Inl. J Rndiakm Onarlo~y Biol Phy.7, Vol. Printed I” the U.S.A. All rights resewed
24. PP. 8 15-8
0360-3016/92 $5.00 + .oO Copyright C 1992 Pergamon Press Ltd.
I7
??Special Feature
SPECIAL REQUIREMENTS FOR RESIDENCY TRAINING IN RADIATION ONCOLOGY JAMES
E. MARKS, M.D., JUDITH S. ARMBRUSTER, PHD., LUTHER W. BRADY, M.D., ROBERT G. PARKER, M.D. AND GERALD E. HANKS, M.D. Radiation Oncology Subcommittee of the Residency Review Committee for Radiotherapy
Radiation oncology is that branch of clinical medicine that uses ionizing radiation to treat patients with cancer and occasionally diseases other than cancer. The radiation oncologist is an integral part of the multidisciplinary management of the cancer patient and must collaborate closely with physicians in related disciplines and be familiar with their role in the management of the patient.
those who plan an academic career, an additional year of clinical or laboratory research is encouraged. Program director. The program director (a) must be a practicing radiation oncologist; (b) must be certified by the American Board of Radiology or possess equivalent qualifications; (c) must contribute sufficient time to the program to ensure adequate direction; (d) is responsible for the total training in radiation oncology which includes the instruction and supervision of residents; (e) must arrange for the provision of adequate facilities, faculty, clinical resources and educational resources, and (f) is responsible for the selection of residents and must ensure that the appointed residents meet the eligibility requirements of the Accreditation Council for Graduate Medical Education. StaJf The program must provide a minimum of three full-time+ radiation oncologists, one full-time radiation biologist or basic scientist and one full-time medical physicist for the teaching of clinical radiation oncology, radiation biology and physics. The radiation oncologists and the medical physicist should be certified by the American Board of Radiology or possess equivalent qualifications. The faculty must be engaged in scholarly activities, such as (a) participation in regional and national scientific societies; (b) participation in their own continuing education; (c) scientific publication and presentation; and (d) active involvement in research as it pertains to the specialty. The curriculum vitae of each faculty member should document his or her qualifications to teach and supervise residents in training. The faculty must be committed to the teaching of the residents and document the time and effort they devote to the educational program. A faculty which does not meet the stated qualifications or fails to devote itself to the teaching of the residents
DISCUSSION Objective of a residency training program The objective of the residency training program is to educate and train physicians to be skillful in the practice of radiation oncology. To accomplish this goal, adequate structure, facilities, faculty, patient resources and educational environment must be provided. Structure of residency program Length of training. Programs shall offer at least 3 years of graduate medical education in radiation oncology; while the program may extend the duration of training beyond 3 years, the Residency Review Committee (RRC) will accredit 3 years as a maximum. Residents shall have completed a suitable first year of postgraduate training before entering a residency program in radiation oncology. No less than 30 months of the radiation oncology program must be spent in clinical radiation therapy and it is recommended that the remaining 6 months include 2 to 3 months of medical oncology and a 2- to 3-month rotation in pathology or an equivalent lecture experience in pathology. No more than 6 months may occur in rotations to affiliated institutions outside the institution in which the program institutions united
resides or outside those participating to form an integrated program.* For
Reprint requests to J. E. Marks, Dept. of Radiotherapy, Loyola University Medical Center, 2160 South First Ave., Maywood, IL 60153. Accepted for publication 19 June 1992. * An institution is considered “integrated” when there is a written agreement between the parent institution and its program and the integrated institution specifying that the program director (a) appoints the members of the faculty and is involved in the
appointment of the chief of service at the integrated institution, (b) determines all rotations and assignments at the integrated institution, and (c) is responsible for the overall conduct of the educational program in the integrated institution. + By full-time, the Residency Review Committee intends that the individual devotes essentially all professional time to the program. 815
816
I. J. Radiation
Oncology
0 Biology 0 Physics
shall be considered unsuitable for conducting of graduate education in radiation oncology.
