Unsolicited Jobs Thread

[sirspamalot]

I'm in a somewhat similar situation right now with my new job. Caveat that there has been part time newer grad presence for a few years working with the long term old doc so there are some more updated standards present.

I'm keeping the standard frac prostate to keep local urologists happy, but doing some other things differently and moving along slowly.

It's shocking to show up and see what has been done to these patients the last few years. Every follow up is an adventure and usually disappointing to see the old plans. Mostly not bad medicine, but just really outdated techniques and questionable decision making. Nobody here knows any differently and it will take a while to change. Very tempting to try and force it all at once but that's not the way. Luckily admin is supportive of me taking ownership (at least for now haha).

The first rule of rad club is NEVER TRUST ADMINISTRATORS

The second rule of rad club is NEVER FORGET RULE # 1 (no matter what including: if they come to your wedding, give you a 2k+ office chair, or tell you you're the most bestest swellest radonc ever)

---

Members don't see this ad.

 

[medgator]

The first rule of rad club is NEVER TRUST ADMINISTRATORS

The second rule of rad club is NEVER FORGET RULE # 1 (no matter what including: if they come to your wedding, give you a 2k+ office chair, or tell you you're the most bestest swellest radonc ever)

 

[IonsAreOurFuture]

I'm in a somewhat similar situation right now with my new job. Caveat that there has been part time newer grad presence for a few years working with the long term old doc so there are some more updated standards present.

I'm keeping the standard frac prostate to keep local urologists happy, but doing some other things differently and moving along slowly.

It's shocking to show up and see what has been done to these patients the last few years. Every follow up is an adventure and usually disappointing to see the old plans. Mostly not bad medicine, but just really outdated techniques and questionable decision making. Nobody here knows any differently and it will take a while to change. Very tempting to try and force it all at once but that's not the way. Luckily admin is supportive of me taking ownership (at least for now haha).

Changing the culture of a practice is not easy. Going from treating based only on skin marks and making 0.5 to 1 centimeter isocenter shifts once a week on port-film-day, to an SBRT mindset where everything is imaged daily with CBCT and 1-2 mm shifts, has been a challenge for more than one therapist I've worked with. It took about 6 months of hand-holding and meetings and enforcing policy for sim and treating a certain way, but it can be done.

One surprising thing I have found when switching to daily IGRT, is how many times a spine will be treated by one vertebral body too high or too low. I would have thought IGRT would prevent that, but it still happens. I guess that was a reason for the old tradition of nuking one level above and below?

 

[medgator]

Changing the culture of a practice is not easy. Going from treating based only on skin marks and making 0.5 to 1 centimeter isocenter shifts once a week on port-film-day, to an SBRT mindset where everything is imaged daily with CBCT and 1-2 mm shifts, has been a challenge for more than one therapist I've worked with. It took about 6 months of hand-holding and meetings and enforcing policy for sim and treating a certain way, but it can be done.

One surprising thing I have found when switching to daily IGRT, is how many times a spine will be treated by one vertebral body too high or too low. I would have thought IGRT would prevent that, but it still happens. I guess that was a reason for the old tradition of nuking one level above and below?

Even with daily cbct? I think that may be one disadvantage of kV vs that

 

[IonsAreOurFuture]

Even with daily cbct? I think that may be one disadvantage of kV vs that

Yes, even with CBCT. I think that auto-alignment on too small an area of spine is one way to fall into the trap.

We try to reinforce the need to verify the intended shift in relation to a "unique" landmark like the carina, iliac crests, or T12-L1 junction.

May vertebral bodies look alike. Need a 2nd check.

 

[taserlaser]

Yes, even with CBCT. I think that auto-alignment on too small an area of spine is one way to fall into the trap.

We try to reinforce the need to verify the intended shift in relation to a "unique" landmark like the carina, iliac crests, or T12-L1 junction.

May vertebral bodies look alike. Need a 2nd check.

Early in my practice I had a patient who had auto alignment to the wrong VB. Easier than one hopes to have happened.

 

[elementaryschooleconomics]

Across multiple practices now, I've observed several therapists lack any understanding of how "auto-alignment" works, which has included not only placing an insanely small ROI box in soft tissue (because that's where the PTV is!) but having the ROI box just...off in a corner, out in space.

