Pelvic IMRT and Vaginal Dilators

[medgator]

Totally agree. Obviously, getting into specifics will be on the internet forever, so - meetings, phone calls, and discussions have been had (about the schedule...about everything). It's multifactorial.

@temujim is exactly correct. People hate conflict, perhaps RadOncs more than others. I'm the first to say/do anything about it, either because I'm the first to know it's a problem or the first to care. It doesn't matter, really.

The larger point for on-treatment dilators or anything in that realm - forest for the trees. After months and months of "discussions", for example, I'm no longer routinely getting plans from Dosimetry with hotspots >115%. However, as far as they're concerned, it's a limitation of reality to get a plan below 110% hotspot, ever. Until I break Dosi of thinking a 112% hotspot outside the PTV is an OK thing to do, I'm not going to ask for on-treatment dilators.

Totally with you.... Walk before you can run.... Dilators can come after you've got your therapists perfectly trained on cbct (pipedream for me), tatooing correctly, not farking your schedule etc.

Not all of us get to fight with the army we want, rather the one we have.

Many people are in a bubble on this issue if they are practicing in a low volume (often academic/PPS-exempt) center which is overstaffed for the patient load compared to those of us out in the wild

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[Krukenberg]

Totally agree. Obviously, getting into specifics will be on the internet forever, so - meetings, phone calls, and discussions have been had (about the schedule...about everything). It's multifactorial.

@temujim is exactly correct. People hate conflict, perhaps RadOncs more than others. I'm the first to say/do anything about it, either because I'm the first to know it's a problem or the first to care. It doesn't matter, really.

The larger point for on-treatment dilators or anything in that realm - forest for the trees. After months and months of "discussions", for example, I'm no longer routinely getting plans from Dosimetry with hotspots >115%. However, as far as they're concerned, it's a limitation of reality to get a plan below 110% hotspot, ever. Until I break Dosi of thinking a 112% hotspot outside the PTV is an OK thing to do, I'm not going to ask for on-treatment dilators.

I’ve noticed hotter plans as well since leaving residency, but regrettably I don’t know enough about IMRT planning to understand why, besides “try harder.” Anyone know what is the #1 reason for a hot IMRT plan?

 

[elementaryschooleconomics]

I’ve noticed hotter plans as well since leaving residency, but regrettably I don’t know enough about IMRT planning to understand why, besides “try harder.” Anyone know what is the #1 reason for a hot IMRT plan?

I can only speak for my hypothesis in my situation -

While we all joke about "boomer RadOncs" who got left behind after the year 2000, there are Dosimetrists in the same boat who had to teach themselves IMRT/VMAT.

For those of us who trained in the "modern" era, IMRT just "makes sense", in that we're not trying to frame IMRT within our understanding of radiotherapy - it is our understanding of radiotherapy. The people still in this job who trained and worked pre-2000 built their understanding of radiotherapy in a 2D/3D era, and have to frame current treatment practices within that context.

I don't think there's an appreciation for how much refinement can be done in VMAT compared to what we had to do 20 years ago. What I get are plans that strive for best coverage no matter what - best coverage even if the hotspot is 119%, best coverage even if the lens is 2-3x QUANTEC guidelines. What I keep reiterating with them is that this is a conversation with me - when they get to a point where coverage is amazing but the hotspot is 119%, they know I have NEVER accepted a plan like that. Instead of saying "best I can do", we should have a discussion about tradeoffs.

I also suspect they don't understand local vs global minimum, but that's for next year...

Now, if you're having these conversations and your Dosi still can't do it...I don't know, haha.

 

[deleted1111261]

I have had the pleasure to work with a handful of dosimetrists at each job I have been at that “get it”. Almost all at my DC private practice ones got it - none formally trained - mostly college science major undergrads that we trained in house. Banner ones were really good, especially the two I worked with were awesome.

I need to learn more from them.

 

[pikachu]

I’ve noticed hotter plans as well since leaving residency, but regrettably I don’t know enough about IMRT planning to understand why, besides “try harder.” Anyone know what is the #1 reason for a hot IMRT plan?

What constraints do you use for PTV coverage and hot spots within the PTV? Insisting on 100% of PTV getting 100% of dose can drive big hot spots, so relaxing that a bit may help. You can also put a constraint on % PTV getting >103/105/108%.

