P/I)s
Inr J Radiul,on Onn~lo~v Biol Vol. 24. pp. 833-835 Pnntcd I” the US A. All nghts reserved.
CopyrIght
l~3htl-3olh/Y? $5.00 + .oo Cc 1992 Prrgamon Press Ltd
0 Special Feature
PRINCIPLES OF RADIATION ONCOLOGY TRAINING AND MANPOWER REQUIREMENTS IN CANADA B. J. CUMMINGS, MB, CHB, FRCPC,
FRCR,
Department of Radiation Oncology, The Princess Margaret Hospital, 500 Sherbourne INTRODUCTION
FRACR St., Toronto,
Ontario
M4X I K9, Canada
Association of Radiologists. The Association has the general objects of providing a national organization of radiation oncologists to promote the interests of Radiation Oncology in Canada and to represent the specialty to governments, RCPSC, and other national and international societies.
Organization of radiation oncology in Canada The two national organizations responsible for the general and educational objectives of the specialty of Radiation Oncology in Canada are the Canadian Association of Radiation Oncologists (CARO) and the Royal College of Physicians and Surgeons of Canada (RCPSC). The Royal College has as its primary function the definition of criteria for the designation of medical specialties, and the establishment and monitoring of the educational objectives leading to the certification and accreditation of medical specialists in Canada (except for Family Practice which has its own College, and in the Province of Quebec which has its own certifying body). The Royal College is not a licensing authority, but certification by RCPSC is a requirement for registration as a medical specialist in most provinces in Canada. The Royal College determines general requirements for educational programs and appoints a committee to represent each specialty. The Specialty Committee, which is made up of members of that specialty and may include representatives of closely related specialties, recommends to RCPSC the specific requirements for the accreditation of training programs in that specialty, the specific training requirements for residents, and nominates examiners. Successful completion of the training and examination requirements leads to certification in the specialty, and certificants may apply for Fellowship in the College. Therapeutic Radiology was first recognized as a specialty by RCPSC Council in 1937 and the first examinations were conducted in 1946. The name of the specialty was changed to Radiation Oncology in 1976. The national specialty organization is the Canadian Association of Radiation Oncologists. This Association was incorporated in 1988, radiation oncologists having previously been represented by a division of the Canadian
Specialty training requirements The detailed objectives established by RCPSC for the training of radiation oncologists are set out below (5), and supplement general requirements which relate to all specialties (4). General objectives. The specialist in Radiation Oncology must possess clinical competence in oncology and technical proficiency in the therapeutic uses of radiation. The radiation oncologist must have a sound background in the sciences basic to the understanding of malignant disease and its treatment by radiation therapy and other modalities. The acquisition of clinical skills in patient assessment and management, developed by undertaking responsibility for the care of both hospitalized and ambulatory patients, must be accompanied by proficiency in planning and executing radiation treatments using external beams, intracavitary and interstitial radioactive sources, and radionuclides. Spec$c objectives. On completion of the training program, each resident will demonstrate, with respect to patients of all age groups:
Chairman, Specialty Committee in Radiation Oncology, Royal College of Physicians and Surgeons of Canada, 19871992; President, Canadian Association of Radiation Oncologists,
1989-199 1; Chief, Department of Radiation Princess Margaret Hospital, Toronto. Accepted for publication I5 June 1992.
