ASTRO Town Hall Discussion (Poll % on site)

[drowsy12]

Why can’t the “role of the physician” be to oversee four rural centers with the aid of virtual supervision and make 2 million a year while doing so.

Some very smart, ethical, well-intentioned rad oncs have seen this as a role.

"In China they are working on 'washing machine' radiation. Four buttons will do the treatment with a remote doctor: one doctor, 70 clinics, 70 million people."

Sure maybe. But that also means making a bunch of unemployed rad oncs in the process.

The comparisons to residency expansion are apt. The collective vs the individual.

Ultimately what you describe is the way it may end up becoming in the future, but I’ll tell you what - the rad onc won’t make 2 million.

Don’t make me laugh!

Ask an anesthesiologist how this works.

---

Members don't see this ad.

 

[radoncle]

Of course we shouldn’t over train.

But I don’t see how one thing being bad means that we can’t also not do another bad thing.

ASTRO has clear conflicts of interest. They’ve expressly stated and made policies suggesting that palliative radiation should not take place in the community and should be directed to self proclaimed experts at academic centers. They have also suggested that proton being radiation offered at academic centers provides superior care to photon radiation delivered in the community without any clinical evidence to support this. Do you genuinely think they care about the solo docs practicing in the community? Or do you think they would prefer perhaps for every patient to drive whatever the distance may be to the closest academic center and receive treatment? I don’t see this behavior of academics claiming superiority over the community physicians or trying to end community practices to this degree in any other specialty. This is uniquely a radiation oncology issue.

 

[drowsy12]

ASTRO has clear conflicts of interest. They’ve expressly stated and made policies suggesting that palliative radiation should not take place in the community and should be directed to self proclaimed experts at academic centers. They have also suggested that proton being radiation offered at academic centers provides superior care to photon radiation delivered in the community without any clinical evidence to support this. Do you genuinely think they care about the solo docs practicing in the community? Or do you think they would prefer perhaps for every patient to drive whatever the distance may be to the closest academic center and receive treatment? I don’t see this behavior of academics claiming superiority over the community physicians or trying to end community practices to this degree in any other specialty. This is uniquely a radiation oncology issue.

This is what I mean by talking about unrelated issues and grievances. I don’t make the connection for any of those issues to this current topic.

But just to clarify:

1) I don’t agree with palliative radiation networks (was this even an ASTRO thing? Or are we just conflating things)
2) I don’t think patients need to drive to academic centers
3) I don’t think patients need proton therapy

My only bias is that I and many of my friends work in nice jobs that could no longer exist if virtual supervision was taken to its full extent, as TheWallnernus outlines above

 

[TheWallnerus]

I don’t see this behavior of academics claiming superiority over the community physicians to this degree in any other specialty

ASTRO's harping on "rural rad onc" recently struck me as some clever, subconscious propaganda. The "rural rad onc" is the clear opposite of the urban, citified, academic rad onc.

The words "villager" and "villain" share a surprisingly common etymology. In Middle English, there was a "villein": a village peasant enslaved to a feudal lord... a farmer working the land whose toil and efforts ultimately flowed upward to the aristocracy. Over time, "villein" became not just a rural peasant but a "very bad hombre" (in the vernacular of Trump), an evil-doer, etc.

A villein... a villain... someone not in the city... a villager... a rural rad onc.

 

[drowsy12]

Join Luh who I have the utmost respect for is the voice of rural rad onc for ASTRO as far as I am concerned and was publicly vocal about the negative impact of the RO-APM as was planned at the time.

 

[medgator]

This is what I mean by talking about unrelated issues and grievances. I don’t make the connection for any of those issues to this current topic.

Maybe you should, they are more connected than you realize.

ASTROs initial letter from Michalski was a direct slap in the face of rural rad onc, no blanket exemption or nuance was made in it to address them at all. Rural rad onc centers closing benefits urban centers (where many ASTRO-member docs practice)

 

[radoncle]

ASTRO's harping on "rural rad onc" recently struck me as some clever, subconscious propaganda. The "rural rad onc" is the clear opposite of the urban, citified, academic rad onc.

