Mistakes

[radoncFLASHer]

Senior resident here, trying to mentally prepare myself for practice next year. How do you guys mentally deal with mistakes or judgment calls you may have made with respect to radiation contouring and planning where you ended up getting burned? Such as not boosting a gross node, or not covering a certain elective region where there eventually was a failure. Or even if there was no adverse outcome, looking back onto a case and realizing you should have contoured this area differently or covered this area. Is this something that you felt happened more in your early career?

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[Lamount]

Senior resident here, trying to mentally prepare myself for practice next year. How do you guys mentally deal with mistakes or judgment calls you may have made with respect to radiation contouring and planning where you ended up getting burned? Such as not boosting a gross node, or not covering a certain elective region where there eventually was a failure. Or even if there was no adverse outcome, looking back onto a case and realizing you should have contoured this area differently or covered this area. Is this something that you felt happened more in your early career?

Always have a reason for every decision. if you discover your reasoning was unsound, change your approach on future cases. However, if your reasoning WAS sound and you still get burned, do NOT change your approach in the future. Reason should always trump an n=1 outcome in terms of your future practice.

 

[RADONC4285]

Senior resident here, trying to mentally prepare myself for practice next year. How do you guys mentally deal with mistakes or judgment calls you may have made with respect to radiation contouring and planning where you ended up getting burned? Such as not boosting a gross node, or not covering a certain elective region where there eventually was a failure. Or even if there was no adverse outcome, looking back onto a case and realizing you should have contoured this area differently or covered this area. Is this something that you felt happened more in your early career?

To me the key is to not be lazy. If I know I thought about the case thoroughly, looked up appropriate guidelines, reviewed history/imaging carefully, asked colleagues when needed, I can sleep well at night. We will all get burner at some point. Just learn from it and try to put it behind you. But it'll be hard to put it behind you if it was a mistake due to negligence/laziness

 

[TheWallnerus]

Senior resident here, trying to mentally prepare myself for practice next year. How do you guys mentally deal with mistakes or judgment calls you may have made with respect to radiation contouring and planning where you ended up getting burned? Such as not boosting a gross node, or not covering a certain elective region where there eventually was a failure. Or even if there was no adverse outcome, looking back onto a case and realizing you should have contoured this area differently or covered this area. Is this something that you felt happened more in your early career?

You're covering a very wide swath of not-good things here...

Using respiratory gating or not for Stage III lung cancer IMRT, or using SIB for HNSCC, or using 20 or 25 fractions for superficial skin cancers: judgment calls. Not delivering the proper dose to gross disease or giving no coverage to an elective region otherwise considered standard of care: malpractice. Looking back at cases and thinking "might have done it different" or added a little extra coverage: we all do that.

 

[Palex80]

There is a considerable bias in here. We can mainly focus on cases where we later on see a recurrence in field (questionning if we should have pushed the dose higher) or out of field (questionning whether or not we should have covered that area too), yet we focus only on the good side.
What if pushing the dose higher or treating a larger area may have led to worrisome toxicity for the patient.

I mainly see these issues in palliative cases. Often I get asked to irradiate again for a symptomatic bone met that was asymptomatic when I treated something else in a patient a while back or I get asked to re-irradiate cause I thought 5 x 5 Gy was a good idea for that bone met 1 year ago, yet here is the patient again and that bone met is painful or growing again.

 

[RadOncDoc21]

I’ve seen some messed up treatment plans work and “perfect” plans fail. If a patient of mine is seen by another rad onc for a recurrence at the ivory tower, how confident am I to believe they won’t just throw me under the bus even if I did everything “right?”

Similar to docs with other incentives… had a patient I got from a new surgeon who referred to me and a med onc I’ve never worked with at the same time. The patient complained of having pain on the very first day of radiation, the med onc who is financially affiliated with one group of rad oncs, tells the patient it was the radiation she got from “our center” and tries to send the patient to their own rad onc knowing damn well it wasn’t the radiation.

I say this to say that yes we all make mistakes, some directly from personal misjudgment and it’s best to learn from them and to always do your due diligence in every case, but our field is extremely unforgiving and sometimes judgement is made on your behalf for many reasons outside your control. Also, it is cancer, so bad outcomes are inherently common even when centers are claiming protons are the only solution!

