What is your Boomer/Mendoza Line?

[jondunn]

what is the line you use for when you consider someone a boomer dinosaur?

I saw a patient this week who saw another rad onc at the local regional hospital before coming to us for treatment. i looked up the rad onc and he was about 12 years out of practice - but he wanted the patient to get a prophy tube before HN chemoRT.

the prophylactic tube prior to starting is my Boomer Line that separates the fresh from the yesterdays news.

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[RADONC4285]

what is the line you use for when you consider someone a boomer dinosaur?

I saw a patient this week who saw another rad onc at the local regional hospital before coming to us for treatment. i looked up the rad onc and he was about 12 years out of practice - but he wanted the patient to get a prophy tube before HN chemoRT.

the prophylactic tube prior to starting is my Boomer Line that separates the fresh from the yesterdays news.

I don't think that's necessarily yesterday's news. 50 to 60% of pts end up with PEG tubes. Sometimes the writing is on the wall. If I have a patient who's arealdy losing weight, having odynophagia, and I know I need to tx BOT and b/l neck, it's very reasonable to set them up with a peg before tx.

 

[medgator]

what is the line you use for when you consider someone a boomer dinosaur?

I saw a patient this week who saw another rad onc at the local regional hospital before coming to us for treatment. i looked up the rad onc and he was about 12 years out of practice - but he wanted the patient to get a prophy tube before HN chemoRT.

the prophylactic tube prior to starting is my Boomer Line that separates the fresh from the yesterdays news.

Sounds like someone is a noob who doesn't know when or when to not peg someone before tx @RADONC4285 summarized it well

 

[jondunn]

I don't think that's necessarily yesterday's news. 50 to 60% of pts end up with PEG tubes. Sometimes the writing is on the wall. If I have a patient who's arealdy losing weight, having odynophagia, and I know I need to tx BOT and b/l neck, it's very reasonable to set them up with a peg before tx.

fair enough for some cases. but that PEG rate seems quite high to me.

 

[elementaryschooleconomics]

I don't think that's necessarily yesterday's news. 50 to 60% of pts end up with PEG tubes. Sometimes the writing is on the wall. If I have a patient who's arealdy losing weight, having odynophagia, and I know I need to tx BOT and b/l neck, it's very reasonable to set them up with a peg before tx.

Sometimes, the writing is in the chart too. I had a PEG prophylactically placed because one of the docs in the patient's care team documented, thoroughly, about their concern with pursuing chemo-RT without a PEG tube placed upfront. I generally agreed with that assessment, but felt like I was caught in a medico-legal trap, where if I opted to not do it and things went south, that would be an easy malpractice suit for me to lose.

To the question of the thread though, the obvious answer for me is contouring. People who trained "in the old days" and had to teach themselves contouring understandably struggle with it. I would, too. I eagerly await some sort of magic technology to come on the scene in 15 or so years that I will also not do well with.

 

[medgator]

Sometimes, the writing is in the chart too. I had a PEG prophylactically placed because one of the docs in the patient's care team documented, thoroughly, about their concern with pursuing chemo-RT without a PEG tube placed upfront. I generally agreed with that assessment, but felt like I was caught in a medico-legal trap, where if I opted to not do it and things went south, that would be an easy malpractice suit for me to lose.

To the question of the thread though, the obvious answer for me is contouring. People who trained "in the old days" and had to teach themselves contouring understandably struggle with it. I would, too. I eagerly await some sort of magic technology to come on the scene in 15 or so years that I will also not do well with.

No way in hell I'm starting someone with a BMI barely in their 20s presenting with dysphagia/trismus with a bulky symptomatic OP primary without a peg

 

[RADONC4285]

No way in hell I'm starting someone with a BMI barely in their 20s presenting with dysphagia/trismus with a bulky symptomatic OP primary without a peg

another consideration is the set up at your practice/hospital. If you're at a place that can get a peg in within a couple of days, it's reasonable to start without a PEG. But if you're out in the community and getting a PEG tube takes time, then inserting one mid-way through treatment can result in serious treatment delays, especially if the patient is admitted for malnutrition and hydration and you don't have the ability to treat them inpatient

 

[medgator]

another consideration is the set up at your practice/hospital. If you're at a place that can get a peg in within a couple of days, it's reasonable to start without a PEG. But if you're out in the community and getting a PEG tube takes time, then inserting one mid-way through treatment can result in serious treatment delays, especially if the patient is admitted for malnutrition and hydration and you don't have the ability to treat them inpatient

Even if you can, administration in most places frown on it, if they are Medicare, which many of them are, that comes out of the hospitals daily DRG payment

 

[jondunn]

To the question of the thread though, the obvious answer for me is contouring.

