• Livestream AMA: Join SDN as we welcome Dr. John Ligon, a Pediatric Oncologist with the National Cancer Institute on May 11th at 8:00 PM Eastern. Register now!

elementaryschooleconomics

Sharp Dissector of the Avascular Plane
Nov 2, 2019
1,137
4,499
Everyone's favorite Vinay Prasad just posted this on Twitter:

1602585975058.png

Here's the link to the article: LINK

For those who saw the thread on Twitter, he's talking about HemeOnc/Fellowships in Medicine in general, but a few of the regular anonymous RadOnc Twitter accounts joined in. There are 8 points he makes in the article on why extra fellowships are a problem - I think the points are incredibly germane to Radiation Oncology:

1) It won't stop with one year

2) Hospitals are taking the labor of fellows and money of fellows

3) Longer training keeps medicine a profession for kids of aristocrats. Some of us have to earn sooner in life.

4) More training means fewer women. Many of these fields already male-dominated.

5) Parental leave for fellows is an embarrassment.

6) The less we participate in these fellowships, the less chance they will become mandatory.

7) The alternative is training people on the job...which always happens eventually.

8) There is an irony in terms of who benefits and runs these fellowships, but did not attend them.

These eight points, I think, just succinctly nail everything that's wrong with this rise in unaccredited fellowships in RadOnc. This is personally extremely relevant to me, as a PGY-5 resident during the COVID/APM era. I have been groomed my entire career to follow an academic path. Once universities started to enact hiring freezes due to COVID, and the entire academic job market started to lock up, I asked senior faculty administration and mentors for advice. The only thing I was offered was "I guess you could do a post-doc or fellowship, it wouldn't hurt your career".

I fall squarely into point #3. I don't know if I technically meet the definition of "disadvantaged", but I was the first in my family to go to college, and am the primary income earner for my household. I have delayed getting a "real job" for many, many years, and my spouse and now kids have ridden that wave with me. I'm deep into my 30s at this point, how much more am I expected to sacrifice? Why do the people who have their jobs without doing extra training (point number 8) think recommending this to us is OK? Ironically, this advice immediately catalyzed me looking for a way out of academia.

As programs such as Moffitt's "Future of Radiation Therapy" fellowships start to materialize, how can anyone continue to argue this field is healthy? We're barrelling straight down Canada's path, where residents do cycle after cycle of fellowships, waiting for someone to retire so they can finally have a job. So maybe Moffitt is right - their fellowship is the future of RadOnc.
 
  • Like
  • Care
  • Angry
Reactions: 17 users

Grubbe-a-dub-dub

7+ Year Member
Oct 27, 2013
96
161
Status (Visible)
  1. Attending Physician
I agree with the blog post and commend him for calling out this predatory practice. Not much will change though...

The draw to do a fellowships for US grads in rad onc is real and will only continue.

I'll be real honest, I'm out from training with a decent job and I too have considered going back for a fellowship if for nothing else to be closer to friends and family. Money alone doesn't buy happiness... Fortunately I have an awesome spouse that quickly slapped some sense into me!
 
  • Like
  • Haha
Reactions: 3 users

thecarbonionangle

5+ Year Member
Aug 23, 2014
2,022
3,126
Status (Visible)
  1. Attending Physician
Absolutely do not take an exploitative “fellowship”. Take the highest paying job somewhere you can stomach and never look back. Your family is what matters and they need you making money. It will never end with one year, they will always want “just another year”.
 
  • Like
Reactions: 6 users
About the Ads

thecarbonionangle

5+ Year Member
Aug 23, 2014
2,022
3,126
Status (Visible)
  1. Attending Physician
I agree with the blog post and commend him for calling out this predatory practice. Not much will change though...

The draw to do a fellowships for US grads in rad onc is real and will only continue.

I'll be real honest, I'm out from training with a decent job and I too have considered going back for a fellowship if for nothing else to be closer to friends and family. Money alone doesn't buy happiness... Fortunately I have an awesome spouse that quickly slapped some sense into me!
The wife is always right man!
 
  • Like
Reactions: 3 users

Grubbe-a-dub-dub

7+ Year Member
Oct 27, 2013
96
161
Status (Visible)
  1. Attending Physician
Happy wife happy life.

