ROCR

[RadOncDoc21]

Reminds me of the Spratt era when he was on here.

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[Fpg1245]

Reminds me of the Spratt era when he was on here.

He’s been absent since that time. Big talk/no actual anything.

 

[elementaryschooleconomics]

Big talk/no actual anything.

 

[thecarbonionangle]

He’s been absent since that time. Big talk/no actual anything.

The dude turned out to be just another cog wheel turner, meat moving, warm body loving SOAPER. The field had plenty of these folk. SAD

 

[DebtRising]

Give Spratt credit for coming on an engaging. Give anyone credit. But in the end he managed his residency program just like the old guard have, benefiting themselves without providing a need to society and certainly not helping those going into the field. Predatory on human capital. Bummed me out, he’s a cool dude and there are institutional pressures, but made a lot of the engagement hollow. Still points for trying.

 

[NotMattSpraker]

Give Spratt credit for coming on an engaging. Give anyone credit. But in the end he managed his residency program just like the old guard have, benefiting themselves without providing a need to society and certainly not helping those going into the field. Predatory on human capital. Bummed me out, he’s a cool dude and there are institutional pressures, but made a lot of the engagement hollow. Still points for trying.

It seems like he’s running a strong department, caveat this is based on Twitter and a few personal convos. I do not know him at all.

I agree shutting down a residency would be better, but it is probably not realistic to be his unilateral decision, and it would hinder the education career of at least one faculty who is doing a lot of good. If he was the only one to do it, it would not fix the oversupply.

It’s early, but he seems to treat people really well and seems to support their passions. He also seems to advocate for the department and faculty with the hospitals and med school, which is really important.

I wish most chairs were like him. I bet ASTRO would be better and it would be easier for people like Sameer to make change.

IMO a single young rad onc would have to be a unicorn to change culture.

 

[sirspamalot]

"We're really very sorry."... "Sorry."

-last ASTRO President
-next ASTRO President?

 

[Rad Onc SK]

It seems like he’s running a strong department, caveat this is based on Twitter and a few personal convos. I do not know him at all.

I agree shutting down a residency would be better, but it is probably not realistic to be his unilateral decision, and it would hinder the education career of at least one faculty who is doing a lot of good. If he was the only one to do it, it would not fix the oversupply.

It’s early, but he seems to treat people really well and seems to support their passions. He also seems to advocate for the department and faculty with the hospitals and med school, which is really important.

I wish most chairs were like him. I bet ASTRO would be better and it would be easier for people like Sameer to make change.

IMO a single young rad onc would have to be a unicorn to change culture.

In my opinion, ASTRO is in good shape. It’s lacking a few things. Every organization does. That’s the point of bringing different voices into leader ship tracks. Different voices can raise different views. I’ve been open about this.

I think the single biggest thing I am seeing is the lack of private practice Small business owners entering committee membership. That’s the way to go through the ranks and become a board member at some point. This allows the board to have discussions which can be shaped in viewed differently.

In the past few weeks, I have spoken to at least 50 different stakeholders from every aspect of the Radiation Oncology community. Many people are not ASTRO members. In many ways, I’m more interested in talking to them. I want to find out why they’re not members.

Most of these folks are in private practice, but not all

The PP small business owners who are ASTRO members, hopefully, are going to be on committees sooner rather than later. This process will open up in April. This past cycle, I was able to get a few on to health policy committees. I think they will be terrific and give a different perspective. They are all practicing in rural parts of the country and are small business owners. These folks have a perspective that’s very hard to attain without actually practicing in that environment. Their big issue is time (in terms of committing to ASTRo) but they are going to give it a go. I hope to add more private practice doctors next year, if there is an interest from this segment of our community.

In this scenario, the short term measure of success will be if we can get more private practice Doctors engaged in the committee structure at ASTRO. The long-term measure, 10 years or so, will be if we have greater representation at Committee leadership or board levels of ASTRO.

I haven’t been on the board for five years. I’m not on the board right now. That’s going to start in October at the annual meeting.

The staff and the board are good people. They do listen better than some (many?) people in SDN give them credit for. What makes it hard for them is that there is a lot of noise on the social media sites. From what I have seen, 90% of the posters are rational and raise. Good ideas. There’s definitely a 10% that I will never reach.

