Auto-contouring continues to advance

[Chartreuse Wombat]

Not sure who should be more nervous, dosimetrists or radiation oncologists?

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[RadOncDoc21]

I would say both. In regards to the dosimitrist, somebody still still has to “approve” the plan but for the rad onc somebody still needs to send them patients.

 

[Ray D. Ayshun]

Ultimately, we'll realize that not only can AI contour well, but it also has a cancer incidence of 0.

Was trying to figure out where to post the interesting quote from this story,

https://www.washingtonpost.com/technology/2020/12/03/timnit-gebru-google-fired/

about how the AI ethicist/researcher felt "dehumanized" at work. LOL, isn't that the point?

 

[scarbrtj]

This is not a question of if, but when. Totally feasible, one day: the patient is scanned. As the scan is downloaded, the AI has already contoured all structures, including the tumor regions (using a combo of scan, MRI, PET, etc.), calculated the dose from some pre-spec'd "recipe," and then the MD will briefly review it on the PC. In a nod to @evilbooyaa ...

Narrator: Over time, disagreement by the doctor with the AI became non-existent.

 

[Palex80]

Narrator: Over time, disagreement by the doctor with the AI became non-existent.

Papers already argue that disagreement between doctor and AI is similar to disagreement between individual (certified) doctors.

 

[IonsAreOurFuture]

This is not a question of if, but when. Totally feasible, one day: the patient is scanned. As the scan is downloaded, the AI has already contoured all structures, including the tumor regions (using a combo of scan, MRI, PET, etc.), calculated the dose from some pre-spec'd "recipe," and then the MD will briefly review it on the PC. In a nod to @evilbooyaa ...

Narrator: Over time, disagreement by the doctor with the AI became non-existent.

It's already started. I currently have my Dosimetrists auto-threshold everything on PET with an SUV of 4 and I only tweak from there.

 

[medgator]

It's already started. I currently have my Dosimetrists auto-threshold everything on PET with an SUV of 4 and I only tweak from there.

Definitely would miss low grade lungs with sbrt or borderline nodes in lung or h&n, but to each his/her own

 

[IonsAreOurFuture]

Definitely would miss low grade lungs with sbrt or borderline nodes in lung or h&n, but to each his/her own

I should clarify, this is not for all tumors, but it sure is handy for clysters of multiple lytic bone mets.
The first step to fully automatic is semi-automatic.

 

[Palex80]

It's already started. I currently have my Dosimetrists auto-threshold everything on PET with an SUV of 4 and I only tweak from there.

Auto-threshold WBRT !

 

[Gfunk6]

Narrator: Over time, disagreement by the doctor with the AI became non-existent.

Plot twist, this occurs not because AI will become so proficient but because of a technological singularity.

 

[DoctwoB]

I should clarify, this is not for all tumors, but it sure is handy for clysters of multiple lytic bone mets.
The first step to fully automatic is semi-automatic.

Correct. For our careers AI will be an adjunct, not a replacement. It will give a first pass at contouring and you will review, change, and approve. It may increase efficiency and reduce overall workload.

As a surgeon it will likely play a role in image processing, eg highlight tumor is here whilst covered in fat, etc.

Seeing the contouring the software does on the prostate for my MRI fusion biopsies I’ll tell you guys don’t quit your day jobs just yet.

 

[scarbrtj]

Correct. For our careers AI will be an adjunct, not a replacement. It will give a first pass at contouring and you will review, change, and approve. It may increase efficiency and reduce overall workload.

As a surgeon it will likely play a role in image processing, eg highlight tumor is here whilst covered in fat, etc.

Seeing the contouring the software does on the prostate for my MRI fusion biopsies I’ll tell you guys don’t quit your day jobs just yet.

That said, I haven't manually contoured a lung or a spinal cord in a loooong time.

 

[medgator]

That said, I haven't manually contoured a lung or a spinal cord in a loooong time.

I will love it when AI figures out large/small bowel

 

[dieABRdie]

I will love it when AI figures out large/small bowel

Every time I hear someone say AI contouring will replace me... I reply "HURRY THE **** UP!"

 

[w00tz]

Every time I hear someone say AI contouring will replace me... I reply "HURRY THE **** UP!"

Waiting for the day I don't have to draw neck levels II-IV on a resim

 

[taserlaser]

Waiting for the day I don't have to draw neck levels II-IV on a resim

Last place I was at had dosimetry trained so each level was segmented prior to the RO. Some errors/babysitting on the final volumes, but not lying that there wasn’t some satisfaction to just clicking nodal levels as I saw fit for inclusion in a mad happy spree.