DISCUSSION
1. Knowledge. A comprehensive knowledge of: (a) The natural history of the full range of malignant diseases, including the pathology of such diseases; (b) The natural history and pathology of those benign conditions which may be treated by radiation; (c) The indications for, and complications of, the various modalities em-
833
Oncology,
The
834
I. J. Radiation Oncology 0 Biology 0 Physics
ployed, alone or in combination, in the management of patients suffering from malignant diseases, including a recognition of the curative and palliative achievements of specific treatment modalities such as surgery, radiation therapy, cytotoxic chemotherapy, hormone therapy, immunotherapy, and such other modalities as may be used to treat patients with malignant tumors; (d) Radiation physics; (e) Radiobiology; (f) The gross and histopathological changes caused in normal tissues by radiation; (g) The results of various treatment methods, including the interpretation of clinical trials and statistical analyses; (h) The medical-legal and ethical aspects of radiation oncology. 2. Clinical skills. The capability of independent care of ambulatory and hospitalized patients in all aspects of radiation oncology, including investigation, diagnosis, treatment planning, supervision of radiation therapy, and the ongoing care of patients who have received radiation therapy and/or other treatment for malignant disease. These skills will include the recognition and treatment of oncologic emergencies. 3. Technical skills. Competence in the planning and execution of radiation therapy. This will include knowledge of relevant clinical examination and imaging techniques to acquire information on the extent of the volume to be treated; use of treatment simulating equipment; interaction with physics and radiation therapy planning personnel; familiarity with the preparation and interpretation of radiation treatment plans; familiarity with all common types of external beam radiation equipment, familiarity with techniques of intracavitary and interstitial radiation therapy; knowledge of the therapeutic uses of unsealed radioisotopes. 4. Other skills. The ability to communicate effectively with the patient and family, and to recognize their additional needs beyond those related directly to radiation therapy; The ability to communicate clearly with other members of the health-care team for each patient; An understanding and acceptance of the obligation of continuing self-education in radiation oncology and in all relevant associated disciplines. Length of training In general a minimum post-graduate medical education of 5 years is required. The program is intended to ensure adequate experience in general medical care, together with a minimum of 33 months training directly under the supervision of radiation oncologists. There is an opportunity to obtain experience in related specialties and in research. However, subspecialization in any area of radiation oncology practice, or more extended periods in laboratory research, are undertaken outside the residency training period. The most common training pathway is shown below. Internship. An approved clinical internship of at least 1 year’s duration in addition to 4 years of specialty training.
Volume 24, Number 5, 1992
Specialty training requirements. Four years of approved training. The various elements may be undertaken in any sequence. This period must include: (a) Three years of approved resident training in radiation oncology, which may include up to 3 months in chemotherapy and/or hematology; (b) One year, which will include: six months of approved resident training in internal medicine, and either six months of approved resident training in internal medicine or general surgery or pediatrics or gynecology or medical oncology/hematology, or six months of approved training in clinical or basic science or research activities relevant to the objectives of the specialty and acceptable to the director of the training program and to the Royal College, at a hospital or university center in Canada or abroad. An overall minimal training of 5 years duration (internship plus 4 years specialty training) is considered necessary for most candidates. In general, oncology is not well taught at undergraduate level, and radiation oncology is often not taught at all, so that in contrast to many specialties, a resident has only a limited knowledge base at the time of entry to training. Part of the training period is spent developing essential general medical skills, and learning the principles of important disciplines related to oncology. It is considered that at least 33 months training in radiation therapy and related skills under the direction of radiation oncologists are required to familiarize the trainee with the indications for, and contra-indications to, radiation treatment and with treatment techniques, and to allow the development of graded responsibility. The program is not intended to produce academic faculty or clinician-scientists, but does help to identify those who wish to follow such career pathways. Resident evaluation The performance of each resident is evaluated periodically by the training center faculty and Program Director. The latter is required to communicate the results of these evaluations to the resident regularly and to submit a written report to RCPSC near the completion of the resident’s training, indicating that the trainee has reached a satisfactory level of competence and knowledge. The RCPSC examinations are held in the final month of residency training. Since June 199 1 the examinations have a condensed format, with the written, clinical and oral components being conducted within a 1 week period. Success in the written component is no longer a prerequisite to proceed to the oral and clinical examination. A composite mark is determined for all sections of the examinations and partial passes are not awarded. The written examinations consist of three 3 hr papers entitled The Principles and Practice of Radiation Therapy, General Oncology, and Basic Sciences as Applied to Radiation Therapy. An essay and short answer (not multiple choice) format is used. It is considered that the essay format best allows demonstration by a candidate of ability to synthesize data from various sources, and examination of the
Canadian radiation oncology requirements 0 B. J. CUMMINGS
many areas of oncology on which opinions differ. The oral and clinical section includes examination of a patient, a requirement to demonstrate physical findings on that patient, and a 1 hr oral examination in which questions are directed to the broad fields of radiation oncology and general oncology. There is also a 1 hr oral examination on the clinical application of basic sciences relating to radiation oncology. Approximately 15 to 20 candidates take the examinations each year and the pass rate averages 80%. Manpowu