Ding. Ding. Ding.

 

[Mandelin Rain]

Poor nutritional reserve -and-
Pre-existing weight loss and/or dysphagia -and-
Bulky primary, especially hypopharynx/supraglottic larynx

These folks get PEGs in my clinic.

I try to push the rest through and maybe 1/4-1/3 need an urgent PEG during treatment.

 

[Mandelin Rain]

To answer the initial question... using tape to immobilize head

 

[TheWallnerus]

what is the line you use for when you consider someone a boomer dinosaur?

I saw a patient this week who saw another rad onc at the local regional hospital before coming to us for treatment. i looked up the rad onc and he was about 12 years out of practice - but he wanted the patient to get a prophy tube before HN chemoRT.

the prophylactic tube prior to starting is my Boomer Line that separates the fresh from the yesterdays news.

"Poetic influence, as I conceive it, is a variety of melancholy or the anxiety-principle." New poets become inspired to write because they have read and admired the poetry of previous poets; but this admiration turns into resentment when the new poets discover that these poets whom they idolized have already said everything they wish to say. The poets become disappointed because they "cannot be Adam early in the morning. There have been too many Adams, and they have named everything." In order to evade this psychological obstacle, new poets must be convinced that previous poets have gone wrong somewhere and failed in their vision, thus leaving open the possibility that they may have something to add to the tradition after all. The new poets' love for their heroes turns into antagonism towards them: "Initial love for the precursor's poetry is transformed rapidly enough into revisionary strife, without which individuation is not possible."

 

[RadOncG]

1. Can't start your palliative treatment on Friday. Tumor will explode over the weekend and you'll die
2. Can't wear deodorant during breast irradiation. A physicist in 1950 said it was bad
3. Can't use silvadene is radiation field. There's metal there too
4. One vertebral body above and below. What if there's tumor there? And what if there is tumor 2 above. Let's just do the whole spine
5. Don't get too cute with palliative radiation
6. Treat there too..."But boomer, there's no tumor"...yes but we don't want to miss
7. Call's the medical oncologist to ask what to treat. "I know it's a stage 3 lung but the medical oncologist didn't tell me what to do"
8. Emergent CSI for solid tumor leptomeningeal carcinomatosis
9. I've seen a lot of toxicity with 50 in 25. I do 50.4 in 28
10. Let me measure the breast separation then I'll determine fractionation
11. I don't like to hypofractionate DCIS, once it becomes cancer then it's safe to hypofrac
12. Can you show me this contour on a plain film?
13. The skin needs a boost and bolus. "But doctor there was no skin involvement"...yes but I need to leave my mark

 

[jondunn]

1. Can't start your palliative treatment on Friday. Tumor will explode over the weekend and you'll die
2. Can't wear deodorant during breast irradiation. A physicist in 1950 said it was bad
3. Can't use silvadene is radiation field. There's metal there too
4. One vertebral body above and below. What if there's tumor there? And what if there is tumor 2 above. Let's just do the whole spine
5. Don't get too cute with palliative radiation
6. Treat there too..."But boomer, there's no tumor"...yes but we don't want to miss
7. Call's the medical oncologist to ask what to treat. "I know it's a stage 3 lung but the medical oncologist didn't tell me what to do"
8. Emergent CSI for solid tumor leptomeningeal carcinomatosis
9. I've seen a lot of toxicity with 50 in 25. I do 50.4 in 28
10. Let me measure the breast separation then I'll determine fractionation
11. I don't like to hypofractionate DCIS, once it becomes cancer then it's safe to hypofrac
12. Can you show me this contour on a plain film?
13. The skin needs a boost and bolus. "But doctor there was no skin involvement"...yes but I need to leave my mark

haha love it.

