funny thing is i have heard that the astro chair is in clinic like 2 days a week.
so it doesn't really even affect him. if he is away doing ASTRO things, there is 30+ other docs at WashU to provide supervision for his patients.
This is true, but I don't think 30 physicians are still there. I suspect they will be perpetually hiring if anyone is interested. The presidente also reguarly does telemedicine and holds a license in Utah, and we published two papers on the exceptional safety of virtually supervising SBRT and on table adaptive therapies. Real honest with their opinions, these people.
Anyway.
Simul wrote a very long letter to the ASTRO Policy email and he asked me to post that here. I think it is good and I want people to see it. Enjoy.
I know that we have had some contentious moments in the past, but I think this is an opportunity to find some common ground. I do hope you take the time to read this in detail and perhaps set up a call.
The letter sent by you to CMS was a very good example of why members and former members (like myself) remain frustrated with the society and why membership will continue to fall. Our “memberships” are very different. I.e. – the people that join and participate in ASTRO are often not the same people that listen to The Accelerators / Out of The Basement podcasts and are active on SDN/Twitter. Because of the lack of overlap, there can be a perception that what seems completely reasonable to ASTRO leadership is a hill to die on for non-members, and vice-versa. We have tried to engage, but ASTRO has decided to stop being guests on the show, and that’s okay. I have reached out to the CEO about a year and half ago to chat and she said yes that sounds great, but then when I followed up, was ignored. I’ve also tried to connect with Sue Yom, and she has told people that I was not worth talking to since I am not academic. So, I’ve tried and here goes one more time …
If it’s not clear, I will go over the main issues that the greater radonc community is frustrated with:
- This was done unilaterally without comments. This blindsided both ASTRO members, some non-high level staff/leadership and non-members alike. We have been living in relative peace since 2020 when they strengthened autonomy and allowed for general supervision at the hospital level. This came out of nowhere and without discussion with members and non-members. We are not children. We are not here to serve you. ASTRO is for radiation oncologists. Not the other way around. When a diktat comes like this from the top without discussion it is infuriating and disrespectful. Does this not occur to you that we may want to be part of the conversation? Jeff – none of the Astro leadership works rural like I do. Most of you don’t know community hospital medicine. None of you have zero partners like me. This is a different world and many of us live/work in places like this. It’s like if rich people said to poor people, “Guys, you really should just work hard and play by the rules. You’ll be fine if you do.” You have to understand our circumstances and that is by talking to us and including us.
- General supervision has existed since 2020 and has not been an issue. I have general supervision. How many days has the center operated without a physician present? Perhaps 5 times in 520 days, 2-3 for my dad’s funeral in summer of 2022***, and a few other travel days, when there were no 1) new starts 2) SBRT/SRS 3) CT simulations 4) virtual simulations 5) Challenging setups. If you think doctors are going to abuse this, maybe you have to consider better training in residency or pick better humans. That being said, I know 100s of radoncs personally and they are not sleazebags. I wonder why this assumption that people will behave badly.
***We could not get a locums to Port Huron. We are talking $2000 to sit for 6 hours to have 4-10 patients get treated. I know the VA in St Louis pays like $1500 for way harder work. If my hospital didn’t let me take the day from home when my father was sick / died, I would have let the center not treat patients. Every single patient would have missed their treatments. And, I would have them email you and then have you explain why having a physician on site for every treatment is vital. Please do consider the human cost of these types of policies.
- It’s not ASTRO or any society’s role to police ethics. I’m a small town doc, so I provide access 24/7 – every patient and caregiver has my cell phone – and can reach me nights/weekends/vacations. That is not a requirement. It’s my internal quality policy. I know that when I find the right person to hire as my partner, they will share similar values. They will know that general supervision is reasonable, but we don’t say we are working from home on a Friday but are on a beach somewhere out of the state or on a mountain and unreachable. ASTRO making a blanket recommendation that feels very “parental” but it is not the society’s role to manage or discipline for this (and, obviously, they can’t). This is not a guardrail. This is punitive.
- There is simply no data to support regulating this. If there were multiple errors due to lack of supervision, if there were a dozen centers operating in Michigan (where the CON lets us virtually supervise) without a doc on site, if patients and referrings were complaining of lack of presence – yes, then we have an issue. We simply don’t have the data to make another change. ASTRO’s Red Journal studies so many non-cancer related things like carbon emissions from linacs or demography counting or whatever, but to make a huge policy shift, they didn’t consider having anyone study this in a meaningful way? If you publish a good study that says it benefits patients to be here all the time, trust me, many of our minds will be changed. Think about Mantz’ wrong side treatment – this was in the news. Direct supervision occurred and yet, still this happened. Wrong site treatment and grade 4/5 toxicity is what we get sued for in radonc – neither have to do with supervision.
