International Journal of
Radiation Oncology biology
physics
www.redjournal.org
EDITORIAL
Image Guided Radiation Therapy: Really? Paul E. Wallner, DO, FACR, FASTRO,* and Dennis C. Shrieve, MD, PhD, FACR, FASTROy *21st Century Oncology, Inc, Bethesda, Maryland, and the American Board of Radiology, and yDepartment of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah Received Dec 7, 2014, and in revised form Dec 10, 2014. Accepted for publication Dec 10, 2014.
In this issue of the journal, Palma et al (1) describe in meticulous detail a Canadian-developed integrated training program designed to increase radiation oncology residents’ knowledge and skills in anatomy, radiology, and contouring. The authors’ initial hypothesis was that training to recognize normal and abnormal radiographic anatomy and contouring was suboptimal and significantly heterogeneous across training programs and that a centralized, intensive instruction experience might improve that problem. Preprogram and postprogram assessment did demonstrate a significant improvement in all metrics, but clearly, as noted by the authors, the brief follow-up interval does not permit assessment of the long-term impact on either performance in standardized testing such as the initial certification examinations of the American Board of Radiology (ABR) or the Royal College of Physicians and Surgeons of Canada (RCPSC) or, more importantly, on the quality of care in actual clinical practice. As interesting as we find the project and its conclusions, in our estimation there is an underlying question of even greater significance: In this era of image guided radiation therapy (IGRT), where we often use smaller fields with tighter margins, and shorter courses of treatment with higher daily dose fractions, are we training physicians with sufficient imaging knowledge and skills to optimally meet the daily clinical needs they will encounter? To answer this basic question, it is first essential that we examine the underlying education and exposure to imaging modalities received by undergraduate medical students
before they enter residency training and by residents in radiation oncology during their postgraduate programs. The American College of Radiology (ACR) and the Alliance of Medical Student Educators in Radiology (AMSER) (2, 3) have carried out several surveys to establish benchmarks for the exposure of medical students to imaging education and the quality of that experience. The conclusions of these surveys are generally not encouraging, in that the majority of medical schools did not require radiology rotations, much of the teaching of imaging was carried out by nonradiologists on clinical rotations, often in informal settings, and no standardized curriculum existed for medical student imaging education. The ACR and AMSER, along with individual schools of medicine, have also made a series of recommendations to correct these concerns and have developed proposals for standardized medical student curricula and testing (4-6). As is often the case, these recommendations faced pushback because of perceived time and cost constraints at the medical school level. In this regard, although not specifically addressed by the ACR/ AMSER initiatives, we are concerned that lack of sufficient imaging education poorly prepares students to be appropriate requesters of imaging services and interpreters of imaging reports as they enter the medical workplace. When young physicians enter radiation oncology training programs, their exposure to imaging education remains heterogeneousda problem that may be exacerbated by the small size of the majority of our training programs. Guided
Reprint requests to: Dr Paul E. Wallner, DO, FACR, FASTRO, 5013 Cedar Croft Lane, Bethesda, MD 20814. Tel: (239) 910-0056; E-mail: [email protected] Conflict of interest: Neither author declares any conflicts. Dr Shrieve serves as a trustee of the American Board of Radiology (ABR) and a member of the Accreditation Council for Graduate Medical Education
(ACGME) Radiation Oncology Residency Review Committee (RO RRC). Dr Wallner serves as Associate Executive Director for Radiation Oncology of The American Board of Radiology and as an ex officio member of the RO RRC. The opinions expressed in this editorial represent the views of the authors and are not the official positions of the ABR, the ACGME, or the RO RRC.
