Why is rad onc not more competitive?

[UndecidedMS2]

You know the work habits of 30 different academic based assistant professors, not only based on the amount of time that they spend at the office, but also the amount of work they do at home?

I don't think I know how much the other attendings in the same department as me consistently work at home, on nights/weekends/etc.
I make it a point to minimize spending time at home doing work and would rather spend an extra hour in the office as necessary, but I know my situation is not the same as others.

Obviously i don’t know what they do at home but considering they only had 4-6 consults a week, residents and APPs writing the notes, seeing the f/u and OTVs and doing the contours. They also had at least one academic day. Could they be doing some work/research at home? Sure but if I had to bet the total time they did work, mine would be on under 40 hours

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[CurbYourExpectations]

Obviously i don’t know what they do at home but considering they only had 4-6 consults a week, residents and APPs writing the notes, seeing the f/u and OTVs and doing the contours. They also had at least one academic day. Could they be doing some work/research at home? Sure but if I had to bet the total time they did work, mine would be on under 40 hours

This is kind of my point to everything. You're yourself admitting these people are not very busy. That to me should be the scariest thing to medical students. Derms and their NPs see about 40-50 patients a day and are doing procedures and working hard. If you think that just seeing 4-6 consults a week while other people do the rest of your work is a sustainable future, I have bad news for you my friend. This is a temporary now, and will not be the future for young/future RadOncs.

 

[thecarbonionangle]

A lot of academic places have the salaries as public record. I think the majority fall in $320-400k starting for assistant professors. However, in my personal experience (n≈30), they barely work 40 hours a week. Obviously those fresh out of residency might not be effiecient yet so the first couple years they might hit 45-50 but after that it’s closer to 36-40hrs. Again, it’s just my personal experience which is limited to attendings that work at main site with multiple residents and APPs.

You have a weird perception of what it is like to be an attending and if these are your expectations, you will be unhappy

 

[drowsy12]

You have a weird perception of what it is like to be an attending and if these are your expectations, you will be unhappy

To be clear there are absolutely many rad oncs who work 40-50 hours a week.

But the part where this guy thinks just because someone is at home, especially in academics, doesn’t mean they don’t have other responsibilities and stuff they’re doing, is funny.

 

[UndecidedMS2]

Yeah.

Undecided you make some points in this forum. But this thing where you think you understand what it’s like to be a rad onc attending - that ain’t it, son.

I never said that but i’ve seen people here saying “med oncs have it great” “rads have it amazing” “surgeons operating and then going to europe immediately after” all based on the personal observations so I think what I said based on my personal experience wasn’t out line. If it was, I apologize. Once again, MY PERSONAL EXPERIENCE, could be totally opposite for others, but i’ve met surgeons who have regretted picking surgery. I’ve met EM doc who loved EM but felt burnt out after just couple years. Met IM attending and resident who wished they did something else. Met IR residents who told me it wasn’t worth it and one of them is gonna do half IR/half DR… guess what? I have yet to meet a single rad onc who wished they specialized in something else. Then you come into this forum and everyone saying rad onc bad, pick something else! I’m just trying to find out the reason for such huge difference in the sentiment, that’s it.

 

[CurbYourExpectations]

I never said that but i’ve seen people here saying “med oncs have it great” “rads have it amazing” “surgeons operating and then going to europe immediately after” all based on the personal observations so I think what I said based on my personal experience wasn’t out line. If it was, I apologize. Once again, MY PERSONAL EXPERIENCE, could be totally opposite for others, but i’ve met surgeons who have regretted picking surgery. I’ve met EM doc who loved EM but felt burnt out after just couple years. Met IM attending and resident who wished they did something else. Met IR residents who told me it wasn’t worth it and one of them is gonna do half IR/half DR… guess what? I have yet to meet a single rad onc who wished they specialized in something else. Then you come into this forum and everyone saying rad onc bad, pick something else! I’m just trying to find out the reason for such huge difference in the sentiment, that’s it.

The job is great and everyone has said that, so I don't know what you're talking about. The issue is the concern for future unemployment. Again, if you think these people seeing 4 consults a week while NPs and residents are doing their work is sustainable even though we are outsupplying demand STILL, I have bad news for you, it ain't sustainable.

I am not even sure I'm going to be able to work my full career with how things are happening, much less you or anyone after you. That's just me being candid.

 

[thecarbonionangle]

The economics have to make sense. If one thinks that they have found some sort of secret cush field where residents and PAs do all the work and you “barely” work? Is this healthy or sustainable. Of course not.

