Radiation Oncology Job Market - ACR Webinar

[2014XRT]

Two people firmly in academics - Olivier and Vapiwala
Two in private practice - Gondi with ROC and Butler with SERO
Savioz works in 'academics' now but seems to have been in PP before.

Seems decent.

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[tomballunger]

I think it has been discussed somewhere that vapiwala has pushed for more rigorous standards amongst residency programs so that may be a good start.

 

[Chartreuse Wombat]

I think it has been discussed somewhere that vapiwala has pushed for more rigorous standards amongst residency programs so that may be a good start.

Talk is cheap. "More rigorous standards" is sufficiently vague as to mean nothing. Her attempts last year met with dramatic pushback such that most were never implemented. ACGME is another large ship that takes years to move in any particular direction.

 

[2014XRT]

I believe that she will do anything she can from letting a new program open, which is better than anything we had before.

 

[scarbrtj]

The data that will "prove" dramatic oversupply is exactly what we're trying to avoid by acting now. This is a big ship and it takes at least 5 years to turn it. If you wait for the bottom to completely fall out, 5 years worth of good doctors are destined to suffer needlessly.

This is all the data I need to know there is a problem:
1. Residency positions have doubled in the past decade or so.
2. Treatment fractions have declined by 50% or more (if not eliminated completely) in the most common indications for radiation
3. Unaccredited fellowship positions (most of dubious merit) have dramatically increased over the past decade
4. Treatment supervision is no longer, in and of itself, an indication to hire in the vast majority of practices
5. Smart medical students have looked at 1-4 and (correctly, IMO) synthesized that this field is in real trouble and are actively avoiding

Why smart attending physicians can't synthesize the same is mind boggling.

This is setting aside threats to reimbursement, shifting practice models, increased competition for services (IR, immunotherapy). Just those 5 "data" points above tell the story. First step is admitting you have a problem. Just do it already. Clearly and definitively, so that you can begin working on solutions.

Sticky??

Suddenly, antitrust is no more a worry than supervision.

 

[2014XRT]

Suddenly, antitrust is no more a worry than supervision.

Good.

I have no problem that people have changed their minds or are trying to work around things.

we should care about solutions only.

 

[Chartreuse Wombat]

I believe that she will do anything she can from letting a new program open, which is better than anything we had before.

Believe away...Of course with the current pandemic not a lot of hospitals are keen to increase GME budget

 

[Mandelin Rain]

24 Prostate Brachy (LDR or HDR)
24 Tandem Based GYN
20 Cylinder Based GYN
30 Lung SBRT
30 Intracranial SRS/SBRT
45 H&N IMRT
0 Pediatrics (fellowship required)

Good start

 

[RadOncDoc21]

24 Prostate Brachy (LDR or HDR)
24 Tandem Based GYN
20 Cylinder Based GYN
30 Lung SBRT
30 Intracranial SRS/SBRT
45 H&N IMRT
0 Pediatrics (fellowship required)

Good start

Prostate brachy was challenging in my dept since the only group that did them was a private group affiliated with a urorads group.

We had a few docs that did them but they definitely only avg around 1-2 a month. I may have seen about 10 total during my training.

 

[Chartreuse Wombat]

24 Prostate Brachy (LDR or HDR)
24 Tandem Based GYN
20 Cylinder Based GYN
30 Lung SBRT
30 Intracranial SRS/SBRT
45 H&N IMRT
0 Pediatrics (fellowship required)

Good start

Good luck getting that past ACGME. The two questions posed for this sort of change:
1) What is the evidence to justify these numbers? Answer none but this SDN crew seems like they know what they are doing.
2) How many programs will be negatively impacted by these changes. Urr, we estimate 30-50%...
Never gonna happen

 

[medgator]

Good luck getting that past ACGME. The two questions posed for this sort of change:
1) What is the evidence to justify these numbers? Answer none but this SDN crew seems like they know what they are doing.
2) How many programs will be negatively impacted by these changes. Urr, we estimate 30-50%...
Never gonna happen

Could probably decrease brachy numbers and increase SBRT ones to make it more real world applicable. Would still help weed out many positions

 

[Mandelin Rain]

Where is the data that doing lap choles as part of a gen surg residency is needed?

This is why I think the problem needs to be clearly, and publicly stated so that people in charge can stop being obstructionist just to be obstructionist.

There are 48 months of rad onc residency. 24 cases of anything mean (on average) you're doing at least 1 case every other month, which is probably the minimum you should be doing higher risk procedures to maintain an adequate comfort level.

