Dosimetrist Discussion

[RadOncDoc21]

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Not going to lie, I envy my dosimitrist. Yes, I make substantially more but she literally works about 3-5 hrs a day making 110-125k a year, no weekends, no call.

 

[PhotonBomb]

Not going to lie, I envy my dosimitrist. Yes, I make substantially more but she literally works about 3-5 hrs a day making 110-125k a year, no weekends, no call.

Why do you have a full time dosimetrist if you don’t need one though?

 

[medgator]

Why do you have a full time dosimetrist if you don’t need one though?

Ours carry 25-30 pts generally

 

[RadOncDoc21]

Why do you have a full time dosimetrist if you don’t need one though?

hospital employed but I agree!

 

[Mandelin Rain]

One could argue that one good dosimetrist is worth more than two average docs in rad onc.

Dirty secret how much of the actual work they do. They can make or break your whole practice.

I know, I'm self hating, etc... But now that an NP (or no one) can run the clinic, our chief role for most patients has become NCCN reciter and GTV circler.

 

[RadOncDoc21]

One could argue that one good dosimetrist is worth more than two average docs in rad onc.

Dirty secret how much of the actual work they do. They can make or break your whole practice.

I know, I'm self hating, etc... But now that an NP (or no one) can run the clinic, our chief role for most patients has become NCCN reciter and GTV circler.

My PTV expansions alone require a fellowship!

 

[OTN]

Not going to lie, I envy my dosimitrist. Yes, I make substantially more but she literally works about 3-5 hrs a day making 110-125k a year, no weekends, no call.

Ours works incredibly hard and is a huge asset to our practice. She was carrying 50 patients on her own for awhile. Incredibly intelligent, has a nuclear engineering degree, etc. I agree that a really good dosimetrist makes a big, big difference in a practice.

 

[theradiator]

One could argue that one good dosimetrist is worth more than two average docs in rad onc.

Dirty secret how much of the actual work they do. They can make or break your whole practice.

I know, I'm self hating, etc... But now that an NP (or no one) can run the clinic, our chief role for most patients has become NCCN reciter and GTV circler.

I think this rhetoric has gone too far. The physician has sole responsibility to approve the plan. If the plan is rubbish, don't sign it and make constructive suggestions. If you have enough experience with treatment planning, you would know what type of dose distribution is expected for a given volume. If there is a systemic problem, implement additional constraints or speak to physics about implementing a better planning strategy or additional training.

I also disagree with the narrow definition of what radiation oncologists bring to the table. We can play a major role in the care of cancer patients beyond the technical side. NCCN guidelines while useful are quite broad. As an example, have you looked at the RT guidelines for endometrial cancer? Also, practice building is obviously beyond the scope of a NP.

 

[medgator]

I think this rhetoric has gone too far. The physician has sole responsibility to approve the plan. If the plan is rubbish, don't sign it and make constructive suggestions. If you have enough experience with treatment planning, you would know what type of dose distribution is expected for a given volume. If there is a systemic problem, implement additional constraints or speak to physics about implementing a better planning strategy or additional training.

I also disagree with the narrow definition of what radiation oncologists bring to the table. We can play a major role in the care of cancer patients beyond the technical side. NCCN guidelines while useful are quite broad. As an example, have you looked at the RT guidelines for endometrial cancer? Also, practice building is obviously beyond the scope of a NP.

Yup. A dosimetrist or np is only as busy as the RO doctor they are working under. A crap doctor will ultimately lead to a crap practice

 

[Mandelin Rain]

Meh, my guess is you've never worked with a good dosimetrist. I could offer a few suggestions to turn a bad dosimetrist into a below average dosimetrist. But my current one has forgotten more about treatment planning than I'll ever know.

 

[Mandelin Rain]

Yup. A dosimetrist or np is only as busy as the RO doctor they are working under. A crap doctor will ultimately lead to a crap practice

We both know that's not true.

 

[medgator]

We both know that's not true.

Maybe not in an area with zero competition....

 

[evilbooyaa]

Meh, my guess is you've never worked with a good dosimetrist. I could offer a few suggestions to turn a bad dosimetrist into a below average dosimetrist. But my current one has forgotten more about treatment planning than I'll ever know.

That's a cop out, IMO.

I've worked with a number of good dosimetrists. I have learned what is a reasonable ask and what is not a reasonable ask in regards to treatment planning. If there is no back and forth to your discussion on any patient ever, your dose constriants are too lax.

I will say our dosimetrists do FiF for say breast much, much better than I can but my focus has been more so for IMRT plans because that's where a dose-constraint besides "keep it homogenous" and "block the kidney" come into play.

Regardless, this is all off-topic and will be getting shuffled into its own thread.

 

[RickyScott]

That's a cop out, IMO.