 

[deleted1111261]

What constraints do you use for PTV coverage and hot spots within the PTV? Insisting on 100% of PTV getting 100% of dose can drive big hot spots, so relaxing that a bit may help. You can also put a constraint on % PTV getting >103/105/108%.

Yes! Rather than hotspot, a volumetric constraint is more helpful to planner - v105 < X ccs

 

[temujim]

I’ve noticed hotter plans as well since leaving residency, but regrettably I don’t know enough about IMRT planning to understand why, besides “try harder.” Anyone know what is the #1 reason for a hot IMRT plan?

Many different reasons, but one that pops up often is dosi trying to pushing too hard to spare an adjacent structure, limiting your geometry to the PTV.

 

[jondunn]

Many different reasons, but one that pops up often is dosi trying to pushing too hard to spare an adjacent structure, limiting your geometry to the PTV.

Yes but I take the exact opposite view. I would love for my dosimetrists to take it hotter to get better sparing, as long as hot spot in the PTV

 

[temujim]

Yes but I take the exact opposite view. I would love for my dosimetrists to take it hotter to get better sparing, as long as hot spot in the PTV

For a long time people worshiped at the temple of homogeneity because that is what plans looked like in the 3D era. For many situations it might not matter. For HN I believe it does, but for other situations where say 110-120% may not matter so much, it may matter exactly where that hotspot resides in the volume and care should still be exercised.

 

[Reaganite]

Maybe im overreaching here but Ive always felt the supervision requirement is the key contributor to the strange power dynamics that exist in radiation departments. ""Patient can only come in at 7AM and you HAVE to be here so suck it up." "Do things my way or ill report you for the time you left 5 minutes early when a patient was on beam." Its emboldened staff to dictate department policy at a level you dont traditionally see in other specialties.

 

[deleted1111261]

Maybe im overreaching here but Ive always felt the supervision requirement is the key contributor to the strange power dynamics that exist in radiation departments. ""Patient can only come in at 7AM and you HAVE to be here so suck it up." "Do things my way or ill report you for the time you left 5 minutes early when a patient was on beam." Its emboldened staff to dictate department policy at a level you dont traditionally see in other specialties.

You are not. This is 💯 correct.
Plus, threat of a whistleblower lawsuit that calls treating a patient “fraud”.
I can’t get over how stupid this is.

 

[medgator]

Maybe im overreaching here but Ive always felt the supervision requirement is the key contributor to the strange power dynamics that exist in radiation departments. ""Patient can only come in at 7AM and you HAVE to be here so suck it up." "Do things my way or ill report you for the time you left 5 minutes early when a patient was on beam." Its emboldened staff to dictate department policy at a level you dont traditionally see in other specialties.

Virtual supervision really has been helpful in that regard

 

[TheWallnerus]

I can only speak for my hypothesis in my situation -

While we all joke about "boomer RadOncs" who got left behind after the year 2000, there are Dosimetrists in the same boat who had to teach themselves IMRT/VMAT.

For those of us who trained in the "modern" era, IMRT just "makes sense", in that we're not trying to frame IMRT within our understanding of radiotherapy - it is our understanding of radiotherapy. The people still in this job who trained and worked pre-2000 built their understanding of radiotherapy in a 2D/3D era, and have to frame current treatment practices within that context.

I don't think there's an appreciation for how much refinement can be done in VMAT compared to what we had to do 20 years ago. What I get are plans that strive for best coverage no matter what - best coverage even if the hotspot is 119%, best coverage even if the lens is 2-3x QUANTEC guidelines. What I keep reiterating with them is that this is a conversation with me - when they get to a point where coverage is amazing but the hotspot is 119%, they know I have NEVER accepted a plan like that. Instead of saying "best I can do", we should have a discussion about tradeoffs.

I also suspect they don't understand local vs global minimum, but that's for next year...

Now, if you're having these conversations and your Dosi still can't do it...I don't know, haha.

In a twist of ironic, and bad, timing, ICRU 62 (which came out in 1999) recommended the PTV always get 95%-107% of the dose; i.e., the report recommended homogeniety and to keep the PTV at 107% of Rx dose or less. With the IMRT era right around the corner, some people didn't "leave ICRU 62 behind," even to this day.

ICRU 83 came out in 2010 and essentially said "maybe we need to forget homogeneity." You almost never hear ICRU 83 mentioned in polite conversation

ICRU 50 (1993), which first formally defined the PTV I think, defined a hot spot as any dose >100% the Rx dose *outside* the PTV with a *minimum* diameter of 15mm or more unless the hot spot was occurring in or near a "small organ" (larynx, eyeball, optic chiasm). Any dose >100% Rx *inside* the PTV was defined merely as: inhomogeneity. (FWIW I feel plans with ICRU 50 hot spots are not good and can always be avoided.)