Each and every time, the therapist has been someone who trained in the 90's (or 80's), and somehow this "30 years of experience" is seen as a "good thing".

Heck, on Monday it was revealed to me that they'd been setting up a palliative treatment with the wrong SSD because they...forgot that knee rolls lift the limb a few centimeters off the table? You would think something like "bone met SSD" would be in the Boomer RTT wheelhouse but...alas.

Anyway, the moral of the story is don't fret so much about that dose cloud you see in Eclipse, since there's a non-zero chance your therapists go rogue and because of the nature of radiotherapy, no one will ever know, and attempts at safety measures will be met with "we've always delivered excellent care".

Huzzah, RadOnc!

 

[RadOncDoc21]

Across multiple practices now, I've observed several therapists lack any understanding of how "auto-alignment" works, which has included not only placing an insanely small ROI box in soft tissue (because that's where the PTV is!) but having the ROI box just...off in a corner, out in space.

Each and every time, the therapist has been someone who trained in the 90's (or 80's), and somehow this "30 years of experience" is seen as a "good thing".

Heck, on Monday it was revealed to me that they'd been setting up a palliative treatment with the wrong SSD because they...forgot that knee rolls lift the limb a few centimeters off the table? You would think something like "bone met SSD" would be in the Boomer RTT wheelhouse but...alas.

Anyway, the moral of the story is don't fret so much about that dose cloud you see in Eclipse, since there's a non-zero chance your therapists go rogue and because of the nature of radiotherapy, no one will ever know, and attempts at safety measures will be met with "we've always delivered excellent care".

Huzzah, RadOnc!

The ambiguity helps me sleep better at night.

 

[elementaryschooleconomics]

The ambiguity helps me sleep better at night.

Same.

In RadOnc, you fall into one of two camps -

Ambiguity is melatonin

or

Ambiguity leads to adaptive replanning for hypofrac GBM

There is no middle ground.

 

[medgator]

Ambiguity leads to adaptive replanning for hypofrac GBM

On an MR Linac

 

[sirspamalot]

Across multiple practices now, I've observed several therapists lack any understanding of how "auto-alignment" works, which has included not only placing an insanely small ROI box in soft tissue (because that's where the PTV is!) but having the ROI box just...off in a corner, out in space.

Each and every time, the therapist has been someone who trained in the 90's (or 80's), and somehow this "30 years of experience" is seen as a "good thing".

Heck, on Monday it was revealed to me that they'd been setting up a palliative treatment with the wrong SSD because they...forgot that knee rolls lift the limb a few centimeters off the table? You would think something like "bone met SSD" would be in the Boomer RTT wheelhouse but...alas.

Anyway, the moral of the story is don't fret so much about that dose cloud you see in Eclipse, since there's a non-zero chance your therapists go rogue and because of the nature of radiotherapy, no one will ever know, and attempts at safety measures will be met with "we've always delivered excellent care".

Huzzah, RadOnc!

Thou shalt always go into the tx room on first treatment day.. and pay extra vigilance at the vsim film review.

If you have a VisionRT it's harder for them to make errors...lol But insurers often won't pay for that as a daily imaging IGRT.. and we were told we can't do something we don't bill for.. At least not routinely..

 

[taserlaser]

Thou shalt always go into the tx room on first treatment day.. and pay extra vigilance at the vsim film review.

If you have a VisionRT it's harder for them to make errors...lol But insurers often won't pay for that as a daily imaging IGRT.. and we were told we can't do something we don't bill for.. At least not routinely..

Proper bolus set up is the bane of my existence. And I feel like I still have a pretty good team. But being extra hawkish early on I do believe pays off and improves overall quality of treatment and care.

 

[elementaryschooleconomics]

But being extra hawkish early on I do believe pays off and improves overall quality of treatment and care.

...probably. Maybe? Probably.

In an open, public internet forum that will theoretically record everything forever, I'll be cautious with my anecdotes.

The practice of medicine is an inherently flawed endeavor. We can only survive this job by engaging in some level of self-delusion.

