So would you advise rising M4s to enter this field at this point?

[Mandelin Rain]

Since we are all piling on IR, my pet peeve is that they take absolutely no ownership of patients. They do their job and leave you to deal with the crap. Prime case is IR PEG-tube insertion for H&N cancer patients undergoing definitive radiation.

Me: "What happened? The patient was discharged from the hospital without a nutrition consult and without any means to get cans for tube feeding!"

IR: "What do you want from me? You asked me to put a hole in the patient with a connecting tube and I did that. You deal with that ****."

"So, like, um... you want us to teach them how to use/care for the tube?"

My God, I've seen such a wide variety of tubes placed. Some have buttons by the skin that have to be removed. Some don't. Some have Luer Lock connectors. Some have crazy connectors that don't accommodate anything (in this country at least). But it's cool, as long as you put a drain sponge and 4 pieces of paper tape around it, your job is finished.

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[DrfluffyMD]

if you read my original post, I never even alluded IR will take over oncology. I don’t think IR’s role in onc will ever be as big as radonc. My issue is with future targeted therapies taking over all of oncology.

It’s rather regretable how the discussion has devolved.

We are trying to strive toward a more clinical based model with patient ownership. The issue however, in the setting of g tube for head and neck cancer, is that we are performing a service for the primary team (rad onc). A lot of IRs who are doing this service do not have a clinic or the capacity to clinically take care of patients because the way our groups are structured. We cannot sustain our practice a big clinical presence in many setting due to lack of appropriate reimbursement for patient care related activities. Unlike radonc which reimbursement is high, we need to read many imaging modality just to stay afloat, taking time away from the clinic.

 

[DrfluffyMD]

"So, like, um... you want us to teach them how to use/care for the tube?"

My God, I've seen such a wide variety of tubes placed. Some have buttons by the skin that have to be removed. Some don't. Some have Luer Lock connectors. Some have crazy connectors that don't accommodate anything (in this country at least). But it's cool, as long as you put a drain sponge and 4 pieces of paper tape around it, your job is finished.

Have you ever considered read up about those tubes or ask your IR colleagues for a recommendation on how to manage them rather than complaining about the wide variety of tubes? Despite radonc not even being my specialty I try to read up on the latest.

 

[medgator]

. The issue however, in the setting of g tube for head and neck cancer, is that we are performing a service for the primary team (rad onc). A lot of IRs who are doing this service do not have a clinic or the capacity to clinically take care of patients because the way our groups are structured. We cannot sustain our practice a big clinical presence in many setting due to lack of appropriate reimbursement for patient care related activities. Unlike radonc which reimbursement is high, we need to read many imaging modality just to stay afloat, taking time away from the clinic.

Which is why I'm happy to send my pegs and ports to gen surg who are happy to do them in a well-insured patient.

 

[medgator]

if you read my original post, I never even alluded IR will take over oncology. I don’t think IR’s role in onc will ever be as big as radonc.

Doesn't really jive with:

I can see surgery being there 100 years from now. I can see angio/IR techniques being there 100 years from now, but I am not sure that radiation therapy will be there 100 years from now.

 

[medgator]

Since we are all piling on IR, my pet peeve is that they take absolutely no ownership of patients. They do their job and leave you to deal with the crap. Prime case is IR PEG-tube insertion for H&N cancer patients undergoing definitive radiation.

Why would I send my pegs and occasional ports to the unscrupulous IR in town who tries to RFA any lung tumor he can instead of the general surgeon who sends me breast ca (and occasional gi/skin ca) and isn't going to b****h about doing a peg tube?

 

[DrfluffyMD]

Why would I send my pegs and occasional ports to the unscrupulous IR in town who tries to RFA any lung tumor he can instead of the general surgeon who sends me breast ca (and occasional gi/skin ca) and isn't going to b****h about doing a peg tube?

You don’t have to. But with the coming consolidation of health care systems you may have less and less choices about who to send what to.

 

[DrfluffyMD]

Doesn't really jive with:

I am not seeing any issue with that. As you know, surgery and angios are used in more than oncology therapy. For example, surgeries and angios are used in traumas and infection such as appendicitis. I did not mean to imply surgery and angios in this setting to be for oncology.

I can just see a future where everything is med onc in the world of oncology. Radiation as a modality is mostly for oncology as I am aware besides the rare ablative use for cardiac stuff and benign tumors.

 

[medgator]

I can just see a future where everything is med onc in the world of oncology. .

You certainly wouldn't be the first, nor the last

 

[MDACCRules]

You certainly wouldn't be the first, not the last

I liked it better when the fight was with urologists. At least they don’t wear the “radiology tuxedo” with scrub top and khakis. Vomit. Dude is just saying when we are all dead a 100 years or 200 years from now medicine may change and he’s making a prediction. It’s uninformed, but he’s putting it out there. When we thawed out from our cryogenic state 140 years from now, let’s see who gets the last hearty laugh.

 

[Mandelin Rain]

Have you ever considered read up about those tubes or ask your IR colleagues for a recommendation on how to manage them rather than complaining about the wide variety of tubes? Despite radonc not even being my specialty I try to read up on the latest.

Yeah. This never occurred to me. Too often though, the answer is that they need a return visit to remove said buttons that was never arranged for or an adapter piece that was not provided.

But this is the attitude that the one specialty on-par or many cases lower on the referral chain than Rad Onc should probably avoid. "Well, yeah... why don't you figure my problem out for me. I need more reimbursement."

 

[OTN]

We really shouldn't feed the troll (and coming on a radonc message board to state that we won't be around in 100 years certainly is trolling) but I couldn't resist.

Here are the facts:
- At the present, radiation is an integral modality in cancer care in nearly all cancers.
- Systemic treatment has improved, but with only a few exceptions has it excluded the use of XRT.
- In my clinic, improved systemic treatments has led to a situation where my use of SBRT has exploded, as we have been very successful at "cherry-picking" non-responding mets so patients can stay on their systemic treatment longer. While the U. Colorado data is all we have showing a benefit, I'm confident that as the academics move on from just doing hypofractionation studies and get some real clinical data, we will see a benefit. I've had patients be able to stay on Alimta, for example, for 2-3 years while I take care of 3-4 non-responding mets during that time. As a result, I really do think improvement in systemic treatment will lead to an increase in demand for our services.
- Population age is increasing (baby boomers), which over the next 10-20 years will lead to increased demand for oncology services.
- Naturally, reimbursement per patient will fall, or else Medicare would become insolvent, though improvement in AI/software/machine hardware should allow us to see and treat more patients to maintain income.
- Our patients have experienced improved short- and long-term outcomes from XRT due to improvements in technology over the last two decades. I'm not sure where Dr. Fluffy's experience with long-term toxicity from XRT came from, but those would not be expected in the modern era, and my patients do not experience them.
- IR doctors are not adequately trained in oncology to be considered oncologists, do not have any clinic capability for follow-up, and their procedures, with the exception of some liver procedures (Y90, chemoembo) are not as efficacious as ours...the data on RFA specifically is poor.
- Pathology and radiology are the two specialties at highest risk for displacement by AI. As stated in this thread, radiologists rely on reading as many films as possible to maintain their incomes, even those who focus on IR.

