Rad Onc Twitter

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RealSimulD said:
Not as hard as we think

People not that interested in knowing for themselves
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Hospital based specialties have peer review and credentialing committee systems built in, surgeons work with other surgeons in the OR etc. Completely different than RO which is often either in a separate location altogether or freestanding center away from the hospital
 
Lamount said:
So you think the insurance company who is questioning our claim would pay out on a bill for our trouble?

I certainly appreciate the sentiment...
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Agreed it'll never happen.

But how about if they pay us for every P2P that successfully overturns a denial?

Something like 80% + of peer to peers result in an approval. It's an enormous waste of resources for something that's usually approved
 
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CaesarRO said:
Agreed it'll never happen.

But how about if they pay us for every P2P that successfully overturns a denial?

Something like 80% + of peer to peers result in an approval. It's an enormous waste of resources for something that's usually approved
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Won't this just lead to them never approving a P2P again?
 
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fiji128 said:
Same could be said about a GI doc as well. As a MD, you will probably only be aware if another specialty doc is operating in the bottom 5 or 10% of what would be expected.
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A radonc can tell if another radonc is incompetent but another specialist usually cannot. I have met radoncs that absolutely have no clue what they are doing and haven’t read a paper in 20 years and other specialists (also usually sh*** ones) don’t see it and think they are good. It absolutely blows my mind.
 
thesauce said:
A radonc can tell if another radonc is incompetent but another specialist usually cannot. I have met radoncs that absolutely have no clue what they are doing and haven’t read a paper in 20 years and other specialists (also usually sh*** ones) don’t see it and think they are good. It absolutely blows my mind.
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Decent ENTs and Gyn Oncs will know who the sh***ty rad oncs are pretty quickly.
 
fiji128 said:
Decent ENTs and Gyn Oncs will know who the sh***ty rad oncs are pretty quickly.
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It's still hard to tell in the short term. They will figure out who is familiar with SOC and the literature fairly quickly.

Just make your volumes smaller, reduce toxicity and you will be viewed favorably until recurrences happen.

Recurrences can take a long time. Endometrial? May be years and years after treatment. H&N? These do tend to occur earlier but you need enough volume to demonstrate abnormal outcomes.
 
You can always argue this and that and what abouts. But ents and gyn oncs will definitely note abnormal outcomes and recurrences pretty quickly even in the community. Ya, no way to tell if you are only getting one patient a year from these services.
 
sirspamalot said:
Dat true. Also, a younger / academic medonc who is sharp will figure it out esp. if recently trained at a high quality institution.
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When their gyn patients keep having bowel obstructions and necrosis and die even the not so sharp ones will start asking questions and figure it out. Oh, SBRTing a para-aortic node twice after prior paraaortic radiation isn't normal? And given enough time, when the early stage breast patients keep having local recurrences. And eventually they will get curious enough to want to look at the plans and ask questions. Wait, you are supposed to flash the skin? What's the point of blocking air? The medial blocks are set before the ribs? Shouldn't we have a little "wiggle room"? Hmm, those are good questions

(this is what happens when you take someone trained before the CT era and apply the Dunning kruger effect. They think what is drawn on the CT is exactly what will happen - very dangerous rad oncs out there who think like this and would be better off practicing 2D rad onc, forget IMRT and SBRT). Maybe the ABR, could like, address this somehow instead of focusing on young rad oncs with 270 USMLE steps for being dangerous due to lack of intricate rad bio knowledge?

Gyn onc will probably be able to appreciate the difference of a rad onc who takes the time to do image based planning each fraction vs. one who does point based planning fraction 1 and repeats as they surely trained in centers where only the former was done. If there is no gyn onc, med onc will need more egregious behavior like the above especially if that is what they are historically used to.
 
