"Why do I need to keep seeing you?" How do you answer this?

[iradi8u]

I have had a string of patients who refuse to return for follow up lately, mostly because one PCP and one urologist told them that they don't need to follow up with radonc for breast or prostate cancer.

I walk through the standard explanation of late effects and the fact that they need to be monitored because they have had cancer, but these docs (especially the PCP) have convinced them that seeing me is redundant and unnecessary. I've spoken with the urologist, who is willing to stop saying this, but the PCP is hopeless.

From now on, an explanation of follow up expectations will be part of my consult spiel, but I'm wondering if anyone has a particularly useful nugget to include in the answer to the "why" question. Thanks!

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[napoleondynamite]

Like you mentioned, I always include this in my consult shpeel by addressing potential late effects and say "we'll be friends for a long time."

One potential solution with the PCP and urologist is to alternate visits with them. Clears up your schedule too - you may only need to see them once a year if the others are also participating in f/u and sending you notes/PSA's.

 

[Gfunk6]

In my practice, we have med oncs, rad oncs, and surgeons all of whom follow-up with the patient in the short-term. However, sooner or later the patient gets tired of three separate follow-ups (not to mention co-pays!) every few months and then gravitates towards one of us for long-term follow-up. I think this is reasonable to do as long as your colleagues are not shy about re-referring the patient back to you if problems arise.

 

[medgator]

I find my head and neck, prostate, lung and (some) breast pts stick with me. I usually let palliative pts follow up with the med onc after a visit or two unless I'm concerned about possible need for treatment going forward.

In a lot of cases, I review scans sometimes for the above pts and they find it a lot more gratifying than just hearing a report. And sometimes we have to clarify things found on fu scans after xrt

 

[Gfunk6]

In a lot of cases, I review scans sometimes for the above pts and they find it a lot more gratifying than just hearing a report. And sometimes we have to clarify things found on fu scans after xrt

Agree, this is a MAJOR advantage of RO follow-up. Unlike the Med Oncs we actually review imaging ourselves.

 

[xrthopeful]

Lots of med oncs look at their own imaging

 

[napoleondynamite]

I'm sure some medoncs also do DRE's and pelvic exams - but not the norm from what I've seen, lol

 

[medgator]

I'm sure some medoncs also do DRE's and pelvic exams - but not the norm from what I've seen, lol

I've point blank asked med oncs if they do them on anal pts and it's usually a no....and why should they. Doesn't change 5fu/mmc management anymore than a h&n exam changes cis vs erbitux.

Some med oncs look at imaging but I agree that most don't

 

[napoleondynamite]

No exam on an anal cancer pt? Stage smage.

 

[Reaganite]

I almost always defer to my referring doctors on this one, and most seem to prefer I not do any sort of follow up. Being in private practice in a highly competitive area, I'm in no position to question their wishes. PCPs make their money on follow up visits. The only exception for me is head and neck, which I feel obligated to follow, but even then, I called my referring ENT to ask him if it was okay. He said "sure, but I want to do all the scoping." I would never in a million years call a referring doctor and tell him he was "wrong" for telling a patient he didn't need to follow up with me!

 

[medgator]

I almost always defer to my referring doctors on this one, and most seem to prefer I not do any sort of follow up. Being in private practice in a highly competitive area, I'm in no position to question their wishes. PCPs make their money on follow up visits. The only exception for me is head and neck, which I feel obligated to follow, but even then, I called my referring ENT to ask him if it was okay. He said "sure, but I want to do all the scoping." I would never in a million years call a referring doctor and tell him he was "wrong" for telling a patient he didn't need to follow up with me!

I miss scoping my h&n patients (used to do it in residency), but alas you are correct, pp imposes certain demands. I haven't gotten pushback otherwise. I generally try to get direct specialty referrals so I'm not pressured by med onc not to follow pts. Most surgeons in my area, don't follow our breast pts, ditto for the medically inoperable stage I nsclc pts I treat

 

[napoleondynamite]

Perhaps a dumb question - but why can't you scope if ENT does? Is billing only allowed for one?

 

[medgator]

Perhaps a dumb question - but why can't you scope if ENT does? Is billing only allowed for one?

The protocol is usually a scope every 6-8 weeks and ent would rather collect that charge every time (it's a separate charge for the flexible NPL procedure).

