you personal concerns.

on the other hand - the organization exists to do this. It is like the government. We won't agree with all they do, and may not know it all either, but ultimately the big picture stuff is presented, individual people (many of whom we like, including community folks) are on these panels and are decision makers.

if every decision is voted on, that's how we end up like California where every proposition needs to be voted on.


I'm not pro ASTRO - but this is more to say, like this is sort of their job.... so I guess I can understand why 'they' would do things without running every single thing past every member. that's not how organizations like this work, right?

The great part is that they didn't even do it right and that's why it is back in. They simply are not competent.
People picked up on it, it wasn't in the appropriate period of time to take it out, and boom it's back in.

I'm not saying everything should be a referendum.

I'm saying if many of us have a differing opinion (say 30% are in my camp), shouldn't we take the temperature about the issue, because it is something every other specialty is allowed to do.

And, I hear you. I am clearly biased against ASTRO, I'm aware. They have shown little competence, leadership or behaved in a way that makes me think they actually value community radiation oncologists.

 

[thecarbonionangle]

A nice start would be to stop pretending like people who are just asking for discussion are calling for the "death of ASTRO" or labeling them as misanthropes or negative.

Ah yes the “negative” label. This seems to be a very favorite word by these groups. Easy to always character asassinate than engage in ideas. My frustration is that many careerists are always talking about “diversity” but they do not welcome this really. They want minority faces to rubberstamp their views and collective actions. There is no attempt to have diversity of thought. If you had a minority outspokenly going against the group think, they would also be labeled as “negative” and “hard to work with” and cancelled.

 

[OTN]

The reality for me is that I do so much SBRT it really doesn't make much of a difference.

 

[communitydoc13]

COLD, BRO

I know nothing about either of your practices, other than what is shared here.

I just imagine OTN seeing 16-20 consults a week and single handedly servicing the equivalent of a medium sized city while you see 4 consults a week, have 6 side hustles and are strategizing regarding a wellness clinic that will make you like a billion dollars.

I'm just jelly. Looking for regulation as a form of retribution.

 

[deleted1111261]

I know nothing about either of your practices, other than what is shared here.

I just imagine OTN seeing 16-20 consults a week and single handedly servicing the equivalent of a medium sized city while you see 4 consults a week, have 6 side hustles and are strategizing regarding a wellness clinic that will make you like a billion dollars.

I'm just jelly. Looking for regulation as a form of retribution.

Wait, do I have a billion dollar idea??

OTN is definitely the GOAT, or at least a GOAT.

Regulation as a form of retribution. I actually do the like the sound of that.

Fine. I'll come in and do all visits in person.

 

[NotMattSpraker]

The reality for me is that I do so much SBRT it really doesn't make much of a difference.

Me either. State law requires my presence and our practice has agreed it is good to do, so we do it.

But here's a wild idea that a certain ASTRO president did not seem to be able to grasp when he called me on his little campaign. It's not just about me.

We should also care about each other and learn about practice variation so we can intelligently make policies.

Wild.

 

[temujim]

Medonc is becoming a significantly APP driven service in the community, because it has to be. Because doc leverage is so great and the supply to demand ratio of docs is so low.

And I hear it from patients. They don't know who their med onc is; only saw them once prior to treatment. And now I get to manage all the concurrent chemo side effects, because the APPs in general don't do a great job or at worst are counter productive with their recommendations.

 

[Mandelin Rain]

And I hear it from patients. They don't know who their med onc is; only saw them once prior to treatment. And now I get to manage all the concurrent chemo side effects, because the APPs in general don't do a great job or at worst are counter productive with their recommendations.

 

[Reaganite]

There was a period of time at the height of supervision litigation where people were getting reported to department chairs for leaving the clinic to grab lunch. There was a time some of us legitimately stressed about arranging lunch time coverage so we could attend an off-site tumor board. There was a time RTTs held us by the balls and/or other private parts when it came to the schedule. "Sorry, Dr. Johnson, 80 year old Mrs Brown with the T1a breast cancer getting partial breast radiation can only come in at 630 AM...you better be here or else." I would fight anything that moves the needle back including telehealth for 77427. Make no mistake--Ron and Astro don't want to stop at 77427. Academics hate virtual anything because it gives the community guys a chance to compete. No reasonable rad onc thinks it's okay to routinely do head and neck OTVs via telehealth. But Mrs. Brown at 630 AM? Sign me up. Right now, academic centers can open satellite clinics with fewer than 10 on beam, staff them with 2 docs, and at minimum break even. I have seen data showing some break even on 5. That's a much bigger problem than a community guy doing a telehealth OTV on a partial breast patient week 1 of therapy.

 

[Mandelin Rain]

It's kind of quaint that we think we as doctors are still in charge of how rules will be implemented practically.

We're about to convenience ourselves right out of a field of medicine.

Random surgeon: Wait, so a therapist does all the simming and treatment? AI does the contouring. A dosimetrist does the planning? Computer models ensure standardized dose constraints met? A physicist does all the QA and machine maintenance. Why surely, the rad onc has to at least be there to check in on the patients, right? I mean, I can circle the tumor on a CT and prescribe the same dose over and over again. Nope? Just a phone call once per week? Hmm.....

 

[communitydoc13]

We're about to convenience ourselves right out of a field of medicine.

I tend to believe this.

It's not that every example above isn't pertinent. They are all reasonable and any doc with an unassailable position of employment is going to want maximum flexibility. This is common sense.

