The True Enemy

[RickyScott]

I’m usually the first to make snarky comments but even I can’t be mad at this. Let’s just hope other programs follow the “MDACC way!” I’m sure someone has already started working on a retrospective review for this move (ok there was one snarky comment).

Definitely respectable. Seems like the move by MDACC directly contradicts SCAROP.

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[medgator]

There's this weird dichotomy I've run into. There are programs with strong clinical training, but the residents have to work hard and sometimes are unhappy about it. There are programs with weak clinical training, but the residents don't work hard and are pretty happy.

Which is the right type of program?

Here at SDN the mantra has always been "NO DOUBLE COVERAGE RAH RAH RAH", ok but what happens when you're in clinic with attendings who are in clinic like 2 days a week? You only work 2 days a week? Oddly enough, I've seen several programs now where the answer is yes. Clinic 2 days a week, then read or research or contour or go to the beach the other days. I'm sure you're happy with that, but are you actually getting well trained? Also, will the more clinical attendings want to go to bat for you for research and jobs when they are working way harder than you are as a resident?

Just putting it out there. I don't know that there's a right answer. The programs in the past few posts fit into both ends of the spectrum. Nowadays resident evals are taken very seriously at many places, especially with the drop in rad onc matches, so there's an increasing number of opportunities to take it easy during residency to the possible detriment of your career.

Well said. I went to a midtier place that required multiple coverage and was weak on research. In retrospect, that was far better for getting me prepared for a clinically busy PP position.

It's all about what your goals are at the end, but being a strong clinician should always be a part of that

 

[medgator]

If you’re looking for a truly great place to go then consider U of Chicago

So tone deaf. That's a chair who will go to bat for you to look for a non academic, clinical position after training. /S

Not only that, sounds like he is a fan of cheap lab labor and exploitative fellowships. I guess that is what excess acgme funded rad onc residents are good for, these days.

 

[RickyScott]

Training is 95% the resident, 5% program.

 

[RickyScott]

So tone deaf. That's a chair who will go to bat for you to look for a non academic, clinical position after training. /S

Not only that, sounds like he is a fan of cheap lab labor and exploitative fellowships. I guess that is what excess acgme funded rad onc residents are good for, these days.

If every resident just works hard, this will somehow create more total jobs. Love that logic.

 

[medgator]

If every resident just works hard, this will somehow create more total jobs. Love that logic.

It's like losing money on every sale, but making it up in volume!

 

[RickyScott]

It's like losing money on every sale, but making it up in volume!

Real Irony here is that UC center of academic economic world and free market/Austrian school principles.

 

[OTN]

Real Irony here is that UC center of academic economic world and free market/Austrian school principles.

So you would think Ralph would understand that, given the very limited mobility, lack of geographic options, and emotional difficulty in providing cancer care, there may, in fact, be reasons a radonc would need to make more money than a pediatrician in order to attract talent to the specialty.

However, you would be incorrect, because he clearly understands nothing about economics.

 

[Neuronix]

He's also assuming that there are a ton of physician-scientist jobs out there for people who want them. But, there aren't. Even most academic jobs are mostly clinical.

He assumes that there are fellowship jobs for those who want them. They don't exist. A very small number maybe. I was willing to do a research fellowship upon graduating residency and could not identify one.

This further kicks the can down the road anyway. The reply to the fellow then becomes "you get a faculty job when you get your grant", except at 10% funding rates, who knows if you'll ever get one. Also, even for K08 nowadays, they typically want the applicant to be in an assistant professor position, because we all know that institutions reneg on their agreements to fellows who get the K08s and don't hire them, which angers the NIH. This is because a lot of "academic" departments don't even want funded physician-scientists because unless you have multiple R level grants, you're still going be a money loser. The NIH knows that the institution needs to show support by hiring someone because a K award and a successful transition to R requires significant institutional investment. In the NIH's eyes, if the institution won't commit to someone, why should they? And guess what, in other specialties, they do invest in promising people!

So when you don't get significant grants as a fellow (which are very uncommon), the nay sayers can just say "your ideas weren't good enough", so you stay as a fellow. This is a hampster wheel that is impossible to get off of unless you are lucky or get sick of the wheel and move on.

