Programs that have increased/decreased resident numbers and closed 2019 to 2024

[ramsesthenice]

The concern is always: If APRT is allowed to contour adaptive structures on the table, what prevents some 60-plus chairman from asking APRT to contour routine target volumes such as lung, prostate or breast, which are not that hard to contour and potentially hire fewer attendings?. The current group of attendings are happy because they can maximize the number of consults/new starts. The whole story of CRNA in anesthesia would permeate into radiation oncology as well.

APRT is the least of your concerns. AI and automated/assistive contouring tools will greatly reduce the effort dedicated to target/OAR delineation. There is no if in that statement. Some of what is out there is almost ready for primetime. Any affect the APRT may have on FTE calculations will more than likely be moot.

Save for unscrupulous management, this really shouldn't be anything to fear for those of us already in the game. It will probably make life more efficient. And how many positions will this eliminate? Time will tell but do some simple math. How much of your effort is spent contouring? 15-20% (unless you have a crazy H&N volume). In competitive markets where growing your volume with adequate resourcing is possible, I don't see many people deciding to reduce staffing because they can. Probably more likely to try to divert the existing FTEs to growing the patient volume (ie...make it rain). Now, Im not ignorant. Even if positions are not shed, added efficiency absolutely means that fewer positions will be created in the future and will still be a net loss to the job market over the long run.

Less competitive/rural markets where growth potential is limited/non-existent...potentially a different story. You can't do more with the same workforce. But you can try to do what you are already doing with less. Fortunately most of these places are only 1-2 physician joints and I just don't see autocontouring alone reducing FTE needs enough to drop from 2 to 1. But again, could definitely save you from needing to go from 2 to 3.

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[fiji128]

APRT is the least of your concerns. AI and automated/assistive contouring tools will greatly reduce the effort dedicated to target/OAR delineation. There is no if in that statement. Some of what is out there is almost ready for primetime. Any affect the APRT may have on FTE calculations will more than likely be moot.

Save for unscrupulous management, this really shouldn't be anything to fear for those of us already in the game. It will probably make life more efficient. And how many positions will this eliminate? Time will tell but do some simple math. How much of your effort is spent contouring? 15-20% (unless you have a crazy H&N volume). In competitive markets where growing your volume with adequate resourcing is possible, I don't see many people deciding to reduce staffing because they can. Probably more likely to try to divert the existing FTEs to growing the patient volume (ie...make it rain). Now, Im not ignorant. Even if positions are not shed, added efficiency absolutely means that fewer positions will be created in the future and will still be a net loss to the job market over the long run.

Less competitive/rural markets where growth potential is limited/non-existent...potentially a different story. You can't do more with the same workforce. But you can try to do what you are already doing with less. Fortunately most of these places are only 1-2 physician joints and I just don't see autocontouring alone reducing FTE needs enough to drop from 2 to 1. But again, could definitely save you from needing to go from 2 to 3.

Truly remarkable that in this environment and with potential permanent changes in supervision requirements that there are training programs out there like Mt. Sinai still expanding resident training numbers while none have officially contracted in the past five years except MDACC.

 

[MidwestRadOnc]

Truly remarkable that in this environment and with potential permanent changes in supervision requirements that there are training programs out there like Mt. Sinai still expanding resident training numbers while none have officially contracted in the past five years except MDACC.

They are training caribbean grads and washouts from other residencies. They literally don’t care.

 

[medgator]

Truly remarkable that in this environment and with potential permanent changes in supervision requirements that there are training programs out there like Mt. Sinai still expanding resident training numbers while none have officially contracted in the past five years except MDACC.

CCF contracted as well I thought. Or at least reduced a spot temporarily which is what I think Anderson did

 

[medgator]

They are training caribbean grads and washouts from other residencies. They literally don’t care.

Too many medical schools, not enough residency spots. So literally med students with no other options will take any open spot so they can complete any type of graduate medical education.

