What does your documentation look like in 2022?

[deleted1111261]

Good to know.

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[DrZap]

Yeah, I think we're going to pretty significantly disagree on the whole "shared decision making isn't something I value with my patients" thing... So you did discuss APBI, but didn't document it as an option? I will correct a resident who 1) documents something that was not done or 2) does not document something that was done and is clinically relevant.

Observation not an option for this low-risk DCIS patient as per RTOG 9804? Because of a LC benefit?
Do all of your 65-70+ T1N0 IDC patients get RT too, no discussion about observation?

How does anyone know you talked about side effects? The amount of times I've seen a patient in follow-up or covering and the patient has ZERO idea of what toxicities to expect is astronomically high. The PCPs are not calling you about RT toxicity because they're telling their patients it's because of it! This is like the entire reason we still have so many people in the current generation who as either laymen or even other physicians are so incredibly biased against RT.

If you write a barebones note in a paternalistic manner with zero description of the thought process and lack of nuance necessary for clinical situations, it makes you sound like a boomer rad onc. Now you and I both know that you're not a boomer rad onc when it comes to planning based on your post history, but how would you expect anyone who reads THAT A/P to think that you would do anything differently than a boomer?

Your note sounds like this to me: "Patient has L Breast DCIS. Got surgery. To receive radiation. Thank you for this interesting consult." Bill 99205.

I describe the convo about alternatives when applicable, mostly so referring docs are aware I’m not just phoning it in

 

[seper]

Note writing art across all specialties has taken a dive since mandatory EMR (early 2010's I guess). It is now so bad that pertinent Oncology info lives outside of doctor's notes. Embrace the new world and let the old ways go.

 

[Fpg1245]

Note writing art across all specialties has taken a dive since mandatory EMR (early 2010's I guess). It is now so bad that pertinent Oncology info lives outside of doctor's notes. Embrace the new world and let the old ways go.

The records are just so bad. It’s almost completely made up at this point. Copy forward a billion times can’t even tell what’s true anymore

 

[deleted1111261]

The records are just so bad. It’s almost completely made up at this point. Copy forward a billion times can’t even tell what’s true anymore

This is where narrative / time based has advantages, as the story is a story, not a mish mash of copy pasta and unimportant labs and imaging

 

[deleted1116990]

I am slowly moving away from the "Shared decision making" thing as I progress more and more into my career. Yes, I was taught this as well and accepted it as proper as a trainee, but I am realizing that it has some flaws.

Airplane passengers care about getting from point A to point B. The pilot doesn't come back and have a conversation with everyone about which route they are going to take, what kind of approach and what runway to land on, etc. He figures out in his judgement the best way to get to point A to B. Obviously, there is more nuance in medical decision making but it illustrates the point. So I tend to have a conversation with the patient about what the goals are, what risk side effect tolerance exists, etc, and then try to make a recommendation. If that recommendation is met with reservation, I discuss alternatives. I have moved away from the hour long, lets discuss every permutation of treatment regimens of prostate cancer per the NCCN chart and the data that supports them, which I used to do and document as such. If it's a high risk patient with existing urinary symptoms and a large prostate, I am going to flat out recommend 45 fractions, yes. If the patient says no that's too long, I think I'll take the cyberknife center up on their offer for 5 fractions instead and take my chances, I'll say, ok well here are some alternatives I can offer you if you are declining my official recommendation.

 

[seper]

This is where narrative / time based has advantages, as the story is a story, not a mish mash of copy pasta and unimportant labs and imaging

you guys were just scolding me for wanting an oncology textbook... narrating disease history is just as ancient.
Gotta go straight for Oncology History bullet points in Epic

 

[deleted1111261]

you guys were just scolding me for wanting an oncology textbook... narrating disease history is just as ancient.
Gotta go straight for Oncology History bullet points in Epic

Ha!
I’m a fiction reader. Want some flow and some ups and downs. Maybe some tension

 

[RadOncDoc21]

I like how everything is starting to get streamlined more. I’m a big fan of virtual tumor board and meetings in which I can actually get things done more efficiently.

I actually haven’t even physically met my main referral docs and they keep feeding me.

 

[evilbooyaa]

I am slowly moving away from the "Shared decision making" thing as I progress more and more into my career. Yes, I was taught this as well and accepted it as proper as a trainee, but I am realizing that it has some flaws.

