Climate change is real. Denialists have been using a variety of tactics to make the claim that it is a hoax for decades even though experts widely agree that it is happening and anthropogenic. Sometimes climate denial arguments are made in good faith, but mostly they seem made to allow people and corporations to behave self-servingly. This same phenomenon is occurring in radiation oncology. There has been a substantial increase in the number of radiation oncologists with concomitant decreases in utilization, fractions, and reimbursement. The people that study these radiation oncology issues in detail have noted problems for nearly a decade, and yet their voices continue to be dismissed or their claims denied.
There are echoes of climate deniers’ rhetoric here in radiation oncology.
“Where is the data?”
Both national organizations and individuals keep asking for present-day data to show that harm has been done. This is like climate change denialists that say:
The sky is blue, the mercury’s barely rising, and there was an early snow in October this year.
In radiation oncology (RO), there has been an ever-increasing number of physicians, decreasing utilization for our modality, decreasing number of treatments per case, and stagnant or decreasing reimbursement. Incrementally, it is difficult to show current changes. But just like in climate science where much of the damage is projected or yet to come, in RO the data also points toward future worsening problems.
However… there are data which show RO problems now. There has been a significant decrease in resident case experience over the last decade. In 2003, ASTRO claimed approximately 1.2 million people a year received radiation therapy, but in 2020 a nationwide survey revealed that the number of patients treated per year has fallen 13% to 1.06 million a year. Astoundingly, this 13% reduction in absolute patients has been associated with a 57% increase in radiation oncologists (approximately 3500 in 2003 and 5500 now). There has been a 30% reduction in treatment fractions (15.7 visits per patient in 2020 vs 22.5 in 2010) as well.
A call of “Show me the data!” was not needed to justify widespread residency expansion before Smith’s original analysis showing future under-supply of ROs. And no data seems needed to justify continuation of expansion now given Smith et. al’s later re-analysis predicting future RO over-supply.
The utilization of radiotherapy among all cases declined from 33.9% to 31.2% ( P < .001), and systemic therapy and surgical therapy use went from 37.3% to 44.1% ( P < .001) and 67.7% to 67.5% ( P = .79), respectively. Radiotherapy utilization decreased most in genitourinary, HN, and CNS cases with relative declines of −42.5% (−12.4% absolute decrease, P < .001), −10.3% (−6.1%, P < .001), and −9.6% (−3.2%, P = .001), respectively. Radiotherapy utilization increased in gastrointestinal (+0.6% absolute increase, P < .001), musculoskeletal (+1.0%, P = .002), skin (+0.7%, P = .002), and thoracic (+0.1%, P = .46) malignancies. In patients receiving EBRT, the mean number of fractions delivered per patient declined from 28.7 to 25.2 ( P < .001); declines were evident in all disease sites but CNS.
“I am not a climate scientist; are you?”
One of the more creative arguments from leadership and prominent voices in RO is that they are not equipped (i.e. have no legal or business or economics degrees or credentials) to study supply/demand issues. And since almost no one else in RO has these credentials either, rad oncs can’t even hope to discuss supply/demand issues cogently.
No radiation oncologists are climatologists or environmental scientists. That does not mean they can’t make informed choices regarding the environment. People (some of which, presumably, are radiation oncologists) recycle, drive electric cars, donate to causes that promote environmental health, divest from funds that include environmentally unsound corporations, and so forth. People use the data that experts give to make choices. There are plenty of data that show the road ahead is perilous, and rad oncs do not need advanced legal or economic degrees to understand that.
“But we have data from today that says everything is fine”
This is the argument where people confuse weather with climate and/or “cherry-pick” data that has a good connotation to refute data which doesn’t. A single day, or even year, of data is not applicable to climate science modeling; and some data does occasionally conflict with the modeling. For example, NASA has satellite data that shows the earth is getting greener. With this one data point, a person might say “See, the environment is fine”… which of course would be dishonest way of looking at the data. If a young rad onc found a partnership track job in greater Los Angeles that pays her $1 million a year in 2019, this doesn’t mean that all residents are experiencing the job search equally. This is anecdotal and it may reflect a time period just before the tipping point. ROs know the numbers are not adding up, and that creates uncertainty about the future. How else to explain the need to SOAP nearly 30 residents in the 2019–2020 cycle (the majority of whom did not initially apply to radiation oncology or would have been deemed to be not “traditionally qualified” prior to 2020). American medical school graduates sense RO’s uncertainty in a way that the field itself has been reluctant to voice openly.
“Environmentalists are hippies, naïve, and dangerous”
Although not scientifically effective, ad hominem attacks are nonetheless still commonly used in the “climate debate” (on both sides, to be fair). But this same sort of behavior is occurring now in RO, calling those that worry about the future “miscreants,” “misanthropes,” “unhappy internet bloggers,” “annoying,” “clueless,” “haters” — and these are the milder appellations. Rather than discuss the issues and the data many have resorted to name-calling and cancellation. Voices on social media that promote the viewpoint that RO is in a crisis are ignored and blocked. ABR executives have written angry, litigious emails to RO’s young physicians.
Many academic leaders tell their residents not to listen to those voices that dissent. This is like saying, “Don’t read any of the studies showing climate change exists–only focus on the studies that say it doesn’t.” This silo-ing is all too common in today’s era of divisiveness. Epistemic closure is not just a problem in politics: it is affecting the very work that we do. This worked for decades with regards to the environment, but the data proved too strong. The same will occur in our specialty. Those that speak up and want the numbers (of residents and radiation oncologists) to decrease are not “anti-RO.” They love RO and feel ignoring problems and attacking those who speak out are the real “anti-radonc-ites.” Ignoring things will worsen RO’s existential problems by postponing effective action.
