Rad Onc Twitter

[communitydoc13]

Radiation Dosimetry in 177Lu-PSMA-617 Therapy Using a Single Posttreatment SPECT/CT Scan: A Novel Methodology to Generate Time- and Tissue-Specific Dose Factors - PubMed

Calculation of radiation dosimetry in targeted nuclear medicine therapies is traditionally resource-intensive, requiring multiple posttherapy SPECT acquisitions. An alternative approach is to take advantage of existing pharmacokinetic data from these smaller cohorts to enable dose computation...

pubmed.ncbi.nlm.nih.gov

Doing cool stuff in OZ.

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[maxxor]

Even if RVU value is low seems like this should be radiation oncology...because we are a vital part of the treatment team.

Maybe you guys can merge back with another dying specialty: Nuc Med. At my academic institution, the Nucs are getting a clinical service started in anticipation of PSMA therapies. At least they are creating new treatments

 

[thecarbonionangle]

I think when even nuc med makes fun of us you know it is bad folks!

 

[fiji128]

Maybe you guys can merge back with another dying specialty: Nuc Med. At my academic institution, the Nucs are getting a clinical service started in anticipation of PSMA therapies. At least they are creating new treatments

Look, I’ve always argued we need to be a fellowship after general radiology residency. The speciality is not quite there yet but I suspect it will be before too long.

 

[RadOncDoc21]

Maybe you guys can merge back with another dying specialty: Nuc Med. At my academic institution, the Nucs are getting a clinical service started in anticipation of PSMA therapies. At least they are creating new treatments

Sometimes two bad ideas are better then one!

 

[elementaryschooleconomics]

Sometimes two bad ideas are better then one!

Two wrongs don't make a right, but three lefts do!

Sorry, working on some material for open mic before APM is enacted...

 

[jondunn]

Look, I’ve always argued we need to be a fellowship after general radiology residency. The speciality is not quite there yet but I suspect it will be before too long.

The idea that some of you think it’s important we waste years learning mostly about knee tears, lung blebs, and brain bleeds is so wild to me!

We are cancer doctors.

 

[maxxor]

The idea that some of you think it’s important we waste years learning mostly about knee tears, lung blebs, and brain bleeds is so wild to me!

We are cancer doctors.

Just to devils advocate: spending years memorizing clinical trial minutia and whether to give chemo that you don’t administer is more relevant?

If you returned to the radiology fold, you could at least have something to do when fractions drop and cancer incidence declines.

It’s a more realistic pivot than infiltrating academic Med onc industrial complex and giving chemo.

 

[jondunn]

People get tested on minutae their entire educational lives. We can argue about standardized testing and the way education works all day; that’s a good conversation and important one. But at the end of the day learning about the trials that affect how we generally treat patients and knowing about systemic therapies that affect our patients is way more relevant than anything else.

 

[maxxor]

People get tested on minutae their entire educational lives. We can argue about standardized testing and the way education works all day; that’s a good conversation and important one. But at the end of the day learning about the trials that affect how we generally treat patients and knowing about systemic therapies that affect our patients is way more relevant than anything else.

So is learning about the pathology that can present on their routine restaging exams that you could be interpreting when there’s no new consults or OTVs.

This is the same argument ad absurdum as “why do Med students destined for radonc have to do OBGYN”?

Is an incidental brain bleed not a “toxicity”?

 

[jondunn]

So is learning about the pathology that can present on their routine restaging exams that you could be interpreting when there’s no new consults or OTVs.

This is the same argument ad absurdum as “why do Med students destined for radonc have to do OBGYN”?

Is an incidental brain bleed not a “toxicity”?

Ok you lost the plot.

 

[RickyScott]

People get tested on minutae their entire educational lives. We can argue about standardized testing and the way education works all day; that’s a good conversation and important one. But at the end of the day learning about the trials that affect how we generally treat patients and knowing about systemic therapies that affect our patients is way more relevant than anything else.

culturally, radonc goes “overboard” stressing minutiae (ie radiobiology). Oncology was way ahead of other fields in championing EBM over bioplausibiIity (think ortho) but radonc takes it to an unhealthy level. I attribute this to insecurity among many of the “leaders” of the older generation who were probably not the cream of the crop when they fell into the specialty. (And why they had a fetish for md/phds). Talmudic study of the data somehow provides equalizing legitimacy for the one trick pony at tumor boards?

