Rad Onc Twitter

[deleted774703]

I can’t figure this Katz guy out.

Sometimes he seems to advocate for community sites.

Others times he shows sub-servitude to academic centers

Maybe he’s just king at playing the game and I should learn lol

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[Mandelin Rain]

You'd think it's ****ing impossible to draw circles after spending 4 years learning how to draw circles.

 

[scarbrtj]

I can’t figure this Katz guy out.

Sometimes he seems to advocate for community sites.

Others times he shows sub-servitude to academic centers

Maybe he’s just king at playing the game and I should learn lol

He is very good. Known as "subatomicdoc" on Twitter right? Subatomic particles: wave/particle duality. The more we know position, less we know velocity, and vice versa. Makes sense.

 

[PhotonBomb]

I can’t figure this Katz guy out.

Sometimes he seems to advocate for community sites.

Others times he shows sub-servitude to academic centers

Maybe he’s just king at playing the game and I should learn lol

I think you don’t get that people don’t have to be on a ‘team’ haha

 

[deleted774703]

I think you don’t get that people don’t have to be on a ‘team’ haha

haha yes I’ve chosen my team

radonc is like NFL NBA MLB (RW). Need a team

throws me off when a golfer joins the mix

 

[Mandelin Rain]

This whole debate is a bit sad. Why train residents if you view them as unfit to treat the moment they step outside of your department? Whose fault is that?

The daisy chain of academic types looking to coyly lap this up is equally disturbing. It isn't the ranting of a demented old man (well, in part it is), it's what these people honestly believe in their hearts. That they are better solely by virtue of the name above their own on the white coat.

Med students: Is this the field you want? It's gross.

 

[scarbrtj]

I think you don’t get that people don’t have to be on a ‘team’ haha

TEAM. Together Everyone Achieves More.

 

[PhotonBomb]

This whole debate is a bit sad. Why train residents if you view them as unfit to treat the moment they step outside of your department? Whose fault is that?

The daisy chain of academic types looking to coyly lap this up is equally disturbing. It isn't the ranting of a demented old man (well, in part it is), it's what these people honestly believe in their hearts. That they are better solely by virtue of the name above their own on the white coat.

Med students: Is this the field you want? It's gross.

Yo he got Ratioed man.

 

[elementaryschooleconomics]

Simul nailed it here (as always).

This is currently a serious issue in American politics as well (I won't approach that topic any closer than that). People simultaneously seem to understand and not understand that their names and position have power on Twitter (see above: position v. velocity).

I've hung around Ralph. I've seen him speak in person a few times. He knows what he contributed to the field. He should understand that someone in his position SHOULD NOT make claims like "all curative cases should be treated at high volume centers" outside of, hmm, I dunno - a manuscript with sufficient data to back that claim up?

A term I heard recently which infects and describes all of Medicine but especially Radiation Oncology:

For the love of God, people, stop practicing Eminence Based Medicine.

Ralph, either back your claims up or stop making them.

 

[elementaryschooleconomics]

Ralph, just now: Wait what words have consequences?

 

[Mandelin Rain]

Yo he got Ratioed man.

Being ratioed is a "complex subject" but an "important topic" that "needs more data". There are several "retrospective reviews" and "post hoc analyses" demonstrating that being ratioed doesn't mean anything.

 

[scarbrtj]

View attachment 288068

Simul nailed it here (as always).

This is currently a serious issue in American politics as well (I won't approach that topic any closer than that). People simultaneously seem to understand and not understand that their names and position have power on Twitter (see above: position v. velocity).

I've hung around Ralph. I've seen him speak in person a few times. He knows what he contributed to the field. He should understand that someone in his position SHOULD NOT make claims like "all curative cases should be treated at high volume centers" outside of, hmm, I dunno - a manuscript with sufficient data to back that claim up?

A term I heard recently which infects and describes all of Medicine but especially Radiation Oncology:

For the love of God, people, stop practicing Eminence Based Medicine.

Ralph, either back your claims up or stop making them.

It's an eminence front!

View attachment 288069

Ralph, just now: Wait what words have consequences?

