Become a Proton Master in 2.5 days

[Chartreuse Wombat]

Johns Hopkins Proton Therapy Certificate Course - Proton Therapy Certificate Course

medicine.learnmore.jhu.edu

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[medgator]

What about all those suckers who did 1 year "fellowships" already?

Assuming they didn't pick up on the scent of unaccreditation...

 

[OTN]

Fractionated RT ----> SBRT is a bigger jump than Fractionated RT with photons ----> Fractionated RT with protons

 

[elementaryschooleconomics]

GREATEST

GRIFT

EVER

(you guys can guess as to what I'm calling a grift...is it this course? Proton "Fellowships"? Protons themselves? Who even knows!)

 

[Mandelin Rain]

Many cyclotrons being built in departments where no one knows how to prescribe/treat with protons.

1.5 day course will make this all legit, imo.

 

[drowsy12]

I’m surprised it’s so cheap

 

[thesauce]

No thanks. Let me know when they have a course on phrenology

 

[elementaryschooleconomics]

Unfortunately, I suspect we're only going to see this more and more.

"Microcertificates" are the future. The trend is already well underway in colleges and universities, given they've discovered the "tuition pain point" (also the fact that we're now am imbalanced society with more older folks, enrollment ain't exactly going up).

It was only a matter of time before this infected medicine, too. Once a business model is seen as working...well, game over.

It will just continue to devalue our existing credentials.

 

[drowsy12]

Gamma knife certification has existed for a long time.

 

[Neuronix]

I don't understand the derision towards this course.

I think getting some training in protons is a good idea if you're going to start using them and don't have prior experience or training.

The cost and time investment for this particular course seems reasonable to me.

 

[drowsy12]

Can throw this in while you’re there

Hyperthermia Therapy Practice School Thermal Therapy Course | University of Maryland School of Medicine

www.medschool.umaryland.edu

 

[elementaryschooleconomics]

I don't understand the derision towards this course.

I think getting some training in protons is a good idea if you're going to start using them and don't have prior experience or training.

The cost and time investment for this particular course seems reasonable to me.

To be clear, I'm not deriding the course itself.

I'm deriding the concept.

More accurately, I'm deriding the concept of pre-existing proton "fellowships".

These are not compatible entities. Either this course is way too short, or a 12-month fellowship is way too long and objectively exploitative.

I actually think this course is probably sufficient for any practicing RadOnc. I'm upset about what this represents, in consideration of the entire landscape.

Protons are easily the most costly item in radiation on a per-unit basis. The field appears to be pursuing two mutually incompatible paths: making protons easier to get and use, while defending direct supervision and authoring their own version of APM.

Madness.

 

[Ray D. Ayshun]

Can someone give me a per proton vs per photon cost on average? Probably better to compare protons to electrons on a per particle basis. I'm sure protons aren't 2000x more expensive. Let's give the protonists a break.

 

[evilbooyaa]

I would, personally, be VERY upset if I was a Rad Onc who had done a 1-year long fellowship at JHU for proton training.

The certificate itself, probably no harm, only $1k. Probably some clinical utility kinda like the Gamma knife certification...

 

[MidwestRadOnc]

If I'm using CME funds to get a proton thingy to hang on the wall and put on the website, I'm going to Japan, Switzerland, or Germany, not Baltimore.

Edit: Does Maui have proton center yet?

 

[Neuronix]

I don't think anyone does a one year fellowship in protons because they believe that's the only way they can treat with protons as an attending...

 

[TheWallnerus]

Can someone give me a per proton vs per photon cost on average? Probably better to compare protons to electrons on a per particle basis. I'm sure protons aren't 2000x more expensive. Let's give the protonists a break.

Medicare proton rate is about 3x more than IMRT per fraction.

Private insurance can reimburse protons something insane like 20 to 30x the Medicare IMRT rate per fraction.

Everyone’s mileage does and will vary.

 

[RickyScott]

Hopkins has only has protons for a couple years.

 

[Ray D. Ayshun]

Medicare proton rate is about 3x more than IMRT per fraction.

