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Rad-Onc plus Heme-Onc

RexKD

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    Rand-Onc + Heme-Onc, would it be advantageous to the patient for his doctor to be trained in both?

    Would it be advantageous to the doctor to be trained in both?
     

    Gfunk6

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      Yes, to both questions. Similarly, if you are specialized in CNS tumors then it would be advantageous to be board certified in Neruology, Radiology, Neuro-Radiology, Neurosurgery, and Radiation Oncology.

      But sadly, we only have one life to live. Well . . . actually two if you count one for your dreams. ;)
       

      stephew

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        RexKD said:
        Rand-Onc + Heme-Onc, would it be advantageous to the patient for his doctor to be trained in both?

        Would it be advantageous to the doctor to be trained in both?
        you know what? no it wouldnt. if you want the knowledge, you'll learn it anyway. but as a radonc doc you'll not be maintaining an inpt service and you wont really want the responsibilities of one; you can't effectively be both in a practical sence. the set up to admin care on both sides is so different you have to be one or the other.
         
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        doc05

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          Ursus Martimus said:
          Who says stuff like that. Of course it would be of benefit. Last I checked you learn more in a heme/onc pathway than just inpatient management. The real question becomes: who wants to willingfully go through all that training?

          nonsense. no one person can do everything -- medical knowledge and therapies are far too specialized for that. While you theoretically could learn both, it's useless as noone practices both. If you want to do best for your patients, focus on one specialty and know who you to call when you're going to consult.
           

          RexKD

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            stephew said:
            Ursus Martimus said:
            Who says stuff like that. Of course it would be of benefit. [\QUOTE]
            i do after being in the field for 5 years.

            In that case, could you give us a summary of your work? Do heme-oncs refer patients to you for procedures? After the procedure you send them back. So basically you are a surgeon with a blade?
             

            RadOncFever

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              RexKD said:
              Rand-Onc + Heme-Onc, would it be advantageous to the patient for his doctor to be trained in both?

              Would it be advantageous to the doctor to be trained in both?

              I have to agree with Steph. The real question is: Are you more effective as a doctor to be trained in both? I really don't think so. I don't think most who are double boarded thought in med school that in order for them to be better oncologists, they need to be trained in both fields. I think they just switched for whatever reason (maybe seeing the light as some alluded to in another thread). You ask any double boarded radiation oncologist what they are doing now. Majority of them are not giving chemo to patients. They are full time radiation oncologist. To be 1/2 day as radiation oncologist and 1/2 day as medical oncologist plus managing an inpatient service would probably be crazy for most people. The knowledge about the type of chemo and the nuance about how to deliver chemotherapy might be good to have, but most of the important information you need to know to deliver quality care to your patients as a radiation oncologist is in the text book and from experience working with fellow medical oncologists and tumor board. I don't need to be physically giving 5FU CI or Capecitabine PO to know that it is standard of care when combined with radiation in rectal/anal cancers. I don't need 3 years of IM/3 years Hemonc fellowship to know that.
               

              Ursus Martimus

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                I don't remember advocating someone being both at the same time or, for that matter, pursuing both in an attempt to be a better provider. I do however disagree with Steph. I think you would find Ted Lawrence disagree with you too, Steph. And how about Lewis Constance or Jay Douglas, both of whom I have spoken at length with regarding the utility of their peds heme onc training prior to radonc. Next thing you will probably tell me is that having a PhD in physics is not helpful either because their are medical physicist. And what the heck, how about lets forget dosimetry as well. And how about there being no benefit to being a radiation therapist before becoming a RadOnc physician - I mean people do that job too. I can't believe you guys think there is no benefit. All things being equal, if you, yourself, had a choice between being treated by some one with both training and only RadOnc, you would honestly see no difference?
                 

                stephew

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                  I can cope with their disagreeing with me. And I dont think its bad, I just think its not of great practical benefit. If you go into a field you learn all about the chemo and medical management relative to that area anyway. I dont see the great advantage to a full licensure and cert in peds or IM or whatever. Full med onc or peds or obsgyn training is just not going to give you so much that you wont get just doing your job appropriately and learning the things you should about it. And the things that truely fall under a pediatric or hemeonc umbrella are things that you wouldnt be able to really maintain in a clinic practice anyway. What Im saying is you likely wont be able to practice both things fully, you will be a radonc or medonc first and foremost, so the stuff you learn from the other field will be time spent and not used, and the things that would translate into your practice are things we learn anyway doing out specialities.

