What med oncs think of the rad oncs (hint: not good)

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scarbrtj

scarbrtj

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Radiation Oncologists' Role in End-Of-Life Care: A Perspective From Medical Oncologists

In a way, you kind of know as a practicing rad onc this is the way the med oncs (your referring physicians, the butterers of your bread, your lieges, your benefactors) think about rad onc but c'mon! Don't kid yourself and think this prejudicial (dare I say microaggressive) way of thinking about rad onc is confined purely to end-of-life issues. I guess two ways to think about this for a future rad onc or someone who's rad onc curious: 1) "I will enter the system and change the system; by sheer effort and shining example I will positively affect others' opinions" or 2) "Screw this."

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This perspective is silly but true. I have a genuine interest in palliative care and aiding in the transition to end of life care and really appreciate when the med oncs engage me in the process. We have great med oncs in our practice and I try to be proactive by talking to them frequently when the situation arises. I'm new-ish to the practice and I hope that overtime they will see I want to actively participate.
 
Awesome paper. Thanks for sharing. All of it is true - we see a lesion but not the patient.
 
In my experience, med onc have a negative view of us. They see us as people who did not want to round, dump on them, many rad oncs dont even prescribe pain meds and send all to med onc (even ADT). General perception, we do not like to bother with patient care. Behind closed doors, get little to no respect. Also many rad oncs just do not speak up, and have a passive personality which does not command much respect! We are the catfish doormats of oncology...
 
thecarbonionangle said:
In my experience, med onc have a negative view of us. They see us as people who did not want to round, dump on them, many rad oncs dont even prescribe pain meds and send all to med onc (even ADT). General perception, we do not like to bother with patient care. Behind closed doors, get little to no respect. Also many rad oncs just do not speak up, and have a passive personality which does not command much respect! We are the catfish doormats of oncology...
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Unfortunately, those in our specialty who are scared of doing things like discussing hospice, prescribing narcotics and ADT, getting primary specialty referrals etc have enabled those med oncs and allowed this to occur. Heck one of my now retired partners once called a PCPs office for an Ativan Rx for simulation!

Like many things, it's a product of where and when you were trained. The old timers are the most guilty of this, in my experience
 
medgator said:
Unfortunately, those in our specialty who are scared of doing things like discussing hospice, prescribing narcotics and ADT, getting primary specialty referrals etc have enabled those med oncs and allowed this to occur. Heck one of my now retired partners once called a PCPs office for an Ativan Rx for simulation!

Like many things, it's a product of where and when you were trained. The old timers are the most guilty of this, in my experience
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Unfortunately not just old timers, have seen it in young faculty too. May depend on training institution and their personalities. I have worked with multiple people over the years unfortunately who are uncomfortable/unwilling to do most basic management. Easy to see how little respect we have...
 
It’s a bit damned if you do and damned if you don’t. If you don’t, the med oncs think you’re useless. If you do, the med oncs quit using you because you eventually inexplicably piss someone off. As much as it pains me to say it, reality hits you hard bro and often the former seems a better option than the latter. Also, I will say it’s TOTALLY different when a med onc is a partner versus an outside referrer.
 
Interesting study not totally surprising but also it’s a matter of perspective. Med oncs aren’t always good gatekeepers of local control. As much as it is important to be involved in end of life planning it just pales in comparison to be an arbiter and gatekeeper of local control. They can spend their time on palliation I’ll spend my energies on locoregional control. It’s a fair balance bc not infrequently palliation is pushed incorrectly and catching this or reframing the arc can drastically alter a patients life and outlook.
 
I have very strong relationships with the medoncs in our practice. I can say unequivocally that they don't look down on us radoncs and consider us a valuable part of the care team. We prescribe narcotics, initiate hospice conversations, and do help with end-of-life care and management when appropriate. I believe any radonc who is unable/unwilling to do those things for their patients is not providing the level of care their team should be providing.

Having said that, it does make sense to have a "quarterback" of the oncology team, and it makes sense that the medonc is in that role. With some of my medoncs they really want to control things 100% and be that quarterback, and with some they appreciate the help with any and all issues we can help with. It's important to read the preferences of your referring medoncs and act accordingly, as you should with any referring physician.

They're right about one thing, though: I do not like to round.
 
