New resident needing insight

[anon_RT]

Sorry for the semi-long post, but I need to vent a little bit.

Started rad onc residency at a mid tier program this year, currently 2 months in. Just wanted to get some perspective from other residents/attendings regarding how long I should be spending on volumes/plans (on average), workflow in general, and identify ways to become more efficient? I find myself spending hours on plans contouring normals/tumor volumes because I'm reviewing atlases/guides and find myself being very meticulous with my contours that it seems to eat a lot of my time. When I see attendings reviewing contours, they usually modify them and they end up not as "clean" and instead just contouring the general area. So how does one get the feel for how "clean" something needs to be contoured versus just getting in the general area being good enough. I'm not looking for an exact answer, but really just need someone to hear my concerns lol

Also, by the time I finish clinic and notes every night (usually around 7PM), I have a very hard time finding motivation/time to read/study after spending 12 hours in clinic/tumor boards/lectures or even finishing contours for patients that were simulated 2-3 days ago. We usually see new patients/continued consults almost everyday (at least 4 days/week) so I'm writing notes/reviewing pts for the next day late into the evening. I was just wondering if other new residents arAe experiencing similar things and/or what their experiences are. I just can't see how this is sustainable for me in the long run. I feel like I'm not learning as efficiently as I could be with so much other work to be done.

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[RO2019]

PGY2 year is the toughest, especially the first 6 months. It's hard for sure, but it's not going to be sustainable, because it doesn't have to be, luckily. I promise it gets easier, and what you are experiencing is not uncommon.

 

[Radiator20]

First get good, then get fast. This is too early in residency to be worrying about the latter. PGY2 can be very challenging. For now, just focus on doing each case as well as possible. The rest will come later.

 

[thaddeus]

Once you're familiar with things, I'd say 5-10 min for a simple breast or palliative plan, less than 30 min for normals/targets for a locally advanced H&N case.

Really? I am a PP attending and treat H&N fairly regularly. But it usually takes me at least an hour (and sometimes more) to contour a locally advanced H&N. There are ways to cut corners and make things more efficient clinically, but I don't think contouring is one of them. This would be like a surgeon boasting that he was able to do a Whipple in 45 minutes. Better to take your time and do it right, especially as a resident.

 

[domestique]

Really? I am a PP attending and treat H&N fairly regularly. But it usually takes me at least an hour (and sometimes more) to contour a locally advanced H&N. . . .

Completely agree with this. You could call me PP but our practice is large enough that we are set up in quasi-academic fashion in the sense that we are fairly sub-specialized. The vast majority of my curative/definitive cases are HN. For locoregionally advanced cases, it takes me an average of 60 - 80 minutes.

Regarding the original question, take your time especially now. Keep your eyes and ears always open also as you can learn a lot during your ~12 hours in the building. Later on, you'll be able to read more.

 

[medgator]

H&n and pelvic imrt cases can take me well over 30 mins to contour. Esp when I get an NPC or something

 

[Joinedsolate]

Agree with what has been posted, and would also encourage you to embrace the struggle - it's how you learn. Kind of like when you're at the gym, you build the most muscle pushing through those last reps (for my fellow meatheads). I had a hell of a time figuring out what was small bowel and what wasn't, learning all the structures and LN levels for H&N, etc. Especially at first. But the more meticulous you are now the more it will pay off later. I do think you can hit a point of diminishing returns - for instance if you go back and forth 20 times on the same 2 slices of a contour because you can't quite make it out (I still do this all the time), might be time to just go with your gut and hand it over to your attending to review. I would say in general the most important thing is to not miss the tumor and pay particularly close attention to the immediate/adjacent OARs and worry less about the OARS the farther you get from the target.

As far as motivation to read, as others said that will come as you get more comfortable. But I would instead use every case as a reading/learning opportunity. Try to take the extra 20-30 minutes per case (easier said than done) to check out the basics on Uptodate, look at the NCCN guidelines, and check out a couple pertinent papers on radonc wiki. It's easier to be motivated to read when there's an actual patient in front of you who may benefit from it. This also goes for your contouring. When you have a case try to understand the patterns of failure, LN drainage, dose limiting OARs, etc. This will also help you contour since you'll learn why you're covering a particular target and not just copying it from an atlas. I think if you do that you're okay waiting until you're more efficient before setting aside time to formally study. Those are my two cents at least.

 

[RadOncDoc21]

It’s the attendings job to “tweak” your contours, even if they are “perfect.” Now if they call you dangerous or an idiot, that’s another issue.

 

[scarbrtj]

Expertise is obtained by journeying through the stages of unconscious incompetence, to conscious incompetence, to conscious competence, and finally to unconscious competence. You're at conscious incompetence; aka first year of any specialty residency. Perfectly normal.

When I see attendings reviewing contours, they usually modify them and they end up not as "clean" and instead just contouring the general area.

It may not really matter that much where your contours go, at least in some disease sites. Try not to worry.

This would be like a surgeon boasting that he was able to do a Whipple in 45 minutes.

"Time me, gentlemen."

Kind of like when you're at the gym, you build the most muscle pushing through those last reps

Embrace the suck!