We have been fighting that battle for physician-scientists for years in this specialty. There is a very small pool of die hards who try to make it work. The idea that you're going to expand a pool of physician-scientists to create jobs for the oversupply of radiation oncologists is ludicrous to someone actually living that life. That was the idea of the red journal paper (alternative careers in rad onc), which is still crazy to me. It would be one thing if those "alternative careers" were abundant and paid reasonably well compared to clinical medicine, but they're not and they don't.

This "field of dreams" mentality was the norm many years ago when NIH grant funding rates were 40% or more (periods in the 80s and 90s) when a lot of senior people in our field thrived. The field of dreams was "If you build research facilities, the NIH money will come." As the investigator, if you couldn't get funding in that sort of environment, maybe you weren't cut out for it. But it's been a long time since then, and everyone who grew up in the 00s and 10s knows it. Unfortunately, it's still a lot easier to keep a lab going from the good times than it is to start a new one in the bad times.


PS: I hate twitter. How can you have a reasonable discussion with those tiny little posts?

 

[bluebubbles]

Decisions regarding residency slots & job market shouldn't be made to optimize the physician-scientist training experience. There are ~200 residents per year and <5 of these residents, if that, will go on to be physician-scientists. In a bygone era, physician-scientists did quite well and are now long-standing chairs like Ralph Weichselbaum, Dennis Hallahan, Ted Lawrence, etc. They may be well-meaning in championing the physician-scientist experience for their trainees, but it's not appropriate to apply that logic (e.g. the logic of a 3 year research fellowship prior to faculty appointment) across all radiation oncology training programs.

It's heartening to see residents and recent graduates express their honest opinions on Twitter. Very courageous! Fight the good fight.

 

[RickyScott]

Decisions regarding residency slots & job market shouldn't be made to optimize the physician-scientist training experience. There are ~200 residents per year and <5 of these residents, if that, will go on to be physician-scientists. In a bygone era, physician-scientists did quite well and are now long-standing chairs like Ralph Weichselbaum, Dennis Hallahan, Ted Lawrence, etc. They may be well-meaning in championing the physician-scientist experience for their trainees, but it's not appropriate to apply that logic (e.g. the logic of a 3 year research fellowship prior to faculty appointment) across all radiation oncology training programs.

It's heartening to see residents and recent graduates express their honest opinions on Twitter. Very courageous! Fight the good fight.

Ralph is probably harmed by residency expansion, but may not have intellectual reserve to appreciate it: small amount of medical scientist positions in radonc, so in his interest spots are filled with top quality people. When job market takes a hit/overs supply, many of those candidates will pursue that research out of medonc tract. (I have heard from medoncs anecdotally that fellowships are attracting a lot more md/phds!)

 

[deleted774703]

Ralph is probably harmed by residency expansion, but may not have intellectual reserve to appreciate it: small amount of medical scientist positions in radonc, so in his interest spots are filled with top quality people. When job market takes a hit/overs supply, many of those candidates will pursue that research out of medonc tract. (I have heard from medoncs anecdotally that fellowships are attracting a lot more md/phds!)

No hes either
1) Just trying to start shiz OR
2) UofC ignores him when it comes to hiring and financial decisions

Pretty sure Dan Golden, Matt Koshy, Christina Son, Aditya Juloori (new hire), among others are not sitting in any lab...

 

[evilbooyaa]

There's this weird dichotomy I've run into. There are programs with strong clinical training, but the residents have to work hard and sometimes are unhappy about it. There are programs with weak clinical training, but the residents don't work hard and are pretty happy.

Which is the right type of program?

Here at SDN the mantra has always been "NO DOUBLE COVERAGE RAH RAH RAH", ok but what happens when you're in clinic with attendings who are in clinic like 2 days a week? You only work 2 days a week? Oddly enough, I've seen several programs now where the answer is yes. Clinic 2 days a week, then read or research or contour or go to the beach the other days. I'm sure you're happy with that, but are you actually getting well trained? Also, will the more clinical attendings want to go to bat for you for research and jobs when they are working way harder than you are as a resident?

Just putting it out there. I don't know that there's a right answer. The programs in the past few posts fit into both ends of the spectrum. Nowadays resident evals are taken very seriously at many places, especially with the drop in rad onc matches, so there's an increasing number of opportunities to take it easy during residency to the possible detriment of your career.

