VVPN Livestream 7PM EST, "What Did We Learn from 2021 Match?"

[w00tz]

My explanation is ignorance and denial. Many have not considered the implications of overtraining (i.e. lower salaries). I was PD for >15 years at two programs and every year I asked the residents if they wanted more residents in the program. Every year the majority said yes. I held the complement steady but I eventually couldn't convince the faculty that growth was a bad thing and I stepped down and the complement increased. I have not worked with a resident on my service in more than 3 years. My meager contribution to trying to slow growth.

I talked a current PGY3 resident recently about the SOAP and he said he wanted his program to fill through the SOAP instead of going unfilled....because he would have to take less call with more residents! I was quite sad to hear this. It made me realize things are not going to change quickly or any time soon.

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[Mandelin Rain]

I talked a current PGY3 resident recently about the SOAP and he said he wanted his program to fill through the SOAP instead of going unfilled....because he would have to take less call with more residents! I was quite sad to hear this. It made me realize things are not going to change quickly or any time soon.

Yeah. Less residents means more work for current residents. More calls to take. More lectures to give. More services to cover. More notes to write. More circles to draw. More BS retrospective reviews to be forced into.

the whole nine

 

[Ray D. Ayshun]

I think we all have some form of radonc Stockholm syndrome

We all love the field and are trying to fix it

We cheer when we see progress, albeit minuscule

Hard to battle the machine who refuses to admit their is an issue and tries to recruit more raw numbers daily

As far as I can tell, the machine is still refusing to admit it. One can look at this livestream as a recognition of the problem by faculty and a step towards resolution. One can also look at it as a "jump the shark moment," where there's a dramatic attempt to save the viewership that in the end is meaningless and embarrassing. I see it as the latter. I think med students will too, and given that the program run by the president elect soaped a candidate, in what fantasy world would anyone think this any more than misdirection, intentional or not?

 

[CurbYourExpectations]

I would gladly take double the amount of call if it meant the oversupply issue would be fixed.

 

[elementaryschooleconomics]

I talked a current PGY3 resident recently about the SOAP and he said he wanted his program to fill through the SOAP instead of going unfilled....because he would have to take less call with more residents! I was quite sad to hear this. It made me realize things are not going to change quickly or any time soon.

I was rooting hard for my program to go unmatched and not SOAP.

As I talked to others in my department, I discovered one of three attitudes regarding this:

1) My own, from people who are concerned about the overall health of the field (and to "stick it" to my program).

2) The faculty were morbidly afraid of not matching because it would "reflect poorly on them" and "the [institution] might take away funding for those spots if we don't fill and give it to a different specialty" and "we deserve to Match, because we provide good training gosh darnit".

3) There were some residents who were worried not so much about the increased workload with fewer residents, but more about the perceived "loss of prestige" if we went unfilled. As I said earlier, everyone wants to be wanted. The junior residents felt that if we began to go unfilled, it would be a negative comment on our department and this would negatively affect them in their own job search.

As I have begun to talk more and more openly about this in real life as the tides have turned with continued medical student disinterest, one of the main things I've learned is how tightly people tied their identity to the prestige of Radiation Oncology.

Cutting spots is an explicit acknowledgement that the field is bloated, in trouble, and has been led down the wrong path, which is a huge hit to egos. Right now we're still in a denial phase, where, to paraphrase Potters - "if the med students are voting with their feet, they must know something we don't!"

 

[medgator]

Yes! When I rotated as a med student in 2012, the residents were signing contracts in July-Oct in their geographic preference. In residency, I watched my senior residents struggle more and more each year - interviewing in towns I had never heard of just to get close-ish to their preferred location and signing later and later. It was such a radical change in a short period of time for me. I remember in my PGY3 year I started having this really sinking feeling about the job market and where I would potentially end up. I started prepping my wife mentally about the possibility of ending up in BFE for maybe a couple years, saving aggressively, then FIRE. Fortunately, the stars aligned and I ended up in what I considered a decent job. But I also really lowered my standards of what I considered a decent job over the years (must have decent biriyani) after seeing where my senior residents were going (some had no biriyani). I'm sure it's only gotten worse since then and will continue to get worse. I see no light at the end of this tunnel right now. I feel bad for current residents. Future residents are at least aware of what they signed up for.

Definitely saw that story play out in my metro area... Most open time for jobs in 2008-2013.... Pretty much all filled by 2015 or so.

Finally one opened up this year because of malignant hospital administration at a competing practice. That position was filled literally in a month by a BC grad with experience who had been trying to move to the general geographic area. 5+years ago, no one would take that job given the hospital's rep

 

[elementaryschooleconomics]

Definitely saw that story play out in my metro area... Most open time for jobs in 2008-2013.... Pretty much all filled by 2015 or so.

~10 years ago, a current faculty member at my institution was able to get multiple (2-3) job offers in our geographic area (~1 hour drive in any direction), which they used to leverage a better position with our Chair (common academic technique).

This year, there was only one job available in an even larger (but similar) geographic area, and the competition was fierce (and it did not go to someone from my institution).

 

[TheWallnerus]

~10 years ago, a current faculty member at my institution was able to get multiple (2-3) job offers in our geographic area (~1 hour drive in any direction), which they used to leverage a better position with our Chair (common academic technique).

This year, there was only one job available in an even larger (but similar) geographic area, and the competition was fierce (and it did not go to someone from my institution).

Next 5 years as the Grand Rad Onc Experiment unfolds and programs try to inject ~1000 grads into the workforce it's going to be like those scary, grotesque experiments you used to read about in old Mother Russia. Sure the scientists learned some things, but at what cost?

 

[RickyScott]

Ylearned is how tightly people tied their identity to the prestige of Radiation Oncology.

Exactly, and if you meet some of these guys in person (new hampshire group) and the one from SERO, it is very obvious.

