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He's not wrong...
In the CMS manual, up until a couple years ago the section on radiation therapy made no mention of radiation oncologists… we were called radiologists.
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Oncology would make more sense than radiology if you consider our daily work and fund of knowledge
I consider myself an oncologist first and radiation oncologist second.
So much love this. I get sent occasional patients for abnormal scans, rule out malignancy. Some docs, even rad and med oncs, tell me that's med oncs job... NOPE.
That's my default too, but funny that they do separate out surgical oncology
Just need a path report and I'm good. Sometimes it's not even that, just a mass on a lung CT
I hear ya.
But maybe 25-30% of the questions for our written board certification exams would come under an unequivocally oncology heading?…
Heard a big name neurosurgeon say “We are neurologists who happen to operate.”
As Sheryl Crow says IF IT MAKES YOU HAPPY.
Have also heard nsg say: "neurologists are good historians/note writers"
eContour posted this on Twitter
Is that chiasm janky?
Is that chiasm janky?
Not terrible... Just a little overcontouredeContour posted this on Twitter
Is that chiasm janky?
This next slice is more interesting:
Do you guys contour the chiasm like this? I bet it's accurate on a per-slice basis, but I don't want Eclipse thinking there's a sweet little spot to dump some dose in.
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No. Would rather make it a single structure
The posterior part of the optic nerves are contoured as chiasm... and it looks like they are a few mm too inferior with the chiasm. Better to overcontour it, but looks like they probably missed part of it superiorly (superior to the presented images). While on the subject, their body contour an right orbit are also janky.
geez. let's get back to rad onc privilege. Is that this thread or a different one?
eContour posted this on Twitter
Is that chiasm janky?
I don't draw the intracranial portion of the optic nerves as chiasm--that's still optic nerve until chiasm IMO. It's not a crucial distinction given that the constraint is the same.
The major difference is that chiasm toxicity can cause blindness while optic optic nerve toxicity causes vision loss in one eye.
I'm not sure that the drawings are accurate though, whether they are meant to outline optic nerve or chiasm. But without having the images on hand it's hard to know.
This appearance happens, if it's the discontinuity you're talking about. The chiasm doesn't live in a flat plane; if I visit Flatland, even though I'm a single entity, to the people of Flatland I will appear to be discontinuous. My issue is: I can see the chiasm on that CT. The contours don't match the CT anatomy. I'd give this person a D-plus. C-minus if generous. I'd have to redo it.
probably done by auto-contouring or a medstudent
Shoot you're right, I forgot that we aren't actual Radiation Oncologists who care about our work, we're magically-thinking Internet Trolls who hate everything!
Back to our regularly scheduled programming - has Ralph done anything ludicrous in the last 48 hours?
The chiasm is "the intersection of where all people who are oppressed meet.”
This is what the malpractice attorney's face will look like when the patient sues you for giving him radiation-induced optic neuritis because you relied on auto-contouring. 😉
Are we saying odds of optic neuritis is around 5% at 5 years with a dmax of 60 Gy? Right around the odds of still being alive if that's a gbm. So odds of optic neuritis are 0.25% dmax 60, which seems acceptable. Therefore, do we need to contour the chiasm? 😉 💩
I think of my chiasm contour like I think of my gun and condoms: I'd rather have it and not need it than need it and not have it!
Lol. Nice examples, or perhaps just example, as you never need one without the other. You must've taken a job in west Virginia.
Are you the wise one, or the take no prisoners one?
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I was trying to be generous. Looks like a med student or PGY-2 drawing to me though.
Just put a 3 mm PRV on there and constrain to that. It's in there somewhere.
Just kidding, sort of.
I don't do this, but I've seen docs who do.
I think that’s reasonable if you only have CT or a poor quality MRI. Just draw a big PRV and you know you’ll be safe. If there a good MRI I draw the true structure
eContour posted this on Twitter
Is that chiasm janky?
I mean... does it really matter clinically? This is a GBM case. The closest line to chiasm (Orange) is probably PTV46? PTV60 is (for a Rad Onc) miles away from the chiasm and won't be an issue. Imagine the chiasm as drawn can easily get doses < 50Gy, or a 3mm PRV easily kept below 54Gy by a competent dosimetrist.
It prob means nothing clinically.
But if someone is trying to show contouring proficiency, then …
I think what some people are trying to say is that the chiasm/optic structures aren't static, and are unlikely to be in that exact sad-face position every day during treatment. If you had someone who didn't know what a PRV was, and had some sort of strange edge-case, I guess you could run in to a situation where your planning system tries to put full dose in to that tiny space in-between your contours.
Apparently we're all bored today. Uh oh. Are everyone's numbers down!? No jobs!? Are we all dying alone?!
Apparently we're all bored today. Uh oh. Are everyone's numbers down!? No jobs!? Are we all dying alone?!
It could be a meta way of passing along the message that goes through our head every time: it's gbm.
Tangential anecdote, and forgive me if I get some small details wrong:
Few years ago, there was one plan that got sent to physics here, a brain/base of skull case, high dose near chiasm. Planning had jaw tracking turned off in the plan. The IMRT plan passed gamma test, but gamma QA output still looked odd to the physicist QA’ing the case, so the physicist delved a bit deeper. Turned out when the plan was ran on the linac, the jaw positions weren’t specified correctly and remained open from the previous plan delivery, and was just dumping dose into the chiasm as supposedly the plan wasn’t mlc shielded there but by the jaw edge, for which the position wasn’t reliably specified. Plan would have passed gamma criteria though, and likely by checks alone would have otherwise been passed through by an inattentive physicist. Caught before patient started treatment, but definitely a near miss.