Maybe we can start a list:
1) Do not take advice about sex from people who've had low volume sexual encounters
#commonsensesneedstoprevail

 

[Mandelin Rain]

How many here, currently in PP, were offered an academic job out of residency? I for one, could have IMMEDIATELY been the GI, Lung, Head and Neck, GU expert at varying different "high-volume" institutions. At that point, my volume was exactly 0.

 

[medgator]

From that standpoint.... even palliative cases are complex! We can consider doses, long-term effects, patient milieu, family dynamics, sociodemographics, the mechanisms/operation of the linear accelerator, if my therapist has a flu prodrome, etc. It's all pretty damn complex. And these trained-before-IMRT MDs... in the majority of cases, they will have sharp physicists and dosimetrists in their departments. Which nearly always cover a multitude of sins. And beyond that, I used to go out and train these "old guys." It might blow some folks' minds, but many are trainable and right now doing good IMRT. You're never as good, or as smart, or as irreplaceable, or as God's-gift-to-medicine, as you think you are. (EDIT: I have seen far too many academic site-specialized rad oncs do shiznit that is crazy/harmful for me to ever worship at that altar either.)

Palliative cases can be some of the most difficult imo esp if re tx and pt has other Comorbid pain syndromes like OA or a herniated disc or something. Very much exam and scan driven

 

[medgator]

How many here, currently in PP, were offered an academic job out of residency? I for one, could have IMMEDIATELY been the GI, Lung, Head and Neck, GU expert at varying different "high-volume" institutions. At that point, my volume was exactly 0.

Bingo. I found pp to be far more intellectually, emotionally and financially fulfilling compared to what I saw in academics a decade ago. Given what has gone since, I think I chose wisely

 

[RadOncMegatron]

He is very good. Known as "subatomicdoc" on Twitter right? Subatomic particles: wave/particle duality. The more we know position, less we know velocity, and vice versa. Makes sense.

Nerd joke level 100%

Well... I'm just waiting till someone brings up the fact that patients know satellite centers =/= The Academic campus they come from. I'm hoping this thing does not go off the rails, but I think I saw at least one patient chime in. Really very crappy if patients are looking at all this on Twitter. Doubt, they would come to SDN, but who knows... If you do there are competent people outside the academic center! In the era of trying to sell yourself and hospital PR machine inc. TV commercials, it gets difficult to say "I am an academic expert at an academic institution, but you can get the same level of care elsewhere."

Patients looking: God help us...

 

[theradiator]

This discussion shows that everyone is insecure in this climate. The academic centers need to justify their higher cost. Moreover, technology promises to democratize high quality through technology empowered information sharing (contouring atlases, eCountour, MedNet, NCCN guidelines, SDN) and technology solutions (automated contouring/planning).

This whole discussion is patently absurd. The most common diagnosed treated in a radiation oncology clinic is breast cancer. This can obviously be handled well in in both academic and community settings. The second most common diagnosis is prostate and many of the highest volume providers are UroRads-affiliated community radiation oncologists and not academic medical centers who have very active surgery programs. Only then do we even get to lung where 74 Gy is irrelevant in the Infinzi era. The cutpoint of 3 in the RTOG 0617 sounds suspiciously like an agenda-driven fishing expedition. Very nice data on the Twitter feed posted by Clive Peedell that volume does not predict outcomes for SBRT lung.

Can we please stop trying to turn radiation oncology into a commodity and aim higher?!? Can we just acknowledge that there is a wide distribution of competence and incompetence but this cannot be predicted with blunt instruments like "academic", "community" or even "volume".

 

[RadOncDoc21]

How many here, currently in PP, were offered an academic job out of residency? I for one, could have IMMEDIATELY been the GI, Lung, Head and Neck, GU expert at varying different "high-volume" institutions. At that point, my volume was exactly 0.

Same here, I turned down 2 academic positions and would have been considered a “high volume” lung, H&N and GI god.

 

[OTN]

What, EXACTLY, is Dr. Willers going to do differently to treat that Stage III NSCLC than I, a lowly "community" radonc will? He thinks he can treat lung cancer better as a radonc, because that's all he treats. Ok, so tell me exactly what he's going to do differently? Anything? I don't want to hear the "hard for community docs to rally PT/dietician/etc resources" because that's 100% a lie.