 

[yesmaster]

24 Prostate Brachy (LDR or HDR)
24 Tandem Based GYN
20 Cylinder Based GYN
30 Lung SBRT
30 Intracranial SRS/SBRT
45 H&N IMRT

There's something seriously wrong with your training program if you can't meet those minimums.

Each of those treatments is either curative or has a uniquely advantageous side effect profile.

If you compare us to the minimum case log requirements for ANY surgical specialty, ours are laughable. Literally a joke. For example, they all have detailed requirements by disease/anatomic site. Imagine if your board-certified surgeon had case logs as rigorous as ours. 450+ incisions required by graduation!

 

[Mandelin Rain]

450+ incisions required by graduation!

Could be all lipomas and PEGs.

 

[Chartreuse Wombat]

Where is the data that doing lap choles as part of a gen surg residency is needed?

This is why I think the problem needs to be clearly, and publicly stated so that people in charge can stop being obstructionist just to be obstructionist.

There are 48 months of rad onc residency. 24 cases of anything mean (on average) you're doing at least 1 case every other month, which is probably the minimum you should be doing higher risk procedures to maintain an adequate comfort level.

The major problem with this list is brachytherapy experience. Resident cases have been falling for more than a decade (especially insterstitial and prostate).

Resident-reported brachytherapy experience in ACGME-accredited radiation oncology training programs

To describe resident-reported experience in brachytherapy in Accreditation Council of Graduate Medical Education–accredited radiation oncology trainin…

www.sciencedirect.com

Prostate Brachytherapy Case Volumes by Academic and Nonacademic Practices: Implications for Future Residency Training

The use of prostate brachytherapy has continued to decline in the United States. We examined the national practice patterns of both academic and nonac…

www.sciencedirect.com

Resident experience in brachytherapy: An analysis of Accreditation Council for Graduate Medical Education case logs for intracavitary and interstitial brachytherapy from 2007 to 2018

We sought to characterize temporal trends of radiation oncology resident–reported case experience with intracavitary brachytherapy (ICBT) and intersti…

www.sciencedirect.com

I am a prostate brachytherapist. I recieved NO TRAINING in residency (a long time ago); I learned along with many others in practice in the mid 1990's.

 

[RollTideRadOnc]

98% of radoncs don't do prostate brachy. is it really an essential part of residency? Ditch it as a requirement and make it a fellowship. Then you would get better trained practitioners who are passionate about it. That would be a better fellowship than 99% of the garbage out there.

 

[Gfunk6]

Why smart attending physicians can't synthesize the same is mind boggling.

Not mind boggling at all.

“It is difficult to get a man to understand something, when his salary depends on his not understanding it.”

- Upton Sinclair

 

[Mandelin Rain]

I would not advocate for spending a year of your life learning a single treatment for a single diagnosis.

If we want external beamists coming out of residency (which is a reasonable take, IMO), shorten Rad Onc residency by 1 year. Allow those interested to do research fellowships, or brachy fellowships, or peds fellowships, or proton fellowships. Just dispense with the sham.

 

[yesmaster]

I am a prostate brachytherapist. I recieved NO TRAINING in residency (a long time ago); I learned along with many others in practice in the mid 1990's.

98% of radoncs don't do prostate brachy. is it really an essential part of residency? Ditch it as a requirement and make it a fellowship.

I'm going to play devil's advocate and push back.

Unlike pediatrics, 98% of rad onc's don't do prostate brachytherapy, not because of rarity of disease, but because of lack of training. And economics. Lack of training is the cause, lack of prostate HDR/LDR in practice is the effect. Now, you're using lack of prostate HDR/LDR in practice, to justify that training isn't needed?

If we as a field determined that prostate brachytherapy is important and offers QOL or disease control benefits compared to VMAT or SBRT, it should be reflected in the training of radiation oncologists. If only we had some mechanism to ensure that residents got sufficient experience......

Plus no one wants to do fellowships. That's a non-starter.

 

[Chartreuse Wombat]

I'm going to play devil's advocate and push back.

Unlike pediatrics, 98% of rad onc's don't do prostate brachytherapy, not because of rarity of disease, but because of lack of training. And economics. Lack of training is the cause, lack of prostate HDR/LDR in practice is the effect. Now, you're using lack of prostate HDR/LDR in practice, to justify that training isn't needed?

