Rad Onc Twitter

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fiji128 said:
I got a gastric case on oral boards circa five years ago. Saw maybe one curative case in residency. Only the very rare palliative cases while in practice.
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The year the intergroup study came out, it was one of the most talked about studies in academic rad onc depts. Is there a gastric cancer rad onc expert anywhere anymore? My general sense is gastric has become less common as well.
 
communitydoc13 said:
Uro/optho/ortho/ENT/NS (especially NS) have a huuuge self selection aspect in terms of residency interest. Lots of medstuds don't have what it takes to make it through these residencies and don't have an interest in committing to a surgical lifestyle.

Radonc has essentially zero self-selection. At some point the market dictated that you be a very good medstud, but radonc does not have long hours or long call or high acuity. Once the secret was out, market forces took over and supply of talent itself drove demand.

I've mentioned this before. Say's Law.

Say's law - Wikipedia

en.wikipedia.org en.wikipedia.org
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I don't think this is it. There are plenty of folks who would love a Uro/ENT/ophtho spot but can't get one. The limiting factor is number of spots, not quality applicants.

Now the same forces do apply to us. Expanding academic medical centers = expanding case loads = more sites and cases to cover = expanding residencies. But I do think that surgical programs are more careful about expanding programs, due to the fact that our training is so volume dependent. You can learn a lot of urology from books, but to learn to operate you need to operate. Add in the fact that we need to learn open, lap, endo, robotic, and microscopic surgery in one residency and fewer and fewer open surgeries are being done and programs (reasonably) worry about diluting the experience. Due to the fact that call is more of a burden it is also an issue, since it is hard to cover overnight surgery call at hospitals an hour away.
 
Chartreuse Wombat said:
1) Never happen...CMS wants to lower reimbursement
2) Admins will spread the riches...any increase will go to them first and then subsidize the other "loss leaders" like (non-proton) peds cases
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Cms may never double rates, but if they did, our salary will still be determined by the 100 other great candidates who are willing to take the job. Hospital negotiated prices, including those in radiation have dramatically increased over the past 15 years- more than doubled! - but that has not increased salaries. If hospital prices were halved to what they had been 7 years ago, at the very least my salary should be what it was 7 years ago, which is very close to what is today.

If I could keep the same salary but academic centers were reimbursed 25% less, would be in my interest as it may stop them from building predatory satellites at some point.

There have been silly attempts to link salaries to anything but supply and demand. Rvu, garbage formulas SRvu=klog$ Etc
 
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DoctwoB said:
I don't think this is it. There are plenty of folks who would love a Uro/ENT/ophtho spot but can't get one. The limiting factor is number of spots, not quality applicants.

Now the same forces do apply to us. Expanding academic medical centers = expanding case loads = more sites and cases to cover = expanding residencies. But I do think that surgical programs are more careful about expanding programs, due to the fact that our training is so volume dependent. You can learn a lot of urology from books, but to learn to operate you need to operate. Add in the fact that we need to learn open, lap, endo, robotic, and microscopic surgery in one residency and fewer and fewer open surgeries are being done and programs (reasonably) worry about diluting the experience. Due to the fact that call is more of a burden it is also an issue, since it is hard to cover overnight surgery call at hospitals an hour away.
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We have published data in rad onc that definitive case load volume has fallen significantly per resident over the last ten years
 
TheWallnerus said:
We have published data in rad onc that definitive case load volume has fallen significantly per resident over the last ten years
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TheWallnerus said:
We have published data in rad onc that definitive case load volume has fallen significantly per resident over the last ten years
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As someone that graduated in the last 5 years - just want to point out that work per patient for contouring is WAY more than back in the day. Always loved as a resident to hear some attending from training the late 90s or early 2000s talk about how many head and neck patients they had to plan at once and it’s like ‘Bit&h, you drew a box with a wax pencil on an X-ray and called it a day’
 
jondunn said:
As someone that graduated in the last 5 years - just want to point out that work per patient for contouring is WAY more than back in the day. Always loved as a resident to hear some attending from training the late 90s or early 2000s talk about how many head and neck patients they had to plan at once and it’s like ‘Bit&h, you drew a box with a wax pencil on an X-ray and called it a day’
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Then again Nancy Lee twenty years ago said it takes her 3 hours to do a head neck case. (But she was a rarity w/ IMRT utilization at that time, granted.)