Most of these things I'm honestly OK with. Maybe I'm part of the problem. I certainly think that telling a patient about hospice while they are on active chemo without discussing with the med-onc directly is not appropriate. If you discuss and there is a disagreement, then I can see it. I don't want to be the captain of the ship for a metastatic patient, and med-onc and chemo is so much more important than RT in that scenario.

Happy to be captain of the ship in any definitive case involving RT though.

If a patient needs narcs/benzos because of something related to my department, I'm going to take care of it. Ativan for simulation, narcs for H&N pain, antinausea meds for abdomen/pelvic RT, etc. However, if a patient with diffusely metastatic disease is coming with diffusely worsening pain and is already on say a fentanyl patch, am I going to unilaterally adjust that? No, I'll either need to discuss with med-onc or pain management (if they're seeing one) or prescribe breakthrough pain meds with a "hey tell your med onc the pain is worse" in addition to whatever reason they're seeing me.

Some med-oncs feel we don't take a big enough role - others feel that if we did take a bigger role it would be overstepping. Everyone is different in that regard. That being said, I feel that the most important thing in these situations where you're trying to get involved further than "radiate the painful lesion" is to have a discussion with the referring physician.
 
evilbooyaa said:
I don't want to be the captain of the ship for a metastatic patient, and med-onc and chemo is so much more important than RT in that scenario.

Happy to be captain of the ship in any definitive case involving RT though.

If a patient needs narcs/benzos because of something related to my department, I'm going to take care of it. Ativan for simulation, narcs for H&N pain, antinausea meds for abdomen/pelvic RT, etc. However, if a patient with diffusely metastatic disease is coming with diffusely worsening pain and is already on say a fentanyl patch, am I going to unilaterally adjust that? No, I'll either need to discuss with med-onc or pain management (if they're seeing one) or prescribe breakthrough pain meds with a "hey tell your med onc the pain is worse" in addition to whatever reason they're seeing me.

Some med-oncs feel we don't take a big enough role - others feel that if we did take a bigger role it would be overstepping. Everyone is different in that regard. That being said, I feel that the most important thing in these situations where you're trying to get involved further than "radiate the painful lesion" is to have a discussion with the referring physician.
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Well said. I generally Captain on h&n, anal, dcis etc
 
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scarbrtj said:
It’s a bit damned if you do and damned if you don’t. If you don’t, the med oncs think you’re useless. If you do, the med oncs quit using you because you eventually inexplicably piss someone off. As much as it pains me to say it, reality hits you hard bro and often the former seems a better option than the latter. Also, I will say it’s TOTALLY different when a med onc is a partner versus an outside referrer.
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Maybe, maybe not. I think it comes down to the individual referring relationship.

Regardless of that relationship, you should be able to manage the toxicities you cause to your own patient without needing a med onc, outside of maybe sending them over for fluids
 
Communication is the key, as with many things. I respect my colleagues enough to approach them before I have the hospice discussion. But I have had the hospice discussion numerous times. I have put dozens of people in same day hospice during my consultative visit even if long standing med onc patients. I feel like sometimes med oncs will miss the forest for the trees. Radiographic progression? Another drug available? Do it! Yeah, but the patient weighs 90 pounds and wishes to just sleep all day so they don't hurt. Sometimes a fresh set of eyes and ears helps.
 
I will say, as a resident (less so as an attending but that’s because my med onc is so good and I practice primarily head and neck), I was often if not usually, the first and only person to tell a patient their metastatic cancer was not curable both as inpatients and outpatients. I also discuss dismal prognosis upfront. This process is something I have seen many med oncs ignore until people are at their inevitable last hospitalization. Patients are floored by this.

Ultimately as physicians ensuring people live high quality lives is as, if not more, important than nominal improvements in survival (I.e. the long list of therapies that increase median survival by a month). This is one reason locoregional therapy is so important. Pelvic failure or bone disease or head and neck local failure or thoracic local failure are terrible for quality of life even if sometimes the data doesn’t support they increase quality. Who cares if you may not increase OS with rectal RT. How many of us have seen horrible pelvic recurrences? An NNT of 20 for local failure for something as easy as 5 x 5 is still saving people a lot of misery.