Private insurance can reimburse protons something insane like 20 to 30x the Medicare IMRT rate per fraction.

Everyone’s mileage does and will vary.

I'm talking about a particle-to-particle comparison. Protons are so much more massive. A mole of protons should cost way more than a mole of electrons. I wouldn't really be able to differentiate that personally if you handed me a bag of each, but that's because I work out.

 

[radoncftw]

Medicare proton rate is about 3x more than IMRT per fraction.

Private insurance can reimburse protons something insane like 20 to 30x the Medicare IMRT rate per fraction.

Everyone’s mileage does and will vary.

professional fees are the same or very similar correct?

 

[BobbyHeenan]

professional fees are the same or very similar correct?

Yes...and from my experience talking with a number of colleagues (and depending upon your image guidance capabilities)...in terms of hours-worked to reimbursement the proton docs have been surprised at how they "felt" busier, but their reimbursement was worse than what they had in photon land if purely recouping pro fees alone.

Of course this would depend upon a number of factors or sites treated (prostate vs. head/neck, etc).

In general though not a big difference I believe.

 

[Neuronix]

Prof wRVUs and collections are the same to my knowledge. Protons are on the technical side to feed that expensive machine. The rad onc's global collection there is a tiny single digit percentage.

Contouring and planning are all basically the same amount of work compared to IMRT, IMO.

The problem for the attending physician is that you have to be really on top of your documentation and be ready to fight with insurances and peer reviewers. That's what makes you feel busier, and of course is unreimbursed time.

Still, you have to balance that with the machine bringing you more patients to treat... Whether you care about that depends how busy you are, your own incentive structure, etc...

 

[NotMattSpraker]

To be clear, I'm not deriding the course itself.

I'm deriding the concept.

Me too. Take a step back for a second and look at what is being sold. Proton centers can't invest 7 hours of pre-recorded didactics and 1.5 days to train... maybe at most... a couple new physicians a year? They need to farm that out for $1000? Really?

All of these individuals will at least know proton physics and some trial data.

 

[medgator]

Gamma knife certification has existed for a long time.

So has the CK and the uab truebeam course.

As @elementaryschooleconomics alluded to, why were there 1 yr fellowships in protons in that case? Which is it

 

[drowsy12]

So has CK and the uab truebeam course.

As @elementaryschooleconomics alluded to, why were there 1 yr fellowships in protons in that case? Which is it

I mean there are one year fellowships in SRS too.

No one thinks of these fellowships as necessary to do the job.

Very largely rad onc fellowships are for and are filled by international folks. The US MDs that do them are looking for an angle in to improve their academic job prospects. It’s never been about the learning

 

[seper]

Cheap - so it’s a good value. go and socialize with your peers

 

[seper]

Can throw this in while you’re there

Hyperthermia Therapy Practice School Thermal Therapy Course | University of Maryland School of Medicine

www.medschool.umaryland.edu

Maryland does very good hyperthermia work! maybe the only place (on east coast at least)

 

[TheWallnerus]

. A mole of protons should cost way more than a mole of electrons. I wouldn't really be able to differentiate that personally if you handed me a bag of each, but that's because I work out.

To do some physics jaywalking for a sec...

If someone handed you a mole of protons, we might ordinarily think of a mole as a visible-to-the-eye amount of a particular atom or molecule, and in fact a mole of protons would equal about 1g of protons as a mole of hydrogen is about 1g of hydrogen. Metallic hydrogen (or "metallic protons") would thus probably be about 1cc in size if metallic hydrogen has the density of water (which it probably does).

But to get protons that concentrated you will be dealing with enormous repulsive Coulombic forces... and that 1g of protons would explode with about 21 kilotons of TNT force (E=mc2, or 1E-3*3E8*3E8 joules):

So if handed a mole of protons you and your city would die.

But to actually have 1 cubic centimeter of pure protons you would have to forge that inside a neutron star under incredible gravitational pressure. So that 1cc of protons would have a huge density, maybe 100 billion kilograms packed into just 1cc of space. (This is much, much more than a mole, obviously.) If it didn't explode, the 1cc of protons would just fall through your hand, all the way through the middle of the earth, and just oscillate back and forth (over a long period of time) before coming to rest at the earth's core.

