Im. J. Radialron 0ncolog.v iSo/. Phw Vol. 24. pp. 841-843 Printed in the U.S.A. All rights reserved.
Copyright
0360-3016/92 $5.00 + .oO 0 1992 Pergamon Press Ltd.
??Special Feature
SWEDISH
REQUIREMENTS
FOR RESIDENCY TRAINING IN ONCOLOGY
B. NORDENSIUOLD,
M.D.
University Hospital, 58 185 Linkoping, Sweden nostic radiologists. The oncologist should have basic knowledge of epidemiological theory and practice. She/ he should know national and regional cancer registration, population based screening programs for cancer, and be able to give well-founded advice to hinder or delay the development of malignancy. Malignant disease is often of long duration with profound psychosocial effects on patients and relatives and is often also accompanied by severe symptoms, for example, pain. The oncologist should be trained to deliver psychosocial support and she/ he should have good knowledge of palliative care and psychological intervention.
INTRODUCTION In Sweden radiation oncology and medical oncology are contained in one speciality and in one single Residency Training Program. Oncology is the branch of clinical medicine that uses non-surgical treatment of cancer. It requires an overview of oncological problems, including epidemiology, etiology, prevention, population based screening, early diagnosis, radiological and medical therapy, follow up, handling of treatment side effects, psychosocial care, and care of the dying patient. During residency, the oncologist should be trained in radiotherapy, radioprotection, and radiobiology as it applies to treatment of cancer and diseases other than cancer. This includes knowledge about expected results, side effects, and interaction with other treatment modalities. The oncologist has, with the exception of what is contained in the responsibility of the gynecological oncologist, the responsibility for the planning and delivery of external, interstitial and intraoperative radiotherapy and for isotope therapy. Concerning endocrine therapy and chemotherapy there is overlapping knowledge between the oncologist and other specialists, for example, haematologists, pediatricians, and surgeons. The oncologists, however, has an independent responsibility for the planning and delivery of such treatments and should act so that general principles concerning these treatments are widely applied and that interactions between these forms of therapy and radiotherapy are made use of or avoided as the situation requires. The oncologist should be trained to cooperate with surgical specialists and specialists in internal medicine practising, for example, pulmonary medicine, haematology, and pediatrians. Also, the cooperation should be very close with radiation physicists and oncology nurses. Cooperation with diagnostic radiologists and pathologists are very common. The diagnosis of malignancy is nearly always based on microscopy. Historically oncology and diagnostic radiology were developed out of a common base of knowledge. For these reasons the oncologist should have a good knowledge about and be able to well understand the investigations performed by pathologists and diag-
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 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 approximately 5 years of graduate medical education in oncology. Residents shall have completed 2 years of postgraduate training before entering a residency program in oncology. Approximately 36 months of the oncology program must be spent in an oncology department. If this department is not affiliated to a University, 12 of the 36 months must be spent in a University department. It is recommended that the remaining 18 months include internal medicine, preferably haematology, or pulmonary medicine and a 2 to 3 month rotation in pathology or/and diagnostic radiology. Program director. The program director must be a practicing oncologists; they yet contribute sufficient time to the program to ensure adequate direction; they are responsible for the total training in oncology which includes the instruction and supervision of residents; and they must
Accepted for publication 30 June 1992. 841
842
1. J. Radiation Oncology 0 Biology 0 Physics