The words "villager" and "villain" share a surprisingly common etymology. In Middle English, there was a "villein": a village peasant enslaved to a feudal lord... a farmer working the land whose toil and efforts ultimately flowed upward to the aristocracy. Over time, "villein" became not just a rural peasant but a "very bad hombre" (in the vernacular of Trump), an evil-doer, etc.

A villein... a villain... someone not in the city... a villager... a rural rad onc.

And yet when pressed, ASTRO didn’t have a clear answer to what defines a center as rural. This seems critical if you’re holding these centers to a different set of rules (not sure why safety would be less important in one center versus another if we’re to believe their argument that direct supervision is for safety purposes).

 

[elementaryschooleconomics]

And yet when pressed, ASTRO didn’t have a clear answer to what defines a center as rural. This seems critical if you’re treating holding these centers to a different set of rules (not sure why safety would be less important in one center versus another if we’re to believe their argument, that direct supervision is for safety purposes).

ASTRO didn't really have any answers.

They're more of a "shoot first and hope no one hears the sound" kind of organization.

 

[Mandelin Rain]

The argument is completely disingenuous.

It’s either safe or not.

It’s not okay to be safe 80% or 90% of the time. Or only be safe in certain geographies while accepting unsafe in others.

Literally no one saying this crap believes it.

They made a mess of the job market and rather than address the mechanism that made the mess, they’d prefer to do something completely stupid.

 

[RickyScott]

The argument is completely disingenuous.

It’s either safe or not.

It’s not okay to be safe 80% or 90% of the time. Or only be safe in certain geographies while accepting unsafe in others.

Literally no one saying this crap believes it.

They made a mess of the job market and rather than address the mechanism that made the mess, they’d prefer to do something completely stupid.

Was is last year that Michalski/wash u added a resident so that they would have 4 for every class?

 

[thesauce]

1) I don’t agree with palliative radiation networks (was this even an ASTRO thing? Or are we just conflating things)

Yes. This was an Astro thing.

 

[Mandelin Rain]

Was is last year that Michalski/wash u added a resident so that they would have 4 for every class?

Gotta get those salaries down.

 

[thesauce]

ASTRO continually asks themselves: “what’s the best thing for us big academic centers and how can we make the community centers pay for it?”

 

[radoncle]

ASTRO continually asks themselves: “what’s the best thing for us big academic centers and how can we make the community centers pay for it?”

I was extremely disappointed by ACRO’s representation and stance in this meeting. He clearly was in bed with ASTRO on this and perhaps much more.

 

[drowsy12]

Yes. This was an Astro thing.

Do you have a link?

 

[drowsy12]

ASTRO continually asks themselves: “what’s the best thing for us big academic centers and how can we make the community centers pay for it?”

I guess the part I’m confused by is how this helps major academic centers. If anything it would make it easier to centrally control more sites without having to worry about paying a doc for every site to chill and make a full salary with less than ten on beam.

If I’m a conspiracy theorist and believe that Astro expanded residencies to centrally
Control and depress physician salaries (does not pass the smell test for a second if you have spent any time with people in leadership, they aren’t that organized lol) then they should also want virtual supervision more than anyone else.

There’s an Academic center not too far from me that could take over some of the sites in our system easily and not have to worry about hiring us or as many of us if virtual supervision was taken to its full potential

 

[Mandelin Rain]

Nah, the president of astro published the quiet part out loud over a decade ago. Linked physician salary to physician supply (a concept you can’t seem to grasp) via residency expansion in the Red Journal. While it likely wasn’t an organized effort, each site certainly saw it as beneficial to their self interest and so it went.

As to the other question, the academic centers need to make the community centers non viable so they can close them or take them over, Jack up the prices to profitable rates, and then staff them with some poor soul at 50% of 2013 salary. Once the competition is gone, I bet general supervision will suddenly become VERY safe.

