rad oncs true role? future residency changes?

[asdf13]

I have two related questions:
1. What is the true unique contribution of a radonc that either hem/onc or rads couldn't do with a bit more training?
2. For this reason, I have heard vague talks about potentially combining the rad onc residency with hem/onc or with rads in the future...anyone know more about this?

My own thoughts and analysis from talking to others are as follows:
For one, the hem/onc's have the same understanding of clinical oncology as the rad oncs (both have mastery over the onc literature), and from what I've seen a good hem/onc knows when to refer a pt for radiation - by the time they get to the rad onc, they are mostly worked up fully so the radonc simply decided whether RT is necessary and where to treat. Second, this leads to the treatment planning aspect of rad onc, which relies heavily on looking at CTs/MRs/PETs to select structures to treat and spare. It seems that a radiologist would be better at this since that is their job, and they are the ones who are making the radiologic diagnosis to begin with - I would trust a radiologist over a rad onc anyday to find crucial lymph nodes that need to be in treated in the field. Radiologists have a great understanding of medicine and disease processes, which they often don't get as much credit for, so I think they'd be able to understand how to treat a given cancer - ie what fields to use. Finally, the treatment planning calculations are done by physicists/dosimetrists, which the rad onc then signs off on - this is a simplification, but true in many ways, it's not like the radoncs are doing IMRTs calculations or anything really technical. The question then that many have is what exactly the rad onc's true role is in all of this for the patient? What unique information or skill do they really bring to the table that someone else (hemonc or rads) couldn't do better with some extra training?

I argue (and so do others) that either the hemonc's (who know as much or more onc as the radonc) or the radiologists (who know the most about imaging, esp considering all treatment planning is heading towards using sophisticated cross sect imaging rather than the old days of plain film) could get extra training in radonc and do a better job, and also streamline the whole line of care for a patient.

Lastly, one day when chemo gets better, radiation may be less used, and there might not be a need for a separate profession. In that case, one attending has even told me that the rad oncs would prob have to do another residency in either hem/onc or rads anyway!

With all of this in mind, does anyone know when or if this combination will occur? Also, any general thoughts on the matter or issues I raised above? Thanks....

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[deleted4401]

If you are a medical student, I forgive you for not knowing what you are talking about. If you're a hem-onc fellow or radiology resident ... well, you have got to be kidding me!

A few points to address ... in this era, I'd say it is unlikely that a med-onc has a greater mastery of oncology in general and it is also unlikely that have has much knowledge of the literature. It's a matter of training - medoncs are internists with 3 years of additional training in hematology AND oncology (which may include 1 year of research), while rad-onc is 4 years of training in oncology alone (no hemophilia or anemia or Leiden disease or whatever). Which means there are med-oncs that may have only 1 year of clinical oncology training, and I'm hard pressed to believe they know as much as a rad-onc that has had a minimum of 3 years of clinical onc training.

As far as radiologists, of course they are better at diagnostics. In their four year training period after internship, they focus solely on dx. But, they are definitely not oncologists and they have almost no training on the radiobiology that matters for therapeutics. Most do not know the indications of RT. Radiology is an incredibly broad specialty and because the training is so rigorous, they hardly have time to truly learn onc. They also are not actively involved in patient care, and they would have difficulty managing the toxicity of radiation treatment. They also may have difficulty (and lack of interest) in the difficult discussions with cancer patients/end of life issues, with palliative care, and in general with anything involving a real live patient. The last thing they want to do is leave the reading room and talk about death with a sick patient.

The argument about improved chemotherapy has the exact opposite end result. If the chemo works better, local control becomes more important and RT will play an even greater role.

As for what radiation oncologists contribute, I'll let you read the FAQ on the forum, but it is quite clear that there is absolutely no way that a med-onc or radiologist would be able to be an effective rad-onc in modern times (nor would most want to). I will say that in developing countries or even the US ca. 1960s, the fields could be combined, but it would not make any sense in present times.

Do a rotation ... you'll see that the idea of a med onc using RT is sort of like a endocrinologist doing colonoscopies ... Probably could do it, but wouldn't like it and would do a ****ty job.

-S

 

[Pewl]

If you are a medical student, I forgive you for not knowing what you are talking about. If you're a hem-onc fellow or radiology resident ... well, you have got to be kidding me!

A few points to address ... in this era, I'd say it is unlikely that a med-onc has a greater mastery of oncology in general and it is also unlikely that have has much knowledge of the literature. It's a matter of training - medoncs are internists with 3 years of additional training in hematology AND oncology (which may include 1 year of research), while rad-onc is 4 years of training in oncology alone (no hemophilia or anemia or Leiden disease or whatever). Which means there are med-oncs that may have only 1 year of clinical oncology training, and I'm hard pressed to believe they know as much as a rad-onc that has had a minimum of 3 years of clinical onc training.