arrange for the provision of adequate facilities, faculty, clinical resources, and educational resources. Stafl The program must provide a minimum of five full-time oncologists, and one full-time medical physicist for the teaching of oncology and physics. The faculty must be engaged in scholarly activities, such as participation in regional and national scientific activities and participation in their own continuing education. 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 oncology and has the knowledge specified below. At the end of training, the oncologist should be very familiar with: (1) The diagnosis and staging of malignancy; (2) Treatment planning of malignant disease; (3) Delivery of radiotherapy including the definition of tumor area, target volumes, calculation of dose and simulation; (4) Medical and endocrine therapy of malignancy; (5) Medical and radiological pain relief; (6) Treatment of common complications of cancer therapy (such as infection); and (7) Judgement of psychological reactions during crises and psycological needs of the dying patients. The radiation oncology part of the oncology program 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 dose-response. 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, electron beam irradiation, simulation to localize anatomy, and computerized treatment planning. 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 oncology. The training program must provide curricula for the teaching of basic sciences essential to training in 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
Volume 24, Number 5, 1992
recommended that the program also familiarize the resident with medical statistics and with pathology with special emphasis on neoplasia and radiation effects. 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 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 attendence at multidisciplinary and departmental conferences. 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 1 full day out of 7 away from the hospital, and should be assigned on-call duty in the hospital no more frequently than every seventh 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. Facilities A training program in oncology must have adequate space and equipment to train residents. 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. Clinical resources The training program in oncology must provide a sufficient volume and variety of cancer patients including those with pediatric, gastrointestinal, 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. Follow-up of the patients on an in-
Swedish residency requirements 0 K. NORDENSKJOLD
843
patient 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 a variety of patients for resident training, it is recommended that the parent institution or integrated program treat at least 600 patients yearly and that the number of patients treated 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 specialities of surgical oncology and its subspecialities. There must be access to diagnostic radiology, nuclear medicine, pathology, a clinical laboratory, and a tumor registry.
Educational environment The education in oncology must occur in an environment which 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, may be ongoing in the institution.
Institutional support The administration of the institution(s) sponsoring the program in oncology must provide funding for space, equipment, staff, non-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.
Library resources A sufficient variety of journals, reference books, and resource materials pertinent to oncology and associated fields in oncology and basic sciences must be provided and be immediately accessible for resident study in an oncology library. In addition, residents must have access to a general medical library.
Conferences Conferences and teaching rounds must provide for progressive resident participation. There must be intradepartmental clinical oncology conferences for example, new patient conferences, weekly chart reviews, and problem case conferences. Interdepartmental clinical oncology conferences should include hematologic oncology, gynecologic oncology, pediatric oncology, general surgical oncology. and the oncological surgical subspecialties.
Copyright
0360-3016/92 $5.00 + .oO 0 1992 Pergamon Press Ltd.
??Special Feature
SWEDISH
REQUIREMENTS
FOR RESIDENCY TRAINING IN ONCOLOGY
B. NORDENSIUOLD,
M.D.
University Hospital, 58 185 Linkoping, Sweden nostic radiologists. The oncologist should have basic knowledge of epidemiological theory and practice. She/ he should know national and regional cancer registration, population based screening programs for cancer, and be able to give well-founded advice to hinder or delay the development of malignancy. Malignant disease is often of long duration with profound psychosocial effects on patients and relatives and is often also accompanied by severe symptoms, for example, pain. The oncologist should be trained to deliver psychosocial support and she/ he should have good knowledge of palliative care and psychological intervention.
