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scarbrtj said:
And if one does any of this fanciness and tries to get in the PRT network, no network for you. Because in the PRT network they only countenance the low-complexity treatments (namely 2D/3D). "Outside the box" (for mets... or maybe oligoprogression) means "you suck" in the community center... to some extent, just looking at the premise outlined in the paper.
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I agree that the network idea is silly. “Guidelines” are meant to guide practice, not define it... no “rule” is universal. Plus, we aren’t technicians.
 
I wonder if these so-called academics ever considered that a community oncologist with broad expertise in both curative and palliative radiation (who is happy to receive the referral) might be able to better care for a metastatic patient than an academic who focuses exclusively on a few disease sites and sees inpatient referrals as a burden (largely outsourced to a resident, fellow or mid-level?) that is only detracting from their clinical interest.

This is excluding consideration of travel, negotiated price and continuity of care with primary care and the patient's local hospital, which will likely play a role in end of life care.
 
theradiator said:
I wonder if these so-called academics ever considered that a community oncologist with broad expertise in both curative and palliative radiation (who is happy to receive the referral) might be able to better care for a metastatic patient than an academic who focuses exclusively on a few disease sites and sees inpatient referrals as a burden (largely outsourced to a resident, fellow or mid-level?) that is only detracting from their clinical interest.

This is excluding consideration of travel, negotiated price and continuity of care with primary care and the patient's local hospital, which will likely play a role in end of life care.
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Ah but this misses that the senior author is the “chief of palliative” rad onc at UPenn. No one can do 8 gy x 1 better. Check yourself before you wreck yourself.
 
Lamount said:
I have zero concern with patients referring palliative RT cases to the community -why would I want to make a patient with metastatic cancer spend so much time traveling? With definitive or quasi-definitive cases, I have to concerns that occasionally cause me pause:
1) technology/physics support. Not all PP clinics by me have a 4D CT, not all use daily CBCT for thoracic/abdominal cases. Truth is, I know a few that are top notch, I know a few that have horror stories, and the rest are an unknown
2) I will often offer an aggressive/complex treatment with hypofractionated dose painting/SIB (usually in the context of a patient with a big tumor who can’t get chemo... or has oligoprogression). I can’t be certain that any other doctor (PP or academic) would offer the patient what I offered, because it is commonly “outside the box”. For some reason, these patients make up a decent chunk of my census and may actually be becoming my niche

I have no doubt (especially from conversations here) that there are some excellent physicians in private practice, many of whom are far better clinicians than myself... but there are some legit unknowns and I don’t have time to research every clinic in 100 mile radius.


I don’t know what the solution is. Maybe I should reach out to them or they should reach out to us. I just wanted to let you know that it isn’t “elitism”, at least speaking personally... it’s more that PP is a bit of a black box... and we can’t always be sure that another competent physician in a different practice would approach things the same way. If the patient wants a second opinion, that’s just fine... but often they want to feel like their whole team is in agreement.
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I agree with the above...but academics is also a black box. Not every academic physician is ethical/moral or even a great clinician. Some of them are as bad as the bad private practice doctors. Obviously every program is different, but in my residency, when an attending doctor did a ****ty plan, people during chart rounds were either quiet or would do a "half hearted" questioning, the presenting attending would get mad, the conversation would end, the patient returned at one month follow-up with a marginal recurrence secondary to crappy radiation field/plan and no one cared...sometimes other attending would approach the resident on service and insist the resident change the plan and talk their attending out of it - this outrageous putting the vulnerable resident in this position, because the other attending doesn't want to make his co-worker mad at him but has no problem pushing the resident into the lion's den (do lions have dens? bear's den?) There are ****ty doctors everywhere, including academics. I'm not saying that you should knowingly send your patients to a bad doctor but we should acknowledge that there are plenty bad academic doctors too, including those physicians who don't know how to contour; still can't grasp IMRT because they were trained prior to IMRT.
 
