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

[w00tz]

I will never allow a midlevel to do contours/plan evaluation. They are there to do notes for me. The job market is bad enough as it is, I do not want NPs/PAs replacing MDs in the technical aspect of the field. I think if you are a physician who is having NPs/PAs do contours that is not good practice. Worse than having a dosimetrist do your GTV/CTV/PTV contours.

Not my current practice, but saw it while I was in training. The line was drawn at the mid-levels doing the contours, but always need to be reviewed before sending to dosimetry. Similar to a resident's function. Never would allow plan evaluation, even if were allowed. I don't let dosimetrists do target volumes either. Finding a mid-level that wants to learning contouring is pretty rare, from what I've seen. It seemed like the ones that did wanted to have something over the residents. I don't think we have to worry about this becoming widespread, unless there was a significant financial incentive for the mid-levels to do so, like in anesthesia.

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[deleted573262]

Not my current practice, but saw it while I was in training. The line was drawn at the mid-levels doing the contours, but always need to be reviewed before sending to dosimetry. Similar to a resident's function. Never would allow plan evaluation, even if were allowed. I don't let dosimetrists do target volumes either. Finding a mid-level that wants to learning contouring is pretty rare, from what I've seen. It seemed like the ones that did wanted to have something over the residents. I don't think we have to worry about this becoming widespread, unless there was a significant financial incentive for the mid-levels to do so, like in anesthesia.

the sentiment was similar when nurses started spending time monitoring patients in the OR according to my uncle (anesthesia md).

 

[w00tz]

the sentiment was similar when nurses started spending time monitoring patients in the OR according to my uncle (anesthesia md).

I mean, anesthesiologists in the OR most of the time are reading a book or playing on their phone and get paid a healthy six-figures. Hard to resist encroaching on that.

We used to have something similar with babysitting linacs, but CMS took that away from us already and destroyed the locum market for rad onc.

Could it be AI or mid-levels that bury us further in the ground? We'll see. I'm not saying that I think what we do is easy/simple or doesn't require a lot of specialized training to do a good job. But more and more things just fall into a protocol (see MD Anderson satellite thread) making it easier to be passed on to a mid-level. It's just the way things are moving in other specialties too. Call me jaded, but 7 years ago when I was a med student, radiation oncology was a much healthier field. Since, then so much has been done to crap on the field. Hopefully it gets better, but it may not.

The hospitals control everything and if it makes them more money, then watch out. Anesthesia has a great PAC and anesthesiologists are still worried about how things will go and constantly fighting with CRNAs for turf. Then we look at ASTRO - hah. I think if I'm practicing for another 30+ years, these things are definitely in the realm of possibilities. And with those things swimming in my mind, I'm just trying to prepare by aggressively putting away money in my retirement account.

 

[scarbrtj]

Safety

Lost in the fustian safety talk is zero mention of (possibly? never? selectively?) newly imposing direct supervision on rural hospitals that was never there.

 

[PhotonBomb]

Safety

Lost in the fustian safety talk is zero mention of (possibly? never? selectively?) newly imposing direct supervision on rural hospitals that was never there.

why do you find this rule so distasteful? It's helping everyone in rad onc as a whole. Stop it.

 

[medgator]

why do you find this rule so distasteful? It's helping everyone in rad onc as a whole. Stop it.

You don't see the absurdity of letting certain rural hospitals get away with general this entire time?

Personally CMS should keep direct for where it is needed for everyone, regardless of location. Personally, I think standard fx is fine as general, sbrt should be direct

 

[Chartreuse Wombat]

why do you find this rule so distasteful? It's helping everyone in rad onc as a whole. Stop it.

No it is not helping everyone. As with anything winners and losers. Bad for the job market and new trainees but good for those with established referral patterns looking to lower their fixed costs.

 

[medgator]

No it is not helping everyone. As with anything winners and losers. Bad for the job market and new trainees but good for those with established referral patterns looking to lower their fixed costs.

It'll hurt existing employed docs to a degree as well. I imagine the net is still negative as less and less folks outright own their own practice in full or part

 

[Haybrant]

That's going to tighten medical oncology hiring as well.

Fwiw, I know several med oncs in my area that have hired extenders/NPs in the last 2-3 years without hiring a new partner. They can help see patients in the hospital, cover chemo (at a lower rate), etc.