 

[medgator]

Every time I hear someone say AI contouring will replace me... I reply "HURRY THE **** UP!"

Until AI has to give prognoses, carry med malpractice insurance and receive Attorney presuit letters, rad oncs have nothing to worry about

 

[RadOncDoc21]

Until AI has to give prognoses, carry med malpractice insurance and receive Attorney presuit letters, rad oncs have nothing to worry about

Right, biggest problem for us is with each other, residency expansion and a significant decrease in radiation utilization.

 

[medgator]

Right, biggest problem for us is with each other, residency expansion and a significant decrease in radiation utilization.

And by us, it's really mainly academic chairs and faculty/PDs who go along with them screwing the rest of us collectively

 

[w00tz]

Last place I was at had dosimetry trained so each level was segmented prior to the RO. Some errors/babysitting on the final volumes, but not lying that there wasn’t some satisfaction to just clicking nodal levels as I saw fit for inclusion in a mad happy spree.

Brb, going to training my dosimetrists. Hopefully they don't quit, lol.

 

[Krukenberg]

Every time I hear someone say AI contouring will replace me... I reply "HURRY THE **** UP!"

exactly. It’s not like anyone’s FTE is based off contouring time. Contouring takes place between patients or on off hours—AI will only enhance QoL if it can do OARs and basic targets competently.

 

[scarbrtj]

exactly. It’s not like anyone’s FTE is based off contouring time. Contouring takes place between patients or on off hours—AI will only enhance QoL if it can do OARs and basic targets competently.

UK clinical oncologist *minimally* contour in comparison to US rad oncs. Dosimetrists much more trusted for tumor and normal contouring there.

 

[OTN]

UK clinical oncologist *minimally* contour in comparison to US rad oncs. Dosimetrists much more trusted for tumor and normal contouring there.

I really enjoy contouring, so I would not enjoy practicing in that environment. I even make little "swooping" sounds in my head when I do it. Kind of figure I'm alone in that one.

 

[Chartreuse Wombat]

To return to the initial post. I would be concerned if I were a dosimetrist.

 

[RadOncDoc21]

To return to the initial post. I would be concerned if I were a dosimetrist.

I still like having one around but then again I’m employed so I’m not paying for them either. If anything, I don’t see a need for a RN.

 

[FrostyHammer]

I will love it when AI figures out large/small bowel

Please don't tell me you're one of those people who contours individual bowel loops instead of the bowel bag...

 

[elementaryschooleconomics]

Please don't tell me you're one of those people who contours individual bowel loops instead of the bowel bag...

Far too many "loops of bowel" folks out there in the world...

 

[medgator]

I still like having ones round but then again I’m employed so I’m not paying for them either. If anything, I don’t see a need for a RN.

LPN/MA ftw

 

[radoncopotamus]

LPN/MA ftw

Seriously. My nurses room the PT and the sign out I get is so & so is in room X and their blood pressure is high.

Thanks?

 

[elementaryschooleconomics]

Seriously. My nurses room the PT and the sign out I get is so & so is in room X and their blood pressure is high.

Thanks?

Sometimes we'll get new or travel nurses who give me a med student level H&P and I'm like...what is this? Who are you? What's going on?

Then, as the months and years pass on, it eventually turns into "the consult is in Exam 2" and then back to talking about The Crown.

 

[medgator]

Sometimes we'll get new or travel nurses who give me a med student level H&P and I'm like...what is this? Who are you? What's going on?

Then, as the months and years pass on, it eventually turns into "the consult is in Exam 2" and then back to talking about The Crown.

Eh i just want them to make sure the pet CD is here, the path report is scanned in and they can tell me if the pt is seeing med onc and who it is

 

[RadOncDoc21]

Eh i just want them to make sure the pet CD is here, the path report is scanned in and they can tell me if the pt is seeing med onc and who it is

Exactly! I can train anybody to do that but alas they want us to have a nurse for whatever reason.

 

[Krukenberg]

Seriously. My nurses room the PT and the sign out I get is so & so is in room X and their blood pressure is high.

Thanks?

anyone utilize an RN to triage patient phone calls about symptoms they’re having? Managing dermatitis with an algorithm? I’ve seen good RNs who definitely help the attending in a meaningful way, and others who just want to pass everything on to the MD.

