ASTRO Town Hall Discussion (Poll % on site)

[CurbYourExpectations]

Figured this would need it's own thread.

Overall I think this may have been the best discussion ASTRO has done, much better than the previous discussions and especially workforce discussions. People were allowed to write their comments in multiple chats. People could ask questions by raising their hand. The answers didn't seem avoided, although at times political. Definitely not perfect, and nothing will ever satisfy everyone. Interested to see the discussion further on SDN.

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[NotMattSpraker]

Figured this would need it's own thread.

Overall I think this may have been the best discussion ASTRO has done, much better than the previous discussions and especially workforce discussions. People were allowed to write their comments in multiple chats. People could ask questions by raising their hand. The answers didn't seem avoided, although at times political. Definitely not perfect, and nothing will ever satisfy everyone. Interested to see the discussion further on SDN.

If someone could summarize for me their current position, that would be great. I asked for that at closing since I am now thoroughly confused.

Also, these "comments to CMS" that reflect feedback, are those published anywhere? Does anyone know if that is even happening?

There were a few things that made no sense. They claimed broad agreement among societies, but ACR directly conflicts with the ASTRO letter and ACRO said they are doing their own. That doesnt sound like broad agreement.

 

[CurbYourExpectations]

Seemed very political to me. 90% was quoted as time preferred on site. If I remember correctly "provides a day every other week or an hour every day for people to attend to personal things or tumor board". Not a perfect quote.

Was also interesting to hear that ACRO rep at the end seemed like they knew that limiting RadOncs onsite would negatively impact the field.

How hard is it for people to say that we are significantly oversupplied already?

 

[Reaganite]

Seemed very political to me. 90% was quoted as time preferred on site. If I remember correctly "provides a day every other week or an hour every day for people to attend to personal things or tumor board". Not a perfect quote.

Was also interesting to hear that ACRO rep at the end seemed like they knew that limiting RadOncs onsite would negatively impact the field.

How hard is it for people to say that we are significantly oversupplied already?

Just a bunch of smug academics making s*** up on the spot. They never give any reasonable explanation for why supervision is needed. 90% as a preferred time on site? Why that number? Why not 80% or 95%? They are literally just making this stuff up, and as far as I can tell their only justification for full-time on-site supervision is again some made up % of radiation oncologists think it's necessary. The nerd from ACRO so scared of "high energy x-rays" definitely convinced me to never send a dime to ACRO.

 

[BobbyHeenan]

I caught only parts. Wish the text of the chat was available off line.

 

[MidwestRadOnc]

Please tell me CMS doesn’t care. If you are the patient injured by lack of supervision during the 10% downtime, how are you gonna feel? Either direct supervision matters from a safety standpoint or it doesn’t. 90% is asinine.

Please tell me CMS isn’t going to entertain this nonsense. Leave general supervision in HOPD alone!

 

[thecarbonionangle]

ACRO is on board with this?

 

[medgator]

Please tell me CMS doesn’t care. If you are the patient injured by lack of supervision during the 10% downtime, how are you gonna feel? Either direct supervision matters from a safety standpoint or it doesn’t. 90% is asinine.

Please tell me CMS isn’t going to entertain this nonsense. Leave general supervision in HOPD alone!

Done deal imo since Jan 2020. Someone just needs to let Astro know

 

[Neuronix]

Let's take it to it's logical conclusion then.

You need a day of clinic at the site for OTVs and in person evals.

If MD presence is not needed for treatments, that's all the MD is needed for.

I voted 25% on the above poll for that reason. I meant 20% -- one day a week.

 

[medgator]

Let's take it to it's logical conclusion then.

You need a day of clinic at the site for OTVs and in person evals.

If MD presence is not needed for treatments, that's all the MD is needed for.

I voted 25% on the above poll for that reason. I meant 20% -- one day a week.

I would argue 40-60%. 1-2 days for in person consults/fu pts. I do block scheduling, try not to mix a busy otv clinic with clinic pt schedule if I can help it. Plus allowing for in person brachy and/or srs/sbrt coverage.

But if we are talking minimums, agree, the otv needs to be in person.