I’m spending time here and also listening to different stake holders. I guess you can say I’m on a listening tour for the next couple months. I have my own ideas, but I want to see if they are consistent with a wide variety of people in our community. So far, I think they are. That will help me bring this perspective to the board.

In my first four years on the board (2014-18), I was able to make some changes which we still see today. I was a reason the PRO track at ASTRO annual was created. I want to make it clear that I was not the only person on this. It took a team. PRO track originated from a discussion at the board level about engagement of the private practice community at ASTRO annual meeting. I think there was a lack of recognition that coverage in the clinic, especially a big deal back then, prevented many private practice doctors from attending ASTRO. At that time, David Beyer and me had meaningful small practice experience. Both of us said that coverage prevented Attendance during the week. This led to us to talking about a weekend course that would hit the highlights. From there, the PRO track took off, and I think this has been a success. That’s just one example of a successful outcome due to having diverse views and experiences on the board.

 

[Radonky]

Spratt has some online persona quirks but overall is a phenomenal chair and strong resident advocate. He changed UH for the better, recruited great talent, and published meaningful work. For academica, he offers competitive salaries (far better than his local competitor) and supports junior faculty. As far as chairs go, he is one of the best. I don't work for UH but highly considered it, and have friends in his department.

 

[Mandelin Rain]

I’d love to hear from the folks in Cigna MA pilot

I’m very curious how their case rates compare vs ROCR.

Does anyone here know the answer to that question?

This is a fair question, and it's possible that ROCR will be used as a framework for such models moving forward, but ultimately I think this is a mere distraction. I don't see it as a direct comparison, nor broadly applicable to the wider insurance industry.

1. Most obviously, ROCR excludes MA and traditional commercial plans. As far as I can tell, if ROCR passes, nothing prevents such an MA pilot from moving forward synchronously.
2. MA plans and traditional commercial plans carry different risk and incentives for the insurers. MA plans have full goal of cost containment, which may not be the case for traditional products.
3. At least a couple obvious costs needing containment being 1. monopolistic hospital pricing (PPSE centers being most extreme example) and 2. high-cost, low-value care (protons, adaptive, etc...) are of course exempted from ROCR. As such, I doubt we'll see MA plan adopt it.

 

[thecarbonionangle]

just want to make a general point. Multiple things can be true at same time. What is certain is for those who hoped for a change in SOAP with new “leadership” that certainly did not happen. If we mostly agree that some places must be shut down, then some are going to have to close. This happened in the 90s. The “good people” at these places will continue to have a career and treat patients. If the argument is that a certain attending “needs” residents to have a career due to education passion, then go elsewhere. Residencies are supposed to educate people not there for careerism. The market has spoken and these places go unfilled for a reason. This is why i don’t think any places will be shut down because there is always a reason not to (someone i know is good there, my friend works there, people will be hurt, etc). Ok ok then let’s do nothing then, and stop talking about it.

 

[deleted1111261]

Carbon right. Everyone is right

We have “tragedy of the commons” , zero skin in the game and inverse incentives to grow programs.

There is no stomach to do the right thing.

 

[NotMattSpraker]

Carbon right. Everyone is right

We have “tragedy of the commons” , zero skin in the game and inverse incentives to grow programs.

There is no stomach to do the right thing.

I agree. I was just trying to say that some orgs deserve a residency more than others.

But Carbon is totally right. None of it matters if everyone is just going to hide behind anti-trust laws to avoid having an uncomfortable conversation with, for example, an ASTRO president who keeps SOAPing in to their program.

Maybe that's an unprofessional thing to say though

 

[RickyScott]

I agree. I was just trying to say that some orgs deserve a residency more than others.

But Carbon is totally right. None of it matters if everyone is just going to hide behind anti-trust laws to avoid having an uncomfortable conversation with, for example, an ASTRO president who keeps SOAPing in to their program.

