- Email: [email protected]
Clinical Oncology Training: The Trainees’ Perspective
Clinical Oncology 24 (2012) 22e24 Contents lists available at SciVerse ScienceDirect
Clinical Oncology journal homepage: www.clinicaloncologyonline.net
Editorial
Clinical Oncology Training: The Trainees’ Perspective M. Lei *, J. Stokoe y, N. MacLeod z, L. Yates *, R. Mir * * Department
of Clinical Oncology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK Clinical Investigation and Research Unit, Royal Sussex County Hospital, Brighton, UK z The Beatson West of Scotland Cancer Centre, Glasgow, UK y
Received 25 August 2011; accepted 30 August 2011
Clinical oncology training has changed greatly over recent years. About 350 clinical oncology trainees are distributed across 20 training programmes in the UK, with one third of trainees working in London. Current trainees are a mix of year 4e5 specialist registrars, appointed before 2007 via the ‘old’ Calman training system, and ‘newer’ specialty registrars, appointed via the Modernising Medical Careers reform.
Entry to Clinical Oncology The Kent, Sussex and Surrey Deanery co-ordinates centralised national recruitment to clinical oncology higher specialty training. The interview procedure consists of three 10 min stations: management of clinical scenarios, an ethical scenario and portfolio review/commitment to specialty. A structured scoring system is used, with posts allocated according to performance ranking. One of our authors underwent this process. Her experience was that the process was not sufficiently flexible to facilitate demonstration of thoughtful discussion. For unsuccessful applicants, no alternative posts, such as locumappointments-in-training, were advertised until late July. Given that new posts start on 1 September, the timing seems suboptimal, given the uncertainty and stress associated with impending unemployment. As a specialty, we risk losing potentially good applicants who have not performed well on the day of interview and who previously might have been appointed to locum-appointments-in-training posts, to alternative career paths. Currently, 50% of clinical oncology departments in the UK have vacancies on their trainee rotas [1], which challenges the maintenance of a quality of clinical care. Author for correspondence: M. Lei, Department of Clinical Oncology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK. E-mail address: [email protected] (M. Lei).
Current Challenges to Clinical Oncology Training Opportunities Radiotherapy and Systemic Therapy Training The Oncology Registrars’ Forum carries out national surveys of UK trainees’ experiences of numerous aspects of training, from education to personal career aspirations and impact on personal life [1,2]. Clinical oncologists are trained in both systemic and radiation therapies and therefore we are able to present a full and balanced assessment of the treatment options available to each patient. We believe that our training in systemic therapy skills should be maintained. Competence is examined rigorously in the Final FRCR examination, the content of which has received valuable input from oncology colleagues at the Royal College of Physicians. The quality of training in systemic therapy is sufficiently high that many clinical oncology trainees pursue systemic therapy-related laboratory-based projects during academic research fellowships. With respect to radiotherapy skills, conflict between adequate radiotherapy planning time and the remainder of clinical tasks is common. Radiotherapy planning sessions are not protected for most trainees (80%) and frequently are interrupted by non-emergency work. Many trainees believe that protected and bleep-free radiotherapy planning time will support and maintain a high standard of radiotherapy training. A surgeon does not drop his tools mid-way through an operation and the same should apply when oncologists are planning radiotherapy treatment. Radiotherapy planning is a technical skill and consultant job plans need adequate time-tabled sessions for radiotherapy planning and to provide appropriate training. Departments must recognise this, or risk the training of the next generation of trainees.