 

[elementaryschooleconomics]

In a twist of ironic, and bad, timing, ICRU 62 (which came out in 1999) recommended the PTV always get 95%-107% of the dose; i.e., the report recommended homogeniety and to keep the PTV at 107% of Rx dose or less. With the IMRT era right around the corner, some people didn't "leave ICRU 62 behind," even to this day.

ICRU 83 came out in 2010 and essentially said "maybe we need to forget homogeneity." You almost never hear ICRU 83 mentioned in polite conversation

ICRU 50 (1993), which first formally defined the PTV I think, defined a hot spot as any dose >100% the Rx dose *outside* the PTV with a *minimum* diameter of 15mm or more unless the hot spot was occurring in or near a "small organ" (larynx, eyeball, optic chiasm). Any dose >100% Rx *inside* the PTV was defined merely as: inhomogeneity. (FWIW I feel plans with ICRU 50 hot spots are not good and can always be avoided.)

I didn't realize the timing of ICRU 62...

The radiotherapy timeline sure had some interesting consequences. What if tomotherapy was widely available 10 years earlier? What if the 21C IPO was 5 years later? What if the length of RadOnc residency was mandated to be four years instead of three in 2011?

Who am I kidding, this is the most boring version of Looper possible.

 

[deleted1111261]

In a twist of ironic, and bad, timing, ICRU 62 (which came out in 1999) recommended the PTV always get 95%-107% of the dose; i.e., the report recommended homogeniety and to keep the PTV at 107% of Rx dose or less. With the IMRT era right around the corner, some people didn't "leave ICRU 62 behind," even to this day.

ICRU 83 came out in 2010 and essentially said "maybe we need to forget homogeneity." You almost never hear ICRU 83 mentioned in polite conversation

ICRU 50 (1993), which first formally defined the PTV I think, defined a hot spot as any dose >100% the Rx dose *outside* the PTV with a *minimum* diameter of 15mm or more unless the hot spot was occurring in or near a "small organ" (larynx, eyeball, optic chiasm). Any dose >100% Rx *inside* the PTV was defined merely as: inhomogeneity. (FWIW I feel plans with ICRU 50 hot spots are not good and can always be avoided.)

I feel like the good physicists picked up on this and sort of rolled their eyes at docs that preferred homogeneity (not that there’s anything wrong with that).

 

[pikachu]

I feel like the good physicists picked up on this and sort of rolled their eyes at docs that preferred homogeneity (not that there’s anything wrong with that).

So I understand why hot spots may be preferable in certain sbrt plans. but can anyone explain why homogeneity is undesirable/heterogeneity would be desirable in a run-of-the-mill imrt plan, especially in elective nodal volumes near critical normal structures? Why would you risk setup error overdosing nearby OARs for unproven dose benefit? Isn’t part of the point of imrt being able to precisely control dose distribution in target relative to normal tissue better than 3D?

 

[Burt Radnolds]

So I understand why hot spots may be preferable in certain sbrt plans. but can anyone explain why homogeneity is undesirable/heterogeneity would be desirable in a run-of-the-mill imrt plan, especially in elective nodal volumes near critical normal structures? Why would you risk setup error overdosing nearby OARs for unproven dose benefit? Isn’t part of the point of imrt being able to precisely control dose distribution in target relative to normal tissue better than 3D?

Seeking homogeneity can really hurt you when dealing with a round target or attempting to modulate off an immediately adjacent critical structure but I completely agree that there is not much to lose in other situations. In H&N or in some pelvic cases such as anorectal there are certainly critical structures within your volumes that merit mindfulness. I find with VMAT you can often buff out heterogeneity with literally no penalty. With multiple arcs and small MLCs the sky is the limit.

 

[elementaryschooleconomics]

Perhaps it's spelled out in ICRU 62, but why is homogeneity defined as 95/107? Is there anything special about that? Is it better than 90/110? Worse than 97/103?

With all the other RadOnc dogma in the world, I haven't had a chance yet to explore that one yet.