I've worked with a number of good dosimetrists. I have learned what is a reasonable ask and what is not a reasonable ask in regards to treatment planning. If there is no back and forth to your discussion on any patient ever, your dose constriants are too lax.

I will say our dosimetrists do FiF for say breast much, much better than I can but my focus has been more so for IMRT plans because that's where a dose-constraint besides "keep it homogenous" and "block the kidney" come into play.

Regardless, this is all off-topic and will be getting shuffled into its own thread.

off topic, but for fif Ezfluence has been beating the dosimetrists..

 

[Gfunk6]

I've found linking one's compensation to one's perceived societal worth is at best a fruitless exercise and at worst damaging to your mental health.

Of all technical staff on the RO team, I think Dosimetrists face the highest risk of obsolesce due to AI.

 

[SneakyBooger]

I've found linking one's compensation to one's perceived societal worth is at best a fruitless exercise and at worst damaging to your mental health.

I just got back from bird hunting with a Cardiothoracic surgeon and a high school educated retired state dept. of revenue worker turned tax consultant for the very wealthy. The tax consultant makes over twice as much as the surgeon and I combined.

 

[medgator]

I've found linking one's compensation to one's perceived societal worth is at best a fruitless exercise and at worst damaging to your mental health.

Of all technical staff on the RO team, I think Dosimetrists face the highest risk of obsolesce due to AI.

You aren't planning on using a kiosk to check in patients, Wawa style?

 

[RadRadRad]

One could argue that one good dosimetrist is worth more than two average docs in rad onc.

Dirty secret how much of the actual work they do. They can make or break your whole practice.

I know, I'm self hating, etc... But now that an NP (or no one) can run the clinic, our chief role for most patients has become NCCN reciter and GTV circler.

We are selling ourselves short on this thread. Deciding what to treat is not as easy as drawing a circle. I’ve worked with mediocre radonc and seen the gtv not treated. Deciding elective volume even more complicated. On the flip side I’ve worked with dosimetrists at many institutions. Typically (but not always ), I can optimize a better plan than them. If you disagree I would argue that’s a failure of you to dive into planning not a function of the greatness of your dosimetrists.

 

[Mandelin Rain]

Truth be told, I never did get my CMD. I doubt anybody here did either. So I have not dove into treatment planning to that degree. Is it a failure on my part? Maybe. But it's a failure I suspect we all share.

My bet is if I gave you a complex IMRT head and neck or thoracic or anal volume in Eclipse and said, "Go." you wouldn't out optimize a (my) dosimetrist. I have sincere doubts on whether you'd know the first step. Note: I'm not saying I would.

 

[RadOncDoc21]

True I’ve had experiences with over 10-15 dosimitrist and there are good ones, a lot of fair ones and some bad ones. I believe you have to challenge them and like any professional relationship, it grows the more cases you end up doing together. I apologize for taking the original topic off course but I’m a hating hard! I might tell my kids to either do dosimitry or be a rad onc nurse!

 

[Mandelin Rain]

dosimitry or rad onc nurse!

Best two jobs in health care

 

[medgator]

True I’ve had experiences with over 10-15 dosimitrist and there are good ones, a lot of fair ones and some bad ones. I believe you have to challenge them and like any professional relationship, it grows the more cases you end up doing together. I apologize for taking the original topic off course but I’m a hating hard! I might tell my kids to either do dosimitry or be a rad onc nurse!

Best two jobs in health care

Chief physicist ftw. Better locums rates than RO physicians currently, in some cases

 

[RadRadRad]

Truth be told, I never did get my CMD. I doubt anybody here did either. So I have not dove into treatment planning to that degree. Is it a failure on my part? Maybe. But it's a failure I suspect we all share.

My bet is if I gave you a complex IMRT head and neck or thoracic or anal volume in Eclipse and said, "Go." you wouldn't out optimize a (my) dosimetrist. I have sincere doubts on whether you'd know the first step. Note: I'm not saying I would.

Didn’t learn it over night and don’t have to do it that often. After almost 10 years in practice I’ve learned a lot.

My first job:
“ hi senior radonc. My head and neck plan looks horrible. It starts Monday”
“ well, that dosimetrists is mediocre. I suggest you go in this weekend and optimize it yourself”
“I don’t know how to do that”
“You’ll figure it out”

After all many dosimetrists work as therapists and do their dosimetry training before and after hours over 1 total year

To suggest that md can’t figure it out after 10 years is odd


After all, many dosimetrists learn over 1 year in the side while they work as therapists.

 

[evilbooyaa]

Truth be told, I never did get my CMD. I doubt anybody here did either. So I have not dove into treatment planning to that degree. Is it a failure on my part? Maybe. But it's a failure I suspect we all share.

My bet is if I gave you a complex IMRT head and neck or thoracic or anal volume in Eclipse and said, "Go." you wouldn't out optimize a (my) dosimetrist. I have sincere doubts on whether you'd know the first step. Note: I'm not saying I would.

