The 2019 Match - Letter to Editor in latest PRO

[Gfunk6]

https://www.practicalradonc.org/article/S1879-8500(19)30196-1/fulltext?dgcid=raven_jbs_etoc_email

Two choice quotes:

#1

Some may interpret the 2019 Match as evidence of a simple market correction to the anticipated oversupply of ROs7 and suggest that declining medical student interest in the field will result in a reduction in the absolute number of RO trainees per year via unmatched positions. We urge caution interpreting the Match results as such. Rather, we posit that the increased unmatched rate will not be accompanied by a proportional decrease in the number of graduating trainees for 2 reasons. First, the unfilled spots may be filled via the post-Match Supplemental Offer and Acceptance Program (SOAP) or other means. Second, the absolute number of available (and filled) positions continues to rise.

#2

As the barrier to entry is lowered, it is plausible that RO will become an appealing “back-up specialty” for those considering competitive specialties or will be considered by previously uncompetitive candidates. So long as the absolute number of available positions remains elevated and alternate pathways for RO entry exist (eg, SOAP), the validity of rapid, free market–based solutions to RO workforce imbalances will be tested.

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[OTN]

Don't have access because I refuse to be an ASTRO member. Can anyone else post some choice snippets?

 

[fiji128]

I'm pretty sure just about all available residency positions (except some high end sub specialty type positions like Derm/Plastics) that are not filled through the match will fill via SOAP with FMGs if there are no AMG takers. Never really understood this whole "let the market decide" logic as FMGs will always fill whatever left over positions that are available. At the end of the day this will just water down the talent in the field as we continue our steady march to becoming the new pathology (at least in the eyes of current med students).

 

[scarbrtj]

it is plausible that RO will become an appealing “back-up specialty” for those considering competitive specialties

Ah, cool, rad onc won't be their first choice but it'll be up there pretty high on the list.
Reminds me of the old joke: "Poop jokes aren't my favorite but they're a solid number two!"

 

[fiji128]

Don't have access because I refuse to be an ASTRO member. Can anyone else post some choice snippets?

Crux of the letter:

Of the 30 unfilled positions in the 2019 Match, 19 of 27 available in the SOAP filled. As a result, the total number of RO positionsfilled through the Match and SOAP rose from 192 (of 193 available positions) in 2018 to 196 (of 207 available positions) in 2019, continuing the trend of increased spots per year. Indeed, the realized post-SOAP unfilled rate was 5.3%. Spots may also be filled outside of the Match by international medical graduates or residents switching specialties. It is unknown how many of the 11 positions that did not participate in or fill via the SOAP ultimately filled.

Basically the "leaders" in field (who are the only ones in a position to do anything about this) just can't help themselves from gorging on cheap resident labor.

 

[BobbyHeenan]

The actual number of residents continued to RISE, in spite of less applicants and more unfilled spots through the traditional match (ie the med students who were actually initially interested in radiation oncology).

There is no such thing as a "market correction" when you have an infinite supply of SOAPers willing to come on board.

Yet another thing SDN said would happen comes to fruition.

Unless some leader with guts out there stands up and starts shaming all other chairs and/or some sort of pact is made between programs to quit expanding and actually contract, this will continue. There is ZERO legitimate plan in place to stop this trend.

 

[scarbrtj]

The actual number of residents continued to RISE, in spite of less applicants and more unfilled spots through the traditional match (ie the med students who were actually initially interested in radiation oncology).

There is no such thing as a "market correction" when you have an infinite supply of SOAPers willing to come on board.

Yet another thing SDN said would happen comes to fruition.

Unless some leader with guts out there stands up and starts shaming all other chairs and/or some sort of pact is made between programs to quit expanding and actually contract, this will continue. There is ZERO legitimate plan in place to stop this trend.

What I'm thinking is if I'm a first year RO resident: over the next 4 years there will be *800* new rad oncs in America. That's almost 20 rad oncs per state. How in the heck can a young first year resident right now, given everything, hope to have a shot at a job in his chosen state if *20* new rad oncs will be moving into the state over the next 4 years?? The only plan, legitimately, that would fix this is total new resident moratorium for AT LEAST one year.

