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Hate the game, not the playa!

As for the flying:
Yeah, I've been flying almost 20 years - I take it very seriously. I manage the plane and it gets top quality maintenance love. I have a freshly IRAN'd ALT1, New Emag, and Overhauled (IRAN took too long) Mag2. I've got a dropbox full of thousands of pages of my aircraft's related info. I even wrote a cheat sheet paper with part#'s by system as I was learning the ropes. I don't cut corners with maintenance, ever. Same for flying risk assessment. So yeah, I'm not going to be on the damn news unless a bird flies thru my prop and knocks me out or some jackass tries to kill me (happened a few months ago, first time in my career) by not following the rules. I don't mess with weather and sometimes I don't get to go home.

yeah its # or GTFO, this lifestyle demands compensation.. to be away from family and live in a smallish town.

Your risk of getting into a car crash is real if you are tired, distracted and/or reckless. Flying is no different. Put the time in and be a good pilot, and the freedom is yours.
 
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RealSimulD said:
Wait wait wait.

"We opted out of greed."

But your entire schtick is pay me an inordinate amount of money to not do much work...

Now, I'm thinking this is all an act, you make $600k, work 35 hours with a 15 min commute in a cool city like Austin and spend all your free time with your loved ones and friends and are actually chummy with administrators and staff.

#WillTheRealSpamPleaseStandUp?
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My "schtick" is to get paid fairly, you know, FMV. As in, this is what you would pay plus 10-20% more for locums rotating in and out of here.

That's for me, doing the job.

MOC uses LEVERAGE to ruin THOUSANDS for doing nothing more than issuing a bs piece of paper and claiming (falsely) that doing MOC makes us better. You're paying for NOTHING more than a charade.

Know the difference. "Greed" for individuals negotiating their own pay is good. Greed to use leverage by creating false barriers and touting fake value, to abuse thousands out of their time and $, is abusive.

# for lyfe
 
communitydoc13 said:
I agree 100%....in general.

Some crazy, marginal medical existences out there in the community however. Like docs who lose their hospital privileges but run their own surgical center, horrific plastics practices or very marginal community pathology practices with good relationships with local docs (probably fine for most cases but when it's cancer, it's never adequate).

Most community docs are very good IMO. In radonc, the path to reputation in academic medicine has essentially nothing to do with clinical skills (a few exceptions). In surgery, I think this is a bit different.
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So this point is what drove me to start questioning the value of the current version of board certification in general.

I'm community-based academics now, and have previously been PSA-based private practice and before that in a couple of massive, urban, academic medical centers.

I've seen amazing docs and horrific docs. All licensed and certified. I've seen people who I consider brilliant and who I would let treat myself or my family struggle with or fail initial exams.

There's no pattern I can see, and some of the most insane stuff I've ever seen came from people with board certification. But, that's anecdote, right?

So I went into the literature. There's very minimal data on board certification as it pertains to ability/skill to practice modern medicine, and as far as I can find, there's zero data in Radiation Oncology.

Board certification is supposed to be about protecting the public.

Is that what we're doing with this iteration of the system?
 
elementaryschooleconomics said:
So this point is what drove me to start questioning the value of the current version of board certification in general.

I'm community-based academics now, and have previously been PSA-based private practice and before that in a couple of massive, urban, academic medical centers.

I've seen amazing docs and horrific docs. All licensed and certified. I've seen people who I consider brilliant and who I would let treat myself or my family struggle with or fail initial exams.

There's no pattern I can see, and some of the most insane stuff I've ever seen came from people with board certification. But, that's anecdote, right?

So I went into the literature. There's very minimal data on board certification as it pertains to ability/skill to practice modern medicine, and as far as I can find, there's zero data in Radiation Oncology.

Board certification is supposed to be about protecting the public.

Is that what we're doing with this iteration of the system?
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The problem is when the people who get involved with boards or medical societies like Astro, start twisting the rules, making changes for their own benefit.
 
sirspamalot said:
Your risk of getting into a car crash is real if you are tired, distracted and/or reckless. Flying is no different. Put the time in and be a good pilot, and the freedom is yours.
Click to expand...