In 1987- 1988 the National Specialty Physician Review was conducted by RCPSC in cooperation with the Canadian Medical Association and the National Specialty Societies with the objectives of validating a data bank which could become the base reference for manpower planning, and of reviewing the recommended physician requirements for the base year ( 1986) for each discipline. The submission by CAR0 to the National Specialty Physician Review included recommendations similar to those used by national groups in several other countries (1, 3) and confirmed the shortages described in a previous detailed review of manpower in Radiation Oncology in Canada (2). The submission was based on a model which related the number of radiation oncologists required to the number of patients estimated to need radiation therapy and to recommended physician workload levels as described below. Such a model can be derived more readily for Radiation Oncology than for some other medical spe-
835
cialties, since practice patterns can be established, and the incidence of the diseases to be treated is relatively wellknown and predictable. CAR0 recommended that, given the nature of radiation oncology practice in Canada, appropriate standards of care in clinical service would be achieved if each radiation oncologist treated 200 new patients per year. It was recommended that manpower planning should also be based on an assumption that in the year 2000 45% of invasive cancer cases would be treated by radiation therapy. Data for the proportion of cancer cases currently treated by radiation therapy are not available for Canada as a whole, but in Ontario, one of the largest provinces, the proportion was only 35% in 1984-86, and had fallen steadily from 45% in 197 1, in large part due to shortages of professional staff and insufficient equipment. There were 192 radiation oncologists in practice in Canada (population 26.9 million) in July 199 1, a shortfall of about 90 based on the professional case-load and radiation therapy utilization assumptions given above. It was calculated that with the increase in population, aging of the population, and changes in the risk of cancer anticipated over the next decade, 380 radiation oncologists would be required in the year 2000, according to the assumptions used previously. This estimate did not include any allowance for teaching and research activities. In July 199 1 there were seven fellows and 86 residents in training. This is insufficient to meet current and anticipated needs. In Canada, Radiation Oncology is a specialty which offers many opportunities for prospective trainees.
REFERENCES I. Cleton, F. J.: Coebergh, J. W. W., eds. for the Steering Committee on Future Health Scenarios. Cancer in the Netherlands. Dordrecht, The Netherlands. Kluwer Academic Publishers: 1988. 2. Froud, P. J. Radiation oncology in Canada: The increasing manpower crisis. Can. Med. ASSOC.J. 132:35 l-356; 1985. 3. Inter-Society Council for Radiation Oncology. Radiation
oncology in integrated cancer management. Report to the Director of the National Cancer Institute. Washington, 1986. 4. Royal College of Physicians and Surgeons of Canada. Genera1 information and regulations on training requirements and certification examinations; 1990. 5. Royal College of Physicians and Surgeons of Canada. Specialty training requirements in radiation oncology; 1989.
Inr J Radiul,on Onn~lo~v Biol Vol. 24. pp. 833-835 Pnntcd I” the US A. All nghts reserved.
CopyrIght
l~3htl-3olh/Y? $5.00 + .oo Cc 1992 Prrgamon Press Ltd
0 Special Feature
PRINCIPLES OF RADIATION ONCOLOGY TRAINING AND MANPOWER REQUIREMENTS IN CANADA B. J. CUMMINGS, MB, CHB, FRCPC,
FRCR,
Department of Radiation Oncology, The Princess Margaret Hospital, 500 Sherbourne INTRODUCTION
FRACR St., Toronto,
Ontario
M4X I K9, Canada
Association of Radiologists. The Association has the general objects of providing a national organization of radiation oncologists to promote the interests of Radiation Oncology in Canada and to represent the specialty to governments, RCPSC, and other national and international societies.
Organization of radiation oncology in Canada The two national organizations responsible for the general and educational objectives of the specialty of Radiation Oncology in Canada are the Canadian Association of Radiation Oncologists (CARO) and the Royal College of Physicians and Surgeons of Canada (RCPSC). The Royal College has as its primary function the definition of criteria for the designation of medical specialties, and the establishment and monitoring of the educational objectives leading to the certification and accreditation of medical specialists in Canada (except for Family Practice which has its own College, and in the Province of Quebec which has its own certifying body). The Royal College is not a licensing authority, but certification by RCPSC is a requirement for registration as a medical specialist in most provinces in Canada. The Royal College determines general requirements for educational programs and appoints a committee to represent each specialty. The Specialty Committee, which is made up of members of that specialty and may include representatives of closely related specialties, recommends to RCPSC the specific requirements for the accreditation of training programs in that specialty, the specific training requirements for residents, and nominates examiners. Successful completion of the training and examination requirements leads to certification in the specialty, and certificants may apply for Fellowship in the College. Therapeutic Radiology was first recognized as a specialty by RCPSC Council in 1937 and the first examinations were conducted in 1946. The name of the specialty was changed to Radiation Oncology in 1976. The national specialty organization is the Canadian Association of Radiation Oncologists. This Association was incorporated in 1988, radiation oncologists having previously been represented by a division of the Canadian
Specialty training requirements The detailed objectives established by RCPSC for the training of radiation oncologists are set out below (5), and supplement general requirements which relate to all specialties (4). General objectives. The specialist in Radiation Oncology must possess clinical competence in oncology and technical proficiency in the therapeutic uses of radiation. The radiation oncologist must have a sound background in the sciences basic to the understanding of malignant disease and its treatment by radiation therapy and other modalities. The acquisition of clinical skills in patient assessment and management, developed by undertaking responsibility for the care of both hospitalized and ambulatory patients, must be accompanied by proficiency in planning and executing radiation treatments using external beams, intracavitary and interstitial radioactive sources, and radionuclides. Spec$c objectives. On completion of the training program, each resident will demonstrate, with respect to patients of all age groups:
Chairman, Specialty Committee in Radiation Oncology, Royal College of Physicians and Surgeons of Canada, 19871992; President, Canadian Association of Radiation Oncologists,
1989-199 1; Chief, Department of Radiation Princess Margaret Hospital, Toronto. Accepted for publication I5 June 1992.