Are you going to cover stereo cases virtually on the days you aren't seeing OTVs?

 

[CurbYourExpectations]

Let's take it to it's logical conclusion then.

You need a day of clinic at the site for OTVs and in person evals.

If MD presence is not needed for treatments, that's all the MD is needed for.

I voted 25% on the above poll for that reason. I meant 20% -- one day a week.

Touche, I meant: what do you think is the optimal % of time for your patients for you to be there.

 

[Neuronix]

Touche, I meant: what do you think is the optimal % of time for your patients for you to be there.

Same answer.

I mean, if you have an issue get on the phone or telehealth with me. I can review films remotely.

I want to make it clear. This is not how I practice or would want to practice. But this is what would happen at some facilities.

I would argue 40-60%. 1-2 days for in person consults/fu pts. I do block scheduling, try not to mix a busy otv clinic with clinic pt schedule if I can help it. Plus allowing for in person brachy and/or srs/sbrt coverage.

But if we are talking minimums, agree, the otv needs to be in person.

Are you going to cover stereo cases virtually on the days you aren't seeing OTVs?

Sure why not.

 

[MidwestRadOnc]

Done deal imo since Jan 2020. Someone just needs to let Astro know

DM me your home address I have a bottle of Blantons gold to send you.

 

[medgator]

DM me your home address I have a bottle of Blantons gold to send you.

Tempted 🤤

 

[medgator]

Sure why not.

Can't virtually cover brachy.

I think stereo should be direct. But a certain Astro presidents home institution has published a paper on virtually covering during covid so can't argue with you there

 

[medgator]

. The nerd from ACRO so scared of "high energy x-rays" definitely convinced me to never send a dime to ACRO.

Sad. Honestly hate to say the most sane organization for our specialty might be the rads one (ACR)

 

[Reaganite]

Touche, I meant: what do you think is the optimal % of time for your patients for you to be there.

I think you should be on site as much as you need to be, and I don't think there's a set % for that. I personally support the current system with the option for virtual direct and telehealth OTV without specified percentages. I think it's the cleanest and gives a lot less wiggle room for disgruntled therapists and staff to try to pull a qui tam on you. I don't want to be reported for being on site only 89% of the time. I trust the majority of rad oncs are smart and ethical enough to determine the appropriate level of on site supervision for their practice. I have no concerns about massive proliferation of telehealth-only rad onc practices because I believe, as others have stated here, that cancer patients want to see their doctors in person and a telehealth-only operation is going to be at a significant competitive disadvantage in most geographies. Even at the height of COVID, I was still doing 90+ % of my consults in person at patients' requests. I just want the option to leave my clinic for tumor boards, maybe make a dentist appointment, leave a little early on a Friday afternoon, etc. without fear of being reported for fraud. More than anything, though, I want those pompous pricks at ASTRO to fail.

 

[RickyScott]

I think you should be on site as much as you need to be, and I don't think there's a set % for that. I personally support the current system with the option for virtual direct and telehealth OTV without specified percentages. I think it's the cleanest and gives a lot less wiggle room for disgruntled therapists and staff to try to pull a qui tam on you. I don't want to be reported for being on site only 89% of the time. I trust the majority of rad oncs are smart and ethical enough to determine the appropriate level of on site supervision for their practice. I have no concerns about massive proliferation of telehealth-only rad onc practices because I believe, as others have stated here, that cancer patients want to see their doctors in person and a telehealth-only operation is going to be at a significant competitive disadvantage in most geographies. Even at the height of COVID, I was still doing 90+ % of my consults in person at patients' requests. I just want the option to leave my clinic for tumor boards, maybe make a dentist appointment, leave a little early on a Friday afternoon, etc. without fear of being reported for fraud. More than anything, though, I want those pompous pricks at ASTRO to fail.

I really doubt cms care what Astro thinks

 

[fiji128]

I really doubt cms care what Astro thinks

This is probably the end truth. Also, from CMS point of view in a world with virtual supervision, you can more easily make the case in lower reimbursements.

 

[CurbYourExpectations]

It is interesting to me because most RadOncs still see patients on site 90% of the time, but there is extreme discontent with ASTRO requesting 90%.