As far as radiologists, of course they are better at diagnostics. In their four year training period after internship, they focus solely on dx. But, they are definitely not oncologists and they have almost no training on the radiobiology that matters for therapeutics. Most do not know the indications of RT. Radiology is an incredibly broad specialty and because the training is so rigorous, they hardly have time to truly learn onc. They also are not actively involved in patient care, and they would have difficulty managing the toxicity of radiation treatment. They also may have difficulty (and lack of interest) in the difficult discussions with cancer patients/end of life issues, with palliative care, and in general with anything involving a real live patient. The last thing they want to do is leave the reading room and talk about death with a sick patient.

The argument about improved chemotherapy has the exact opposite end result. If the chemo works better, local control becomes more important and RT will play an even greater role.

As for what radiation oncologists contribute, I'll let you read the FAQ on the forum, but it is quite clear that there is absolutely no way that a med-onc or radiologist would be able to be an effective rad-onc in modern times (nor would most want to). I will say that in developing countries or even the US ca. 1960s, the fields could be combined, but it would not make any sense in present times.

Do a rotation ... you'll see that the idea of a med onc using RT is sort of like a endocrinologist doing colonoscopies ... Probably could do it, but wouldn't like it and would do a ****ty job.

-S

`Atta boy, stick it to them!

 

[Brim]

Ditto what Simul said!

 

[G'ville Nole]

Well, sounds like the OP has resolved his/her "rads vs. rad onc" dilemma...

Best of luck to you in your career choice!

 

[radiaterMike]

while I agree with Simul, in some countries, residents are trained as oncologists in both radiation oncology and medical oncology. Thus some radiation oncologists also deliver chemotherapy.

I of course interpret this to mean that any radiation oncologist can learn to prescribe a cocktail of chemotherapy and manage chemotherapy toxicity with dose reductions and/or more drugs. If the ideal drug is developed, with high efficacy and minimal to no toxcity, why not have radiation oncologists prescribe these drugs.

and one extra comment that Simul did not address... radiologists are not trained in what regions need to be treated electively (i.e. while perhaps radiologists are more adept in identifying head and neck lymph node stations, they are not trained to know what lymph nodes stations are likely to harbor microscopic disease).

 

[ghgi8]

Agree with the above... I also feel strongly that a majority of the progress made in modern day medicine can be attributed to specialization and sub-specialization. We are creating an increasingly complex science to understand and practice. Most advances being made are compounded on prior discoveries within the same field. To propose such a merger of specialties would, in my opinion, be taking a step back in the wrong direction.

 

[stephew]

Actually, home team hostilities aside, it would be easier for a radonc to deliver chemo than the other way around. Raodncs are trained in onc for 4 years, and one internship year. Medoncs 2 years typically (or 3) and have an internal med background. In fact I personally several radoncs are ex-medoncs. (I know one radonc who went into medonc). The line that these converts to radonc give is "well I actually wanted to help my patients". Now that's a simplification and a joke obviously. No one in their right mind suggests that medonc isnt a field that uses great skill. but since you admit to using simplifications to make your point, i will trust you'll get it when i do too.

Now, while ANY oncologist can rise to whatever prominence in their knowledge base that they seek, radoncs tend to know the literature more. (not the other way round as you suggest). And radoncs treat by technique. Its a skill more akin to surgery than IM. Medoncs prescribe drugs (ie not technique oriented). Radoncs tend to know chemo and chemo doses. Medoncs tend not to know radonc doses or which different technologies are appropriate- and frankly i wouldnt say they need to.

Whatever "vague talk" about amalgamation you heard is either a misunderstanding, wishful thinking or ignorence, or any combo of the aforementioned. The fields are getting more and more specialized. As for radiology, there is zero connection to rads in this era. two totally separate fields in terms of what you do, what you need to know, and what your role is. no radiologist today could do radonc. In fact they couldnt even do the "therapeutic radiology" of 40 year ago. The irony is that even with in radonc we're getting more and more specialized. Though trained as generalists, many make careers in a narrow field. its that complex.

Your lack of understanding is actually quite common and Im not surprised that this is the result of your asking around if you've not asked any radoncs. youre just not asking the right people. Spend some time in radonc. youll realize:

1) full work up is only sometimes fully done before they get to us. Most often its the case in a multidisciplinary setting (ie not the typical setting) As a for instance, just this fri a pt was sent to me without workup. and they wanted me to treat. I had to obtain this and found some pretty important things that altered her therapy both in terms of what im doing and what the medonc should do. And this was from a very good referring center.


2) you downplay it, but the "where to treat" is the rub. To know the answer there are so many quesitons to ask. Path? Site? Stage? Primary? met? Surgery? mutlimodality? Margins? lymph nodes? LVI? histology? grade? Clips in? Normal structure? What technique? Dose? fractionation? hypofractionation? Radiobiol issues? what's more important: integral dose or conformality? Its not point and shoot. Common old school misconception. Outdated by a couple decades when that was the mode. Med onc can't make this decision.