 

[Mandelin Rain]

I

Same here, I turned down 2 academic positions and would have been considered a “high volume” lung, H&N and GI god.

But now, you are not fit to treat them. The name on the white coat is all that matters, IMO.

 

[RadOncDoc21]

I

But now, you are not fit to treat them. The name on the white coat is all that matters, IMO.

So sad, I was better qualified as a non board certified chief resident than I am now. We should only have one center in the world treat all cancers!

 

[Mandelin Rain]

What, EXACTLY, is Dr. Willers going to do differently to treat that Stage III NSCLC than I, a lowly "community" radonc will? He thinks he can treat lung cancer better as a radonc, because that's all he treats. Ok, so tell me exactly what he's going to do differently? Anything? I don't want to hear the "hard for community docs to rally PT/dietician/etc resources" because that's 100% a lie.

He's going to have HIS dosimetrist fuse the PET.

 

[OTN]

This discussion shows that everyone is insecure in this climate. The academic centers need to justify their higher cost. Moreover, technology promises to democratize high quality through technology empowered information sharing (contouring atlases, eCountour, MedNet, NCCN guidelines, SDN) and technology solutions (automated contouring/planning).

This whole discussion is patently absurd. The most common diagnosed treated in a radiation oncology clinic is breast cancer. This can obviously be handled well in in both academic and community settings. The second most common diagnosis is prostate and many of the highest volume providers are UroRads-affiliated community radiation oncologists and not academic medical centers who have very active surgery programs. Only then do we even get to lung where 74 Gy is irrelevant in the Infinzi era. The cutpoint of 3 in the RTOG 0617 sounds suspiciously like an agenda-driven fishing expedition. Very nice data on the Twitter feed posted by Clive Peedell that volume does not predict outcomes for SBRT lung.

Can we please stop trying to turn radiation oncology into a commodity and aim higher?!? Can we just acknowledge that there is a wide distribution of competence and incompetence but this cannot be predicted with blunt instruments like "academic", "community" or even "volume".

The academics believe they should be treating all breast cancer as well. Dr. Benjamin Smith of MDACC told a patient of mine I would not be able to spare her heart with radiation, as that could only be done at a "high volume center" such as MDACC. I called him up and talked with him, told him what technique I was going to use, then asked if he had any problem with my plan. Unsurprisingly, he said he did not. At least have the gumption to admit to my face what you told my patient.

 

[Mandelin Rain]

So sad, I was better qualified as a non board certified chief resident than I am now. We should only have one center in the world treat all cancers!

Put it in Peoria!

 

[PhotonBomb]

 

[Mandelin Rain]

Ratioed directly to appreciation.

 

[Mandelin Rain]

You know what is actually real life terrible care? Advertising to treat pediatric patients with "X-Rays or electron beams" when there is a proton setup in town and/or St. Jude's exists.

Mind your own house Ralph.


"All radiation oncology equipment is located on site at the University of Chicago Medicine's Hyde Park medical campus, so there’s no need to go outside or be transported by vehicle to receive treatment. A convenient tunnel connects Comer Children’s to the radiation oncology department, so kids can receive their treatment and then recover in the comfort of their patient room without dealing with weather, traffic or other outside distractions."

Apparently, forcing patients to travel is okay as long as it isn't away from University of Chicago. Even if that travel ends in documented better outcomes for children.

It's this level of hypocrisy that should not be allowed to stand.

 

[metallica81788]

There is definitely a new era in our field where the academic centers are starting to become more aggressive in regards to getting their numbers. I’ve had 3 instances where a patient was told they needed to have “gamma knife” when they easily could have received “Varian-sword.”

This is huge. I've heard that whole brain is "Jurassic" for an ECOG 3-4 instead of 3-4 framed Gamma sessions 2 hours from the patients' home, academic centers filling up their Gamma Knives by poaching potential CyberKnife patients (CyberKnife was closer to home by a lot), and inpatient ENT teams telling their patients they will "die" if they don't get their adjuvant treatment at the academic center. Even basic palliative treatments are being pushed and stolen from community centers.

