APP's in Rad Onc

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FreeRT

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This study should concern us. It was an e-article in PRO, so you had to go online. It talks about the positive feasibility of Advance Practice Providers (NP and PAs) functioning independently in the RO clinic, and that job satisfaction among APP's was poor when they had to see pts 1:1 with a RO.

Since when was APP job satisfaction a priority? The article doesn't mention tx planning, but with this, be prepared to see large employers start hiring APP's instead of RO's, further worsening the job outlook for graduating residents. And what about general supervision? We could just put a "trained" APP in the clinic, have remote dosimetry with AI do all the treatment planning, and you know the rest.
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Having beat this drum myself, prepare...

Clearly self hating propaganda. NO ONE can do what we do! AI can’t draw circles like me. AI can’t plan better than me! APPs can’t line up a cone beam of a prostate to a contour of the same prostate without 4 full years of training. Certainly can’t tell therapists to “not treat” if there is some issue, or “put cream on it” if skin is red. This is why we are needed EVERY day in clinic (uh....). IR doctors can’t handle oligomets. They don’t know about Xrays or referrals from med oncs for specific lesion treatment. Etc... etc... etc...
 
Mandelin Rain said:
Having beat this drum myself, prepare...

Clearly self hating propaganda. NO ONE can do what we do! AI can’t draw circles like me. AI can’t plan better than me! APPs can’t line up a cone beam of a prostate to a contour of the same prostate without 4 full years of training. Certainly can’t tell therapists to “not treat” if there is some issue, or “put cream on it” if skin is red. This is why we are needed EVERY day in clinic (uh....). IR doctors can’t handle oligomets. They don’t know about Xrays or referrals from med oncs for specific lesion treatment. Etc... etc... etc...
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Agree 100%. But can you convince the hospital CEO/CFO of that?
 
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1. This may be largely patient-driven. When it comes to cancer, people want to go to the best. They don’t want to worry that they are getting the short end of the stick. A lot will insist on seeing a doc. In our clinic, we can’t even get patients to agree to see our PA for followup.

2. Our PA has been at it for 2 years and isn’t even close to being trained-up...still needs a ton of assistance for even seemingly straight-forward stuff. And he isn’t dumb by any means.
 
FreeRT said:
be prepared to see large employers start hiring APP's instead of RO's,
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I think the right question to ask is: why haven't they done this way before now? Before the industrial revolution, many scientists and engineers had a strong suspicion/fear that simply going faster than ~30 mph could cause sudden death. It was an irrational fear not anchored in any solid science, but still the fear was there. Guess the same sort of mindset has been at work resisting having NPs and PAs supervise radiation therapy...
Mandelin Rain said:
APPs can’t line up a cone beam of a prostate to a contour of the same prostate without 4 full years of training.
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thesauce said:
Our PA has been at it for 2 years and isn’t even close to being trained-up...still needs a ton of assistance for even seemingly straight-forward stuff.
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... and it's supervision that will be, and could be right now, the first toe-hold for APPs in rad onc... and the first toe-hold for CEOs and employers to have APPs supervise radiation therapy. I have shown previous data on here before where ~1% of all hospitals nationwide admitted in a survey of allowing APPs to supervise radiation therapy (circa ~2016). A small number, but greater than zero, so the sentiment has already been out there. After supervision, then we could be looking at other things years hence like APPs contouring, doing IGRT checking, etc.

But it all could be at least temporarily moot anyways with the upcoming advent of "virtual direct supervision." NB: a company like Siemens would really want to push for this. If one doc can cover multiple sites (or one doc and a few APPs), it means you're going to need more treatment equipment on a per capita basis ultimately. Less docs, but more equipment.
"Virtual direct supervision is still more stringent than general supervision in that it requires the supervising provider to be 'immediately available' via audio and video technology, but this move could foreshadow a permanent relaxation of supervision rules in the physician office and freestanding settings, which could reduce provider burden."