The rah rah against double coverage, IMO, is when you have attendings that ARE in clinic 4-5 days a week. To have to cover 2 sets of 80% clinical attendings in terms of consults, sims, contours, etc. is the issue.

IMO, 2 attendings that are both in clinic 2 days a week (assuming different days) when combined = One 80% clinical attending. My beef with double coverage is when you have a resident covering two attendings that add up to more than 100% clinical effort. I would not at all mind covering 2 attendings who were only in clinic 2 days a week each.

I think residents during their clinical time should be at minimum 80% clinical effort meaning availabilities for clinic (including OTV days) 4 days out of the week. To be on a 'clinical' rotation that only has you in clinic 2 days a week is NOT the point of residency. Is this really a thing happening at more than one place?

 

[Neuronix]

I think residents during their clinical time should be at minimum 80% clinical effort meaning availabilities for clinic (including OTV days) 4 days out of the week. To be on a 'clinical' rotation that only has you in clinic 2 days a week is NOT the point of residency. Is this really a thing happening at more than one place?

Off the top of my head I can name four. I'm sure there are many others. I'm not talking about for the entire residency, but more than one several month block that is that light. The residents at those institutions will cite "double coverage" as the reason not to be in clinic with two attendings who are 3 days and 1 day in clinic, for example.

 

[evilbooyaa]

Off the top of my head I can name four. I'm sure there are many others. I'm not talking about for the entire residency, but more than one several month block that is that light. The residents at those institutions will cite "double coverage" as the reason not to be in clinic with two attendings who are 3 days and 1 day in clinic, for example.

On those clinic days, are those attendings and residents seeing like 3-4 consults and 8-9 follow-ups? I mean I guess if the weekly workload is similar then OK. Like with most of my attendings we'll average somewhere in the range of 7-10 new consults a week in single coverage (on top of follow-ups, OTVs, etc.). If a 2 days in clinic attending is cranking out 8 consults in those 2 days then I get it.

Because if you had 4 days of that across 2 attendings then yeah I get it.

 

[Neuronix]

Your concern is reasonable, but personally I never heard that argument as a problem. It's more about "double coverage" concerns where attendings are asking for residents to handle things on their off day when the resident is in clinic with another attending and the resident feels like they don't have the power to say no if they're unavailable.

I would be fine with a cap of like 8 or 10 or pick some reasonable number of consults per week plus some reasonable amount of follow-ups and OTVs to avoid getting overwhelmed. Or even per day limits. I don't think any attending wants their residents to be beat into the ground and miserable.

 

[Neuronix]

BTW, did you guys see this one in press? Found on Twitter

https://www.redjournal.org/article/S0360-3016(19)33870-2/fulltext

Caveat emptor: Fellowship Training in Radiation Oncology: What, But More Importantly, Why?

My favorite parts:

"Fellowships in RO represent neither a PGY-6 nor R-5 designation, offer no recognized credential, seem to offer no direct pathway to the end-points to many of the reasons for RO trainees to enter the programs, and for the most part, seem to be merely “more of the same.” They do offer the host programs up to one year or more, of non-resident, non-faculty clinical care; because the “fellows” have completed requirements of certification in their primary specialty, programs can legally bill for the services that they provide."

and

"We urge RO stakeholders in these areas to consider development of real subspecialty or focused practice training programs, with ACGME oversight and credentialing. Absent development of those serious educational steps, the term fellowship should be avoided in RO, perhaps to be replaced by more accurate descriptive terminology, such as clerkship or apprenticeship."

 

[radoncgrad2019]

WOW PAUL WALLNER TURNED TO THE LIGHT?

 

[deleted774703]

BTW, did you guys see this one in press? Found on Twitter

https://www.redjournal.org/article/S0360-3016(19)33870-2/fulltext

Caveat emptor: Fellowship Training in Radiation Oncology: What, But More Importantly, Why?

My favorite parts:

"Fellowships in RO represent neither a PGY-6 nor R-5 designation, offer no recognized credential, seem to offer no direct pathway to the end-points to many of the reasons for RO trainees to enter the programs, and for the most part, seem to be merely “more of the same.” They do offer the host programs up to one year or more, of non-resident, non-faculty clinical care; because the “fellows” have completed requirements of certification in their primary specialty, programs can legally bill for the services that they provide."

and

"We urge RO stakeholders in these areas to consider development of real subspecialty or focused practice training programs, with ACGME oversight and credentialing. Absent development of those serious educational steps, the term fellowship should be avoided in RO, perhaps to be replaced by more accurate descriptive terminology, such as clerkship or apprenticeship."