you understood the assignment

 

[deleted171718]

1. Can't start your palliative treatment on Friday. Tumor will explode over the weekend and you'll die
2. Can't wear deodorant during breast irradiation. A physicist in 1950 said it was bad
3. Can't use silvadene is radiation field. There's metal there too
4. One vertebral body above and below. What if there's tumor there? And what if there is tumor 2 above. Let's just do the whole spine
5. Don't get too cute with palliative radiation
6. Treat there too..."But boomer, there's no tumor"...yes but we don't want to miss
7. Call's the medical oncologist to ask what to treat. "I know it's a stage 3 lung but the medical oncologist didn't tell me what to do"
8. Emergent CSI for solid tumor leptomeningeal carcinomatosis
9. I've seen a lot of toxicity with 50 in 25. I do 50.4 in 28
10. Let me measure the breast separation then I'll determine fractionation
11. I don't like to hypofractionate DCIS, once it becomes cancer then it's safe to hypofrac
12. Can you show me this contour on a plain film?
13. The skin needs a boost and bolus. "But doctor there was no skin involvement"...yes but I need to leave my mark

Did my chair write this list?

 

[Palex80]

1. Can't start your palliative treatment on Friday. Tumor will explode over the weekend and you'll die
2. Can't wear deodorant during breast irradiation. A physicist in 1950 said it was bad
3. Can't use silvadene is radiation field. There's metal there too
4. One vertebral body above and below. What if there's tumor there? And what if there is tumor 2 above. Let's just do the whole spine
5. Don't get too cute with palliative radiation
6. Treat there too..."But boomer, there's no tumor"...yes but we don't want to miss
7. Call's the medical oncologist to ask what to treat. "I know it's a stage 3 lung but the medical oncologist didn't tell me what to do"
8. Emergent CSI for solid tumor leptomeningeal carcinomatosis
9. I've seen a lot of toxicity with 50 in 25. I do 50.4 in 28
10. Let me measure the breast separation then I'll determine fractionation
11. I don't like to hypofractionate DCIS, once it becomes cancer then it's safe to hypofrac
12. Can you show me this contour on a plain film?
13. The skin needs a boost and bolus. "But doctor there was no skin involvement"...yes but I need to leave my mark

This. Should. Be. A. Sticky. Post.

 

[Tigerstang]

what is the line you use for when you consider someone a boomer dinosaur?

I saw a patient this week who saw another rad onc at the local regional hospital before coming to us for treatment. i looked up the rad onc and he was about 12 years out of practice - but he wanted the patient to get a prophy tube before HN chemoRT.

the prophylactic tube prior to starting is my Boomer Line that separates the fresh from the yesterdays news.

I view this as a sign of a well trained radonc. Perhaps you need to study for the boards a litter harder.

 

[elementaryschooleconomics]

1. Can't start your palliative treatment on Friday. Tumor will explode over the weekend and you'll die
2. Can't wear deodorant during breast irradiation. A physicist in 1950 said it was bad
3. Can't use silvadene is radiation field. There's metal there too
4. One vertebral body above and below. What if there's tumor there? And what if there is tumor 2 above. Let's just do the whole spine
5. Don't get too cute with palliative radiation
6. Treat there too..."But boomer, there's no tumor"...yes but we don't want to miss
7. Call's the medical oncologist to ask what to treat. "I know it's a stage 3 lung but the medical oncologist didn't tell me what to do"
8. Emergent CSI for solid tumor leptomeningeal carcinomatosis
9. I've seen a lot of toxicity with 50 in 25. I do 50.4 in 28
10. Let me measure the breast separation then I'll determine fractionation
11. I don't like to hypofractionate DCIS, once it becomes cancer then it's safe to hypofrac
12. Can you show me this contour on a plain film?
13. The skin needs a boost and bolus. "But doctor there was no skin involvement"...yes but I need to leave my mark

I nominate this as "best post of 2021".

This post triggered me deeply.

 

[Tigerstang]

This thread makes me concerned about the quality of training newer radoncs are getting.

 

[jondunn]

This thread makes me concerned about the quality of training newer radoncs are getting.

Dude, retire already.