Worth pointing out again the "controversy": in the linked article, it says "[CMS changed] direct supervision to general supervision for all hospital outpatient therapeutic services, explicitly including chemo and radiation therapy" (emphasis added). ASTRO still says, though, that image guided radiation therapy is not radiation therapy, and has changed all of its wording from "image guided radiation therapy" or "IGRT" to simply "image guidance" so as to be internally consistent/avoid cognitive dissonance I suppose. So supervision for this form of radiation therapy which ASTRO says is not actually radiation therapy is still direct... according to ASTRO. AFAIK, there's not been a "test" of this yet. However, needless to say, I think it doesn't take a lot of imagination to see where all the arrows are trending.
 
I may be an outlier in a unique situation, but in my short time in practice, my clinic has gotten very busy. I have consults competing for time with follow ups and 15-20 sick patients under treatment. I won't lie and tell you I hadn't considered what it would be like if I had an APP I could trust to see routine follow ups, knowing that he/she would seek my guidance/refer patients back for complex situation and/or disease progression. I wish that I could see all of my patients for follow up indefinitely, but this is already limiting my ability to see new patients. I also get that the growing role of APPs will result in less work for radiation oncologists... but it's clearly easier/cheaper for my department to get me an APP than to hire another attending, and it could happen much sooner. There's only so many hours in the day, and these patients need to be seen.

I don't know... like I said, perhaps I am in a unique situation.
 
Lamount said:
I may be an outlier in a unique situation, but in my short time in practice, my clinic has gotten very busy. I have consults competing for time with follow ups and 15-20 sick patients under treatment. I won't lie and tell you I hadn't considered what it would be like if I had an APP I could trust to see routine follow ups, knowing that he/she would seek my guidance/refer patients back for complex situation and/or disease progression. I wish that I could see all of my patients for follow up indefinitely, but this is already limiting my ability to see new patients. I also get that the growing role of APPs will result in less work for radiation oncologists... but it's clearly easier/cheaper for my department to get me an APP than to hire another attending, and it could happen much sooner. There's only so many hours in the day, and these patients need to be seen.

I don't know... like I said, perhaps I am in a unique situation.
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You are not. You can't be in three places at once. The stuff like follow ups, on treatment issues on non-OTV days, going to see an inpatient and letting them know your plan and arranging logistics with the floor, etc... allow you to do your consults, sims, contours, brachy, etc... without CONSTANTLY being interrupted. You'll still be interrupted, but it will be filtered through them and you'll have a person to delegate to.

I would add that if your APP is not performing after 2 years, you are either asking WAY too much or you needed to find a new APP about 18 months ago.

Tell them what to look for on followup (PSA trends, women are taking their HT and have mammos ordered, CEA level, scans show no progression, etc...), give them a Texas Oncology handbook for toxicity highlighted with your favored management, and have them follow you for 2-3 months. If they can't handle most routine situations after that, start looking for replacement. Of course they should ask for your input during non-routine situations, but by definition, those are not routine.


EDIT: The other thing that I think is probably universal, is younger attendings tend to hold onto follow ups longer than you will after a few years of practice due to the exact scenario you describe. Start weaning your follow ups if you're just kind of wasting their time (breast patients following with med onc/surgery, prostates following with urology, rectal cancer patients post op, even lung patients on IO, etc...). They'll get back to you if they need you and liked you.
 
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Lamount said:
I don't know... like I said, perhaps I am in a unique situation.
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Not unusual at all. A physician's time is best used in three ways:
1. Complex medical decision making (i.e. consults, re-evals for new/progressive disease or significant side effects)
2. Procedures
3. Interfacing with patients, families, and other members of the team to ensure good care and understanding and execution of plans among all parties. Obviously to attempt high levels of satisfaction among all of the above.

