Rad Onc Twitter

  • Thread starter Thread starter deleted1002574
  • Start date Start date
This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
RealSimulD said:
@evilbooyaa - they aren't good guys. They never have been. They are just people with agendas. I'm not saying I'm a hero or that SDN are heroes. Nobody is. I hope that you all see that. We all have our agendas - mine just happens to be transparent - I hate hypocrisy and I hate residency expansion.

We can't be in this world that - if they agree with me, they are smart and good, but if they disagree with me, they are dumb and evil. I've disagreed with so many people, but in general I feel like we can get along. When these people get disagreed with, they are bloodthirsty. When you say "harrassment" and "mansplaining" you are trying to get someone in trouble. This is nasty and they are behaving in a manner that is unbecoming of a professional.

I can't get in their heads, but I am relatively certain they are talking **** about how to further marginalize us. That's why I'm working with ACRO, because that is probably our only way to have a voice. There is very little to lose by joining ACRO and much to gain. Please sign up!
Click to expand...

I mean... SY came to SDN to engage which was a 'good gal' move in my view. BK dropped a spot from his residency for a year(I think?).

I get what you're saying - I'm not against someone disagreeing with me. I think shutting down an argument with inappropriate use of mainsplaining or sexism is wrong.
 
jondunn said:
Wow!

Where does KO get his facts?!
Click to expand...
It's typical head in the sand ivory tower BS. It shocks me that a thought leader like KO can't think critically. To break it down, what has happened in our field that has caused salaries to go up?

1) Reimbursements either go down or we fight to keep them the same every year
2) Number of fractions per treatment course continues to go down
3) Indications for RT are diminishing or at risk of diminishing
4) We are training more physicians = more mouths to feed = less food for each
5) We are probably treating more metastatic patients with higher cost treatments (SRS/SBRT)

Number 5 doesn't outweight 1-4. On a per physician basis, the only way that salaries could stay the same with the economics above is if we are individually doing more work.

KO wants to say that because starting salaries have gone up based on resident surveys, salaries are going up. The two are not equipoise. We are replacing expensive, high volume, experienced physicians with cheap, high volume, well trained physicians. We're raising the floor a little on salary while completely collapsing the ceilings. There is less and less opportunity for partnership/ownership and we are increasingly hospital employed/commoditized. But hey, I guess a translational scientist that's spent the last 25 years at a single academic institution has all the "facts" on the economics of community practice.
 
RSAOaky said:
It's typical head in the sand ivory tower BS. It shocks me that a thought leader like KO can't think critically. To break it down, what has happened in our field that has caused salaries to go up?

1) Reimbursements either go down or we fight to keep them the same every year
2) Number of fractions per treatment course continues to go down
3) Indications for RT are diminishing or at risk of diminishing
4) We are training more physicians = more mouths to feed = less food for each
5) We are probably treating more metastatic patients with higher cost treatments (SRS/SBRT)

Number 5 doesn't outweight 1-4. On a per physician basis, the only way that salaries could stay the same with the economics above is if we are individually doing more work.

KO wants to say that because starting salaries have gone up based on resident surveys, salaries are going up. The two are not equipoise. We are replacing expensive, high volume, experienced physicians with cheap, high volume, well trained physicians. We're raising the floor a little on salary while completely collapsing the ceilings. There is less and less opportunity for partnership/ownership and we are increasingly hospital employed/commoditized. But hey, I guess a translational scientist that's spent the last 25 years at a single academic institution has all the "facts" on the economics of community practice.
Click to expand...
Lol, His salary didn’t go down so makes sense nobody else’s would.
 
RSAOaky said:
We're raising the floor a little on salary while completely collapsing the ceilings.
Click to expand...

Medicare data; both the floor and the ceiling are getting closer to the chair railing

radonc-Mcr-numbers.jpg
 
RealSimulD said:
Academic twitter has been disgusting about this. Chirag getting f*cked over again.

What a joke.

The problem ... the problem ... is that in 5 years, #meded became democratic. When an authoritarian regime goes forcibly democratic, of course leadership is going to go nuts. All of a sudden, you have residents debating tenured faculty about clinical cases, community nobodies going up against experts and sounding more informed than the so called experts, Simul bothering everybody about everything hypocritical in this field, an entire class of residents pretty much revolted against the system and were able to enact meaningful change.