This could actually worsen as we go to 1-5 fractions and adopt an IR like footprint in pt care of gettting -in -and -getting-out, yet continue to view ourselves as equals to surg and medonc because we bring minutiae to the table.

 

[Palex80]

culturally, radonc goes “overboard” stressing minutiae (ie radiobiology).

Radiobiology is the biggest dumpster fire of radiation oncology.

Now, don't get me wrong, a lot of the things we do nowadays are based on radiobiology research of the past. However...

Think of all the money and resources that have been invested in radiobiology. Good.
Now name me ONE item that came out of radiobiology research conducted in the past 20 years and that made it into clinical practice. Just one.

 

[deleted1111261]

People get tested on minutae their entire educational lives. We can argue about standardized testing and the way education works all day; that’s a good conversation and important one. But at the end of the day learning about the trials that affect how we generally treat patients and knowing about systemic therapies that affect our patients is way more relevant than anything else.

Learning about studies is important.

Getting tested like this:

“What was the pCR rate in the German Rectal Study?
A 8%
B 9%
C 10%
D 12%”

Is why #radoncrocks

“Jondunn gets a ‘Strawman’ sticker”

 

[elementaryschooleconomics]

culturally, radonc goes “overboard” stressing minutiae (ie radiobiology). Oncology was way ahead of other fields in championing EBM over bioplausibiIity (think ortho) but radonc takes it to an unhealthy level. I attribute this to insecurity among many of the “leaders” of the older generation who were probably not the cream of the crop when they fell into the specialty. (And why they had a fetish for md/phds). Talmudic study of the data somehow provides equalizing legitimacy for the one trick pony at tumor boards?

This could actually worsen as we go to 1-5 fractions and adopt an IR like footprint in pt care of gettting -in -and -getting-out, yet continue to view ourselves as equals to surg and medonc because we bring minutiae to the table.

I agree with this with every inch of my soul. This data worship (which you appropriately label Talmudic study) is a great defense mechanism for those who feel insecure about their position. It's like that Feynman quote of "if you can't explain something in simple terms, you don't understand it". Just talking fast and throwing out statistic after statistic - of things that are easily looked up on Google - really sets off my BS radar that someone is either trying to sell me something or they are trying to appear much more confident than they really are.

Very relevant is this Tweet from yesterday:

And this recent study:

Changes in Length and Complexity of Clinical Practice Guidelines in Oncology, 1996-2019

While generally true in all specialties, I feel a sense of urgency about how we're handling complexity of knowledge in Radiation Oncology. Training programs, on balance, long ago shifted away from emphasizing clinical skills vs valuing memorizing trivia. We desperately need to course correct medical education in RadOnc by getting away from vomiting p values out of 30 year old trials and instead focus on learning how to be excellent doctors in an environment where we can carry literally all the knowledge of the world on a 5 inch device in our pockets.

 

[deleted941485]

I agree with this with every inch of my soul. This data worship (which you appropriately label Talmudic study) is a great defense mechanism for those who feel insecure about their position. It's like that Feynman quote of "if you can't explain something in simple terms, you don't understand it". Just talking fast and throwing out statistic after statistic - of things that are easily looked up on Google - really sets off my BS radar that someone is either trying to sell me something or they are trying to appear much more confident than they really are.

Very relevant is this Tweet from yesterday:

View attachment 344378

And this recent study:

Changes in Length and Complexity of Clinical Practice Guidelines in Oncology, 1996-2019

While generally true in all specialties, I feel a sense of urgency about how we're handling complexity of knowledge in Radiation Oncology. Training programs, on balance, long ago shifted away from emphasizing clinical skills vs valuing memorizing trivia. We desperately need to course correct medical education in RadOnc by getting away from vomiting p values out of 30 year old trials and instead focus on learning how to be excellent doctors in an environment where we can carry literally all the knowledge of the world on a 5 inch device in our pockets.

That’s nice but if your going to educate these clinicians in a better way but can it at least be for something that I can use and preferably bill for?

 

[metallica81788]

Learning about studies is important.

Getting tested like this:

“What was the pCR rate in the German Rectal Study?
A 8%
B 9%
C 10%
D 12%”

Is why #radoncrocks

“Jondunn gets a ‘Strawman’ sticker”

I came out of residency with pCR rate of German Rectal Study engrained in my head but did not know how to treat or plan breast cancer

Doubtful I'm alone here

 

[communitydoc13]

This data worship (which you appropriately label Talmudic study) is a great defense mechanism for those who feel insecure about their position.