 

[elementaryschooleconomics]

Eh i just want them to make sure the pet CD is here, the path report is scanned in and they can tell me if the pt is seeing med onc and who it is

I generally agree - but man, is it jarring when a nurse gives me a heads-up about potential immobilization issues at sim based on their interview of the patient.

anyone utilize an RN to triage patient phone calls about symptoms they’re having? Managing dermatitis with an algorithm? I’ve seen good RNs who definitely help the attending in a meaningful way, and others who just want to pass everything on to the MD.

I really wish this was more common than I think it is. Most of the other specialties seem to have this, why not RadOnc? My department has sort of gone halfway in this regard - there are certain nurses which will do phone calls/triage for certain disease subsite patients, and will manage basic issues. In general, however, all calls are immediately kicked to an MD.

 

[OTN]

I generally agree - but man, is it jarring when a nurse gives me a heads-up about potential immobilization issues at sim based on their interview of the patient.



I really wish this was more common than I think it is. Most of the other specialties seem to have this, why not RadOnc? My department has sort of gone halfway in this regard - there are certain nurses which will do phone calls/triage for certain disease subsite patients, and will manage basic issues. In general, however, all calls are immediately kicked to an MD.

My nurse has been doing radonc nursing for 15 years now, so I give her a ton of responsibility and leeway to make decisions and interrupt things before they get to me. She's very, very good about knowing when to get me involved and never goes out on a limb. Incredibly valuable.

 

[elementaryschooleconomics]

My nurse has been doing radonc nursing for 15 years now, so I give her a ton of responsibility and leeway to make decisions and interrupt things before they get to me. She's very, very good about knowing when to get me involved and never goes out on a limb. Incredibly valuable.

That sounds amazing!!

 

[RadOncDoc21]

My nurse has been doing radonc nursing for 15 years now, so I give her a ton of responsibility and leeway to make decisions and interrupt things before they get to me. She's very, very good about knowing when to get me involved and never goes out on a limb. Incredibly valuable.

I’m hating! My nurse is good at telling the patients “let me get the doctor” even if it’s to see what date their next appointment will be.

 

[Krukenberg]

I’m hating! My nurse is good at telling the patients “let me get the doctor” even if it’s to see what date their next appointment will be.

Is it a matter of setting expectations and training him/her?

 

[RadOncDoc21]

Is it a matter of setting expectations and training him/her?

Let’s say I rank far down the institution’s totem poll when it comes to any kind of administrative actions.

With that said, there has been significant improvement over the past year but it takes so much out of me and time that I usually just end up doing everything myself. Now if it something truly important or jeopardizes patient safety/care, I usually can get things handled quickly but I’ve learned to really just focus on the things I can control. My hope is to eventually get my own MA.

 

[dieABRdie]

Sometimes we'll get new or travel nurses who give me a med student level H&P and I'm like...what is this? Who are you? What's going on?

Then, as the months and years pass on, it eventually turns into "the consult is in Exam 2" and then back to talking about The Crown.

I need a couple things from a rad onc nurse:

1) take vitals
2) put patient in room
3) do as much "meaningful use" garbage as possible so I don't have to do it.

And do it quickly.

Where I did residency the nurses would review the chart, then spend 45 minutes in the room with the patient.... then give me some attempt at an H&P that would not contain one shred of useful information for making a clinical decision. More like a "timeline" of studies.

I remember the first few times it happened during PGY2. I just stared at them like "WTF was that??? You just spent 90 minutes prepping a patient. I looked at the chart for 5 minutes and already know more than you." I never understood the point of that "process" and I can not think of a single time it was useful. It certainly did waste time and back the clinic up. But that seems to be par for the course in an academic clinic. I just kept my mouth shut because I didn't want to get on their bad side for the few years I was there.

During the job search I made damn sure to look at that. Here I just get a text "Consult ready in room 2" and I could not be happier

 

[OTN]

I need a couple things from a rad onc nurse:

1) take vitals
2) put patient in room
3) do as much "meaningful use" garbage as possible so I don't have to do it.

And do it quickly.

Where I did residency the nurses would review the chart, then spend 45 minutes in the room with the patient.... then give me some attempt at an H&P that would not contain one shred of useful information for making a clinical decision. More like a "timeline" of studies.

I remember the first few times it happened during PGY2. I just stared at them like "WTF was that??? You just spent 90 minutes prepping a patient. I looked at the chart for 5 minutes and already know more than you." I never understood the point of that "process" and I can not think of a single time it was useful. It certainly did waste time and back the clinic up. But that seems to be par for the course in an academic clinic. I just kept my mouth shut because I didn't want to get on their bad side for the few years I was there.