 

[Lamount]

Med school prepares you very well for a medicine/surgery residency, not so much for rad onc. Rad onc uses a very specialized skill set and knowledge base that you are unlikely to encounter during med school. Additionally, training in our field is more like a fellowship/apprenticeship where we work one-on-one with your Attending, rather than working under senior residents and chief residents. This makes it hard for PGY-2s because there isn't always someone around of whom you are comfortable asking "stupid" (not really stupid) questions. As mentioned above, it gets better. As you get more experienced, you will learn what parts of the history are important and will be able to acurately predict the plan on most patients before you even see them... so writing notes will get much quicker. Similarly, you will contour the H&N, pelvis, breast, etc... so many times that you will not need to look at atlases. You will get a sense for what a CTV is supposed to look like that you won't have to obsess about every pixel. Putting in time during your early years of residency will pay off... so, in short, take as much time as you need.

 

[evilbooyaa]

I agree with everybody else. PGY-2 is rough for everybody and was by far the longest I spent at work as a rad-onc resident.

As long as you are spending a **** ton of time doing clinical things (seeing patients, doing notes, doing contours) and not BS secretarial work (calling for records, attempting to schedule follow-ups personally, etc.) I think it's fine. Sounds like you're at a busy place that will train you well clinically by the end of your time there, and based off your complaints, not too much secretarial work. Most residents have to do some secretarial work from time to time (e-mail scheduler to get something done faster than the normal, calling for records in an urgent case that your secretary/dosimetry don't have time to get or are getting push back from the facility), but based on your concerns, you're going through a pretty normal curve for PGY-2. Fully agree that first 6 months of PGY-2 are long hours learning a whole new skill set that you had essentially zero exposure to as a medical student (even if you were in Rad Onc rotations).

Work on being as perfect as you can, but don't agonize over slice by slice contours, IMO. It also depends on your attendings - if you have attendings that are OCD and are going to change every slice by 0.5mm, then you don't have to spend as much time trying to line yours up to theirs. However, if your attending is going to glance at them and say "looks good" then you really need to be on your A-game because what you draw is what the patient is going to get. Fortunately the latter is not as common as the former, but just something to consider as you go forward.

 

[kimplera]

also encourage you to contour every other or every third slice and either save a separate "interpolated" contour or just review the interval contours with your attending. can do every contour if there are significant slice=to-slice changes. i have my residents do this (and do it myself when i contour de novo).

 

[Haybrant]

The secret is that rad onc isn’t that hard, same thing with the rest of Medicine. It’s just that getting to the point where it isn’t hard may be among the most difficult fields and so pgy-2 year is the hardest. You need to embrace that, not try to cover it up. I was worried about people finding out I didn’t understand things that I spent a lot of energy trying to cover it up. Don’t do that, it slows down your growth. Trajectory is the most important thing

 

[Aphtalyfe]

PGY2 year is the toughest, especially the first 6 months. It's hard for sure, but it's not going to be sustainable, because it doesn't have to be, luckily. I promise it gets easier, and what you are experiencing is not uncommon.

I agree.

 

[AmericanoWithCream]

Unfortunately, the first year or two, you're rotating from one brand new service to another, and there's a steep learning curve. It'll get easier, eventually. But you've got to lay the foundation now, just like you would if you were an intern again :/

About your contouring --- I don't know if you said which software you have, but learn how to use boolean operations if Eclipse and the same function exists in Pinnacle. I can't remember if it does in Brainlab too (but those volumes are usually smaller, so not as big of a deal). Are you contouring individual bowel loops rather than a bowel bag? Also may be good to clarify if dosimetry does certain normals (at my institution, they did kidneys and lungs, but not liver for example...). You could also ask if the department is willing to pay (in the long run) for licenses for residents to contour at home on iPads. I know there are certain programs (MCW, had a friend there) that's had this and residents go home and contour (normals at least) while like riding a stationary bike or watching tv. Have a good relationship with your dosimetrists too - if they wait 3 days to pull in the scans, you'll get behind. Try to be as respectful of their time, but ask them to pull things in asap. Don't wait for them to do fusions if you can get a jump on the normals too. Sometimes I found it easier to come in an hour early before the day started to contour rather than staying late every single night.

About your notes - do you have remote access? Some people don't like to chart from home, but it was better for my overall QOL to sit next to my spouse and do the notes and look up for next day rather than stay at work in the basement. I wrote a lot, the notes were detailed, and it 100% ate into my life. But I wouldn't change it. Every time I needed to find something, it was there and I didn't have to root around looking for path or imaging results bc I had confidence in my notes. I'd suggest using Dragon ASAP. I didn't use it in residency because I thought I typed faster. Now that I'm in practice -- turns out Dragon is way faster!!! The other thing is, I used to spend a certain # hours on the weekend preparing for the next few days in clinic from home, particularly if I knew one day or another would suck and be a long day.. at least I didn't have to cap it off by spending 2 more hours preparing 4 consults for the next day. Another idea is to make Impression/Assessment templates (ie. standard SBRT lung, standard hypofrac early stage breast etc) and put them into your notes so you're not reinventing the wheel every single time. Take the time now to do it (with literature quoted, which is what I did) and update if you need to. But this saves a boat load of time with each consult note in my opinion.

Overall, I did feel burned out by PGY 3/4 but then you start getting more and more elective time, and you feel like you know what's going on.. then you'll replace clinical work anxiety with rad bio/physics anxiety and then with job search anxiety... so pace yourself! It will all be okay in the end, shockingly.