Rad Onc Twitter

[TheWallnerus]

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I am presently doing 5mm posterior margin and 7mm everything else with spaceOAR, fiducials, and daily CBCT and 6 degree couch. I used to do 6 and 8. I am still thinking this is overkill and may start taking to down to 4 and 6 or even 5 isotropically. Unless the therapists really suck, shouldn't we be able to approach SBRT-level margins (physician at machine verifying with intrafraction monitoring) with all this tech?

Definite overkill

 

[radiaterMike]

No question that his COI are relevant if he owns stock in the company and receives money from them. These factors could consciously or 'subconsciously' impact trial design (as others mentioned, it was not a trial that could fail). But he reports those COI and has a COI plan (whatever that is?) and it is no different than any other study with authors who have relevant COI. These types of things often get called out. If one chooses to do so on twitter there are more professional and polite ways to phrase those concerns than what LP chose to do. A classic example of a COI that was not explicitly declared (though obvious to anyone reading the paper) that may have (I dont know) cost someone their job -- Distinguishing “Controversy” From Conflict of Interest: The Wrong Image for Radiation Oncology

 

[evilbooyaa]

I am presently doing 5mm posterior margin and 7mm everything else with spaceOAR, fiducials, and daily CBCT and 6 degree couch. I used to do 6 and 8. I am still thinking this is overkill and may start taking to down to 4 and 6 or even 5 isotropically. Unless the therapists really suck, shouldn't we be able to approach SBRT-level margins (physician at machine verifying with intrafraction monitoring) with all this tech?

That is a lot of overkill, IMO. With daily CBCT alone I personally do 5 in all and 3 posteriorly. No fiducials or SpaceOAR. No need for 6 degree couch with that

*EDIT* - (in my opinion) if you have good therapists

*EDIT 2* - This is for conventional/moderate fractionation. For SBRT I do spaceOAR + Fiducials + 6 degree couch, yes. Still 5mm in all except 3mm posteriorly. We are starting to ask if fiducials are necessary for SBRT.

 

[BobbyHeenan]

That is a lot of overkill, IMO. With daily CBCT alone I personally do 5 in all and 3 posteriorly. No fiducials or SpaceOAR. No need for 6 degree couch with that.

I'm 7 and 4 posterior in mostly 70/28 or 60/20 with daily CBCT, no fiducials. We did this in training too 15 years ago.
for sbrt I am mostly fiducials vast majority of time (but not every case), often spaceOAR...5 mm and 3mm posterior.

I typically do a "lunch and learn" with therapists yearly and go through a lot of prostate CBCTs to refresh skills and show them alignment. They do a great job with a little coaching. For SBRTs I personally align.

*aside* Many men have intraprastatic calcifications that are great "fiducials" with CBCT.

 

[NotMattSpraker]

No question that his COI are relevant if he owns stock in the company and receives money from them. These factors could consciously or 'subconsciously' impact trial design (as others mentioned, it was not a trial that could fail). But he reports those COI and has a COI plan (whatever that is?) and it is no different than any other study with authors who have relevant COI. These types of things often get called out. If one chooses to do so on twitter there are more professional and polite ways to phrase those concerns than what LP chose to do. A classic example of a COI that was not explicitly declared (though obvious to anyone reading the paper) that may have (I dont know) cost someone their job -- Distinguishing “Controversy” From Conflict of Interest: The Wrong Image for Radiation Oncology

Great share. I was so lucky to see EG speak just once, I will never forget that talk.

All due respect to EG, I think times have changed since he wrote that. In 2022, it's a bit rich for a Penn affiliated person to talk about purity of intentions with patient care. Penn with the protons and satellites and CME courses and their palliative care "network".

Also, he glosses over a lot of COI that people just accept as fine while they rant against other types of COI. The ASTRO board members have plenty of COI. ASTRO sells ads at their conferences and in their journals. Why is it okay to have an ad on one page but then an article on the next page written by someone who speaks for Varian is not okay? Why is it okay for ASTRO to sell their virtual access to a conference for $100 more than in person, presumably because they benefit from in-person attendees who visit the exhibit hall?

