Clinical Training Differences

[Haybrant]

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Is it just me or is there a pretty serious deficit of well trained clinicians out there? I guess once you become a specialist it's hard to see things from a generalists perspective but it feels like even at big academic centers the overall quality of clinical decision making is pretty poor. As rad onc we're quite privileged that we are in significant detail with every aspect of oncology and medicine which includes imaging/surgical and med onc data and generally can make good predictions and can guide a thorough workup and can accurately describe to a patient what's going to happen. It seems if you don't learn well in training you're in trouble after that. It feels like medicine residents and attendings are a real significant rung below and that in medicine and many other specialties it's the wild Wild West. Am I overstating it?

 

[medgator]

Where do the smartest people in medical school generally end up (specialty vs.IM/FP/peds/psych)? Average board scores of an IM vs rad onc resident?

You're probably right and this is related to which specialties attract the best talent

 

[RSAOaky]

Some of the smartest people I know went into internal medicine. I spent my intern year in a community hospital with a mostly suspect group of co interns. The range is pretty broad in internal medicine whereas in radonc the lower limit is set pretty high. That being said I've met some less than stellar radonc residents too

 

[fiji128]

Oh man if you go out into private practice some of the stuff you see other docs do will blow you mind (not in a good way).

 

[evilbooyaa]

I make an attempt not to judge people who deal with more than just cancer on a day-to-day basis on their shortcomings on cancer diagnosis and management. Because lord knows that if I had to manage COPD, CHF, or DM2 with anything more than cookie cutter medicine, it would likely not end well.

If you have more details to your original post I'm all ears. Are these med-oncs that you're having an issue with or internists?

 

[BobbyHeenan]

I make an attempt not to judge people who deal with more than just cancer on a day-to-day basis on their shortcomings on cancer diagnosis and management. Because lord knows that if I had to manage COPD, CHF, or DM2 with anything more than cookie cutter medicine, it would likely not end well.

If you have more details to your original post I'm all ears. Are these med-oncs that you're having an issue with or internists?

Agree fully with this. Get to know your hospitalists if you practice in a hospital. It's part of your job to educate them, because they have minimal oncology training.

We take some of the things we know for granted, so dictating basics like median survival, basic outline of plan of care (palliative, curative, etc), and number of fractions they told me is very helpful for their inpatient service. I've had things like T4 disease be mis-interpreted by good internists as stage IV, incurable when that wasn't the case. Other times I had to explain that a solitary brain met from well controlled ER positive breast cancer was not an immediate death sentence...and these were to very good interenists, they just have to take care of such a broad scope of patients it's hard for them to know oncology stuff.

Where I see the most out-of-whack care that surprises me is community general surgeons...cutting on sarcomas without biopsy first, excisional biopsies of breast lesions, surgery for anal cancers... not really understanding cancer care well at all but dabbling in it.

 

[evilbooyaa]

Agree fully with this. Get to know your hospitalists if you practice in a hospital. It's part of your job to educate them, because they have minimal oncology training.

We take some of the things we know for granted, so dictating basics like median survival, basic outline of plan of care (palliative, curative, etc), and number of fractions they told me is very helpful for their inpatient service. I've had things like T4 disease be mis-interpreted by good internists as stage IV, incurable when that wasn't the case. Other times I had to explain that a solitary brain met from well controlled ER positive breast cancer was not an immediate death sentence...and these were to very good interenists, they just have to take care of such a broad scope of patients it's hard for them to know oncology stuff.

Where I see the most out-of-whack care that surprises me is community general surgeons...cutting on sarcomas without biopsy first, excisional biopsies of breast lesions, surgery for anal cancers... not really understanding cancer care well at all but dabbling in it.

To some extent, I've seen similar things to the bolded especially, but when a surgeon sees an abdominopelvic mass in a young female, thinks it's psuedomyxoma peritoneii and cuts it out, and oops it's a combination well/dediff liposarcoma with positive margins everywhere, including along the aorta/IVC, and now RT is impossible b/c of no protection of the intestine.

The worst though is when people get an excision biopsy of a skeletal lesion, it's sarcoma, then there's NO imaging done prior to re-resection. Invariably leads to positive margins everywhere and a giant defect.
Like, if you get a sarcoma either refer it out or know how to stage it and treat it at least somewhat well.

 

[DrfluffyMD]

Lol, just want to say IM at places like MGH can be more competitive than Radonc at similar places from what I was told. Are IM docs in your institution that much worse?

I guess if you are a radonc resident at a pretty lower tier place perhaps the IM residents on the average are less competitive....

 

[medgator]

just want to say IM at places like MGH can be more competitive than Radonc at similar places from what I was told.
...

