International Journal of

Radiation Oncology biology

physics

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EDUCATION EDITORIAL

The Anatomy of Radiation Oncology Residency Training Junzo Chino, MD,* Sara Doyle, PhD,y and Lawrence B. Marks, MDz *Department of Radiation Oncology and yDepartment of Evolutionary Anthropology, Duke University, Durham, North Carolina; and zDepartment of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina Received Sep 5, 2013, and in revised form Sep 20, 2013. Accepted for publication Sep 20, 2013. Gross anatomy has been a cornerstone of the first year of medical school for decades. However, the time spent on anatomy training in medical school has been decreasing recently, and this decline has been noticed; for example, 71% of residency directors noted that their incoming trainees were in need of refresher courses in anatomy (1). This was more apparent in general surgery and diagnostic radiology programs, where this proportion increased to 86%. Traditional medical education places anatomy instruction (eg, gross anatomy laboratory and didactic sessions) at the beginning of medical school. This is logical, inasmuch as anatomy is seen as a foundational topic. This, however, does not dovetail well with the needs of the radiation oncologist in training (Fig. 1). The majority of instruction in, and exposure to, anatomy is in the first year and steadily declines through the third and fourth years (with the exception of surgical and radiologic clerkships), and into the first postgraduate year. By the time an aspiring radiation oncologist enters the first year of residency, it will have been more than 4 years since he or she has seen the cadaver laboratory. The progress of technology in radiation oncology has been a double-edged sword. With the ability to design treatment based on high-quality 3-dimensional imaging, one must now also be able to accurately interpret that image (eg, identification of gross targets and understanding the regional structures). The conformality afforded by intensity modulation, stereotactic techniques, and image guided brachytherapy increases our need to understand the anatomy. Performing these highly conformal techniques with an inadequate grasp of pertinent anatomy is not advisable, putting our patients at risk of earlier recurrence resulting from insufficient coverage, increased toxicity caused by unintended normal tissue exposures, or both. The need for precise anatomic information is evidenced by the increasing number of reference anatomic atlases being used in our field (2-4).

Surgical training programs recognize that the traditional medical education system may not be sufficient for their trainees, and many training programs have incorporated a refresher course in dedicated anatomic education into the first years of postgraduate training. The Accreditation Council for Graduate Medical Education has gone so far as to require cadaver laboratory time in all otolaryngology residency programs (5). An obvious question to ask is, should radiation oncology consider a similar requirement? Given the rapid evolution in our practice, this seems prudent, and it would be consistent with our surgical oncology colleagues. An educational program has been created at the Duke Cancer Insititue (attended by residents from both Duke and the University of North Carolina) that attempts to address this issue. Starting in 2004, we have had approximately monthly Oncoanatomy classes, and formal evaluations of these classes have been positive (6). Each class is dedicated to a particular disease and begins with a resident-led didactic review of the clinically relevant anatomy, diagnostic imaging, and the implications for treatment planning, lasting approximately 30 minutes. This is followed immediately by a 1-hour session in the gross anatomy laboratory, where we review prosections that have been previously prepared by the faculty and graduate trainees of the Department of Evolutionary Anthropology at Duke, who also oversee anatomy instruction for medical students. At both the didactic and laboratory sessions, we strive to have a direct interaction between the trainees, anatomists, and radiation oncology faculty. The prosections and the presence of the anatomists provide a unique educational experience for the radiation oncology residents. For many sessions, we have also invited residents and faculty from relevant surgical specialties to participate in the conference. This course requires advance planning and coordination between the clinicians and anatomists, because there is often a gap between the content of an anatomic review for a medical student and the practical needs of a radiation oncologist. For example, an anatomic

Reprint requests to: Junzo Chino, MD, DUMC 3085, Durham, NC 27710. Tel: (919) 668-7336; E-mail: [email protected]

Supported in part by a grant from the Duke Office of Graduate Medical Education. Conflict of interest: none.

Int J Radiation Oncol Biol Phys, Vol. 88, No. 1, pp. 3e4, 2014 0360-3016/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ijrobp.2013.09.039