During the job search I made damn sure to look at that. Here I just get a text "Consult ready in room 2" and I could not be happier

I actually have my nurse work up the chart and give me a printed out hard copy, on a clipboard, with pre-filled HPI/FHx/SHx/Meds/Allergies/rads/path etc. Path and rads reports are printed out and put on the clipboard with little tabs so I can access if the pt has questions, along with all records from other referring MDs.

This helps the nurse know the patient well (which helps when she's asked to manage down the line), and means my dictations are super quick. I do it for follow ups as well. Clipboard is much faster for info access than a computer, and I can look at the chart and take notes with my pen while facing the patient. Then, a quick dictation and I'm done.

RN also does all the EHR/opioid box checking/depression monitoring/OCM stuff that's necessary as well. She used to be an OR nurse as well, so she's super good at managing all our HDR procedures, too. Finally, I can tell that she likes being given responsibility and enjoys being able to make decisions and present her conclusions to me independently.

Damn. I need to make sure she gets a raise. She's the 4th RN I've had in my 11 years of private practice, and I hope she sticks around for a LONG time.

 

[dieABRdie]

I actually have my nurse work up the chart and give me a printed out hard copy, on a clipboard, with pre-filled HPI/FHx/SHx/Meds/Allergies/rads/path etc. Path and rads reports are printed out and put on the clipboard with little tabs so I can access if the pt has questions, along with all records from other referring MDs.

This helps the nurse know the patient well (which helps when she's asked to manage down the line), and means my dictations are super quick. I do it for follow ups as well. Clipboard is much faster for info access than a computer, and I can look at the chart and take notes with my pen while facing the patient. Then, a quick dictation and I'm done.

RN also does all the EHR/opioid box checking/depression monitoring/OCM stuff that's necessary as well. She used to be an OR nurse as well, so she's super good at managing all our HDR procedures, too. Finally, I can tell that she likes being given responsibility and enjoys being able to make decisions and present her conclusions to me independently.

Damn. I need to make sure she gets a raise. She's the 4th RN I've had in my 11 years of private practice, and I hope she sticks around for a LONG time.

Wow.... that sounds awesome. Definitely a gem!

Let me take a guess... physician led practice right? That kind of thing just doesn't happen in hospital systems with unions or where admin has a strangle hold.

I did join a physician led group this year and was somewhat disappointed with how much work the physicians do that could be done by staff. But the staff are spoiled and very happy.... which makes for a nice environment. What you are doing is exactly what I imagined doing if I ran my own show. I could easily train someone to collect the necessary information for each disease site by giving them a list, which would help me fly through a busy clinic. I'm the new guy so I don't have much say in the matter for now, but that will change in the future.

I've started looking at the other side. If the docs do much of the work... it makes me less reliant on them. So if APM slaughters us they will be easier to fire. Or maybe we can replace them with one person like your nurse.... She definitely deserves a raise.

I feel bad for those docs that have no say in the matter.

 

[Krukenberg]

I actually have my nurse work up the chart and give me a printed out hard copy, on a clipboard, with pre-filled HPI/FHx/SHx/Meds/Allergies/rads/path etc. Path and rads reports are printed out and put on the clipboard with little tabs so I can access if the pt has questions, along with all records from other referring MDs.

This helps the nurse know the patient well (which helps when she's asked to manage down the line), and means my dictations are super quick. I do it for follow ups as well. Clipboard is much faster for info access than a computer, and I can look at the chart and take notes with my pen while facing the patient. Then, a quick dictation and I'm done.

RN also does all the EHR/opioid box checking/depression monitoring/OCM stuff that's necessary as well. She used to be an OR nurse as well, so she's super good at managing all our HDR procedures, too. Finally, I can tell that she likes being given responsibility and enjoys being able to make decisions and present her conclusions to me independently.

Damn. I need to make sure she gets a raise. She's the 4th RN I've had in my 11 years of private practice, and I hope she sticks around for a LONG time.

what you described is my goal for training up an RN. Takes work but I’ve seen examples where they do improve physician efficiency.

 

[drewdog1973]

I actually have my nurse work up the chart and give me a printed out hard copy, on a clipboard, with pre-filled HPI/FHx/SHx/Meds/Allergies/rads/path etc. Path and rads reports are printed out and put on the clipboard with little tabs so I can access if the pt has questions, along with all records from other referring MDs.

This helps the nurse know the patient well (which helps when she's asked to manage down the line), and means my dictations are super quick. I do it for follow ups as well. Clipboard is much faster for info access than a computer, and I can look at the chart and take notes with my pen while facing the patient. Then, a quick dictation and I'm done.

