House of rads rules

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Welcome! Welcome to our newly matched colleagues.

Congratulations on matching into this specialty. It's fun, rewarding and engaging. I can't say the same to your future job search. But I would like to pass on my wisdom to you so that your residency experience will be less tumultuous.

1. Notes come first. In the era of declining reimbursement notes must be done promptly. And please be specific in diagnosis ,laterality and staging !

2. The sun must never set on contours. Dosimetry and physics are overworked. We have to be fast because otherwise plans won't get done quickly.

3. Templates in EPIC. Use these, a lot. It'll help.

4. Keyboard and mice, get good ones. They will be worth it throughout your 4 years.

5. Learn the treatment planning system's tips and tricks

6. Have a truce with co-residents. Yes, the job search sucks but you'll need one another to pass your boards. The ABR is out to get you. Nuff said

7. Have fun in your research year. I'm serious. You'll never get another chance like this. Ever.

8. Never tell your attendings you're set on a career path when it comes to academics vs pp but also don't lie

9. Have a side hustle plan. Don't believe me? Read this point in 4 years

10. Know systemic therapy advancements cold. Your stock portfolio will thank you. It'll also make you seem smarter when talking to those med oncs. 2 in 1 !

Best,

Fat "Rad" Man

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Welcome! Welcome to our newly matched colleagues.

Congratulations on matching into this specialty. It's fun, rewarding and engaging. I can't say the same to your future job search. But I would like to pass on my wisdom to you so that your residency experience will be less tumultuous.

1. Notes come first. In the era of declining reimbursement notes must be done promptly. And please be specific in diagnosis ,laterality and staging !

2. The sun must never set on contours. Dosimetry and physics are overworked. We have to be fast because otherwise plans won't get done quickly.

3. Templates in EPIC. Use these, a lot. It'll help.

4. Keyboard and mice, get good ones. They will be worth it throughout your 4 years.

5. Learn the treatment planning system's tips and tricks

6. Have a truce with co-residents. Yes, the job search sucks but you'll need one another to pass your boards. The ABR is out to get you. Nuff said

7. Have fun in your research year. I'm serious. You'll never get another chance like this. Ever.

8. Never tell your attendings you're set on a career path when it comes to academics vs pp but also don't lie

9. Have a side hustle plan. Don't believe me? Read this point in 4 years

10. Know systemic therapy advancements cold. Your stock portfolio will thank you. It'll also make you seem smarter when talking to those med oncs. 2 in 1 !

Best,

Fat "Rad" Man
Ah God this stings, especially 1-4.

Nothing beats a 4PM head and neck disaster sim and that attending asking for volumes by 8AM because Dosimetry won't have the plan ready in time otherwise, and you still have notes from that day that need to be signed so you can prep for clinic with your other attending tomorrow.

But hey, I have an RGB mechanical keyboard, so that's cool, I guess.
 
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Ah God this stings, especially 1-4.

Nothing beats a 4PM head and neck disaster sim and that attending asking for volumes by 8AM because Dosimetry won't have the plan ready in time otherwise, and you still have notes from that day that need to be signed so you can prep for clinic with your other attending tomorrow.

But hey, I have an RGB mechanical keyboard, so that's cool, I guess.

I sometimes help out with the notes especially if it's a follow up or OTV note. Consults I don't, beyond double checking them because otherwise that's a missed learning opportunity.

If I feel the resident is really overwhelmed especially when working with another attending I'll ask them to at least do the target volumes so they can compare theirs with mine later on. I've no problem doing normals. Then again I don't treat head and neck!

A good keyboard helps ! My kids tell me RGB lights make them type faster !
 
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should have added an 11th rule

Welcome to rad onc: if you’re not plotting your escape from this field then you are doing it wrong
 
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I sometimes help out with the notes especially if it's a follow up or OTV note. Consults I don't, beyond double checking them because otherwise that's a missed learning opportunity.

If I feel the resident is really overwhelmed especially when working with another attending I'll ask them to at least do the target volumes so they can compare theirs with mine later on. I've no problem doing normals. Then again I don't treat head and neck!

A good keyboard helps ! My kids tell me RGB lights make them type faster !
Why do your residents need to be rotating with more than one attending at once?
 
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Why do your residents need to be rotating with more than one attending at once?
Good question!

They don't need to and for the longest time this wasn't the case. But some of my colleagues want resident coverage and as such we've reverted back to the old way of doing things.

It's actually detrimental to run your own service efficiently without residents in my neck of the woods.

