Episode 273 - Radiation Oncology: Past and Future

Chadi sits down with Dr. William “Bill” Small, Jr., a nationally recognized radiation oncologist and cancer center director at Loyola University Chicago, to explore the evolution of radiation oncology from its historical foundations to its rapidly advancing future. They discuss cutting-edge developments including proton therapy, radiopharmaceuticals, and the growing integration of molecular tumor profiling with precision radiation techniques, as well as the field’s increasing collaboration with medical oncology. Dr. Small also shares insights on mentoring the next generation of researchers, expanding clinical trials in radiation oncology, and addressing critical challenges such as overtreatment while shaping the future of the discipline.

Check out Chadi’s website for all Healthcare Unfiltered episodes and other content. https://www.chadinabhan.com/

Watch all Healthcare Unfiltered episodes on YouTube. https://www.youtube.com/channel/UCjiJPTpIJdIiukcq0UaMFsA

Transcript

SPEAKER_00 0:12

It's Healthcare Unfiltered. It's your host, Shadi Navan. Thank you so much for tuning in, folks, to this episode of Healthcare Unfiltered. Today's podcast is on radiation oncology with Dr. Bill Small, a dear friend and colleague, who is currently the Cancer Center Director at Layola University in Chicago here. Bill has had a stellar career. He is well known in the radiation oncology community. He has won many awards, mentored many radiation oncologists, written books, papers, apps, and everything. But most importantly, he has really lived the world of radiation oncology over the 30 years. And he's going to tell us really advances in radiation oncology, what has happened over in the past and what's happening now, and what does the future of radiation oncology look like? And he's going to put that in context with academic medicine. How do we really mentor folks to do more research trials and so on? Bill has had instrumental impact on the field of radiation oncology. And as you listen to this podcast, you're going to understand why. So thank you, Bill, for coming on the show and thank you for taking the time to be my guest on Healthcare Unfiltered. I really appreciate you. I appreciate everything you're doing. And I'm certain that there are so many patients who are very grateful for the amazing care that you have provided and continue to provide. And folks, uh uh don't forget to check out my books, The Cancer Journey, Understanding Diagnosis, Treatment, Recovery, and Prevention, and Toxic Exposure, the true story behind the Monsanto Trials and the Search for Justice. Check out all of these books, check out my website, shadinabhan.com. You can view all of my podcast episodes on my YouTube channel, Shadi Nabhan on Healthcare Unfiltered, and you can listen to my podcast everywhere on Apple, Amazon, Spotify, and so on. Don't forget to subscribe to the show, download the episodes, write a brief review, let others know about the podcast, and please always share your opinions and ideas about how we can make this much better. Without further ado, the one and only Dr. Bill Small on Healthcare Unfiltered. Well, it's really a true pleasure. First of all, to have a first timer on Healthcare Unfiltered. I'm always honored and humbled to uh to bring a new guest on my show. And also a dear friend and colleague, and one of the most phenomenal, important and luminaries in radiation oncology and cancer care in the nation. Bill Small, welcome.

SPEAKER_01 2:51

Well, thank you. And I I guess the check cleared with that introduction. So I appreciate the money well spent.

SPEAKER_00 2:57

Really, really, really thank you for coming in, Bill. We've known each other for over two decades, and um it's really uh wonderful to have you on the show. Um now, a few folks probably don't know you. I know you're not very active on social media, so uh we'd like to make some intro into what you're doing and um and what's your current role, but I really want to want people to understand a little bit how you got here and what got you into radiation oncology, first of all, um early on career-wise, and somebody inspired you. Just what was the story behind the story behind the physician and the scientist?