For a rad onc, this means evaluating and seeing consults and re-evals (not just routine follow-ups), doing RT planning like contouring and plan evals, and doing procedures like SBRT and brachytherapy. Everything else should be handled by scribes, nurses, midlevels, etc.

In academics I've seen a lot of places give "protected time", but then insufficient clinical support to the doc, so the doc spends a lot of time being inefficient handling things they shouldn't be handling, and looking lazy or unproductive academically while trying to provide reasonable patient care to patients. Or the other way, the doc just neglects clinical care and is able to climb the academic ladder because they focus on papers since that's what matters in a lot of academic shops.

I tread lightly in some ways on this, because if everyone was operating at maximum efficiency as supported by APPs and other staff, we'd need even fewer rad oncs. I could even make myself redundant.
 
how about inpatient consults? has anyone hired a PA/NPP to see in-house bone mets, post-op brain mets, etc and has good report?
 
seper said:
how about inpatient consults? has anyone hired a PA/NPP to see in-house bone mets, post-op brain mets, etc and has good report?
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The place I almost took a job had this set-up. They had an NP that would go to the hospital, which was up the hill, and see the patient, gather information, etc, and then present the patient to that day's in-patient doc. Then, a decision would be made on whether to bring the patient down. Everyone liked it, including the NP. I can't recall what her other responsibilities were, but maybe a light follow-up schedule or something.
 
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seper said:
how about inpatient consults? has anyone hired a PA/NPP to see in-house bone mets, post-op brain mets, etc and has good report?
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I have seen this a few places. Valuable b/c inpatient consults eat up a lot of time, are generally not complicated, and most treatment decisions are made based on imaging and discussion with other doctors rather than a true 'preference of the patient'. Not a lot of "here are 3 options, let's discuss pros and cons of each" on the metastatic patient with cord compression.
 
The physician is the Advanced Practice Provider (APP).
PAs and NPs are midlevels. Midlevel should not be an offensive term. If it is, then it's not your problem. Do not grant this premise and accept that this is a term that needs to be "politically corrected." So-called providers have different job titles for a reason. I correct administrators when they try and redefine terms like this.
 
We have a total of 5 1/2 APPs across six sites. I work with a couple of them and it's awesome! The PA I work with will see consults with me, do tumor board notes; and she also does IRB submissions and keeps a tumor-related database going. She made a couple of our EPIC template notes that automatically do quality control on staging, premeds etc and then help feed the database. Her other funding is with med onc; so she can also write fluids, labs etc for the patients as well. The NP I work with also does tumor board notes, and sees all of my follow-ups independently. Per this article, her other half of the job is more of following a physician around and doing consults (which she likes) and OTVs and follow-ups similar to a resident (which she feels kinda useless for). Related to this article, she is the 3rd NP in 5 years to have that 'follow the doctor around' job...; which is a waste in terms of recruitment, training etc.

I'm sure other folks here could comment; but seeing OTVs and starting those notes is well within a good nurse or MA; and follow-ups (esp breast and prostate) don't often need TWO advanced providers.

And the two NPs share the inpatient consults and see all of them for us. I tell the residents here that they are so spoiled 🙂

Our clinical director is using this article to shape the jobs of the PAs to have about 30-40% independent follow-ups; and then 10% administrative support (tumor board notes, etc) and 30-40% physician work with new consults and/or vacation coverage to help with OTVs and the like.
 
I'm a little jealous. We cover two busy hospitals, and some attendings cover both on different days of the week. APPs and residents at our shop refuse to see all of the inpatients, so many of them are handled 100% by the attending.

It's no fun to see 20+ patients in clinic or do several long procedures then go see a few inpatients at 6 or 7 PM. I thought rad onc lifestyle was good? :laugh:
 
Neuronix said:
I'm a little jealous. We cover two busy hospitals, and some attendings cover both on different days of the week. APPs and residents at our shop refuse to see all of the inpatients, so many of them are handled 100% by the attending.

