Questions for Rad onc residents and attendings

[thepit]

Hi All,

I've been eyeing rad onc for a while now and since I'm approaching clerkship I figured I should try to learn more about the field. I've shadowed about a week total in a few different tumour groups/ clinic types, but I wanted to hear from residents and attendings from other clinical sites as well. 

 

There are a lot of things I really enjoy about rad onc. I like how research driven the field is, the cool tech, working with cancer patients, being able to provide therapeutic treatments, making a discernable impact in the lives of people dealing with a life threatening disease, qnd seeing some of my patients get better because of my care. The lifestyle is also a big plus along with being able to have some geographic flexibility when choosing a residency. 

 

I also have some concerns about the field that I was hoping some of you would be able to comment on. It feels like there isn't as much of a diagnostic aspect in rad onc, with most patients already being diagnosed by the time they get to you. I like the diagnostic element of medicine, using your knowledge base to work through a differential and uncover what's going on, etc. and I was worried I would miss that. I'm also worried about having to deal with bad outcomes as I'm not sure how I'll handle having to deal with something like that regularly. I've heard the job market is opening up, but I'm very geographically limited and it's one of my top priorities to be able to live in my home province, is being that geographically constrained feasible in rad onc? I also have some concerns about the future of the field, the rad onc forum on studentdoctor is very doom and gloom with a lot of attendings expressing their misgivings about the field, is the climate in Canada comparable? I see a lot about declining indications for radiation, increasing uptake of hypofraction, and an increasingly saturated job market. 

I like some aspects of how the clinic pace is, in that I feel like you're never rushing through patients and they're getting the time they need, but on the days I shadowed we would spend maybe an hour of a three hour clinic seeing patients (rad oncs salaried in my province), with a lot of breaks in between. I was wondering if you feel stimulated enough day to day, or if start feeling really bored by the slow pace.

 

I also had some general questions about rad onc:

-how interesting is planning and doing brachy, it seems really cool on paper but some attendings have mentioned they find it pretty boring

-what led you to go into rad onc?

-what do you enjoy about the field?

-what do you dislike about the field?

-what is a typical week like for you? (Time spent in clinic, contouring, meetings/tumour boards)

-what advice do you have for a medical student considering rad onc 

[ralk]

I'm not a Rad Onc, but I'll give my two cents as someone who looked into the field semi-seriously through medical school. Hopefully a real Rad Onc can chime in, but I don't believe we have many of them hanging around the boards on a regular basis, unfortunately.

Like you, I was attracted to the field because of the hours, the rewarding patient contact, and the opportunities to dig a bit deeper in research than other fields typically allow. Like you, I was scared off by the job market, and ultimately, I was scared off by it enough to choose not to pursue that field.

The job market for Rad Oncs used to be quite tight and has loosened up a bit. We have been seeing the expansion of the field into new cities as new cancer centres open up, and the specialty is finally old enough that we're seeing some retirements opening up some positions. Cancer care continues to be well funded both publicly and privately, so while there might not be a ton of jobs, there's been opportunity. Even when there haven't been posted jobs, I know of examples of jobs essentially being created for well-liked, capable Rad Onc residents (after they do some fellowship training, of course). It's to the point that if I was finishing a fellowship right this year, I think Rad Onc would have a fine job market that is at least open enough that you can work your way to showing that you are worth employing.

That's the good. Here's the not-so-good. Rad Onc is a small field, so there's a lot of room for randomness to affect opportunities. Especially if you're geographically constrained, options could be wide open or quite limited, and that situation could change very quickly. The job market overall tends to be a bit cyclical as well, meaning tight job markets don't last in Rad Onc, but the good job markets don't either. If this counts as a good job market, and I think it does, then there's little guarantee it lasts until a medical student finishes their residency and fellowship(s). As you note, Rad Onc is a technology-dependent field and, worse, it is one that doesn't have exclusivity over the conditions it treats. If the Med Onc or surgical side of things develop a new approach to treating a certain type of cancer to the point that it supplants or reduces the need for radiation therapy, there's not much Rad Onc can do - they just lose work. That can go the other way of course, as innovations in radiation therapy can result in less work for Med Oncs or surgeons, but based on the scope and potential of the modalities, I'll have to admit that I'm not hopeful for Rad Onc in that match-up. Radiation is indiscriminate in how it works - it damages everything it touches and while it can be focused to hit cancers harder than normal structures in the body, it can't be as targeted as narrowly as surgery or (some) chemotherapeutic agents can. I'd also argue that Med Onc has many more pathways to improving their treatments than Rad Onc does, drawing on new pharmaceutical innovations directed towards multiple biochemical targets, while Rad Onc is more of a one-trick pony relying largely on external beam radiation therapy (there are some newer radiation approaches, but these have some well-established drawbacks and currently appear to have a rather limited clinical role).