Final rant against med oncs: the MA 20 and EORTC trials in breast shows a few percent increase in DFS for a very well tolerated treatment in a relatively low risk population. Other than the very small risk of a catastrophic secondary malignancy, with modern therapy techniques, this treatment is non-toxic and cheap. This is on par with the DFS benefit of adding paclitaxel to AC. Respect the benefit of RT. Too many med oncs and surgeons still believe RT is in the 2D cobalt days...
 
gmsquid said:
I will say, as a resident (less so as an attending but that’s because my med onc is so good and I practice primarily head and neck), I was often if not usually, the first and only person to tell a patient their metastatic cancer was not curable both as inpatients and outpatients. I also discuss dismal prognosis upfront. This process is something I have seen many med oncs ignore until people are at their inevitable last hospitalization. Patients are floored by this.
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Happens quite often in most RO clinics when discussing brain mets I imagine....
 
As others have said it's a double edged sword. I am realistic with my patients and I make sure they understand when their disease is curable and when it is not. I also make sure they have a realistic expectation of therapy.

With regards to pain control: I am happy to manage patients' pain during treatment and beyond. However, I don't believe that I should be the point person on this when, say, they are receiving 6 months of adjuvant chemo or lifelong immunotherapy. We all manage pain differently and I don't want to mess with someone else's pain plan and create a too many cooks in the kitchen kind of situation. It's in the patient's best interest for this to be taken care of by the physician that is actively caring for them and it's fewer appointments for them.

With regards to end of life discussions, again it is a tricky situation. The radiation oncologist's role in end of life treatment is for palliation of symptoms. This is something that improves quality of life but does not typically prolong it. I think that when there are no more REASONABLE systemic options it is appropriate to discuss hospice, and I am not the person that makes this determination. I can guarantee that my medical oncologists would be pretty pissed off if I convinced all their patients to initiate hospice when they were still considering systemic treatments.

This is particularly tough as a resident because you really don't interact a whole lot directly with other attendings. That being said, as an attending I have a great relationship with my medical oncologists and if we both feel it is appropriate I'm happy to have these discussions and I often do.
 
RSAOaky said:
With regards to end of life discussions, again it is a tricky situation. The radiation oncologist's role in end of life treatment is for palliation of symptoms. This is something that improves quality of life but does not typically prolong it. I think that when there are no more REASONABLE systemic options it is appropriate to discuss hospice, and I am not the person that makes this determination. I can guarantee that my medical oncologists would be pretty pissed off if I convinced all their patients to initiate hospice when they were still considering systemic treatments.
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Systemic therapy may take a backseat to bad intracranial disease in a patient with a borderline or bad PS. Usually that's where I'll touch base with MO and give my 2 cents
 
To be fair, I believe these feelings can go both ways. I’ve seen med oncs push chemo on patients too far and I’ve also had med oncs allow patients to experience a neurological death or dying with uncontrolled pain, a preventable cord compression due to making the call on when to use and not use radiation therapy. The vast majority are reasonable but similar to any field in medicine, there will always be bad players.

In my experience (~5 yrs post residency), it’s usually the older more “experienced” med oncs that always seem to know more about the side effects of radiation when everything was based on 2D planning... but whatevs!
 
all I EVER think about the med oncs when I see them in overworked clinics before going to round when they're on service is 'You Poor Sap'.

How you handle this stuff as a rad onc all depends on whether you entered this field to become a technician or an oncologist. It's up to you. We've all seen examples of both.

What we as a good rad onc should want all med oncs to know/hear:

 
RadOncDoc21 said:
In my experience (~5 yrs post residency), it’s usually the older more “experienced” med oncs that always seem to know more about the side effects of radiation when everything was based on 2D planning... but whatevs!
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My biggest pet peeve - med oncs who say "I'm going to send you over to the radiation therapist for radiation" like they're the ones prescribing the damn thing. Of course it's always somebody in their 60s who really should retire, and still advocates for chemo regimens that are 2 regimens old and doesn't stay up to date on current data.
 