 

[medgator]

I was extremely disappointed by ACRO’s representation and stance in this meeting. He clearly was in bed with ASTRO on this and perhaps much more.

Couldn't actually tune in for the whole thing, really disappointing to hear though. Did they even come up with any kind of position statement that was concrete?

 

[drowsy12]

Nah, the president of astro published the quiet part out loud over a decade ago. Linked physician salary to physician supply (a concept you can’t seem to grasp) via residency expansion in the Red Journal. While it likely wasn’t an organized effort, each site certainly saw it as beneficial to their self interest and so it went.

As to the other question, the academic centers need to make the community centers non viable so they can close them or take them over, Jack up the prices to profitable rates, and then staff them with some poor soul at 50% of 2013 salary. Once the competition is gone, I bet general supervision will suddenly become VERY safe.

1) of course supply matters. What you seem to be missing is demand matters too.

2) ‘While it likely wasn’t an organized effort,’

Well that’s kind of the entire point. Which makes the grand cabal conspiracy theories sort of laughable.

 

[medgator]

2) ‘While it likely wasn’t an organized effort,’

Well that’s kind of the entire point. Which makes the grand cabal conspiracy theories sort of laughable.

So all of these random programs that opened over the last decade were just every chair out for themselves? Maybe. Prisoners dilemma? Maybe.

You don't think other chairs have the exact same mentality as Dennis hallahan at wash u?

Scarop is a clandestine and secretive organization that actively tries to obscure its proceedings and reports, @NotMattSpraker has discussed this before

 

[Mandelin Rain]

1) of course supply matters. What you seem to be missing is demand matters too.

2) ‘While it likely wasn’t an organized effort,’

Well that’s kind of the entire point. Which makes the grand cabal conspiracy theories sort of laughable.

1. Artificial and disingenuous demand is tenuous demand, at best.

2. I doubt ASTRO sent out a missive stating “Increase your residencies now!” But I have no doubt that chairs discussed rising salaries in the 00s amongst themselves and figured that increasing supply was the best way to combat. They also engage in price fixing by sharing salary metrics ONLY amongst themselves. ASTRO just allowed a permission structure by shouting “anti trust” at anyone requesting work force analysis that is… until suddenly they stopped and did a work force analysis. No suit has been raised to my knowledge.

 

[drowsy12]

That ‘artificial and disingenuous’ demand has kept many of us employed for decades. I feel like I’m taking crazy pills here.

If some of you think you’re going to pull of what Wallnernus described with the 2 million dollar salary covering 4 sites - god speed.

 

[medgator]

That ‘artificial and disingenuous’ demand has kept many of us employed for decades. I feel like I’m taking crazy pills here.

If some of you think you’re going to pull of what Wallnernus described with the 2 million dollar salary covering 4 sites - god speed.

No one is thinking that. I've said it previously in this thread. Patients and referrings won't stand for it unless we are talking a single practice in a captive market in bfe. @TheWallnerus was being tongue-in-cheek about it, I think

 

[RickyScott]

I guess the part I’m confused by is how this helps major academic centers. If anything it would make it easier to centrally control more sites without having to worry about paying a doc for every site to chill and make a full salary with less than ten on beam.

If I’m a conspiracy theorist and believe that Astro expanded residencies to centrally
Control and depress physician salaries (does not pass the smell test for a second if you have spent any time with people in leadership, they aren’t that organized lol) then they should also want virtual supervision more than anyone else.

There’s an Academic center not too far from me that could take over some of the sites in our system easily and not have to worry about hiring us or as many of us if virtual supervision was taken to its full potential

There is no “conspiracy,” just a tragedy of the commons. Remember these guys expanded residencies more than every other specialty, making them a total outlier.

 

[RickyScott]

No one is thinking that. I've said it previously in this thread. Patients and referrings won't stand for it unless we are talking a single practice in a captive market in bfe. @TheWallnerus was being tongue-in-cheek about it, I think

hospitals/groups will stop employing docs for redundancy/vacation. Ie centers that had 3 docs to cover 2 centers (for redundancy/vacation) will now only employ 2.