 

[Mandelin Rain]

The academic mission of rad onc in this country went out the window a while ago.

Think of all the advances in clinical radiation oncology that have occurred in the past 15 years? How many were born in America? We've had a bunch of poorly designed trials fail. How many breakthroughs?

 

[seper]

Palliation has definitely become more of an opportunity, with advent of new technologies. It's probably like that throughout other specialties. Neurosurgeons used laugh at the notion of craniotomy for a brain met.

This is huge. I've heard that whole brain is "Jurassic" for an ECOG 3-4 instead of 3-4 framed Gamma sessions 2 hours from the patients' home, academic centers filling up their Gamma Knives by poaching potential CyberKnife patients (CyberKnife was closer to home by a lot), and inpatient ENT teams telling their patients they will "die" if they don't get their adjuvant treatment at the academic center. Even basic palliative treatments are being pushed and stolen from community centers.

 

[scarbrtj]

Palliation has definitely become more of an opportunity, with advent of new technologies. It's probably like that throughout other specialties. Neurosurgeons used laugh at the notion of craniotomy for a brain met.

Almost like palliation not the preferred nomenclature anymore for these presumptively non curative cases; “chronic disease management” a better descriptor.

 

[scarbrtj]

It's an eminence front!



Maybe we can start a list:
1) Do not take advice about sex from people who've had low volume sexual encounters
#commonsensesneedstoprevail

2) The IAEA should not be encouraging building new centers in developing countries or getting new rad oncs into developing countries for curative radiation therapy; it should instead be funding travel/mass exodus of cancer patients in developing countries to high volume centers in the developed world
#commonsensesneedstoprevail

 

[Haybrant]

Why is this conversation even happening. What’s the point, are we all of a sudden going to just do it? Its a conversation that literally happened 5 years ago and 5 years before that and 5 years before that and guess what it, it did nothing to change anything we’re all still here treating just like we did before. It’s what happens when academics try to weigh in on big boy topics. RW has an opinion and no practical plan basically ever, he’s not an actual leader.

 

[Bequerel]

Just a dumb community general radiation oncologist here. Should I quit enrolling my p16+ oropharyngeal cancers on RTOG trials? How did my podunk department even get credentialed to participate in these trials?

 

[RadOncMegatron]

Just a dumb community general radiation oncologist here. Should I quit enrolling my p16+ oropharyngeal cancers on RTOG trials? How did my podunk department even get credentialed to participate in these trials?

Nah, you good.

p16 negative >Tis though you should send. Those are tough ones.

 

[PhotonBomb]

no comment?

 

[medgator]

no comment?

Having worked in an example of such a group previously myself, simuls point is spot on and well taken... Basically boomers in pp that wanted to be as busy as possible to rake in the pro fees.

One example, they rather put fields on and prescribe to a depth rather than take the time to contour and properly generate a 3D dvh etc. when treating groin or sclv nodes. Some of them don't even contour parotids for IMRT.

I think it is less common these days, but probably still happens

 

[Old rad onc]

I would trust the old guy trained in the early 90's to treat bread and butter cases glottic, but if I'm choosing to send my patient with the skull base chordoma closer to home, I want to send to someone that knows what they are doing. Nothing to do with academics vs PP or generalist vs specialist. To be honest, even for a standard tonsil IMRT case, I want to send to someone who I would 'guess' knows what they are doing based on when they trained.

I'm an age-ist when it comes to Rad Onc. Sue me. If you trained before IMRT, I don't trust you know what you're doing in head and neck.