But it would explode, because gravity would be not strong enough to hold it together, and by handing you a bag of protons we would destroy the planet. The energy output of 1cc of stellar compressed protons would be ~100,000x greater than the energy released by the asteroid that killed the dinosaurs.

My back of envelope calcs say ~2 Gy of protons irradiating 1kg of matter takes about 1.3E10 protons, and a mole of protons would contain ~50 trillion more protons than that.

And that means that over the history of humanity, (much) less than one mole of protons will treat every single human being ever irradiated with proton beam therapy.

 

[elementaryschooleconomics]

To do some physics jaywalking for a sec...

If someone handed you a mole of protons, we might ordinarily think of a mole as a visible-to-the-eye amount of a particular atom or molecule, and in fact a mole of protons would equal about 1g of protons as a mole of hydrogen is about 1g of hydrogen. Metallic hydrogen (or "metallic protons") would thus probably be about 1cc in size if metallic hydrogen has the density of water (which it probably does).

But to get protons that concentrated you will be dealing with enormous repulsive Coulombic forces... and that 1g of protons would explode with about 21 kilotons of TNT force (E=mc2, or 1E-3*3E8*3E8 joules):

View attachment 382477

So if handed a mole of protons you and your city would die.

But to actually have 1 cubic centimeter of pure protons you would have to forge that inside a neutron star under incredible gravitational pressure. So that 1cc of protons would have a huge density, maybe 100 billion kilograms packed into just 1cc of space. (This is much, much more than a mole, obviously.) If it didn't explode, the 1cc of protons would just fall through your hand, all the way through the middle of the earth, and just oscillate back and forth (over a long period of time) before coming to rest at the earth's core.

But it would explode, because gravity would be not strong enough to hold it together, and by handing you a bag of protons we would destroy the planet. The energy output of 1cc of stellar compressed protons would be ~100,000x greater than the energy released by the asteroid that killed the dinosaurs.

My back of envelope calcs say ~2 Gy of protons irradiating 1kg of matter takes about 1.3E10 protons, and a mole of protons would contain ~50 trillion more protons than that.

And that means that over the history of humanity, (much) less than one mole of protons will treat every single human being ever irradiated with proton beam therapy.

Jesus, can I get a certificate for reading this post???

 

[Gfunk6]

 

[yesmaster]

It seems fantastic. The 1 week practicum courses are way more valuable than the DEI/mentorship/retrospective/KOL opinion garbage at most conferences. GK, CK, ABS to some extent.

Overtraining of residents devalues us, not the practicum courses, assuming they don’t start accepting med/surg onc’s.

The idea that you have to have been a resident or faculty at a Penn/Harvard/MDA or else you’ll cause brainstem necrosis is just a myth perpetuated by those places to conflate added technology with added expertise.

 

[Ray D. Ayshun]

To do some physics jaywalking for a sec...

If someone handed you a mole of protons, we might ordinarily think of a mole as a visible-to-the-eye amount of a particular atom or molecule, and in fact a mole of protons would equal about 1g of protons as a mole of hydrogen is about 1g of hydrogen. Metallic hydrogen (or "metallic protons") would thus probably be about 1cc in size if metallic hydrogen has the density of water (which it probably does).

But to get protons that concentrated you will be dealing with enormous repulsive Coulombic forces... and that 1g of protons would explode with about 21 kilotons of TNT force (E=mc2, or 1E-3*3E8*3E8 joules):

View attachment 382477

So if handed a mole of protons you and your city would die.

But to actually have 1 cubic centimeter of pure protons you would have to forge that inside a neutron star under incredible gravitational pressure. So that 1cc of protons would have a huge density, maybe 100 billion kilograms packed into just 1cc of space. (This is much, much more than a mole, obviously.) If it didn't explode, the 1cc of protons would just fall through your hand, all the way through the middle of the earth, and just oscillate back and forth (over a long period of time) before coming to rest at the earth's core.