SPEAKER_01 3:33

That's a great, it's a great question. Um, first of all, I'm you know, again, honored to be here. It's been it's great talking to you. It's always good to see you, Chatty. We I think it's been over two decades, but that's a that's a whole other story. Um I uh I'm Bill Small. I'm a radiation oncologist. Uh I'm currently I spent 26 years at Northwestern before moving over to Loyola, which is where I'm at now. I'm the chair of the department there. I'm the Cancer Center Director and the Vice President of Oncology Services and enjoying it. Why did I go into radiation oncology? That's a great question. Um when I was in med school, uh, I really thought that you people should look at every specialty. So I was looking at every specialty. In fact, I thought I was gonna go into psychiatry, but I didn't. Um, and I looked at specialties and I just found radiation oncology because it fit. And I used to meet, I still mentor a lot of medical students. I think choosing a profession, choosing especially in medical school is really one of the most important things you do. And I tell medical students, pick it for your personality, nothing else. Nothing else matters. You can, you know, money can come and go, lifestyles come and go, but your personality. So my personality is such that I like doing things, I like technology, I like research, I like serious illness, I like having patients that I'll see forever. So radiation oncology, I like images, I like, I like working with um images. So that kind of fit everything I liked. And then uh my mom got cancer. So I got she had three different types of cancer. She had a colon cancer, a lung cancer, and then she had um died of uh rectal cancer. So I got to know oncology a little bit more. So the fit of radiation oncology was perfect in all those aspects. The why did I why did I do mark on a career that is academic? A lot of it had to do with my mom, because I promised her when she was dying, she died at a pretty young age, that I would try to cure cancer. So I've tried. Um, I haven't quite got there yet, but I think we've we've all made a lot of strides. Um, and it's been a great profession. For those of you that are docs that listen to this, you'll never meet a child of a radiation oncologist that goes to med school that doesn't go into radiation oncology. That kind of shows you about the species. So my daughter's a radiation oncologist up at MCW.

SPEAKER_00 6:04

So so yeah, I was gonna, I mean, so basically you she's not allowed, she wasn't allowed to actually do anything else but radiation oncology.

SPEAKER_01 6:12

Well, it's funny because again, it it was a good definition of your personality. So I've I've been my most active academic thing has been in gynecy. I was a chair of the gyne cancer intergroup and other things. So I've done gyne malignancies my whole career. She was choosing between gynec and ranoch, both great professions. And I went to her and I you absolutely hate making decisions quickly that can kill somebody. You can't be a surgeon. She goes, Oh, you're right. Yeah, for ours field, you can she she calls me a fair amount about cases. You can take your time and decide what you're gonna do. You'll fit that much better.

SPEAKER_00 6:52

So it's uh it is actually it's pretty interesting. I I like the uh I like what you how you moved in the personality piece because you know maybe there's a particular phenotype that fits a particular specialty, and it is as important as the technology itself or the actual specialty. Um so so Bill, you you you carry a lot of hats though. I mean, you you are you still see a lot of patients, I know that about you, but you also have so much administrative work. You still write and publish, and you're involved in the cooperative groups, and you do all of these things. What is a day, what does a day look like in your life? Like, take us through like how do you even do all of this and how do you balance?

SPEAKER_01 7:33

Well, I I I heard the expression work-life balance. I'm not sure what that actually means. But I think we talked about this um last night too. I my work is my hobby. So if I the the stuff I do with research, my um societal things I do, I love it. So I it's not at work. So my typical day starts around four. Um I try to get to work before everybody else because it's nice and quiet.

SPEAKER_00 8:08

Four in the morning.

SPEAKER_01 8:09

Yeah. Four in the morning. Um, I I live an hour away from work, so I'm not getting there that early. Um try to get to work by 5:36, get some stuff done, see patients during the day, um, and try to work at night. I mean, I but it's not really work, it's it's fun. I get a kick out of it. It's easier now because my kids are grown, but when I was young, we I younger, I still made all the kids, I still coach soccer, even though I don't quite understand the game. I know you're supposed to kick that ball into a net.

SPEAKER_00 8:43

Yeah. Well, get ready. World Cup, World Cup is coming soon.

SPEAKER_01 8:47

I know, but we didn't get a game in Chicago, which is weird.

SPEAKER_00 8:50

Yeah, but if you get tickets, I I expect to be in by it. So so, Bill, I I want to talk to you about several things on the show because not it's uh uh and and anytime I have a radiation oncologist, I like to bring up a couple of I don't want to I don't want to say I call them controversial, but I would say they're top of mind for my viewers and listeners to try to understand what is the field thinking about uh from a radiation oncology perspective. And then I want to weave in a little bit into um the you've seen how radiation oncology has changed over the years, over the past 20, 30 years. So it'll be very interesting to get your insight into the past, present, and the future. But let's start by a couple of things. One is proton therapy. We hear a lot of proton therapy. I guess tell us what's the current state of proton therapy uh for those of us who do not do radiation oncology?

