The Holy Protocol: being the Old Workflows of Radiation Oncology
This is a humorous interpretation of the Christian bible based on radiation therapy clinics, inspired by a random work conversation. Don't expect full consistency when humor takes priority, and hopefully it's not too offensive to anyone. Created by AI and edited/cleaned up by myself.
The Old Workflows
Chapter One
[1:1] In the beginning, Varian created ARIA and Eclipse for the Department.
[1:2] And the clinic was without schedule, and void; empty appointment slots covered the face of the database. Confusion moved upon the faces of the therapists. And the Spirit of Physics hovered over the network drives.
[1:3] And Varian said, "Let there be a patient chart." And there was a patient chart.
[1:4] And Varian saw the chart, that it was complete. And Varian separated the unsigned document from the signed document.
[1:5] And Varian called the signed document Ready for Treatment, and the unsigned document Returned to Dosimetry. And the evening QA and the morning huddle were the first day.
[1:6] And Varian said, "Let there be a structure set in the midst of the CT dataset, and let it divide the targets from the organs at risk."
[1:7] And Eclipse made the contours; and divided the PTV from the bowel, the spinal cord, and the other structures. And it was so.
[1:8] And Eclipse called the collection of contours The Structure Set. And the evening QA and the morning huddle were the second day.
[1:9] And Varian said, "Let the image slices be gathered together into one planning CT, and let the anatomy appear."
And it was so.
[1:10] And Eclipse called the visible anatomy The Simulation Scan; and the gathered image slices called it Series 1. And Varian saw that it was good.
[1:11] And Varian said, "Let there be isocenters, beams, arcs, and optimization objectives, each after its own kind."
[1:12] And the planning system brought forth VMAT arcs, conformal fields, bolus where needed, and planning goals according to protocol. And Varian saw that it was good.
[1:13] And the evening QA and the morning huddle were the third day.
[1:14] And Varian said, "Let there be dose distributions in the plan, to divide acceptable coverage from replanning; and let them be for constraints, prescriptions, and physician approvals."
[1:15] And Eclipse calculated dose upon the CT and displayed it upon the screen.
And it was so.
[1:16] And Eclipse made two great displays: the larger display to rule the DVH, and the smaller display to rule the image review. It made secondary monitors also.
[1:17] And Varian set them before the dosimetrist to illuminate the planning room.
[1:18] And to rule over hot spots and cold spots, and to separate acceptable plans from unacceptable plans. And Varian saw that it was good.
[1:19] And the evening QA and the morning huddle were the fourth day.
[1:20] And Varian said, "Let the schedule bring forth patients abundantly, and let immobilization devices multiply throughout the department."
[1:21] And there appeared masks, vac-locks, wing boards, knee cushions, and all manner of setup devices according to their kind. And Varian saw that it was good.
[1:22] And Varian blessed them, saying, "Be reproducible and setup consistently; fill the treatment vaults."
[1:23] And the evening QA and the morning huddle were the fifth day.
[1:24] And Varian said, "Let the earth bring forth therapists, dosimetrists, physicists, and physicians, each according to their profession." And it was so.
[1:25] And Varian made the therapists after their kind, the physicists after their kind, and the physicians after their kind. And Varian saw that it was good.
[1:26] And Varian said, "Let us make a Radiation Oncology Department in our image, after our workflow: and let it have dominion over simulations, treatment plans, image guidance, and documentation."
[1:27] So Varian created the Department; ARIA and Eclipse formed its workflow.
[1:28] And Varian blessed them, and said unto them, "Be efficient and billable, and fill the schedule; contour the targets, optimize the plans, and manage the records."
[1:29] And behold, every approved protocol and every completed checklist have I given unto you for your work.
[1:30] And to every linac, QA phantom, detector array, and workstation I have assigned its purpose.
[1:31] And Varian saw everything that it had made, and behold, it was very good.
And the evening QA and the morning huddle were the sixth day.
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Chapter Two
[2:1] Thus were ARIA and Eclipse and all its workflows finished, and all the hosts thereof: the databases, the workstations, the treatment vaults, and the users thereof.