3) neither can rads (see above).

rads can help looking at the RADIOLOGICAL findings. And SHOULD in many cases. but that's only part of it. so yes you'd be a fool not to use them. but so would med onc. they need to know if its metastatic or not and guess who helps them there? Its also like rads should do the surgery.

4) treatment planning: rad oncs also are involved in tx planning. Dosim. weights the fields, modifies the beams. But docs know what they want and how to get it there. We need planners, just like medonc needs pharmacists and radds needs technicians. That's the analogy.

You assumption about "one day when chemo gets better" has been going on since nixon's war on cancer. See the faq for why its fundamentally the wrong question. Its not sequential therapies ever marching onwards to the "best one". In fact by and large the most effective cyto reductive modality? you guess it! it aint chemo! (some exceptions)

It would be nice to have the magic bullet. Kill tumor. not good cells. but dont hold your breath. (BTW that elusive bullet might involve radiation and radonc should be doing that, i agree. Bad on radonc for not taking the reigns more there. Nuc med does a lot of that.)

In sum, whoever you've been talking seems rather outdated; those are the arguements of 25 years ago. the premise is so wrong its hard to know where to begin. As time goes on radonc is more and more complicated. What you've suggested is the equivilant to my suggestion that the nurse who hangs the chemo drugs should do the prescribing for medonc. After all isnt it merely calcs of area under the curve? mg/M2?

That's rhetoical; anyone would be ignorant to genuinely suggest that. What is unfortunate for radonc is that no one feels embarrassed about ignorance with regard to what the radiation oncologist does. For a student, fair enough. For the medonc etc who proudly forwards these views (and ive seen them), its just embarrassing. You want to see what radoncs do? Sit in on an academic chart rounds for a couple of weeks. youll see what goes into it, the challenges of the decision making, the nuances. You say you are interested in rads or radonc. Few actually think along those lines. The fields are so different. You need to do both and get a clue what's involved in each.

In the meanwhile, seek out GOOD people to talk to.

Just fri my neurosurgical colleague - recently stepped down from chairman-was saying how great it was we all work in a multidisciplinary way, that i can think like a neurosurgeon and he like a radiation oncologist. THAT is someone who gets it. You need to meet someone like that to have your conversations.

 

[deleted4401]

After reading this, I'm annoyed. Think this dude/girl was just trying to get a rise out of us. Succeeded...

But, I think Steph's fine response should be added to the FAQ.

-S

 

[stephew]

Siml, while that thought occured to me i figured that 1) either the user is sincere and we can help their education or 2) they were just trying to get a rise and the user is willfully ignorent, which, frankly, i wouldn't choose to advertise.

If the OP would like more info i would point them to a radiation oncologist who could well be a future dean at harvard, Dr. D'Amico. He is always happy to talk with any student thinking about the field.

 

[Radonc Or Bust]

Actually, home team hostilities aside, it would be easier for a radonc to deliver chemo than the other way around. Raodncs are trained in onc for 4 years, and one internship year. Medoncs 2 years typically (or 3) and have an internal med background. In fact I personally several radoncs are ex-medoncs. (I know one radonc who went into medonc). The line that these converts to radonc give is "well I actually wanted to help my patients". Now that's a simplification and a joke obviously. No one in their right mind suggests that medonc isnt a field that uses great skill. but since you admit to using simplifications to make your point, i will trust you'll get it when i do too.

Great post.

Not to drag the thread on, but I'm curious to hear your(or anyone else's) comments about rad oncs doing more med oncs. With the advent of oral chemo medications with less toxicity, do you see more radoncs getting in to medonc? Say the same that IM and FP have taken away much of what used to be the bread and butter for A&I with the newer meds?

I'm not asking about getting involved with peds chemo, or adult BMT, nothing too complex. But say oral drugs for solid tumors? I've talked to people who argue against this b/c most places don't give admitting privileges for radoncs (except for some simple stuff like brachy). Admitting means changing the "lifestyle" that radonc is so popular for.

 

[stephew]

no i dont. Med once will continue doing what they do, and they should. I could say for no other reason than radonc is an OP service. But even if it weren't, Med onc will be doing their thing. It takes 5 years to be a radiation oncologist, and 3 years of IM and 2 years of onc to be a medonc. What they do is complex and best left to them.

And A&I really hasn't changed so drastically. Claritin hasn't changed the picture so dramatically. true I is a complex field.

 

[Brim]

Great post.

Not to drag the thread on, but I'm curious to hear your(or anyone else's) comments about rad oncs doing more med oncs.

heh.

 

[stephew]

We'd (doctors in general) do very well to appreciate what it is other services do. A good surgeon is not merely a plumber. A good psychiatrist saves lives, minds, and ultimate quality of life and allows it to be meaningful. A good internist keeps us healthy and cures us when we're not. the pissing contests between fields is nothing more than a holdover of that which makes kids pick on others or compels red sox fans to chat "yankees suck" at a football game. You want to use that mentality in your professional setting? Be my guest but you only embarrass yourself.