                  AS for your PhD in physics comment; a degree in physics or being a dosimetrist is much more useful but Id suggest probably a MS would be sufficient and a PhD would add much more time with little more benefit. Though I know less about the specifics of that training than MD training and i wouldnt stick to my guns on that point.Now why do I think this would be more "useful"? Because you'd bring the skills into the clinic with more practical use that you yourself would take advantage of more than someone who got fully trained in peds or medonc. The pure peds/medonc stuff wouldn't be dealt with in the clinic. In my case, I do CNS. I dont have a degree in neuroanatomy. Would it help? The knoweldge yes but i get that just doing my job appropriately. If someone needs surgery, even if i have the N.S degree im not going to do it- i cant be practicing NS and Radonc fully. The extent to which they overlap I get on the job and training myself. In fac tthere was a dual degreed guy at hopkins in Ns and radonc. There was NO WAY he was going to be operating anymore. two reasons; you can fully do both- to have a functioning practise you committ to one. Also, his NS skills were rusty.

                  I suggest after a few years in the field you see if you still disagree with me.
                  Ill leave you with this; another dual degreed person i know was famous for really pissing off medoncs. this person would perscribe things that IM docs do a lot. And this got patients into trouble. There is a reason for speciality- so you can focus on one thing and do it well. To the extent it overlaps with another field you integrate that info as part of being a decent competant doctor. the rest isn't used. Dont let the ego of being dual degreed suck you into spending that sort of time and energy into something that you dont need.

                  And two answer your question: I HONESTLY wouldnt be more inclined to see someone dual degreed. I know of individuals in fact i'd stay away from with dual degrees. the duel degree just wouldnt enter into it.

                  Sorry but you're going to have to accept that i disagree with you on this one.
                   

                  Ursus Martimus

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                    stephew said:
                    Sorry but you're going to have to accept that i disagree with you on this one.

                    I don't think there is a diagreement once you realize I never advocated someone functioning both capacities, rather bringing such experience to the table. I still am interested, especially since you mentioned an example you know of to the last question above, which you neglected answering. All things being equal, would you not prefer the guy who was trained as a nuerosurgeon and radiaton oncologist, functioning as ONLY the Radiation oncologist, over the Radiation Oncologist?

                    I would be surprised since your logic in another thread was to laud the unique experiences of FMG's making them more attractive candidates/clinicians in the field.
                     
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                    stephew

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                      no i wouldnt personally favor someone just because they were dual trained. If every single quality were equal, if they were twins in person and in all other training and accomplishment with the only difference in this clone being that one had two degrees and the other didnt, and they both had the same time slot open for me? Sure I guess I would choose the guy with both degrees. But honestly, in any real circumstance this doesn't AT ALL make me favor one person. It really doesnt.

                      I dont know where I was going on about the wonders of IMGs; I frankly dont think that being an IMG (which I am) brings anything at all special to the table either. In an given individual could it have made them a better person? Sure; just like any experience can. But (and maybe you'll catch me out on this) i dont think I really would have advocated seeing an IMG over a US trained doctor. That would be almost counter-intuitive and against conventional wisdom (bias). But lets say for the sake of arguement I was making some comment about IMGs that implied given a choice of equals, you might pick the img. I think there is still a difference in that distinction versus the benefits of being dual trained. The view would be that you have more to offer if dual trained. Academically speaking probably true more often than not. But not practically speaking. That is what you will do and what you will know and apply to what you do as a radonc doc probably will be mimimal over what any radonc doc will do and know if a specialist in that area (be in neuro, peds what have you). A for instance: I go to brain tumor board every week. I am more often right than wrong regarding which patients are resectable, and regarding potential deficit risks from therapy. Why? Because to practice what i do approrpriately, I know neuroanatomy and function pretty well. I never trained as a neurosurgeon however but I can still know this stuff. now can I *do* the surgery? Lord no. BUT as a radiation oncologist even if I were dual degreed I wouldnt be doing surgery anyway. It would be extraordinarily difficult and even more unlikely that I would be able to carry out both practices. So one comes down on one side of the fence: one then is a radonc doc but who trained in both fields. Youre still left at the end of the day using the same info you use as only a radonc doc. Would I "know more" having done neurosurgery? yes. But things not generally useful to my radonc practice. Now, this is a good example because of the complex realities; I *do* consult with neurosurgeons a lot particuarly with radiosurgery. If i were dual trained I wouldnt have to. (as was the case with the dual trained guy i mentioned before) But its a rare event that i'm learning something I just didnt know when I talk with them. Rarely if ever would you change what your going to do from a radonc perspective because of info that only a neurosurgeon could give you (assuming reasonable competancy). But they can actually do the surgery where I can't. I do get opinions from them as i sometimes do from my radonc colleages.

