On the Protection of Medical Students

Information asymmetry has run amok in the field of radiation oncology in the United States. To rise in ranks in the world of radiation oncology, you must abide by a few rules: keep the status quo, never speak out against leadership, and push the notion that everything is fine. The following will object to this notion. At the risk of being doxxed or other malicious acts, I am here to discuss this issue. I have educated myself, fluctuated in beliefs, argued with everyone, and created many memes. Who better than I to discuss this and foster a dialogue?

As someone who considers themselves a conscientious and empathetic person, I would like to talk in detail about this field for medical students so that they can ascertain their own opinions and determinations of their future. A lot gets clouded in the discussion of Student Doctor Network (SDN). So how do we separate the ultimate truths from the possible truths? Some scenarios described by physicians here often represent worst-case situations, which may lend a negative tone to their posts. Harshness and embellishment are human nature, and while I don’t agree with it because I want everyone to be nice to each other, I don’t think that it is malevolent. It is important to note that most of us are not going to benefit from a reduction in residency spots over the next 5-10 years. Most of the people who you see express disdain on this site are already well set in their life and are either at or near the phase of not needing to work again. If the number of residency spots were reduced by 50% tomorrow, it would likely take 10-15 years for those currently complaining to see any benefit, such as lateral mobility within the job market. Those who most acutely feel the change of number of residents are residencies. Residents can improve lifestyle and decrease burden of work.

Radiation oncology residency spots are the least of the issues we are facing in the field. We are targeted more than most in terms of decreasing reimbursement. The field is changing, and people are trying to make hail Mary moves such as ROCR (read about it and listen to podcasts). There is significant hypofractionation, which leads to a reduction in the number of treatments per patient and inevitably has a reduction in the amount of billing facilities can perform in the United States. Radiation oncology is not like other specialties; we rely heavily on machinery, and you will only be able to get a job in an area that is able to support this very expensive machinery. Many areas in the United States that currently have machines are probably struggling and will not be able to support machines for much longer. There was a large boom and oversupply of machines in our history.

Supervision. Currently heavy supervision of these machines are being employed, which promotes the employment of physicians. If supervision goes away permanently and along the range of direct physician onset supervision to complete virtual supervision, this will significantly decrease the number of radiation oncologists that are needed in the field.

Even though concerns have been raised about the difficulty in the job market, the number of spots has gone up or remained high. Concerns were brought up by physicians, residents, and medical students about the difficulty of the job market, and spots never significantly decreased despite this. Since the late 2010s, spots have begun to go unfilled due to concerns about the future of the field, but people have done everything within their power to maintain the number of people being trained to become radiation oncologists. Even though spots have gone unfilled in the main residency match, there is not a significant decrease in the numbers being trained. Not only are residency numbers remaining very high, but big-name institutions that are training the most physician trainees have started to promote midlevel encroachment as well. Midlevel encroachment will either directly or indirectly influence the number of physicians needed. It depends on how far the encroachment goes. If they see their own patients completely, you may directly need fewer radiation oncology physicians; if they just do some contouring and see follow-ups, you may indirectly need fewer radiation oncology physicians. Either way, you need fewer radiation oncology physicians, and this is in the setting of us already likely oversupplying radiation oncology physicians.

Artificial intelligence. The amount of time required to contour is diminishing, for both radiation dosimetrists and oncologists. As time goes on, I would not be surprised if it becomes near perfect and the extensive time I have spent becoming well educated in the anatomy of sites I treat and my efficiency in contouring are less necessary. No need to even go into further detail on AI because the likelihood that this completely disrupts most fields is so high and to extents that I don’t even want to imagine.

Indications for radiation are being targeted, we do not have the same backing as new medications that generate more money than the whole field of radiation and don’t require expensive machines. Noninferiority studies can destroy the field. Radiation oncology doesn’t even control many new expansions of radiation, nuclear medicine has just as high of a likelihood of overtaking radiopharmaceuticals. If you compare the job market to any other field, radiation oncology is objectively worse. There are very few jobs in many states. Compared to most other specialties, it is numerically worse even when accounting for size. As midlevel encroachment, continued oversupply, and AI become more prevalent, radiation oncology physician jobs won’t increase; they will decrease.

You should only choose to be a radiation oncologist because it is the most interesting specialty to you and you want to support radiation as a modality. You should only choose the field because you wouldn’t be happy in any other field. You should only choose the field because you are understanding that you may not be able to live where you want. You should only choose the field because you understand that there could be hardships in the future and a tightening job market, but it’s still the field you want.

I say all this to you, but hope you understand, I love my work. I am happy to come in to work every day, I love taking care of patients. I enjoy physics, I enjoy the people I work with. The day to day work is good, it is rarely ever too busy. Residency is less time consuming than other specialties. You get to know your patients and can often spend 45+ minutes talking to a single patient and helping them fully understand what is going on with their disease, something that is harder to do in some specialties.

Take it all into consideration and choose the best path for you.

Lol, nothing truly prompted it, it is how I feel about things, some of us feel more strongly about some aspects and less strongly about others.

To StIGMAS point, even if you talk to me in real life, you are doing so under the consideration that I am around my peers, and that I know you will also talk to my peers and likely tell them "Larry David told me the job market is ROUGH!". So it is not lost upon me or anyone else in the field that this is a possibility, but I will still likely tell you about my thoughts in person, especially if you ask me genuinely, much like ESE would probably do in person, and many others here, because it has been something we think about a lot and worry about for the future of the field.

If you, a student, talk to people in real life; I have known many, who will say things to their friends in RadOnc that they will not say to other coworkers or to medical students, so don't expect that everyone is going to be completely transparent. You have to consider some are benefiting directly from having residents, and have had a good life from radiation oncology, so they think you will too. They have not recently looked for jobs. It's not necessarily malevolent either. Keep in mind, most people have a life, it is unlikely you will be talking to someone who sits around thinking about this in their free time. Do some job searches for the field of radiation oncology (physicians, not therapists, not physicists) and see how limited the job market is compared to other fields of similar size. Don't take my word for it or anyones word for it, just do some analysis on your own. Note that even though there has been concern about oversupply of the field, there has been nearly zero positive response to correct for it.