ACGME Proposed Changes

[Mandelin Rain]

These things are common sense. I wonder why they remain fringe and not already being done? What is the issue as people see it

When something is going on that makes no logical sense it's either because it enriches someone in power or it's "just how things have always been done".

I guess in some cases, it's both.

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[GapCalc]

Does anyone else get the sense that our “leadership” is just too weak to be effective in protecting the interests of the field and it’s current and future physicians? They matched at a time when a pulse was enough to join the ranks of the academic elite (in the basement), and when RT became big $$$, they suddenly found themselves in positions of considerable influence. Cancer care became a profit center for hospitals. The era of IMRT made hospital executives take notice of our subterranean existence. Radiation Oncology chairs got the funding they wanted for the residents they never actually needed.

A friend in an ortho residency recently told me his field rarely expanded because their Residency Review Committee is extremely careful about approving expansions or new programs. As far as I can tell, no one has sued for anti-competitive behavior. What’s to stop our field, except a lack of will?

 

[Phantom1]

Knowing that watch dial painters died of leukemia, or when some one would die (and from what) if exposed to a whole body 100Gy, 6Gy, 2Gy in the event of a nuclear war is not something I've incorporated into my practice. Nor is the Taqman assay or RET pathway or any of the other stuff they've just stapled on last year. These are things that may interest radiation biologists but obviously have nothing to do with the minimal competency for a safe clinical radiation oncologist, and should simply be thrown out of any didactic/book/exam we're exposed to.

Sorry, you are wrong here. These topics you mentioned are very important education and general knowledge in order to call yourself an expert radiation oncologist. What if there was a patient incident or exposure to a radioactive source, your colleagues and hospital may turn to you as a radiation oncologist and expect you to have some knowledge about radiation exposure, syndromes, and risk. This is not just for a nuclear war. The fact that radiation equipment has gotten much safer does not preclude your need to understand the risks and consequences of exposure.

We already have to work to maintain professional respect among our colleagues and not be called “radiation therapists”. So this general education is very important.

 

[MadamCurie]

There is definitely some value to knowing basic RadBio. Understanding serial vs parallel OARs. Being able to do a quick EQD2 calculation and the concept of a/B for iso-effectiveness and the inherent uncertainties that come with it. Radiation sensitivity syndromes seem important. Understanding how radiation works to kill cancer cells, as patients will ask. Struggling to come up with other examples, but I'm sure they exist.

Knowing that watch dial painters died of leukemia, or when some one would die (and from what) if exposed to a whole body 100Gy, 6Gy, 2Gy in the event of a nuclear war is not something I've incorporated into my practice. Nor is the Taqman assay or RET pathway or any of the other stuff they've just stapled on last year. These are things that may interest radiation biologists but obviously have nothing to do with the minimal competency for a safe clinical radiation oncologist, and should simply be thrown out of any didactic/book/exam we're exposed to.

Mostly agree, however I do think that basic knowledge of important signaling pathways and what they do can be useful.

For example, you're listening to a talk where somebody is discussing their new favorite targeted drug that is a "CDK4 inhibitor". I feel a radiation oncologist should be able to make the association, "Hmmm, CDK4...oh yeah, that has something to do with cell cycle regulation, so inhibiting it as a clinical strategy would interfere with cell proliferation, hopefully more so in tumor cells than normal ones." PERIOD. That should be sufficient knowledge – along with the clinical indications and a side effects profile for the drug – for the rad onc to make an informed decision as to whether she or he would give such a drug to their patients in combination with radiotherapy.

No signaling pathway intermediates or accessory proteins, no phosphorylation sites on such-and-such an amino acid residue, no mechanisms of protein up or down-regulation and gene silencing strategies, no detailed mechanism(s) of action of the inhibitor, no in depth knowledge of the minutiae of how cells become drug resistant, etc.


(P.S. - The radium dial painters mostly died of bone sarcomas, not leukemia. )

 

[Mandelin Rain]

Sorry, you are wrong here. These topics you mentioned are very important education and general knowledge in order to call yourself an expert radiation oncologist. What if there was a patient incident or exposure to a radioactive source, your colleagues and hospital may turn to you as a radiation oncologist and expect you to have some knowledge about radiation exposure, syndromes, and risk. This is not just for a nuclear war. The fact that radiation equipment has gotten much safer does not preclude your need to understand the risks and consequences of exposure.