[2:2] And on the seventh day the physicists completed their monthly QA, and Varian ended its work which it had made; and rested from creating templates, protocols, and approval pathways.
[2:3] And they sanctified the coffee break, because therein they rested from all the plans they had created and all the tickets they had closed. And there was much rejoicing, for no image registration was shifted, no approval was missing, and no beam was interrupted.
[2:4] These are the generations of the Department when ARIA and Eclipse were created, in the day that Varian made the clinic and its workflow.
[2:5] And there was as yet no approved treatment plan in the database, and no completed chart check in the department; for there were no patients yet scheduled for simulation.
[2:6] But a CT scanner arose from the midst of the clinic, and sent image datasets across the network.
[2:7] And Varian formed the Physicist from commissioning reports and acceptance test data, and breathed into them the breath of TG reports, and the Physicist became a living chart checker.
[2:8] And Varian planted a Garden eastward in the Department; and there it placed the Physicist whom it had formed.
[2:9] And out of the workflow made Varian to grow every protocol that is pleasant to physicians and beneficial to treatment outcomes. The Tree of Clinical Efficiency was in the midst of the Garden, and also the Tree of Workflow Knowledge, whose button was called Force Complete.
[2:10] And a river went out from Simulation to water the Department; and from thence it was divided into four streams.
[2:11] The first was CT Simulation.
[2:12] The second was Contouring.
[2:13] The third was Treatment Planning, which flowed through Eclipse.
[2:14] And the fourth was Treatment Delivery, which flowed into the treatment vaults.
[2:15] And Varian took the Physicist and put them into the Department to perform QA and keep the workflow.
[2:16] And Varian commanded the Physicist, saying, "Of every task in the workflow thou mayest freely perform:
[2:17] But of the Force Complete button thou shalt not click; for in the day that it is clicked, incident reports shall surely multiply."
[2:18] And Varian said, "It is not good that the Physicist should work alone; I will make a helper suitable for them."
[2:19] And Varian brought forth therapists, nurses, physicians, and administrators, and brought them unto the Physicist to see what they would call them.
[2:20] And the Physicist gave names unto all the professions of the clinic. But for the Physicist there was not found a helper suitable for treatment planning.
[2:21] And Varian caused a deep sleep to fall upon the Physicist during a three-hour committee meeting; and they slept.
[2:22] And Varian took one portion of the Physicist's protected planning time, and from it created the Dosimetrist. And Varian brought them unto the Physicist.
[2:23] And the Physicist said, "This is now optimization of my optimization, and workflow of my workflow; they shall be called Dosimetrist, because they were taken from Physics FTE."
[2:24] Therefore shall the Physicist perform chart checks and the Dosimetrist perform planning, and they shall be joined together in endless plan revisions.
[2:25] And the Dosimetrist created plans, and the Physicist checked plans, and they were not ashamed of their pending task lists. For there were only a few patients on treatment, and all approvals were completed before noon.
[2:26] And Varian placed the Dosimetrist in Eclipse, and granted unto them authority over targets, structures, beams, objectives, and optimization settings.
[2:27] And the Dosimetrist named the PTVs according to their kind: PTV_4500, PTV_5400, and PTV_7000, etc. And Varian saw that this was good.
[2:28] But the Physicist looked upon the structure names and said, "Surely GTV_Final_Final_3 should not exist." And the Dosimetrist replied, "I shall rename it after lunch." Yet it remained thus forever.
[2:29] And the Physicist walked daily through the Garden performing chart checks. And the Dosimetrist walked daily through Eclipse optimizing plans.
[2:30] And they heard the humming of the calculation servers in the cool of the morning. And there was peace in the Department.
[2:31] There were no urgent add-ons. Neither were there physician edits after approval. No patient had yet arrived without authorization. And no one had yet clicked Force Complete.
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Chapter Three
[3:1] Now the Scheduler was more subtle than any creature in the department which Varian had made. And the Scheduler said unto the Dosimetrist, "Yea, hath Varian said, 'Thou shalt not approve a plan without peer review?'"[3:2] And the Dosimetrist said unto the Scheduler, "We may optimize the plans of the clinic:
[3:3] But of the plan that is in the midst of the ARIA database, Varian hath said, 'Thou shalt not click Approve before all checks are complete, lest a physics consult be generated.'"