0936-6555/$36.00 Ó 2011 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.clon.2011.09.011
M. Lei et al. / Clinical Oncology 24 (2012) 22e24
Academic Training National Institute for Health Research academic clinical fellowships (ACFs) support selected trainees to develop research skills alongside specialist training. A standard 3 year programme allocates 25% of time (9 months) to research activities, with the remainder devoted to clinical training. The nature of research projects and timetable structure varies. One of our authors, an ACF, found that a 3 month block of dedicated research time was more rewarding than the initial trial of weekly day release. During the day release format, there were competing demands between clinical and laboratory work. The 3 month block, in contrast, supported development of a strong research project and culminated in the successful award of a fully funded PhD fellowship. For an ACF, the award of a Certificate of Completion of Training (CCT) is competency based, rather than time based. The ACF is expected to attempt the Final FRCR examination successfully at the end of the 3 years and embark upon a full-time research career. However, with only 2 years and 3 months’ equivalent of clinical oncology exposure being completed by the end of the fellowship and further reductions due to MSc courses, this author did not feel clinically ready to attempt the final FRCR examination at this time. We suggest that perhaps the structure of the ACF programme specific to clinical oncology could be reviewed. An additional year of oncology experience during or prior to the standard ACF training post would provide a greater component of clinical exposure and might promote interest in radiotherapy-based research projects. Assessment of Training Workplace-based assessments (WPBAs), assessment of competence based on what a trainee actually does in the workplace, were introduced in 2010 [3]. Currently, clinical oncology has six WPBA tools: audit, teaching, case-based discussion, direct observation of radiotherapy planning skills, direct observation of systemic therapy and clinical evaluation [4]. These contribute to ‘ePortfolio’, which is reviewed with a formative rather than a summative approach as part of an Annual Review of Competence Progression. WPBAs have been received with a mixed response. Are they simply tick-box exercises, or have they facilitated opportunities for useful discussions between trainees and their training consultants? Junior trainees in particular report that direct observation of radiotherapy planning skills promotes greater exposure to radiotherapy and have improved the quantity and quality of constructive feedback from their trainers. A widely expressed view is that insufficient time is allocated in trainer and trainee timetables for this process.
23
This will be monitored closely in future Oncology Registrars’ Forum surveys. Cover for trainees who have been rostered ‘EWTD time-off’ is usually carried out by consultants and other trainees, with further challenges to training time. Ward doctors’ training is also affected. Our junior colleagues may have accumulated less clinical experience compared with those who trained before the EWTD and, therefore, may require more support from specialty trainees. Departments need to be imaginative with rota design to maximise training opportunities. In the face of an increasing workload in the coming years, clinical oncology trainee numbers need to be protected and even increased if we are to head towards a truly consultant-delivered service, as recommended in the Temple report [5]. One potential solution explored by some Trusts is an internal ‘ward registrar’ rotation, where specialty trainees are based primarily on the oncology ward for between 1 week and 1 month at a time. The intention is to provide increased support to junior colleagues and to enable clinical oncology trainee colleagues to focus on non-ward-based activities. Trainees’ experiences of this system vary. In centres with large numbers of registrars, the ward-week may only be required on a quarterly basis. In smaller centres, cover may be required every 4e6 weeks, with considerable negative impact on other training experiences. Timely and involved consultant support can enhance the educational aspects of ward cover. However, if consultant input is minimal, the ward-week may be an isolating experience with reduced value in terms of training. Compulsory participation of clinical oncology trainees in ‘Hospital at Night’ (shared acute general medical on-call duties) is an issue in two UK regions currently. Competence in up to date acute general medicine skills is a point of debate for trainees, with 95% feeling that ‘Hospital at Night’ is not beneficial to clinical oncology training [1,2]. These views were supported in a formal statement released by the Royal College of Radiologists in March 2011 [6].
Acute Oncology Acute oncology was developed in response to serious concerns raised in the National Chemotherapy Advisory Group report [7]. To date, around one third of centres have set up an acute oncology service [1], 78% of which involve trainees in delivering acute oncology. Most trainees feel that in-patient care has improved with acute oncology. We do feel, however, that measures have been rushed through without adequate dialogue. Do trainees d oncologists of the future d wish to become ‘acute oncologists’ rather than sitespecialised oncologists? How many are needed? How will the specialties work together? Urgent consultation is needed.
European Working Time Directive The European Working Time Directive (EWTD) became mandatory in August 2009. Many trainees undertake radiotherapy planning training outside of normal working hours [1] and therefore an enforced limitation of hospital hours may threaten radiotherapy training opportunities.