It's no fun to see 20+ patients in clinic or do several long procedures then go see a few inpatients at 6 or 7 PM. I thought rad onc lifestyle was good? :laugh:
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Mandelin Rain said:
I can't imagine being a resident and saying, "Nah. I'm good. You go take care of that cord compression. I've got cross fit to get to."

Maybe I should have.
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I guess in the post peak rad onc era you can?
 
Neuronix said:
I'm a little jealous. We cover two busy hospitals, and some attendings cover both on different days of the week. APPs and residents at our shop refuse to see all of the inpatients, so many of them are handled 100% by the attending.

It's no fun to see 20+ patients in clinic or do several long procedures then go see a few inpatients at 6 or 7 PM. I thought rad onc lifestyle was good? :laugh:
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I echo these sentiments. I am a relatively new attending and find that it is much easier to see inpatients by myself, as the residents and APPs will usually complain or be annoyed that someone would dare ask them to see patients. They have been told to be careful of burnout and resident wellness so I think they are more concerned about the concept of burnout rather than actually working hard enough to experience burnout. Just wait until they become attendings themselves in a few years...
 
SubserviantToABR said:
I echo these sentiments. I am a relatively new attending and find that it is much easier to see inpatients by myself, as the residents and APPs will usually complain or be annoyed that someone would dare ask them to see patients. They have been told to be careful of burnout and resident wellness so I think they are more concerned about the concept of burnout rather than actually working hard enough to experience burnout. Just wait until they become attendings themselves in a few years...
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Definitely have worse hours now as an attending. More hospitals to cover also
 
Mandelin Rain said:
I can't imagine being a resident and saying, "Nah. I'm good. You go take care of that cord compression. I've got cross fit to get to."

Maybe I should have.
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Not sure why programs have expansion if they don't even want to use the residents as labor? Is it just a straight money grab from the hospital/CMS GME fund? Or just flooding the market to drive the salaries of new attendings down a la op-ed from Hallahan et al, WUSTL?
 
SubserviantToABR said:
I echo these sentiments. I am a relatively new attending and find that it is much easier to see inpatients by myself, as the residents and APPs will usually complain or be annoyed that someone would dare ask them to see patients. They have been told to be careful of burnout and resident wellness so I think they are more concerned about the concept of burnout rather than actually working hard enough to experience burnout. Just wait until they become attendings themselves in a few years...
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Must be how the newer residents show their "dedication" to radiation oncology.
 
Neuronix said:
I'm a little jealous. We cover two busy hospitals, and some attendings cover both on different days of the week. APPs and residents at our shop refuse to see all of the inpatients, so many of them are handled 100% by the attending.

It's no fun to see 20+ patients in clinic or do several long procedures then go see a few inpatients at 6 or 7 PM. I thought rad onc lifestyle was good? :laugh:
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I mean, honestly, a good program that focuses on education rather than service is NOT going to make a resident see every inpatient consult. If you have a resident on your service, then I agree they should be seeing the inpatients (or at least most of the inpatients), but one of the biggest marks of a scut heavy residency program is one that makes a resident responsible for every single inpatient consult. Usually goes hand in hand with attendings having 24/7 resident coverage and not wanting to do any notes.

My residency program did not expect residents to see every single inpatient consult - if it went to an attending who didn't have a resident, that attending would see it themselves. Yes residents at times are coddled, I agree with the premise, but I believe the point of residency is education not indentured servitude.

There's a lot of dumb **** that passes for being OK in Rad Onc departments because chairs of Rad Onc are stereotypically weak compared to other specialties - the post-op day 2 Oral Tongue SCC that requires an inpatient rad onc consult before path is even back?
 
evilbooyaa said:
I mean, honestly, a good program that focuses on education rather than service is NOT going to make a resident see every inpatient consult. If you have a resident on your service, then I agree they should be seeing the inpatients (or at least most of the inpatients), but one of the biggest marks of a scut heavy residency program is one that makes a resident responsible for every single inpatient consult. Usually goes hand in hand with attendings having 24/7 resident coverage and not wanting to do any notes.

