Rad Onc Twitter

[RickyScott]

Most of low end programs will just comply with any mandates anyway.

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[CptCrunch]

Cutting spots, closing entire programs? I’m not holding my breath.
Upenn and Mount Sinai will continue to fill for a few years.
Upenn because it’s a good program and MS because it’s a 4yr job with benefits in NYC.
Those 2 docs have no real pressure for now

Under Dr. Rosenzweig's leadership, Mount Sinai has grown from 6 total residents ten years ago to 12 currently (although only 10 are permanent positions per ACGME).

 

[seper]

Under Dr. Rosenzweig's leadership, Mount Sinai has grown from 6 total residents ten years ago to 12 currently (although only 10 are permanent positions per ACGME).

There you go. Thanks for info. Again, Radonc resident training is just a business. A small a somewhat silly one, but still a business

 

[communitydoc13]

Radonc resident training is just a business.

Yep. Their perverse incentive is to train more radoncs. Ours is to treat more fractions. We should both choose wisely.

 

[fiji128]

I'm guessing at the end of the day it will just be just tiny changes at the margins like going from 15 brachy implants (or whatever it is) to like 18. The last RRC changes were only implemented not even a year ago with no substantive new requirements made. At least the current requirements seem to be sufficient enough to prevent any new programs from opening over the last couple of years.

 

[RickyScott]

Under Dr. Rosenzweig's leadership, Mount Sinai has grown from 6 total residents ten years ago to 12 currently (although only 10 are permanent positions per ACGME).

I think UPenn has also grown into 4-5 residents per year like Stanford, Emory and others.

 

[seper]

Yep. Their perverse incentive is to train more radoncs. Ours is to treat more fractions. We should both choose wisely.

Good news on the fractionation front: the government is on the case. For resident trainers, market will have to slowly teach authorities the right way.

 

[elementaryschooleconomics]

Me, internally: "What in the world is this"

*follows link*

"Ah, physics. Ok! Wait..."

If we're writing opinions based on papers from 2004, wait till I tell you guys about this incredible device Apple is working on called the "iPhone", although in 2004, the iPhone was still 3 years away from being announced.

 

[seper]

There is currently a shortage of medical physicists in US. Our network employs many, and is having trouble to recruit. No trouble hiring mid-career attendings

 

[TheWallnerus]

View attachment 335344

Me, internally: "What in the world is this"

*follows link*

View attachment 335345

"Ah, physics. Ok! Wait..."

View attachment 335346

If we're writing opinions based on papers from 2004, wait till I tell you guys about this incredible device Apple is working on called the "iPhone", although in 2004, the iPhone was still 3 years away from being announced.

If we're writing opinions based on analyses from 2011, wait till I tell you guys about these incredible calculations Ben Smith was working on called the "Rad Onc Undersupply", although in 2011, math seemed hard; and later all the calculations and analyses seemed necessary to have been erased from the face of the Earth in order to save some semblance of face.

There is currently a shortage of medical physicists in US

'Tis comforting, to me anyways, physicists' grasp of math.

 

[RickyScott]

There is currently a shortage of medical physicists in US. Our network employs many, and is having trouble to recruit. No trouble hiring mid-career attendings

Follows supply and demand. About 10-15 years ago, board certification started requiring graduation from a certified medical physics masters/phd and a certified physics residency. Previosuly, In early 2000s, medical physics was open to any masters/phd physicist (from optics to solid state to nuclear) with 1-2 years of on the job training, who could then sit for board certification. Several years ago Dosimetry increased training requirements (certified masters) as well, which is why a dosimetrist in the bay area now earns more than a physician/instructor at Stanford.

 

[metallica81788]

What would be easier and/or have better job outlook - us retraining as radiologists or medical physicists?

The breadlines want to know

 

[StIGMA]

The physics job market (at least for new grads) has many similar problems to radiation oncology. I've seen 2-3 look for jobs each year for the past several years and they all have the same gripes we have.

Just because recruiting is difficult doesn't mean there's an undersupply. It means you are not offering a competitive job package. Maybe consider offering better recruitment incentives?