Most importantly, the former "conflicted researcher" is becoming totally common in medical oncology and the issue is accelerating. While a few speak out against this stuff, I've never seen a single person talk about it like the way rad oncs attack each other. When an MO presents results conference of a pharma industry funded trial written up by a medical writer, people give standing ovations.

I think the best way forward for RO is to encourage industry collaboration and be overly transparent with COI and accept that most of it is not inherently bad. I do agree that doctors should not own stock of any medical company, but honestly I'm starting to wonder why I feel that way. Everyone else gets to own stock, even frickin congresspeople.

Doctors should be nicer to ourselves. It's silly to sit on some fake moral high ground while everyone else (including other doctors) is hanging out in the real world.

I also would still like someone to point out how they think COI had a direct impact on design. Propose a mechanism. He has explained the choice of margins in control versus experimental arms and, as someone who has designed a few IITs, his explanation is extremely reasonable.

 

[deleted1111261]

I am presently doing 5mm posterior margin and 7mm everything else with spaceOAR, fiducials, and daily CBCT and 6 degree couch. I used to do 6 and 8. I am still thinking this is overkill and may start taking to down to 4 and 6 or even 5 isotropically. Unless the therapists really suck, shouldn't we be able to approach SBRT-level margins (physician at machine verifying with intrafraction monitoring) with all this tech?

Overkill
5/3 posterior, friend.

 

[deleted1111261]

That is a lot of overkill, IMO. With daily CBCT alone I personally do 5 in all and 3 posteriorly. No fiducials or SpaceOAR. No need for 6 degree couch with that

*EDIT* - (in my opinion) if you have good therapists

*EDIT 2* - This is for conventional/moderate fractionation. For SBRT I do spaceOAR + Fiducials + 6 degree couch, yes. Still 5mm in all except 3mm posteriorly. We are starting to ask if fiducials are necessary for SBRT.

@OTN has excellent results without

 

[deleted1111261]

Said above

“Doctors should be nicer to themselves”

Scream this from the mountain tops.

I don’t believe we deserve millions (but good on you if you make em). I don’t believe we deserve fame or too much of a thank you.

What we deserve is the benefit of the doubt that we put patient care first, above all. Patients, in my opinion, give us this. We do not give it to ourselves or our colleagues.

 

[Ray D. Ayshun]

Thanks, I'll give 3 or 4 a try. Tbh, I occasionally do 7 posterior if I know the patient is gonna have rectum issues. Some guys are pretty gassy.

 

[deleted1116990]

Overkill
5/3 posterior, friend.

I was trained to use 8 and 6 posterior. Glad to hear my decision to deviate from training and start tightening it up was reasonable. Didn't realize how many others were going even tighter.

 

[TheWallnerus]

I was trained to use 8 and 6 posterior. Glad to hear my decision to deviate from training and start tightening it up was reasonable. Didn't realize how many others were going even tighter.

Kupelian was doing 4mm circumferential with Exactrac (which is the Varian equivalent of kV X-ray pair) in 2003 and onward on all low risk prostate, fiducial based obv

By 4mm I mean this was his *PTV* on the prostate *CTV*

 

[Mandelin Rain]

I don't think it's worthless if your contention is that you can ONLY shrink margins on the basis of superior MR imaging.

Is that true? I don't know. Has it been well evaluated with non-MR guided RT? I don't think so. There is considerable variation between centers on that.

 

[Ray D. Ayshun]

If youre contouring your prostate on CT and not MRI, isn't there a paper out there suggesting your already putting a 1-2 mm PTV on it? Though prob mostly laterally.

 

[communitydoc13]

Can you elaborate how you think COI affects this specific study?

@radiaterMike states as below.

These factors could consciously or 'subconsciously' impact trial design (as others mentioned, it was not a trial that could fail).