Out of Programme Experience Most (80%) clinical oncology trainees are extremely interested in developing research or advanced technological skills [2,3]. This suggests that the specialty is attracting
24
M. Lei et al. / Clinical Oncology 24 (2012) 22e24
increasingly academic trainees. Twenty per cent have completed or are currently undertaking out f programme experience (OOPE), with a further 61% planning to undertake a period of OOPE in the future. Most embark on higher degree research programmes, although fellowships in UK or foreign institutions are also popular. The large numbers of trainees pursuing OOPE may also raise a concern that current training and the reality of current job structures do not satisfy modern clinical oncology training needs. The job market is as competitive as ever and specialist experience in advanced radiotherapy and research skills adds strength to applications for consultant posts. Perhaps understandably, given recent low pass rates, many trainees delay organising OOPE until they have undertaken the Final FRCR successfully. From personal experience, we urge colleagues to allow sufficient time d up to 12 months d for this process. Finding, organising and funding a good project is time-consuming and often dependent on numerous factors beyond a trainee’s control. Added pressure results from some Deaneries approving OOPE on condition that a minimum of 12 months of preCCT time remains on the clock.
Academic Careers The 2009 survey identified that 28% of respondents intend to pursue an academic career. Aspirations range from careers as academic clinical oncologists, to clinical oncologists with academic sessions, to a career as a clinical oncologist with 100% clinical commitments, but with participation in research at other levels, for example, in enrolling patients into clinical studies. Perhaps not surprisingly, it was felt that there are insufficient consultant jobs available with academic sessions. Funding for research time within a consultant’s job plan may come from many sources and current economic times are a challenge. It is important that support from National Health Service Trusts and academic institutions continues to facilitate innovative research activities and that appropriate mentorship is provided for keen trainees.
Certificate of Completion of Training and Beyond After passing the Final FRCR, most trainees have 18 months of clinical training left before the award of a CCT. Some will undertake a period of OOPE. For the rest, the looming prospects of working as a consultant clinical oncologist and the associated responsibilities are daunting. Focus shifts to improving experience in selected tumour sites of professional interest, developing research interests or gaining technically advanced therapeutic skills that may be of value to dynamic departments with active research and development programmes. Having devoted so much effort to honing clinical skills, we realise, perhaps belatedly, how little we understand of Trust and departmental management, strategy and business planning. Consultant job plans suddenly become more interesting. There is a growing trend for new posts to be
advertised with only one Supporting Professional Activity (SPA). Revalidation alone requires a minimum of 1.5 SPAs per week [8]. Additional SPAs are needed to support teaching, training, research, service development, clinical governance and contribution to management. Both the Royal College of Radiologists and the British Medical Association recommend 2.5 SPAs [9]. If job plans are poorly designed, how can the clinical oncologists of the future continue to maintain and improve service long term and who will have time to train the next clinical oncologists?
Conclusion During recent years, numerous changes have impacted on the training experience of clinical oncology trainees. Direction and support of trainees in response to these pressures has been excellent in general. Challenges will continue to evolve. Advanced radiotherapy techniques and acute oncology are two differing examples and it is important that trainees and trainers remain alert for changes, remain flexible and respond in a timely manner. Trainers must be provided with sufficient time in their job plans to provide high-quality training. The promotion of research and the important role of radiotherapy in cancer management are issues close to trainees’ hearts. Clinical oncology trainees are the oncologists of the future and we are motivated in the quest to provide a modern, world-class oncology service.
Acknowledgement We would like to acknowledge Anna Campbell, Executive Education Officer and Oncology Registrars’ Forum Secretariat, for her encouragement and support of the Oncology Registrars’ Forum, and in particular, her vital input into the Oncology Registrars’ Forum Trainee Surveys.
References [1] Oncology registrars’ forum trainee survey AprileMay 2011 comprehensive report 2011. [2] Oncology registrars’ forum trainee survey Oct/Nov 2009 comprehensive report 2010. [3] General Medical Council. Workplace based assessment: a guide for implementation (supplementary guidance) 2010. [4] RCR RCoR. Workplace based assessments. Available at: http:// www.rcr.ac.uk/content.aspx?PageID¼1813 [5] Temple J. Time for training. A review of the impact of the European Working Time Directive on the quality of training. Medical Education England 2010. [6] RCR RCoR. Employment of clinical oncology registrars in ‘Hospital at Night’ teams. Guidance from the Royal College of Radiologists 2011. [7] NCAG. Chemotherapy services in England: ensuring quality and safety. A report from the National Chemotherapy Advisory Group 2008. [8] Board of the Faculty of Clinical Oncology. The Royal College of Radiologists. Guide to job planning in clinical oncology 2011. [9] British Medical Association. NHS employers and the British Medical Association (BMA) 2011. A guide to consultant job planning.