SPEAKER_01 9:44

You know, it's it's a good question. Um there's a in the Chicagoland area, there's a single proton center right now. Um, and for about the first eight years of Z Loyola, I had privileges there. So I do have firsthand treating patients with protons. Protons are just radiation, so it's nothing different than typical photon radiation, but it has a different physics capability, meaning the beam the beam, I won't go too much into physics, but it has something called a brag peak. So it's a proton, a charged particle, as opposed to the typical radiation is a photon, which is like light but high energy. The proton delivers its energy, something called a brag peak, which means the radiation stops. So photon radiation doesn't stop, it goes right through the patient. Proton radiation, it can stop. So in certain circumstances, that's really important. So, for example, for pediatric patients that we treat with medulloblastoma and treat the craniospinal axis, to have no exit through the abdomen is incredibly important for long-term cancer, secondary cancer risk. For tumors that are right next to a critical structure like cordomas that you have to give a very high dose to, it's really important. For a lot of tumors, it it doesn't matter, meaning there are tumors where we don't have to be that precise. And protons have a little bit of a downside, they're they're very expensive, and they're the physics of them are tricky. So there it's a it's a very highly complex treatment to deliver. It has its roles in certain cancers and has its roles in recurrent cancers. So I think that protons, one of those things I've always thought of your radiation college, it's nice to have everything in your arm of materium where you can give every different treatment and give the best benefit you can to the patient if possible. So it's got its indications, they're relatively limited in some ways. We need to continue to study it, improve on it, and see which tumors are best treated with it.

SPEAKER_00 11:54

So is it like for folks who say, well, there are no randomized studies between photon, protons, things of that nature? This is, I mean, what do you do? Do we need this kind of trial, or is it just something you just have to do based on the tumor location and things of that nature?

SPEAKER_01 12:10

The it's a good question. I also, whenever someone says there's no randomized trial, there's no randomized trial of jumping out of an airplane without a parachute, but I'm pretty sure I'm not going to put anyone on that trial. Um, pretty sure a parachute is the right thing. So there are certain things that in radiation oncology, we've progressed and done new things a lot without any randomized trials because of the physics. So, for example, for intensity modulated radiation therapy, which came along in the 1990s and radically changed our ability to deliver precise treatments, there's only a handful of randomized trials because the physics is the physics. So if you're prove on a physics standpoint that I can miss a tar an area that I don't need to treat, why would you want to be on a trial that treats that area? So, in a way, um it's more a physics question. Now, when it comes to there are some randomized trials like on breast cancer, looking at postmasectomy radiation, there are some things that we might want to study because we don't know what the monokin of benefit is compared to the risk and the difficulty of delivering it. So there are certain things like I would never put a pediatric clenospinal patient on a randomized trial where I had to treat a critical organ without by doing photons. So the answer is I think it's a balance. You know, for certain tumor sites like prostate, where we've gotten very precise with our photon treatments, maybe that's an area you need a randomized trial to show a difference because photons do pretty well.

SPEAKER_02 13:43

Yeah.

SPEAKER_01 13:44

If that makes if that makes sense to you and your listeners.

SPEAKER_00 13:48

Okay. So you've done radiation oncology. We're not going to give away your age for about 30 years.

SPEAKER_01 13:53

Uh so you you have to I think you just I think you just did, Tony.

SPEAKER_00 13:56

Exactly right. I know you have a you you you know how it was and you're you you saw how it evolves. Can you take us through like what are the biggest advances, I guess, in radiation oncology? Because I want to segue from there into what the future looks like in terms of taking care of patients with cancer. And I do want to actually get your insight into how do we maintain academic medicine and get people enticed to do research and so on. But before that, let's get like what I mean. How was it? How was it doing radiation oncology in the 90s compared to today?

SPEAKER_01 14:31

You know, that's a another good question. It is unbelievably different. You know, when I came out, when I was doing my residency, we didn't always get CTs to plan. We did something called 2D treatments where we just took an x-ray and we literally drew on the x-ray where to treat. We did we had images, CAT scans, but we would draw the tumor on a plane x-ray, put in blocks, and deliver the treatment from various fields. Compared to what we do now, it's night and day. And most of that came along with um computing power. So that up until the mid to late 90s, pretty much everybody did what's called non-inverse planning. What you do is you would get on a machine and do draw a target, and the symmetry and physics team would help you aim for that target. And then IMRT dramatically change our ability to target tumors. So, what IMRT is, is we draw our targets on the images, what we want to treat, are what we call organs at risk, what we want to avoid. We tell the computer get the dose here, don't get the dose there, and then it plans and gives you literally thousands of beams that come in and often circle the patient. And these these multi-leaf columners, which are how shape the beam, are moving at the same time the beam, the machine's moving. So we would go from treating an area of like 100 square centimeters of the dose that we're prescribing to 10 with the same efficacy. So the ability to target became dramatically different. And then as computer and our hardware got better, we're the whole thing of SBRT, which is stereotectic body radiate radiation therapy or stereotectric radiosurgery, where we could target things to like trigeminal neuralgia, where we target things that are just millimeters big with huge doses safely based on all these things couldn't be done in the past. So our the indications for radiation have continued to grow because of our ability technically to deliver the radiation in a more precise and consistent manner. The final thing that's really changed over the last decade is something called image-guided radiation therapy. So every day, most of our patients that we're treating get a CT scan. And then we co-register that CT scan with the planning scan to make sure everything's still in the same position and they're properly aligned. Again, making the ability to treat less of an area better. The other thing we did that is um we're just starting at Loyola that I think is well, you if you want to go in the next wave, I can tell you what the next wave is.