a program
Training content A. The program director is responsible for the structure and content of the educational program and must document that the resident has been trained in clinical radiation oncology, treatment planning, radiation physics, and radiobiology. The clinical curriculum must provide the resident with an in-depth knowledge of clinical radiation oncology, including the indications for irradiation and special therapeutic considerations unique to each site and stage of disease. The program must train the resident in standard radiation techniques, as well as the use of treatment aids and treatment planning to optimize the distribution of radiation dose. The resident must also gain a knowledge of normal tissue tolerance to radiation and tumor doseresponse. The use of combined modality therapy and unusual fractionation schemes should also be part of the clinical curriculum. The resident must be trained in the use of external beam modalities, including superficial irradiation, megavoltage irradiation (Cobalt 60, low and high energy x-rays), electron beam, simulation to localize anatomy, and computerized treatment planning. The faculty must ensure that the resident personally performs all technical procedures such as intracavitary and interstitial placement of radiation sources and that the resident keeps a detailed list of these procedures. The program director should be prepared to submit at the RRC’s request the logs of patients irradiated, procedures performed and modalities used for 3 years of clinical experience for all residents who completed training in the previous year. It is recommended that a resident perform or assist in no fewer than 10 interstitial implants and 10 intracavitary insertions during the course of training. Programs that include the therapeutic use of hyperthermia, radiolabeled antibodies, intraoperative radiotherapy, neutron beam, and other heavy particle radiotherapy must provide instruction in physics and biology as they apply to these areas of clinical treatment. B. Residents must have the opportunity to be educated in the clinical and basic sciences through regularly scheduled lectures, case presentations, conferences and discussions relevant to the practice of radiation oncology. The training program must provide curricula for the teaching of basic sciences essential to training in radiation oncology including radiation biology and medical physics. The curriculum in medical physics should include laboratory demonstrations of radiation safety procedures, calibration of radiation therapy machines, the use of the computer for treatment planning, the construction of treatment aids and the safe handling of sealed and unsealed radiation sources. It is recommended that the program also familiarize the resident with medical statistics and with pathology with special emphasis on neoplasia and radiation effects.
Volume
24, Number
5, 1992
C. The training program should provide the resident with the educational opportunity for exposure to the potential value and limitations of other oncologic disciplines such as medical oncology, surgical oncology, gynecologic oncology, pediatric oncology, and the various surgical subspecialties that play a role in the management of the patient. This will be accomplished by attendance at multidisciplinary and departmental conferences. During their training, residents will be expected to engage in an investigative project under faculty supervision. This may take the form of laboratory research, clinical research, or the retrospective analysis of data from treated patients.
Training complement The Residency Review Committee will accredit a program for a maximum number of residents commensurate with the total capacity of the program to offer an appropriate educational experience in radiation oncology. There should not be more than 1.5 residents for every staff radiation oncologist during any resident’s 30 months of training in clinical radiation therapy. If a program director wants to increase the number of residents in a program beyond the authorized number, prior approval must be obtained from the Residency Review Committee. Supervision. The faculty must supervise the resident and provide the opportunity for the resident to gradually accept more responsibility for patient care as training progresses. Duty hours. While the actual number of hours worked by residents may vary, residents should have sufficient off-duty time to avoid undue fatigue and stress. It is recommended that residents should be allowed to spend, on average, at least one full day out of seven away from the hospital, and should be assigned on-call duty in the hospital no more frequently than every third night. The program director is responsible for monitoring on-duty assignments for residents to assure adherence to this recommendation. Training evaluation. The program director is responsible for the continuing evaluation of the program and documentation of the educational progress and performance of each resident. Resident performance and progress must be documented at least twice yearly using appropriate techniques, such as written faculty appraisal, oral or written tests, or practical demonstration. The results of these evaluations must be discussed with the resident. It is the program director’s responsibility to document adequately any prior training from another institution and to counsel, censure, and after due process to dismiss residents who fail to demonstrate appropriate industry, competence, responsibility, learning abilities, and ethics. One measure of the quality of a program is the performance of its graduates on the examinations given by the American Board of Radiology. The Residency Review Committee may consider this information as part of the overall evaluation of the program.