But what if the job you can stomach doesn't exist? What if you really need or want to be in a particular area?

Even the locums market appears to be saturated or increasing their standards (I know nothing about locums so don't hate if I interpreted the situation incorrectly!).

Short of retraining in another field, there are very few alternatives for US grads but to pick from one of these unaccredited fellowships.
 
  • Like
Reactions: 1 users

BobbyHeenan

7+ Year Member
Mar 20, 2013
1,009
1,280
Status (Visible)
  1. Attending Physician
I'll add #9)

9) it hurts resident experience. When you have a brachy fellow, the resident doesn't get to do the case. The fellow does.

How did every brachy expert learn to be good at their job? By doing a ton of cases as ACTUAL FACULTY with normal attending pay. Why was it OK for them to learn on the job, but now we need fellows?
 
  • Like
  • Love
Reactions: 10 users

Ray D. Ayshun

SDN Bronze Donor
5+ Year Member
Sep 7, 2014
1,228
1,537
Everyone's favorite Vinay Prasad just posted this on Twitter:

View attachment 320364

Here's the link to the article: LINK

For those who saw the thread on Twitter, he's talking about HemeOnc/Fellowships in Medicine in general, but a few of the regular anonymous RadOnc Twitter accounts joined in. There are 8 points he makes in the article on why extra fellowships are a problem - I think the points are incredibly germane to Radiation Oncology:

1) It won't stop with one year

2) Hospitals are taking the labor of fellows and money of fellows

3) Longer training keeps medicine a profession for kids of aristocrats. Some of us have to earn sooner in life.

4) More training means fewer women. Many of these fields already male-dominated.

5) Parental leave for fellows is an embarrassment.

6) The less we participate in these fellowships, the less chance they will become mandatory.

7) The alternative is training people on the job...which always happens eventually.

8) There is an irony in terms of who benefits and runs these fellowships, but did not attend them.

These eight points, I think, just succinctly nail everything that's wrong with this rise in unaccredited fellowships in RadOnc. This is personally extremely relevant to me, as a PGY-5 resident during the COVID/APM era. I have been groomed my entire career to follow an academic path. Once universities started to enact hiring freezes due to COVID, and the entire academic job market started to lock up, I asked senior faculty administration and mentors for advice. The only thing I was offered was "I guess you could do a post-doc or fellowship, it wouldn't hurt your career".

I fall squarely into point #3. I don't know if I technically meet the definition of "disadvantaged", but I was the first in my family to go to college, and am the primary income earner for my household. I have delayed getting a "real job" for many, many years, and my spouse and now kids have ridden that wave with me. I'm deep into my 30s at this point, how much more am I expected to sacrifice? Why do the people who have their jobs without doing extra training (point number 8) think recommending this to us is OK? Ironically, this advice immediately catalyzed me looking for a way out of academia.

As programs such as Moffitt's "Future of Radiation Therapy" fellowships start to materialize, how can anyone continue to argue this field is healthy? We're barrelling straight down Canada's path, where residents do cycle after cycle of fellowships, waiting for someone to retire so they can finally have a job. So maybe Moffitt is right - their fellowship is the future of RadOnc.

When someone tells you who they are, believe them before signing a noncompete and getting a mortgage.

I also had this feeling that I'd be contributing more by staying in academia, and have the education to prove it. Now, I'm doing cool stuff in a rural setting, as in, actually addressing the maldistribution problem, and getting paid professor money on day one. In hindsight, maybe i didn't maximize certain things by choosing radonc, but I think I've minimized risks going forward.
 
  • Like
  • Love
Reactions: 5 users

elementaryschooleconomics

Sharp Dissector of the Avascular Plane
Nov 2, 2019
1,137
4,499
I'll add #9)

9) it hurts resident experience. When you have a brachy fellow, the resident doesn't get to do the case. The fellow does.

How did every brachy expert learn to be good at their job? By doing a ton of cases as ACTUAL FACULTY with normal attending pay. Why was it OK for them to learn on the job, but now we need fellows?

This is exactly what happens at my current institution. A couple of weeks ago I overheard some faculty talking about how weird it was there wasn't more resident involvement with a certain technique.

We have a (non-ACGME) fellowship for that technique.