DISCUSSION
1. Knowledge. A comprehensive knowledge of: (a) The natural history of the full range of malignant diseases, including the pathology of such diseases; (b) The natural history and pathology of those benign conditions which may be treated by radiation; (c) The indications for, and complications of, the various modalities em-
833
Oncology,
The
834
I. J. Radiation Oncology 0 Biology 0 Physics
ployed, alone or in combination, in the management of patients suffering from malignant diseases, including a recognition of the curative and palliative achievements of specific treatment modalities such as surgery, radiation therapy, cytotoxic chemotherapy, hormone therapy, immunotherapy, and such other modalities as may be used to treat patients with malignant tumors; (d) Radiation physics; (e) Radiobiology; (f) The gross and histopathological changes caused in normal tissues by radiation; (g) The results of various treatment methods, including the interpretation of clinical trials and statistical analyses; (h) The medical-legal and ethical aspects of radiation oncology. 2. Clinical skills. The capability of independent care of ambulatory and hospitalized patients in all aspects of radiation oncology, including investigation, diagnosis, treatment planning, supervision of radiation therapy, and the ongoing care of patients who have received radiation therapy and/or other treatment for malignant disease. These skills will include the recognition and treatment of oncologic emergencies. 3. Technical skills. Competence in the planning and execution of radiation therapy. This will include knowledge of relevant clinical examination and imaging techniques to acquire information on the extent of the volume to be treated; use of treatment simulating equipment; interaction with physics and radiation therapy planning personnel; familiarity with the preparation and interpretation of radiation treatment plans; familiarity with all common types of external beam radiation equipment, familiarity with techniques of intracavitary and interstitial radiation therapy; knowledge of the therapeutic uses of unsealed radioisotopes. 4. Other skills. The ability to communicate effectively with the patient and family, and to recognize their additional needs beyond those related directly to radiation therapy; The ability to communicate clearly with other members of the health-care team for each patient; An understanding and acceptance of the obligation of continuing self-education in radiation oncology and in all relevant associated disciplines. Length of training In general a minimum post-graduate medical education of 5 years is required. The program is intended to ensure adequate experience in general medical care, together with a minimum of 33 months training directly under the supervision of radiation oncologists. There is an opportunity to obtain experience in related specialties and in research. However, subspecialization in any area of radiation oncology practice, or more extended periods in laboratory research, are undertaken outside the residency training period. The most common training pathway is shown below. Internship. An approved clinical internship of at least 1 year’s duration in addition to 4 years of specialty training.