Moonbeams said:
When their gyn patients keep having bowel obstructions and necrosis and die even the not so sharp ones will start asking questions and figure it out. Oh, SBRTing a para-aortic node twice after prior paraaortic radiation isn't normal? And given enough time, when the early stage breast patients keep having local recurrences. And eventually they will get curious enough to want to look at the plans and ask questions. Wait, you are supposed to flash the skin? What's the point of blocking air? The medial blocks are set before the ribs? Shouldn't we have a little "wiggle room"? Hmm, those are good questions

(this is what happens when you take someone trained before the CT era and apply the Dunning kruger effect. They think what is drawn on the CT is exactly what will happen - very dangerous rad oncs out there who think like this and would be better off practicing 2D rad onc, forget IMRT and SBRT). Maybe the ABR, could like, address this somehow instead of focusing on young rad oncs with 270 USMLE steps for being dangerous due to lack of intricate rad bio knowledge?

Gyn onc will probably be able to appreciate the difference of a rad onc who takes the time to do image based planning each fraction vs. one who does point based planning fraction 1 and repeats as they surely trained in centers where only the former was done. If there is no gyn onc, med onc will need more egregious behavior like the above especially if that is what they are historically used to.
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lets say you gave sham radiation for early stage breast- did not turn the machine on- do you think referrers would notice? not likely- hormones would push back the failures 5-10 years and only 5-10% of pts eventually fail. we need statistics to resolve differences that are not obvious
 
communitydoc13 said:
Just make your volumes smaller, reduce toxicity and you will be viewed favorably until recurrences happen.
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Exactly. The focus from these people is making sure that nothing bad happens on treatment.

Undertreating anything that involves significant acute tox: H&N, anal, vulvar, even breast. They did great on treatment! Couple years later... recurrence.

On the flip side late tox isn't your problem, if you re-irradiate bowel for the third time, they won't die on treatment. In fact, their post-treatment PET will look great. Good job! 6 months later, grade 4-5 late tox. Chemo probably did that.
 
RickyScott said:
lets say you gave sham radiation for early stage breast- did not turn the machine on- do you think referrers would notice? not likely- hormones would push back the failures 5 years and only 5-10% of pts fail.
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They'd notice the amazingly non toxic regimen you have and referrals would go up.. I've already learned this lesson in rural radonc.
 
Moonbeams said:
When their gyn patients keep having bowel obstructions and necrosis and die even the not so sharp ones will start asking questions and figure it out. Oh, SBRTing a para-aortic node twice after prior paraaortic radiation isn't normal? And given enough time, when the early stage breast patients keep having local recurrences. And eventually they will get curious enough to want to look at the plans and ask questions. Wait, you are supposed to flash the skin? What's the point of blocking air? The medial blocks are set before the ribs? Shouldn't we have a little "wiggle room"? Hmm, those are good questions

(this is what happens when you take someone trained before the CT era and apply the Dunning kruger effect. They think what is drawn on the CT is exactly what will happen - very dangerous rad oncs out there who think like this and would be better off practicing 2D rad onc, forget IMRT and SBRT). Maybe the ABR, could like, address this somehow instead of focusing on young rad oncs with 270 USMLE steps for being dangerous due to lack of intricate rad bio knowledge?

Gyn onc will probably be able to appreciate the difference of a rad onc who takes the time to do image based planning each fraction vs. one who does point based planning fraction 1 and repeats as they surely trained in centers where only the former was done. If there is no gyn onc, med onc will need more egregious behavior like the above especially if that is what they are historically used to.
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It’s hard to be ****ty in this day and age considering you can obtain most modern protocols via a google search. Yes yes I know that boomers won’t but they are dying out and being replaced
 
Moonbeams said:
When their gyn patients keep having bowel obstructions and necrosis and die even the not so sharp ones will start asking questions and figure it out. Oh, SBRTing a para-aortic node twice after prior paraaortic radiation isn't normal? And given enough time, when the early stage breast patients keep having local recurrences. And eventually they will get curious enough to want to look at the plans and ask questions. Wait, you are supposed to flash the skin? What's the point of blocking air? The medial blocks are set before the ribs? Shouldn't we have a little "wiggle room"? Hmm, those are good questions

(this is what happens when you take someone trained before the CT era and apply the Dunning kruger effect. They think what is drawn on the CT is exactly what will happen - very dangerous rad oncs out there who think like this and would be better off practicing 2D rad onc, forget IMRT and SBRT). Maybe the ABR, could like, address this somehow instead of focusing on young rad oncs with 270 USMLE steps for being dangerous due to lack of intricate rad bio knowledge?

