Rad Onc Twitter

[DoctwoB]

Good way of picking a treatment. Another way of reducing CO2 emissions would be picking a regimen with a worse OS.

You guys are missing a killer marketing opportunity. Throw some solar panels on the roof and “go green while curing cancer”. “Killing cancer with the power of the Sun” and so on. You could even offer a package to offset their future CO2 use by planting one tree for every QALY gained.

It would also answer the question about why radiation treatments don’t work before 9 and after 5.

In all seriousness though, what’s the power draw on a true beam?

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[Radonc90]

So, the famous Urologist is picking on this radonc crowd.

Haha we are the "button pusher" and he recommends tri-modality for high-risk prostate ca.
I am so glad I don't know him IRL...

PS: The gen surgeons I trained with yrs ago did not consider Urologists surgeons lol...

 

[elementaryschooleconomics]

So, the famous Urologist is picking on this radonc crowd.

Haha we are the "button pusher" and he recommends tri-modality for high-risk prostate ca.
I am so glad I don't know him IRL...

PS: The gen surgeons I trained with yrs ago did not consider Urologists surgeons lol...

Cooperberg sure does seem like a winner. I hope he's not as ham-fisted in the OR as he is on Twitter.

 

[TheWallnerus]

So, the famous Urologist is picking on this radonc crowd.

Haha we are the "button pusher" and he recommends tri-modality for high-risk prostate ca.
I am so glad I don't know him IRL...

Cooperberg sure does seem like a winner. I hope he's not as ham-fisted in the OR as he is on Twitter.

God wasted a perfectly good penis when he put ears on Matt Cooperberg*

*urology joke

 

[TheWallnerus]

45/15 is great. all things being considered I think that’s what makes the most sense, in many ways.

well I will say this and say it sadly

45/15 makes a hellll of a lot more sense than 60/40 under the APM

 

[Lamount]

Well that is a reasonable idea about how OS can improve without PFS or local control improving, which is what was seen in the trial, and to me doesn’t pass the smell test and deserves to be further explored to see if there is some mechanism here.

However my question was about the study being underpowered for PFS, which doesn’t make sense and is simply untrue based on my understanding of statistics.

I *think* you are correct about power, assuming you are trying to detect the same HR for both PFS and OS. If I recall, a simple approximation of sample size is dependent on # events in the control arm… and PFS, by definition, will have the same or more events than OS

 

[jondunn]

well I will say this and say it sadly

45/15 makes a hellll of a lot more sense than 60/40 under the APM

other than the concern for increased toxicity in terms of 3 Gy/fx to the esophagus with concurrent chemotherapy, radio biologically, I am not sure how 3 Gy/day, but giving it at one time, would be worse than splitting it up 6 hours apart at 1.5 Gy/fraction, in terms of tumor control

either way it is 45 Gy delivered in 3 weeks, which I think is probably the most important part of the treatment. would love to see this explored more.

 

[Mandelin Rain]

other than the concern for increased toxicity in terms of 3 Gy/fx to the esophagus with concurrent chemotherapy, radio biologically, I am not sure how 3 Gy/day, but giving it at one time, would be worse than splitting it up 6 hours apart at 1.5 Gy/fraction, in terms of tumor control

either way it is 45 Gy delivered in 3 weeks, which I think is probably the most important part of the treatment. would love to see this explored more.

Wasnt Walsh trial 2.67Gy x 15 directly to the entire esophagus with chemo?

This isnt a big jump really.

 

[jondunn]

i agree, but many will be scared.

 

[radiation]

other than the concern for increased toxicity in terms of 3 Gy/fx to the esophagus with concurrent chemotherapy, radio biologically, I am not sure how 3 Gy/day, but giving it at one time, would be worse than splitting it up 6 hours apart at 1.5 Gy/fraction, in terms of tumor control

either way it is 45 Gy delivered in 3 weeks, which I think is probably the most important part of the treatment. would love to see this explored more.

I think people have started to lose the point of the original turrisi study which was that total dose in SCLC is less important than total number of fractions. Each time you give a fraction of treatment, whether it is 1.5 gy, 1.8 gy, 2 gy, 2.67 gy or 3 gy, you are likely getting some proportional cell kill that is roughly similar amongst the different doses because of a lack of shoulder. So going past 1.5 gy each fraction doesnt help you any more cell kill-wise, but extra dose beyond that goes to normal tissue. Thus, it makes the most sense to get the highest number of fractions in the shortest period of time for small cell given its doubling time. The total dose is likely less important.