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Fig. 1. Schematic of time spent in anatomic instruction and the need to apply knowledge of anatomy for the radiation oncologist in training. There is a large temporal separation between instruction and application. IORT Z intraoperative radiation therapy; PGY Z postgraduate year; Rad Onc Z radiation oncology; SBRT Z stereotactic body radiation therapy; SRS Z stereotactic radiosurgery. review for students may concentrate on blood supply, nerves, and musculature, but the radiation oncologist might be more interested in patterns of lymphatic spread, natural barriers to local invasion, and proximity to critical structures. Before each session, 1 or 2 radiation oncology residents review with the anatomists the relevant oncologic considerations, and the anatomists review the unique anatomic and embryologic considerations. Together, they decide on the issues and topics to be discussed in the conference and the prosections that might be most useful for the clinicians to view. A side benefit of this approach is to give the anatomy instructors a better perspective of the clinical relevance of their work, which they then integrate into their presentations to medical students. As radiation oncologists, we take pride in our ability to safely and effectively deliver therapeutic doses of radiation to anatomically defined targets. We are most satisfied when we (with the help of our colleagues in physics, dosimetry, and therapy) are able to create and deliver an elegant treatment plan that addresses challenging anatomy, much as a surgeon reflects on a challenging but ultimately successful operation. Conversely, our greatest disappointment is when a patient is treated to the wrong region through ignorance or inattention. Indeed, some of the high-profile radiation misadministrations recently reported in the lay press may be understood to stem from a lack of anatomic knowledge. Similarly, we may find marginal recurrences much more distressing than systemic or in-field failures. We suggest that it is time that we improve the quality of anatomy education for our trainees in radiation oncology. This could be approached from multiple, non-mutually exclusive, directions. For example, one can explore a top-down approach of exporting a model of our oncoanatomy course to other sites, and we have been capturing video and audio of our sessions to facilitate this in the future. Another approach would be to increase the amount of anatomy-based questions and tasks during the inservice examinations with the recent initiatives in contouring atlases from the Radiation Therapy Oncology Group (and other groups) serving as potential references (7). Along this line, the

International Journal of Radiation Oncology  Biology  Physics American Board of Radiology has already turned more attention to integrating the testing of normal and pathologic radiographic anatomy into the boarding process. Treatment planning software tools may be modified to serve an anatomic-educational role (8). Similarly, treatment planning software tools can be modified to provide atlas-based decision support during the actual treatment planning process (9). Here, tools that aid the educational mission can also serve the clinical mission. Additionally, quality assurance tools, again based on a library of “anatomic gold standards” or previously planned cases, can be used to both train learners and improve clinical practice. Creative ideas on how to address this challenge are needed. Another intriguing possibility would be to develop a shared curriculum to address both the increasing needs of aspiring radiation oncologists to understand radiographic anatomy and the needs of radiologists in training to have more experience with therapeutic approaches to disease. The rising specialty of interventional radiology evidences this need on the part of radiology programs. One can imagine foundational courses, perhaps integrating gross anatomy and the fundamentals of cross-sectional imaging, that are attended by junior residents from both radiation oncology and radiology. Perhaps after having spent the better part of 4 decades pursuing divergent training pathways, we now have enough common ground between us to consider reintegrating portions of the curriculum for the educational benefit of both. Regardless of how this is accomplished, it is time that we more formally and consistently make anatomic instruction part of the anatomy of our residency training programs.

References 1. Cottam WW. Adequacy of medical school gross anatomy education as perceived by certain postgraduate residency programs and anatomy course directors. Clin Anat 1999;12:55-65. 2. Gay HA, Barthold HJ, O’Meara E, et al. Pelvic normal tissue contouring guidelines for radiation therapy: A Radiation Therapy Oncology Group consensus panel atlas. Int J Radiat Oncol Biol Phys 2012;83:e353-e362. 3. Li XA, Tai A, Arthur DW, et al. Variability of target and normal structure delineation for breast cancer radiotherapy: An RTOG multiinstitutional and multiobserver study. Int J Radiat Oncol Biol Phys 2009;73:944-951. 4. Kong FM, Ritter T, Quint DJ, et al. Consideration of dose limits for organs at risk of thoracic radiotherapy: Atlas for lung, proximal bronchial tree, esophagus, spinal cord, ribs, and brachial plexus. Int J Radiat Oncol Biol Phys 2011;81:1442-1457. 5. ACGME Program Requirements for Graduate Medical Education in Otolaryngology. 2013. http://www.acgme.org/acgmeweb/tabid/141/ ProgramandInstitutionalGuidelines/SurgicalAccreditation/Otolaryng ology.aspx. Accessed August 7, 2013. 6. Chino JP, Lee WR, Madden R, et al. Teaching the anatomy of oncology: Evaluating the impact of a dedicated oncoanatomy course. Int J Radiat Oncol Biol Phys 2011;79:853-859. 7. Breunig J, Hernandez S, Lin J, et al. A system for continual quality improvement of normal tissue delineation for radiation therapy treatment planning. Int J Radiat Oncol Biol Phys 2012;83:e703e708. 8. Szumacher E, Harnett N, Warner S, et al. Effectiveness of educational intervention on the congruence of prostate and rectal contouring as compared with a gold standard in three-dimensional radiotherapy for prostate. Int J Radiat Oncol Biol Phys 2010;76:379-385. 9. Pekar V, McNutt TR, Kaus MR. Automated model-based organ delineation for radiotherapy planning in prostatic region. Int J Radiat Oncol Biol Phy 2004;60:973-980.

The anatomy of radiation oncology residency training.

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