My residency program did not expect residents to see every single inpatient consult - if it went to an attending who didn't have a resident, that attending would see it themselves. Yes residents at times are coddled, I agree with the premise, but I believe the point of residency is education not indentured servitude.

There's a lot of dumb **** that passes for being OK in Rad Onc departments because chairs of Rad Onc are stereotypically weak compared to other specialties - the post-op day 2 Oral Tongue SCC that requires an inpatient rad onc consult before path is even back?
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I don't disagree about focusing on education (I'm only a couple of years out so I remember! I also do not have any resident coverage at all so don't @ me.). I don't mind taking care of the BS consults, but I have treated a number of cases like SVC syndrome, vaginal bleeding, or HO prophylaxis without residents because of what was cited above and find that it is hard to have an opportunity to discuss the case and literature supporting the treatment decision with them if they are not there. Any person with a pulse can put APPA on, but it's the thought that goes into the treatment decision that matters.
 
'Discuss the case and literature supporting the treatment decision with them' for SVC syndrome? Vaginal bleeding I can get if you're going to convert it to a definitive course for say a locally advanced cervical. We need to 'discuss the literature' on HO prophylaxis? Maybe one or up to say 5-10 cases (which I agree that residents should be seeing the inpatients that their attendings are assigned, but not covering inpatients for every single faculty), but this is a weird outlook on residents who should be educated and not used solely for service obligations.
 
Most inpatient consults have no intrinsic educational component.

Certainly the situation described with the postop head neck without path where the surgeon just wants a follow-up appointment to be scheduled in our clinic was common place and annoying.

Bone Mets, brain Mets, lung masses are all seen routinely as an outpatient in residency and seeing them as inpatients does not really at all too much.

Despite that, I can not imagine ever refusing to see them as a resident. I probably dislike seeing them even more now as an attending, but I still go.
 
evilbooyaa said:
'Discuss the case and literature supporting the treatment decision with them' for SVC syndrome? Vaginal bleeding I can get if you're going to convert it to a definitive course for say a locally advanced cervical. We need to 'discuss the literature' on HO prophylaxis? Maybe one or up to say 5-10 cases (which I agree that residents should be seeing the inpatients that their attendings are assigned, but not covering inpatients for every single faculty), but this is a weird outlook on residents who should be educated and not used solely for service obligations.
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totally agree. Unfortunately there are many places where the service component vastly outsizes the education component. It is in my experience the norm at many places that residents see all inpatients. Absolutely scut filled bottomless hell pits. Most of the time there is zero education involved just triaging and note writing, making calls, etc.

i can’t imagine there are places where people are allowed to “refuse” work. I guess this happens when you know if you fire someone they will get someone much worst in current market? How times have changed!
 
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I mean I get it to some extent, but in what other specialty training situation can residents just skip cases? “Oh, there’s no educational value in admitting that alcohol withdrawal/chf exacerbation/copd flare, lets just have the attending do it”.

totally reasonable to have an inpatient consult pager that rotates.

agree that nonsense consults should be blocked though
 
All I can say to the residents is be careful.

1. You want your attendings to help you find jobs. If you won't help them, will they help you?

2. You may just end up working where you trained or in a similar environment. You not helping with inpatients for 4 years leads to you not having help with inpatients when you are much busier for the rest of your life.
 
aspiring rapper said:
FWIW: My med school and residency program Internal Medicine department had a teaching and non-teaching service. EtOH withdrawal, COPD, ADCHF often went to non-teaching service, staffed only by an attending doc.
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Most places do have that for overflow. But not for all. Those are bread and butter diagnoses and I would imagine it would be critical for Im residents to be very familiar with those cases
 
aspiring rapper said:
FWIW: My med school and residency program Internal Medicine department had a teaching and non-teaching service. EtOH withdrawal, COPD, ADCHF often went to non-teaching service, staffed only by an attending doc.
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Additionally, IM residencies are capped at a certain number of patients based on team size because the focus is on educational cases, not every single CP R/O that comes into the hospital, which is why there are always non-teaching hospitalist services to cover the dumb stuff.