What is the benefit of having more flexibility getting to 0-50%? I see none, I just see it as an opportunity to harm RadOncs in the field through unemployment and benefit companies pursuing profits.

So, I am interested in who is saying there should be a RadOnc 0-50% of the time on site. If able to talk about it more, are you treating people at a site with less than 50% on site? And if so, would you want your loved ones treated there? I wouldn't personally, but this is what I'm most interested in hearing about. 80-90%, don't care. I want to hear from people telling me they're only on site 25% of the time lol

 

[TheWallnerus]

Correct me if I’m wrong…

But from the average patient’s viewpoint, he/she only solipsistically knows the doctor is there one day a week. Especially a five fraction patient.

 

[TheWallnerus]

It is interesting to me because most RadOncs still see patients on site 90% of the time, but there is extreme discontent with ASTRO requesting 90%.

What is the benefit of having more flexibility getting to 0-50%? I see none, I just see it as an opportunity to harm RadOncs in the field through unemployment and benefit companies pursuing profits.

So, I am interested in who is saying there should be a RadOnc 0-50% of the time on site. If able to talk about it more, are you treating people at a site with less than 50% on site? And if so, would you want your loved ones treated there? I wouldn't personally, but this is what I'm most interested in hearing about. 80-90%, don't care. I want to hear from people telling me they're only on site 25% of the time lol

A rad onc who tried 0-50% onsite time would essentially torpedo their clinic into oblivion imho. However, I have no data for this. However, in terms of supervision arguments, no one needs data to actually back up any claims!

 

[MidwestRadOnc]

Leave general alone
Get rid of “virtual”
This is not hard.

 

[elementaryschooleconomics]

The question is: what are we even doing here?

Direct Supervision only came into existence for Hospital Outpatient departments on January 1st, 2010.

It went away on January 1st, 2020.

1) Did it help patient safety at all, in any specialty?

No. There was never a signal in either direction. When rural hospitals expressed concern the first time around, CMS created a policy of non-enforcement and thus, a two-tiered system. MedPac wrote a report to Congress on this in 2017, saying they had interviewed a bunch of hospitals in a bunch of geographic settings, and found no safety issues or benefits with either Direct or General. They did find confusion over the two tiered system.

So, making all Hospital Outpatient departments go under General Supervision was the (reasonable) solution.

2) What did it do in RadOnc specifically?

It caused a bunch of whistleblower cases.

3) Did it help the job market?

Well, you tell me. How did the job market in RadOnc look from 2010 --> 2020?

Yeah.

4) With General Supervision and then Virtual Direct starting in early 2020...you mean that's been like, over 4 years since the change?

Yeah.

We've been living in this world for over 4 years. General/Virtual Direct has been the status quo for almost an entire residency cycle. The class of 2025 was in med school when this started.

I would personally never argue for a 0-50% physical presence practice.

But I will definitely argue against a policy which has done absolutely nothing other than line the pockets of some attorneys, expert witnesses, and Relators.

 

[RickyScott]

The question is: what are we even doing here?

Direct Supervision only came into existence for Hospital Outpatient departments on January 1st, 2010.

It went away on January 1st, 2020.

1) Did it help patient safety at all, in any specialty?

No. There was never a signal in either direction. When rural hospitals expressed concern the first time around, CMS created a policy of non-enforcement and thus, a two-tiered system. MedPac wrote a report to Congress on this in 2017, saying they had interviewed a bunch of hospitals in a bunch of geographic settings, and found no safety issues or benefits with either Direct or General. They did find confusion over the two tiered system.

So, making all Hospital Outpatient departments go under General Supervision was the (reasonable) solution.

2) What did it do in RadOnc specifically?

It caused a bunch of whistleblower cases.

3) Did it help the job market?

Well, you tell me. How did the job market in RadOnc look from 2010 --> 2020?

Yeah.

4) With General Supervision and then Virtual Direct starting in early 2020...you mean that's been like, over 4 years since the change?

Yeah.

We've been living in this world for over 4 years. General/Virtual Direct has been the status quo for almost an entire residency cycle. The class of 2025 was in med school when this started.