 

[NotMattSpraker]

If I’m a conspiracy theorist and believe that Astro expanded residencies to centrally
Control and depress physician salaries

Just a point of clarification. ASTRO and their leadership are highly disorganized and seem to have very little clout on the hill. I never envision movie-style government cover up conspiracy stuff with them.

But if a chair literally says that they will expand in order to combat rising salaries in the flagship journal of the society, is it fair to call it a conspiracy theory? haha

This idea is not central to everything they do, but the point is there is a clear conflict of interest. They seem to be unable to recognize and/or address the problem that the supervision policy differentially impacts centers around the country and this impacts the market, broadly speaking.

Same goes for ROCR and residency expansion.

It's not tin foil hat to simply point out some of these leaders have serious COI that is not being managed well.

 

[drowsy12]

I absolutely agree both that individual members of ASTRO have COI, as does the group as a whole. See the proton guidelines as the latest example.

My point moreso here is that along those same lines it seems to me that ASTRO, if there is a conflict of interest conspiracy to be espoused here, has more reason to want virtual supervision to go through than not.

 

[RickyScott]

I absolutely agree both that individual members of ASTRO have COI, as does the group as a whole. See the proton guidelines as the latest example.

My point moreso here is that along those same lines it seems to me that ASTRO, if there is a conflict of interest conspiracy to be espoused here, has more reason to want virtual supervision to go through than not.

For whatever reason (and I have my take) “leaders” in radonc are incredibly self interested and flawed vs other specialties in which they typically act as responsible stewards. The extent of residency expansion and emphasis on decreased utilization (hypofract/ommission) are unique.

 

[TheWallnerus]

That ‘artificial and disingenuous’ demand has kept many of us employed for decades. I feel like I’m taking crazy pills here.

If some of you think you’re going to pull of what Wallnernus described with the 2 million dollar salary covering 4 sites - god speed.

You could easily pull off 4 sites one rad onc and 2 million

If there were like 1000 rad oncs total in the US

You could pull off one site one rad onc and 2 million 20 years ago

Society won’t mind paying a few people a lot, but it will wind up paying a lot of people not a lot if given the stress/chance

 

[sloh]

I just took a gander at the Diagnostic Rads forum and there are posts where it is being openly discussed that the rise in pay right now because of increased studies being ordered will be counteracted with CMS cuts.

Have these cuts actually come to fruition meaningfully?

This is the story we have seen over the last 30 years. Ask GI docs from the early 90s about colonoscopies. When something is made much easier or more commonly ordered, CMS cuts.

How much have colonoscopies been cut in the past 30 years?

 

[elementaryschooleconomics]

So all of these random programs that opened over the last decade were just every chair out for themselves? Maybe. Prisoners dilemma? Maybe.

You don't think other chairs have the exact same mentality as Dennis hallahan at wash u?

This is exactly what I think.

Over the years, I've asked many Chairs and senior academic faculty specifically about this topic. Either, "do you feel like it was reasonable to expand given the current concerns", or "would you ever consider decreasing spots", etc.

Obviously, this was primarily before or during the Great Crash of 2018/2019.

Always, always, always, I got two answers:

1) "We believe we give excellent training here."
- This would then be followed by some further justification about how if they cut their "excellent" training, the newer/"lower quality" programs would not, thus, they were doing the "right" thing by making sure residents could get quality training.
- Editor's Note: their programs were NEVER as good as they thought they were.

2) "We've seen increased patient volume at XYZ University RadOnc, and expanded our residents accordingly."
- This is a weird one. I never, ever heard this argument in isolation - it was always accompanied by the "we give quality training" song and dance. But what this was actually saying was "we increased our cheap resident labor so the faculty workload didn't increase in a 1:1 ratio".

Remember, the ASTRO CEO who is now retiring - she's been there for 22 years.

Just...think about that.