Where is the room for the resident? Am I supposed to take time out from my current clinical duties and actively snipe cases from fellows? Then what are the fellows going to do? How in the world do faculty find it "weird" that residents aren't involved given the current setup?!?
 
  • Haha
Reactions: 1 users

scarbrtj

I Don't Like To Bragg
5+ Year Member
Dec 18, 2015
3,216
4,907
Status (Visible)
  1. Attending Physician
Everyone's favorite Vinay Prasad just posted this on Twitter:

View attachment 320364

Here's the link to the article: LINK

For those who saw the thread on Twitter, he's talking about HemeOnc/Fellowships in Medicine in general, but a few of the regular anonymous RadOnc Twitter accounts joined in. There are 8 points he makes in the article on why extra fellowships are a problem - I think the points are incredibly germane to Radiation Oncology:

1) It won't stop with one year

2) Hospitals are taking the labor of fellows and money of fellows

3) Longer training keeps medicine a profession for kids of aristocrats. Some of us have to earn sooner in life.

4) More training means fewer women. Many of these fields already male-dominated.

5) Parental leave for fellows is an embarrassment.

6) The less we participate in these fellowships, the less chance they will become mandatory.

7) The alternative is training people on the job...which always happens eventually.

8) There is an irony in terms of who benefits and runs these fellowships, but did not attend them.

These eight points, I think, just succinctly nail everything that's wrong with this rise in unaccredited fellowships in RadOnc. This is personally extremely relevant to me, as a PGY-5 resident during the COVID/APM era. I have been groomed my entire career to follow an academic path. Once universities started to enact hiring freezes due to COVID, and the entire academic job market started to lock up, I asked senior faculty administration and mentors for advice. The only thing I was offered was "I guess you could do a post-doc or fellowship, it wouldn't hurt your career".

I fall squarely into point #3. I don't know if I technically meet the definition of "disadvantaged", but I was the first in my family to go to college, and am the primary income earner for my household. I have delayed getting a "real job" for many, many years, and my spouse and now kids have ridden that wave with me. I'm deep into my 30s at this point, how much more am I expected to sacrifice? Why do the people who have their jobs without doing extra training (point number 8) think recommending this to us is OK? Ironically, this advice immediately catalyzed me looking for a way out of academia.

As programs such as Moffitt's "Future of Radiation Therapy" fellowships start to materialize, how can anyone continue to argue this field is healthy? We're barrelling straight down Canada's path, where residents do cycle after cycle of fellowships, waiting for someone to retire so they can finally have a job. So maybe Moffitt is right - their fellowship is the future of RadOnc.
Here's an incongruity. Not sure we have fully explained this one, but if so let's explain it again.
Number of rad onc fellowships is significantly increasing and is 30+/year now.
However only ~2 U.S. rad onc residency grads per year enter U.S. fellowships???
We all have seen a correlation with rising fellowships and rising resident numbers.
But it seems the latter is not "causing" the former?
In other words, I feel like the ballooning fellowship phenom is a sign of bad employment prospects, but the data refutes that.

This is, once again, one of those situations where I feel it's really strange (and at worst intentional and at best dereliction of duty) that we have a lack of good, easily findable to data on which to base some very important conclusions about the health and standing of our specialty. If we find >3 (maybe 4) people from separate institutions to come here and say "my site took a U.S. grad for fellowship" I would suspect a problem with the above-linked survey process. Soon we will have more fulsome presentation re the "2 lone American fellowship-takers" at ASTRO by ARRO...
 
Last edited:
  • Like
Reactions: 1 users

Grubbe-a-dub-dub

7+ Year Member
Oct 27, 2013
96
161
Status (Visible)
  1. Attending Physician
Does anyone find it weird that this blog article was written by a med onc?

I thought they were immune to these types of predatory apprenticeships but I guess I was wrong.
 
  • Like
Reactions: 1 user

thecarbonionangle

5+ Year Member
Aug 23, 2014
2,022
3,126
Status (Visible)
  1. Attending Physician
Its a downward spiral because brachy fellow takes cases away from residents then residents graduate not being comfortable with standard brachytherapy and would have to do a “fellowship” to get what they should have gotten in residency. Its an ongoing devaluing of your residency experience. Soon you would have “just only graduated from residency” and be passed over people with fellowships like it happened in radiology. Then the people in good jobs are also locked in because there is no way to lateral. The people in dead end jobs are locked in because they can only find something worst. There are people with 5+ yr experience competing with current grads.
 