 

[udrag14]

You have a weird perception of what it is like to be an attending and if these are your expectations, you will be unhappy

You can work less and get paid less or work harder and get paid more.

 

[drowsy12]

I never said that but i’ve seen people here saying “med oncs have it great” “rads have it amazing” “surgeons operating and then going to europe immediately after” all based on the personal observations so I think what I said based on my personal experience wasn’t out line. If it was, I apologize. Once again, MY PERSONAL EXPERIENCE, could be totally opposite for others, but i’ve met surgeons who have regretted picking surgery. I’ve met EM doc who loved EM but felt burnt out after just couple years. Met IM attending and resident who wished they did something else. Met IR residents who told me it wasn’t worth it and one of them is gonna do half IR/half DR… guess what? I have yet to meet a single rad onc who wished they specialized in something else. Then you come into this forum and everyone saying rad onc bad, pick something else! I’m just trying to find out the reason for such huge difference in the sentiment, that’s it.

Well that’s a different point and I agree for the most part.

What I would say is that the academic rad oncs you’re talking about are doing work outside of work. For sure. Like no question.

 

[drowsy12]

The economics have to make sense. If one thinks that they have found some sort of secret cush field where residents and PAs do all the work and you “barely” work? Is this healthy or sustainable. Of course not.

It has been a pretty sweet gig, pound for pound, for decades.

 

[drowsy12]

My future outlook is that there are many reasons to be concerned. But that I truly don’t know what will happen. I think that’s pretty obvious though and most people feel the same way.

 

[RickyScott]

My future outlook is that there are many reasons to be concerned. But that I truly don’t know what will happen. I think that’s pretty obvious though and most people feel the same way.

Agree with that sentiment, but almost no other specialty has these quasi existential joys market concerns, do they?

 

[drowsy12]

Agree with that sentiment, but almost no other specialty has these quasi existential joys market concerns, do they?

Absolutely I think so yeah right now, agree

 

[medgator]

Ah, well...there were many issues very specific to that practice and situation which could not be resolved on a timescale I was willing to tolerate - if they could be resolved at all.

The core of it was really around safety, and I don't mean silly things with no clinical consequences. I mean things like...well, like if I was a manager at a Boeing factory and I had brought a bunch of concerns to the C-suite, and they ignored me, and then doors starting falling off planes mid-flight. That kind of stuff.

But, contributing to that was simply my concerns over the future of the last vestige of private practice Radiation Oncology. The group was on a PSA with a couple of hospitals spread out over a small geographic region. Just like literally everywhere else in the country, consolidation had started to rapidly increase in the years before and after I joined.

The hospitals the group covered did not merge with the same networks. The networks had their own Radiation Oncologists in other hospitals. As I recall, they were all employed in some form or the other.

I strongly suspect that there will come a time in the near future where the group's PSA contract will not be renewed. At that time, the best they can hope for is the network(s) off to keep them on as employees, and the deal isn't wildly different (in terms of compensation) than it is now.

Because: this is Radiation Oncology. The hospitals can offer employment with a 50% pay cut, because they know there's no other linacs in a commuting distance. Or, they could have other RadOncs waiting in the wings, already employed, to take over the positions immediately (also cheaper).

Which just brings us to the most important point in business, or the business of medicine:

Always be prepared to walk away.

That's what I did. I had started the job hunt when it became clear the "doors falling off planes" was not going to be addressed. I made one last big plea at a partners meeting.

It fell on deaf ears.

So my resignation letter fell on them, instead.

They never saw it coming. Because it's RadOnc. They knew there were no linacs in commuting distance. They knew geography was important to me.

Always be prepared to walk away.

💯

Similar story except I was with a malignant group with a wide non compete. And they never saw it coming either. Had to leave the area or keep getting ****ed

This isn't psych or im or even radiology. Probably one of the worst geographic determinablities in all of medicine

 

[RickyScott]

💯

Similar story except I was with a malignant group with a wide non compete. And they never saw it coming either. Had to leave the area or keep getting ****ed

This isn't psych or im or even radiology. Probably one of the worst geographic determinablities in all of medicine

I got f’d by some grifters and then moved across the country and ended up in desirable location. Wouldn’t happen today- would have probably ended up as a roving locums.