 

[deleted1111261]

Weekend treatments … bane of my existence.

What’s so bad about giving a fraction on Friday and then picking up on Monday?

Good list overall!

PEG tube was a really odd one to start out with. Two very reasonable schools of thoughts. I used to work in clinics far from hospitals and putting in a tube mid treatment was a huge issue. And the local medoncs wanted it in if combined modality. Part of practice is understanding your locale and not presuming that what you did at your PPS exempt training grounds is exactly what you should do in practice.

 

[jondunn]

Weekend treatments … bane of my existence.

What’s so bad about giving a fraction on Friday and then picking up on Monday?

Good list overall!

PEG tube was a really odd one to start out with. Two very reasonable schools of thoughts. I used to work in clinics far from hospitals and putting in a tube mid treatment was a huge issue. And the local medoncs wanted it in if combined modality. Part of practice is understanding your locale and not presuming that what you did at your PPS exempt training grounds is exactly what you should do in practice.

Hmm. Don’t put down high quality community fare. I am proud to be a part of it. What I offer my patients is high quality head and neck treatment, the same they would get in an academic center.

 

[elementaryschooleconomics]

Weekend treatments … bane of my existence.

What’s so bad about giving a fraction on Friday and then picking up on Monday?

Whenever this topic comes up, I like to remind folks about this paper:

Role of the overall treatment time of radiotherapy with 10 × 3 Gy for outcomes in patients with metastatic spinal cord compression - PubMed

Since an OTT of 14-15 days had no negative impact on outcomes compared to 12 days, compensation in form of an additional radiation fraction or continuation of radiotherapy during weekends is not required, if radiotherapy cannot be started on a Monday.

pubmed.ncbi.nlm.nih.gov

(or sometimes, it's the first time they're seeing it!)

 

[deleted1111261]

Hmm. Don’t put down high quality community fare. I am proud to be a part of it. What I offer my patients is high quality head and neck treatment, the same they would get in an academic center.

Did you read my post? I didn’t put down anyone - except saying putting in PEG pre RT being a boomer behavior.

Your issue seems to be “if it’s different than what I do (or think) then it’s not correct” and it comes off in your posts.

Embrace the questioning mindset (“be curious, not judgmental”)

 

[jondunn]

Did you read my post? I didn’t put down anyone - except saying putting in PEG pre RT being a boomer behavior.

Your issue seems to be “if it’s different than what I do (or think) then it’s not correct” and it comes off in your posts.

Embrace the questioning mindset (“be curious, not judgmental”)

Citing PPS exempt training grounds out of nowhere is a weird slant.

 

[deleted1111261]

Citing PPS exempt training grounds out of nowhere is a weird slant.

They are my bogeyman. I’m yours

 

[TheWallnerus]

This thread makes me concerned about the quality of training newer radoncs are getting.

I think you're about as old as this guy, right 'stang? I'm feeling very literary today.

 

[communitydoc13]

new poets must be convinced that previous poets have gone wrong somewhere and failed in their vision

PEG thing bad starting point (I prophy PEG on most bilateral neck concurrent pts and some others who are demonstrating nutritional vulnerability before treatment).

RadOncG's list above very good. But I agree with Wallnerus' oblique reference to a "school of resentment" among the younger crowd.

The question is: How much do we help patients by not doing these boomer things?

I would say very little. Less ENI-->some toxicity benefit (and some regional failures), hypofractionation-->convenience, deodorant-->our own toxicity, one vertebral body rule-->very minimal toxicity benefit, skin bolus-->unless you are bolusing skin on post-op sarcoma extremity and aren't watching your pt, most skin bolus is a slight increase in acute toxicity (so too is hypofractionation), separation rule on breast (pretty standard until recently and trying to avoid toxicity in a patient who you know will have some is not ignoble (FWIW, I don't measure separation on breast)).

Contouring is spot on. But many boomer docs learned on their own how to contour damn well. And any consensus rec on contouring in an amalgam of boomer contours.

So the young guns can feel good about their sometimes decreased toxicity with marginal increase in locoregional failure, their sometimes increased toxicity with the convenience of hypofractionation and their less smelly patients.