 

[elementaryschooleconomics]

What would be easier and/or have better job outlook - us retraining as radiologists or medical physicists?

The breadlines want to know

I personally will choose Dosimetry.

Still get to draw circles, MS-Paint style, don't have to get those CVS automatic refill request faxes for Zofran. Win-win!

 

[StIGMA]

I personally will choose Dosimetry.

Still get to draw circles, MS-Paint style, don't have to get those CVS automatic refill request faxes for Zofran. Win-win!

And work 9-3

 

[seper]

The physics job market (at least for new grads) has many similar problems to radiation oncology. I've seen 2-3 look for jobs each year for the past several years and they all have the same gripes we have.

Just because recruiting is difficult doesn't mean there's an undersupply. It means you are not offering a competitive job package. Maybe consider offering better recruitment incentives?

Perhaps you're right. However, physicists have better prospects for job mobility than physicians due to: no noncompete, non-cllinical opportunities, better acceptance of them always switching jobs

 

[Neuronix]

Job market is far better for medical physics than for rad onc. I'm not saying it has always been that way or always will be that way. Medical physics has a lot of options and mobility within this state that is very difficult to get a job in for MDs.

Pay is better for MD of course, though training pathway is longer and educational debt is higher. Hours worked I would guess on average is 10+ more per week for MD in my experience as well. Stress and liability less for medical physicist as well (guess who gets sued when they screw up?).

 

[drewdog1973]

Job market is far better for medical physics than for rad onc. I'm not saying it has always been that way or always will be that way. Medical physics has a lot of options and mobility within this state that is very difficult to get a job in for MDs.

Pay is better for MD of course, though training pathway is longer and educational debt is higher. Hours worked I would guess on average is 10+ more per week for MD in my experience as well. Stress and liability less for medical physicist as well (guess who gets sued when they screw up?).

No way. Physicists may work more, just depends on work setting

 

[Neuronix]

No way. Physicists may work more, just depends on work setting

That has not been the case where I trained or work now. But hey that's anecdote for you.

 

[Mandelin Rain]

And work 9-3

10-2. From home.

 

[TheWallnerus]

I'd like to have that ~$50K "commission your new linac in a weekend" cheddar that physicists get. I know a medical physicist that runs his own regional shop and makes ~$500K/year (a few med phys's work for him; he handles the largest two centers). He isn't working more than MDs and sure as hell isn't doing constant, inane EMR fluffing. Grass is greener yada yada, I know!

 

[Gfunk6]

In my read of the RO job market, opportunities for radiation therapists are by far the greatest. I think there is a dearth of training programs and perhaps an over-concentration of RTTs on the East Coast with a relative paucity in the Midwest and West. Next are Radiation Physicists as Neuronix and others have pointed out above. Dosimetry has moved significantly to remote, accelerated by COVID-19 which is not great for their market. Physicians of course have it bad - we've talked about it ad nauseum on this forum.

Rather than useless talk about cross-training to administer oral chemo, maybe ASTRO should advocate for its constituent physicians to be cross-trained as therapists or physicists? I can see it now - a center with 25 on-treatment per day with five physicians who are able to do everything! If they could also learn to man the front desk and check in patients we could argue for a 6th physician!

 

[medgator]

.

Rather than useless talk about cross-training to administer oral chemo, maybe ASTRO should advocate for its constituent physicians to be cross-trained as therapists or physicists? I can see it now - a center with 25 on-treatment per day with five physicians who are able to do everything! If they could also learn to man the front desk and check in patients we could argue for a 6th physician!

I front desk from time to time, gotta be quick with the phones!

That being said, i think therapist jobs are at highest risk from an apm/hypofx standpoint. Dosimetrists have the remote issue as well as improving AI factor in the software to worry about

 

[medgator]

That has not been the case where I trained or work now. But hey that's anecdote for you.