Clinical Oncology journal homepage: www.clinicaloncologyonline.net
Editorial
Clinical Oncology Training: The Trainees’ Perspective M. Lei *, J. Stokoe y, N. MacLeod z, L. Yates *, R. Mir * * Department
of Clinical Oncology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK Clinical Investigation and Research Unit, Royal Sussex County Hospital, Brighton, UK z The Beatson West of Scotland Cancer Centre, Glasgow, UK y
Received 25 August 2011; accepted 30 August 2011
Clinical oncology training has changed greatly over recent years. About 350 clinical oncology trainees are distributed across 20 training programmes in the UK, with one third of trainees working in London. Current trainees are a mix of year 4e5 specialist registrars, appointed before 2007 via the ‘old’ Calman training system, and ‘newer’ specialty registrars, appointed via the Modernising Medical Careers reform.
Entry to Clinical Oncology The Kent, Sussex and Surrey Deanery co-ordinates centralised national recruitment to clinical oncology higher specialty training. The interview procedure consists of three 10 min stations: management of clinical scenarios, an ethical scenario and portfolio review/commitment to specialty. A structured scoring system is used, with posts allocated according to performance ranking. One of our authors underwent this process. Her experience was that the process was not sufficiently flexible to facilitate demonstration of thoughtful discussion. For unsuccessful applicants, no alternative posts, such as locumappointments-in-training, were advertised until late July. Given that new posts start on 1 September, the timing seems suboptimal, given the uncertainty and stress associated with impending unemployment. As a specialty, we risk losing potentially good applicants who have not performed well on the day of interview and who previously might have been appointed to locum-appointments-in-training posts, to alternative career paths. Currently, 50% of clinical oncology departments in the UK have vacancies on their trainee rotas [1], which challenges the maintenance of a quality of clinical care. Author for correspondence: M. Lei, Department of Clinical Oncology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK. E-mail address: [email protected] (M. Lei).
Current Challenges to Clinical Oncology Training Opportunities Radiotherapy and Systemic Therapy Training The Oncology Registrars’ Forum carries out national surveys of UK trainees’ experiences of numerous aspects of training, from education to personal career aspirations and impact on personal life [1,2]. Clinical oncologists are trained in both systemic and radiation therapies and therefore we are able to present a full and balanced assessment of the treatment options available to each patient. We believe that our training in systemic therapy skills should be maintained. Competence is examined rigorously in the Final FRCR examination, the content of which has received valuable input from oncology colleagues at the Royal College of Physicians. The quality of training in systemic therapy is sufficiently high that many clinical oncology trainees pursue systemic therapy-related laboratory-based projects during academic research fellowships. With respect to radiotherapy skills, conflict between adequate radiotherapy planning time and the remainder of clinical tasks is common. Radiotherapy planning sessions are not protected for most trainees (80%) and frequently are interrupted by non-emergency work. Many trainees believe that protected and bleep-free radiotherapy planning time will support and maintain a high standard of radiotherapy training. A surgeon does not drop his tools mid-way through an operation and the same should apply when oncologists are planning radiotherapy treatment. Radiotherapy planning is a technical skill and consultant job plans need adequate time-tabled sessions for radiotherapy planning and to provide appropriate training. Departments must recognise this, or risk the training of the next generation of trainees.