                      I will say this; youre not alone in your personal prefernce. many of the patients who saw this dual degreed radonc/neurosurgeon just loved that fact. But I will tell you this I dont think this made him better technically at being a radiation oncologist over other CNS specialsts I know (as impressive as all that time in education was.) It did give him a credibility factor when you had a guy with both degrees telling you to get RT over surgery for a lesion that could be treated either way.
                       

                      pretzel

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                        Let's say you have a "typical" brain cancer and don't have any other accompanying issues -- then a rad onc might make the same treatment decision as a rad onc who was also trained in neurosurgery. Let's say all goes as planned and you become well. The additional neurosurgery training did not make any difference in that particular case.

                        But let's say you have a brain tumor with unusual anatomy or pathology, your clinical course is unusual, you have multiple other morbidity issues, and so your treatment is based on individual clinical judgment -- this is bizarre for most physicians, but not so bizarre for referral to a tertiary care center.

                        If it were me with the tumor, I would specifically look for advice from a hem-onc, a neurosurgeon, and a rad onc -- all of them. And I would specifically seek out a physician who had experience in any combination of these fields -- this would be even better to me than individual physicians discussing their ideas in tumor board.

                        I say this, because it is somewhat analogous to the 3 blind men who describe an elephant, and one views the elephant like a snake because he concentrates on the trunk, and another views the elephant like a tree because he concentrates on a leg, etc. They are all correct, but they don't understand each other's views as well, because each person only brings his own specialized experience to the table. Not to stretch the analogy to death, but if one person knew the trunk and leg both very well, he would likely have a clearer picture of the whole animal than either person alone.

                        Many of you likely know this story, but there is an interesting anecdote of how Judah Folkman started thinking that angiogenesis might be crucial to cancer growth and survival.

                        Being a surgeon (not a cancer specialist), Folkman stated that any surgeon knows that many tumors bleed like mad in the OR when excised, and that the bleeding is unusually difficult to stop. He said the angiogenesis concept seems obvious now, but years ago, he could never convince pathologists that there might be a reason for all of this bleeding. He said pathologists could never be convinced because they only saw the tissue and fixed vessels, not the bleeding in the OR. Some pathologists even politely informed him that all tissue bleeds when it is cut.

                        Folkman said that the primary clue behind his hypothesis came because he had an intimate understanding of how difficult it was to stop the bleeding from excised tumors, in comparison to normal tissue that was cut. He said that unless he had seen the excessive bleeding with his own eyes and understood that it was consistent and unusual, he would never have had a true understanding that angiogenesis was important to contemplate. So despite much antagonism to his crazy angiogenesis idea from cancer specialists who had much more experience in treating cancer than himself, he stuck to his guns.

                        My point is that a specialty is often much enhanced by the addition of what is often thought of as irrelevant basic science or clinical knowledge in a completely different field.

                        The difficulty, of course, is the time to train in all of these fields. Even if I had a "typical" brain tumor, I would seek out the unusual rad onc who also has experience in hem-onc, neurosurgery, or even in any other field typically thought of as "irrelevant" to rad onc. If I couldn't find one, then I would go to the second best choice and go to an only hem-onc or only neurosurgery physician for additional advice. Yes, even for a very typical brain tumor that manifests typically. You just never know.

                        I do not think it is the right attitude, that a rad onc thinks of his field as the only field he really needs to know well, and that hem-onc or neurosurgery experience would add so little to his patient care as to not make a difference. I guess one could argue that after all, a rad onc only does rad onc tasks on the vast majority of days, so "irrelevant" knowledge he has never used doesn't matter, right?

                        An anesthesiologist has "irrelevant" general medicine knowledge that he almost never uses on a daily basis. Nurse anesthetists often have the SAME anesthesia-specific clinical knowledge as an anesthesiologist.