This will accelerate that trend

SO is that who lobbied for all this, NP and PA groups?

 

[RadOncDoc21]

SO is that who lobbied for all this, NP and PA groups?

I’m leaning more towards Boomer. As he gets older, instead of retiring, he can still be “present” while playing golf and not have to hire a partner to cover the on treatments on the multiple machines he owns. Boomer is always strategizing and adapting making it harder for his new “partner” Avocado toast who just completed his 3rd fellowship. Avocado toast graduated at the top of his class, has many publications and completed a palliative care fellowship, clinical instructor fellowship and is excited to be the first US trained fellow in carbon ion therapy at Mayo!

At the age of 42, Avocado toast is excited to start his career only 4.5 hrs away from his ideal location making 200k a year seeing 95% of all of Boomer’s patients with no commitment for a partnership.

This is what could happen in a couple of years, if so call me “Boomer!”

 

[scarbrtj]

why do you find this rule so distasteful? It's helping everyone in rad onc as a whole. Stop it.

I think you and I do not have the same definition for "everyone." How many press releases did ASTRO make to the effect of "Patient safety at risk in rural hospitals across America" before 2020? I'd wager ASTRO would have made zero peeps had a direct supervision rule been imposed on rural hospitals. Now that general supervision has been imposed on non-rural hospitals, "patient safety" has become a cause célèbre. Who knew that direct supervision kept patient safety at a higher level in non-rural hospitals? Answer: no one. There is more data that carbon ions are unsafe to use on humans than general supervision is unsafe in radiation oncology. In medicine you can win a lot of arguments by dropping the good 'ol "patient safety" into the discussion. It's a lazy way to win this argument at best; at worst, transparent.

 

[Mandelin Rain]

Yeah, blindly shouting "patient safety" will definitely perk the ears up of your local hospital administrator. I'm guessing it won't move the needle for the US government.


My best bet is we hear of some bad dermatitis episodes and a few misadministrations (that may have happened anyway), but overall life will roll on and patients will be treated well. As well as the chemo patients being supervised by an NP or radiology patients being supervised by, huh, ummmmm.....

 

[medgator]

As well as the chemo patients being supervised by an NP or radiology patients being supervised by, huh, ummmmm.....

You need an MD on site at a rads facility if you're doing contrast studies afaik

 

[PhotonBomb]

I think you and I do not have the same definition for "everyone." How many press releases did ASTRO make to the effect of "Patient safety at risk in rural hospitals across America" before 2020? I'd wager ASTRO would have made zero peeps had a direct supervision rule been imposed on rural hospitals. Now that general supervision has been imposed on non-rural hospitals, "patient safety" has become a cause célèbre. Who knew that direct supervision kept patient safety at a higher level in non-rural hospitals? Answer: no one. There is more data that carbon ions are unsafe to use on humans than general supervision is unsafe in radiation oncology. In medicine you can win a lot of arguments by dropping the good 'ol "patient safety" into the discussion. It's a lazy way to win this argument at best; at worst, transparent.

how much data do we have that patients getting radiation need weekly treatment management visits? why does a prostate patient need to be seen every week, why not every two weeks? why does so much of our billing come from some of these sometimes not meaningful visits? Where is the data supporting them? Why should you bill more for IMRT?

don't play games you aren't ready for. Don't bite the hand that has fed you since the early 2000's.

 

[RadOncDoc21]

how much data do we have that patients getting radiation need weekly treatment management visits? why does a prostate patient need to be seen every week, why not every two weeks? why does so much of our billing come from some of these sometimes not meaningful visits? Where is the data supporting them? Why should you bill more for IMRT?

don't play games you aren't ready for. Don't bite the hand that has fed you since the early 2000's.

Technically speaking, if you bite one hand off, couldn’t they just use the other hand to feed you? Just saying, we may make the feeder angry but they love us too much to get rid of us permanently.

 

[scarbrtj]

how much data do we have that patients getting radiation need weekly treatment management visits? why does a prostate patient need to be seen every week, why not every two weeks? why does so much of our billing come from some of these sometimes not meaningful visits? Where is the data supporting them? Why should you bill more for IMRT?

don't play games you aren't ready for. Don't bite the hand that has fed you since the early 2000's.

You have just described APM. The toothless pose zero bite risk.