Neuronix said:
All I can say to the residents is be careful.

1. You want your attendings to help you find jobs. If you won't help them, will they help you?

2. You may just end up working where you trained or in a similar environment. You not helping with inpatients for 4 years leads to you not having help with inpatients when you are much busier for the rest of your life.
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We're going to have to agree to disagree on this. In regards to 1 - if the resident is ON X attending's service, yes they should be seeing most if not all of the inpatient consults. An attending who wants me to see all the inpatients they get when I am not on their service, on top of whatever responsibilities I have in clinic on my current service, else he/she will not help me find a job, is an attending I don't want any help from and don't want anything from.

In regards to 2 - Tasks that are decidely non-educational should only be done by a resident who is on the service with the attending. Expecting other residents to 'cover' during the week inpatient consults for an attending is a program that smacks of scutting out residents. Yes, many of you may have trained in such environments, but if we can agree that the focus of residency is educating residents and not just making them scut monkeys for 4 years, this is an outlook I 100% do not agree with.

This is much more in line with "you kids have it too easy nowadays, in my days we walked to work uphill both ways!"

I consider myself extremely fortunate that I did not do residency at a place that did (IMO) dumb **** like this.
 
Do you learn from seeing and taking care of patients or not? If you're close to 80 hours a week, I get it. Where I trained and where I work now, residents are nowhere near ACGME limits. If you've just decided to see the ACGME minimum number of patients, is that the bar you set for yourself? The minimum?

Also, I'm not saying that I don't help residents find jobs. But I've seen it out there. Repeatedly. I've also been in the position of seriously helping attendings who wouldn't lift a finger to help me. So it does go both ways.

A good mentor creates opportunities for and advises their mentees for strategy and on their work. A good mentee goes out of their way to do more than expected and earlier than expected. That's as true in the research world as it is in the clinical world. It's a two way street. if the mentee isn't willing to go the extra mile, the mentor isn't going to do that either. Going out of the way for someone who does the bare minimum is just not how the world works, nor should it IMO.

But yeah, best of luck in your own career. Your views may change when you're an attending, and every little thing is given to you to take care of and take care of perfectly right when you are the hardest working person in the building.
 
evilbooyaa said:
In regards to 2 - Tasks that are decidely non-educational should only be done by a resident who is on the service with the attending. Expecting other residents to 'cover' during the week inpatient consults for an attending is a program that smacks of scutting out residents.
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evilbooyaa said:
if the resident is ON X attending's service, yes they should be seeing most if not all of the inpatient consults.
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IMHO... if an attending, and it doesn't matter who he/she is, asks you to do something as a resident, you first say "Yes." If it's a traditional ask, like "will you see this inpatient consult *we* just got" when you're on the service, it's a hard "yes." There is no debate. If it's a non-traditional ask, like "I need you to see this inpatient or do this SCUT just because you're in my line of sight or because you got the bad luck today"... you just say "yes." Then you see if you can, and you probably should even though it might suck. I know you probably are Mr. Yes. But on the off chance someone out there is not a Mr. or Mrs. Yes... you can't imagine the big downside of not being Mr. or Mrs. Yes. The upside of standing your ground, or drawing a line in the sand or whatever... there is no upside (for a resident).
 
evilbooyaa said:
My residency program did not expect residents to see every single inpatient consult - if it went to an attending who didn't have a resident, that attending would see it themselves. Yes residents at times are coddled, I agree with the premise, but I believe the point of residency is education not indentured servitude.
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evilbooyaa said:
There's a lot of dumb **** that passes for being OK in Rad Onc departments because chairs of Rad Onc are stereotypically weak compared to other specialties - the post-op day 2 Oral Tongue SCC that requires an inpatient rad onc consult before path is even back?
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These statements bring up bad memories of my program (and I'm sure myriad others). Glad you trained at a better place.