                        Would you consider a nurse anesthetist commensurate to an anesthesiologist because they can perform the exact same clinical tasks the exact same way? What about a midwife vs. an ob-gyn, or an optometrist vs. an optho? The exact same field-specific knowledge in the exact same cases can sometimes translate into very different clinical decisions.

                        One might argue that rad oncs are very knowledgable in rad onc, so it isn't the same thing to compare technicians, but it is. What about the unusual cases that even puzzle superb rad oncs? For many clinical scenarios, there is no protocol-based, evidence-based treatment, so treatment is just based on clinical judgment.

                        Where does that judgment come from? If rad onc-specific experience is the same between 2 rad oncs, then a difference in judgment for a given patient might come from additional training in any other field of medicine, no matter how "irrelevant" it may seem. If anesthesia-specific experience is the same between an anesthesiologist and a nurse anesthetist, then a difference in judgment might come from "irrelevant" general medicine knowledge about say, a patient's rare renal disease.

                        As a nonsequitur, if one is practicing in the States, I don't understand why a U.S. physician would specifically choose an IMG over a U.S. med grad as his doc. For the extra clinical judgment or experience? How does being an IMG give one better clinical judgment or experience for U.S. disease than being a U.S. med grad?

                        On the contrary, an IMG has to be aware of how specifically Americans manifest a particular disease. The same disease does not manifest the same way or have similar prevalence in all countries, between different races and cultures. The same symptoms bring up very different diff dx in different countries. If I were practicing in South America, I would feel at a disadvantage to counterparts who trained in South America all along, because I would be wary that I might be thinking CAD and angina while they might be thinking myocarditis. I might ask about pharyngitis rather than skin infections for post-strep GN. It's not a big deal, but I think it is not the right attitude to not realize the differences.

                        If your training was pretty much the same as in the States, then you might as well have trained in the States. If your training was in a 3rd world country, then the additional experience might give better clinical judgment in loa loa infection or in physical exam assessment as an internist, but I don't see the advantage as a rad onc.

                        Anyway, the main point is that even the most experienced physicians cannot predict when a surprise case will come, especially when it looks so simple or "typical", or there would be no such thing as M&M conference. It depends on if one plays by statistics, or plays by absolute numbers -- is "overall" your goal, or does every individual matter to you? The problem is that one can never predict when that "unneeded" additional knowledge could not only be of use, but could be crucial.

                        I am not saying that rad oncs who don't have additional training in another field are incompetent in rad onc. I am saying, however, that I would always choose the rad onc with additional training, even if the extra training isn't used on a daily basis in rad onc.

                        Steph, academic attending physicians who teach future generations should be the last people to perpetuate the idea that additional knowledge that is rarely used would not make any difference for clinical care delivery in his field. If field-specific experience is the same between 2 people, a broader knowledge base, even if it may seem irrelevant or unneeded on a daily basis, is always preferable. I thought it was only non-physicians that physicians had to convince of this.
                         

                        stephew

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                          I think your post is a good example of the difference in inductive and deductive reasoning; between something that theoretically sounds good and trying to assume that things work that way in reality, versus seeing what is really important in the real world and making a theory that fits the real world. Politics have been hampered by this (See "communism").

                          In fact this is very much the argument of the layman: "well since Dr X is also a hemeonc doc it must make him a better radonc doc.". This is why this sort of stuff is great in advertising. But it doesnt hold up. (And in a couple of real life situations, boy have I seen it fall apart). if you really read what I wrote you'll I didn't say the knowledge of chemo issues, etc, whatever isnt important. I said it is inherently important. What I said is one doesnt need dual degrees to know these things as it applies to your field.
                          How you managed to make the leap to my even coming close to suggesting that additional knowedlge isn't relevant or good or important is beyond me. But if I returned the favor of offering advice, mine to a future attending would be that you don't try to politicize the statements of your coleages, particularly with regard to patient care/medicine issues. Disagree if you will. That's healthy enough. But don't try to finesse what I've said. (though by your own argument, perhaps you bring more to your field by being the consumate politician! :) )
                           

                          Ursus Martimus

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                            stephew said:
                            "well since Dr X is also a hemeonc doc it must make him a better radonc doc."