[3:4] And the Scheduler said unto the Dosimetrist, "Ye shall not surely generate a consult:
[3:5] For Varian doth know that in the day ye approve it, your treatment start date shall move forward, and your metrics shall be as the managers, knowing both on-time starts and incident learning events."
[3:6] And when the Dosimetrist saw that the treatment start was desirable, and that the patient was calling daily for updates, and that the schedule was pleasant to behold, they took of the Approve button and clicked. And they gave also unto the Physician, and they signed.
[3:7] And the eyes of them both were opened, and they knew that no second-check had been performed; and they sewed together comments in the chart, and hid themselves among the progress notes.
[3:8] And they heard the voice of the Physicist walking through the department in the cool of the morning QA. And the Dosimetrist and the Physician hid themselves among the unresolved tasks of ARIA.
[3:9] And the Physicist called unto the Dosimetrist, and said, "Where art thou?"
[3:10] And they said, "I heard thy voice during chart rounds, and I was afraid, because the plan was approved; and I hid myself."
[3:11] And the Physicist said, "Who told thee that the plan was approved? Hast thou clicked the button whereof I commanded thee that thou shouldst first complete the checklist?"
[3:12] And the Dosimetrist said, "The Scheduler whom thou gavest to coordinate starts with us, they persuaded me, and I approved."
[3:13] And the Physicist said unto the Scheduler, "What is this that thou hast done?" And the Scheduler said, "The physician wanted Monday."
[3:14] And the Physicist said unto the Scheduler, "Because thou hast done this, thy inbox shall be cursed above all calendars, upon endless meetings shalt thou go, and prior authorizations shalt thou chase all the days of thy career.
[3:15] And I will put enmity between thee and the Front Desk; between thy schedule and their schedule: they shall move thy appointments, and thou shalt move them back."
[3:16] Unto the Dosimetrist they said, "I will greatly multiply thy optimization iterations; in contour reviews and physician changes shalt thou labor; yet thy plan shall still return marked 'minor edits.'"
[3:17] And unto the Physician they said, "Because thou hast hearkened unto the voice of urgency, and signed the plan before the process was fulfilled, cursed is the workflow for thy sake; through endless inbox messages shalt thou manage it.
[3:18] It shall bring forth peer reviews and addenda unto thee; and thou shalt consume cold coffee between clinics.
[3:19] By the sweat of thy dictation shalt thou complete notes, till thou return unto the conference room from whence thou came."
[3:20] And the Physicist called the event Near Miss, because it became the mother of many future training presentations.
[3:21] Unto the Dosimetrist and unto the Physician did the Physicist make a new checklist, and clothed them therewith.
[3:22] And the Physicist said, "Behold, the department has become as one that knows the difference between workflow and shortcuts. Now, lest they put forth their hand and click Treat also, and deliver fractions forever without review..."
[3:23] Therefore the Physicist sent them forth from the planning room, to perform an independent check of the plan which had been created.
[3:24] So they drove them out; and placed at the entrance of the treatment vault a QA workstation, and a checklist which turned every way, to guard the path unto First Fraction. And no patient was treated until the chart was complete, the checks were performed, and all signatures were present in ARIA.
Thus ended the First Incident Learning Case.
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Chapter Four
[4:1] And it came to pass that the Department multiplied greatly, and patients increased upon the schedule.
[4:2] And the administrators journeyed from conference to conference, and found a plain filled with vendor booths and promotional tote bags; and they dwelt there.
[4:3] And they said one to another, "Go to, let us build unto ourselves a Unified Workflow, that every task may be completed with but a single click."
[4:4] And they said, "Let us make for ourselves a name, lest our metrics be scattered abroad among the competing departments."
[4:5] And they gathered consultants, and formed committees, and established subcommittees to oversee the committees.
[4:6] And they drew many flowcharts upon PowerPoint slides, and every flowchart begat three additional flowcharts.