I would personally never argue for a 0-50% physical presence practice.

But I will definitely argue against a policy which has done absolutely nothing other than line the pockets of some attorneys, expert witnesses, and Relators.

And consultants like ron

 

[CurbYourExpectations]

A rad onc who tried 0-50% onsite time would essentially torpedo their clinic into oblivion imho. However, I have no data for this. However, in terms of supervision arguments, no one needs data to actually back up any claims!

So what is the point in supporting it? How often are you on site? What is the harm in requesting someone on site for >50%? Why open the field up to the possibility of exploitation of a stupid rule when the people calling for it are still like "yeah, but i'm there 90%"?

@ ESE
1) What is the stringency with which errors have been looked for?
2) No one is talking about direct supervision anymore, we are talking about flexibilities.
3) Yeah, it probably did.
4) Agreed 0-50% is complete BS, clearly you need good docs on site at least a large majority of the time, but not 100% of the time.

 

[NotMattSpraker]

It is interesting to me because most RadOncs still see patients on site 90% of the time, but there is extreme discontent with ASTRO requesting 90%.

People keep glossing over the vastness of the US, both geographically and varied aspects of cancer programs.

My 2 MD practice has a doc on site for 100%.

I would never assume that is what is best for all patients and physicians nationwide. In fact our supervision policy even respects the differences between centers in our network.

That is the difference between serious thoughtful people trying to work this out for their practice and Jeff sitting at home basking in his achievements.

It was totally clear today that they think they know best and should just be trusted. People tried to make this a rational discussion but they will not answer a single detail question.

They couldn’t even give a straight answer about ROILS, which is so easy! There were no events, just say that! That’s all an incident learning data base can tell you anyway.

They can’t even get the details right in their answers because they don’t know enough about the policy, the science of quality and safety, or apparently the sentiments of the rest of the “house of medicine”. haha what a bizarre monologue from that guy.

This is a huge mess and an embarrassment. There is so much arrogance, dishonesty, insecurity, political pandering that we didn’t even have a real conversation about the issue at hand.

Finally, I’m really getting frustrated with ACRO. Show us your letter, say your position, or get off the pot.

Bizarre stuff.

 

[elementaryschooleconomics]

So what is the point in supporting it? How often are you on site? What is the harm in requesting someone on site for >50%? Why open the field up to the possibility of exploitation of a stupid rule when the people calling for it are still like "yeah, but i'm there 90%"?

@ ESE
1) What is the stringency with which errors have been looked for?
2) No one is talking about direct supervision anymore, we are talking about flexibilities.
3) Yeah, it probably did.
4) Agreed 0-50% is complete BS, clearly you need good docs on site at least a large majority of the time, but no 100% of the time.

1) Across all hospitals across all of medicine? Not great, but not zero. MedPac was at least out in the field talking to doctors and hospitals, I'll give them that.

I would highlight to everyone the most recent "error" in RadOnc (wrong site breast treatment) was done under Direct Supervision (by ASTRO leadership no less).

2) Ok but like, what are these "flexibilities"? Who is defining them? What is the mechanism of enforcement? Is CMS is going to create very niche carve-out Supervision rules for just RadOnc?

3) To clarify: you're saying that for as bad as the job market became, it would have been worse if not for Direct Supervision?

It's an interesting thought experiment. Obviously I can't really refute it in the same way you can't support it, but I see where you're coming from and don't think it's crazy.

4) Far and away the easiest thing to do is to just approach this from the other direction. Mandate minimal time-on-site. No need for any definitions of flexibilities, or exemptions, etc.

Why open the field up to the possibility of exploitation of a stupid rule when the people calling for it are still like "yeah, but i'm there 90%"?

"Open up the field to the possibility of exploitation" implies exploitation has not taken place.

I would argue the exploitation ship has long ago sailed. Cheap, abundant resident labor. PPS-exempt centers engaged in consolidation to make more PPS-exempt centers. 21C/GenesisCare docs in ASTRO/ABR leadership positions lobbying for policy which benefits freestanding centers while the majority of the field is hospital outpatient. The proliferation of unaccredited fellowship positions. And on and on and on.

