Hazardous Attitudes and their Role in Radiology Oncology

Hazardous Attitudes and their Role in Radiology Oncology

A recent study published in the November edition of Advanced in Radiation Oncology, the American Society of Radiation Oncology’s scientific journal, revealed lower levels of hazardous attitudes (HA) in radiology oncologists compared to neurosurgeons and orthopedic surgeons.

The study, led by Nadia Saeed, BA, and Adriana Blakaj, MD, PhD, both of Yale, adapted a method utilized by the Federal Aviation Administration to measure the presence of five “hazardous attitudes” linked to risky behaviors in flight.


The Federal Aviation Administration officially recognized five hazardous attitudes implicated in plane crashes.

More recently, the medical field has begun utilizing the Hazardous Attitudes concept. Higher HA expressions in orthopedic surgeons are linked to higher rates of reoperation and patient readmission.

Hazardous Attitude Definition Antidote
Macho I can do it. Taking chances is foolish.

Don’t tell me.

Follow the rules. They are usually right.

What’s the use?

I’m not helpless. I can make a difference.
Impulsivity Do it quickly. Not so fast. Think first.
Invulnerability It won’t happen to me. It could happen to me.


Because of the FAA’s positive experience with HA, the Yale researchers believed this approach could be constructive for radiation oncologists, a subset of physicians who render high-stake treatment decisions that directly impact patients with cancer.

The researchers utilized a revised version of the FAA HA scale. The scale was sent, via email, to 809 radiology oncologists who were members of ASTRO and worked in cities where the top 25 cancer treatment centers in the US are located.

The research team developed 70 closed-end multiple-choice questions with four parts:

  1. Attitude survey adapted for radiology oncologists
  2. Treatment scenarios to determine willingness to prescribe a risk-tolerant treatment plans
  3. Sample scenarios, based on 5 ASTRO Choosing Wisely recommendations
  4. Demographic information

Thirty questions were agree/disagree questions, like statements similar to “I like to practice unusual treatment paradigms in radiation oncology.”

The survey explored prescribing habits and adherence to society guidelines. Four simulated cases helped researchers understand respondents’ prescribing practices and risk tolerance. The cases included:

  1. Radiation therapy for an elderly woman diagnosed with Stage 1 breast cancer, who is eligible for RT omission
  2. Prescribing habits for an ultracentral lung tumor
  3. Retreatment dose-fractionation of the supraclavicular fossa in a symptomatic breast cancer patient who received prior RT
  4. Balancing risk of RT pneumonitis against sufficient target volume coverage in lung cancer

Respondents were questioned about their preferences for patient scenarios representing ASTRO’s Choosing Wisely campaigns.


Of the surveys sent, the response rate was 17.1% — it’s important to note that some RO surveys have response rates as low as 5%. A total of 103 surveys were eligible for analysis. Their demographic analysis includes the following:

  • 61 male — 41 female — 1 unreported
  • Ages — evenly distributed
  • 85% worked in academic university settings
  • 79% averaged 11-30 patients weekly
  • Just over 70% worked with 6 or more colleagues
Hazardous Attitude Median (Range of Attitude Reported)
Macho 15 (7 – 24)
Anti-Authority 9 ( 5 – 20)
Worry 15 (6 – 23)
Resignation 12 (6 – 19)
Impulsivity 15 (8 – 21)


Analysis by the research team revealed median scores for each of the five hazardous attitudes were below pilots’ and surgeons’ scores.

The researchers found that radiology oncologists over 50 with >5 years of experience were 4.45 times more likely to recommend risk-tolerant prescriptions. Radiology oncologists crediting careful planning for avoiding treatment complications were nearly 5 times more likely to recommend retreatment, including for their high-risk patients.

Do more experienced radiology oncologists prioritize suppressing recurrence over avoiding complications?

Researchers were not certain why risk-tolerant prescriptions were so closely aligned with older age and more experience. They postulate two factors that may influence treatment prescriptions from this subset of radiology oncologists.

  1. The advent of the 3-dimensional era that provides more dose-volume metrics allows them to focus on preventing complications
  2. Five years of practice allowed radiology oncologists sufficient time to witness recurrences, and they may shift their focus from preventing complications to preventing recurrences

Nadia Saeed and her team believe this to be the first time that Hazardous Attitudes have been studied in radiation oncology. The research team noted a potential bias in the ratio of academic radiation oncologists. They added this note, “The influence of training site, disease-site specialization, local practice culture, peer influence, and era of training cannot be reliably assessed by these data but is likely to contribute to prescribing preferences. In addition, given that prescribing too much or too little radiation therapy can both be risky, it would be worthwhile to determine whether hazardous attitudes are correlated with prescriptions that are risk tolerant for recurrence.”

Their report is available here at no cost.