You know those stories of the the British “barbers” whose skills were based solely on how quickly they could operate (in the pre-anesthesia era this was very important)… I fancy myself a rad onc barber!
 
TheWallnerus said:
Then again Nancy Lee twenty years ago said it takes her 3 hours to do a head neck case. (But she was a rarity w/ IMRT utilization at that time, granted.)

You know those stories of the the British “barbers” whose skills were based solely on how quickly they could operate (in the pre-anesthesia era this was very important)… I fancy myself a rad onc barber!
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I think 2d is often more time consuming especially when you had to project volumes from a ct or mri onto a 2d X-ray. Overall patient care today is much less time consuming, mostly because you are not dealing with as large a side effect burden. Prostate and breast on treats last 30 second.
 
RickyScott said:
I think 2d is often more time consuming especially when you had to project volumes from a ct or mri onto a 2d X-ray. Overall patient care today is much less time consuming, mostly because you are not dealing with as large a side effect burden. Prostate and breast on treats last 30 second.
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Really ? I’ve never heard anyone say 2D is more challenging. I trained in cusp where we learned both.

I’m just wondering with 1.8s and drawing field borders and reviewing max point doses .. what were docs doing all day ?
 
DoctwoB said:
There are plenty of folks who would love a Uro/ENT/ophtho spot but can't get one. The limiting factor is number of spots, not quality applicants.
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Great post.

Also, totally agree with you. From the outside, the emphasis on case load has always seemed much more important to the powers that be in surgery. I grew up (professionally) after the initial limits on residency hours took place (which NS managed to lobby to retain 100 hour work weeks, imagine!) I remember transplant fellows and the like working so ridiculously hard to pick up volume in cases. I remember multiple fellows who did residency from less prestigious hospitals, complaining that the OR volume that the residents were seeing in fancy academic place A were insufficient.

The fact is, doing radiation oncology is easier than doing surgery.

I do wonder if the the general interest and quality of applicants is specialty surgery ever changed as rapidly and drastically as it did in radonc? My premise is that the intrinsic difficulty of doing surgery safely acts as a buffer to rapid or volatile changes in medstud interest.

These fields have decades now of being selective enough to reject good applicants every year but demanding enough that interest is relatively predictable.

In the span of roughly 10 years, radonc went from a specialty where any reasonable US medstud had a shot at a good program and good programs were sometimes taking US born IMGs, to a an environment where roughly 10 students from Harvard were applying for radonc and every serious applicant at top 10 programs was an award winning student. Ten years later, the field is rejecting no one (truly pathologic) and scrambling for bodies.

In 2012, there were single programs with multiple Rhodes Scholars in them.

I still remember that 2012 match. I knew it was dumb. I knew there were not enough jobs commensurate to these CVs. I'm just not sure anything like that ever happened in specialty surg.
 
communitydoc13 said:
Great post.

Also, totally agree with you. From the outside, the emphasis on case load has always seemed much more important to the powers that be in surgery. I grew up (professionally) after the initial limits on residency hours took place (which NS managed to lobby to retain 100 hour work weeks, imagine!) I remember transplant fellows and the like working so ridiculously hard to pick up volume in cases. I remember multiple fellows who did residency from less prestigious hospitals, complaining that the OR volume that the residents were seeing in fancy academic place A were insufficient.

The fact is, doing radiation oncology is easier than doing surgery.

I do wonder if the the general interest and quality of applicants is specialty surgery ever changed as rapidly and drastically as it did in radonc? My premise is that the intrinsic difficulty of doing surgery safely acts as a buffer to rapid or volatile changes in medstud interest.

These fields have decades now of being selective enough to reject good applicants every year but demanding enough that interest is relatively predictable.

In the span of roughly 10 years, radonc went from a specialty where any reasonable US medstud had a shot at a good program and good programs were sometimes taking US born IMGs, to a an environment where roughly 10 students from Harvard were applying for radonc and every serious applicant at top 10 programs was an award winning student. Ten years later, the field is rejecting no one (truly pathologic) and scrambling for bodies.

In 2012, there were single programs with multiple Rhodes Scholars in them.