This is, IMO, a failure of your residency training. In the current era there should be a curriculum to teach the basics of treatment planning, including IMRT optimization. Doesn't have to the best, but you should understand how to do it, IMO.

 

[Mandelin Rain]

I do understand the basics of treatment planning. But how does that change anything when my dosimetrist is really really good? I give suggestions on rare occasions the plan doesn’t look great, but if I started talking PTVopt volumes and whatnot she’d laugh in my face.

like I said, I could take a bad dosimetrist and make them below average. But a good dosimetrist? I don’t have to go in on the weekend and learn an entirely different profession over ten years. That is, of course, my point. They can make or break your practice. And believe me, your practice is broken if you’re there every weekend playing dosimetrist.

Again, every time I’m accused of self hating here I just see a fair amount of hubris on the other side. I’m pretty realistic about what we actually do, and I doubt 99.999% (yes, there’s that many now) of rad Oncs are optimizing imrt head and necks over the weekend. I’ve met hundreds and literally not a single one has ever done this. Good on you if you are, but I’m calling BS. And if you’re one of the (liberally) 2-3 practicing rad oncs currently optimizing a plan this Saturday morning, please do yourself a favor and find a better dosimetrist.

 

[RadOncDoc21]

Mine definitely won’t be available, she’s hardly around on the weekdays.

 

[temujim]

Used to be you had to guess how "good" a dosimetrist was. Now that can be measured. I don't bother interviewing a dosimetrist for a position unless they come in with plan challenge score above a certain level. If you want to know how good they can contour -- that can be measured objectively as well against a "gold standard".

Agree with GFunk that ML/AI approaches are going to winnow out a lot of dosimetry positions. I don't think they'll go away completely, but not a growing market...

I do understand the basics of treatment planning. But how does that change anything when my dosimetrist is really really good? I give suggestions on rare occasions the plan doesn’t look great, but if I started talking PTVopt volumes and whatnot she’d laugh in my face.

like I said, I could take a bad dosimetrist and make them below average. But a good dosimetrist? I don’t have to go in on the weekend and learn an entirely different profession over ten years. That is, of course, my point. They can make or break your practice. And believe me, your practice is broken if you’re there every weekend playing dosimetrist.

Again, every time I’m accused of self hating here I just see a fair amount of hubris on the other side. I’m pretty realistic about what we actually do, and I doubt 99.999% (yes, there’s that many now) of rad Oncs are optimizing imrt head and necks over the weekend. I’ve met hundreds and literally not a single one has ever done this. Good on you if you are, but I’m calling BS. And if you’re one of the (liberally) 2-3 practicing rad oncs currently optimizing a plan this Saturday morning, please do yourself a favor and find a better dosimetrist.

 

[medgator]

Used to be you had to guess how "good" a dosimetrist was. Now that can be measured. I don't bother interviewing a dosimetrist for a position unless they come in with plan challenge score above a certain level. If you want to know how good they can contour -- that can be measured objectively as well against a "gold standard".

Agree with GFunk that ML/AI approaches are going to winnow out a lot of dosimetry positions. I don't think they'll go away completely, but not a growing market...

Auto contouring, expansion of mid-levels and reduction in supervision requirements will do the same to MD labor as well

 

[radiation]

I would bet most prostate plans will be autoplanned in 2-3 years as it is the most straight forward to autosegment and plan.

Automated volumetric modulated arc therapy planning for whole pelvic prostate radiotherapy - PubMed

Automated VMAT planning for complex WPRT dose distributions is feasible and creates treatment plans that are generally dosimetrically superior to manually optimized plans.

www.ncbi.nlm.nih.gov

 

[RadRadRad]

Will also be interesting to see what happens with consolidation/corporate takeover of dosimetry. I know varian is hiring dosimetrists and allowing hospitals to outsource dosimetry to Varian’s dosimetry team. Right now it pays well but I assume over time either workload will be increased or salary will go down or available positions will decrease (or all 3)

 

[RadOncDoc21]

Will also be interesting to see what happens with consolidation/corporate takeover of dosimetry. I know varian is hiring dosimetrists and allowing hospitals to outsource dosimetry to Varian’s dosimetry team. Right now it pays well but I assume over time either workload will be increased or salary will go down or available positions will decrease (or all 3)

Also see the same with radiation therapists... that’s one job I do not envy and I noticed they are already feeling a squeeze.

 

[Krukenberg]

I would bet most prostate plans will be autoplanned in 2-3 years as it is the most straight forward to autosegment and plan.