 

[Mandelin Rain]

The thing to remember about this rule is it's still your ass if something goes south. You can't call CMS as a defendant if you're being negligent. That will be what holds back the flood gates a bit. It will take some time for people to find their own comfort level with this rule, but my guess is many places will start by staffing with an NP/PA a couple days per week and see how it goes. And I think that's fine. I would never schedule a SBRT, SRS, brachy procedure if not present. I'd be very iffy on a sim as well. But daily treatment? Meh. Not sure what I do, that couldn't be done remotely with a cell phone and a computer. Have someone capable of evaluating a patient at the clinic, either NP or realllllly good RN. What else is there?

 

[Mandelin Rain]

You have just described APM. The toothless pose zero bite risk.

Bingo. APM will make all these codes/notes/ceremonies obsolete. You could just wave at people in the hall as you treat them in 5 days.

 

[Mandelin Rain]

You need an MD on site at a rads facility if you're doing contrast studies afaik

What about x-rays? The stuff we use?

 

[scarbrtj]

What about x-rays? The stuff we use?

Nope. Not even in freestanding.

 

[imhopeful432]

Bingo. APM will make all these codes/notes/ceremonies obsolete. You could just wave at people in the hall as you treat them in 5 days.

Unclear that these codes (i.e. weekly status check) go away with APM. RO APM still requires you to post non-billable codes for everything you would do in the FFS during the APM. Was not clear from the rule whether this would mean not doing a status check would mean you did not finish the RO APM episode (which would affect your reimbursement).

 

[Mandelin Rain]

Probably a test period thing. It will allow them to directly compare cost of a care episode to calculate savings. Once it's widely adopted and rates have been determined, I almost guarantee you won't be coding all the nonsense we do now to get paid.

Though it's the government, so who knows?

 

[RadRadRad]

Can someone tell me in what scenarios the general supervision changes apply

1. Is it only hospital based centers
2. What about hospital owned centers/satellites that are free standing? Does this change if its a JV and only partially owned by hospital?
3. What about hospital based centers that are not within the hospital but on the grounds of some other hospital owned multispecialty outpatient office building.
4. I assume non hospital owned and free standing is still direct supervision?


Thanks

 

[RickyScott]

Can someone tell me in what scenarios the general supervision changes apply

1. Is it only hospital based centers
2. What about hospital owned centers/satellites that are free standing? Does this change if its a JV and only partially owned by hospital?
3. What about hospital based centers that are not within the hospital but on the grounds of some other hospital owned multispecialty outpatient office building.
4. I assume non hospital owned and free standing is still direct supervision?


Thanks

For freestanding centers, language says a MD is needed. It does not state that radiation oncologist/provider proficient in radiation is required. (it used to have that qualification for the provider in an inpatient setting). therefore, some national organizations do have MDs other than radoncs babysit freestanding centers.

 

[medgator]

For freestanding centers, language says a MD is needed. It does not state that radiation oncologist/provider proficient in radiation is required. (it used to have that qualification for the provider in an inpatient setting). therefore, some national organizations do have MDs other than radoncs babysit freestanding centers.

Is that true? I thought the qualification was someone who could assist with furnishing the procedure (aka looking up an igrt)

 

[OTN]

Can someone tell me in what scenarios the general supervision changes apply

1. Is it only hospital based centers
2. What about hospital owned centers/satellites that are free standing? Does this change if its a JV and only partially owned by hospital?
3. What about hospital based centers that are not within the hospital but on the grounds of some other hospital owned multispecialty outpatient office building.
4. I assume non hospital owned and free standing is still direct supervision?


Thanks

1. Yes
2. If they bill under HOPPS, then general applies
3. Same as above- depends under which entity they bill
4. Correct, though other non-radonc MDs can fill in

 

[Bequerel]

I’m at a hospital based facility and my department manager is difficult to say the least. This person states that cpt codes trump CMS rule which would require rad onc to be present for every sim. I don’t know enough about billing to combat this...is this person correct? I am writing a department policy that would require a rad onc to be present at console for every SBRT and SRS treatment and at ct sim for every ct sim, but didn’t want to make it set in stone for every verification sim on machine.