 

[PhotonBomb]

The new era of rad oncs coming up are going to be a lot more aggressive in taking ownership of their patients.

y'all aren't even ready

 

[medgator]

The new era of rad oncs coming up are going to be a lot more aggressive in taking ownership of their patients.

y'all aren't even ready

Hard to be too "aggressive"with ownership when your specialty is dependent on referrals of some sort

 

[thecarbonionangle]

Radiation oncologists need to take absolutely full ownership of their patients if they are to survive as a specialty. ONCOLOGISTS above all else. I've seen rad oncs that are afraid to give lupron because they let med onc do it because that is "chemotherapy". Deferring to a med onc to follow your patients when you give the definitive treatment is not the way to go and one should make this clear to patients.


What are your thoughts on Zietman's article on the future of radiation oncology? I fully agree that the specialty must "evolve, diversify."

http://www.ncbi.nlm.nih.gov/pubmed/18513631

 

[Mandelin Rain]

Some patients need/want follow up with rad onc. Others don't.

It's not tough to identify who is who. It's part of the job. You should definitely see people you made sick until they get better, or those who other oncologists are not following (or not appropriately following), or those who just really enjoy seeing you.

You should not shotgun follow everyone forever though. Many of our patients work, or have transport difficulty, or are scraping by on limited means. Your job is to treat the patient as a whole. Giving them all a copay/deductible and inconvenience to check their skin again-and-again, when two other doctors are following their breast cancer does not enhance care or make you a better physician. Quite the opposite.

My advise to the opening poster... Most patients have their own (usually good) reasons to suggest stopping follow up with us. If their reasoning is poor, let them know. If it's sound, don't take it personal. You're busy enough.

 

[OTN]

The new era of rad oncs coming up are going to be a lot more aggressive in taking ownership of their patients.

y'all aren't even ready

If they're entering private practice, they're the ones who are going to need to adjust. If you start taking dollars away from your referral base you'll find that base start to dry up pretty quickly.

Having said that, I've found the ENTs in my area actually like that I scope my patients. I usually defer to them if a scope has been/will be done recently, but I find many of them feel as if being good at endoscopy is a necessary part of being a good H+N radonc.

 

[hot sauce]

Radiation oncologists need to take absolutely full ownership of their patients if they are to survive as a specialty. ONCOLOGISTS above all else. I've seen rad oncs that are afraid to give lupron because they let med onc do it because that is "chemotherapy". Deferring to a med onc to follow your patients when you give the definitive treatment is not the way to go and one should make this clear to patients.

I agree with the sentiment that we should be involved with our patients as oncologists. However, we should do so from a team approach not by trying to take other people's business. Are the rad oncs that are afraid to give lupron worried about giving it because they aren't comfortable with it or is it because they don't want to piss off their colleagues? You need to establish relationships with both your patients and your colleagues from other fields. This is both professional and practical. Like it or not we are generally at the end of the referral chain. If you are difficult to work with and try to take others business you won't have patients to take ownership of.

 

[PhotonBomb]

The real question is how does rad onc do a workaround and actually get to do more definitive prostates who would never see you of a urologist sees them first. Or how does rad onc get to do sbrt for stage 1 lung cancers that may otherwise go to get lobectomies. And that's just the start. What about sbrt for liver lesions that we now only do when IR sends us their leftovers?


This is the challenge we face as a field. We have to believe in our modality. Fifty percent of all cancer patients get radiation. We have to stop acting like we are nobodies.

 

[medgator]

The real question is how does rad onc do a workaround and actually get to do more definitive prostates who would never see you of a urologist sees them first. Or how does rad onc get to do sbrt for stage 1 lung cancers that may otherwise go to get lobectomies. And that's just the start. What about sbrt for liver lesions that we now only do when IR sends us their leftovers?


This is the challenge we face as a field. We have to believe in our modality. Fifty percent of all cancer patients get radiation. We have to stop acting like we are nobodies.

Nobody is acting like "nobody" whatever that means. I get direct pulmonary referrals when appropriate and sometimes I even work up the occasional SPN and send them to surgery when appropriate.

Prostate is a tough nut to crack as we depend on gu to establish the diagnosis and I doubt you're insinuating we should start getting elevated psa cases direct from primary care and start working them up ourselves and doing trus biopsies.