I am not sure why people would use 45 gy in 15 fx in any scenario (except for APM reasons). RTOG 0937 used 45/15 and that was a negative trial. The locoregional control was not particularly good plus it was toxic. Its just classic radonc to have a perfect radbio study showing fractionation actually matters and has a survival benefit, then just ignore it. Its also strange to me that BID regimens are not used in extensive stage and PCI (maybe hard to justify BID in mostly palliative cases)

Shout out to the OG Jeremic, who people probably thought 54 gy in 36 fx was crazy 30 years ago. But 17 month median OS for complete responders with some basic 2D radiation still ages pretty well (even in the atezo era)

 

[medgator]

I think people have started to lose the point of the original turrisi study which was that total dose in SCLC is less important than total number of fractions. Each time you give a fraction of treatment, whether it is 1.5 gy, 1.8 gy, 2 gy, 2.67 gy or 3 gy, you are likely getting some proportional cell kill that is roughly similar amongst the different doses because of a lack of shoulder. So going past 1.5 gy each fraction doesnt help you any more cell kill-wise, but extra dose beyond that goes to normal tissue. Thus, it makes the most sense to get the highest number of fractions in the shortest period of time for small cell given its doubling time. The total dose is likely less important.

I am not sure why people would use 45 gy in 15 fx in any scenario (except for APM reasons). RTOG 0937 used 45/15 and that was a negative trial. The locoregional control was not particularly good plus it was toxic. Its just classic radonc to have a perfect radbio study showing fractionation actually matters and has a survival benefit, then just ignore it. Its also strange to me that BID regimens are not used in extensive stage and PCI (maybe hard to justify BID in mostly palliative cases)

Shout out to the OG Jeremic, who people probably thought 54 gy in 36 fx was crazy 30 years ago. But 17 month median OS for complete responders with some basic 2D radiation still ages pretty well (even in the atezo era)

View attachment 345990

You're going to bring an extensive stage patient in for 30-40 fractions? I'm not

 

[TheWallnerus]

I *think* you are correct about power, assuming you are trying to detect the same HR for both PFS and OS. If I recall, a simple approximation of sample size is dependent on # events in the control arm… and PFS, by definition, will have the same or more events than OS

other than the concern for increased toxicity in terms of 3 Gy/fx to the esophagus with concurrent chemotherapy, radio biologically, I am not sure how 3 Gy/day, but giving it at one time, would be worse than splitting it up 6 hours apart at 1.5 Gy/fraction, in terms of tumor control

either way it is 45 Gy delivered in 3 weeks, which I think is probably the most important part of the treatment. would love to see this explored more.

 

[jondunn]

agree that response rates aren’t easy to assess, however distant metastasis is easier, why wasnt that different?

It is intersting that the time from metastasis to death was what led to increased OS. Just would love to know more about how more radiation dose makes that happen. It seems possibly spurious or unaccounted for (because we don’t know about it yet fully) imbalance in biologic factors. Perhaps different immune subtypes.

Response rates are really not good markers in any trial involving radiation, as the imaging changes are very confounding. See SABR COMET, for example

 

[Burt Radnolds]

A few comments. I think 45Gy / 30 is great. Constraints are easier to meet, looks to works as well or better than conventional fractionation. Patients deserve to be offered this if interested. I serve a very rural and poor population as part of my practice and they are categorically unwilling to travel for BID, so I am left to utilize alternatives for those patients. Maybe your pitch is better than mine, but they have no means to temporarily live closer to clinic, no interest in hanging out for 6 hours each day, and no local support organizations that can resolve these issues.

For those patients willing to do BID, I'm just not sure I'm willing to make the jump to 60Gy yet. I made a provocative statement earlier about "dragging" patients in for this, as I wanted to see what the defenders had to say. Would love for the effect to be real, and maybe it is. The PFS/OS thing is strange though and I just can't fully explain it away with what has been said so far.

When I pore over this study, I feel like there are a lot of small imbalances in the study that start to stack up.

In the 45Gy arm, there are more patients >70, worse ECOG, more current smokers, more with >5% weight loss.

I think this likely translated some to the treatment delivery side where you see less chemotherapy given, more dose reductions, more carbo given, and less people completing their radiation in the 45 Gy arm.