                            Well I agree with this: that being TRAINED as a HemeOnc Doc doesn't make him/her a better RADONC DOC. The crux of the argument is that I do believe that someone trained in both does indeed make a better doctor overall. By the way Steph, that doesn't make you any less a doctor, despite the chip that may remain on your shoulder after all these years.
                             

                            pretzel

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                              There is a reason that when it comes to their own cancer care, even if it is "standard", prominent politicians seek out the specialized tertiary care center with rad onc, rather than just going to the nearest local hospital with rad onc. The tertiary care centers are where the super-specialized Ph.D. geeks or those with multiple residencies or the super-new technologies are.

                              The rad onc physicians at tertiary care centers aren't any better at quotidian practice than those at the local hospital if they have the same technology and nothing goes wrong. Politicians just seek out these centers just in case they happen to be that rare case where things turn complicated. It might just be that multiply-boarded freak who comes up with a solution. Either that, or they like getting on a plane to see their doctor. :)
                               

                              stephew

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                                Ursus Martimus said:
                                Well I agree with this: that being TRAINED as a HemeOnc Doc doesn't make him/her a better RADONC DOC. The crux of the argument is that I do believe that someone trained in both does indeed make a better doctor overall. By the way Steph, that doesn't make you any less a doctor, despite the chip that may remain on your shoulder after all these years.

                                meow.

                                Interesting point Pretzel; the second time today ive read the word quotidian. Just a fun fact.

                                Actually when i was talking about politicians, that wasn't what I meant but you probably know that. As for why they and all the other beautiful people come to teritary centers, I think its because they feel the "best" care is there. I dont think they look for the dual degreed. But even if they did, as I said, what the lay person is impressed with isn't often what's important.

                                Anyway I asked a few people their opinion on this topic at work today. Turns out one colleage was also boarded in IM (which I hadn't known). There was a lot of shoulder shrugging. No one firmly felt there was any real benefit over and above what an expert in their area would have. My IM guy did say there was maybe a "nonsignificant" benefit. Interestingly , and I can see this point, he felt maybe surgical fields brought more to bear than IM which -ihis own words- added "the least". Anyway that's his view. What he expressed well, in fact better than i had, was this; that much of the training in other fields isn't onc related. Knowledge that would be concentric to your practice in your own field you'll learn if youre competant anyway so the extra residency is a bit much and not necessary. i agree. But to sum up, I do not feel that the added information that someone who went through for two residencies makes a doc more attractive in and of itself. I very fully believe other qualities- and dedication to study of your field and para-medical areas-are much more important. If I change my mind I'll let you know.
                                 

                                doc05

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                                  pretzel said:
                                  There is a reason that when it comes to their own cancer care, even if it is "standard", prominent politicians seek out the specialized tertiary care center with rad onc, rather than just going to the nearest local hospital with rad onc. The tertiary care centers are where the super-specialized Ph.D. geeks or those with multiple residencies or the super-new technologies are.

                                  The rad onc physicians at tertiary care centers aren't any better at quotidian practice than those at the local hospital if they have the same technology and nothing goes wrong. Politicians just seek out these centers just in case they happen to be that rare case where things turn complicated. It might just be that multiply-boarded freak who comes up with a solution. Either that, or they like getting on a plane to see their doctor. :)

                                  no, politicians seek out these centers because they are narcissists and thus "must" be treated by the "best."
                                   

                                  CameronFrye

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                                    Aren't heme-onc and rad-onc two fields that you must continously stay on top of? If you are boarded in heme-onc and then do a rad-onc residency, it seems that most of the heme-onc details would become outdated. I assume most rad-onc residents get plenty of exposure to the general principles of heme-onc, so I don't see how the double board would be worth it. Who would you want directing your cancer therapy? Option A: up to date expert in heme-onc plus an up to date expert in rad-onc OR Option B: one doctor with rusty heme-onc knowledge and up to date on rad onc knowledge.
                                     

                                    carrigallen

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                                      imo, many of the double-boarded internists just entered the field after deciding they didn't like medicine. Also, I think that having too many credentials is sometimes a red flag that you are a dilettante.
                                       

                                      Ursus Martimus

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                                        stephew said:
                                        meow.
                                        Anyway I asked a few people their opinion on this topic at work today. Turns out one colleage was also boarded in IM (which I hadn't known). There was a lot of shoulder shrugging. No one firmly felt there was any real benefit over and above what an expert in their area would have. My IM guy did say there was maybe a "nonsignificant" benefit.