Automated volumetric modulated arc therapy planning for whole pelvic prostate radiotherapy - PubMed

Automated VMAT planning for complex WPRT dose distributions is feasible and creates treatment plans that are generally dosimetrically superior to manually optimized plans.

www.ncbi.nlm.nih.gov

actually it’s the opposite. Saw a presentation recently that auto planning wasn’t able to top most dosimetrists in prostate. It topped them the more complex the planning became (I.e. head and neck) because the # of degrees of freedom are so much higher than for prostate.

For prostate there are only so many optimal solutions to the cost function and fosimetrists are pretty good at finding a good one.

 

[radiation]

actually it’s the opposite. Saw a presentation recently that auto planning wasn’t able to top most dosimetrists in prostate. It topped them the more complex the planning became (I.e. head and neck) because the # of degrees of freedom are so much higher than for prostate.

For prostate there are only so many optimal solutions to the cost function and fosimetrists are pretty good at finding a good one.

Can you point to me this presentation? Agree AI benefit should be greater with more complex cases. However I think autosegmentation in H&N super challenging and will be difficult to do without human correction. Mostly because the ground truth is based on physician contours, and even an individual physician will have day to day variation in how they contour HN targets and OARs.

Prostate contours much easier and reliable to autosegment. Agree that there are only so many optimal solutions for prostate planning and I think for that reason its much easier to implement automation. Easier to QA that the AI picked reasonable plan. AI doesn't have to beat dosimetrists in prostate, but if it can automate and do same job in half the time then its a success.

 

[Krukenberg]

Can you point to me this presentation? Agree AI benefit should be greater with more complex cases. However I think autosegmentation in H&N super challenging and will be difficult to do without human correction. Mostly because the ground truth is based on physician contours, and even an individual physician will have day to day variation in how they contour HN targets and OARs.

Prostate contours much easier and reliable to autosegment. Agree that there are only so many optimal solutions for prostate planning and I think for that reason its much easier to implement automation. Easier to QA that the AI picked reasonable plan. AI doesn't have to beat dosimetrists in prostate, but if it can automate and do same job in half the time then its a success.

I’ll look for it. It was actually about Planning not auto-segmentation. So yea head and neck would definitely be harder auto-seg but the AI planning produces better plans.

 

[evilbooyaa]

I do understand the basics of treatment planning. But how does that change anything when my dosimetrist is really really good? I give suggestions on rare occasions the plan doesn’t look great, but if I started talking PTVopt volumes and whatnot she’d laugh in my face.

like I said, I could take a bad dosimetrist and make them below average. But a good dosimetrist? I don’t have to go in on the weekend and learn an entirely different profession over ten years. That is, of course, my point. They can make or break your practice. And believe me, your practice is broken if you’re there every weekend playing dosimetrist.

Again, every time I’m accused of self hating here I just see a fair amount of hubris on the other side. I’m pretty realistic about what we actually do, and I doubt 99.999% (yes, there’s that many now) of rad Oncs are optimizing imrt head and necks over the weekend. I’ve met hundreds and literally not a single one has ever done this. Good on you if you are, but I’m calling BS. And if you’re one of the (liberally) 2-3 practicing rad oncs currently optimizing a plan this Saturday morning, please do yourself a favor and find a better dosimetrist.

I'm not saying to do the process yourself. I'm saying to understand the process sufficiently to know what is feasible and where you can push an IMRT plan.

For example - what is the maximum drop-off you can have in a homogenous plan per millimeter in terms of distance of an OAR away from a PTV? While you're unlikely to reach that number in say a complex H&N plan (due to multiple OARs all with various weights) you know what is theoretically possible. A graduating resident should know that if I'm prescribing 70Gy to X and want 56Gy to be the point dose for Y how far apart do X and Y have to be when optimizing for the TPS to respect my inputs. Or at least have some idea of the potential drop-offs possible.

If you don't, spend time with the 'good' dosimetrists that can teach you these factors. Because when you go and practice by yourself the only real QA on whether a plan is crap or not may fall onto you, the physician, and if you're just blindly accepting what dosimetry puts in front of you..... well that's not ideal.

But I would say most attendings that are more than 10-15 years out probably don't have this thought process, and to understand what is feasible, so they just have generic constraints (not up-to-date on dosimetric predictors of toxicity that have been more recently published) that are easily meetable within 5 minutes of 'optimization', accept a plan, and move on with their lives. People want to practice as they were trained and are inherently resistant to change.

 

[Mandelin Rain]

Yeah, I get all that. The other guy said during his first year of work he went in and optimized a head and neck plan over the weekend for a patient starting Monday (perhaps he also taught himself to shoot IMRT QA), and after that implied that he taught himself dosimetry over 10 years. I'm not saying it's impossible that happened, just exceedingly unlikely to the point that I would bet massive sums of money that it didn't.

I'll just stand by my original statement;

"One could argue that one good dosimetrist is worth more than two average docs in rad onc. Dirty secret how much of the actual work they do. They can make or break your whole practice."