My reasons against a career in radiation oncology (2023)

Let me say that this answer is someone trained in the US system and I'm not privy to the (probable) differences between US and German medical training.

I support anyone who has previously shown a strong interest in Radiation Oncology or Rad Bio and will change their mind as they learn more about the field and what is important to them as a career in medicine.

This thread is once again turning into a discussion about the poor job prospects, expanding grants, reducing reimbursements, increasing hospital employment, etc. woe is me heaven is falling a discussion that appears in almost every thread dedicated to the Negative uses of radiation oncology. For the record, I believe all of these things are extremely important to the health of the field as a whole.

However, I would like to focus on the actual field of radiation oncology and the concerns of ORs.
Here are the main cons of Rad Onc (as a field) for me:
Rarely do you have to use your diagnostic skills, which are so emphasized in medical school.
Reliance on external referrals from specialists as almost all patients are not referred to a radiation oncologist by the PCP.

There are a lot of positives as to why I actually went into the field. I won't list them all because I think there are too many.

I am a German medical student nearing the end of medical school. With this thread I would like to present the reasons that prevent me from deciding on radiation oncology. I thought this might be useful for people who are undecided as well. I am also very interested in hearing your opinion on my argument. I have no experience or great knowledge in the field of radiation oncology and therefore the reasons I give may be "immature".

These are the reasons that speak against getting into radiation oncology:

1. Little room for improvement
In my view, locoregional control can be achieved by surgery or RT with acceptable side effects in most cases and entities. Sure you can play with selective sensitizers/radioprotectors, fractionation, gene signatures for better predictions, in vivo imaging to assess tumor susceptibility, respiratory gating, use of more angles in Sbrt, particle therapy and so on, but in the end what it all improves something that is already very good. The only great potential in cancer treatment lies in the control of systemic, disseminated diseases.
The potential for improvement is important to me because I'd rather be paid to improve sth than to keep sth.

Locoregional control is NOT good on a variety of locally advanced diseases - straight out of the box - pancreatic cancer, GBM (actually most primary intracranial diseases), cholangiocarcinoma, HCC, sarcoma, some H&N stuff, to a lesser extent stomach cancer.
Yes, distant metastases are a bigger problem for most patients with locally advanced cancer.
One thing confirmed time and time again by those who have experienced clinical radiation oncology is that as systemic treatments continue to improve, localized treatments will continue to be of value when (rather in metastatic patients) these drugs eventually fail.

So yes, the potential to increase overall survival when you can come up with magical systemic therapy is certainly greater than a new radiation technique.
If your focus is on making things better for the entire population (through the development of novel systemic agents that will blow all current therapies out of the water) then you honestly need to become a primary investigator, be it a doctor-scientist or a regular scientist. Clinical practice is mostly about getting stuff. Clinical trials can sometimes lead to improved results, but I think these are pretty widespread regardless of whether you choose Rad-onc or Med-onc.

2. Too much evidence for evidence-based medicine in radiation oncology
Any treatment should be as close as possible to evidence-based medicine. I am in favor. I believe that the most important requirement for being a good radiation oncologist is the extremely close adherence (compared to other fields) to hard evidence. This is what a radiation oncologist can be most proud of and that is the great value of a radiation oncologist. He/she knows all relevant studies and can interpret them and then estimate very well how likely a certain patient will benefit to a certain extent from a certain dose/fractionation/modality. I think there are historical reasons for this, since this specialty tried to "tame" a very dangerous animal (= high-energy radiation). But what's negative about it? As radiation oncologists have attempted to find ways to use radiation in the most effective and safest way, there is much hard, objective evidence of its best use. This data can be read by anyone. So a radiation oncologist copies that data into his brain and matches his patients against that data to find the right treatment. This is the first intellectual achievement. If a patient does not exactly meet certain criteria of study xy, the radiation oncologist has to “improvise” a bit, using his experience, basic medical knowledge and logic to find the treatment that will bring the most benefit/least harm . This is the second intellectual achievement. However, the more hard evidence there is for each and every tiny subset of patients, the less need there is for the second intellectual achievement. And I have a feeling this is the case. Even when you "improvize", you are improvising in a very narrow safety zone. Correct me if I'm very wrong. When the need to improvise (= make decisions based on your unique, subjective knowledge rather than following guidelines) wears off, your only medical value is to copy guidelines into your brain and match patients to them. A computer could do this faster and better...
Therefore, I would not feel very valuable in my job. I want to do sth where I know a pc is no better at it. Take for example the ability as a GP to make and assess a good differential diagnosis: this is where my own unique experience and ability to assess facial expressions/body language/social status etc. in a split second makes me very valuable as a human being (also because it there is no such good, tight-knit network of objective evidence for every decision as there is in radiation oncology).