Ftr, I give my own adt and place fiducials on my prostate patients when the urologists won't do the above, and I know I'm not the only one. I never did any of that in residency. I also write for plenty of narcs, anti emetics, antibiotics, appetite stimulants, decadron for cns etc

Maybe it's time for you to step into the real world of pp instead of just assuming how rad onc is.

 

[thecarbonionangle]

There's an interesting discussion in the article by Zietman posted above regarding a potential future for the field where rad onc learns more interventional procedures to broaden the reach of the field in the treatment of cancer. Right now I don't think there is a way to do an IR fellowship from rad onc (or a way to get some training in it) but it could be interesting in the future perhaps since you ask about prostate biopsies?

Going forward there is potential for more turf wars with other specialties as the field advances and more indications for radiation are explored (just a few that come to mind, there are others): so it should be interesting to see how these things play out in the future. I am personally very excited for the future!

1) http://www.ncbi.nlm.nih.gov/pubmed/24751407
2) http://www.ncbi.nlm.nih.gov/pubmed/23107102
3) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1867089/
4) Lobectomy vs. Radiation trial at the VA system.
5) coronary artery brachytherapy for re-stenosing drug eluding stents in some academic centers being brought back.
6) improved techniques for bladder preservation in bladder cancer?

 

[Neuronix]

ITT, we have two medical students telling attendings how they should practice radiation oncology.

Protip: The referring doctors control the patients. Don't piss them off.

 

[Gfunk6]

With respect to Zeitman and the other posters on this thread . . . it is probably just better for me to come out and say that Rad Oncs are 'bottom feeders' when it comes to the referral chain. The only people who directly refer to us are Med Oncs and Surgeons. If you are REALLY friendly with a PCP, you may be able to convince him to send you dual referrals (e.g. to you and derm for suspicious skin cancer and you and pulmonologist for suspicious lung nodule). However at the end of the day, you have to be careful what you say/do lest you ruin your livelihood. There are multiple, appropriate ways to treat patients and you have to be sensitive to that.

 

[medgator]

With respect to Zeitman and the other posters on this thread . . . it is probably just better for me to come out and say that Rad Oncs are 'bottom feeders' when it comes to the referral chain. The only people who directly refer to us are Med Oncs and Surgeons. If you are REALLY friendly with a PCP, you may be able to convince him to send you dual referrals (e.g. to you and derm for suspicious skin cancer and you and pulmonologist for suspicious lung nodule). However at the end of the day, you have to be careful what you say/do lest you ruin your livelihood. There are multiple, appropriate ways to treat patients and you have to be sensitive to that.

I respectfully disagree. GI and pulmonary can be instrumental in making a primary cancer diagnosis well before a patient sets foot in a surgeon's office. Why would a pulmonologist send someone on oxygen with a dlco of 28% to a surgeon?

As for med onc, remember a friendly med onc one day can go help build an xrt center the next, so depending on them preferentially is less than ideal

 

[thecarbonionangle]

ITT, we have two medical students telling attendings how they should practice radiation oncology.

Protip: The referring doctors control the patients. Don't piss them off.

You are very defensive if you interpret that as "telling someone what to do". Don't worry I learned how to be a good dog during medical school and know my place but that doesn't mean I can't add to the discussion and my views are completely invalid. Another pro-tip is that you will be calling me a colleague soon too and we will both be lowly resident bottom dwellers so I'll catch ya in the deep end brother!

 

[Reaganite]

I miss scoping my h&n patients (used to do it in residency), but alas you are correct, pp imposes certain demands. I haven't gotten pushback otherwise. I generally try to get direct specialty referrals so I'm not pressured by med onc not to follow pts. Most surgeons in my area, don't follow our breast pts, ditto for the medically inoperable stage I nsclc pts I treat

I have built my practice the same way as you...mainly by getting patients before the med oncs. Surgeons are my biggest source of referrals, and I have also gone after pulmonologists and GI docs. I took over all the breast and GI cases in my area that way, so I have the med oncs coming to me rather than the other way around. Personally, I can't stand most med oncs, but that's another thread in itself!

 

[radninja]

Nobody is acting like "nobody" whatever that means. I get direct pulmonary referrals when appropriate and sometimes I even work up the occasional SPN and send them to surgery when appropriate.