  • Like
Reactions: 3 users

Lamount

7+ Year Member
Mar 21, 2012
530
913
Status (Visible)
  1. Attending Physician
Speaking as someone who benefited from a fellowship, I acknowledge that many fellowships likely add little to the training you would get during residency.

For a fellowship to be useful, it has to serve a specific purpose... and that purpose shouldn't be to learn a little more about something that you already know pretty well.
 
  • Like
Reactions: 2 users

RickyScott

2+ Year Member
Oct 4, 2017
2,157
3,463
Status (Visible)
  1. Attending Physician
Speaking as someone who benefited from a fellowship, I acknowledge that many fellowships likely add little to the training you would get during residency.

For a fellowship to be useful, it has to serve a specific purpose... and that purpose shouldn't be to learn a little more about something that you already know pretty well.
A fellowship could always be substituted with an instructor level/junior faculty position. This was the case when I came out, even for peds.
 
  • Like
Reactions: 1 user
About the Ads

thecarbonionangle

5+ Year Member
Aug 23, 2014
2,022
3,126
Status (Visible)
  1. Attending Physician
The utility of it is likely minimal as far as your skills unless you have some serious holes in your training. It may help securing a job if you went to a bad program but even that is questionable. The proliferation of proton fellowships does not match the amount of knowledge that is required to treat with protons. Do you really need a whole year for this? nope.
 
  • Like
Reactions: 1 user

OTN

Member
15+ Year Member
Nov 6, 2003
1,359
2,824
The only acceptable fellowship is peds. Departments that cannot provide enough brachytherapy training for their residents should not be training residents.

Protons are not nearly as difficult as SBRT. A proton fellowship is a joke.
 
  • Like
Reactions: 10 users

Grubbe-a-dub-dub

7+ Year Member
Oct 27, 2013
96
161
Status (Visible)
  1. Attending Physician
Yea, but how many places are kicking and screaming for a peds radiation oncologist?

Probably many more that want to establish or grow their brachy practices to stay competitive with the market.
 

RollTideRadOnc

7+ Year Member
Jan 26, 2013
81
221
Status (Visible)
  1. Podiatrist
Agree. Only legit fellowship is peds. All others are predatory. And brachy is extremely problematic for the reasons above.

the only real purpose for a grad to take one of these fellowships is as an audition job in a limited geographic region, but that doesn’t change the fact that the fellowship likely shouldn’t have existed in the first place

these are just another nail in the coffin.

The funny thing to me is that most chairs I know couldn’t even perform most of the techniques for these fellowships (peds, brachy, protons, sabr, let alone bread n butter like HN, gyn, etc). Pretty hilarious when luminaries become chairs of major centers but can’t even do simple techniques. This a corrupt transfer of power from the vulnerable to those already on top of the food chain.

Not to go off on too much of a rant, but grandfathered board cert should not exist. We should make these outdated 2D, plain film bags of **** prove their worth.
 
Last edited by a moderator:
  • Like
Reactions: 4 users

scarbrtj

I Don't Like To Bragg
5+ Year Member
Dec 18, 2015
3,216
4,907
Status (Visible)
  1. Attending Physician
The utility of it is likely minimal as far as your skills unless you have some serious holes in your training.
The only acceptable fellowship is peds. Protons are not nearly as difficult as SBRT. A proton fellowship is a joke.
Agree. Only legit fellowship is peds. All others are predatory. And brachy is extremely problematic for the reasons above.
Only reasons for fellowship pre-2000: resident training remediation for a "bad" resident, or peds.
My how times have changed.
 
  • Like
Reactions: 1 user

OTN

Member
15+ Year Member
Nov 6, 2003
1,359
2,824
Agree. Only legit fellowship is peds. All others are predatory. And brachy is extremely problematic for the reasons above.

the only real purpose for a grad to take one of these fellowships is as an audition job in a limited geographic region, but that doesn’t change the fact that the fellowship likely shouldn’t have existed in the first place

these are just another nail in the coffin.