Of course this should terrify them. They have to be accountable now. Do you think ASTRO or The Red Journal have any interest in being accountable to, you know, their members/the people that pay them? No, they don't like it. It makes them very upset. Many ASTRO staff have recently jumped ship. It is stagnant. The CEO of this "non-profit" has been there way longer than one should stay head of a non-profit to keep it fresh/innovative/vibrant. They feel the same way - their employees aren't listened to either.

What comes out of Red Journal that is practice changing? When they are talking about video introductions, that means they have either run out of more important things to work on or they don't want to listen to membership. Why do they charge for submission but other major journals do not? These are reasonable questions to ask?

You can be approachable on social media and be kind and curious, but assertive when you are done talking. Or you can be closed off on social media, but be open in other ways. This is the new world. The new guard does not want to do either and are having temper tantrums publicly and behind closed doors. You know what, Sue? I'm exhausted to. I am tired of ASTRO not listening to us. I'm sad that the R J is not what it once was. I'm fatigued that you all create this wall between rank and file members and the elites. I'm tired of everything being social justice when it can just be people talking to people.

Accelerators will be talking about this soon. It isn't one person and I am not an innocent. I'm guilty of being a ****, too, but the fact is I want to be questioned. I want to learn and improve and be wrong so that I can be right, eventually. We have paleo-leadership that just doesn't want to change with the times.
Click to expand...
this type of behavior needs to be called out. it was utterly absurd. i think BK and HW should get called out for this nonsense.

twitter sucks.
 
RealSimulD said:
Academic twitter has been disgusting about this. Chirag getting f*cked over again.

What a joke.

The problem ... the problem ... is that in 5 years, #meded became democratic. When an authoritarian regime goes forcibly democratic, of course leadership is going to go nuts. All of a sudden, you have residents debating tenured faculty about clinical cases, community nobodies going up against experts and sounding more informed than the so called experts, Simul bothering everybody about everything hypocritical in this field, an entire class of residents pretty much revolted against the system and were able to enact meaningful change.

Of course this should terrify them. They have to be accountable now. Do you think ASTRO or The Red Journal have any interest in being accountable to, you know, their members/the people that pay them? No, they don't like it. It makes them very upset. Many ASTRO staff have recently jumped ship. It is stagnant. The CEO of this "non-profit" has been there way longer than one should stay head of a non-profit to keep it fresh/innovative/vibrant. They feel the same way - their employees aren't listened to either.

What comes out of Red Journal that is practice changing? When they are talking about video introductions, that means they have either run out of more important things to work on or they don't want to listen to membership. Why do they charge for submission but other major journals do not? These are reasonable questions to ask?

You can be approachable on social media and be kind and curious, but assertive when you are done talking. Or you can be closed off on social media, but be open in other ways. This is the new world. The new guard does not want to do either and are having temper tantrums publicly and behind closed doors. You know what, Sue? I'm exhausted to. I am tired of ASTRO not listening to us. I'm sad that the R J is not what it once was. I'm fatigued that you all create this wall between rank and file members and the elites. I'm tired of everything being social justice when it can just be people talking to people.

Accelerators will be talking about this soon. It isn't one person and I am not an innocent. I'm guilty of being a ****, too, but the fact is I want to be questioned. I want to learn and improve and be wrong so that I can be right, eventually. We have paleo-leadership that just doesn't want to change with the times.
Click to expand...

I am not sure I agree with your assessment. She was challenged… and got defensive -perhaps more defensive than was necessary, but who among us is ALWAYS proportional in their responses?

The problem is Twitter, not SY. In the real world, this would have been a 20 second argument in a conference room… but on Twitter, thousands of us can imagine what this debate is REALLY about.

My take… he came on a little too strong, she got a little too defensive. Nbd
 
Lamount said:
I am not sure I agree with your assessment. She was challenged… and got defensive -perhaps more defensive than was necessary, but who among us is ALWAYS proportional in their responses?