The conclusion I took from talking to current Rad Oncs about the job market is that there are no guarantees. Doesn't mean it's bad, doesn't mean it's good, just that it's unreliable. Being geographically constrained could be a non-issue, or it could be a significant hurdle to getting a good job (and it's quite likely you'd need to move at least temporarily for a fellowship or two). Choosing Rad Onc, to me, meant accepting the risk that I might have to move for work, probably not half-way across the country like some other fields, but perhaps further than I'd like to.

[JohnGrisham]

Many of the residents i've met recently are all taking the USMLEs, so that must say something about the job market. As "bad" as it is in the US, if you're flexible with location its not that bad. You have many options in the US. In Canada, since majority dont have a choice of employment(almost all are via Cancer centres), you dont have that same option.  Might not be bad as before, but it still not great.

[mavrik13]

Your post hits on so many topics it is tough to combine it all into one answer that isn't a 4000 word essay. I would encourage you to spend more time with rad onc residents/staff, and hear their answers and opinions, particularly since it seems you want to stay in a particular province.

Overall, I'm happy with my choice (rad onc resident) - it is an intellectually stimulating field, rewarding patient interactions, very multidisciplinary, and has a decent work-life balance (my view on this has changed a little bit - there isn't much that gets you in through the night, other than emergency department consults and inpatient care, but the days can still be quite busy from 8-6... though as I write that, I think of my friends who would consider that a dream day). Feel free to send me a PM.

On 3/27/2018 at 3:27 AM, thepit said:

I also have some concerns about the field that I was hoping some of you would be able to comment on. It feels like there isn't as much of a diagnostic aspect in rad onc, with most patients already being diagnosed by the time they get to you. I like the diagnostic element of medicine, using your knowledge base to work through a differential and uncover what's going on, etc. and I was worried I would miss that.

There is definitely less of a diagnostic element, but it is not completely absent. The cancer workup is still present. In addition, you still have to work up people for general medical issues i.e. delirium, failure to thrive, etc. I don't miss it.

I'm also worried about having to deal with bad outcomes as I'm not sure how I'll handle having to deal with something like that regularly.

It's a tough balance. It is not unique to radiation oncology. Providing palliative care is rewarding (IMO).

I've heard the job market is opening up, but I'm very geographically limited and it's one of my top priorities to be able to live in my home province, is being that geographically constrained feasible in rad onc? I also have some concerns about the future of the field, the rad onc forum on studentdoctor is very doom and gloom with a lot of attendings expressing their misgivings about the field, is the climate in Canada comparable? I see a lot about declining indications for radiation, increasing uptake of hypofraction, and an increasingly saturated job market. 

Job prospects will depend on your province, feel free to send a PM if you want specifics. Overall, it is not a field with great geographic flexibility, but the job market is much better now than 5 years ago. Don't worry about SDN, the radiation oncology market is completely different south of the border, and does not reflect issues in Canada (they are still present, but different).

I like some aspects of how the clinic pace is, in that I feel like you're never rushing through patients and they're getting the time they need, but on the days I shadowed we would spend maybe an hour of a three hour clinic seeing patients (rad oncs salaried in my province), with a lot of breaks in between. I was wondering if you feel stimulated enough day to day, or if start feeling really bored by the slow pace.

You're clearly in a different province than I am. Things are very fast paced here, and clearly reflected in the billing model (Ontario is fee for service).