COI does not indicate mendacity or bad professional values. The whole concept is rooted in the fact that there are things that may affect our judgement and actions in ways that we cannot consciously adjust for. COI is why jurists recuse themselves from certain cases and why admissions officers (or radonc chairs) should not assess their children's applications.

It would be a better look if Kishan did not have stock in VR. It does not mean that the research was not done honestly, just that there may be some "unconscious bias" by the researcher that is a result of financial interests.

I also would still like someone to point out how they think COI had a direct impact on design. Propose a mechanism. He has explained the choice of margins in control versus experimental arms and, as someone who has designed a few IITs, his explanation is extremely reasonable.

The explanation regarding margins is reasonable. It also means that there is no direct comparison between techniques because we have introduced a confounder (margin size). The margins are themselves pretty arbitrary and are rooted in "comfort levels". Fine but not very scientific. The important counterpoint to any toxicity outcome is cancer control, of course this trial will not answer if there is any meaningful impact on pCa control by reducing margins.

Regarding toxicity assessment? On 100 patients and including Grade 2 and low total numbers, the stats are not going to mean much to me. I have no idea if Kishan was personally involved in toxicity assessment or if there was a "vibe" given off to investigators who assigned toxicity, but all of these things can be impacted by unconscious bias. Is transient Grade 2 toxicity worth extra time and investment regarding treating prostate Ca? Well, we accept increased acute toxicity with every accelerated course anyway.

Most important regarding the COI issue is how this paper is used or quoted to support investment in VR. I recently saw a patient from a procure center and in their brochure they included short interval, retrospective 2nd malignancy data, which we all know represents differences the populations who receive protons and photons. If this paper becomes a meaningful part of the pro MRI linac movement, I think it is probably bad.

Now if an investigator knew what they going to publish and decided with that knowledge to buy a bunch of VR stock in late 2021, that would be bad and should be known. I have zero evidence that this was done.

I think the best way forward for RO is to encourage industry collaboration and be overly transparent with COI and accept that most of it is not inherently bad.

Industry needs to take the risk and needs to believe in their own product. IMO the proton story is one of docs wanting something to be better and knowing that they could establish value culturally from positions of high esteem when true clinical value of a technology was dubious in most cases. What should have been done with Protons is to have industry take the risk, build the centers and then have non-invested docs run the trials. When the trials were negative, industry should have been asked to regroup, come up with a better product or consider abandoning their initial investment.

I don't know if any given drug has ever had the impact on a MO department that something like protons has had on numerous RO departments.

How many MOs have stock in the companies that make the drugs that they are doing Phase II or Phase III trials on?

Disclosure: I do not know Kishan or Potters and never expect to meet them. I do not have Twitter. I have no stock in tech companies that is not bundled into my retirement portfolio. I do have a COI in that I want my relatively poor, community cancer center to remain competitive throughout the remainder of my career.

 

[temujim]

It would be a better look if Kishan did not have stock in VR. It does not mean that the research was not done honestly, just that there may be some "unconscious bias" by the researcher that is a result of financial interests.

If the man has stock, we should be worried about bias against VR.

 

[deleted1111261]

4D chess

He’s making stock go down to show this wasn’t for the money.

Then, years later, when the hedge funds buy options to short it, SDN goes super long and leads to a short squeeze.

TO THE MOON

 

[deleted1116990]

If youre contouring your prostate on CT and not MRI, isn't there a paper out there suggesting your already putting a 1-2 mm PTV on it? Though prob mostly laterally.

You are almost certainly including anterior fibromuscular stroma and periprostatic fat in your CTV, yes. One of the reasons I've been less comfortable going below 5mm margins is because I contour prostate on MRI.

 

[taserlaser]

You are almost certainly including anterior fibromuscular stroma and periprostatic fat in your CTV, yes. One of the reasons I've been less comfortable going below 5mm margins is because I contour prostate on MRI.

One man’s CTV is another man’s PTV. Isn’t rad onc great

 

[deleted1116990]

One man’s CTV is another man’s PTV. Isn’t rad onc great

Yet it's treated as a failable offense on boards (supposedly) even if you both arrive at the same final volume. Yes, really great!