 

[deleted1116990]

Maybe im overreaching here but Ive always felt the supervision requirement is the key contributor to the strange power dynamics that exist in radiation departments. ""Patient can only come in at 7AM and you HAVE to be here so suck it up." "Do things my way or ill report you for the time you left 5 minutes early when a patient was on beam." Its emboldened staff to dictate department policy at a level you dont traditionally see in other specialties.

When I started at my first job out of residency I showed up in the department around 8:15 one day the first week. The department manager came and made a big stink and told me that I had to report at 8 AM. I continued to show up between 7 - 9 at my discretion. No laws were broken and patients were treated appropriately. Similar stinks were made when I left at 3PM after the machine was done treating. Of course other times I left at 10 PM and nothing was said then. I was expected to sit there until 5 PM even if I had nothing to do for appearance's sake. Did I spend a decade in medical training to punch a clock? Part of being a professional is taking responsibility for your work and getting it done as you deem appropriate, whether that's during regular business hours or in the middle of the night on a weekend if needed.

Given that so much can be done remotely now, admin is keenly aware that many are (often appropriately) looking to deviate from the traditional 8-5 M-F schedule and you would think would use that to help with recruiting, but nope. It's about image, not patient care, and this nonsensical managerial mentality of hospital admin getting their money's worth if you are forced to sit there and watch youtube with nothing else to do.

 

[TheWallnerus]

Did I spend a decade in medical training to punch a clock

This could have been a #radoncrocks thing way back when

“Hey want to spend a decade in medical training to get a job punching a clock? Rad onc may be for you! #radoncrocks”

 

[deleted1116990]

This could have been a #radoncrocks thing way back when

“Hey want to spend a decade in medical training to get a job punching a clock? Rad onc may be for you! #radoncrocks”

It would be fine if radiation treatments were given 7 days a week (convenient how cancer works like that) and we negotiated shifts and there were ample moonlighting opportunities to sit around on nights and weekends and get paid a decent amount of money for hanging out if you want to. But not only are there not ample of these opportunities in rad onc, there are exactly zero.

Rad onc is completely backwards compared to other fields that have shifts. There's something to be said to setting your own schedule and working as many shifts as you want and taking as much vacation as you want vs. being tied to an 8-5 M-F 4 weeks of vacation annually mentality. For certain people, there is just something soul-crushing about knowing your life is constrained to physical presence M-F 8-5 with no more than a week at a time off a few times a year for the next 30 years. Yes, we make a lot of money and don't have call or work nights and weekends and have a lot of down time in the office, but radiologists typically get 10-12+ weeks of vacation and can use it to moonlight it they want. I would imagine that freedom is exhilarating. My buddy who is a rads sure seems to enjoy it. If you try to negotiate that with a rad onc practice you will be laughed out of the room. #maybeshouldadonerads

 

[medgator]

It would be fine if radiation treatments were given 7 days a week (convenient how cancer works like that) and we negotiated shifts and there were ample moonlighting opportunities to sit around on nights and weekends and get paid a decent amount of money for hanging out if you want to. But not only are there not ample of these opportunities in rad onc, there are exactly zero.

Rad onc is completely backwards compared to other fields that have shifts. There's something to be said to setting your own schedule and working as many shifts as you want and taking as much vacation as you want vs. being tied to an 8-5 M-F 4 weeks of vacation annually mentality. For certain people, there is just something soul-crushing about knowing your life is constrained to physical presence M-F 8-5 with no more than a week at a time off a few times a year for the next 30 years. Yes, we make a lot of money and don't have call or work nights and weekends and have a lot of down time in the office, but radiologists typically get 10-12+ weeks of vacation and can use it to moonlight it they want. I would imagine that freedom is exhilarating. My buddy who is a rads sure seems to enjoy it. If you try to negotiate that with a rad onc practice you will be laughed out of the room. #maybeshouldadonerads

Rads >>> rad onc in the current environment for multiple reasons, not the least of which include lots more flexibility in geography as well as schedule.

 

[TheWallnerus]

It would be fine if radiation treatments were given 7 days a week (convenient how cancer works like that) and we negotiated shifts and there were ample moonlighting opportunities to sit around on nights and weekends and get paid a decent amount of money for hanging out if you want to. But not only are there not ample of these opportunities in rad onc, there are exactly zero.