 

[Med Director New England]

Yeah, I wonder this as well. People that will encourage new people to go in to the field on social media who never considered it or those that will say things to the tune of people they know are getting jobs right now.

Do they not realize that the whole concern is the future of the field? There is a 5 year lag with 1000 people entering the work force. THAT IS ~20% of current RadOncs, without any sign that there is an increased demand and job openings. If that rate continues there will be 7000 radoncs in the USA, unfortunately there is a decreasing demand with less people getting radiation and RadOncs will be able to treat more patients as a result of hypofractionation. All signs pointing towards less jobs, not more. So... what is the gain?

To encourage someone with options and loads of debt to go into a field with the most uncertain future, unless they are extremely interested in RadOnc in general is a little concerning. It is a tough sell to be in a lot of debt as a US medical student and to go into the field with the least certainty in the future. Half of the field is mad at the other half of the field, is this the case in any other specialty?

I hope things work out and everyone gets jobs in a place where they can find happiness, but... what if they can't? What if a lot of people can't? What if some people start going unemployed and can't get back into residency because they are now >5 years out of medical school? What if the people you are trying to entice into a field that they previously had no interest in are now unemployed and >200k in debt? Is that okay?

Fix the issues, educate the students about everything (positives and negatives), and then encourage them to join the field. In that order. These are real people, the residents in training are real people, the young attendings are real people. It does no help to patients to have an oversupply and unemployed doctors with loads of debt.

Yes, treating patients with cancer is a true honor, and it is an interesting field. We all agree on this, literally everyone, even the biggest troll on twitter/sdn/reddit/google docs.

Half the field mad at each other ....
There is another field with exactly the same problem - pathology.

the key difference is the decreasing US med student interest in path training spots is being me with IMGs and not soap’ing.
It has become mainstream for 2nd and 3rd tier programs in path to fill every spot with IMG.
In path there is a growing contingent of folks raising the same concerns about training in excess of job demand. I am not aware of any path residency reducing spots yet. At least rad/onc has taken that first step.

 

[medgator]

. I am not aware of any path residency reducing spots yet. At least rad/onc has taken that first step.

We should start a thread documenting this maybe? I get the sense it's "pissing in the wind" unfortunately when you look at it in relation to the total or even where spots were a decade or two ago

 

[Neuronix]

Where'd my man Tom T. Thespian post this putrescent, dissembling drivel. On the tweet tweet? Can't find it. Lemme know. I'll at-at him faster than an Imperial walker.

ASTRO forum.

"Are we over training the number of Radiation Oncologists?" thread -- Originally started in 1/14/19 and discussed on SDN previously.

There was a post yesterday (and then edited by ASTRO moderator staff for some reason?)

And here we are... Over two years later with the problem only getting worse. Great livestream from multiple parties regarding the issue this week

and Tom Eichler's reply:

ASTRO appreciates the University of Colorado Department of Radiation Oncology's leadership in convening the most recent Virtual Visiting Professor Network session, and to the panelists who shared their perspectives about the 2021 Match. Insofar as many important concerns were raised, ASTRO will examine how we can work together to best address these issues. As previously outlined in a series of blog posts and the recently released workforce statement, ASTRO, as a membership organization, has no role in the selection of residents by institutions, but we also recognize that the Society has a strong influence on the culture of the specialty and certain aspects of workforce training. We aspire to be an inclusive organization, take this feedback seriously and seek to bridge divisions, working together to address the protean challenges that confront us.

Blog posts:
A Commitment to the Field - Dr. Theodore DeWeese, March 10, 2020
The Residency Training Landscape, Continued - Dr. Paul Harari, May 28, 2019
The Residency Training Landscape - Dr. Paul Harari, March 20, 2019

I agree with the sentiment that this is a bunch of words that amount to nothing. ASTRO--if you really appreciated Simul Parikh's perspective, why were his posts deleted from the ASTRO forum?

Similarly, I would have liked to criticize Potters for his rambling speech during the seminar, most of which was unrelated to the matter at hand. I have seen this a lot from chairs and other "leaders"--they tend to ramble on about some nonsense until they're out of time or nobody wants to talk to them anymore because they realize they'll get nothing out of the discussion. But, I actually did like the SCAROP letter to the RRC. If implemented, that could actually make some meaningful change in the number of residency positions. Knowing many of the RRC members personally, I don't think that this is something they truly intend to push through, but I'd be happy to be pleasantly surprised.

We should start a thread documenting this maybe? I get the sense it's "pissing in the wind" unfortunately when you look at it in relation to the total or even where spots were a decade or two ago

Hopefully I'm not being overly pessimistic when I point out that a lot of programs have variability in the number of residents they take per year, and I know that more than one just decided to more recently take some down years in residency numbers without actually committing to long-term contraction. I strongly suspect we'll see upticks again in many of those programs in future years rather than take permanent losses in residency positions. I also heard that Harvard cut one of its training sites due to some issue, and I wonder if that led to one spot being reduced regardless of the job market issues.

Next 5 years as the Grand Rad Onc Experiment unfolds and programs try to inject ~1000 grads into the workforce it's going to be like those scary, grotesque experiments you used to read about in old Mother Russia. Sure the scientists learned some things, but at what cost?

While we're on the topic of job boards... I love that if you sign up for job notifications from ASTRO's "career center", 90% of what is e-mailed are jobs in other specialties. There are many days where you get the e-mail from the ASTRO job board and it just lists 10 jobs in other specialties without a single job in rad onc. I mean... What is the meaning of this? Why should rad oncs get almost all of their job notifications for jobs other specialties? Is even ASTRO stealthily suggesting we go into another specialty?

 

[Med Director New England]

We should start a thread documenting this maybe? I get the sense it's "pissing in the wind" unfortunately when you look at it in relation to the total or even where spots were a decade or two ago

I am a mid career path btw.
I follow the rad / onc boards b/c I am certain my field is heading toward the same bad outcome as rad / onc. Just at a slower pace b/c we are bigger and paths can go into pharma or a non clinical job as a lab director after path training. Path leadership in academia is currently & firmly in the denial phase.