Gyn onc will probably be able to appreciate the difference of a rad onc who takes the time to do image based planning each fraction vs. one who does point based planning fraction 1 and repeats as they surely trained in centers where only the former was done. If there is no gyn onc, med onc will need more egregious behavior like the above especially if that is what they are historically used to.
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Not sure who you are working with or what expected differences are between techniques, but this is not jiving with my experience. At least in the external beam world.

That a non-radonc in the community would ask to review a plan is almost laughable to me. Hasn't happened in 10+ years and if it did, I would be able to snowball anyone who wasn't going to put hours into thinking about these things. Your thoughts above are the product of years of training.

I guess I haven't seen the egregiously bad in terms of docs, but I have seen bad outcomes with good plans.

While there is a difference between IMRT pelvis (eg post-op endometrial) and 3D, its not that big of a difference and in certain circumstances it may be negligible. Unless a gyn-onc is seeing patients on treatment (which I would discourage), they are unlikely to pick up the difference.

Laryngeal edema for OP patients? Yes, this I buy. A contemporarily trained radonc will have very little laryngeal edema exempting the most advanced BOT cancers. I have seen historical cases with very bad laryngeal or hypopharyngeal/upper esophageal toxicity. Again, usually a late effect.

A good vs bad brachytherapist? This is much more likely to declare itself. (Or it should, how long did it take for the UPENN VA doc to be exposed?)
 
communitydoc13 said:
Not sure who you are working with or what expected differences are between techniques, but this is not jiving with my experience. At least in the external beam world.

That a non-radonc in the community would ask to review a plan is almost laughable to me. Hasn't happened in 10+ years and if it did, I would be able to snowball anyone who wasn't going to put hours into thinking about these things. Your thoughts above are the product of years of training.

I guess I haven't seen the egregiously bad in terms of docs, but I have seen bad outcomes with good plans.

While there is a difference between IMRT pelvis (eg post-op endometrial) and 3D, its not that big of a difference and in certain circumstances it may be negligible. Unless a gyn-onc is seeing patients on treatment (which I would discourage), they are unlikely to pick up the difference.

Laryngeal edema for OP patients? Yes, this I buy. A contemporarily trained radonc will have very little laryngeal edema exempting the most advanced BOT cancers. I have seen historical cases with very bad laryngeal or hypopharyngeal/upper esophageal toxicity. Again, usually a late effect.

A good vs bad brachytherapist? This is much more likely to declare itself.
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I'm not sure what you are trying to say. Yes, I have witnessed med onc who had a bad outcome with a patient want to do a deep dive M&M style meeting on the radiation plans. I believe that it hasn't happened to you.

With regards to the bad outcomes from gyn patients, I wasn't really talking about IMRT vs 3D. 3D has a little worse acute tox in my experience, but outcomes are fine. So you're not a bad rad onc if you treat pelvis 3D for gyn cases, I wasn't saying that. In fact, I was saying that I wish these guys would. The issue is undertreating with IMRT (not covering nodes adequately - I'm talking about stupid stuff about not giving anywhere close to adequate margin around the vessels, not covering commons let alone P-As, not making ITVs to account for bladder filling, etc), and inappropriately re-irradiating the locoregional failures when they occur causing severe late tox.
 
Moonbeams said:
and inappropriately re-irradiating the locoregional failures when they occur causing severe late tox.
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Got ya.

I have seen this behavior (very small initial volumes with high re-irradiation rates in clinic) by an academic H&N specialist. I believe they are still employed at brand name academic institution.
 
RealSimulD said:
I don’t think most practices do internal assessments. This alone puts your group in great standing.
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I would point to ACR/ACRO/ASTRO accreditation paired with CoC accreditation.

There are extensive surgical data suggesting a correlation between volume and quality. Also a correlation between surgical speed and complication rates.