This is understandably how we've always been IMO. It is definitely how I am presently. Once medonc started getting off the ground, I believe that a common "goal" of cancer care from the medical oncology perspective was to eliminate XRT when possible based on the visceral understanding that "radiation is bad for you". This is clearly manifested in the treatment of lymphomas, where present day XRT is fairly benign in older patients but sort of excluded "based on principle". Back when I was in residency, a lymphoma specialist medonc would come down every 1-2 years to give an update on lymphoma treatment. He explicitly told us that he refused to refer most patients to our lymphoma specialist up front because "he would confuse the patient with data".

Agree with the exponential knowledge growth rates....in medical oncology. Check out the Aggrego Oncology newsletter every damn week. I did see a study looking at the robustness of MRI guided alignment as a function of treatment time in a recent update. Meanwhile Keynote 522 just massively reduced the applicability of CREATE-X. We should actually know the later so we can at least be coordinators of care out in the community. We don't need to know the former for the most part.

 

[RickyScott]

This is understandably how we've always been IMO. It is definitely how I am presently. Once medonc started getting off the ground, I believe that a common "goal" of cancer care from the medical oncology perspective was to eliminate XRT when possible based on the visceral understanding that "radiation is bad for you". This is clearly manifested in the treatment of lymphomas, where present day XRT is fairly benign in older patients but sort of excluded "based on principle". Back when I was in residency, a lymphoma specialist medonc would come down every 1-2 years to give an update on lymphoma treatment. He explicitly told us that he refused to refer most patients to our lymphoma specialist up front because "he would confuse the patient with data".

Agree with the exponential knowledge growth rates....in medical oncology. Check out the Aggrego Oncology newsletter every damn week. I did see a study looking at the robustness of MRI guided alignment as a function of treatment time in a recent update. Meanwhile Keynote 522 just massively reduced the applicability of CREATE-X. We should actually know the later so we can at least be coordinators of care out in the community. We don't need to know the former for the most part.

When I think about data onanism, it is more about sites like prostate and breast than lymphoma. With breast and prostate radonc it seems like thought leaders create and often cite exponentially accruing retrospective crap. Ontologically, there is just not much depth to prostate and breast radiation vs the systemic treatment of those diseases. Pumping out hundreds of papers as a breast radonc just seems like desperation to stay academically relevant to med/surg onc peers. It almost feels like data is so heavily emphasized because there is just not that much to the delivery and management of these pts.

 

[deleted941485]

When I think about data onanism, it is more about sites like prostate and breast than lymphoma. With breast and prostate radonc it seems like thought leaders create and often cite exponentially accruing retrospective crap. Ontologically, there is just not much depth to prostate and breast radiation vs the systemic treatment of those diseases. Pumping out hundreds of papers as a breast radonc just seems like desperation to stay academically relevant to peers. It almost feels like data is so heavily emphasized because there is just not that much to the delivery and management of those pts.

That’s what I didn’t understand until it was too late. I used to marvel at their command of the data but when it came to actually caring for patients day to day there was precious little to do. It was only after years of listening to attendings castigate residents for not understanding the data and seeing how RO is done day to day that I began to question how this might not be the best use of our time. If you remove this emphasis, I don’t see how you could train someone to do this is 2 years rather than 4.

 

[jondunn]

Learning about studies is important.

Getting tested like this:

“What was the pCR rate in the German Rectal Study?
A 8%
B 9%
C 10%
D 12%”

Is why #radoncrocks

“Jondunn gets a ‘Strawman’ sticker”

you literally didn't read what I said. Like i said we can argue about how this is tested, but we are in medicine and have been tested about minutae since birth it feels like. do you think radiology doesn't get tested on minutae? JFC.

my point was that if we are going to be in residency training, oncology (and the minutae that clearly comes with it) is better for us to know than radiology (and their minutae)


I urge, actually BEG, you to try to read and understand.


the irony of you invoking strawman and then posting that....

 

[jondunn]

and im a huge supporter of Bryan Carmody and his efforts and activism to change the minutae of medical education.

I was very happy to see that Step 1 has been changed to pass/fail, good step. I know many disagree, and there are surely downsides to it too, but I think we should be thinking about how to improve education and assessment of education too rather than sticking with the status quo

 

[thecarbonionangle]

The important question is: is our children learnin’? The answer in many hellpits is undoubtedly not and people are basically teaching themselves. The amount of terrible places is embarassing for this field. The hellpit story is very similar from many people who trained at these places: little educational value, attendings who have no skin in game in success of residents, absent chairs, clinic all day writing notes as a grunt, tons of scut. It is not surprising how someone can graduate and have no idea how to treat breast when basically their only job was doing scut. A good resident keeps their head down, says yes sir, and writes a good note and contours on time. Who the hell cares if they know what is going on?
But hey at least they know pCR in german was about <10%, or was it? They ain’t even sure about that either!