But it would explode, because gravity would be not strong enough to hold it together, and by handing you a bag of protons we would destroy the planet. The energy output of 1cc of stellar compressed protons would be ~100,000x greater than the energy released by the asteroid that killed the dinosaurs.

My back of envelope calcs say ~2 Gy of protons irradiating 1kg of matter takes about 1.3E10 protons, and a mole of protons would contain ~50 trillion more protons than that.

And that means that over the history of humanity, (much) less than one mole of protons will treat every single human being ever irradiated with proton beam therapy.

You basically just presented a good argument for protons reimbursing more. Don't let this get out.

 

[RickyScott]

I mean there are one year fellowships in SRS too.

No one thinks of these fellowships as necessary to do the job.

Very largely rad onc fellowships are for and are filled by international folks. The US MDs that do them are looking for an angle in to improve their academic job prospects. It’s never been about the learning

Remember Billy Loos one year fellowship in lung sbrt at Stanford?

 

[medgator]

Remember Billy Loos one year fellowship in lung sbrt at Stanford?

Can't top the "proton fellowship" at Inova which include doc of the day photon responsibilities

 

[RickyScott]

Can't top the "proton fellowship" at Inova which include doc of the day photon responsibilities

Do they offer any proton seminars? The director at inova once told a patient of mine she needed protons for a t spine met because she was on IO.

 

[Doctorer]

Can't top the "proton fellowship" at Inova which include doc of the day photon responsibilities

I loved this one. Taking "see one, do one, teach one" very literally.

 

[communitydoc13]

to conflate added technology with added expertise

How many docs are actually "experts" regarding proton therapy. On this board, long term proton practitioners have acknowledged reviewing plans as though they are photon plans. The details of modern photon dosimetry are a mystery to all but a tiny fraction of MDs (I'm pretty sure JHH doesn't have any docs with a detailed knowledge of dose engines, although they may show up on papers regarding this topic).

The physicists are the "experts".

What we need to be experts on is the scale of uncertainty associated with our intervention, the sources of those uncertainties and when those uncertainties become dangerous (based on clinical data). This is the sort of expertise that allows us to actually look at plans in a meaningful way. Also imperative is a detailed discussion of the nature of toxicity, (less grade 1, more grade 4-5 needs to be honestly discussed) as well as the ethics of proton therapy in the setting of cost, resource utilization, uncertain differential efficacy, and potential for increased very high grade toxicity.

IMO, the most important goal of any practicum course on protons would be to facilitate attendees ability to make ethical decisions regarding the use of protons vs their more readily available alternative.

Is the JHH course going to do this...or is it going to be a primer of standard proton prescriptions, beam selection and immobilization...as well as a primer on the potential benefits of proton therapy.

 

[MidwestRadOnc]

Do they offer any proton seminars? The director at inova once told a patient of mine she needed protons for a t spine met because she was on IO.

Future Evicore material right there. Will soon be semi-retired in Fort Lauderdale insinuating other rad oncs are trying to commit fraud by delivering lung SBRT to a new nodule with a history of treated stage I dz.

 

[Lamount]

I don't think anyone does a one year fellowship in protons because they believe that's the only way they can treat with protons as an attending...

...i did (n=1)

 

[Lamount]

How many docs are actually "experts" regarding proton therapy. On this board, long term proton practitioners have acknowledged reviewing plans as though they are photon plans. The details of modern photon dosimetry are a mystery to all but a tiny fraction of MDs (I'm pretty sure JHH doesn't have any docs with a detailed knowledge of dose engines, although they may show up on papers regarding this topic).

The physicists are the "experts".

What we need to be experts on is the scale of uncertainty associated with our intervention, the sources of those uncertainties and when those uncertainties become dangerous (based on clinical data). This is the sort of expertise that allows us to actually look at plans in a meaningful way. Also imperative is a detailed discussion of the nature of toxicity, (less grade 1, more grade 4-5 needs to be honestly discussed) as well as the ethics of proton therapy in the setting of cost, resource utilization, uncertain differential efficacy, and potential for increased very high grade toxicity.

IMO, the most important goal of any practicum course on protons would be to facilitate attendees ability to make ethical decisions regarding the use of protons vs their more readily available alternative.