0936-6555/$36.00 Ó 2011 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.clon.2011.09.011
M. Lei et al. / Clinical Oncology 24 (2012) 22e24
Academic Training National Institute for Health Research academic clinical fellowships (ACFs) support selected trainees to develop research skills alongside specialist training. A standard 3 year programme allocates 25% of time (9 months) to research activities, with the remainder devoted to clinical training. The nature of research projects and timetable structure varies. One of our authors, an ACF, found that a 3 month block of dedicated research time was more rewarding than the initial trial of weekly day release. During the day release format, there were competing demands between clinical and laboratory work. The 3 month block, in contrast, supported development of a strong research project and culminated in the successful award of a fully funded PhD fellowship. For an ACF, the award of a Certificate of Completion of Training (CCT) is competency based, rather than time based. The ACF is expected to attempt the Final FRCR examination successfully at the end of the 3 years and embark upon a full-time research career. However, with only 2 years and 3 months’ equivalent of clinical oncology exposure being completed by the end of the fellowship and further reductions due to MSc courses, this author did not feel clinically ready to attempt the final FRCR examination at this time. We suggest that perhaps the structure of the ACF programme specific to clinical oncology could be reviewed. An additional year of oncology experience during or prior to the standard ACF training post would provide a greater component of clinical exposure and might promote interest in radiotherapy-based research projects. Assessment of Training Workplace-based assessments (WPBAs), assessment of competence based on what a trainee actually does in the workplace, were introduced in 2010 [3]. Currently, clinical oncology has six WPBA tools: audit, teaching, case-based discussion, direct observation of radiotherapy planning skills, direct observation of systemic therapy and clinical evaluation [4]. These contribute to ‘ePortfolio’, which is reviewed with a formative rather than a summative approach as part of an Annual Review of Competence Progression. WPBAs have been received with a mixed response. Are they simply tick-box exercises, or have they facilitated opportunities for useful discussions between trainees and their training consultants? Junior trainees in particular report that direct observation of radiotherapy planning skills promotes greater exposure to radiotherapy and have improved the quantity and quality of constructive feedback from their trainers. A widely expressed view is that insufficient time is allocated in trainer and trainee timetables for this process.
23
This will be monitored closely in future Oncology Registrars’ Forum surveys. Cover for trainees who have been rostered ‘EWTD time-off’ is usually carried out by consultants and other trainees, with further challenges to training time. Ward doctors’ training is also affected. Our junior colleagues may have accumulated less clinical experience compared with those who trained before the EWTD and, therefore, may require more support from specialty trainees. Departments need to be imaginative with rota design to maximise training opportunities. In the face of an increasing workload in the coming years, clinical oncology trainee numbers need to be protected and even increased if we are to head towards a truly consultant-delivered service, as recommended in the Temple report [5]. One potential solution explored by some Trusts is an internal ‘ward registrar’ rotation, where specialty trainees are based primarily on the oncology ward for between 1 week and 1 month at a time. The intention is to provide increased support to junior colleagues and to enable clinical oncology trainee colleagues to focus on non-ward-based activities. Trainees’ experiences of this system vary. In centres with large numbers of registrars, the ward-week may only be required on a quarterly basis. In smaller centres, cover may be required every 4e6 weeks, with considerable negative impact on other training experiences. Timely and involved consultant support can enhance the educational aspects of ward cover. However, if consultant input is minimal, the ward-week may be an isolating experience with reduced value in terms of training. Compulsory participation of clinical oncology trainees in ‘Hospital at Night’ (shared acute general medical on-call duties) is an issue in two UK regions currently. Competence in up to date acute general medicine skills is a point of debate for trainees, with 95% feeling that ‘Hospital at Night’ is not beneficial to clinical oncology training [1,2]. These views were supported in a formal statement released by the Royal College of Radiologists in March 2011 [6].
Acute Oncology Acute oncology was developed in response to serious concerns raised in the National Chemotherapy Advisory Group report [7]. To date, around one third of centres have set up an acute oncology service [1], 78% of which involve trainees in delivering acute oncology. Most trainees feel that in-patient care has improved with acute oncology. We do feel, however, that measures have been rushed through without adequate dialogue. Do trainees d oncologists of the future d wish to become ‘acute oncologists’ rather than sitespecialised oncologists? How many are needed? How will the specialties work together? Urgent consultation is needed.
European Working Time Directive The European Working Time Directive (EWTD) became mandatory in August 2009. Many trainees undertake radiotherapy planning training outside of normal working hours [1] and therefore an enforced limitation of hospital hours may threaten radiotherapy training opportunities.