 

[sirspamalot]

To me the key is to not be lazy. If I know I thought about the case thoroughly, looked up appropriate guidelines, reviewed history/imaging carefully, asked colleagues when needed, I can sleep well at night. We will all get burner at some point. Just learn from it and try to put it behind you. But it'll be hard to put it behind you if it was a mistake due to negligence/laziness

I'd say it'd be impossible to put behind you, unless you are a sociopath. We are not allowed to make life-altering mistakes. Period. Do you f*$)% job or find another profession. It sucks when people fail when they "shouldn't" but what allows me to go on is knowing I did the right thing, and that I did it correctly (yeah, I go and look again at my plan). And it still feels bad anyway. Nothing angers me more than seeing someone do sloppy work or have a nonchalant attitude. And then there is the special case of greed. Working so hard that things cannot possibly be done with any measure of quality or consistency. Horrible... and particularly common in freestanding centers that are running over capacity. They could hire more people and get paid 5% less... but nope.

 

[StIGMA]

Senior resident here, trying to mentally prepare myself for practice next year. How do you guys mentally deal with mistakes or judgment calls you may have made with respect to radiation contouring and planning where you ended up getting burned? Such as not boosting a gross node, or not covering a certain elective region where there eventually was a failure. Or even if there was no adverse outcome, looking back onto a case and realizing you should have contoured this area differently or covered this area. Is this something that you felt happened more in your early career?

You get to define for yourself what your standards are. You hopefully had some 'good' attendings that you desired to be like over others, and you will get to mature into your own routine. If I have any uncertainty, I run the case/contours by a colleague. I almost always double check contours/original imaging a second (or third) time before approving a plan to make sure I didn't miss or wouldn't want to change anything should there be an undesired outcome. I had a rare (stochastic) toxicity recently and double checked the plan-- I still wouldn't change anything about the plan or treatment decisions. It helps to have good relationships with patients and their families especially when something undesired occurs, so that's something to prioritize early. Same goes for your medonc/surgical colleagues, especially if they are the ones advocating for higher risk treatment in advanced cases ie: oligomets or extended fields or reRT (and you know distant/local failure is inevitable).

 

[kimplera]

I’ve seen some messed up treatment plans work and “perfect” plans fail. If a patient of mine is seen by another rad onc for a recurrence at the ivory tower, how confident am I to believe they won’t just throw me under the bus even if I did everything “right?”

Similar to docs with other incentives… had a patient I got from a new surgeon who referred to me and a med onc I’ve never worked with at the same time. The patient complained of having pain on the very first day of radiation, the med onc who is financially affiliated with one group of rad oncs, tells the patient it was the radiation she got from “our center” and tries to send the patient to their own rad onc knowing damn well it wasn’t the radiation.

I say this to say that yes we all make mistakes, some directly from personal misjudgment and it’s best to learn from them and to always do your due diligence in every case, but our field is extremely unforgiving and sometimes judgement is made on your behalf for many reasons outside your control. Also, it is cancer, so bad outcomes are inherently common even when centers are claiming protons are the only solution!

I hope the number of "ivory tower" who throw you under the bus is exceptionally small. Unless you are treating the wrong side most radiation decisions are judgement calls and can be justified. When i see patients i try to deal with the "now" problem and not spend time worrying about what was done in the past. That doesn't help the patient. Helps to have good relationships with the providers in the area as well.

 

[medgator]

. And then there is the special case of greed. Working so hard that things cannot possibly be done with any measure of quality or consistency. Horrible... and particularly common in freestanding centers that are running over capacity. They could hire more people and get paid 5% less... but nope.

Definitely true pre pandemic. Now it's just a free for all when it comes to hiring, we've been looking for physics and dosimetry help for months offering above aapm median comp and getting very few bites. The physics residency requirements now have absolutely tightened up the physics supply side things for the foreseeable future and that isn't going to go away overnight.

While we take CMS cuts directly at a practice/physician level, our physics, therapy and dosimetry staff are seeing single to double digit pay hikes over the last year to retain the staff we do have.