 

[seper]

Different issues from overseeing LINAC delivery here IMO... Simulation CT and verification sim are billable procedures (for non-IMRT I guess), so yes, you need a physician in the building. I would also argue a physician need to see his own simulation CT to deliver RT properly, but I know a lot of departments have been slacking off on that front.

I’m at a hospital based facility and my department manager is difficult to say the least. This person states that cpt codes trump CMS rule which would require rad onc to be present for every sim. I don’t know enough about billing to combat this...is this person correct? I am writing a department policy that would require a rad onc to be present at console for every SBRT and SRS treatment and at ct sim for every ct sim, but didn’t want to make it set in stone for every verification sim on machine.

 

[scarbrtj]

I’m at a hospital based facility and my department manager is difficult to say the least. This person states that cpt codes trump CMS rule which would require rad onc to be present for every sim. I don’t know enough about billing to combat this...is this person correct? I am writing a department policy that would require a rad onc to be present at console for every SBRT and SRS treatment and at ct sim for every ct sim, but didn’t want to make it set in stone for every verification sim on machine.

how/why are you billing sims for 3D/IMRT patients? I know we've had a bit of discussion re: 3DCRT patients but OIG has said in effect "don't do that" (not even 77280)...
I guess we will all "discover" that "everyone" is now an "expert" about CPT codes, and sims, and what not.
"Who cares what the govt says, I know what is correct"
(but department managers--not MDs--govern the standard of rad onc care in most cases!)

 

[radiaterMike]

Though you can’t bill the sim code you still bill for some of the technical codes associated with the sim (ie immobilization device). I am no expert either - but I think with IMRT you are technically billing for the sim but the sim is bundled into the planning code.

 

[Bequerel]

Though you can’t bill the sim code you still bill for some of the technical codes associated with the sim (ie immobilization device). I am no expert either - but I think with IMRT you are technically billing for the sim but the sim is bundled into the planning code.

Let’s get past the if we should be billing for sims. My question is, if we are billing (bundled or not) for a sim, do we have to be in the building? More specifically, in 2020, as a hospital based department, would I need to be in the building to bill for a simple sim for a bone met port film verification? My department manager argues yes because of some CPT verbiage that would trump CMS ruling. This person is usually full of SH—, but I don’t know enough to win the argument. I think checking film remotely prior to start could be sufficient if I were not in the building. Please assist with this specific situation. Thanks

 

[scarbrtj]

Let’s get past the if we should be billing for sims. My question is, if we are billing (bundled or not) for a sim, do we have to be in the building? More specifically, in 2020, as a hospital based department, would I need to be in the building to bill for a simple sim for a bone met port film verification? My department manager argues yes because of some CPT verbiage that would trump CMS ruling. This person is usually full of SH—, but I don’t know enough to win the argument. I think checking film remotely prior to start could be sufficient if I were not in the building. Please assist with this specific situation. Thanks

Probably at the end of the day you will have to thank your dept manager for single-handedly solving the "national rad onc supervision crisis" by discovering a previously hitherto unknown loophole in CPT codes which, from their outset, were designed to "trump" the Social Security Act's supervision policies or any CMS declarations all along. ASTRO was whinging about nothing. Everyone can go back about their business now: rad oncs still have to be on site in the hospital. (Radiologists do not have to be in building to check a film, but rad oncs do. Why? "It's the CPT verbiage.") This "CPT verbiage" would, presumably, only affect certain radiation therapy outpatient procedures, not the vast swath of other outpatient procedures also affected by CMS's recent supervision declarations. Also, in a strange twist, when CMS said general supervision now applies to all outpatient therapy, a simulation is (and never was?) considered a part of outpatient therapy. By that logic, essentially everything in radiation therapy (planning, devices, physics consult, special treatment procedure, complex planning) that isn't expressly therapy... isn't outpatient therapy.

Or, alternatively, the person is indeed full of SH—. It's like when the Supreme Court legalized gay marriage, yet there will still people pointing to the Bible and saying "but it says right here 'man shalt not lie with another man.'"

In medical care, it's almost always about which care is right and which is wrong. But in medical administration, it's almost never about what's right or what's wrong. It's about who has the power to win the argument.

 

[2021Doctor]

Agree. On top of that, this rule couldn't have come at a worse time, honestly, esp with the way academics has been asleep at the wheel with residency expansion

This will hurt many, many individuals who've put in a big chunk of their lives towards RO.