Out of Programme Experience Most (80%) clinical oncology trainees are extremely interested in developing research or advanced technological skills [2,3]. This suggests that the specialty is attracting
24
M. Lei et al. / Clinical Oncology 24 (2012) 22e24
increasingly academic trainees. Twenty per cent have completed or are currently undertaking out f programme experience (OOPE), with a further 61% planning to undertake a period of OOPE in the future. Most embark on higher degree research programmes, although fellowships in UK or foreign institutions are also popular. The large numbers of trainees pursuing OOPE may also raise a concern that current training and the reality of current job structures do not satisfy modern clinical oncology training needs. The job market is as competitive as ever and specialist experience in advanced radiotherapy and research skills adds strength to applications for consultant posts. Perhaps understandably, given recent low pass rates, many trainees delay organising OOPE until they have undertaken the Final FRCR successfully. From personal experience, we urge colleagues to allow sufficient time d up to 12 months d for this process. Finding, organising and funding a good project is time-consuming and often dependent on numerous factors beyond a trainee’s control. Added pressure results from some Deaneries approving OOPE on condition that a minimum of 12 months of preCCT time remains on the clock.
Academic Careers The 2009 survey identified that 28% of respondents intend to pursue an academic career. Aspirations range from careers as academic clinical oncologists, to clinical oncologists with academic sessions, to a career as a clinical oncologist with 100% clinical commitments, but with participation in research at other levels, for example, in enrolling patients into clinical studies. Perhaps not surprisingly, it was felt that there are insufficient consultant jobs available with academic sessions. Funding for research time within a consultant’s job plan may come from many sources and current economic times are a challenge. It is important that support from National Health Service Trusts and academic institutions continues to facilitate innovative research activities and that appropriate mentorship is provided for keen trainees.
Certificate of Completion of Training and Beyond After passing the Final FRCR, most trainees have 18 months of clinical training left before the award of a CCT. Some will undertake a period of OOPE. For the rest, the looming prospects of working as a consultant clinical oncologist and the associated responsibilities are daunting. Focus shifts to improving experience in selected tumour sites of professional interest, developing research interests or gaining technically advanced therapeutic skills that may be of value to dynamic departments with active research and development programmes. Having devoted so much effort to honing clinical skills, we realise, perhaps belatedly, how little we understand of Trust and departmental management, strategy and business planning. Consultant job plans suddenly become more interesting. There is a growing trend for new posts to be
advertised with only one Supporting Professional Activity (SPA). Revalidation alone requires a minimum of 1.5 SPAs per week [8]. Additional SPAs are needed to support teaching, training, research, service development, clinical governance and contribution to management. Both the Royal College of Radiologists and the British Medical Association recommend 2.5 SPAs [9]. If job plans are poorly designed, how can the clinical oncologists of the future continue to maintain and improve service long term and who will have time to train the next clinical oncologists?
Conclusion During recent years, numerous changes have impacted on the training experience of clinical oncology trainees. Direction and support of trainees in response to these pressures has been excellent in general. Challenges will continue to evolve. Advanced radiotherapy techniques and acute oncology are two differing examples and it is important that trainees and trainers remain alert for changes, remain flexible and respond in a timely manner. Trainers must be provided with sufficient time in their job plans to provide high-quality training. The promotion of research and the important role of radiotherapy in cancer management are issues close to trainees’ hearts. Clinical oncology trainees are the oncologists of the future and we are motivated in the quest to provide a modern, world-class oncology service.
Acknowledgement We would like to acknowledge Anna Campbell, Executive Education Officer and Oncology Registrars’ Forum Secretariat, for her encouragement and support of the Oncology Registrars’ Forum, and in particular, her vital input into the Oncology Registrars’ Forum Trainee Surveys.
References [1] Oncology registrars’ forum trainee survey AprileMay 2011 comprehensive report 2011. [2] Oncology registrars’ forum trainee survey Oct/Nov 2009 comprehensive report 2010. [3] General Medical Council. Workplace based assessment: a guide for implementation (supplementary guidance) 2010. [4] RCR RCoR. Workplace based assessments. Available at: http:// www.rcr.ac.uk/content.aspx?PageID¼1813 [5] Temple J. Time for training. A review of the impact of the European Working Time Directive on the quality of training. Medical Education England 2010. [6] RCR RCoR. Employment of clinical oncology registrars in ‘Hospital at Night’ teams. Guidance from the Royal College of Radiologists 2011. [7] NCAG. Chemotherapy services in England: ensuring quality and safety. A report from the National Chemotherapy Advisory Group 2008. [8] Board of the Faculty of Clinical Oncology. The Royal College of Radiologists. Guide to job planning in clinical oncology 2011. [9] British Medical Association. NHS employers and the British Medical Association (BMA) 2011. A guide to consultant job planning.