Also exception of tighter PTV margin posteriorly because that's where rectum is. That's not how PTV concept works. If anything, probably needs more PTV there due to uncertainty of rectum size. SpaceOAR to the rescue.

 

[deleted1116990]

4D chess

He’s making stock go down to show this wasn’t for the money.

Then, years later, when the hedge funds buy options to short it, SDN goes super long and leads to a short squeeze.

TO THE MOON

The idea of being a stockholder as that serious a COI is also asinine. How many shares does he own? Does he have options. Short or long? When do they expire? There is a lot of nuance to this. It looks like someone was just looking for a reason to attack this person. To suggest he fabricated or massaged data and drafted a biased conclusion so his $25k of viewray stock could bump to $30k so he could dump it and realize a 5k profit or something is just insane. You need to come to the table with a lot more evidence that just being a "stockholder" if you are going to make serious accusations like that. Ridiculous.

If you have a broad market index fund, then you are technically a stockholder. I am sure I own it in my 401k.

 

[deleted1111261]

I know that icru wise it seems odd to have different posterior margin

But, if you think of it as probability - it makes sense - “I’m willing to cheat posteriorly bc I value reducing/avoiding toxicity over marginal increase in biochem control” then it makes more sense. The idea of PTV is give you highest probability of covering target. But, you can modify your idealized probability.

 

[taserlaser]

Also, if that is what you are matching to, your certainty at the prostate/rectum interface is higher than perhaps other cardinal directions.

 

[OTN]

I know that icru wise it seems odd to have different posterior margin

But, if you think of it as probability - it makes sense - “I’m willing to cheat posteriorly bc I value reducing/avoiding toxicity over marginal increase in biochem control” then it makes more sense. The idea of PTV is give you highest probability of covering target. But, you can modify your idealized probability.

I've never had a different posterior margin for the coherence/logical reasons you alluded to. For fractionated, 6 mm all around. For SBRT, 3 mm all around.

For SBRT: Body Pro lok without abdominal compression. Sim with contrast and fuse with MRI for planning. 6-degree couch. No fiducials. No SpaceOAR. CBCT immediately before tx and halfway through. Bladder comfortably full. Close monitoring of rectum size/filling, and we won't treat if it's not the same as sim. My therapists are excellent at finding the rectum/prostate interface.

Clinical outcomes in terms of both disease control and toxicity have been excellent.

 

[communitydoc13]

I've never had a different posterior margin for the coherence/logical reasons you alluded to. For fractionated, 6 mm all around. For SBRT, 3 mm all around.

For SBRT: Body Pro lok without abdominal compression. Sim with contrast and fuse with MRI for planning. 6-degree couch. No fiducials. No SpaceOAR. CBCT immediately before tx and halfway through. Bladder comfortably full. Close monitoring of rectum size/filling, and we won't treat if it's not the same as sim. My therapists are excellent at finding the rectum/prostate interface.

Clinical outcomes in terms of both disease control and toxicity have been excellent.

Why contrast?

 

[NotMattSpraker]

The whole concept is rooted in the fact that there are things that may affect our judgement and actions in ways that we cannot consciously adjust for.

I really appreciated your whole answer, but I think this kind of statement is a problem.

It slides back to saying categorically that if you have COI, there is some problem, but I can't describe it or even recognize it. Sometimes in the DEI space people structure arguments about racism in this way and it's not very constructive. Like racism, I do agree with you it exists, but practically that just doesn't help. If ROs avoid industry collaboration out of fear for COI, we are screwed. If ROs work for industry for free, we are suckers.

And again, what about all the other conflicts that we all have that no one describes? If a prostate patient hits your room, you are motivated to treat them on the machine you have there, of course its great. You might do SpaceOAR to be a good citizen to your referring urologists, even if you've read the paper and you know whats really going on. If esophagus pans out to have proton benefit, I bet many will keep those patients at their photon centers. Isn't that a COI against the data? Acceptable to be sure, but these people walking around saying they have no COI, that's a joke to me.