I would think rad onc would be more competitive than IM at MGH

 

[maruchan]

Ironically, I often feel the other way around. A good number of radiation oncology attendings, especially older ones, have atrocious clinical diagnosis/management skills (for non-oncologic medical issues that anyone who's done an internship should be familiar with).

 

[medgator]

Ironically, I often feel the other way around. A good number of radiation oncology attendings, especially older ones, have atrocious clinical diagnosis/management skills (for non-oncologic medical issues that anyone who's done an internship should be familiar with).

Very true as well. A product of how easy it was to get in a few decades ago. Many programs struggled to fill and ended up recruiting FMGs as a last resort. That all changed around the turn of the century I think.

One of my semi retired partners use to never write for narcotics, or ativan prn for h&n patients with the mask etc

 

[Neuronix]

You guys act as if there are not questionable rad onc decisions out there. I just got referred a guy with a newly diagnosed GBM, now with a 6 cm resection cavity, who got post-op Gammaknife to the cavity.

My wife is a family practice physician. I don't envy her seeing 20 patients a day and coming home with a stack of notes every night. The system is rigged against them. They incentivize them to do pap smears and not refer to specialists. PCPs (including IM and hospitalists) end up having to make snap judgments on all kinds of things so their work life doesn't totally consume them.

 

[DrfluffyMD]

I still think just because someone had a higher step 1, it doesn't mean they have "better clinical acumen". You get clinical acumen by being a clinician....

 

[medgator]

Lol ok. Many of you know what I'm talking about when it comes to residents back then vs now in rad onc. We've all seen it. I'm patting no one's back.... It was pretty embarrassing to watch one of my former partners refer pts back to med onc for narcotics for xrt-assiciated pain, or the pcp for ativan prior to daily radiation

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[evilbooyaa]

Ironically, I often feel the other way around. A good number of radiation oncology attendings, especially older ones, have atrocious clinical diagnosis/management skills (for non-oncologic medical issues that anyone who's done an internship should be familiar with).

I don't think that's 'ironically'. People who don't treat things ever lose functional capability to treat those things. Regardless of the field.

Older rad onc attendings likely didn't even need to go through an internship, so they may not have any of the experience that you had. Again, this is why I advocate to not throw stones from glass houses, because hospitalists could say the exact same to us about a patient with CHF/COPD/DM2 (are there any Rad Oncs that are managing the insulin dosing in diabetic patients who they are starting on steroids?). I would advocate to maintain your role, and do what you do well, and what you can't do well (or well enough), send to the person who CAN do it well (or well enough).

Newer Rad Onc attendings can potentially take control of their patients a bit better than Rad Onc attendings of old with basic clinical principles. There are some things, related to cancer treatment, that I'd say most Rad Oncs can pick up on - Shingles, Thrush, etc.

I guess once you become a specialist it's hard to see things from a generalists perspective

Re-read OP, and yes, it is hard to see things from a generalists perspective while sitting on our specialty hill. End of sentence. No use in looking down over horn-rimmed glasses and sneering at the hospitalists who are doing most if not all of the inpatient work for us, about how did they miss X,Y,Z. Certainly OK to vent at misses/delays, but don't let that carry over into your multidisciplinary work-life.

 

[Haybrant]

Ya im not saying who the smartest or not smartest is. Like, most of us know that smart doesnt really have much to do with anything. The smart people arent even in medicine if you want to go down that road

the problem is when you see the same mistakes over and over. I get it that its hard at the generalist level but to me its like they dont have that very important filter that at least alot of us younger Rad Oncs have which is that if something doesnt quite add up that you need to stop and question it and question your bias and then act. They just kind of go with the flow. Its like they arent real physicians, they are just there to check boxes.

 

[medgator]

Re-read OP, and yes, it is hard to see things from a generalists perspective while sitting on our specialty hill. End of sentence. No use in looking down over horn-rimmed glasses and sneering at the hospitalists who are doing most if not all of the inpatient work for us, about how did they miss X,Y,Z. Certainly OK to vent at misses/delays, but don't let that carry over into your multidisciplinary work-life.

Agreed. Ditto for outpt pcps. Lots of complex issues. I don't envy them at all

 

[Neuronix]

My PCP wife asked me about a post-op prostate patient with a slowly rising PSA at 1.0. I told her to send the patient to rad onc. Patient's insurance insisted that they use a particular rad onc in her area.

What happened? Rad onc said "nothing to do, refer to urology when the PSA gets above 2.0." I can't blame a PCP for being confused after things like this.

This thread boggles my mind. Acting like other specialties are the only ones that make mistakes or don't make good decisions is silly.