Could something come up in the next century which would replace XRT for all cancers? Sure it's possible, but there is zero (0) data/drug at the moment which fits this bill. We've been hearing about that possibility for decades, and it hasn't come to fruition.
Could AI read films instead of radiologists over the next century? Not only is it possible in the future, it's something which is being explored at this very moment.

As a result, the future of radonc looks brighter to me than that of diagnostic radiology over the next century.

p.s. One final aside: Let's do a thought experiment. Let's imagine we hadn't discovered that XRT could be used for cancer treatment until, say, the 2000s (it was an accidental discovery after all is my understanding). Suddenly, a discovery was made, and all of the sudden we have a new cancer modality which is the most efficacious for nearly all cancers (this is a true statement about XRT). I don't think we'd be calling it antiquated/brutal/etc, but rather an elegant use of incredibly advanced technology, the press would love it, etc.

p.p.s. The question which started this thread was "would you advise rising MS4s to enter the field" - unfortunately, due to the rampant disregard of the future of our specialty by those who "lead" it, I would think loooooong and hard about entering a field for which the job prospects at graduation would be unknown at best. If you're geographically restricted at ALL, don't do it, don't even think about it.

 

[DrfluffyMD]

I am glad, that despite being labeled as a “troll”, I stimulated discussion. So let me break down your points.

First, I am not sure why my specialty is relevant to the discussion. The point of contention is “Will radonc be around in 100 years”.

So let’s look at the year 1917. At that point, many essential aspect of medicine have not been invented. Antibiotics weren’t here yet. Neither did vitamin D. Transfusion is either not there or in its very infancy.

We used to treat TB with surgery. Now, except the very very rare resistant cases, such therapy is unheard of. We also used to induce artifical pneumothroax. That’s no more.

Sure, people in the 50s proclaimed victory of chemo over radiation, but our time is different. We actually have near full understanding of more and more types of cancer at a molecular level. We know what gene causes what. We have sophisicated molecular targets.

We have therapies right now that are replacing surgery and radiation. What about certain lymphomas? When is the last time you’ve seen someone getting splenectomy for splenic marginal zone lymphoma? Or radiation for that matter (which used to have a role).

So here’s the problem. I am saying surgery and IR will be around 100 years from now because you can’t treat a bullet (or laser) wound with medicine alone. Angiography will remain the easiest way to get into the middle cerebral artery until teleportation happen. I am certain of those two things above. Will IR treat cancer then? Probably not but that’s not what I am talking about. I am talking about the fact that surgery, medicine, radiology and IR will be there as a field, with or without AI involvement.

On the other hand, radiation deals with a narrow indication and have significant side effects. We suffer through radiation because we have to. Because of limitation of our healing arts.

Lastly, a bit about AI. You are right that there is exploration of using AI for imaging diagnosis, but you know what’s beyond exploration and in operational stage?

Watson oncology. It’s here. What is it to stop a NP/PA plus sophisificated AI to do your job? Or Medonc plus AI to do your job? Why would a medonc refer to you when a computer program autocontoura and proscribe the treatment? Oh, you own the machines? What about the big hospitals that also own the machines? What then? Can you afford to compete with the big bad AI with similar or better outcome and software package you can’t afford.

Here’s the problem with AI and radonc. Any AI sophisticated enough to replace radiology will replace radonc first.

Again, I appreciate radonc as a service for my patient and I have nothing but respect for my mentors in NYC during my radonc research years and the friends I made now who are at big deal places now, but in 100 years? I am not so sure.

 

[DrfluffyMD]

And for the record, for all those reasons people stated above (better long term control), I can see radonc thrive in the next 20 years. I merely worry about it 100 years from now.

 

[OTN]

I am glad, that despite being labeled as a “troll”, I stimulated discussion. So let me break down your points.

First, I am not sure why my specialty is relevant to the discussion. The point of contention is “Will radonc be around in 100 years”.

So let’s look at the year 1917. At that point, many essential aspect of medicine have not been invented. Antibiotics weren’t here yet. Neither did vitamin D. Transfusion is either not there or in its very infancy.

We used to treat TB with surgery. Now, except the very very rare resistant cases, such therapy is unheard of. We also used to induce artifical pneumothroax. That’s no more.

Sure, people in the 50s proclaimed victory of chemo over radiation, but our time is different. We actually have near full understanding of more and more types of cancer at a molecular level. We know what gene causes what. We have sophisicated molecular targets.

We have therapies right now that are replacing surgery and radiation. What about certain lymphomas? When is the last time you’ve seen someone getting splenectomy for splenic marginal zone lymphoma? Or radiation for that matter (which used to have a role).

So here’s the problem. I am saying surgery and IR will be around 100 years from now because you can’t treat a bullet (or laser) wound with medicine alone. Angiography will remain the easiest way to get into the middle cerebral artery until teleportation happen. I am certain of those two things above. Will IR treat cancer then? Probably not but that’s not what I am talking about. I am talking about the fact that surgery, medicine, radiology and IR will be there as a field, with or without AI involvement.

On the other hand, radiation deals with a narrow indication and have significant side effects. We suffer through radiation because we have to. Because of limitation of our healing arts.

Lastly, a bit about AI. You are right that there is exploration of using AI for imaging diagnosis, but you know what’s beyond exploration and in operational stage?

Watson oncology. It’s here. What is it to stop a NP/PA plus sophisificated AI to do your job? Or Medonc plus AI to do your job? Why would a medonc refer to you when a computer program autocontoura and proscribe the treatment? Oh, you own the machines? What about the big hospitals that also own the machines? What then? Can you afford to compete with the big bad AI with similar or better outcome and software package you can’t afford.

Here’s the problem with AI and radonc. Any AI sophisticated enough to replace radiology will replace radonc first.

Again, I appreciate radonc as a service for my patient and I have nothing but respect for my mentors in NYC during my radonc research years and the friends I made now who are at big deal places now, but in 100 years? I am not so sure.

'
Watson Oncology has been one of the biggest letdowns in oncology in the modern era:

IBM pitched Watson as a revolution in cancer care. It's nowhere close

Edit: I'm not saying XRT will be around for sure in 100 years, as you're correct, we certainly COULD see advances which obviates its use. 100 years is just too long of a timeline to really make any statement with certainty, however.

2nd edit: I actually did treat a spleen for lymphoma last year, but I also agree with your statement that it's not common for us to do that anymore.

 

[evilbooyaa]

OK, we need to take this (IMO) silly thought experiment of where the field will be in 100 years and make it it's own thread. Nobody on this message board will be alive and practicing Radiation Oncology in 100 years. Can we get back to the topic at hand?

