Do you guys enjoy contouring?

[Swaggy109010]

I am a M3 considering rad onc, and I have shadowed a bit, but mainly during clinic time obviously, so I haven't seen much of the contouring/treatment planning aspect of the job, as the physicians here often do that after hours or at home. Is this a part of the joy you tend to enjoy, as you are making important decisions, or do you find it very tedious?

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[RadOncDoc21]

I am a M3 considering rad onc, and I have shadowed a bit, but mainly during clinic time obviously, so I haven't seen much of the contouring/treatment planning aspect of the job, as the physicians here often do that after hours or at home. Is this a part of the joy you tend to enjoy, as you are making important decisions, or do you find it very tedious?

I rather contour than do notes or dictations.

 

[deleted18755]

I went to a book store (an actual brick and mortar store) for the first time in many years and saw that they were selling "adult coloring books" ... I thought to myself "I honestly love doing that, but I call it 'contouring' and actually get paid (a lot) to do it!

Seriously though for me contouring generally comes in two varieties: something simple I've done so many times I just do it while enjoying a cup of coffee and listening to music or very intense and individualized that requires complete thought and attention (and maybe multiple sessions, reviewing anatomy with radiologist or textbooks) but is very satisfying in the end.

At some point in my career I tried as much as possible to sim during my least busy clinical times so I can review the images right before the sim, think about what I'm going to do again real quick, then contouring immediately after the sim while everything is fresh in my mind. Although it seems impossible if you are lucky enough to have a dedicated CT scanner and amenable staff it really helps not only get the volumes done more efficiently (and at least for me make it seem less tedious one or two at a time) but it makes your dosimetrist's (and therefore your) life much easier to get the volumes one at a time rather than all at once if you spend an entire afternoon knocking out a bunch all at once, which for me would make the task more tedious and time consuming.

 

[Neuronix]

I enjoy contouring when I have time for it. That is--when clinic isn't crazy, I'm not covering for multiple people, and I'm contouring at 4 PM.

When my clinic is overbooked, I've got inpatient consults to see, and I am end up contouring at 10 PM or 6 AM, I don't like it as much.

Point here is that when being a rad onc, often your time for things like contouring is not protected. But it's an extremely important and time consuming part of what we do.

Since it doesn't pay, many practices skimp by having dosimetrists do all of the contouring. Some of the older guys practicing don't seem to know how to contour at all. How accurate or appropriate those end up being are somewhat up to the practice doing them.

 

[medgator]

Since it doesn't pay, many practices skimp by having dosimetrists do all of the contouring. Some of the older guys practicing don't seem to know how to contour at all. How accurate or appropriate those end up being are somewhat up to the practice doing them.

I could see that happening in a urorads setup... but outside of that, I can't imagine the dosimetrist would even know where to start on a h&n or complicated gi/pelvic imrt case. I think most places use dosimetry to contour the normal structures but I've never heard of a place using them to contour gtv/ctv.

 

[Neuronix]

Moonlighting opened my eyes to all sorts of weirdness.

I went on a job interview where I taught the dosimetrist how to contour the retrostyloid lymph nodes. The dosimetrist contoured all the regional nodes for H&N cases. They had no idea about covering retrostyloid for involved level 2. That dosimetrist then had me give them some pointers on how to draw anal cancer volumes a la RTOG 0529.

Of course the rad onc approved all of this, but typically without or with minimal modification. I know for a fact there are several more rad oncs in the area where I trained who practiced similarly. These are all rad onc owned and run practices. Urorads shops are simple--contouring the prostate and area OARs is super easy. No evidence for LN irradiation in prostate, so they never did it.

I know that some of the senior academic guys out there basically do the same thing except they have residents to do the contouring for them more accurately than dosimetrists.

 

[thecarbonionangle]

Some days yes and some days no. I hate contouring when I am overwhelmed and there is no time. I enjoy contouring when there is plenty of time to look at images and really polish complex CTVs/GTVs and think about an approach. There is no free lunch in any field of medicine. Overall residency will suck. Attendings will ride you and you are underpaid and taken advantage of. That's the nature of the abusive system we call "residency". What you gotta find is a field where those "tedious" things aren't as bad as the other fields. On my worst rad onc days, im nowhere near as miserable as a USUAL day slaving away without much sleep and being hammer paged at a grueling academic medicine program. Perspective is important. Nothing like intern year to give you that. I had some very very dark days my intern year.

 

[Gfunk6]

I love contouring, in my view one of the most entertaining parts of my job. Unlike my colleagues I contour EVERYTHING except lung/liver.


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[thesauce]

Same here. I do really love contouring. I usually put on some tunes in my headphones and take my time.

 

[evilbooyaa]

I'm of the opinion that if it's an IMRT plan, an MD should be doing the contours. Same with 3D. If you're kind of doing 2D (like whole breast, no LN coverage) then usually there isn't even a contour of the breast.

I think dosimetry contouring normal structures is reasonable, but I like to think that for any truly critical OARs that might be dose limiting, if you don't have a dedicated dosimetrist, it would be good to do it yourself.

Stuff like:
Parotids/Submandibulars and Constrictors in H&N
Brachial Plexus in low H&N nodes requiring high dose (if it's microscopic dose then whatever) or high lungs
Anything that requires you to dose paint

 

[medgator]

I'm of the opinion that if it's an IMRT plan, an MD should be doing the contours. Same with 3D. If you're kind of doing 2D (like whole breast, no LN coverage) then usually there isn't even a contour of the breast.

