Rad Onc Twitter

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
RickyScott said:
i have had fleeting thoughts abt doing remote dosimetry. I think I can plan 3x faster and better than most and could probably make a killing on a per plan basis.
Click to expand...

How did you learn to do it on your own?
Members don't see this ad.
 
RickyScott said:
i have had fleeting thoughts abt doing remote dosimetry. I think I can plan 3x faster and better than most and could probably make a killing on a per plan basis.
Click to expand...

I probably couldn't resist the urge to edit the doc's volumes...

"just take off a little off the top on that CTV, no one will notice..."

"why TF is this doc treating elective nodes on this palliative pancreas plan...let's just tighten up that margin there, he won't notice...."
 
Last edited:
  • Like
  • Haha
Reactions: 7 users
Members don't see this ad :)
HolySmokes said:
By necessity, mostly.
Click to expand...
Same for me.

I had been shown some basics in residency and was fortunate enough to be using the same TPS (Eclipse). There's some YouTube videos, a PDF here and there (nothing comprehensive sadly), and some friends I could ask.

Re: remote Dosimetry and rural.

Yes. Remote Dosimetry should be the way it goes.

However.

As @MidwestRadOnc pointed out - "no" is definitely an answer you will often encounter to reasonable ideas out here in the Wild West.

In my particular instance: I had a full-time, on-site, human Dosimetrist.

Well. I mean. There was a person with blood and bones who appeared to breathe the air and collected a paycheck for being employed as a Dosimetrist.

Apathy and inertia are often insurmountable forces in the Wild West. Because bad radiation won't kill someone instantly, like bad surgery can, most of our complaints seem dramatic. Who cares if your PTV is only getting 70% coverage because that's the only way they can figure out how to meet your demanding QUANTEC constraints that no one had ever heard of before you started working here?

70% is like, more than 2/3rds. That's good enough. Stop being a perfectionist. The staff hates it.
 
  • Like
  • Haha
Reactions: 14 users
elementaryschooleconomics said:
Same for me.

I had been shown some basics in residency and was fortunate enough to be using the same TPS (Eclipse). There's some YouTube videos, a PDF here and there (nothing comprehensive sadly), and some friends I could ask.

Re: remote Dosimetry and rural.

Yes. Remote Dosimetry should be the way it goes.

However.

As @MidwestRadOnc pointed out - "no" is definitely an answer you will often encounter to reasonable ideas out here in the Wild West.

In my particular instance: I had a full-time, on-site, human Dosimetrist.

Well. I mean. There was a person with blood and bones who appeared to breathe the air and collected a paycheck for being employed as a Dosimetrist.

Apathy and inertia are often insurmountable forces in the Wild West. Because bad radiation won't kill someone instantly, like bad surgery can, most of our complaints seem dramatic. Who cares if your PTV is only getting 70% coverage because that's the only way they can figure out how to meet your demanding QUANTEC constraints that no one had ever heard of before you started working here?

70% is like, more than 2/3rds. That's good enough. Stop being a perfectionist. The staff hates it.
Click to expand...

One of the many reasons I won't go back to the Midwest.

Say what you will about in Florida, even the "shady" operations here usually put out pretty high quality radiation plans.
 
  • Like
Reactions: 4 users
BobbyHeenan said:
I probably couldn't resist the urge to edit the doc's volumes...

"just take off a little off the top on that CTV, no one will notice..."

"why TF is this doc treating elective nodes on this palliative pancreas plan...let's just tighten up that margin there, he won't notice...."
Click to expand...
thats the rub. A lot of docs sometimes provide impossible volumes for the constraints "on the wall" and waste a huge amount of the dosimetrists time with back and forth. would be able to tell them this from the get go and where to compromise the volume. After being in the field for a while, get a sense of what is a "reasonable" ptv and plan looks like in most cases. Ex: have seen boomers ask for 1+ cm expansion on pelvic nodes and then go back and forth with dosimetrists as they cant meet some "wall constraint" where certain volume of small bowel (often adjacent) gets less than 30 Gy.
 
Last edited:
  • Like
Reactions: 4 users
elementaryschooleconomics said:
Well. I mean. There was a person with blood and bones who appeared to breathe the air and collected a paycheck for being employed as a Dosimetrist.

Apathy and inertia are often insurmountable forces in the Wild West. Because bad radiation won't kill someone instantly, like bad surgery can, most of our complaints seem dramatic. Who cares if your PTV is only getting 70% coverage because that's the only way they can figure out how to meet your demanding QUANTEC constraints that no one had ever heard of before you started working here?