SPEAKER_00 17:20

Yeah, we're gonna do the next wave. But before we go to the next wave, these advances that you mentioned, what um what were they because companies were investing in the devices? Was it because you guys, as academicians, you go back to these companies and say, can you change this? Like how how did we get here, I guess?

SPEAKER_01 17:41

The answer to your question is yes, both. You know, companies, you know, it's it's kind of like pharmaceutical companies, they're innovating, you know, to do good, but with a profit margin. So if they can come up with the new gadget that we like, we buy. So there's the big accelerator companies had a vested interest in improving the treatment, but I don't, but also to help people. And then the academic industry partnership, we have a grant with the NZ NIH that we subcontract with one of the vendors that we're working on trying to do better imaging during treatment. So it truly is an academic vendor partnership. And you're right, we there's always they're always asking us what do you want to, what do you want differently, what do you want to do differently, what would help the patient get better treatment. So it really has been a just like in pharmaceuticals, it's a clinician company partnership in vascular initiated trials, people beta testing things. Um, it's been a real joy to see us be able to do so much better treatments.

SPEAKER_00 18:46

And then, I mean, you we talk uh cyber knife and gamma knife are you know the the more precise way of uh delivering therapy. Um and uh you you I think you mentioned those a little bit.

SPEAKER_01 18:58

Yeah, I think they're the same kind of thing. You can do that on a linear accelerator. It's it's just basically just treating a small target precisely as you can. So they're all fancy tanes for photon treatments that deliver a lot of dose to a small area and less dose elsewhere.

SPEAKER_00 19:12

Yeah, yeah. Okay, so well, this is where we are with radiation oncology. Let's put your futuristic hat on, and where are we heading in terms of um radiation therapy? Because I do have some questions personally into how do you really integrate the molecular aspects of uh a tumor of the cancer uh with radiation therapy? Are we gonna get to a point where in medical oncology, as you know, we have predictive and prognostic mutations and genomic aberrations? Some are predicting what we can treat with, and some maybe tell us that this is bad prognosis and so on. Are we gonna move? Uh hopefully you're gonna tell me that we, you know, in the future, you can do the molecular profile of the tumor, can tell me maybe the dose of radiation, what type of radiation, do I give radiation, or so on. But I want to put words in your mouth. I want you to tell us what the future, according to Bill Small, looks like.