At the end of the day, there is literally no regulation that any of us can dream up that won't, in some way, be circumvented. Further exploitation will occur.

Direct Supervision turned RadOnc into clock-punching technicians. Tele-RadOnc is already here, and has been here for awhile.

But all that aside, I'm very troubled by the behavior of the ASTRO leadership tonight.

We deserve better.

 

[CurbYourExpectations]

1) I don't think that we can rely on data in any direction, because I don't think it has been tracked well
2) A good discussion for doctors to have about what is the best way for them to handle their center, not for opening it up to make it so third parties answer it for them.
3)Probably, we don't know what the answer is. The way ASTRO has continuously pretended they can't make a comment on the oversupply is outrageous. There is an oversupply, say it.
4) This would be fine if not for all of the other issues that have been discussed, this is just begging to open the realm to business people and take it away from radiation oncologists.


I never said exploitation hasn't taken place. I don't agree with the pretending that we aren't oversupplied, that is the fault of them for not being willing to admit it.
Disagree with technicians, that is an over exaggeration, but I understand the frustations that these issues have caused.
I think this is the best I have seen the ASTRO leadership act, and I hope they continue to do better, but there needs to be more effort.

 

[elementaryschooleconomics]

Disagree with technicians, that is an over exaggeration, but I understand the frustations that these issues have caused.

You disagree that we're viewed as technicians, or that Direct Supervision is the reason we're viewed as technicians?

 

[CurbYourExpectations]

You disagree that we're viewed as technicians, or that Direct Supervision is the reason we're viewed as technicians?

I think it is more complex than that because our thoughts are still valued in the care of patients in tumor boards and when we speak with patients. We take into account what we know about who should be treated and how they should be treated. Making it so that we don't even have to actually be involved with most of the care of patients (virtual) makes us technicians or worse, makes us not needed.

 

[RadRadRad]

I think patients prefer having more access not less. I suppose many things could be handled over phone but if I’m sick during cancer treatment, telling me the doctor won’t be available to see/examine me for a week would be concerning.

 

[elementaryschooleconomics]

I think patients prefer having more access not less. I suppose many things could be handled over phone but if I’m sick during cancer treatment, telling me the doctor won’t be available to see/examine me for a week would be concerning.

That's "Evaluation and Management", not "Supervision", though.

Supervision is only about who's around when the linac is on. That's different than who's around when a patient needs side effect management.

 

[CurbYourExpectations]

@elementaryschooleconomics Would you rather be treated at a site where there is a regular good physician and physicist team working towards quality delivery with the linac on site to provide you the best care? Or do you not think that stuff matters and virtual signing off on papers from different cities/states is probably fine?

 

[elementaryschooleconomics]

@elementaryschooleconomics Would you rather be treated at a site where there is a regular good physician and physicist team working towards quality delivery with the linac on site to provide you the best care? Or do you not think that stuff matters and virtual signing off on papers from different cities/states is probably fine?

I don't think Direct Supervision is the most likely mechanism by which I will receive care from a regular, good physician and physicist team.

I can tell you from personal, direct experience that it will not do that.

 

[CurbYourExpectations]

I don't think Direct Supervision is the most likely mechanism by which I will receive care from a regular, good physician and physicist team.

I can tell you from personal, direct experience that it will not do that.

Agree with that, I don't think anyone is pushing for Direct as far as I know. I am almost as concerned with direct only as I am with <50% doctor on site and virtual supervision talk. I would probably prefer direct if I had to choose between those two.

 

[NotMattSpraker]

@elementaryschooleconomics Would you rather be treated at a site where there is a regular good physician and physicist team working towards quality delivery with the linac on site to provide you the best care? Or do you not think that stuff matters and virtual signing off on papers from different cities/states is probably fine?

Say you’re getting 6 weeks of chemoradiation for lung cancer.

Would you rather be treated by a permanent doctor on site 50% of the time or 4 different locums?

This is the real life version of the question.

 

[elementaryschooleconomics]

ASTRO literally said they were pushing for in-person Direct tonight, though.

I mean yeah, they kept saying "flexibility" I know but - this is like ROCR where they keep saying "new technology will be evaluated as time goes on for inclusion"...