To answer DrFluffy's question - The data for radiation in lymphoma persists. Smaller fields, smaller amount of the body treated, but the proper treatment in a lot of lymphoma cases still includes radiation. Less than 100% (which was the historical standard). I look forward to the next tumor that chemotherapy alone can cure without surgery or radiation.

 

[DrfluffyMD]

'
Watson Oncology has been one of the biggest letdowns in oncology in the modern era:

IBM pitched Watson as a revolution in cancer care. It's nowhere close

Edit: I'm not saying XRT will be around for sure in 100 years, as you're correct, we certainly COULD see advances which obviates its use. 100 years is just too long of a timeline to really make any statement with certainty, however.

2nd edit: I actually did treat a spleen for lymphoma last year, but I also agree with your statement that it's not common for us to do that anymore.

Precisely. AI is no where close to replace us. Point is, all of our career should be safe in the next 20 years. I personally think that radonc is one of the best field in medicine right now with a nice balance of everything. Imaging, clinical work, procedures, etc.

 

[Fpg1245]

Precisely. AI is no where close to replace us. Point is, all of our career should be safe in the next 20 years. I personally think that radonc is one of the best field in medicine right now with a nice balance of everything. Imaging, clinical work, procedures, etc.

Yeah if a specialty has a viability of less than 25- 30 years it’s probably worth looking elsewhere. Reason being most people in Rad Onc are practicing 30-35 years. It’s not a physically taxing job and people can and do this well into there 70s. Just think many grads that go straight through will be done in their early 30s meaning in 20 years they will be in their 50s. Many people at that stage are supporting college age kids, a spouse, etc, and likely do not have enough savings to retire. If your specialty tanks at that point you’re limited in your options and will likely take a significant financial hit as well because the alternatives will likely be worse. You’ll be handcuffed to a sinking ship.

 

[DrfluffyMD]

Yeah if a specialty has a viability of less than 25- 30 years it’s probably worth looking elsewhere. Reason being most people in Rad Onc are practicing 30-35 years. It’s not a physically taxing job and people can and do this well into there 70s. Just think many grads that go straight through will be done in their early 30s meaning in 20 years they will be in their 50s. Many people at that stage are supporting college age kids, a spouse, etc, and likely do not have enough savings to retire. If your specialty tanks at that point you’re limited in your options and will likely take a significant financial hit as well because the alternatives will likely be worse. You’ll be handcuffed to a sinking ship.

I don’t think radonc is going to “tank”. Not in our work life time. Not suddenly.

Take another example. Nuclear medicine. Once truly the most amazing job in medicine. Still is. My attending come in at 7am and leave at 2pm yet making regular rad salary.

You can see what happened to the field in the nuclear medicine forum. First, radiologist start dabble in nucs. Despite nuc trained nucs specialist swear up and down about how much more skilled they are at doing their job, automated computer curves and training during rad residency made most rads and cards comfortable doing their own nucs.

What happened now is that nucs residency no longer fill at all. Even places like UCSF or MGH cannot fill. No AMG ever go into it. Last match 2 spots were in nucs.

Meanwhile, the nucs only attending who had the job for awhile still live comfortably. We just havent hired a nucs trained guy for awhile. As far as I know, actual jobs only open to nucs trained physician (not rads) is essentially nonexistent.

More strikingly, nucs, just like radonc, also separated from the house of radiology (IR is to be the third)

I imagine that will be what radonc’s final years look like if 90% of the work is gone and other specialist is fine doing the last 10%.

 

[Fpg1245]

I don’t think radonc is going to “tank”. Not in our work life time. Not suddenly.

Take another example. Nuclear medicine. Once truly the most amazing job in medicine. Still is. My attending come in at 7am and leave at 2pm yet making regular rad salary.

You can see what happened to the field in the nuclear medicine forum. First, radiologist start dabble in nucs. Despite nuc trained nucs specialist swear up and down about how much more skilled they are at doing their job, automated computer curves and training during rad residency made most rads and cards comfortable doing their own nucs.

What happened now is that nucs residency no longer fill at all. Even places like UCSF or MGH cannot fill. No AMG ever go into it. Last match 2 spots were in nucs.

Meanwhile, the nucs only attending who had the job for awhile still live comfortably. We just havent hired a nucs trained guy for awhile. As far as I know, actual jobs only open to nucs trained physician (not rads) is essentially nonexistent.

More strikingly, nucs, just like radonc, also separated from the house of radiology (IR is to be the third)

I imagine that will be what radonc’s final years look like if 90% of the work is gone and other specialist is fine doing the last 10%.

Doesn’t matter if it tanks or if it dies slowly, students should have the foresight to see a bad thing coming and stay away. I’m so tired of reading these mile long resumes with research and Onc publications. If you have such a strong interest in oncology then do heme Onc. If you can’t stomach the IM residency and fellowship then maybe you should rethink your “passion for oncology” Applying to Rad Onc residency just so you can figure out RTs role in the age of targeted therapy is a ridiculous waste of an applicants time. For people that are supposedly accomplished and reasonably intelligent, applying to Rad Onc is not so intelligent decision. it would be a waste of resources letting people with said resumes that could potentially contribute academically to oncology to develop a focus in Radiation. those newly prized MD PhDs that came to RO ended up on the immunotherapy side of things or just becoming regular clinicians.

 

[thecarbonionangle]

The biggest threat to our field is not necessarily from "targeted" therapies or IR but from lack of foresight in many levels in our field. As already stated, I think improved systemic therapy will likely lead to even more importance placed on local therapy. Local control is important for sure but a lot of what we do does not have a survival benefit. Sure LC is important but no OS in many cases.

1) complete lack of true "leadership" on many levels: "leaders" leading the field down a very bad path for short term gains in reputation and in their pocketbook. leads to below...

2) Keepers of a "single" modality: advances in radiation technology will only get us so much (rad bio advances non-existent), the shilling for protons is not going to improve our clinical outcomes, and sadly many academics are going this route (many more places opening up proton centres). Other countries allow rad oncs to receive training in systemic therapy. Somehow that has never made it over here and currently as far as I know (unless you do a neuro-onc fellowship which takes rad onc and there are some!), there is no way to get training in systemic therapy if you wanted to. The expansions in "functional neurosurgery", cardiac radiosurgery, or any benign treatment will not be enough to grow our spectrum. There is no push to have true valuable fellowships for people looking for ways to improve in a tight job market. I think this is directly tied to point 3.

3) The people. This is a pro and a con. I've met some very nice people in rad onc, people that really care about their patients, but the field seems to attract a lot of people of similar personalities, low key. These are people who are overall very passive, compared to other fields, and just do not want to do anything/much to expand the field outside the box. There's a lot of self-selection in rad onc and I think many positive things about the field tend to attract people that just do not want to get their fingers burned. Overall though, the field is destined for stagnancy if the majority of people are too afraid to turn the stove on. leads to point 4

4) as a field we are bad advocates for the value we provide overall. Somehow we have allowed surgeons and med oncs to dominate things on so many levels, at leadership, at media coverage, at advocating, at NCCN, in policy. Some of this may be from the "bottom-feeder" aspect of our field and dependance on these specialties to send us referrals, but some of it does not. As a med student and even as a resident, I have seen rad oncs sit quiet, say little at tumor boards, allow other people to dictate things, even when there are valuable things to say or unique perspectives to offer. Frankly, I overall feel that a lot of medicine just does not appreciate the overall contribution to patient care we offer. This is why I am not surprised to read what an IR colleague reads, because I have seen this many times. We need to do a much better job advocating for our field and earning respect.