The funny thing to me is that most chairs I know couldn’t even perform most of the techniques for these fellowships (peds, brachy, protons, sabr, let alone bread n butter like HN, gyn, etc). Pretty hilarious when luminaries become chairs of major centers but can’t even do simple techniques. This a corrupt transfer of power from the vulnerable to those already on top of the food chain.

Not to go off on too much of a rant, but grandfathered board cert should not exist. We should make these outdated 2D, plain film bags of sh1t prove their worth.

Agree about the grandfathering, but board certification legally represents a contract which cannot be unilaterally changed once granted. That's how it's been explained to me at least. Not only a problem in radonc at all.
 

scarbrtj

I Don't Like To Bragg
5+ Year Member
Dec 18, 2015
3,216
4,907
Status (Visible)
  1. Attending Physician
Agree about the grandfathering, but board certification legally represents a contract which cannot be unilaterally changed once granted.
I got board certified. Then was mandated to go to a Pearsonvue center 7 years later (I did it early) and take a controlled test on PC to recertify. Also had to do some "projects" in the clinic etc. Then they said, let's change all that. No more testing center tests, no more Type I projects etc. Now it's OLA. I say all that to say: it must be a heckuva malleable contract and it's felt unilateral (to me).
 

Lamount

7+ Year Member
Mar 21, 2012
530
913
Status (Visible)
  1. Attending Physician
The only acceptable fellowship is peds. Departments that cannot provide enough brachytherapy training for their residents should not be training residents.

Protons are not nearly as difficult as SBRT. A proton fellowship is a joke.

Would disagree with this.

Protons are dangerous if uncertainty is not properly considered, as range errors may be systematic. You can't just look at a treatment plan and a DVH and sign off without understanding how likely it is that your ideal plan will actually be what the patient receives... or at least you shouldn't.

I did a proton fellowship because I wanted to learn how to safely push the limit with protons. I did the bulk of my fellowship research with physicists so that I could really wrap my mind around all the relevant considerations... and was hired for my current position based upon this training.

I had a very specific reason for doing a proton fellowship. It served me well, and prior fellows from this particular program have had similar success.

Reputable fellowships are just fine for people who have an interest in becoming an expert in a specific skill or field where they didn't have that opportunity during residency (peds, brachy, protons, IORT etc...). This may seem silly to you, but everyone comes at this from a different perspective.

Unfortunately, many fellowships are a predatory means of leveraging the poor job market for cheap labor. It's easy enough to do some homework and figure out which are useful and which aren't.
 
About the Ads

RickyScott

2+ Year Member
Oct 4, 2017
2,157
3,463
Status (Visible)
  1. Attending Physician
Would disagree with this.

Protons are dangerous if uncertainty is not properly considered, as range errors may be systematic. You can't just look at a treatment plan and a DVH and sign off without understanding how likely it is that your ideal plan will actually be what the patient receives... or at least you shouldn't.

I did a proton fellowship because I wanted to learn how to safely push the limit with protons. I did the bulk of my fellowship research with physicists so that I could really wrap my mind around all the relevant considerations... and was hired for my current position based upon this training.

I had a very specific reason for doing a proton fellowship. It served me well, and prior fellows from this particular program have had similar success.

Reputable fellowships are just fine for people who have an interest in becoming an expert in a specific skill or field where they didn't have that opportunity during residency (peds, brachy, protons, IORT etc...). This may seem silly to you, but everyone comes at this from a different perspective.

Unfortunately, many fellowships are a predatory means of leveraging the poor job market for cheap labor. It's easy enough to do some homework and figure out which are useful and which aren't.
Once you leave fellowship, you will not be at a proton center on your own. Many colleagues at centers that purchased protons and nobody did a fellowship.
 

scarbrtj

I Don't Like To Bragg
5+ Year Member
Dec 18, 2015
3,216
4,907
Status (Visible)
  1. Attending Physician
Protons are dangerous if uncertainty is not properly considered, as range errors may be systematic. You can't just look at a treatment plan and a DVH and sign off without understanding how likely it is that your ideal plan will actually be what the patient receives... or at least you shouldn't.

I did a proton fellowship because I wanted to learn how to safely push the limit with protons. I did the bulk of my fellowship research with physicists so that I could really wrap my mind around all the relevant considerations... and was hired for my current position based upon this training.