 

[RadOncDoc21]

I hope the number of "ivory tower" who throw you under the bus is exceptionally small. Unless you are treating the wrong side most radiation decisions are judgement calls and can be justified. When i see patients i try to deal with the "now" problem and not spend time worrying about what was done in the past. That doesn't help the patient. Helps to have good relationships with the providers in the area as well.

Last one I was around claimed brain mets could only be treated with a gamma knife. Today it’s more only “insert disease site” can be treated with protons.

To be fair, I honestly don’t know if I am being thrown under the bus but if they can straight face make these claim, saying that my care was inadequate shouldn’t be that much of a stretch.

 

[TheWallnerus]

You get to define for yourself what your standards are. You hopefully had some 'good' attendings that you desired to be like over others, and you will get to mature into your own routine. If I have any uncertainty, I run the case/contours by a colleague. I almost always double check contours/original imaging a second (or third) time before approving a plan to make sure I didn't miss or wouldn't want to change anything should there be an undesired outcome. I had a rare (stochastic) toxicity recently and double checked the plan-- I still wouldn't change anything about the plan or treatment decisions. It helps to have good relationships with patients and their families especially when something undesired occurs, so that's something to prioritize early. Same goes for your medonc/surgical colleagues, especially if they are the ones advocating for higher risk treatment in advanced cases ie: oligomets or extended fields or reRT (and you know distant/local failure is inevitable).

I agree with your sentiment completely but I recoil from calling toxicities stochastic

 

[evilbooyaa]

Senior resident here, trying to mentally prepare myself for practice next year. How do you guys mentally deal with mistakes or judgment calls you may have made with respect to radiation contouring and planning where you ended up getting burned? Such as not boosting a gross node, or not covering a certain elective region where there eventually was a failure. Or even if there was no adverse outcome, looking back onto a case and realizing you should have contoured this area differently or covered this area. Is this something that you felt happened more in your early career?

For the first 3-6 months, I would recommend re-reviewing every set of contours. Take an extra long look at each plan. Try to not jump directly into a 30+ on treat practice with significant complexity if you can. Give yourself time to re-read what you already know and be comfortable applying it without the security blanket of an attending.

Despite all this, there will be things you learn in the first 6-12 months of being an attending, and life long. Any scenario that you have a patient who recurs, take a second and third look at what you did. See what maybe could have been done differently. If there's nothing, then OK, cancer sucks some percentage of the time, and you could have a perfect plan that didn't end up with the result you wanted. But, a recurrence where you think, maybe I coulda just drawn that a bit better, will make you more thoughtful for the next time.

Nobody does Rad Onc perfect 100% of the time. Even if you do it partially wrong 10% of the time, you're not going to get burned all of the cases. Even if you do it completely right 90% of the time, that doesn't mean 90% of your patients won't recur.

All you can do is learn and figure out what you can do to get better.

This applies to both recurrence risk AND toxicity.

 

[sirspamalot]

maybe I coulda just drawn that a bit better

Its not usually so much the pretty CTV you draw.. its the decision of "did I plan to include that" .. having a recurrence squarely in field or far away is not so upsetting, because most of the time, it has nothing to do with your CTVs.

On the other hand a closely adjacent failure.. those can really be upsetting but again, as advised above, look thru everything carefully and see if there is anything you could have done different.

Sometimes tumors just recur, they don't care, and they don't know how to read. I suspect the vast majority of the time, it has little to do with us...however... as a newbie, be slightly paranoid. It might just be you.

Or, as pilots say "Trust but verify" everything that you do..

 

[Lamount]

I agree with your sentiment completely but I recoil from calling toxicities stochastic

stochastic: having a random probability distribution or pattern that may be analyzed statistically but may not be predicted precisely.

I would saw that is fairly accurate. The probability distribution is related to DVH, but with some degree of random noise.

 

[RadOncDoc21]

For the first 3-6 months, I would recommend re-reviewing every set of contours. Take an extra long look at each plan. Try to not jump directly into a 30+ on treat practice with significant complexity if you can. Give yourself time to re-read what you already know and be comfortable applying it without the security blanket of an attending.