I've noticed staffing ratios play a huge part in all of that. In general, freestanding/pp settings may have a higher ratio of patients under treatment to physics/dosimetrists than academic centers, with community hospital staffing somewhere between that

 

[TheWallnerus]

Rather than useless talk about cross-training to administer oral chemo, maybe ASTRO should advocate for its constituent physicians to be cross-trained as therapists or physicists? I can see it now - a center with 25 on-treatment per day with five physicians who are able to do everything!

Don't throw a shoe at me but in small centers if the therapist calls out sick for the day I have *wished* for the ability to know how to mode up the machine and do a quick-like-I-know-what-I'm-doing patient setup and IMRT delivery on a patient as the "MD therapist." Instead of shutting down the clinic for the day. Lemme tell ya folks, it happens, these patient cancellations in leanly ran centers.

 

[Conn Seannery]

10-2. From home.

If the dosimetrist is good and does good plans quickly, who cares? It motivated me to be a good dosimetrist, because now I can do good plans in a short period of time, and do market trading and side-work the rest of my time. Great gig.

 

[Ray D. Ayshun]

If the dosimetrist is good and does good plans quickly, who cares? It motivated me to be a good dosimetrist, because now I can do good plans in a short period of time, and do market trading and side-work the rest of my time. Great gig.

We're just saying how we'd all rather be dosimetrists.

 

[RadOncDoc21]

In my read of the RO job market, opportunities for radiation therapists are by far the greatest. I think there is a dearth of training programs and perhaps an over-concentration of RTTs on the East Coast with a relative paucity in the Midwest and West. Next are Radiation Physicists as Neuronix and others have pointed out above. Dosimetry has moved significantly to remote, accelerated by COVID-19 which is not great for their market. Physicians of course have it bad - we've talked about it ad nauseum on this forum.

Rather than useless talk about cross-training to administer oral chemo, maybe ASTRO should advocate for its constituent physicians to be cross-trained as therapists or physicists? I can see it now - a center with 25 on-treatment per day with five physicians who are able to do everything! If they could also learn to man the front desk and check in patients we could argue for a 6th physician!

This could work in the NBA as well, my team would be made up of all athletic Power Forwards. This is the opposite of the current “small ball” model.

In the clinic, this would equate to a physicist who can take vitals and do treatment planning while running the machine and answering phones. This would knock out a nurse, dosimitrist, front desk, therapist and physicist.

 

[TheWallnerus]

This could work in the NBA as well, my team would be made up of all athletic Power Forwards. This is the opposite of the current “small ball” model.

In the clinic, this would equate to a physicist who can take vitals and do treatment planning while running the machine and answering phones. This would knock out a nurse, dosimitrist, front desk, therapist and physicist.,

I would make a team of guys who could drain it from half-court and beyond, but we can agree to disagree.

But MDs who don't do plans, and physicists who don't do plans, are a huuuuge market inefficiency. Recently saw this MD e.g. give a talk on "treatment planning." In reality, it's not about treatment planning but plan evaluation.

The dosimetrist should not exist. MDs should "walk their contours" through optimization and dose calculation.
Radiation oncologist : TPS :: surgeon : scalpel
Discuss.

 

[Lamount]

I would make a team of guys who could drain it from half-court and beyond, but we can agree to disagree.

But MDs who don't do plans, and physicists who don't do plans, are a huuuuge market inefficiency. Recently saw this MD e.g. give a talk on "treatment planning." In reality, it's not about treatment planning but plan evaluation.

The dosimetrist should not exist. MDs should "walk their contours" through optimization and dose calculation.
Radiation oncologist : TPS :: surgeon : scalpel
Discuss.

Planning can be cumbersome because optimization takes a long time and then if it isn't right, you have to re-optimize.

Multi criteria optimization is a game changer in this regard. It allows you to decide which trade offs are important a priori and you can adjust the trade offs after optimization. In essense, the physician can tweak the plan on their own. I do this frequently on my catch-22 cases where I want to see what I can get away with in terms of coverage vs. OAR dose.

 

[RickyScott]

This could work in the NBA as well, my team would be made up of all athletic Power Forwards. This is the opposite of the current “small ball” model.