hbosch said:
I agree with the above...but academics is also a black box. Not every academic physician is ethical/moral or even a great clinician. Some of them are as bad as the bad private practice doctors. Obviously every program is different, but in my residency, when an attending doctor did a ****ty plan, people during chart rounds were either quiet or would do a "half hearted" questioning, the presenting attending would get mad, the conversation would end, the patient returned at one month follow-up with a marginal recurrence secondary to crappy radiation field/plan and no one cared...sometimes other attending would approach the resident on service and insist the resident change the plan and talk their attending out of it - this outrageous putting the vulnerable resident in this position, because the other attending doesn't want to make his co-worker mad at him but has no problem pushing the resident into the lion's den (do lions have dens? bear's den?) There are ****ty doctors everywhere, including academics. I'm not saying that you should knowingly send your patients to a bad doctor but we should acknowledge that there are plenty bad academic doctors too, including those physicians who don't know how to contour; still can't grasp IMRT because they were trained prior to IMRT.
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Unfortunately, we all have dirty laundry on each other. Right now we still do not want to unload on academia, but if the ivory tower keeps the “we are better than everyone else” thing going it’s only a matter of time before all the secrets come out like “superstar chairman” don’t know how to contour or “you are seeing an expert but a resident is actually doing most your care.” We are getting ever closer to negative marketing tactics (discontent over the freestanding vs academic billing as an example) and that won’t be good for any of us.
 
RadOncMegatron said:
Unfortunately, we all have dirty laundry on each other. Right now we still do not want to unload on academia, but if the ivory tower keeps the “we are better than everyone else” thing going it’s only a matter of time before all the secrets come out like “superstar chairman” don’t know how to contour or “you are seeing an expert but a resident is actually doing most your care.” We are getting ever closer to negative marketing tactics (discontent over the freestanding vs academic billing as an example) and that won’t be good for any of us.
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Certainly know of one former Astro president/chairman who has no idea how to contour in his area of specialty.
 
RickyScott said:
Certainly know of one former Astro president/chairman who has no idea how to contour in his area of specialty.
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I want to clarify I do respect many many academics and do defer to their expertise. Back in the day the system was implicitly academics get paid less but in in exchange respect, prestige, and honor was given. I even heard some older PP docs (another field) that back in the day they could refer to the academic center and not fear losing their patient. Now a days not so much. We knew that academics did not participate much in the $ part of it and that a lot of that poison was from admins, insurance, and broken system, but now with residency expansion, fellowship proliferation, and now this palliative care referral network the good vibes are being challenged.
 
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hbosch said:
I agree with the above...but academics is also a black box. Not every academic physician is ethical/moral or even a great clinician. Some of them are as bad as the bad private practice doctors.
Click to expand...
RadOncMegatron said:
Unfortunately, we all have dirty laundry on each other. Right now we still do not want to unload on academia, but if the ivory tower keeps the “we are better than everyone else” thing going it’s only a matter of time before all the secrets come out like “superstar chairman” don’t know how to contour or “you are seeing an expert but a resident is actually doing most your care.”
Click to expand...
If you think you know who I'm talking about, you don't. That said...

First year of residency, my second rotation. I'm seeing a followup patient first before the attending. CT scan report said something like "right upper lobe lesion shows progression, but lower lobe lesion looks treated and shows a favorable response. Interval development of adrenal metastasis." "Hmm" I thought. Wonder why radiation works in one place and not another? (I was a neophyte!) So I start reviewing the plan. To my surprise, I saw a perfect plan for a lower lobe lesion but a second lesion a couple inches superior was not even contoured much less irradiated. The patient was about 3 months out from treatment. So I showed all this to the attending... and he turned pale. "I'm going to go in and explain all this to the patient and family" he told me. "You can sit this one out. And let's keep this quiet." My impression was the patient was essentially told "sorry, them's the breaks."

