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[elementaryschooleconomics]

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This is great:

So the task is contouring.

The arms are "expert" vs "non-expert".

"Expert" is defined as a subjective call based on "development of national guidelines or other extensive scholarly activities, board certified".

Well:

1) Board certified when? Would any of these experts hold lifetime certs, which were last awarded in the mid-90s?
2) Board certified in the same general process everyone takes? I assume, then, the "non-expert" arm includes residents at every level, PGY2-PGY5? Because otherwise, there are no subspecialty certifications for RadOnc, meaning the board certification held by a generalist is of equal value to the one held by an academician who only sees head and neck patients.
3) How/why are we making the leap that publishing papers and getting grants correlates even slightly with contouring ability?
4) What about treatment planning? This is only half the battle...maybe less than half. What about "expert" Dosimetrists? What kind of plans are "experts" vs "non-experts" willing to accept?

I could go on. To be clear, I love this project, I love C3RO, and am cheering them on.

But this needs to be explicitly talked about: there is absolutely no known correlation between scholarly activity and contouring ability. I would actually argue they inversely correlate, and the more papers someone has published, the less excited I would be for them to contour my case if I was on the receiving end of a linac.

Especially since their resident is probably doing it for them.

 

[fiji128]

This is great:

View attachment 354693

So the task is contouring.

The arms are "expert" vs "non-expert".

"Expert" is defined as a subjective call based on "development of national guidelines or other extensive scholarly activities, board certified".

Well:

1) Board certified when? Would any of these experts hold lifetime certs, which were last awarded in the mid-90s?
2) Board certified in the same general process everyone takes? I assume, then, the "non-expert" arm includes residents at every level, PGY2-PGY5? Because otherwise, there are no subspecialty certifications for RadOnc, meaning the board certification held by a generalist is of equal value to the one held by an academician who only sees head and neck patients.
3) How/why are we making the leap that publishing papers and getting grants correlates even slightly with contouring ability?
4) What about treatment planning? This is only half the battle...maybe less than half. What about "expert" Dosimetrists? What kind of plans are "experts" vs "non-experts" willing to accept?

I could go on. To be clear, I love this project, I love C3RO, and am cheering them on.

But this needs to be explicitly talked about: there is absolutely no known correlation between scholarly activity and contouring ability. I would actually argue they inversely correlate, and the more papers someone has published, the less excited I would be for them to contour my case if I was on the receiving end of a linac.

Especially since their resident is probably doing it for them.

The further I get along with practicing the more laughable does the idea of self described “experts” become for rad onc. Like either your very meticulous/studious or not. There are plenty of “academic experts” that are neither. Like just think how “good” you could become by treating only lung day in and day out.

 

[TheWallnerus]

But this needs to be explicitly talked about: there is absolutely no known correlation between scholarly activity and contouring ability. I would actually argue they inversely correlate, and the more papers someone has published, the less excited I would be for them to contour my case if I was on the receiving end of a linac.

Imagine if a guy named Fred Jones walked up to you one day and said "Hi, I'm a basketball expert." But this is an alternate universe where no one has any stats on basketball experts: no one tracks stats, and no one actually watches basketball experts play games to see who wins or loses in real life. It is a sport, but I can't really tell you Fred's win-loss percentage because all the games he plays are hidden. He publishes a lot about hypothetical games, and shows some brief snapshots and videos of games he plays. TBH some of the videos look a little weird like he can barely dribble or something but we overlook it for some reason. He runs basketball clinics and teaches others to play. According to the popular press, he is a leading expert. He has some friends who are similarly productive... write basketball books and host clinics... and he and the friends all agree that they are experts. Other basketball players who don't write books or host clinics agree that Fred and friends are experts not based on W-L percentages or FT percentages or rebounds or assists but just because they talk about basketball and comment about it a lot and write books and things. Everyone plays basketball games, and everyone knows "you win some and you lose some," but everyone just assumes Fred and friends must win more games than the non-experts. Because why wouldn't they?

No one has heard of a guy named Michael Jordan in this alternate universe. He's a nobody, certainly not an expert. but loves to play basketball. In fact some experts have seen him play; "He sticks his tongue out too much" was an overheard criticism. One day you're talking to Fred, and Michael walks in the door. "Hey, Fred, you and Michael should play a quick pickup game." Fred says OK. Michael destroys him. The game is not broadcast, or recorded, no one will ever see the outcome, and as far as the world knows Fred is still the foremost basketball expert.

