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deleted941485
The zeitman approach is the do nothing approach. THe approach you should have taken was the coordinated refusal to train more residents and utilize the acgme to stop new approvals and take a hardball approach with their respective institutions but alas doctors are cheap nowadays and docile as they’ve ever been despite all the saber rattling about sexism and racism in the work place.
Sometimes the kool-aid is too good to put down!
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Problem with zeitman approach in the us is that there is an infinite supply of fmgs who programs can always select from. If medicine were a field like dentistry that makes it very difficult to recognize fmgs etc, it could work. Even if radoncs involved an infinite amount of fellowships, you would still get fmgs to fill residencies.
I appreciate zeitman for tactfully raising this issue 5 years ago.but solution is plain stupid.
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deleted1002574
Yeah, it worked there because they don’t really take FMGs in Canada. They hardly take any (if any at all) Canadians that trained abroad, unless its US medical school.
Come to think of it, when the editor of the red journal is referring to medstudents as "canaries in a coal mine" and bringing up fellowships in syphilis, ..... not legitimate to completely dismiss concerns of SDN.
theMednet - Login
SDN's favorite resident/wunderkind pontificating yet again against standard-of-care medical practice... this time against CT contrast precautions. I'm sure he's practiced long enough to have developed these opinions on his own after many years of carefully deviating from the standard of care with his patients to determine what's really safe based on evidence.
SDN's favorite resident/wunderkind pontificating yet again against standard-of-care medical practice... this time against CT contrast precautions. I'm sure he's practiced long enough to have developed these opinions on his own after many years of carefully deviating from the standard of care with his patients to determine what's really safe based on evidence.
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deleted1002574
His attendings must love him. Spearheading departmental policy changes via TheMedNet... We are just lucky to bear witness to the greatest oncologist of the modern era.
In interest of being intellectually honest, and someone who has had to implement contrast in our system, I agree with his post. Do resent that he is so outspoken and obviously wrong about resident supply. Aren’t mdacc and Harvard reducing spots by 1 each. Does he believe he knows better and these programs are making mistake from his point of view, since there is nothing wrong with the status quo?
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yeah he's right about the contrast.
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deleted1002574
It’s not the substance of the post, it’s the “I’m smarter than everybody” mentality.
(He is right about the contrast)
(He is right about the contrast)
Yep. The point about over-worrying with regards to contrast-induced AKI has some merit, certainly. However, it's the brazen in-your-face-ness that's the issue here. Making broad, sweeping recommendations/generalizations based off one's own (limited) experience on an expert forum. Saying things as a resident about how you are redesigning "our" clinic, etc.
It's all of these things put together, and the general sense of being gods-gift-to-everything-that-is-radiation-oncology that are not going to end well for this guy.
A little bit of humility goes a long way. Like I alluded to before, the best knowledge you can have is the knowledge of what you don't know. I don't know anything about Alabama, but I'd be curious if there have been... "issues." Just a hunch.
Certainly true. When your ass is on the line because you pushed through a change in contrast policy, you approach risks differently. (You can also be blamed for adverse effects that may not really have been due to the contrast!) this is the part of implementing a policy in which a bit of humilty would go a long way.
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i think everyone on same page about his arrogance. the guy didn't match into rad onc on his first try for a reason.
Hesitate to make this too personal, but status
anxiety is going to be most damning in that kind of person. Imagine the cognitive dissonance of reconciling a very high opinion of yourself with being in such an uncompetitive field. Would be tempting to reduce the dissonance by denying that the field was in free fall. Sorry for the free style psychobabble, but only way to explain denying the obvious.
The resident is correct. Here's to those who are blessed with the gift of constant correctness. Here's to residents who change departmental policies, too. He's the best. But you know what'd be nice? If insurance and CMS would pay rad onc for contrasted scans like it pays radiology for contrasted scans. The contrast ain't cheap, and as we all know CMS doesn't even pay for simulations for 3DCRT or IMRT anymore. And as the resident alludes to, it (a contrast sim) does require more MD work and worry. Most insurances have followed suit w/ CMS's no-payment-for-sim policy unfortunately.
