CMS changes supervision rule. Rad Oncs no longer needed for daily operation of clinics. Med Students. Please read. You deserve to know implications.

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medgator said:


The irony of course being KOs complete denial of the ills of residency expansion and multiple recent Mayo residency programs being a part of the problem
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KO's response to the new CMS rule is ridiculous:

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He links to a 2010 article where a group was investigated for not providing direct supervision.

Let's break that down -

CMS: We are now legalizing general supervision, whereas formerly that was not allowed.
Us: Wow this seems like it will really negatively affect RadOnc physicians.
KO: Don't worry! This was tried before and didn't work. * provides article from era where direct supervision was required *

This, to me, seems to be the equivalent of -

Colorado: We are now making marijuana legal to purchase and use, whereas formerly that was not allowed.
Random People: Wow this seems like you can buy weed in stores.
Other Random People: Don't worry! It's against the law to buy marijuana. *provides article from an era where marijuana was illegal*

Unless I'm missing something...?
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I agree, his reply was missing the point. I don't think he read what was going on.

it was like scarbtj level non-sequiter
 
radoncgrad2019 said:
or more that there are like only 7 people total that think there are 'sides' you weirdo
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There are people on Twitter who still don't get it. I wouldn't call it sides but there are definitely folks that are still in their academia "bubble", oblivious to the ground shifting beneath them.

At least folks like Tendulkar, Beriwal etc see that and are acknowledging reality. And then you have KO who tells us onc patients are the best (duh!) and they deserve dedicated Oncologists (non sequitur response)
 
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medgator said:
There are people on Twitter who still don't get it. I wouldn't call it sides but there are definitely folks that are still in their academia "bubble", oblivious to the ground shifting beneath them.

At least folks like Tendulkar, Beriwal etc see that and are acknowledging reality. And then you have KO who tells us onc patients are the best (duh!) and they deserve dedicated Oncologists (non sequitur response)
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I’m no KO lover, but he’s not wrong. Also hear he is much more resident friendly than getting credit for

Also RT took forever to see the light. Guy is naive like no other thx to living in Cleveland Clinic

The worst offenders though are the radonc rocks crew. Straight embarrassment. Emma Holliday and posse
 
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medgator said:
There are people on Twitter who still don't get it. I wouldn't call it sides but there are definitely folks that are still in their academia "bubble", oblivious to the ground shifting beneath them.

At least folks like Tendulkar, Beriwal etc see that and are acknowledging reality. And then you have KO who tells us onc patients are the best (duh!) and they deserve dedicated Oncologists (non sequitur response)
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...And that chearleader/ top virtue signaler from med college of Wisconsin who is constantly trying to screw over women and disadvantaged minorities by luring them into this field.
 
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ROwROwROw_yourboat said:
I agree that my perspective is limited since I am in an academic center. However, I really am trying to learn more about this since I am involved with our residency. I do know a little about the "real world" of medicine since I am also involved with the administration of our department and management of our satellites. It sounds like the main worry here is about my exact situation (main campus with multiple satellites suddenly downsizing) and I am telling you that I just cannot see how this would work, at least for us. But I am eager to hear if I am missing something.
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I'm also at a main academic center and worried about the field. It's not that the jobs that are going to be lost with this change are necessarily "great" jobs, but they're jobs. Fewer jobs puts downward pressure on everyone. Combine that with the explosion in residency positions, and that means worse jobs for new trainees, "top program" trainees, junior attendings, mid level attendings, private practitioners, hospital employed physicians, and so on.
 
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I think the Twitter crew will generally be mum about this. They know there is no positive way to spin this. They know enough that this will ravage the job market. It may even make them feel bad enough to not gaslight impressionable medical students.
 
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Its just a proposal though, It has not been passed yet.......
 
shemer77 said:
Its just a proposal though, It has not been passed yet.......
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Nah. It’s November 3rd. This is to be enacted January 1st (less than two months). The comment period is over. ASTRO already voiced their opinion in September, and were unsuccessful. This is happening.
 