If we tracked overall survivals and toxicity outcomes of patients we and The Experts treated, and published those, I bet we would see a shift in what we call experts. I have a hypothesis that the outcomes of patients treated by rad onc vary significantly from rad onc to rad onc and do not correlate at all with the "expert" appellation...

 

[fiji128]

Imagine if a guy named Fred Jones walked up to you one day and said "Hi, I'm a basketball expert." But this is an alternate universe where no one has any stats on basketball experts: no one tracks stats, and no one actually watches basketball experts play games to see who wins or loses in real life. It is a sport, but I can't really tell you Fred's win-loss percentage because all the games he plays are hidden. He publishes a lot about hypothetical games, and shows some brief snapshots and videos of games he plays. TBH some of the videos look a little weird like he can barely dribble or something but we overlook it for some reason. He runs basketball clinics and teaches others to play. According to the popular press, he is a leading expert. He has some friends who are similarly productive... write basketball books and host clinics... and he and the friends all agree that they are experts. Other basketball players who don't write books or host clinics agree that Fred and friends are experts not based on W-L percentages or FT percentages or rebounds or assists but just because they talk about basketball and comment about it a lot and write books and things. Everyone plays basketball games, and everyone knows "you win some and you lose some," but everyone just assumes Fred and friends must win more games than the non-experts. Because why wouldn't they?

No one has heard of a guy named Michael Jordan in this alternate universe. He's a nobody, certainly not an expert. but loves to play basketball. In fact some experts have seen him play; "He sticks his tongue out too much" was an overheard criticism. One day you're talking to Fred, and Michael walks in the door. "Hey, Fred, you and Michael should play a quick pickup game." Fred says OK. Michael destroys him. The game is not broadcast, or recorded, no one will ever see the outcome, and as far as the world knows Fred is still the foremost basketball expert.

If we tracked overall survivals and toxicity outcomes of patients we and The Experts treated, and published those, I bet we would see a shift in what we call experts. I have a hypothesis that the outcomes of patients treated by rad onc vary significantly from rad onc to rad onc and do not correlate at all with the "expert" appellation...

Hilarious.

 

[elementaryschooleconomics]

Imagine if a guy named Fred Jones walked up to you one day and said "Hi, I'm a basketball expert." But this is an alternate universe where no one has any stats on basketball experts: no one tracks stats, and no one actually watches basketball experts play games to see who wins or loses in real life. It is a sport, but I can't really tell you Fred's win-loss percentage because all the games he plays are hidden. He publishes a lot about hypothetical games, and shows some brief snapshots and videos of games he plays. TBH some of the videos look a little weird like he can barely dribble or something but we overlook it for some reason. He runs basketball clinics and teaches others to play. According to the popular press, he is a leading expert. He has some friends who are similarly productive... write basketball books and host clinics... and he and the friends all agree that they are experts. Other basketball players who don't write books or host clinics agree that Fred and friends are experts not based on W-L percentages or FT percentages or rebounds or assists but just because they talk about basketball and comment about it a lot and write books and things. Everyone plays basketball games, and everyone knows "you win some and you lose some," but everyone just assumes Fred and friends must win more games than the non-experts. Because why wouldn't they?

No one has heard of a guy named Michael Jordan in this alternate universe. He's a nobody, certainly not an expert. but loves to play basketball. In fact some experts have seen him play; "He sticks his tongue out too much" was an overheard criticism. One day you're talking to Fred, and Michael walks in the door. "Hey, Fred, you and Michael should play a quick pickup game." Fred says OK. Michael destroys him. The game is not broadcast, or recorded, no one will ever see the outcome, and as far as the world knows Fred is still the foremost basketball expert.

If we tracked overall survivals and toxicity outcomes of patients we and The Experts treated, and published those, I bet we would see a shift in what we call experts. I have a hypothesis that the outcomes of patients treated by rad onc vary significantly from rad onc to rad onc and do not correlate at all with the "expert" appellation...