Maybe that's an unprofessional thing to say though

Just listened to the podcast from 2 weeks ago. So ASTRO/SCAROP surveys salaries and then ASTRO only sells this information to chairs (for collusion), and refuses to sell it to any other members. Scarop/chairs represent a tiny group within ASTRO but hire half of graduating residents. How does ASTRO claim to represent the members interests of newly graduated residents when they are acting directly against them, putting the greed of a small cabal above the interests of everyone else? How is this not blatantly contradicting their mission. Some members are very much more equal than others? would any other specialty society behave this way?

 

[deleted1168505]

Radiation Oncology community. Many people are not ASTRO members. In many ways, I’m more interested in talking to them. I want to find out why they’re not members.

Please scroll back through the past few pages.

This was explicitly addressed.

The number one issue in the opinion of myself and many community radiation oncologist is SEVERE overtraining in terms of new rad oncs looking for work every July leading to oversupply in many areas and significantly reduced bargaining power with health systems threatening physician autonomy and ability of health systems to directly employ more and more of us while paying out less and less of the PC collected for our services. Along with this, the overtraining is resulting in the production of physicians with aptitude and/or personality limitations that precluded them from training in other specialized fields with higher barriers to entry, which threatens the reputation of our profession and the safety of our patients.

To date, we have seen ASTRO either deny or ignore this problem.

 

[RadOncDoc21]

You’re not going to get a commitment from him or anybody on the ASTRO bandwagon. Change isn’t going to happen.

 

[deleted1168505]

You’re not going to get a commitment from him or anybody on the ASTRO bandwagon. Change isn’t going to happen.

The first step to fixing a problem is admitting that you have a problem.

Ask any recovered alcoholic. ASTRO is deep in the "9 beers a night is not a problem if they are light beers" denial phase.

 

[communitydoc13]

Very important for prospective radoncs to recognize that this angst among community radoncs developed between 2016 and the present time, a period when national demographics are propping up patient numbers. Even SK acknowledges impending demographic concerns. In 2040, the youngest boomer will be 80. Gen-X is small.

You won’t be able to prop up your treatment numbers with 75 year olds with intermediate risk prostate cancer discovered on MRI fusion biopsy anymore.

Either we transition to clinical oncologists or we become so much less.

If they eliminate carve outs on ROCR, I will support, rejoin ASTRO and pursue opportunities within the organization to try and make this happen.

 

[deleted1168505]

If they eliminate carve outs on ROCR, I will support, rejoin ASTRO and pursue opportunities within the organization to try and make this happen.

Every proton center would instantly become insolvent. You wouldn't want that, would you?

 

[communitydoc13]

Every proton center would instantly become insolvent. You wouldn't want that, would you?

Even today, protons should be for research and some kids (although I think parent's should still get consents discussing the specific risks of protons relative to their children's health).

4 national centers are fine. The rest can go away.

 

[yesmaster]

ASTRO benefits from representation by small business owners but more broadly, from representation by young radiation oncologists (less than 5-10 years from board certification).

A middle or late career small business owner can frankly ride off into the sunset if things go south with demographics or reimbursements or indications (PROSPECT, neo-aegis, etc).

Radiation oncologists skew young — thanks overtraining!! — but the folks representing us are in their golden years. Our interests are not aligned, particularly when it comes to the job market.

Can anyone run for ASTRO president or do you have to be preselected by an inner circle? Not this year but in the past, ASTRO president seemed to be some kind of retirement sendoff/celebration-of-life rather than somebody with a real vision for a specialty going through a lot of turmoil, mostly self inflicted.

 

[Mandelin Rain]

Even today, protons should be for research and some kids (although I think parent's should still get consents discussing the specific risks of protons relative to their children's health).

4 national centers are fine. The rest can go away.

EDIT: Not many Wu Tang fans on here.

 

[DireMoose]

Please scroll back through the past few pages.

This was explicitly addressed.

The number one issue in the opinion of myself and many community radiation oncologist is SEVERE overtraining in terms of new rad oncs looking for work every July leading to oversupply in many areas and significantly reduced bargaining power with health systems threatening physician autonomy and ability of health systems to directly employ more and more of us while paying out less and less of the PC collected for our services. Along with this, the overtraining is resulting in the production of physicians with aptitude and/or personality limitations that precluded them from training in other specialized fields with higher barriers to entry, which threatens the reputation of our profession and the safety of our patients.

