{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,11,15]],"date-time":"2025-11-15T11:48:04Z","timestamp":1763207284910,"version":"3.45.0"},"reference-count":17,"publisher":"Wiley","issue":"11","license":[{"start":{"date-parts":[[2025,10,27]],"date-time":"2025-10-27T00:00:00Z","timestamp":1761523200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["aapm.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["J Applied Clin Med Phys"],"published-print":{"date-parts":[[2025,11]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Radiation oncology residents report a lack of understanding and confidence in assessing radiotherapy plan quality. A contributing factor is the environment in which plan review is taught during residency, that is, routine clinical practice, which does not provide ample time for self\u2010guided practice in a low\u2010stakes setting. Expertise in plan review requires diverse case presentation and many examples, which are often not achievable in smaller programs and for less common cancer types. As plan quality affects patient outcomes, it is important to address these pitfalls in the education of residents on plan review.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Purpose<\/jats:title>\n                    <jats:p>To address the identified pitfalls of clinic\u2010based training, we have developed techniques to create realistic dose distributions that appear suboptimal in a controllable way. These plans can provide many more case examples in the training curriculum and present a low\u2010stakes technique for safe and effective education of radiation oncology residents.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>High\u2010quality dose distributions were first generated with a pre\u2010trained deep learning model (trained using only high\u2010quality plans). The dose distributions were then altered directly to create three classes of suboptimal dose distributions: (1) decreased organ\u2010at\u2010risk sparing, (2) decreased target conformality, and (3) hotspots in the target. Experienced clinicians then reviewed a subset of these suboptimal dose distributions to assess realism.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      We successfully decreased the quality of radiotherapy dose distributions. The decreased organ\u2010at\u2010risk sparing, decreased target conformality, and increased target hotspots were statistically significant (\n                      <jats:italic>p<\/jats:italic>\n                      \u00a0&lt;\u00a00.05) when assessed by dose\u2010volume histogram metrics for all parameters evaluated, and the magnitude of dose change was controllable. The resulting dose distributions were overall scored by experienced clinicians as realistic.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>In this study, we developed techniques to generate realistic but suboptimal dose distributions. The techniques operate directly on existing dose distributions without the need for a treatment planning system and produce dose distributions that appear realistic to experienced clinicians.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/acm2.70305","type":"journal-article","created":{"date-parts":[[2025,10,28]],"date-time":"2025-10-28T13:27:12Z","timestamp":1761658032000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Intentional creation of suboptimal, realistic dose distributions"],"prefix":"10.1002","volume":"26","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4659-0766","authenticated-orcid":false,"given":"Skylar S.","family":"Gay","sequence":"first","affiliation":[{"name":"Department of Radiation Physics The University of Texas MD Anderson Cancer Center  Houston Texas USA"},{"name":"The University of Texas MD Anderson Cancer Center UTHealth Houston Graduate School of Biomedical Sciences  Houston Texas USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0121-9579","authenticated-orcid":false,"given":"Mary P.","family":"Gronberg","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology UT Southwestern Medical Center  Dallas Texas USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Raymond","family":"Mumme","sequence":"additional","affiliation":[{"name":"Department of Radiation Physics The University of Texas MD Anderson Cancer Center  Houston Texas USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5497-2831","authenticated-orcid":false,"given":"Beth M.","family":"Beadle","sequence":"additional","affiliation":[{"name":"Stanford University  Stanford California USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anuja","family":"Jhingran","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology The University of Texas MD Anderson Cancer Center  Houston Texas USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tze Yee","family":"Lim","sequence":"additional","affiliation":[{"name":"Department of Radiation Physics The University of Texas MD Anderson Cancer Center  Houston Texas USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2441-4457","authenticated-orcid":false,"given":"Zhiqian H.","family":"Yu","sequence":"additional","affiliation":[{"name":"Department of Radiation Physics The University of Texas MD Anderson Cancer Center  Houston Texas USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3093-6913","authenticated-orcid":false,"given":"Christine","family":"Chung","sequence":"additional","affiliation":[{"name":"Department of Radiation Physics The University of Texas MD Anderson Cancer Center  Houston Texas 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