I applaud this group for raising awareness on SDN. I hope path will learn some lessons from the rad onc world.

 

[elementaryschooleconomics]

I am a mid career path btw.
I follow the rad / onc boards b/c I am certain my field is heading toward the same bad outcome as rad / onc. Just at a slower pace b/c we are bigger and paths can go into pharma or a non clinical job as a lab director after path training. Path leadership in academia is currently & firmly in the denial phase.

I applaud this group for raising awareness on SDN. I hope path will learn some lessons from the rad onc world.

RadOnc is an interesting case study in medicine, as a one of the smallest specialties you can Match into directly from med school with a very limited scope of practice (tied to a machine). Our problems can develop more quickly and more intensely due to our small size.

It's frustrating, because obviously RadOncs have other skills which can translate to other positions but no one knows who we are or what we do, and it can be difficult.

This is, of course, documented in my favorite "bottom feeding catfish" paper by Dr Halperin, Chancellor and CEO of New York Medical College:

Why Have So Few Radiation Oncologists Become U.S. or Canadian Medical School Deans or University Presidents?

 

[TheWallnerus]

ASTRO forum.

"Are we over training the number of Radiation Oncologists?" thread -- Originally started in 1/14/19 and discussed on SDN previously.

There was a post yesterday (and then edited by ASTRO moderator staff for some reason?)



and Tom Eichler's reply:



I agree with the sentiment that this is a bunch of words that amount to nothing. ASTRO--if you really appreciated Simul Parikh's perspective, why were his posts deleted from the ASTRO forum?

Similarly, I would have liked to criticize Potters for his rambling speech during the seminar, most of which was unrelated to the matter at hand. I have seen this a lot from chairs and other "leaders"--they tend to ramble on about some nonsense until they're out of time or nobody wants to talk to them anymore because they realize they'll get nothing out of the discussion. But, I actually did like the SCAROP letter to the RRC. If implemented, that could actually make some meaningful change in the number of residency positions. Knowing many of the RRC members personally, I don't think that this is something they truly intend to push through, but I'd be happy to be pleasantly surprised.



Hopefully I'm not being overly pessimistic when I point out that a lot of programs have variability in the number of residents they take per year, and I know that more than one just decided to more recently take some down years in residency numbers without actually committing to long-term contraction. I strongly suspect we'll see upticks again in many of those programs in future years rather than take permanent losses in residency positions. I also heard that Harvard cut one of its training sites due to some issue, and I wonder if that led to one spot being reduced regardless of the job market issues.



While we're on the topic of job boards... I love that if you sign up for job notifications from ASTRO's "career center", 90% of what is e-mailed are jobs in other specialties. There are many days where you get the e-mail from the ASTRO job board and it just lists 10 jobs in other specialties without a single job in rad onc. I mean... What is the meaning of this? Why should rad oncs get almost all of their job notifications for jobs other specialties? Is even ASTRO stealthily suggesting we go into another specialty?

Twenty-five years ago ASTRO was screaming that there were too many rad oncs. Now we get hopes & prayers from Tom.

 

[deleted969641]

As I have begun to talk more and more openly about this in real life as the tides have turned with continued medical student disinterest, one of the main things I've learned is how tightly people tied their identity to the prestige of Radiation Oncology.

I find it funny to think people value prestige in their role as a radiation oncologist in a world where most people, including many doctors, don't even know what that is. In my time as a radiation oncologist, I was treated as a low level employee and was disrespected as a physician on a daily basis by non-physician staff members (hospital admin, department manager, dosimetrist, etc.). The theme from admin was that I was not valuable and was severely overpaid for operating an x ray machine in the basement.

Whereas admin constantly fawns over subspecialist surgeons and don't bat an eye at paying them 1M/year. Staff members would not dare offend them or insult them on a professional level.

Eventually you just give up and accept your role as a technician. The fight on a daily basis to convince everyone else that you're a physician is too exhausting. Let alone trying to convince anyone that you actually deserve a fair portion of the professional fees you generate.

ASTRO forum.



and Tom Eichler's reply:


ASTRO appreciates the University of Colorado Department of Radiation Oncology's leadership in convening the most recent Virtual Visiting Professor Network session, and to the panelists who shared their perspectives about the 2021 Match. Insofar as many important concerns were raised, ASTRO will examine how we can work together to best address these issues. As previously outlined in a series of blog posts and the recently released workforce statement, ASTRO, as a membership organization, has no role in the selection of residents by institutions, but we also recognize that the Society has a strong influence on the culture of the specialty and certain aspects of workforce training. We aspire to be an inclusive organization, take this feedback seriously and seek to bridge divisions, working together to address the protean challenges that confront us.

The use of the word "protean" tells me everything I need to know about this man. He certainly hasn't accepted his role as a technician.

Of course academics and national organizations are filled with smug elitists. It's funny to see it when it occurs in private practices too (When you see a large practice that only hires out of Harvard and MDACC). It's increasingly difficult these days to come out of the training pipeline and navigate through the toxic exploitative waters of academics and private practices to find a rare place inbetween a hospital where you are viewed as an overpaid circle drawer and a prestigious practice of therapeutic radiology where people are obsessed with delighting in the superior smells of their own farts all day.

 

[fiji128]

While in general I think its great that everyone is somehow now on board for at least have some increased standards for residency training, I would like to review some very recent history regarding the RRC that may call into question how serious any of this talk actually is.