I'm definitely not singling out Radiation Oncology. Putting an inpatient on a "diabetic diet" and watching blood glucose is only effective until they're discharged back to home and their fully stocked fridge. Prescribing a medication that needs to be taken four times a day is asking a lot of someone...heck, any sort of daily PO medication can be asking a lot.

If anyone wants to engage in some existential dread, go pull the charts from patients currently on-beam getting VMAT, ideally with at least two arcs. Check the timestamp from when the CBCT was obtained and compare that to when the last MU was delivered. Then go try to lay flat and still for that amount of time. Fun!

Obviously I think there's value in doing everything possible to deliver excellent care, and full-fledged nihilism is not the answer.

But...just returning to the "Silver Tsunami Cautionary Tales for New Grads" - it's important to strike a balance between demanding perfection and upsetting Elder RTTs. There's no "right answer" to any of this, but especially in small/solo practices, push too hard and staff will turn on you. Unfortunately not even in the "good" way, as in, you know it's happening - more likely in the subversive "admin will start to find a way to push you out" way.

Ugh this reads darker than I mean it to. I guess - from my own personal experience, I know teaching faculty can engage in a borderline abusive level of demanding perfection in residents, which can produce new grads who think that's how they can practice medicine themselves. That can definitely fly in some environments...but it's unlikely. Everything in moderation!

 

[TheWallnerus]

Matt Canter’s rad onc openings nationwide

 

[sirspamalot]

Who is Matt Canter?

 

[TheWallnerus]

Who is Matt Canter?

Matt Canter is to MD recruiting what Tom Snyder is to talk shows.

 

[sirspamalot]

Matt Canter is to MD recruiting what Tom Snyder is to talk shows.

Google says nada. Got a link?

 

[CaesarRO]

If anyone wants to engage in some existential dread, go pull the charts from patients currently on-beam getting VMAT, ideally with at least two arcs. Check the timestamp from when the CBCT was obtained and compare that to when the last MU was delivered. Then go try to lay flat and still for that amount of time. Fun!

I feel like I've gotten to know your online persona well enough that I can actually picture you having done just this very exercise.

 

[elementaryschooleconomics]

I feel like I've gotten to know your online persona well enough that I can actually picture you having done just this very exercise.

I uh...I definitely have a PowerPoint slide with a graph from an Excel file...yes....

So if anyone wants a step-by-step guide for how to do this using Aria...hit me up...

 

[communitydoc13]

If anyone wants to engage in some existential dread, go pull the charts from patients currently on-beam getting VMAT, ideally with at least two arcs. Check the timestamp from when the CBCT was obtained and compare that to when the last MU was delivered. Then go try to lay flat and still for that amount of time. Fun!

For some very high risk fractionated stereotactic treatments, I will repeat the CBCT after treatment (rationale is that I can drop a fraction if need be if there is a discrepancy in position). So far so good.

I do not repeat the CBCT after the final treatment.

 

[sirspamalot]

For some very high risk fractionated stereotactic treatments, I will repeat the CBCT after treatment (rationale is that I can drop a fraction if need be if there is a discrepancy in position). So far so good.

I do not repeat the CBCT after the final treatment.

Just add one eh?

 

[Gfunk6]

Another one “$600k + incentives”

I hope all is well! My name is John Vivas with HealthRight staffing. We are currently working with a fantastic Hospital in Ohio that is looking for a permanent full-time Radiation Oncologist that I thought would be worth mentioning to you. Here are some details about the job below. If you have any interest at all, or just interested in hearing more about the job market, I am available by phone or email at your convenience. My contact info is also below.

Hospital in Ohio seeking a full time Radiation Oncologist to join their group!