 

[Lamount]

1. Can't start your palliative treatment on Friday. Tumor will explode over the weekend and you'll die
2. Can't wear deodorant during breast irradiation. A physicist in 1950 said it was bad
3. Can't use silvadene is radiation field. There's metal there too
4. One vertebral body above and below. What if there's tumor there? And what if there is tumor 2 above. Let's just do the whole spine
5. Don't get too cute with palliative radiation
6. Treat there too..."But boomer, there's no tumor"...yes but we don't want to miss
7. Call's the medical oncologist to ask what to treat. "I know it's a stage 3 lung but the medical oncologist didn't tell me what to do"
8. Emergent CSI for solid tumor leptomeningeal carcinomatosis
9. I've seen a lot of toxicity with 50 in 25. I do 50.4 in 28
10. Let me measure the breast separation then I'll determine fractionation
11. I don't like to hypofractionate DCIS, once it becomes cancer then it's safe to hypofrac
12. Can you show me this contour on a plain film?
13. The skin needs a boost and bolus. "But doctor there was no skin involvement"...yes but I need to leave my mark

Great list! Would add 'You must treat the entire target to the same dose, even if it requires underdosing the entire PTV'

 

[thecarbonionangle]

Did my chair write this list?

This could be any of our chairs sadly

 

[thecarbonionangle]

This thread makes me concerned about the quality of training newer radoncs are getting.

Wait until the +\- pulse crew gets out in practice. You might be very concerned

 

[medgator]

Weekend treatments … bane of my existence.

.

That's where single fraction data comes in handy

 

[TheWallnerus]

That's where single fraction data comes in handy

Sometimes I start and give a palliative treatment on Friday. And then skip Monday. And Tuesday. And Wednesday. And...

 

[Tigerstang]

Dude, retire already.

Yeah I'm not that old. Just well trained.

 

[Tigerstang]

I think you're about as old as this guy, right 'stang? I'm feeling very literary today.

I love how me disagreeing with the millenials here makes me a dinosaur, and irrelevant. Good luck to you all. Perhaps the reason many of you can't get good jobs is not because of the market, but because of how you approach the practice of medicine. Just food for thought.

 

[Palex80]

Sometimes I start and give a palliative treatment on Friday. And then skip Monday. And Tuesday. And Wednesday. And...

But had you given only 2 Gy on the Friday!!!


I don't start emergency treatments on Friday anymore. I call this the "weekend filter".
Every patient with a superior vena cava syndrome that I didn't treat on Friday and didn't survive the weekend, is a patient that wouldn't have survived the weekend anyway even if I had treated on that Friday. Prove me wrong.

 

[metallica81788]

But had you given only 2 Gy on the Friday!!!


I don't start emergency treatments on Friday anymore. I call this the "weekend filter".
Every patient with a superior vena cava syndrome that I didn't treat on Friday and didn't survive the weekend, is a patient that wouldn't have survived the weekend anyway even if I had treated on that Friday. Prove me wrong.

I've been doing this since out of training and I love it. Weekend litmus test. Just this year have had a few Friday urgent consults not make it to their sim on Monday.

 

[dieABRdie]

another consideration is the set up at your practice/hospital. If you're at a place that can get a peg in within a couple of days, it's reasonable to start without a PEG. But if you're out in the community and getting a PEG tube takes time, then inserting one mid-way through treatment can result in serious treatment delays, especially if the patient is admitted for malnutrition and hydration and you don't have the ability to treat them inpatient

Definitely depends on environment. Try getting a PEG (i.e. elective procedure) done quickly at some hospitals in the COVID era. Consult note will say "PEG is by definition an elective procedure... and will only be done on an outpatient basis."

 

[RadOncMegatron]

But had you given only 2 Gy on the Friday!!!


I don't start emergency treatments on Friday anymore. I call this the "weekend filter".
Every patient with a superior vena cava syndrome that I didn't treat on Friday and didn't survive the weekend, is a patient that wouldn't have survived the weekend anyway even if I had treated on that Friday. Prove me wrong.

This is the general rad onc experience for SVC syndrome consults:

1st year resident: Drop everything you are doing and run up to see the emergent consult.

2nd year resident: Brisk jog on to the inpatient floor.

