Lost my job and can't move . . . now what?

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It’s gotta be real rural to pull off having poor quality docs
I’ve found that patients are willing to travel about an hour if the community knows the doctors are no good. And they figure this out fast
I’ve seen practices go from 25-30 on beam to 10-15 within 2 years of losing stable doc
(Without any competing center opening). All just driving to other locations.
Yep.... That's what i tell people when they are first getting out trying to build a new practice.. sometimes you aren't just competing with one other smaller center in your area, a lot of patients will travel an hour away if needed

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It’s gotta be real rural to pull off having poor quality docs
I’ve found that patients are willing to travel about an hour if the community knows the doctors are no good. And they figure this out fast
I’ve seen practices go from 25-30 on beam to 10-15 within 2 years of losing stable doc
(Without any competing center opening). All just driving to other locations.
But most non radoncs Can’t tell who sucks?
 
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But most non radoncs Can’t tell who sucks?
Agree, still have seen the phenomenon happen nonetheless. 3 A's with a hardworking perm doc is going to do better for a machine load than a revolving door septu/octo-locums, even if both might suck. Engaging with the local physician community is going to yield fruit at the end of the day vs just showing up to collect a daily babysitting check
 
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It’s gotta be real rural to pull off having poor quality docs
I’ve found that patients are willing to travel about an hour if the community knows the doctors are no good. And they figure this out fast
I’ve seen practices go from 25-30 on beam to 10-15 within 2 years of losing stable doc
(Without any competing center opening). All just driving to other locations.

I have also seen the reduction in volume but I think it's more about med oncs and surgeons nudging patients not to stay locally rather than patients making that call on their own. Employed med oncs refuse to send anything even remotely complicated to the locums across the hall and tell them to drive 3 hours to the university. Unfortunately some patients just refuse to leave town or are unaware they are not in competent hands. They think they have a deadly disease, so poor outcomes aren't surprising. Health literacy is not high in rural areas.

I actually do this myself. There are a couple surgical subspecialists in the community that are so bad I nudge patients that they need to leave town.

Admin doesn't care about quality of care. Even if it's a financial wash, they will let a competent doctor walk away and staff with locums and take the hit on volume if he pisses off staff by increasing productivity and quality demands and/or asks for what they deem as too much. BTDT.

Agree, still have seen the phenomenon happen nonetheless. 3 A's with a hardworking perm doc is going to do better for a machine load than a revolving door septu/octo-locums, even if both might suck. Engaging with the local physician community is going to yield fruit at the end of the day vs just showing up to collect a daily babysitting check
Agree, I work with someone who is permanent but more dangerous than octolocums and still manages to have a very busy clinic through local relationships despite being on the no-refer list from many (it takes many years of egregious nonsense to get on this list but it eventually will happen). Patients have no clue they are not getting standard of care.
 
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Agree that this is multi factorial and probably driven more by referring.
But patients understand that if they see a different doctor every 1-2 weeks or every visit, they aren’t likely to get good care

I’ve tried to send a couple right sided breast patients back to closest facility and they looked at me like I was trying to kill them
 
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You also have to factor in the liability you are exposing yourself to by walking into some of these places and attaching your name to a trainwreck clinic. What's that worth? A hell of a lot more than $1500/day and dinners at Applebee's.
This is a huge factor for me to even consider locums again. I did it to fill some time before. My name is attached to at least two centers that make it hard for me to sleep.
 
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Agree that this is multi factorial and probably driven more by referring.
But patients understand that if they see a different doctor every 1-2 weeks or every visit, they aren’t likely to get good care

I’ve tried to send a couple right sided breast patients back to closest facility and they looked at me like I was trying to kill them
I offer patients to get RT in their local cities all the time. At least 3 separate places have quite poor reputations. Unclear if it's the Rad Onc care or just general poor hospital care. "OSH killed my mother!"
 
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I offer patients to get RT in their local cities all the time. At least 3 separate places have quite poor reputations. Unclear if it's the Rad Onc care or just general poor hospital care. "OSH killed my mother!"
Love how it’s always the hosp or the docs that are the murderers and not the life threatening disease

A somewhat similar thing is when med oncs worry about the cognitive toxicity of whole brain RT for someone with cancer growing in their brain
 
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They were fine until the surgery let air hit the tumor.
 
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Love how it’s always the hosp or the docs that are the murderers and not the life threatening disease

A somewhat similar thing is when med oncs worry about the cognitive toxicity of whole brain RT for someone with cancer growing in their brain

Can't change perception of a hospital being poorly run, unfortunately...

With RT you can SEE who the bad players (or perhaps a good player who just had a really ****ty day) are if you ever get their outside DICOMs for the re-treat/marginal recurrence cases...
 
my team gets me dicoms all the time no problem. Rarely has this request been denied
 
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Can't change perception of a hospital being poorly run, unfortunately...

