Rad Onc Twitter

[elementaryschooleconomics]

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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.

I can only speak from my personal experience, as being someone who trained in the VMAT area and forced to work closely with Boomers who trained in the pre-IMRT era.

1) It's cliché but - technology changed everything. I say this a lot on SDN: I can access all of human knowledge from a small device I carry in my pocket.

2) Technology facilitated the explosion of information, both good and bad (CV-padding papers aren't helpful).

3) The NCCN guidelines aren't even 30 years old (first published 1996). While some decry "cookbook medicine", this is a great equalizer in bringing practices closer to "the middle", rather than have some exceptional institutions and a lot of podunk departments doing their own thing.

However, our training and certification pathway is almost a century old (oral boards are from the 1930s).

Radiotherapy is unrecognizable today compared to 30 years ago. If you put me in a time machine and sent me back to 1990, I wouldn't be able to practice with my current skills. Obviously the same is true if you took someone from 1990 and brought them to 2022.

The value in doctors memorizing textbooks worth of trivia stems from a time where it was more difficult to access knowledge and information. Now, it's SIGNIFICANTLY more important to know how/where/when to access information, critically evaluate new information, and know when to apply it.

Boomers are, on average, TERRIBLE about knowing the limitations of the human mind. Asking for help, saying you don't know something - it's seen as a weakness. There are obviously exceptions, but it's a fundamental shift in the culture.

In my training:

- I did a traditional medicine intern year. I derived a lot of value from it. I would say it got repetitive around month 6 or 7, but that might be because I exclusively covered inpatient wards (floors and ICU).
- The first year of RadOnc residency is brutal. The learning curve is steep.
- I felt a lot better as a PGY3.

Most of us have/had a significant chunk of "elective" time. Maybe at some places your PGY5 year is a lot more "independent" or whatever. At my program, the structure and expectations were similar, regardless what year you were. I spent A LOT of time studying information with little practical relevance for all of our board exams at the end.

Just based on my personal experience:

PGY1: half the year doing inpatient medicine wards, then half the year in RadOnc. Since I'm dreaming anyway, these 6 months could include rotations in Radiology, Surgery, Pathology, Dosimetry, and Physics.
PGY2: unchanged.
PGY3: unchanged.

No built-in elective time. A single, mostly clinical written exam at the end of residency. Almost zero radbio, and only the most physician-practical physics topics. At the end of your first year as an attending, an "oral" exam which is two examiners giving you standard cases to workup and treat, and it's "open book", so they know how you really practice.

Maybe my experience is/was unique, but I spent a lot of time doing a lot of things with no relevance to my current practice.

 

[NotMattSpraker]

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.

This should be the most popular take.

 

[Fpg1245]

We have an image problem as being perceived as technicians not “holistic experts” or strategists. Matching the dregs of medicine is also not helping the optics here.

Yeah we lost the plot on that nonsense a long time ago.

 

[jondunn]

Yeah we lost the plot on that nonsense a long time ago.

This is very variable I think. In the right setups - if you do a good job, speak up at tumor board, make it clear you know what you're doing - you will be respected. Will you ever have the power of a med onc or a surgeon? No. but we all knew that. I'm fine with that.

Med Oncs don't know that much. Many times my med onc colleagues call me for my opinion on staging, imaging, treatment, even if I end up not seeing a patient, I do get curbsided a decent amount.

Of course some local communities or hospital settings are different

 

[elementaryschooleconomics]

I can attest that, on a local level, if you want to involve/insert yourself into "the system" and be seen more as a more "complete" doctor instead of a technician, the sky's the limit.

This might be more difficult in big academic places. But in smaller environments, you can become everyone's "first call" for opinions and advice. You can even have the "level of influence" the "real" doctors have, too!

 

[jondunn]

It’s why I’m grateful for my residency experience. Did we learn a a lot of stuff? Yes. Is all of it useful? Of course not.

But I definitely feel like I have the best solid tumor oncology training in my tumor board, and it has impacted the way I practice and interact with my colleagues.