I don't have the answers. Im inexperienced and I have a long way to go, but a lot of this I did not realize when I was applying to this field. Unfortunately, the people who know far more than me and have experience are often letting us down.

 

[napoleondynamite]

Reading this thread has been fascinating to me.. I must live in a different universe of radonc. I still totally love my job. Work 4 days a week and have 12 weeks vacation making a very comfortable salary. I say this not to brag. The job I'm at didn't start that good - I made it that good. In fact, this job sat unfilled for 18 months as a red-headed step child position. I took the job and made myself invaluable to the group and then was able to dictate what I wanted. There are a lot of jobs out there that have the potential my job has..they go untapped by geographic constraints people have. If you have your heart set on top 10 big city as your number 1 priority, don't go into radonc.

I just can't believe all the pessimism. Not much has been said about areas where our field is gaining significant ground. I treat metastatic patients much more aggressively than i used to. I use SBRT a lot. I treat the primary on metastatic prostate cancer patients, we didn't use to do that. PSMA PET/CT's are also generating a lot of oligometastatic prostates. There is an expanding role for radonc in benign disease if you have balls. I'm treating my first plantar fasciitis case next week. Brain mets have never been easier to treat with a linac. My medonc loves the abscopal effect and sends me a lot of business...with the low morbidity of SBRT, why not zap a small met when the patient is on immunotherapy?

I guess I'm glass half full. I see much more to be optimistic about.

Yes, hypofrac and active surveillance have caused a down tick in patients under beam. But if you can supplement with SBRT then you're working smarter rather than harder...

Sent from my Pixel 2 XL using SDN mobile

 

[napoleondynamite]

So yes, even today I'd choose radonc. I honestly don't know what else I would choose!!

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[deleted18755]

Reading this thread has been fascinating to me.. I must live in a different universe of radonc. I still totally love my job. Work 4 days a week and have 12 weeks vacation making a very comfortable salary. I say this not to brag. The job I'm at didn't start that good - I made it that good. In fact, this job sat unfilled for 18 months as a red-headed step child position. I took the job and made myself invaluable to the group and then was able to dictate what I wanted. There are a lot of jobs out there that have the potential my job has..they go untapped by geographic constraints people have. If you have your heart set on top 10 big city as your number 1 priority, don't go into radonc.

I just can't believe all the pessimism. Not much has been said about areas where our field is gaining significant ground. I treat metastatic patients much more aggressively than i used to. I use SBRT a lot. I treat the primary on metastatic prostate cancer patients, we didn't use to do that. PSMA PET/CT's are also generating a lot of oligometastatic prostates. There is an expanding role for radonc in benign disease if you have balls. I'm treating my first plantar fasciitis case next week. Brain mets have never been easier to treat with a linac. My medonc loves the abscopal effect and sends me a lot of business...with the low morbidity of SBRT, why not zap a small met when the patient is on immunotherapy?

I guess I'm glass half full. I see much more to be optimistic about.

Yes, hypofrac and active surveillance have caused a down tick in patients under beam. But if you can supplement with SBRT then you're working smarter rather than harder...

Sent from my Pixel 2 XL using SDN mobile

There must be dramatic differences between our practice locations and payers . . .

I honestly had this exact line of reasoning up until 1-2 years ago but my payers are ruthless (when you ask "why not zap a small met when the patient is on immunotherapy?" my answer is": because it won't be compensated and I don't want a patient who is dying (or his widow) to get a $60,000 bill). Like you hypofractionation and active surveillance severely decreased my consults and number of patients under treatment but I cannot supplement with SBRT so I'm not allowed to work smarter or harder, just not working as much (unless you count creative consult notes and peer to peer arguments as working smart and hard)!

For example, I just reviewed my practice and my use of SBRT has DECREASED over the past 12 months vs the previous 12 months. I think the concept of ablative doses of SBRT for oligo-metastatic disease is well established but also think it makes a lot of sense to treat people who are on immunotherapy or any systemic therapy who are tolerating it very well but have just 1 or 2 sites of active disease with SBRT, which is what I was doing with great success but one day just like that they dropped the hammer on me.

I currently have a patient with breast cancer in her 40's who had metastatic disease but no active disease on MRI or PET/CT after a lengthy course of systemic therapy. She took a chemo "holiday" to go get married and enjoy her life, now is admittedly more fit and active then I am, and the 9 month scan shows a single liver met (biopsy proven). She was referred to me for SBRT, which we all know is safe and effective and will avoid toxicity of systemic therapy for who knows how long while she enjoys her life but the insurance denied it and said it is their policy that the patient must be off of systemic therapy for a full 12 months before we can use SBRT, otherwise just strictly palliative dose/regimens are allowed. I even asked if I can just wait 2.5-3 months and treat it then with SBRT at the 12 month point, assuming no disease elsewhere, but they said now since it was documented at 9 months. The clown literally suggested that perhaps in the future we only do 6 and 12 month scans (wait to scan until exactly 12 months to the date of last day of systemic therapy, even if we think there is disease at 10 months) just so there is technically no disease documented for a full 12 months!

I am very sure that with the recent ASTRO guidelines for breast I will be required to use hypofractionation in every single case without a huge fight and I'm waiting for the same in intact prostate any day now and post-prostatectomy soon enough (looks like post-mastectomy will follow soon enough).

I see these interesting discussions such as the other thread about treating multiple brain mets with WBRT vs SRS and I'm agreeing but totally scratching my head how you guys get it paid for and then I see you are allowed to use RT, let alone SBRT, to stimulate the abscopal effect while I'm forced to use 8 Gy x 1 AP/PA for a spine met in a man with prostate cancer who isn't a pro-athlete but KPS 60 or maybe even 70 on a good day!?!?

I hope it isn't the case my friend (for you and your patients) but you may have a lot of pain coming your way really soon. Alternatively, if you have some secrets on how you get this approved please share. Also, does anybody have any suggestions on my case above (am I expected to literally treat 3 Gy x 10 in this case!?!)

PS: Just for the record I still love my job and would do it for half the pay, but I'm pretty sure I would happily mow lawns or work on an assembly line for a living if I had a 4 day week with 12 weeks vacation schedule and partner in private practice radiation oncology salary like our friend above!!!

 

[seper]

This is a very detailed guideline on liver SBRT approach (no freedom to choose dose per fraction)? Wound you mind sharing, who is the insurer and which geographic area.

There must be dramatic differences between our practice locations and payers . . .