“You are selfish and don’t care about others”
There was an incredible amount of gaslighting in the early era of the discussion of climate change. “You’re making it hard for ordinary families to succeed with these policies.” “Sure, you have time to separate your garbage, but we are working class and have limited means so we can’t recycle.” The idea that doing good for the environment is selfish became quite common. And there is certainly something to be said about the costs of environmentalism. But the irony is that the opposite is true — not actively participating in pro-environmental policies is the selfish act even though there may be some economic harm. In medicine this is also known as the “risk/benefit ratio.” This is the same for RO … “You want less of you so you can make more money,” or “You had it so good, why don’t you let others join and have it, as well?” This is backwards. People in RO have had it very good. It is an amazing field. Rad oncs want it to be that way for all the newcomers. All of us should want the field’s newest inductees to enjoy their work, take pride in it, and not be forced to take revolving-door jobs with no path to partnership. RO’s “enlightened minds” want the next generation to be able to make the hospital responsive to their needs rather than be an easily replaceable cog in a machine. We want the younger generation to experience why RO was once the greatest field in medicine.
“Climate change is real, sure, but it’s been going on forever; we didn’t cause it, so how can we fix it?”
Some people admit climate change is real, but either 1) there’s nothing humans can do about it, or 2) humans didn’t cause it in the first place. Because climate change has occurred without trying very hard to do anything about it, this makes disasters more likely and frequent. Furthermore, mitigating efforts before disasters occur are lacking infrastructure and social foundations are not strong enough to withstand certain events. Similarly, because the foundation is not strong in RO (it’s one of the smallest medical specialties), “shocks” affect the field quite violently. RO has had issues in the past when shortages created an environment where only ~40% of graduates were satisfied with their job opportunities. Many ROs remember after the 2008 financial crisis how difficult it was to find employment as retirement essentially vanished. That took several years to correct. More recently, several offers were pulled or delayed from major cancer centers nationally because of the global pandemic. This happened at a very high rate because of the small number of radiation oncology residents compared to residents in other fields. RO cannot sustain these shocks very well because it is already stretched very thin. As shown above, there are only about 200 XRT patients per rad onc in the U.S. today (1.06E6/5500) compared with 350 (1.2E6/3500) in 2003. So when other shocks hit — APM, changes in supervision, absolute decreases in reimbursement rates, further decreases in fractions and utilization — the field will be much less prepared for what happens.
“Sometimes bad things just happen. It’s no one’s fault.”
When the Three Mile Island disaster occurred there was a race to avoid blame at all costs. Instead of doing root cause analyses early on, leaders and stakeholders’ sole mission was to avoid being labeled at fault. This happens routinely — people wanted to avoid blame for Deepwater Horizon, Exxon Valdez spill, unending wildfires and hurricanes complicated by pandemics, as well as many other environmental disasters. This parallels issues with the Physics and Radiobiology Board exam fiasco of a few years back. The ABR in public and private statements put blame on the “low quality” of residents. Recent publications have debunked that fallacy. In addition, if it were truly the quality of the residents, how did 99% of those that failed pass on the second try? When the leadership and certifiers’ failures lead to crisis and then the blame is put on the residents, RO has no meaningful way to fix the problem. The exam still tests minutiae:
There is no evidence that passing the test improves patient safety or outcomes. The national syllabus is bare of any fruitful information for the candidates. There are groups focusing on improving resident education, however the ABR has still not commented on their “low quality of residents” statement.
“We are mitigating the problem until we have a real solution”
This leads to developments like “clean coal”, carbon taxes (“let rich polluters just pay more”), token reductions on emissions, increasing miles per gallon minimally, and adding a few bike lanes. Similarly, in RO, the field has held on to direct supervision to bolster the job market. And freestanding centers continue to treat with extended fractionation for curative and palliative treatments. And more recently the field has created unaccredited fellowships — some based out of private practices that do not have infrastructure, labs, or techniques that cannot be learned during residency. There are “Advanced Radiation Oncology” and “Inpatient Radiation Oncology” fellowships that are of questionable value. (In fact, all fellowships in radiation oncology, whether in private practices or universities, are unaccredited by the ACGME.) According to webinars and discussions with national leaders, “you have to network” to get a job. As if having a beer at ASTRO with practicing physicians will create a job within 100 miles from one’s hometown. There is also the idea of not SOAPing residents when there are open positions, but the reality is that people do SOAP and they tend to pick residents that had no prior interest in oncology or do not have the qualifications that that last two decades of applicants have had.
The crisis in the field is real. One cannot look at the data honestly and say “The job market will be fine in the future.” RO has double the number of residents and a steadily decreasing workload. There are measures to delay (fellowships) or maintain employment (artificial “props” like direct supervision and underutilization of hypofractionation). Interest in the field is decreasing amongst American medical students and it has nothing to do with lack of awareness of RO. In fact, it has to do with increasing awareness of the problems in RO. Climate change debate rhetoric limiting effective solutions and cooperation arguably led to the climate problems seen today getting worse and worse. This would be tragic were a similar scenario to play out in radiation oncology. Bad-faith arguments, ad hominem attacks, and less-than-candid discussions with future physicians can’t be allowed to continue. Students, residents, and young faculty must be the change as senior leadership have abandoned their duty. Having communicated with so many of our young stars over the last few years, we remain optimistic that our field can take corrective action and strengthen the foundation so the field can sustain, and hopefully improve, the outlook for the specialty.
-Graypeace, December 2020