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elementaryschooleconomics said:
View attachment 285315

From the email ASTRO sent to members...this isn't a proposal. "ASTRO opposed" = past tense.
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Over the years, Speculated that something like this would be an absolute disaster for specialty,but didnt see coming so soon. Intellectually, it always seemed clear to me we are headed for a total s— storm. Yet,there are so many smart people in this field, it baffled me how so many others couldn’t see residency expansion debacle combined with hypofractionation is killing us, and now this.

kind of callous that recent Astro leadership like hariri and kavenaugh did not even take a position on residency expansion, and they must have known cms was considering this? Paul Hariri spent more time showing picture of his family as a tribute to himself than residency expansion. trying to keep an open mind, but believe current Canadian lady who heads Astro will be equall worthless.
 
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It’s always been a simple math problem.

More doctors + Less treatments = unfavorable imbalance
 
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RickyScott said:
kind of callous that recent Astro leadership like hariri and kavenaugh did not even take a position on residency expansion, and they must have known cms was considering this? Paul Hariri spent more time showing picture of his family as a tribute to himself than residency expansion. trying to keep an open mind, but believe current Canadian lady who heads Astro will be equall worthless.
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Boomers are the worst
 
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RickyScott said:
Over the years, Speculated that something like this would be an absolute disaster for specialty,but didnt see coming so soon. Intellectually, it always seemed clear to me we are headed for a total s— storm. Yet,there are so many smart people in this field, it baffled me how so many others couldn’t see residency expansion debacle
Combined with hypofractionation is killing us, and now this.

kind of callous that recent Astro leadership like hariri and kavenaugh did not even take a position on residency expansion, and they must have known cms was considering this? Paul Hariri spent more time showing picture of his family as a tribute to himself than residency expansion.
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I believe this has been discussed previously on SDN, but it appears to be a matter of everyone in our Senior Leadership coming from an era where RadOnc WAS NOT competitive. These were not the best of their class. To take our favorite examples:

Wallner = completed Fellowship in RO in 1972
Kachnic = completed residency 1996

From what I can gather, RadOnc didn't truly become hyper-competitive until perhaps 2001-2002. Those classes (graduating maybe 2005-2007) are just coming into Senior Leadership roles.

This entire field reeks of the "Peter principle", which perhaps has been discussed on SDN before, but to quote Wiki:

"an employee is promoted based on their success in previous jobs until they reach a level at which they are no longer competent, as skills in one job do not necessarily translate to another"

We witnessed an entire era of people who naturally fell into leadership positions due to the inherent belief in Medicine that time spent doing this = skill, concurrent with technology and cancer care (and reimbursement) advancing in such a way that the field becomes extremely competitive. The 2000-2015 Golden Era happened by accident, not by design.

Many of the people I've talked to in the past few years - either in-training or recently done with training - had some inkling that this would be a problem, but no one has any power to do anything about it.

Medicine trains you to take care of sick people. It does not train you in business or economics or forecasting or anything like that. It does, however, train your ego to BELIEVE you know to to succeed in business or economics or whatever.

And that is how we arrived here.
 
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RickyScott said:
Over the years, Speculated that something like this would be an absolute disaster for specialty,but didnt see coming so soon. Intellectually, it always seemed clear to me we are headed for a total s— storm. Yet,there are so many smart people in this field, it baffled me how so many others couldn’t see residency expansion debacle combined with hypofractionation is killing us, and now this.

kind of callous that recent Astro leadership like hariri and kavenaugh did not even take a position on residency expansion, and they must have known cms was considering this? Paul Hariri spent more time showing picture of his family as a tribute to himself than residency expansion. trying to keep an open mind, but believe current Canadian lady who heads Astro will be equall worthless.
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To be fair to the new head, despite the geographical anomaly, I’m a believer in giving someone a chance at proving themselves in their position. And people should be doing their damnest to be communicating their concerns to the top, especially since there’s been a change. Not that it’s worked well in the past, but that doesn't mean the effort is always useless.
 
taserlaser said:
To be fair to the new head, despite the geographical anomaly, I’m a believer in giving someone a chance at proving themselves in their position. And people should be doing their damnest to be communicating their concerns to the top, especially since there’s been a change. Not that it’s worked well in the past, but that doesn't mean the effort is always useless.
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It’s just Canada is the one place they care less about oversupply than here. However, in Canada docs lack college and med school debt...
 
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RickyScott said:
It’s just Canada is the one place they care less about oversupply than here. However, in Canada docs lack college and med school debt...
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They did reduce the amount amount rad onc trainees in the 2000s. But those decisions were separate from her control, too.
 