March 2019 the ACGME releases proposed changes for radiation oncology programs requirements.
https://www.acgme.org/Portals/0/PFA...t/430_RadiationOncology_2019-04-01_Impact.pdf

Pasted from else where on SDN:

-No increase in EBRT cases from 450 and no distinction between definitive and palliative?
-No increase in SBRT/ SRS cases? Still require more peds cases than SBRT to graduate...
-Only four FTE rad oncs at the main site seems like a very low bar to open a program...
-Programs with <6 residents will be "allowed time to increase their complement" was a painful sentence to read
-Going from 5 to 7 interstitial cases is barely even a change, not sure what that will actually accomplish educationally or otherwise
-They are really taking the rad bio faculty presence seriously I assume in light of the high boards fail rate and I'm happy to see some changes being made but it's funny because the actual problem was just the Angoff method and the decision to fail too many people
-Residents can now do up to 350 simulations a year (up from 250 simulations a year).


ACGME releases the final changes in September 2019 due to take effect July 2020.

https://www.acgme.org/Portals/0/PFAssets/ProgramResources/RadiationOncology_Summary_PR-Changes2019.pdf?ver=2019-08-26-120824-023

- Personal: Must be a PD with 20% of protected admin time. There must be a core faculty member-to resident ratio of at least 0.67 FTE faculty members for every resident in the program.
- Program size: The proposed requirement to included an increase in the minimum number of resident positions offered by the programs was removed and will remain unchanged at 4 resident minimum.
- Simulations: During the course of their residency program, residents should perform no more than 350 simulations (previously 250 simulated patients) with external beam radiation therapy per year. With the change from “patients” to “simulations,” the RCC expects logged procedure number to inflate, as a given patient may undergo multiple simulations by one (or more) residents.
- Brachytherapy: resident must perform at least 7 (previously 5) interstitial and 15 intracavitary brachytherapy procedures, with at least five being tandem-based insertions for at least two patients, and no more than five being cylinder insertions.
- Radiopharm: The number of radioimmunotherapy, other targeted therapeutic radiopharmaceuticals, or unsealed sources was increased from six to eight procedures
- Educational: Programs must have efforts in at least three of the following: Research in basic science, education, translational science, patient care, or population health; Peer-reviewed grants; Quality improvement and/or patient safety initiatives; Systematic reviews, meta-analyses, review articles, chapters in medical textbooks, or case reports; Creation of curricula, evaluation tools, didactic educational activities, or electronic educational materials; Contribution to professional committees, educational organizations, or editorial boards; Innovations in education.
- Resident scholarly activity: Residents must complete at least one investigative project, which must be submitted for publication in peer-reviewed scholarly journals or for presentation at scientific meetings. Previously, this requirement indicated that the project must be suitable for publication.


Obviously all of this is basically just a joke in terms of raising the standards in any substantive and meaningful way. The final rule changes were basically put in place (not even a year ago) seemingly to protect low quality unnecessary programs. Now all the sudden I'm supposed to believe that SCAROP cares about program training standards after previously fighting against them?


The only way forward is reducing training spots (probably drastically). The only way of doing that is by having real standards for training programs so that those programs that can't provide that training will close or reduce complement. Personally, I don't see that ever happening. Just way too much conflict of interest from those at the helm of the ship.

Review Committee Members

www.acgme.org

In my view, as stated elsewhere, the only real way forward is folding everything back into radiology as a fellowship so the market can be allowed to dictate the size of the specialty.

 

[dieABRdie]

I find it funny to think people value prestige in their role as a radiation oncologist in a world where most people, including many doctors, don't even know what that is. In my time as a radiation oncologist, I was treated as a low level employee and was disrespected as a physician on a daily basis by non-physician staff members (hospital admin, department manager, dosimetrist, etc.). The theme from admin was that I was not valuable and was severely overpaid for operating an x ray machine in the basement.

Whereas admin constantly fawns over subspecialist surgeons and don't bat an eye at paying them 1M/year. Staff members would not dare offend them or insult them on a professional level.

Eventually you just give up and accept your role as a technician. The fight on a daily basis to convince everyone else that you're a physician is too exhausting. Let alone trying to convince anyone that you actually deserve a fair portion of the professional fees you generate.



The use of the word "protean" tells me everything I need to know about this man. He certainly hasn't accepted his role as a technician.

Of course academics and national organizations are filled with smug elitists. It's funny to see it when it occurs in private practices too (When you see a large practice that only hires out of Harvard and MDACC). It's increasingly difficult these days to come out of the training pipeline and navigate through the toxic exploitative waters of academics and private practices to find a rare place inbetween a hospital where you are viewed as an overpaid circle drawer and a prestigious practice of therapeutic radiology where people are obsessed with delighting in the superior smells of their own farts all day.

Took the words right out of my mouth. The idea of "prestige" as a radiation oncologist is laughable. I certainly didn't do it for that and could not care less.

 

[communitydoc13]

The only way forward is reducing training spots (probably drastically). The only way of doing that is by having real standards for training programs so that those programs that can't provide that training will close or reduce complement.

I just don't think you are going to "standard" your way out of this, nor do I think the standards are that meaningful to begin with. (They should be there, but I doubt standards can be transformative).

Number of sims? What does that even mean? Were you fabricating the vac bag and placing the block between feet? Did you contour every structure or just the CTVs. Did you review the final plan from dosi? A sim counted basically means you were on service for the sim or went down to the sim room for the scan. It may or may not mean all or some of the above. Nor do you have to fabricate 200 vac bags or any such nonsense to be a good radonc. Two sims a week taken from beginning to end could be better than 5 sims a week where you were present for scan and attending contoured final structures and didn't go through review of plan.

None of the standards regarding interstitial brachy are adequate for a new grad to do interstitial on me. We all know that you can get through 5-7 interstitial cases without ever being fully independent or confident or certainly able to to problem solve on the fly. I personally think there should be an optional interstitial certification with pretty high standards, (20 independent cases?) which would be required to practice brachy outside of basic GYN work.