Rad onc is completely backwards compared to other fields that have shifts. There's something to be said to setting your own schedule and working as many shifts as you want and taking as much vacation as you want vs. being tied to an 8-5 M-F 4 weeks of vacation annually mentality. For certain people, there is just something soul-crushing about knowing your life is constrained to physical presence M-F 8-5 with no more than a week at a time off a few times a year for the next 30 years. Yes, we make a lot of money and don't have call or work nights and weekends and have a lot of down time in the office, but radiologists typically get 10-12+ weeks of vacation and can use it to moonlight it they want. I would imagine that freedom is exhilarating. My buddy who is a rads sure seems to enjoy it. If you try to negotiate that with a rad onc practice you will be laughed out of the room. #maybeshouldadonerads

Seems like 10 weeks vacay has become the norm in rads

 

[metallica81788]

It would be fine if radiation treatments were given 7 days a week (convenient how cancer works like that) and we negotiated shifts and there were ample moonlighting opportunities to sit around on nights and weekends and get paid a decent amount of money for hanging out if you want to. But not only are there not ample of these opportunities in rad onc, there are exactly zero.

Rad onc is completely backwards compared to other fields that have shifts. There's something to be said to setting your own schedule and working as many shifts as you want and taking as much vacation as you want vs. being tied to an 8-5 M-F 4 weeks of vacation annually mentality. For certain people, there is just something soul-crushing about knowing your life is constrained to physical presence M-F 8-5 with no more than a week at a time off a few times a year for the next 30 years. Yes, we make a lot of money and don't have call or work nights and weekends and have a lot of down time in the office, but radiologists typically get 10-12+ weeks of vacation and can use it to moonlight it they want. I would imagine that freedom is exhilarating. My buddy who is a rads sure seems to enjoy it. If you try to negotiate that with a rad onc practice you will be laughed out of the room. #maybeshouldadonerads

This is my main problem with the "lifestyle" of Radonc. It's great not having the nights, weekends, etc, but we pay for it in other ways. Plus there are some of us working more hours than outsiders would believe. The volume is the volume - very rarely can you manipulate how much or little you work.

Want to pick up extra shifts to pay off those student loans as a new hungry grad? Nope
Want to give away shifts to spend more time with your young family? Maybe but it will cost you
Want to take a one month safari to Africa? Sure but there's your vacation for the year and good luck with your clinic before and afterward
I feel like I can't take off more than a week at a time because it would destroy my continuity and clinic plus use up nearly all my vacation for the year. There are some groups with 8-12 weeks of vacation like rads but those are becoming less and less common.

 

[evilbooyaa]

What I do for my anal cases is draw a "Genitalia" avoidance structure and ask Dosi to reduce dose to that area (I also draw a "Gluteal Cleft" structure and auto-segment "Bones" to represent bone marrow, all with vague requests to "reduce dose", I'm super popular). Obviously, being able to reduce dose to the area is dependent on the nature of the case ("easy" with a T2N0, never going to happen with T3N1).

I would love to see a trial with:

1) An arm using a dilator on-treatment
2) An arm using dilator post-treatment and avoidance structures
3) An arm using dilator post-treatment and "regular" consensus structures

Re: positioning and therapists. For my theoretical trial, in addition to daily CBCT, you could also get triggered images every 90 degrees or so (if using VMAT) and/or surface imaging (if your system allows for imaging during treatment) to check infra-fraction motion (hypothesis being initial setup is more difficult and a prone patient with a dilator inserted causing pain will have worse immobilization as treatment progresses).

Actually, I'd also throw the BeamSite in this trial for fun as well.

This trial is never happening, of course. But I come to the internet to dream.

In anal cancer:
I always maintain external genitalia to a mean < 25. I have not seen this impact my coverage in any anal cancer cases.
I do not personally do gluteal cleft although this is a good idea.
I do aggressively constrain pelvic bone marrow as per UChicago dosimetric analysis: Hematologic Nadirs During Chemoradiation for Anal Cancer: Temporal Characterization and Dosimetric Predictors - PubMed
It's much lower than cervical constraints FWIW.

 

[evilbooyaa]

I don’t draw bone marrow because I want the dose pushed outward. It needs to have somewhere to go

Generally agree - I sometimes draw things and ask Dosi to do what they can. If it's not going to work, it's not going to work. But I won't know if I don't try.

(For the record - I'm generally against bone marrow as an OAR for exactly your reason)

How many of your folks anal cancer patients receiving mito end up hospitalized? Had an attending who didn't constraint bone marrow despite me showing him the above paper. G4 leukopenia and thrombocytopenia, unscheduled treatment delay of a week. No point of preventing vaginal stenosis if they end up with G4 cytopenias and require treatment breaks during their treatment portion in a disease where total treatment time is known (squamous cell carcinomas)

The UChicago paper is more validated for bone marrow constraints than 75% of dose constraints RTOG trials use.