SPEAKER_01 20:12

Are you sure we didn't talk about this? Because you're pretty close to what I think. We didn't talk about it. Um the most immediate thing that I was talking about is a machine that we just we used to have an MRI Linux, which an MRI attached to a linear accelerator. Um, we now have a machine that is a CT base, but it's adaptive planning, I think, is the next big physics change we're gonna do. And what do I mean by adaptive planning? Traditionally, when you give radiation, you do a CT sim, a CT scan, you draw your targets, and then you treat to those targets over the course of whatever treatment you're gonna do. Um, as listeners may know, we've shortened the course of treatment dramatically because we're able to target better. But you have that same treatment plan. Now, if you notice the tumor shrinks, the patient lost weight, you then have to take the patient off the machine, redo that stuff, takes a day or two, and replan. The machines now, you can do that on the fly. So you can adapt the treatments every day to the tumor and the internal motion of the organs, which is will be the next big thing in our physics aspects. So we won't do a course of treatment and do the same thing every day. We'll change a treatment every day to where the bowel sits, where the tumor sits, well, how much gas does a patient have in their whatever target we're treating? Are they moving a little bit? That's an exciting physics change. Now, when you ask me about molecular stuff, it's one of my pet peeves. I, you know, I think that how do we decide the dose we give? It's what we give everybody. You know, it's not very scientific. We're at the we're starting to incorporate that. There's a there's a trial that we did with my colleagues from Michigan led, and we did it called the idea trial. The idea trial was women between 50 and 69 who had breast cancer with a partial with a lumpectomy or a breast conserving therapy who had an oncotype below 18, was a phase two study of just giving hormones. That looked pretty successful. So there's a randomized trial called the Deborah trial that's flipping a coin between radiation or not for low onchotype tumors, which again, for those of you who don't know, oncotype is something we use all the time in breast cancer to decide the benefit of chemotherapy. So we're at the we're at the beginning stages of using some forms of molecular markers to treat. There's a test called the decision RT test, which is a test that for DCIS that looks at clinical and pathological features, some mark molecular markers, and gives you a score of how much benefit the radiation will have. I think the the hard part about moving this forward, because I I got asked by uh reporter once, where do you think cancer is going? I think cancer is going uh where you're gonna take a piece of the tumor, a piece of the normal tissue, you're gonna sequence them, and you're gonna say, you should give this treatment to this dose, and this is the toxicity the patient's gonna have, and everyone's gonna be treated a little bit differently. I mean, we're getting much closer in that in the medical oncology field. The problem with radiation oncology is most of these will be academic trials, meaning there's no, there's not a lot. We've got to get incentive for companies to invest significant amounts of money in this because there's not a new drug, it's just a different way of giving a treatment. But if you had to think of radiation as a drug, it'd be a miracle drug. I mean, we cure so many cancers with radiation as the primary treatment. I really would love to see more investment in that kind of next generation sequencing to tailor the radiation, for lack of a better term.

SPEAKER_00 23:57

So I like the idea of personalizing the treatment because you and I know that we over-treat a lot of patients to save a few. Um, and adjuvant therapy is a perfect example of that. I would love to be able to have a scenario where you normally would give radiotherapy post-lumpectomy for a woman with breast cancer. However, in that particular patient, although again she's young and could be 50 years old, you could say, I am confident that in your particular situation, radiotherapy is not going to add any benefit. Are we going to get there someday?

SPEAKER_01 24:39

Yeah, I mean, that's that's like I said, the Jebber trial is that. You know, it's a radiation or no radiation for low onchotte tests. We the we just published NSA NRG B51, which was a trial of no radiation versus radiation and complete responders in neoagomic chemotherapy and post-mastomy radiation didn't seem to help. So we're trying. I'm pretty proud of our specialty. A lot of the trials we do are trying to put us out of business, which is great. I'd I'd love to be out of business. I'd love that we didn't have to give any cancer care. I could find something to do. Um, but I think we're trying to do that. I think that's a that's a pretty I think from our specialty, we also have embraced hypofractionation, which means giving less treatments. That's less money, and we don't care. You know, as long as you're doing the right thing for the patient, it really is gratifying. So I agree with you. I think we over-treat tons of patients. When I'm giving informed consent to a patient, I'm like, you know, 80% of the time, this isn't helping you. I just wish I knew exactly who we needed to treat. And on the reverse, there are people that we need to treat more. You know, there are people that probably need a higher dose or need multimodality therapy when we would usually just give one therapy. So I think it goes in both ways. We under treat people we might need to be more aggressive with, we over-treat a lot of patients that don't need treatment. But it is the data is pretty solid that from a population basis, it's better. From an individual basis, who knows?

SPEAKER_00 26:17

Yeah. So so that is in terms of the personalized radiotherapy. Um, technology-wise, um, any fancy schmancy machines coming up in the next uh five years?

SPEAKER_01 26:29

Um well, the the uh the the adaptive machines where we can plan on the machine is is something I think is important. There are individual machines, MR Linux, where the MR is attached. You know, there's there's fancy semanti machines that have yet to be proven. I I think we talked about this. I I visited Abu Dhabi and Cleveland Clinic. Abu Dhabi is putting in a carbon ion machine, which is like the next generation of charged particles. It can do a lot of really cool things. I think it's about $300 million. So we better we we we better prove that it works really well. Our toys are not cheap. So the the next uh in the radiation oncology world, where one of the areas we overlap with other specialties is an unsealed radioactive sources, so radiopharmaceuticals. Those are probably also the next big thing as we get better ability to attach a radioactive source that can kill the cells with an antibody that attack goes just to the tumors, that's becoming more and more um indicated and popular. The other fancy Smanchy machine that I wanted, I would love to buy if uh if you have a few million, six or seven million dollars, that would be great.

