Why is rad onc not more competitive?

[yesmaster]

Why?

The fact that they’re rad onc’s is, frankly, irrelevant to their success.

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[drowsy12]

The fact that they’re rad onc’s is, frankly, irrelevant to their success.

Sure. What does that have to do with them having a more successful career in med onc?

 

[drowsy12]

Also:

‘The academics who publish on nomograms, machine learning, big data on Lupron duration using retrospective studies, those rad oncs probably would be PI’s of phase 3 trials and heads of phase I/II centers if they’d gone into med onc.’

Seems a bit like magical thinking.

Also ignores the vast majority of what academic med oncs do. Very few are heard of phase I centers.

 

[yesmaster]

What are the appealing IM subspecialties in your opinion? GI and med onc? I feel like everyone on this forum trashes on IM

In order of appeal:

1. GI, heme onc
2. Cardiology
3. Critical care/pulmonology
4. Sleep

IM by itself is not the greatest, being a hospitalist is not a great job to me, but then again rad onc’s typically dislike inpatient environments.

 

[yesmaster]

Also:

‘The academics who publish on nomograms, machine learning, big data on Lupron duration using retrospective studies, those rad oncs probably would be PI’s of phase 3 trials and heads of phase I/II centers if they’d gone into med onc.’

Seems a bit like magical thinking.

Also ignores the vast majority of what academic med oncs do. Very few are heard of phase I centers.

Is it?

At the same career level, I see med onc’s have more opportunities and doing more substantive work in academics than their rad onc counterparts.

If you take the top or most senior 5% of academics in both fields, what I said is ballpark correct. Feel free to disagree. I don’t work in academics so I may be wrong or outdated.

 

[drowsy12]

I absolutely agree that med oncs have more Industry opportunity as well as more access to trial based research. I don’t agree that people with unique skills like Tim Chan would have had more success in med onc. Kind of hard to beat what he has done.

But to be clear, the vast majority of academic med oncs are not doing these high level things.

But anyways I don’t think this aspect is that important to most of us or most med students.

We all got research on our resumes to match into rad onc, but for most of us, it was a means to an end, not the goal.

 

[Doctorer]

Is it?

At the same career level, I see med onc’s have more opportunities and doing more substantive work in academics than their rad onc counterparts.

If you take the top or most senior 5% of academics in both fields, what I said is ballpark correct. Feel free to disagree. I don’t work in academics so I may be wrong or outdated.

Nope, you're right. At least at major academic medical centers, the average medical oncologist will have significantly easier/more opportunities to get industry sponsored research going.

 

[TexasMed22]

FWIW, at my academic center the average medonc is making like half as much as the average rad onc. Grass is not always greener

 

[elementaryschooleconomics]

FWIW, at my academic center the average medonc is making like half as much as the average rad onc. Grass is not always greener

Uh

Does your center have excellent location or high prestige? There has to be something else going on there.

Because I know MedOncs making twice as much as me.

 

[drowsy12]

The AAMC academic salary data is pretty clear - rad oncs make significantly higher across the board at each percentile or promotion level. Not the whole story but reflective of places that are rank level ‘main site’ academic type places. Not true of all places

 

[elementaryschooleconomics]

Not the whole story

Understatement of the century.

The benchmark data is...more convoluted than people might think.

The AAMC is like the Human Resources Department for medicine: it protects the organization, not the employee.

Here's a recent (2021) slide from AAMC/Sullivan Cotter drilling down on where numbers might come from.

My favorite part is the 41% "Chair Discretion" for base, and 59% "Chair Discretion" for variable:

 

[drowsy12]

there's no question that academic salaries are associated with little transparency.

academic salaries are generally higher in rad onc than in med onc.

most main site true academic med oncs I am aware of work 4-6 half clinics a week (so 2-3 days in clinic). Their expectations for clinical productivity are lower, and their salaries are a good amount lower as a result as well. on AAMC it's about a 20-25% lower.

for example, numbers I have from some 3-4 years ago now - median/mean/75th for professor in rad onc was 530/550/615 whereas med onc was 390/415/480

pseudo-academic network/satellite rural/smaller city sites can be different, as it's hard to get med onc out there, and they can demand a premium

 

[metallica81788]

3) While many of us think "home call" is easier than hospital call (myself included), it means you can't really go anywhere or commit 100% to things on nights and weekends. Is your kid having a birthday party on Saturday at 1PM? Ah darn, cord compression page at 12:30PM. Spouse spontaneously suggests camping with friends at a park ~4 hours away? Ah can't, on call.