If we as a field determined that prostate brachytherapy is important and offers QOL or disease control benefits compared to VMAT or SBRT, it should be reflected in the training of radiation oncologists. If only we had some mechanism to ensure that residents got sufficient experience......

Plus no one wants to do fellowships. That's a non-starter.

The question is whether prostate brachytherapy is essential. I do it but don't think it is essential. I do think that GYN brachytherapy is essential.

Before everyone sends me the ASCENDE-RT trial I am aware and I do use brachy as a boost in young, healthy high risk men but I inform them that there is no evidence of a survival benefit (although the trial is underpowered) and there is an increase in complications.

 

[2014XRT]

98% of radoncs don't do prostate brachy. is it really an essential part of residency? Ditch it as a requirement and make it a fellowship. Then you would get better trained practitioners who are passionate about it. That would be a better fellowship than 99% of the garbage out there.

I think it’s an Important barrier of entry. If you can’t provide internal cases or support your residents for away rotations to get numbers, you have no business existing. The point of residenxy is to get exposure and comfort for broad general practice

 

[Mandelin Rain]

I think it’s an Important barrier of entry. If you can’t provide internal cases or support your residents for away rotations to get numbers, you have no business existing. The point of residenxy is to get exposure and comfort for broad general practice

I agree so much. A residency program can't be allowed to use the argument, "Well, we don't see prostate cancer 'cause there's a urorad in town."

That holds no water. Shut it down.

 

[Mandelin Rain]

Biochemical control is disease control in prostate cancer, but whatever, that's fine, your point is well-taken.

Yeah. I read that and thought, "Man, I treated a lot of guys to 79.2Gy based on biochemical control, even if more toxic."

 

[RollTideRadOnc]

If you really want to shut down half of all residencies, then focus on in house pediatric case hold. A much easier target than brachytherapy

 

[RollTideRadOnc]

A few points worth noting. First, the toxicity of going from 70 to 78 Gy is peanuts compared to the potential toxicity of adding brachy. For those who have been practicing long enough with these pts, this should be clear.

Second, going from 70 to 78 does actually decrease mets. Unlike best evidence for brachy, which does not show this.

https://www.redjournal.org/article/S0360-3016(19)30289-5/abstract

https://www.redjournal.org/article/S0360-3016(19)30619-4/fulltext

Mets is a real end pont.

 

[Chartreuse Wombat]

Perhaps one of the good things that will result from the pandemic is that GME budgets will shrink as the large margin cases are pushed off.

It is just naive to think that the ACGME will change requirements to shut half of the programs down.

 

[Mandelin Rain]

Perhaps one of the good things that will result from the pandemic is that GME budgets will shrink as the large margin cases are pushed off.

It is just naive to think that the ACGME will change requirements to shut half of the programs down.

What they "will", and what they "should" do, are certainly different things.

 

[tomballunger]

Case logging in other fields:
I just couldn't help myself.... urology

I just couldn't help myself.... gen surg

And just because many private practice urologists will never do urinary diversions w bowel in practice doesn't mean there shouldn't be an acgme minimum (there is a minimum). or a private practice gen surgeon who will never touch peds, doesn't mean there shouldn't be a minimum either.

 

[medgator]

Plus no one wants to do fellowships. That's a non-starter.

That's been standard in rads for several years. And they are all acgme accredited. IR was a fellowship before it became its own specialty.

There's a way to do this properly but the rad onc community both academic and some larger pp have been exploiting the fellowship loophole in rad onc for too long.

 

[FreeRT]

80% academics including one that is pretty aloof on job market and expansion concerns. I wish they had taken simul up on their offer, although maybe they were striving to represent where most of the jobs are these days....

Agree with the imbalance. Maybe if people here could participate and then give the same feedback to the organizers that we're seeing here, then future programs can reflect your needs. To make your voice heard, get involved and speak up in these platforms.

 

[Chartreuse Wombat]

As scarb has pointed out the % of positions labeled "academic" has been increasing over the years. ABout 50/50 if memory serves from last survey.

 

[thesauce]

To put some perspective for ARS, the science and data quality are critical if you are competing for a resident essay award and travel grant--these are generous awards. Agree it's not as important if you're just accepted for a poster.

Easy to demonize RSNA since it's primary DR and in Chicago every year when temperatures drop. I went just because I had family there. Nevertheless, 2 former ASTRO presidents were also president of RSNA (David Hussey and Sarah Donaldson) and there are RO tracks and more opportunities for oral presentations and moderating a session. The exhibit hall rocks with a ton of vendors and the atmosphere is pretty festive. So although the RO attendance is small, it again gives you a better chance to get to know your RO colleagues better and party with DR's. Unlike ACR which is heavy on health policy and advocacy, RSNA is more research oriented.