Exactly, similar to how I don't recall any amazing films directed by Roger Ebert, but I think you could find a lot of people to call him an expert on film.

To be clear - maybe I'm wrong. Maybe scholarly output does correlate with contouring ability. We just don't know, and it's a GIANT leap to go from "20 years of continuous R01 funding" to "really nailed circling pixels in that complicated base of skull case".

 

[Palex80]

I agree. The question is how do we establish the evidence base for safety? Or safety culture?

Could you imagine airlines doing trials regarding reducing redundancy on outcomes? They'd likely find 1 event in 1 million flights saved by certain redundancies. Of course, I like that they're there, and the air travel industry has a strong safety culture.

We might as well do a trial of mid-plane calc vs 3D for all single fraction palliative cases. We know what the answer will be.

Absolutely correct. This trial is going to recruit 33 patients... 🙂

 

[RadOncDoc21]

The further I get along with practicing the more laughable does the idea of self described “experts” become for rad onc. Like either your very meticulous/studious or not. There are plenty of “academic experts” that are neither. Like just think how “good” you could become by treating only lung day in and day out.

So true… I tend to use the circular option to contour these days. The pencil is so pgy-2. Pgy-3 was when I started to dabble in the crop off body + margin feature. I’m still too much of a chicken to use any 3D brushes or auto-contours but my dosimitrist and physicists all seem to make up for my lack of skills!

There was a time I used to do my own image fusion but now a days I’m acting more like a boomer. My lung SBRT cases take approximately 5 minutes to do!

We have a serious complex in our field that starts with us needing to be respected by our medical and surgical colleagues. We are always begging for acceptance and to prove how smart we are. I guess in order to separate ourselves, we need to tear each other down. We’re crabs in a bucket folks!

 

[Chartreuse Wombat]

"Expert" is becoming like identity politics. Can you self-identify as an expert?

The image below is the original postop prostate CTV contours of 12 "experts" in GU from a paper in 2009.

 

[TheWallnerus]

tell me how to feel about the world’s leading radiation oncology company pivoting into oncology areas that leave out radiation oncologists

 

[elementaryschooleconomics]

Ah, yes, I know I've read this paper simply from this:

Dear "expert" who has the brown contour: WHAT ON GOD'S GREEN EARTH ARE YOU DOING?

I want to meet this person and hear about the patterns of failure within and beyond the obturator internus they've seen in their career which caused them to draw this.

 

[Ray D. Ayshun]

Why do the experts not seem to recognize that we non experts do use the literature and forums like themednet to inform decisions? Again, perhaps the experts could help by making the rj interface less ****ty.

 

[RadRadRad]

Ah, yes, I know I've read this paper simply from this:

View attachment 354701

Dear "expert" who has the brown contour: WHAT ON GOD'S GREEN EARTH ARE YOU DOING?

View attachment 354702

I want to meet this person and hear about the patterns of failure within and beyond the obturator internus they've seen in their career which caused them to draw this.

You can ask them about their rectal toxicity while you’re at it

 

[elementaryschooleconomics]

You can ask them about their rectal toxicity while you’re at it

I suspect this is the real reason Boomers fell in love with SpaceOAR -

"I notice a huge difference in rectal tox!"

Yeah, idiot, it's because you put almost the entire rectum in your target.

 

[jondunn]

experts getting spicy

 

[SneakyBooger]

"Expert" is becoming like identity politics. Can you self-identify as an expert?

The image below is the original postop prostate CTV contours of 12 "experts" in GU from a paper in 2009.

View attachment 354700

Yes, and as I recall, they threw out the contours of one of the so called "experts" because they were so bad.

@TheWallnerus hit the nail on the head. They are experts because they call themselves experts.

 

[TheWallnerus]

I suspect this is the real reason Boomers fell in love with SpaceOAR -

"I notice a huge difference in rectal tox!"

Yeah, idiot, it's because you put almost the entire rectum in your target.

Real, actually-prostate-expert-crafted prostate PTVs from the early 2000s below.

Real prostate expert statement: “I don’t think IMRT really spares the rectum that well.”

The problem with IMRT is that it was over-abstrusified and black-boxified by the experts. It’s like when people say “The government should” do whatever. The government doesn't do anything; it’s the people in government who do things. IMRT doesn’t do anything special, or bad, unless the people using it do.