As someone who is on call 24/7 unless I am on vacation, I'm going to disagree with this point. I work in a historically difficult-to-staff place an hour away from a mid sized city (where I live). I put in a ton of work running this department during the week to be bothered on the weekend.
I will generally always answer my phone, buy my "call" doesn't prevent my from doing anything in my personal life. When I leave work, I am off unless the rare patient or inpatient call comes through. If I happen to be doing something personally or with my family when something I truly am needed for comes in, the answering service can wait for me to get back to them or the patient can go to the emergency room (although not preferred) where acute intervention can actually happen.
I can use Epic app to look at images, notes, etc, and decide what is truly important for me to do at that moment. It takes me a minimum of 50 minutes just to get to the hospital if I leave instantly.

Nothing I can do on the weekend that can *actually make a difference is truly that urgent. There are rare situations - treated a bleeding mass just this weekend. The answering service can leave me messages and other inpatient services generally agree with my approach and will send the appropriate patients that need surgical evals where they need to go (bigger more well-staffed centers not too far from me).
Luckily, these episodes are rare. If that ever changes, I will have to strongly consider changing jobs.

One thing that is a holdover from academic/tertiary residencies is this idea that we are available to treat inpatients 24/7 and that it actually matters. Radoncs in those places so desperately want to be relevant and needed they will ruin multiple people's and/or families' day jumping through hoops to treat an inpatient who could have waited until the next day or Monday with no clinical difference. Steroids, pain meds, and surgery can do more over a few days than radiation can in almost all scenarios.
Some of you probably feel differently, but that is the way I approach things and it has done well for my work/life balance being solo.

 

[medgator]

As someone who is on call 24/7 unless I am on vacation, I'm going to disagree with this point. I work in a historically difficult-to-staff place an hour away from a mid sized city (where I live). I put in a ton of work running this department during the week to be bothered on the weekend.
I will generally always answer my phone, buy my "call" doesn't prevent my from doing anything in my personal life. When I leave work, I am off unless the rare patient or inpatient call comes through. If I happen to be doing something personally or with my family when something I truly am needed for comes in, the answering service can wait for me to get back to them or the patient can go to the emergency room (although not preferred) where acute intervention can actually happen.
I can use Epic app to look at images, notes, etc, and decide what is truly important for me to do at that moment. It takes me a minimum of 50 minutes just to get to the hospital if I leave instantly.

Agree. Treating on the weekends requires a call schedule of therapists/dosimetrists/physics etc, I've heard of places paying for call for them but logistically, for all intents and purposes, not sure how anyone can do this in the community these days esp if freestanding or smaller hospital with limited staffing/resources.

Our consults are almost always routine, which means 24 hours to see them. I can be out a 2-3 hour drive away and potentially see them the following weekend day or weekday so, no @elementaryschooleconomics , I don't think call impacts me that greatly, at least not to the level you describe.

Small cell, lymphoma etc can respond as quickly to chemo, bad cord compression with acute neuro sx on presentation needs a nsg more than it needs us etc.

And isn't the data on late stage/end of life/inpatient RT pretty bad? Probably not a lot out there, but anecdotally many of the pts we've treated inpt because they were admitted with whatever the RT could potentially help still end up passing away weeks or months later. So what have we accomplished?