I currently have a patient with breast cancer in her 40's who had metastatic disease but no active disease on MRI or PET/CT after a lengthy course of systemic therapy. She took a chemo "holiday" to go get married and enjoy her life, now is admittedly more fit and active then I am, and the 9 month scan shows a single liver met (biopsy proven). She was referred to me for SBRT, which we all know is safe and effective and will avoid toxicity of systemic therapy for who knows how long while she enjoys her life but the insurance denied it and said it is their policy that the patient must be off of systemic therapy for a full 12 months before we can use SBRT, otherwise just strictly palliative dose/regimens are allowed. I even asked if I can just wait 2.5-3 months and treat it then with SBRT at the 12 month point, assuming no disease elsewhere, but they said now since it was documented at 9 months. The clown literally suggested that perhaps in the future we only do 6 and 12 month scans (wait to scan until exactly 12 months to the date of last day of systemic therapy, even if we think there is disease at 10 months) just so there is technically no disease documented for a full 12 months!

I am very sure that with the recent ASTRO guidelines for breast I will be required to use hypofractionation in every single case without a huge fight and I'm waiting for the same in intact prostate any day now and post-prostatectomy soon enough (looks like post-mastectomy will follow soon enough).

I see these interesting discussions such as the other thread about treating multiple brain mets with WBRT vs SRS and I'm agreeing but totally scratching my head how you guys get it paid for and then I see you are allowed to use RT, let alone SBRT, to stimulate the abscopal effect while I'm forced to use 8 Gy x 1 AP/PA for a spine met in a man with prostate cancer who isn't a pro-athlete but KPS 60 or maybe even 70 on a good day!?!?

I hope it isn't the case my friend (for you and your patients) but you may have a lot of pain coming your way really soon. Alternatively, if you have some secrets on how you get this approved please share. Also, does anybody have any suggestions on my case above (am I expected to literally treat 3 Gy x 10 in this case!?!)

PS: Just for the record I still love my job and would do it for half the pay, but I'm pretty sure I would happily mow lawns or work on an assembly line for a living if I had a 4 day week with 12 weeks vacation schedule and partner in private practice radiation oncology salary like our friend above!!!

 

[seper]

My experience with radiation oncologists as "people" is different. We are not just willing to "expand the field outside the box". Just a few years into practice, almost everyone I know is perfectly willing to maximize utilization in the name of productivity.

The biggest threat to our field is not necessarily from "targeted" therapies or IR but from lack of foresight in many levels in our field. As already stated, I think improved systemic therapy will likely lead to even more importance placed on local therapy. Local control is important for sure but a lot of what we do does not have a survival benefit. Sure LC is important but no OS in many cases.

3) The people. This is a pro and a con. I've met some very nice people in rad onc, people that really care about their patients, but the field seems to attract a lot of people of similar personalities, low key. These are people who are overall very passive, compared to other fields, and just do not want to do anything/much to expand the field outside the box. There's a lot of self-selection in rad onc and I think many positive things about the field tend to attract people that just do not want to get their fingers burned. Overall though, the field is destined for stagnancy if the majority of people are too afraid to turn the stove on. leads to point 4

4) as a field we are bad advocates for the value we provide overall. Somehow we have allowed surgeons and med oncs to dominate things on so many levels, at leadership, at media coverage, at advocating, at NCCN, in policy. Some of this may be from the "bottom-feeder" aspect of our field and dependance on these specialties to send us referrals, but some of it does not. As a med student and even as a resident, I have seen rad oncs sit quiet, say little at tumor boards, allow other people to dictate things, even when there are valuable things to say or unique perspectives to offer. Frankly, I overall feel that a lot of medicine just does not appreciate the overall contribution to patient care we offer. This is why I am not surprised to read what an IR colleague reads, because I have seen this many times. We need to do a much better job advocating for our field and earning respect.

I don't have the answers. Im inexperienced and I have a long way to go, but a lot of this I did not realize when I was applying to this field. Unfortunately, the people who know far more than me and have experience are often letting us down.

 

[ramsesthenice]

There must be dramatic differences between our practice locations and payers . . .

I honestly had this exact line of reasoning up until 1-2 years ago but my payers are ruthless (when you ask "why not zap a small met when the patient is on immunotherapy?" my answer is": because it won't be compensated and I don't want a patient who is dying (or his widow) to get a $60,000 bill). Like you hypofractionation and active surveillance severely decreased my consults and number of patients under treatment but I cannot supplement with SBRT so I'm not allowed to work smarter or harder, just not working as much (unless you count creative consult notes and peer to peer arguments as working smart and hard)!

For example, I just reviewed my practice and my use of SBRT has DECREASED over the past 12 months vs the previous 12 months. I think the concept of ablative doses of SBRT for oligo-metastatic disease is well established but also think it makes a lot of sense to treat people who are on immunotherapy or any systemic therapy who are tolerating it very well but have just 1 or 2 sites of active disease with SBRT, which is what I was doing with great success but one day just like that they dropped the hammer on me.

I currently have a patient with breast cancer in her 40's who had metastatic disease but no active disease on MRI or PET/CT after a lengthy course of systemic therapy. She took a chemo "holiday" to go get married and enjoy her life, now is admittedly more fit and active then I am, and the 9 month scan shows a single liver met (biopsy proven). She was referred to me for SBRT, which we all know is safe and effective and will avoid toxicity of systemic therapy for who knows how long while she enjoys her life but the insurance denied it and said it is their policy that the patient must be off of systemic therapy for a full 12 months before we can use SBRT, otherwise just strictly palliative dose/regimens are allowed. I even asked if I can just wait 2.5-3 months and treat it then with SBRT at the 12 month point, assuming no disease elsewhere, but they said now since it was documented at 9 months. The clown literally suggested that perhaps in the future we only do 6 and 12 month scans (wait to scan until exactly 12 months to the date of last day of systemic therapy, even if we think there is disease at 10 months) just so there is technically no disease documented for a full 12 months!

I am very sure that with the recent ASTRO guidelines for breast I will be required to use hypofractionation in every single case without a huge fight and I'm waiting for the same in intact prostate any day now and post-prostatectomy soon enough (looks like post-mastectomy will follow soon enough).

I see these interesting discussions such as the other thread about treating multiple brain mets with WBRT vs SRS and I'm agreeing but totally scratching my head how you guys get it paid for and then I see you are allowed to use RT, let alone SBRT, to stimulate the abscopal effect while I'm forced to use 8 Gy x 1 AP/PA for a spine met in a man with prostate cancer who isn't a pro-athlete but KPS 60 or maybe even 70 on a good day!?!?

I hope it isn't the case my friend (for you and your patients) but you may have a lot of pain coming your way really soon. Alternatively, if you have some secrets on how you get this approved please share. Also, does anybody have any suggestions on my case above (am I expected to literally treat 3 Gy x 10 in this case!?!)

