Supervision by mid levels

[heavyluva]

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I believe this may have been discussed, but is there a likely probability of supervision even in freestanding centers to be provided by mid-levels permanently?

This is from the Astro website section VI.. seems like it may eventually be a permanent change?

COVID-19 Coding Guidance - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

ASTRO has issued coding guidance to provide radiation oncology practices with information regarding proper coding for telehealth services during this public health emergency.

www.astro.org

 

[medgator]

Probably won't fly for accreditation and will probably look bad in court, but yes it should fly for CMS i think

 

[TheWallnerus]

As Bugs Bunny says to Elmer Fudd "Ha ha; it is to laugh." ASTRO remains concerned about the safety of doing IGRT with NPs hanging out in the building instead of MDs. For an MD, IGRT equals looking at a computer screen. Screens are remote-shareable etc etc. But by ASTRO's logic, an NP pooping in a building when IGRT is being done is less safe than an MD pooping in the building. Well ASTRO should be concerned as hell if a center had no IGRT at all. The most unsafe form of image guided radiotherapy must be IGRT which can never be done. Has anyone heard ASTRO say that all XRT machines must be IGRT capable for patient safety? I missed that memo. But I'm just an illiterate, illogical wascally wabbit.

 

[medgator]

As Bugs Bunny says to Elmer Fudd "Ha ha; it is to laugh." ASTRO remains concerned about the safety of doing IGRT with NPs hanging out in the building instead of MDs. For an MD, IGRT equals looking at a computer screen. Screens are remote-shareable etc etc. But by ASTRO's logic, an NP pooping in a building when IGRT is being done is less safe than an MD pooping in the building. Well ASTRO should be concerned as hell if a center had no IGRT at all. The most unsafe form of image guided radiotherapy must be IGRT which can never be done. Has anyone heard ASTRO say that all XRT machines must be IGRT capable for patient safety? I missed that memo. But I'm just an illiterate, illogical wascally wabbit.

No... Wouldn't want to piss off their next door neighbor, evilcore

 

[TheWallnerus]

Has anyone heard ASTRO say that all XRT machines must be IGRT capable for patient safety?
No... Wouldn't want to piss off their next door neighbor, evilcore

Guess what. S**t you not! If you have a tomo machine as your only machine, word on street is Evilcore "must" allow the IGRT in every case. You didn't hear it from me.

 

[goodkerma]

Am I missing something... IGRT doesn't equal a diagnostic test - though this is still concerning.

 

[dieABRdie]

Does this mean I can leave the building during the day now?

 

[TheWallnerus]

Am I missing something... IGRT doesn't equal a diagnostic test - though this is still concerning.

In 2019 when supervision began changing, ASTRO suddenly (suspiciously, transparently) quit referring to image guided radiation therapy as IGRT anymore and began calling it merely image guidance:

"It should also be noted that the new supervision policy does not apply to diagnostic services such as image guidance."

In one brushstroke ASTRO converted "image guided radiation therapy" from a therapy to a diagnostic test. I mean who knew that IGRT was really IGDT (image guided diagnostic testing). ASTRO said nary a word to CMS, ever, that IGRT was not diagnostic and/or that any assertions otherwise were asinine and incorrect. This is why I no longer give ASTRO money. "First, do no harm" is not a concept to which they hew. They make things worse, objectively.

But yeah I already told you guys this was the way.

 

[medgator]

Does this mean I can leave the building during the day now?

Some leeway i believe as long as you are available via A/V 2-way communication

 

[elementaryschooleconomics]

Does this mean I can leave the building during the day now?

Some leeway i believe as long as you are available via A/V 2-way communication

I was under the impression this was explicitly allowed if you're in a hospital outpatient facility now?

Unless you're asking about freestanding, which I'm less clear on.

 

[medgator]

I was under the impression this was explicitly allowed if you're in a hospital outpatient facility now?

Unless you're asking about freestanding, which I'm less clear on.

Telesupervision guidelines have applied to both since the start of the pandemic. CMS renewed that earlier this year through the end of the year

 

[elementaryschooleconomics]

Telesupervision guidelines have applied to both since the start of the pandemic. CMS renewed that earlier this year through the end of the year

Ah interesting, it's been hard to keep up with all these q2month updates from what's OK vs what's not over the last year.