Despite all this, there will be things you learn in the first 6-12 months of being an attending, and life long. Any scenario that you have a patient who recurs, take a second and third look at what you did. See what maybe could have been done differently. If there's nothing, then OK, cancer sucks some percentage of the time, and you could have a perfect plan that didn't end up with the result you wanted. But, a recurrence where you think, maybe I coulda just drawn that a bit better, will make you more thoughtful for the next time.

Nobody does Rad Onc perfect 100% of the time. Even if you do it partially wrong 10% of the time, you're not going to get burned all of the cases. Even if you do it completely right 90% of the time, that doesn't mean 90% of your patients won't recur.

All you can do is learn and figure out what you can do to get better.

This applies to both recurrence risk AND toxicity.

Spoken much more eloquently then I ever could have stated!

 

[evilbooyaa]

Its not usually so much the pretty CTV you draw.. its the decision of "did I plan to include that" .. having a recurrence squarely in field or far away is not so upsetting, because most of the time, it has nothing to do with your CTVs.

On the other hand a closely adjacent failure.. those can really be upsetting but again, as advised above, look thru everything carefully and see if there is anything you could have done different.

Sometimes tumors just recur, they don't care, and they don't know how to read. I suspect the vast majority of the time, it has little to do with us...however... as a newbie, be slightly paranoid. It might just be you.

Or, as pilots say "Trust but verify" everything that you do..

The bolded are the majority of my learning experiences. I learned from some of my attendings who didn't believe in standard PTV margins or standard contouring guidelines for volumes in H&N cases. At least one or two of these I learned from myself.

Trying to balance recurrence risk vs toxicity in say gyn brachy as an attending has been one of my biggest learning experiences when you realize a certain patient's anatomy, even with the most up-to-date planning, use of interstitial needles, etc., does not make it conducive to meet EQD2 goals for tumor coverage AND optimal dose constraints simultaneously. I used to be able to present two options as a resident (one where HR-CTV met but OARs went over, and one where HR-CTV was a little light but OARs met) and the attending would make final tweaks off one of them. Having to make those decisions for each patient... and seeing the occasional recurrence (is 1/20 local recurrences a bad thing?) and the potential toxicities is a process one needs to repeat quite a bit to feel comfortable moving forward with.

 

[TheWallnerus]

Its not usually so much the pretty CTV you draw.. its the decision of "did I plan to include that" .. having a recurrence squarely in field or far away is not so upsetting, because most of the time, it has nothing to do with your CTVs.

On the other hand a closely adjacent failure.. those can really be upsetting but again, as advised above, look thru everything carefully and see if there is anything you could have done different.

Sometimes tumors just recur, they don't care, and they don't know how to read. I suspect the vast majority of the time, it has little to do with us...however... as a newbie, be slightly paranoid. It might just be you.

Or, as pilots say "Trust but verify" everything that you do..

The older I get the more I become convinced that the greatest clinical outcome variations between rad oncs is not their oncological success rates but their toxicity rates

My toxicity rates were much lower many years out in practice versus my first few months in practice

 

[RadOncDoc21]

The older I get the more I become convinced that the greatest clinical outcome variations between rad oncs is not their oncological success rates but their toxicity rates

My toxicity rates were much lower many years out in practice versus my first few months in practice

I was definitely more aggressive my first few years, then I became overly conservative. I think (or at least I hope), presently I’ve found a good balance.

 

[deleted1116990]

How do you guys mentally deal with mistakes or judgment calls you may have made with respect to radiation contouring and planning where you ended up getting burned?

It's a good sign that you are at least asking this question. You got some good advice about how to avoid making mistakes, but nothing addressing your specific question, which is dealing with an actual mistake (presumably something that could be uncomfortable to defend in a courtroom) when it happens.

You're not going to find too many people willing to raise their hand and say "yeah, been there" when you are talking about malpractice-y stuff. But it can happen, and likely will to some degree, even to people who are otherwise good doctors.

There's the marginal miss. Your patient comes back with a local recurrence at the edge of your volume. Maybe you used 3mm margins when you usually use 5. Maybe you only circled disease on the PET. Maybe you didn't check the image fusion. You messed up. Were you busy that day? How did this happen? You don't remember. You do the best you can and figure out how to best salvage it.