Contraction is the only solution. Every spot will fill otherwise under current circumstances

 

[MidwestRadOnc]

CCF contracted as well I thought. Or at least reduced a spot temporarily which is what I think Anderson did

Oh wow one whole spot. That’s like Trump making a spectacle of taking a $1 salary like some magnanimous thought leader.

 

[MidwestRadOnc]

Too many medical schools, not enough residency spots. So literally med students with no other options will take any open spot so they can complete any type of graduate medical education.

Contraction is the only solution. Every spot will fill otherwise under current circumstances

I posted this on another residency forum. We should encourage anyone who wants to work part time or pursue a non clinical career or just needs to complete any residency without intending on practicing to pursue rad onc. Fill those spots with people who aren’t going to work.

 

[fiji128]

CCF contracted as well I thought. Or at least reduced a spot temporarily which is what I think Anderson did

MDACC officially decreased their resident complement by 1 per year via the acgme. Colorado and Cleveland Clinic just said they will take 1 less resident once every four years but technically they are still approved for same number of residents and could fill that spot at any time.

 

[medgator]

Oh wow one whole spot. That’s like Trump making a spectacle of taking a $1 salary like some magnanimous thought leader.

Better than the shameless expansion and weak program creation that's been going on for several years.

Call out the good behavior where you see it. Honestly the programs contracting are actually decent teaching programs and then you have crap places like LIJ, Tennessee, Mississippi etc that were recent creations and have no intention of doing that at all

 

[fiji128]

Better than the shameless expansion and weak program creation that's been going on for several years.

Call out the good behavior where you see it. Honestly the programs contracting are actually decent teaching programs and then you have crap places like LIJ, Tennessee, Mississippi etc that were recent creations and have no intention of doing that

Well Tennessee is closing down at the end of this academic year. Texas A and M has 1 resident enrolled currently out of 8 total positions so they might also be preparing to close down as well (I have no info on the program other then that).

 

[NotMattSpraker]

Call out the good behavior where you see it.

Sorry, but I see none these days. I don't think there is any point to making a PD feel proud for dropping 1 resident, perhaps temporarily. Some may not have the power to do anything significant, that is fine, cant blame them, but not sure that deserves praise either?

ASTRO shut down any workforce discussion and everyone went along with it without much of a peep. Some people that were supposedly "bummed" at the behavior still volunteer with ASTRO, sometimes in substantial roles. I guess they aren't that bummed.

The demographics have also changed in a significant way, we may now be an FMG gateway field. You're not going convince someone on the ropes not to join this field when the alternative is unemployment.

I now just tell people Id investigate medical oncology because they seem to have less selfish leadership. Yes, even though I really love my day to day job.

 

[medgator]

Sorry, but I see none these days. I don't think there is any point to making a PD feel proud for dropping 1 resident, perhaps temporarily. Some may not have the power to do anything significant, that is fine, cant blame them, but not sure that deserves praise either?

ASTRO shut down any workforce discussion and everyone went along with it without much of a peep. Some people that were supposedly "bummed" at the behavior still volunteer with ASTRO, sometimes in substantial roles. I guess they aren't that bummed.

The demographics have also changed in a significant way, we may now be an FMG gateway field. You're not going convince someone on the ropes not to join this field when the alternative is unemployment.

I now just tell people Id investigate medical oncology because they seem to have less selfish leadership. Yes, even though I really love my day to day job.

Completely agree. Still, I think the right programs are leading by example. If everyone followed suit, that would probably get us really close to that magic number of 100-120 where things were much better back in the day.

It bothers me though that the programs that are doing the right thing are the programs that actually offer decent training and the ones that are recently accredited and don't have enough in house peds and brachy are the ones who will never think they are the problem

 

[NotMattSpraker]

Completely agree. Still, I think the right programs are leading by example. If everyone followed suit, that would probably get us really close to that magic number of 100-120 where things were much better back in the day.

It bothers me though that the programs that are doing the right thing are the programs that actually offer decent training and the ones that are recently accredited and don't have enough in house peds and brachy are the ones who will never think they are the problem

I think leading by example would be a program cutting 40% of spots or so if one believes the magic number.