I've seen one attending oversee about 50 H&N patients (accidentally) get ~60-65 Gy to portions of cervical cord (but not a single patient got paralyzed that I know of). I've seen an attending give 72 Gy at 2.4 Gy a day in HNSCC and what profound acute and long-term side effects that can cause. I've seen an attending routinely give 78 Gy/39 fx for GBM. I've seen an attending give 78 Gy/39 fx for prostate cancer whilst dosimetrically ensuring the adjacent rectum received the same dose or more.

One time I was on H&N service and taking care of a nationally well known person who had developed a maxillary sinus cancer. I had just rotated on to the service about midway through XRT and the attending was out on vacation for a week. The patient was developing a lot of tongue surface mucositis and I decided to resim with a bulky tongue depressor thing to keep the tongue away from the maxillary sinus and significant dose. At resim I discovered a growing Level 1 LN that hadn't been included in the initial ENI regions. It was essentially impossible, even with the best IMRT, to try and get that node "dosed up" since he was already halfway through tx. (That case was a bit of a disaster the whole way 'round.)

... I have seen some stuff.
 
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scarbrtj said:
If you think you know who I'm talking about, you don't. That said...

First year of residency, my second rotation: lung service w/ the asst chairman. I'm seeing a followup patient first before the attending. CT scan report said something like "right upper lobe lesion shows progression, but lower lobe lesion looks treated and shows a favorable response. Interval development of adrenal metastasis." "Hmm" I thought. Wonder why radiation works in one place and not another? (I was a neophyte!) So I start reviewing the plan. To my surprise, I saw a perfect plan for a lower lobe lesion but a second lesion a couple inches superior was not even contoured much less irradiated. The patient was about 3 months out from treatment. So I showed all this to the attending... and he turned pale. "I'm going to go in and explain all this to the patient and family" he told me. "You can sit this one out. And let's keep this quiet." My impression was the patient was essentially told "sorry, them's the breaks."

I've seen one attending oversee about 50 H&N patients (accidentally) get ~60-65 Gy to portions of cervical cord (but not a single patient got paralyzed that I know of). I've seen an attending give 72 Gy at 2.4 Gy a day in HNSCC and what profound acute and long-term side effects that can cause. I've seen an attending routinely give 78 Gy/39 fx for GBM. I've seen an attending give 78 Gy/39 fx for prostate cancer whilst dosimetrically ensuring the adjacent rectum received the same dose or more.

One time I was on H&N service and taking care of a nationally well known person who had developed a maxillary sinus cancer. I had just rotated on to the service about midway through XRT and the attending was out on vacation for a week. The patient was developing a lot of tongue surface mucositis and I decided to resim with a bulky tongue depressor thing to keep the tongue away from the maxillary sinus and significant dose. At resim I discovered a growing Level 1 LN that hadn't been included in the initial ENI regions. It was essentially impossible, even with the best IMRT, to try and get that node "dosed up" since he was already halfway through tx. (That case was a bit of a disaster the whole way 'round.)

... I have seen some stuff.
Click to expand...

My saddest experiences as a rotating student were from a chairman who should not have been teaching residents.

He would use metal needles in his Syed cases and had very poor understanding of the female anatomy and would routinely spear the rectum (as he put in all his needles blind in the OR without any CT or US guidance then would adjust in the CT sim). Couldn’t see anything in the mess of needles and no MRI fusion so he routinely ran dose through the needles in the rectum. He never saw his patients in follow up so always assumed he was perfect.

I rotated on Gyn Onc and saw all of the aftermath. One patient developed a fistula and got an exenteration. Then she got a nodal recurrence from a marginal miss of a tiny gross node.

Gyn onc doesn’t like awkward conversations thus the chairman still thinks he’s a great rad onc.
 
Music Man Stan said:
My saddest experiences as a rotating student were from a chairman who should not have been teaching residents.

He would use metal needles in his Syed cases and had very poor understanding of the female anatomy and would routinely spear the rectum (as he put in all his needles blind in the OR without any CT or US guidance then would adjust in the CT sim). Couldn’t see anything in the mess of needles and no MRI fusion so he routinely ran dose through the needles in the rectum. He never saw his patients in follow up so always assumed he was perfect.