With RT you can SEE who the bad players (or perhaps a good player who just had a really ****ty day) are if you ever get their outside DICOMs for the re-treat/marginal recurrence cases...
After practicing for awhile when I use to believe I could never ever do anything wrong, I found myself on the other end. It was a palliative case (at that time) in which the patient surprisingly lived much longer and had better results then anyone expected. Long story short, there was a recurrence/marginal miss and to this day I believe it was due to me being “cute” with my margins and dose. I attempted to salvage things by doing a more definitive course, larger volume and although there was more local control, after a period of time, there was another recurrence.

I ended up sending her to an academic center but can only guess what they told the patient about my plan. Haunts me to this day as the patient and their family members trusted and valued my opinion and what I was doing.
 
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After practicing for awhile when I use to believe I could never ever do anything wrong, I found myself on the other end. It was a palliative case (at that time) in which the patient surprisingly lived much longer and had better results then anyone expected. Long story short, there was a recurrence/marginal miss and to this day I believe it was due to me being “cute” with my margins and dose. I sent her to an academic center but can only guess what they told the patient about my plan. Haunts me to this day as the patient and their family members trusted and valued my opinion and treatment plan.
Palliation is tough sometimes . I've definitely become more aggressive dose and technique wise when possible in some of my palliative cases over the years as IO and better systemic therapies are keeping patients alive longer.

It would be nice to SBRT everyone but it doesn't always get approved by evilcore, Optum etc. I've definitely retreated my fair share after 30/10 a few years later as well
 
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I offer patients to get RT in their local cities all the time. At least 3 separate places have quite poor reputations. Unclear if it's the Rad Onc care or just general poor hospital care. "OSH killed my mother!"

I usually offer closer treatment to home but will wash my hands if it isn't our center. I make it quite clear with the patient that it is their responsibility to keep on top of OSH rad onc.

There have been so many disasters at these center. Patients forgotten, work up not completed, inaccurate treatment.
 
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After practicing for awhile when I use to believe I could never ever do anything wrong, I found myself on the other end. It was a palliative case (at that time) in which the patient surprisingly lived much longer and had better results then anyone expected. Long story short, there was a recurrence/marginal miss and to this day I believe it was due to me being “cute” with my margins and dose. I attempted to salvage things by doing a more definitive course, larger volume and although there was more local control, after a period of time, there was another recurrence.

I ended up sending her to an academic center but can only guess what they told the patient about my plan. Haunts me to this day as the patient and their family members trusted and valued my opinion and what I was doing.

The longer you practice the more this stuff happens.

You aren't perfect. We make judgements all the time balancing margins/toxicity concern with tumor control. You just hope you're right most of the time.
 
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my team gets me dicoms all the time no problem. Rarely has this request been denied
Agreed, realize my post was unclear - meaning if you are doing re-RT you will see whether the previous treatment was reasonable, questionable, or at times, just pretty garbage and it's not surprising to you that the patient has recurred/progressed.
 
After practicing for awhile when I use to believe I could never ever do anything wrong, I found myself on the other end. It was a palliative case (at that time) in which the patient surprisingly lived much longer and had better results then anyone expected. Long story short, there was a recurrence/marginal miss and to this day I believe it was due to me being “cute” with my margins and dose. I attempted to salvage things by doing a more definitive course, larger volume and although there was more local control, after a period of time, there was another recurrence.

I ended up sending her to an academic center but can only guess what they told the patient about my plan. Haunts me to this day as the patient and their family members trusted and valued my opinion and what I was doing.

Anyone who has never had a marginal recurrence that they feel bad about it is lying to themselves or are subjecting most of their patients to excessive toxicity. I've certainly had learning cases from the first 6-12 months I was an attending that I've bounced off colleagues and got a "well, in hindsight, maybe should've covered 1-2cm higher"... and I'm sure that number will only increase with time.

If you're looking at all of your local/marginal recurrence patients closely and seeing how you can do better, you're ahead of the game, IMO. A scary number of Rad Oncs (in academics or community) feel that they could do no wrong and have no process of analyzing their recurrences and thus their practice patterns.

It's definitely a ****ty situation to be in and makes me sad that I may not have delivered *optimal* treatment but I do a deep dive on any of my locoregional recurrences to see if I could have done anything differently.
 
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What I've learned in my time as a CNS attending is:

1. If I'm giving you SRS, radiology and I reserve the right to miss a little brain met here and there. This is part of why I'm getting MRIs every few months.

2. The EORTC glioblastoma margins have led me astray several times with marginal recurrences in FLAIR 2-3 cm from enhancing disease. I cover the FLAIR now when reasonable to do so.
 