They'll ask you to help out with coverage in a satellite clinic despite being senior. Then they'll try to get you to permanently relocate there. This is what I'm up against right now.

I hope the soon to be residents are reading this!
 
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If two attendings are only in clinic 1-2 days a week each, I don't see the issue.
Sometimes clinical responsibilities clash especially with sick patients, OTVs , reviewing on board imaging....etc
 
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Good question!

They don't need to and for the longest time this wasn't the case. But some of my colleagues want resident coverage and as such we've reverted back to the old way of doing things.

It's actually detrimental to run your own service efficiently without residents in my neck of the woods.

They'll ask you to help out with coverage in a satellite clinic despite being senior. Then they'll try to get you to permanently relocate there. This is what I'm up against right now.

I hope the soon to be residents are reading this!
This is exactly why i went into PP and never looked back.... And with each passing year i feel better assured with that decision. I'm sure they won't pay you for being more efficient, unfortunately
 
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This is exactly why i went into PP and never looked back.... And with each passing year i feel better assured with that decision. I'm sure they won't pay you for being more efficient, unfortunately
No extra money for being efficient I'm afraid

I just do it because I like running my practice well

Base salary is the same no matter what and the bonus comes if you fulfill the objectives of it whether you had a resident helping out most of the year or not
 
If two attendings are only in clinic 1-2 days a week each, I don't see the issue.

A resident who covers 0.8-1.0 FTE of an attending physician is reasonable, whether this is 1 or 2 attendings.

That being said, most double coverage rotations are not like that, where it's > 1.0 FTE that the attendings are in clinic, but that the resident doesn't do 'follow-up days' or picks and chooses consults. Has to do double the contours in the same amount of time. No time for resident education.

It's a real problem.
 
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A resident who covers 0.8-1.0 FTE of an attending physician is reasonable, whether this is 1 or 2 attendings.

That being said, most double coverage rotations are not like that, where it's > 1.0 FTE that the attendings are in clinic, but that the resident doesn't do 'follow-up days' or picks and chooses consults. Has to do double the contours in the same amount of time. No time for resident education.

It's a real problem.
Having double covered, agree. You essentially become an extender/app, which is why all these programs have been expanding to begin with
 
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Sorry you're right, all academics are evil and all residents are abused.

The pendulum can swing too far the other way.

I'm done responding to this. I'm sorry, I know better than to make arguments I can't win.

For the record I double covered many times as a resident and am stronger as an attending for it. You learn by seeing and treating patients. Board exams and books are necessary, but a poor surrogate for being an outstanding physician.
 
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Sorry you're right, all academics are evil and all residents are abused.

The pendulum can swing too far the other way.

I'm done responding to this. I'm sorry, I know better than to make arguments I can't win.

For the record I double covered many times as a resident and am stronger as an attending for it. You learn by seeing and treating patients. Board exams and books are necessary, but a poor surrogate for being an outstanding physician.
For what it's worth I triple and quadrupled coverage in residency and I think rotating with two attendings can bring valuable experience especially if you want the resident to have exposure to a breadth of cases.

But I also think at the same time it shouldn't involve scut or delay patient care.

E.g. I don't want them doing notes if it means the urgent contours on the other attending's patient won't get done on time

One of the most criminal things we do to residents is we chuck them in clinic and say have at it. How about giving tips and teaching them the tricks of the trade ? How about effective communication so that clinic work isn't disrupted?
 
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Sorry you're right, all academics are evil and all residents are abused.

The pendulum can swing too far the other way.

I'm done responding to this. I'm sorry, I know better than to make arguments I can't win.

For the record I double covered many times as a resident and am stronger as an attending for it. You learn by seeing and treating patients. Board exams and books are necessary, but a poor surrogate for being an outstanding physician.
I agree. My program prioritized clinical coverage above all else... To the detriment of missing out on the other attending's cases being planned in dosimetry.

This is in contrast to a place like fox chase where it seemed like it was too lax with a PA on every service... Felt like you might miss out on things for another reason*

*- this is 2000-2010 info, not sure what it is like there now
 
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One of the most criminal things we do to residents is we chuck them in clinic and say have at it. How about giving tips and teaching them the tricks of the trade ? How about effective communication so that clinic work isn't disrupted?
I agree. My program prioritized clinical coverage above all else... To the detriment of missing out on the other attending's cases being planned in dosimetry

Agreed. Nearly my entire residency experience can be described with "chucked in the deep end with clinic coverage/notes a clear priority to the detriment of learning".
 
