MPLA Case 4: A physicist’s consult with a patient

Received: 2 December 2020 | Revised: 29 January 2021 | Accepted: 5 February 2021 DOI: 10.1002/acm2.13211 MANAGEMENT AND PROFESSION MPLA Case 4: A physicist’s consult with a patient Lee Xu1 | Leonard Kim2 | Patricia Sansourekidou3 | Dongxu Wang4 1 Department Department 3 Department 4 Department 2 of of of of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA Radiation Oncology, MD Anderson Cancer Center at Cooper, Camden, NJ, USA Radiation Oncology, University of New Mexico Comprehensive Cancer Center, Albuquerque, NM, USA Medical Physics, Memorial Sloan Kettering Cancer Center, Middletown, NJ, USA Author to whom correspondence should be addressed. Lee Xu E‐mail: [email protected] Funding information NIH/NCI Cancer Center, Grant/Award Number: P30 CA008748; Keywords: case study, leadership, MPLA, professionalism This work of fiction is part of a case series by the Medical Physics Leadership Academy (MPLA) demonstrating the use of case studies as an “Good, good,” Dr. Abbasi replied as he entered the room. “Do you have a moment by chance?” educational method for the development of professionalism, leadership, “Yeah of course, what’s going on?” and communication skills within the medical physics community1 Dr. Abbasi sat down, tucking the end of his white coat neatly A facilitator's or self‐study guide is available. Please contact the beneath him. He crossed one leg over the other and rested his MPLA Cases Subcommittee (https://www.aapm.org/org/structure/ hands on his knee. “Listen,” he said, letting out a sigh. “I have a little default.asp?committee_code=MPLACA) for access. situation I was hoping you could help me with.” “Sure,” Wendi answered, intrigued. Over the past few months, Wendi had gotten along with Dr. Abbasi quite well, but had never 1 | SYNOPSIS encountered him like this. “What can I do for you?” It was an unusual day for Wendi Lin, a physicist who was just supposed to start VMAT five weeks ago. It’s a prostate. The problem 10 months into her clinical career and very much still getting the is, he refuses to be treated with photons. He only wants protons.” “I just came from the clinic. I have a patient—Vaughn—who was hang of things. At the request of Dr. Abbasi, one of the radiation “I see…” Wendi replied, wondering how she could possibly help. oncologists, Wendi was preparing to enter a consult room to explain “I agreed to switch him over a month ago, but we still haven’t to a patient — who was adamant on receiving proton therapy — the heard back from his insurance. It could be a few more weeks,” he practical differences between two particles used in treatment. continued. Dr. Abbasi took a deep breath in, taking a moment to Although initially surprised by Dr. Abbasi’s request, Wendi was organize his thoughts. “I just tried to convince him again to start rather excited to meet with the patient, for she had always enjoyed treatment, but he just won’t budge. He is convinced that proton interacting with patients in the past. This time, however, the encoun- therapy is some kind of miracle therapy.” ter did not go as she had expected. “Hmm, that does sound like quite the situation…” Wendi responded, hoping to lighten the mood. “And why would he think that?” 2 | THE REQUEST “After our initial consult he did some research and concluded that protons are the way to go. I tried explaining to him that there “Wendi?” Dr. Abbasi said, knocking on her office door. “It’s John.” “Hi John, please come in,” Wendi responded, looking up from her computer. “How are you doing?” are pros and cons to each method, but he just doesn’t seem to buy it.” Dr. Abbasi took a moment to organize his thoughts. “Do I think he’ll tolerate protons better? Maybe. But the point is his outcome is ---------------------------------------------------------------------------------------------------------------------------------------------------------------------This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2021 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals LLC on behalf of American Association of Physicists in Medicine. J Appl Clin Med Phys 2021; 22:5:147–149 wileyonlinelibrary.com/journal/jacmp | 147 148 | going to be similar either way…as long as he starts treatment that is. His PSA is rising.” XU ET AL. since she had started, most of the work she had done was behind the scenes. She reviewed patient charts in her office, resolved treat- “Oh, well it definitely sounds like he’s got his mind made up,” ment issues from the console areas, and waited patiently for the Wendi replied, somewhat impressed. She paused to see if Dr. Abbasi clinical days to end before hopping on the machines after hours. would prompt her. “So what can I do to help?” Aside from the select few on the brachytherapy team, the physicists “The patient is actually still here, right now,” Dr. Abbasi almost never interacted with any of the patients. She wondered responded, uncrossing his legs. “I was wondering if you would be whether they even knew she existed. It is not like medical physicists willing to talk to him.” “Just briefly,” he added. “Maybe you could were the physicists typically portrayed on T.V. or in the movies. clarify some of his notions on photons vs protons from a physics Wendi glanced at the time on her phone and picked up her pace — perspective?” she had lost track of time. It had already been 20 minutes and she “Oh really?” Wendi responded. “I mean sure, I wouldn’t mind did not want the patient to wait any longer. doing that,” she added. “Great, I’d really appreciate it,” Dr. Abbasi said as he stood up. “He should still be in the clinic…you can just ask one of the nurses 4 | WENDI’S CONSULT which room he’s in. It’s Richard Vaughn: V‐A‐U‐G‐H‐N.” Dr. Abbasi turned to leave the room before peering back, his phone now buzz- “Hi, Mr. Vaughn? I’m Wendi—I’m one of the physicists here,” she ing in his hand. “Thanks again Wendi.” said in a cheerful tone. Wendi reached forward and shook his hand. “It’s nice to meet you.” “Very nice to meet you Wendi. I have heard that medical physi- 3 | WENDI’S PREPARATION cists are employed here to oversee radiation technology.” he replied. Wendi was taken aback. Out of all the scenarios she had imagined tweed sport coat with matching slacks. A check‐patterned flat cap happening, this was not one of them. Physicists were not supposed adorned his head. Mr. Vaughn was a gentleman in his late 60’s, dressed in a brown to consult with patients, were they? Even if they were, surely no one had told her