Volume 24, Number 5, 1992
Specialty training requirements. Four years of approved training. The various elements may be undertaken in any sequence. This period must include: (a) Three years of approved resident training in radiation oncology, which may include up to 3 months in chemotherapy and/or hematology; (b) One year, which will include: six months of approved resident training in internal medicine, and either six months of approved resident training in internal medicine or general surgery or pediatrics or gynecology or medical oncology/hematology, or six months of approved training in clinical or basic science or research activities relevant to the objectives of the specialty and acceptable to the director of the training program and to the Royal College, at a hospital or university center in Canada or abroad. An overall minimal training of 5 years duration (internship plus 4 years specialty training) is considered necessary for most candidates. In general, oncology is not well taught at undergraduate level, and radiation oncology is often not taught at all, so that in contrast to many specialties, a resident has only a limited knowledge base at the time of entry to training. Part of the training period is spent developing essential general medical skills, and learning the principles of important disciplines related to oncology. It is considered that at least 33 months training in radiation therapy and related skills under the direction of radiation oncologists are required to familiarize the trainee with the indications for, and contra-indications to, radiation treatment and with treatment techniques, and to allow the development of graded responsibility. The program is not intended to produce academic faculty or clinician-scientists, but does help to identify those who wish to follow such career pathways. Resident evaluation The performance of each resident is evaluated periodically by the training center faculty and Program Director. The latter is required to communicate the results of these evaluations to the resident regularly and to submit a written report to RCPSC near the completion of the resident’s training, indicating that the trainee has reached a satisfactory level of competence and knowledge. The RCPSC examinations are held in the final month of residency training. Since June 199 1 the examinations have a condensed format, with the written, clinical and oral components being conducted within a 1 week period. Success in the written component is no longer a prerequisite to proceed to the oral and clinical examination. A composite mark is determined for all sections of the examinations and partial passes are not awarded. The written examinations consist of three 3 hr papers entitled The Principles and Practice of Radiation Therapy, General Oncology, and Basic Sciences as Applied to Radiation Therapy. An essay and short answer (not multiple choice) format is used. It is considered that the essay format best allows demonstration by a candidate of ability to synthesize data from various sources, and examination of the
Canadian radiation oncology requirements 0 B. J. CUMMINGS
many areas of oncology on which opinions differ. The oral and clinical section includes examination of a patient, a requirement to demonstrate physical findings on that patient, and a 1 hr oral examination in which questions are directed to the broad fields of radiation oncology and general oncology. There is also a 1 hr oral examination on the clinical application of basic sciences relating to radiation oncology. Approximately 15 to 20 candidates take the examinations each year and the pass rate averages 80%. Manpowu
In 1987- 1988 the National Specialty Physician Review was conducted by RCPSC in cooperation with the Canadian Medical Association and the National Specialty Societies with the objectives of validating a data bank which could become the base reference for manpower planning, and of reviewing the recommended physician requirements for the base year ( 1986) for each discipline. The submission by CAR0 to the National Specialty Physician Review included recommendations similar to those used by national groups in several other countries (1, 3) and confirmed the shortages described in a previous detailed review of manpower in Radiation Oncology in Canada (2). The submission was based on a model which related the number of radiation oncologists required to the number of patients estimated to need radiation therapy and to recommended physician workload levels as described below. Such a model can be derived more readily for Radiation Oncology than for some other medical spe-
835
cialties, since practice patterns can be established, and the incidence of the diseases to be treated is relatively wellknown and predictable. CAR0 recommended that, given the nature of radiation oncology practice in Canada, appropriate standards of care in clinical service would be achieved if each radiation oncologist treated 200 new patients per year. It was recommended that manpower planning should also be based on an assumption that in the year 2000 45% of invasive cancer cases would be treated by radiation therapy. Data for the proportion of cancer cases currently treated by radiation therapy are not available for Canada as a whole, but in Ontario, one of the largest provinces, the proportion was only 35% in 1984-86, and had fallen steadily from 45% in 197 1, in large part due to shortages of professional staff and insufficient equipment. There were 192 radiation oncologists in practice in Canada (population 26.9 million) in July 199 1, a shortfall of about 90 based on the professional case-load and radiation therapy utilization assumptions given above. It was calculated that with the increase in population, aging of the population, and changes in the risk of cancer anticipated over the next decade, 380 radiation oncologists would be required in the year 2000, according to the assumptions used previously. This estimate did not include any allowance for teaching and research activities. In July 199 1 there were seven fellows and 86 residents in training. This is insufficient to meet current and anticipated needs. In Canada, Radiation Oncology is a specialty which offers many opportunities for prospective trainees.
REFERENCES I. Cleton, F. J.: Coebergh, J. W. W., eds. for the Steering Committee on Future Health Scenarios. Cancer in the Netherlands. Dordrecht, The Netherlands. Kluwer Academic Publishers: 1988. 2. Froud, P. J. Radiation oncology in Canada: The increasing manpower crisis. Can. Med. ASSOC.J. 132:35 l-356; 1985. 3. Inter-Society Council for Radiation Oncology. Radiation
oncology in integrated cancer management. Report to the Director of the National Cancer Institute. Washington, 1986. 4. Royal College of Physicians and Surgeons of Canada. Genera1 information and regulations on training requirements and certification examinations; 1990. 5. Royal College of Physicians and Surgeons of Canada. Specialty training requirements in radiation oncology; 1989.