We already have to work to maintain professional respect among our colleagues and not be called “radiation therapists”. So this general education is very important.

I'm struggling to understand if this is sarcasm or not.

We are oncologists. We treat cancer. With radiation. We are not hazmat teams. If in the event of reactor explosion or bomb dropping, you stick around to triage exposed patients just so you're not seen as a therapist in the doctor lounge, more power to you. I'm running with everyone else, and would be whether or not I knew I'd die within 2 weeks due to massive GI fluid loss at 6 Gy. I don't think surgeons are required to learn the outcome of every blade related injury/accident through history. I guess, if you somehow give someone an unplanned TBI exposure it may be embarrassing to have to do a quick lit search to figure it out, but that hardly seems like your greatest concern in the situation.

EDIT: I've been called once on something tangentially related to this. After an I-131 treatment in nuc med, a patient wet their bed. The staff took the urine soaked sheets, put them in the normal bag and the linen company took them away. A couple hours later, someone realized this was the wrong thing to do. For some reason, they paged me. Unfortunately, nothing in my oncologic training allowed me to offer them advice on this radiation/linen based accident beyond what a lay person would. Contact the RSO. Contact the linen company.

 

[Mandelin Rain]

(P.S. - The radium dial painters mostly died of bone sarcomas, not leukemia. )

The ABR claims another failure.

 

[thecarbonionangle]

Sorry, you are wrong here. These topics you mentioned are very important education and general knowledge in order to call yourself an expert radiation oncologist. What if there was a patient incident or exposure to a radioactive source, your colleagues and hospital may turn to you as a radiation oncologist and expect you to have some knowledge about radiation exposure, syndromes, and risk. This is not just for a nuclear war. The fact that radiation equipment has gotten much safer does not preclude your need to understand the risks and consequences of exposure.

We already have to work to maintain professional respect among our colleagues and not be called “radiation therapists”. So this general education is very important.

LMAO you ACTUALLY believe this mate? WOW

 

[thecarbonionangle]

Does anyone else get the sense that our “leadership” is just too weak to be effective in protecting the interests of the field and it’s current and future physicians? They matched at a time when a pulse was enough to join the ranks of the academic elite (in the basement), and when RT became big $$$, they suddenly found themselves in positions of considerable influence. Cancer care became a profit center for hospitals. The era of IMRT made hospital executives take notice of our subterranean existence. Radiation Oncology chairs got the funding they wanted for the residents they never actually needed.

A friend in an ortho residency recently told me his field rarely expanded because their Residency Review Committee is extremely careful about approving expansions or new programs. As far as I can tell, no one has sued for anti-competitive behavior. What’s to stop our field, except a lack of will?

Ya we have some very weak low energy people in leadership who got in back in day by stumbling into the department in the basement, now want to lecture residents on not being smart and not having a good work ethic. IRONY???

 

[thecarbonionangle]

I'm struggling to understand if this is sarcasm or not.

We are oncologists. We treat cancer. With radiation. We are not hazmat teams. If in the event of reactor explosion or bomb dropping, you stick around to triage exposed patients just so you're not seen as a therapist in the doctor lounge, more power to you. I'm running with everyone else, and would be whether or not I knew I'd die within 2 weeks due to massive GI fluid loss at 6 Gy. I don't think surgeons are required to learn the outcome of every blade related injury/accident through history. I guess, if you somehow give someone an unplanned TBI exposure it may be embarrassing to have to do a quick lit search to figure it out, but that hardly seems like your greatest concern in the situation.

EDIT: I've been called once on something tangentially related to this. After an I-131 treatment in nuc med, a patient wet their bed. The staff took the urine soaked sheets, put them in the normal bag and the linen company took them away. A couple hours later, someone realized this was the wrong thing to do. For some reason, they paged me. Unfortunately, nothing in my oncologic training allowed me to offer them advice on this radiation/linen based accident beyond what a lay person would. Contact the RSO. Contact the linen company.

Agree. Our field has this massive inferiority complex where people think they have to know all these things. We are surgeons, radiation safety officers, physicists, med oncs, you name it! Yet, all this bending the knee has gotten us nothing, remain the catfishes of oncology, hoping that some morsels of the meal trickle down to us!

some things are important to know but lets focus on practical things to know about other fields and disciplines. Nobody is staying around and dying of GI syndrome after "little rocket man" sends a gift to the orange man.