 

[radoncftw]

Obviously i don’t know what they do at home but considering they only had 4-6 consults a week, residents and APPs writing the notes, seeing the f/u and OTVs and doing the contours. They also had at least one academic day. Could they be doing some work/research at home? Sure but if I had to bet the total time they did work, mine would be on under 40 hours

dude i will say this. I am a junior attending now in PP.
I had no idea what my attendings did when i was a resident. I thought many of my attendings did absolutely nothing while i was faxing poetic on this massive consult notes and stuff.
but now i realize alot of the stuff i did didn't really save attendings that much time. i was a good resident i think so maybe my contours were helpful, but to be honest, now being on the other side i probably would not blindly trust resident contours and would just do them myself. some of my attendings did just that.
I now spend a lot of time writing specific notes (that residents cannot write), supervising procedures (i.e. covering SBRTs that residents cannot do).
I now spend 0 time writing papers and doing stupid research. so thats great.

 

[NotMattSpraker]

A lot of academic places have the salaries as public record. I think the majority fall in $320-400k starting for assistant professors. However, in my personal experience (n≈30), they barely work 40 hours a week. Obviously those fresh out of residency might not be effiecient yet so the first couple years they might hit 45-50 but after that it’s closer to 36-40hrs. Again, it’s just my personal experience which is limited to attendings that work at main site with multiple residents and APPs.

I genuinely feel like we don’t work on the same planet.

I do not know a single person at any academic level that genuinely works <40 hours a week.

How many physicians in any field walk in to work at 9am? Do they not attend tumor boards ever?

I am in clinic only 3 days a week and those days alone are probably 30-34 hours.

Even the lab folks with no clinic writing several grants a year, it has to be more.

 

[evilbooyaa]

Obviously i don’t know what they do at home but considering they only had 4-6 consults a week, residents and APPs writing the notes, seeing the f/u and OTVs and doing the contours. They also had at least one academic day. Could they be doing some work/research at home? Sure but if I had to bet the total time they did work, mine would be on under 40 hours

You're more than welcome to your opinion. And maybe that does exist. And I appreciate you admitting you have no idea what these folks do at home. Can I ask where you are in the pathway right now? Resident? Attending?

But to assume that an academic rad onc is doing zero or limited work on their academic day.... somewhat eliminates the point of an academic day.
People coming in at 9-3 or 9-4 each day? No early morning or late afternoon tumor boards? No significant work from home?

Fixing notes and contours is not a trivial matter. Sometimes contours need to be re-done from scratch. Are attendings educating the residents? Many in our field don't take a proactive approach to that, so certainly not a guarantee.

There's a lot of things that residents are shielded from, whether that be because they can't bill (iso checks/SBRTs/CT Sims) or it's felt to not be educational (p2p, behind the scenes patient / procedural coordination).

 

[communitydoc13]

But to assume that an academic rad onc is doing zero or limited work on their academic day

I have never been an academic attending (would have liked a shot) and have only been associated with two programs. But in my limited experience, even the attendings that I held in the lowest regard were deeply committed to their careers. They were doing lots of things outside of clinic, including planning presentations, writing grants, writing papers (often not very meaningful, but writing papers is still work), networking (outside of the department), participating in collaborative groups, running tumor boards etc.

Maybe I could critique some attendings commitment to resident education or the details of clinical care, but never their commitment to their careers and the associated work involved.

I'm guessing there are places where this is not the case, but I think most academic docs always have work on their minds. This should kinda be standard for an academic doc. It's a privileged position.

 

[radoncftw]

You're more than welcome to your opinion. And maybe that does exist. And I appreciate you admitting you have no idea what these folks do at home. Can I ask where you are in the pathway right now? Resident? Attending?

But to assume that an academic rad onc is doing zero or limited work on their academic day.... somewhat eliminates the point of an academic day.
People coming in at 9-3 or 9-4 each day? No early morning or late afternoon tumor boards? No significant work from home?

Fixing notes and contours is not a trivial matter. Sometimes contours need to be re-done from scratch. Are attendings educating the residents? Many in our field don't take a proactive approach to that, so certainly not a guarantee.

There's a lot of things that residents are shielded from, whether that be because they can't bill (iso checks/SBRTs/CT Sims) or it's felt to not be educational (p2p, behind the scenes patient / procedural coordination).

i agree whole heartedly.
Most use their academic docs to catch up on clinic, work on research, or both.
Most use their evenings and weekends too.
It was one of the things that pushed me away from academics. I felt like at least where I trained it would be really tough to have a good work-life balance. Only the most senior folks seemed to, but they clearly had to grind to get there.

There is a big difference between resident and attending.
The clinic + treatment-related responsibilities are a major component.
Also the sheer ownership of your patients causes alot of stress sometimes. I try to dis-engage, but its tough when patients die or recur

 

[HolySmokes]

i agree whole heartedly.
Most use their academic docs to catch up on clinic, work on research, or both.
Most use their evenings and weekends too.
It was one of the things that pushed me away from academics. I felt like at least where I trained it would be really tough to have a good work-life balance. Only the most senior folks seemed to, but they clearly had to grind to get there.