Research time or other initiative? Basically meaningless. Use same standards as IM. Maybe one abstract total? Minimum standard for research should be very low.

 

[RadOncMegatron]

Took the words right out of my mouth. The idea of "prestige" as a radiation oncologist is laughable. I certainly didn't do it for that and could not care less.

haha so true. We are so entrenched in the field that in the real world we have to say we are oncologist because when we say radiation oncologist people get confused with radiology (you know you do it!). Also, we see urology and ENT as high-powered subspecialties, but most people I meet laugh and go "oh the PP docs" and "why would you want to clean out ears and look in noses." If you pull a regular person off the street, they don't know Urology and ENT are surgical subspecialists. TL;DR message is Don't do this for the prestige folks!

 

[Gfunk6]

Posts on this thread from medical students who initially were interested in Rad Onc and invested appropriately, only to later realize their future and successfully switch to another specialty are reassuring. I'm glad that they are doing their due diligence and making decisions that align with their professional aspirations.

On the other hand, it is sad for me to read posts which essentially say "I quit. Rad Onc, so can you!" It makes this sound less like a Student Doctor Network and more like Narcotics Anonymous.

Never forget this was what Anthony ZIetman proposed as the correct solution to over supply.

This was from my posting history almost exactly five years ago:

He raised the concept of the "canary in a coal mine." In other words, medical students will weight their future prospects in RO vs. the "toxic smell" of the drawbacks of the field. If fewer med students apply, the field will become less competitive and the # of radiation oncologists will eventually self-regulate.

 

[CurbYourExpectations]

For a real difference to be made if scarbs data is accurate, even the top programs would have to cut spots drastically (3 spots a year at the top top programs). Most other residencies would have to go down to one spot a year. Most of the programs who have been vocal about there being a need to change have not yet done so.

 

[Chartreuse Wombat]

Posts on this thread from medical students who initially were interested in Rad Onc and invested appropriately, only to later realize their future and successfully switch to another specialty are reassuring. I'm glad that they are doing their due diligence and making decisions that align with their professional aspirations.

On the other hand, it is sad for me to read posts which essentially say "I quit. Rad Onc, so can you!" It makes this sound less like a Student Doctor Network and more like Narcotics Anonymous.

Never forget this was what Anthony ZIetman proposed as the correct solution to over supply.

This was from my posting history almost exactly five years ago:

US medical graduates are getting (sending?) the message. Yet we are still training 180 new people per year.

 

[OTN]

Posts on this thread from medical students who initially were interested in Rad Onc and invested appropriately, only to later realize their future and successfully switch to another specialty are reassuring. I'm glad that they are doing their due diligence and making decisions that align with their professional aspirations.

On the other hand, it is sad for me to read posts which essentially say "I quit. Rad Onc, so can you!" It makes this sound less like a Student Doctor Network and more like Narcotics Anonymous.

Never forget this was what Anthony ZIetman proposed as the correct solution to over supply.

This was from my posting history almost exactly five years ago:

Dr. Anthony Zietman and Dr. Benjamin Smith were not only wrong five and ten years ago, respectively, they were spectacularly wrong. Not only has the market for radiation oncologists gone in precisely the opposite direction as predicted, programs have simply SOAPed to fill their spots, as anyone could easily have predicted.

In fact, they were so very wrong, one has to ask whether they truly did the work to try and evaluate the field, or started with the conclusion they preferred and worked backwards from there. I'll never be convinced it wasn't the latter.

 

[RadOncMegatron]

For a real difference to be made if scarbs data is accurate, even the top programs would have to cut spots drastically (3 spots a year at the top top programs). Most other residencies would have to go down to one spot a year. Most of the programs who have been vocal about there being a need to change have not yet done so.

To make a bad situation worse, what will happen if all the good programs dec. spots, but none of the bad ones do? My head is hurting...

 

[TheWallnerus]

Number of sims? What does that even mean? Were you fabricating the vac bag and placing the block between feet? Did you contour every structure or just the CTVs. Did you review the final plan from dosi? A sim counted basically means you were on service for the sim or went down to the sim room for the scan. It may or may not mean all or some of the above. Nor do you have to fabricate 200 vac bags or any such nonsense to be a good radonc. Two sims a week taken from beginning to end could be better than 5 sims a week where you were present for scan and attending contoured final structures and didn't go through review of plan.

As you probably know, the simulation process meant something SO different 25 or more years ago when all these standards were being set. It really did require a dedicated simulator suite, lots of X-raying on the (usu fluoro) simulator, and fiddling and skin marking and tattooing and hanging venetian blind rods with dangling chains off of patients what not. A good well done sim could take an hour easily (and eat up a lot china markers in the process). The virtual sim did away with that. But in the old days the rad onc resident was running around the dept, sleeves rolled up, looking reeeeal busy.

 

[TheWallnerus]

Dr. Anthony Zietman and Dr. Benjamin Smith were not only wrong five and ten years ago, respectively, they were spectacularly wrong. Not only has the market for radiation oncologists gone in precisely the opposite direction as predicted, programs have simply SOAPed to fill their spots, as anyone could easily have predicted.

In fact, they were so very wrong, one has to ask whether they truly did the work to try and evaluate the field, or started with the conclusion they preferred and worked backwards from there. I'll never be convinced it wasn't the latter.

the best excuse I can make for them, summed up in a picture

 

[RickyScott]

I just don't think you are going to "standard" your way out of this, nor do I think the standards are that meaningful to begin with. (They should be there, but I doubt standards can be transformative).

Number of sims? What does that even mean? Were you fabricating the vac bag and placing the block between feet? Did you contour every structure or just the CTVs. Did you review the final plan from dosi? A sim counted basically means you were on service for the sim or went down to the sim room for the scan. It may or may not mean all or some of the above. Nor do you have to fabricate 200 vac bags or any such nonsense to be a good radonc. Two sims a week taken from beginning to end could be better than 5 sims a week where you were present for scan and attending contoured final structures and didn't go through review of plan.