But, aren't they pretty much prescribing? I mean we ultimately make the call, but will never see the patient if the medonc doesn't want us to. I don't blame them for viewing us the way they do. Look at Twitter interactions. The radiation oncologists are followers. They're panderers. That's what we should change our name to. Pandering Oncologist.
 
evilbooyaa said:
My biggest pet peeve - med oncs who say "I'm going to send you over to the radiation therapist for radiation" like they're the ones prescribing the damn thing.
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Not that long ago, geologically speaking, this is exactly what would happen: another physician would send the patient down to radiation therapy to see the radiation therapist, who was a radiologist, for so-and-so rads to wherever for whatever. This changed for a host of reasons; the prescribers never got anything of value out of doing the prescribing, medicine became more specialized, medicolegally it became invidious for the prescribers, the therapeutic radiologist became a radiation oncologist, (garbage men became sanitation engineers), etc and etc. For us, in our world, the culture has moved far past this antediluvian mindset. But that idea of "sending to the radiotherapists for radiation" was a real thing. So it probably lingers on, lurking in the recessed psyches of specialties outside of ours. Much like a doctor might send a patient, now (and it has always been this way), to the radiologist for a chest X-ray. So I don't totally hate it when the med onc says something like that. But then in talking with the med onc one day in the future I just make sure to drop a subtle conversational turd in the care discussion pool such as: "Are you sure there's a benefit to poisoning the patient at this stage?"
 
scarbrtj said:
Not that long ago, geologically speaking, this is exactly what would happen: another physician would send the patient down to radiation therapy to see the radiation therapist, who was a radiologist, for so-and-so rads to wherever for whatever. This changed for a host of reasons; the prescribers never got anything of value out of doing the prescribing, medicine became more specialized, medicolegally it became invidious for the prescribers, the therapeutic radiologist became a radiation oncologist, (garbage men became sanitation engineers), etc and etc. For us, in our world, the culture has moved far past this antediluvian mindset. But that idea of "sending to the radiotherapists for radiation" was a real thing. So it probably lingers on, lurking in the recessed psyches of specialties outside of ours. Much like a doctor might send a patient, now (and it has always been this way), to the radiologist for a chest X-ray. So I don't totally hate it when the med onc says something like that. But then in talking with the med onc one day in the future I just make sure to drop a subtle conversational turd in the care discussion pool such as: "Are you sure there's a benefit to poisoning the patient at this stage?"
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I send patients to the "chemotherapist" for chemo all the time. Not sure what the big deal is. I'll sometimes even drop the drug I was thinking of in my note and/or referral order (when it comes to head and neck, anal etc).
 
Some peoples minds can't be changed. We don't do inpatient medicine and don't "pay our dues" like surgeons and med oncs and there are some people who just won't see it otherwise.

But in my experience (both personal and observational) being an outstanding general oncologist with a deep understanding of issues related to common surgeries and systemic therapies can go a long way toward helping get a seat at the grown up table. Particularly in large centers with lots of specialization. In a lot of ways we are often the closest to a generalist of the three disciplines. For me, Gyn Onc was the toughest nut to crack but I think three things got me a full seat at the table. First, I sat back and took my time observing the lay of the land and figuring out how everyone operated. Easily the best advice I got leaving residency. Second, I know my data and was confident to hold my ground when appropriate. Third, I can speak to the work up, natural history, and treatment of most cancers (including pediatrics and lymphomas). It is possible to make up some ground and fight perceptions. Not always obviously, but some times at least.
 
The wonderful thing about practicing radiation oncology is the freedom to choose how to practice based on your interests and environment. For some, it may be most appropriate to delegate some of the end of life responsibilities to the medical oncologist. For others, it's more appropriate to take a more active role.

If the relationship with medical oncology is strained, it's probably not just because of this particular issue. In my experience, even skeptical medical oncologists can be won over with time, respect, education about modern radiotherapy methods (i.e. demonstrating successful outcomes in mutual patients, making sure to include screenshots in treatment summaries that show the precision of modern RT plans) and frequent verbal communication (whether in person or by getting on the phone). Like any relationship, you get out of it what you put into it.
 
This is exactly right, and a reason why RadOnc had become so competitive in 2000's. It's an opportunity to delegate patient care to others, while maintaining the benefits of being reimbursed/treated/counted as a physician.

bobloblaw said:
The wonderful thing about practicing radiation oncology is the freedom to choose how to practice based on your interests and environment. For some, it may be most appropriate to delegate some of the end of life responsibilities to the medical oncologist. For others, it's more appropriate to take a more active role.

If the relationship with medical oncology is strained, it's probably not just because of this particular issue. In my experience, even skeptical medical oncologists can be won over with time, respect, education about modern radiotherapy methods (i.e. demonstrating successful outcomes in mutual patients, making sure to include screenshots in treatment summaries that show the precision of modern RT plans) and frequent verbal communication (whether in person or by getting on the phone). Like any relationship, you get out of it what you put into it.
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