Int J Radiation Oncol Biol Phys, Vol. 91, No. 4, pp. 708e709, 2015 0360-3016/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ijrobp.2014.12.024
Volume 91 Number 4 2015
by the ACGME Program Requirements for Graduate Medical Education in Radiation Oncology, these requirements include “The program must educate resident physicians in adult medical oncology, pediatric medical oncology, oncologic pathology, and diagnostic imaging in a way that is applicable to the practice of radiation oncology,” but then proceed to indicate that “there are multiple ways to meet this requirement,” including “attendance at conferences.” In addition, the requirements include this: “provide a 2-month rotation in medical oncology to include adult and pediatric patients, as well as a 1-month rotation in both oncologic pathology and diagnostic imaging, or document attendance at regularly scheduled conferences” (7). Multidisciplinary conferences are often oriented to specific cases rather than dedicated to the unique needs of trainees, they may entirely overlook various organs and systems, and they may include a variety of nononcologic topics of uncertain relevance to our trainees. Regrettably, the “Competencies” required for satisfactory completion of radiation oncology training programs, effective on July 1, 2014, remain equally vague regarding imaging knowledge and skills (8). Informal communications with current trainees at a variety of academic centers further define the heterogeneity of imaging training. Some programs have didactic sessions in oncologic imaging and others do not; some programs encourage elective rotations in oncologic imaging, but the relative lack of time for electives apparently disincentivizes trainees from availing themselves of those opportunities; some service-oriented attending radiation oncologists have the time, interest, and knowledge to effectively teach residents the essential anatomy and imaging skills, and others do not (9). Beginning in the 1960s, our colleagues in diagnostic radiology recognized the value of an intensive, centralized educational experience for their trainees, despite their generally larger size and directed training focus. The Armed Forces Institute of Pathology (AFIP) course in radiologic pathology correlation, which was initially created to support military medicine, was opened to civilian trainees in 1961 with 3month courses. During subsequent decades, the program was shortened to 4 weeks and has been an integral part of diagnostic radiology training for more than 20,000 trainees. With reduced Pentagon budgets, the AFIP program was discontinued in 2010, but in recognition of the critical nature of the centralized program to diagnostic radiology training, the courses were revived by the American Institute for Radiologic Pathology (AIRP) of the ACR in 2011 (10, 11). Our concerns are not based on any sense of educational or intellectual elitism, suggesting that larger programs are training our future colleagues better than smaller programs or that our trainees are generally poorly grounded in imaging knowledge and skills. Instead, we have had an opportunity to directly observe the actual knowledge of residents at the completion of training, during the ABR certifying (oral) examinations. At that time, we find not only that there remains a distressingly heterogeneous level of knowledge, but at one extreme, that trainees are sometimes unable to identify normal radiographic anatomy or define appropriate
Image guided radiation therapy
709
targets for contouring (12). Admittedly, as with Palma et al (1), we are unable to demonstrate the impact of these observations on the subsequent practice of radiation oncology, but intuitively we remain concerned. Perhaps we have reached a time for consideration of more stringent imaging training requirements and possibly a centralized program of intensive imaging, anatomy, and contouring exposure similar to that described by Palma et al (1) and provided initially by the AFIP and now by the AIRP. The ABR scope of responsibilities does not extend to these areas of training, but for its part, it has indicated clearly that going forward, the identification of normal radiographic anatomy, margins of pathology, interfaces between normal and pathologic anatomy, and contouring will have an increased emphasis in its qualifying (written) and certifying examinations in radiation oncology and also on the Maintenance of Certification (MOC) Part III examination (12, 13). Increasing reliance on a wider range of imaging modalities to design optimized treatment plans for radiation oncology interventions such as intensity modulated radiation therapy, stereotactic radiosurgery and stereotactic body radiation therapy, and particle beam radiation therapy, and to verify daily treatment setups (IGRT) requires sophisticated knowledge of radiographic anatomy. The study by Palma et al (1) suggests that some of our training programs may not be adequately preparing residents in this area. The field of radiation oncology has its roots in diagnostic radiology, and the ability to define anatomy on a variety of imaging modalities must remain an integral component of training.
References 1. Jaswal J, D’Souza L, Johnson M, et al. Evaluating the impact of a Canadian National Anatomy and Radiology Contouring boot camp for radiation oncology residents. Int J Radiat Oncol Biol Phys 2015;91:701-707. 2. Straus CM, Webb EM, Kondo KL, et al. Medical student radiology education: Summary and recommendations from a national survey of medical school and radiology department leaders. J Am Coll Radiol 2014;11:606-610. 3. Straus CM, AMSER. Personal communication. Nov. 28, 2014. 4. http://www.med-u.org/core. Accessed Nov. 30, 2014. 5. https://www.aur.org/Secondary-Alliances.aspx?idZ139. Accessed Nov. 30, 2014. 6. Brooks WS, Woodley KT, Jackson JR. Integration of gross anatomy in an organ system-based medical curriculum: Strategies and challenges. Anat Sci Educ. 2014 Aug 6; Available at: http://dx.doi.org/10.1002/ ase.1483 [Epub ahead of print]. 7. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequire ments/430_radiation_oncology_07012014.pdf. Accessed Nov. 13, 2014. 8. https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramResour ces/430_CompetencyDefinitions_RO_ED_10182007.pdf. Accessed Dec. 2, 2014. 9. ARRO members. Personal communications. November-December, 2014. 10. Murphey MD, Madewell JE, Olmsted WW, et al. A history of radiologic pathology correlation at the Armed Forces Institute of Pathology and its evolution into the American Institute for Radiologic Pathology. Radiology 2012;262:623-634. 11. http://airp.org/about-us. Accessed Nov. 28, 2014. 12. American Board of Radiology. Personal communications. Nov. 15, 2014. 13. http://www.theabr.org/sites/all/themes/abr-media/pdf/Annual_Report_ 2012-2013.pdf. Accessed Dec. 2, 2014.