To date, we have seen ASTRO either deny or ignore this problem.

This needs to remain the focus. There needs to be a systematic approach to break down the barriers that ASTRO hides behind to avoid addressing this.

Independent third party anti trust lawyer sounds like a great place to start. ASTRO isn’t going to do it. Perhaps that could be sponsored by ACRO? Spend a few thousand, get an expert anti trust opinion on “job market influence of professional societies. Put that barrier out of the way. Check. On to the next one. I’d be ok with my ACRO dues going to support this.

 

[CaesarRO]

As far as admitting the problem out loud, I think Dr. Eichler made a first step in 2021 on the ASTRO blog

Since that time, there has been little follow through and we had the workforce study put out with the problems noted by The Accelerator's Podcast and out.of.the.basement Podcast.

ASTRO has maintained that they aren't in control of residency spots and Neha Vapiwala has done a lot of work on the RRC/ACGME front to try to make it harder for new programs to open.

All that said, I think ASTRO underestimates the ability of "name and shame" to work. If ASTRO highlights the concerns, voices those concerns, and makes the academic chairs understand that it's frowned upon to grow and laudable to shrink in the current environment, I think that'd go a long way from where we are today... even if ASTRO can't directly shut programs down.

 

[RickyScott]

As far as admitting the problem out loud, I think Dr. Eichler made a first step in 2021 on the ASTRO blog
View attachment 374565

Since that time, there has been little follow through and we had the workforce study put out with the problems noted by The Accelerator's Podcast and out.of.the.basement Podcast.

ASTRO has maintained that they aren't in control of residency spots and Neha Vapiwala has done a lot of work on the RRC/ACGME front to try to make it harder for new programs to open.

All that said, I think ASTRO underestimates the ability of "name and shame" to work. If ASTRO highlights the concerns, voices those concerns, and makes the academic chairs understand that it's frowned upon to grow and laudable to shrink in the current environment, I think that'd go a long way from where we are today... even if ASTRO can't directly shut programs down.

They can certainly officially caution medical students about the risks. Wouldn’t that just be basic decency?

 

[NotMattSpraker]

They can certainly officially caution medical students about the risks. Wouldn’t that just be basic decency?

Its good to remember that for a lot of individuals it is a basic calculation, deciding whether saying/advocating for the important and true thing is worth taking on that professional risk.

This is a small field with some powerful vindictive people. We all know it.

ASTROs main goal is to grow the membership and enrolling trainees is an important strategy for medical societies. There is a reason you never see McDonald's out there telling people about the importance of a healthy diet.

 

[RickyScott]

Its good to remember that for a lot of individuals it is a basic calculation, deciding whether saying/advocating for the important and true thing is worth taking on that professional risk.

This is a small field with some powerful vindictive people. We all know it.

ASTROs main goal is to grow the membership and enrolling trainees is an important strategy for medical societies. There is a reason you never see McDonald's out there telling people about the importance of a healthy diet.

wanted to touch on your experience on Astro committees you mentioned in the podcast. I once overhead a senior radonc basically boasting to a newbie about being a senior member on some sort of committee and implying that if the newbie plays his cards right, he too could one day rub shoulders with astro movers and shakers. The Astro committee somehow confered elitism and exclusivity in his mind.

Striking contrast to how most of us view serving on hospital committees- irb, credentialing, cancer, radiation safety etc.

 

[NotMattSpraker]

wanted to touch on your experience on Astro committees you mentioned in the podcast. I once overhead a senior radonc basically boasting to a newbie about being a senior member on some sort of committee and implying that if the newbie plays his cards right, he too could one day rub shoulders with astro movers and shakers. The Astro committee somehow confered elitism and exclusivity in his mind.

Striking contrast to how most of us view serving on hospital committees- irb, credentialing, cancer, radiation safety etc.

Weird take by that senior rad onc haha. This idea that you "progress" through service is also what was told to me, and that contributed to me scaling back my involvement. That whole hierarchy progression waiting in line for the throne is not for me.