Prostate is a tough nut to crack as we depend on gu to establish the diagnosis and I doubt you're insinuating we should start getting elevated psa cases direct from primary care and start working them up ourselves and doing trus biopsies.


Ftr, I give my own adt and place fiducials on my prostate patients when the urologists won't do the above, and I know I'm not the only one. I never did any of that in residency. I also write for plenty of narcs, anti emetics, antibiotics, appetite stimulants, decadron for cns etc


Maybe it's time for you to step into the real world of pp instead of just assuming how rad onc is.

As a med student applying to residency next year, its nice to hear that there are rad oncs out there who do much more beyond "just" radiation, such as adt and writing scripts for antibiotics, appetite stimulants, etc. I love radiation oncology, but I would like to be able to manage my patients around their cancer needs in a more holistic sense as well.


Do you have any suggestions, in terms of residency, which types of programs provide more holistic training? Are there specific questions I should be asking of residents on the interview trail?


Also, what avenues do you have to train yourselves/become comfortable with these other areas that you don't receive training for during residency (CME? Through colleagues? Self-learning? Remember from medical school?)

 

[medgator]

As a med student applying to residency next year, its nice to hear that there are rad oncs out there who do much more beyond "just" radiation, such as adt and writing scripts for antibiotics, appetite stimulants, etc. I love radiation oncology, but I would like to be able to manage my patients around their cancer needs in a more holistic sense as well.


Do you have any suggestions, in terms of residency, which types of programs provide more holistic training? Are there specific questions I should be asking of residents on the interview trail?


Also, what avenues do you have to train yourselves/become comfortable with these other areas that you don't receive training for during residency (CME? Through colleagues? Self-learning? Remember from medical school?)

Seek out busy clinical programs with wide patient draw areas. If you want to be a good clinician, that doesn't mean you have to go to a top 10-15 program. Know what you want up front. If going into academics and research are you thing, you may be better off in one of those top-tier programs, but if solid clinical training for PP is what you are looking for, a good mid-tier program may be exactly what you are seeking. A lot of this you may pick up after residency so it's important to stay up to date on the current data/guidelines (see my original post you quoted).

 

[Gfunk6]

I think the differing responses that you see here from attending physicians is based on our practice environment. I am already in an integrated groups of Med Oncs/Rad Oncs/Surg Oncs. So I don't have to worry about becoming 'too chummy' with the Med Oncs in fear of them purchasing accelerators because that ship has already sailed .

There is still a major role to play for referrals from outside the group however, but it is still quite different from the attendings above who (I assume) practice in single-specialty Rad Onc groups.

Perhaps to gravitate back to the OPs question however, I think as groups continue to consolidate and/or be bought out by large hospital systems there will be a decreasing role for physician autonomy. When you have a Med Onc/Rad Onc/Surg Onc/PCP/Palliative Care MD/Social Worker/Nurse Navigator as part of a holistic process the idea is to eliminate redundant tests, imaging, and having MDs do things that are at odds with one another. My two cents.

 

[vokey588]

Seek out busy clinical programs with wide patient draw areas. If you want to be a good clinician, that doesn't mean you have to go to a top 10-15 program. Know what you want up front. If going into academics and research are you thing, you may be better off in one of those top-tier programs, but if solid clinical training for PP is what you are looking for, a good mid-tier program may be exactly what you are seeking. A lot of this you may pick up after residency so it's important to stay up to date on the current data/guidelines (see my original post you quoted).

This is an interesting catch-22. On the one hand, the consensus on here seems to be that if you go to a top tier program you can get the job of your choice. On the other hand going to a mid-tier, clinical-heavy residency may make you a more well-rounded and productive physician (you can bill for those extras like lupron, fiducials, scoping, etc) but make you a less competitive job candidate than a top tier grad. It's hard to believe that employers/practices looking for a clinical-focused physician wouldn't be jumping to hire the mid-tier well-rounded guy. Of course in hardcore academics it's a moot point.

 

[medgator]

This is an interesting catch-22. On the one hand, the consensus on here seems to be that if you go to a top tier program you can get the job of your choice. On the other hand going to a mid-tier, clinical-heavy residency may make you a more well-rounded and productive physician (you can bill f

Tier matters less in PP than you think. It's more about the 3 "A's" and overall personality and fit (there are always regional exceptions of course).