None of the standards regarding interstitial brachy are adequate for a new grad to do interstitial on me. We all know that you can get through 5-7 interstitial cases without ever being fully independent or confident or certainly able to to problem solve on the fly. I personally think there should be an optional interstitial certification with pretty high standards, (20 independent cases?) which would be required to practice brachy outside of basic GYN work.

Research time or other initiative? Basically meaningless. Use same standards as IM. Maybe one abstract total? Minimum standard for research should be very low.

I am in total agreement. When push comes to shove, almost every program will comply with new standards. Going to say this until blue in the face: Even if we shut down all residencies, there still will be over 6000+ radoncs entering the 2030s

 

[fiji128]

Never forget this was what Anthony ZIetman proposed as the correct solution to over supply.

This was from my posting history almost exactly five years ago
He raised the concept of the "canary in a coal mine." In other words, medical students will weight their future prospects in RO vs. the "toxic smell" of the drawbacks of the field. If fewer med students apply, the field will become less competitive and the # of radiation oncologists will eventually self-regulate.

In rad onc we pay so much attention to prestige. Well look what Zietman said. Canary in the Coal Mine. This was brought up a ton of time in this forum as some sort of end solution. He's high up at Harvard so he must be right. Clearly, by saying things will just somehow self-regulate, he had no idea how the match works at non elite institutions (90% of programs) b/c of the scramble and now the soap.

Same with B Smith. Well he's from MDACC. He must be right. Don't even question the crazy amount of assumptions that went into that paper of his, dude is from MDACC, we must expand the number of trainee's by 50%. Can't risk even one marginal center out in the middle of nowhere being unstaffed.

 

[RickyScott]

In rad onc we pay so much attention to prestige. Well look what Zietman said. Canary in the Coal Mine. This was brought up a ton of time in this forum as some sort of end solution. He's high up at Harvard so he must be right. Clearly, by saying things will just somehow self-regulate, he had no idea how the match works at non elite institutions (90% of programs) b/c of the scramble and now the soap.

Same with B Smith. Well he's from MDACC. He must be right. Don't even question the crazy amount of assumptions that went into that paper of his, dude is from MDACC, we must expand the number of trainee's by 50%. Can't risk even one marginal center out in the middle of nowhere being unstaffed.

I am not sure Zeitman believed what he was saying about self regulation- I think he was just trying to put a gentlemanly spin on it, Give him credit for raising the issue 5+ years ago. Ben Smith work is just stupid.

 

[Mandelin Rain]

In rad onc we pay so much attention to prestige. Well look what Zietman said. Canary in the Coal Mine. This was brought up a ton of time in this forum as some sort of end solution. He's high up at Harvard so he must be right. Clearly, by saying things will just somehow self-regulate, he had no idea how the match works at non elite institutions (90% of programs) b/c of the scramble and now the soap.

Same with B Smith. Well he's from MDACC. He must be right. Don't even question the crazy amount of assumptions that went into that paper of his, dude is from MDACC, we must expand the number of trainee's by 50%. Can't risk even one marginal center out in the middle of nowhere being unstaffed.

I really don't think anyone here was buying what either of them were selling. Superficial analysis and solutions without regard to most likely logical outcome.

 

[RadOncMegatron]

I really don't think anyone here was buying what either of them were selling. Superficial analysis and solutions without regard to most likely logical outcome.

Yea, but that JCO article though...

Perhaps, have enough shame not to put it on your CV...

 

[IRattending2021]

I remember in my year of med school, someone was gunning for radonc the whole time but decided that they werent competitive enough so they went into radiology instead and matched at a Harvard program for DR.

I never seriously contemplated radonc because despite a step 1 and 2 over 250s I didn’t honor all my third year classes so I went into rad instead.

How the mighty radonc have fallen.

 

[DireMoose]

The only way forward is reducing training spots (probably drastically). The only way of doing that is by having real standards for training programs so that those programs that can't provide that training will close or reduce complement. Personally, I don't see that ever happening. Just way too much conflict of interest from those at the helm of the ship.

Absolutely have to reduce spots drastically, but as noted, the effect of that measure will take a while. What about culling the dinosaur herd? To quote Simul, "This same board [ABR] grandfathered in people who have no business contouring simple IMRT plans."

 

[OTN]

Absolutely have to reduce spots drastically, but as noted, the effect of that measure will take a while. What about culling the dinosaur herd? To quote Simul, "This same board [ABR] grandfathered in people who have no business contouring simple IMRT plans."

My understanding is that board certification represents a legal contract, so it cannot simply be rescinded by one party. That's at least how the ABIM has seen things when it comes to grandfathering.

 

[RadOncMegatron]

the best excuse I can make for them, summed up in a picture

Absolutely have to reduce spots drastically, but as noted, the effect of that measure will take a while. What about culling the dinosaur herd? To quote Simul, "This same board [ABR] grandfathered in people who have no business contouring simple IMRT plans."

Problem here is there is no formal external mechanism for adding or taking away spots, with the additional problem that taking away spots is about x10 harder than adding spots. Now we are in a very bad spot with no way to control spots and many programs in pure defiance taking whoever they can to say "hey we matched" and SOAPing to fill their spots. The system was built upon trust, shared interest, and mutual respect among physicians. This is obviously no longer the case and now people are depending upon, what?, the goodness of academic chairs to reduce spots?

Seriously, isn't the mechanism, the good will of chairs? Don't tell me a PD can do what they want without a chairs blessing. Someone tell me I'm wrong. If this is so, then really, we are screwed and can only resort to publicly shaming them and even so, can this lead to a decrease in spots? How do we incentivize decreasing spots? Sadly, it may be that we'd have to win in court to bring this thing down, but boy, that is going to be difficult...

