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NotMattSpraker said:
This is exploitation because you could easily hire a true junior faculty and train them on the clinical use of the Viewray while they work. It could likely be done in one or a few days. This is how every single non-resident clinician who is "proficient" on Viewray has been trained to date.

Viewray and UCLA are free to spend their money however they like, but it's easy to think of many other ways this money could be used in more productive ways. Funding an advanced therapist to improve the workflow or a clinical trial are good examples.

Certainly I can see the upside of funding a training position for the company. It's not like they are charitably making MRgRT education better.
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I see industry-funded faculty and staff positions in RadOnc as a form of kickback. "We buy a bunch of machines, you help us hire some fellows and physicists". Win-win for UCLA and Viewray, but society pays and RadOnc oversupply worsens
 
NotMattSpraker said:
I watched admins blame physicians outright and implement one of the most disastrous policies I've ever seen to "penalize" physicians that contoured "slowly".
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To be fair, at some point physicians need to be accountable to get their work done and not put increased pressure on the rest of the workflow to make up for their slowness. We are dealing with this at some of our clinics now where some MDs will get contours done within a day or two which gives dosimetry/physics ~1 week to get a plan done, approved, and QA'd. Others will take 4-5 days to get contours done and then expect a plan and QA to be done within an afternoon so the patient can start the following day.
 
HolySmokes said:
To be fair, at some point physicians need to be accountable to get their work done and not put increased pressure on the rest of the workflow to make up for their slowness. We are dealing with this at some of our clinics now where some MDs will get contours done within a day or two which gives dosimetry/physics ~1 week to get a plan done, approved, and QA'd. Others will take 4-5 days to get contours done and then expect a plan and QA to be done within an afternoon so the patient can start the following day.
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There needs to be set aside a time block for contouring like the OR. Rad oncs don’t have as much clinical assistance as in other fields with a PA or nursing who can help decrease some of the work load. Add in tumor boards, multi-d clinics, and “personalized medicine” to every single patient. Not to mention, we are constantly interrupted and have to await for the images to be fused or sometimes other people to contour first (residents, dosimitrist students, physics, etc).

I’m not saying that there aren’t inefficient docs out there but as someone who always tries to get all my work done before I leave, there’s a lot that goes on behind the scenes and not everyone has the luxury to be able to contour plans during normal business hours or have uninterrupted time at our desk to focus on the plan. This is why I made sure to block out time for contouring in my day at my new job. Admin gave me hell, but I stayed firm and reminded them that it is the most important part of my job and should be valued.
 
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NotMattSpraker said:
I dont think the surgical data can be ported over to Rad Onc for many reasons. Probably most important is that the final "quality" relies on a whole team of people, not the dexterity of one surgeon and a small number of recovery physicians/nurses. A lot of people probably assume "the craft" means contouring as its an easy analogy to operating, but Id argue a skilled rad onc needs to do a lot more than define targets and OARs. Or maybe not. Our field has done a very poor job of defining quality. The quality efforts of ASTRO compared to the American College of Surgeons is a complete joke.

Sometimes people incorrectly look at timing of the end to end RO workflow and incorrectly identify contouring as the "most inefficient" because it takes the longest. I've seen this declared in two different clinics. In one of them, I watched admins blame physicians outright and implement one of the most disastrous policies I've ever seen to "penalize" physicians that contoured "slowly". Considering we all work in healthcare, it is a feat to hold the crown of most disastrous policy.

Too bad the case mix has a huge impact on contouring speed and contouring is an activity that many don't block time to do, so it is impacted by your clinical schedule as well. Busy physicians doing complex cases might have the most skill, but if you pick the wrong metric they are deemed inefficient. Ridiculous.

My guess is many self-proclaimed disease site experts actually carry very few cases because they hold <80% clinical appointments. Are they skilled? If not, how can one be an unskilled expert in a technical field?

I agree with your opinion, but would love data here because I dont think anyone is making a good faith argument on this topic out in the real world. The only people that have ever told me it's important to be busy in order to be a good Rad Onc are people that directly or indirectly benefitted from me taking on a big case load.