I still remember that 2012 match. I knew it was dumb. I knew there were not enough jobs commensurate to these CVs. I'm just not sure anything like that ever happened in specialty surg.
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Who were the Rhodes scholars ?
 
RealSimulD said:
Really ? I’ve never heard anyone say 2D is more challenging. I trained in cusp where we learned both.

I’m just wondering with 1.8s and drawing field borders and reviewing max point doses .. what were docs doing all day ?
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Helping the therapists change out cerrobend blocks, wedges and compensators?
 
RickyScott said:
I think 2d is often more time consuming especially when you had to project volumes from a ct or mri onto a 2d X-ray. Overall patient care today is much less time consuming, mostly because you are not dealing with as large a side effect burden. Prostate and breast on treats last 30 second.
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Total planning time way quicker today. I remember doing a nasopharynx case in early 3D days. The calcs on a multi beam plan would take 4 or 5 hours computer time. Wanna change something? Another 4 or 5 hours. Dosimetry and physics really earned their keep back then. (In some ways, well maybe in most ways, I feel like a lot of today’s dosimetrist activities should he handled or far more overseen by the MD.)

2D sims could be very time consuming. In residency I remember being in sim minimum one hour on all 3 field breast cases. So it’s an interesting “debate,” but I definitely feel like overall rad onc is easier and less time consuming for the MD than 30 years ago.
 
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communitydoc13 said:
Great post.

Also, totally agree with you. From the outside, the emphasis on case load has always seemed much more important to the powers that be in surgery. I grew up (professionally) after the initial limits on residency hours took place (which NS managed to lobby to retain 100 hour work weeks, imagine!) I remember transplant fellows and the like working so ridiculously hard to pick up volume in cases. I remember multiple fellows who did residency from less prestigious hospitals, complaining that the OR volume that the residents were seeing in fancy academic place A were insufficient.

The fact is, doing radiation oncology is easier than doing surgery.

I do wonder if the the general interest and quality of applicants is specialty surgery ever changed as rapidly and drastically as it did in radonc? My premise is that the intrinsic difficulty of doing surgery safely acts as a buffer to rapid or volatile changes in medstud interest.

These fields have decades now of being selective enough to reject good applicants every year but demanding enough that interest is relatively predictable.

In the span of roughly 10 years, radonc went from a specialty where any reasonable US medstud had a shot at a good program and good programs were sometimes taking US born IMGs, to a an environment where roughly 10 students from Harvard were applying for radonc and every serious applicant at top 10 programs was an award winning student. Ten years later, the field is rejecting no one (truly pathologic) and scrambling for bodies.

In 2012, there were single programs with multiple Rhodes Scholars in them.

I still remember that 2012 match. I knew it was dumb. I knew there were not enough jobs commensurate to these CVs. I'm just not sure anything like that ever happened in specialty surg.
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Yeah it’s definitely harder and despite this the level of pseudo sanctimony about being a rad onc in those years was enough to make anyone vomit.
 
RealSimulD said:
Really ? I’ve never heard anyone say 2D is more challenging. I trained in cusp where we learned both.

I’m just wondering with 1.8s and drawing field borders and reviewing max point doses .. what were docs doing all day ?
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Did you ever do a old school sim? Calipers and molding metal wires and **** around people. Having to determine the beam angles. They could easily be hour long affairs. Hand calcs to mid plane. Whatever the hell they did. Different set of problems, but still problems.
 
RealSimulD said:
I have!
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I remember my old school attendings in those old school days being reverentially deferential toward the simulation. ‘Twas the most important step in the patient’s whole care. The dosimetrist came to the sim. Took two therapists (one to run the X-ray, one to dance back and forth in the suite, eg). Physics showed up for sim too. Now it’s (the sim… the Simul… the simulation) essentially just a 5 minute CT scan, most times, ran by one therapist. Dosimetrists going to the sim? Antediluvian!
 