You don't think Potters is out there making moves for the greatness of Northwell so that he can preserve his salary? I fail to understand how those kinds of people have a moral high ground over Amar (stock pump and dump or timing aside, if thats even true). Very reasonable to agree to disagree here, but its worth considering these issues and how the rest of medicine behaves if we want to grow Rad Onc or at least stop it from shrinking.

Your points about toxicity attribution are fair, but also valid for every single non-blinded prospective randomized study out there that uses independent toxicity monitoring. It's impossible to blind the MR vs CT study so you we'll just need to accept it as a limitation. Also, in my experience the way you describe is not exactly how toxicity attribution works, but thats kind of getting in the weeds and beside the point.

 

[Palex80]

I know that icru wise it seems odd to have different posterior margin

But, if you think of it as probability - it makes sense - “I’m willing to cheat posteriorly bc I value reducing/avoiding toxicity over marginal increase in biochem control” then it makes more sense. The idea of PTV is give you highest probability of covering target. But, you can modify your idealized probability.

Well, the only problem is that most tumors are in the peripheral (posterior) parts of the prostate. 🙂

 

[deleted1111261]

Well, the only problem is that most tumors are in the peripheral (posterior) parts of the prostate. 🙂

we’ve used differential margins for years ..
i think maybe Fox Chase was first to? They did like zero margin for boost. Someone even older than me can confirm

 

[temujim]

It slides back to saying categorically that if you have COI, there is some problem, but I can't describe it or even recognize it. Sometimes in the DEI space people structure arguments about racism in this way and it's not very constructive. Like racism, I do agree with you it exists, but practically that just doesn't help. If ROs avoid industry collaboration out of fear for COI, we are screwed. If ROs work for industry for free, we are suckers.

Huh that is an interesting conjunction. Does one have COI if a minority and doing DEI research?

 

[thecarbonionangle]

Wow that Urbanic, LP exchange in public when they think its private is hilarious. Urbanic seems totally unpleasant from many of his posts, so cannot say he surprises me here. Funny to see LP bad mouth his “dear friend” UCLA chair to urbanic. Total snake pit of boomers. Our field is in great hands! Cheers to a great match folks.

 

[NotMattSpraker]

Huh that is an interesting conjunction. Does one have COI if a minority and doing DEI research?

LOL, not what I meant. Front of mind example for me (not sure why) is that ASTRO abstract on how men versus women are addressed at ASTRO. The data did not support the conclusion. If people pointed that out, the responses I saw were: well sexism is just there, trust me. Very ASTRO-y 🙂

No question it's around, but maybe it's not everywhere.

Wow that Urbanic, LP exchange in public when they think its private is hilarious. Urbanic seems totally unpleasant from many of his posts, so cannot say he surprises me here. Funny to see LP bad mouth his “dear friend” UCLA chair to urbanic. Total snake pit of boomers. Our field is in great hands! Cheers to a great match folks.

I have to admit the most striking thing through all of this is the number of people that reached out privately denouncing LP. Horrible look. Pushing the idea that the chair is at fault for letting a junior get in to "trouble" he doesnt even know hes in... our leaders have an unusual approach to leadership.

 

[deleted1111261]

LOL, not what I meant. Front of mind example for me (not sure why) is that ASTRO abstract on how men versus women are addressed at ASTRO. The data did not support the conclusion. If people pointed that out, the responses I saw were: well sexism is just there, trust me. Very ASTRO-y 🙂

No question it's around, but maybe it's not everywhere.



I have to admit the most striking thing through all of this is the number of people that reached out privately denouncing LP. Horrible look. Pushing the idea that the chair is at fault for letting a junior get in to "trouble" he doesnt even know hes in... our leaders have an unusual approach to leadership.

I don’t know him from anything except a zoom call and that VVPN panel.

What was striking was his complete dismissiveness of peoples concerns and empathy about real or perceived issues in our specialty. What an odd way to wade back in.