I serve on a hospital committee and like it. My opinions might be outside the norm

One obvious difference though is how people express gratitude (or not) for volunteer service. My hospital is thrilled to have an engaged physician on committee and they say it all the time. That's... uh... not how how it went at ASTRO. I guess Ill leave it at that.

 

[sirspamalot]

In my opinion, ASTRO is in good shape. It’s lacking a few things. Every organization does. That’s the point of bringing different voices into leader ship tracks. Different voices can raise different views. I’ve been open about this.

I think the single biggest thing I am seeing is the lack of private practice Small business owners entering committee membership. That’s the way to go through the ranks and become a board member at some point. This allows the board to have discussions which can be shaped in viewed differently.

In the past few weeks, I have spoken to at least 50 different stakeholders from every aspect of the Radiation Oncology community. Many people are not ASTRO members. In many ways, I’m more interested in talking to them. I want to find out why they’re not members.

Most of these folks are in private practice, but not all

The PP small business owners who are ASTRO members, hopefully, are going to be on committees sooner rather than later. This process will open up in April. This past cycle, I was able to get a few on to health policy committees. I think they will be terrific and give a different perspective. They are all practicing in rural parts of the country and are small business owners. These folks have a perspective that’s very hard to attain without actually practicing in that environment. Their big issue is time (in terms of committing to ASTRo) but they are going to give it a go. I hope to add more private practice doctors next year, if there is an interest from this segment of our community.

In this scenario, the short term measure of success will be if we can get more private practice Doctors engaged in the committee structure at ASTRO. The long-term measure, 10 years or so, will be if we have greater representation at Committee leadership or board levels of ASTRO.

I haven’t been on the board for five years. I’m not on the board right now. That’s going to start in October at the annual meeting.

The staff and the board are good people. They do listen better than some (many?) people in SDN give them credit for. What makes it hard for them is that there is a lot of noise on the social media sites. From what I have seen, 90% of the posters are rational and raise. Good ideas. There’s definitely a 10% that I will never reach.

I’m spending time here and also listening to different stake holders. I guess you can say I’m on a listening tour for the next couple months. I have my own ideas, but I want to see if they are consistent with a wide variety of people in our community. So far, I think they are. That will help me bring this perspective to the board.

In my first four years on the board (2014-18), I was able to make some changes which we still see today. I was a reason the PRO track at ASTRO annual was created. I want to make it clear that I was not the only person on this. It took a team. PRO track originated from a discussion at the board level about engagement of the private practice community at ASTRO annual meeting. I think there was a lack of recognition that coverage in the clinic, especially a big deal back then, prevented many private practice doctors from attending ASTRO. At that time, David Beyer and me had meaningful small practice experience. Both of us said that coverage prevented Attendance during the week. This led to us to talking about a weekend course that would hit the highlights. From there, the PRO track took off, and I think this has been a success. That’s just one example of a successful outcome due to having diverse views and experiences on the board.

I guess I'm headed for the 10% club because I think you're tone deaf to what is being loudly and clearly stated I here as problematic for our specialty.

-eliminate pps/Proton carve outs
-neutralize site of care
-crush via shame or other actions the legion of worthless soapy residencies

"talking to small business owners in rural areas and hope to see them give their free time to committee work" falls somewhere between coke zero and diet Pepsi on the scale of effective diet soda.

Maybe talk to non members. Cut the committee hierarchy / elitism, quit putting academia on a pedestal as an organization (let it's members do so) and design the meetings to address the vast majority of practicing radoncs needs (the last one has been slightly improved as of late but nowhere near as good as ACRO)

I'm not paying ASTRO dues until I see some meat on the table. Win us back.

 

[deleted1111261]

And end Simul and Todd’s ban!!!

 

[Neuronix]

And end Simul and Todd’s ban!!!

This is a meaningful step that would take minimal effort from Sameer.

@Rad Onc SK Ball is in your court.

 

[Rad Onc SK]

And end Simul and Todd’s ban!!!

Have you been banned?

I.E., have you been told that if you pay dues that you cannot be a member of ASTRO?

If the answer is yes, then we should talk offline. I would need to understand this better.