Honestly if 0/195 match in April, it'll be a good thing for the specialty. Plenty of slack that could be picked up by existing practitioners and it would give academic RO the wakeup call they've been needing all these years

0/195 never come close to happening. PDs will not give us on that nice GME $$$$ from CMS. If they do not fill the slots, they do not get the $$$$. They will fill all 195 slots with FMGs if they have to.

 

[PhotonBomb]

0/195 never come close to happening. PDs will not give us on that nice GME $$$$ from CMS. If they do not fill the slots, they do not get the $$$$. They will fill all 195 slots with FMGs if they have to.

I don't think you understand how residency programs work if you think freaking PDs have anything to do with the money.

 

[PhotonBomb]

I do not think you understand how GME works. Hospitals want that GME money. PDs who do not keep the GME $$ flowing in will be replaced by PDs that toe the line.

Yes, hopsitals do want that GME money (so they can pay for resident salary and benefits, it's not like this money is more than a drop in the bucket to overall budget, I hope you do know that, especially when talking about 1-2 residents a year at many of these programs who aren't going to match).

The machinations of variable residency fills or non-fills in a small program like radiation oncology is not of big interest to a hospital admin. Yes - a chair would see if he or she could get someone else to take the PD job if it was felt that the PD's performance (if deemed to be poor) was tied to the poor match results.

but you're acting literally like this is NCAA athletics, it's funny. it's not that dramatic.

 

[Chartreuse Wombat]

GME funding from Medicare has been largely capped since 1996. Most of the $$ for increased resident positions comes from the hospital system or the physicians

 

[Mandelin Rain]

Exactly. Departments want residents because they are cheaper/(typically) better than midlevels and they drive down the price of hiring faculty once they graduate.

If they get GME money, it’s just a bonus.

 

[evilbooyaa]

I've moved discussion of physician replacements in Chicago to its own thread as it had zero to do with radiation oncology.

Ditto with derm rads because they are not related to the topic of supervision requirements.

 

[BobbyHeenan]

I'm bumping this thread to ask a question - my apologies if it has been answered elsewhere....

It seems that ASTRO is going to oppose this. So if you want to have your cancer center/radiation dept astro certified (APEx) they're probably going to demand around the clock rad onc md supervision. What about other bodies like ACRO or ACR? Anyone know their stances on this supervision?

 

[medgator]

I'm bumping this thread to ask a question - my apologies if it has been answered elsewhere....

It seems that ASTRO is going to oppose this. So if you want to have your cancer center/radiation dept astro certified (APEx) they're probably going to demand around the clock rad onc md supervision. What about other bodies like ACRO or ACR? Anyone know their stances on this supervision?

Someone had mentioned ACR having it in their guidelines but I've never heard about it during a site visit one way or the other

 

[Mandelin Rain]

ACR already requires it. ACRO does not.

 

[Haybrant]

ACR already requires it. ACRO does not.

So how is that gonna play out will ACR change that in their guidelines or they'll just keep it in place. Before 2017 their language didn’t mandate then it changed. If they keep it will people drop ACR certification and look elsewhere

 

[BobbyHeenan]

This will be interesting to watch out for. I may reach out to ACRO and ACR and see if they’re going to issue a stance on this. If anyone has any links or anything firm on this please post it.

 

[radsisrad]

it is overwhelmingly clear that the field is in a a very tough spot. Anybody early on in a midtier or mediocre program should consider based on their risk tolerance to switch a different specialty. Current employed rad oncs should save even more and prepare to potentially be out of a job. This is particularly worrisome to anybody who just joined and is not yet partner. Guess what? They don’t need you or like you THAT much.

Anybody sitting on a decent contract in a tolerable location where you will not hang yourself, should strongly consider signing it and praying it is honored and not taken back. You have very little power this year.

It is funny how some of the usual “positive” posters (Find repulsive) on here are SHOOK. Some people are just clueless and cannot see the light, like that thing they put on horses eyes so they walk straight. Some people are just BLIND!. That is SAD.

Trump, or as the right calls him “daddy” absolutely did ruin RO with his crony Azar. For those expecting known Trump high money doner Hahn to save us, you will be waiting for a while.

To paraphrase the left-wing quip from 2008-2016, "thanks, Trump!"