 

[medgator]

If the man has stock, we should be worried about bias against VR.

View attachment 360351

Looks like tomotherapy/accuray stock a few years ago....

 

[communitydoc13]

I fail to understand how those kinds of people have a moral high ground over Amar (stock pump and dump or timing aside, if thats even true).

I'm sure no one has the moral high ground. I'm not sure what Potters was doing with this tweet and I don't know the actors. It's weird and I wish it didn't happen.

If ROs avoid industry collaboration out of fear for COI, we are screwed. If ROs work for industry for free, we are suckers.

ROs don't need to avoid industry collaboration. Avoiding stock is probably reasonable. There are already exceptions in place for broad index funds. I have to fill out COI for being a community investigator through NCORP. They don't count broad index funds. If the potential earnings are low, there is no reason to not forego them. Some calculations will tell you however that even a modest 25K in stock now may not be trivial in terms of earnings long term.

Agree that COI is everywhere and impossible to eliminate in entirety. We make calculations assessing each others COI all the time.

how the rest of medicine behaves if we want to grow Rad Onc or at least stop it from shrinking

I'm admittedly a skeptic about this (although I'm intrigued by arthritis!). We wouldn't act this way if our pie was organically getting bigger (as it is for many physicians). Meaningful advances are difficult in radonc and even more difficult to scale to the community. I'm in the expand the scope of radonc practice outside of just XRT camp. That's not happening any time soon.

 

[Lamount]

Said above

“Doctors should be nicer to themselves”

Scream this from the mountain tops.

I don’t believe we deserve millions (but good on you if you make em). I don’t believe we deserve fame or too much of a thank you.

What we deserve is the benefit of the doubt that we put patient care first, above all. Patients, in my opinion, give us this. We do not give it to ourselves or our colleagues.

Agree! When you are surrounded by overachieving colleagues, getting beaten down by cynical admins, or encountering petty folks on twitter, it is easy to forget how many patients out there mention you in their evening prayers, or how many trainees, students, or staff look up to you.

Every so often, it's important to zoom out and look at the big picture

 

[OTN]

Why contrast?

I think it can help delineate prostate from non-prostate tissue somewhat. While I do fuse a prostate MRI for treatment planning, I'm wary of geometric distortion with MRI, so I like to get the best-quality simulation CT I can. Not critical at all, though. I think I give contrast a little more often than some do with planning.

 

[RickyScott]

A small company like viewray probably has relatively little cash on hand and can’t pay cash consulting fees to advisors at major academic centers, so probably gives them a few thousand dollars in stock. If amar actually bought view ray stock because he saw it as a good investment, I would have a major concern about his financial judgement.

 

[RadOncDoc21]

Great share. I was so lucky to see EG speak just once, I will never forget that talk.

All due respect to EG, I think times have changed since he wrote that. In 2022, it's a bit rich for a Penn affiliated person to talk about purity of intentions with patient care. Penn with the protons and satellites and CME courses and their palliative care "network".

Also, he glosses over a lot of COI that people just accept as fine while they rant against other types of COI. The ASTRO board members have plenty of COI. ASTRO sells ads at their conferences and in their journals. Why is it okay to have an ad on one page but then an article on the next page written by someone who speaks for Varian is not okay? Why is it okay for ASTRO to sell their virtual access to a conference for $100 more than in person, presumably because they benefit from in-person attendees who visit the exhibit hall?

Most importantly, the former "conflicted researcher" is becoming totally common in medical oncology and the issue is accelerating. While a few speak out against this stuff, I've never seen a single person talk about it like the way rad oncs attack each other. When an MO presents results conference of a pharma industry funded trial written up by a medical writer, people give standing ovations.

I think the best way forward for RO is to encourage industry collaboration and be overly transparent with COI and accept that most of it is not inherently bad. I do agree that doctors should not own stock of any medical company, but honestly I'm starting to wonder why I feel that way. Everyone else gets to own stock, even frickin congresspeople.