There are a lot of cases that don't have a simple answer that can be fixed by guidelines or studies. For this reason, multidisciplinary tumor boards are almost ubiquitous for all sites in all major hospital systems. Sure, there are guidelines, but a good radiation oncologist is the one who, at the end of the day, knows when to push for RT and when to say RT is no longer an option. Check out the discussion in this forum - there are several gray areas in radiation oncology right now. There are studies giving conflicting recommendations for the same disease process, such as MAGIC vs. ARTIST vs. McDonald (possibly vs. CRITICS vs. TOPGEAR), and that only applies to locally advanced gastric cancer. In pancreatic cancer, there are studies (ESPAC) that say RT kills people and other studies that say RT absolutely helps.

Older studies are not cited as often as techniques have advanced - 70 Gy as the definitive RT for prostate cancer is now not a standard of care, although all the old studies used it. Therefore, there are new studies investigating the possibility of omitting certain areas of treatment (entire pelvis vs. prostate RT only, need for ADT) to ameliorate unnecessary toxicities. Treatment of primary metastatic prostate cancer may improve survival

3. We are not trained for this
I won't need 95% of the knowledge I've acquired in medicine in radiation oncology. I could maybe become a very good radiation oncologist with a 2 year degree. I don't have to go to med school for 6 years. I want to make the best use of the skills and knowledge I have acquired over the years. And I think that will be in an area like general medicine/pediatrics.

Medical students are not trained for the vast majority of areas outside of core rotations (given our forced exposure to IM, FM, Pediatrics, Psychiatry, Surgery, and OB/GYN as 3rd year students).

Regardless, you're still a doctor as a radiation oncologist. H&P is still the most important aspect of our day-to-day activities, even if most of it comes from chart review. While most of the day is not spent diagnosing, there are several diagnoses that have been captured by the Rad Oncs I've worked with in my short career - PE, DVT, CHF exacerbation, shingles, cellulitis, abscess, overt infections wounds etc. If you focus on putting what you learned in medical school into practice in the simplest way possible, then I agree that general medicine (IM/FM) is the area we are most exposed to .

As you can see,All of my reasons are based on being valuable to my community.I know that this is only a fraction of what can affect my decisions or others (lifestyle, physical disabilities
etc. of course also play a role). But at least in Germany medical school is free and so I feel like I belong to my community rather than a bank or myself.

Incidentally, I've already been doing research in a radiation biology laboratory for 1 1/2 years because I saw this area as my future, but now I'm very unsure about it.

I think a radiation oncologist is extremely valuable to a community. In the US, there are vast areas of the country waiting for radiation oncologists to come and work full-time to serve the community. In a smaller country like Germany maybe not such a big problem.

If you don't like the field because it's not enough for diagnosis, then so be it. Rad onc will not be a winner there.
If you think automation and policies are too overwhelming, I would work in a Rad Onc division first to see the level of customization most plans have, especially in this day and age of the IMRT boom. If that's not enough for you, then so be it.
You still need to know the basics of medical school because Rad Oncs don't practice in a vacuum. A complete lack of knowledge of the basic anatomy, physiology, and procedures that other fields perform will make you nothing but the person who simply does as they are told, with no backbone to stand for (or in some situations against) radiation to urge.

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