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For what it's worth I triple and quadrupled coverage in residency and I think rotating with two attendings can bring valuable experience especially if you want the resident to have exposure to a breadth of cases.

Triple and Quadruple coverage? Paradise. If you aren't quintuple or sextupling coverage, you might as well be on vacation.
 
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A resident who covers 0.8-1.0 FTE of an attending physician is reasonable, whether this is 1 or 2 attendings.

That being said, most double coverage rotations are not like that, where it's > 1.0 FTE that the attendings are in clinic, but that the resident doesn't do 'follow-up days' or picks and chooses consults. Has to do double the contours in the same amount of time. No time for resident education.

It's a real problem.

A major part of training (any field) is to learn how to manage being overwhelmed. You can either learn how to do this as a resident (when someone else bears the ultimate responsibility) or you can do this as an attending.

Personally, I completed a residency that is well regarded by most where I almost always at least double-covered attendings, and often triple covered. I would even sometimes lose my office day when another resident was out.

Was it enraging at times? sure. ...but in retrospect, I wouldn't have wanted things different because I ended up learning all the studies, how to contour, and got a fair amount of research done despite always feeling under the gun. Plus, now, I don't hyperventilate when I get an add on.

They got from me what they wanted, I got from them what I wanted.

(Granted n = 1)
 
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I don't recall ever having an "office day" as a resident unless you count coming in on the weekends to do work.
 
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Again, people feeling like they “need” a resident is a huge problem. This is not uncommon and programs use residents as PAs where work flow and bottom line come first and education last. Field please , DO BETTER or we may not have a field.
 
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You can be overwhelmed even when working with one attending if they're busy enough. Being overwhelmed and appeasing two masters is pointless. You can bring any resident to 1 FTE if you get their schedule in order when working with two attendings.

The last thing you want is to overwhelm residents with scut and delay patient care. It's not good for you, for the residents or patients.

And since this field is going down the toilet I guarantee you'll get more people leaving the field after their PGY1 year.

Food for thought
 
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You can be overwhelmed even when working with one attending if they're busy enough. Being overwhelmed and appeasing two masters is pointless. You can bring any resident to 1 FTE if you get their schedule in order when working with two attendings.

The last thing you want is to overwhelm residents with scut and delay patient care. It's not good for you, for the residents or patients.

And since this field is going down the toilet I guarantee you'll get more people leaving the field after their PGY1 year.

Food for thought

My old program took an NSX reject. They are still gonna do a surg internship. Guarantee you they will apply during his intern year and try again. Would be dumb if they didn’t.
 
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My old program took an NSX reject. They are still gonna do a surg internship. Guarantee you they will apply during his intern year and try again. Would be dumb if they didn’t.
I certainly don't advocate anyone going down the NSX path from RO, it's something I can't fathom. But if they absolutely love NSX, and only those that do should take it up then all the best to them!

I hope that they can match into a program that helps them become a very competent and skilled Neurosurgeon!
 
You can be overwhelmed even when working with one attending if they're busy enough. Being overwhelmed and appeasing two masters is pointless. You can bring any resident to 1 FTE if you get their schedule in order when working with two attendings.

The last thing you want is to overwhelm residents with scut and delay patient care. It's not good for you, for the residents or patients.

And since this field is going down the toilet I guarantee you'll get more people leaving the field after their PGY1 year.

Food for thought

Double coverage is not intrinsically bad... for example, you can learn two entirely disparate ways of approaching the same disease.

You seem to have made a substitution where you assume that double covering means that you are overwhelmed with "scut work". Prepping notes is not scut work. Contouring is not scut work. Triaging patients who have toxicities is not scut work.

On the other hand, if you are asking residents to dig up records, THAT is scut work.
 
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Double coverage is not intrinsically bad... for example, you can learn two entirely disparate ways of approaching the same disease.

You seem to have made a substitution where you assume that double covering means that you are overwhelmed with "scut work". Prepping notes is not scut work. Contouring is not scut work. Triaging patients who have toxicities is not scut work.

On the other hand, if you are asking residents to dig up records, THAT is scut work.

Digging up records, organizing appointments for sim and other things, the absolute mountain of messages on EPIC.

We don't have a particularly good support system for this stuff where I'm at. Residents can drown in it and learn nothing from the service they're in.

Contouring is a weird one. There are places where dosimetry does all the normals. I'm not at one of those. So in those places it's considered scut?