Requirements for residency training 0 J. E. MARKSel al.
Residents who plan to seek certification by the American Board of Radiology should communicate with the Secretary of the Board regarding the full requirements for certification. Facilities. A training program in radiation oncology must have adequate space and equipment to train residents in state of the art radiation therapy. There must be access to two or more megavoltage machines, kilovoltage and/or electron beam capabilities, a dedicated therapy simulator, computerized treatment planning, a mould room and/or machine shop for the construction of treatment aids and equipment to do interstitial and intracavitary brachytherapy. Compensation for the absence of any of this equipment in the parent program must be provided by training the resident in the missing technology through a rotation to another institution.
Clinical resources The training program in radiation oncology must provide a sufficient volume and variety of cancer patients including those with pediatric, gastrointestinal, gynecologic, genitourinary tract, reticuloendothelial system, upper respiratory tract (including the head, neck and lung), breast (both primary and metastatic), central nervous system, skin, bone, and soft tissue tumors. Sufficient number of these patients should be treated by interstitial implants and intracavitary insertions to provide the resident with an adequate brachytherapy experience. Follow-up of the irradiated patient on an inpatient or outpatient basis is an essential part of resident training and must be demonstrated by the program to assure that residents have the opportunity to learn about the problems of recurrent and disseminated tumors, late aftereffects and complications of radiation therapy. To assure adequate numbers and variety of patients for resident training, it is recommended that the parent institution or integrated program treat approximately 600 patients yearly and that the number of patients irradiated by the resident each year be no fewer than 125. The residents’ experience must not be significantly diminished by the presence of other trainees, such as fellows and post-graduate trainees or residents rotating from another accredited residency program. Adequate medical support must be available in the specialties of medical oncology, surgical oncology and its subspecialties, gynecologic oncology, and pediatric oncology. There must be access to diagnostic radiology, nuclear medicine, pathology, a clinical laboratory, and a tumor registry. Institutional support. The administration of the institution(s) sponsoring the program in radiation oncology must provide funding for space, equipment, staff, non-
817
professional personnel and residents. They must assist the program director in teaching, recruiting faculty, as well as selecting, evaluating, and dismissing residents whose performance is unsatisfactory. Assurances of due process for faculty and residents must be demonstrated. Afiliation agreements. Extramural educational experience may be used to complement the training program, but the preponderance of the educational experience must take place in the parent institution. If residents are sent to an affiliated institution to obtain experience lacking in the parent institution, the program director should specify to the RRC the reason for the rotation and should document the number and types of patients available to the residents. When resources of two or more institutions are used for the clinical or basic science education of a resident in radiation oncology, a letter of agreement must be approved by the institutional governing boards. Affiliations should be avoided with institutions which do not add to the educational value of the program or which are at such a distance from the parent institution as to make resident attendance at rounds and conferences difficult. Clinical responsibility alone does not constitute a suitable educational experience. Educationul environment. The education in radiation oncology must occur in an environment that encourages exchange of knowledge and experience among residents in the program and with residents in other oncology specialties located in the same institution participating in the program. Other residency training programs, including medicine and surgery, be ongoing in the institution. Cor@rences. Conferences and teaching rounds must provide for progressive resident participation. Adequate frequency of conferences and attendance by residents, radiation oncologists, and other staff should be documented. Adequate conference room and audio-visual facilities must be provided. There must be intradepartmental clinical oncology conferences, including new patient conferences, weekly chart reviews, and problem case conferences: other conferences should include morbidity and mortality, physics, dosimetry, radiation biology, and journal review. interdepartmental clinical oncology conferences should include medical oncology, hematologic oncology, gynecologic oncology, pediatric oncology, general surgical oncology, and the oncological surgical subspecialties. Library resources. A sufficient variety of journals, reference books, and resource materials pertinent to radiation oncology and associated fields in oncology and basic sciences must be provided and be immediately accessible for resident study in a radiation oncology library. In addition, residents must have access to a general medical library.