 

[Old rad onc]

I remember in my year of med school, someone was gunning for radonc the whole time but decided that they werent competitive enough so they went into radiology instead and matched at a Harvard program for DR.

I never seriously contemplated radonc because despite a step 1 and 2 over 250s I didn’t honor all my third year classes so I went into rad instead.

How the mighty radonc have fallen.

Never be too cocky in any specialty. The future is hard to predict. Radiology may someday fall to AI and mid levels. The competition and nastiness amongst Diagnostic radiology groups is much worse than Rad Onc. Pride goeth before a fall......

 

[IRattending2021]

Never be too cocky in any specialty. The future is hard to predict. Radiology may someday fall to AI and mid levels. The competition and nastiness amongst Diagnostic radiology groups is much worse than Rad Onc. Pride goeth before a fall......

all those are true and that’s why we need to reduce rad spots. It’s a good thing that rad did not increase spot in the past 5-10 years but in my opinion with AI threat looming on the horizon, some spots need to be cut.

 

[Carrot0123]

- So why can't we be like this "Nephrologist"? Just teach M3, M4 students normally. Teach them what they need to know about oncology, whether they become PCP, surgeon or radiologist. Out of 100 students doing electives in radonc, roughly 3-5% (in my experience) decide to go into radonc, this is great, tell them honestly:

1. "This is a great field, you will do well in this field."
2. Job market is an issue, do your own research and make an informed decision.

This is basically what my mentor is doing for me. He gives me great summer research opportunities and tries his best to get me funding and organises abstracts that are not solely focussed on radiation so I don't get shoehorned into one specialty. He lets me work with the med oncs as well and isn't pressuring me to go into the field at all. Honesty one of the best doctors I've ever met and even if I don't end up going into rad onc I will always appreciate the teaching and opportunities he has given me.

 

[RSAOaky]

The second your specialty needs to be “sold” to Med students, you know it’s in the ****ter. If something is great, people do not need to be convinced that it is great. I think we need to give medical students credit for how smart and resourceful they truly are and we as radiation oncologists need to shoulder the blame for creating the elitist environment that we live in. The field has always been an embarrassment of riches but there's also a reason that even in the most competitive of times there were only slightly more applicants than there were positions.

As for programs cutting spots, I've said time and again that it's not going to happen in any significant degree without the intervention of some governing body. Kudos to MDACC and UC and everyone else for cutting spots, but it's sad that excellent training programs are putting on their big boy pants while we are still allowing programs that no one wants to be at exist or, even worse, opening up new programs that nobody wants to be at. We've learned that the "geographic maldistribution" of radiation oncology jobs will not be solved by opening programs in rural America and that's truer now than ever because the solution was right in front of us all along: pump out enough radiation oncologists to oversaturate places people want to be and we will be forced to go to places that we don't.

While everyone agrees with cutting spots, no one wants to cut THEIR spots or THEIR FRIENDS' spots. Anthony Zietman doesn't want to tell Louis Potters that Long Island doesn't need a radiation oncology residency program and Louis Potters doesn't want to tell Lisa Kachnic that Columbia's malignant and perpetually on probation radiation oncology program should be shut down either. Attendings don't want to go uncovered. Residents want better job opportunities but they don't want to cover more attendings, do more work, have more call. No one wants to "lose prestige" but yet everyone is willing to SOAP.

Everyone cares but no one cares enough to make the hard decisions and actually do something about it. Even if the job market sucks, those of us with jobs are still sufficiently content, and the only people with any power to make things change are people getting paid $750k-$2MM to do relatively little, so why would those people want to piss off their friends?

edit: some grammar and stuff

 

[Ray D. Ayshun]

The second your specialty needs to be “sold” to Med students, you know it’s in the ****ter. If something is great, people do not need to be convinced that it is great. I think we need to give medical students credit for how smart and resourceful they truly are and we as radiation oncologists need to shoulder the blame for creating the elitist environment that we live in. The field has always been an embarrassment of riches but there's also a reason that even in the most competitive of times there were only slightly more applicants than there were positions.

As for programs cutting spots, I've said time and again that it's not going to happen in any significant degree without the intervention of some governing body. Kudos to MDACC and UC and everyone else for cutting spots, but it's sad that excellent training programs are putting on their big boy pants while we are still allowing programs that no one wants to be at exist or, even worse, opening up new programs that nobody wants to be at. We've learned that the "geographic maldistribution" of radiation oncology jobs will not be solved by opening programs in rural America and that's truer now than ever because the solution was right in front of us all along: pump out enough radiation oncologists to oversaturate places people want to be and we will be forced to go to places that we don't.

While everyone agrees with cutting spots, no one wants to cut THEIR spots or THEIR FRIENDS' spots. Anthony Zietman doesn't want to tell Louis Potters that Long Island doesn't need a radiation oncology residency program and Louis Potters doesn't want to tell Lisa Kachnic that Columbia's malignant and perpetually on probation radiation oncology program should be shut down either. Attendings don't want to go uncovered. Residents want better job opportunities but they don't want to cover more attendings, do more work, have more call. No one wants to "lose prestige" but yet everyone is willing to SOAP.

Everyone cares but no one cares enough to make the hard decisions and actually do something about it. Even if the job market sucks, those of us with jobs are still sufficiently content, and the only people with any power to make things change are people getting paid $750k-$2MM to do relatively little, so why would those people want to piss their friends off?

It's hard to fully understand the resident want. As a new attending, I recognize that having a resident would slow me down and annoy the **** out of me. I'd be begging to go uncovered.

 

[RSAOaky]

It's hard to fully understand the resident want. As a new attending, I recognize that having a resident would slow me down and annoy the **** out of me. I'd be begging to go uncovered.

Young attendings, who are more likely to give a damn about resident education, are also more likely to be slowed down by residents.

Old attendings, who couldn't care less about resident education and are oftentimes outdated in their own practice, could not survive without residents.