In the clinic, this would equate to a physicist who can take vitals and do treatment planning while running the machine and answering phones. This would knock out a nurse, dosimitrist, front desk, therapist and physicist.

Bill bellichick patriot way- you must be in boston

 

[Krukenberg]

Planning can be cumbersome because optimization takes a long time and then if it isn't right, you have to re-optimize.

Multi criteria optimization is a game changer in this regard. It allows you to decide which trade offs are important a priori and you can adjust the trade offs after optimization. In essense, the physician can tweak the plan on their own. I do this frequently on my catch-22 cases where I want to see what I can get away with in terms of coverage vs. OAR dose.

Does eclipse have MCO? How much extra $$$ is the package?

 

[drewdog1973]

I think that’s Raystation’s big selling point.

 

[TheWallnerus]

Planning can be cumbersome because optimization takes a long time and then if it isn't right, you have to re-optimize.

Multi criteria optimization is a game changer in this regard. It allows you to decide which trade offs are important a priori and you can adjust the trade offs after optimization. In essense, the physician can tweak the plan on their own. I do this frequently on my catch-22 cases where I want to see what I can get away with in terms of coverage vs. OAR dose.

I don’t know from “multi criteria optimization.” When I’m doing a plan, I always have multiple criteria I look it while optimizing. Which is a real time interactive iterative process. Sometimes a priori choices are too idealistic, or not aggressive enough. Going through optimization teaches you, just like going through a chess match teaches you who’s the better player even though one has a higher ELO than the other. At the end of the optimization and the plan that calcs about 30-60 seconds later, I have the plan that is like what Bobby Fischer called “best by test.” In the somewhat rare situation I “can’t get there from here,” I have to make contouring or margination adjustments. Again something that can only be “taught” or learned during the optimization/planning process. Add on to this beam choices etc (non coplanarity, arcs vs static, number of beams/arcs, “fluence smoothing,” “base dose” planning, fix the fields or no, multi iso or no, inhomogeneity allowance, and on and on) and post priori tweaking won’t give the degrees of freedom that “intra priori” tweaking will. I recently did a plan on a very large anal margin/anal ca case. Bolus application each day (patient prone) was too fidgety and wouldn’t “lay right.” Felt the best choice was a hybrid 20 MeV e- (to give skin and anal margin dose) and IMRT plan (nodes, deep, etc), done in two different ways (with four different plans running concurrently) to non overlap inhomogeneity. Didn’t know if would work until I ran the planning “experiment.” Not the only way to skin the cat, but it was a great way and the contouring and planning were all done in an hour. (It would have taken me an hour just to explain to dosi what in hell I was after.) Mostly because I knew the exact ending point to where I wanted to arrive. Not being flippant but I rarely, rarely re-optimize.

 

[Radonc 2013]

Does eclipse have MCO? How much extra $$$ is the package?

Varian has a MCO product, but not sure how it prices out for it specifically.

 

[Krukenberg]

Varian has a MCO product, but not sure how it prices out for it specifically.

Yea did some googling and it looks like it came out recently. I’m sure it’s a chunk of change, but the marketing claims it speeds up the planning process so maybe will save you more money in dosimetry time

 

[w00tz]

Yea did some googling and it looks like it came out recently. I’m sure it’s a chunk of change, but the marketing claims it speeds up the planning process so maybe will save you more money in dosimetry time

Not sure what it costs. Randomly got an email from Varian saying that I needed training in it. Wasn't aware we had it, but apparently came with our latest Aria upgrade

 

[communitydoc13]

Multi criteria optimization is a game changer in this regard.

What the what?!! I'm curious what this actually means. I did a quick search and seems like they generate a set of "pareto optimal" plans (for example: the plan with the best rectal sparing and the plan with the best bladder sparing). Do you then get to use these plans as a "basis set" like in linear algebra to create an aggregate plan? How do we know that the plans generated are a good basis?

Sincerely interested. I can see how a computer could create 100 inverse planned plans very quickly with very simple optimization objectives and then we use these plans as a basis for a good plan. (Of course 100 would be too many for a person to work with.)