There is a big difference between resident and attending.
The clinic + treatment-related responsibilities are a major component.
Also the sheer ownership of your patients causes alot of stress sometimes. I try to dis-engage, but its tough when patients die or recur

Okay I'm getting the sense that y'all all went to way different residencies than I did if you think being an academic attending isn't a completely cush gig. Because as a resident I was responsible for: seeing/documenting all new, follow up, and on treatment patients from start to finish with attending popping their head in the door at the end to ask "any questions," all contouring (rarely reviewed let alone modified), plan approval (we reviewed with dosimetry, attending would often sign prescription without looking), completion notes, peer to peer requests, and educating ourselves. Attendings were on site around 8 and their offices were empty by 4. Oh, and we were required to be at the machine for all SBRTs and new starts. And we were required to be at the sim for every patient because half the time the attending couldn't be there. But at least only one of our rotations required us to do all the IGRT as well.

This was the case for all but the most junior faculty, but last I heard it only took the new faculty about 3-4 years to fall into this pattern as well...

 

[medgator]

Okay I'm getting the sense that y'all all went to way different residencies than I did if you think being an academic attending isn't a completely cush gig. Because as a resident I was responsible for: seeing/documenting all new, follow up, and on treatment patients from start to finish with attending popping their head in the door at the end to ask "any questions," all contouring (rarely reviewed let alone modified), plan approval (we reviewed with dosimetry, attending would often sign prescription without looking), completion notes, peer to peer requests, and educating ourselves. Attendings were on site around 8 and their offices were empty by 4. Oh, and we were required to be at the machine for all SBRTs and new starts. And we were required to be at the sim for every patient because half the time the attending couldn't be there. But at least only one of our rotations required us to do all the IGRT as well.

This was the case for all but the most junior faculty, but last I heard it only took the new faculty about 3-4 years to fall into this pattern as well...

Is your residency the same now? Does it even fill? It's a buyers market now

 

[HolySmokes]

Is your residency the same now? Does it even fill? It's a buyers market now

Same attendings are there, so same stuff happens. And no, it doesn't. Not within the regular match at least for the last several years.

I'll give it credit, the transition from resident to attending wasn't as jarring given our experience.

 

[communitydoc13]

Same attendings are there, so same stuff happens. And no, it doesn't. Not within the regular match at least for the last several years.

I'll give it credit, the transition from resident to attending wasn't as jarring given our experience.

So I guess "hell pits" really do exist.

Were the attendings academically productive?

If not, this is the gig I was born for.

 

[elementaryschooleconomics]

Okay I'm getting the sense that y'all all went to way different residencies than I did if you think being an academic attending isn't a completely cush gig. Because as a resident I was responsible for: seeing/documenting all new, follow up, and on treatment patients from start to finish with attending popping their head in the door at the end to ask "any questions," all contouring (rarely reviewed let alone modified), plan approval (we reviewed with dosimetry, attending would often sign prescription without looking), completion notes, peer to peer requests, and educating ourselves. Attendings were on site around 8 and their offices were empty by 4. Oh, and we were required to be at the machine for all SBRTs and new starts. And we were required to be at the sim for every patient because half the time the attending couldn't be there. But at least only one of our rotations required us to do all the IGRT as well.

This was the case for all but the most junior faculty, but last I heard it only took the new faculty about 3-4 years to fall into this pattern as well...

Exactly!!!

It's all different.

I went to a very big residency program. There were some attendings who...well I'm not sure why they got a paycheck, really.

There were some attendings covering 3 sites with 25+ on beam, mostly head & neck (but also a "generalist" at one of the satellites).

RadOnc is too small of a specialty in too big of a country to make generalizations about lifestyle, salary, etc.

Everything we talk about in RadOnc should be percentile-based, if I had a magic wand.

"He's working 80th percentile hours."

"She's at 50th percentile salary but 90th percentile total comp."

"Those poor residents are at 35th percentile elective time."

"That professional society is at 15th percentile IQ."

And so on.

 

[thecarbonionangle]

So I guess "hell pits" really do exist.

Were the attendings academically productive?

If not, this is the gig I was born for.

hellpits are absolutely real. There are many awful places to train like that where residents do all except actually get an education. We must close these places.

 

[medgator]

hellpits are absolutely real. There are many awful places to train like that where residents do all except actually get an education. We must close these places.