 

[salubalu]

Yes, and as I recall, they threw out the contours of one of the so called "experts" because they were so bad.

@TheWallnerus hit the nail on the head. They are experts because they call themselves experts.

Does one truly believe that if someone contours the prostate the same and the rectum is pushed back 0.5-1+ cm that there will be no difference in rectal toxicity at all?

 

[medgator]

Does one truly believe that if someone contours the prostate the same and the rectum is pushed back 0.5-1+ cm that there will be no difference in rectal toxicity at all?

When i did f/u's on pts at my previous practice who were treated by boomers where they routinely did 1cm posterior margins, the proctitis rates long term were astronomical

 

[salubalu]

Following pts at a previous practice treated by boomers where they routinely did 1cm posterior margins, the proctitis rates long term were astronomical

I meant if you used a space oar that pushed things back 0.5-1+cm. I typically use 5 mm margins except post 3 mm. I’m able to meet nrg gu 09 constraints with and without space oar but it’s definitely easier with

 

[elementaryschooleconomics]

I meant if you used a space oar that pushed things back 0.5-1+cm. I typically use 5 mm margins except post 3 mm. I’m able to meet nrg gu 09 constraints with and without space oar but it’s definitely easier with

In a vacuum, yes, you should absolutely expect that.

My personal experience is that guys will have very different levels of rectal side effects despite having almost identical levels of rectal dose. By and large, if I spend a little extra time making sure they get into a good bowel/bladder regimen, and Dosimetry doesn't try any funny business (making sure the entire rectum isn't within the 50% IDL at any point, for example), ~80-90% of my patients have Grade 0-1 rectal tox during/after treatment. The other 10-20% might have a run of Grade 2, but it's exceedingly uncommon.

Knowing this, it's very hard for me to advocate for the hydrogel outside of SBRT. My group does the procedure ourselves, so I am personally there every step of the way, prescribing Ativan and Cipro, making sure the patients know they might be on the hook for $4,000 if their insurance doesn't cover it, jamming ultrasounds into rectums and needles into perineums. Every couple weeks/months one of my friends texts me about some SpaceOAR complication which might mean that patient won't be able to finish treatment.

I was much more agnostic about it when the Urologists were the ones placing it. Out of sight, out of mind I guess. But when I can't tell in OTV visits who has SpaceOAR and who doesn't...putting giant needles into these guys gets less and less appealing.

 

[RadOncDoc21]

In a vacuum, yes, you should absolutely expect that.

My personal experience is that guys will have very different levels of rectal side effects despite having almost identical levels of rectal dose. By and large, if I spend a little extra time making sure they get into a good bowel/bladder regimen, and Dosimetry doesn't try any funny business (making sure the entire rectum isn't within the 50% IDL at any point, for example), ~80-90% of my patients have Grade 0-1 rectal tox during/after treatment. The other 10-20% might have a run of Grade 2, but it's exceedingly uncommon.

Knowing this, it's very hard for me to advocate for the hydrogel outside of SBRT. My group does the procedure ourselves, so I am personally there every step of the way, prescribing Ativan and Cipro, making sure the patients know they might be on the hook for $4,000 if their insurance doesn't cover it, jamming ultrasounds into rectums and needles into perineums. Every couple weeks/months one of my friends texts me about some SpaceOAR complication which might mean that patient won't be able to finish treatment.

I was much more agnostic about it when the Urologists were the ones placing it. Out of sight, out of mind I guess. But when I can't tell in OTV visits who has SpaceOAR and who doesn't...putting giant needles into these guys gets less and less appealing.

Great marketing also but if I can get fiducials, CBCT with tighter margins, I’m good to go. I actually don’t even bring up space OAR unless the urologist wants to do it.

 

[salubalu]

In a vacuum, yes, you should absolutely expect that.

My personal experience is that guys will have very different levels of rectal side effects despite having almost identical levels of rectal dose. By and large, if I spend a little extra time making sure they get into a good bowel/bladder regimen, and Dosimetry doesn't try any funny business (making sure the entire rectum isn't within the 50% IDL at any point, for example), ~80-90% of my patients have Grade 0-1 rectal tox during/after treatment. The other 10-20% might have a run of Grade 2, but it's exceedingly uncommon.