                                        Let's put some names on record. I certainly did for my case. If your IM guy really feels this to be of "nonsignificant benefit", surely there will be no qualms with holding such opinion or admitting to such.
                                         

                                        IndyXRT

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                                          radiaterMike said:
                                          not necessarily true .. MSKCC and Indiana have inpatient services, as well as hospital based practces in Canada and UK (and elsewhere Im sure).

                                          This is not necessarily a good thing. Trust me: Rad Onc + managing inpatients = bad idea. And there is no "service" in the traditional sense (at least not here, I can't speak for MSKCC). It is just the radiation oncology resident, rounding in the morning and evening and taking calls from the floor on top of a busy clinic schedule.

                                          My two cents: it is good to be knowledgeable. One does not need to formally train in a field to gain knowledge in that area. Someone with more degrees may or may not have more knowledge (at least, useful knowledge) in a particular situation. I think having multiple degrees is fine, but I do not believe it is essential to being a good radiation oncologist.
                                           

                                          RadOncFever

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                                            If there is any advantage to be gained from having multiple board certification is the real-life experience gained by working in a particular field. To make you a better radiation oncologist, this maybe true for some fields. I could see how if you are both a neurosurgeon in a past life and a radiation oncologist now you may know the relevant neuroanatomy better for planning purposes (and that is why neurosurgeons are still recruited to do planning at many center). I don't see how hem/onc would benefit though. You may know from real life experience the management of postchemo patients better than radonc docs, but as far as giving the chemo itself or know what to prescribe there may not be as big an advantage gained from the time served in a hem/onc fellowship. And generally radoncs wouldn't prescribe chemo in the first place. You do it in collaboration with hem/oncs.
                                             

                                            stephew

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                                              Ursus Martimus said:
                                              Let's put some names on record. I certainly did for my case. If your IM guy really feels this to be of "nonsignificant benefit", surely there will be no qualms with holding such opinion or admitting to such.

                                              indy and radonc fever make my blathering point very succintly. (though with the neuroanatomy point Id just add that I dont need to be a neurosurgeon to learn that)

                                              as for your suggestion martimus; no indeed I will not. If my colleague chooses to post that's their perrogative. But I am not going to formally speak for anyone else by involuntarily dragging their name into a debate (even if a friendly one) if they choose not to do so on their own. Indeed the hostility here argues my stance. Frankly I am perfectly comfortable if you dont agree with me. I dont really know why youre not.
                                               
                                              OK - I finally had to weigh in on this. First of all this thread got kind of snippy, I'm unused to seeing this in the Rad Onc forum - I thought we were more civilized than, for example, the surgeons.

                                              That said, I find it really interesting that we're all debating about whether it would be more advantageous for a rad onc to master yet another area of oncology - I bet there are no medical oncologists out there thinking, "Gee, it would be really great if I was double trained in med onc and/or surgery/rad onc." The surgeons aren't kicking themselves for not also going through IM residencies so they can manage their diabetic patients better. They know the medicine they need to know to take care of their diabetic patients postop and that's it. And sometimes they need to call med con for someone they can't manage. You know what - FINE! that's why we have med consult, and med onc, and any other specialty.

                                              I'm not criticizing the drive to want to know everything about everything. I think that desire is what makes radiation oncologists such a unique brand of doctor - those who want to apply as much knowledge as possible to take the optimal care of cancer patients. However, rather than having radiation oncologists who also are double trained in medical oncology (who will be rare birds in any instance) I think that patients would be better served if the average medical oncologist or surgeon knew more about rad onc and had more of a desire to participate in multidisciplinary care. Many of these practitioners don't know much about rad onc and when radiation treatments should be applied. So often people are undertreated (esophageal cancer is a great example here) when if any given member of an oncology treatment team knew more about what the other facets were doing, outcomes could be so much better...
                                               

                                              powermd

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                                                Einstein once said "Never argue with an idiot, people might have difficulty telling you apart."

                                                Okay, maybe it wasn't Einstein.

                                                This whole thread is utterly absurd. It will never become the standard of care to be treated by someone double-boarded in rad-onc and med-onc for very practical and, in previous posts, well-articulated reasons. The few who feel they are inadequately trained without being double-boarded have personality disorders and probably have no buisness treating real live people, much less cancer patients.
                                                 
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