 

[BobbyHeenan]

I'm on the fence about supervision.

In one respect, it's absolutely ridiculous to strap a doctor to the building the whole day just for supervision.

On the other hand, I get called to the machine a TON to look at CBCT alignments (I don't go for every fraction, only go if therapists are uncomfortable). I try to promote a culture of if you're not sure, ask...so they don't hesitate to get me. I worry about a lot of decisions about alignment may be made by therapists (more than normal) with a once-a-week in the building physican (this absolutely is going on in some clinics I know of).

 

[TheWallnerus]

I'm on the fence about supervision.

In one respect, it's absolutely ridiculous to strap a doctor to the building the whole day just for supervision.

On the other hand, I get called to the machine a TON to look at CBCT alignments (I don't go for every fraction, only go if therapists are uncomfortable). I try to promote a culture of if you're not sure, ask...so they don't hesitate to get me. I worry about a lot of decisions about alignment may be made by therapists (more than normal) with a once-a-week in the building physican (this absolutely is going on in some clinics I know of).

I agree with your point 100%. In a future world “place” of person(s) will mean less and less. There’s no reason a CBCT on a patient in Poughkeepsie couldn’t be aligned via an iPhone or iPad in Peoria. As Oscar in the Six Million Dollar Man used to say “We have the technology.”

 

[heavyluva]

Telesupervision guidelines have applied to both since the start of the pandemic. CMS renewed that earlier this year through the end of the year

I wonder if telesupervision will be extended post-COVID. If mid levels or zoom could be utilized to supervise freestanding practices, that would dramatically impact hiring at a number of practices. It would also impact QOL for rad oncs lucky enough to have jobs.

 

[OTN]

Some practices would be impacted more than others. With the amount of SBRT I do on a daily basis, there's simply no way a midlevel would be able to cover.

 

[RickyScott]

Relaxation of supervision now (redundantly) solved (fake) rural radonc maldistribution. Can still deliver good quality xrt in cornfields with radonc showing up once per week, and midlevel rest of the time. (same for all those centers with 5-10 patients)

 

[GI_RadOnc]

Some practices would be impacted more than others. With the amount of SBRT I do on a daily basis, there's simply no way a midlevel would be able to cover.

I'm super SBRT and single fraction therapy heavy myself; but I have utilized technology to cover SBRT, adaptives, OTVs, plan approval, online adaptive treatments and consults and follow-ups to expand my reach across our system. As a site specialist; I need to be available to a large number of referring physicians to stay busy; and I've embraced working with our mid-level providers to assist with this.

Same day consult and I'm at another facility? Easy; send the patient down; patient seen by a mid-level provider and I see them via a video visit from where I'm at. Patient and referring physician happy.

Two complex SBRT or adaptive cases at the same time; but in different facilities? No problem; just a matter of the proper screen share or record and verify system. Our therapy team and physics team, after some testing and validation; really appreciate this and have noticed I'm even faster to approve things when doing it from my office (or whereever) than walking over to the machine! And they feel it's a better option for the patient than waiting for the floor physician or someone else to assist.

As I've said before, I got a great job; and I want to keep doing it over the next 20 years. It's better for me to be seeing new patients, standing up at tumor boards then being chained to a linear accelerator or treatment planning system. None of our European colleagues spend as much time at the machine as we do!

 

[TheWallnerus]

I'm super SBRT and single fraction therapy heavy myself; but I have utilized technology to cover SBRT, adaptives, OTVs, plan approval, online adaptive treatments and consults and follow-ups to expand my reach across our system. As a site specialist; I need to be available to a large number of referring physicians to stay busy; and I've embraced working with our mid-level providers to assist with this.

Same day consult and I'm at another facility? Easy; send the patient down; patient seen by a mid-level provider and I see them via a video visit from where I'm at. Patient and referring physician happy.

Two complex SBRT or adaptive cases at the same time; but in different facilities? No problem; just a matter of the proper screen share or record and verify system. Our therapy team and physics team, after some testing and validation; really appreciate this and have noticed I'm even faster to approve things when doing it from my office (or whereever) than walking over to the machine! And they feel it's a better option for the patient than waiting for the floor physician or someone else to assist.