24. PP. 8 15-8
0360-3016/92 $5.00 + .oO Copyright C 1992 Pergamon Press Ltd.
I7
??Special Feature
SPECIAL REQUIREMENTS FOR RESIDENCY TRAINING IN RADIATION ONCOLOGY JAMES
E. MARKS, M.D., JUDITH S. ARMBRUSTER, PHD., LUTHER W. BRADY, M.D., ROBERT G. PARKER, M.D. AND GERALD E. HANKS, M.D. Radiation Oncology Subcommittee of the Residency Review Committee for Radiotherapy
Radiation oncology is that branch of clinical medicine that uses ionizing radiation to treat patients with cancer and occasionally diseases other than cancer. The radiation oncologist is an integral part of the multidisciplinary management of the cancer patient and must collaborate closely with physicians in related disciplines and be familiar with their role in the management of the patient.
those who plan an academic career, an additional year of clinical or laboratory research is encouraged. Program director. The program director (a) must be a practicing radiation oncologist; (b) must be certified by the American Board of Radiology or possess equivalent qualifications; (c) must contribute sufficient time to the program to ensure adequate direction; (d) is responsible for the total training in radiation oncology which includes the instruction and supervision of residents; (e) must arrange for the provision of adequate facilities, faculty, clinical resources and educational resources, and (f) is responsible for the selection of residents and must ensure that the appointed residents meet the eligibility requirements of the Accreditation Council for Graduate Medical Education. StaJf The program must provide a minimum of three full-time+ radiation oncologists, one full-time radiation biologist or basic scientist and one full-time medical physicist for the teaching of clinical radiation oncology, radiation biology and physics. The radiation oncologists and the medical physicist should be certified by the American Board of Radiology or possess equivalent qualifications. The faculty must be engaged in scholarly activities, such as (a) participation in regional and national scientific societies; (b) participation in their own continuing education; (c) scientific publication and presentation; and (d) active involvement in research as it pertains to the specialty. The curriculum vitae of each faculty member should document his or her qualifications to teach and supervise residents in training. The faculty must be committed to the teaching of the residents and document the time and effort they devote to the educational program. A faculty which does not meet the stated qualifications or fails to devote itself to the teaching of the residents
DISCUSSION Objective of a residency training program The objective of the residency training program is to educate and train physicians to be skillful in the practice of radiation oncology. To accomplish this goal, adequate structure, facilities, faculty, patient resources and educational environment must be provided. Structure of residency program Length of training. Programs shall offer at least 3 years of graduate medical education in radiation oncology; while the program may extend the duration of training beyond 3 years, the Residency Review Committee (RRC) will accredit 3 years as a maximum. Residents shall have completed a suitable first year of postgraduate training before entering a residency program in radiation oncology. No less than 30 months of the radiation oncology program must be spent in clinical radiation therapy and it is recommended that the remaining 6 months include 2 to 3 months of medical oncology and a 2- to 3-month rotation in pathology or an equivalent lecture experience in pathology. No more than 6 months may occur in rotations to affiliated institutions outside the institution in which the program institutions united
resides or outside those participating to form an integrated program.* For
Reprint requests to J. E. Marks, Dept. of Radiotherapy, Loyola University Medical Center, 2160 South First Ave., Maywood, IL 60153. Accepted for publication 19 June 1992. * An institution is considered “integrated” when there is a written agreement between the parent institution and its program and the integrated institution specifying that the program director (a) appoints the members of the faculty and is involved in the
appointment of the chief of service at the integrated institution, (b) determines all rotations and assignments at the integrated institution, and (c) is responsible for the overall conduct of the educational program in the integrated institution. + By full-time, the Residency Review Committee intends that the individual devotes essentially all professional time to the program. 815
816
I. J. Radiation
Oncology
0 Biology 0 Physics
shall be considered unsuitable for conducting of graduate education in radiation oncology.