 

[RickyScott]

This is very variable I think. In the right setups - if you do a good job, speak up at tumor board, make it clear you know what you're doing - you will be respected. Will you ever have the power of a med onc or a surgeon? No. but we all knew that. I'm fine with that.

Med Oncs don't know that much. Many times my med onc colleagues call me for my opinion on staging, imaging, treatment, even if I end up not seeing a patient, I do get curbsided a decent amount.

Of course some local communities or hospital settings are different

I have worked with some f-g smart medoncs, and some of our recent grads topped 40 on the wunderlich at the combine.

 

[Ray D. Ayshun]

I have worked with some f-g smart medoncs, and some of our recent grads topped 40 on the wunderlich at the combine.

I basically aced the Montreal Cognitive Assessment. Think I missed one, but can't remember which.

 

[jondunn]

I have worked with some f-g smart medoncs, and some of our recent grads topped 40 on the wunderlich at the combine.

I don't know how the Wunderlich is scored actually. But I know it is popular here to **** on recent grads, and will only get more popular, but sorry chief - this ain't it.

 

[temujim]

I can only speak from my personal experience, as being someone who trained in the VMAT area and forced to work closely with Boomers who trained in the pre-IMRT era.

1) It's cliché but - technology changed everything. I say this a lot on SDN: I can access all of human knowledge from a small device I carry in my pocket.

2) Technology facilitated the explosion of information, both good and bad (CV-padding papers aren't helpful).

3) The NCCN guidelines aren't even 30 years old (first published 1996). While some decry "cookbook medicine", this is a great equalizer in bringing practices closer to "the middle", rather than have some exceptional institutions and a lot of podunk departments doing their own thing.

However, our training and certification pathway is almost a century old (oral boards are from the 1930s).

Radiotherapy is unrecognizable today compared to 30 years ago. If you put me in a time machine and sent me back to 1990, I wouldn't be able to practice with my current skills. Obviously the same is true if you took someone from 1990 and brought them to 2022.

The value in doctors memorizing textbooks worth of trivia stems from a time where it was more difficult to access knowledge and information. Now, it's SIGNIFICANTLY more important to know how/where/when to access information, critically evaluate new information, and know when to apply it.

Boomers are, on average, TERRIBLE about knowing the limitations of the human mind. Asking for help, saying you don't know something - it's seen as a weakness. There are obviously exceptions, but it's a fundamental shift in the culture.

In my training:

- I did a traditional medicine intern year. I derived a lot of value from it. I would say it got repetitive around month 6 or 7, but that might be because I exclusively covered inpatient wards (floors and ICU).
- The first year of RadOnc residency is brutal. The learning curve is steep.
- I felt a lot better as a PGY3.

Most of us have/had a significant chunk of "elective" time. Maybe at some places your PGY5 year is a lot more "independent" or whatever. At my program, the structure and expectations were similar, regardless what year you were. I spent A LOT of time studying information with little practical relevance for all of our board exams at the end.

Just based on my personal experience:

PGY1: half the year doing inpatient medicine wards, then half the year in RadOnc. Since I'm dreaming anyway, these 6 months could include rotations in Radiology, Surgery, Pathology, Dosimetry, and Physics.
PGY2: unchanged.
PGY3: unchanged.

No built-in elective time. A single, mostly clinical written exam at the end of residency. Almost zero radbio, and only the most physician-practical physics topics. At the end of your first year as an attending, an "oral" exam which is two examiners giving you standard cases to workup and treat, and it's "open book", so they know how you really practice.

Maybe my experience is/was unique, but I spent a lot of time doing a lot of things with no relevance to my current practice.

This plan lowers the barrier to entry. More rad oncs at dare I say lower quality. Like my boomer attending who argued that a photon CANNOT be both a particle and a wave.

 

[deleted1116990]

- The first year of RadOnc residency is brutal. The learning curve is steep.