As I've said before, I got a great job; and I want to keep doing it over the next 20 years. It's better for me to be seeing new patients, standing up at tumor boards then being chained to a linear accelerator or treatment planning system. None of our European colleagues spend as much time at the machine as we do!

This is the way.

 

[RickyScott]

I'm super SBRT and single fraction therapy heavy myself; but I have utilized technology to cover SBRT, adaptives, OTVs, plan approval, online adaptive treatments and consults and follow-ups to expand my reach across our system. As a site specialist; I need to be available to a large number of referring physicians to stay busy; and I've embraced working with our mid-level providers to assist with this.

Same day consult and I'm at another facility? Easy; send the patient down; patient seen by a mid-level provider and I see them via a video visit from where I'm at. Patient and referring physician happy.

Two complex SBRT or adaptive cases at the same time; but in different facilities? No problem; just a matter of the proper screen share or record and verify system. Our therapy team and physics team, after some testing and validation; really appreciate this and have noticed I'm even faster to approve things when doing it from my office (or whereever) than walking over to the machine! And they feel it's a better option for the patient than waiting for the floor physician or someone else to assist.

As I've said before, I got a great job; and I want to keep doing it over the next 20 years. It's better for me to be seeing new patients, standing up at tumor boards then being chained to a linear accelerator or treatment planning system. None of our European colleagues spend as much time at the machine as we do!

It will be more acceptable common place for radonc to cover multiple facilities w/mid level assists. Can run multiple 5-10 pt rural centers concurrently- legally and w/good quality care

 

[medgator]

It will be more acceptable common place for radonc to cover multiple facilities w/mid level assists. Can run multiple 5-10 pt rural centers concurrently- legally and w/good quality care

Perfect timing for 200/y graduating

 

[evilbooyaa]

I'm super SBRT and single fraction therapy heavy myself; but I have utilized technology to cover SBRT, adaptives, OTVs, plan approval, online adaptive treatments and consults and follow-ups to expand my reach across our system. As a site specialist; I need to be available to a large number of referring physicians to stay busy; and I've embraced working with our mid-level providers to assist with this.

Same day consult and I'm at another facility? Easy; send the patient down; patient seen by a mid-level provider and I see them via a video visit from where I'm at. Patient and referring physician happy.

Two complex SBRT or adaptive cases at the same time; but in different facilities? No problem; just a matter of the proper screen share or record and verify system. Our therapy team and physics team, after some testing and validation; really appreciate this and have noticed I'm even faster to approve things when doing it from my office (or whereever) than walking over to the machine! And they feel it's a better option for the patient than waiting for the floor physician or someone else to assist.

As I've said before, I got a great job; and I want to keep doing it over the next 20 years. It's better for me to be seeing new patients, standing up at tumor boards then being chained to a linear accelerator or treatment planning system. None of our European colleagues spend as much time at the machine as we do!

Sounds like a perfect opportunity for the hiring of another physician who does similar disease site work to you. The fact that you have the ability to multi-task like this is great (for you and your RVUs) but if you only cover 2 facilities you are doing the job of, historically, 2 rad oncs. Which is an abject disaster to the job market on top of all of the other factors in play.

 

[RickyScott]

Sounds like a perfect opportunity for the hiring of another physician who does similar disease site work to you. The fact that you have the ability to multi-task like this is great (for you and your RVUs) but if you only cover 2 facilities you are doing the job of, historically, 2 rad oncs. Which is an abject disaster to the job market on top of all of the other factors in play.

if each facility has 7 patients, it is reasonable. Academic centers can hire docs with such anemic case loads because they have very high negotiated prices, but they will come around at some point as well.

 

[TheWallnerus]

Which is an abject disaster to the job market on top of all of the other factors in play.

Speaking of abject disasters. Reading about how prostate will go from most or 2nd most common cancer now to 14th most common (only 60-70K cases/year) by 2040. Right now, prostate cancer is the second most common clinical indication for RT in America (breast a close first), and was the most common clinical indication for many private equity pro formas for proton therapy centers.

