Do you ever miss inpatient care?

[Raygun77]

Howdy,

My understanding is that rad-onc has a lot of outpatient hospital clinic as well as procedure planning, but not so much in the actual wards. This may be totally off; beyond one or two PBLs radiation oncology hasn't even come up in my course yet, though we're doing our micro, immu and cancer semester now.

To be honest, one thing I love about medicine is the ward dynamic. I like the team-care idea- being part of something bigger than yourself, and I can see myself enjoying medical management. In hospitals I've been in, the medical ward just carries with it an energy (which may be ironic).

Anyway, I do have a few questions to follow up that spiel-

Is there much medical management of patients as a radiation oncologist? For example, would the rad onc be the one prescribing say, opiates, anti-emetics and anxiety/depression medication if such was necessary, or would that all fall to the med oncologist?

Is there any ward work as a rad onc?

Do any of you miss the inpatient experience, or is (in your eyes) outpatient clinic the way to go?

Any thoughts would be appreciated!

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[Palex80]

I'm not sure how the situation is in the US, but in Europe radiation oncology clinics often have wards, where patients currently receiving radation treatment are hospitalised.
Usually this results in other wards sending multimorbid patients to the radiation oncologists' ward, who are receiving palliative treatment. Therefore the work load can be substantial, when you have to deal with huge recurrent, bleeding and painful tumours or patients with brain metastasis, glioblastoma, intraspinal tumours.
Apart from that H&N patients often land in the wards, because of treatment toxicity.
In my previous clinic the radiation oncologists took care of the chemo, whenever simultaneous radiochemo was to be delivered. So we did lots of Cisplatin, 5FU, Taxanes, etc.
Supportive care, antiemetics, pain treatment etc. are all stuff every radiation oncologist should know. It helps a lot working in a ward, if you have to treat mostly patients on outpatient basis, because you know how the meds work and when the situation of a patient demands hospitalisation or not.
In my current clinic, we don't have our own ward and we only see patients during visits on the wards of the other clinics. I cannot definetely say, I miss ward-work. I can definetely say however that every radiation oncologist should get some ward experience with oncologic patients during his training.

 

[Adawaal]

Here in the US, Rad Oncs having inpatient services is not all that common. For me, that was a big draw. Frankly, I'm glad I don't have formal admitting privileges and don't have to round all over the hospital.

But there's a far more important reason that it's not a great idea. Rad Onc tends to be positioned away in a corner of the hospital (often in the basement, although that's becoming less common). In addition to seeing your consults, follow-ups, on treatment visits, walk-ins with issues, simulations, etc., a lot of time is spent in front of treatment-planning workstations contouring and designing radiation fields. These workstations aren't found elsewhere in the hospital. Some treatments we do require the doc to physically be present during that treatment. Add to that physicists and dosimetrists always looking for you to approve a plan, and every minute you spend outside the department on the floors just complicates everyone's day.

Now the new in-vogue thing is multidisciplinary clinics where a patient comes in and sees the surgeon, Rad Onc and Med Onc all at once. Definitely best for the patients. However, it does present additional problems (for the reasons described above) for the radiation oncologist being absent from their clinic space. Some institutions have masterfully perfected such a system. Most, however, struggle with these problems and it looks like some are ending (or considering ending) the multidisciplinary clinic experiments.

 

[nod]

it is very rare in the us for rad oncs to have an inpatient service. as mentioned above, very few rad onc docs have admitting privileges in hospitals. if we have a patient that is ill enough to be admitted, we call either med onc or general medicine.

absolutely do NOT miss inpt service. working the wards is very hard on your lifestyle, since SOMEONE has to be there 24/7, and that someone is often you. many of us in rad onc like the regular hours of a clinic, so we have time for other parts of life. you have very ill patients as an inpt, but you also have the patients that are not really ill that are just dispo issues. if you have not experienced that yet, you just have not spend enough time on the wards for me, clinic work has a dynamic of its own, since it is often also very busy, and it is an art form juggling between new patient consults, taking care of your on treatment patients and making sure they are okay, turning in contours/evaluating plans of patients about to start radiation, and following the patients you already treated.

rad oncs manage a lot of medical problems, because our patients are often very ill. in my program we write for pain meds, antiemetics, anxiety meds all the time (i carry a stack of narcotic scripts that goes down pretty quick on some services). i guess you can punt some of that responsibility over to med onc if you want to, if your patients are also getting chemo, but that depends on the type of doctor you want to be.