The problem is Twitter, not SY. In the real world, this would have been a 20 second argument in a conference room… but on Twitter, thousands of us can imagine what this debate is REALLY about.

My take… he came on a little too strong, she got a little too defensive. Nbd
Click to expand...
I’ve had similar interactions. Very prickly.

I think you do agree - it’s nothing - it’s a small debate and people were defensive - but it was called “mansplaining” and “harassment”.
 
the interesting thing about a 5 minute conference room disagreement happening on twitter is likes and replies. You can see who supports who. Def seems like it ended up being a proxy war for big rad onc vs little rad onc.
 
RealSimulD said:
I’ve had similar interactions. Very prickly.

I think you do agree - it’s nothing - it’s a small debate and people were defensive - but it was called “mansplaining” and “harassment”.
Click to expand...
Definitely was not misogynistic... just a little irritating. Like an interaction one would see in the first half of a faculty meeting.
 
I mean isn’t editing a PTV the very definition of changing a case?

Did you mean deleting part of the chiasm contour?

Editing a PTV to not send dose somewhere you don’t want it to go seems like a pretty great thing to me and is kind of the definition of our job.
 
jondunn said:
I mean isn’t editing a PTV the very definition of changing a case?

Did you mean deleting part of the chiasm contour?

Editing a PTV to not send dose somewhere you don’t want it to go seems like a pretty great thing to me and is kind of the definition of our job.
Click to expand...
Can't tell if sarcasm or not, haha.

If the ICRU catches wind of you editing part of a PTV to make the plan look better they'll do a no-knock raid in your clinic and send you to an offshore prison.
 
elementaryschooleconomics said:
Can't tell if sarcasm or not, haha.

If the ICRU catches wind of you editing part of a PTV to make the plan look better they'll do a no-knock raid in your clinic and send you to an offshore prison.
Click to expand...

Lol it’s just to me having a rule about not being able to shave a PTV is peak boomer material. Anyone that taught you that - forget it.

It’s the same exact thing as not shaving the PTV and under covering it.

It doesn’t matter which one you do - ultimately you’re not frying the chiasm.

The only wrong answer is giving the chiasm the 60 and not taking the 60 gy out of it. I don’t care if you call it PTV or not.
 
Have had a lot of conflict over this. I am a big fan of editing ptv, but many physicists think ptv should be divided into overlap structures that get less, but makes harder for dosimeters to plan. ( Radiation can only fall off 5% per mm with hot spot under 10% for most plans- heuristic for editing ptv)
 
jondunn said:
Lol it’s just to me having a rule about not being able to shave a PTV is peak boomer material. Anyone that taught you that - forget it.

It’s the same exact thing as not shaving the PTV and under covering it.

It doesn’t matter which one you do - ultimately you’re not frying the chiasm.

The only wrong answer is giving the chiasm the 60 and not taking the 60 gy out of it. I don’t care if you call it PTV or not.
Click to expand...
I guess it depends on how you're using the PTV.

To me, I adhere to the original intent of the ICRU definition where a PTV margin represents the risk of geometric error and the probability that your CTV receives prescribed dose. It should be a "rolling ball" expansion and generally uniform, except in circumstances where you know error is greater in a certain dimension (i.e. 7mm sup/inf and 5mm radial for lung SBRT).

Editing a PTV, at least with IMRT/VMAT, makes the treatment plan in the computer look better but increases your risk of undertreating your CTV. Is it always a clinically significant risk? No. Am I guilty of doing it myself? Of course.

The majority of the time though, I'll use PRV structures with various expansions (usually 3mm or 5mm) and PRV/PTV overlap structures with requests to Dosi/Physics regarding how I want them to handle it. Is the result functionally the same? Perhaps.

It's definitely not the same thing as intentionally undercovering the PTV, at least in IMRT. The optimizer is "seeing" a different, smaller structure with an artificially cropped PTV vs "seeing" an overlap structure (or whatever you're using to accomplish whatever you're asking for).

At the end of the day, I doubt it has much clinical significance. I doubt we'll ever know even if it does.

To circle back to the jokes...there's a very high correlation between "misunderstanding planning structures" and "holds a lifetime board cert".
 
elementaryschooleconomics said:
I guess it depends on how you're using the PTV.