or prepared her for it. But as much as her anxiety ramped up, surprisingly so did her excitement. After all, she knew how to talk to patients from her days as a hospital volunteer in high “Sorry to keep you waiting—I heard from Dr. Abbasi that you might have some questions regarding photon and proton therapy?” “Not really any questions, but I don’t want photon therapy. When will the insurance be approved for protons?” school. In fact, she enjoyed doing it, so what was there to worry “Well,” Wendi sighed. “That’s something I could check with bill- about? Wendi reminded herself why she became a medical physicist ing for you, but usually it takes anywhere from four to eight weeks. in the first place — it was for moments like these. Ever since college In the meantime, however, Dr. Abbasi would like you to start treat- she wanted to work in healthcare and help patients get the treat- ment with photons. What are your hesitations regarding that?” ments they needed. Her training in physics provided her knowledge “It seems proton therapy is the newest technology—I’ve spent on the intricate behavioral differences between various particles. some time reading about it. I would like the best treatment avail- Now the question was whether she knew how to convey those dif- able.” He responded. ferences to a patient. Wendi opened Mr. Vaughn’s electronic chart and pulled up “Yes of course—I totally understand. The interesting thing about your case is that proton therapy isn’t necessarily better than photon both the VMAT (photon) and PBS (proton) plans in the treatment therapy. With proton therapy there is a theoretical benefit in normal planning system. She noticed that both plans exhibited good PTV tissue sparing, but there really hasn’t been anything definitive to coverage and dose conformality. The VMAT plan utilized two full show this. Like you mentioned, it is a newer technology, and arcs whereas the PBS plan utilized two lateral fields. The dose dis- because of that it also comes with uncertainties that haven’t been tribution in the VMAT plan was fairly homogeneous with the low studied as well.” Wendi explained. dose evenly distributed along the rotational axis of the beam. Compared to the VMAT plan, the PBS plan had a lower mean rectal and bladder dose, but the entrance dose was higher. The PBS plan also had a lower integral dose, as expected. Overall, Wendi found Mr. Vaughn sat up in his chair, taking a moment to adjust his posture. His demeanor seemed to change. “What kind of uncertainties are you talking about?” he asked. “I thought protons could be directly targeted to the tumor.” both plans to be reasonable, but the proton plan did have a more “Well, yes ideally we want the proton beam stop in the tumor favorable dose distribution. Wendi wondered what she would say itself, but protons suffer from something known as end‐of‐range if the patient asked about this. Would knowing this information do uncertainty. And this is a phenomenon where the end of the beam more harm than good? She decided she would not bring it up of becomes somewhat blurred out. Because of this, we don’t always her own volition. know precisely where the proton beam ends and have to add a mar- Wendi put on the white coat hanging behind the door, smooth- gin to account for it.” ing out the wrinkles as best as she could. As she made her way “What do you mean you don’t know where the proton beam toward the clinic, a flood of thoughts rushed through her head. Ever ends?” Mr. Vaughn said, somewhat agitated. “I thought you guys XU | ET AL. were the experts at this.” Wendi could sense she had said something she shouldn’t have. “I mean… we do know where the proton beam ends,” Wendi countered, somewhat flustered. “It’s just that protons are very sensitive to tissue density which affects how far they travel in a medium. 149 “We all have your best interests here I can promise you that,” Wendi reassured him. “Why don’t you take a day or two to think about it and get back to us. Does that sound alright?” “Fine,” Mr. Vaughn muttered. “I’ll need some time to give it another thought. It’s just a lot to take in.” And this is especially important in the pelvic region where you have “I completely understand,” Wendi said. bone, fat and muscle. Of course, we always try our best to account Wendi closed the door behind her, feeling a mixed wave of for this.” “Is that only for protons then, or should I be worried about photons too?” Mr. Vaughn asked. relief and unease rush over her. She completed her first ever patient consult as a physicist, even if it did not go as well as she hoped. At least the patient was somewhat skeptical of proton “Photons are affected too, to an extent,” Wendi answered. “But therapy now, she joked to herself. On her way out of the clinic, protons are especially affected just based on their nature—being Wendi wondered if she would ever return to do another consult. charged—and how they interact with matter. Protons are also pla- She definitely wanted to work on her communication skills before- gued by uncertainties in their biological effect, but that’s an entirely hand if so. Until then, she would send Dr. Abbasi a quick update separate topic of its own.” before heading back to her office to continue on with her weekly “So you guys also don’t know the biological effect of protons? chart checks. What else don’t you know? Should I be coming here at all?” Mr. Vaughn asked, raising his voice. Wendi could tell she was quickly ACKNOWLEDGEMENT losing control of the conversation. “Mr. Vaughn,” Wendi responded, somewhat distressed. “Proton therapy really is an excellent modality, but it’s certainly not perfect. This work was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Are there cases where protons are the preferred way to go? Definitely. But then there are cases like yours, where at the moment the benefit isn’t as clear. Photon therapy has its own downsides but it’s CONFLICT OF INTEREST been around for quite a while now and is a tried and true method. I’m sure Dr. Abbasi reviewed your case extensively before deciding The authors report no conflicts of interest and are solely responsible on the appropriate treatment for you.” for the content and writing of the paper. Mr. Vaughn had somewhat of a blank stare on his face as if he were processing his thoughts. Wendi wondered if she had given him too much information at once. He shifted his posture again before letting out a small sigh. REFERENCE 1. Gronberg M, Wang D. Introduction of MPLA case studies. J Appl Clin Med Phys; 2021. In Press.