I have done the 20+ hour/week of driving thing before. For sure that will raise your risk of a fatal or career-ending MVA.
However, PPL GA is not even in the same league. It's a double edged sword. If you rarely fly then your odds of an incident go down because of less time in the air, however your risk of death goes up if there is a problem due to lack of currency. On the other hand, if you are in the air all the time, you are more current and better able to handle an emergency, but the risk of actually experiencing a potentially catastrophic event go way up.

I have < 200 flight hours. In those only 200 hours I have experienced:
- Inadvertent controlled flight into IMC
- Loss of vacuum pump while in IMC (single engine, single pilot, partial panel... good luck), thankfully I could dip out of the clouds quickly and fly visually.
- Spatial disorientation at night having to rely on GPS to find my way home.
- Passenger door flew open during flight
- Rapidly deteriorating weather resulting in severe turbulence on the edge of a thunderstorm (try reading instruments when your head is literally banging against the ceiling)
- Failed nose strut on landing

And not to mention the numerous times I took off in a single, knowing that if I lost the engine on climb out I would die (ie, impossible to clear the obstacle or no landing area straight ahead at wooded airports, etc).

That was enough for me. Not even close to being in the same league as driving a lot of miles. Do it long enough and you will become another doctor-pilot statistic. It's fun, but I can't in good conscious argue that people should do it as a reasonable way of commuting to #750 gigs.

Give me a cirrus jet and a way to pay for it and I might change my mind 😛
 
Mandelin Rain said:
Florida is the state that DEFINITELY needed less guard rails protecting the quality of health care within their state.

When RFK Jr is in Tampa prescribing folks hydroxychloroquine penile suppositories to make their dong bigger, this will look like a much worse idea.
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Quite the visual.
 
elementaryschooleconomics said:
There's no pattern I can see, and some of the most insane stuff I've ever seen came from people with board certification. But, that's anecdote, right?
Click to expand...

The absolute scariest stuff without a doubt comes from the grandfathered boomers who trained in the pre-CT era and adopted very hypofractionated IMRT and SBRT plans on their own. I have just seen some wildly reckless stuff.

Meanwhile evicore boomers school me on how I can't give a modest SIB with IMRT for 5 fraction breast because "doses that high are too dangerous without data to show that's safe"
 
mehrlicht said:
The absolute scariest stuff without a doubt comes from the grandfathered boomers who trained in the pre-CT era and adopted very hypofractionated IMRT and SBRT plans on their own. I have just seen some wildly reckless stuff.
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Ding. Ding. Ding.

It's funny, I obviously engage a lot on here and other venues and talk about the problems facing the field.

But, at the end of the day, it's the stuff I hold back that really makes my skin crawl.
 
elementaryschooleconomics said:
Board certification is supposed to be about protecting the public.

Is that what we're doing with this iteration of the system?
Click to expand...
It's very very hard to prove that board certification works. Just as it's hard to prove the efficacy of most safety measures, particularly when things are pretty safe to begin with.

In the absence of actionable statistics (we are the stats gen here), hypotheticals are important.

Do you think that board certification requirements have ever prevented an incompetent med-stud or resident from practicing (now I know the converse is true, there are some brilliant and conscientious bad test takers out there)?

Do you think that board certification has ever prevented a mal administration of XRT?

I would say the answers to these questions are probably yes.
 
mehrlicht said:
I have done the 20+ hour/week of driving thing before. For sure that will raise your risk of a fatal or career-ending MVA.
However, PPL GA is not even in the same league. It's a double edged sword. If you rarely fly then your odds of an incident go down because of less time in the air, however your risk of death goes up if there is a problem due to lack of currency. On the other hand, if you are in the air all the time, you are more current and better able to handle an emergency, but the risk of actually experiencing a potentially catastrophic event go way up.

I have < 200 flight hours. In those only 200 hours I have experienced:
- Inadvertent controlled flight into IMC
- Loss of vacuum pump while in IMC (single engine, single pilot, partial panel... good luck), thankfully I could dip out of the clouds quickly and fly visually.
- Spatial disorientation at night having to rely on GPS to find my way home.
- Passenger door flew open during flight
- Rapidly deteriorating weather resulting in severe turbulence on the edge of a thunderstorm (try reading instruments when your head is literally banging against the ceiling)
- Failed nose strut on landing

And not to mention the numerous times I took off in a single, knowing that if I lost the engine on climb out I would die (ie, impossible to clear the obstacle or no landing area straight ahead at wooded airports, etc).