In those 22 years, we've essentially seen the same crew of people (SCAROP and their disciples) rotate through the same leadership positions.

The size of an echo chamber you can build in two decades is immense.

What we're witnessing now is the late-stage collapse of the empire. 22 years ago was the rise of IMRT. None of these current leaders did anything to earn what made RadOnc competitive or "good". Thus, they had no idea what good stewardship/leadership looks like. They were lucky.

When the wheels started to come off, that lack of skill was glaring ("the residents are getting dumber, that's why they failed the basic science board exams more").

Friday's Town Hall was just a tour de force of "please retire, all of you".

 

[drowsy12]

Have these cuts actually come to fruition meaningfully?

How much have colonoscopies been cut in the past 30 years?

Ummm the amount of money that a colonoscopy pays has fallen by a ton over the past 30 years.

I have close family that were GI docs. The late 80s and early 90s were like stealing money lol (only kind of joking). Once the uptake of screening colonoscopies really skyrocketed, the per procedure pay declined.

 

[sloh]

Ummm the amount of money that a colonoscopy pays has fallen by a ton over the past 30 years.

I have close family that were GI docs. The late 80s and early 90s were like stealing money lol (only kind of joking). Once the uptake of screening colonoscopies really skyrocketed, the per procedure pay declined.

Thanks! I wasn't asking out of disagreement. Just curiosity

 

[communitydoc13]

Take the 90%. 80% might have been nice, but 90% is something and gives docs at smaller places some legitimacy regarding pushback on doctors hours and draconian admins/toxic RTT culture.

I like docs on site. Take this away and our value plummets in aggregate. Very simple IMO.

ASTRO, if there is a conflict of interest conspiracy to be espoused here, has more reason to want virtual supervision to go through than not.

I don't know. The scale of the institutions overwhelmingly represented by ASTRO leadership makes supervision moot. Also, the typical expansion model favors these places (lots of docs, hire one (often a recent grad) to be chained to new site with periodic coverage from mothership). Virtual would open a bidding war for these types of contracts. Nobody really wants national competition for providing local/regional care...I sure don't.

This is the last thing I want to sh%t on ASTRO about. It's proton guidelines, attempts at carveouts and residency expansion.

 

[TheWallnerus]

I was always concerned if gay marriage became legal, everyone would go gay and quit marrying the opposite sex. Family life would break down, population would plummet, Gerber’s would go bankrupt, etc. I don’t think gay marriage has been legal long enough yet to know for sure this WON’T happen.

 

[Radadabbadoo]

Not only are procedural codes billed better than cognitive codes, our specific procedures are incredibly in our favor when you compare an 20/5 bone met to other procedures, such as idk, complex IR biopsies or total laryngectomies with reconstruction.

I do IDK all the time. It’s easier than 20/5.

 

[TheWallnerus]

I do IDK all the time. It’s easier than 20/5.

How about 8 gray in one fraction?!

 

[Radadabbadoo]

This is exactly what I think.

Over the years, I've asked many Chairs and senior academic faculty specifically about this topic. Either, "do you feel like it was reasonable to expand given the current concerns", or "would you ever consider decreasing spots", etc.

Obviously, this was primarily before or during the Great Crash of 2018/2019.

Always, always, always, I got two answers:

1) "We believe we give excellent training here."
- This would then be followed by some further justification about how if they cut their "excellent" training, the newer/"lower quality" programs would not, thus, they were doing the "right" thing by making sure residents could get quality training.
- Editor's Note: their programs were NEVER as good as they thought they were.

2) "We've seen increased patient volume at XYZ University RadOnc, and expanded our residents accordingly."
- This is a weird one. I never, ever heard this argument in isolation - it was always accompanied by the "we give quality training" song and dance. But what this was actually saying was "we increased our cheap resident labor so the faculty workload didn't increase in a 1:1 ratio".

Remember, the ASTRO CEO who is now retiring - she's been there for 22 years.

Just...think about that.

In those 22 years, we've essentially seen the same crew of people (SCAROP and their disciples) rotate through the same leadership positions.