I trained in the 90's and over the years I learned alot of new techniques, IMRT, Gamma knife, HDR, XOFT, SBRT. I'm 57 and while some may consider me old, I feel I'm at the peak of my career. I will not be practicing into my 70's. I am far from any academic centers but send out complicated patients that may benefit. I did retraining with all new procedures and had help from younger partners who were in academics. Mine was the first class to recertify so I have taken the written test 3 times including recertification. I treat 60 cases of head and neck/ year and have been doing so for 24 years. I learned things about Body surface anatomy, principles about cancer therapy that are not considered by some so called major academic centers now. (Ie, aggressively treating a lung cancer patient with extensive mets to Brain, lung, Bone, adrenal scalp with SBRT with no viable targeted or chemo available.) I personally think it's about money. I have many friends in academics that i curbside if need be. So I disagree with the comments of ageism. When guys are getting senile or don't know how to treat something then refer it. But you and Medgator will eventually learn a new technique that you have not been trained in but will learn and I suspect will not give those patients up to every new partner that comes.Guys in their 50's are still smart and in some ways better docs than in the first few years of practice..... A good rBut don't take this that I'm putting down the new Intelligence that comes with technology and youth. But protons are not the holy grail, great for brain and chordomas and retreating around the eye but not better in prostate or most other sites.

 

[PhotonBomb]

57 isn’t that old. You still got it.

 

[scarbrtj]

Speaking of dogs... and at the risk of triggering Ralph W...


Varian radiotherapy units coming to VCA cancer centers
All 35 hospitals eventually will install TrueBeam or Halcyon systems
Five VCA Pet CancerCare Centers will be the first of 35 to house Varian radiotherapy systems under a partnership announced between the national hospital chain and manufacturer. VCA Animal Hospitals reported in August that nearly three dozen of its more than 930 clinics would be branded Pet CancerCare Centers and employ board-certified oncology teams that collaborate with a patient’s primary care veterinarian.

 

[GapCalc]

Patients reading this Twitter nonsense is... uncomfortable/cringe-y. I'm not interested in bringing my professional disagreements into a forum where current or future patients can get involved. Hard pass for me on Twitter for that reason.

An anecdote from another field: I happened to chat with a colleague who is a gastroenterologist following a recent tumor board. We were discussing our respective training pathways, and she elected to join a local PP after fellowship. The hospital where we work is roughly a 20 min drive from where she did her GI fellowship. I asked if she and her former training program were on friendly terms, and if they competed for patients in our metro area. She said something illuminating: her GI program wanted to be a tertiary referral center, where only the most complex/difficult cases went. They weren't trying to do everyone's screening colonoscopy or IBS workup. Contrast this to rad onc, where academic centers are trying to be all things to all patients, and if you have to travel an hour each way for 6 weeks, well, don't you want the best?

In residency, we had a visiting professor who was a Breast Cancer Specialist say they had their right-sided DCIS patients drive >1 hr to their Fancy University Program because they had "all the amenities in-house", and could coordinate their care better. This person truly believed that they could deliver better radiation than somewhere closer/more convenient to the patient for patients with low-risk, early stage disease. I don't know what kind of residents this Breast Cancer Specialist was training, but by the end of PGY2 I would say that I was competent to take care of early stage breast cancer patients on treatment, and coordinate their care.

 

[Old rad onc]

57 isn’t that old. You still got it.

Thanks. Part of the reason I came on here 10 years ago is I love this field and hate to see whats going to happen to it. But there really are a lot of smart people on SDN and while this fight won't be easy, the rebellion is in good hands! And could be worse.... we could be protestors in Hong Kong,,,,,,

 

[AlreadyRegretThis]

An anecdote from another field: I happened to chat with a colleague who is a gastroenterologist following a recent tumor board. We were discussing our respective training pathways, and she elected to join a local PP after fellowship. The hospital where we work is roughly a 20 min drive from where she did her GI fellowship. I asked if she and her former training program were on friendly terms, and if they competed for patients in our metro area. She said something illuminating: her GI program wanted to be a tertiary referral center, where only the most complex/difficult cases went. They weren't trying to do everyone's screening colonoscopy or IBS workup. Contrast this to rad onc, where academic centers are trying to be all things to all patients, and if you have to travel an hour each way for 6 weeks, well, don't you want the best?

Where I did residency, we actually could not get our own institution's GI service to do outpatient PEGs in our H&N patients, had to send them out to a nearby PP group. Very different mindset.

 

[medgator]

Where I did residency, we actually could not get our own institution's GI service to do outpatient PEGs in our H&N patients, had to send them out to a nearby PP group. Very different mindset.

That was too mundane for them? Low reimbursement?