Residents obviously care about their job prospects, but they don't want to be the fall guy unless everyone is paying a price. UC dropping a spot is a drop in the bucket. It makes no difference to the health of the job market, but it means that UC residents and attendings will suffer the consequences, so in the grand scheme of things they experience all of the heartache with absolutely no long term benefit. This is no doubt the same dilemma that any program nationally must deal with when deciding whether to cut spots or not, and given the obvious conclusion it is the reason that none do.

 

[elementaryschooleconomics]

It's hard to fully understand the resident want. As a new attending, I recognize that having a resident would slow me down and annoy the **** out of me. I'd be begging to go uncovered.

I think it depends on the setup of your department.

At my department, residents do all the "heavy lifting" of note prep before clinic, and the attendings never even look at their clinic schedules beforehand (gross generalization, there are exceptions). So they basically get to show up to a hectic clinic day, have all the information spoon fed to them by the resident presentation, double-check things they think are important with the patient/in the chart, and sign with an attending addendum of "I have reviewed and agree with Dr Elementary School's note above". The attendings have flat out told me their clinic schedules would be "unworkable" without resident coverage.

Then, for volumes, it's really just tweaking things here and there for more cases for most residents. Obviously, more junior residents or delicate cases require more attention, but if you've got a PGY5 with a peripheral lung SBRT or breast tangents? Chip shot.

Further, all patient phone calls and problem visits are routed to the residents, as well as things like FMLA paperwork and the like.

Not to mention the "research" that happens, where really the faculty might throw out ideas and our residents do all the data collection, analysis, and paper writing, with some input along the way...maybe.

Again, gross generalizations, some faculty are much more involved with things, but I assume my department is an average snapshot of how many departments work, because I have a lot of friends at a lot of institutions who tell me their experience is similar.

 

[RSAOaky]

Again, gross generalizations, some faculty are much more involved with things, but I assume my department is an average snapshot of how many departments work, because I have a lot of friends at a lot of institutions who tell me their experience is similar.

This is the way.

 

[Mandelin Rain]

This is the way.

This is the way.

 

[Ray D. Ayshun]

I think it depends on the setup of your department.

At my department, residents do all the "heavy lifting" of note prep before clinic, and the attendings never even look at their clinic schedules beforehand (gross generalization, there are exceptions). So they basically get to show up to a hectic clinic day, have all the information spoon fed to them by the resident presentation, double-check things they think are important with the patient/in the chart, and sign with an attending addendum of "I have reviewed and agree with Dr Elementary School's note above". The attendings have flat out told me their clinic schedules would be "unworkable" without resident coverage.

Then, for volumes, it's really just tweaking things here and there for more cases for most residents. Obviously, more junior residents or delicate cases require more attention, but if you've got a PGY5 with a peripheral lung SBRT or breast tangents? Chip shot.

Further, all patient phone calls and problem visits are routed to the residents, as well as things like FMLA paperwork and the like.

Not to mention the "research" that happens, where really the faculty might throw out ideas and our residents do all the data collection, analysis, and paper writing, with some input along the way...maybe.

Again, gross generalizations, some faculty are much more involved with things, but I assume my department is an average snapshot of how many departments work, because I have a lot of friends at a lot of institutions who tell me their experience is similar.

This was my experience as a res as well. But with dictation software, macros, and no proofreading, notes are quick. Plans are why I went into this, so I have no interest in abdicating that, etc. Would be fun to teach, but preferrably through conferences. In any case, I get why this won't get fixed, and why it's the **** departments that will be the problem. Would any of the attending really notice of MDACC shut down it's program from a workflow POV? Probably not. Would West Va? Yes. And that's the problem in the long-run if this is meant to fix itself without intervention by ASTRO, ABR, etc.

 

[OTN]

I think it depends on the setup of your department.

At my department, residents do all the "heavy lifting" of note prep before clinic, and the attendings never even look at their clinic schedules beforehand (gross generalization, there are exceptions). So they basically get to show up to a hectic clinic day, have all the information spoon fed to them by the resident presentation, double-check things they think are important with the patient/in the chart, and sign with an attending addendum of "I have reviewed and agree with Dr Elementary School's note above". The attendings have flat out told me their clinic schedules would be "unworkable" without resident coverage.

Then, for volumes, it's really just tweaking things here and there for more cases for most residents. Obviously, more junior residents or delicate cases require more attention, but if you've got a PGY5 with a peripheral lung SBRT or breast tangents? Chip shot.

Further, all patient phone calls and problem visits are routed to the residents, as well as things like FMLA paperwork and the like.

Not to mention the "research" that happens, where really the faculty might throw out ideas and our residents do all the data collection, analysis, and paper writing, with some input along the way...maybe.

Again, gross generalizations, some faculty are much more involved with things, but I assume my department is an average snapshot of how many departments work, because I have a lot of friends at a lot of institutions who tell me their experience is similar.

Us private practitioners always get a chuckle out of what academicians consider "unworkable." Spoiler: It's always workable.

 

[randomname2018]

I would describe most academic departments as bloated. Schedules aren't "unworkable" but more so inefficient. Scheduling staff, administrators, and nursing are almost never given instruction. When they are they generally do not answer to physicians. The typical answer is to bring on more residents and mid-levels when the answer should be top down department improvements. Leaders have little to no clinical responsibility so as long as their boat isn't rocked they don't care about the tsunami of bull****.

 

[medgator]

I would describe most academic departments as bloated. Schedules aren't "unworkable" but more so inefficient. Scheduling staff, administrators, and nursing are almost never given instruction. When they are they generally do not answer to physicians. The typical answer is to bring on more residents and mid-levels when the answer should be top down department improvements. Leaders have little to no clinical responsibility so as long as their boat isn't rocked they don't care about the tsunami of bull****.

Even for the simplest processes like getting a referral in....