This is where SDN can have an impact on shaping narrative. If the narrative is controlled by academia or Big Rad Onc, the focus will be on site-specific volumes and experience because this favors them. Total volume would place the busy generalist Little Rad Onc in a much more favorable light.
 
theradiator said:
I would point to ACR/ACRO/ASTRO accreditation paired with CoC accreditation.

There are extensive surgical data suggesting a correlation between volume and quality. Also a correlation between surgical speed and complication rates.


This is where SDN can have an impact on shaping narrative. If the narrative is controlled by academia or Big Rad Onc, the focus will be on site-specific volumes and experience because this favors them. Total volume would place the busy generalist Little Rad Onc in a much more favorable light.
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I just went through ACR accreditation and tweeted about the experience. They actively do not engage in clinical quality assessment. If you gave 100 Gy / 100 Fx, as long as you had a sim order, a written directive and a treatment summary, that would be passing.
 
Ray D. Ayshun said:
They'd notice the amazingly non toxic regimen you have and referrals would go up.. I've already learned this lesson in rural radonc.
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Bingo... breast patients be asking for me by name here. 🙂

Also, failure to control disease.

That is... if they have something to compare it to.
 
dieABRdie said:
I wonder if maybe they *WERE* a full professor at an academic institution....

I know of at least two of them. The last reviewer I spoke with admitted they would be unemployed if it were not for Optum.
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I can confirm an active faculty member at a major place has been my Evicore reviewer within the past 2 years. May be same person referred to above.
 
fiji128 said:
You can always argue this and that and what abouts. But ents and gyn oncs will definitely note abnormal outcomes and recurrences pretty quickly even in the community. Ya, no way to tell if you are only getting one patient a year from these services.
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Yep... If you stay in one place long enough, people figure out who hands out extra toxicity and recurrences.
 
communitydoc13 said:
I can confirm an active faculty member at a major place has been my Evicore reviewer within the past 2 years. May be same person referred to above.
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Yes, I confirmed mine as well. I would like to think a chair would fire anybody who did this, whether during business hours using university IT resources or at home on their own time. Most contracts forbid outside medical work and often any work at all without corporate approval, so presumably the chair signed off on this, which is insane.
 
dieABRdie said:
I wonder if maybe they *WERE* a full professor at an academic institution....

I know of at least two of them. The last reviewer I spoke with admitted they would be unemployed if it were not for Optum.
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Is any of this public information. i.e. a website that lists who are on these panels ? A quick search did not turn up anything. I dont recall having any academic P2P reviewers but I generally dont bother looking up the reviewer either.
 
Man I don’t know ..

At 10 years, the recurrence rate for early stage low risk breast cancer is 1-2%. Grade 2 toxicity is quite low these days.

If someone was terrible and recurrence rates and toxicity was 50% higher, it would take a decade or more to have some certainty that there is a difference between providers.

Brachy for cervical is probably one of those where we could figure out a “quality” measure, but same problem.
 
radiaterMike said:
Is any of this public information. i.e. a website that lists who are on these panels ? A quick search did not turn up anything. I dont recall having any academic P2P reviewers but I generally dont bother looking up the reviewer either.
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I don’t know that the chair would sign off!!

I think that it’s a “forgiveness/permission” scenario
 
RealSimulD said:
Man I don’t know ..

At 10 years, the recurrence rate for early stage low risk breast cancer is 1-2%. Grade 2 toxicity is quite low these days.

If someone was terrible and recurrence rates and toxicity was 50% higher, it would take a decade or more to have some certainty that there is a difference between providers.

Brachy for cervical is probably one of those where we could figure out a “quality” measure, but same problem.
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Harder in breast i think vs skin/h&n/anal/cervix, maybe even prostate, other than the obvious 6+ weeks for N0 post-lumpectomy breast, which, even then, you get boomer surgeon and boomer rad onc and no one cares
 
RealSimulD said:
I don’t know that the chair would sign off!!