The size of an echo chamber you can build in two decades is immense.

What we're witnessing now is the late-stage collapse of the empire. 22 years ago was the rise of IMRT. None of these current leaders did anything to earn what made RadOnc competitive or "good". Thus, they had no idea what good stewardship/leadership looks like. They were lucky.

When the wheels started to come off, that lack of skill was glaring ("the residents are getting dumber, that's why they failed the basic science board exams more").

Friday's Town Hall was just a tour de force of "please retire, all of you".

Dr Potters on line 1

 

[thecarbonionangle]

This is exactly what I think.

Over the years, I've asked many Chairs and senior academic faculty specifically about this topic. Either, "do you feel like it was reasonable to expand given the current concerns", or "would you ever consider decreasing spots", etc.

Obviously, this was primarily before or during the Great Crash of 2018/2019.

Always, always, always, I got two answers:

1) "We believe we give excellent training here."
- This would then be followed by some further justification about how if they cut their "excellent" training, the newer/"lower quality" programs would not, thus, they were doing the "right" thing by making sure residents could get quality training.
- Editor's Note: their programs were NEVER as good as they thought they were.

2) "We've seen increased patient volume at XYZ University RadOnc, and expanded our residents accordingly."
- This is a weird one. I never, ever heard this argument in isolation - it was always accompanied by the "we give quality training" song and dance. But what this was actually saying was "we increased our cheap resident labor so the faculty workload didn't increase in a 1:1 ratio".

Remember, the ASTRO CEO who is now retiring - she's been there for 22 years.

Just...think about that.

In those 22 years, we've essentially seen the same crew of people (SCAROP and their disciples) rotate through the same leadership positions.

The size of an echo chamber you can build in two decades is immense.

What we're witnessing now is the late-stage collapse of the empire. 22 years ago was the rise of IMRT. None of these current leaders did anything to earn what made RadOnc competitive or "good". Thus, they had no idea what good stewardship/leadership looks like. They were lucky.

When the wheels started to come off, that lack of skill was glaring ("the residents are getting dumber, that's why they failed the basic science board exams more").

Friday's Town Hall was just a tour de force of "please retire, all of you".

Yes this is why there will never be a contraction. Hellpits believe they have amazing programs. Even if they admit that things used to be bad, they point out that things are “improving”. They point to the volume and highlight they could actually support more residents so they are already showing restraint by not expanding. The places that are good at providing education, also do not want to contract and point to places that should to do the right thing. Nothing is ever fixed. SOAP continues and they all get a warm body.

 

[MidwestRadOnc]

Take the 90%. 80% might have been nice, but 90% is something and gives docs at smaller places some legitimacy regarding pushback on doctors hours and draconian admins/toxic RTT culture.

I like docs on site. Take this away and our value plummets in aggregate. Very simple IMO.


I don't know. The scale of the institutions overwhelmingly represented by ASTRO leadership makes supervision moot. Also, the typical expansion model favors these places (lots of docs, hire one (often a recent grad) to be chained to new site with periodic coverage from mothership). Virtual would open a bidding war for these types of contracts. Nobody really wants national competition for providing local/regional care...I sure don't.

This is the last thing I want to sh%t on ASTRO about. It's proton guidelines, attempts at carveouts and residency expansion.

Disagree completely. This percentage idea is nonsense. Either direct supervision is needed for certain codes in certain settings or it's not. There is no credible argument I have heard for direct supervision of 3D and IMRT treatments in a hospital-based setting. I need to be immediately available? For what exactly? The photons got stuck in the patient and I have to remove them? I need to approve the images in person before each treatment? Literally nobody has ever done that for non-stereo cases. It's asinine.