And then in the survival curves, you had a fairly immediate separation in survival, again I surmise due to some of these imbalances manifesting well before the treatment effect would be likely to manifest.

I think these imbalances undoubtedly magnified any benefit. Median survival in the 45Gy arm was 22.6 months, which compares unfavorably with CONVERT (30 months) and RTOG 0538 (29 months) (yeah yeah, cross trial comparison bad...). Also is a very small study at 170 pts and susceptible to a few outliers driving results. However, there does seem to be something going on here than can't be fully explained away either. Having had some time to think about it more, if a highly motivated healthier younger patient wanted to try it, I think there is enough there that I would be willing to discuss and perhaps include it as part of my standard initial consultation discussion. I can't say many of my small cell patients fit that bill, but always nice to have options as we attempt to maximize survival in a horrible disease. Ironically, these patients will be the most likely to have private insurance with higher probably of unpleasant evilcore interactions.

All this small cell talk probably needs another thread so we can keep appropriately gawking at radoncrocks twitter nonsense.

 

[theradiator]

View attachment 345967

This is an absolute gem of a statement.

"[Hypofractionation] doesn't change the need for RadOnc, just the reimbursement." - Kenneth Olivier

In the context of "we're not training too many Radiation Oncologists". Man, I think one or two things have changed since March 12th, 2019. I don't want to pile on the other folks in that series of Tweets, so I'll just say that reading everything there is like opening a time capsule...and that wasn't even three years ago!

Just a pet peeve but the whole notion that we should celebrate saving patients 2 weeks of radiation to achieve statistically non-inferior disease control is really *****ic. Needs to be called out every time

 

[TheWallnerus]

Maybe your pitch is better than mine, but they have no means to temporarily live closer to clinic, no interest in hanging out for 6 hours each day

(Usually goes one of two ways)
Me: This is a cancer that's a little bit unusual in that we give radiation two times a day 6 hours apart.
Patient: OK.

Me: This is a cancer that's a little bit unusual in that we give radiation two times a day 6 hours apart.
Patient: I don't want to come in two times a day. Do I have to?
Me: No. We can treat once a day. But twice a day probably offers better survival and cure rates.
Patient: OK.

I once visited an RT clinic in Indonesia. A bus would bring rural patients in from surrounding villages in the morning like at 7 am. It wouldn't return until 5 to take them back home. Patients and their whole families would arrive, bringing snacks and sack lunches, prepared to encamp in and around the center for the whole day. They were seemingly happy, no one complained, etc.

Having had some time to think about it more, if a highly motivated healthier younger patient wanted to try it, I think there is enough there that I would be willing to discuss and perhaps include it as part of my standard initial consultation discussion.

This was the "take" I expected from the lung literati; and then I remembered, no one really "loves" the Turrisi study in the way that we seem to love other level 1 evidence. We are rad oncs, and here is a radiotherapy that offers increased survival (surpassing the unloved Turrisi study) for a very lethal cancer. You'd think we'd be rather enthused. Instead cold water was immediately dumped on the study's head by American rad oncs. We won't see another survival improving pure radiotherapy study of its sort maybe for another decade (or more). And to Ashwin Shinde's point, it should be f**king illegal that Evicore can say they won't approve it. It's one of the best examples we have where Evicore is killing people. (*NOT* hyperbolic.)

 

[RickyScott]

(Usually goes one of two ways)
Me: This is a cancer that's a little bit unusual in that we give radiation two times a day 6 hours apart.
Patient: OK.

Me: This is a cancer that's a little bit unusual in that we give radiation two times a day 6 hours apart.
Patient: I don't want to come in two times a day. Do I have to?
Me: No. We can treat once a day. But twice a day probably offers better survival and cure rates.
Patient: OK.

I once visited an RT clinic in Indonesia. A bus would bring rural patients in from surrounding villages in the morning like at 7 am. It wouldn't return until 5 to take them back home. Patients and their whole families would arrive, bringing snacks and sack lunches, prepared to encamp in and around the center for the whole day. They were seemingly happy, no one complained, etc.