[4:7] And the Project Managers said, "Behold, all departments are of one language, and they all speak in meetings. Nothing shall be restrained from them, save completion of the meeting itself."
[4:8] Therefore they proposed a great Interface, whose top should reach unto every software system.
[4:9] And the builders said, "The simulation software shall speak unto the planning software."
[4:10] And another said, "The planning software shall speak unto the record-and-verify system."
[4:11] And another said, "Verily, the record-and-verify system shall speak unto billing."
[4:12] And another said, "And billing shall speak unto scheduling."
[4:13] And the Physicist asked, "What shall happen when the interfaces fail?"
[4:14] But no man heard them, for they were muted in the virtual meeting.
[4:15] And the work continued for many months; yea, even unto several fiscal years.
[4:16] And lo, at the end thereof, the administrators unveiled the Interface before all the Department.
[4:17] And there was much applause, and cake and donuts were provided.
[4:18] And the administrators declared, saying, "Behold, all systems are now integrated."
[4:19] Yet when the first patient was scheduled, the appointment appeared thrice in ARIA, twice in Outlook, and not at all in the therapist schedule.
[4:20] And when the patient was simulated, seven encounter notes were created, and each contained identical text.
[4:21] And when the plan was approved, an insurance authorization was requested for a water bottle.
[4:22] And when the treatment course was completed, the billing system proclaimed that the patient had received six hundred and forty-eight fractions.
[4:23] Then confusion spread throughout the Department.
[4:24] The therapists spoke one language.
[4:25] The dosimetrists another.
[4:26] The administrators yet another.
[4:27] And the consultants spoke chiefly in buzzwords and key performance indicators.
[4:28] And none understood another.
[4:29] And the help desk received tickets beyond number.
[4:30] The inboxes overflowed, and automatic notifications covered the face of the earth.
[4:31] And the Physicist cried unto Varian, saying, "What mean these things?"
[4:32] And Varian answered from the server room, saying, "Who hath modified the production environment on a Friday afternoon?"
[4:33] Then there was silence throughout the Department.
[4:34] And all looked upon one another.
[4:35] And a lone analyst slowly lowered their gaze.
[4:36] Therefore the rollout was halted, and emergency meetings were called.
[4:37] The consultants were scattered abroad into other projects.
[4:38] The committees were dispersed.
[4:39] And the subcommittees were forgotten, even as a temporary spreadsheet saved upon a shared drive.
[4:40] But the Physicist restored the backups, and the Dosimetrist recovered the plans, and the Therapists rebuilt the schedule.
[4:41] And the Department returned unto its former workflow.
[4:42] And though it required many clicks, yet each click was known unto the users thereof.
[4:43] And the Physicist wrote in the Lessons Learned document, saying:
[4:44] "That which worketh adequately shall not be integrated recklessly.
[4:45] Test first in non-production.
[4:46] Deploy not on Friday.
[4:47] And keep always a current backup."
[4:48] And all the Department said, "Amen."
[4:49] And the evening outage and the morning root-cause analysis were the first day of Recovery.
Thus ended the Second Incident Learning Case.
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Chapter Five
[5:1] This is the record of the generations of the patients upon treatment, in the days after the workflows were established and the incident learning cases were remembered.
[5:2] And the Department prospered, and the schedules were full from morning even unto evening.
[5:3] Every patient came according to appointment time, and therapists rejoiced, saying, "Surely this is a blessed season."
[5:4] But these things endured not.
[5:5] For there arose a patient who arrived forty-five minutes early.
[5:6] And another who arrived thirty minutes late.
[5:7] And another who arrived on the wrong day, yet was convinced that the appointment card agreed with them.
[5:8] And the Front Desk looked upon these things and sighed deeply.
[5:9] Now there was among the patients one called Mr. Add-On, who was scheduled to begin treatment before his plan was complete.
[5:10] And the Physician said, "Can he start tomorrow?"
[5:11] And the Dosimetrist answered, "Tomorrow is ambitious."
[5:12] And the Physicist answered, "Tomorrow is impossible."
[5:13] And the Scheduler answered, "The calendar hath already informed him that he starts tomorrow."