 

[MidwestRadOnc]

As someone who is on call 24/7 unless I am on vacation, I'm going to disagree with this point. I work in a historically difficult-to-staff place an hour away from a mid sized city (where I live). I put in a ton of work running this department during the week to be bothered on the weekend.
I will generally always answer my phone, buy my "call" doesn't prevent my from doing anything in my personal life. When I leave work, I am off unless the rare patient or inpatient call comes through. If I happen to be doing something personally or with my family when something I truly am needed for comes in, the answering service can wait for me to get back to them or the patient can go to the emergency room (although not preferred) where acute intervention can actually happen.
I can use Epic app to look at images, notes, etc, and decide what is truly important for me to do at that moment. It takes me a minimum of 50 minutes just to get to the hospital if I leave instantly.

Nothing I can do on the weekend that can *actually make a difference is truly that urgent. There are rare situations - treated a bleeding mass just this weekend. The answering service can leave me messages and other inpatient services generally agree with my approach and will send the appropriate patients that need surgical evals where they need to go (bigger more well-staffed centers not too far from me).
Luckily, these episodes are rare. If that ever changes, I will have to strongly consider changing jobs.

One thing that is a holdover from academic/tertiary residencies is this idea that we are available to treat inpatients 24/7 and that it actually matters. Radoncs in those places so desperately want to be relevant and needed they will ruin multiple people's and/or families' day jumping through hoops to treat an inpatient who could have waited until the next day or Monday with no clinical difference. Steroids, pain meds, and surgery can do more over a few days than radiation can in almost all scenarios.
Some of you probably feel differently, but that is the way I approach things and it has done well for my work/life balance being solo.

I agree with (and am in the same boat as) Metallica. Am I willing to be bothered on the weekdays I cover remotely? Of course. Driving in is no easy feat however.

But to say you can’t leave town on the weekends because of a possible cord compression sim and treat, ouch. You need to be getting compensated for that, like a lot. If not you are getting hosed.

 

[elementaryschooleconomics]

As someone who is on call 24/7 unless I am on vacation, I'm going to disagree with this point. I work in a historically difficult-to-staff place an hour away from a mid sized city (where I live). I put in a ton of work running this department during the week to be bothered on the weekend.
I will generally always answer my phone, buy my "call" doesn't prevent my from doing anything in my personal life. When I leave work, I am off unless the rare patient or inpatient call comes through. If I happen to be doing something personally or with my family when something I truly am needed for comes in, the answering service can wait for me to get back to them or the patient can go to the emergency room (although not preferred) where acute intervention can actually happen.
I can use Epic app to look at images, notes, etc, and decide what is truly important for me to do at that moment. It takes me a minimum of 50 minutes just to get to the hospital if I leave instantly.

Hahaha there's no disagreement from me on this point actually.

You're not alone. I definitely know RadOncs like you around the country.

I really did spend a good chunk of time a few years ago talking to people in very different jobs/geographies, trying to get a sense of what "average" on-call setups were like.

I discovered it's...absolutely wild. There's so much variation.

I briefly entertained formally collecting the information and publishing it, but my concern was it somehow being weaponized by ASTRO/SCAROP etc etc etc

These days I mostly focus on potential "bad" butterfly effects of anything I put into the world. I didn't see how anything good could come from this data...perhaps I'm wrong.

 

[TheWallnerus]

A lot of hospitals will not let you take call if you don’t live in town, or live more than 30 minutes from the hospital, or both. Functionally this often means if you want to be a rad onc in that hospital you can’t be a “rad onc carpetbagger.” But clearly some hospitals are allowing this now.

 

[metallica81788]

A lot of hospitals will not let you take call if you don’t live in town, or live more than 30 minutes from the hospital, or both. Functionally this often means if you want to be a rad onc in that hospital you can’t be a “rad onc carpetbagger.” But clearly some hospitals are allowing this now.

For other more immediately useful specialties, this policy makes sense. It doesn't for us.

 

[Ray D. Ayshun]

If there's no in-house neurosurgery, there needn't be radonc call.

 

[MidwestRadOnc]

I agree with (and am in the same boat as) Metallica. Am I willing to be bothered on the weekdays I cover remotely? Of course. Driving in is no easy feat however.

But to say you can’t leave town on the weekends because of a possible cord compression sim and treat, ouch. You need to be getting compensated for that, like a lot. If not you are getting hosed.

