- Email: [email protected]
Program director and chief resident perspectives on the educational environment of US radiation oncology programs
Practical Radiation Oncology (2016) xx, xxx–xxx
www.practicalradonc.org
Basic Original Article
Program director and chief resident perspectives on the educational environment of US radiation oncology programs Camille Berriochoa MD, Michael Weller MD, Danielle Berry BS, Chandana A. Reddy MS, Shlomo Koyfman MD, Rahul Tendulkar MD ⁎ Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH Received 13 April 2016; revised 26 May 2016; accepted 1 June 2016
Abstract Purpose: Our goals were to examine the educational approaches used at radiation oncology residency programs nationwide and to evaluate program director (PD) and chief resident (CR) perceptions of their educational environment. Methods and materials: We distributed a survey regarding curricular structure via email to all identified US radiation oncology residency PDs and CRs. Pearson χ 2 test was used to evaluate whether differences existed between answers provided by the 2 study populations. Results: The survey was disseminated to 200 individuals in 85 US residency programs: 49/ 85 PDs (58%) and 74/115 (64%) CRs responded. More than one-half of PDs and CRs report that attending physicians discussed management, reviewed contours, and conducted mock oral board examinations with the residents. At nearly 50% of programs, the majority of teaching conferences use a lecture-based approach, whereas only 20% reported predominant utilization of the Socratic method. However, both PDs (63%) and CRs (49%) reported that Socratic teaching is more effective than didactic lectures (16% and 20%, respectively), with the remainder responding that they are equally effective. Teaching sessions were reported to be resident-led ≥ 75% of the time by 50% of CRs versus 18% of PDs (P = .002). Significantly more CRs than PDs felt that faculty-led teaching conferences were more effective than resident-led conferences (62% vs 26%, respectively; P b .001). There was a difference in perception regarding the protection of educational time, with 85% of PDs versus 59% of CRs reporting this time as being “never” or “infrequently” compromised by clinical duties (P = .005). Conclusions: There is considerable variability between PDs and CRs in the perceived structure and effectiveness of resident education in US radiation oncology residency programs. These data suggest opportunity for improvement in radiation oncology residency training, such as encouraging more faculty-led, Socratic-based teaching conferences. Increased communication between PDs and CRs can better align perceptions with educational goals. © 2016 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
Supplementary material for this article (http://dx.doi.org/10.1016/j.prro.2016.06.001) can be found at www.practicalradonc.org. Conflicts of interest: None. ⁎ Corresponding author. Department of Radiation Oncology, Desk T28, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail address: [email protected] (R. Tendulkar). http://dx.doi.org/10.1016/j.prro.2016.06.001 1879-8500/© 2016 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
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Introduction Radiation oncology is a unique field within medicine, with residents having little exposure to the specialty before commencement of their training. Physics and radiation biology are integral components of clinical practice and represent 2 of the 4 areas of examination required to pass for board certification. The general curriculum structure of radiation oncology residency programs has not been well-characterized in the literature. However, of the few published relevant studies, most have shown that the development of explicit radiation oncology and oncoanatomy curricula improve learner satisfaction and knowledge retention. 1-6 These findings, though limited in scope, suggest that the way in which curriculum is implemented has an important impact on outcomes in radiation oncology education. By disseminating an anonymous online survey, we sought to quantify and characterize the academic structure employed by radiation oncology programs nationwide. Given the potential for varying perceptions in describing the educational environment of each of their programs, we divided our study population into 2 cohorts, chief residents (CRs) and program directors (PDs). Each cohort received identical surveys. Areas of agreement and difference in the responses between these 2 populations were identified.
Practical Radiation Oncology: Month 2016
survey and to guarantee the anonymity of responses. Multiple responses from the same internet protocol address were prohibited. Three online reminders were delivered between February 11, 2015, and March 10, 2015, with an open response period of approximately 3 months. No cash awards, raffles, or other incentives were offered to solicit responses. The complete survey is in Appendix EI (available as supplementary material online only at www.practicalradonc.org).
Statistics Pearson χ 2 test was used to evaluate whether statistically significant differences existed between answers provided by the 2 study groups (ie, PD and CR), with P b .05 considered statistically significant. To simplify the way in which responses were categorized, responses on either end of the Likert scale (eg, “moderately” and “frequently,” “rarely” and “infrequently,” respectively) were combined before statistical analysis. Statistical analysis was performed using JMP Pro V10 software (SAS Institute, Cary, NC).