Is there a good paper to reference? In your clinic is dosi still working on a basis set of plans that you then linearly combine (using a slide icon?) to come up with your clinically preferred plan?

 

[Lamount]

What the what?!! I'm curious what this actually means. I did a quick search and seems like they generate a set of "pareto optimal" plans (for example: the plan with the best rectal sparing and the plan with the best bladder sparing). Do you then get to use these plans as a "basis set" like in linear algebra to create an aggregate plan? How do we know that the plans generated are a good basis?

Sincerely interested. I can see how a computer could create 100 inverse planned plans very quickly with very simple optimization objectives and then we use these plans as a basis for a good plan. (Of course 100 would be too many for a person to work with.)

Is there a good paper to reference? In your clinic is dosi still working on a basis set of plans that you then linearly combine (using a slide icon?) to come up with your clinically preferred plan?

MCO is a feature in Eclipse (may also be in other TPS as well) where you can play with trade offs by yourself without re-optimizing. You essentially define certain objectives (e.g. PTV D95 > 95%; Bronchus Dmax <48 Gy; GTV max dose... I think it theoretically can be an unlimited number of them) and rather than calculating an optimal plan, it calculates a range of plans around these objectives (which takes a bit longer than a normal optimization).

When it is done calculating and you pull up the workspace, it gives you a dose distribution and a series of slider bars for each of your defined objectives. You can use the slider bar to increase or decrease the priority of that objective. For example, maybe you want to try to improve coverage so you move the slider on the D95 objective higher. As you do this, you will see the dose distribution change in real time and you will also see other objective bars sliding as well. As you can imagine, increasing coverage can also increase dose to OARs... so as you move the slider for coverage to higher priority, you MAY see some of the OAR bars move to lower priority as the dose to those structures increases.

Sometimes, you will notice that it is a zero sum game where any attempt to improve coverage will necessarily give some critical OAR a higher dose... but other times, you realize that you can push harder on an objective without any negative consequences.

I like using this for really complex cases because I am OCD and this lets me micromanage the tradeoffs -i.e. I can tune the coverage and toxicity based upon the clinical indications, histology, functional status etc... It also lets me make sure that I have an optimal plan that couldn't be better.

Here is a link to Varian's MCO software.

 

[Ray D. Ayshun]

Technically speaking, isn't "multi" redundant?

 

[TheWallnerus]

MCO is a feature in Eclipse (may also be in other TPS as well) where you can play with trade offs by yourself without re-optimizing. You essentially define certain objectives (e.g. PTV D95 > 95%; Bronchus Dmax <48 Gy; GTV max dose... I think it theoretically can be an unlimited number of them) and rather than calculating an optimal plan, it calculates a range of plans around these objectives (which takes a bit longer than a normal optimization).

When it is done calculating and you pull up the workspace, it gives you a dose distribution and a series of slider bars for each of your defined objectives. You can use the slider bar to increase or decrease the priority of that objective. For example, maybe you want to try to improve coverage so you move the slider on the D95 objective higher. As you do this, you will see the dose distribution change in real time and you will also see other objective bars sliding as well. As you can imagine, increasing coverage can also increase dose to OARs... so as you move the slider for coverage to higher priority, you MAY see some of the OAR bars move to lower priority as the dose to those structures increases.

Sometimes, you will notice that it is a zero sum game where any attempt to improve coverage will necessarily give some critical OAR a higher dose... but other times, you realize that you can push harder on an objective without any negative consequences.

I like using this for really complex cases because I am OCD and this lets me micromanage the tradeoffs -i.e. I can tune the coverage and toxicity based upon the clinical indications, histology, functional status etc... It also lets me make sure that I have an optimal plan that couldn't be better.

Here is a link to Varian's MCO software.

So if this is just post-optimization optimization ... why not just do the optimization yourself.

 

[Doctorer]

Because this is just part of the optimization process. He’s getting a set of radiation therapy plans, in a space of lots of potentially acceptable plans. Rather than having his Dosimetrist “optimize” 100 plans, he gets to quickly review them this way.