SVC syndrome seems to be the best bang for your buck emergency in my experience. Just brought somebody back from the verge of death quickly with 20/5 started emergently.

 

[BobbyHeenan]

For other more immediately useful specialties, this policy makes sense. It doesn't for us.

...and if you're going to demand a rad onc take 24/7 call, then you also have to have a therapist and maybe a physicist on call too. It doesn't matter if the patient needs treatment, is seen by the rad onc, but no therapist is available. By law I believe the therapist has to be paid for their on call duty (though I have seen departments pay as little as $1/hour, then 2x hourly rate for time spent actually coming in if needed).

We cover a network of hospitals. The outlying rural hospitals make it clear they can't do emergent weekend treatments. Everything emergent gets filtered in to the metro hospitals where there is advanced interventional pulm, IR, neurosurg, and a rad onc team on call 24/7.

 

[seper]

A lot of hospitals will not let you take call if you don’t live in town, or live more than 30 minutes from the hospital, or both. Functionally this often means if you want to be a rad onc in that hospital you can’t be a “rad onc carpetbagger.” But clearly some hospitals are allowing this now.

correct. I’ve read GynOnc contracts with a hospital forbidding them to live > 30 min drive away. Have not seen a similar clause for RadOncs, however

 

[communitydoc13]

correct. I’ve read GynOnc contracts with a hospital forbidding them to live > 30 min drive away. Have not seen a similar clause for RadOncs, however

I believe this phenomenon is dying. It's a real killer for recruitment for a lot of places. There's a good sized city 45 min to 1:15 away with the best schools in the area and a job for your spouse, but you can't live there? It is better to live in the community you serve IMO (sort of like a police officer), but this just isn't always happening with today's hospitals and doctor demographics.

APPs take first call. Bridge the gap. Docs get there ASAP. Semi-rural places (central PA, up-state NY, Harrisonburg VA) make APPs. They don't make a whole lot of doctors.

Two Americas.

 

[elementaryschooleconomics]

correct. I’ve read GynOnc contracts with a hospital forbidding them to live > 30 min drive away. Have not seen a similar clause for RadOncs, however

My hospital has the clause for all medical staff regardless of specialty (it's 45 minutes though).

 

[Ray D. Ayshun]

You’re very busy. I work weekends sometimes too. MANY don’t.

I think it’s not intellectually honest to say rad onc doesn’t have a good QOL. Is it what it used to be when some were throwing a few wax drawings on and hitting the links? No. But the fact that it’s even possible to not be on site in the current environment or can leave work at 2 fares VERY favorably to many other fields. Can we be honest about this?

I agree as well, lots of radoncs can leave early and don't need to be on-site all the time. that can have other implications with respect to QOL, though, not all of which are positive.

 

[medgator]

A lot of hospitals will not let you take call if you don’t live in town, or live more than 30 minutes from the hospital, or both. Functionally this often means if you want to be a rad onc in that hospital you can’t be a “rad onc carpetbagger.” But clearly some hospitals are allowing this now.

Use an office address, or a temp address. Or move after you get credentialed and privileged. They aren't going to enforce this against an RO the same way they might against a surgeon or interventional cards

 

[medgator]

My hospital has the clause for all medical staff regardless of specialty (it's 45 minutes though).

This is exactly where I've seen it. Part of medical staff bylaws indicating where you need to reside

 

[medgator]

SVC syndrome seems to be the best bang for your buck emergency in my experience. Just brought somebody back from the verge of death quickly with 20/5 started emergently.

IR does stents, not sure how effective, i rec chemo inpatient if heme or small cell/testicular

 

[TheWallnerus]

Use an office address, or a temp address. Or move after you get credentialed and privileged. They aren't going to enforce this against an RO the same way they might against a surgeon or interventional cards

This scheme reminds me of that time I went to South Korea, made a clone of myself, and sent him back to the states to directly supervise my radiation therapies. I’m still trying to get that guy approved for the SDN rad onc business forum.