 

[Chartreuse Wombat]

Watch for radonc residents transferring specialties. Difficult to do and PDs will be p*ssed but likely to be another trend.

 

[Neuronix]

Pasting in my thoughts from the other thread from my post on Friday:

Unfilled Positions in the 2019 National Resident Matching Program Radiation Oncology Match and Supplemental Offer and Acceptance Program

www.sciencedirect.com

Generally I agree with the authors of the letter to the editor. Specifically, I'm not clear that 11 spots not filling in the SOAP meant anything when it comes to contraction.

Spots may also be filled outside of the Match by international medical graduates or residents switching specialties.9 It is unknown how many of the 11 positions that did not participate in or fill via the SOAP ultimately filled.

That is the easiest survey to conduct. Just ask those programs. A few e-mails would solve that dilemma for publication purposes.

Nevertheless, we all know that programs have a lot more options if they don't fill. They could just roll those spots over to the class the following year by expanding next year's class. They could take extra fellows and put them on ABR accreditation pathway, locking them in for four years. Or they could take residents from elsewhere in transfer. I know from personal discussions that all of these things did happen.

I am really curious what will happen this year. That is: how many spots won't fill in the first round of the match, and how many really will go unfilled this year and in the long term. I don't know if UPMC is serious about being willing to contract their residency program, but I know again from personal discussions that most programs are not going to willingly contract. And even if we go from 210 spots on offer to say 190-200 actually filled, does a 5-10% contraction make any meaningful difference?

Further, what is "demonstrated interest in rad onc" ? One fourth year rotation to get you in as a backup specialty in case you don't match something else? Or has the fourth year now picked rad onc because they didn't want to take a chance on what was previously their more competitive first choice specialty? I'm seeing this now.

 

[medgator]

What I'm thinking is if I'm a first year RO resident: over the next 4 years there will be *800* new rad oncs in America. That's almost 20 rad oncs per state. How in the heck can a young first year resident right now, given everything, hope to have a shot at a job in his chosen state if *20* new rad oncs will be moving into the state over the next 4 years?? The only plan, legitimately, that would fix this is total new resident moratorium for AT LEAST one year.

Said it yesterday

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

There would still be enough ROs if one years worth didn't hit practice in 5 years

 

[Mandelin Rain]

I can't see a small group of individuals who control the supply of 100% and salary of 41% of a labor force flooding the market with said labor force to, in part, suppress salaries as anything but "anti-competitive".

THIS is a much more interesting anti-trust argument than the one they've hidden behind. It is not unique to Rad Onc.

 

[seper]

I've trained in a "lower-tier" program and old enough to remember unmotivated, unprofessional residents getting into RadOnc. Once chairpersons experience that firsthand, the correction will occur IMO.

 

[Neuronix]

BTW, just got the PRO table of contents for November...

7 Monologues ("Narrative Oncology")
2 Editorials
1 Consensus statement ("Minimum Data Elements for Radiation Oncology")
9 Research papers

Can't we do more research? I mean... I'm a little sad we can't do better than this as a specialty with all this growth in academics.

 

[FrostyHammer]

BTW, just got the PRO table of contents for November...

7 Monologues ("Narrative Oncology")
2 Editorials
1 Consensus statement ("Minimum Data Elements for Radiation Oncology")
9 Research papers

Can't we do more research? I mean... I'm a little sad we can't do better than this as a specialty with all this growth in academics.

PRO is a bit of a unique journal in this sense. It also has very strict page limits that preclude too much publishing.

 

[Mandelin Rain]

This is a true story. I remember being excited when I heard about PRO and what it was supposed to be, i.e. guidelines, white papers, consensus statements, and "practical" research articles for busy clinicians.

Then, I picked up the inaugural issue and saw...

First use of electromagnetic setup and real-time tracking in a pediatric patient with vaginal rhabdomyosarcoma

My enthusiasm waned.

 

[OTN]

BTW, just got the PRO table of contents for November...

7 Monologues ("Narrative Oncology")
2 Editorials
1 Consensus statement ("Minimum Data Elements for Radiation Oncology")
9 Research papers

Can't we do more research? I mean... I'm a little sad we can't do better than this as a specialty with all this growth in academics.