So I understand why hot spots may be preferable in certain sbrt plans. but can anyone explain why homogeneity is undesirable/heterogeneity would be desirable in a run-of-the-mill imrt plan, especially in elective nodal volumes near critical normal structures? Why would you risk setup error overdosing nearby OARs for unproven dose benefit? Isn’t part of the point of imrt being able to precisely control dose distribution in target relative to normal tissue better than 3D?

 

[deleted1116990]

This is my main problem with the "lifestyle" of Radonc. It's great not having the nights, weekends, etc, but we pay for it in other ways. Plus there are some of us working more hours than outsiders would believe. The volume is the volume - very rarely can you manipulate how much or little you work.

Want to pick up extra shifts to pay off those student loans as a new hungry grad? Nope
Want to give away shifts to spend more time with your young family? Maybe but it will cost you
Want to take a one month safari to Africa? Sure but there's your vacation for the year and good luck with your clinic before and afterward
I feel like I can't take off more than a week at a time because it would destroy my continuity and clinic plus use up nearly all my vacation for the year. There are some groups with 8-12 weeks of vacation like rads but those are becoming less and less common.

I actually ended up being able to take over 12 weeks of vacation in my first year of practice due to a fluke in the way my contract was written by the hospital. The guy who made the mistake with the contract was fired and it was pretty clear that it would not last. Still it was nice while it did. When I re-negotiated, I was told that PTO would be fixed at 6 weeks and was non-negotiable. I was not surprised. Having a week off every month was nice, but your point about the work being the work is important. Taking that much time off actually required a lot of effort to tee up everything for locums and clean up the mess when you got back. Almost to the point it wasn't worth it. Almost.

 

[RickyScott]

How many of your folks anal cancer patients receiving mito end up hospitalized? Had an attending who didn't constraint bone marrow despite me showing him the above paper. G4 leukopenia and thrombocytopenia, unscheduled treatment delay of a week. No point of preventing vaginal stenosis if they end up with G4 cytopenias and require treatment breaks during their treatment portion in a disease where total treatment time is known (squamous cell carcinomas)

The UChicago paper is more validated for bone marrow constraints than 75% of dose constraints RTOG trials use.

What dose do you take the pelvic nodes to in node negative cases?

 

[deleted1116990]

What dose do you take the pelvic nodes to in node negative cases?

Doses (and really everything else you need to treat anal cancer) here:

http://analimrtguidance.co.uk/national-anal-imrt-guidance-v3.pdf

 

[RickyScott]

Thanks. Most of my experience is treating sequentially with elective regions receiving 30-36 gy.

 

[evilbooyaa]

What dose do you take the pelvic nodes to in node negative cases?

I've done both 9811 and 0529 dosing regimens using IMRT for either. I don't think it makes a huge oncologic difference but perhaps the bone marrow constraint is an interesting reason to stick with 9811 since elective nodal doses can stay below 40Gy...

 

[deleted1111261]

9811 dosing - are you adjusting for the fact they prescribed to a point and you’re (hopefully) prescribing to a PTV?

 

[thecarbonionangle]

Interesting discussion about culture and friction with dosi, therapy etc. i would say this dynamic is present at PP and academic departments. It can be very hard coming in from outside and try to make a change that you believe is to the betterment of patient care if it goes against the MO. Say the chair does not do what you want to do, prepare for push back. Its a weird dynamic that is likely unique to radiation departments. Dr so and so is great and doesn’t constrain what you are asking me, so why are you asking me to do this? Ive heard many stories from people in all settings who have experienced this issue.

And yeah I agree that supervision really affects certain things. Have a patient at 7 am who needs to be seen for OTV? Well you have to be there. Want to take over a week of vacation? You will pay for this for weeks one way or another. Compared to other fields, most people are slaves to less than two months of vacation and this is widely accepted as norm.

 

[OTN]

In my opinion oncology is a field in general where it’s tough to be in private practice and take long periods of time off. If you do, it’s going to be harder to build the kind of practice you would be happy with.

I honestly think that goes for radonc, medonc, surg onc, breast surgeons, etc. People do not want to wait to see an oncologist, and it’s tough to manage things through the relatively quick pace of cancer care if you take a lot of time off.