If you believe the data, were all getting less busy over time as well. Is the entire field becoming less skilled?

Important questions.
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Nice post. I would define radiation oncology skill much more broadly than contouring alone to include everything that might help the patient and help the department run effectively.

This includes how to speak to patients, how to interact with referring physicians and administration, judgement, appropriate use of outside tools and resources to aid decision making, personally reviewing images and fusions, etc.

I agree that no one has isolated what factors contribute to success and in what percentage. Also, likely highly context specific. Much work has been done on improving and standardizing contouring but not the other factors.
 
HolySmokes said:
To be fair, at some point physicians need to be accountable to get their work done and not put increased pressure on the rest of the workflow to make up for their slowness. We are dealing with this at some of our clinics now where some MDs will get contours done within a day or two which gives dosimetry/physics ~1 week to get a plan done, approved, and QA'd. Others will take 4-5 days to get contours done and then expect a plan and QA to be done within an afternoon so the patient can start the following day.
Click to expand...

Fair point, but you need to look deeper than just the.number of hours it takes for a doctor to go from sim to contours approved. There are many reasons this could be happening... the doctor could be objectively slow, or maybe the workflow sucks. Maybe they have software UI issues.

Or is it that they are over scheduled? We have so many activities and daily interruptions that are not charted and therefore do not exist to ignorant admin types. I suspect this is one of the most common causes.

The "slow" doctors in the dumpster fire clinic where I used to work were not "slow", they were over scheduled beyond belief and were skipping lunch to get through clinic plus contouring on nights and weekends. On QI meetings, we'd point out that they were over scheduled and it was completely ignored. Triaging or managing volumes were out of the question. Totally not surprising this remains a problem (or so I hear). Keep whipping that workhorse and see what happens. We all know.

It's making me angry just thinking about it.

This sounds nit picky, but I suspect the majority of rad oncs, especially current junior faculty who graduated at peak competitiveness, are not lazy but instead exploited. It should be enraging to all of us that doctors are needled about "clinical efficiency" while we are all working in this current system.

Anyway, the lazy approach is to call the doctor slow and yell at them to be faster or penalize them in some way. That said, telling an admin their approach is lazy is not super successful in my experience either. 🤣
 
NotMattSpraker said:
Fair point, but you need to look deeper than just the.number of hours it takes for a doctor to go from sim to contours approved. There are many reasons this could be happening... the doctor could be objectively slow, or maybe the workflow sucks. Maybe they have software UI issues.

Or is it that they are over scheduled? We have so many activities and daily interruptions that are not charted and therefore do not exist to ignorant admin types. I suspect this is one of the most common causes.

The "slow" doctors in the dumpster fire clinic where I used to work were not "slow", they were over scheduled beyond belief and were skipping lunch to get through clinic plus contouring on nights and weekends. On QI meetings, we'd point out that they were over scheduled and it was completely ignored. Triaging or managing volumes were out of the question. Totally not surprising this remains a problem (or so I hear). Keep whipping that workhorse and see what happens. We all know.

It's making me angry just thinking about it.

This sounds nit picky, but I suspect the majority of rad oncs, especially current junior faculty who graduated at peak competitiveness, are not lazy but instead exploited. It should be enraging to all of us that doctors are needled about "clinical efficiency" while we are all working in this current system.

Anyway, the lazy approach is to call the doctor slow and yell at them to be faster or penalize them in some way. That said, telling an admin their approach is lazy is not super successful in my experience either. 🤣
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where I am at now - we block out time for each sim. Typically an hour, though this can be double booked sometimes if things get busy. This encompasses a fu visit if needed to review consent, physically be present at sim if needed for marks or reviewing scan, and then ideally to contour. I contour in the sim sometimes. If you need a fusion, then obviously you can't. I do like this setup because it acknowledges that sim/contour/planning take time. You can have a day with 8 sims and 0 consults/fu/otv...and you best believe that is a busy day and requires time. Nice to have it reflected on the schedule.