"Academics"

 

[medgator]

BTW, just got the PRO table of contents for November...

7 Monologues ("Narrative Oncology")
2 Editorials
1 Consensus statement ("Minimum Data Elements for Radiation Oncology")
9 Research papers

Can't we do more research? I mean... I'm a little sad we can't do better than this as a specialty with all this growth in academics.

 

[fiji128]

Are there any other specialties with the PDs fishing for applicants like this? This just reeks of total desperation.

 

[Mandelin Rain]

If the content doesn't capture their interest, the graphic design from 1987 certainly will.

 

[Lamount]

I had mentioned this previously, but does anyone know if there would be any "anti-Trust" violations if there was a rule mandating that all residency slots be filled in the match at least once in the previous two years? i.e. if a residency had a slot filled by the SOAP two years in a row, perhaps they should lose that slot. It seems that this would sidestep the anti-trust argument because residency expansion would be impartially curtailed by a lack of demand.

 

[Chartreuse Wombat]

One could imagine that the SOAP is a marker for a poor educational program; just as high fail rates are used in that manner by the RRC to "punish programs". It would require action by the RRC...Dr Vapiwala are you listening?

 

[RickyScott]

One could imagine that the SOAP is a marker for a poor educational program; just as high fail rates are used in that manner by the RRC to "punish programs". It would require action by the RRC...Dr Vapiwala are you listening?

that may encourage programs to rank crappy applicants so they don’t go unmatched? There will always be warm bodies.

 

[fiji128]

I had mentioned this previously, but does anyone know if there would be any "anti-Trust" violations if there was a rule mandating that all residency slots be filled in the match at least once in the previous two years? i.e. if a residency had a slot filled by the SOAP two years in a row, perhaps they should lose that slot. It seems that this would sidestep the anti-trust argument because residency expansion would be impartially curtailed by a lack of demand.

Doubtful. I'm not sure how it exactly plays out now but it used to be (circa 2012) there were a ton of non university based IM residencies, path and even psychiatry that would fill through the scramble/soap every year not to mention things like surgery intern years. There was never any sort of penalty for this except for maybe bragging rights saying you were able to fill.

 

[Mandelin Rain]

What I'm thinking is if I'm a first year RO resident: over the next 4 years there will be *800* new rad oncs in America. That's almost 20 rad oncs per state. How in the heck can a young first year resident right now, given everything, hope to have a shot at a job in his chosen state if *20* new rad oncs will be moving into the state over the next 4 years?? The only plan, legitimately, that would fix this is total new resident moratorium for AT LEAST one year.

In a strange twist of irony, I am providing literally nothing but "direct supervision" today at a clinic (which is how I've been able to make so many witty posts). Literally not a single patient visit on my schedule. Clearly, all the weekly work here could be done in 4 days. As is the case at my other clinic. Some of my partners' clinics could probably even be done in 3. But we staff these things to meet supervision requirements.

Your post got me thinking. Let's assume the the "average" clinic that is currently being staffed by 5 physician days could be staffed equally effectively in 4. I don't think that this is a far fetched idea. That's a 20% decrease in labor demand for rad onc in America. Instantly. January 1st of this year. I believe you settled on there being about 5,000 practicing rad oncs in America currently. That means about 1,000 of them are immediately unnecessary if our assumption about supervision is true. If we assume the average career of a rad onc is about 30 years, only 1/6 of the current practice pool will retire in the next 5 years when we actually need 1/5 to immediately retire to be at equipoise.

So, if you are a first year resident as you describe on the same 5 year horizon, not only are there 800 new rad oncs in front of you to take your job, the truth of the matter is that literally NONE of them are needed based on this rule change. Not only are none of those in front of you required, neither is your entire cohort, nor the cohort behind you. If literally no one was hired in those 6 years, year 7 is when people would "need" to start hiring new grads again.

Scary place to be.

 

[lhl]

I thought the rule changes for direct supervision only applied to hospital based rad onc? what proportion of employed rad oncs would anyone guess work at a single physician hospital based practice? It would be this type of practice that most likely would shift the need for covering rad oncs.