3rd year resident: Finish my note and / or contour and walk to the floor.

4th year resident: Asks attending, "Hey Dr. XYZ, have you ever actually seen a true SVC syndrome?"

As an attending: "Oh, did a SVC syndrome consult come in? Schedule it for next week, I'm busy right now."

 

[TheWallnerus]

This is the general rad onc experience for SVC syndrome consults:

1st year resident: Drop everything you are doing and run up to see the emergent consult.

2nd year resident: Brisk jog on to the inpatient floor.

3rd year resident: Finish my note and / or contour and walk to the floor.

4th year resident: Asks attending, "Hey Dr. XYZ, have you ever actually seen a true SVC compression?"

As an attending: "Oh, did a SVC syndrome consult come in? Schedule it for next week, I'm busy right now."

I really insist med onc be as urgent or moreso with the plat/etop as I with the RT. I also take the same approach with small asympt brain met in SCLC.

 

[evilbooyaa]

But had you given only 2 Gy on the Friday!!!


I don't start emergency treatments on Friday anymore. I call this the "weekend filter".
Every patient with a superior vena cava syndrome that I didn't treat on Friday and didn't survive the weekend, is a patient that wouldn't have survived the weekend anyway even if I had treated on that Friday. Prove me wrong.

Eh, I'm a believer in 4Gy Friday to avoid having to come on the weekend. Can continue to 4Gy x 5 or transition to 3Gy/day following week.

what is the line you use for when you consider someone a boomer dinosaur?

I saw a patient this week who saw another rad onc at the local regional hospital before coming to us for treatment. i looked up the rad onc and he was about 12 years out of practice - but he wanted the patient to get a prophy tube before HN chemoRT.

the prophylactic tube prior to starting is my Boomer Line that separates the fresh from the yesterdays news.

As others have said, this isn't the great 'gotcha'. Someone who prophylactically PEGs ALL of their H&Ns, yes I would agree that is bad practice, IMO. But, there are certainly players who would benefit from a prophylactic tube. As others have said, consideration of how quickly one can get a tube (and with how much disruption to their ongoing RT schedule) is a HUGE factor in determining PEG rates.

I do agree with another one of your posts that 50-60% PEG rate seems a bit high. I think I'm at about 25-30% of those getting b/l necks radiated. Of course, it depends on the stage of disease and location (hypopharynx/larynx gonna do worse than Tonsil/BoT or say nasal cavity)

1. Can't start your palliative treatment on Friday. Tumor will explode over the weekend and you'll die
2. Can't wear deodorant during breast irradiation. A physicist in 1950 said it was bad
3. Can't use silvadene is radiation field. There's metal there too
4. One vertebral body above and below. What if there's tumor there? And what if there is tumor 2 above. Let's just do the whole spine
5. Don't get too cute with palliative radiation
6. Treat there too..."But boomer, there's no tumor"...yes but we don't want to miss
7. Call's the medical oncologist to ask what to treat. "I know it's a stage 3 lung but the medical oncologist didn't tell me what to do"
8. Emergent CSI for solid tumor leptomeningeal carcinomatosis
9. I've seen a lot of toxicity with 50 in 25. I do 50.4 in 28
10. Let me measure the breast separation then I'll determine fractionation
11. I don't like to hypofractionate DCIS, once it becomes cancer then it's safe to hypofrac
12. Can you show me this contour on a plain film?
13. The skin needs a boost and bolus. "But doctor there was no skin involvement"...yes but I need to leave my mark

Very, very well done list. I still do 1 above and 1 below to avoid penumbra issues and to avoid treaitng half a vertebral body, but otherwise I agree. Breasts going to 50.4 in 28 for RNI.... gets the attending an additional OTV.

 

[OTN]

This is the general rad onc experience for SVC syndrome consults:

1st year resident: Drop everything you are doing and run up to see the emergent consult.

2nd year resident: Brisk jog on to the inpatient floor.

3rd year resident: Finish my note and / or contour and walk to the floor.

4th year resident: Asks attending, "Hey Dr. XYZ, have you ever actually seen a true SVC syndrome?"

As an attending: "Oh, did a SVC syndrome consult come in? Schedule it for next week, I'm busy right now."