So you gotta ask. Is the contrast vital? I used to say yes. Now I'm not so sure anymore. A.I. contouring programs don't need contrast AFAIK. And radiologists can read CTs OK without them (when patient has a contrast contraindication) even though the radiologist complains. I like to think I'm at least as capable as an always-correct resident, a radiologist, or an A.I. contouring program heh. When one factors in PET/CT fusion, the ability to fuse outside contrast CTs, and the ability to fuse MRIs, the necessity to do contrast has become less and less (even in H&N e.g.). I find that contrast is nice, but I doubt its lack has clinical impacts on toxicity, LC, survival, etc. And it has some departmental financial toxicity as mentioned. And the way I operate I guess I'll have a 0% contrast toxicity rate in my patients, and that's without arguing with anybody in my department or checking Cr clearance etc.
So you gotta ask. Is the contrast vital? I used to say yes. Now I'm not so sure anymore. A.I. contouring programs don't need contrast AFAIK. And radiologists can read CTs OK without them (when patient has a contrast contraindication) even though the radiologist complains. I like to think I'm at least as capable as an always-correct resident, a radiologist, or an A.I. contouring program heh. When one factors in PET/CT fusion, the ability to fuse outside contrast CTs, and the ability to fuse MRIs, the necessity to do contrast has become less and less (even in H&N e.g.). I find that contrast is nice, but I doubt its lack has clinical impacts on toxicity, LC, survival, etc. And it has some departmental financial toxicity as mentioned. And the way I operate I guess I'll have a 0% contrast toxicity rate in my patients, and that's without arguing with anybody in my department or checking Cr clearance etc.
You don’t need contrast except head and neck. Not that you NEED it for head and neck obviously but it Helps a lot. Doesn’t help in most other sites Imo
It is an absolute nightmare contouring a post-op HN without contrast. Probably the biggest pain to contour other than a mesothelioma...
I trained on conventional sims and when ct sim debuted, even in big name places contrast was sparingly used for many years. Only site where I feel strongly about contrast is brain srs, because I have had fusion and target delineation changes
Based on contrast.
I was about to rant about 3D vs IMRT on this paper given that their primary diagnoses were Head and Neck and Lung, but 93% of patients were treated with IMRT. At least interested to get away from protons for prostate for once. I think if protons do show benefit it will be in what are currently the most toxic treatments like H&N.
Real benefit for head and neck will come from dose deescalation, limiting volumes in elective treatment, treating ipsalateral neck only in tonsil when appropriate etc.
I woulndt assume protons are less toxic based purely on dose distributions. I have heard this from enough urologists now following salvage prostatectomies for xrt failure: a lot more fibrosis and damage with protons. They very well could be worse!
I'm not assuming that to be the case. While this is certainly not the end-all be all, this is a signal that maybe protons decreases toxicity. H&N and lung were their most treated sites. I've heard H&N proton folks talk about treating bilateral necks and not seeing any oral mucositis in patients.
They're also comparing to an era where we didn't do any of those 3 things so maybe in a current era of decreasing elective volumes and dose it won't have the same benefit.
ummm... not sure I agree with this one. Sure, I have treated almost every site without contrast under less-than-ideal circumstances, but I like to know where the vessel/bowel/heart/soft tissue ends, and the tumor/LN begins
Have heard the same from a high volume surgeon who does a fair amount of salvage RP
Well I am concerned that biologically protons are worse and am worried about signals of increased toxicity. Not many centers do post xrt prostatectomies, but have heard from now 2-3 urologists and docs who work with them that fibrosis from protons is so much worse. (Wouldn’t expect this from dose distribution) also, again have seen almost no late rectal bleeding in prostate over my career that requires laser/coag yet it is something you encounter with protons despite fact that they all use spacers or balloons, and I Don’t. In the jco lung study, trend towards worse survival with protons? Not sure how this will play out, but really wouldn’t surprise me if they are worse. Out of curiosity would like to hear from residents at large centers if they have also anecdotally heard that salvage surgeries after proton treatment encounter more fibrosis as this would be a concern with head and neck.
Even ptv/CTv expansions have changed over past 10 yrs. look at Nancy lee and cliff chao examples from 10-15 yrs ago....