This was the "take" I expected from the lung literati; and then I remembered, no one really "loves" the Turrisi study in the way that we seem to love other level 1 evidence. We are rad oncs, and here is a radiotherapy that offers increased survival (surpassing the unloved Turrisi study) for a very lethal cancer. You'd think we'd be rather enthused. Instead cold water was immediately dumped on the study's head by American rad oncs. We won't see another survival improving pure radiotherapy study of its sort maybe for another decade (or more). And to Ashwin Shinde's point, it should be f**king illegal that Evicore can say they won't approve it. It's one of the best examples we have where Evicore is killing people. (*NOT* hyperbolic.)

Can also give radiation 4 hours apart as cord almost never a concern here.

 

[madchemist89]

I think that the primary advantage of bid treatment in sclc is acceleration. Hyperfractionation was done to try to reduce late toxicity from the accelerated schedule.

 

[TheWallnerus]

Can also give radiation 4 hours apart as cord almost never a concern here.

True. BTW for the residents, they came completely "off cord" in the Turrisi Intergroup study after 36 Gy (usually AP/PA to 36 Gy and the last 9 Gy using opposed tangents). Tx volumes were MUCH larger back then. They were very cautious about possible late side effects from hyperfractionating even though there was at least theoretical data at the time that small fraction sizes led to less late effects. The first mention of "linear quadratic" in the Red Journal was in the 1980s, the same decade this study started accruing. I can promise you that Andrew Turrisi could not do a BED calc at neither the start nor the finish of this study.

 

[jondunn]

‘ But twice a day probably offers better survival and cure rates.’

I don’t think we can accurately say this and be confident about it. What do you base this on?

I agree with getting it done quickly, but you’re more bold than I to say this.

 

[jondunn]

A few comments. I think 45Gy / 30 is great. Constraints are easier to meet, looks to works as well or better than conventional fractionation. Patients deserve to be offered this if interested. I serve a very rural and poor population as part of my practice and they are categorically unwilling to travel for BID, so I am left to utilize alternatives for those patients. Maybe your pitch is better than mine, but they have no means to temporarily live closer to clinic, no interest in hanging out for 6 hours each day, and no local support organizations that can resolve these issues.

For those patients willing to do BID, I'm just not sure I'm willing to make the jump to 60Gy yet. I made a provocative statement earlier about "dragging" patients in for this, as I wanted to see what the defenders had to say. Would love for the effect to be real, and maybe it is. The PFS/OS thing is strange though and I just can't fully explain it away with what has been said so far.

When I pore over this study, I feel like there are a lot of small imbalances in the study that start to stack up.

In the 45Gy arm, there are more patients >70, worse ECOG, more current smokers, more with >5% weight loss.

View attachment 345992

I think this likely translated some to the treatment delivery side where you see less chemotherapy given, more dose reductions, more carbo given, and less people completing their radiation in the 45 Gy arm.

View attachment 345993

And then in the survival curves, you had a fairly immediate separation in survival, again I surmise due to some of these imbalances manifesting well before the treatment effect would be likely to manifest.

View attachment 345994


I think these imbalances undoubtedly magnified any benefit. Median survival in the 45Gy arm was 22.6 months, which compares unfavorably with CONVERT (30 months) and RTOG 0538 (29 months) (yeah yeah, cross trial comparison bad...). Also is a very small study at 170 pts and susceptible to a few outliers driving results. However, there does seem to be something going on here than can't be fully explained away either. Having had some time to think about it more, if a highly motivated healthier younger patient wanted to try it, I think there is enough there that I would be willing to discuss and perhaps include it as part of my standard initial consultation discussion. I can't say many of my small cell patients fit that bill, but always nice to have options as we attempt to maximize survival in a horrible disease. Ironically, these patients will be the most likely to have private insurance with higher probably of unpleasant evilcore interactions.

All this small cell talk probably needs another thread so we can keep appropriately gawking at radoncrocks twitter nonsense.

Thanks this is what we needed. Great info.

Is it possible that people in experimental arm, due to being better protoplasm as you outline here, were thus more eligible for further second and third line therapies, leading to the increased time between progression and death?

 

[TheWallnerus]

'But twice a day probably offers better survival and cure rates.’

I don’t think we can accurately say this and be confident about it. What do you base this on?

Probably about 4 things off the top of my head.