Two weeks at a time is doable, though, and that’s as much as most professionals can take off as well.

The big difference between what we do as clinicians (as opposed to some radiologists who don’t have a clinic for example), versus other professions is our inability to work remotely. That wasn’t even on the horizon when I went to college, but now when looking at a potential profession, that would certainly have to factor in. Would be an issue for most physicians though I would guess.

 

[TheWallnerus]

In my opinion oncology is a field in general where it’s tough to be in private practice and take long periods of time off. If you do, it’s going to be harder to build the kind of practice you would be happy with.

I honestly think that goes for radonc, medonc, surg onc, breast surgeons, etc. People do not want to wait to see an oncologist, and it’s tough to manage things through the relatively quick pace of cancer care if you take a lot of time off.

Two weeks at a time is doable, though, and that’s as much as most professionals can take off as well.

The big difference between what we do as clinicians (as opposed to some radiologists who don’t have a clinic for example), versus other professions is our inability to work remotely. That wasn’t even on the horizon when I went to college, but now when looking at a potential profession, that would certainly have to factor in. Would be an issue for most physicians though I would guess.

I think it’s now time for the shared job in rad onc. Makes us kind of Sith like no. But in seriousness I would take 300K a year and another guy take 300K a year and we provide full time always there service. Except you can take 26 weeks of vacation a year.

 

[RadOncDoc21]

I think it’s now time for the shared job in rad onc. Makes us kind of Sith like no. But in seriousness I would take 300K a year and another guy take 300K a year and we provide full time always there service. Except you can take 26 weeks of vacation a year.

Unfortunately, the admins will see a “shared job” as 150k for each of you.

 

[SneakyBooger]

I think it’s now time for the shared job in rad onc.

Had 2 strong partners do this many years ago - combined income dropped by over 30%. It was a failure. They lost their referrers and could never get them back again. Both tried to come back full time but struggled and ultimately moved on.

 

[medgator]

Had 2 strong partners do this many years ago - combined income dropped by over 30%. It was a failure. They lost their referrers and could never get them back again. Both tried to come back full time but struggled and ultimately moved on.

Continuity of care is our big double edged sword... PP is so referring specific, esp when people are referring to the doctor and not the practice. Just echoing what others have said.

Really it's better to do hospitalist, ED, gas, or rads if lots of vacation is of high importance to someone long term imo

 

[deleted1111261]

Continuity of care is our big double edged sword... PP is so referring specific, esp when people are referring to the doctor and not the practice. Just echoing what others have said.

Really it's better to do hospitalist, ED, gas, or rads if lots of vacation is of high importance to someone long term imo

Good practices do offer 9-11 weeks. I had 48 days + holidays with DC practice. Inova had similar. Annapolis had similar. SERO had similar. Princeton has similar. Many offer 5-6 weeks and 4 day weeks. Katz’ group in NH offers 8-10 weeks I think. Yah there are a lot of bad jobs. But I don’t think 8 weeks is that hard to find.

 

[medgator]

Good practices do offer 9-11 weeks. I had 48 days + holidays with DC practice. Inova had similar. Annapolis had similar. SERO had similar. Princeton has similar. Many offer 5-6 weeks and 4 day weeks. Katz’ group in NH offers 8-10 weeks I think. Yah there are a lot of bad jobs. But I don’t think 8 weeks is that hard to find.

Would be interesting to see how they pull it off... Easier to work in a split pot practice where you aren't referring to a specific physician I'm guessing

 

[Krukenberg]

Would be interesting to see how they pull it off... Easier to work in a split pot practice where you aren't referring to a specific physician I'm guessing

I think this would only work if the pot is split evenly and referrings are conditioned to not expect a specific physician every time. Sure you can refer to physician A, but 10 weeks out of the year it will be physician B, C, D…

 

[medgator]

I think this would only work if the pot is split evenly and referrings are conditioned to not expect a specific physician every time. Sure you can refer to physician A, but 10 weeks out of the year it will be physician B, C, D…

Some of us don't partner into those kind of practices... That being said, i took 8-9 weeks off in 2019 (luckily). Generally a week or a long weekend+week at a time. We all pay for our own locums so really it's pretty open in terms of how much we take

 

[deleted1116990]

But I don’t think 8 weeks is that hard to find.