If every program cuts only 1 spot it’s not enough.

They are not all the same obviously, but we have no objective way to compare programs.

If one meets updated requirements, they “deserve” to stay open as much as everyone else in my opinion.

It would be a very fair solution just to reduce all programs, but that requires altruism.

 

[CurbYourExpectations]

The craziest thing to me personally is that while people were concerned about oversupply there were some programs like "maybe we need some mid level encroachment?".

 

[RickyScott]

https://x.com/digiaimoron/status/1787596939489390803?s=46&t=bNjInwwyz2DPnd4UFJOtbg

Such an a#%

https://x.com/digiaimoron/status/1788700936384167956?s=46&t=bNjInwwyz2DPnd4UFJOtbg

 

[ramsesthenice]

I’ve learned a lot about the politics of this crap. There are unscrupulous chairs for sure. I’ve also seen plenty of pressure from deans to make sure spots are filled to maintain “prestige.” You know, the stupid pride that goes along with filling every spot for X years in a row. I wonder how those deans are going to feel in 4-5 years when their first time boards pass rate falls under 50%. Id wager to say at least a third of the applicants the last few years have almost zero chance of passing all 3 sets of exams on the first try. I am not looking to start a debate about the significance of board exam performance. Just pointing out the obvious folly of bringing in low performers as a solution to maintaining prestige.

Silver lining: when it hits the fan, the deans are going to blame the chairs who went along for the decline in performance.

 

[TheWallnerus]

Id wager to say at least a third of the applicants the last few years have almost zero chance of passing all 3 sets of exams on the first try

If this comes to pass, it will be quite the feces storm won’t it?

Long term view… I had this thought yesterday. What if I could walk up to the planning system and tell it “Give me a plan for this T2N2 tonsillar case,” and it expert-level contours everything and spits me out a beautiful VMAT plan in 60 seconds. (And this done as the AI system views with full appreciation of all published data, consensus guidelines, all the patient data, etc.) What is the purpose of a “high performing applicant” then? What is the purpose of learning physics and rad bio minutiae? What is the purpose… of a rad onc (as we knew it on the day peak rad onc occurred some 8 to 10 years ago)?

Ultimately, if one third of all incoming residents today who couldn’t have passed boards 10 years ago somehow become rad oncs (passing standards might need some lowering) the “purpose of a rad onc” question will get answered on its own, in due time.

 

[RickyScott]

If this comes to pass, it will be quite the feces storm won’t it?

Long term view… I had this thought yesterday. What if I could walk up to the planning system and tell it “Give me a plan for this T2N2 tonsillar case,” and it expert-level contours everything and spits me out a beautiful VMAT plan in 60 seconds. (And this done as the AI system views with full appreciation of all published data, consensus guidelines, all the patient data, etc.) What is the purpose of a “high performing applicant” then? What is the purpose of learning physics and rad bio minutiae? What is the purpose… of a rad onc (as we knew it on the day peak rad onc occurred some 8 to 10 years ago)?

Ultimately, if one third of all incoming residents today who couldn’t have passed boards 10 years ago somehow become rad oncs (passing standards might need some lowering) the “purpose of a rad onc” question will get answered on its own, in due time.

Better yet, a urologist who took a weekend course on how to radiate prostates. He has an “advanced” rt- Samantha “you are going to love her according to Ron” Skubish. They can work radiation just fine without a radonc. Maybe someone to review charts once a week. Same for breast.

radiation is easier to pick up than a new technique such as Holep or aquablation for Luts.

 

[NotMattSpraker]

What is the purpose of a “high performing applicant” then?

Counseling, therapeutic selection (multi-D), symptom management.

Of course this could be done by a mid level but I still think a trained oncologist does a better job.

 

[ramsesthenice]

If this comes to pass, it will be quite the feces storm won’t it?