Amazing editorial!! Hopefully this wakes up those few residents who continue to try for fellowships in hopes that they will magically sign on to a job in NYC, SF, etc

 

[medgator]

accurate descriptive terminology, such as clerkship or apprenticeship."

I can think of some choice colorful language that would be a lot shorter and equally descriptive

 

[Gfunk6]

GIve Dr. Wallner an ASTRO Gold Medal!!

Oh . . . wait . . .

Another awesome quote:

The notion that “advanced radiation oncology,” including IGRT, SRS and SBRT, should require additional training seems odd, since these modalities have become intrinsic to the routine practice of RO, and should be an integral part of every resident’s basic experience.

 

[Mandelin Rain]

Medical Students, if you rank University of Chicago, there is a decent chance Ralph Weichselbaum will be your boss for 4 years. And... you'll be relying on his recommendation to get a job at the end of those 4 years.

 

[medgator]

Medical Students, if you rank University of Chicago, there is a decent chance Ralph Weichselbaum will be your boss for 4 years. And... you'll be relying on his recommendation to get a job at the end of those 4 years.

Yup

Better figure out a way to pay back those loans and support your family during your mandatory 3-year post-residency pre-faculty "research period", because I doubt Ralph is going to help you out with that one.

 

[RickyScott]

Would like to hear from someone lab based, but if you plan for your whole career to be lab based, wouldnt medonc route be so much safer at this point? Other than Ralph, probably 1 or 2 radoncs in the entire country are engaged in meaningful bench research, have multiple pubs in Nature/Science type journals. Now add to that geographic restrictions, job market concerns, and the money pharm is throwing into cancer, seems like xrt is very unappealing...

 

[theradiator]

Ralph is a well known (and highly entertaining) flame thrower on Twitter. Take him figuratively but not literally?

In fairness to Ralph, he essentially co-invented and followed through on the oligometastasis concept - extensively heralded as an exemplar of specialty enhancing research on this forum. Also, he is specifically promoting laboratory-based research that addresses a comment lament on this forum of poor quality research.

In other words, there are far more worthy targets for vitriol ie., those that expanded residency programs, started fellowship programs and those that wrote the disgraceful response to ARRO.

 

[evilbooyaa]

Ralph is a well known (and highly entertaining) flame thrower on Twitter. Take him figuratively but not literally?

In fairness to Ralph, he essentially co-invented and followed through on the oligometastasis concept - extensively heralded as an exemplar of specialty enhancing research on this forum. Also, he is specifically promoting laboratory-based research that addresses a comment lament on this forum of poor quality research.

In other words, there are far more worthy targets for vitriol ie., those that expanded residency programs, started fellowship programs and those that wrote the disgraceful response to ARRO.

There is enough vitriol to go around.

The issue with Ralph (I guess SDN may be on a first name basis) is that he assumes that all rad oncs should be like him, not understanding that he is the minority within the field (including desire).

 

[medgator]

, there are far more worthy targets for vitriol ie., those that expanded residency programs, started fellowship programs and those that wrote the disgraceful response to ARRO.

Well then can you reduce your salary to median peds salary and send us all the difference? Thx

 

[Mandelin Rain]

Ralph is a well known (and highly entertaining) flame thrower on Twitter. Take him figuratively but not literally?

In fairness to Ralph, he essentially co-invented and followed through on the oligometastasis concept - extensively heralded as an exemplar of specialty enhancing research on this forum. Also, he is specifically promoting laboratory-based research that addresses a comment lament on this forum of poor quality research.

In other words, there are far more worthy targets for vitriol ie., those that expanded residency programs, started fellowship programs and those that wrote the disgraceful response to ARRO.

There's a big difference between reading someone's "hilariously" mean spirited posts on twitter or quality journal entriesfrom afar, and working as a direct subordinate to that person. Perhaps his persona on twitter is 180 degrees different from who he actually is in person, but in the past couple weeks he's made it clear that he doesn't see residents/young faculty as humans so much as means to whatever end he desires. Work for less (primary care pediatric). Don't have concerns about your livelihood. Do a fellowship. Do a mandatory 3 year research (basically a PhD) internment after residency.