First, the Intergroup. Better survival with 45/30 bid vs 45/25. Always this is met with cries of "inadequate control arm," but...
Second, every attempt at QD dose escalation, even up to 70 Gy, using larger fx sizes, has been bootless in toppling 45/30.
Third, why would we attempt going to beyond 60 Gy total doses in large-volume thoracic RT when we have data to suggest this decreases survival? That seems quite...weird...to be a fan of larger-fraction-size 66-70Gy for SCLC but eschew it in NSCLC.
Fourth, we now have the first dose-escalation data that did topple the OS of 45/30... and it's a twice a day regimen.

Again, to repeat, it seems like the data is attempting to show us that (small fx size) twice a day is good for SCLC.

 

[jondunn]

Probably about 4 things off the top of my head.

First, the Intergroup. Better survival with 45/30 bid vs 45/25. Always this is met with cries of "inadequate control arm," but...
Second, every attempt at QD dose escalation, even up to 70 Gy, using larger fx sizes, has been bootless in toppling 45/30.
Third, why would we attempt going to beyond 60 Gy total doses in large-volume thoracic RT when we have data to suggest this decreases survival? That seems quite...weird...to be a fan of larger-fraction-size 66-70Gy for SCLC but eschew it in NSCLC.
Fourth, we now have the first dose-escalation data that did topple the OS of 45/30... and it's a twice a day regimen.

Again, to repeat, it seems like the data is attempting to show us that (small fx size) twice a day is good for SCLC.

Yeah but both the 66 Gy and 70 gy trials, while
Not showing that it was BETTER, looked to be equivalent. I know, I know, not designed to be non inferiority trials.

But having two modern trials show the same OS with daily vs BID is a far cry from showing that BID is BETTER!

 

[TheWallnerus]

Yeah but both the 66 Gy and 70 gy trials, while
Not showing that it was BETTER, looked to be equivalent not significantly different. I know, I know, not designed to be non inferiority trials.

But having two modern trials show the same OS OSs not significantly different with daily vs BID is a far cry from showing that BID is BETTER!

I don't need to run a trial to show you that the OAR DVHs of a 45 Gy plan will be better than the OAR DVHs of a 70 Gy plan, do I?

ALARA.

 

[jondunn]

I don't need to run a trial to show you that the DVHs of a 45 Gy plan will be better than the DVHs of a 70 Gy plan, do I?

No of course not but this is a totally different factor than what we are discussing.

For the record, I like short treatment courses for small cell. I just don’t think I can confidently tell a patient it offers better OS or better cure rates and think that’s supported by the current data.

Long course Daily treatment has not proven to be better. That doesn’t mean we know that BID cures more people. Leap.

 

[TheWallnerus]

Long course Daily treatment has not proven to be better. That doesn’t mean we know that BID cures more people. Leap.

It would be cruel to bring patients in twice a day if you didn't have evidence that it was better than once a day. "Leap" here is not a leap, it's fake news. (There's always fake news surrounding twice a day in SCLC.)

People have to intellectually contort themselves so as not to admit the fact that twice a day radiotherapy in small cell lung cancer has proven itself better than once a day. (Again I think it comes from twice a day counter-programming in residency.) If you're saying it's not proven to be better as in "Can anything really ever be proven?"... OK. I'll grant you that. But are there two randomized trials showing twice a day is survival-improving better? Yes. (Will you need three?) And how many showing that once a day is better than twice a day?

 

[jondunn]

Okay, I think we have gotten to the point of the discussion where you are being intentionally obtuse. I made the points. Others reading can make their own interpretations.

 

[medgator]

People have to intellectually contort themselves so as not to admit the fact that twice a day radiotherapy in small cell lung cancer has proven itself better than once a day. (Again I think it comes from twice a day counter-programming in residency.) If you're saying it's not proven to be better as in "Can anything really ever be proven?"... OK. I'll grant you that. But are there two randomized trials showing twice a day is survival-improving better? Yes. (Will you need three?) And how many showing that once a day is better than twice a day?

Still never understood if 45/25 was actually considered an appropriate treatment regimen back then. Guess it was, but just seems odd.

 

[TheWallnerus]

Still never understood if 45/25 was actually considered an appropriate treatment regimen back then. Guess it was, but just seems odd.

45/25 was oft gainsaid. People were quite sure 70/35 would be better. Keep hope alive and so forth. Almost a quarter century later to quote the @jondunn's: it's a "leap" to think 45/30 (a LOT less dose, and less fractions, than 70/35) is better.