 

[GI_RadOnc]

@evilbooyaa You are absolutely correct. Pre-pandemic we would not consider this; and even with pandemic, there is a difference of opinions on this level of virtual utilization. Some will go away... I think it says in the ASTRO guideline that 77427 (OTVs) will not be covered virtually after the pandemic.

I'm not in a leadership position; so hiring decisions are not up to me.. but even in the employed setting in which I work, our leadership is already being thoughtful about making sure there is enough work and related revenue for everyone who is currently in the department; and awaiting the changes with APM that will be coming next year balanced with retirements.

We do have some small volume centers; and in my practice, as I've stated previously here, I rarely get above 10 patients on treatment at a time.

 

[theradiator]

Speaking of abject disasters. Reading about how prostate will go from most or 2nd most common cancer now to 14th most common (only 60-70K cases/year) by 2040. Right now, prostate cancer is the second most common clinical indication for RT in America (breast a close first), and was the most common clinical indication for many private equity pro formas for proton therapy centers.

I'm as gloom and doom as anyone but Figure 1D (straight line heading down) is eerily reminiscent of Ben Smith's future cancer incidence projections in the opposite direction.

 

[seper]

I'm super SBRT and single fraction therapy heavy myself; but I have utilized technology to cover SBRT, adaptives, OTVs, plan approval, online adaptive treatments and consults and follow-ups to expand my reach across our system. As a site specialist; I need to be available to a large number of referring physicians to stay busy; and I've embraced working with our mid-level providers to assist with this.

Same day consult and I'm at another facility? Easy; send the patient down; patient seen by a mid-level provider and I see them via a video visit from where I'm at. Patient and referring physician happy.

Two complex SBRT or adaptive cases at the same time; but in different facilities? No problem; just a matter of the proper screen share or record and verify system. Our therapy team and physics team, after some testing and validation; really appreciate this and have noticed I'm even faster to approve things when doing it from my office (or whereever) than walking over to the machine! And they feel it's a better option for the patient than waiting for the floor physician or someone else to assist.

As I've said before, I got a great job; and I want to keep doing it over the next 20 years. It's better for me to be seeing new patients, standing up at tumor boards then being chained to a linear accelerator or treatment planning system. None of our European colleagues spend as much time at the machine as we do!

This requires an agreeable physics chief... 2 large networks I've worked for were the opposite - physics wanted MD's to see, review, and sign everything and in person.

 

[TheWallnerus]

This requires an agreeable physics chief... 2 large networks I've worked for were the opposite - physics wanted MD's to see, review, and sign everything and in person.

Glad the MDs were in charge of the patients' care and could tell physics no.

 

[wamcp]

I believe this may have been discussed, but is there a likely probability of supervision even in freestanding centers to be provided by mid-levels permanently?

This is from the Astro website section VI.. seems like it may eventually be a permanent change?

COVID-19 Coding Guidance - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

ASTRO has issued coding guidance to provide radiation oncology practices with information regarding proper coding for telehealth services during this public health emergency.

www.astro.org

View attachment 334779

Illinois SB1949 | 2021-2022 | 102nd General Assembly

Summary (2021-04-16) RADIATION ADMINISTRATION [Rule 3-9(a) / Re-referred to Assignments]

legiscan.com

IL SB1949 | 2021-2022 | 102nd General Assembly​

Status​

Spectrum: Partisan Bill (Democrat 1-0)
Status: Introduced on February 26 2021 - 25% progression
Action: 2021-03-24 - Postponed - Licensed Activities
Text: Latest bill text (Introduced)
Amends the Radiation Protection Act. In provisions regarding limitations on the application of radiation and accreditation of administrators of radiation, provides that, notwithstanding the provisions or any other law to the contrary, an advanced practice registered nurse licensed under the Nurse Practice Act may intentionally administer radiation to a human being through a fluoroscope without acting under the supervision, prescription, or direction of a licensed person described the provisions. Effective immediately.