It's a steep learning curve as the material has nothing to do with the past 5 years of your medical education, but brutal? If rad onc residency is brutal, what is surgery? PGY-2 I arrived at 8AM every day and was almost always back home by 7PM. Very rarely 8-9PM. Rarely was in on a weekend, and if so, only for a few hours. Attending has a research day one day a week that you don't have to see patients and can study and get caught up during business hours. From a residency perspective, this is about as good as it gets, up there with derm and PM&R.

The last 2 years of rad onc typically involve 6+ months of research/elective that in many places can be done from home, and senior residents in clinic can get work done faster and usually be out of there by 5.

People will keep coming to rad onc residency for the above reason alone, the dirty little secret. Programs know this and I'm sure will use it to fill with warm bodies if they have to. 10 years ago it was "we expect you to spend your nights and weekends studying and writing papers -- if you don't regularly publish and score well on in service, you may lose your spot." Asking about duty hours, vacation, parental leave, etc was verboten. Now it's "rad onc residency is so awesome, you will have so much free time for a great quality of life, here's some photos of our residents on research block hanging out at the beach, etc"

 

[temujim]

Now it's "rad onc residency is so awesome, you will have so much free time for a great quality of life, here's some photos of our residents on research block hanging out at the beach, etc"

An understandable reaction, but reeks of desperation. Race to the bottom.

 

[medgator]

An understandable reaction, but reeks of desperation. Race to the bottom.

That's what it's always been pre IMRT

 

[RickyScott]

I don't know how the Wunderlich is scored actually. But I know it is popular here to **** on recent grads, and will only get more popular, but sorry chief - this ain't it.

So are you believe that a lot of medstudents going for radonc are not dumb AF?

 

[RickyScott]

This plan lowers the barrier to entry. More rad oncs at dare I say lower quality. Like my boomer attending who argued that a photon CANNOT be both a particle and a wave.

Attending may be right. Photons behave like a wave when you are not looking at them and a particle when you do actually observe them. Not so much ontologically a wave/particle duality vs we just don’t have the precise description or correct analogy to truly describe quantum objects. I am assuming he has a physics background vs old school dumbaxx

 

[pikachu]

I basically aced the Montreal Cognitive Assessment. Think I missed one, but can't remember which.

Person, woman, man, camera, TV?

 

[Neuronix]

Attending may be right. Photons behave like a wave when you are not looking at them and a particle when you do actually observe them. Not so much ontologically a wave/particle duality vs we just don’t have the precise description or correct analogy to truly describe quantum objects.

Eh, it depends on how many particles you're looking at.

 

[elementaryschooleconomics]

It's a steep learning curve as the material has nothing to do with the past 5 years of your medical education, but brutal? If rad onc residency is brutal, what is surgery? PGY-2 I arrived at 8AM every day and was almost always back home by 7PM. Very rarely 8-9PM. Rarely was in on a weekend, and if so, only for a few hours. Attending has a research day one day a week that you don't have to see patients and can study and get caught up during business hours. From a residency perspective, this is about as good as it gets, up there with derm and PM&R.

The last 2 years of rad onc typically involve 6+ months of research/elective that in many places can be done from home, and senior residents in clinic can get work done faster and usually be out of there by 5.

People will keep coming to rad onc residency for the above reason alone, the dirty little secret. Programs know this and I'm sure will use it to fill with warm bodies if they have to. 10 years ago it was "we expect you to spend your nights and weekends studying and writing papers -- if you don't regularly publish and score well on in service, you may lose your spot." Asking about duty hours, vacation, parental leave, etc was verboten. Now it's "rad onc residency is so awesome, you will have so much free time for a great quality of life, here's some photos of our residents on research block hanging out at the beach, etc"

My PGY2 experience was...very different.

Regardless, like "dose escalation" or "hypofrac", adjectives like "brutal" are relative terms. Didn't mean for folks to read too much into my word choice there. Insert whatever feels applicable! We all know what I mean.

 

[RickyScott]

Eh, it depends on how many particles you're looking at.

View attachment 358587

Put a photon detector in one of the slits and the interference pattern disappears! True for elecltons as well. Look at it and the wave dissapears.(no longer superposition) Very disturbing. What counts as an observer- a cat a flea on the cat etc? Solvay conference in 1920s concluded with the Copenhagen interpretation of quantum mechanics.