Airplane passengers care about getting from point A to point B. The pilot doesn't come back and have a conversation with everyone about which route they are going to take, what kind of approach and what runway to land on, etc. He figures out in his judgement the best way to get to point A to B. Obviously, there is more nuance in medical decision making but it illustrates the point. So I tend to have a conversation with the patient about what the goals are, what risk side effect tolerance exists, etc, and then try to make a recommendation. If that recommendation is met with reservation, I discuss alternatives. I have moved away from the hour long, lets discuss every permutation of treatment regimens of prostate cancer per the NCCN chart and the data that supports them, which I used to do and document as such. If it's a high risk patient with existing urinary symptoms and a large prostate, I am going to flat out recommend 45 fractions, yes. If the patient says no that's too long, I think I'll take the cyberknife center up on their offer for 5 fractions instead and take my chances, I'll say, ok well here are some alternatives I can offer you if you are declining my official recommendation.

Not to derail, but - Can I ask why, on the bolded? Besides simply just 'dogma'? Anyone you're just 'flat our recommending' 20-28 fractions to?

I find that most patients won't tell you no to your face - they'll say they'll think about it, get a second opinion, and you may never see that patient again. Even the folks I see as a second opinion.... when I call their Rad Onc to discuss the original plan I can hear the surprise most of the time that the patient sought a second opinion at all...

 

[ramsesthenice]

Was a consultant in a lawsuit that revolved around this point. Patient had a surgery with a poor outcome. Sued bc patient said surgeon did not discuss alternatives (RT). No documentation that alternatives were discussed. Never saw a rad onc prior to surgery. Surgeon lost.

Probably enough to say you discussed alternatives without specifying, particularly if patient has seen other specialist.

This is the way it can help. Most successful cases are based on negligence and lack of documentation can present a compelling case.

What people get wrong is assuming good documentation will save you in tricky situations. And it could! If you don’t acknowledge something is non-standard then it’s quite easy to present a case of negligence. So clearly smart to do it. But, that same documentation can be used to support the notion that you knew something was risky and you did it anyways. Which can also be interpreted as negligence. The good news is we don’t get sued that often.

Honestly, level of documentation depends on where you are and what you are trying to do. There is no one size fits all. If I were somewhere that no one was ever going to read them (and they definitely exist) then I would do the minimum. Every. Time. I’m in a place people do read them and I have been told by more than one referring MD they specifically refer to me because my notes are brief but clearly articulate my thinking and the overall plan. It helps my referral base so I am probably more detailed in my thinking than some. But to be clear, I don’t site papers or give detailed talks about fractionation etc unless there is a very compelling reason to do so (like patient has an artificial heart valve with very high bleeding risk and no increased risk of late GI toxicity is acceptable). its not a review paper and I hate overly detailed templates. We all know there are a lot of options for prostate cancer. But as the note writer, you (usually) know what the patient us opting for. I just list EBRT over several weeks, SBRT, or Brachy as options. If the patient is a good candidate for SBRT or Brachy and that’s what they want to do then who gives a **** about conventional vs hypofrac?

 

[deleted1116990]

Not to derail, but - Can I ask why, on the bolded? Besides simply just 'dogma'? Anyone you're just 'flat our recommending' 20-28 fractions to?

I find that most patients won't tell you no to your face - they'll say they'll think about it, get a second opinion, and you may never see that patient again. Even the folks I see as a second opinion.... when I call their Rad Onc to discuss the original plan I can hear the surprise most of the time that the patient sought a second opinion at all...

I used to treat a lot of prostate with probably a 50-50 mixture of 45 and 20 fractions, and the conventional guys sailed through treatment with zero complaints. The 20 fraction guys usually had acute urinary issues.

In some cases I will recommend SBRT, such as a patient with logistical issues or an older patient who doesn't really need treatment but insists on it anyway, and they meet NCCN guidelines for treatment as an option. In one case I had a patient with early stage Alzheimer's with Gleason 10 disease. Not treating didn't make sense nor did pelvic RT + BT boost + ADT. He had trouble with treatments. 5 fractions made the most sense for him IMO to prostate only, and that's what I recommended.

I usually frame it as, "there are a number of different, options, but I think this is good one for you..." I do the same thing with breast. a 64 year old with stage I luminal A, I "flat out recommend" 5 fraction APBI.