 

[Chartreuse Wombat]

MCO sounds like Radiation Oncology pron to me

 

[communitydoc13]

Because this is just part of the optimization process. He’s getting a set of radiation therapy plans, in a space of lots of potentially acceptable plans. Rather than having his Dosimetrist “optimize” 100 plans, he gets to quickly review them this way.

I was wondering about that. If the MCO is just generating " a big plan space" to choose from, that is one thing. I'm guessing its subtly responsive to little tweaks in optimization priorities, which makes me think it's either creating an aggregate plan from this plan space by creating combinations of plans (a huge feat in terms of real dynamic MLC program etc.) or it's created a huge number of plans to choose from.

I guess another possibility is you "pick an appoximate plan" from a big plan space and then there is very little additional (and quick) optimization as you are already close to a solution that you want?

Very cool work, regardless. I'll ask my physicist about it.

For those using this, do you ever get really strange plans in terms of MU, time for delivery etc?

 

[RickyScott]

So if this is just post-optimization optimization ... why not just do the optimization yourself.

Saw a ray station demonstration that was very impressive, but would still prefer to optimize myself and draw structures to achieve rapid fall off in certain locations. Ray station also seemed to have the capability to graphically push in isodose lines in real time. I think a lot of the technology in eclipse including Mco and the license to now use graphics cards for planning comes from ray station. Unfortunately, as a community hospital, would only want to deal with one vendor.

 

[medgator]

 

[SubserviantToABR]

Geez, just took a look at his Twitter. This guy is a freaking weirdo. I hope he always have a chaperone with him.

 

[medgator]

Geez, just took a look at his Twitter. This guy is a freaking weirdo. I hope he always have a chaperone with him.

View attachment 335492

View attachment 335490

Well he did just transfer from one VA job to another....

USA TODAY Investigation: VA knowingly hires doctors with past malpractice claims, discipline for poor care

The VA has repeatedly hired doctors with problem pasts in recent years, some of whom went on to harm veteran patients, a USA TODAY investigation found.

www.usatoday.com

 

[Krukenberg]

MCO is a feature in Eclipse (may also be in other TPS as well) where you can play with trade offs by yourself without re-optimizing. You essentially define certain objectives (e.g. PTV D95 > 95%; Bronchus Dmax <48 Gy; GTV max dose... I think it theoretically can be an unlimited number of them) and rather than calculating an optimal plan, it calculates a range of plans around these objectives (which takes a bit longer than a normal optimization).

When it is done calculating and you pull up the workspace, it gives you a dose distribution and a series of slider bars for each of your defined objectives. You can use the slider bar to increase or decrease the priority of that objective. For example, maybe you want to try to improve coverage so you move the slider on the D95 objective higher. As you do this, you will see the dose distribution change in real time and you will also see other objective bars sliding as well. As you can imagine, increasing coverage can also increase dose to OARs... so as you move the slider for coverage to higher priority, you MAY see some of the OAR bars move to lower priority as the dose to those structures increases.

Sometimes, you will notice that it is a zero sum game where any attempt to improve coverage will necessarily give some critical OAR a higher dose... but other times, you realize that you can push harder on an objective without any negative consequences.

I like using this for really complex cases because I am OCD and this lets me micromanage the tradeoffs -i.e. I can tune the coverage and toxicity based upon the clinical indications, histology, functional status etc... It also lets me make sure that I have an optimal plan that couldn't be better.

Here is a link to Varian's MCO software.

Would this help get better plans in the setting of a mediocre dosimetrist? Or is it still garbage in, garbage out?

 

[CaesarRO]

Too many to quote but imo in the physics, dosi, therapists, doc job prospects discussion: dosi is most likely to become obsolete with AI, therapists are at risk from APM/hypofrac resulting in more patients coming through on fewer machines. I think physics has done a good job limiting their supply and contrary to other anecdotes here my anecdotes suggest a very strong physics job market. Plans will always need to be QA'd, and the number of plans depends on the number of patients not the number of fractions.

I think even if the nature of physician work and compensation changes with time, we've still got a secure gig relative to Dosi and therapists