Knowing this, it's very hard for me to advocate for the hydrogel outside of SBRT. My group does the procedure ourselves, so I am personally there every step of the way, prescribing Ativan and Cipro, making sure the patients know they might be on the hook for $4,000 if their insurance doesn't cover it, jamming ultrasounds into rectums and needles into perineums. Every couple weeks/months one of my friends texts me about some SpaceOAR complication which might mean that patient won't be able to finish treatment.

I was much more agnostic about it when the Urologists were the ones placing it. Out of sight, out of mind I guess. But when I can't tell in OTV visits who has SpaceOAR and who doesn't...putting giant needles into these guys gets less and less appealing.

90% of my patients get SBRT. So I usually offer it. The logic being it may help and likely won’t have that much increased risk. Coming from one of those residencies y’all recommmended to get shut down where we did a lot of ldr for prostate and syeds for gyn I don’t consider the needles giant 😛.

 

[medgator]

Great marketing also but if I can get fiducials, CBCT with tighter margins, I’m good to go. I actually don’t even bring up space OAR unless the urologist wants to do it.

One prostate/rectal abcess complication leading to IV abx and a 6 month elective colostomy was enough for me. Thankfully wasn't my placement, but that was enough for me to stop doing them in combination with a review of some of the other data regarding spaceoar safety out there.

The GU who did place it had done dozens before then and continues to do them now. I don't think he placed it wrong, i think it's an inherent risk to the product itself

 

[elementaryschooleconomics]

90% of my patients get SBRT. So I usually offer it. The logic being it may help and likely won’t have that much increased risk. Coming from one of those residencies y’all recommmended to get shut down where we did a lot of ldr for prostate and syeds for gyn I don’t consider the needles giant 😛.

Hahaha fair point - I mean giant compared to no needles!

 

[RickyScott]

In a vacuum, yes, you should absolutely expect that.

My personal experience is that guys will have very different levels of rectal side effects despite having almost identical levels of rectal dose. By and large, if I spend a little extra time making sure they get into a good bowel/bladder regimen, and Dosimetry doesn't try any funny business (making sure the entire rectum isn't within the 50% IDL at any point, for example), ~80-90% of my patients have Grade 0-1 rectal tox during/after treatment. The other 10-20% might have a run of Grade 2, but it's exceedingly uncommon.

Knowing this, it's very hard for me to advocate for the hydrogel outside of SBRT. My group does the procedure ourselves, so I am personally there every step of the way, prescribing Ativan and Cipro, making sure the patients know they might be on the hook for $4,000 if their insurance doesn't cover it, jamming ultrasounds into rectums and needles into perineums. Every couple weeks/months one of my friends texts me about some SpaceOAR complication which might mean that patient won't be able to finish treatment.

I was much more agnostic about it when the Urologists were the ones placing it. Out of sight, out of mind I guess. But when I can't tell in OTV visits who has SpaceOAR and who doesn't...putting giant needles into these guys gets less and less appealing.

I always have 50% in front of posterior rectum on every slice of every prostate. It can almost always fall within 1 cm posterior to ptv (per doc from uchicago at Astro). Just don’t see rectal issues. As medgator says, 1 major complication from space oar probably offsets the benefits of a 1000 placements.

 

[TheWallnerus]

Does one truly believe that if someone contours the prostate the same and the rectum is pushed back 0.5-1+ cm that there will be no difference in rectal toxicity at all?

With IGRT and precise RT and rational margin choices, grade zero rectal toxicity rates in prostate cancer should be 95% or greater

However, you can design the radiotherapy in a way where there will be significant benefits to the SpaceOAR

 

[jondunn]

However, you can design the radiotherapy in a way where there will be significant benefits to Proton therapy

also true.

 

[RickyScott]

With IGRT and precise RT and rational margin choices, grade zero rectal toxicity rates in prostate cancer should be 95% or greater

However, you can design the radiotherapy in a way where there will be significant benefits to the SpaceOAR

what margin did they mandate on the trial?

 

[salubalu]

Great marketing also but if I can get fiducials, CBCT with tighter margins, I’m good to go. I actually don’t even bring up space OAR unless the urologist wants to do it.