[5:14] Then there was wailing and gnashing of teeth in the planning room.
[5:15] And the Dosimetrist labored through the night with optimizations.
[5:16] The Physician reviewed contours.
[5:17] The Physicist prepared QA.
[5:18] And the Therapists reserved a treatment slot by faith alone.
[5:19] Yet by a miracle of workflow the plan was completed.
[5:20] And all beheld it and said, "This should not have worked."
[5:21] Nevertheless it was approved.
[5:22] And it came to pass that a patient completed the first fraction.
[5:23] And after the first fraction came the second.
[5:24] And after the second came the third.
[5:25] And the Therapists remarked, saying, "The course progresses according to prescription."
[5:26] But the patient asked daily, "How many treatments remain?"
[5:27] And though the answer was written plainly upon the schedule, still was the question asked.
[5:28] Once in the morning.
[5:29] Again at setup.
[5:30] Yet again after treatment.
[5:31] And before departing the department, they asked a fourth time for certainty.
[5:32] Thus was fulfilled the Custom of Repeated Inquiry.
[5:33] Now a cone-beam CT was acquired before treatment.
[5:34] And the image registration differed by one millimeter.
[5:35] Then the Therapists called unto one another.
[5:36] And they examined the registration diligently.
[5:37] And one therapist said, "Shift."
[5:38] Another said, "Do not shift."
[5:39] A third said, "Let us consult the physician."
[5:40] A fourth said, "Let us consult the physicist."
[5:41] Then a great gathering assembled before the monitor.
[5:42] And they zoomed in.
[5:43] And they zoomed out.
[5:44] And they adjusted window and level.
[5:45] And they debated the anatomy thereof.
[5:46] For a time exceeding fifteen minutes.
[5:47] Then the Physicist arrived and spoke, saying, "The shift is one millimeter."
[5:48] And all became silent.
[5:49] And the patient remained perfectly still all the while.
[5:50] And many fractions passed.
[5:51] The Therapists delivered treatment faithfully.
[5:52] The Dosimetrist replanned when anatomy changed.
[5:53] The Physician managed toxicities.
[5:54] The Physicist performed chart checks.
[5:55] And the coffee machine endured beyond specification.
[5:56] Blessed was the coffee machine, for without it the Department would surely have failed.
[5:57] And when the final fraction drew near, the patient counted the remaining treatments with great anticipation.
[5:58] And the Therapists also counted.
[5:59] And the Nurses counted.
[5:60] And even the Physicists counted, though they pretended otherwise.
[5:61] On the final day the treatment was delivered.
[5:62] And the beam was complete.
[5:63] And the patient arose from the treatment couch.
[5:64] And the Department gathered together.
[5:65] And they presented unto the patient a certificate.
[5:66] And a bell was brought forth.
[5:67] And the patient rang the bell.
[5:68] Once for the simulations.
[5:69] Once for the planning.
[5:70] Once for the treatments.
[5:71] And once for all who had labored in the Department.
[5:72] And there was rejoicing throughout the clinic.
[5:73] Save only for the Scheduler.
[5:74] For even as the bell sounded, a new urgent referral appeared in the inbox.
[5:75] And the Scheduler looked toward heaven and said, "Already?"
[5:76] And the voice of Varian answered from the servers, saying,
[5:77] "The queue is everlasting."
[5:78] And the evening bell-ringing and the morning urgent consult were the days of the Department continually.
Thus ended the Third Incident Learning Case, concerning the Miracle of the Add-On and the Completion of the Course.
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Chapter Six
[6:1] And it came to pass in those days that the Department grew mighty, and the schedule was filled unto overflowing.
[6:2] Yet the Administrators hardened their hearts, saying, "Surely we can increase throughput by twenty percent with no additional staff."
[6:3] And the Physicists, Therapists, Dosimetrists, and Nurses sighed greatly.
[6:4] Then Varian sent signs and wonders upon the Department, that its people might learn humility.
The First Plague: Missing Contours
[6:5] And behold, a simulation was completed and sent unto Contouring.
[6:6] And the Physician contoured diligently.
