Underemployment In Radiation Oncology

Business is not booming for many of us

The central premise of why we are underemployed hinges on the supply of radiation oncologists. We have been talking about this since at least 2013. We have explained this, provided supportive data. We were gaslit for years. Finally, after I made a fiery speech at a Virtual Visiting Professors event (which was taken down but the transcript remains available), enough grassroots support led to open discussion about this. ASTRO even paid a consultancy to examine this - here is the report. My interpretation (and most others, including the authors) was that we may be okay, but there is a strong probability we are oversupplied. ASTRO had this presented at its annual meeting and then killed it - it is the one presentation that you cannot view any more from that year. The reason is the author shared that there is a strong possibility we will be severely oversupplied in the years to come. This does not go along with their narrative. Anyway, I’m not going to spend time on the whys and the evidence. I’ve already spent countless hours on Twitter, giving talks, etc. If you don’t believe me, that’s okay. Call 10 of your community radonc friends and ask them their opinion about the below.

In times of yore (let’s call that before 2010 or so), the average number of patients per FTE was about 25-30 EBRT on treatment. People would see ~5 consults or so a week and start most of them. There was no omission for breast cancer, there was no surveillance for prostate cancer and palliative schemes would range from 10-20 fx. Curative cases were all conventionally fractionated - 33 fractions for breast and 44 fractions for prostate were the norm. There was relatively little SRS / SBRT. Referring doctors would tease us that we were earning “a buck a rad” (rad = cGy).

5 new consults a week does not sound like very many to most modern radiation oncologists. Keep in mind, the computers were very slow, there were no contouring atlases and limited training, OTVs were very different (so much Imodium for prostate, so much Silvadene for breast, Zofran was not generic and not commonly used, etc.). Auto-contouring was not a thing and at many centers, the physician was responsible for many of the OARs. EHRs were not fully developed and collecting and interpreting data took much more time in the past compared to now - this made both consults and follow-ups more arduous. Simulations required the physician to not only be present, but more hands-on. Plan review and approvals required much more time - ClearCheck and similar tools were not available, you received a printout and may not have had easy to read DVHs. Dosimetry until the early 2000s was very automated and many people performing the treatment planning were not formally trained. ‘Best practices’ and plan libraries were not quite ready for prime time. Cell phones were not common in the clinic and getting people on the phone took time. Very little was done asynchronously—in-person meetings took up significant time. I can give more examples, but I hope the younger readers are getting the picture. Main thing is - 5 new consults with 25 on beam took the better part of your work week.

As technology improved, knowledge increased and 3D / IMRT became common, many of the technical tasks became much simpler. Favorable risk prostate? Contour some circles. Physics added PTV. A few days later a plan meeting your constraints comes back and the worst plan is better than the best plan of 20 years ago. The rectal and bladder doses are so low that the OTV is mostly spent discussing the Lions on Victory Monday and what the patient did over the holidays. For breast patients, most of us don’t set the beams or even contour anything other than a lump cavity. The weekly visits tend to be me sharing pics of my kids and them showing me patients of their grandkids. When I do a skin check, I often wonder if the beam is on. The weekly notes are templated with the doses pushed from ARIA. “Patient doing well, no complaints. PE: no changes; Grade 0 toxicity; con’t RT as planned”. Four-week follow-ups for patients who experienced Grade 1–2 toxicity take very little time and documentation,. as these notes are also templated. Chart rounds vary by center, but with excellent IT connectivity, scorecards/checklists, we do an even better job reviewing cases than we did before. Tumor boards are at your desk or on your commute and that time is saved, as well. As with discussing the past, I can give more examples but our day to day life for an equivalent number of patients is much easier than it was in the past.

(Here is the part where readers say, “But, Simul, I see 10 consults a week. Mine are very sick. I have X head / neck and Y gyn brachytherapy cases”. I am not saying all of us are seeing stage I breast and intermediate prostate cases - but many of us in the community are. So, hold off your commentary until you get to the end.)

So, in today’s world, if you see 5 consults a week with a typical breakdown of patients (~30% breast, 20% prostate, 25% other curative, 25% palliative), it will not feel very hard. It, in fact, will feel quite easy. But, with the fractionation schemes we currently use, that 25 patients on beam will now be 15 patients. Maybe more like 12. So, now, your weekly management visits are also cut in half. And, the follow ups you see are much less sick. Many of us are twiddling our thumbs … or writing Substack posts.