 

[Burt Radnolds]

I don't need to run a trial to show you that the OAR DVHs of a 45 Gy plan will be better than the OAR DVHs of a 70 Gy plan, do I?

ALARA.

I agree with this premise. There have been some patients that I have explicitly told I can only treat them BID as it was apparent I could only achieve constraints for that regimen.

However I also do not see significantly worse esophagitis and pneumonitis in CONVERT and RTOG for dose escalated Qday, despite the ALARA point.

Also, of the two studies with "appropriate" dose escalation for Qday regimens vs 45 BID, one showed numerically better median survival for Qday and another for BID (yeah I know neither met endpoint). I'm not a nonbeliever or believer, I'm a realist using the tools at my disposal to care for patients. Maybe I'm too much of an empath, but I just don't see enough to fully twist a patients arm if I think they are somewhat close.

Me: This is a cancer that's a little bit unusual in that we give radiation two times a day 6 hours apart.
Patient: I don't want to come in two times a day. Do I have to?
Me: No. We can treat once a day. But twice a day probably offers better survival and cure rates.
Patient: OK.

I'm dead serious here but some of my patients will straight up say they want the once daily when given this, no BS. Typically the ones who can barely afford to get to clinic and live an hour plus away.

 

[evilbooyaa]

How can you be underpowered for PFS, when it is a more commonly occurring event than seen with OS? That doesn’t make sense.

Am I incorrect in my understanding?

I will give you that this is a fair criticism, as is @radmonckey 's analysis of differences between the groups driving the OS benefit. I agree, that it is not the cleanest, most slam dunk trial that checks off all the boxes in our brain of --> RT helps LC, thus RT should help PFS, and if that PFS difference is significant enough, then OS will benefit.

Perhaps all of this can be explained by small difference sin baseline characteristics, that on their own are not SS, but combined have a hidden 'protoplasm' score that is worse in the group getting 45/30.

I will not pretend to now statistics well enough to come up with statistical alternatives as to why PFS was not SS improved, but OS was. The mechanism of why that happened would be conjecture. Below is a potential example:

The distant met rate progression is the same (so PFS is the same) but the local disease is completely eradicated at a higher rate (which would not be captured with either 'response rate' or 'PFS' variables) with the higher local RT dose, with less of a probabilityin terms of seeding future metastases (similar to treating the primary paradigm in STAMPEDE improving OS in M1 prostate cancer), thus the length of time from when patients developed mets to when they died was longer, because the time it took for small volume metastatic disease, on its own, to kill a patient is less than if the same small volume metastatic disease PLUS local recurrence seeding new mets. Perhaps patients in 45/30 had more late local recurrences leading to patient death directly to the effects of long-term local recurrence.

 

[TheWallnerus]

I'm dead serious here but some of my patients will straight up say they want the once daily when given this, no BS. Typically the ones who can barely afford to get to clinic and live an hour plus away.

Very true. And then...

"You go to war with the army you have. Not the army you want."
- Don Rumsfeld

 

[CurbYourExpectations]

 

[CurbYourExpectations]

 

[CurbYourExpectations]

please protect my anonymity and delete if i'm being too much

 

[elementaryschooleconomics]

please protect my anonymity and delete if i'm being too much

 

[jondunn]

please protect my anonymity and delete if i'm being too much

Let me ask you one question - do you respect wood?

 

[Ray D. Ayshun]

Let me ask you one question - do you respect wood?

This is a tempting christmas present for my wife no less

This item is unavailable - Etsy

Find the perfect handmade gift, vintage & on-trend clothes, unique jewelry, and more… lots more.

www.etsy.com

 

[elementaryschooleconomics]

Meanwhile, we can't even get Wallner et al to stop giving us a test with Western Blots and making sure we know what DNA-PK phosphorylates.

 

[brushbeamscanning]

Not to be devil's advocate but what's stopping some PDs from delaying graduation for some residents that they deem unfit? I don't think increasing subjectivity is the answer, would opt for better objective measures.

As a counterpoint, alternative pathway folks who some are probably competent enough to be independently practicing with minimal additional training.

 

[Radonc90]

I agree...

Some PGY-3 gensurg residents do very well in the O.R.
Some PGY-5 gensurg residents are terrible.
It is more than that, not just surg skills, it is maturity, experience, wisdom.
Too complicated to reduce gensurg to < 5 yrs.
Pt's life is at stake.
You are not talking about playing violin here, although playing violin is 100x harder than operating...