This was very different from where I trained where sim schedule was completely independent of clinic schedule.

edit: I'm in PP, so my "boss" or "admin" is my senior partner who carries more patients than I do as a new grad...
 
grenz said:


De-escalated 60Gy +cis arm inferior interim analysis. Nivo arm continues. Shocked and disappointed by this development.
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I have experienced significant pressure (nothing pathologic, just a "this is how we'd do it") from larger places to de-escalate HPV positive OP. Glad that we have not capitulated to date.
 
communitydoc13 said:
I have experienced significant pressure (nothing pathologic, just a "this is how we'd do it") from larger places to de-escalate HPV positive OP. Glad that we have not capitulated to date.
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I used to get pressure from the dip**** ENT Tors cowboys who woild
Lie to patients about needing RT and then when PNI or LVI showed up on the path report they were like you better ****ing give them less dose…
 
Fpg1245 said:
I used to get pressure from the dip**** ENT Tors cowboys who woild
Lie to patients about needing RT and then when PNI or LVI showed up on the path report they were like you better ****ing give them less dose…
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Or they flat out ignore massive nodes/ece and say no role for post op concurrent chemo since the studies didn't break down hpv+ patients back in the day, knowing full well trimodality treatment is terrible for these patients and they should have never had tors to begin with
 
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RickyScott said:
pubmed.ncbi.nlm.nih.gov

Osteoradionecrosis of the Jaw Following Proton Radiation Therapy for Patients With Head and Neck Cancer - PubMed

In this case series, the prevalence of ORN following PRT was found to be 10.6%, indicating that ORN remains a clinical challenge even in the era of highly conformal PRT. Clinicians treating patients with OOPC with PRT should be mindful of this complication.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
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Henning Willers implying previously we just haven't seen signals of excessive toxicity with protons…

*ignores breast rib fractures, breast reconstruction toxicity, peds brainstem enhancement, mandible necrosis, etc*

Add this to the list.

I still think we can find a benefit for some patients with protons but come on…signals are there you better be very careful with high doses around critical structures.

 
grenz said:


De-escalated 60Gy +cis arm inferior interim analysis. Nivo arm continues. Shocked and disappointed by this development.
Click to expand...

I recall people saying, they were already treating with lower doses with cis, given the favorable results of the Phase II trial.
forums.studentdoctor.net

E3311 Results, TORS and reduced postoperative RT dose in Intermediate Risk HPV+ OPC

In JCO this week. https://ascopubs.org/doi/abs/10.1200/JCO.21.01752 Basically T1-2 HPV+ OPC SSC resected to negative or
forums.studentdoctor.net forums.studentdoctor.net

Once again, a reminder that favorable Phase II trial results do not translate into favorable Phase III trial results.
 
Palex80 said:
I recall people saying, they were already treating with lower doses with cis, given the favorable results of the Phase II trial.
forums.studentdoctor.net

E3311 Results, TORS and reduced postoperative RT dose in Intermediate Risk HPV+ OPC

In JCO this week. https://ascopubs.org/doi/abs/10.1200/JCO.21.01752 Basically T1-2 HPV+ OPC SSC resected to negative or
forums.studentdoctor.net forums.studentdoctor.net

Once again, a reminder that favorable Phase II trial results do not translate into favorable Phase III trial results.
Click to expand...
Borderline malpractice imo if those pts gets a recurrence. Terrible salvage
 
Palex80 said:
I recall people saying, they were already treating with lower doses with cis, given the favorable results of the Phase II trial.
forums.studentdoctor.net

E3311 Results, TORS and reduced postoperative RT dose in Intermediate Risk HPV+ OPC

In JCO this week. https://ascopubs.org/doi/abs/10.1200/JCO.21.01752 Basically T1-2 HPV+ OPC SSC resected to negative or
forums.studentdoctor.net forums.studentdoctor.net

Once again, a reminder that favorable Phase II trial results do not translate into favorable Phase III trial results.
Click to expand...
For randomized phase 2 trials, outcomes are about as predictive as chance when it comes to subsequent phase 3
 