While I agree with the overall sentiment that these rule changes will decrease the need for rad onc labor, i'm not so sure the degree of impact is nearly as large as you have estimated.

 

[medgator]

i'm not so sure the degree of impact is nearly as large as you have estimated.

The overriding message is clear, when summated with things like hypofx, APM etc

 

[Mandelin Rain]

I thought the rule changes for direct supervision only applied to hospital based rad onc? what proportion of employed rad oncs would anyone guess work at a single physician hospital based practice? It would be this type of practice that most likely would shift the need for covering rad oncs.

While I agree with the overall sentiment that these rule changes will decrease the need for rad onc labor, i'm not so sure the degree of impact is nearly as large as you have estimated.

That's definitely fair. My post was based on an assumption that may be WAY off base, but at least in my experience seems reasonable. Garbage in, garbage out type situation.

I think hospital employed groups (this includes academic departments) and professional service groups that collectively staff multiple hospitals will see the biggest shifts in need. If you have a 7 doc practice covering 5 sites, three of which are busy and two of which are not, are you replacing the guy who is about to retire? With direct supervision? Probably, just so 2 of you can take vacations/PTO/ASTRO/break a leg and still be covered without resorting to locums. With general supervision? Definitely not. You're just reducing physician presence at less busy hospitals when a crunch hits and splitting the same pot 6 ways instead of 7.

I guess my point is the supervision rule will immediately reduce demand by some %. No one will increase staffing. Some (many, in my estimation) will decrease. Some will remain static. The net effect will be an immediate decreased need.

So we WILL be in the scenario where we have too many practicing rad oncs AND we're training too many every year. This is the equivalent to opening up the faucet completely while the sink is already overflowing.

 

[qwerty89]

In a strange twist of irony, I am providing literally nothing but "direct supervision" today at a clinic (which is how I've been able to make so many witty posts). Literally not a single patient visit on my schedule. Clearly, all the weekly work here could be done in 4 days. As is the case at my other clinic. Some of my partners' clinics could probably even be done in 3. But we staff these things to meet supervision requirements.

Your post got me thinking. Let's assume the the "average" clinic that is currently being staffed by 5 physician days could be staffed equally effectively in 4. I don't think that this is a far fetched idea. That's a 20% decrease in labor demand for rad onc in America. Instantly. January 1st of this year. I believe you settled on there being about 5,000 practicing rad oncs in America currently. That means about 1,000 of them are immediately unnecessary if our assumption about supervision is true. If we assume the average career of a rad onc is about 30 years, only 1/6 of the current practice pool will retire in the next 5 years when we actually need 1/5 to immediately retire to be at equipoise.

So, if you are a first year resident as you describe on the same 5 year horizon, not only are there 800 new rad oncs in front of you to take your job, the truth of the matter is that literally NONE of them are needed based on this rule change. Not only are none of those in front of you required, neither is your entire cohort, nor the cohort behind you. If literally no one was hired in those 6 years, year 7 is when people would "need" to start hiring new grads again.

Scary place to be.

What does this mean? You simply sit there the whole day and do nothing?

 

[medgator]

What does this mean? You simply sit there the whole day and do nothing?

Don't knock "executive time" till you've tried it.

TBH, I'm still catching up on documentation, doing planning etc when I'm in the office for personal supervision, and I imagine many others are also

 

[deleted774703]

Crux of the letter:

Of the 30 unfilled positions in the 2019 Match, 19 of 27 available in the SOAP filled. As a result, the total number of RO positionsfilled through the Match and SOAP rose from 192 (of 193 available positions) in 2018 to 196 (of 207 available positions) in 2019, continuing the trend of increased spots per year. Indeed, the realized post-SOAP unfilled rate was 5.3%. Spots may also be filled outside of the Match by international medical graduates or residents switching specialties. It is unknown how many of the 11 positions that did not participate in or fill via the SOAP ultimately filled.

Basically the "leaders" in field (who are the only ones in a position to do anything about this) just can't help themselves from gorging on cheap resident labor.

Good letter. SDN been bringing this up informally but now that it is officially published i hope it wakes up ignorant radonc chairs and PDs

Thx Agarwal, Royce, Goodman, Chowdhary