I rotated on Gyn Onc and saw all of the aftermath. One patient developed a fistula and got an exenteration. Then she got a nodal recurrence from a marginal miss of a tiny gross node.

Gyn onc doesn’t like awkward conversations thus the chairman still thinks he’s a great rad onc.
Click to expand...
Gets back to the fact that the quality of residents matching from 70s through 90s was abysmal in many cases
 
The "fact" is that most "good" programs did not participate in the match until the late 1990's. I matched at a "good" program in 1988 outside of the match. Of course the youngsters will say OK boomer but I will put my achievements up against any that matched in the next 10 years.
 
Great news friends, Wake Forest posted a "physician-scientist" job today...the numbers look a little off though...

1598292867522.png
 
They probably should clarify that your 20-25% clinical research activities is on weekends and holidays. Also the "scientist" in physician-scientist is meant to reference basic (bench) research. However, I'm sure this position will offer a lot of exposure to laboratory work as you walk by labs to see your inpatient bone met consult.

elementaryschooleconomics said:
Great news friends, Wake Forest posted a "physician-scientist" job today...the numbers look a little off though...

View attachment 316798
Click to expand...
 
Gfunk6 said:
They probably should clarify that your 20-25% clinical research activities is on weekends and holidays. Also the "scientist" in physician-scientist is meant to reference basic (bench) research. However, I'm sure this position will offer a lot of exposure to laboratory work as you walk by labs to see your inpatient bone met consult.
Click to expand...

Or the labs you will need to review prior to seeing the inpatient. You would be lucky to walk by labs!
 
evilbooyaa said:
Reminds me of Second Life. Makes sense given the amount of cringey stuff I've seen from RadOnc as a field in recent history.
Click to expand...

Totally agree - Second Life was my first thought as well, but I wanted to minimize showing off my high level turbo nerdiness, so I went with Everquest 🤣

In all seriousness - is this what we're doing? I assumed it would be a similar format to how I can currently access content from previous conferences. They're creating some sort of avatar-based experience?

2020 just gets weirder and weirder.
 
A virtual convention? But how will the 50 year old male attendings know which poster presenter to flirt and drink beer with? You know, without being able to identify which are being presented by the hottest 23 year old female medical students?
 
hbosch said:
I agree with the above...but academics is also a black box. Not every academic physician is ethical/moral or even a great clinician. Some of them are as bad as the bad private practice doctors. Obviously every program is different, but in my residency, when an attending doctor did a ****ty plan, people during chart rounds were either quiet or would do a "half hearted" questioning, the presenting attending would get mad, the conversation would end, the patient returned at one month follow-up with a marginal recurrence secondary to crappy radiation field/plan and no one cared...sometimes other attending would approach the resident on service and insist the resident change the plan and talk their attending out of it - this outrageous putting the vulnerable resident in this position, because the other attending doesn't want to make his co-worker mad at him but has no problem pushing the resident into the lion's den (do lions have dens? bear's den?) There are ****ty doctors everywhere, including academics. I'm not saying that you should knowingly send your patients to a bad doctor but we should acknowledge that there are plenty bad academic doctors too, including those physicians who don't know how to contour; still can't grasp IMRT because they were trained prior to IMRT.
Click to expand...

agree. There are some truly scary people in academics. I know of practicing rad oncs who are borderline demented and people are constantly looking over their shoulder to make sure nobody is hurt. This is allowed to go on!
 
Music Man Stan said:
My saddest experiences as a rotating student were from a chairman who should not have been teaching residents.

He would use metal needles in his Syed cases and had very poor understanding of the female anatomy and would routinely spear the rectum (as he put in all his needles blind in the OR without any CT or US guidance then would adjust in the CT sim). Couldn’t see anything in the mess of needles and no MRI fusion so he routinely ran dose through the needles in the rectum. He never saw his patients in follow up so always assumed he was perfect.