 

[UndecidedMS2]

Thank you everyone for all your comments. It was great reading all the different view points.

 

[seper]

This scheme reminds me of that time I went to South Korea, made a clone of myself, and sent him back to the states to directly supervise my radiation therapies. I’m still trying to get that guy approved for the SDN rad onc business forum.

The way life works, there is usually a price to pay for being too creative (? karma or something).

 

[CurbYourExpectations]

We are as competitive as we should be currently. The job market is temporarily better and will not persist. But even not considering that truth (most likely): RadOnc is a very niche field, the majority of people are not physics enjoyers, and there is a real likelihood that the state you want to work in may not have a job for you.

 

[TheWallnerus]

We are as competitive as we should be currently. The job market is temporarily better and will not persist. But even not considering that truth (most likely): RadOnc is a very niche field, the majority of people are not physics enjoyers, and there is a real likelihood that the state you want to work in may not have a job for you.

What are you… a physics enjoyer???

 

[CurbYourExpectations]

What are you… a physics enjoyer???

I dabble

 

[CurbYourExpectations]

What are you… a physics enjoyer???

 

[steponecloser]

For the lurkers regarding lifestyle during residency- I'm coming up on 30 days of skiing this year while in residency, which is a common number to get to. Could get to 50 if I really wanted to drive that much.

 

[MidwestRadOnc]

For the lurkers regarding lifestyle during residency- I'm coming up on 30 days of skiing this year while in residency, which is a common number to get to. Could get to 50 if I really wanted to drive that much.

If you are looking for a super chill 4 year residency and don’t care about your 40 year career, then rad onc just might be for you!

 

[steponecloser]

If you are looking for a super chill 4 year residency and don’t care about your 40 year career, then rad onc just might be for you!

I mean this forum is full of disgruntled people, and don't get me wrong, there's plenty that could be improved with leadership and whatnot. But to say rad onc is a bad career is pretty laughable. Feel free to DM me

 

[TexasMed22]

A resident telling attendings about their own speciality is certainly unique

 

[Ray D. Ayshun]

A resident telling attendings about their own speciality is certainly unique

A person who skis 30-50 days a year offering to break down the "way things are" also sounds like a skit.

 

[drowsy12]

I mean this forum is full of disgruntled people

Honestly most people here are pretty happy with their situation. I do agree that the number of truly unhappy Rad Oncs I know in real life is fairly small (maybe n of 1). I think the concerns are about the future.

 

[elementaryschooleconomics]

For the lurkers regarding lifestyle during residency- I'm coming up on 30 days of skiing this year while in residency, which is a common number to get to. Could get to 50 if I really wanted to drive that much.

This is actually my main point!!!!!

All med students and other residents get to see IS THE RESIDENCY LIFESTYLE.

It's generally good!

It's not representative.

And I also don't think anyone here has ever said the attending lifestyle was "bad" either.

It's average. Other than the, you know, geography lock.

I mean this forum is full of disgruntled people, and don't get me wrong, there's plenty that could be improved with leadership and whatnot. But to say rad onc is a bad career is pretty laughable. Feel free to DM me

What year are you?

 

[SBRTreble]

Honestly most people here are pretty happy with their situation. I do agree that the number of truly unhappy Rad Oncs I know in real life is fairly small (maybe n of 1). I think the concerns are about the future.

I tend to agree with this - I'm pretty happy with this field and find it incredibly interesting. Having said that, residency and attending are very different. It might actually help if that gap was bridged a little better.

 

[MidwestRadOnc]

A person who skis 30-50 days a year offering to break down the "way things are" also sounds like a skit.

Even with a season pass, no one is self funding 30-50 days of skiing a year (did we even have that many with this pathetically short season?) on a resident's income while also affording rent in what has got to be a HCOL western or northeastern area. This would require night skiing for a decent amount of this time since even skiing every saturday and sunday would not get you to these numbers, and I am suspicious that a rad onc resident anywhere is getting out of clinic early enough to drive to the mountains, gear up, get a couple hours of night skiing in, then drive home and get enough sleep to be at work at 7-8AM the next day. Vail does not have a rad onc residency so we are talking about at least 1 hour from denver in perfect conditions and no traffic, which if you've ever done this is less than half the time. Salt Lake City to the canyons is closer, sure but I've been stuck, and is the only location I can think of off the top of my head where this would even be remotely doable.