a program
Training content A. The program director is responsible for the structure and content of the educational program and must document that the resident has been trained in clinical radiation oncology, treatment planning, radiation physics, and radiobiology. The clinical curriculum must provide the resident with an in-depth knowledge of clinical radiation oncology, including the indications for irradiation and special therapeutic considerations unique to each site and stage of disease. The program must train the resident in standard radiation techniques, as well as the use of treatment aids and treatment planning to optimize the distribution of radiation dose. The resident must also gain a knowledge of normal tissue tolerance to radiation and tumor doseresponse. The use of combined modality therapy and unusual fractionation schemes should also be part of the clinical curriculum. The resident must be trained in the use of external beam modalities, including superficial irradiation, megavoltage irradiation (Cobalt 60, low and high energy x-rays), electron beam, simulation to localize anatomy, and computerized treatment planning. The faculty must ensure that the resident personally performs all technical procedures such as intracavitary and interstitial placement of radiation sources and that the resident keeps a detailed list of these procedures. The program director should be prepared to submit at the RRC’s request the logs of patients irradiated, procedures performed and modalities used for 3 years of clinical experience for all residents who completed training in the previous year. It is recommended that a resident perform or assist in no fewer than 10 interstitial implants and 10 intracavitary insertions during the course of training. Programs that include the therapeutic use of hyperthermia, radiolabeled antibodies, intraoperative radiotherapy, neutron beam, and other heavy particle radiotherapy must provide instruction in physics and biology as they apply to these areas of clinical treatment. B. Residents must have the opportunity to be educated in the clinical and basic sciences through regularly scheduled lectures, case presentations, conferences and discussions relevant to the practice of radiation oncology. The training program must provide curricula for the teaching of basic sciences essential to training in radiation oncology including radiation biology and medical physics. The curriculum in medical physics should include laboratory demonstrations of radiation safety procedures, calibration of radiation therapy machines, the use of the computer for treatment planning, the construction of treatment aids and the safe handling of sealed and unsealed radiation sources. It is recommended that the program also familiarize the resident with medical statistics and with pathology with special emphasis on neoplasia and radiation effects.
Volume
24, Number
5, 1992
C. The training program should provide the resident with the educational opportunity for exposure to the potential value and limitations of other oncologic disciplines such as medical oncology, surgical oncology, gynecologic oncology, pediatric oncology, and the various surgical subspecialties that play a role in the management of the patient. This will be accomplished by attendance at multidisciplinary and departmental conferences. During their training, residents will be expected to engage in an investigative project under faculty supervision. This may take the form of laboratory research, clinical research, or the retrospective analysis of data from treated patients.
Training complement The Residency Review Committee will accredit a program for a maximum number of residents commensurate with the total capacity of the program to offer an appropriate educational experience in radiation oncology. There should not be more than 1.5 residents for every staff radiation oncologist during any resident’s 30 months of training in clinical radiation therapy. If a program director wants to increase the number of residents in a program beyond the authorized number, prior approval must be obtained from the Residency Review Committee. Supervision. The faculty must supervise the resident and provide the opportunity for the resident to gradually accept more responsibility for patient care as training progresses. Duty hours. While the actual number of hours worked by residents may vary, residents should have sufficient off-duty time to avoid undue fatigue and stress. It is recommended that residents should be allowed to spend, on average, at least one full day out of seven away from the hospital, and should be assigned on-call duty in the hospital no more frequently than every third night. The program director is responsible for monitoring on-duty assignments for residents to assure adherence to this recommendation. Training evaluation. The program director is responsible for the continuing evaluation of the program and documentation of the educational progress and performance of each resident. Resident performance and progress must be documented at least twice yearly using appropriate techniques, such as written faculty appraisal, oral or written tests, or practical demonstration. The results of these evaluations must be discussed with the resident. It is the program director’s responsibility to document adequately any prior training from another institution and to counsel, censure, and after due process to dismiss residents who fail to demonstrate appropriate industry, competence, responsibility, learning abilities, and ethics. One measure of the quality of a program is the performance of its graduates on the examinations given by the American Board of Radiology. The Residency Review Committee may consider this information as part of the overall evaluation of the program.