I think that it’s a “forgiveness/permission” scenario
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I feel 99% confident that if the chair at my residency found out a junior faculty member was secretly doing evicore reviews on the side to juice their income, there would be no forgiveness and they would be looking for a new job immediately. Sadly I know not all chairs are as ethical.

I also don't see how you could keep it a secret for long. Presumably anywhere this is occurring, the chair/admin is aware and is tolerating it.
 
theradiator said:
This is where SDN can have an impact on shaping narrative. If the narrative is controlled by academia or Big Rad Onc, the focus will be on site-specific volumes and experience because this favors them. Total volume would place the busy generalist Little Rad Onc in a much more favorable light.
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We should just have like, you know, a network of places that we know are "safe" to send patients for high quality radiation therapy. This would really help for those times when a Big Rad Onc feels kind of bad patients have travelled very far to get care that is offered closer to home, but isn't sure it is safe out there at Little Rad Onc Cancer Center.

We could start with palliative treatments since they are simple and it's easy to pontificate on what makes for high quality. You don't even have to hold your nose that high in the air.

We should really write this idea up in a letter, who is in?
 
NotMattSpraker said:
We should just have like, you know, a network of places that we know are "safe" to send patients for high quality radiation therapy. This would really help for those times when a Big Rad Onc feels kind of bad patients have travelled very far to get care that is offered closer to home, but isn't sure it is safe out there at Little Rad Onc Cancer Center.

We could start with palliative treatments since they are simple and it's easy to pontificate on what makes for high quality. You don't even have to hold your nose that high in the air.

We should really write this idea up in a letter, who is in?
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I honestly thought that arrogance would change after 10 years of a high selectivity and it did not budge.
 
RealSimulD said:
Worse now
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What else do they have? They make less money than pp docs (in some cases an order of magnitude less) and aren't exactly doing Earth-shattering research that's moving the field in any appreciable way. Might as well be arrogant. No other benefit to being an academic radonc from what I can tell.
 
OTN said:
What else do they have? They make less money than pp docs (in some cases an order of magnitude less) and aren't exactly doing Earth-shattering research that's moving the field in any appreciable way. Might as well be arrogant. No other benefit to being an academic radonc from what I can tell.
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From what I can tell even being “faculty” is nonsense as everyone is monster “academic” mega health system is in fact “faculty”. Which also dilutes the brand.

The fact that idiots like this are arrogant makes me laugh. They are enthusiastically being exploited by their employer to an ever increasing extent. I do however admire the mental gymnastics these people will do to convince themselves they are actually in a very good position.

What exactly are you trying to convince of You’re somehow superior at getting a bad deal? That’s it’s not about money but the pursuit of research…that would be convincing if by and large RO had a progressive research program (it’s largely does not). Also how morally superior can you be when you open up proton centers
 
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RealSimulD said:
Worse now
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Nailed it.

Now the emperor truly has no clothes and you have the Dr Olivers and Dr Potters of the field gaslighting us about the need to pivot to dei (to keep 200 spots matched per year!!), or how the most recent entering class was the most dedicated he'd ever seen to the specialty etc, while even places like Emory are soaping warm bodies at this point
 
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medgator said:
Nailed it.

Now the emperor truly has no clothes and you have the Dr Olivers and Dr Potters of the field gaslighting us about the need to pivot to dei, or how the most recent entering class was the most dedicated he'd ever seen to the specialty etc, while even places like Emory are soaping warm bodies at this point
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I don’t blame them. For almost 2M a year? Most people would piss on your head and tell you it’s raining!
 
sirspamalot said:
Academic chairs are making 2M while their arrogant peons make 500k ? Lulz.
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Lmk where those peons are and I’ll gladly join. Peons are essentially at 275K in desirable areas which their predecessors 15 years ago were getting. Why these people haven’t burned the place down or commuted ritual suicide remains a mystery.
 
sirspamalot said:
They must be on the drug known as institutional pride. Or, they are so interpersonally deficient they know they cannot survive in private practice. I know a guy who fits this to a T. Schmuck!
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In the end, the institution will always f you. As medstudent, saw this happen to guys who had been very prominent in their day.
 
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