I rotated on Gyn Onc and saw all of the aftermath. One patient developed a fistula and got an exenteration. Then she got a nodal recurrence from a marginal miss of a tiny gross node.

Gyn onc doesn’t like awkward conversations thus the chairman still thinks he’s a great rad onc.
Click to expand...

we need to start a post where people share stories like these. Boy they are out there!
 
Why the heck would you do fellowship in head and neck IORT or adult and pediatric CNS? The only way you should do fellowship in CNS is if it comes with neuro-oncology training and ability to practice as a neuro-onc at the end.
 
Neuronix said:
Why the heck would you do fellowship in head and neck IORT or adult and pediatric CNS? The only way you should do fellowship in CNS is if it comes with neuro-oncology training and ability to practice as a neuro-onc at the end.
Click to expand...

I suppose the pediatric component of the CNS fellowship has value since Peds is something most graduates do not feel comfortable treating out of residency.

The brachy fellowship has value if it is high volume. The head and neck IORT fellowship befuddles me. No idea how or why that fellowship would work.
 
Zahramar said:
I suppose the pediatric component of the CNS fellowship has value since Peds is something most graduates do not feel comfortable treating out of residency.
Click to expand...

If that's the goal, it should be a pediatrics fellowship including body peds. You don't want to come out with no experience treating non-CNS peds.
 
Neuronix said:
If that's the goal, it should be a pediatrics fellowship including body peds. You don't want to come out with no experience treating non-CNS peds.
Click to expand...
Don’t know about their peds volume - but residents shouldn’t be splitting peds cases (or brachy cases) with a fellow at most programs. Would keep an eye on that if you’re a med student.
 
elementaryschooleconomics said:
We are 100% watching the birth of the Fellowship Era in Radiation Oncology. Institutions will claim these new 2021 Fellowships are due to COVID but, once the genie is out of the bottle - the genie is not going back.
Click to expand...

So if you've got all these fellows, is that cutting into the resident experience then? I remember hearing the surgery residents complain that the fellows get the cases...wouldn't this be the case in rad onc?

Completely agree with Neuronix - only a CNS fellowship that allows you give chemo would be worth it. In this era, a minimally competent resident should be able to do a very good job with CNS.
 
BobbyHeenan said:
So if you've got all these fellows, is that cutting into the resident experience then? I remember hearing the surgery residents complain that the fellows get the cases...wouldn't this be the case in rad onc?

Completely agree with Neuronix - only a CNS fellowship that allows you give chemo would be worth it. In this era, a minimally competent resident should be able to do a very good job with CNS.
Click to expand...

I agree that this is a serious problem with fellowships. At UCLA/MSKCC the brachy fellows basically take the majority of cases from the residents. If you have a peds fellow, it is very likely that they will take the majority of cases and the residents will get their 12-minimum (or "share" cases since the fellow doesn't have to actually report cases to the ACGME). I enjoy brachytherapy and my chairman once asked if I would like to stay on as a brachytherapy fellow. I stated that I thought it would hurt the educational quality for the rest of the residents. He tried to brush that bit aside.
 
So, if you're a resident, graduate and take, say, the Adult and Peds CNS fellowship, do you then have to try and find a job within your specific sub-sub-specialty? What are the odds of that? Infinitesimal? So, if you don't find one, you're then supposed to go and find a job as a radonc, having not done anything else other than CNS over the prior year?

Good luck with that.

ALL fellowships other than peds should not exist.
 
elementaryschooleconomics said:
We got some real barn-burners on the ASTRO Career Center today folks. Looks like Ohio State is offering 3 brand new Fellowships for 2021! Also, a nice RadTech job in North Carolina. Is it too late for me to go back and be a therapist?