I had a very specific reason for doing a proton fellowship. It served me well, and prior fellows from this particular program have had similar success.
Asking for open-mindedness. How do you KNOW fellowship is necessary for abolishment of systematic errors w/ protons. Heard stories? Are first-day fellows riskier or more error-prone than last-day fellows. A lot of your arguments re: "protons are very nuanced and delicate" were the same exact arguments people made about IMRT back in the day. The IMRT fellowship never existed AFAIK. (Nor did anyone, anywhere, govt included, call for a trial for that markedly different technology/paradigm before fully implementing it in the clinic for definitive treatments.)
 
  • Like
Reactions: 3 users

Lamount

7+ Year Member
Mar 21, 2012
530
913
Status (Visible)
  1. Attending Physician
Once you leave fellowship, you will not be at a proton center on your own. Many colleagues at centers that purchased protons and nobody did a fellowship.

While this is certainly true, there are established centers who (in my opinion) don't always employ this modality wisely. I wanted to really learn the ins and outs so that I could confidently push the limits.

...just as I am sure there are people who perform brachytherapy with less-than-ideal technique. Someone who wants to become a brachy expert may want to do a fellowship so they can learn from Dr. X... and I think this would be a reasonable choice. Like I said, everyone comes at this from a different perspective.

There is no utility in painting all fellowships with a broad brush.
 

Lamount

7+ Year Member
Mar 21, 2012
530
913
Status (Visible)
  1. Attending Physician
Asking for open-mindedness. How do you KNOW fellowship is necessary for abolishment of systematic errors w/ protons. Heard stories? Are first-day fellows riskier or more error-prone than last-day fellows. A lot of your arguments re: "protons are very nuanced and delicate" were the same exact arguments people made about IMRT back in the day. The IMRT fellowship never existed AFAIK. (Nor did anyone, anywhere, govt included, call for a trial for that markedly different technology/paradigm before fully implementing it in the clinic for definitive treatments.)


I don't KNOW it was necessary, as one never knows would could/would have been. During fellowship, range uncertainties was the focus of my research, and I had the opportunity to pepper some of the best minds on the topic with endless questions and hypotheticals. I don't feel confident in something unless I feel I have my mind wrapped around it, and that is a high bar for me. Fellowship allowed me to get to that place.

Perhaps I could have gotten a job where I got similar knowledge/confidence via on-the-job training... who knows? If it even exists, such a job would likely be hard to come by these days.
 
  • Like
Reactions: 1 users

scarbrtj

I Don't Like To Bragg
5+ Year Member
Dec 18, 2015
3,216
4,907
Status (Visible)
  1. Attending Physician
pepper some of the best minds
Wagering ~100% of those "best minds" (the best mind?) never did a fellowship in the subject in which you peppered them. Somebody has to be "first," I get that. But I have seen various different IMRT approaches in silico and in vivo. It was the in-the-clinic differences related to the differing approaches I'd see with my own two eyes that helped me wrap my mind around things. A majority of the things the "best minds" in IMRT (or IGRT) were saying in the early days were either directly falsified or softened in tone/stance as years went by. That came about from getting data vs the Socratic method. I'm not picking on you, please don't misunderstand. I'm picking on the fact that if we get into the situation of "I did a fellowship, and I learned stuff, and the stuff that non-fellowship trained people do is questionable" it's a very slippery slope. Fellowship turtles all the way down.
 
  • Like
Reactions: 3 users

thecarbonionangle

5+ Year Member
Aug 23, 2014
2,022
3,126
Status (Visible)
  1. Attending Physician
Once you understand the RBE uncertainty, range uncertainties, how changes in density affect dose deposition and uncertainty, how changes in weight are relevant, etc I’m not sure that this really takes 1 yr. Not knocking anybody’s experience. The key to doing particle therapy is having a good physics team. Involving them in your decisions is paramount. Routine review of images to get thoughts from physics to see if someone is a good candidate is important even if you already know likely. As far as the way you contour, you often give them a CTV and no PTV, though you can in some cases because the margin is built in to account for “uncertainties”. Overall in most cases, i don’t see the need for a dedicated one yr fellowship though I do recognize the utility for people who have has success with this approach.
 