PS: Just for the record I still love my job and would do it for half the pay, but I'm pretty sure I would happily mow lawns or work on an assembly line for a living if I had a 4 day week with 12 weeks vacation schedule and partner in private practice radiation oncology salary like our friend above!!!

That sucks. I am somewhere int he middle but closer to Napoleon. My SBRT volume has skyrocketed recently. Biggest contributers are post-immuno residual disease, PSMA-PET detected disease, and liver SBRT (our med onc doing all the TACE sends me most of the patients with favorable tumor sites for post-TACE SBRT).

I often can't bill for SBRT because none of the carriers recognize SBRT for bone or nodal disease (even in oligometastatic setting) but I can bill for VMAT in most cases. These are patients I wouldn't have treated at all before, so its definitely a win for me.

Brachy volume has exploded too since ASCEND RT. We have a great urologist who genuinely believes the toxicity from combo EBRT/brachy is still better than RALP and salvage RT and sends a lot of them our way.

Last thing I will say, because the biologist in me just can't let this go, our understanding of biology and tumor targeting is a double-edged sword. We know a lot more about biology than we did before but if you look collectively at our experience with targeted therapy and cell signalling what we have learned is that it is unbelievably complicated and there are almost no true "driver mutations." With the exception of Gleevec for a very limited number of disease there are no curative targeted therapies. They improve DFS but resistance is inevitable. The most realistic intermediate future for targeted, systemic therapy is that we get to an HIV-like management where patients stay on multi-agent drug regimens long term. Realistically, that is what we get with immunotherapy as well. Not cure, but control. I am not downplaying this at all. Being able to convert something like metastatic lung cancer into an asymptomatic chronic disease is a big deal. But in this scenario local therapy becomes more, not less important.

 

[deleted18755]

That sucks. I am somewhere int he middle but closer to Napoleon. My SBRT volume has skyrocketed recently. Biggest contributers are post-immuno residual disease, PSMA-PET detected disease, and liver SBRT (our med onc doing all the TACE sends me most of the patients with favorable tumor sites for post-TACE SBRT).

I often can't bill for SBRT because none of the carriers recognize SBRT for bone or nodal disease (even in oligometastatic setting) but I can bill for VMAT in most cases. These are patients I wouldn't have treated at all before, so its definitely a win for me.

Brachy volume has exploded too since ASCEND RT. We have a great urologist who genuinely believes the toxicity from combo EBRT/brachy is still better than RALP and salvage RT and sends a lot of them our way.

Last thing I will say, because the biologist in me just can't let this go, our understanding of biology and tumor targeting is a double-edged sword. We know a lot more about biology than we did before but if you look collectively at our experience with targeted therapy and cell signalling what we have learned is that it is unbelievably complicated and there are almost no true "driver mutations." With the exception of Gleevec for a very limited number of disease there are no curative targeted therapies. They improve DFS but resistance is inevitable. The most realistic intermediate future for targeted, systemic therapy is that we get to an HIV-like management where patients stay on multi-agent drug regimens long term. Realistically, that is what we get with immunotherapy as well. Not cure, but control. I am not downplaying this at all. Being able to convert something like metastatic lung cancer into an asymptomatic chronic disease is a big deal. But in this scenario local therapy becomes more, not less important.

Please allow me to clarify: I am not allowed to bill for SBRT and/or a 3-5 fraction course, but they have no problem with me doing everything exactly the same (SBRT technique with gating and everything) but using 6 fractions. Since it's 6 fractions they say it can't be billed as SBRT (since for whatever something magically changes between 5 and 6 fractions even with the same technique) and it's 3DCRT, and since it's 3DCRT they don't allow IGRT but they'll "do me a favor" and allow it.

Napolean: is this what you are doing or are you truly using and billing for SBRT?

Rams: it seems like you are in the same situation as me but they actually let you use VMAT, which isn't as ideal as SBRT but obviously better than 3DCRT. Do you have to argue with them or does it just go through.

As an update, thanks to somebody's brilliant suggestion awhile ago on another thread , when I did the second peer to peer for the woman above an hour ago after the reviewer stated that this was a recorded conversation I told him I was also recording and plan to play the entire conversation to the patient. He seemed quite startled and then I wondered if this was legal on my end (I went out of my way to say "I would like to verify that you acknowledge and accept my record as well") but guess what . . . within 90 seconds SBRT approved!

PS: I wasn't actually recording

 

[DrfluffyMD]

They improve DFS but resistance is inevitable. The most realistic intermediate future for targeted, systemic therapy is that we get to an HIV-like management where patients stay on multi-agent drug regimens long term. Realistically, that is what we get with immunotherapy as well. Not cure, but control. I am not downplaying this at all. Being able to convert something like metastatic lung cancer into an asymptomatic chronic disease is a big deal. But in this scenario local therapy becomes more, not less important.

Not to be a party pooper, but wouldn’t future like that precisely decrease the role of radiation and surgery to the role of emergent control? When targeted therapies are so effective that tumors just melt? We are already begin to see those types of drastic response.

Further more, if targeted therapy become HIV therapy good, wouldn’t we try to phase out anything that has a mechanism of uncontrolled DNA strand break because the risk of secondary carcinogenesis?

 

[radiaterMike]

Not to be a party pooper, but wouldn’t future like that precisely decrease the role of radiation and surgery to the role of emergent control? When targeted therapies are so effective that tumors just melt? We are already begin to see those types of drastic response.

Further more, if targeted therapy become HIV therapy good, wouldn’t we try to phase out anything that has a mechanism of uncontrolled DNA strand break because the risk of secondary carcinogenesis?

I think the difference is that those tumors that melt away also grow back at some point. These new drugs are not curing patients but rather prolonging survival and disease control. This of course can change but ultimately you will always have a drug delivery problem to tumors (ie necrotic centers) and cancer cells undergo mutations which eventually can beat out the drugs. Local therapy has similar issues but allows you to attack the cancer on a different way.

 

[evilbooyaa]

Please allow me to clarify: I am not allowed to bill for SBRT and/or a 3-5 fraction course, but they have no problem with me doing everything exactly the same (SBRT technique with gating and everything) but using 6 fractions. Since it's 6 fractions they say it can't be billed as SBRT (since for whatever something magically changes between 5 and 6 fractions even with the same technique) and it's 3DCRT, and since it's 3DCRT they don't allow IGRT but they'll "do me a favor" and allow it.

Napolean: is this what you are doing or are you truly using and billing for SBRT?

Rams: it seems like you are in the same situation as me but they actually let you use VMAT, which isn't as ideal as SBRT but obviously better than 3DCRT. Do you have to argue with them or does it just go through.

As an update, thanks to somebody's brilliant suggestion awhile ago on another thread , when I did the second peer to peer for the woman above an hour ago after the reviewer stated that this was a recorded conversation I told him I was also recording and plan to play the entire conversation to the patient. He seemed quite startled and then I wondered if this was legal on my end (I went out of my way to say "I would like to verify that you acknowledge and accept my record as well") but guess what . . . within 90 seconds SBRT approved!

