RO Job? 58% chance it will be "low volume"

[TheWallnerus]

I have been spending the past hour looking at the #ESTRO2021 Twitter discussions regarding less and less use of XRT in cancer management.

I suspect the definition of "low volume" will rapidly change...

In this graph, definition of low volume is the lower quartile of number of centers treating the lower quartile number of patients. So in the graph what you're seeing is that 772 centers treat 25% of America's (definitive dx's, I think) patients. And there are 97 busy centers that treat 25% of America's patients. And in the middle 462 centers treat the remaining 50% of patients. (I don't know if the author included every center in America but this is probably a pretty good sample obv.)

If you define low volume this way, that definition wouldn't change. You would just have more centers entering the bottom quartile and fewer in the upper quartiles as radiation therapy patient volume becomes scarcer. This could in theory lead to the bottom centers "dying off" and the graph getting less skewed. As Trump said, we will see.

---

Members don't see this ad.

 

[communitydoc13]

and the docs who work in these centers volume?

A very significant confounder is any radiation group that serves multiple sites. There are many of these groups. Any given site may be quite low volume, but in aggregate, the practice may have a reasonable volume. (I absolutely agree that we don't need any more radoncs BTW.)

 

[RadOncDoc21]

There are some places that function well with “low volumes” if the expenses are low. I’ve seen a place with an old Linac, 7-10 patients on treatment with like 5 employees outlast the bigger groups in the area.

Of course, as the volumes continue to decrease, fractions and reimbursements, even these places are in trouble.

 

[TheWallnerus]

A very significant confounder is any radiation group that serves multiple sites. There are many of these groups. Any given site may be quite low volume, but in aggregate, the practice may have a reasonable volume. (I absolutely agree that we don't need any more radoncs BTW.)

Would it be a confounder. In my mind I picture a group of 5 docs covering 5-6 centers. I don't picture 5 docs covering 2-3 centers brainfart 2-3 docs covering 5 centers. That is to say, we will still see >50% of US rad oncs treating less than 200 patients per year (per RO).

I have had a lot of time to think about this, and the Equations of Rad Onc Workforce math decocts to a simple numerator and denominator which is ~1 million patients, ~5500 rad oncs. Let's just call that 200 patients per rad onc. Now in the mind's eye, one pictures a normal distribution about this 200 average and top of a bell curve with fading off distributions left and right of 200. So I am cheating you a bit: 200 is the average but it's a misleading stat. Why? We now have ABUNDANT evidence that work and pay and patients in rad onc are very Pareto.

Here is CMS payment distribution per RO:

The average payment per RO is $327K but the median is $147K. So 50% of ROs get $147K or less per year from CMS but the average payment per RO is $327K.

In Pareto distributions, averages are far away from medians.

The graph above again.

I don't know the average exactly but I would guess the average patients per facility is >200/year.

BUT... the majority (ie >50%) of centers are seeing <200 patients a year.

 

[communitydoc13]

Would it be a confounder.

I think it's a confounder because the data may not be reflected in true practice experience and certainly the individual practitioner's experience is hidden by institutional size in this data. A large institution (MDACC for example) is going to qualify as high volume center even if an attending sees 3 new cases per week. In the community, many practices don't have a 1:1 ratio of docs to sites and 3 docs/2 sites or some other odd ratio is common. Often there is a site that would qualify as moderate volume as well as a site that is low volume. (Even a low volume site can be quite profitable for a small hospital collecting technical fees).

There are 2 issues: low volume docs and low volume centers. This particular data references low volume centers (and the tweet made some very weak inferences regarding center size and outcomes, super weak sauce when you think of the patient selection bias). I think the CMS data may actually reflect lots of academic docs in centers that are large actually seeing very few CMS patients per person.

 

[TheWallnerus]

In the community, many practices don't have a 1:1 ratio of docs to sites and 3 docs/2 sites or some other odd ratio is common... I think the CMS data may actually reflect lots of academic docs in centers that are large actually seeing very few CMS patients per person.

Agree 100.

But the "community" is likely to be these majority of lowest 25%ile volume centers. So 3 MDs per 2 centers means the patient numbers per MD are even worse than the patient numbers per center on this graph which are pretty bad in the "community" already.

And for sure a lot of academics are not seeing many patients.

Given the two things above, World of Rad Onc... why do we keep pumping out ever increasing numbers of rad oncs?

 

[TheWallnerus]

What metrics did they use to define volume and come up with the groups?

Late response.

They looked at volume of patients treated per center and then ranked center volume in quartiles. The number of centers treating the lowest quartile makes up 58% of all centers nationally. Almost 2/3 of RT centers nationally handle only 1/4 of America’s RT patient volume is what the graph appears to say.