 

[scarbrtj]

These topics you mentioned are very important education and general knowledge in order to call yourself an expert radiation oncologist. What if there was a patient incident or exposure to a radioactive source, your colleagues and hospital may turn to you as a radiation oncologist and expect you to have some knowledge about radiation exposure, syndromes, and risk. This is not just for a nuclear war

Yes I agree. Also, what if Hollywood came calling and wanted some scientific advisory help in crafting a screenplay about some sort of nuclear accident or using a linac as a murder weapon? Who would the movie studios turn to if not a radiation oncologist?

Grey's Anatomy is hiring surgeons to help craft their show's story lines. If there's ever a TV series about the exciting field of radiation oncology, I wanna be the guy who's there getting all the glory...

MARY: Robert, you don't love me anymore and your lack of appreciation for the linear quadratic formula proves it.
ROBERT: You know that equation has as many problems as you and I do in the bedroom!
MARY: Damn you Robert. I wish I could perform radiosurgery on the spot you hold in my heart.

 

[Phantom1]

Well its easy to make jokes, the fact of the matter is if you dont want to be an expert in your field and know more than just what you immediately need to do your job, then you are a technician. God forbid you know how chemotherapy works or why it radiosensitizes to help cure patients.

I agree that Rad Bio boards should not be tested on minutia. Understanding why and how someones dies when exposed to excess radiation is not minutia, especially when you are a radiation oncologist!

 

[scarbrtj]

Well its easy to make jokes, the fact of the matter is if you dont want to be an expert in your field and know more than just what you immediately need to do your job, then you are a technician. God forbid you know how chemotherapy works or why it radiosensitizes to help cure patients.

I agree that Rad Bio boards should not be tested on minutia. Understanding why and how someones dies when exposed to excess radiation is not minutia, especially when you are a radiation oncologist!

No one is calling the rad onc in case of a “chemo accident,” although we arguably learn way more bits and bytes of knowledge about chemo than we do radiation syndromes and radiation protection. Why? We never treat chemo misadmins, don’t routinely give chemo, etc. Now not to say that learning stuff is not good. Knowledge for knowledge’s sake is great. But in the case of a patient with hematopoietic syndrome or GI syndrome, the radiation oncologist never treats that. Doesn’t perform the bone marrow transplant, doesn’t administer fluids or supportive care, etc. So is one really an expert in something wherein one can make no tangible real-world impacts with all of one’s expertise? We keep piling on “expertise” in rad onc training which the rad onc never uses. I had some romantic notions prior to rad onc training that somehow I would be a radiation expert and know what to do and how to do it for radiation accidents and that sort of thing. Those notions were dispelled in time. Osler said the physician who studies medicine without books sails an uncharted sea, but the physician who studies medicine without books patients never goes to sea at all. Rad oncs get seduced by the book instead of the boat, or at the very least stand on shore saying to other sailors “Have you read this book?!”

 

[Chartreuse Wombat]

No one is calling the rad onc in case of a “chemo accident,” although we arguably learn way more bits and bytes of knowledge about chemo than we do radiation syndromes and radiation protection. Why? We never treat chemo misadmins, don’t routinely give chemo, etc. Now not to say that learning stuff is not good. Knowledge for knowledge’s sake is great. But in the case of a patient with hematopoietic syndrome or GI syndrome, the radiation oncologist never treats that. Doesn’t perform the bone marrow transplant, doesn’t administer fluids or supportive care, etc. So is one really an expert in something wherein one can make no tangible real-world impacts with all of one’s expertise? We keep piling on “expertise” in rad onc training which the rad onc never uses. I had some romantic notions prior to rad onc training that somehow I would be a radiation expert and know what to do and how to do it for radiation accidents and that sort of thing. Those notions were dispelled in time. Osler said the physician who studies medicine without books sails an uncharted sea, but the physician who studies medicine without books never goes to sea at all. Rad oncs get seduced by the book instead of the boat, or at the very least stand on shore saying to other sailors “Have you read this book?!”

but the physician who studies medicine without books patients?