70% is like, more than 2/3rds. That's good enough. Stop being a perfectionist. The staff hates it.
Click to expand...
GET OUT OF MY HEAD

Edit: Minutes after posting this I went to review a plan. I had to send this text to one of my dosimetrists about a 3D plan, "I am concerned that we are not treating the entire PTV."
 
  • Like
Reactions: 2 users
HolySmokes said:
GET OUT OF MY HEAD

Edit: Minutes after posting this I went to review a plan. I had to send this text to one of my dosimetrists about a 3D plan, "I am concerned that we are not treating the entire PTV."
Click to expand...

Dosimetrist response: That's just what you're seeing on the computer. Things change day to day so you really have no idea what's getting what and need to be more reasonable. Also, there is no such thing as max point dose. Don't you even dare mention min.
 
HolySmokes said:
GET OUT OF MY HEAD

Edit: Minutes after posting this I went to review a plan. I had to send this text to one of my dosimetrists about a 3D plan, "I am concerned that we are not treating the entire PTV."
Click to expand...
The saddest part of all is I know we're not alone.

This is more common than people realize, because most of actual RadOnc is more or less walled off from the residency version of RadOnc.

The SCAROP institutions obviously have a ton of problems, and Lord knows my residency institution is well known across the region for being a garbage fire in terms of Dosimetry.

However, they all have one thing in common: more than one Dosimetrist. And lots of turnover.

Because in a large department, the Dosimetry division can be a "hot mess" through turnover and culture/morale.

But the SCAROP institutions represent, at max, perhaps 25% of the total practicing Radiation Oncologists (approximately 1,200 attendings).

The rest - something north of 4,000 - the rest of us work in places without residents.

No one warns you about the community hospital that's loosely part of "the network" that functions like a republic. And in this community hospital, where you're either a W2 employee or staffing it full time for your group on a PSA, there's only one Dosimetrist. And that one Dosimetrist has been there since the late 1990s.

And yeah, maybe that one Dosimetrist has fallen off in recent years. The senior partner noticed it too. But you know, who hasn't had a rough go of things lately? Don't you know about the family stuff that happened to that one Dosimetrist? Of course, then the pandemic happened, and that was hard for everyone.

You really don't want to be "that" guy, the "young hotshot doctor", coming here and telling people what to do. This QUANTEC thing, yeah, I know you say its been around for like a decade at this point, but that sounds like some Ivory Tower crap. You need to check your attitude because it upsets the staff.

My point being:

You. Yes you, lurking resident. The one who made an SDN account years ago for pre-med but hasn't posted since then.

I know what you're thinking. This isn't real, or if it is, it won't happen to you.

I hope you're right. But if you're not, the one thing I can offer you is the concrete knowledge that you are NOT alone.

Sorry this happened, current and future lurking resident.

I hope it gets better.
 
  • Like
Reactions: 4 users
Love the idea of us being the ones that are encroaching. Other groups are trying to encroach on us, uno reverse card.
 
  • Like
Reactions: 2 users
ESE is exactly correct. The last thing you expect after 10 years of med school and residency is to show up to a small midwestern town to takeover a clinic from a solo retiring doc and encounter a dosimetrist that surfs facebook all day, wears scrubs to work, takes 3 week vacations, tells you how he treats prostates, prefaces every plan presentation with "I worked on this forever, and this is the best I've got... (ie, I'm not doing any more work on it)" and when you bring this up with admin you are told to play nice because "it's really hard to recruit rad onc staff here" Good ol' boys club, and you're not in it.

The staff are allowed to not show up for weeks because of this or that, but if you complain about chart rounds or something, you're a "problem doctor" and scheduled for replacement.
 
  • Like
Reactions: 7 users
Members don't see this ad :)
elementaryschooleconomics said:
The saddest part of all is I know we're not alone.

This is more common than people realize, because most of actual RadOnc is more or less walled off from the residency version of RadOnc.

The SCAROP institutions obviously have a ton of problems, and Lord knows my residency institution is well known across the region for being a garbage fire in terms of Dosimetry.

However, they all have one thing in common: more than one Dosimetrist. And lots of turnover.

Because in a large department, the Dosimetry division can be a "hot mess" through turnover and culture/morale.

But the SCAROP institutions represent, at max, perhaps 25% of the total practicing Radiation Oncologists (approximately 1,200 attendings).

The rest - something north of 4,000 - the rest of us work in places without residents.

No one warns you about the community hospital that's loosely part of "the network" that functions like a republic. And in this community hospital, where you're either a W2 employee or staffing it full time for your group on a PSA, there's only one Dosimetrist. And that one Dosimetrist has been there since the late 1990s.