• Cancer program is accredited by the Commission on Cancer
• Varian True Beam linear accelerator
• Aria scheduling/EHR and Eclipse for treatment planning
• hospital-based Medical Oncologist
• contracted physics/dosimetry group who do a great job for us. Either physics or dosimetry are available every day or can remote in
• Oncology nurses who are cross-trained in administering chemotherapy, biotherapy, and working in Radiation
• Social Services and Nutritional assistance for patients and families
• patient navigators who assist with assuring our patients get thru the system with appropriate appointments with providers and staff
• 2 Nurse Practitioners

Thank you,

John Vivas
Client Account Manager

 

[Lamount]

Changing the culture of a practice is not easy. Going from treating based only on skin marks and making 0.5 to 1 centimeter isocenter shifts once a week on port-film-day, to an SBRT mindset where everything is imaged daily with CBCT and 1-2 mm shifts, has been a challenge for more than one therapist I've worked with. It took about 6 months of hand-holding and meetings and enforcing policy for sim and treating a certain way, but it can be done.

One surprising thing I have found when switching to daily IGRT, is how many times a spine will be treated by one vertebral body too high or too low. I would have thought IGRT would prevent that, but it still happens. I guess that was a reason for the old tradition of nuking one level above and below?

We get an AP prior to CBCT to avoid this specific issue

 

[thecarbonionangle]

Boomer/early gen X voice: “i keep telling you this but you don’t wanna miss”

 

[Gfunk6]

Another one

Position: Radiation Oncology Location: Pennsylvania Role Type: Perm / full-time​

Full-time opportunity for BC/BE Radiation Oncologist to join our dedicated, nationally-recognized Cancer Care team. State-of-the-art outpatient facility rivals the nation’s best – radiation oncology services with two Varian Linear Accelerators: Trilogy & EDGE, Varian Brachytherapy HDR unit, GE CT, Eclipse planning and premiere office space Stereotactic, IMRT and 3D treatment options Eclipse treatment planning software Full complement of certified technical staff Cancer specific international EMR (ARIA) Related cancer specific services include patient navigation, physical therapy, financial and nutritional counseling, survivorship care clinics and more Experienced colleagues & effective leadership Benefits may include: MGMA competitive salary Annual incentive bonuses Relocation Generous CME days and dollars Medical malpractice/tail insurance coverage Robust retirement and benefits package About the area: The area offers the appealing attributes of a larger city with the charm and atmosphere of a small town. Most visitors are pleasantly surprised to discover how much this community has to offer. Aside from being voted the #1 city in Pennsylvania for the outdoor enthusiast, we have a vibrant downtown with great dining and active arts/cultural scene, excellent schools, affordable and attractive housing options and a dynamic medical community dedicated to providing the best patient care no matter what!​

​

 

[salubalu]

Changing the culture of a practice is not easy. Going from treating based only on skin marks and making 0.5 to 1 centimeter isocenter shifts once a week on port-film-day, to an SBRT mindset where everything is imaged daily with CBCT and 1-2 mm shifts, has been a challenge for more than one therapist I've worked with. It took about 6 months of hand-holding and meetings and enforcing policy for sim and treating a certain way, but it can be done.

One surprising thing I have found when switching to daily IGRT, is how many times a spine will be treated by one vertebral body too high or too low. I would have thought IGRT would prevent that, but it still happens. I guess that was a reason for the old tradition of nuking one level above and below?

“Nuking?” That sounds “brutal”

 

[TheWallnerus]

Changing the culture of a practice is not easy. Going from treating based only on skin marks and making 0.5 to 1 centimeter isocenter shifts once a week on port-film-day, to an SBRT mindset where everything is imaged daily with CBCT and 1-2 mm shifts, has been a challenge for more than one therapist I've worked with. It took about 6 months of hand-holding and meetings and enforcing policy for sim and treating a certain way, but it can be done.

One surprising thing I have found when switching to daily IGRT, is how many times a spine will be treated by one vertebral body too high or too low. I would have thought IGRT would prevent that, but it still happens. I guess that was a reason for the old tradition of nuking one level above and below?

You saying IGRT causes misadministrations?! Is that the IGRT or the user (therapist). I don’t see how you go off a full perfect vertebral body on a coronal or even sagittal CBCT view.

 

[IonsAreOurFuture]

I don't think IGRT causes missed spine targets, I think it reveals that we've been missing more than we probably thought we were historically. When it looks like you're off by 1/2 a vertebral body, a shift is usually made, sometimes in the wrong direction, especially if one is hyperfocused only on a few vert bodies which can all look alike. We've had to train our therapists to confirm: where is the carina, where are the iliac crests, where is the lowest rib, etc - unique pieces of anatomy to corroborate where one is Sup-Inf.