If you are independently wealthy and like the work, sure, rad onc is not a "bad career." There is certainly no shortage of people who fit this bill in the field, especially in the heyday of top USMLE scores reflecting the end of the prep school-->ivy league-->family/trust fund supported T10 med school pipeline.

 

[steponecloser]

This is actually my main point!!!!!

All med students and other residents get to see IS THE RESIDENCY LIFESTYLE.

It's generally good!

It's not representative.

And I also don't think anyone here has ever said the attending lifestyle was "bad" either.

It's average. Other than the, you know, geography lock.


What year are you?

I'm a signed to a great job PGY-5.

Even with a season pass, no one is self funding 30-50 days of skiing a year (did we even have that many with this pathetically short season?) on a resident's income while also affording rent in what has got to be a HCOL western or northeastern area. This would require night skiing for a decent amount of this time since even skiing every saturday and sunday would not get you to these numbers, and I am suspicious that a rad onc resident anywhere is getting out of clinic early enough to drive to the mountains, gear up, get a couple hours of night skiing in, then drive home and get enough sleep to be at work at 7-8AM the next day. Vail does not have a rad onc residency so we are talking about at least 1 hour from denver in perfect conditions and no traffic, which if you've ever done this is less than half the time. Salt Lake City to the canyons is closer, sure but I've been stuck, and is the only location I can think of off the top of my head where this would even be remotely doable.

If you are independently wealthy and like the work, sure, rad onc is not a "bad career." There is certainly no shortage of people who fit this bill in the field, especially in the heyday of top USMLE scores reflecting the end of the prep school-->ivy league-->family/trust fund supported T10 med school pipeline.

I know the skiing was horrible in the Midwest but that's not the case for the entire country. I don't know why you think what I've said is not believable. Did I take some vacation to accomplish 30 days- yes, I did. But I also haven't gone every weekend, and I'm not going during the work week. It's just a ton of driving. It is also all self funded and done frugally.

 

[Neuronix]

My residency was totally cush and my wife was an attending physician in another specialty. I could totally have skiied 50 days if I lived in a mountain area. I probably averaged about 30 hours a week of time I had to be physically present.

As an attending life has been different.

 

[medgator]

My residency was totally cush and my wife was an attending physician in another specialty. I could totally have skiied 50 days if I lived in a mountain area. I probably averaged about 30 hours a week of time I had to be physically present.

As an attending life has been different.

Definitely worse hours in practice than in residency at times, but I'm being compensated appropriately and no scut. Geography is the big elephant in the room, imagine being in a decent area for residency with a cush schedule and then having to move to bfe to work harder with no other options.

 

[drowsy12]

My residency was not Cush per se. Rad onc residency depending on the program and how well trained you want to be IMO requires a lot of out of work prep time and studying.

Attending life is different but you have more autonomy and control and aren’t seeing someone else’s followups. Still work.

Both different, neither ‘easy’ but pretty decent overall on both sides for being a physician.

 

[Ray D. Ayshun]

Some of these arguments are fallacious in that they seem to be based on the premise that most of us went into radonc in order to do as little as possible. If, on the other hand, most of us went in to radonc for more noble reasons and looked forward to being busy, then being under-used might actually be undesirable.

 

[Neuronix]

Definitely worse hours in practice than in residency at times, but I'm being compensated appropriately and no scut. Geography is the big elephant in the room, imagine being in a decent area for residency with a cush schedule and then having to move to bfe to work harder with no other options.

Our cohort of rad oncs went from hyper competition for residency to hyper competition for jobs. I've never felt that location was under my control.

At least the current cohort has a lot of choices when it comes to residency programs. They're also well aware of the job market. I think expectations are a lot lower now, and grads are more pleasantly surprised with outcomes given the degree of gloom and doom.