And yeah, maybe that one Dosimetrist has fallen off in recent years. The senior partner noticed it too. But you know, who hasn't had a rough go of things lately? Don't you know about the family stuff that happened to that one Dosimetrist? Of course, then the pandemic happened, and that was hard for everyone.

You really don't want to be "that" guy, the "young hotshot doctor", coming here and telling people what to do. This QUANTEC thing, yeah, I know you say its been around for like a decade at this point, but that sounds like some Ivory Tower crap. You need to check your attitude because it upsets the staff.

My point being:

You. Yes you, lurking resident. The one who made an SDN account years ago for pre-med but hasn't posted since then.

I know what you're thinking. This isn't real, or if it is, it won't happen to you.

I hope you're right. But if you're not, the one thing I can offer you is the concrete knowledge that you are NOT alone.

Sorry this happened, current and future lurking resident.

I hope it gets better.
Click to expand...
A lot
MidwestRadOnc said:
ESE is exactly correct. The last thing you expect after 10 years of med school and residency is to show up to a small midwestern town to takeover a clinic from a solo retiring doc and encounter a dosimetrist that surfs facebook all day, wears scrubs to work, takes 3 week vacations, tells you how he treats prostates, prefaces every plan presentation with "I worked on this forever, and this is the best I've got... (ie, I'm not doing any more work on it)" and when you bring this up with admin you are told to play nice because "it's really hard to recruit rad onc staff here" Good ol' boys club, and you're not in it.

The staff are allowed to not show up for weeks because of this or that, but if you complain about chart rounds or something, you're a "problem doctor" and scheduled for replacement.
Click to expand...
Staff are absolutely more valued than doctors in this field given the under/over supply. Imagine having any kind of dispute with a young Ron D before his license was revoked. Whose side do you think the cancer admin (nurse with associate degree in business) will take?
 
  • Like
Reactions: 2 users
1714708921828.png


Underserved.
 
  • Haha
  • Like
Reactions: 7 users
The injustice of the Yale crowd and surrounding areas lacking protons is finally over. Let us thank the gods!
 
RickyScott said:
A lot

Staff are absolutely more valued than doctors in this field given the under/over supply. Imagine having any kind of dispute with a young Ron D before his license was revoked. Whose side do you think the cancer admin (nurse with associate degree in business) will take?
Click to expand...

License revoked? Say more...
 
drowsy12 said:
I'm not sure why remote dosimetry isn't bigger than it is.
Click to expand...
It's pretty big. If you advertise for remote, you will get a lot of reasonable apps.

The barrier is the institution. Some of these still have ridiculous ideas of who needs to be on site (absolutely no need for dosi to be onsite IMO, particularly if adequate physics staffing). This is coming from a doc mostly on-site advocate.

The above tales of the legacy, incompetent, on-site dosimetrist should not be happening. There is a workforce out there for remote service.

Now it is highly variable, and I do encourage for all remote hires an on-site visit, meeting pertinent folks (physics and docs) face to face, maybe even a few days on site for on-boarding and discussion.

Remote dosi should be at your chart rounds, and your chart rounds should be meaningful.

My 2 cents.
 
  • Like
Reactions: 4 users
What the dosis are not going to like as their position transistions to remote/WFH, there will be an oversupply and pay will go down. I don’t think these days of having 3 or more jobs paying historically full time wages will last. I’m sure PE is already on it. The cat’s out of the bag that an average rad onc clinic does not require 40 hours a week of full time dosimetry work. There’s a lot of downtime, enough to work other jobs, even. So admins will start to wonder, we are paying them this much why exactly? And they will find themselves doing 2 remote jobs for what they used to get paid for 1 in person.
 
  • Like
Reactions: 4 users
communitydoc13 said:
It's pretty big. If you advertise for remote, you will get a lot of reasonable apps.

The barrier is the institution. Some of these still have ridiculous ideas of who needs to be on site (absolutely no need for dosi to be onsite IMO, particularly if adequate physics staffing). This is coming from a doc mostly on-site advocate.

The above tales of the legacy, incompetent, on-site dosimetrist should not be happening. There is a workforce out there for remote service.

Now it is highly variable, and I do encourage for all remote hires an on-site visit, meeting pertinent folks (physics and docs) face to face, maybe even a few days on site for on-boarding and discussion.

Remote dosi should be at your chart rounds, and your chart rounds should be meaningful.

My 2 cents.
Click to expand...

Fully agree.

I do think its worth while to have them come a few times a year because meeting people face to face can enhance culture on teams. I've been talking a lot with dosis my institution deals with the existential dread of letting them be remote. They all seem to agree with that.
 