I don’t do much CNS now, just H&N cases, and haven’t seen a case of rt optic neuritis in a long time. But there was the odd patient in my resident rotations in SRS/CNS clinics that had it. Not a fun time.
And yeah, to me that chiasm looks janky af
Few years ago, there was one plan that got sent to physics here, a brain/base of skull case, high dose near chiasm. Planning had jaw tracking turned off in the plan. The IMRT plan passed gamma test, but gamma QA output still looked odd to the physicist QA’ing the case, so the physicist delved a bit deeper. Turned out when the plan was ran on the linac, the jaw positions weren’t specified correctly and remained open from the previous plan delivery, and was just dumping dose into the chiasm as supposedly the plan wasn’t mlc shielded there but by the jaw edge, for which the position wasn’t reliably specified. Plan would have passed gamma criteria though, and likely by checks alone would have otherwise been passed through by an inattentive physicist. Caught before patient started treatment, but definitely a near miss.
I don’t do much CNS now, just H&N cases, and haven’t seen a case of rt optic neuritis in a long time. But there was the odd patient in my resident rotations in SRS/CNS clinics that had it. Not a fun time.
And yeah, to me that chiasm looks janky af
Interesting article...or, medical students have adequate exposure to our field, see the flamin' bag of 💩 that our leaders have created, proton people pushing an expensive but phase III RCT-less modality, and are running the opposite direction.
Had a med student this week. They told me how cool they thought our field is (which it is!) but is worried that he is not going to have a job that he would be satisfied with in 7-8 years. They are worried the impact it would have on their partner and future children. I didn't have to say anything. I just told him to reach out to the new grads or current PGY5s. 🤷♂️
Offering more of the same old tired mayonnaise. This is like thinking that for a patient recently diagnosed with lung cancer we should get him an appointment with a psychologist to help quit smoking. Rad onc hasn’t had a “seat at the table” forever. Med student interest didn’t just suddenly, mysteriously decline due to a chronic problem. The authors are suffering from Stockholm syndrome, or had their arms twisted behind their backs, or worse think we are dumb!
And I think that our residency leaders have demonstrated...they don't care if your medical school have adequate RO exposure. As long as you're not a convicted felon, they will take anyone to fill our slots, your future be damned!
Highly encourage everyone to provide comments to the ACGME on Radiation Oncology Residency program requirements. The ultimate result of changing requirements, say minimum number of residents (from 4 to ??) or minimum faculty complement (from 5 to ??), may be program closure. Oh well.
"The ACGME invites comments from the community of interest regarding the proposed requirements listed below.
As part of the ongoing effort to encourage the participation of the graduate medical education community in the process of revising requirements, the ACGME may publish some or all of the comments it receives on the ACGME website. By submitting your comments, the ACGME will consider your consent granted. If you or your organization does not consent, please indicate such in your comments directly, or in the space provided on the Comment Form (below)."
Review and Comment
The ACGME invites comments from the community of interest regarding the proposed Requirements listed below.
Good call except for Maybe not the PGY5s or new grads who wrote this nonsense
Definitely Stockholm syndrome lol
Does anyone have their arm twisted while writing for whatever the heck journal applied radiation oncology is?
I don’t recall there being much of an outreach/visibility problem when I was interviewing a little over a decade ago with a half dozen AOA grads and 250+ steps at nearly every interview - even at “mid tier” programs.
Or when id have to duck out of sub-I rounds quickly to answer an email to reserve an interview date before they filled up in literally an hour.
Or how I took out more loans to do an extra away rotation and had to beg places to allow an extra student on their rotation.
Nothing is different from an exposure standpoint from then vs now….
except the med students are pretty good at Reddit, SDn, and other semi anonymous platforms where they can ask real questions they can’t ask in real life. Real questions like :
- can I find a job in a region I want?
- can I find a job period?
- if my spouse is in a competitive field, can I follow them and still find a job?
they’re getting (truthful) answers they don’t like. it has nothing to do with them not knowing about our field. They didn’t have a bunch of rad onc lectures in 2005 either, yet the rock stars were lining up to join our great specialty. It absolutely is great and I love it, but if you can’t see what the problem is you’re blind.
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Some of these guys are just trying to ingratiate themselves to academic departments because they are so desperate for a job. Willing to “sell” others.
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I first heard about rad onc when I started my MD/PhD program in the mid-2000s. It seemed cool so I asked around. I did some shadowing and was told that it was very competitive, requiring high scores and research productivity. So, I worked hard to try to clear those hurdles to get in. We had absolutely ZERO exposure in our curriculum yet we sought out this field in droves.
At the same time, I was also told how dismal the job market was for pathology and radiology (around the 2008-2012, sounds like rads is getting better now?) so I stayed away from those specialties as did my classmates. Medical students aren't stupid, so it is really disappointing to see all of the gaslighting with articles like this, pretending that they are.
Rads definitely improving.. think of CT lung screening alone. They just relaxed criteria to allow more eligibility driving more need for their labor. Opposite of what is going on in rad Onc
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Opposite of our folks where RO is trying to omit RT and suffocate ourselves at every chance possible, just so that those in academic RO can get their promotions.
Me: *scrolling through cat pics on Twitter, briefly forgetting my day job*
Twitter: "HEY HAVE YOU EVER BEEN ANNOYED BY BOWEL AND WANTED TO PHYSICALLY DO SOMETHING ABOUT IT? TRY THIS ONE EASY TRICK!"
Twitter: "HEY HAVE YOU EVER BEEN ANNOYED BY BOWEL AND WANTED TO PHYSICALLY DO SOMETHING ABOUT IT? TRY THIS ONE EASY TRICK!"
Is that automatically at least a grade 2 toxicity, if not grade 3? Definitely not ribbed for your pleasure.