 

[NotMattSpraker]

You saying IGRT causes misadministrations?! Is that the IGRT or the user (therapist). I don’t see how you go off a full perfect vertebral body on a coronal or even sagittal CBCT view.

I made a trainee simulation that was based exactly off this type of error, maybe someone on here was part of the pilot. There is a lot written about this error. It's easier than you think because the field of view is often small, visceral organs may not align since it is a free breathing set up, and vertebral bodies in the same region look very similar.

IGRT doesn't cause misadmins, but it will catch the ones you would not otherwise detect if youre not imaging.

 

[taserlaser]

I made a trainee simulation that was based exactly off this type of error, maybe someone on here was part of the pilot. There is a lot written about this error. It's easier than you think because the field of view is often small, visceral organs may not align since it is a free breathing set up, and vertebral bodies in the same region look very similar.

IGRT doesn't cause misadmins, but it will catch the ones you would not otherwise detect if youre not imaging.

Great idea for a trainee case. I’m totally stealing that - thanks

 

[NotMattSpraker]

Great idea for a trainee case. I’m totally stealing that - thanks

If you go to the RO-ILS website and education, they have a bunch of quarterly reports. Several of them discuss real life cases of vertebral body misalignment. Great starting point to build a trainee case.

RO-ILS Education - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

Read recent RO-ILS data reports and other educational publications (e.g., case studies, themed reports).

www.astro.org

 

[Dare2Dream]

I don't think IGRT causes missed spine targets, I think it reveals that we've been missing more than we probably thought we were historically. When it looks like you're off by 1/2 a vertebral body, a shift is usually made, sometimes in the wrong direction, especially if one is hyperfocused only on a few vert bodies which can all look alike. We've had to train our therapists to confirm: where is the carina, where are the iliac crests, where is the lowest rib, etc - unique pieces of anatomy to corroborate where one is Sup-Inf.

Misalignments also have implications for future treatment in the vicinity (e.g. cord dose) when later treating a level or two above/below.

 

[ramsesthenice]

I don't think IGRT causes missed spine targets, I think it reveals that we've been missing more than we probably thought we were historically.

I have done a lot of MR IGRT with cine imaging and what becomes immediately obvious is just how imprecise our treatments are. You can do anything you want at simulation to try to capture OAR motion and deformation but it’s either too small or so big you end up compromising target coverage for the off chance something might spend 5% of the duty cycle in field. And oh, we miss more than you would like to think. And yet, our standard non-adaptive IGRT treatments work very well. Not saying throw all caution to the wind, but we lose too much sleep as a profession.

 

[RadOncDoc21]

I have done a lot of MR IGRT with cine imaging and what becomes immediately obvious is just how imprecise our treatments are. You can do anything you want at simulation to try to capture OAR motion and deformation but it’s either too small or so big you end up compromising target coverage for the off chance something might spend 5% of the duty cycle in field. And oh, we miss more than you would like to think. And yet, our standard non-adaptive IGRT treatments work very well. Not saying throw all caution to the wind, but we lose too much sleep as a profession.

I lose sleep because my colleagues love to flaunt their knowledge during case review and question why I decided to use a 0.5 cm instead of 0.7cm margin for my PTV. We also have competing rad oncs at our tumor boards and it becomes a measuring contest while the med oncs and surgeons enjoy the show.

 

[Neuronix]

We also have competing rad oncs at our tumor boards and it becomes a measuring contest while the med oncs and surgeons enjoy the show.

As a resident I rotated at a place like this. It was so uncomfortable watching the rad oncs trying to one up each other to curry favor with referrings.

 

[deleted1111261]

I lose sleep because my colleagues love to flaunt their knowledge during case review and question why I decided to use a 0.5 cm instead of 0.7cm margin for my PTV. We also have competing rad oncs at our tumor boards and it becomes a measuring contest while the med oncs and surgeons enjoy the show.

This would be entertaining. Can you record and post??