...and literally none of their documents or plans spell that process out.

This is policy at the federal level. Hand-wave answers like "flexibility" are precisely how exploitation happens.

I just keep returning to mandating minimum on-site time as the simplest answer to some level of guardrails without bringing back the copycat whistleblower cases.

 

[CurbYourExpectations]

I just keep returning to mandating minimum on-site time as the simplest answer to some level of guardrails without bringing back the copycat whistleblower cases.

Minimum on-site time relays itself to exploitation of Radiation Oncologists because we don't have access to other modalities of treatment. MedOncs are not oversupplied like RadOncs, they can also go back to being Hospitalists or doing other fellowships in a worst case scenario. What you are talking about is an insurmountable thing for RadOncs to overcome in the same scenario because there are no outs, we are oversupplied, and leadership is not looking out for the young in the field.

 

[elementaryschooleconomics]

Minimum on-site time relays itself to exploitation of Radiation Oncologists because we don't have access to other modalities of treatment. MedOncs are not oversupplied like RadOncs, they can also go back to being Hospitalists or doing other fellowships in a worst case scenario. What you are talking about is an insurmountable thing for RadOncs to overcome in the same scenario because there are no outs, we are oversupplied, and leadership is not looking out for the young in the field.

Hmmm I don't understand what you mean here - I mean obviously I understand and totally agree with 95% of your post haha.

But specifically, can you explain more about how minimum "time on site" is worse than Direct Supervision?

To me, it's the same thing as "Direct Supervision with flexibility".

Except we don't need to worry about getting into the weeds about "what kind of flexibility".

 

[medgator]

1) I don't think that we can rely on data in any direction, because I don't think it has been tracked well

Thank you for saying this, so now we can stop with the FUD and just agree it’s not a safety issue.

Ready to dispel the stupid RUC fetish whenever people wanna do that. Man, they are so obsessed with the RUC for a group that has no representative.

Frick and Frack those two.

Except there is data. CMS has it and has likely looked at it internally. First from 2009-2020 when CAH (critical access hospital) facilities were treating with general supervision the entire time and then from Jan 2020 when hospitals were allowed to go "general" (March 2020+ is when virtual direct pretty much started for both HOPPS and freestanding/Medicare PFS)

Data is definitely there. CMS has likely used this data to guide their decision making which is certainly better than the appeal-to- authority logical fallacy data-free 💩 sandwich that ASTRO has been trying to feed us since that letter came out at the end of Feb

 

[CurbYourExpectations]

Hmmm I don't understand what you mean here - I mean obviously I understand and totally agree with 95% of your post haha.

But specifically, can you explain more about how minimum "time on site" is worse than Direct Supervision?

To me, it's the same thing as "Direct Supervision with flexibility".

Except we don't need to worry about getting into the weeds about "what kind of flexibility".

Maybe it is a terminology issue lol. I'm thinking of minimum time on site as 0% on site.

 

[CurbYourExpectations]

Except there is data. CMS has it and has likely looked at internally. First from 2009-2020 when CAH (critical access hospital) facilities were treating with general supervision the entire time and then from Jan 2020 when hospitals were always to go general (March 2020+ is when virtual direct pretty much started)

Data is definitely there. CMS has likely used this data to guide their decision making which is certainly better than the appeal-to- authority logical fallacy data-free 💩 sandwich that ASTRO has been trying to feed us since that letter came out at the end of Feb

Do you think those sites I keep hearing about with no RadOncs on site would report a bad outcome or even know if there was a bad outcome? I have seen some really bad plans during salvage cases from people that I don't think have been reported anywhere, even though they probably should have been.

Also, I am curious, how often are you on site? >90%?

 

[elementaryschooleconomics]

Maybe it is a terminology issue lol. I'm thinking of minimum time on site as 0% on site.

Hahaha!

Ok yeah I would also disagree with me, too.

I mean something to the effect of "linear accelerators directly supervised by a Radiation Oncologist at least 90% of the time they are in operation".

We do get into the issue of "how are you tracking that", but to me, that's much less problematic than trying to draft a comprehensive list of "flexibilities".