There's the bad referral. Patient is sent to you by outside med onc and surgeon all wrapped with a neat little bow. Patient is stage X, so radiate Y here to Z. Ok. Simple enough. Everything looks good and straightforward on the surface. Like a 100 other patients you have treated. Patient recurs. Then you realize the workup that was done before the patient got to you was totally botched and miscommunicated. Again, salvage it the best you can. Always verify everything. Get the original images, reports, op notes, etc (which can still be wrong). Don't rely on second hand documentation.

Always be honest with the patient.

How do you mentally deal with a mistake? First you have to care. There are lots of rad oncs out there that just don't, unfortunately, and deal with it by denial and mentally checking out. They circle the disease on the PET, add a margin, boom done, send them on their way, no follow-up, convinced they did everything perfectly. So you strive to be better and learn from your mistakes. You have malpractice insurance for a reason (if you're convinced you are 100% immune to mistakes that could burn you, then why are you paying for it?). Mistakes happen to humans, just don't let them be borne out of gross negligence. If a mistake like that happens to you then maybe you need a hard look in the mirror, but unfortunately those that those happen to never question themselves. Sounds like you'll be just fine.

 

[kimplera]

Also - be defensive if someone comes to you with a problem that could be attributed to RT in the future... First year saw a woman with a dominant hand brachialplexopathy after an (unnecessary) axillary dissection. Documented my exam, referred to OT/PT and to the brachial plexus clinic at the U. Then started her adjuvant RT. Several years later was deposed in the case by the defense attorney - trying to point blame towards me - that documentation and referral was perfect.

 

[sirspamalot]

It's a good sign that you are at least asking this question. You got some good advice about how to avoid making mistakes, but nothing addressing your specific question, which is dealing with an actual mistake (presumably something that could be uncomfortable to defend in a courtroom) when it happens.

You're not going to find too many people willing to raise their hand and say "yeah, been there" when you are talking about malpractice-y stuff. But it can happen, and likely will to some degree, even to people who are otherwise good doctors.

There's the marginal miss. Your patient comes back with a local recurrence at the edge of your volume. Maybe you used 3mm margins when you usually use 5. Maybe you only circled disease on the PET. Maybe you didn't check the image fusion. You messed up. Were you busy that day? How did this happen? You don't remember. You do the best you can and figure out how to best salvage it.

There's the bad referral. Patient is sent to you by outside med onc and surgeon all wrapped with a neat little bow. Patient is stage X, so radiate Y here to Z. Ok. Simple enough. Everything looks good and straightforward on the surface. Like a 100 other patients you have treated. Patient recurs. Then you realize the workup that was done before the patient got to you was totally botched and miscommunicated. Again, salvage it the best you can. Always verify everything. Get the original images, reports, op notes, etc (which can still be wrong). Don't rely on second hand documentation.

Always be honest with the patient.

How do you mentally deal with a mistake? First you have to care. There are lots of rad oncs out there that just don't, unfortunately, and deal with it by denial and mentally checking out. They circle the disease on the PET, add a margin, boom done, send them on their way, no follow-up, convinced they did everything perfectly. So you strive to be better and learn from your mistakes. You have malpractice insurance for a reason (if you're convinced you are 100% immune to mistakes that could burn you, then why are you paying for it?). Mistakes happen to humans, just don't let them be borne out of gross negligence. If a mistake like that happens to you then maybe you need a hard look in the mirror, but unfortunately those that those happen to never question themselves. Sounds like you'll be just fine.

Please note: ALWAYS consult risk management and a competent attorney before speaking with the patient. Think carefully about whether you are creating a fact issue where none may in fact be occurring. Recurrences happen : how do you know its your fault? Etc.

Talk to your carrier. Read about medmal and please talk to the grizzled vets who care about patients and the practice of medicine.

 

[TheWallnerus]

There's the bad referral. Patient is sent to you by outside med onc and surgeon all wrapped with a neat little bow. Patient is stage X, so radiate Y here to Z. Ok. Simple enough. Everything looks good and straightforward on the surface. Like a 100 other patients you have treated. Patient recurs. Then you realize the workup that was done before the patient got to you was totally botched and miscommunicated. Again, salvage it the best you can. Always verify everything. Get the original images, reports, op notes, etc (which can still be wrong). Don't rely on second hand documentation.

