January, 2014

Next, Part I

By Michael J. Katin, MD

It has been said that the major question for humankind is, "what happens after we die?" Religions, philosophies, and websites have been devoted for thousands of years to finding the answer. For radiation oncologists, the answer is simple: we are replaced by other radiation oncologists.

At least that used to be the answer. Recent developments may require us to accept being cast away with other failed experiments of evolution.

The first part of the problems is whether there will be anyone at all left to replacd us, and the second is that even if they do, what kind of world will they encounter? I'm not referring to climate change, terrorism, or even MERS, but to forces far more destructive.

There is the issue of the nature of our potential successors. ASTRO circulated a survey in 2012, published in December, 2013, of radiation oncologists and radiation oncology residents. Twenty-nine per cent of 3,618 radiation oncologists responded and, coincidentally, 29% of 568 radiation oncology residents responded (did responders live longer than non-responders?). Should it be considered that the low percentages would have skewed the results, although the authors did not consider that enough to skip publishing the paper? For example, is it possible that those who did not respond failed to do so because they were too busy, or was it the ones who were less compulsive than the rest? In any event, more than 86% of responding radiation oncologists said they were "satisfied " or "very satisfied" with their careers, even though 14% said they felt "burned out often" 32% "occasionally" and fewer than one per cent "always." Presumably those who were truly "burned out" would never have even looked at the survey. Forty-six per cent of academic radiation oncologists responding felt their work load was "busy" or "very busy," compared to 29% of those in private practice. Twenty per cent of the residents thought their training program was "fair" or "not so good." 33% of radiation oncologists thought the supply of radiation oncologists was greater than needed. Amazingly, it was not reported what percentage of residents felt that way.

In terms of undersupply or oversupply, it would be worthwhile looking at the state of graduate education, certification, and opportunity.

The American Medical Association has a yearly assessment of training programs and some of the data are profound. The population of Abilene, Texas, is about the same as the number of physicians, 115,111, currently in graduate medical training in the United States. The idea of every inhabitant in Abilene being a specialist in training is somewhat frightening, but not overwhelming in a national population of over 300 million. There are 9,384 "active" training programs although not all currently have trainees. The largest number of programs, 462, are in Family Medicine, with 385 in Internal Medicine, but the largest number of physicians in training (without even counting subspecialists) is in Internal Medicine, with 22,710. Way, way, way down this list is Radiation Oncology, with 87 programs and 663 residents. The number of programs is actually lower than those in Pain Medicine, 97, with 280 residents, and Hospice and Palliative Care, 809, with 164 residents. Is this a sign of the philosophy of medical intervention for the future? Add to this the number of programs and residents in Addiction Psychiatry, 45 and 64, in case medication for palliation goes bad. Our specialty is approximated in number by residents in Neonatal-Perinatal Medicine, 655, and outnumbered by those in Child and Adolescent Psychiatry, 851.

The most concern should be that there are 151 training programs in Hematology, Oncology, or the combination, for a total of 1,675 persons, over 2.5 times the number of radiation oncologists in training!

For some reason, the AMA continues to break down the number of resident physicians by race and ethnic origin. I'm not sure what this is supposed to prove, although I have to confess some fascination with the fact that there are no residents in our specialt of American Indian/Alaskan Native origin and only one of Native Hawaiian/Pacific Islander ancestry. This type of ethnographic demography may be meaningful to some, but it wouldn't it be more interesting (and probably of equal value) to have tabulations of how many mesomorphs, gnostics, geeks, dorks, dweebs, albinos, wiccans, dilettantes, or high myopes are in each specialty? .

If we cannot increase our number of residents, at least we need to make sure that those who graduate are able to cope with the ever-increasing hordes of medical oncologists and be able to make sure that referring physicians understand what we do. It was disturbing to see a report from the University of Michigan of a survey of 750 surgeons (67% responded, much better than radiation oncologists responded to our survey) in which 16% passed a seven-item knowledge test about the use of radiation therapy in breast cancer management. Granted there could still be controversy about making a radiation oncology referral when two out of twenty nodes are found at mastectomy (30% wouldn't) but this emphasizes the value of patiently working with other specialists. To this end, it is noted that the above-mentioned ASTRO survey reported that 14% of radiation oncology residents thought they had lack of training in communications skills on end of life issues and 7% had lack of training in communication with patients and family members. Whether they thought they had communication skills in dealing with other physicians was not asked. Keeping in mind that 20% of responding residents ranked their training programs as "fair" or "not very good," note that the Accreditation Council for Graduate Medical Education has set goals for its programs to encourage the pursuit of independent practice, including allowing decisions to be made in the absence of a supervisor. All we would need now is undertrained persons going rogue. Considering all these things together, there is the specter of the last one or two generations of our specialty dwindling in effectiveness and finally fading into obscurity. In the words of G. K. Chesterton, "It isn't that they can't see the solution. It is that they can't see the problem."

Fortunately, this will all be straightened out in Part II.