They were always "looking into getting an NP/PA" but it never happened, but don't worry they'll take any transfer resident off the street if they brought their own funding.
 
Mandelin Rain said:
Seeing dumb inpatient consults, usually called in at Friday at 4 PM after the patient has sat in the hospital for 8 days, is the worst part (clinically) of being a rad onc.

It's a pretty good gig; if you can find a job.
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pubmed.ncbi.nlm.nih.gov

Always on a Friday? Time pattern of referral for spinal cord compression - PubMed

For patients with spinal cord compression, radiotherapy should be initiated as soon as possible to optimize the chances for restoration of neurological function. The speed of referral in the region of our radiotherapy institution with nine general hospitals was analysed based on a tumour and...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

This is something that has always held true haha
 
Neuronix said:
Do you learn from seeing and taking care of patients or not? If you're close to 80 hours a week, I get it. Where I trained and where I work now, residents are nowhere near ACGME limits. If you've just decided to see the ACGME minimum number of patients, is that the bar you set for yourself? The minimum?

Also, I'm not saying that I don't help residents find jobs. But I've seen it out there. Repeatedly. I've also been in the position of seriously helping attendings who wouldn't lift a finger to help me. So it does go both ways.

A good mentor creates opportunities for and advises their mentees for strategy and on their work. A good mentee goes out of their way to do more than expected and earlier than expected. That's as true in the research world as it is in the clinical world. It's a two way street. if the mentee isn't willing to go the extra mile, the mentor isn't going to do that either. Going out of the way for someone who does the bare minimum is just not how the world works, nor should it IMO.

But yeah, best of luck in your own career. Your views may change when you're an attending, and every little thing is given to you to take care of and take care of perfectly right when you are the hardest working person in the building.
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You do, but ideally the majority of those patients should be of curative intent. I will re-iterate that a resident who is either 1) pulled from their service or 2) given additional inpatient consults on top of the responsibilities they are given in clinic is not done with their education in mind.

The concept of "you're not close to 80 hour work weeks per ACGME" doesn't make sense because no Rad Onc resident ever should be approaching such hours. Given that we are a M-F specialty that would mean residents should be working 16 hour days. Hopefully we can agree that is unnecessary to make a good radiation oncologist.

Not seeing BS inpatient consults that have zero education value (say after completion of PGY-3 year, just so we can all learn how to palliate a bone met) does not mean that I advocate for residents to do the minimum. I wish case logs said you must do 450 DEFINITIVE cases rather than 450 including metastatic cases.

I say this is as a brand new attending that does not have a resident currently. If I have a resident on my service, yes he/she will be expected to see inpatients with me. Otherwise, no. But, my clinic days are not busy enough to see anything approaching 20 patients in a single day (unless you count OTV day), so it may not feel as onerous.
 
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evilbooyaa said:
You do, but ideally the majority of those patients should be of curative intent. I will re-iterate that a resident who is either 1) pulled from their service or 2) given additional inpatient consults on top of the responsibilities they are given in clinic is not done with their education in mind.

The concept of "you're not close to 80 hour work weeks per ACGME" doesn't make sense because no Rad Onc resident ever should be approaching such hours. Given that we are a M-F specialty that would mean residents should be working 16 hour days. Hopefully we can agree that is unnecessary to make a good radiation oncologist.

Not seeing BS inpatient consults that have zero education value (say after completion of PGY-3 year, just so we can all learn how to palliate a bone met) does not mean that I advocate for residents to do the minimum. I wish case logs said you must do 450 DEFINITIVE cases rather than 450 including metastatic cases.