 

[Rad Onc SK]

I guess I'm headed for the 10% club because I think you're tone deaf to what is being loudly and clearly stated I here as problematic for our specialty.

-eliminate pps/Proton carve outs
-neutralize site of care
-crush via shame or other actions the legion of worthless soapy residencies

"talking to small business owners in rural areas and hope to see them give their free time to committee work" falls somewhere between coke zero and diet Pepsi on the scale of effective diet soda.

Maybe talk to non members. Cut the committee hierarchy / elitism, quit putting academia on a pedestal as an organization (let it's members do so) and design the meetings to address the vast majority of practicing radoncs needs (the last one has been slightly improved as of late but nowhere near as good as ACRO)

I'm not paying ASTRO dues until I see some meat on the table. Win us back.

You will not get the PPSE and proton carve outs to go away. Including either one of thise 2 makes ROCR, or any case rate solution, DOA.

ROCR should result in site neutrality.

Personally, I think revisiting the workforce discussion is reasonable. I think I’ve made that pretty clear.

I have spoken to at least 10 nonmembers in the past week, mostly by phone, but otherwise by electronic communication. That includes Simul, Todd, and Matt. I have more calls set up for the next few weeks. You can private message me and we can set up a time to talk as well. I am willing to hear you out as long as you can give me the same courtesy.

You think I’m tone deaf just because I don’t agree with you. You don’t like what I’m saying, that’s clear. I have received dozens of private messages from members on this board who think what I am saying is pretty reasonable. That has been very rewarding and made me glad that I joined SDN.

(to those of you who have taken the time to send me private messages, I genuinely appreciate it)

You have a right to your opinion and you can make your own decision on whether or not to join ASTRO. There are so many things I love about living in America, none more than freedoms of (reasonable/legal) choice.

Have a great night!

 

[Neuronix]

Have you been banned?

I.E., have you been told that if you pay dues that you cannot be a member of ASTRO?

If the answer is yes, then we should talk offline. I would need to understand this better.

Yes, they have both been banned from the ASTRO forums aka ROhub.

https://rohub.astro.org/home

They have been banned for no reason other than having a reasonable discussion. This is what I was referring to in my other post linked below.

Congrats to new ASTRO President..is this the first time that the President is on SDN?

https://www.astro.org/About-ASTRO/Governance/Elections

forums.studentdoctor.net

Please let us know whether ASTRO is interested in a dialogue with its members by having them unbanned from ROhub.

Some ASTRO members want to deride SDN, but SDN is the only place where an open dialogue about radiation oncology is permitted.

 

[RadOncDoc21]

Also why can’t we have some of the discussions you’re having on an open forum vs private messaging/phone conversations?

 

[communitydoc13]

You will not get the PPSE and proton carve outs to go away

Yeah, never getting my support. Now 42 regional proton centers and academics employing over 50% of new grads.

Nobody has ever assuaged my proton concerns and I have never met a good clinician who wasn't willing to abandon protons personally for all adult malignancies. Had somebody recently tout improved imaging on proton machines. With standard fractionation, this could make things worse. They didn't understand this.

All of the best proton work that I see points to the notion that our "clinical dosimetry"...think erythema dose in the old days...is not correlating with our calculated dose.

Brain necrosis in adult patients after proton therapy: Is there evidence for dependency on linear energy transfer (LET)?

To investigate if radiographic imaging changes defined as necrosis correlate with regions in the brain with elevated linear energy transfer (LET) for proton radiation therapy treatments with partial brain involvement in central nervous system (CNS) and ...

www.ncbi.nlm.nih.gov

Wishing you the best. Radonc is what it is. An academic specialty trying to excise as much value for academic institutions as it can with very little concern for societal value. Your colleagues in other fields know what you are.

For the community docs out there doing calculations. Think about your hospitals bottom line and competitive position within your market. Pro-fees collection alone shouldn't be your only calc.

 

[Mandelin Rain]

You will not get the PPSE and proton carve outs to go away. Including either one of thise 2 makes ROCR, or any case rate solution, DOA.

Is there any other way of taking this other than a tacit admission that ASTRO is powerless without the proton lobby?

I guess it could also be a tacit admission that "We only care about enriching 25-ish centers. The rest of you be damned."