Fpg1245 said:
These people should be hauled out of their homes and put up against the wall.
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friday ice GIF
 
medgator said:


ASTRO gonna ASTRO
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pikachu said:
Don’t forget about the submission fees for astro abstract not to mention the “video poster” grift where the cost to produce a poster now goes straight to astro and each authors poster is only visible for the allocated 5 minutes rather than standard 2-ish hours to browse and discuss. Shah is right on in calling this out.
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Post has aged well if I do say so myself
 
BobbyHeenan said:
Henning Willers implying previously we just haven't seen signals of excessive toxicity with protons…

*ignores breast rib fractures, breast reconstruction toxicity, peds brainstem enhancement, mandible necrosis, etc*

Add this to the list.

I still think we can find a benefit for some patients with protons but come on…signals are there you better be very careful with high doses around critical structures.

Click to expand...

Or actually model the LET/RBE, which seems like almost nobody does.
 
communitydoc13 said:
I have experienced significant pressure (nothing pathologic, just a "this is how we'd do it") from larger places to de-escalate HPV positive OP. Glad that we have not capitulated to date.
Click to expand...

Stark reminder that not all ph II data is ready for prime time. I wasn't enthusiastic for it a year ago.... do I put more stock in a randomized ph II instead for TORS for 50 vs 60?

NotMattSpraker said:
Fair point, but you need to look deeper than just the.number of hours it takes for a doctor to go from sim to contours approved. There are many reasons this could be happening... the doctor could be objectively slow, or maybe the workflow sucks. Maybe they have software UI issues.

Or is it that they are over scheduled? We have so many activities and daily interruptions that are not charted and therefore do not exist to ignorant admin types. I suspect this is one of the most common causes.

The "slow" doctors in the dumpster fire clinic where I used to work were not "slow", they were over scheduled beyond belief and were skipping lunch to get through clinic plus contouring on nights and weekends. On QI meetings, we'd point out that they were over scheduled and it was completely ignored. Triaging or managing volumes were out of the question. Totally not surprising this remains a problem (or so I hear). Keep whipping that workhorse and see what happens. We all know.

It's making me angry just thinking about it.

This sounds nit picky, but I suspect the majority of rad oncs, especially current junior faculty who graduated at peak competitiveness, are not lazy but instead exploited. It should be enraging to all of us that doctors are needled about "clinical efficiency" while we are all working in this current system.

Anyway, the lazy approach is to call the doctor slow and yell at them to be faster or penalize them in some way. That said, telling an admin their approach is lazy is not super successful in my experience either. 🤣
Click to expand...

There are certainly lots of Rad Oncs at workhorse PP or academic locations that are overworked.

There are also at least a few Rad Oncs who maybe aren't as quick and high quality with their contours.

Not all that is slow is lazy. Not all that is slow is overworked.
 
evilbooyaa said:
Stark reminder that not all ph II data is ready for prime time. I wasn't enthusiastic for it a year ago.... do I put more stock in a randomized ph II instead for TORS for 50 vs 60?



There are certainly lots of Rad Oncs at workhorse PP or academic locations that are overworked.

There are also at least a few Rad Oncs who maybe aren't as quick and high quality with their contours.

Not all that is slow is lazy. Not all that is slow is overworked.
Click to expand...
Sometimes with contouring, you may not have everything you need after the sim to deliver the contour. Could be waiting on an mri/pet or something else. I have simmed pts, looked at the volume and said “I think I really should get an mri.” Etc.
 
RickyScott said:
Sometimes with contouring, you may not have everything you need after the sim to deliver the contour. Could be waiting on an mri/pet or something else. I have simmed pts, looked at the volume and said “I think I really should get an mri.” Etc.
Click to expand...
Big issue for us with srs needing outside MRI. CD has to sent via courier or mail
 
Penn TORS people have always been on the omission side, so I would just ignore his opinion
 
radoncftw said:
Our program used to take us out to lunch.
Of course it was not truly protected - so 1/3 of the residents were either seeing inpatients or on busy services stuck in clinic.
Click to expand...
Now, you get a Tweet!
 
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