Imagine after your 9 year residency/fellowship/research mandate you come out making <200k. That is what Ralph has proposed publicly in the past week.

 

[Doctorer]

Man, that rascal Ralph sure is a jokester! Almost thought he was serious!

 

[deleted774703]

Too many ppl make excuses for Ralph. Great researcher but stupid with emotional intelligence

 

[thecarbonionangle]

Some people are trying very hard not to match this year. The canaries will speak. Don’t sleep.

 

[medgator]

Some people are trying very hard not to match this year.

Let those residency programs eat cake and make faculty do their own damn contouring and dictating

 

[Krukenberg]

BTW, did you guys see this one in press? Found on Twitter

https://www.redjournal.org/article/S0360-3016(19)33870-2/fulltext

Caveat emptor: Fellowship Training in Radiation Oncology: What, But More Importantly, Why?

My favorite parts:

"Fellowships in RO represent neither a PGY-6 nor R-5 designation, offer no recognized credential, seem to offer no direct pathway to the end-points to many of the reasons for RO trainees to enter the programs, and for the most part, seem to be merely “more of the same.” They do offer the host programs up to one year or more, of non-resident, non-faculty clinical care; because the “fellows” have completed requirements of certification in their primary specialty, programs can legally bill for the services that they provide."

and

"We urge RO stakeholders in these areas to consider development of real subspecialty or focused practice training programs, with ACGME oversight and credentialing. Absent development of those serious educational steps, the term fellowship should be avoided in RO, perhaps to be replaced by more accurate descriptive terminology, such as clerkship or apprenticeship."

Vapiwala again on the right side of this issue. glad the new chair of the RRC gets it

 

[radOresident]

Let those residency programs eat cake and make faculty do their own damn contouring and dictating

A dangerous prospect for patient care. Many faculty at my program, and I would assume at many others, are simply not capable of doing their own contouring. They will (and have in some cases) go back to 2D planning.

 

[medgator]

A dangerous prospect for patient care. Many faculty at my program, and I would assume at many others, are simply not capable of doing their own contouring. They will (and have in some cases) go back to 2D planning.

I don't doubt that for a second. It's crazy to see how many pre-2000 trained folks practice in this day and age.

Unfortunately, this rests squarely on the RRC and chairs that facilitated this crisis in the first place

 

[deleted774703]

I don't doubt that for a second. It's crazy to see how many pre-2000 trained folks practice in this day and age.

Unfortunately, this rests squarely on the RRC and chairs that facilitated this crisis in the first place

Up to the chairs of those programs to show some spine and replace their incompetent employees w/ some well trained rad oncs

Its not residents job to clean up bad attendings messes

 

[Lamount]

a narcissistic mentality, indeed.

The issue with Ralph (I guess SDN may be on a first name basis) is that he assumes that all rad oncs should be like him, not understanding that he is the minority within the field (including desire).

It’s a good thing that none of his critics are guilty of such narcissism

 

[Haybrant]

I’m not totally against what RW has said as long as it has been a consistent drumbeat he has parroted for many years and would speaking in the same demeaning manor to the older physicians of his own generation, the ones that raped and pillaged medicine to what it is today. Something tells me he didn’t though and he is using this as a card now to silence younger physicians. If that is the case he should be rebuked and called out bc that would be a sick thing to do. I just don’t know yet but I’m going to search.

 

[OTN]

I’m not totally against what RW has said as long as it has been a consistent drumbeat he has parroted for many years and would speaking in the same demeaning manor to the older physicians of his own generation, the ones that raped and pillaged medicine to what it is today. Something tells me he didn’t though and he is using this as a card now to silence younger physicians. If that is the case he should be rebuked and called out bc that would be a sick thing to do. I just don’t know yet but I’m going to search.

He's consistent and has been saying all this stuff for years. Doesn't make him right, but I do know he will say the same stuff to senior attendings, junior attendings, medical students, residents and always has.

 

[medgator]

He's consistent and has been saying all this stuff for years. Doesn't make him right, but I do know he will say the same stuff to senior attendings, junior attendings, medical students, residents and always has.