Both feel somewhat right.

The proton boondoggle must stop for the health of our specialty. It's the "bone marrow transplant to cure metastatic breast cancer" of Rad Onc.

 

[SneakyBooger]

Ok I’m curious - Honda or Toyota?

Ford -

 

[deleted1111261]

It is pure capitulation at this point.

You will not believe what people are requesting - and who the requesters are - with regards to protons. It is truly stunning and completely let's me off the hook for anything I've done. When you see Dr. BigName request protons for DCIS or GS6/PSA5.1/T1c prostate cancer that almost all of us would observe, you realize talk is cheap. Their actions speak louder than their words.

Every proton center claims they do things rationally and what's best for patients. Every proton center is at the same time requesting things that make you cringe.

I'm seeing it with my own eyes. I wish I could say more.

 

[SneakyBooger]

...and THEN some.

SOOOOO much more!

 

[Mandelin Rain]

It is pure capitulation at this point.

You will not believe what people are requesting - and who the requesters are - with regards to protons. It is truly stunning and completely let's me off the hook for anything I've done. When you see Dr. BigName request protons for DCIS or GS6/PSA5.1/T1c prostate cancer that almost all of us would observe, you realize talk is cheap. Their actions speak louder than their words.

Every proton center claims they do things rationally and what's best for patients. Every proton center is at the same time requesting things that make you cringe.

I'm seeing it with my own eyes. I wish I could say more.

 

[deleted1168505]

You will not get the PPSE and proton carve outs to go away. Including either one of thise 2 makes ROCR, or any case rate solution, DOA.

At least you're honest and will directly answer the question, which is more than can be said for most people these days. And I don't think anybody realistically expects that you would advocate for a policy that would shut down all the proton centers.

But I hope you can see how stunningly corrupt this all is. Nonsense like this is why American healthcare costs multiple standard deviations above the norm of the rest of the developed world. How will the policy not incentivize further proton misuse, urorad centers putting them in, etc.? Eventually the scam will get big and stupid enough that it results in a Michael Moore style documentary exposing it to the public.

 

[metallica81788]

It is pure capitulation at this point.

You will not believe what people are requesting - and who the requesters are - with regards to protons. It is truly stunning and completely let's me off the hook for anything I've done. When you see Dr. BigName request protons for DCIS or GS6/PSA5.1/T1c prostate cancer that almost all of us would observe, you realize talk is cheap. Their actions speak louder than their words.

Every proton center claims they do things rationally and what's best for patients. Every proton center is at the same time requesting things that make you cringe.

I'm seeing it with my own eyes. I wish I could say more.

Since you're already a rebel, could you post these examples on Twitter and tag leadership as you get them? Obviously no identifying information, just as you've listed here.
People need to open their eyes to what is actually happening

Proton machines running 12 hours a day and you know they aren't full of chordomas and medulloblastomas

 

[thecarbonionangle]

Is there any other way of taking this other than a tacit admission that ASTRO is powerless without the proton lobby?

I guess it could also be a tacit admission that "We only care about enriching 25-ish centers. The rest of you be damned."

Both feel somewhat right.

The proton boondoggle must stop for the health of our specialty. It's the "bone marrow transplant to cure metastatic breast cancer" of Rad Onc.

Do we really think he has the power to shut down protons? He is simply admitting the truth that it is DOA because of proton lobby. He is not necessarily saying he disagrees with you. Getting things done takes some pragmatism. If there is more “good” to come to having them as an ally, i’ll embrace anything that helps this field at this point. Remember dont let perfect be the enemy of the good. This is the making of the sausage. You want something, proton lobby wants something. You agree on something, you find common ground and you get it passed assuming it will help the specialty (ROCR).

 

[NotMattSpraker]

Yeah, never getting my support. Now 42 regional proton centers and academics employing over 50% of new grads.

Nobody has ever assuaged my proton concerns and I have never met a good clinician who wasn't willing to abandon protons personally for all adult malignancies. Had somebody recently tout improved imaging on proton machines. With standard fractionation, this could make things worse. They didn't understand this.