Since the SOAP has shown time and time again recently they damn well won't close themselves

 

[radoncftw]

Okay I'm getting the sense that y'all all went to way different residencies than I did if you think being an academic attending isn't a completely cush gig. Because as a resident I was responsible for: seeing/documenting all new, follow up, and on treatment patients from start to finish with attending popping their head in the door at the end to ask "any questions," all contouring (rarely reviewed let alone modified), plan approval (we reviewed with dosimetry, attending would often sign prescription without looking), completion notes, peer to peer requests, and educating ourselves. Attendings were on site around 8 and their offices were empty by 4. Oh, and we were required to be at the machine for all SBRTs and new starts. And we were required to be at the sim for every patient because half the time the attending couldn't be there. But at least only one of our rotations required us to do all the IGRT as well.

This was the case for all but the most junior faculty, but last I heard it only took the new faculty about 3-4 years to fall into this pattern as well...

i went to a "top 10-15" program
i joke that the thing i learned best in residency was writing notes on time.
i was fortunate that many of my attendings had decent bedside manner and let us see how they examined/talked/consented patients.
i probably sat down to review contours or plans <10 times all of residency.
probably got feedback on 10% of contours, maybe less.
most of my attendings were still pretty busy, but ultimately did not want to do the extra part to teach.
I learned alot studying for oral boards and am still learning as an attending. i actually probably have learned more practical stuff from my partners in practice (and my coresidents in training) than actual attendings while in residency. i guess the expectation was that we were supposed to know everything as a PGY-2. i did match during the golden years...

i cant believe that that program could bill with residents covering SBRTs, new starts, etc.

 

[TheWallnerus]

i cant believe that that program could bill with residents covering SBRTs, new starts, etc.

Jeff Michalski at the ASTRO town hall said residents don’t supervise

Was he wrong, lying, or both

 

[radoncftw]

Jeff Michalski at the ASTRO town hall said residents don’t supervise

Was he wrong, lying, or both

clearly its happening at certain places.
did not happen where i trained.
it actually sucks because i didn't get much experience supervising stuff until i was an attending.

 

[MidwestRadOnc]

i went to a "top 10-15" program
i joke that the thing i learned best in residency was writing notes on time.
i was fortunate that many of my attendings had decent bedside manner and let us see how they examined/talked/consented patients.
i probably sat down to review contours or plans <10 times all of residency.
probably got feedback on 10% of contours, maybe less.
most of my attendings were still pretty busy, but ultimately did not want to do the extra part to teach.
I learned alot studying for oral boards and am still learning as an attending. i actually probably have learned more practical stuff from my partners in practice (and my coresidents in training) than actual attendings while in residency. i guess the expectation was that we were supposed to know everything as a PGY-2. i did match during the golden years...

i cant believe that that program could bill with residents covering SBRTs, new starts, etc.

Similar experience. After intern year, rad onc residency felt like going back to med student level shadowing and rote memorizing for tests. I didn't really start to understand what the job entailed until my last year and figured out most of it in practice. Went basically the entire 4 years without understanding really anything about what RTTs and dosi do day-to-day.

 

[elementaryschooleconomics]

i went to a "top 10-15" program
i joke that the thing i learned best in residency was writing notes on time.
i was fortunate that many of my attendings had decent bedside manner and let us see how they examined/talked/consented patients.
i probably sat down to review contours or plans <10 times all of residency.
probably got feedback on 10% of contours, maybe less.
most of my attendings were still pretty busy, but ultimately did not want to do the extra part to teach.
I learned alot studying for oral boards and am still learning as an attending. i actually probably have learned more practical stuff from my partners in practice (and my coresidents in training) than actual attendings while in residency. i guess the expectation was that we were supposed to know everything as a PGY-2. i did match during the golden years...

i cant believe that that program could bill with residents covering SBRTs, new starts, etc.

Did we...did we go to the same program?

This is exactly how I would describe my "educational experience".

The most confusing thing to me is hearing people talk about how they text/call their old attendings from residency for advice about cases.

I've only talked to my old attendings ~4 times since leaving, and only because I had to (positions they have in journals I publish in etc).

I learned RadOnc from eContour, MedNet, and Google Scholar.

They're who I ask for advice still, to this day!

 

[IonsAreOurFuture]

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

45 minutes could be pretty far away depending on how fast you drive; Distance equals Rate x Time

Maybe you could get a police escort for a true radiation emergency

 

[medgator]

45 minutes could be pretty far away depending on how fast you drive; Distance equals Rate x Time

Maybe you could get a police escort for a true radiation emergency

It's medical staff bylaw theater.

Just get an address that works for initial credentialing and privileging and then do wtf you want. Fwiw I know a med onc who lives over an hour away from one of the main hospitals we are privileged at