Radiation Oncology biology
physics
www.redjournal.org
EDITORIAL
Image Guided Radiation Therapy: Really? Paul E. Wallner, DO, FACR, FASTRO,* and Dennis C. Shrieve, MD, PhD, FACR, FASTROy *21st Century Oncology, Inc, Bethesda, Maryland, and the American Board of Radiology, and yDepartment of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah Received Dec 7, 2014, and in revised form Dec 10, 2014. Accepted for publication Dec 10, 2014.
In this issue of the journal, Palma et al (1) describe in meticulous detail a Canadian-developed integrated training program designed to increase radiation oncology residents’ knowledge and skills in anatomy, radiology, and contouring. The authors’ initial hypothesis was that training to recognize normal and abnormal radiographic anatomy and contouring was suboptimal and significantly heterogeneous across training programs and that a centralized, intensive instruction experience might improve that problem. Preprogram and postprogram assessment did demonstrate a significant improvement in all metrics, but clearly, as noted by the authors, the brief follow-up interval does not permit assessment of the long-term impact on either performance in standardized testing such as the initial certification examinations of the American Board of Radiology (ABR) or the Royal College of Physicians and Surgeons of Canada (RCPSC) or, more importantly, on the quality of care in actual clinical practice. As interesting as we find the project and its conclusions, in our estimation there is an underlying question of even greater significance: In this era of image guided radiation therapy (IGRT), where we often use smaller fields with tighter margins, and shorter courses of treatment with higher daily dose fractions, are we training physicians with sufficient imaging knowledge and skills to optimally meet the daily clinical needs they will encounter? To answer this basic question, it is first essential that we examine the underlying education and exposure to imaging modalities received by undergraduate medical students
before they enter residency training and by residents in radiation oncology during their postgraduate programs. The American College of Radiology (ACR) and the Alliance of Medical Student Educators in Radiology (AMSER) (2, 3) have carried out several surveys to establish benchmarks for the exposure of medical students to imaging education and the quality of that experience. The conclusions of these surveys are generally not encouraging, in that the majority of medical schools did not require radiology rotations, much of the teaching of imaging was carried out by nonradiologists on clinical rotations, often in informal settings, and no standardized curriculum existed for medical student imaging education. The ACR and AMSER, along with individual schools of medicine, have also made a series of recommendations to correct these concerns and have developed proposals for standardized medical student curricula and testing (4-6). As is often the case, these recommendations faced pushback because of perceived time and cost constraints at the medical school level. In this regard, although not specifically addressed by the ACR/ AMSER initiatives, we are concerned that lack of sufficient imaging education poorly prepares students to be appropriate requesters of imaging services and interpreters of imaging reports as they enter the medical workplace. When young physicians enter radiation oncology training programs, their exposure to imaging education remains heterogeneousda problem that may be exacerbated by the small size of the majority of our training programs. Guided
Reprint requests to: Dr Paul E. Wallner, DO, FACR, FASTRO, 5013 Cedar Croft Lane, Bethesda, MD 20814. Tel: (239) 910-0056; E-mail: [email protected] Conflict of interest: Neither author declares any conflicts. Dr Shrieve serves as a trustee of the American Board of Radiology (ABR) and a member of the Accreditation Council for Graduate Medical Education
(ACGME) Radiation Oncology Residency Review Committee (RO RRC). Dr Wallner serves as Associate Executive Director for Radiation Oncology of The American Board of Radiology and as an ex officio member of the RO RRC. The opinions expressed in this editorial represent the views of the authors and are not the official positions of the ABR, the ACGME, or the RO RRC.