Long term view… I had this thought yesterday. What if I could walk up to the planning system and tell it “Give me a plan for this T2N2 tonsillar case,” and it expert-level contours everything and spits me out a beautiful VMAT plan in 60 seconds. (And this done as the AI system views with full appreciation of all published data, consensus guidelines, all the patient data, etc.) What is the purpose of a “high performing applicant” then? What is the purpose of learning physics and rad bio minutiae? What is the purpose… of a rad onc (as we knew it on the day peak rad onc occurred some 8 to 10 years ago)?

Ultimately, if one third of all incoming residents today who couldn’t have passed boards 10 years ago somehow become rad oncs (passing standards might need some lowering) the “purpose of a rad onc” question will get answered on its own, in due time.

Well, we are not unique in that regard. How many medical fields could largely be replaced by good AI. It’s science fiction now, but deep learning has the potential to master the medical literature in ways not possible for us. How many internists and generalists will we need to diagnose and manage common diseases? There are a scary number of Gen Zs who would rather talk to an app than a person and would have little to no concern moving from seeing a doctor to a program. Medical oncology…it’s just algorithms and writing orders. Radiology? At some point, computers will be hands down better than people at analyzing every pixel. Ditto for path. I don’t see any/many fields completely going away but I can see future growth plummeting. I’d wager that surgical and procedural specialties are probably the safest…for now.

 

[medgator]

Counseling, therapeutic selection (multi-D), symptom management.

Of course this could be done by a mid level but I still think a trained oncologist does a better job.

As long as they can be named in a malpractice suit and carry liability insurance, we should be worried. Until that happens, nope

 

[RickyScott]

Midlevel replacement is not a unique threat to radonc, but we are much more fragile. My guess is that at least 1/3 but probably more of the job market is propped up artificially by supervision requirements. The average radonc sees 4 (but maybe less per acr) new consults a week but there is no reason that this couldn’t be 7 or 8. I doubt there is any other specialty where the workforce is so dependent on artificial inflation. Also there has been very little penetration of physician extenders into radonc vs other specialties so the job market does not presently account for it.

 

[medgator]

replacement is not a unique threat to radonc, but we are much more fragile. My guess is that at least 1/3 but probably more of the job market is propped up artificially by supervision requirements. The average radonc sees 4 (but maybe less per acr) new consults a week but there is no reason that this couldn’t be 7 or 8. I doubt there is any other specialty where the workforce is so dependent on artificial inflation. Also there has been very little penetration of physician extenders into radonc vs other specialties so the job market does not presently account for it.

7-8 a week is a very normal and doable workload imo, esp in the era of sbrt and hypofrac.

Seeing less than that won't justify median mgma salary for an established RO if you are billing pro fees only I would guess, so that's where a good hospital employed setup will win out.

 

[temujim]

If this comes to pass, it will be quite the feces storm won’t it?

Long term view… I had this thought yesterday. What if I could walk up to the planning system and tell it “Give me a plan for this T2N2 tonsillar case,” and it expert-level contours everything and spits me out a beautiful VMAT plan in 60 seconds. (And this done as the AI system views with full appreciation of all published data, consensus guidelines, all the patient data, etc.) What is the purpose of a “high performing applicant” then? What is the purpose of learning physics and rad bio minutiae? What is the purpose… of a rad onc (as we knew it on the day peak rad onc occurred some 8 to 10 years ago)?

Ultimately, if one third of all incoming residents today who couldn’t have passed boards 10 years ago somehow become rad oncs (passing standards might need some lowering) the “purpose of a rad onc” question will get answered on its own, in due time.

This is a potential future for rad onc. ML/AI for contouring and plans. Physics still around for LINAC QA and software maintenance. RTTs still deliver. Surgeon or med onc approves contours/plan -- they are the responsible/liable MD. Rad onc fades away like nuc med.

 

[medgator]

This is a potential future for rad onc. ML/AI for contouring and plans. Physics still around for LINAC QA and software maintenance. RTTs still deliver. Surgeon or med onc approves contours/plan -- they are the responsible/liable MD. Rad onc fades away like nuc med.