Requirements for residency training 0 J. E. MARKSel al.
Residents who plan to seek certification by the American Board of Radiology should communicate with the Secretary of the Board regarding the full requirements for certification. Facilities. A training program in radiation oncology must have adequate space and equipment to train residents in state of the art radiation therapy. There must be access to two or more megavoltage machines, kilovoltage and/or electron beam capabilities, a dedicated therapy simulator, computerized treatment planning, a mould room and/or machine shop for the construction of treatment aids and equipment to do interstitial and intracavitary brachytherapy. Compensation for the absence of any of this equipment in the parent program must be provided by training the resident in the missing technology through a rotation to another institution.
Clinical resources The training program in radiation oncology must provide a sufficient volume and variety of cancer patients including those with pediatric, gastrointestinal, gynecologic, genitourinary tract, reticuloendothelial system, upper respiratory tract (including the head, neck and lung), breast (both primary and metastatic), central nervous system, skin, bone, and soft tissue tumors. Sufficient number of these patients should be treated by interstitial implants and intracavitary insertions to provide the resident with an adequate brachytherapy experience. Follow-up of the irradiated patient on an inpatient or outpatient basis is an essential part of resident training and must be demonstrated by the program to assure that residents have the opportunity to learn about the problems of recurrent and disseminated tumors, late aftereffects and complications of radiation therapy. To assure adequate numbers and variety of patients for resident training, it is recommended that the parent institution or integrated program treat approximately 600 patients yearly and that the number of patients irradiated by the resident each year be no fewer than 125. The residents’ experience must not be significantly diminished by the presence of other trainees, such as fellows and post-graduate trainees or residents rotating from another accredited residency program. Adequate medical support must be available in the specialties of medical oncology, surgical oncology and its subspecialties, gynecologic oncology, and pediatric oncology. There must be access to diagnostic radiology, nuclear medicine, pathology, a clinical laboratory, and a tumor registry. Institutional support. The administration of the institution(s) sponsoring the program in radiation oncology must provide funding for space, equipment, staff, non-
817
professional personnel and residents. They must assist the program director in teaching, recruiting faculty, as well as selecting, evaluating, and dismissing residents whose performance is unsatisfactory. Assurances of due process for faculty and residents must be demonstrated. Afiliation agreements. Extramural educational experience may be used to complement the training program, but the preponderance of the educational experience must take place in the parent institution. If residents are sent to an affiliated institution to obtain experience lacking in the parent institution, the program director should specify to the RRC the reason for the rotation and should document the number and types of patients available to the residents. When resources of two or more institutions are used for the clinical or basic science education of a resident in radiation oncology, a letter of agreement must be approved by the institutional governing boards. Affiliations should be avoided with institutions which do not add to the educational value of the program or which are at such a distance from the parent institution as to make resident attendance at rounds and conferences difficult. Clinical responsibility alone does not constitute a suitable educational experience. Educationul environment. The education in radiation oncology must occur in an environment that encourages exchange of knowledge and experience among residents in the program and with residents in other oncology specialties located in the same institution participating in the program. Other residency training programs, including medicine and surgery, be ongoing in the institution. Cor@rences. Conferences and teaching rounds must provide for progressive resident participation. Adequate frequency of conferences and attendance by residents, radiation oncologists, and other staff should be documented. Adequate conference room and audio-visual facilities must be provided. There must be intradepartmental clinical oncology conferences, including new patient conferences, weekly chart reviews, and problem case conferences: other conferences should include morbidity and mortality, physics, dosimetry, radiation biology, and journal review. interdepartmental clinical oncology conferences should include medical oncology, hematologic oncology, gynecologic oncology, pediatric oncology, general surgical oncology, and the oncological surgical subspecialties. Library resources. A sufficient variety of journals, reference books, and resource materials pertinent to radiation oncology and associated fields in oncology and basic sciences must be provided and be immediately accessible for resident study in a radiation oncology library. In addition, residents must have access to a general medical library.