In our neck of the woods, gen surg, IR and gi all do it

 

[OTN]

Patients reading this Twitter nonsense is... uncomfortable/cringe-y. I'm not interested in bringing my professional disagreements into a forum where current or future patients can get involved. Hard pass for me on Twitter for that reason.

An anecdote from another field: I happened to chat with a colleague who is a gastroenterologist following a recent tumor board. We were discussing our respective training pathways, and she elected to join a local PP after fellowship. The hospital where we work is roughly a 20 min drive from where she did her GI fellowship. I asked if she and her former training program were on friendly terms, and if they competed for patients in our metro area. She said something illuminating: her GI program wanted to be a tertiary referral center, where only the most complex/difficult cases went. They weren't trying to do everyone's screening colonoscopy or IBS workup. Contrast this to rad onc, where academic centers are trying to be all things to all patients, and if you have to travel an hour each way for 6 weeks, well, don't you want the best?

In residency, we had a visiting professor who was a Breast Cancer Specialist say they had their right-sided DCIS patients drive >1 hr to their Fancy University Program because they had "all the amenities in-house", and could coordinate their care better. This person truly believed that they could deliver better radiation than somewhere closer/more convenient to the patient for patients with low-risk, early stage disease. I don't know what kind of residents this Breast Cancer Specialist was training, but by the end of PGY2 I would say that I was competent to take care of early stage breast cancer patients on treatment, and coordinate their care.

This is a very important point, and not one that I understood when coming out of medical school. Trying to compete with state-funded entities with very, very large marketing budgets who do not have to follow the same payment rules as the rest of us (at least for the 11 centers which are exempt) is not easy.

I underestimated the pressure which would be placed on departmental chairs to expand and did not forsee the growth of academic centers. Naively, I thought radonc departments- like the GI department above- would focus on research which would then be pushed out to the community as new protocols were developed. Clearly, that is not what is happening.

 

[elementaryschooleconomics]

Patients reading this Twitter nonsense is... uncomfortable/cringe-y. I'm not interested in bringing my professional disagreements into a forum where current or future patients can get involved. Hard pass for me on Twitter for that reason.

Ah, but shouldn't we strive for this in the era of patient autonomy? If they're making truly informed decisions, they should see our dirty laundry.

Who wants to tell stories of med school parties first?

 

[AlreadyRegretThis]

That was too mundane for them? Low reimbursement?

In our neck of the woods, gen surg, IR and gi all do it

I never entirely understood but my impression was it was a matter of "not interesting," as these weren't pts with actual GI pathology & procedure schedules were filled in perpetuity with pts they felt more ownership of. Ultimately had to come down to a judgment that the reimbursement wasn't worth chasing, though, right? Because you could increase capacity if it were.

Don't know where IR was in all of this.

 

[RadDoc11]

View attachment 288069

Ralph, just now: Wait what words have consequences?

By his logic, most physician scientists should never treat a patient since many are 20% to maybe 50% clinical at the most. If they aren’t seeing patients as he suggests, maybe we shouldn’t train them clinically at all. So therefore we should only have researchers or clinicians and no clinically active rad oncs should do research and no researchers should be permitted to see patients. Great thinking!!

 

[PhotonBomb]

I never entirely understood but my impression was it was a matter of "not interesting," as these weren't pts with actual GI pathology & procedure schedules were filled in perpetuity with pts they felt more ownership of. Ultimately had to come down to a judgment that the reimbursement wasn't worth chasing, though, right? Because you could increase capacity if it were.

Don't know where IR was in all of this.

IR's bread and butter is 'Boring as **** but keeps the chains moving'

 

[AlreadyRegretThis]

IR's bread and butter is 'Boring as **** but keeps the chains moving'

Yeah, no idea why we weren't sending our PEG tubes to our own IR, I was just told as a resident the first time I dealt with the situation "send them here" and I did like a good minion. & also the patient was getting what they needed in a timely manner so what did I care who was getting the business?

But the interesting thing is those other departments also didn't seem to care about getting the business. GI had other interests, IR either did too or just felt there was enough to go around, no one was making this hard sell that the pp group down the road was worthless or incompetent for even a routine procedure.