Perfect example!

A 49-year-old man presented to a local ENT with chronic right ear pain...

 

[ramsesthenice]

It’s great to be critical when you see something bad happen. I agree with so many above you are probably going to have more issues with toxicity than failures. Marginal misses are far less common than in-field failures or unexpected toxicities. Walrus is right, over time you can refine your approaches and see fewer issues.

The thing you have to understand is some of the worst things you are going to do to people are going to come from absolutely normal plans. I’ve caused 2 grade 5 toxicities that I I’m aware of. Both were GI bleeds with max doses to the bowel <52 Gy (and other acceptable volumetric criteria) with conventional fractionation and no dose escalation. Neither had seen biologics or had any significant bleeding risks. These cases are so hard. You feel awful but also a little helpless. It’s a hard reality to face. You can deliver a beautiful plan and that seriously injures or even kills someone. Thankfully these are extremely rare and you will do far more good than harm. The simple fact you asked tells me you will do well by people 🙂

 

[RSAOaky]

Aside from the obvious stuff, accept that you are not God. There are people that are going to recur regardless of what you do right and people that are going to be cured regardless of your mistakes. Similarly, there are people that will have toxicity despite meeting constraints and others that will be totally fine despite exceeding them. When you have an unexpected outcome, it's important that you care enough to look back at your plans and see if there's anything you could have or would have done differently, but hindsight will always be 20/20.

 

[Mandelin Rain]

It’s great to be critical when you see something bad happen. I agree with so many above you are probably going to have more issues with toxicity than failures. Marginal misses are far less common than in-field failures or unexpected toxicities. Walrus is right, over time you can refine your approaches and see fewer issues.

Definitely agree.

True marginal misses are pretty rare in my experience. It's usually, dead center of high dose field or distant. I've seen a couple pelvic node recurrences in guys with low/intermediate risk prostate patients that I didn't treat the pelvis, but that's not really a marginal thing. When someone recurs in the mediastinum 1cm above a typical esophageal field with already broad sup/inf coverage or in the abdomen 1cm above a typical PA field for cervical, you'll beat yourself up but ultimately if you're doing it by the book you have to draw the line to end the field somewhere.

If you miss obviously PET avid disease, that is bad. Don't do that.

 

[IonsAreOurFuture]

I recommend the book, "When the air hits your brain" by Frank Vertosick Jr, MD

In surgery, the complications are much more immediate and in neurosurgery, often much more devastating that what we usually see in Rad Onc. As an example, when is the last time you consented somebody for death as a possible outcome? One of the sayings among his team is: "You can always make somebody worse."

He shares an interesting observation about the callousness and even sociopathic nature of medical training which tends to convert optimistc, personable and idealistic young students into people who just want to get done with "this case" (not a person) so they can go do something else - make their tee time, attend a meeting, get home in time for dinner or pick up the kids from daycare.

(As an aside, "Get-home-itis" is a well- known cause of small aircraft crashes in which bad weather, low fuel, fatigue, poor visibility, or other factors that would normally abort a flight are over-ridden in the interest of simply getting home on time.)

Vertosick shares a great story about one patient who is disabled and another who dies after an aneurysm repair. He considers getting out of neurosurgery altogether after the 2nd experience, with some serious soul searching about Whose fault is it when an aneurysm bleeds?

As Clint Eastwood says in one of his movies, "A man's gotta know his limitations." It's really important to ours as well, get training where weak or rusty, don't hesitate to refer out, transfer to a colleague, get a 2nd opinion, listen to your gut, just say no, or abort a procedure when you're not comfortable treating a patient.

 

[sirspamalot]

As an aside, I have over 2k flight hours and more than 15 years flying a single. Many, many times I've pulled over. Low ceilings and getting worse? Gone. Icing? Get out or go land (juice on). Thunderstorms? Nope. Lightning? Wide wide berth. Even being NEAR the edge of storm gives you a taste of the power and fury of a building cell. I am perhaps extra conservative. I am still here and refuse to be a statistic because I had to be there..

 

[Ray D. Ayshun]