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Wow this is a very surprising and disappointing decision by CMS. I'm floored. I can't believe we are loosening our standards for patient care! We can debate how big of a factor this will play in the number of available jobs, but the locums market is clearly dead. Many academics might not care but that's a huge loss to the field. I know of several really good rad oncs that relied on locums while they were in a rough patch, either in between jobs or waiting for the right job to open up. To lose that little bit of flexibility in a field that already has extreme geographic limitations is just so sad.
 
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PointA said:
Wow this is a very surprising and disappointing decision by CMS. I'm floored. I can't believe we are loosening our standards for patient care! We can debate how big of a factor this will play in the number of available jobs, but the locums market is clearly dead. Many academics might not care but that's a huge loss to the field. I know of several really good rad oncs that relied on locums while they were in a rough patch, either in between jobs or waiting for the right job to open up. To lose that little bit of flexibility in a field that already has extreme geographic limitations is just so sad.
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i don't think it's good.

but just to put it out there, it cuts both ways. Yes, no locums need anymore, but also people in practice don't need to pay for locums anymore either.
 
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I am employed by a hospital and they will gladly not paY for locums, and if I have to leave an hour early they hopefully will not sweat it.
 
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RickyScott said:
It does not cut both ways.
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Just like hypofx allows docs to see and treat more patients per year, this will also allow a given number of docs to see and treat more patients, esp in rural geographies where it has been difficult to recruit a full time doc.

It absolutely would be no sweat for us to incorporate another rural satellite and not hire someone, knowing that clinic would only need 1-2 days of RO staffing per week.

It definitely hurts those folks who retired thinking they could just locums from here on out the next several years too
 
PointA said:
Wow this is a very surprising and disappointing decision by CMS. I'm floored. I can't believe we are loosening our standards for patient care!
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According to CMS... this was everything but a safety issue. America has had a two-tiered supervision system for almost a decade. Rural CAHs and smaller hospitals have had the general-only supervision requirement since 2010. "CMS noted in the proposed rule that it has not learned of any data or information from CAHs and small rural hospitals indicating that the quality of outpatient therapeutic services has been affected by the direct supervision enforcement moratorium." To my knowledge, there has never been any evidence that the mere physical presence of a rad onc makes radiation more safe. Maybe it could if we personally supervised the treatments; but personal treatment (just direct, ie in the office somewhere) supervision has never been mandated AFAIK. If you get radiation in Detroit, where direct supervision was/is mandated, but go 10 miles across the river to Windsor, Canada, where there are no supervision requirements for radiation oncology, is the radiation less safe in Canada? If so I've never heard that Canadian radiation was less safe than American. Medgator posted this article where a lawyer said "Without a properly trained radiation oncologist supervising the delivery of radiation, there could be burns.” Humorous (and if only it were more widely known that radiation dermatitis is inversely correlated with physician presence). Quote from a Kiwi rad onc: "Here we don't have the concept of direct supervision because why would we have all these exceedingly well-trained therapists?" I have also seen some arguments from CMS claiming that the supervision requirements were limiting patient access for other types of therapies.

It seems physical therapists might be welcoming this change.
 
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medgator said:
Just like hypofx allows docs to see and treat more patients per year, this will also allow a given number of docs to see and treat more patients, esp in rural geographies where it has been difficult to recruit a full time doc.

It absolutely would be no sweat for us to incorporate another rural satellite and not hire someone, knowing that clinic would only need 1-2 days of RO staffing per week.

It definitely hurts those folks who retired thinking they could just locums from here on out the next several years too
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Right, as stated above by other posters, this actually makes my job easier as I can now leave the clinic, not have to hire another doc if we do expand or have to have a locums cover. This however does not help out our “worth” overall.
 
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Academic rad oncs.......aka satellite staffers. No wonder our research is going nowhere
 
FrostyHammer said:
There is something seriously flawed with this diagram. Ortho w equal research effort as family med? Rad onc below peds and psych? Seriously?
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JCI Insight - The national MD-PhD program outcomes study: Relationships between medical specialty, training duration, research effort, and career paths

insight.jci.org insight.jci.org

It's a survey of MD/PhDs in academics in each specialty. The figure is showing self reported 50% research effort or more among MD/PhD faculty in academics in those specialties.

I will agree that the rad onc number is kind of sad. But it shouldn't come as a surprise that there isn't a whole lot of basic research in family medicine or Ortho.
 