Doctors should be nicer to ourselves. It's silly to sit on some fake moral high ground while everyone else (including other doctors) is hanging out in the real world.

I also would still like someone to point out how they think COI had a direct impact on design. Propose a mechanism. He has explained the choice of margins in control versus experimental arms and, as someone who has designed a few IITs, his explanation is extremely reasonable.

Doctors were taught to believe they should be “above” their own pleasures. I think we are slowly starting to see how the “real world” works and starting to feel undervalued as other fields (business, finance, industries, marketing, etc) make the money and rules significany impacting our lives.

I never forgot the days during my intern year I had to look after my patients way past my 24hr call while nurses would literally change shifts during the middle of a code. During my years as an attending, I got to see hospital admins coming in at 9, leave anytime during the day, yet I couldn’t leave because my schedule was packed with patients and there were patients in the machine. Don’t get me wrong, some docs enjoy the extra burden and the “privilege” to “serve” but many are starting to realize the truth about medicine.

I say all this to say there shouldn’t be anything wrong with having stocks or financials incentives in our field if we fully disclose our conflicts of interests. At the end of the the day, money is the key to the majority of all decisions.

 

[RadOncDoc21]

A small company like viewray probably has relatively little cash on hand and can’t pay cash consulting fees to advisors at major academic centers, so probably gives them a few thousand dollars in stock. If amar actually bought view ray stock because he saw it as a good investment, I would have a major concern about his financial judgement.

Have to say… I bought viewray stock this year, it’s actually one of a handful of stocks that has made me money this year (bought when it was really low). Don’t get me wrong, I’m still not Oprah rich yet

 

[Fpg1245]

Doctors were taught to believe they should be “above” their own pleasures. I think we are slowly starting to see how the “real world” works and starting to feel undervalued as other fields (business, finance, industries, marketing, etc) make the money and rules significany impacting our lives.

I never forgot the days during my intern year I had to look after my patients way past my 24hr call while nurses would literally change shifts during the middle of a code. During my years as an attending, I got to see hospital admins coming in at 9, leave anytime during the day, yet I couldn’t leave because my schedule was packed with patients and there were patients in the machine. Don’t get me wrong, some docs enjoy the extra burden and the “privilege” to “serve” but many are starting to realize the truth about medicine.

I say all this to say there shouldn’t be anything wrong with having stocks or financials incentives in our field if we fully disclose our conflicts of interests. At the end of the the day, money is the key to the majority of all decisions.

That’s the problem. The old guard pre boomers im referring to. Made sure they got theirs and were willing to fight for it. They were needed and they made sure the set up was such that they got paid for what they do.

The new generation of pseudo free market demigods mixed with buzzword managerial techniques coupled with a government that as far I can see hates doctors - see “value” based care. Money always governed these decisions but who has the power in the relationship has made all the difference.

 

[Palex80]

 

[Palex80]

 

[CaesarRO]

View attachment 360585

More like they'll just conveniently ignore this

 

[medgator]

"pretty sure i went into medical physics to get an entry level RO salary without the patient contact"

 

[Ray D. Ayshun]

Typically, when I write "lol," I'm not being literal. In this case I am. Lol.

Also, I guess talking to the physicist will allow them to ring the bell again without feeling the bell-induced anxiety?

 

[Gfunk6]

"pretty sure i went into medical physics to get an entry level RO salary without the patient contact"

 

[Ray D. Ayshun]

Shouldn't the control arm have been optune?

 

[Fpg1245]

View attachment 360650

I wanna thank the red journal for further subverting my role in cancer care

 

[Fpg1245]

 

[Lamount]

“Hello, nice to meet you. I am the one insisting that we hold your urgent palliative treatment because the accumulating fluid in your lung will attenuate your radiation dose (albeit, arbitrarily chosen) by ~5%".

I kid, I kid! (truly, nothing but love for my physicists)

 

[w00tz]

I have a physicist that is super book smart, but I've had to coach him several times to refrain from say things like "Wow, this disease is horrible!" in front of the patient.