 

[RickyScott]

Late response.

They looked at volume of patients treated per center and then ranked center volume in quartiles. The number of centers treating the lowest quartile makes up 58% of all centers nationally. Almost 2/3 of RT centers nationally handle only 1/4 of America’s RT patient volume is what the graph appears to say.

consolidation of centers would absolutely devastate the job market. Even in academic departments, loads of centers with 10-15 on beam that are still profitable because of price gouging, but that will won’t last much longer, especially in apm zips

 

[medgator]

consolidation of centers would absolutely devastate the job market.

Will be facilitated by APM soon enough

 

[TheWallnerus]

Will be facilitated by APM soon enough

Alarmingly and amazingly the APM if you look at the map appears to inordinately pick on these low volume centers.

 

[SneakyBooger]

Alarmingly and amazingly the APM if you look at the map appears to inordinately pick on these low volume centers.

What happens to the equity argument when that occurs? Or does it really just not matter?

 

[DireMoose]

Translation:
I got another line on my CV, come get you one, then I can get another!

This is when I wish there was some type of penalty for publishing superfluous research. Not a harsh penalty, but some type of down-voting that could manifest in the replacement of the h-index or something.

 

[medgator]

Translation:
I got another line on my CV, come get you one, then I can get another!

This is when I wish there was some type of penalty for publishing superfluous research. Not a harsh penalty, but some type of down-voting that could manifest in the replacement of the h-index or something.

At least he isn't getting that residency at Penn state he wanted to before

 

[elementaryschooleconomics]

At least he isn't getting that residency at Penn state he wanted to before

Don't worry, forces are still at work at PSU trying to make a residency happen. I would guess we see one there within 5 years, but hopefully I'm wrong about that and it's all talk.

 

[evilbooyaa]

i got 2 NPs and 4-5 dosimetrists...so no note writing or normal structure contouring if that matters

You have all that, to.... yourself? My goodness if so. Do they also carry you around from room to room?

That sounds like a practice that needs at least 1 more physician.

 

[Radonky]

Don't worry, forces are still at work at PSU trying to make a residency happen. I would guess we see one there within 5 years, but hopefully I'm wrong about that and it's all talk.

Zoarsky left to go to Chase, hope that set residency dreams back permanently

Edit - Case western folks. He would probably do well in banking though!

 

[Chartreuse Wombat]

Zoarsky left to go to Chase, hope that set residency dreams back permanently

The credit card company? or do you mean FCCC?

 

[brushbeamscanning]

The credit card company? or do you mean FCCC?

I think he typo'd Case Western. Spratt said something to that effect on twitter.

 

[Radonky]

I think he typo'd Case Western. Spratt said something to that effect on twitter.

Yeah Case Western - edited my post

 

[hal9k]

You have all that, to.... yourself? My goodness if so. Do they also carry you around from room to room?

That sounds like a practice that needs at least 1 more physician.

of course there is 1 more....rad onc life cannot be that good

 

[RO28]

A very significant confounder is any radiation group that serves multiple sites. There are many of these groups. Any given site may be quite low volume, but in aggregate, the practice may have a reasonable volume. (I absolutely agree that we don't need any more radoncs BTW.)

This is me. I’m newer to the group (on year 3) with three sites covered by 4 rad oncs. We don’t often cover the other sites because of geographic distance but holy hell as the low volume person I am BORED! And constantly anxious about generating enough volume.

 

[elementaryschooleconomics]

This is me. I’m newer to the group (on year 3) with three sites covered by 4 rad oncs. We don’t often cover the other sites because of geographic distance but holy hell as the low volume person I am BORED! And constantly anxious about generating enough volume.

My group is like this too.

Fortunately, I'm not at the low volume site and therefore not bored, but the low volume site serves a community that would otherwise have a long drive to the nearest RadOnc if the low volume site didn't exist.

 

[RO28]

My group is like this too.

Fortunately, I'm not at the low volume site and therefore not bored, but the low volume site serves a community that would otherwise have a long drive to the nearest RadOnc if the low volume site didn't exist.

Yeah, I do tell myself that like weekly. We’re outside of a major metropolitan area, so mileage wise we’re not far, but traffic wise we’re so much more convenient. That being said…I’m starting to explore leadership roles or something cuz I don’t have enough to do many days. Don’t get me wrong, I like leaving early, but also don’t want to make myself dispensable.

 

[TheWallnerus]

This is me. I’m newer to the group (on year 3) with three sites covered by 4 rad oncs. We don’t often cover the other sites because of geographic distance but holy hell as the low volume person I am BORED! And constantly anxious about generating enough volume.

Most RT centers are not that busy with the most common indication for RT in the U.S.