- I utilize general supervision often – to run out for a late lunch, to take a stroll on a nice day, to be able to drop my kid off to school but take them for donuts before that, to pick them up from school if sick, to get a quick workout in mid-day. If there are no clinic patients and no sims or new starts, occasionally I say I’ll work from home on Friday, but it rarely happens because I am the sole doc and I feel a responsibility to be around, even if just for a few hours. You see, I had good mentorship and training and now how to police myself I hope you have done this for your trainees. But, this is important. When your mentors are teachers are good human beings, your trainees usually end up that way. Sushil Beriwal taught us to be good humans first then good doctors. He’s a gem. Wish more people like him were in ASTRO leadership.
- There are many working mothers out there that will be unfairly penalized to try to be a good parents and a good doctor. Let’s be honest – is it safer for me to view my own films from home of patients I know very well or to have a retiree babysit my linac that has no idea about what’s going on? This is the quiet part that needs to be said aloud – the current group of linac babysitters out there willing to take $1000-2000 to sit in a chair for 8 hours are not as good as Laura Dover or me or Join Luh at our home with a laptop and an iphone. We are going to lose talented women (and some men) that will just not want to have a job where they are tied to a linac for regulatory reasons – not patient safety reasons. Our specialty is much less attractive than others now. Nobody wanted to be a psychiatrist when I was a med student. It was an FMG field. Now, it’s fire – telemedicine has helped the specialty attract better docs and it’s also improved access for patients. Win win!
- “Existential threat” – this is being bandied about. Please stop. The number one existential threat is increasing the number of residents when fractions, patients, indications and reimbursement are decreasing. This is so incredibly tone deaf that it makes it very challenging to have a meaningful discussion. When I see these phrases, especially from senior leadership (president-elect, for one), I understand that I cannot take this person seriously. These are the words of an unserious person. For 3.5 years we have had general supervision and nothing bad has happened. Use language carefully – we are not fools, please do not treat us as such. This is not a threat. Bridge Oncology is not a threat. Hospital consolidation, APPs and Academic Medical Centers playing hardball are existential threats to me. The guy in Saginaw covering his center 4 days a week is not.
- We feel like ASTRO has either ignored the wording about who can provide supervision or is wanting APPs to increase their scope. This is problematic. All of the recent ASTRO documents have said “physicians preferred, but APPs if credentialed are fine”. This lines up with Medicare, but Medicare doesn’t even say physicians are best. If ASTRO wants someone to be on site for 5 days a week for every treatment, then please make it a board certified radiation oncologist. I know that GenesisCare uses retired OB-Gyns in MI to babysit the linac. Mantz, one of your board members, was senior leadership there so he must be aware of this. This is not good. We need radoncs supervising. Preferably direct, but general in a pinch. Please work on making this an important part of ASTRO’s upcoming business. Oh, and please stop calling me provider. It’s “doctor”, actually.
ASTRO comes off as anti-community practice constantly. I have heard that this proposal takes priority over worrying about small town docs. This is unfortunate. Your residents don’t want to work where I do. Your residents don’t want to live where I live. Who do you want to run these small centers? Locums rotating every few weeks? People who cannot pass their boards? Ethically challenged docs? It is far better to have a competent doc on site 4 days a week, working from home for a day a week vs rotating locums covering 5 days / week. And you all know this. You know that you’d want a hard working doc be there for 25 years and take care of your community. Places like Rice Lake WI, Alma MI, Portsmouth OH, and I can list a dozen others (just look on your website and PracticeLink) – simply cannot get a full time doc for years. Locums are far more expensive than having a full time doctor with benefits, but they are not the solution. If you want to make this specialty attractive for a wide group of people, if you want the best and brightest doctors, please consider changing the wording dramatically on this letter and re-submitting to CMS.
Finally, please invite non-members to the Town Hall. If this is a members-only meeting, you’re just going to continue to anger people. Open it up, let people actually talk. If it is scheduled for one hour, limit your own talking to 5-7 minutes and let the people talk. We know the issue, we do not need a lecture. Very few of you are currently running a single linac site in a small town. Let those people speak.
I hope we can find common ground. There is a chance for ASTRO to come out on top, rather than looking inept, yet again. This is a chip shot. LFG!
Simul
It’s worth a read of this thread starting from this post, to get a sense of the discussion
CMS changes supervision rule. Rad Oncs no longer needed for daily operation of clinics. Med Students. Please read. You deserve to know implications.