Private practice attending: "The patient will be seen immediately, simulated right away, started soon thereafter, and treated over the weekend if necessary. Thanks for the consult- I gave everyone in our current zip code my cell phone in case anyone needs anything."

 

[RadOncMegatron]

All the inside baseball here is so true it's scary, esp. given we have trained through out the county (world?) and relate to this ...

I know that #7 "Call's the medical oncologist to ask what to treat. "I know it's a stage 3 lung but the medical oncologist didn't tell me what to do"" was something after a year or two into practice, I realized, why the heck am I calling the med onc so much? I realized it was ingrained into me via my training, rephrase that OUR training (geez... it this so common it's a joke here on SDN?). After building more rapport, self-confidence, and artfully asking when I really do need to help, I've fully been weaned off this, well almost... LOL

 

[elementaryschooleconomics]

9. I've seen a lot of toxicity with 50 in 25. I do 50.4 in 28

The close cousin of this is "I prefer 180 cGy fractions as opposed to 200 cGy fractions because..."

 

[Palex80]

This is the general rad onc experience for SVC syndrome consults:

1st year resident: Drop everything you are doing and run up to see the emergent consult.

2nd year resident: Brisk jog on to the inpatient floor.

3rd year resident: Finish my note and / or contour and walk to the floor.

4th year resident: Asks attending, "Hey Dr. XYZ, have you ever actually seen a true SVC syndrome?"

As an attending: "Oh, did a SVC syndrome consult come in? Schedule it for next week, I'm busy right now."

I am now 11 years out of residency, but I acted exactly like a 1st year resident this year. February, 1st 2021: Paraparesis due to metastatic prostate cancer, no improvement after surgery the night before. It took 2 hours and 15 minutes from the moment the consult-request came out of the printer until the patient was on the linac couch getting a VMAT plan. I saw the patient again this summer and he was able to walk. I am such a newb...

 

[TheWallnerus]

what is the line you use for when you consider someone a boomer dinosaur?

I saw a patient this week who saw another rad onc at the local regional hospital before coming to us for treatment. i looked up the rad onc and he was about 12 years out of practice - but he wanted the patient to get a prophy tube before HN chemoRT.

the prophylactic tube prior to starting is my Boomer Line that separates the fresh from the yesterdays news.

How now Harambe?

"[Prophylactic] PEG reduced the rate of radiotherapy delay relative to that of reactive interventions (23.1 percent vs 47.1 percent; p=0.007)."

 

[Ray D. Ayshun]

How now Harambe?

"[Prophylactic] PEG reduced the rate of radiotherapy delay relative to that of reactive interventions (23.1 percent vs 47.1 percent; p=0.007)."

You revived a dead thread from a dead person.

 

[radoncftw]

You revived a dead thread from a dead person.

i got excited initally. i thought jd was back

 

[RadOncDoc21]

In the world of the internet, trolls never die…it’s similar to the fast and furious franchise.

 

[thesauce]

1. Can't start your palliative treatment on Friday. Tumor will explode over the weekend and you'll die
2. Can't wear deodorant during breast irradiation. A physicist in 1950 said it was bad
3. Can't use silvadene is radiation field. There's metal there too
4. One vertebral body above and below. What if there's tumor there? And what if there is tumor 2 above. Let's just do the whole spine
5. Don't get too cute with palliative radiation
6. Treat there too..."But boomer, there's no tumor"...yes but we don't want to miss
7. Call's the medical oncologist to ask what to treat. "I know it's a stage 3 lung but the medical oncologist didn't tell me what to do"
8. Emergent CSI for solid tumor leptomeningeal carcinomatosis
9. I've seen a lot of toxicity with 50 in 25. I do 50.4 in 28
10. Let me measure the breast separation then I'll determine fractionation
11. I don't like to hypofractionate DCIS, once it becomes cancer then it's safe to hypofrac
12. Can you show me this contour on a plain film?
13. The skin needs a boost and bolus. "But doctor there was no skin involvement"...yes but I need to leave my mark

The bolded is something I’ve seen with new grads and it’s downright frightening. Probably a program-dependent issue, but maybe just a reflection of the decreased competitiveness and poor quality of trainees coming out.