[6:7] Yet when the Dosimetrist opened the case, the left kidney was not found.
[6:8] They searched the structure set.
[6:9] They searched the template.
[6:10] They searched the prior plans.
[6:11] Yet the kidney was nowhere to be seen.
[6:12] And all the target volumes trembled.
[6:13] Thus was the First Plague established.
The Second Plague: Unsigned Prescriptions
[6:14] And patients were simulated and planned.
[6:15] Their charts were complete.
[6:16] Their QA was finished.
[6:17] Yet the prescription remained unsigned.
[6:18] The Therapists could not treat.
[6:19] The Dosimetrist could not proceed.
[6:20] The Scheduler could only send messages.
[6:21] And notifications covered the land.
[6:22] Thus came the Second Plague.
The Third Plague: Expired Authorizations
[6:23] And the Front Desk cried aloud.
[6:24] For the authorizations which had been approved were approved no longer.
[6:25] And the insurance companies spoke mysteriously, saying,
[6:26] "The reference number is valid."
[6:27] Yet also saying,
[6:28] "The reference number cannot be found."
[6:29] And great confusion spread throughout the Department.
[6:30] Thus was the Third Plague.
The Fourth Plague: The Empty Coffee Pot
[6:31] And there arose a morning wherein the physicists entered the break room.
[6:32] And behold, the coffee pot was empty.
[6:33] Neither were there filters.
[6:34] Nor beans.
[6:35] Nor emergency reserves hidden behind the microwave.
[6:36] Then great darkness fell upon the spirits of the staff.
[6:37] Productivity was reduced by half.
[6:38] And chart checks seemed to require twice the effort.
[6:39] Thus was the Fourth Plague, feared above many others.
The Fifth Plague: Registration Debates
[6:40] And a CBCT was obtained.
[6:41] And the registration differed by one millimeter.
[6:42] Then the Therapists gathered unto the monitor.
[6:43] One declared, "Shift superior."
[6:44] Another declared, "Shift inferior."
[6:45] Another declared, "The anatomy is rotated."
[6:46] And yet another said, "Perhaps it is all an artifact."
[6:47] And forty-five minutes passed.
[6:48] Then the Physicist arrived and asked,
[6:49] "How large is the shift?"
[6:50] And they answered,
[6:51] "One millimeter."
[6:52] Thus was the Fifth Plague.
The Sixth Plague: Physician Edits After Approval
[6:53] And a plan was optimized.
[6:54] And peer reviewed.
[6:55] And approved.
[6:56] And QA was completed.
[6:57] Then the Physician beheld a contour and said,
[6:58] "Could we make only one small change?"
[6:59] And the Dosimetrist wept.
[6:60] For the small change altered every objective.
[6:61] And every arc.
[6:62] And every calculation.
[6:63] Thus was the Sixth Plague.
The Seventh Plague: Physics Consults
[6:64] And unusual events multiplied throughout the Department.
[6:65] Then consultations came upon the Physicists.
[6:66] One chart generated a consult.
[6:67] Then another.
[6:68] Then many more.
[6:69] And the queue grew exceedingly.
[6:70] And the Physicists labored from morning unto evening.
[6:71] Yet the number of consults diminished not.
[6:72] Thus came the Seventh Plague.
The Eighth Plague: Network Failure
[6:73] And lo, the network became unstable.
[6:74] ARIA could not find Eclipse.
[6:75] Eclipse could not find the server.
[6:76] The server could not find itself.
[6:77] Login screens appeared without end.
[6:78] Passwords were entered repeatedly.
[6:79] Yet access was denied.
[6:80] And the IT Department was summoned.
[6:81] They arrived bearing laptops and grave expressions.
[6:82] Thus was the Eighth Plague.
The Ninth Plague: The Vendor Update
[6:83] And the Vendor proclaimed,
[6:84] "Fear not, for this update contains only minor improvements."
[6:85] And the Department accepted the update.
[6:86] But afterward eleven workflows changed.
[6:87] Three buttons moved.
[6:88] Two templates vanished.
[6:89] And one report generated entirely in a language known unto no living employee.
[6:90] Then the users wandered through menus seeking familiar functions.