PS: I wasn't actually recording

I plan to frequently use the "Your refusal to cover what I deem a medically necessary and beneficial radiation technique for this patient and only approve something that is of inferior quality for this clinical situation and would harm or provide no benefit to the patient will be documented in the patient's medical record and the patient will be informed regarding your decision" line, or something along it, when I get a peer-to-peer that's resistant to reasonable discourse, especially if I feel really strongly about it (like SBRT rather than 3DCRT for a single liver met). I've done a limited number of peer to peers as a resident (usually for surveillance imaging rather than actual treatment) but I've never failed thus far with that one.

Anyone have any cautionary tales regarding a line like that?

 

[ramsesthenice]

Not to be a party pooper, but wouldn’t future like that precisely decrease the role of radiation and surgery to the role of emergent control? When targeted therapies are so effective that tumors just melt?

They usually don't. That's the problem. Even when you get an immunologic response most established tumors are not eradicated. It is far more common for them to be held in check. Most of the good receptor assays suggest polyclonal responses to no more than 3-5 neoantigens. That is a scary low number. It is likely that clonal resistance to stimulated immunity will happen eventually. I suspect we will find that we probably should treat stable, asymptomatic disease with some form of focal therapy in those situations. Obviously a lot of speculation on my part, but the belief that immunotherapy frequently melts tumors is to this point erroneous.

 

[ramsesthenice]

Rams: it seems like you are in the same situation as me but they actually let you use VMAT, which isn't as ideal as SBRT but obviously better than 3DCRT.

I don't think so. I just know that they don't approve SBRT for nodal or bone mets. It does't change anything on my end. I generally use VMAT with KV-imaged guidance for non-CNS radiosurgical treatments. Its only a question of how it is billed.

 

[seper]

Being mean to peer reviewers on the phone doesn't do any good. It only serves to increase the amount of nastiness in interpersonal communication.

 

[medgator]

Being mean to peer reviewers on the phone doesn't do any good. It only serves to increase the amount of nastiness in interpersonal communication.

Crossing over to the dark side and selling your soul doesn't do our field any favors either. I routinely have to argue with P2P Rad oncs to get IMRT approved in Stage III lung, despite the very good data that came out of 0617, which they poo poo as a secondary analysis blah blah blah.... sorry but having my patients tolerate chemo/XRT better with lower esophagitis is meaningful IMO

 

[seper]

But still. They are colleagues. They all have seen IMRT for hip mets and understand the game. Threatening them and lying to them is not appropriate.

 

[medgator]

They also think anything palliative deserves 10 fractions or less at 2D techniques with no igrt*










* - only get 10 fractions approved for ECOG 0-1

 

[radiaterMike]

I believe that most peer reviewers have to adhere to the the insurer’s policy. So even if they agree with you they might not be able to use their judgement. I believe you can send it to independent review though (depending on the state).

i don’t think that oligoprogression is covered in many - if any - policies. Arguably it is still investigational but you could argue that changing systemic therapy would be detrimental to the patient. The question then is — do you need to use sbrt ? and that is where insurers say no.

Medicare will pay. The question is whether or not they’ll take the money back in a few years.

 

[evilbooyaa]

Crossing over to the dark side and selling your soul doesn't do our field any favors either. I routinely have to argue with P2P Rad oncs to get IMRT approved in Stage III lung, despite the very good data that came out of 0617, which they poo poo as a secondary analysis blah blah blah.... sorry but having my patients tolerate chemo/XRT better with lower esophagitis is meaningful IMO

The issue is that peer to peer routinely ISN'T a Rad Onc. It's a family doctor just spouting the insurance company's policy or like a medical oncologist. If I was discussing with a Rad Onc consistently it'd be a lot nicer. Of course maybe it's hard in the community to get anything besides 2D, 10 fx, no IGRT approved for palliative patients.

 

[medgator]

The issue is that peer to peer routinely ISN'T a Rad Onc. It's a family doctor just spouting the insurance company's policy or like a medical oncologist. If I was discussing with a Rad Onc consistently it'd be a lot nicer. Of course maybe it's hard in the community to get anything besides 2D, 10 fx, no IGRT approved for palliative patients.

Most of my xrt p2p requests have been with rad oncs (evicore, AIM etc). My diagnostic imaging requests end up getting handled by pcps.

I've had rad oncs tell me I don't need igrt or to check a dvh on the kidneys for palliative L spine plans. It's like they wish I'd just take a conventional sim film, draw a field on it, set a depth and treat it like the old days.

I've also had rad oncs tell me what the insurers think of the imrt data in stage III lung.....but then I ask them, how do you feel about insurers practicing medicine now?

 

[napoleondynamite]

Being mean to peer reviewers on the phone doesn't do any good. It only serves to increase the amount of nastiness in interpersonal communication.

Oh, I've gotten downright nasty with them. I get their full name, I make sure they know it's going into my note and I also make sure to tell them I'm logging onto Healthgrades right now to leave them a horrific peer review specifically discussing their role in impeding patient care as a sellout to insurance companies. Yes, I've actually done exactly that. And it has actually worked.

 

[napoleondynamite]

I really do not lose a lot of peer to peers. I do a lot of them. If something is denied, I insist to speak to a peer radiation oncologist until they provide one for me. Each one of these reviews I see as a precedent that is possibly set for the next patient with that insurer, so I push every single one to multiple levels if needed until I get the approval. I write letters. I cite data in all of my notes, even if the data is pretty scant.

I'm sure others do this also... I'm just telling you my approach. It does take some time. But when I jump through all the hoops, at least in my area of the country, I'm not losing very many appeals when I finally get to a radiation oncologist. In fact, I can only think of one in the last 4 years. It was a patient under 50 who I wanted to treat with standard fractionation breast. She also had large breasts. Radiation oncologist denied, but after I ran two plans, called him back and he issued an approval.

Sent from my Pixel 2 XL using SDN mobile

 

[kristofer]

The issue is that peer to peer routinely ISN'T a Rad Onc. It's a family doctor just spouting the insurance company's policy or like a medical oncologist. If I was discussing with a Rad Onc consistently it'd be a lot nicer. Of course maybe it's hard in the community to get anything besides 2D, 10 fx, no IGRT approved for palliative patients.

There's some funny stuff going on here. Attendings should take ownership of their patients. It is unacceptable IMO to scut off such crucial (albeit highly annoying) tasks to residents or midlevels. If you were the patient, how would you feel if you knew that a first year resident was the one responsible for making sure your plan got approved by insurance? Additionally family doctors should not be responsible for signing off on radiation treatment plans. I have never heard of such a thing, but then again residents are expressly forbidden to do peer-to-peers at my program.

 

[thecarbonionangle]

Lol. So many programs where attendings dont “take ownership”. This is a huge driver for residency expansion. Everyone wants coverage. I know of attendings who couldnt tell you a single thing of their patients on treatment. it is not surprising that many programs use residents as cheaper PAs who cant bargain and just put their heads down. Our “leaders” apparently know many programs are just glorified private practices yet they do nothing about it. What a joke.