 

[temujim]

Attending may be right. Photons behave like a wave when you are not looking at them and a particle when you do actually observe them. Not so much ontologically a wave/particle duality vs we just don’t have the precise description or correct analogy to truly describe quantum objects. I am assuming he has a physics background vs old school dumbaxx

nope just old school. if this boomer actually responded such as you and there was a discussion it wouldn't have been so... embarrassing. But that sort of understanding bled over into non-sensical dosimetric demands.

 

[jondunn]

So are you believe that a lot of medstudents going for radonc are not dumb AF?

Yes.


You believe that they are dumb AF? Like really?

And certainly the recent grads have been stellar by any measure

 

[RickyScott]

Yes.


You believe that they are dumb AF? Like really?

Yes really- I think they have really poor judgment. Maybe they are not on twitter or sdn etc, but as mentioned previously,knowing how to use electronic resources is a key skill.

 

[Ray D. Ayshun]

Person, woman, man, camera, TV?

it's still hilarious in hindsight how proud he was to remember those 5 words, which really requires you to remember 2. Letting everyone know those were the 5 words he was given makes it clear to me the docs administering the test had very little confidence in his cognitive abilities. They actually dumbed it down.

 

[TheWallnerus]

Eh, it depends on how many particles you're looking at.

View attachment 358587

everyone knew photons behaved as waves and made interference patterns

It was very surprising to see electrons behave this way (who did this first?)

Just a single electron fired at the double slit can/will “tunnel” through, ignoring the slit, and land in some area on the other side in keeping with the pattern

So I don’t think it matters how many particles you’re “looking at”

We have had some good hard physics discussions here!

 

[RickyScott]

everyone knew photons behaved as waves and made interference patterns

It was very surprising to see electrons behave this way (who did this first?)

Just a single electron fired at the double slit can/will “tunnel” through, ignoring the slit, and land in some area on the other side in keeping with the pattern

So I don’t think it matters how many particles you’re “looking at”

We have had some good hard physics discussions here!

What is disturbing is that the pattern dissapears- wether electron or photon- if the particle is observed by putting a detector in the slit.

 

[Lamount]

Observing a photon/electron (and/or any form of matter) as a particle will eradicate wave-like properties and vice versa. This "observation" phenomenon (whereby the wave function collapses upon making a measurement) exists throughout experimental quantum physics... though surprisingly, it is not explained by the mathematics of quantum physics.

From my perspective, the only satisfying explanation is the "many worlds" hypothesis.

 

[communitydoc13]

What is disturbing is that the pattern dissapears- wether electron or photon- if the particle is observed by putting a detector in the slit.

Bothers me.

Like @TheWallnerus said, one photon at a time will create the interference pattern.

Like @RickyScott said, block one slit to know where the photon/electron is and there is no interference pattern.

What doesn't bother me....

Quantum suicide and immortality - Wikipedia

en.wikipedia.org

What @Lamount said.

 

[RickyScott]

Bothers me.

Like @TheWallnerus said, one photon at a time will create the interference pattern.

Like @RickyScott said, block one slit to know where the photon/electron is and there is no interference pattern.

What doesn't bother me....

Quantum suicide and immortality - Wikipedia

en.wikipedia.org

What @Lamount said.

Apparently, observation is a challenging technical problem in quantum computing. If an observable photon, heat,or any tiny bit of quantum information leaks out of the system, superposition is destroyed and the calculations are ruined.

 

[pikachu]

 

[TheWallnerus]

Is the corollary of this statement that no openings currently exist in any profession

 

[Mandelin Rain]

Is the corollary of this statement that no openings currently exist in any profession

My local Taco Bell disagrees.

 

[Palex80]

 

[medgator]

Didn't even interview me back in the day

 

[fiji128]

Didn't even interview me back in the day

I know from personal experience that it was difficult to even get an away rotation there as a med student in the not too distant past.