TheWallnerus said:
I remember my old school attendings in those old school days being reverentially deferential toward the simulation. ‘Twas the most important step in the patient’s whole care. The dosimetrist came to the sim. Took two therapists (one to run the X-ray, one to dance back and forth in the suite, eg). Physics showed up for sim too. Now it’s (the sim… the Simul… the simulation) essentially just a 5 minute CT scan, most times, ran by one therapist. Dosimetrists going to the sim? Antediluvian!
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My experience as well and I could never really wrap my head around some of the off cord lungs/ball and chain in breast etc. sims took up a lot of time and you actually had to be present. In good programs, nobody was just contouring bony landmarks, putting wide fields and treating everything ap/pa at 1.8. On treats also took a lot of time with all the diarrhea, dermatitis, mucositis etc, trying to motivate the patient to get through it all etc
 
TheWallnerus said:
I remember my old school attendings in those old school days being reverentially deferential toward the simulation. ‘Twas the most important step in the patient’s whole care. The dosimetrist came to the sim. Took two therapists (one to run the X-ray, one to dance back and forth in the suite, eg). Physics showed up for sim too. Now it’s (the sim… the Simul… the simulation) essentially just a 5 minute CT scan, most times, ran by one therapist. Dosimetrists going to the sim? Antediluvian!
Click to expand...

We have three CT techs in our sim, I bring dosimetry all the time to help with questions, and I am serious about checking the set up. Taking simulation seriously is an important part of QA which leads to much smoother treatments down the line and increased therapy efficiency, which is critical for a very busy department.

I'm probably an outlier to some extent, but I really do believe that making treatment easy for therapy and patients all starts with good simulation.
 
OTN said:
We have three CT techs in our sim, I bring dosimetry all the time to help with questions, and I am serious about checking the set up. Taking simulation seriously is an important part of QA which leads to much smoother treatments down the line and increased therapy efficiency, which is critical for a very busy department.

I'm probably an outlier to some extent, but I really do believe that making treatment easy for therapy and patients all starts with good simulation.
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have been in department where there is zero history of docs being called into sim and the amount of replanning was incredible
 
We did a few 2-D sims in residency with an old Ximatron, that stuff was an absolute hack and nightmare to deal with compare to CT simulation.
 
as expected the usual crew comes in with their 'Greatest Generation' takes.

we all have our biases of course.
 
Fpg1245 said:
Wow Manisha…this was the trial that did it for you? Really this was the one that made you think maybe all that BS you had go through wasn’t really worth it?
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One can’t truly discuss how fruitless a rad onc residency can be until one has gone through a rad onc residency and become a rad onc

It’s one of the stranger ironies known to man imho

Like Spock in Star Trek IV trying to explain to Bones how fruitless discussing death with him was

Med students… if you are REALLY interested in all the headwinds facing rad onc… like really want to know the answer from head to toe…

Enter a rad onc residency and become a rad onc

It’s the only way to know for sure if the feelings/scenarios espoused on rad onc SDN are legit

IOW … don’t just believe everything you read online, become a rad onc and see for yourself
 
Mandelin Rain said:
Did you ever do a old school sim? Calipers and molding metal wires and **** around people. Having to determine the beam angles. They could easily be hour long affairs. Hand calcs to mid plane. Whatever the hell they did. Different set of problems, but still problems.
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2D-planning of a craniospinal irradiation on the simulator was the biggest fun of all.

Get out your trigonometry schoolbooks!
 
TheWallnerus said:
One can’t truly discuss how fruitless a rad onc residency can be until one has gone through a rad onc residency and become a rad onc

It’s one of the stranger ironies known to man imho
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Completely agree.

5 years, more board exams than any other specialty (antiquated in style and substance), a culture of memorizing the most USELESS of trivial factoids with limited applicability, and the majority of research is dedicated to feeding the government/private payors ammunition to reduce reimbursement year after year...or tell us we're not even needed at all.

I practice as a very busy generalist. I like to think that, at worst, I'm at least average in skill.

I have no idea why this isn't a 3-year residency.
 
jondunn said:
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Does seem like immunotherapy will radically change management of those 10-15% of local/locoregional GI cancers that are MSI high.

GE jxn/Gastric ripe for some organ preservation however. Do we even need the surgery? Is there a trial with IO/XRT integrated for cure in these patients?
 
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communitydoc13 said:
Does seem like immunotherapy will radically change management of those 10-15% of local/locoregional GI cancers that are MSI high.