We need a massive closing of bad programs.

 

[jondunn]

The important question is: is our children learnin’? The answer in many hellpits is undoubtedly not and people are basically teaching themselves. The amount of terrible places is embarassing for this field. The hellpit story is very similar from many people who trained at these places: little educational value, clinic all day writing notes as a grunt, tons of scut. It is not surprising how someone can graduate and have no idea how to treat breast when basically their only job was doing scut.

We need a massive closing of bad programs.

Oh absolutely! So many programs where education is not great.

 

[TheWallnerus]

I came out of residency with pCR rate of German Rectal Study engrained in my head but did not know how to treat or plan breast cancer

And you're obviously a very good doctor. But, man, that residency program totally failed in its mission. Call it "residency education malpractice"... and thus, it should lose its license to educate residents.

 

[deleted941485]

And you're obviously a very good doctor. But, man, that residency program totally failed in its mission. Call it "residency education malpractice"... and thus, it should lose its license to educate residents.

Call it Medicare fraud. These Dept leaders should be looking at decade long sentences.

 

[thecarbonionangle]

Call it Medicare fraud. These Dept leaders should be looking at decade long sentences.

Throw them all in jail, agreed

 

[RickyScott]

The important question is: is our children learnin’? The answer in many hellpits is undoubtedly not and people are basically teaching themselves. The amount of terrible places is embarassing for this field. The hellpit story is very similar from many people who trained at these places: little educational value, attendings who have no skin in game in success of residents, absent chairs, clinic all day writing notes as a grunt, tons of scut. It is not surprising how someone can graduate and have no idea how to treat breast when basically their only job was doing scut. A good resident keeps their head down, says yes sir, and writes a good note and contours on time. Who the hell cares if they know what is going on?
But hey at least they know pCR in german was about <10%, or was it? They ain’t even sure about that either!

We need a massive closing of bad programs.

This is why we need to keep ranking the hellpit programs.

 

[jondunn]

I avoid hiring from hell pit programs. Sorry to say.

 

[deleted1111261]

Squid Game style competition leading to end of 80% of programs?

 

[fiji128]

Squid Game style competition leading to end of 80% of programs?

Haven’t seen it yet but sounds like an excellent idea.

 

[RadOncDoc21]

When I think about data onanism, it is more about sites like prostate and breast than lymphoma. With breast and prostate radonc it seems like thought leaders create and often cite exponentially accruing retrospective crap. Ontologically, there is just not much depth to prostate and breast radiation vs the systemic treatment of those diseases. Pumping out hundreds of papers as a breast radonc just seems like desperation to stay academically relevant to med/surg onc peers. It almost feels like data is so heavily emphasized because there is just not that much to the delivery and management of these pts.

Breast is the worst!

 

[CaesarRO]

I avoid hiring from hell pit programs. Sorry to say.

Would be great to have a list (could be anonymously sent to mods? Maybe new thread?) of actual programs that people in positions to hire avoid hiring from due to reputation.

 

[RickyScott]

Would be great to have a list (could be anonymously sent to mods? Maybe new thread?) of actual programs that people in positions to hire avoid hiring from due to reputation.

In truth, up until a year or 2 ago, even some of the worst programs were graduating high achievers, but that’s going to change on a dime.

 

[jondunn]

In truth, up until a year or 2 ago, even some of the worst programs were graduating high achievers, but that’s going to change on a dime.

High achiever or not, if not trained well, takes longer to be ready for good practice. I also like to
Work with oncologists, not technicians

 

[thecarbonionangle]

Would be great to have a list (could be anonymously sent to mods? Maybe new thread?) of actual programs that people in positions to hire avoid hiring from due to reputation.

If Someone is BC no matter where they trained they have earned my respect. Graduates from bad places are not my goal to hurt. It is the enabler people at these places which hurt us all

 

[CaesarRO]

In truth, up until a year or 2 ago, even some of the worst programs were graduating high achievers, but that’s going to change on a dime.

Hence the suggestion. I think it's a lot more concrete than just listing rumored bad places.