ACRO was Luther Brady's protest against the ACR (although he remained an active ACR member his whole life and attended their annual mtgs until his passing). It was also formed to address the lack of ASTRO's involvement in health policy, since ASTRO was heavily research oriented (of course, that's changed and ASTRO's come a long way). ACRO has stronger private practice membership and has provided lots of resources in terms of billing, coding, and policy (Ron DiGiamo of RevenueCycle is there every year and is a major supporter). Again, you get a smaller, more intimate meeting with the ability to network more intimately. They also offer travel grants to residents--based on the quality of the research. Nevertheless, the leadership within ACRO has been heavy on 21st C RO's, the reason why the mtgs are always in Florida (to serve all the 21st C practices on the Eastern seaboard. I miss the days when they would have mtgs on the west coast (2007 in Coronado Beach was awesome).

I would take San Antonio any day over an ASTRO mtg in New England. Boston in 2012 was a total disaster. A fall mtg, esp Oct, runs too close to winter storms in the NE. Both times I was in San Antonio, everything was within walking or Lime scooter distance. Food was great and there were plenty of venues outside the Riverwalk--if you're afraid of falling in. Hotel rooms were very affordable. I spent a fortune Ubering everywhere b/c everything in Chicago is so spread out. In any case, I wouldn't mind having a meeting in Denver (it's been a while--2005), New Orleans (1999?), Houston, Dallas, Las Vegas, Seattle--Eastern Standard Time is tough to adjust to. Los Angeles was a blast, and I'm always game for San Diego--easy to adjust to west coast time.

Sorry for the ignorance but what is ARS? When I search that, there are several. Most are Rhinology. There’s an ARRS which is radiology/radonc related. Just checking

 

[deleted774703]

Sorry for the ignorance but what is ARS? When I search that, there are several. Most are Rhinology. There’s an ARRS which is radiology/radonc related. Just checking

American radium society

 

[2014XRT]

Is Simul trolling?

There literally actually is one rep from SERO and one from ROC

 

[medgator]

Is Simul trolling?

There literally actually is one rep from SERO and one from ROC

The guy from roc is nw faculty

 

[2014XRT]

The guy from roc is nw faculty

barely. in so much as ROC's proton center has Northwestern's name on it as an affiliation

no doubt that Vinai Gondi is famous and is probably the most 'academic' guy you're going to meet in PP given that he's PI on multiple national trials, but make no mistake the guy is private practice as they come.

 

[CaesarRO]

Is Simul trolling?

There literally actually is one rep from SERO and one from ROC

The linked tweet was from a few weeks ago. They just announced the panel yesterday

 

[2014XRT]

The linked tweet was from a few weeks ago. They just announced the panel yesterday

My apologies. I quite like Simul Parikh. This makes more sense

 

[Lamount]

24 Prostate Brachy (LDR or HDR)
24 Tandem Based GYN
20 Cylinder Based GYN
30 Lung SBRT
30 Intracranial SRS/SBRT
45 H&N IMRT
0 Pediatrics (fellowship required)

Good start

Should the 68 brachy procedures be required because it is likely that this knowledge will hope most of our practices, or is this meant to weed out programs?

I would be curious to find out how many practicing rad oncs routinely do brachy. I know that may prove your point to some extent, but I also think brachy is a little more idiosyncratic in practice than your proposed numbers would indicate. Is your point that we should all be doing more of it?

 

[DukeNukem]

barely. in so much as ROC's proton center has Northwestern's name on it as an affiliation

no doubt that Vinai Gondi is famous and is probably the most 'academic' guy you're going to meet in PP given that he's PI on multiple national trials, but make no mistake the guy is private practice as they come.

Really? Nobody remembers this thread?

Private practice opens fellowship

http://careers.astro.org/jobs/8295644/chicago-proton-therapy-and-advanced-radiation-oncology-fellowship Granted this is a big, well-regarded private practice and surely they went through all the loopholes of ACGME. But . . . damn.

forums.studentdoctor.net

Why should academia have all the cheap labor!?

 

[Mandelin Rain]

Should the 68 brachy procedures be required because it is likely that this knowledge will hope most of our practices, or is this meant to weed out programs? They are the only two GYN cancers you’ll see any volume of.