 

[deleted4401]

I know what you mean ... I liked the teamwork of a ward team and some parts of inpatient care. Rad onc has very little of a team approach when it comes to individual management of patients. Sure - you work with multidisciplinary teams to decide on a plan of action, but you're the physician that evaluates the patient, decides to treat, contours, approves plan, sees the patient during treatment, etc.

I started inpatient moonlighting, once every two weeks or so to get a little of that inpatient action. It's actually interesting, not that hard, and you get paid a fair amount. But two shifts a month is plentry enough... I don't want to be an internist by any means!

-S

 

[medgator]

At my institution, we can get a significant number of inpatient consults which can lead to us having between 2-5 patients in the hospital daily. However, after the consult we do not round on them everyday. If we treat them we see them when they come down. If we're waiting for studies or going to treat them later we just follow them.

A lot of places have indpendent cancer centers where the rad onc programs are based and going to the hospital to see consults can be a pain when you are seeing on treatments, folloup ups, consults, and doing contouring.

It can definitely get busy trying to jungle a full outpatient practice and inpatient consults that get called in

 

[IndyXRT]

every minute you spend outside the department on the floors just complicates everyone's day.

You've cut right to the heart of the problem. We actually bring most of our inpatient consults down to the department and see them there. Other services don't seem to understand that it is problematic for us to spend much time out of clinic.

To answer the OP's question: I do not miss working on wards at all. Having to take responsibility for every little detail (e.g. when a patient can have Tylenol) drives me nuts.

 

[Raygun77]

Cheers for all the responses guys.

Palex, that's interesting to hear. One of our profs once told us that the UK had a 'clinical oncologist' and 'medical oncologist' dichotomy, with the clinical oncologist doing both chemo and radiotherapy. Is this true for the rest of europe (at least, where you're from) too?
I think i'd like to do my final year elective in a European oncology service, to experience first hand that set up.
I'm studying in Australia, and as far as I know the system parallels that in the states. I can say for sure that radiotherapy is housed in the 'lower basement' of the big cancer hospital in my city, and don't have any dedicated ward of sorts.

Anyway, it's nice to know that rad oncs still take care of the basic medical management of their patient. I suppose one of my root concerns is becoming too sub specialised such as to forget these other basic skills you learn through med school. It doesn't seem like that's the case.

 

[Palex80]

Palex, that's interesting to hear. One of our profs once told us that the UK had a 'clinical oncologist' and 'medical oncologist' dichotomy, with the clinical oncologist doing both chemo and radiotherapy. Is this true for the rest of europe (at least, where you're from) too?

Nope.
In Germany, Switzerland, Austria for example we have radiation oncologists and medical oncologists, while some hospital have hematologists as well.
Every of these 3 professions deals with its own patients.
Radiation oncologists treat every patient that is receiving radiation therapy at that time, delivering chemotherapy as well and doing all the supportive care. Medical oncologists take care of the patients that are currently receiving only chemotherapy, which means they mostly treat patients in adjuvant/palliative situations (lots of breast, colon, lung patients). Hematologists take care of lymphoma-chemotherapy and do all the stem cell transplantations.
A patient often switches between clinics. For example a patient with SCLC may get his first couple of cycles chemotherapy from the radiation oncologist, while he receives radiation treatment, then will go to the medical oncologist for the third and fourth cycle and the come back to the radiation oncologist for the prophylactic brain irradiation.

Not every hospital however has a radiation oncology ward. Most hospitals have one, but there are some (like mine) who don't. We distribute our patients among the wards and the M.D.s there take care of them mostly. Our head+neck patients are in the head+neck ward. Our lung patients are in the pulmonology ward, our palliative patients are in internal medicine ward.

I suppose one of my root concerns is becoming too sub specialised such as to forget these other basic skills you learn through med school. It doesn't seem like that's the case.

This is indeed very important. Otherwise we may forget about the big picture. It's not all about contouring.