RN also does all the EHR/opioid box checking/depression monitoring/OCM stuff that's necessary as well. She used to be an OR nurse as well, so she's super good at managing all our HDR procedures, too. Finally, I can tell that she likes being given responsibility and enjoys being able to make decisions and present her conclusions to me independently.

Damn. I need to make sure she gets a raise. She's the 4th RN I've had in my 11 years of private practice, and I hope she sticks around for a LONG time.

I’ve had that, as well. I even just sent her a screenshot and let her know how great she was. Now, no longer...

 

[w00tz]

I actually have my nurse work up the chart and give me a printed out hard copy, on a clipboard, with pre-filled HPI/FHx/SHx/Meds/Allergies/rads/path etc. Path and rads reports are printed out and put on the clipboard with little tabs so I can access if the pt has questions, along with all records from other referring MDs.

This helps the nurse know the patient well (which helps when she's asked to manage down the line), and means my dictations are super quick. I do it for follow ups as well. Clipboard is much faster for info access than a computer, and I can look at the chart and take notes with my pen while facing the patient. Then, a quick dictation and I'm done.

RN also does all the EHR/opioid box checking/depression monitoring/OCM stuff that's necessary as well. She used to be an OR nurse as well, so she's super good at managing all our HDR procedures, too. Finally, I can tell that she likes being given responsibility and enjoys being able to make decisions and present her conclusions to me independently.

Damn. I need to make sure she gets a raise. She's the 4th RN I've had in my 11 years of private practice, and I hope she sticks around for a LONG time.

This is amazing.
Only thing I know of that's more amazing is this thing called a "PGY-5 looking to get a job at their home institution", which, in addition to dictation capabilities, has really good auto-contouring function.

 

[RadOncDoc21]

This is amazing.
Only thing I know of that's more amazing is this thing called a "PGY-5 looking to get a job at their home institution", which, in addition to dictation capabilities, has really good auto-contouring function.

I hear they “slow attendings down” even though the attending is usually locked away somewhere while that residents does pretty much all the work.

 

[GI_RadOnc]

Let’s say I rank far down the institution’s totem poll when it comes to any kind of administrative actions.

With that said, there has been significant improvement over the past year but it takes so much out of me and time that I usually just end up doing everything myself. Now if it something truly important or jeopardizes patient safety/care, I usually can get things handled quickly but I’ve learned to really just focus on the things I can control. My hope is to eventually get my own MA.

For the younger folks on this thread: When you start your job; take the time to train up folks. It's a time suck, for sure; but very well worth it.

I've been in my current job two years. In that time frame: 3/4 of the dosimetrists now contour bowel as well as all the other normal structures; therapists contour on the MRI linac and create on-table plans with physics independently, nurse practitioner does GI tumor board notes and has 3-5 independent follow-ups per week; nurse practitioners have created standard consult and follow-up templates along with staging quality assurance steps for all my patients; and physics exports all my SBRT plans to the radiology PACS system to see during tumor board and follow-up.

There are talented people in your department who are underutilized. Find them, train them and speak their praises to all of their supervisors/managers.

EDIT: This is an employed practice.. but everyone (from therapy to physics to docs to admins) reports to the department chair.

 

[Krukenberg]

For the younger folks on this thread: When you start your job; take the time to train up folks. It's a time suck, for sure; but very well worth it.

I've been in my current job two years. In that time frame: 3/4 of the dosimetrists now contour bowel as well as all the other normal structures; therapists contour on the MRI linac and create on-table plans with physics independently, nurse practitioner does GI tumor board notes and has 3-5 independent follow-ups per week; nurse practitioners have created standard consult and follow-up templates along with staging quality assurance steps for all my patients; and physics exports all my SBRT plans to the radiology PACS system to see during tumor board and follow-up.

There are talented people in your department who are underutilized. Find them, train them and speak their praises to all of their supervisors/managers.

EDIT: This is an employed practice.. but everyone (from therapy to physics to docs to admins) reports to the department chair.

Great insight for new attendings! Thank you!

 

[seper]

SBRT to PACS is a neat idea."Hey look I did not miss"

 

[Palex80]

SBRT to PACS is a neat idea."Hey look I did not miss"

Indeed, but you will need to export dose too. I am not sure if all PACS-systems can facilitate that (importing dose and making it available for viewing).
We export treatment plan printouts as PDFs into the patient's hospital EMR, but having a PACS viewer that can actually be used to demonstrate dose during a tumor board would be great!