SPEAKER_00 27:47

Easy.

SPEAKER_01 27:48

Okay, good. It's called a reflexon machine, and it is in a machine where it's a linear accelerator, but you inject radioactive material. Right now it's pet uh FTG, this the stuff we use for pet. And then the pet tracer goes out and the machine shoots back at where it's at. So it's biologically targeted therapy. So instead of anatomy, which is what we do, we biologically target. How cool is that? I mean, I can see scenarios where that replaces systemic therapy if we can get down to a micro dosing of where the cells are at. You know, chemo, same thing. We're giving chemo the whole body, but the cells that need to be treated are probably in just a few sanctuary sites or maybe just in the blood. If we can clear those sanctuary sites, give less chemo. I mean, those are really exciting things to think about. So uh the um adaptive planning, biologically targeted therapies, carbon ions, there's a lot of innovation happening that may be really, really cool.

SPEAKER_00 29:03

So, one of the things you mentioned though is that in order for us to be able to do some of these things, requires this uh, you know, academic medicine trials and investments from the next generation of radiation oncologists and oncologists to conduct a lot of research and so on. You're heavily involved in this. What is the current status of academic medicine and research medicine, in your opinion, broadly, and maybe radiation oncology specifically?

SPEAKER_01 29:30

You know, broadly, you know, in this country, there's two different forms of research, as you know. There's a lot of different forms, but there's bench science, which clinic there's physician scientists or pure scientists that are doing laboratory, preclinical animal studies to come up with new treatments. But those new treatments need to be translated into the clinic, and that's where clinical researchers come into play. And that's pretty much what I've been as a clinical researcher. I did some benchwork, but mostly I've done clinical trials. Clinical trials are difficult, they're they take a lot more time for the individual practitioner, um, and they they don't have any financial incentive. So it's an act of altruism and what you really love to do. I I hope we keep getting recruiting people in medicine that want to do that. I think that as reimbursement has notched down and as hospitals have become more economically under stress, the work productivity aspects of the physicians have gone up. So their dichotomy of goals. So I think academic medicine, when it comes to clinical research, is in trouble if we don't kind of reimagine it and rethink it. There's there should be some way where we can encourage and incentivize people to do clinical trials more than altruism. They love they love making things better, they love um the research, talking, all that kind of stuff. Because I do worry about the next generation. I think it's been a little bit harder sometimes to find people who are that interested in it. I I always tell the story I've I've done 400 papers, seven books. I've never done it during work time because I'm working. So I'm not sure everyone will always want to do that. And I I also, when I mentor our female colleagues, there's a lot of life things that go on. You can't, you know, working 100 hours a week is probably not the right thing. So I think we need to really try to focus as a society if we want to continue moving forward in the oncology cancer care world, or in any medicine that has clinical research, into finding ways to make sure we properly support that. As you know, if you do a cooperative oncology, since I'm also the cancer director, a lot of the academic trials, the not the trials that don't have pharmaceutical background where there's a profit margin. So trials that are doing things. Yeah, a lot of most radiation trials are that way because there's no profit to not treating, it's supported by the governments or or private um uh philanthropy, but mostly by government research. In the US, it's the NIH. Um the amount of money we get for doing that is way less than it costs us. So most clinical trial offices for oncology, especially NCI designated cancer centers, run at about a 50%. Um we'll need to find 50% of the money to support it. So if we get $2,000 for a trial, it usually costs us $5,000. I don't know if that's a model that's sustainable when the the healthcare reimbursement and reimbursement in general goes down. So I worry a lot about that.

SPEAKER_00 33:08

So what's the I mean, I guess what's the solution to that? I mean, I think these are important points, but um how do you counter that? Like what things you can't control the government and the government shutdown and things like that, but what are things under your control where you think you can hopefully salvage what you believe needs to be salvaged?