Never got an interview at UC and now am grateful I never had the chance to rank that place. Heard about the malignancy on the trail back then. Sheesh

 

[RickyScott]

Vapiwala again on the right side of this issue. glad the new chair of the RRC gets it

Suggest supporting her if she runs for anything in ASTRO, as this is only way to make changes.

 

[seper]

Coming from Wallner, had to read this with suspicion.
I was correct. It is a piece promoting his own initiative: Focused Practice Recognition in Brachytherapy.
As far as I see, this recognition has not gained any track since inception in 2012.

BTW, did you guys see this one in press? Found on Twitter

https://www.redjournal.org/article/S0360-3016(19)33870-2/fulltext

Caveat emptor: Fellowship Training in Radiation Oncology: What, But More Importantly, Why?

My favorite parts:

"Fellowships in RO represent neither a PGY-6 nor R-5 designation, offer no recognized credential, seem to offer no direct pathway to the end-points to many of the reasons for RO trainees to enter the programs, and for the most part, seem to be merely “more of the same.” They do offer the host programs up to one year or more, of non-resident, non-faculty clinical care; because the “fellows” have completed requirements of certification in their primary specialty, programs can legally bill for the services that they provide."

and

"We urge RO stakeholders in these areas to consider development of real subspecialty or focused practice training programs, with ACGME oversight and credentialing. Absent development of those serious educational steps, the term fellowship should be avoided in RO, perhaps to be replaced by more accurate descriptive terminology, such as clerkship or apprenticeship."

 

[medgator]

Coming from Wallner, had to read this with suspicion.
I was correct. It is a piece promoting his own initiative: Focused Practice Recognition in Brachytherapy.
As far as I see, this recognition has not gained any track since inception in 2012.

I think he mentioned that fact in the editorial. Honestly I can't say I blame him. There should be some accountability and legitimacy to these so called "fellowships."

It's a far cry from what occurs in radiology

 

[Chartreuse Wombat]

The ABR program Focused Practice in Brachytherapy ended secondary to lack of interest.

Roughly 2 dozen MDs applied. I was one.

If interested he outlines the story in reference 7.

 

[deleted947887]

Wow. Dreams do come true.

 

[CaesarRO]

The ASTRO leadership editorial comes off a lot more sympathetic than the SCAROP one



Sent from my Pixel 2 XL using Tapatalk

 

[qwerty89]

Pharmacy has the same over-saturation problem A Looming Joblessness Crisis for New Pharmacy Graduates and the Implications It Holds for the Academy

"In 2001, the Pharmacy Manpower Project sponsored a conference of 2 dozen pharmacy experts to project a vision of pharmacy services and manpower deployment for the year 2020.4 The participants envisioned a significant expansion of the pharmacist workforce and a shift in their roles and responsibilities from order fulfillment to patient care. Based on a needs forecast, they estimated that by 2020 there would be a 27% decrease in the number of pharmacist full-time equivalents (FTEs) engaged predominantly in order filling (136,400 to 100,000) and an increase in the pharmacist FTEs providing primary patient services (30,000 to 165,000). Overall, they projected a need for 417,000 pharmacist FTEs by 2020, and given the expected supply of only 260,000 pharmacist FTEs, a shortfall of 157,000 by 2020.4 However, their analysis assumed that the academy would add only 3 new PharmD programs every 10 years.

The size of the academy was relatively stable during the 1980s and 1990s. In 2000, there were 80 colleges and schools of pharmacy in the United States. Since then, 48 new programs have been established and 2 schools combined into 1 college, bringing the total to 127 accredited colleges and schools as of fall 2012—a 60% increase from 2000"

 

[Reaganite]

I don't know if it's been said enough, but seriously: kudos to all of you on this board for what you've done.

 

[evilbooyaa]

I don't know if it's been said enough, but seriously: kudos to all of you on this board for what you've done.

I'm just glad that it is finally getting some mainstream recognition. It appears it took a drop in med student applicants for folks to ask: "How can we improve the resident experience in Radiation Oncology". I suppose we have an incentive-based model all around, so when they learned that the pipeline of academically outstanding residents was drying up it was time to at minimum admit there is a problem. Step 1 to fixing a problem.

 

[Haybrant]

I don't know if it's been said enough, but seriously: kudos to all of you on this board for what you've done.

thank you Reaganite