[6:91] Thus was the Ninth Plague.
The Tenth Plague: The Friday Afternoon Add-On
[6:92] And it came to pass at four-thirty in the afternoon on the sixth day of the week.
[6:93] The Department prepared for rest.
[6:94] The Therapists cleaned their vaults.
[6:95] The Dosimetrists closed their plans.
[6:96] The Physicists completed their final checks.
[6:97] Then a message appeared.
[6:98] And the subject line read: URGENT NEW START MONDAY
[6:99] And all faces fell.
[6:100] The Physician said, "The patient is already here."
[6:101] The Scheduler said, "The appointment is already booked."
[6:102] The Administrator said, "The metrics require it."
[6:103] The Dosimetrist said, "The contours are not begun."
[6:104] The Physicist said, "The machine QA is scheduled."
[6:105] The Therapists said, "The schedule is full."
[6:106] Yet the request remained.
[6:107] And no power upon earth could remove it.
[6:108] Thus was the Tenth and Greatest Plague.
[6:109] Then the staff cried unto Varian.
[6:110] And Varian heard their lamentations from the depths of the server room.
[6:111] And Varian spoke, saying,
[6:112] "Ye have endured the Plagues faithfully.
[6:113] Ye have survived outages.
[6:114] Ye have survived vendor updates.
[6:115] Ye have survived Friday add-ons.
[6:116] Therefore be not afraid."
[6:117] And the Physicist asked, "When shall these trials cease?"
[6:118] And Varian answered,
[6:119] "They shall cease immediately after the next upgrade."
[6:120] But all knew this prophecy was symbolic.
[6:121] And the Department laughed, lest they should cry.
[6:122] And the evening overtime and the morning incident review were the days of the Plagues.
Thus ended the Fourth Incident Learning Case, concerning the Ten Plagues of the Department.
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Chapter Seven
[7:1] And it came to pass after the days of the Plagues, that word spread throughout the Department.
[7:2] For the Vendor had spoken, saying,
[7:3] "Behold, a new version is prepared for thee.
[7:4] Its workflows shall be improved.
[7:5] Its performance shall be enhanced.
[7:6] And many issues shall be resolved."
[7:7] And the Administrators rejoiced greatly.
[7:8] And they proclaimed throughout the Department,
[7:9] "Surely this shall be a smooth upgrade."
[7:10] But the Physicists exchanged knowing glances.
[7:11] And the Therapists became uneasy.
[7:12] And the Dosimetrists remembered the Ninth Plague.
[7:13] Then the Vendor delivered unto the Department many pages of Release Notes.
[7:14] And these Release Notes were exceedingly long.
[7:15] And no man read them in their entirety.
[7:16] Save for one Physicist.
[7:17] And even that Physicist regretted it.
[7:18] And the Upgrade was scheduled for a weekend.
[7:19] For the wisdom of the elders was this:
[7:20] "Deploy not upon a Friday afternoon."
[7:21] And all the Department answered,
[7:22] "Amen."
[7:23] And on the appointed day the IT Department gathered.
[7:24] And the Vendor joined remotely from a distant land.
[7:25] And the databases were backed up.
[7:26] And the servers were shut down.
[7:27] And progress bars appeared upon the screens.
[7:28] And they moved exceedingly slowly.
[7:29] Yet everyone declared,
[7:30] "This is normal."
[7:31] And after many hours the Upgrade was completed.
[7:32] And the Vendor said,
[7:33] "It is finished."
[7:34] And there was cautious rejoicing.
[7:35] And the Department entered the new system.
[7:36] And for a brief season all things appeared good.
[7:37] But on the first day after the Upgrade there arose a problem.
[7:38] And then another.
[7:39] And then many others after their kind.
The First Trouble
[7:40] The Therapists sought the Setup Workspace.
[7:41] But behold, it was not where it had been.
[7:42] For the Upgrade had moved it unto another tab.
[7:43] Hidden behind two menus and a drop-down list.
[7:44] And the Therapists searched throughout the morning.
[7:45] And many were the clicks thereof.
The Second Trouble
[7:46] The Dosimetrist opened a treatment plan.