  • Like
Reactions: 1 user

scarbrtj

I Don't Like To Bragg
5+ Year Member
Dec 18, 2015
3,216
4,907
Status (Visible)
  1. Attending Physician
I changed two words :)

Once you understand the RBE uncertainty, range uncertainties, how changes in density affect dose deposition and uncertainty, how changes in weight are relevant, etc I’m not sure that this really takes 1 yr. Not knocking anybody’s experience. The key to precision X-ray therapy is having a good physics team. Involving them in your decisions is paramount. Routine review of images to get thoughts from physics to see if someone is a good candidate is important even if you already know likely. As far as the way you contour, you often give them a CTV and no PTV, though you can in some cases because the margin is built in to account for “uncertainties”.
 
  • Haha
  • Like
Reactions: 1 users

thecarbonionangle

5+ Year Member
Aug 23, 2014
2,022
3,126
Status (Visible)
  1. Attending Physician
I changed two words :)

Once you understand the RBE uncertainty, range uncertainties, how changes in density affect dose deposition and uncertainty, how changes in weight are relevant, etc I’m not sure that this really takes 1 yr. Not knocking anybody’s experience. The key to precision X-ray therapy is having a good physics team. Involving them in your decisions is paramount. Routine review of images to get thoughts from physics to see if someone is a good candidate is important even if you already know likely. As far as the way you contour, you often give them a CTV and no PTV, though you can in some cases because the margin is built in to account for “uncertainties”.

yes i agree i think having a good support team is important for ALL radiation therapy.
 
  • Like
Reactions: 1 user

Lamount

7+ Year Member
Mar 21, 2012
530
913
Status (Visible)
  1. Attending Physician
Wagering ~100% of those "best minds" (the best mind?) never did a fellowship in the subject in which you peppered them. Somebody has to be "first," I get that. But I have seen various different IMRT approaches in silico and in vivo. It was the in-the-clinic differences related to the differing approaches I'd see with my own two eyes that helped me wrap my mind around things. A majority of the things the "best minds" in IMRT (or IGRT) were saying in the early days were either directly falsified or softened in tone/stance as years went by. That came about from getting data vs the Socratic method. I'm not picking on you, please don't misunderstand. I'm picking on the fact that if we get into the situation of "I did a fellowship, and I learned stuff, and the stuff that non-fellowship trained people do is questionable" it's a very slippery slope. Fellowship turtles all the way down.

Ha ha, I wouldn't mind it if you WERE picking on me. By virtue of where we ended up, I assume we have all been teased at one point in our lives. The "greatest minds" that I refer to are physicists. The clinicians were great minds in their own right and I certainly learned quite a bit from them as well.

I don't think that all people who treat with protons without a fellowship are dangerous, nor do I think that all who do a fellowship emerge well-trained -(and probably very few -if any- cared as much as I did about the uncertainties). All I am saying is that I applied for a fellowship hoping to acquire a certain knowledge base, and I am more than satisfied with the outcome. It may not have been the only path, but it worked just fine.
 
  • Like
Reactions: 3 users

RadOncMegatron

Blasting Away Cancer!
10+ Year Member
Mar 30, 2009
537
923
Status (Visible)
  1. Attending Physician
Ha ha, I wouldn't mind it if you WERE picking on me. By virtue of where we ended up, I assume we have all been teased at one point in our lives. The "greatest minds" that I refer to are physicists. The clinicians were great minds in their own right and I certainly learned quite a bit from them as well.

I don't think that all people who treat with protons without a fellowship are dangerous, nor do I think that all who do a fellowship emerge well-trained -(and probably very few -if any- cared as much as I did about the uncertainties). All I am saying is that I applied for a fellowship hoping to acquire a certain knowledge base, and I am more than satisfied with the outcome. It may not have been the only path, but it worked just fine.

Proton fellowships seem very reasonable. I had no exposure in residency. If I were to do protons, I would definitely need more training. Now, a fellowship for the Future of Radiation Oncology on the other hand...
 
  • Haha
Reactions: 1 users
About the Ads

beamotherapy

7+ Year Member
Nov 25, 2011
22
74
Status (Visible)
  1. Attending Physician
Let's not forget that radiation oncology residencies are for 4 years and only required to have 3 years of core rotations (or less for Holman). If a resident needs extra experience in some topic they can ask the program director to use some of that extra year to go to another institution for a visiting rotation in Peds or whatever. This should totally eliminate the theoretical need for fellowships. But of course practical solutions don't actually matter.
 