That was enough for me. Not even close to being in the same league as driving a lot of miles. Do it long enough and you will become another doctor-pilot statistic. It's fun, but I can't in good conscious argue that people should do it as a reasonable way of commuting to #750 gigs.

Give me a cirrus jet and a way to pay for it and I might change my mind 😛
Click to expand...
Sorry you had such a rough introduction to flying. Yeah, I fly 150-200 hours a year, and I feel unhappy if I don't fly for 3 weeks in a row. Cirrus SR22 is the sweet spot for under 500 mile trips as far as price, performance and safety but well, unless anyone wants me to espouse for a few hours, it ain't perfect. But having the parachute option has saved hundreds of lives.

Inadvertent controlled flight into IMC? Can't recall it happening. And since I'm on autopilot when it would happen typically, its a nonevent. I got my instrument rating immediately following PP. Training and experience make this a nonissue for most competent pilots. I wouldn't buy/fly hard IFR in a plane with vacuum pumps, without an electronic standby AHI but thats just me. I've had a door crack, and yeah first time its alarming but I had been informed it could happen (passenger and I failed to check carefully enough the door closing) and so training kicked in and I just went and landed.

Rapidly deteriorating weather is a real issue. I've only gotten caught once or twice, and I was PUSHING MY LUCK a bit which I never do. I knew what the outs were (or weren't) and it hasn't happened for many years. I just won't take the risk - having nearly 20 years flying experience helps me avoid even getting close to being in a real jam.

I've had stuff break. Competent pilots may not like it, but we can manage. Mag failure, Alt failure, nosewheel tire blows. More likely a novice pilot or one who is pushing boundaries without requisite will land poorly, force it, boing boing and cartwheel into crispy bbq. I don't want to end up on Kathryn's report.. and as such, I've tried hard to be a good pilot.

If you're going to fly, take it very seriously. Your life may depend on it.
 
communitydoc13 said:
Yep. Absolutely no reason to be giving 34Gy in 1 fraction out in the community. Some of these docs are like. "paper shows it can be done". Fractionation is a safety tool.
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Huh? That's not what I meant. There is no reason you have to be at an academic center to deliver single fraction lung SBRT if you have the equipment and correct physics support and the volume is appropriate. It can happen if you have patients coming from 2-3 hours a way and that's the only way they will agree to treatment.

What I am talking about is boomers doing 54 Gy in 3 fractions with volumes their dosimetrist drew and expanded into esophagus or mainstem bronchus.
 
mehrlicht said:
Huh? That's not what I meant. There is no reason you have to be at an academic center to deliver single fraction lung SBRT if you have the equipment and correct physics support and the volume is appropriate. It can happen if you have patients coming from 2-3 hours a way and that's the only way they will agree to treatment.

What I am talking about is boomers doing 54 Gy in 3 fractions with volumes their dosimetrist drew and expanded into esophagus or mainstem bronchus.
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If you can do it and you can't find a way to get them in 1x a week for 3 weeks, then go ahead. It should be exceptionally rare. I have seen it done in urban environments and suburban environments. I would consider it by definition more dangerous than a fractionated regimen.
 
communitydoc13 said:
If you can do it and you can't find a way to get them in 1x a week for 3 weeks, then go ahead. It should be exceptionally rare. I have seen it done in urban environments and suburban environments. I would consider it by definition more dangerous than a fractionated regimen.
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Are you making the argument that 34 Gy x 1 should be done by no one or that it should only be done at academic centers? I disagree with both, but for different reasons.
 
communitydoc13 said:
If you can do it and you can't find a way to get them in 1x a week for 3 weeks, then go ahead. It should be exceptionally rare. I have seen it done in urban environments and suburban environments. I would consider it by definition more dangerous than a fractionated regimen.
Click to expand...

Ha, I am simming this today. It is rare in my practice.

A little over a year ago I was on this board hyping 34/1 and people were implying I was an academic using it steal patients from the local center. I was the local center and the only one in the practice regularly using that fractionation.

Now I am in the community and it should be left to academics?

Follow the data. 34 Gy in 1 fraction should be offered to anyone offered 4 fraction (or 3). The RTOG/NRG believes both are excellent choices. There are limitations to the data for 34/1. Many of my patients choose 3 (I don't do 4 really) due to those limitations.