Fpg1245 said:
When I think underserved I think CT. Those poor souls on Greenwich and New Canaan!! They will suffer no longer!
Click to expand...

I probably speak for many of us when I say about a third of my patients drive similar distances for treatment with me (closest to them) as going from New Haven to Boston (or NYC) for protons. And we're not talking CT demographics.
 
  • Like
Reactions: 1 user
metallica81788 said:
I probably speak for many of us when I say about a third of my patients drive similar distances for treatment with me (closest to them) as going from New Haven to Boston (or NYC) for protons. And we're not talking CT demographics.
Click to expand...

It is a 1.5 hour drive from Yale to the NY Proton Center. I saw someone yesterday that drove further to see me and I have the closest Linac.

I am embarrassed with how our field approaches "financial toxicity", "the underserved", and "rural" patients. It is super gross.
 
  • Like
Reactions: 5 users
NotMattSpraker said:
It is a 1.5 hour drive from Yale to the NY Proton Center. I saw someone yesterday that drove further to see me and I have the closest Linac.

I am embarrassed with how our field approaches "financial toxicity", "the underserved", and "rural" patients. It is super gross.
Click to expand...
It's not underserved, it's undeserved.
 
  • Like
Reactions: 1 users
Mandelin Rain said:
[Aaron Hernandez has entered the chat]
Click to expand...
Literally the only thought my mind had when the idea of "rough Connecticut" came up. I'm sure there is a rough Connecticut (including right next to Yale) but it is obviously not the "underserved" region being targeted.

A "proton desert" refers to a place where people shop at Fresh Market or better yet Dean & Deluca but don't yet have convenient access to protons.

It is interesting is that (presumably due to regulatory environment and strong managed care presence) California has not seen this type of behavior to date.
 
  • Haha
  • Love
Reactions: 1 users
communitydoc13 said:
It's pretty big. If you advertise for remote, you will get a lot of reasonable apps.

The barrier is the institution. Some of these still have ridiculous ideas of who needs to be on site (absolutely no need for dosi to be onsite IMO, particularly if adequate physics staffing). This is coming from a doc mostly on-site advocate.

The above tales of the legacy, incompetent, on-site dosimetrist should not be happening. There is a workforce out there for remote service.

Now it is highly variable, and I do encourage for all remote hires an on-site visit, meeting pertinent folks (physics and docs) face to face, maybe even a few days on site for on-boarding and discussion.

Remote dosi should be at your chart rounds, and your chart rounds should be meaningful.

My 2 cents.
Click to expand...
Still a big fan of hybrid. All of them (gulp) actually enjoy their WFH days but still like being in the office a couple days a day to give input on setups/sims for complex cases
 
communitydoc13 said:
.

It is interesting is that (presumably due to regulatory environment and strong managed care presence) California has not seen this type of behavior to date.
Click to expand...
Many commercial insurers there won't pay for protons esp in low risk PCA afaik, so it isn't just the medi-cal and KP folks putting a quash on it
 
  • Like
Reactions: 2 users
medgator said:
Many commercial insurers there won't pay for protons esp in low risk PCA afaik, so it isn't just the medi-cal and KP folks putting a quash on it
Click to expand...
Still won’t stop the patients from seeing commercials and inquiring about protons. I spend the majority of my days explaining to patients how misleading the academic center is being.
 
  • Like
Reactions: 1 user
NotMattSpraker said:
I am embarrassed with how our field approaches "financial toxicity", "the underserved", and "rural" patients. It is super gross.
Click to expand...
Correct. If there were a way to use radiation for cosmetic purposes for wealthy suburban elites, these same people that spout this nonsense would be all over it.
 
  • Like
Reactions: 1 user
NotMattSpraker said:
Fully agree.

I do think its worth while to have them come a few times a year because meeting people face to face can enhance culture on teams. I've been talking a lot with dosis my institution deals with the existential dread of letting them be remote. They all seem to agree with that.
Click to expand...
Have suggested to my (excellent) dosimetrist(s) that are almost entirely remote that they show up once a month or so. A little harder to fire someone when you know their face.
 
  • Like
Reactions: 3 users
MidwestRadOnc said:
What the dosis are not going to like as their position transistions to remote/WFH, there will be an oversupply and pay will go down. I don’t think these days of having 3 or more jobs paying historically full time wages will last. I’m sure PE is already on it. The cat’s out of the bag that an average rad onc clinic does not require 40 hours a week of full time dosimetry work. There’s a lot of downtime, enough to work other jobs, even. So admins will start to wonder, we are paying them this much why exactly? And they will find themselves doing 2 remote jobs for what they used to get paid for 1 in person.
Click to expand...
We have noticed an opposite trend.