GE jxn/Gastric ripe for some organ preservation however. Do we even need the surgery? Is there a trial with IO/XRT integrated for cure in these patients?
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Surgeons run those boards…so progress will be slowly and painful and in the end not enough to reverse the damage we have done to ourselves

You want to fix RO? Marry it off to something that’s going places like med onc or IR.
 
elementaryschooleconomics said:
Completely agree.

5 years, more board exams than any other specialty (antiquated in style and substance), a culture of memorizing the most USELESS of trivial factoids with limited applicability, and the majority of research is dedicated to feeding the government/private payors ammunition to reduce reimbursement year after year...or tell us we're not even needed at all.

I practice as a very busy generalist. I like to think that, at worst, I'm at least average in skill.

I have no idea why this isn't a 3-year residency.
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I do find these kind of laments interesting.

On one hand -- radiation is so easy! Make it a 3 year instead of a 4 year residency. So many exams! But they're useless and easy! Except for physics one year and that was a scandal! Clear them away and make the process of becoming a radiation oncologist easier!

On the other hand -- there's so many boomer rad oncs who don't know what they're doing! They're old and dangerous! Make them retire early! Wait there's also too many new rad oncs! Not enough jobs! Cancel and shut programs!

If what we do is so easy, then should fulfill the stated dream of one administrator I knew --> get rid of rad oncs, just have a medical physicist, a remote dosimetrist (until AI planning takes over and the physicist can press the "plan" button), and therapists, and let surgeons or med oncs or whoever else sign off on the plans.
 
communitydoc13 said:
Does seem like immunotherapy will radically change management of those 10-15% of local/locoregional GI cancers that are MSI high.

GE jxn/Gastric ripe for some organ preservation however. Do we even need the surgery? Is there a trial with IO/XRT integrated for cure in these patients?
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that 10-15% will expand. Just getting started with 1st generation io regimens. This is abt paradigm change not pigeon holing.
 
Fpg1245 said:
Another thing that we just don’t understand. We think there is some limit to this and patients will always need us…really not true in the least.
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Eg Active chemo followed by lesser surgery could easily kick xrt out of rectal cancer. Again, absolute benefit of radiation over nothing is so small (5%)! An active chemo regimen- which we already have - will almost certainly eat into this 5% and enable a minor surgery. And
What are the chances that a superior regimen to folfox emerges in next 20 years. How could that not cross the xrt out of rectal?

 
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Fpg1245 said:
Another thing that we just don’t understand. We think there is some limit to this and patients will always need us…really not true in the least.
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The far future is hard to foresee. But, I agree. If I were to bet on a dominant paradigm regarding oncology 100 years from now, it would be:

1. Avoidance--both by massive investment in reduction in behavioral and environmental risk factors and by gene modification (load up the elephantine levels of p53 diversity, crispr correct those with defective oncogenes or tumor-suppressor genes).
2. Treatment of vast majority of malignancies as a chronic and systemic disease as systemic therapy becomes less toxic and more effective. Rare, minimally invasive cancer surgeries. Very rare XRT.
3. XRT for the poor.
 
communitydoc13 said:
The far future is hard to foresee. But, I agree. If I were to bet on a dominant paradigm regarding oncology 100 years from now, it would be:

1. Avoidance--both by massive investment in reduction in behavioral and environmental risk factors and by gene modification (load up the elephantine levels of p53 diversity, crispr correct those with defective oncogenes or tumor-suppressor genes).
2. Treatment of vast majority of malignancies as a chronic and systemic disease as systemic therapy becomes less toxic and more effective. Rare, minimally invasive cancer surgeries. Very rare XRT.
3. XRT for the poor.
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Even 50 years from now, drugs like rapamycin will be preventing many cancers and delaying chronic diseases.
Even in the next 20, we will be able to increasingly select which cancers really need adjuvant or intense treatment with ngs, biomarkers, Ct dna etc
 
Fpg1245 said:
Surgeons run those boards…so progress will be slowly and painful and in the end not enough to reverse the damage we have done to ourselves

You want to fix RO? Marry it off to something that’s going places like med onc or IR.
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I know this will be an unpopular take. Certainly the promise that each generation will have a more prosperous future than those who came before has been possibly irreparably broken.

Instead of kvetching about what likely is a less promising future, can we try to control what is within our power? As a declining power (think Thucydides Trap), our role will have to evolve and we should view the world with radical transparency.