You should apply the same logic for 28 Gy in 1 fraction for metastasis.
 
RickyScott said:
i dont think it should be done in either, except for rare exceptions
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Because the consequences of an error are too great or because you don't believe the safety and efficacy data?

Similar to my flying analogy above about more episodes = more risk but more mitigatable consequences, I would argue that delivering 3-5 fractions of very high dose increases the chance of an error by 3-5 times over single fraction. How this increased risk of error due to multiple deliveries is weighed against the increased consequence of error by higher dose is arguable.

My personal preference is 3 fraction based on my subjective feeling of wanting to hit it multiple times. I really hate routine 5 fraction for everything (due to a lack of data for dose escalation to comparable BED), but I don't have any issues with doing single fraction if someone demands it (although I'll admit the concept of BED for single fraction is also less than satisfying). But I agree this is rare. I've only done it a few times ever.
 
mehrlicht said:
Because the consequences of an error are too great or because you don't believe the safety and efficacy data?
Click to expand...

Point 1, I agree. However, the consequences of an error for 3 fraction SBRT are also pretty large. Administratively and clinically. IMO you should either trust your SBRT program or dont. Im not sure how you can trust giving 18 Gy x1 but not 34 Gy.

Point 2, thats totally fair, but Im curious what data you would want to "believe" it? 34 Gy for NSCLC and 28 Gy for mets are both prospectively tested and the former has long term follow up. There are limitations, but it's hard to argue the quality of the data is not high.

It's totally valid to say that 3-4 fractions serve your patients well, 1 is less well tested and you don't feel its worth implementing a new dose/fractionation in your center, especially when case volumes are an issue.

You can say all that and still be okay with others using a valid dose/fractionation in well selected patients.
 
1690993254027.png
I
Is this the data we are using to justify single fraction? Not for me.
 
Haha not a shame thing

If you’re pro fee, it’s not so much different

I was just wondering if there was something about safety I was missing

If you can do 54/3 you can do 34/1, at least based on my experience

Nothing wrong with either approach!
 
communitydoc13 said:
View attachment 375124I
Is this the data we are using to justify single fraction? Not for me.
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That trial was designed to find an experimental arm for future trials, not to compare to two. They ultimately decided not to further assess this question.

However, if hypothetically NRG opened a trial that was designed to test a comparison of single fraction versus four fraction, would you offer it to a patient?
 
communitydoc13 said:
It's very very hard to prove that board certification works. Just as it's hard to prove the efficacy of most safety measures, particularly when things are pretty safe to begin with.

In the absence of actionable statistics (we are the stats gen here), hypotheticals are important.

Do you think that board certification requirements have ever prevented an incompetent med-stud or resident from practicing (now I know the converse is true, there are some brilliant and conscientious bad test takers out there)?

Do you think that board certification has ever prevented a mal administration of XRT?

I would say the answers to these questions are probably yes.
Click to expand...
Oh man. I could talk about this for days straight.

Do I think board certification has prevented misadministration of XRT?

No.

Do I think the process of training to attain board certification has prevented misadministration of XRT?

Yes.

And that's my point. To become an independently practicing physician:

High School Diploma
Undergrad Degree
Medical School Degree
At least 1 year supervised GME (most states are 2 years now, but a handful it's still one)

That's just to get a medical license.

Then, for RadOnc, we have the intern year but 4 years of supervised training.

Then...everyone MUST practiced for a year at minimum without board certification because of orals. However, you technically remain board eligible for 5 years after residency.

In an ideal world, there are multiple "choke points" where you MUST demonstrate a level of competence to progress. There's also the additional layer of hospital credentialing, which will be repeated over and over and over again forever.

So...what part is broken here? Why do we allow people to practice for at least a year without certification? Doing so is an implied acceptance that if someone got through all those hurdles, they are minimally competent.

Thought experiment: COVID forced boards to be delayed. There was, for the first time in modern history, a cohort of people practicing RadOnc without certification for longer than ever previously seen.

Was there an increase in safety incidents? Nope. So what does that say?

I could go on but - I don't support abolishing board certification entirely. I support thoughtful reform, or at least having a concrete answer for "why" something is done.
 
elementaryschooleconomics said:
Was there an increase in safety incidents? Nope. So what does that say?
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I would never expect to see a signal here.