SPEAKER_01 33:30

You know, I that's a great, another great question. Um the I'd love to take, you know, take some of the the stuff that doesn't help patients out of the system to free up some more revenue, tort reform. Um uh some of the regulations we we do that might maybe don't help, but that's a whole big thing. I I believe in a single payer system so that we can take some of the the work that we do to get reimbursed is probably work that doesn't help people, but those are pie in the sky things. You know, the question is what can we do as individual places? And I think what we should be doing is there are a lot of people that love seeing patients. That's all they want to do. They want to see patients, they want to do their clinical work, they don't really like research. And there's some people that like research. I think we need to let's say, let's say you have a hundred RVUs you need to generate, um, which again, for the if there's any non-docs, it's just how we get paid. So you generate you have to generate 100 RVUs to get keep your salary the same. And it's between two people. The person that wants to do clinical research will generate 35. The person that wants to produce, um, just wants to see patients, produces 65, they get paid the same because you're incentivizing the clinical research. I think that's a practical way of doing it in hospitals if we can get the systems to kind of allow that. Um, and I would say for the first part of my career, I was in private practice, and um Barat Middle, who was my chair, a good friend of mine, we kind of did that, you know, because we all kind of some people saw our patients, some people did some research, we all shared the revenue. So group RVU models with with that kind of way of doing things, I think is one practical thing to do in institutions.

SPEAKER_00 35:21

Are there statistics of how many radiation oncologists are there in the US?

SPEAKER_01 35:25

About 5,500. Pretty small, pretty small, specially.

SPEAKER_00 35:29

And 5,500 US wide, is there any projections whether there's shortage? Like, are people looking at uh the future in five years? We're gonna have more per capita, less per capita, per per cancer patient, I mean.

SPEAKER_01 35:43

Are you trying to get me in trouble? The yeah, the answer is that is um with a small specialty, it's you know, and the fact that the only way to have residents, you only have to prove that you can teach them and do a good job with them. It we can't collab, we can't collude the number of residents. Um, we as early as the you know, 10 years ago, maybe eight years ago, we were by by far one of if not the most competitive residency. And then it's still for a while it wasn't because we expanded our residency uh numbers, and the rumor came out that there wasn't going to be jobs, and we became not very popular. Nothing changed in the specialty, and everyone was getting jobs, and we contracted a little bit. Now we're getting more popular, and the job hasn't changed at all. It's I think it's very, very hard to predict. I think we're at a good stage of producing the right number of residents that we need to maintain kind of a good we I think the best is not an oversupply, not a shortage. We we we want it to be uh to try to match the need with the the um number of residents coming out.

SPEAKER_00 37:02

Yeah, I was trying to think like how many people apply, how many positions there are, how many, like you know, there's probably because you know, I mean, you know, you know what us medical oncologists we say about traditional oncology, Bill, right? I mean, you guys Why didn't I go into that?

SPEAKER_01 37:15

Yeah, okay.

SPEAKER_00 37:17

Pretty much because you're we think that you're never you're never at the hospital on weekends, um, you're never on call, and uh you don't have to have uh primary, you can you don't need to be the primary team caring for the patient in the hospital. You're always the consultant, so we always thought like, why? Why did I think about that?

SPEAKER_01 37:41

I mean, that's a really good point. I we well, a couple things is we do take all, but our emergency is we can take it from home. So we do come in on the weekend. Um, but I don't know if you know, radiation usually doesn't work on the weekends.

SPEAKER_00 37:54

It's just after 5 p.m., after actually 3 p.m. or something.

SPEAKER_01 37:58

Um the those those are all very, very true points. I don't, but I don't think I think people, and actually some places do have inpatient services. We I haven't at the two places I've been at. I think that if you're doing especially for that, you're gonna be very disappointed. Because we all work hard. And the flip side, our days are really are really crammed, and we do our planning on weekends and nights. You know, we can do everything remote. So, yes, you're right. You everything you said is absolutely right, but it's uh it you it can be seen as a good uh a nice um work-life balance if you make it. But like I said, most of us are working on the weekends, we're just working contouring and doing our treatment plan.

SPEAKER_00 38:41

I'm I'm exaggerating a lot about that. But but then then I mean I think the the um um one of the key things when it comes to the research piece that you mentioned, um, it does a lot of the research that you guys do require collaboration with medical oncology and surgery, I presume. I mean, like you can have a trial in medical oncology that doesn't involve radiation at all. Um I find it hard, like in radiation therapy for the most part, except for a few exceptions, is integrated as part of multidisciplinary care. So you need like how do you how do you balance that?