1) If the footprint of radiation oncology practice is shrinking, we can still take leadership of tumor boards and cancer centers. Often these administrative duties are considered thankless and obviously our field has the human capital to succeed in these roles that increase the visibility and relevance of the physician.
2) The field's excessive focus on number of fractions is awful and corrosive. When hypofractionation is discussed at tumor board, I don't think I've ever heard a surgeon or medical oncologist comment wow that's great for patients. They just want their patients to get better. Let's stop talking about number of fractions and be laser focused on providing value to our patients and referring physicians.
3) For the patients that are still being referred to us, we can maximize our role. The increased demands on Medical Oncology and IR where business is booming creates that opportunity to offer services that they are too busy to address. Of course, these services such as radiopharmaceuticals, co-managing supportive care and survivorship, ordering tests are less remunerative and glamorous than what recent trainees may have signed up for.
 
theradiator said:
I know this will be an unpopular take. Certainly the promise that each generation will have a more prosperous future than those who came before has been possibly irreparably broken.

Instead of kvetching about what likely is a less promising future, can we try to control what is within our power? As a declining power (think Thucydides Trap), our role will have to evolve and we should view the world with radical transparency.

1) If the footprint of radiation oncology practice is shrinking, we can still take leadership of tumor boards and cancer centers. Often these administrative duties are considered thankless and obviously our field has the human capital to succeed in these roles that increase the visibility and relevance of the physician.
2) The field's excessive focus on number of fractions is awful and corrosive. When hypofractionation is discussed at tumor board, I don't think I've ever heard a surgeon or medical oncologist comment wow that's great for patients. They just want their patients to get better. Let's stop talking about number of fractions and be laser focused on providing value to our patients and referring physicians.
3) For the patients that are still being referred to us, we can maximize our role. The increased demands on Medical Oncology and IR where business is booming creates that opportunity to offer services that they are too busy to address. Of course, these services such as radiopharmaceuticals, co-managing supportive care and survivorship, ordering tests are less remunerative and glamorous than what recent trainees may have signed up for.
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Perfect IMO. I believe that our present day role should be as the holistic experts of solid tumor oncology. Medoncs don't have the time outside of academics. Community surgeons are unlikely to commit to this mindset.
 
writing an order for nivo seems more boring than planning bone met palliation. I get it if the argument is about job stability or longevity, but rad onc and med onc are two very different skill sets and daily expectations. I don't find my favorite part of the job being writing notes or typing, or even telling people what to do. I like thinking strategically.
 
theradiator said:
I know this will be an unpopular take. Certainly the promise that each generation will have a more prosperous future than those who came before has been possibly irreparably broken.

Instead of kvetching about what likely is a less promising future, can we try to control what is within our power? As a declining power (think Thucydides Trap), our role will have to evolve and we should view the world with radical transparency.

1) If the footprint of radiation oncology practice is shrinking, we can still take leadership of tumor boards and cancer centers. Often these administrative duties are considered thankless and obviously our field has the human capital to succeed in these roles that increase the visibility and relevance of the physician.
2) The field's excessive focus on number of fractions is awful and corrosive. When hypofractionation is discussed at tumor board, I don't think I've ever heard a surgeon or medical oncologist comment wow that's great for patients. They just want their patients to get better. Let's stop talking about number of fractions and be laser focused on providing value to our patients and referring physicians.
3) For the patients that are still being referred to us, we can maximize our role. The increased demands on Medical Oncology and IR where business is booming creates that opportunity to offer services that they are too busy to address. Of course, these services such as radiopharmaceuticals, co-managing supportive care and survivorship, ordering tests are less remunerative and glamorous than what recent trainees may have signed up for.
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What makes radoncs think that radiology will permit them to dispense radiopharm. Not going to happen in most large systems.
 
communitydoc13 said:
Perfect IMO. I believe that our present day role should be as the holistic experts of solid tumor oncology. Medoncs don't have the time outside of academics. Community surgeons are unlikely to commit to this mindset.
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We have an image problem as being perceived as technicians not “holistic experts” or strategists. Matching the dregs of medicine-the match’s version of special Ed -is also not helping the optics here.
 
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