This decision might be the final straw for Rad Onc, but Trump didn't create the mess. The oversupply created by greedy administrators/chairs/PDs is obviously what's to blame here. Rad Onc is not alone here; just ahead of the curve. EM grads will likely discover nasty surprises in a few years, but the chief difference is that EM applicants won't have to live with the same opportunity cost (many Rad Onc applicants, at least as of a few years ago, could easily have pursued Derm, Ortho, etc... not to mention the relative length of training).

The situation is not lost, however. What needs to happen is a draconian downsizing in residency spots. If I were a Rad Onc resident, I'd be meeting with all my co-residents right now and organizing a unanimously-signed letter demanding that starting either this cycle (unsure whether this is possible) or the next, there be a one- or two-year break from matching in NRMP.

 

[thecarbonionangle]

To paraphrase the left-wing quip from 2008-2016, "thanks, Trump!"

This decision might be the final straw for Rad Onc, but Trump didn't create the mess. The oversupply created by greedy administrators/chairs/PDs is obviously what's to blame here. Rad Onc is not alone here; just ahead of the curve. EM grads will likely discover nasty surprises in a few years, but the chief difference is that EM applicants won't have to live with the same opportunity cost (many Rad Onc applicants, at least as of a few years ago, could easily have pursued Derm, Ortho, etc... not to mention the relative length of training).

The situation is not lost, however. What needs to happen is a draconian downsizing in residency spots. If I were a Rad Onc resident, I'd be meeting with all my co-residents right now and organizing a unanimously-signed letter demanding that starting either this cycle (unsure whether this is possible) or the next, there be a one- or two-year break from matching in NRMP.

I agree except for last part. If i turned in a signed letter with my co-residents to my greedy chair with sticky fingers, person would laugh at my face and maybe even ruin my career. This is a field filled with very vindictive petty people. This would only have any effect if a large majority (not just like 51%) of all current residents penned a letter demanding collective action. Even then, we would probably be ignored.....

 

[medgator]

I agree except for last part. If i turned in a signed letter with my co-residents to my greedy chair with sticky fingers, person would laugh at my face and maybe even ruin my career. This is a field filled with very vindictive petty people. This would only have any effect if a large majority (not just like 51%) of all current residents penned a letter demanding collective action. Even then, we would probably be ignored.....

All the more reason to spare folks from this nonsense going forward.

Let radonc residency programs eat cake

 

[thecarbonionangle]

All the more reason to spare folks from this nonsense going forward.

Let radonc residency programs eat cake

Agree I think so many places need to be unmatched and the specialty needs to completely crash and burn before these "leaders" will do anything which may stop the flow of money into their sticky hands.

 

[radsisrad]

I agree except for last part. If i turned in a signed letter with my co-residents to my greedy chair with sticky fingers, person would laugh at my face and maybe even ruin my career. This is a field filled with very vindictive petty people. This would only have any effect if a large majority (not just like 51%) of all current residents penned a letter demanding collective action. Even then, we would probably be ignored.....

A program will not simultaneously fire or even screw over the entire complement of its residency program.

For residents who foolishly don't want to take the "risk" (I maintain that there is none) of the above step... well, you can't get fired for being an uninterested and deprecating ***hole on residency interview days. If it were my career at stake, I wouldn't be taking half-measures.

Again, just outsider advice.

 

[radsisrad]

Agree I think so many places need to be unmatched and the specialty needs to completely crash and burn before these "leaders" will do anything which may stop the flow of money into their sticky hands.

If there are hundreds if not thousands of American med students who still think that rad onc is a great field, just imagine how many IMGs and FMGs haven't gotten the memo about the field's decline.

Don't expect all that many places to go truly unmatched anytime soon (apart from conscious decisions on the parts of programs to, for instance, not participate in SOAP).

 

[thecarbonionangle]

If there are hundreds if not thousands of American med students who still think that rad onc is a great field, just imagine how many IMGs and FMGs haven't gotten the memo about the field's decline.

Don't expect all that many places to go truly unmatched anytime soon (apart from conscious decisions on the parts of programs to, for instance, not participate in SOAP).

the sad reality is many people in field just want a warm FMG body with a pulse , rather than contract so we will continue to sink. I can’t remember the last time understood what half of what a path fellow was saying at tumor board, pretty much our future, in a field where communication is so important