To me, I adhere to the original intent of the ICRU definition where a PTV margin represents the risk of geometric error and the probability that your CTV receives prescribed dose. It should be a "rolling ball" expansion and generally uniform, except in circumstances where you know error is greater in a certain dimension (i.e. 7mm sup/inf and 5mm radial for lung SBRT).

Editing a PTV, at least with IMRT/VMAT, makes the treatment plan in the computer look better but increases your risk of undertreating your CTV. Is it always a clinically significant risk? No. Am I guilty of doing it myself? Of course.

The majority of the time though, I'll use PRV structures with various expansions (usually 3mm or 5mm) and PRV/PTV overlap structures with requests to Dosi/Physics regarding how I want them to handle it. Is the result functionally the same? Perhaps.

It's definitely not the same thing as intentionally undercovering the PTV, at least in IMRT. The optimizer is "seeing" a different, smaller structure with an artificially cropped PTV vs "seeing" an overlap structure (or whatever you're using to accomplish whatever you're asking for).

At the end of the day, I doubt it has much clinical significance. I doubt we'll ever know even if it does.

To circle back to the jokes...there's a very high correlation between "misunderstanding planning structures" and "holds a lifetime board cert".
Click to expand...
Also, this is more a "lifestyle" choice for me. If I'm gonna be wrong, I try to be consistently wrong. On coin flips I always call "heads", on multiple choice exams I always guess "C" if I don't know the answer. I don't crop PTVs on some cases and use overlap structures on others, I almost always use overlap structures.

It's the most boring lifestyle choice possible.
 
‘It's definitely not the same thing as intentionally undercovering the PTV, at least in IMRT. The optimizer is "seeing" a different, smaller structure with an artificially cropped PTV vs "seeing" an overlap structure (or whatever you're using to accomplish whatever you're asking for).’

Of course - but when we are talking about shaving something back - few mm, it will end up being very similar, a few gray less than your PTV dose.

Ultimately no matter what, if your PTV is 60, and you’re taking it a few mm out of the chiasm/PRV, or leaving it on the chiasm and saying ‘give this part less’, it’s accomplishing the similar thing. You’re ultimately at the same risk of ‘under dosing’ your CTV that you’re worried about underdosing.

You’re much more dogmatic than I about the definitions. You could be a physicist!
 
Palex80 said:
View attachment 353727
Click to expand...
Ah! To continue down Dork River -

Sticking with ICRU again, the CTV to PTV expansion can implicitly include your ITV (as in, you don't have to have an ITV volume and then an additional expansion on top of that to your PTV). The PTV is supposed to represent "geometric uncertainty", which means not only external (setup), but also internal (breathing).

For lung SBRT, I think most people draw a GTV then expand into an ITV based on the 4D/MIP, then expand from there - probably 5mm geometrically? That's what I normally do for vanilla lung SBRT cases anyway.

However, sometimes I'll get like, a 6'4" (1.93m for you Europeans) guy with severe emphysema who has huge lungs and the tumor jumps up and down a crazy amount. Those are the times I do a 7mm/5mm expansion on the PTV because I feel (note: feeling is not evidence based, I know) that there's a higher probability for setup error.

jondunn said:
You’re much more dogmatic than I about the definitions. You could be a physicist!
Click to expand...
Guilty as charged.

It's actually where my "Mr Clean" joke came from. Really, REALLY early on in residency, on two different services, I watched faculty edit my volumes by taking the eraser to my PTV. Since I was brand new, I had put a lot of effort into those volumes, including looking up why we did a PTV. So, when certain parts were erased (but not others), I was confused and asked them why they did that. I literally was told "because dose shouldn't go there".

Thus, I went on a magical journey of learning and discovery via Google and the disillusionment with RadOnc began to creep in.

I hung out with the physics crew after that.
 
Isn't a ptv itself kind of a boomer thing? Particularly around the chiasm. It's not to say I don't see setup differences, but in the brain, treating gbms even, I'm pretty comfortable feeling like we're within 1 mm or so on daily setup. In turn, I don't really feel uncomfortable having smaller ptv expansions in some places and more liberal expansions in others wrt the same ptv. It's a lazy way of making two ptvs. Or perhaps a harder way.
 