Very rarely need peg anymore - Partly less toxicity and partly because best evidence from rtog is that weight loss/poor nutrition leads to better local control.
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deleted774703
Drew M really does not seem like a fun person to be around
read next few tweets as well
Loved to challenge ppl but does not like if you challenge him
read next few tweets as well
Loved to challenge ppl but does not like if you challenge him
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deleted1002574
I bet he and SDN's favorite resident high five a lot and "bro out". I think that means something, I'm just not sure what it means. And, I HIGHLY doubt that they eat biryani.
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PA field only
Character wise, beware of those with this kind of righteousness. These are the kind of docs who think you deserve the death penalty if you show up 5 minutes late.
Never gets old
Attachments
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deleted956486
The face of academic radiation oncology. What ever happened to that #radoncrocks campaign? I guess it's on hold until summer?
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deleted1002574
What does this mean?
What data was this from regarding weight los -> better LC? I wasn't aware of that.
I'd like to tell my recent patient who lost 60lbs it was in his best interest
There may be "something to this." There is reasonably interest-piquing data that the old wives' tale of "don't feed the tumor (sugar)" may be true. In a state of fasting, not only may the tumor be deprived of nutrients, the body will release "cachexin" as it becomes cachectic. Cachexin is more commonly known as tumor necrosis factor alpha... a thing that makes tumors, well, necrose.What data was this from regarding weight los -> better LC? I wasn't aware of that.
I'd like to tell my recent patient who lost 60lbs it was in his best interest
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In my experience, it usually means the cancer has run out of places to go.
I made the mistake of going down a rabbit hole with Drew Moghanaki's Twitter:
I literally have no idea what he is talking about, but based on the content of his tweets, he either has some type of psychopathological issue or he drinks too much late at night then tweets. Either way, Drew Moghanaki is a nutcase.
It’s pretty sad actually. He will be remembered for this type of BS and his time will come where he will be held accountable. Had a chance to be one of the greats only to trash his reputation Bc of stubbornness.
What data was this from regarding weight los -> better LC? I wasn't aware of that.
I'd like to tell my recent patient who lost 60lbs it was in his best interest
Pts with pegs may have had worse tumors but they tried to control for it. Pts who lost more weight had less local failure. Tumors really appreciate good nutrition. They love protein - mtor activation; and many can only utilize glycolysis not oxidative phosphyrlation (Warburg effect) which is why they show up on pet scan.
Impact of nutrition support on treatment outcome in patients with locally advanced head and neck squamous cell cancer treated with definitive radiotherapy: a secondary analysis of RTOG trial 90-03 - PubMed
In this study, the largest prospective evaluation of nutrition data in treated patients with cancer, BNS was associated with inferior treatment outcome in the patients with HNSCC undergoing XRT. These results should be considered hypothesis generating and encourage prospective clinical research...
www.ncbi.nlm.nih.gov
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It's remarkable to watch an otherwise intelligent individual behave like a complete assclown behind his own name and picture. What's going on in his head where he thinks good will come of this?
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deleted1002574
Does he do these messages in the evening or night? That may point to alcohol related behavior. I’ve also heard he’s not the most pleasant in real life.
Oh, and what do you mean “greats”? What has he done that would make you say he is great? Not that prolific publication-wise, and no big studies or anything practice changing (though, who is doing anything practice changing in our field?)
Oh, and what do you mean “greats”? What has he done that would make you say he is great? Not that prolific publication-wise, and no big studies or anything practice changing (though, who is doing anything practice changing in our field?)
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deleted774703
he’s only relevant bc twitter ass kissing
there is a bunch of academic attendings (Esp lung) that literally loop each other in every possibility of which he is part of
on the other hand, VALOR is a good trial
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deleted774703
Lmao our PGY4 friend introducing himself as a CNS attending
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deleted1002574
not many people do a bang up job of standing up to the bully surgeons and the holier than thou prolong life 1 month med oncs - drew does. That’s how Valor got through. Just have no idea how acting as a bully to younger gen (one that is on the correct side of history at that) benefits him one bit, like even a single ounce.