 

[TheWallnerus]

Therapeutic radiographers now deliver MR-linac treatments without clinical oncologist present - RAD Magazine

Therapeutic radiographers at The Royal Marsden NHS Foundation Trust have started treating patients for the first time without a clinical oncologist present.

www.radmagazine.com

 

[MegaVoltagePhoton]

Therapeutic radiographers now deliver MR-linac treatments without clinical oncologist present - RAD Magazine

Therapeutic radiographers at The Royal Marsden NHS Foundation Trust have started treating patients for the first time without a clinical oncologist present.

www.radmagazine.com

Great....

 

[Gfunk6]

Since we are a combined specialty practice we have a lot of Med Onc NPs around. I look forward to the day I can sit at home, count my doubloons, and remotely check IGRT and have the NPs "supervise" treatment just because they happen to be in the same building.

 

[GI_RadOnc]

Great....

I have worked with the lead author on this topic, and she is fantastic; and we continue to implemented these thoughts / ideas into our program as well. While I know some members of this group lament each loss of physician involvement/billing; I see others here looking to improve their efficiency and frankly, their costs. MR linacs are expensive; and MD involvement can be a bottleneck.

In the US, we feel we have a need a MD to bill the plan approval; and therefore sign off in real time; but all the other stuff in MR linac adaptive treatments (alignment, contouring, plan generation) can be done by others. Safely. After an extensive training program. Our therapists and physicists are doing this part really well; and though we still are requiring MD approval of contours as well as plan approval; we look to stop approving contours after the first fraction by 2022.

 

[ROforbetterorworse]

I have worked with the lead author on this topic, and she is fantastic; and we continue to implemented these thoughts / ideas into our program as well. While I know some members of this group lament each loss of physician involvement/billing; I see others here looking to improve their efficiency and frankly, their costs. MR linacs are expensive; and MD involvement can be a bottleneck.

In the US, we feel we have a need a MD to bill the plan approval; and therefore sign off in real time; but all the other stuff in MR linac adaptive treatments (alignment, contouring, plan generation) can be done by others. Safely. After an extensive training program. Our therapists and physicists are doing this part really well; and though we still are requiring MD approval of contours as well as plan approval; we look to stop approving contours after the first fraction by 2022.

Did they do residency?

If not, then the “extensive training” is not good enough

This is hilarious that academics wax poetically about Rad oncs not being technicians, be a doctor blah blah

but then they can teach an RTT to contour and spin it as a good thing

MRI Linac is not a useful machine for the price. I agree that some abdominal tumors being better a la pancreas etc, but not nearly enough cases nationwide to justify it

 

[TheWallnerus]

I have worked with the lead author on this topic, and she is fantastic; and we continue to implemented these thoughts / ideas into our program as well. While I know some members of this group lament each loss of physician involvement/billing; I see others here looking to improve their efficiency and frankly, their costs. MR linacs are expensive; and MD involvement can be a bottleneck.

In the US, we feel we have a need a MD to bill the plan approval; and therefore sign off in real time; but all the other stuff in MR linac adaptive treatments (alignment, contouring, plan generation) can be done by others. Safely. After an extensive training program. Our therapists and physicists are doing this part really well; and though we still are requiring MD approval of contours as well as plan approval; we look to stop approving contours after the first fraction by 2022.

This is correct. And pragmatic. However it makes the 100 patients for every 1 rad onc ratio (de novo RT-treatable cancer cases per rad onc per year in the US) look like a horribly inefficient and wasteful ratio.

 

[RickyScott]

I have worked with the lead author on this topic, and she is fantastic; and we continue to implemented these thoughts / ideas into our program as well. While I know some members of this group lament each loss of physician involvement/billing; I see others here looking to improve their efficiency and frankly, their costs. MR linacs are expensive; and MD involvement can be a bottleneck.

In the US, we feel we have a need a MD to bill the plan approval; and therefore sign off in real time; but all the other stuff in MR linac adaptive treatments (alignment, contouring, plan generation) can be done by others. Safely. After an extensive training program. Our therapists and physicists are doing this part really well; and though we still are requiring MD approval of contours as well as plan approval; we look to stop approving contours after the first fraction by 2022.

With apm, presence won’t be required for billing . Clinical oncologists have chemo patients to deal with, while us radoncs have YouTube and sm.