Let's pose another hypothetical: What if all those boomer, grandfathered out docs had to take meaningful recertification periodically? Do you think this would have prevented occasional maladministration?

NotMattSpraker said:
However, if hypothetically NRG opened a trial that was designed to test a comparison of single fraction versus four fraction, would you offer it to a patient?
Click to expand...
Good question. I don't know but probably.

To me, there is very little upside to extreme hypofractionation (I almost never go below 3 fxns) except in the enormously poor performance patient. There is marginal convenience benefit, there is real biological concern regarding late toxicity, (brain mets and necrosis for instance), and there is a greater consequence to rare misadministration (won't show up in data),

So given my biases, The NRG trial data is just not very reassuring. Massive censoring means no real meaningful long term toxicity data, patients dying quickly (is your median survival really 2 years for these folks?) and curves that aren't really perfectly on top of each other regarding local control.

If you trained doing 34Gy in 1, then fine by me. If you are 60 y/o and all of a sudden you are presenting a 34 Gy in 1 fraction plan at chart rounds, I am thinking, "Why?"
 
communitydoc13 said:
Let's pose another hypothetical: What if all those boomer, grandfathered out docs had to take meaningful recertification periodically? Do you think this would have prevented occasional maladministration?
Click to expand...
Yes!!!! This is what I want.

The current exams are not meaningful. I'm specifically criticizing their reflection of reality.

Last week, I was doing case peer review with a colleague who is brilliant. This person made a comment about my margin expansion in a way that implied it wasn't appropriate.

When I asked why, it basically boiled down to "a physicist said that once". I asked if they had their own opinion on the topic, or if they knew why a physicist would say something like that.

The short answer is no. There was no knowledge or understanding of anything deeper. Despite this person being brilliant and board certified.

In that case, my margin choice was based specifically on the immobilization equipment I had chosen, the TPS I'm using, and the brand/age of linac delivering the treatment. All things I learned myself and was never taught to me, or tested on. Yet very practical.

I strongly support meaningful initial and maintenance of certification exams.
 
communitydoc13 said:
Let's pose another hypothetical: What if all those boomer, grandfathered out docs had to take meaningful recertification periodically? Do you think this would have prevented occasional maladministration?
Click to expand...

No I don't think it would, but this field has a ridiculous culture of different rules for different people so at least that aspect would go away!
 
NotMattSpraker said:
No I don't think it would, but this field has a ridiculous culture of different rules for different people so at least that aspect would go away!
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In a field where we are allowed to prescribe an Infinite range of numbers (dose and fractionation) with a lot of anecdotal experience mixed in with the need to feel heard by other providers… we created this monster.

I’m all for standardization because the more years I’m out of residency, the less I feel that anything I do even matters. I believe we should spend less time analyzing each other’s plans and more time finding ways to advance the field outside of doing omission trials and less fractions. Even less time trying to support new toys.
 
MOC from the ABR as it stands now is a joke. The important part is paying your annual dues.

The questions are ******edly simple or absurdly out of your knowledge sphere and irrelevant to practice. Neither has anything to do with my day to day work.

Tired of the nonsense. Kill it off. #NBPASorGTFO
 
sirspamalot said:
MOC from the ABR as it stands now is a joke. The important part is paying your annual dues.

The questions are ******edly simple or absurdly out of your knowledge sphere and irrelevant to practice. Neither has anything to do with my day to day work.

Tired of the nonsense. Kill it off. #NBPASorGTFO
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I admit the questions are a joke and I feel bad whenever I do get one wrong (usually me doing something else and not reading the entire question) but it’s way better then taking another exam. I will gladly pay my dues and keep answering simple questions if it means I don’t have to worry about another board exam.
 
RadOncDoc21 said:
I admit the questions are a joke and I feel bad whenever I do get one wrong (usually me doing something else and not reading the entire question) but it’s way better then taking another exam. I will gladly pay my dues and keep answering simple questions if it means I don’t have to worry about another board exam.
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Haha so mafia-like.

Once I got a question wrong because it was on a timer and I was interrupted for a clinical issue, like on a real patient in the real clinic. So peak.
 