But there are bigger players and cultural trends out there. Any piece of regulation that supports our role as "essential" is going to protect us from the forces of consolidation, automation and diminution of our credentials (the APP phenomenon).

 

[Mandelin Rain]

We've done more to minimize our presence in front of patients over the last 20 year than any other field in medicine. I think celebrating the ability to eliminate it completely outside of a single initial visit, is VERY shortsighted.

People here want to rail against the old rad onc "leaders" making decisions to benefit themselves at the detriment of all future rad oncs and the field at large. This is one of those things.

 

[deleted1111261]

We've done more to minimize our presence in front of patients over the last 20 year than any other field in medicine. I think celebrating the ability to eliminate it completely outside of a single initial visit, is VERY shortsighted.

You're saying "we".

I have an admin day. I have work from home privileges. And I don't think it's right for me as a solo doc to try to take care of patients like this. Even if we finish at 1, I have a lot of other things to do here and also to set the tone at the office that the doctor is part of the overall team.

I've been given the privilege. I've done 77427 via phone one time in 2023.

Do you all know people that are different than me? Most radoncs I know are very conscientious and spend a lot of time with patients. We tease my competitor to the South of me that spends 90 minutes on a simple consult. You don't hear MOs doing that, you don't hear surgeons doing that. I'm just surprised that the perception is that we are all just chomping at the bit to be at home. I got a 4 and near 3 year old at home, you better believe I like coming in to work during day (done early, of course). I like being at my job, I like spending time with patients. Yes, we have OTV day, but any day is OTV day or shoot the **** with Simul day.

I understand the concerns, but most of us actually do care about our patients and seeing them in person.

What I don't like is mandates from people that claim to speak for me. At least ask my opinion if you do something that affects 100% of us that we are not in lockstep about.

Also: I'm in the minority on this and appreciate the civil way that many are disagreeing with me about this.

 

[RO28]

I think my challenge is I occasionally treat patients across two sites and I can't leave one site because of that direct supervision issue to see the OTV at the other site. If the patient has the means and I REALLY need to do a physical exam (like cervix or head and neck for example) I'll make them come to me once a week for an OTV, but if its a prostate patient I do think virtual is appropriate.

But yeah the principle of someone telling me what can and cannot be done without discussion is just not great.

 

[TheWallnerus]

How about if you're a solo doc in a rural location, maybe legally you'll be able to do telehealth 25 days a year. Like instead of casual Fridays it's casual telehealth days. Perhaps the sky's not falling if we do that. But if you have two or more docs in practice, no jeans days and and no telehealth EVER. I want to be a uniter and not a divider.

It is quite the sleight of hand for the tertiary referral centers to be so gung ho on telehealth consults (and oh my do the MSKCCs of the world love telehealth consults) but derisive about telehealth OTVs.

 

[Tigerstang]

Yeah. I'm not sure that a site should be open if a doctor isn't available to see each patient on treatment once per week.

Jordan Johnson wants it that way because it (now) suits his business model (as opposed to previously when he'd be screaming fraud and fear mongering people into buying his services).

I could not have said this better myself

 

[NotMattSpraker]

It is quite the sleight of hand for the tertiary referral centers to be so gung ho on telehealth consults (and oh my do the MSKCCs of the world love telehealth consults) but derisive about telehealth OTVs.

"Everyone. Just please be quiet and trust me. I will advocate for what is best for you on this complex issue, I promise."

 

[Mandelin Rain]

Do you all know people that are different than me?

Legitimately every single person in VC.

 

[communitydoc13]

It is quite the sleight of hand for the tertiary referral centers to be so gung ho on telehealth consults (and oh my do the MSKCCs of the world love telehealth consults) but derisive about telehealth OTVs.

I'm gonna disagree on this one.

Let's imagine I'm a tertiary center run in the way I want it run.

This means that they are:
1. Happy to see the toughest cases despite payor status
2. Doing world class research, including enrollment in investigator initiated trials (we should have a separate thread about this. Perhaps decentralized, investigator initiated trials in the US are hurting progress).
3. Not looking to provide more community care than is necessary themselves. (This would mean for instance that JHH is happy to provide world class community care in east Baltimore but does not feel the need to be the initial provider in affluent Suburbs). Could you imagine.

I am very happy for them to offer tele consults to provide second opinions or discuss experimental care.

I would be pissed if they convinced my patient that care was better given there, but were only going to have them seen remotely.

 

[Reaganite]

We've done more to minimize our presence in front of patients over the last 20 year than any other field in medicine. I think celebrating the ability to eliminate it completely outside of a single initial visit, is VERY shortsighted.

People here want to rail against the old rad onc "leaders" making decisions to benefit themselves at the detriment of all future rad oncs and the field at large. This is one of those things.

I don't think any reasonable rad onc wants a telehealth-only practice (JJ isn't a radonc, right?). We just want clinically-appropriate flexibility. Supervision rules should be consistent and based on clinical outcomes. CMS has already basically acknowledged there is no clinical justification for in person supervision. After all, they made hospital supervision GENERAL pre-pandemic. Similarly, people have been safely using telehealth to manage serious conditions across specialties for years now. Is there any data showing this has compromised outcomes in any specialty? (legitimately asking here). These unnecessary rules are just another attempt to artificially prop up the job market to avoid addressing the real issue ...overtraining. I also personally think the FFS ship has sailed, and telehealth vs. no telehealth for 77427 won't change that. There are case rate pilots being discussed across the country. You'll thank JJ later when you get your bundled payment.