I would be curious to find out how many practicing rad oncs routinely do brachy. I know that may prove your point to some extent, but I also think brachy is a little more idiosyncratic in practice than your proposed numbers would indicate. Is your point that we should all be doing more of it?

I mean depending on the fractionation, it’s 5 cervix patients and 7 endometrial patients in 4 years. That should be a given, no brainer.

24 prostates is tougher, buts it’s the most common non skin cancer in men. I’m bidding 6 brachy cases a year. Lower it to 20 or 16, whatever. I probably did 5 or 6 in residency, and even that was a stretch (running in, in the middle of a case or something). Obviously not enough to come out feeling confident to do it solo. I saw more in a day as a med student. It’s a standard of care for cancer. Should we expect after 4 years of sole radiation focus to be able to offer established, evidence based, long standing standard of care treatments?

Or should we allow “that’s too hard on residency programs” to be a valid excuse?

lot of talk about dedication of applicants. Much less about dedication of educators.

 

[RickyScott]

Really? Nobody remembers this thread?

Private practice opens fellowship

http://careers.astro.org/jobs/8295644/chicago-proton-therapy-and-advanced-radiation-oncology-fellowship Granted this is a big, well-regarded private practice and surely they went through all the loopholes of ACGME. But . . . damn.

forums.studentdoctor.net

Why should academia have all the cheap labor!?

Was about to bring that up

 

[2014XRT]

Yep just as private practice as it gets. Cheap labor. Economics, baby.

don’t hate the player, hate the game.

 

[Lamount]

I mean depending on the fractionation, it’s 5 cervix patients and 7 endometrial patients in 4 years.

Ah... i totally forgot that you got credit for each fraction for Gyn.

 

[CaesarRO]

The more I see, the more I like the ACR.

 

[CptCrunch]

'direct OR of OR radiation OR oncology OR clinical OR service OR chair OR of OR academic OR dept. OR radiation OR oncology OR STATECODE:"NY"' Jobs | ASTRO Radiation Oncology Career Center

2,875 'direct OR of OR radiation OR oncology OR clinical OR service OR chair OR of OR academic OR dept. OR radiation OR oncology OR STATECODE:

careers.astro.org

"It is the long-term aspiration of the department to develop a residency program in radiation oncology. "

 

[thecarbonionangle]

'direct OR of OR radiation OR oncology OR clinical OR service OR chair OR of OR academic OR dept. OR radiation OR oncology OR STATECODE:"NY"' Jobs | ASTRO Radiation Oncology Career Center

2,875 'direct OR of OR radiation OR oncology OR clinical OR service OR chair OR of OR academic OR dept. OR radiation OR oncology OR STATECODE:

careers.astro.org

"It is the long-term aspiration of the department to develop a residency program in radiation oncology. "

sounds like get ready for another NY program soon to fill the great need in that state. We commend NY medical college for stepping up

 

[fiji128]

sounds like get ready for another NY program soon to fill the great need in that state. We comment NY medical college for stepping up

There are no radiation oncology residency programs in Westchester County. No reason at all why those docs should be forced to do their own contours and dictations.

 

[thecarbonionangle]

There are no radiation oncology residency programs in Westchester County. No reason at all why those docs should be forced to do their own contours and dictations.

why have a PA who demands 100k, 8-5, 401k and other benefits when you have a resident lukewarm body for 50k with minimal benefits and he doesn’t complain or you’ll fire him. ‘Tis a treat to be a rad onc these days. We are gonna feast!

 

[thompa]

There are no radiation oncology residency programs in Westchester County. No reason at all why those docs should be forced to do their own contours and dictations.

I love a good snark as much as the next guy. However, I happen to know these people.

Some perspective. I trained at NYMC and it's an excellent medical school. Did my home rotation with Dr. Moorthy at Westchester Medical Center. Great guy with a real passion for education. Edward Halperin is also the Chancellor at NYMC and still sees patients. I remember during the handful of weeks I was there I "logged" like 4 pedatric cases, including a bone marrow transplant. Also did a total skin electon treatment (not a ped case). They did a lot of HDR brachy too. Educational quality was pretty high.

They actually used to have a residency program a while back. It closed down a while ago and I never got the inside scoop on why. But I can tell you he was talking about trying to re-open it back when I was rotating through the department.

There's still no reason to open any more residency programs in this country. I think we're all in agreement on that point. For WMC specifcally though, I don't think it's laziness or a desire for cheap labor. There are multiple dedicated educators there and I think that's their motivation.

Carry on with your snarking.