I say this is as a brand new attending that does not have a resident currently. If I have a resident, yes he/she will be expected to see inpatients with me. Otherwise, no. But, my clinic days are not busy enough to see anything approaching 20 patients in a single day (unless you count OTV day), so it may not feel as onerous.
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I'm actually going to disagree with #2 above. If you have a busy service/clinic day and an inpatient consult comes through, the resident on your service should see it*. There may be days when she/he, as an attending, is very busy and has to work efficiently to get everything done. Learning how to do this should be a part of training.

*Residents should NEVER be pulled from their service or cover more than one attending.
 
OTN said:
I'm actually going to disagree with #2 above. If you have a busy service/clinic day and an inpatient consult comes through, the resident on your service should see it*. There may be days when she/he, as an attending, is very busy and has to work efficiently to get everything done. Learning how to do this should be a part of training.

*Residents should NEVER be pulled from their service or cover more than one attending.
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Fully agreed - I see how my previous post was unclear - I meant to say that #2 should be as follows - resident A who is on attending Y's service is required to go see an inpatient for attending Z while still doing all of attending Y's work (meaning not that he's getting "pulled" from attending Y's service), because "all inpatient consults require a resident".

Resident A, who is on attending Y's service, should routinely see inpatient consults meant for attending Y during their time together as attending and resident.
 
@evilbooyaa @Neuronix - this is a really good thread!

We have the NPs do the inpatient consults for the reasons described above. Especially in our urban setting; it's often a challenging social situation along with palliative intent. Once the consult may turn to treatment, the treatment planning etc does go to the resident / attending team, if said attending is working with a resident at that time.

When the NPs get overloaded, the residents jump in and help without complaint. They know they have a good thing, they read SDN.

For the younger members of the group, especially those worried about job issues...Even as an employed gray-haired staff member; I physically staff all of my inpatient consults. I think, as a resident, you get frustrated about how many patients don't "need" radiation, and certainly not inpatient. But that's not why you're getting the consult. You're getting the consult because the other members of the team don't know what they are doing, and they need your EXPERTISE.

So, I encourage it. Call me. I'll help you out. And I'll make sure you don't need to call someone else. Because I do have expertise, and I know oncology really well and can make a difference for the patient. And, because, I really like my job and want to keep it.
 
I'm not going to comment any further about my expectations of residents. This is too personal, and too many people know who I am IRL. Resident evaluations of attendings are taken very seriously here, and I don't want to get into trouble.

GI_RadOnc said:
Especially in our urban setting; it's often a challenging social situation along with palliative intent.
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Same

For the younger members of the group, especially those worried about job issues...Even as an employed gray-haired staff member; I physically staff all of my inpatient consults.
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Same. Except the attending physician does everything, including work out the social situation, no matter how busy their clinic and/or procedure day was. I'm happy for you that you have people to help you with this, though not all of us do.
 
Neuronix said:
All I can say to the residents is be careful.

1. You want your attendings to help you find jobs. If you won't help them, will they help you?

2. You may just end up working where you trained or in a similar environment. You not helping with inpatients for 4 years leads to you not having help with inpatients when you are much busier for the rest of your life.
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“It would be a shame if you just did not get a job because you were not enthusiastic enough about that bone met inpatient consult.”
 
Neuronix said:
I'm not going to comment any further about my expectations of residents. This is too personal, and too many people know who I am IRL. Resident evaluations of attendings are taken very seriously here, and I don't want to get into trouble.



Same



Same. Except the attending physician does everything, including work out the social situation, no matter how busy their clinic and/or procedure day was. I'm happy for you that you have people to help you with this, though not all of us do.
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“It would be a shame if a resident identified your comment on sdn and you were hurt professionally for your comment”

what a wonderful field rad onc is folks! It is filled with petty people. It sucks to be in this situation of not being able to speak your mind. Someone is always watching
 
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