I think dosimetry contouring normal structures is reasonable, but I like to think that for any truly critical OARs that might be dose limiting, if you don't have a dedicated dosimetrist, it would be good to do it yourself.

Stuff like:
Parotids/Submandibulars and Constrictors in H&N
Brachial Plexus in low H&N nodes requiring high dose (if it's microscopic dose then whatever) or high lungs
Anything that requires you to dose paint

Also cns stuff.

Parotids, cns, and in some cases normal esophagus/small vs large bowel is stuff that I will do that my dosimetrist feels uncomfortable doing. I'm sure it's probably not the case as those sketchy centers, but there should been an open dialogue between the MD and dosimetrist on things like that

 

[evilbooyaa]

Also cns stuff.

Parotids, cns, and in some cases normal esophagus/small vs large bowel is stuff that I will do that my dosimetrist feels uncomfortable doing. I'm sure it's probably not the case as those sketchy centers, but there should been an open dialogue between the MD and dosimetrist on things like that

So I get CNS if you're doing SRS close to the optics or brainstem or treating something like within the spinal cord. I don't normally do optics/brainstem if it's not going to realistically affect the plan.

 

[medgator]

So I get CNS if you're doing SRS close to the optics or brainstem or treating something like within the spinal cord. I don't normally do optics/brainstem if it's not going to realistically affect the plan.

GBMs mainly. I do the optic chiasm, nerves and brainstem

 

[MedPhys2MD]

As a physicist, I've contoured all of the above... Critical structures, GTVs, CTVs, pelvic nodes, H&N nodes etc. I think workflow varies drastically from practice to practice - impacted by the age of the attendings, if residents are available to help with contouring, how busy the practice is and how much you trust your planners

I will say that at our center it seems like many new partners initially start contouring for themselves, but after some time even the attendings that were adamant about contouring their own targets gradually began requesting that we contour their lymph nodes and GTVs/CTVs (not always, but frequently - we have a relatively busy clinic). When I do the target contouring though, I always have it verified and adjusted by the physicians before planning. And before contouring for a physician I always read through the medical chart, consult, outside records and any imaging studies. Even if I don't do the contouring for the patient, I think it's important for the planner to analyze the records because when we're optimizing, we frequently have to sacrifice part of OARs or modify target coverage to get an acceptable plan. Making an informed choice about what parameters to push is much better than using generic planning methods

On the other end of the spectrum, we also have physicians that I wouldn't start planning a 2D breast case without the physician seeing and approving the treatment fields because they'd like to be integrally involved in the setup.

One thing to inquire about if your center doesn't have it and you have a hard time contouring is if they can get large (or small) tablets so that you can contour with a stylus vs using a mouse... It can be an easier/more natural way to work for some people

 

[Gfunk6]

While an argument can be made for non-MDs to contour easy to identify normal structures (liver, lung, parotid, spinal cord, brainstem), in my opinion it is close to malpractice for non-MDs to contour GTVs/CTVs and some more complicated structures (cochlea, optic apparatus, brachial plexus).

MDs who allow their staff to contour such structures will invariably use the argument that "well, I check and modify the contours appropriately before planning." However, I can tell you from personal experience after auditing various plans/charts with a fine tooth comb, this does not always happen. YMMV.

 

[evilbooyaa]

When I do the target contouring though, I always have it verified and adjusted by the physicians before planning. And before contouring for a physician I always read through the medical chart, consult, outside records and any imaging studies. Even if I don't do the contouring for the patient, I think it's important for the planner to analyze the records because when we're optimizing, we frequently have to sacrifice part of OARs or modify target coverage to get an acceptable plan. Making an informed choice about what parameters to push is much better than using generic planning methods

To me, this is the core of what a Radiation Oncologist does in the dosimetry setting.

Yeah, GTV/CTV/PTV is important, but knowing how to relax or tighten on your OARs (and convey that information to dosimetry) is also the physician's job, IMO, not the dosimetrist or medical physicist. Not that it shouldn't be a two-way street (dosimetrist tells physician that certain constraint is unachievable without dropping target coverage, etc.), but these are things that a good radiation oncologist thinks about (IMO) BEFORE the planning starts so dosimetry isn't wasting their time trying to meet something unachievable.

You are an extremely motivated person to be a non-MD reviewing the medical chart for planning purposes. I've never seen any of our dosimetrists/physicists do that.

While an argument can be made for non-MDs to contour easy to identify normal structures (liver, lung, parotid, spinal cord, brainstem), in my opinion it is close to malpractice for non-MDs to contour GTVs/CTVs and some more complicated structures (cochlea, optic apparatus, brachial plexus).

MDs who allow their staff to contour such structures will invariably use the argument that "well, I check and modify the contours appropriately before planning." However, I can tell you from personal experience after auditing various plans/charts with a fine tooth comb, this does not always happen. YMMV.

So I do agree with you, with the caveat that if the optic nerves/chiams, cochlea, and brachial plexus aren't going to be obviously dose limiting organs (but are just there to minimize entry on an IMRT plan directly through the cochlea for example), then I personally feel it's OK to have dosimetry contour them. I do agree that if there's any sort of PTV even close to those lesions (with concerns of going over dose limits, like over 66Gy to the brachial plexus or whatever) then it should be contoured by the MD.

For palliative cases I'm OK if some motivated dosimetrists contour what they think is the GTV, but I generally just contour my own anyways to stop lines from being blurred.