 

[evilbooyaa]

My PCP wife asked me about a post-op prostate patient with a slowly rising PSA at 1.0. I told her to send the patient to rad onc. Patient's insurance insisted that they use a particular rad onc in her area.

What happened? Rad onc said "nothing to do, refer to urology when the PSA gets above 2.0." I can't blame a PCP for being confused after things like this.

This thread boggles my mind. Acting like other specialties are the only ones that make mistakes or don't make good decisions is silly.

Bolded for emphasis.

Tough scenario for that patient. I'd recommend he request a second opinion, and if that is denied by insurance, he can sue the insurance company whenever he presents with metastatic disease.

 

[evilbooyaa]

Ya im not saying who the smartest or not smartest is. Like, most of us know that smart doesnt really have much to do with anything. The smart people arent even in medicine if you want to go down that road

the problem is when you see the same mistakes over and over. I get it that its hard at the generalist level but to me its like they dont have that very important filter that at least alot of us younger Rad Oncs have which is that if something doesnt quite add up that you need to stop and question it and question your bias and then act. They just kind of go with the flow. Its like they arent real physicians, they are just there to check boxes.

They don't know enough about cancer pathology and what presentations are common or not common to make those distinctions that you're thinking about. Things like "Oh, that looks like a glioma, low-grade" vs "That's pretty much guaranteed to be a GBM" based off imaging alone. Similarly that if we saw and were managing chest pain patient we'd go down the road of an MI, PE, costochondritis, and maybe GERD, and ignore Prinzmetal's angina or Takutsubo cardiomyopathy, or whatever other chest pain pathologies I don't remember off the top of my head right now.

It happens to the best of oncologists, even when we are trained in those intracacies. I remember a case of a patient with well-controlled LS-SCLC who developed singular relatively large brain met with significant edema, asymptomatic, referred for SRS, by the thoracic medical oncologist. Sent it to NSG given the presentation (SCLC with single brain met?), who did surgery showing GBM.

In regards to bolded, if you're not educating the hospitalist, in a non-judgemental e-mail regarding the difference in presentation from what they thought, then they're 1) not going to know they are making a mistake at all, and 2) obviously won't become better. This is why I prefer to have medical oncologists be the de facto hospitalist for cancer patients, because even if they are admitted for non-cancer reasons, there's innate knowledge to not ignore things given the patient's history.

H/o cancer with new onset neurological symptoms at my institution? R/o mets Brain MRI is pretty reliably ordered if it hasn't been in at least some time. That might not be an immediate consideration for somebody who doesn't see cancer as the primary thing the patient has, but is just one of the 20 things in the PMH (H/o breast cancer).

 

[medgator]

It happens to the best of oncologists, even when we are trained in those intracacies. I remember a case of a patient with well-controlled LS-SCLC who developed singular relatively large brain met with significant edema, asymptomatic, referred for SRS, by the thoracic medical oncologist. Sent it to NSG given the presentation (SCLC with single brain met?), who did surgery showing GBM..

Reminds of a case I just had, Nasopharynx case with a solitary cerebellar mass/met read on MRI. Med onc mentioned SRS, but my knee jerk reaction was a neurosurgical consult. The pt was diagnosed with a Grade 2 ependymoma in the 4th ventricle s/p GTR. MRI workup negative in the spine. Now i have to figure out how to deal with both at the same time 🙂

. This is why I prefer to have medical oncologists be the de facto hospitalist for cancer patients, because even if they are admitted for non-cancer reasons, there's innate knowledge to not ignore things given the patient's history.

And most med oncs would rather be consultants like we are in the hospital, which is pretty much what happens in most places these days (at least in the community, haven't heard of med oncs admitting their own patients in years).

 

[OTN]

Reminds of a case I just had, Nasopharynx case with a solitary cerebellar mass/met read on MRI. Med onc mentioned SRS, but my knee jerk reaction was a neurosurgical consult. The pt was diagnosed with a Grade 2 ependymoma in the 4th ventricle s/p GTR. MRI workup negative in the spine. Now i have to figure out how to deal with both at the same time 🙂



And most med oncs would rather be consultants like we are in the hospital, which is pretty much what happens in most places these days (at least in the community, haven't heard of med oncs admitting their own patients in years).

Our medoncs in our private practice see our own patients in the hospital.

 

[medgator]

Our medoncs in our private practice see our own patients in the hospital.

Do they admit them or does the pcp or hospitalist service admit them?

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[thecarbonionangle]

Lets not pat ourselves in the back here too much. One of the most dangerous things in medicine, in any specialty, is people who do not know what they do not know and they have an ego big enough to do something they don't have knowledge to really do. I've seen radiation oncologists completely mismanage very basic medical issues. You can become and excellent doctor or a terrible doctor regardless of specialty.