 

[Lamount]

I may be in the minority here, but I think there is value in learning radiation biology. Sure, we may not use it in clinic every day, but is has undoubtedly informed many of our standards of care... and can help keep you out of trouble when you need to adapt to an atypical situation. It's like long division... you should probably learn how to do it at some point before becoming completely dependent on calculators. Radiation is our drug, and this is our pharmacology.

 

[Carotenoid]

I may be in the minority here, but I think there is value in learning radiation biology. Sure, we may not use it in clinic every day, but is has undoubtedly informed many of our standards of care... and can help keep you out of trouble when you need to adapt to an atypical situation. It's like long division... you should probably learn how to do it at some point before becoming completely dependent on calculators. Radiation is our drug, and this is our pharmacology.

If we had unlimited time, sure, there are lots of cool things to learn. But let's be honest, rad bio is a luxury - great to have in theory but not at the expense of other more basic things we currently have no training in, like radiology or the technicalities of how the machines run, are calibrated etc. In my residency, there was exactly zero training re: what's going on at the machine. Sure, on your own time you went and bugged the physicists - but this for sure must be in the curriculum.

 

[Mandelin Rain]

Do surgeons know how the iron ore that creates the steel that made their scalpels is mined? Have they toured the scalpel making facilities? Are they tested on bovie thermodynamics?

A basic understanding of rad bio and physics is very important. None of it is more important than knowing how to threat the patient in front of you though.

I submit, it would be much more useful to spend two hours a week at the linac watching therapists set up patients to understand the uncertainties of translating a highly conformal plan to a real world situation, or two hours in dosimetry to see whats is/isn't possible in treatment planning, than it is to spend two hours a week learning about alpha vs beta emission or how technetium 99 is created.

We pretend like this stuff matters, because ultimately, 97% of what we do is draw circles around increasing obvious tumors. Got to keep the mystique high.

 

[Mandelin Rain]

A chemo truck tipped over on the freeway spilling thousands of gallons of cisplatin onto the highway. Fortunately, the area's 17 local medical oncologists responded quickly to clean up the incident.

 

[scarbrtj]

I submit, it would be much more useful to spend two hours a week at the linac watching therapists set up patients to understand the uncertainties of translating a highly conformal plan to a real world situation, or two hours in dosimetry to see whats is/isn't possible in treatment planning, than it is to spend two hours a week learning about alpha vs beta emission or how technetium 99 is created.

You just made some heads explode man.

 

[radbioistheworst]

A basic understanding of rad bio and physics is very important. None of it is more important than knowing how to threat the patient in front of you though.

I submit, it would be much more useful to spend two hours a week at the linac watching therapists set up patients to understand the uncertainties of translating a highly conformal plan to a real world situation, or two hours in dosimetry to see whats is/isn't possible in treatment planning, than it is to spend two hours a week learning about alpha vs beta emission or how technetium 99 is created.

You really think that’s more pertinent than knowing that the active form of ATM is a monomer and not, in fact, a dimer?

Good luck curing prostate cancer without that clinical pearl

 

[Gfunk6]

A chemo truck tipped over on the freeway spilling thousands of gallons of cisplatin onto the highway. Fortunately, the area's 17 local medical oncologists responded quickly to clean up the incident.

Too bad they can't just call the Taq man to do it like we can

 

[evilbooyaa]

Too bad they can't just call the Taq man to do it like we can

Nananananananananana Taq Man!

Do surgeons know how the iron ore that creates the steel that made their scalpels is mined? Have they toured the scalpel making facilities? Are they tested on bovie thermodynamics?

A basic understanding of rad bio and physics is very important. None of it is more important than knowing how to threat the patient in front of you though.

I submit, it would be much more useful to spend two hours a week at the linac watching therapists set up patients to understand the uncertainties of translating a highly conformal plan to a real world situation, or two hours in dosimetry to see whats is/isn't possible in treatment planning, than it is to spend two hours a week learning about alpha vs beta emission or how technetium 99 is created.

We pretend like this stuff matters, because ultimately, 97% of what we do is draw circles around increasing obvious tumors. Got to keep the mystique high.

Anyways, on topic, completely agree with this. Especially the bolded. I'd say it's only 80%. The other 20% is drawing circles around areas where there ISN'T obvious tumor (elective nodal irradiation)