 

[medgator]

With apm, presence won’t be required for billing . Clinical oncologists have chemo patients to deal with, while us radoncs have YouTube and sm.

Pretty certain KO at mayo was clear about the need for an extender so he could have more Twitter time. Maybe he won't need that extender anymore...

 

[metallica81788]

Pretty certain KO at mayo was clear about the need for an extender so he could have more Twitter time. Maybe he won't need that extender anymore...

If he was truly efficient he could Twitter/sm in between patients, contours, approving plans, and notes without a resident.

You know, like the rest of us do. While carrying more patients on beam.

 

[Mandelin Rain]

After an extensive training program the OR tech will be deploying the stent, so the doctor can be focused on the Spotify playlist.

EDIT: I don't think allowing physicists and RTT to contour simple structures is outrageous or anything. I'm sure it's just fine. I do think it speaks to the long-term viability of this as a separate specialty though. Once the surgeons hear that someone else can do all the work for them, why wouldn't they just start prescribing radiation?

 

[evilbooyaa]

I have worked with the lead author on this topic, and she is fantastic; and we continue to implemented these thoughts / ideas into our program as well. While I know some members of this group lament each loss of physician involvement/billing; I see others here looking to improve their efficiency and frankly, their costs. MR linacs are expensive; and MD involvement can be a bottleneck.

In the US, we feel we have a need a MD to bill the plan approval; and therefore sign off in real time; but all the other stuff in MR linac adaptive treatments (alignment, contouring, plan generation) can be done by others. Safely. After an extensive training program. Our therapists and physicists are doing this part really well; and though we still are requiring MD approval of contours as well as plan approval; we look to stop approving contours after the first fraction by 2022.

You're going to stop physician approval of GTV/CTV/PTV contours on adaptive MRI Linac treatments in 2022? I get if you want dosimetry or physics to confirm the OARs in an adaptive workflow and only bring in physician at time of contours, plan review, and plan approval, but this seems insanely problematic. Would you trust a resident with the same responsibilities?

Will physician still have to come to the machine to sign off on the final plan, or will that be trusted to non-physicians as well? Will the physician even look at the adaptive plan or just sign off on whatever therapists and physicists have approved?

 

[MegaVoltagePhoton]

I actually do think mr Linacs could be useful and I’m always hopeful about new tech. However one of the reasons our department has not bought in is how slow adaptive is.

but I think the solution to that should be pressure on the company to make it faster…not outsourcing our clinical duties because the machinery is slow. Very bad precedent.

 

[GI_RadOnc]

You're going to stop physician approval of GTV/CTV/PTV contours on adaptive MRI Linac treatments in 2022? I get if you want dosimetry or physics to confirm the OARs in an adaptive workflow and only bring in physician at time of contours, plan review, and plan approval, but this seems insanely problematic. Would you trust a resident with the same responsibilities?

Will physician still have to come to the machine to sign off on the final plan, or will that be trusted to non-physicians as well? Will the physician even look at the adaptive plan or just sign off on whatever therapists and physicists have approved?

For the large majority of our adaptive plans (>95%), there is no change to the GTV/CTV/PTV. So, correct, we would just bring in a physician at the time of contour review, plan review and plan approval. Good point, as always.

We wouldn't do this for every patient, every fraction. We would look at starting on 2nd-5th fractions for things we do a lot of, like pancreas. And some patients are not going to have good enough imaging; the docs would be called. Or when we treat something we don't treat a lot of.

The doc would be responsible for reviewing the new contours, the plan and the dosimetry. Would they take the time to review everything in detail? We all know the answer to that... some do, and some don't - same with films, plans, OTVs etc. Same with our therapists and physicists! Everyone here is either a resident or has been through a residency; and has the same stories to tell that I do! We have been selective on the staff supervising this to date, similar to how we staff SRS/SBRT/brachy.

@MegaVoltagePhoton With regards to make the machinery faster... so we will be waiting for better adaptive contour propagation, plan generation? And we would trust this 'more' then specialized therapists and physicists?