Marketing is everywhere…we have Cyberknife…we have Gamma knife…we cure cancer!…we have grads from ivy universities..we have proton apbi trials…it’s part of the industry

 

[TheWallnerus]

what margin did they mandate on the trial?

IIRC this was sfumato

 

[RickyScott]

One of the issues I have with “expert contours” is that these contours are sometimes sent to a dosimetrist (who said expert has no interaction with) that then just meets some checklist and often prioritizes pretty isodose lines, and irrelevant homogeneities ; however, the plan clearly could be better given the pts individual volume/anatomy based on experience . Don’t be a dvh monkey.

 

[jondunn]

One of the issues I have with “expert contours” is that these contours are sent to dosimetrist (who expert has no interaction with) that then just meets some checklist and is obsessed with pretty isodose lines and other irrelevancies, but the plan clearly could be better given the volume/anatomy based on experience . Don’t be a dvh monkey.

I mean this exact statement could be made of anyone, wherever they work. It doesn't have anything to do with 'experts' or non-experts

the point is anybody anywhere should do more than the bare minimum of meeting the scorecard, if they can.

 

[RickyScott]

I mean this exact statement could be made of anyone, wherever they work. It doesn't have anything to do with 'experts' or non-experts

the point is anybody anywhere should do more than the bare minimum of meeting the scorecard, if they can.

Of course, but if you claim to be an expert and given head and neck plans all day long, does it really matter if you are not incorporating that experience?

 

[RadOncDoc21]

One of the issues I have with “expert contours” is that these contours are sent to dosimetrist (who expert has no interaction with) that then just meets some checklist and often obsessed with pretty isodose lines and other irrelevancies; however, the plan clearly could be better given the volume/anatomy based on experience . Don’t be a dvh monkey.

Learned this early out of training… I literally approved a plan once just briefly looking at the color wash and DVH, but when I went through looking at the Isodose lines, I saw a dip in the 90% coverage over the target due to a tertiary volume constraint. I’ve learned to never trust the DVH.

 

[RickyScott]

Btw anyone hear about Jordan Johnson’s dosimetry talk? Varian uses India for remote dosimetry and the physicist in charge owns a school that accredits these dosimetrists w/us credentials/board eligibility. Not sure what to think. Has anyone used them?

 

[TheWallnerus]

Learned this early out of training… I literally approved a plan once just briefly looking at the color wash and DVH, but when I went through looking at the Isodose lines, I saw a dip in the 90% coverage over the target due to a tertiary volume constraint. I’ve learned to never trust the DVH.

The inventor of the DVH would have said this exact same thing

 

[RadOncDoc21]

The inventor of the DVH would have said this exact same thing

Of course as the new doc, I had to “school” the team regarding goals of care vs passing a DVH sheet with 9 billion constraints that I really don’t believe make that much of an impact compared to actually targeting the cancer.

One example is something like a specific amount of the bladder receiving over 40 Gy… I’m like we use to treat pelvic field boxes to 45 Gy with no shame. I know I’m sounding boomery the more years I gain but I feel like we focus too much on the trees that don’t matter!

 

[Lamount]

One of the issues I have with “expert contours” is that these contours are sent to a dosimetrist (who said expert has no interaction with) that then just meets some checklist and often prioritizes pretty isodose lines, and irrelevant homogeneities ; however, the plan clearly could be better given the pts individual volume/anatomy based on experience . Don’t be a dvh monkey.

This is why I create subvolumes and planning structures on many cases, and individualized constraints on all cases.

My 2 cents on “expertise”… I don’t think this has anything to do with academic v PP

Being able to produce textbook contours makes you competent

Expertise has little to do with technique… mostly comes from knowing enough about the patient and the capabilities of other specialties to see the big picture that you can craft the best possible plan.

 

[RickyScott]

This is why I create subvolumes and planning structures on many cases, and individualized constraints on all cases.

My 2 cents on “expertise”… I don’t think this has anything to do with academic v PP

Being able to produce textbook contours makes you competent

Expertise has little to do with technique… mostly comes from knowing enough about the patient and the capabilities of other specialties to see the big picture that you can craft the best possible plan.