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What I've learned in my time as a CNS attending is:

1. If I'm giving you SRS, radiology and I reserve the right to miss a little brain met here and there. This is part of why I'm getting MRIs every few months.

2. The EORTC glioblastoma margins have led me astray several times with marginal recurrences in FLAIR 2-3 cm from enhancing disease. I cover the FLAIR now when reasonable to do so.
Are you doing SRS at first sign of recurrence/progression on imaging (when not operable and far enough out from initial chemorads) in the absence of symptoms?
 
2. The EORTC glioblastoma margins have led me astray several times with marginal recurrences in FLAIR 2-3 cm from enhancing disease. I cover the FLAIR now when reasonable to do so.

Agree, but in defense of the guidelines, they allow for optional FLAIR into CTV


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What I've learned in my time as a CNS attending is:

1. If I'm giving you SRS, radiology and I reserve the right to miss a little brain met here and there. This is part of why I'm getting MRIs every few months.

2. The EORTC glioblastoma margins have led me astray several times with marginal recurrences in FLAIR 2-3 cm from enhancing disease. I cover the FLAIR now when reasonable to do so.
I guess you’ve considered how #2 could be some false comfort… I remember the old data about hemispherectomies and the GBM still coming back
 
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I just wanted to provide an update on a previous comment abt next generation io that will further marginalize xrt in lung and other cancers. Steve Rosenbergs work at nci w/tils has been amongst the most important in all of oncology. I have had several melanoma pts with amazing responses.

Unfortunately Melanoma TILs at the NCI take months to produce and just getting into the NCI is a long drawn out process during which many pts progress. Apparently, commercial super active tils - that can be made in several weeks will be available next year for melanoma and trials in lung cancer have already started with a til that has pdl knocked out.

combining tils with checkpoint inhibitors is going to be the next generation of trials that may provide the knockout punch for xrt in stage 3 nsclc
 
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I just wanted to provide an update on a previous comment abt next generation io that will further marginalize xrt in lung and other cancers. Steve Rosenbergs work at nci w/tils has been amongst the most important in all of oncology. I have had several melanoma pts with amazing responses.

Unfortunately Melanoma TILs at the NCI take months to produce and just getting into the NCI is a long drawn out process during which many pts progress. Apparently, commercial super active tils - that can be made in several weeks will be available next year for melanoma and trials in lung cancer have already started with a til that has pdl knocked out.

combining tils with checkpoint inhibitors is going to be the next generation of trials that may provide the knockout punch for xrt in stage 3 nsclc
Wouldn’t that be somethin’? I got a bridge to sell ya brotha!
 
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Wbrt or bust
Tried as well!
How cool. Did you see the illustrator's name... Dorcas Hager Padget? "This is interesting," I thought, because the reference is from the 1930s... and Dorcas is a female name! (The name is completely out of favor today because it sounds like "dorkus.") So, then I thought, "Being a female medical illustrator in the 1930s, this lady must've really been something."

And sure 'nuff, she was.
 
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This is wild, first time seeing images or hearing of something like this. Doesn’t surprise me that someone attempted it. Also goes with whatever paper someone posted a while back that shows modern day GBM deaths due to brainstem recurrences. These ****ers are grow everywhere. I wonder if anyone would try something like this combined with aggressive CRT for microscopic spread. I imagine it would be super toxic for not much/if any gain.
 
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This is wild, first time seeing images or hearing of something like this. Doesn’t surprise me that someone attempted it. Also goes with whatever paper someone posted a while back that shows modern day GBM deaths due to brainstem recurrences. These ****ers are grow everywhere. I wonder if anyone would try something like this combined with aggressive CRT for microscopic spread. I imagine it would be super toxic for not much/if any gain.
Was told about this as a medstudent. Whole brain to 45 also didn’t help.
 
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I think there Evan was a whole brain to 60 that was too toxic.

That would be the Walker study that everyone quotes as why we use 60 gy as the standard for GBM. Nevermind that it was whole brain, non-randomized, and used cobalt radiation prescribed to midplane so who knows what the actual tumor dose was. But for whatever reason 60 gy stuck.
 
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That would be the Walker study that everyone quotes as why we use 60 gy as the standard for GBM. Nevermind that it was whole brain, non-randomized, and used cobalt radiation prescribed to midplane so who knows what the actual tumor dose was. But for whatever reason 60 gy stuck.
I think many of our current treatments can be described with variations of these 3 sentences.
 
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This is wild, first time seeing images or hearing of something like this. Doesn’t surprise me that someone attempted it. Also goes with whatever paper someone posted a while back that shows modern day GBM deaths due to brainstem recurrences. These ****ers are grow everywhere. I wonder if anyone would try something like this combined with aggressive CRT for microscopic spread. I imagine it would be super toxic for not much/if any gain.
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Could also make a fine "how it started - how it's going" meme with that...
 
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