Is the JHH course going to do this...or is it going to be a primer of standard proton prescriptions, beam selection and immobilization...as well as a primer on the potential benefits of proton therapy.

To be fair, the new version of Raystation has a robust evaluation tool that allows you to -fairly effortlessly- see the worst-case-scenario dosimetry for any metric. Its not terribly complex... so long as docs know they need to check such things

 

[evilbooyaa]

To do some physics jaywalking for a sec...

If someone handed you a mole of protons, we might ordinarily think of a mole as a visible-to-the-eye amount of a particular atom or molecule, and in fact a mole of protons would equal about 1g of protons as a mole of hydrogen is about 1g of hydrogen. Metallic hydrogen (or "metallic protons") would thus probably be about 1cc in size if metallic hydrogen has the density of water (which it probably does).

But to get protons that concentrated you will be dealing with enormous repulsive Coulombic forces... and that 1g of protons would explode with about 21 kilotons of TNT force (E=mc2, or 1E-3*3E8*3E8 joules):

View attachment 382477

So if handed a mole of protons you and your city would die.

But to actually have 1 cubic centimeter of pure protons you would have to forge that inside a neutron star under incredible gravitational pressure. So that 1cc of protons would have a huge density, maybe 100 billion kilograms packed into just 1cc of space. (This is much, much more than a mole, obviously.) If it didn't explode, the 1cc of protons would just fall through your hand, all the way through the middle of the earth, and just oscillate back and forth (over a long period of time) before coming to rest at the earth's core.

But it would explode, because gravity would be not strong enough to hold it together, and by handing you a bag of protons we would destroy the planet. The energy output of 1cc of stellar compressed protons would be ~100,000x greater than the energy released by the asteroid that killed the dinosaurs.

My back of envelope calcs say ~2 Gy of protons irradiating 1kg of matter takes about 1.3E10 protons, and a mole of protons would contain ~50 trillion more protons than that.

And that means that over the history of humanity, (much) less than one mole of protons will treat every single human being ever irradiated with proton beam therapy.

Jesus, can I get a certificate for reading this post???

 

[evilbooyaa]

It seems fantastic. The 1 week practicum courses are way more valuable than the DEI/mentorship/retrospective/KOL opinion garbage at most conferences. GK, CK, ABS to some extent.

Overtraining of residents devalues us, not the practicum courses, assuming they don’t start accepting med/surg onc’s.

The idea that you have to have been a resident or faculty at a Penn/Harvard/MDA or else you’ll cause brainstem necrosis is just a myth perpetuated by those places to conflate added technology with added expertise.

I think the faculty at those places are most likely to be the ones who caused all those horrible brainstem necroses published in the literature.... Treating with their OG PSPT machines, no IGRT, putting their faith in the TPS without variable RBE modeling, claiming it was all better than IMRT, simply because the computer screen said so.

 

[TheWallnerus]

The physicists are the "experts

Even this I doubt. The physicists took it in their own hands to lower the delivered gray for what would, say, normally be a 2 Gy fraction, downwards by 10% to a 1.8 Gy dose. And instead of calling that a misadministration they call it a cobalt gray equivalent… how neat!… and call the 1.8 Gy a dose of 2.0 Gy instead. (Back in the day I know a lot of old boomer MDs who would have loved physics’ cover for lowering their IMRT doses by 10% across the board, but still writing the same numerical Rx dose in the chart.)

Physicists meddled mightily in what should have been our purview: biology.

 

[evilbooyaa]

How many docs are actually "experts" regarding proton therapy. On this board, long term proton practitioners have acknowledged reviewing plans as though they are photon plans. The details of modern photon dosimetry are a mystery to all but a tiny fraction of MDs (I'm pretty sure JHH doesn't have any docs with a detailed knowledge of dose engines, although they may show up on papers regarding this topic).

The physicists are the "experts".