There has been many discussion about how much clinical work the average full time radiation oncologist does. I know a lot of radoncs, I’ve worked 4 different jobs in 3 different settings. Based on what I know, the median community radonc is probably seeing about 7-9 new patients a week and keeps about 15-20 patients on beam. And for that amount of work, they generate about 9000-1000 RVUS and earn about $600,000. And, I bet almost all of them have the bandwidth to see at least 25% more patients without breaking a sweat. In fact, if they had some help (part time APP, better software), many could see 40-50% more patients. Personally, my sweet spot would be about 10 consults a week and low 20s on beam. I would be hustling during the day, probably have to play catch up on notes once a week and that would keep me there past treatment hours, but most days I’d still be out by end of treatments. I would occasionally have to contour outside of work hours if I have a vacation coming up or a particularly busy week. In my current job, I am nowhere near this and that’s why you are reading this. In contrast, I have a small number of friends that routinely see 13-15 consults a week and earn >$1m a year. This is not common, but it certainly is not rare. I know some people that do even more than that and still have time for a fulfilling family life, hobbies and rest/relaxation. Many of these people are doing this with 4 clinic days and an admin day that is blocked for patients and they can work from home. And even they have the capacity to see more patients.

But, locally, I know very few people that are that busy. The vast majority of my radiation oncologist friends in SE Michigan would love to have more work. They would love to be busier, help more patients, and earn more income. My friends are leaving during the work day to go work out or to have lunch with their husband or stop by their kids school for career day. Very few of them miss children’s extra-curriculars in the evenings or weekends. The majority of practices in the state have reached out to me at some point to learn about LD-RT for osteoarthritis and plantar fasciitis (I’m kind of a big deal in that world). This is not because they have a passion to treat musculoskeletal diseases. This is because there are 2 days a week they aren’t seeing consults and there are 7 slots open on the linac. Many of us do drop-ins on referring physicians and are constantly available by phone, text, email, or EPIC to discuss a new patient. A radiation oncologist could be at a funeral of a loved on and will still answer the phone, “Yeah, no problem, Mike, I’m not busy at all. Tell me about this new patient…”

If you need me to see a patient, I can do it right now. Like, literally now, I can put down my laptop and see a new consult. But, the phone isn’t ringing. If I need to have a rheumatologist or dermatologist see a patient ASAP, they get scheduled for 2 months out. If I need the medonc to get a patient in right away, it could be three or four days, even though I’ve simmed them and the plan is cooking.

I didn’t mention a few of the other variables. There are more women in medicine and personally this is a win. RadOnc is still predominantly men, but less so than it was 30-40 years ago. Because of this, I have noted a greater focus on work-life balance. This has also benefited the men (at least those that like their families, friends and hobbies). Many of us are happy to be salaried and put in our 35-40 hours and get home by 415p. If this trend continues, perhaps this will allow more aggressive physicians to be busier, while people like me continue at a slower pace. Younger people in general “work to live” rather than “live to work”. They are satisfied with the (very high) median salary of a full-time radiation oncologist and have no interest in making a million dollars. The hospital administrators have discovered this phenomenon called “burnout” and instead of making doctor’s working lives better, they say schedule post-work drinks or yoga and say things like “If you are doing more than 10,000 RVUS, we are going to have to hire another doctor” instead of creating efficiencies and harnessing automation to increase our productivity and make us happier at our jobs. Young doctors are also really f*cking smart, and they do things way faster and more efficiently than I do. I used to think they cut corners, but I have some amazing young folks cover for me and they often point out the boomer-ish things that I do that make my day longer.

And I didn’t mention the most obvious reason for underemployment - oversupply of radiation oncologists. I am no longer going to have these debates, because our leadership has not conducted this discussion in good faith (see above note). If we had kept our numbers around 150 a year rather (the number when I graduated) than closer to 200 (the number now), we would have about 750 less working radiation oncologists. Each individual radiation oncologist could have been busier. The masochists could work even more, while the bored docs would reach a number that made them feel busy and fulfilled.

Technologic progress, automation, hypofractionation and elite human capital have all played a role in the lessening of our workload in a given week. However, oversupply of physicians has magnified this and those that want to be busy cannot. I have far too many friends and colleagues that are willing to do so much more, but there simply are not enough patients to go around. This is going to continue to be a challenge for our specialty.

I’d love to hear feedback or commentary - you can leave comments or email me directly at simul.parikh@gmail.com

Love you all,

Sim