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Neuronix said:

JCI Insight - The national MD-PhD program outcomes study: Relationships between medical specialty, training duration, research effort, and career paths

insight.jci.org insight.jci.org

It's a survey of MD/PhDs in academics in each specialty. The figure is showing self reported 50% research effort or more among MD/PhD faculty in academics in those specialties.

I will agree that the rad onc number is kind of sad. But it shouldn't come as a surprise that there isn't a whole lot of basic research in family medicine or Ortho.
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That helps to understand. Perhaps the only conclusion is that MD PhDs in rad onc are dropping the ball, which is being carried by MDs. Who knows.
 
FrostyHammer said:
That helps to understand. Perhaps the only conclusion is that MD PhDs in rad onc are dropping the ball, which is being carried by MDs. Who knows.
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I think that the better conclusion is that PhDs are routinely wasted and rarely used in Rad Onc. I think the dearth of quality bench and/or clinical research done in this country over the past decade supports this.

It's like when the money got big enough, all other considerations were just completely set aside.
 
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Mandelin Rain said:
I think that the better conclusion is that PhDs are routinely wasted and rarely used in Rad Onc. I think the dearth of quality bench and/or clinical research done in this country over the past decade supports this.

It's like when the money got big enough, all other considerations were just completely set aside.
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Totally agree. Music to the WashU chairman's ears (not).
 
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FrostyHammer said:
That helps to understand. Perhaps the only conclusion is that MD PhDs in rad onc are dropping the ball, which is being carried by MDs. Who knows.
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It's very hard to find a physician scientist job out there in rad onc, even if you're desperate for one and well qualified. This is partially due to limited grant funding support for rad onc research and partially due to academic departments not wanting to support young physician scientists because they lose money.
 
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Neuronix said:
It's very hard to find a physician scientist job out there in rad onc, even if you're desperate for one and well qualified. This is partially due to limited grant funding support for rad onc research and partially due to academic departments not wanting to support young physician scientists because they lose money.
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"...we came to the concerning conclusion that although an estimated 50% to 60% of all patients with cancer receive radiation therapy, only 1.6% of total funding from the NIH for cancer research went to radiation oncology investigators." Will this ever change? Unlikely that *more* MD/PhDs than in previous eras will enter rad onc.
 
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scarbrtj said:
"...we came to the concerning conclusion that although an estimated 50% to 60% of all patients with cancer receive radiation therapy, only 1.6% of total funding from the NIH for cancer research went to radiation oncology investigators." Will this ever change? Unlikely that *more* MD/PhDs than in previous eras will enter rad onc.
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As far as I am concerned they have enough MD PhDs mulling around working on absolutely nothing. I remember when I was applying the MD PhD was so coveted that nothing else mattered. Now they have them and most cannot get anywhere near the fundinng to do what they want. Their best bet is to link it to a pharma study.

Steve Hahn isn’t going to save us.
 
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Neuronix said:
It's very hard to find a physician scientist job out there in rad onc, even if you're desperate for one and well qualified. This is partially due to limited grant funding support for rad onc research and partially due to academic departments not wanting to support young physician scientists because they lose money.
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Quick relevant anecdote-
Two decades ago I attended the SCAROP meeting at the behest of my Chair. The meeting was held at a lovely spot. The assembled Chairs organized the meeting and one session was devoted to "ensuring the future of radiation oncology depends on good science" (or something similar). The Chairs described how important it was to take some of the $$ and reinvest in "physician-scientists" allowing them to have 80:20 lab:clinic positions. At the completion of the session I was presumptuous enough to ask how many of the assembled Chairs had a similar position available. Sadly none of them raised their hand. It's all about the $$$. This was two decades ago when reimbursement was higher.
 
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Did the most recent rules also finalize site neutral payments? I’ve seen references to it but couldn’t tell if it was for rad onc.

revcycleintelligence.com

CMS Releases Physician Fee Schedule, OPPS, Pushes Site-Neutral Pay

CMS finalized the Medicare Physician Fee Schedule and Outpatient Prospective Payment System (OPPS) rules, which will advance site-neutral and 340B payment cuts.
revcycleintelligence.com revcycleintelligence.com
 
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With new rules would Radiation Oncologist need to be in the building for SBRT treatments and simulations?
 
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