@ROforbetterorworse And to need a residency to contour normal tissue structures; on a subsequent volumetric image? I know we talk about 'hellpit residencies' on this site; but I never had to draw all the normal structures in residency - we had either dosimetrists or the software do that; and we would edit it in those edge cases. But it quickly became like that call when you were an intern to 'start an IV on a hard stick'... the nurse with way more experience than you couldn't do it; and you're not that likely to be better than him at it!

The adaptive SBRT time slots are coming down to 60 minutes each right now for the abdomen; faster for simpler anatomy that doesn't move (like prostate). But there is definitely more room for improvement.

 

[ROforbetterorworse]

For the large majority of our adaptive plans (>95%), there is no change to the GTV/CTV/PTV. So, correct, we would just bring in a physician at the time of contour review, plan review and plan approval. Good point, as always.

We wouldn't do this for every patient, every fraction. We would look at starting on 2nd-5th fractions for things we do a lot of, like pancreas. And some patients are not going to have good enough imaging; the docs would be called. Or when we treat something we don't treat a lot of.

The doc would be responsible for reviewing the new contours, the plan and the dosimetry. Would they take the time to review everything in detail? We all know the answer to that... some do, and some don't - same with films, plans, OTVs etc. Same with our therapists and physicists! Everyone here is either a resident or has been through a residency; and has the same stories to tell that I do! We have been selective on the staff supervising this to date, similar to how we staff SRS/SBRT/brachy.

@MegaVoltagePhoton With regards to make the machinery faster... so we will be waiting for better adaptive contour propagation, plan generation? And we would trust this 'more' then specialized therapists and physicists?

@ROforbetterorworse And to need a residency to contour normal tissue structures; on a subsequent volumetric image? I know we talk about 'hellpit residencies' on this site; but I never had to draw all the normal structures in residency - we had either dosimetrists or the software do that; and we would edit it in those edge cases. But it quickly became like that call when you were an intern to 'start an IV on a hard stick'... the nurse with way more experience than you couldn't do it; and you're not that likely to be better than him at it!

The adaptive SBRT time slots are coming down to 60 minutes each right now for the abdomen; faster for simpler anatomy that doesn't move (like prostate). But there is definitely more room for improvement.

do you bill for each adaptive session?

even in the cases there is no edits?

 

[GI_RadOnc]

do you bill for each adaptive session?

even in the cases there is no edits?

Nope. No changes to the plan, no new bill. That means we can go through the whole exercise of new contours and new plans; but it doesn't show an improvement in any meaningful way and we don't bill it.

New plans, with pre-determined tolerances on why it was needed (ie, normal tissue planned at 0.5cc max dose; now exceeds 1cc at that dose, greater than 10% improvement in CTV coverage) are billed.

Of course, we are in APM zip codes. So this will become a moot point...

 

[evilbooyaa]

For the large majority of our adaptive plans (>95%), there is no change to the GTV/CTV/PTV. So, correct, we would just bring in a physician at the time of contour review, plan review and plan approval. Good point, as always.

We wouldn't do this for every patient, every fraction. We would look at starting on 2nd-5th fractions for things we do a lot of, like pancreas. And some patients are not going to have good enough imaging; the docs would be called. Or when we treat something we don't treat a lot of.

The doc would be responsible for reviewing the new contours, the plan and the dosimetry. Would they take the time to review everything in detail? We all know the answer to that... some do, and some don't - same with films, plans, OTVs etc. Same with our therapists and physicists! Everyone here is either a resident or has been through a residency; and has the same stories to tell that I do! We have been selective on the staff supervising this to date, similar to how we staff SRS/SBRT/brachy.

@ROforbetterorworse And to need a residency to contour normal tissue structures; on a subsequent volumetric image? I know we talk about 'hellpit residencies' on this site; but I never had to draw all the normal structures in residency - we had either dosimetrists or the software do that; and we would edit it in those edge cases. But it quickly became like that call when you were an intern to 'start an IV on a hard stick'... the nurse with way more experience than you couldn't do it; and you're not that likely to be better than him at it!

The adaptive SBRT time slots are coming down to 60 minutes each right now for the abdomen; faster for simpler anatomy that doesn't move (like prostate). But there is definitely more room for improvement.