All of the best proton work that I see points to the notion that our "clinical dosimetry"...think erythema dose in the old days...is not correlating with our calculated dose.

Brain necrosis in adult patients after proton therapy: Is there evidence for dependency on linear energy transfer (LET)?

To investigate if radiographic imaging changes defined as necrosis correlate with regions in the brain with elevated linear energy transfer (LET) for proton radiation therapy treatments with partial brain involvement in central nervous system (CNS) and ...

www.ncbi.nlm.nih.gov

Wishing you the best. Radonc is what it is. An academic specialty trying to excise as much value for academic institutions as it can with very little concern for societal value. Your colleagues in other fields know what you are.

For the community docs out there doing calculations. Think about your hospitals bottom line and competitive position within your market. Pro-fees collection alone shouldn't be your only calc.

I love your ROCR posts.

Frankly, ASTRO needs to say more than "it's DOA" here given the clearly biased updated payment model and ROCR exclusion. If they don't say anything more, I will have serious concerns about integrity and I'm not sure I could join the society again regardless of other actions. Their behavior on this narrow issue is disgraceful so far.

That said, I don't think its useful to name and shame individual treating physicians. Very reasonable to call out their COI, but many deal with significant pressure to treat from local leadership and its not like its so easy to go get another job these days. We also should have nuance when discussing the modality. Some patients can benefit. We don't want parents afraid to seek out proton care for their children.

Physicians and patients are most harmed by the behavior of the "proton cabal".

I think the only way forward is to educate our colleagues and patients about the truth and head this off in clinic and online on our own. More to come.

 

[communitydoc13]

Remember dont let perfect be the enemy of the good

Capitulating to the proton lobby will be worse for me in the long run.

I have multiple proton centers in my region. I know several of these are running damn long. (None of them are running damn long on peds cases alone).

Supporting protons does not help my hospital or my job security. I have yet to be convinced that it will help my patients.

The biggest threat to my livelihood is further hospital consolidation. I can streamline my practice if need be with payment changes.

I have no great ethical concern if I have to take a pay cut (not that I want one).

I have a big ethical concern with the way protons have proliferated and are being marketed to patients. I have a big ethical concern with further healthcare consolidation.

From an ethical standpoint, the protons are emblematic of the problem.

From a pragmatic standpoint, what am I going for here? Eventual employment as a satellite doc at one of these places? Of course, I know that I would have no value over a new graduate to these places.

 

[Upgrayedd]

I think a lot of the focus on proton centers is essentially friendly fire. The major medical/governmental powers won’t be able to discern the details, and we risk loosing more ground to the ballooning costs of immunotherapy. Close ranks, thats my advise. Seems like SK is on the right track.

 

[deleted1111261]

I think a lot of the focus on proton centers is essentially friendly fire. The major medical/governmental powers won’t be able to discern the details, and we risk loosing more ground to the ballooning costs of immunotherapy. Close ranks, thats my advise. Seems like SK is on the right track.

Wasn't going after UroRads a decade of friendly fire?

I would argue this is even worse, b/c it is "our own" applying misinformation and lies (I appreciate that is a strong word, but have you seen the literature?) to enrich themselves and their centers. It has nothing to do with patient care when you give a prostate patient a worse treatment (per existing data). It is not patient centered to have to switch a breast patient to photons midway through b/c of skin reaction. It is not patient centered to make someone pay a co-pay for a treatment that is just as good as a cheaper one.

I don't know. I feel like "closing ranks" would be coming up with a common sense policy on proton usage, not using it as a cash register.

 

[deleted1168505]

Assume positive intent until proven otherwise. It is possible that low risk prostate receiving 81 GyE is patient-driven in affluent areas where proton centers are located rather the clinicians routinely pushing them on the unsuspecting public.

I would hate to have the job of routinely trying to talk Jim Jimmers Jr., VP of operations at Jimmers Lexus, out of protons on a daily basis. It's too bad there's even that option.

 

[yesmaster]

With all this talk of proton overuse, I suddenly believe in utilization review and prior auth. Maybe I’ll even try for a part time PA gig myself. One of the few ways that we as individuals can reign in protons.

“The enemy of my enemy is my friend.”