It is for hospital employees. 6 weeks is pretty standard and often they are more willing to negotiate on pay than PTO because they know they are contractually obligated to cover it and it is such a pain to do so, especially if you are solo. That said, I do know a group of hospital employees that have a sweet deal where they cover for each other and each get 10 weeks so the hospital doesn't have to worry about arranging and paying for locums.

I have never taken off more than 10 days at a time because it's really just not practical unless you are a locums or something. I went to Australia and the south pacific multiple times during that fluke year but it was like spend 20 hours travelling, hang out for 5 or 6 days then come back. Again, almost not worth it.

Good practices do offer 9-11 weeks.

The other problem, is that unless you get in with one of these places right out of residency, this is kind of tough. If you are a hospital employee making $600k stuck at 6 weeks of PTO and would like to move to one of these more lifestyle oriented practices, it's going to be hard to compete with new grads willing to work on a partnership track for $300k/year for 3 years with 3 weeks of PTO. You're either going to have to convince the practice it's worth bringing you on at your current salary and benefits until partnership given your experience or else take the huge step backwards for a few years (which I have done, and I don't recommend because circumstances can and do change rapidly, plus you are not in your 20s anymore where a few years don't really matter much).

 

[ramsesthenice]

Flexibility regarding time off is definitely a perk of being at main with an academic center. As long as we block our clinics at least 8 weeks in advance it is no problem to take 2+ weeks at a time. We get the standard 6 weeks per year but it rolls over and doesn't expire. Thanks to Covid, I am set for a long time to come. My risk of melanoma and alcoholic cirrhosis will quickly return to their prepandemic levels in short order

 

[deleted1111261]

I’m not saying it’s easy or super common - it’s just incorrect to say it is not available. Even hospitals can give 35-40 days PTO.

And yeah, it is hard to switch to a lifestyle practice and costs you money upfront - but that’s a choice, right?

Covering each other requires A LOT of trust. I’ve had that at a few places. One of the great parts about Banner was the “plug and play” aspect of it that people seem to hate - but because there is “the MDACC way” covering really isn’t that hard to arrange. My private group was great about that, too - we had faith in each others skills and competence, so you left for 2 weeks without too much worry (don’t even check email if you’re out of country).

 

[deleted1116990]

I think it’s now time for the shared job in rad onc. Makes us kind of Sith like no. But in seriousness I would take 300K a year and another guy take 300K a year and we provide full time always there service. Except you can take 26 weeks of vacation a year.

I could see this working in a rural area where they are struggling to recruit and administrators are not in denial about their recruiting problem. I don't think it would work literally anywhere else. But even then, it would take a special place to consider it.

The problem is that there are many rural hospitals are in serious denial, holding out hope for many years for "the one" who will come and interview and fall in love with their tiny town (that none of them have ever left), accept a median salary, promise to basically always be on site, build a house, raise children, become involved in the community, and stay there for 30 years just like old Dr. Boomer did (who almost always billed independently). They don't understand just how ridiculous of an ask this is when they are offering a new grad a 60ish percentile salary and 6 weeks of PTO and that's it.

When you start talking with these places about more reasonable ways to provide their patients with consistent non-locums standard of care given the fact that nobody wants to relocate there, such as shared working arrangements, 90+ percentile compensation, 3-4 days on site so you can fly-in/fly-out, lots of PTO to make living there more tolerable, etc, they hang up the phone.

 

[TheWallnerus]

The problem is that there are many rural hospitals are in serious denial, holding out hope for many years for "the one" who will come and interview and fall in love with their tiny town (that none of them have ever left), accept a median salary, promise to basically always be on site, build a house, raise children, become involved in the community, and stay there for 30 years just like old Dr. Boomer did (who almost always billed independently).

The bolded part wasn’t really a thing or part of far and wide rad onc culture until around about 2005-10. Prior to then, docs left department all the time. Even academic attending docs. I remember in residency on “big occasion days” no resident or attending would be at any of our sites but we were definitely treating. It wasn’t intentional per se, just the culture of “it’s illegal if you aren’t there” just didn’t exist because no one thought of it needing to exist. No one gave it a first thought much less second thought. Some may remember it differently but I remember it this way. And of course the other twist to your anecdote is “billed independently.” Which meant being your own boss and having more autonomy.

 

[evilbooyaa]

9811 dosing - are you adjusting for the fact they prescribed to a point and you’re (hopefully) prescribing to a PTV?

Yes I am prescribing to PTVs. No I am not adjusting for that.

 

[deleted1111261]

So, dose escalating