Of course, I am biased. What ASTRO is trying to do is an existential threat for my current position that I literally just moved for and started. If I have to be here 8-5 M-F, I will likely not be able to continue this as it will not be worth it to me unless the hospital increases my salary guarantee to 7 figures or gives me a share of technical revenue. So I will leave and the hospital will have to staff with locums or someone desperate for any job because of issues. It's a lose-lose, but ASTRO doesn't give a rats asz about rural centers. We've known that for a long time. I thought I had FINALLY found a decent gig in this dumpster fire of a specialty self-inflicted by ASTRO and the academics, and then they come out with this hot garbage.

Does anybody know how to write a letter directly to CMS? I suspect my letter to Jeff Michalski was promptly printed and used as toilet paper.
.

 

[Mandelin Rain]

Disagree completely. This percentage idea is nonsense. Either direct supervision is needed for certain codes in certain settings or it's not. There is no credible argument I have heard for direct supervision of 3D and IMRT treatments in a hospital-based setting. I need to be immediately available? For what exactly? The photons got stuck in the patient and I have to remove them? I need to approve the images in person before each treatment? Literally nobody has ever done that for non-stereo cases. It's asinine.

Of course, I am biased. What ASTRO is trying to do is an existential threat for my current position that I literally just moved for and started. If I have to be here 8-5 M-F, I will likely not be able to continue this as it will not be worth it to me unless the hospital increases my salary guarantee to 7 figures or gives me a share of technical revenue. So I will leave and the hospital will have to staff with locums or someone desperate for any job because of issues. It's a lose-lose, but ASTRO doesn't give a rats asz about rural centers. We've known that for a long time. I thought I had FINALLY found a decent gig in this dumpster fire of a specialty self-inflicted by ASTRO and the academics, and then they come out with this hot garbage.

Does anybody know how to write a letter directly to CMS? I suspect my letter to Jeff Michalski was promptly printed and used as toilet paper.
.

 

[elementaryschooleconomics]

Does anybody know how to write a letter directly to CMS? I suspect my letter to Jeff Michalski was promptly printed and used as toilet paper.

Yes - there are several of us.

I've wanted to see how ASTRO would react to the reaction of THEIR letter first, and/or see how CMS reacts to like, everyone else in medicine supporting Virtual Direct.

RadOnc already looks like the Dunce in the House of Medicine, and I don't want to author some letter that arrives the day CMS announces permanent Virtual Direct, for example.

CMS already rolls their eyes whenever a letter from Radiation Oncology crosses their desk - trying to not make it more obvious how much of a dumpster fire we are...

 

[communitydoc13]

ASTRO doesn't give a rats asz about rural centers

Of course they don't.

How many rural centers are there in Canada?...which is a freaking rural country.

Their position (if somewhat tacit) is undoubtedly one in which they view centers that are potentially not staffed by docs every day as being centers that are not providing the highest level of care.

They almost certainly think that these centers should be shut down with XRT services provided by the nearest reasonably large center operating at a scale they are comfortable with.

Although, I suspect ASTRO would claim that their real position is that even rural patients deserve a doc on site everyday. In fact, they deserve a doc living in the community...and despite the perversion of the only doc in some of these communities being a radonc, this is better than none at all.

There is a darker narrative regarding whether urban academics and professionals in general care about rural people. This narrative has of course dramatically impacted our national discourse on all matters and is particularly important in the setting of our present electoral system.

But, for those not personally invested in these situations, a general cultural shift away from in-person supervision (once it is perceived as generally reasonable) will devastate the market.

I think some folks are looking at this in terms of personal behavior...they are wrong. Only a few individual docs will abuse a change in policy...as has already been shown.

I have no doubt that @elementaryschooleconomics and @MidwestRadOnc will remain conscientious docs who provide reasonable supervision under any regulatory environment.

However, medicine is largely corporate at this point (non-profits in medicine behave in a very corporate manner). That next merger or PSA with an academic place 100 miles away...doc comes down twice a week with virtual only all other days.

 

[MidwestRadOnc]

But, for those not personally invested in these situations, a general cultural shift away from in-person supervision (once it is perceived as generally reasonable) will devastate the market.

