When in a Hole, Stop Digging

One could reasonably ask whether any aspect of health care should be subject to market capitalism with its natural winners and losers. The COVID-19 pandemic has exposed the faults of market-based medicine, with physician practices, health systems, and hospitals all having experienced significant financial stress while the insurance industry has seen record profits. We have witnessed the failure of national policy in health care and an erosion of national institutions. The disparities in morbidity and mortality from COVID-19 seen among our minority communities lay bare longstanding underlying health inequities and chronic illness. Is this market approach something to be proud of, and how can we strive for a better, new normal?

It is in this context that I comment on the editorial by Shah and Royce.¹ These authors express their opinion that in the radiation oncology employment marketplace, there is an oversupply of radiation oncologists, with a risk of physician unemployment. This problem may be solved by reducing residency slots and by rejecting Supplemental Offer and Acceptance Program (SOAP) candidates. Although this may be beneficial in the short term, I have some skepticism that this is the whole solution, or even part of it. The supply–demand mismatch may actually be a symptom of a more fundamental problem in the way we define radiation oncology (RO), in the candidates we have been attracting, and in the training model we have used. Indeed, the sudden decline in interest of medical students in radiation oncology seen in this year’s Match creates an opportunity that we could seize.

It has, during recent years, been a badge of honor to note the extraordinary level of intellectual talent among radiation oncology residents. They come from the top medical schools, with an impressive number of publications and the highest possible test scores. If we look beyond that pride, however, we might ask ourselves whether the need for research and high examination scores might not have actually limited the diversity of the applicant pool. It could be argued, based on anecdotal conversations with medical students in recent years, that such a high level of competition has hindered opportunities for women and minorities, or for those with less of a research mindset, to explore RO. We may have been too competitive for our own good. If we now have the space for others to consider RO, that is not all bad.

Let us explore Shah and Royce’s premise that, by accepting students through the SOAP program, we will diminish the engagement or culture of RO. Is that really so? One’s dedication to career can be both purposeful and accidental. I find this logic disturbing, as if SOAP candidates represent a lower tier of physician who will taint the specialty in the long term. If one is to cut residency slots, then do just that. But we should not discriminate against SOAP applicants. Many of us came into radiation oncology accidentally and later in our training, myself included. We should not assume, simply because these candidates have not had their eyes on radiation oncology from an early age, that they will not be as motivated as those who have.

Let us move on to markets and explore what potentially attracted so many medical students into RO during the past 2 decades. Was it all high intellectual principles and the balance between hands-on patient care and modern technology? Unfortunately, if we are honest, we might not be so proud of the answer. I suspect it is not a coincidence that radiation oncology has become one of the top-5-paying specialties during that period, specialties which all have been very popular among medical students. The increase in interest is contemporaneous with the advent of intensity modulated radiation therapy (IMRT) in the late 1990s and 2000s. If we were to analyze the impact of IMRT as a business-school case study, we would note how one Current Procedural Terminology code, and the gold rush that followed, appeared to co-opt an entire specialty. Not only has IMRT distorted the markets for radiation oncology, but within radiation oncology, it has narrowed our scope of practice, giving space for a brand-new field, “interventional oncology,” to rise up and compete with us. Shah and Royce are correct in speculating that a value-based payment model will help “invigorate time-intense/less lucrative facets” of RO. It is that future potential that will ultimately fix our specialty.

The sharp decline in the number of applicants this year needs analysis. Medical students, through discussion and on social media, are sensing that ours is not a specialty to enter if they wish to have a job at the end of their training. The talk is of an oversupply of radiation oncologists through an expansion of residency programs while changes in use of radiation oncology treatments and hypofractionation have suppressed demand. But is it that simple? We know that RO graduates are still obtaining jobs, that the population is still aging, and that new indications for radiation are arising. There remains room for us to flex our inner “therapeutic radiologist” and broaden our scope of practice beyond external beam radiation therapy into brachytherapy and radionuclide therapy. The influence of COVID-19 is also uncertain. Will physicians retire later because of income lost, or will they retire earlier because of concerns about exposure and work–life balance? To me, it does not seem clear that we are oversubscribed as a specialty.

Shah and Royce suggested a rapid remedy to address the perceived problem. Fewer medical students are applying, so let us allow that to happen and put supply and demand back in balance. Many residency programs, including mine, have already chosen to hold back 1 resident position this year in deference to that view. While the dust settles on how the specialty will address its future, this certainly cannot hurt in the short term. The suggestion, however, that we “liberalize” our position on the question of antitrust and market manipulation troubles me. I believe we need a strategic plan that addresses the concerns of Shah and Royce, but does so in a more sustainable way than year-on-year tinkering with the inflow spigot.

The core solution to address the future of radiation oncology is to rethink our education competencies. Modernizing our curriculum and competency metrics will serve to drive downstream outcomes that will get at the heart of the Shah and Royce argument. Redefining our specialty based on training requirements will affect the board examinations and requirements for residency training programs. By doing this honestly and effectively, we will retire those programs incapable of meeting contemporary requirements. Better that we reduce the number of bad programs than that we ask all programs, regardless of quality, to reduce their intake. This process is already underway, and the buy-in of the Radiation Oncology Education Collaborative Study Group (https://voices.uchicago.edu/roecsg/) can serve as the transitional work needed to define the next 10 or more years of our field.

The final year of training in any specialty, not knowing where one will live and practice, is one of the most stressful times in a young physician’s life. When there is high uncertainty, there is high anxiety. Unpredictable year-to-year variability for a specialty in the United States of just over 4500 physicians is inevitable. That was the case 30 years ago, as it is now. The remedy to manage this stress is more mentorship from attendings, program directors, and chairs working with our graduating residents to help them develop a strategy for success. In the meantime, we can take some pride in knowing that our residents are achieving their desired goals up to 82% of the time in a first job. That is a darn good batting average for such a small specialty.

Trying to “play the market” by manipulating resident positions is a risky game because it involves making predictions about the future. Although I worry about the negative impression of radiation oncology that is being created by the recent Match cycles, I also take a longer view. As a way of moving forward, we need to embrace the changes happening in medicine that will inevitably affect RO as well. Once we stop counting fractions and start focusing on our patients and the broader opportunities to help them, I remain ferociously bullish that there will be plenty to go around. Wringing our hands in despair at the shortfall in medical student applications is misguided. This is a glass half full that gives us the space needed to fix many aspects of our specialty. It is an opportunity to bring in great clinicians as well as great researchers and to attract more minorities and women. A fresh education base, good caregivers, and an equitable profile can only serve to enhance our key position within the arch of cancer care.