 

[Gfunk6]

Dear med students: If you're looking for that dream residency with the ideal blend of case volume and academic time for studying/research, a nurturing training environment with wonderfully kind faculty, and a workplace that looks more like a hotel than a hospital, then

 

[Ray D. Ayshun]

What does "nurturing" even look like? That's weird. "Supportive" is fine. Of course, I was born before 1990, so maybe the newer trainees need to be nurtured. I suspect those older than me would say "non-caustic" would be adequate.

 

[TheWallnerus]

What does "nurturing" even look like

Breast feeding.

 

[RadRadRad]

Breast feeding.

View attachment 358659

Maybe there will be a shortage of radoncs. Current practicing docs aren’t gonna work til 70 bc medicine has been nearly ruined and the upcoming generation will want to have 10 on treat and spend the rest of the time talking about being nurtured and having work life balance

 

[TheWallnerus]

IRL
At the end of the day
Worldwide

Who owns Therasphering

IR or rad onc

Rad onc just wanna be’s?

 

[medgator]

IRL
At the end of the day
Worldwide

Who owns Therasphering

IR or rad onc

Rad onc just wanna be’s?

Mostly IR doing it from what I've seen

 

[elementaryschooleconomics]

IRL
At the end of the day
Worldwide

Who owns Therasphering

IR or rad onc

Rad onc just wanna be’s?

As a med student, at Giant Health System A?

IR.

As a resident, at Giant Health System B?

IR.

As an attending, at...well, calling them "health systems" is a stretch unless you're Anthem, but we can say multiple hospitals across multiple states across multiple "alliances"?

IR.

 

[DrZap]

IRL
At the end of the day
Worldwide

Who owns Therasphering

IR or rad onc

Rad onc just wanna be’s?

It's RO where I am, in the sense the referrals mostly go MO--> RO, however the procedure is done with RO/IR jointly present

 

[medgator]

It's RO where I am, in the sense the referrals mostly go MO--> RO, however the procedure is done with RO/IR jointly present

Agree I've never seen RO do it on their own. Almost always a joint procedure, out in the community though, if IR can get their own AU certification, they have no need for an RO to do it

 

[TheWallnerus]

Agree I've never seen RO do it on their own. Almost always a joint procedure, out in the community though, if IR can get their own AU certification, they have no need for an RO to do it

isn’t it interesting that IRs can handle/place radioactivity in a patient’s body (or NSG with gammatile eg) and not be an AU. The RO in the procedure is standing there, at best, as trusted observer I would think. Certainly not a “user” in the English sense of the word.

 

[maxxor]

isn’t it interesting that IRs can handle/place radioactivity in a patient’s body (or NSG with gammatile eg) and not be an AU. The RO in the procedure is standing there, at best, as trusted observer I would think. Certainly not a “user” in the English sense of the word.

AU for unsealed sources is more of a managerial position where you create / implement / uphold radiation safety procedures to keep everyone safe. You don’t need the physician to be the one injecting the dose per se. After all, it’s the techs that are drawing up the radioactivity in the hot lab anyway. I’m not sure our IRs even know where the hot lab is…

When we have non-AUs giving Y90, I stand in the room too. It’s not like I scrub in, but I’m there to make sure if there is a spill, it’s noticed and cleaned up promptly.

We have had catheters burst and spray Y90 all over the angio suite. Not a good day.

 

[Mandelin Rain]

If there’s a source “sprayed” around the room, I’m saying “Page the RSO and hazmat team, I’m running back to clinic.”

 

[medgator]

Nice HIPAA fail, @emt409 style

 

[ROforbetterorworse]

Nice HIPAA fail, emt409 style

It would be nice if radoncs "leaders" would spend less time trying to be influencers...

Gotta immortalize this stupidity

 

[CaesarRO]

Fwiw, even in the original I can't actually read any pt names

 

[medgator]

Fwiw, even in the original I can't actually read any pt names

I saw an age of 69 along with a med rec # and what i think is the name. Wouldn't have hurt Percy to take a millisecond before tweeting the photo out to black out the HIPAA sensitive areas on the screenshot