OK so the auto contouring software does the GTV/CTV/PTV, then it's edited by who... therapist? Physicist?
Then, the physician comes in when the contour review is ready, and the physician is there for plan review and plan approval, I suppose?

If the physician is at least reviewing GTV/CTV/PTV contours, then OK I suppose, although with SBRT dosing you guys are way more ballsy than I would feel comfortable. I'm not overtly familiar with clinical workflow on MRI linac - is there auto contouring of GTV/CTV/PTV (or deformable registration with auto-fusion, etc.) based on scheduled contours (done by the physician)?

You say for fractions 2-5, so you're talking SBRT dosing for all your adaptive patients. Next to pancreas (since you're a GI Rad Onc). Where duodenum is. And you're considering not having the physician verify the duodenum contour for every patient, every fraction? Or are the OARs part of contour review? I can only speak for Ethos where OAR screen and GTV/CTV/PTV screens are two separate screens that you can't go back and forth on - if MR Linac workflow is different then OK.

In regards to whatever the physician is supposed to review and edit appropriately is on the physician (and the variabilities from physician, won't argue with you on that. Ideally it's the physician who initially met, simmed, planned and knows the patient and what the game plan is, with minimal cross coverage.

Sorry for the challenge, but adaptive takes up physician time (appropriately, IMO), and outsourcing out components of adaptive, especially when doing adaptive SBRT from the physician, seems unwise to me.

 

[MegaVoltagePhoton]

I would assume if you have faster and better autocontour, it will be easier for the physician to tweak and approve.

 

[Lamount]

Great....

Thanks... but no thanks.

I am not ok with someone else tweaking my plans without my approval.

 

[Neuronix]

Thanks... but no thanks.

I am not ok with someone else tweaking my plans without my approval.

Maybe I'm overcomplicating things, and honestly GI_RadOnc has more experience with adaptive radiotherapy than probably anyone, but I'm not willing to give control of the adaptive process to others.

Physics, residents, therapists can certainly assist, and I even have them take a first crack at contours (briefly so not to hold things up too much), but that's all the control I've been willing to give.

I've run into too many situations in the abdomen where things just are not what they first appear, and close scrutiny is necessary.

I suppose you might feel comfortable doing a full review at the final plan approval stage. I change way too much at the contouring stage to just come in and approve at the end. I am a perfectionist, so YMMV I guess.

 

[deleted1111261]

For the large majority of our adaptive plans (>95%), there is no change to the GTV/CTV/PTV. So, correct, we would just bring in a physician at the time of contour review, plan review and plan approval. Good point, as always.

We wouldn't do this for every patient, every fraction. We would look at starting on 2nd-5th fractions for things we do a lot of, like pancreas. And some patients are not going to have good enough imaging; the docs would be called. Or when we treat something we don't treat a lot of.

The doc would be responsible for reviewing the new contours, the plan and the dosimetry. Would they take the time to review everything in detail? We all know the answer to that... some do, and some don't - same with films, plans, OTVs etc. Same with our therapists and physicists! Everyone here is either a resident or has been through a residency; and has the same stories to tell that I do! We have been selective on the staff supervising this to date, similar to how we staff SRS/SBRT/brachy.

@MegaVoltagePhoton With regards to make the machinery faster... so we will be waiting for better adaptive contour propagation, plan generation? And we would trust this 'more' then specialized therapists and physicists?

@ROforbetterorworse And to need a residency to contour normal tissue structures; on a subsequent volumetric image? I know we talk about 'hellpit residencies' on this site; but I never had to draw all the normal structures in residency - we had either dosimetrists or the software do that; and we would edit it in those edge cases. But it quickly became like that call when you were an intern to 'start an IV on a hard stick'... the nurse with way more experience than you couldn't do it; and you're not that likely to be better than him at it!

The adaptive SBRT time slots are coming down to 60 minutes each right now for the abdomen; faster for simpler anatomy that doesn't move (like prostate). But there is definitely more room for improvement.

Makes sense, actually. The hard stick / call the intern is a completely appropriate analogy. Interesting way this field is going.. lot of potential automation. Lot of error reduction possible, too. But drawbacks, as other people are saying exist, as well. Would like to see how this works in practice, keep us posted!