❤️ to hear that. You can “craft” many plans with sub volumes based on the heuristic that imrt can fall off around 4-6% per mm based on size and concavity of ptv, assuming hotspot of around 10%. Would like to name this heuristic after myself, but I am sure others have found it as well.

 

[Mandelin Rain]

One example is something like a specific amount of the bladder receiving over 40 Gy… I’m like we use to treat pelvic field boxes to 45 Gy with no shame. I know I’m sounding boomery the more years I gain but I feel like we focus too much on the trees that don’t matter!

I’ve had this exact conversation at least a dozen times.

 

[elementaryschooleconomics]

I know I’m sounding boomery the more years I gain but I feel like we focus too much on the trees that don’t matter!

I agree 1000%.

I think we got trapped in the trees for many reasons, but primarily:

1) It is very, very hard for the human brain to live in abstraction. What I mean is illustrated by this contouring discussion. We're acting like contouring has the same impact as a surgeon operating, or an artist painting, or a craftsman welding, or literally any other sort of dexterous process. It definitely looks and feels that way...but it isn't. It's so, so far removed. A surgeon absolutely needs to worry about an errant 2mm cut, that could mean a pierced artery and death. While we toil and argue about the same 2mm...our mouse cursor which has a cute little clipart paintbrush and an eraser function driven by a factory Dell mouse on a 7 year old fabric mousepad next to a stock Dell monitor that wasn't calibrated after it was installed 4 years ago IS NOT A SCALPEL.

2) While we're all aware of the downstream processes that happen between us sending contours to Dosimetry and the patient receiving their last fraction, I don't think we can easily feel the weight of all the compounding errors which could/do occur. Are you REALLY sure your Truebeam is optimally calibrated? Really? How do you know? Even if you're doing daily CBCT, how long from when that image was taken till the last MUs of that day's fraction are delivered? 5 minutes? 10? More? We all know about "obvious" sources of error, like suboptimal setup or poor treatment planning, but that's just the start.

Similar to how hard it is for us to conceptualize the distance of a "light year", or how big "one billion" is, etc etc - we didn't evolve to work at this scale of abstraction. But we did evolve to see how well we can draw lines, and drawing those lines feels the same as when we're creating something else with our hands...and boom, we're just surrounded by trees. We can only see trees.

What's a forest?

 

[TheWallnerus]

It is very, very hard for the human brain to live in abstraction. What I mean is illustrated by this contouring discussion. We're acting like contouring has the same impact as a surgeon operating, or an artist painting, or a craftsman welding, or literally any other sort of dexterous process. It definitely looks and feels that way...but it isn't. It's so, so far removed. A surgeon absolutely needs to worry about an errant 2mm cut, that could mean a pierced artery and death. While we toil and argue about the same 2mm...our mouse cursor which has a cute little clipart paintbrush and an eraser function driven by a factory Dell mouse on a 7 year old fabric mousepad next to a stock Dell monitor that wasn't calibrated after it was installed 4 years ago IS NOT A SCALPEL.

... we didn't evolve to work at this scale of abstraction. But we did evolve to see how well we can draw lines, and drawing those lines feels the same as when we're creating something else with our hands...

On a 70cm FOV thin slice CT w/ a 512 x 512 matrix, each pixel (voxel) has dimensions of 70cm/512 ≈ 1.3x1.3mm

A scalpel has a sharpness of 300Å = 3E-5mm (= length of a ribosome = length of a hep B viral particle)

So a scalpel is ~40,000x sharper than the highest resolution radiotherapy contouring

GOOD NITE

 

[jondunn]

 

[OTN]

I would love for one of these academic types to call me a "non-expert" to my face. Would be an entertaining conversation.

Data does not show any benefit to SpaceOAR placement in either fractionated RT or SBRT. I never use it and don't have rectal complications.

 

[SubserviantToABR]

Is it really mentorship when our leadership, as a whole, is leading our specialty and young trainees off a cliff through their lies? Don't forget DEI! We will be diverse but dead.

I was naïve and grossly misled when I applied to residency nearly 10 years ago that opportunities were plentiful. Now, I am in an academic gig, producing 10K+ wRVUs per year for an assistant professor salary (sub-25%ile MGMA). Thank you to rad onc leadership and mentorship for screwing our generation over. Now, please leave your money on my nightstand and leave quietly.