It's been generally reasonable for nearly 5 years, and the protection is through accreditation. If academic center XYZ wants its fancy pants urban center and satellites to be accredited by whoever, then you can staff on site 5 days a week and do the incident-to babysitting charade and let the rural hospitals do what's in their best interests to staff appropriately rather than try and cram what's best for you on everyone else from the top down because you're worried the RVUs for your codes might get cut.

 

[communitydoc13]

It's been generally reasonable for nearly 5 years

This is the rub...is it? It's not the cultural norm at most places that are fairly well populated (83% of the country).

 

[thesauce]

Disagree completely. This percentage idea is nonsense. Either direct supervision is needed for certain codes in certain settings or it's not. There is no credible argument I have heard for direct supervision of 3D and IMRT treatments in a hospital-based setting. I need to be immediately available? For what exactly? The photons got stuck in the patient and I have to remove them? I need to approve the images in person before each treatment? Literally nobody has ever done that for non-stereo cases. It's asinine.

Of course, I am biased. What ASTRO is trying to do is an existential threat for my current position that I literally just moved for and started. If I have to be here 8-5 M-F, I will likely not be able to continue this as it will not be worth it to me unless the hospital increases my salary guarantee to 7 figures or gives me a share of technical revenue. So I will leave and the hospital will have to staff with locums or someone desperate for any job because of issues. It's a lose-lose, but ASTRO doesn't give a rats asz about rural centers. We've known that for a long time. I thought I had FINALLY found a decent gig in this dumpster fire of a specialty self-inflicted by ASTRO and the academics, and then they come out with this hot garbage.

Does anybody know how to write a letter directly to CMS? I suspect my letter to Jeff Michalski was promptly printed and used as toilet paper.
.

I’ll sign that letter. Include the hot garbage that ROCR is and the threats it poses to small businesses and rural centers in particular

 

[MidwestRadOnc]

This is the rub...is it? It's not the cultural norm at most places that are fairly well populated (83% of the country).

Yes, because you are talking about taking away something greatly beneficial to rural centers (10% of rad onc delivery) to protect against theoretical threats to rad onc demand everywhere else. There are ways to protect the market value of rad oncs in competitive urban environments, but creating a specious safety argument with the supervision boogey-man that throws the 10% rural minority under the bus is not the right way to do that.

I don't give a crap about virtual direct. It can stay or go and makes no difference to me. This is about the appropriateness of general supervision in HOPDs.

 

[communitydoc13]

Yes, because you are talking about taking away something greatly beneficial to rural centers (10% of rad onc delivery) to protect against theoretical threats to rad onc demand everywhere else. There are ways to protect the market value of rad oncs in competitive urban environments, but creating a specious safety argument with the supervision boogey-man that throws the 10% rural minority under the bus is not the right way to do that.

So are you on-site less than 80% of the time?

Are patients treated without MD supervision 2 or more days a week?

Safety arguments are usually based on a zero tolerance principle (airline model). You will never get the stats you want for safety initiatives BTW. 12 commercial airline crashes per year is just about the same as 0...statistically.

Maybe we really are just technicians?

But, I do agree with you and @elementaryschooleconomics that the best course would have been to do nothing about present supervision rules. Most of the US would keep docs on site because it is important in a competitive market and important for preserving perceived value of the doc within a given institution. Leave the the true rural docs with more leeway.

...too late now.

 

[MidwestRadOnc]

Are patients treated without MD supervision 2 or more days a week?

What is MD supervision? Standing at the machine watching a CCTV of the gantry move?
I am available to answer any therapist questions while patients are getting treated. This is general supervision. If needed, I can and do facetime them and provide real time audiovisual guidance from my office, down the hall, across the street, from South Vietnam, whereever. Same for checking images. The number of days I am in my office providing general supervision is irrelevant.

 

[communitydoc13]

What is MD supervision

There if there is a problem. Patient anxious getting on the table due to trach issues, intractable nausea for first time in a brain met patient, code (it happens), patient wants to quit today (and probably shouldn't).

But if there is no real value to being there....eff us all.