We had dosimetrists go remote because I guess our local pay is less than what they were able to fetch on a national playing field. They came back quick after realizing the difference between in-person comraderie with physician input and the hamster-wheel of work when they are employed by a pay-per-plan setup with little physician input. Pushed to accept what they (the dosimetrist!!) considered inferior plans to get more throughput for their employer
 
  • Like
Reactions: 1 user
CaesarRO said:
We have noticed an opposite trend.

We had dosimetrists go remote because I guess our local pay is less than what they were able to fetch on a national playing field. They came back quick after realizing the difference between in-person comraderie with physician input and the hamster-wheel of work when they are employed by a pay-per-plan setup with little physician input. Pushed to accept what they (the dosimetrist!!) considered inferior plans to get more throughput for their employer
Click to expand...
A lot of varying situations out there. Best dosimetrists I know have remote side gigs and come in 2-3 days week
 
Last edited:
  • Like
Reactions: 2 users
communitydoc13 said:
Literally the only thought my mind had when the idea of "rough Connecticut" came up. I'm sure there is a rough Connecticut (including right next to Yale) but it is obviously not the "underserved" region being targeted.

A "proton desert" refers to a place where people shop at Fresh Market or better yet Dean & Deluca but don't yet have convenient access to protons.

It is interesting is that (presumably due to regulatory environment and strong managed care presence) California has not seen this type of behavior to date.
Click to expand...
Speaking of CT

www.nytimes.com

I-95 in Connecticut Will Be Closed for Days After Fiery Crash

A gasoline tanker crashed on Thursday, causing a fire that damaged a bridge in Norwalk, Conn. Early Friday morning, commuters were facing clogged roadways, and one school district canceled classes.
www.nytimes.com www.nytimes.com
 
1714983789457.png


So, 25 x 2.5 Gy = 62.5 Gy is well tolerable.


However, isn't there a "hidden" dose escalation when going for hypofractionation with this regime?

Isn't 25 x 2.5 Gy = 62.5 Gy "more dose" than 33 x 2 Gy = 66 Gy?

With ab a/b of 3 Gy, 24 x 2.5 Gy would be equivalent to 33 x 2 Gy (BED 110 Gy).
 
  • Like
Reactions: 1 user
1715007943925.png


Potentially practice changing
 
  • Like
Reactions: 1 users
Palex80 said:
View attachment 386301

Potentially practice changing
Click to expand...

Tracks with my anecdotal experiences. I've struggled with these cases and ones where we decided to SBRT I've had a number of regional nodal failures. It's so tempting in the PSMA era to just shoot at what you see....but more is lurking...

I'd be curious to see if cases with longer disease free intervals prior to trial enrollment/initial biochemical failure are ones that do OK with just MDT. Those are ones where I have felt more comfortable with SBRT.
 
  • Like
Reactions: 1 user
Was this trial in post-op patients without prior RT?

I feel like our experience in these cases is also more in patients with prior prostate-only RT with a nodal failure

We've favored ENRT, but I agree with the temptations to treat the node-only. It's nice to have hard numbers to compare the approaches
 
  • Like
Reactions: 1 user
CaesarRO said:
Was this trial in post-op patients without prior RT?
Click to expand...
Patients will all kinds of primary treatment were eligible
a) prostatectomy without adjuvant/salvage prostate bed RT
b) prostatectomy with adjuvant/salvage prostate bed RT
c) primary RT of the prostate

Patients with prior WPRT (either in the setting of primary or postop RT) were excluded.


CaesarRO said:
I feel like our experience in these cases is also more in patients with prior prostate-only RT with a nodal failure

We've favored ENRT, but I agree with the temptations to treat the node-only. It's nice to have hard numbers to compare the approaches
Click to expand...
I've seen both (post resection or post primary RT). Whether or not you prescribe ENI for high-risk localized disease in the context of primary RT and whether or not your urologists perform an EPLND when performing prostatectomies likely influences which patients you end up seeing the most.
 
You must log in or register to reply here.
Next unread thread

Similar threads

P
Rad Onc oral boards
Replies
10
Views
904
Barcelona PSG
B
Gfunk6
Rad Onc? Burnt Out?
Replies
36
Views
2K
thecarbonionangle
thecarbonionangle
TheWallnerus
Rad onc supervision, the epilogue
Replies
10
Views
1K
elementaryschooleconomics
elementaryschooleconomics
U
Why is rad onc not more competitive?
2 3 4 5
Replies
239
Views
11K
fiji128
fiji128
D
Rad onc as a second residency?
Replies
25
Views
2K
SneakyBooger
SneakyBooger
Top