 

[jondunn]

I was naïve and grossly misled when I applied to residency nearly 10 years ago that opportunities were plentiful.

People lied to you. I was applying about 10 years ago and knew jobs were an issue, and there were plenty of threads on SDN around the time as well (it has been nearly 10 years since bloodbath post for example). It's in the FAQ on this forum that you may not be able to get jobs in the city you want/need.

the fact that this was well known for a long time and people still lied is sad.

 

[SubserviantToABR]

People lied to you. I was applying about 10 years ago and knew jobs were an issue, and there were plenty of threads on SDN around the time as well (it has been nearly 10 years since bloodbath post for example). It's in the FAQ on this forum that you may not be able to get jobs in the city you want/need.

the fact that this was well known for a long time and people still lied is sad.

I remember the letter Chirag wrote and the bloodbath post quite well, remember reading it in real time. Many people in leadership told us the future was fine, despite these concerns, but this was certainly before many hypofractionation and omission studies came out since then, concomitantly with the decline in prostate screening and smoking rates.

It was always: no, no, you're smart and hardworking, you'll get to do what you want just fine, don't listen to what you read online.

I just didn't listen.

 

[RickyScott]

I would love for one of these academic types to call me a "non-expert" to my face. Would be an entertaining conversation.

Data does not show any benefit to SpaceOAR placement in either fractionated RT or SBRT. I never use it and don't have rectal complications.

Would think that 15 +years of taking top medstudents would put a dent in this eliticism.

 

[fiji128]

Is it really mentorship when our leadership, as a whole, is leading our specialty and young trainees off a cliff through their lies? Don't forget DEI! We will be diverse but dead.

I was naïve and grossly misled when I applied to residency nearly 10 years ago that opportunities were plentiful. Now, I am in an academic gig, producing 10K+ wRVUs per year for an assistant professor salary (sub-25%ile MGMA). Thank you to rad onc leadership and mentorship for screwing our generation over. Now, please leave your money on my nightstand and leave quietly.

With mentors like these …….

 

[Lamount]

I agree 1000%.

I think we got trapped in the trees for many reasons, but primarily:

1) It is very, very hard for the human brain to live in abstraction. What I mean is illustrated by this contouring discussion. We're acting like contouring has the same impact as a surgeon operating, or an artist painting, or a craftsman welding, or literally any other sort of dexterous process. It definitely looks and feels that way...but it isn't. It's so, so far removed. A surgeon absolutely needs to worry about an errant 2mm cut, that could mean a pierced artery and death. While we toil and argue about the same 2mm...our mouse cursor which has a cute little clipart paintbrush and an eraser function driven by a factory Dell mouse on a 7 year old fabric mousepad next to a stock Dell monitor that wasn't calibrated after it was installed 4 years ago IS NOT A SCALPEL.

2) While we're all aware of the downstream processes that happen between us sending contours to Dosimetry and the patient receiving their last fraction, I don't think we can easily feel the weight of all the compounding errors which could/do occur. Are you REALLY sure your Truebeam is optimally calibrated? Really? How do you know? Even if you're doing daily CBCT, how long from when that image was taken till the last MUs of that day's fraction are delivered? 5 minutes? 10? More? We all know about "obvious" sources of error, like suboptimal setup or poor treatment planning, but that's just the start.

Similar to how hard it is for us to conceptualize the distance of a "light year", or how big "one billion" is, etc etc - we didn't evolve to work at this scale of abstraction. But we did evolve to see how well we can draw lines, and drawing those lines feels the same as when we're creating something else with our hands...and boom, we're just surrounded by trees. We can only see trees.

What's a forest?

I agree…ish. Would say that it is important for us to keep in mind that there is a normal distribution about every component of treatment planning. There are two parameters that define a normal distribution: mean (expectation value) and standard deviation. The mean is what we ask for (contouring constraints etc.), the standard deviation is how much blurring there is from uncertainty. While there are many cases where significant uncertainty makes small differences in target location meaningless, this is not always the case and the mean is frequently an important parameter.

Perhaps I will become more nihilistic when I have a few more years under my belt, but I am still of the mindset at 2 to 5 mm differences matter in some cases (but clearly not all)