View attachment 317145
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Our esteemed friend @Zahramar said re: breast IORT that "it'll never be that popular." However at THE Ohio State U, they'll get you in on the lucrative field of H&N IORT! Maybe I should say "?" instead of "!" at the end there.
 
scarbrtj said:
Our esteemed friend @Zahramar said re: breast IORT that "it'll never be that popular." However at THE Ohio State U, they'll get you in on the lucrative field of H&N IORT! Maybe I should say "?" instead of "!" at the end there.
Click to expand...

These Fellowships are a brilliant business move by institutions, especially if they're paid at Fellow/PGY-6 levels, which is what? Half the salary of an APP?

Who wants to take bets on the new Fellowships which pop up in September? Sarcoma at WashU?

Mobile Orthovoltage Unit at Moffit?

Endless possibilities.
 
Ohio State is a relatively new program, however great they are, new place, notheless. Arguable the residency should have never been started. Maybe or maybe not. However, its a shame seeing the lead the way on predatory fellowships. It would really suck if in the future a job posting reads “head and neck fellowship trained only” or insert your favorite site. Basically a residency alone becomes useless. Our degree and experience is being slowly devalued and diluted.
 
thecarbonionangle said:
Ohio State is a relatively new program, however great they are, new place, notheless. Arguable the residency should have never been started. Maybe or maybe not. However, its a shame seeing the lead the way on predatory fellowships. It would really suck if in the future a job posting reads “head and neck fellowship trained only” or insert your favorite site. Basically a residency alone becomes useless. Our degree and experience is being slowly devalued and diluted.
Click to expand...

I think there are two arguments that are frequently conflate.
1) the fact that fellowships are necessary reflects poorly on the job market.
2) fellowships are predatory

I would agree on point 1)... but I KNOW that in the right context, the right fellowship can open doors... as it did for me. My experience is no more anectodal than any assumption to the contrary. Like it or not, this might be the new normal.

This is all to say, if these fellows get good jobs, then it is clearly not predatory... because that is likely the reason they enrolled.
**edited to fix iPhone-related errors
 
RickyScott said:
Never understood this approach. Should be grateful for the consult in this environment as new pts per radonc is approaching 150/year.
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Inpatient consults are a lot of time if attending is only one staffing and a pathetic number of wRVUs if you don't end up treating.
 
forums.studentdoctor.net

Opportunity for MS4s to Learn More about Radiation Oncology Residency

Hi all, Just wanted to post this opportunity with our Radiation Oncology residency program at City of Hope in Duarte, CA. I'm a current resident in the program. Happy to answer any questions about this, our program, or radiation oncology in general.
forums.studentdoctor.net forums.studentdoctor.net

Thoughts?
 
RickyScott said:
Never understood this approach. Should be grateful for the consult in this environment as new pts per radonc is approaching 150/year.
Click to expand...

Agreed!
Zaorsky is somewhat correct that the requesting MD should know what he/she wants before placing a consult.
However, life is not perfect, many MDs do not know much about radonc, thus "a call for help", and the consult.
If we act like a real MD, people treat us like an MD.
If we act like a technician, they will treat us like a technician.

I help PCPs etc with oncology work-up. Sometimes they have a lung mass and wonder what to do next, they ask me to get involved with work-up.
You get the ideas. If the PCPs or internists see that you have a vast knowledge of medicine, they will respect you.

Sadly, the many current programs teach residents how to be technicians...
 
On Twitter, some academics were saying they charge SBRT rates when doing 5fx breast (which I think is technically correct). When you get in that SBRT/SRS arena, that's where the academic centers have ninja skill billing ability to jack up the prices.
 
scarbrtj said:
On Twitter, some academics were saying they charge SBRT rates when doing 5fx breast (which I think is technically correct). When you get in that SBRT/SRS arena, that's where the academic centers have ninja skill billing ability to jack up the prices.
Click to expand...

I admittedly do not treat much breast... but it is 6 Gy x 5, right?

With this dose, it seems very reasonable to use more precise targeting and image guidance, and charge as such.
 
My hospital employer decided to bill this breast regimen as IMRT
 
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