You hit a plateau with normals anyway. Targets on the other hand are unique. Which is why as I said above, if they need to get to something for the other attending, I'll ask them to at least do the target volumes.
 
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Double coverage is not intrinsically bad... for example, you can learn two entirely disparate ways of approaching the same disease.

You seem to have made a substitution where you assume that double covering means that you are overwhelmed with "scut work". Prepping notes is not scut work. Contouring is not scut work. Triaging patients who have toxicities is not scut work.

On the other hand, if you are asking residents to dig up records, THAT is scut work.
It's scut work if all you do is manage the clinic and miss out in everything going on in dosimetry
 
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During my residency on a “double coverage” rotation, I had one attending literally wait for me to finish seeing my other attending’s patients to see his patients just so he wouldn’t have to write a note. He would have patients wait sometimes 30 minutes if I ran over.
 
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During my residency on a “double coverage” rotation, I had one attending literally wait for me to finish seeing my other attending’s patients to see his patients just so he wouldn’t have to write a note. He would have patients wait sometimes 30 minutes if I ran over.

Yes! this does happen and it delays care.
 
During my residency on a “double coverage” rotation, I had one attending literally wait for me to finish seeing my other attending’s patients to see his patients just so he wouldn’t have to write a note. He would have patients wait sometimes 30 minutes if I ran over.

unfurtunately not uncommon in hellpit places. You run around basically as a scribe doing scut. The attendings go plan and approve plans. No feedback. No learning. But hey you wrote a damn good note!!!
 
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It's scut work if all you do is manage the clinic and miss out in everything going on in dosimetry
I have always thought that residents should rotate through dosimetry...

The fear I see on my residents' faces when I ask them to tell me the difference between 3DCRT vs. DCA vs. IMRT vs. VMAT...
 
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A dosimetry rotation would be fantastic but if you value residents as very important to “run” the clinic, that is never happening
 
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A dosimetry rotation would be fantastic but if you value residents as very important to “run” the clinic, that is never happening
Agreed, a Dosimetry rotation would never fly at my program unless you created your own on your elective time.

For those in a similar situation, may I recommend:




Teach yourself Dosimetry in your spare time!
 
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I think there are ways to do double coverage responsibly. For example, a chairperson who is 0.4 FTE and a basic science researcher who is 60-80% in lab (so basically 0.2-0.4 FTE) having one resident to cover the entire service? Very reasonable.

For what it's worth I triple and quadrupled coverage in residency and I think rotating with two attendings can bring valuable experience especially if you want the resident to have exposure to a breadth of cases.

But I also think at the same time it shouldn't involve scut or delay patient care.

E.g. I don't want them doing notes if it means the urgent contours on the other attending's patient won't get done on time

One of the most criminal things we do to residents is we chuck them in clinic and say have at it. How about giving tips and teaching them the tricks of the trade ? How about effective communication so that clinic work isn't disrupted?

You sound like an attending who would be reasonable with a resident who was responsible for double covering you and another attending. However, many may not have that same bend, especially any rad onc who can't do their own notes/contours/run the service without a resident.

A major part of training (any field) is to learn how to manage being overwhelmed. You can either learn how to do this as a resident (when someone else bears the ultimate responsibility) or you can do this as an attending.

Personally, I completed a residency that is well regarded by most where I almost always at least double-covered attendings, and often triple covered. I would even sometimes lose my office day when another resident was out.

Was it enraging at times? sure. ...but in retrospect, I wouldn't have wanted things different because I ended up learning all the studies, how to contour, and got a fair amount of research done despite always feeling under the gun. Plus, now, I don't hyperventilate when I get an add on.

They got from me what they wanted, I got from them what I wanted.

(Granted n = 1)

I feel like I was on very busy services as a resident (80% clinical attendings who had 20-30 H&Ns and Lungs on treatment), and at times saw multiple add-on consults in a day, and saw > 10-15 consults a week, but I was still 1:1 and still learned a ton without having the added pressure of another attending's crap to do. I appreciate those who have other perspectives, but just stating my personal opinions that a resident covering 2 attendings who, when added together, are > 1.0 FTEs, has a relatively high risk of being a rotation that is more focused on scut and service rather than resident education.

Perhaps the attendings I saw (which sparked changes from 2:1 to single coverage in my own residency program) and heard of (at different programs) just didn't play nice in the sandbox, and there are attendings elsewhere that habitually think about the resident as an educational tool and not for service.
 
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