Ray D. Ayshun said:
Isn't a ptv itself kind of a boomer thing?
Click to expand...

How do you mean? Unless you are willing to bet a patient's life that your setup is absolutely flawless and is completely identical to the positioning at CTSIM, a PTV is necessary.

Now, if you mean using a 1cm PTV margin for a GBM when you've got the patient in the exact same setup that you'd use for a tonsil (and a 3mm PTV margin), sure, THAT'S a boomer thing.

Our jobs are bizarre. Strictly speaking, the treatment plan you approve isn't real. It's a computer's guess as to the probability that ionizing radiation will interact with matter in a certain way. It might do just that. Or it might not. We can never actually know.

However, just like buying a lot of lottery tickets increases the odds of winning the lottery, making a bigger PTV increases the odds you treat your CTV with the dose you want.

Buy too many lottery tickets without winning has the opposite of the desired effect. Similarly, make your PTV too big and ionizing radiation does exactly what the computer guesses it will do might give you a case to present at M&M.
 
elementaryschooleconomics said:
How do you mean? Unless you are willing to bet a patient's life that your setup is absolutely flawless and is completely identical to the positioning at CTSIM, a PTV is necessary.

Now, if you mean using a 1cm PTV margin for a GBM when you've got the patient in the exact same setup that you'd use for a tonsil (and a 3mm PTV margin), sure, THAT'S a boomer thing.

Our jobs are bizarre. Strictly speaking, the treatment plan you approve isn't real. It's a computer's guess as to the probability that ionizing radiation will interact with matter in a certain way. It might do just that. Or it might not. We can never actually know.

However, just like buying a lot of lottery tickets increases the odds of winning the lottery, making a bigger PTV increases the odds you treat your CTV with the dose you want.

Buy too many lottery tickets without winning has the opposite of the desired effect. Similarly, make your PTV too big and ionizing radiation does exactly what the computer guesses it will do might give you a case to present at M&M.
Click to expand...
the latter. As in, the presently generally accepted PTV expansions seem to be used to allow for sloppy contouring and no setup vigilance. Of course there are daily setup differences, but the daily setup differences are different in different anatomic locations, even with the same plan. Or, you could have therapists align to the chiasm (more or less), which wouldn't be cheating should you shave your PTV there. OTOH, I'd agree with your point, which is to say, shaving the PTV to meet the constraints seems like more of a medicolegal exercise, which is very much a grift.
 
elementaryschooleconomics said:
How do you mean? Unless you are willing to bet a patient's life that your setup is absolutely flawless and is completely identical to the positioning at CTSIM, a PTV is necessary.

Now, if you mean using a 1cm PTV margin for a GBM when you've got the patient in the exact same setup that you'd use for a tonsil (and a 3mm PTV margin), sure, THAT'S a boomer thing.

Our jobs are bizarre. Strictly speaking, the treatment plan you approve isn't real. It's a computer's guess as to the probability that ionizing radiation will interact with matter in a certain way. It might do just that. Or it might not. We can never actually know.

However, just like buying a lot of lottery tickets increases the odds of winning the lottery, making a bigger PTV increases the odds you treat your CTV with the dose you want.

Buy too many lottery tickets without winning has the opposite of the desired effect. Similarly, make your PTV too big and ionizing radiation does exactly what the computer guesses it will do might give you a case to present at M&M.
Click to expand...
KtrZtq2.png
 
You must log in or register to reply here.

Similar threads

uchihastan
Rad Onc vs. Heme/Onc
Replies
16
Views
2K
medgator
M
B
Rad Onc Procedures and RVUs
Replies
35
Views
5K
CurbYourExpectations
CurbYourExpectations
D
Saving Rad Onc
2
Replies
60
Views
7K
RickyScott
R
TheWallnerus
Rad Onc is in a dark place
Replies
13
Views
3K
RickyScott
R
M
Rad Onc Oral Boards: To quote or not quote studies?
Replies
5
Views
737
RSAOaky
R
Top