SPEAKER_01 39:24

Probably, probably, it's probably 50-50, actually, Chatty, because like the Deborah trial is pure us, fractionation trials, technique trials are pure radiation trials. So a lot of things we do, it's but it's just us, you know, it's just us doing the radiation differently, and probably half, or maybe more than half, are different combinations of chemo radiation, different ways of putting together different targeted agents. So I think it's it's it's both. Um and I, you know, I think that we have, at least at our current institution, very strong multi-dysmoral teams. I think we we wouldn't put a person on a trial. We I when someone says, is there a captain of the ship? No, there's we're colleagues. We're all got our specialty, we all talk to each other. So yeah, I think it's and I think one of the nice things about oncology in general is it's very team science related. You know, there's I think that uh we medical oncologists, radiation oncologists work closely together on so many things. Surgical oncologists, I have an intraoperative radiation trial. Obviously, I have to have surgeon involved because we're doing it during the operation. So there's there's um a real team thing. And even our radiation alone trials, we talk about it. You know, should we put this person on a trial where we're not going to give them radiation? Um I think it's I think that's one of the really nice things about oncology in general. It really is a collaborative team approach. We all have we all have our specialties, we all work together, we all try and do the best we can for the patient.

SPEAKER_00 40:59

I guess my last question to you, and then whatever, and then just open-ended, whatever you want to say, is um in the field of radiation oncology, are you guys becoming super subspecialized as well, like medical oncology, where you would only irradiate the the prostate, nothing else?

SPEAKER_01 41:16

I think that over the years we've we've always been that. I think we were more, we were probably earlier on that than maybe medical oncologists. But yes, you know, in academics for sure, we we treat, depending on the size of the institution, sometimes only one tumor site, sometimes two. Um, but even in my private practice colleagues that have bigger that have bigger um groups, they're even subspecialized a little bit. You know, as we get better, more and more treatments, it it does help to be able to concentrate on a couple tumor sites when it comes to the literature and the treatment techniques. So at most, especially academic sites, yes, we subspecialize. Um, not necessarily just on like treating the right toe, but GU. Or I treat breasts and gyne and GI. Um, I've always only treated those three. So I don't treat head and neck, brain, thoracic. I I could, but I'd have to kind of relearn those tumor sets. I think there's a benefit to that, but we have to. I was on the board of the ACR and the ACR we're still a part of, but we talked a lot about generalists, especially when it came to radiology. There's a danger in that too, because we there are there are places, rural places, that need these treatments and they can't be subspecialized. So we have to have people that are strong and also very comfortable trying to treat everything so we can get access to care to people. So I I always struggle with that. You know, we we need to, I think it's there's some benefit to being sub-specialized, but there's some decrement too, especially when it comes to access in in rural communities or communities with limited resources.

SPEAKER_00 43:01

Yeah. Bill, what other questions I should have asked you that I may have completely overlooked that we you want to share with listeners and viewers in the last couple of minutes?

SPEAKER_01 43:10

You know, I I thought about this a lot. It's such an honor and a privilege to take care of patients. It's such an honor to be an oncologist that we sometimes get way bogged down in reimbursement and insurance companies and this and that. Um, for those of anybody that listens to this that is either thinking about it going to medicine or in medical school, it I I it's it's the best specialty ever. It's such a privilege and honor to take care of patients. You know, you get so much more than you give that, and I love doing academics. I mean, I just love it. I love teaching residents, I love teaching medical students, I love trying to set a bar that's a little bit higher. Because if you, for those of you that are thinking about academics or not, if you write a paper or do a trial. It changes the standard of care even a little bit. You've not only helped the patients you have, but potentially patients all around the world. And how cool is that? What a legacy to give the next generation. So I I always think that there's so many naysayers talking about how hard things are. They're always going to be hard. If you're doing something great, it's not easy. And being a doc and doing the best you can is a wonderful thing. I think we all have to kind of remember that when certain challenges come up that are out of our control.

SPEAKER_00 44:35

Dr. Bill Small, thank you so much for coming on Healthcare Unfiltered. I really appreciate it. Okay, everyone, thank you so much for being on Healthcare Unfiltered. Thank you for listening. Thank you, Bill, for coming on the show and for providing your insights and amazing ideas into where we are and where we are heading. Uh, folks, again, you can follow me on Twitter at Shadi Nabhan, Instagram, Shadi underscore healthcare unfiltered, on Facebook, on LinkedIn, on TikTok, and uh again on YouTube. Uh please share your opinions, your ideas, how we can make things better, provide uh any ideas about any uh future guests that you would like to see on the show or any topics. My line is always open, and you can email me at shadinabhan oo at outlook.com. Before I let you go, I'm gonna leave you with a saying by Isaac Newton. Plato is my friend, Aristotle is my friend, but the greatest friend is truth. Until next time, take care.