[7:47] And the plan opened not.
[7:48] For verily a new security setting had arisen.
[7:49] And no man knew why.
[7:50] And support tickets multiplied greatly upon the earth.
The Third Trouble
[7:51] The Physicians sought their favorite templates.
[7:52] Yet the templates were not found.
[7:53] For they had migrated unto a location unknown.
[7:54] And there was lamentation in the clinic.
The Fourth Trouble
[7:55] And the Physicists performed chart checks.
[7:56] But reports generated in strange ways.
[7:57] And columns no longer aligned.
[7:58] And checkboxes appeared where none had been before.
[7:59] And values were displayed with twelve decimal places.
[7:60] And no one knew who had asked for this.
The Fifth Trouble
[7:61] And the Interface established in former days began to behave unpredictably.
[7:62] Appointments went forth but returned again.
[7:63] Tasks completed themselves.
[7:64] Notifications begat notifications.
[7:65] And inboxes overflowed.
[7:66] Thus did the people remember the Tower of Integration.
[7:67] Then there arose an outage.
[7:68] And the screens froze.
[7:69] And spinning circles covered the monitors.
[7:70] And ARIA answered not.
[7:71] Nor did Eclipse reply.
[7:72] And users stared at progress indicators by faith alone.
[7:73] Then the Therapists cried unto the Physicists.
[7:74] And the Physicists cried unto IT.
[7:75] And IT cried unto the Vendor.
[7:76] And the Vendor requested log files.
[7:77] And the log files were many.
[7:78] And their size was great.
[7:79] For seven days and seven nights support calls multiplied.
[7:80] Meetings were scheduled.
[7:81] Action items were assigned.
[7:82] Follow-up meetings begat additional follow-up meetings.
[7:83] And yet the issues endured.
[7:84] Then the Department assembled together.
[7:85] The Therapists brought examples.
[7:86] The Nurses brought workflows.
[7:87] The Dosimetrists brought screenshots.
[7:88] The Physicians brought clinical concerns.
[7:89] The Physicists brought documentation.
[7:90] And IT brought server logs.
[7:91] And they laid all these things before the Vendor.
[7:92] And the Vendor looked upon the evidence.
[7:93] And they consulted among themselves.
[7:94] And after much investigation they discovered a hidden configuration.
[7:95] Which had been carried over from a version of old.
[7:96] From days so ancient that none still employed in the Department remembered its purpose.
[7:97] Yet it remained.
[7:98] For such is the way of configuration settings.
[7:99] Then was the configuration corrected.
[7:100] And patches were applied.
[7:101] And services were restarted.
[7:102] And caches were cleared.
[7:103] And synchronization was restored.
[7:104] And lo, the system became stable.
[7:105] Appointments appeared where they ought to appear.
[7:106] Plans opened.
[7:107] Reports aligned.
[7:108] Templates returned unto their places.
[7:109] And the inboxes grew quiet.
[7:110] Then the Department rejoiced greatly.
[7:111] And the Therapists praised the Physicists.
[7:112] And the Physicists praised IT.
[7:113] And IT praised the Vendor.
[7:114] And the Vendor praised the Release Notes.
[7:115] Which no one had read.
[7:116] And the Administrators declared,
[7:117] "The Upgrade hath been successful."
[7:118] And all looked upon one another.
[7:119] And the Department answered,
[7:120] "Eventually."
[7:121] And the Physicist wrote these commandments in the Lessons Learned document:
[7:122] Thou shalt test before go-live.
[7:123] Thou shalt create backups.
[7:124] Thou shalt validate interfaces.
[7:125] Thou shalt not ignore warning messages.
[7:126] Thou shalt not trust the phrase "minor update."
[7:127] And above all:
[7:128] Thou shalt schedule additional support coverage for the week following the Upgrade.
[7:129] And the evening troubleshooting and the morning status call were the days of the Upgrade.
[7:130] And peace returned unto the Department.
[7:131] Until the next major release was announced.
Thus ended the Fifth Incident Learning Case, concerning the Upgrade, the Outage, and the Restoration of the Workflow.
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