January 2011

Ironic Deficiency

By Michael J. Katin, MD

Now that 2010 has passed into history, it's time to reminisce about the top news stories of the past 12 months. Most publications have included the disastrous Haitian earthquake, the European financial crises , passage of the increasingly inappropriately-named Affordable Care Act , leaks from the Deep Water Horizon well and from Julian Assange , and the confinement and rescue of 33 Chilean miners . The biggest story of all developed at the end of the year, when it was reported that there is a projected severe shortage of radiation oncologists developing over the coming decade.

For a specialty that was supposed to fade into obscurity, the turnaround has been impressive. The review by Benjamin Smith in the Journal of Clinical Oncology estimates an increase in radiation oncologists from 3,943 to 4,022 by 2020, only a 2% increase when 20% will be needed to meet demand. The increase of 2% probably will be much less than increases of populations of the Cambodian white-rumped vulture , the gelada baboon and the Wyoming toad . Granted, the Cambodian white-rumped vulture, gelada baboon, and the Wyoming toad probably have better survival instincts than do radiation oncologists.

Over the years there have been continuous efforts to diminish the role of radiation therapy, either by competition from chemotherapy , use of improved surgical techniques , innovative although unproven technologies , or even scientific proof Not only has the profession managed to survive these onslaughts, recently there has been increasing value shown to its use, such as in breast cancer and bladder cancer. The population is aging, and with decreases in deaths from heart disease and stroke there will be more people developing diseases with indications for radiation therapy. At the same time, several training programs have closed or reduced their number of residents, funding for medical education has decreased, and the length of the training program has increased. What can be done to allow adequate staffing for administration of radiation oncology treatment in the next few decades, at least until nanoparticle-delivered suicide gene therapy is perfected?

Several options are available to increase the number of radiation oncologists to fulfill this upcoming need. These would involve increased production, increased retention and improved efficiency.

  1. Increased Recruitment. We were all educated years ago regarding the four "R"'s of radiation oncology: Repair of sublethal damage, Redistribution, Repopulation, and Reoxygenation, To these we should add a fifth "R", Recruitment. We need to get over concern about creating our own competition, for the good of the specialty as a whole. We never see public service announcements encouraging persons to go into the field of radiation oncology. It may be necessary for ASTRO to start promotional efforts to interest young people in our specialty, as do many other professions. We could at least sponsor organizations in high school and college such as ROTC (Radiation Oncology Training Corps). It may also be helpful to try to glamorize the specialty through entertainment media, possibly with a television series such as "Law and Order: IMRT".
  2. Alternative Pathways. Some of the most intelligent persons in our culture did not complete college and some did not even graduate from high school . It seems somewhat overly "academic" to require extensive prerequisites for someone to become a radiation oncologist. Is it possible that a certain number of persons can be accepted to medical schools and placed directly into the radiation oncology tract to eliminate a lot of unnecessary preliminaries, such as literature , biology , and social studies?
    Would it also be possible to have a limited number of board eligibility designations granted to individuals who have extensive knowledge of radiation oncology through their work as physicists, dosimetrists, radiation therapists, nurses, or front desk personnel? In times of crisis, battlefield commissions were given to deserving persons and perhaps times are no less perilous today.
  3. International Search. In 2008, a baseball agent initiated a "Million Dollar Arm" reality show, with the expectation that a country that size would certainly have persons with the ability to learn to pitch in major league baseball. Possibly a similar effort could be made to solicit . . . . actually, some of the leading figures in radiation oncology have already been produced by India . . . . never mind.
  4. Increased Retention. The number of radiation oncologists available to work can be maintained by reducing the number of practitioners who leave the specialty. This can be accomplished by making it impossible for anyone to retire. This has essentially been accomplished already , with pension investments wiped out by the volatile market situation, with the probability of taxes increasing substantially over the next several years, inflation pending, prices of gasoline and food skyrocketing, and decreased faith that social safety nets will be available to the elderly. For all practical purposes, the term "life's work" will have literal meaning.
  5. Increased Efficiency. It may be hard to believe, but it may not be necessary for the radiation oncologist to be present at every treatment, steadfastly observing each setup and making sure all calculations are correct. If it can be concluded that the radiation oncologist's presence in the general area is adequate, then perhaps this can be expanded to allow "presence" to the extended gradually At some point the concept of the "virtual" radiation oncologist might be considered. With efforts being made to convert everything to electronic medical records, could the radiation oncologist also be present in the electronic environment?

Another way to allow more patients to be treated with a fewer number of radiation oncologists would be for a Manhattan project type effort by the NCI to prove that hypofractionation works as well as standard fractionation. It would not be necessary for new studies to be done but for the proper statisticians to be recruited to be able to derive the desired conclusion from previous data. There are certainly many other possible ways to solve the potential problem of decreased personnel to deal with the increasing need for radiation oncology. In the interest of time it would be just as well to skip down to the two methods least likely to be implemented . . . . . . .

  1. Provide assurance that current reimbursement levels will be maintained.
  2. Tort reform.