 

[Gfunk6]

Oh, I've gotten downright nasty with them. I get their full name, I make sure they know it's going into my note and I also make sure to tell them I'm logging onto Healthgrades right now to leave them a horrific peer review specifically discussing their role in impeding patient care as a sellout to insurance companies. Yes, I've actually done exactly that. And it has actually worked.

Damn napoleon, you play for keeps!

 

[kristofer]

Lol. So many programs where attendings dont “take ownership”. This is a huge driver for residency expansion. Everyone wants coverage. I know of attendings who couldnt tell you a single thing of their patients on treatment. it is not surprising that many programs use residents as cheaper PAs who cant bargain and just put their heads down. Our “leaders” apparently know many programs are just glorified private practices yet they do nothing about it. What a joke.

If, for nothing else, M4s who are going into this eyes-wide-open should think about these things when they are interviewing. Ask the residents. Do they do peer-to-peer reviews for treatment plans? Peer-to-peer for imaging? Prior Auths? Do they field patient calls when they request to speak to their doctor (the attending)? Do they draw labs and run them upstairs and call for lab results? Do they do the nurses or transporters job? Do they do intake/survivorship surveys on patients? It's one thing to volunteer for this kind of stuff in a pinch, but it's another to be an environment where you are scolded for not doing so. And on a similar train of thought, do the residents have to do things that are dangerous (checking films as first years, placing skin blocks or checking light fields unsupervised, making shifts on their own, staffing the machines alone, approving plans that the attending never checks, etc.)? Med students never, never ask this stuff. It's always, what linac do you have, can you contour and do notes from home, when are you getting protons, how far away is the beach, what do you guys do on the weekend, etc? Great way to choose a program guys. Think about your day to day work and whether the faculty have your back and want you to succeed or just want you to do their work so they can go home early. These kind of things speak volumes as to how residents are treated in programs, and it's important for applicants to understand that such culture varies widely. Unless senior leadership protects residents from scut, there will be scut.

 

[ramsesthenice]

Lol. So many programs where attendings dont “take ownership”. This is a huge driver for residency expansion. Everyone wants coverage. I know of attendings who couldnt tell you a single thing of their patients on treatment. it is not surprising that many programs use residents as cheaper PAs who cant bargain and just put their heads down. Our “leaders” apparently know many programs are just glorified private practices yet they do nothing about it. What a joke.

Wow. That is beyond sad. I just don’t get it. I am a physician scientist that is not even a full time clinician and even I think that the single best part of the job is getting to have a strong relationship with my patients and doing everything I can to help them.

Where I trained and where I work now this kind of behavior would never fly. If we didn’t also take ownership of our patients we would be publically chastised. Worst thing you could do is call someone “our sarcoma patient” etc.

And doing peer-to-peers for RT issues? That’s just redicous. Take ethics out of the picture and it’s still a financial risk. They don’t know enough of the fine details to do this well. I do make my residents to peer-peer evaluations for things like Zofran or narcotics. I think it’s good for them to practice. I also have them sit in the room with me on speaker phone to hear how I handle it.

Finally, I make them write detailed plans on consult to avoid them as able. They don’t usually approve IMRT for esophagus. But, if in a very detailed way we write out that the tumor is large with multistation nodal involvement and that we will probably need to utilize IMRT to meet lung and heart constraints we can often avoid doing one. Ditto for the SBRT comment above. If you just say I’m going to SBRT for a bone met you will (and should) get denied. Instead I spell out that I will use palliative hypofracionated radiotherapy with the goal of delaying or preventing the need for systemic therapy and regular blood monitoring. Since doing that I rarely have to do peer-to-peers anymore.

There are good places to train. Anyone interested can feel free to PM me and I will give specifics on places that I know this doesn’t fly. Don’t ask me about places that do too much scuttling. I honestly haven’t seen them first hand so I don’t want to pass any rumors along but they do exist so you need to do your research.

 

[ramsesthenice]

Everyone wants coverage.

This should be one of the biggest red flags for prospective residents. If attendings are not willing to go uncovered then that is a very loud testament to how they value the residents. I know a lot of programs require a lot of cross coverage and multi-attending rotations. The rationalization is that residents learn by doing in the clinic but come on.

At my current program we have an equal number of residents and attendings. Our residents all do a research rotation (some even do Holman), a dedicated physics/dosimetry/radiology elective and we also have them do rotations at two of our satellite locations. We value our residents and think that these kinds of experiences are critical to making them well-rounded physicians ready to practice in the community or academic centers. In order to do this, we all go uncovered for 2-3 months each year. Even when we have residents on service do not require cross coverage except in very rare instances ( like days when I have several brachy procedures and need to be in more than one place at once). We are genuinely committed to giving our residents a well-rounded education and back up that commitment with our willingness to go uncovered.

I would be wary of programs that require frequent cross-coverage or multi-service rotations. The idea that residents learn best by seeing a million patients in clinic is antiquated. Worse, this behavior might be a true testament of how they value your time, regardless of their motives.

 

[evilbooyaa]

There's some funny stuff going on here. Attendings should take ownership of their patients. It is unacceptable IMO to scut off such crucial (albeit highly annoying) tasks to residents or midlevels. If you were the patient, how would you feel if you knew that a first year resident was the one responsible for making sure your plan got approved by insurance? Additionally family doctors should not be responsible for signing off on radiation treatment plans. I have never heard of such a thing, but then again residents are expressly forbidden to do peer-to-peers at my program.

I don't disagree, and it's not common at my program. While I agree that residents shouldn't be scutted out to do this on every case that gets denied, it does happen, sometimes, from some attendings. I don't feel that doing a small number of these, to get exposure to it (similar to reviewing CBCTs, Port films, etc.) is useless to my education.

I whole-heartedly agree that a residency program that has 100% resident coverage for all attendings who are absolutely unwilling to go uncovered, requiring cross-coverage systems to keep the attendings happy, is painful and should not occur outside of very specific scenarios (two 80% research attendings paired with each other or something). I wish it was a requirement that all academic rad oncs need to have a block of time (in months) where they have no resident coverage and have to draw their own volumes. Even at my (IMO) non-scutty, non-malignant program, you can tell who has a resident just by looking at number of on treatments when an attending (who would usually run at 10pts on treat) balloons to 20+. Attendings mostly only take vacation when they don't have a resident because it gets them out of a week of clinic.

 

[fiji128]

Lol. So many programs where attendings dont “take ownership”. This is a huge driver for residency expansion. Everyone wants coverage. I know of attendings who couldnt tell you a single thing of their patients on treatment. it is not surprising that many programs use residents as cheaper PAs who cant bargain and just put their heads down. Our “leaders” apparently know many programs are just glorified private practices yet they do nothing about it. What a joke.

I think in one of my ACGME evaluation I once wrote the residents where I was training were nothing more then PAs b/c of all the stuff kristofer wrote. That did not go over well when the evaluation were reviewed.