 

[Mandelin Rain]

I don’t think “patient preference” is a good argument for mandating anything to be honest.

Most patients would prefer their surgeon give them their cell phone number for 24/7 accessibility or even move in with them until they’ve fully convalesced. Many preferences are unreasonable.

Different clinics, in differing geographies have different needs. Trying to get too granular with broad mandates makes no sense. If you provide crappy service, you’ll lose your patients/referrals. If you provide negligent care, malpractice exists as a remedy.

If you show up one day per week to a rural clinic treating like 8 patients, provide excellent and compassionate care, and are accessible whenever needed between those weekly visits, what are you doing wrong? Who is being hurt by this? Is it better those patients receive no care?

 

[Reaganite]

I have seen some really bad plans during salvage cases from people that I don't think have been reported anywhere, even though they probably should have been.

Hey, but at least someone was on site when they were getting treated, amiright?! You can't supervise away bad outcomes. Much more acutely toxic therapies are being administered all around the world without direct physician supervision. Your patient is more likely to die of an od on the Norco you're prescribing than to have a life threatening acute reaction on the treatment table. You're better off supervising their med ingestion than watching em on a linac if you're concerned about some seriously bad acute outcome.

 

[TheWallnerus]

Leave general alone
Get rid of “virtual”
This is not hard.

So one set of supervision (general) for hospital solo rad onc and one set (direct) for freestanding solo rad onc.

Sounds easy

 

[medgator]

Do you think those sites I keep hearing about with no RadOncs on site would report a bad outcome or even know if there was a bad outcome? I have seen some really bad plans during salvage cases from people that I don't think have been reported anywhere, even though they probably should have been.

Also, I am curious, how often are you on site? >90%?

I don't see how direct supervision would have prevented docs from generating and signing off on bad plans.

I'm probably at 85-95% direct on any given week depending on meetings, inpt consults, TBs, childcare issues etc.

 

[medgator]

Different clinics, in differing geographies have different needs. Trying to get too granular with broad mandates makes no sense. If you provide crappy service, you’ll lose your patients/referrals. If you provide negligent care, malpractice exists as a remedy.

If you show up one day per week to a rural clinic treating like 8 patients, provide excellent and compassionate care, and are accessible whenever needed between those weekly visits, what are you doing wrong? Who is being hurt by this? Is it better those patients receive no care?

This x100 @CurbYourExpectations I just don't see how we keep some of these rural sites treating with single or low double digit pt loads with a doc on site every day. They'll close and larger sites (many of whom are likely run/staffed by ASTRO docs) won't shed a tear about it.

Anyone who thinks they'll be able to run a successful practice by just having mid-levels or no one be there while they run the office virtually from home on zoom or Microsoft teams has never really run a busy and successful independent practice imo. It's probably the silliest Boogeyman anyone could come up with

Unless you are in bfe with no competition, patients and referring docs simply will not stand for it

 

[NotMattSpraker]

Except there is data. CMS has it and has likely looked at it internally. First from 2009-2020 when CAH (critical access hospital) facilities were treating with general supervision the entire time and then from Jan 2020 when hospitals were allowed to go "general" (March 2020+ is when virtual direct pretty much started for both HOPPS and freestanding/Medicare PFS)

Data is definitely there. CMS has likely used this data to guide their decision making which is certainly better than the appeal-to- authority logical fallacy data-free 💩 sandwich that ASTRO has been trying to feed us since that letter came out at the end of Feb

Are there data that are rad onc specific or more generally for all fields, but not including Rad Onc?

My point though is that a lack of data does not guarantee future safety for many reasons.

The goal is to maximize safety given changing tech and practices. We will create new risk no matter what.

If RO-ILS had a single report of even a near miss where they thought lack of direct supervision was an important root cause, there would be something to discuss.

It definitely it affects “quality”, vaguely defined. The national policy is an enforceable floor.

If we mislead and make up stories about safety when it’s really about job security and pay, no one will trust us.

That certainly can make things suck for everyone.

We should talk about the job security aspect of supervision! Let’s address that issue that’s likely inevitable.

We do literally nothing to make jobs and security better for those just starting their careers. Literally nothing.