INTRODUCTION In Sweden radiation oncology and medical oncology are contained in one speciality and in one single Residency Training Program. Oncology is the branch of clinical medicine that uses non-surgical treatment of cancer. It requires an overview of oncological problems, including epidemiology, etiology, prevention, population based screening, early diagnosis, radiological and medical therapy, follow up, handling of treatment side effects, psychosocial care, and care of the dying patient. During residency, the oncologist should be trained in radiotherapy, radioprotection, and radiobiology as it applies to treatment of cancer and diseases other than cancer. This includes knowledge about expected results, side effects, and interaction with other treatment modalities. The oncologist has, with the exception of what is contained in the responsibility of the gynecological oncologist, the responsibility for the planning and delivery of external, interstitial and intraoperative radiotherapy and for isotope therapy. Concerning endocrine therapy and chemotherapy there is overlapping knowledge between the oncologist and other specialists, for example, haematologists, pediatricians, and surgeons. The oncologists, however, has an independent responsibility for the planning and delivery of such treatments and should act so that general principles concerning these treatments are widely applied and that interactions between these forms of therapy and radiotherapy are made use of or avoided as the situation requires. The oncologist should be trained to cooperate with surgical specialists and specialists in internal medicine practising, for example, pulmonary medicine, haematology, and pediatrians. Also, the cooperation should be very close with radiation physicists and oncology nurses. Cooperation with diagnostic radiologists and pathologists are very common. The diagnosis of malignancy is nearly always based on microscopy. Historically oncology and diagnostic radiology were developed out of a common base of knowledge. For these reasons the oncologist should have a good knowledge about and be able to well understand the investigations performed by pathologists and diag-
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 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 approximately 5 years of graduate medical education in oncology. Residents shall have completed 2 years of postgraduate training before entering a residency program in oncology. Approximately 36 months of the oncology program must be spent in an oncology department. If this department is not affiliated to a University, 12 of the 36 months must be spent in a University department. It is recommended that the remaining 18 months include internal medicine, preferably haematology, or pulmonary medicine and a 2 to 3 month rotation in pathology or/and diagnostic radiology. Program director. The program director must be a practicing oncologists; they yet contribute sufficient time to the program to ensure adequate direction; they are responsible for the total training in oncology which includes the instruction and supervision of residents; and they must
Accepted for publication 30 June 1992. 841
842
1. J. Radiation Oncology 0 Biology 0 Physics
arrange for the provision of adequate facilities, faculty, clinical resources, and educational resources. Stafl The program must provide a minimum of five full-time oncologists, and one full-time medical physicist for the teaching of oncology and physics. The faculty must be engaged in scholarly activities, such as participation in regional and national scientific activities and participation in their own continuing education. 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 oncology and has the knowledge specified below. At the end of training, the oncologist should be very familiar with: (1) The diagnosis and staging of malignancy; (2) Treatment planning of malignant disease; (3) Delivery of radiotherapy including the definition of tumor area, target volumes, calculation of dose and simulation; (4) Medical and endocrine therapy of malignancy; (5) Medical and radiological pain relief; (6) Treatment of common complications of cancer therapy (such as infection); and (7) Judgement of psychological reactions during crises and psycological needs of the dying patients. The radiation oncology part of the oncology program 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 dose-response. 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, electron beam irradiation, simulation to localize anatomy, and computerized treatment planning. 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 oncology. The training program must provide curricula for the teaching of basic sciences essential to training in 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
Volume 24, Number 5, 1992
recommended that the program also familiarize the resident with medical statistics and with pathology with special emphasis on neoplasia and radiation effects. 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 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 attendence at multidisciplinary and departmental conferences. 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 1 full day out of 7 away from the hospital, and should be assigned on-call duty in the hospital no more frequently than every seventh 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. Facilities A training program in oncology must have adequate space and equipment to train residents. 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. Clinical resources The training program in oncology must provide a sufficient volume and variety of cancer patients including those with pediatric, gastrointestinal, 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. Follow-up of the patients on an in-
Swedish residency requirements 0 K. NORDENSKJOLD
843
patient 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 a variety of patients for resident training, it is recommended that the parent institution or integrated program treat at least 600 patients yearly and that the number of patients treated 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 specialities of surgical oncology and its subspecialities. There must be access to diagnostic radiology, nuclear medicine, pathology, a clinical laboratory, and a tumor registry.
Educational environment The education in oncology must occur in an environment which 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, may be ongoing in the institution.
Institutional support The administration of the institution(s) sponsoring the program in oncology must provide funding for space, equipment, staff, non-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.
Library resources A sufficient variety of journals, reference books, and resource materials pertinent to oncology and associated fields in oncology and basic sciences must be provided and be immediately accessible for resident study in an oncology library. In addition, residents must have access to a general medical library.
Conferences Conferences and teaching rounds must provide for progressive resident participation. There must be intradepartmental clinical oncology conferences for example, new patient conferences, weekly chart reviews, and problem case conferences. Interdepartmental clinical oncology conferences should include hematologic oncology, gynecologic oncology, pediatric oncology, general surgical oncology. and the oncological surgical subspecialties.