What we need to be experts on is the scale of uncertainty associated with our intervention, the sources of those uncertainties and when those uncertainties become dangerous (based on clinical data). This is the sort of expertise that allows us to actually look at plans in a meaningful way. Also imperative is a detailed discussion of the nature of toxicity, (less grade 1, more grade 4-5 needs to be honestly discussed) as well as the ethics of proton therapy in the setting of cost, resource utilization, uncertain differential efficacy, and potential for increased very high grade toxicity.

IMO, the most important goal of any practicum course on protons would be to facilitate attendees ability to make ethical decisions regarding the use of protons vs their more readily available alternative.

Is the JHH course going to do this...or is it going to be a primer of standard proton prescriptions, beam selection and immobilization...as well as a primer on the potential benefits of proton therapy.

Photon dosimetry - what the TPS shows is what the patient gets within 5%, maybe within 7% if your physicist is lazy. If > 10% discordant, alarm bells start going off.

Proton dosimetry - we don't understand enough of it, we treat with fixed RBE of 1.1 but RBEs can be up to 1.7, leading up to 50% variability in deposited dose. No alarm bells go off, keep treating, world keeps spinning.

Keep putting holes in brainstems, temporal lobes, ribs, mandibles, all in situations where the computer screen said it was gonna be just fine

 

[OTN]

Photon dosimetry - what the TPS shows is what the patient gets within 5%, maybe within 7% if your physicist is lazy. If > 10% discordant, alarm bells start going off.

Proton dosimetry - we don't understand enough of it, we treat with fixed RBE of 1.1 but RBEs can be up to 1.7, leading up to 50% variability in deposited dose. No alarm bells go off, keep treating, world keeps spinning.

Keep putting holes in brainstems, temporal lobes, ribs, mandibles, all in situations where the computer screen said it was gonna be just fine

That can't be true I was told IMRT causes brain impairment and protons don't cause any side effects

 

[MidwestRadOnc]

That can't be true I was told IMRT causes brain impairment and protons don't cause any side effects

"Salim in the private jet he uses to commute between his home in Houston, Texas, and his office in Natchitoches."

The round trip on that jet costs probably costs $30k, even after the tax write-off.

"Fuller told Salim that he might have to use a cheaper form of radiation that is less precise."

Veblen good - Wikipedia

en.wikipedia.org

 

[temujim]

Even this I doubt. The physicists took it in their own hands to lower the delivered gray for what would, say, normally be a 2 Gy fraction, downwards by 10% to a 1.8 Gy dose. And instead of calling that a misadministration they call it a cobalt gray equivalent… how neat!… and call the 1.8 Gy a dose of 2.0 Gy instead. (Back in the day I know a lot of old boomer MDs who would have loved physics’ cover for lowering their IMRT doses by 10% across the board, but still writing the same numerical Rx dose in the chart.)

Physicists meddled mightily in what should have been our purview: biology.

Most of what I see in the literature recently is driven by physicists bc the setups to examine biological effects across the proton track/energy are in their purview. All of this should have been done 40+ years ago, but squeezing money out of the NCI for radbio is tough. Particularly after the field hand waved and said 1.1 CGE and we've treated people and its fine.

 

[evilbooyaa]

Most of what I see in the literature recently is driven by physicists bc the setups to examine biological effects across the proton track/energy are in their purview. All of this should have been done 40+ years ago, but squeezing money out of the NCI for radbio is tough. Particularly after the field hand waved and said 1.1 CGE and we've treated people and its fine.

There was no need to prove safety 40 years ago b/c proton machines were minting money and KOLs in Rad Onc said it was unethical to treat with anything besides protons, if protons were available.

Only when those folks retired or DIED was there an interest in actually evaluating need.

 

[NotMattSpraker]

There was no need to prove safety 40 years ago b/c proton machines were minting money and KOLs in Rad Onc said it was unethical to treat with anything besides protons, if protons were available.

Only when those folks retired or DIED was there an interest in actually evaluating need.

40 years ago at least there were KOLs that were willing to disagree with the proton evangelists publicly and in writing. Huge names.

Must have been nice.

 

[drowsy12]

The issue is that nearly every major institution has proton now, so people have huge biases. Ralph W is one of the only people I've seen on twitter push back on this proton agenda. Everyone else is in bed with them.