RealSimulD said:
Haha not a shame thing

If you’re pro fee, it’s not so much different

I was just wondering if there was something about safety I was missing

If you can do 54/3 you can do 34/1, at least based on my experience

Nothing wrong with either approach!
Click to expand...
I don’t like to do 1 fraction unless I have to… more chance of missing completely, but I wouldn’t shame anyone for doing it. Data are data
 
RickyScott said:
Random errors average out unless it is one fraction
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All safety arguments favor multi-fraction treatment and even real time fluoro with fiducials and gating is not that beautiful in a bad breather or a cough.

A total miss is very, very unlikely (although still more impactful with 1 fraction if it happens). A total miss is an extraordinary event and while you are more likely to have one given 4 shots at the target instead of 1, it is likely a less than 1/1000 event. (also, 36 Gy in 3 fractions with 140% hot still going to give some control).

What is not that unlikely is a marginal miss with some portion of the target getting 70% or 50% of intended dose. If this happens in a 4 fraction regimen, you are treating to 89-93% of the prescribed dose (as opposed to 50-70% for a single fraction treatment). Roughly 90 percent of our intended 3-4 fraction dose is likely to get the job done in terms of durable control.

Of course, the most catastrophic event is putting your prescribed dose into an OAR. This is crazy rare, but nearly all structures can handle 10-12 Gy in a single fraction. 34 Gy?

Finally, it is almost always true that equivalent BED regimens for tumor control tend to mean less effective dose regarding late toxicity as they become more fractionated. Classic radbio and the original rationale for fractionated treatment to begin with.

The more chances to miss argument is just not strong.
 
That’s all fine and well theoretically.

But in practice, it works.

At least, based on outcomes.
 
RealSimulD said:
That’s all fine and well theoretically.

But in practice, it works.

At least, based on outcomes.
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I just want to make it clear. I'm not fraction shaming. I'm fraction promoting!

Outcomes? I don't know.

I do know that RTOG 0927 evaluated just over 80 patients and less than 40 in the single fraction arm.

I do know that no statistically significant differences were appreciated between single fraction and four fraction arms in terms of toxicity, local control or survival outcomes.

I do know that the two groups do not look the same in terms of outcomes (survival, local control or even toxicity). Toxicity numbers are tiny and actually favored single fraction regimen. Survival and local control outcomes favored fractionated treatment.

The tiny size of the trial means that only enormously large differences could be designated as statistically significant. Two year survival was actually markedly different between the two groups.

So I could draw the following conclusions:

1. The groups looked different because of randomness, and these interventions are totally equivalent
2. The groups looked different because the interventions meant something different to the patients, but the trial was not powered to detect these differences at a level of statistical significance.

If you think single fraction represents the best care for the patient based on this information, go ahead.

Misadministration does happen. I haven't had a major one in my clinic, but a colleague of mine had a fraction of SBRT given without a proper shift. Thank goodness it was fractionated treatment.
 
I prefer 3-5.

But not for safety reasons.

There is a residual "trained in mid-to-late aughts" that still thinks fractionations works if you can get more dose in.

Maybe I should worry about miss more?

I don't know. We do all the things - 4D, ITV, CBCT before first arc and another one midway through.
 
communitydoc13 said:
I just want to make it clear. I'm not fraction shaming. I'm fraction promoting!

Outcomes? I don't know.

I do know that RTOG 0927 evaluated just over 80 patients and less than 40 in the single fraction arm.

I do know that no statistically significant differences were appreciated between single fraction and four fraction arms in terms of toxicity, local control or survival outcomes.
Click to expand...

Again, it was never designed as a comparative trial, so it's really not worth your time to try to use the trial to compare the two fractionations. People should also not tell patients that they were compared and "its the same". That's not the truth. The truth is a small number of patients were prospectively tested and these are the outcomes you get.

communitydoc13 said:
If you think single fraction represents the best care for the patient based on this information, go ahead.
Click to expand...

There is more information, the SAFRON II trial: Single- vs Multifraction Stereotactic Ablative Body Radiotherapy for Pulmonary Oligometastases

I would guess that if you presented the data honestly to 100 patients with NSCLC, 99 of them would chose 3-4 fractions instead of 1. I would.

I would guess I've used single fraction SBRT on a lung met <20 times in my entire career, and 90% of those are in an oligometastatic/oligoprogressive patient where I thought their life expectancy could be <2 years and delaying or stopping chemo could be harmful.

This is a niche tool, not a standard of care for a whole practice.
 
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