  • Like
Reactions: 4 users

elementaryschooleconomics

Sharp Dissector of the Avascular Plane
Nov 2, 2019
1,137
4,499
Ouch. Double ouch b/c it's crossed my mind as a back up field, but I do think Palliative / Hospice medicine is wonderful. I wouldn't mind doing it later in life, but only if I want to not if I am forced too.

It's definitely my #1 backup plan, because I sincerely enjoy it. I know we all like to rag on palliative radiation, but I love those patients and those encounters!
 
  • Like
Reactions: 2 users

thecarbonionangle

5+ Year Member
Aug 23, 2014
2,022
3,126
Status (Visible)
  1. Attending Physician
Man imagine if a good amount of graduates ended up after all that research and effort being pain docs and MJ docs, what a waste of talent for a field which badly needs to keep its members engaged and grow indications for radiation. I think a palliative care fellowship or a neuro onc one would be my back up
 
D

deleted605854

what about the abr pain fellowship? does it even truly exist?

.

All that means is that an RO grad can pursue said fellowship. Getting accepted into one is another matter. These are very competitive fellowships and you're competing with Anesthesia, IM, Neurology and PMR. Most programs are not even aware that ROs qualify for admission into a pain fellowship and I'm not aware of a single one that has ever accepted a Radiation Oncology grad.
 
  • Like
Reactions: 2 users
Jul 16, 2019
10
34
Status (Visible)
  1. Attending Physician
Speaking as someone who benefited from a fellowship, I acknowledge that many fellowships likely add little to the training you would get during residency.

For a fellowship to be useful, it has to serve a specific purpose... and that purpose shouldn't be to learn a little more about something that you already know pretty well.

I agree with you Lamount. If there is something that you want to pursue professionally but weren't able to learn during your normal course of training, education is the answer.

Whether it's an MBA program or away rotation, lots of focused CME or a fellowship, education always takes time, effort and yes, money. Be a wise consumer and know what you're buying so you make a purchase that fits your needs. Not all fellowships or other educational opportunities are created equal and will offer different benefits and downsides. Still though, the best investment you can make is in yourself, which is why we all went to medical school, did abusive internships, and worked 3 to 4 years doing attending level work for resident pay.

The work I'm doing now and enjoying professionally would not have been possible without first doing a fellowship in modern proton therapy techniques. Note the word modern, meaning a facility with all pencil beams, CBCT at all isocenters, lots of IMPT, and other things you won't necessarily find at older proton places like MD Anderson or Loma Linda.
 
  • Like
Reactions: 5 users

Aphtalyfe

SDN Gold Donor
10+ Year Member
Jul 28, 2009
312
72
Status (Visible)
  1. Attending Physician
Its a downward spiral because brachy fellow takes cases away from residents then residents graduate not being comfortable with standard brachytherapy and would have to do a “fellowship” to get what they should have gotten in residency. Its an ongoing devaluing of your residency experience. Soon you would have “just only graduated from residency” and be passed over people with fellowships like it happened in radiology. Then the people in good jobs are also locked in because there is no way to lateral. The people in dead end jobs are locked in because they can only find something worst. There are people with 5+ yr experience competing with current grads.

Just wanted to point out that not all brachy fellowships are this way. There should be plenty of cases and after a few months (give or take depending on the procedure) the fellow can teach the resident with the attending doing some light direction/supervision.

My experience with applying for brachy attending positions was that a lot of places gave preference to people with brachy fellowships. For the simple reason that they would be plug-and-play. Minimal clinical training needed.
 
  • Like
Reactions: 1 user
About the Ads

Your message may be considered spam for the following reasons:

  1. Your new thread title is very short, and likely is unhelpful.
  2. Your reply is very short and likely does not add anything to the thread.
  3. Your reply is very long and likely does not add anything to the thread.
  4. It is very likely that it does not need any further discussion and thus bumping it serves no purpose.
  5. Your message is mostly quotes or spoilers.
  6. Your reply has occurred very quickly after a previous reply and likely does not add anything to the thread.
  7. This thread is locked.