Int J Radiation Oncol Biol Phys, Vol. 91, No. 4, pp. 708e709, 2015 0360-3016/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ijrobp.2014.12.024
Volume 91 Number 4 2015
by the ACGME Program Requirements for Graduate Medical Education in Radiation Oncology, these requirements include “The program must educate resident physicians in adult medical oncology, pediatric medical oncology, oncologic pathology, and diagnostic imaging in a way that is applicable to the practice of radiation oncology,” but then proceed to indicate that “there are multiple ways to meet this requirement,” including “attendance at conferences.” In addition, the requirements include this: “provide a 2-month rotation in medical oncology to include adult and pediatric patients, as well as a 1-month rotation in both oncologic pathology and diagnostic imaging, or document attendance at regularly scheduled conferences” (7). Multidisciplinary conferences are often oriented to specific cases rather than dedicated to the unique needs of trainees, they may entirely overlook various organs and systems, and they may include a variety of nononcologic topics of uncertain relevance to our trainees. Regrettably, the “Competencies” required for satisfactory completion of radiation oncology training programs, effective on July 1, 2014, remain equally vague regarding imaging knowledge and skills (8). Informal communications with current trainees at a variety of academic centers further define the heterogeneity of imaging training. Some programs have didactic sessions in oncologic imaging and others do not; some programs encourage elective rotations in oncologic imaging, but the relative lack of time for electives apparently disincentivizes trainees from availing themselves of those opportunities; some service-oriented attending radiation oncologists have the time, interest, and knowledge to effectively teach residents the essential anatomy and imaging skills, and others do not (9). Beginning in the 1960s, our colleagues in diagnostic radiology recognized the value of an intensive, centralized educational experience for their trainees, despite their generally larger size and directed training focus. The Armed Forces Institute of Pathology (AFIP) course in radiologic pathology correlation, which was initially created to support military medicine, was opened to civilian trainees in 1961 with 3month courses. During subsequent decades, the program was shortened to 4 weeks and has been an integral part of diagnostic radiology training for more than 20,000 trainees. With reduced Pentagon budgets, the AFIP program was discontinued in 2010, but in recognition of the critical nature of the centralized program to diagnostic radiology training, the courses were revived by the American Institute for Radiologic Pathology (AIRP) of the ACR in 2011 (10, 11). Our concerns are not based on any sense of educational or intellectual elitism, suggesting that larger programs are training our future colleagues better than smaller programs or that our trainees are generally poorly grounded in imaging knowledge and skills. Instead, we have had an opportunity to directly observe the actual knowledge of residents at the completion of training, during the ABR certifying (oral) examinations. At that time, we find not only that there remains a distressingly heterogeneous level of knowledge, but at one extreme, that trainees are sometimes unable to identify normal radiographic anatomy or define appropriate
Image guided radiation therapy
709
targets for contouring (12). Admittedly, as with Palma et al (1), we are unable to demonstrate the impact of these observations on the subsequent practice of radiation oncology, but intuitively we remain concerned. Perhaps we have reached a time for consideration of more stringent imaging training requirements and possibly a centralized program of intensive imaging, anatomy, and contouring exposure similar to that described by Palma et al (1) and provided initially by the AFIP and now by the AIRP. The ABR scope of responsibilities does not extend to these areas of training, but for its part, it has indicated clearly that going forward, the identification of normal radiographic anatomy, margins of pathology, interfaces between normal and pathologic anatomy, and contouring will have an increased emphasis in its qualifying (written) and certifying examinations in radiation oncology and also on the Maintenance of Certification (MOC) Part III examination (12, 13). Increasing reliance on a wider range of imaging modalities to design optimized treatment plans for radiation oncology interventions such as intensity modulated radiation therapy, stereotactic radiosurgery and stereotactic body radiation therapy, and particle beam radiation therapy, and to verify daily treatment setups (IGRT) requires sophisticated knowledge of radiographic anatomy. The study by Palma et al (1) suggests that some of our training programs may not be adequately preparing residents in this area. The field of radiation oncology has its roots in diagnostic radiology, and the ability to define anatomy on a variety of imaging modalities must remain an integral component of training.
References 1. Jaswal J, D’Souza L, Johnson M, et al. Evaluating the impact of a Canadian National Anatomy and Radiology Contouring boot camp for radiation oncology residents. Int J Radiat Oncol Biol Phys 2015;91:701-707. 2. Straus CM, Webb EM, Kondo KL, et al. Medical student radiology education: Summary and recommendations from a national survey of medical school and radiology department leaders. J Am Coll Radiol 2014;11:606-610. 3. Straus CM, AMSER. Personal communication. Nov. 28, 2014. 4. http://www.med-u.org/core. Accessed Nov. 30, 2014. 5. https://www.aur.org/Secondary-Alliances.aspx?idZ139. Accessed Nov. 30, 2014. 6. Brooks WS, Woodley KT, Jackson JR. Integration of gross anatomy in an organ system-based medical curriculum: Strategies and challenges. Anat Sci Educ. 2014 Aug 6; Available at: http://dx.doi.org/10.1002/ ase.1483 [Epub ahead of print]. 7. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequire ments/430_radiation_oncology_07012014.pdf. Accessed Nov. 13, 2014. 8. https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramResour ces/430_CompetencyDefinitions_RO_ED_10182007.pdf. Accessed Dec. 2, 2014. 9. ARRO members. Personal communications. November-December, 2014. 10. Murphey MD, Madewell JE, Olmsted WW, et al. A history of radiologic pathology correlation at the Armed Forces Institute of Pathology and its evolution into the American Institute for Radiologic Pathology. Radiology 2012;262:623-634. 11. http://airp.org/about-us. Accessed Nov. 28, 2014. 12. American Board of Radiology. Personal communications. Nov. 15, 2014. 13. http://www.theabr.org/sites/all/themes/abr-media/pdf/Annual_Report_ 2012-2013.pdf. Accessed Dec. 2, 2014.