The idea of graduating based on skill (and not time) comes from the world of music.
FYI, Midori, the violinist, performed publicly at the age of 6, and at the age of 15 already became a professional violinist...

PS: At the age of 15, I was learning how to wipe my nose...

Midori (violinist) - Wikipedia

en.wikipedia.org

 

[Clean7795]

Competency based education will very rarely (if ever) be used to graduate residents early, especially surgical residents.

Academic programs cannot run without medicine & surgery residents handling the floors. That means the program needs X number of residents per year (otherwise the workload becomes more unbearable than it already is).

In the best case it will empower residents to ask staff to let them do more of X procedure or maybe chop off one or two useless months at the very end of residency.

 

[evilbooyaa]

@CurbYourExpectations you have picked an excellent avatar for your posts ITT, thank you for your meme contributions.

 

[elementaryschooleconomics]

Competency based education will very rarely (if ever) be used to graduate residents early, especially surgical residents.

Academic programs cannot run without medicine & surgery residents handling the floors. That means the program needs X number of residents per year (otherwise the workload becomes more unbearable than it already is).

In the best case it will empower residents to ask staff to let them do more of X procedure or maybe chop off one or two useless months at the very end of residency.

Not to be devil's advocate but what's stopping some PDs from delaying graduation for some residents that they deem unfit? I don't think increasing subjectivity is the answer, would opt for better objective measures.

As a counterpoint, alternative pathway folks who some are probably competent enough to be independently practicing with minimal additional training.

These are excellent points.

I guess the question I think we need to ask is: do we believe we have perfected our training? Obviously, this question can be directed at all of medicine. But for RadOnc, I would argue that the rules of our modern training pathway are over 20 years old (from when residency length officially became four years long). Sure, certain things have been tinkered with (written board exams used to be delivered over two consecutive days, for example) but it's fundamentally the same.

It goes without saying that a lot has changed over the last 20 years, and I think Radiation Oncology - a specialty so tied to technology - has changed more than most. Change for the sake of change is bad. But, if our goal is truly to produce excellent physicians, I think it is worth re-evaluating a system that was designed when Blockbuster asked us to rewind our VHS tapes before returning them. I think I'm being generous with my timeline estimate - I think the majority of our training pathway ideas predate even Blockbuster.

If competency-based education isn't possible because a hospital system can't survive without cheap resident labor, then perhaps it's worth questioning if that system is appropriate in the first place. If a resident has reached the end of a time-limited pathway and hasn't acquired the necessary skills for independent practice, shouldn't that resident be held back for the safety of patients?

However, maybe the system as it exists is the best we can do, and we shouldn't try to improve it. I just sometimes get the feeling that we're given an Oculus Quest VR headset and, when we ask how to use it, we're given a dusty instruction manual to the original Nintendo console and told "this was good enough for us, and it's good enough for you, too".

 

[jondunn]

This was posted today and then deleted. Did Koong break the streak by posting this?!

 

[elementaryschooleconomics]

This was posted today and then deleted. Did Koong break the streak by posting this?!

Interesting, what does that even mean? I'm not aware of any sort of universal definition of a "Level 1" or "Level 2" safety event classification, is this an Anderson thing? Or am I out of the loop?

 

[thecarbonionangle]

Interesting, what does that even mean? I'm not aware of any sort of universal definition of a "Level 1" or "Level 2" safety event classification, is this an Anderson thing? Or am I out of the loop?

It is all in Brocade, brah, you will see!

 

[medgator]

 

[TheWallnerus]

Not a Pollyanna.

But he was, once upon a time,* a Cassandra. Which for a moment made it seem like he had channeled Pandora.

Minerva save us. He is now 100% he/him/his.



* MODS: could be a sticky

 

[elementaryschooleconomics]

Not a Pollyanna.

But he was, once upon a time,* a Cassandra. Which for a moment made it seem like he had channeled Pandora.

Minerva save us. He is now 100% he/him/his.



* MODS: could be a sticky

“If someone is able to show me that what I think or do is not right, I will happily change, for I seek the truth, by which no one was ever truly harmed. It is the person who continues in his self-deception and ignorance who is harmed.”

― Marcus Aurelius

I mean, if the authors of that piece are going to bring Aurelius in, there's some other passages they could consider, too.