 

[deleted1111261]

As a resident I rotated at a place like this. It was so uncomfortable watching the rad oncs trying to one up each other to curry favor with referrings.

You messing with my people??

Just kidding, I love curry jokes almost as much as I love curry.

 

[RadOncDoc21]

This would be entertaining. Can you record and post??

It’s embarrassing, just imagine every case discussed where a ref is made for radiation, another rad onc has to one up the other one with either less fractions or omission and they are all fighting for the last word.

There are a lot of numbers thrown around and “data” most other docs could care less about. Compare this to the surgeons and med oncs who literally are just sitting there watching the rad oncs beg for attention. It’s truly a sad sight to see.

 

[deleted1111261]

It’s embarrassing, just imagine every case discussed where a ref is made for radiation, another rad onc has to one up the other one with either less fractions or omission and they are all fighting for the last word.

There are a lot of numbers thrown around and “data” most other docs could care less about. Compare this to the surgeons and med oncs who literally are just sitting there watching the rad oncs beg for attention. It’s truly a sad sight to see.

atlanta area it is common
i wonder where else? doesn't happen in mi

 

[Fpg1245]

I lose sleep because my colleagues love to flaunt their knowledge during case review and question why I decided to use a 0.5 cm instead of 0.7cm margin for my PTV. We also have competing rad oncs at our tumor boards and it becomes a measuring contest while the med oncs and surgeons enjoy the show.

It’s like the nerds in highschool trying so hard to impress the popular kids. Pathetic attempts to convince everyone they’re cool while all you will ever be is a form of entertainment.

 

[ramsesthenice]

I lose sleep because my colleagues love to flaunt their knowledge during case review and question why I decided to use a 0.5 cm instead of 0.7cm margin for my PTV. We also have competing rad oncs at our tumor boards and it becomes a measuring contest while the med oncs and surgeons enjoy the show.

"Well at HARVARD..."

 

[Neuronix]

"Well at HARVARD..."

When I was a resident at THE JOINT CENTER

What does orthopedics have to do with this ?

atlanta area it is common
i wonder where else? doesn't happen in mi

As usual, I'm talking about Florida, this time a biryani challenged part of it. In the parts of Florida with more biryani, the rad oncs fight for cases within their own groups in addition to fighting with other groups. Just kidding--sort of.

 

[NotMattSpraker]

atlanta area it is common
i wonder where else? doesn't happen in mi

Denver. It is very weird and was jarring to me the first time I saw it. This is an employed practice; the tumor board is a PSA breast surgeon, employed everything else and they let this rad onc just come there. I have no idea why they allow it, my guess is its a relic from the old PSA days when med onc and rad onc was not employed. The person does exactly as described except the surgeon sends all the patients to us, so its hard to do anything other than laugh.

 

[RadOncDoc21]

Florida tumor boards can literally be the Wild West. I’ve seen 4-5 different groups at one of the hospital tumor boards!

 

[Fpg1245]

Florida tumor boards can literally be the Wild West. I’ve seen 4-5 different groups at one of the hospital tumor boards!

Is that even constructive?

 

[RadOncDoc21]

Is that even constructive?

Only if you’re the group with the most med oncs and surgeons on your team!

 

[evilbooyaa]

I lose sleep because my colleagues love to flaunt their knowledge during case review and question why I decided to use a 0.5 cm instead of 0.7cm margin for my PTV. We also have competing rad oncs at our tumor boards and it becomes a measuring contest while the med oncs and surgeons enjoy the show.

Get a new job. Having competing rad oncs at my TBs would be a hard no...

 

[RadOncDoc21]

Get a new job. Having competing rad oncs at my TBs would be a hard no...

I like my biriyani too much! I’ve actually adapted because I’m part of the bigger group so I don’t have to say anything except for “yes, I’ll zap that” and get the referral. That wasn’t always the case. Which is why it kills me that my colleagues try so hard.

 

[RadOncDoc21]

AI cuts treatment time for cancer radiotherapy

The technology will be offered at cost price to all NHS trusts in England, following successful pilot studies.

www.bbc.com

Not sure where else to put this but figured this is as good of a place as any.

 

[sirspamalot]

Aka Radformation?