If someone can actually say "I don't hire out of program X because of the reputation of their training" that's a much starker red flag than some of the general hearsay, imo.

Some of the places mentioned here in the past I know have excellent practical training even though they are busier programs that are definitely not as "chill" as other programs, which is often looked down on by applicants.

I'm interested in actual hiring decisions based on these things.

 

[CaesarRO]

If Someone is BC no matter where they trained they have earned my respect. Graduates from bad places are not my goal to hurt. It is the enabler people at these places which hurt us all

So at least a year or of training. May have had some good post-grad mentoring from whoever did take them on

 

[RadOncDoc21]

Seems like a very subjective measure. Hell, there were some residents I could see myself working with forever and others I couldn’t stand at my own program. Different skill sets, etc. We all graduated and seemed to be doing well in very different environments. I’m not sure there is much of an indicator of which programs pedigree is superior to another one.

 

[medgator]

High achiever or not, if not trained well, takes longer to be ready for good practice. I also like to
Work with oncologists, not technicians

ROs that graduated 5-10 years ago are going to be great irrespective of program. Look at the candidate, not the program imo

 

[jondunn]

‘peak’ rad onc applicants if we want to go by the Med school gunner era is still ongoing, 2-3 more years of peak classes graduating

 

[radoncftw]

I can speak as someone from a higher "pedigree" program that the training aint that great here either. Even though we are 1:1. Resident is in clinic all day seeing consults, OTVs, f/u. Writing all the notes. This gives attending time to do the things that require more brain power like plan review, image review.
Little time for learning other practical component like simulation, planning, image review. It is sad. I thought I'd have more time as a senior resident to learn some of these things but it just is not a priority. I guess that it was what my PGY-6 year (1st year attending) will be for. We have a strong reputation nonetheless and graduates from our program succeed in both community + academic settings.

 

[deleted1111261]

If Someone is BC no matter where they trained they have earned my respect. Graduates from bad places are not my goal to hurt. It is the enabler people at these places which hurt us all

💯

 

[jondunn]

I can speak as someone from a higher "pedigree" program that the training aint that great here either. Even though we are 1:1. Resident is in clinic all day seeing consults, OTVs, f/u. Writing all the notes. This gives attending time to do the things that require more brain power like plan review, image review.
Little time for learning other practical component like simulation, planning, image review. It is sad. I thought I'd have more time as a senior resident to learn some of these things but it just is not a priority. I guess that it was what my PGY-6 year (1st year attending) will be for. We have a strong reputation nonetheless and graduates from our program succeed in both community + academic settings.

Yeah prestige isn’t 1 and 1 with good residency program all the time. This is why word of mouth is good for people applying to residency. If you’re still going to go into rad onc in 2021, make sure it’s a good program for education and culture

 

[RickyScott]

Training aside, the 100 or so us mds can all match in mid to top tier programs. I have concerns about their lack of judgement to begin with that would be compounded should they decide on a program with a sh—y rep like Arkansas, miss, Tennessee, Columbia etc.
For the next 10-20 years, you really don’t have to hire a new grad! There will be plenty of itinerant grads from radoncs prime years- with experience- looking to change jobs, leave fellowships or toxic academic department etc. Since most of us are employed, it’s not like it helps my bank account to hire newbie at a low salary, just the opposite. (The more the hospital pays another radonc, better for me when it comes to contract renewal)

 

[jondunn]

 

[Ray D. Ayshun]

Why don't we just approach that trend like all of the trials attempting to eliminate radiotherapy? A 3% drop isn't significant. In all seriousness, that trend pretty much exactly corresponds to the competitiveness of the field.

 

[elementaryschooleconomics]

Why don't we just approach that trend like all of the trials attempting to eliminate radiotherapy? A 3% drop isn't significant. In all seriousness, that trend pretty much exactly corresponds to the competitiveness of the field.

Yeah, I think Dan forgot about that pesky confounder of "we became the least desirable speciality in all of medicine during the time frame of this study":

 

[jondunn]

‘For the next 10-20 years, you really don’t have to hire a new grad!’

when do we think this is going to start? What is the prediction?

 

[RickyScott]

‘For the next 10-20 years, you really don’t have to hire a new grad!’

when do we think this is going to start? What is the prediction?

I would say match toally tanked 3 years ago. If I was looking, maybe next year or the following would be last year to consider hiring a new grad . Even today there are plenty of radoncs with several years experience and on paper far exceed me, looking to get out of exploitative or rural jobs.