Makes sense in a country like the UK, where clinical onc already does this. I just don't see the medicolegal climate allowing this to change in the US, personally

 

[RickyScott]

Makes sense in a country like the UK, where clinical onc already does this. I just don't see the medicolegal climate allowing this to change in the US, personally

Maybe a big university center reviews all the plans?

 

[thecarbonionangle]

Well, we are not unique in that regard. How many medical fields could largely be replaced by good AI. It’s science fiction now, but deep learning has the potential to master the medical literature in ways not possible for us. How many internists and generalists will we need to diagnose and manage common diseases? There are a scary number of Gen Zs who would rather talk to an app than a person and would have little to no concern moving from seeing a doctor to a program. Medical oncology…it’s just algorithms and writing orders. Radiology? At some point, computers will be hands down better than people at analyzing every pixel. Ditto for path. I don’t see any/many fields completely going away but I can see future growth plummeting. I’d wager that surgical and procedural specialties are probably the safest…for now.

The DaVinci robot is recording the moves of thousands of surgeons. Imagine having the meta data of how the world’s best surgeons do an operation from millions of cases. What could you possibly do with that? It will happen too.

 

[drowsy12]

when you start to consider the possibilities of AI, this **** goes way beyond medicine. It's scarily depressing. your kids will live totally different lives than you did.

 

[ramsesthenice]

The DaVinci robot is recording the moves of thousands of surgeons. Imaging having the meta data of how the world’s best surgeons do an operation from millions of cases. What could you possibly do with that? It will happen too.

Precisely why I said…for now. Timescale is different and I think it will be longer before people would accept something artificial cutting them without human direction. But everything is potentially replaceable.

 

[Mandelin Rain]

Better yet, a urologist who took a weekend course on how to radiate prostates. He has an “advanced” rt- Samantha “you are going to love her according to Ron” Skubish. They can work radiation just fine without a radonc. Maybe someone to review charts once a week. Same for breast.

radiation is easier to pick up than a new technique such as Holep or aquablation for Luts.

This has always been my main concern and why I'd REALLY caution anyone from this specialty.

The barrier for adequately prescribing and managing radiation keeps dropping. Need to know beam arrangements? No, two arcs is cool. Need to review CBCTs? No, an APRT will do that for you. Need to contour? No, AI will do that for you. Need to review plans? No an odds rated NTCP model will figure out the best plan for you. Need to manage side effects? No, an APP will do that for you.

Right now, today, already (vast majority of us) we don't sim cases, plan cases, treat patients, maintain the machine, run QA. We formulate treatment plans, circle some stuff, sign a bunch of paper primarily for billing purposes, look briefly at a daily image, and do our weekly "How are ya?". Important stuff to be sure, but not exactly proprietary stuff.

So the question becomes.... why don't the referring docs just prescribe the radiation? Derm does it. It ain't illegal. Some neurosurgeon will just start doing it one day and then it will suddenly be everywhere.

I see this as the real risk for our specialty, and if I had a 30 year career horizon, it's not a risk I'd be willing to take.

 

[drowsy12]

Medicolegal issues and board certifications are our best protections, which is why I’m in favor of continuing the boards process. You’re not wrong though.

 

[RickyScott]

Medicolegal issues and board certifications are our best protections, which is why I’m in favor of continuing the boards process. You’re not wrong though.

These could be avoided by having a radonc/big center review plans for new pts remotely once a week etc

 

[drowsy12]

These could be avoided by having a radonc/big center review plans for new pts remotely once a week etc

But that is not as easy as it sounds. It would probably be easier for companies to exist that do this.

Having it be other institutions means that Individual centers and docs need to have contracts with large centers with data use agreements and HIPAA protections and legal protections. Won’t be worth it to academic centers probably.

But a private company to come fill that need that hires physicists and docs, yeah could see that

 

[temujim]

These could be avoided by having a radonc/big center review plans for new pts remotely once a week etc

MDACC on it.