Results Response rates and demographics
Methods and materials Survey creation This survey was created to specifically address 3 domains: (1) clinical resident education, (2) the conference structure employed during dedicated educational time, and (3) the resident’s weekly academic and clinical responsibilities. To assess the demographic information as it relates to the respondent’s program, respondents were asked to describe their residency program (community hospital, tertiary care center, university-based hospital) and the size of the program both in number of residents and number of clinical faculty.
Survey dissemination We distributed our 21-question online survey regarding curricular structure and culture via email to all identified 2014-2015 PDs and CRs of US radiation oncology residency programs. E-mail addresses of the individuals serving these roles during this academic year were verified by contacting program coordinators if the published contact information was noted to be out of date. An institutional survey software program entitled Class Apps SelectSurvey.Net (Microsoft 2008) was used to deploy the
The survey was disseminated to 200 individuals in 85 US residency programs as some programs identified more than 1 CR. Overall, 49/85 PDs (58%) and 74/115 (64%) CRs responded. Among PDs and CRs, 88% and 85% described themselves as practicing at a university-based hospital, respectively. There were no significant differences between the 2 groups of respondents in terms of program size or description (community, tertiary care, university-based) (Table 1). Select results are described in the following section, with complete results available for review in the eTable.
Weekly resident duties More than 60% of programs report dedicating at least 5 hours per week for educational conferences (73% per PDs, 62% per CRs; P = .19). In terms of preparation for each educational conference, 77% of CRs responded that residents devoted 2 hours or less preparing for each conference. Among PDs, 51% perceived that residents spent 2 hours or less preparing for these conferences, with 27% stating that they are unsure of how much time residents spend doing so. At more than half of programs, residents are required to cover multiple attending physicians in clinic within the same week (53% per both PDs and CRs). At approximately 30% of programs, residents
Practical Radiation Oncology: Month 2016 Table 1
Survey on U.S. radiation oncology residency education
3
Composition of respondents Program director (N = 49)
Chief resident (N = 74)
% (N)
% (N)
Residency program setting Community hospital 2% (1) Tertiary care hospital 10% (5) University-based hospital 88% (43) Number of clinical faculty in program 7 or fewer 27% (13) 8 to 11 29% (14) 12 or more 45% (22) Number of residents in program 7 or fewer 35% (17) 8 to 11 37% (18) 12 or more 29% (14)
P value
.68 0% (0) 15% (11) 85% (63) .95 28% (21) 30% (22) 42% (31) .85 39% (29) 32% (24) 28% (21)
are required to find co-resident cross-coverage when they are away from clinic (31% per CRs, 27% per PDs).
Clinical resident education More than half of PDs and CRs agreed that attending physicians discussed evidence-based management following patient consults ≥ 75% of the time (53% per PDs, 55% per CRs). More than 60% of both PDs and CRs reported that attending physicians personally review contours with residents ≥ 75% of the time (74% per PDs, 61% per CRs; P = .14). Seventy-three percent of PDs responded that faculty conduct mock oral examinations ≥ 50% of the time while only 56% of CRs responded likewise (P = .04). Regarding visiting professors, 48% of CRs and 51% of PDs responded that their programs host a visiting professor ≥ 3 times per year, whereas 12% of both PDs and CRs stated that their program never invites a visiting professor.
Conference structure PDs and CRs were asked whether academic conferences were most frequently didactic-based (ie, lecture) or Socratic-based (ie, question and answer). Respondents agreed that at nearly 50% of programs, the majority of teaching conferences use a didactic lecture-based approach (49% of PDs, 46% of CRs, respectively), whereas only 20% of programs have the majority of conferences conducted in a Socratic manner (22% of PDs, 19% of CRs, respectively; P = .78; Fig 1A). Approximately 30% of each group (29% of PDs and 35% of CRs) reported an equal distribution of Socratic- and lecture-based approaches. Regarding efficacy of teaching methods, 63% of PDs and 49% of CRs felt that Socratic teaching is more effective and 14% of PDs and 20% of CRs felt that
Figure 1 Bar chart comparing perceptions of frequency (A) and efficacy (B) of lecture-based versus Socratic-based teaching methods.
lecture-based teaching was more effective, with the remainder (23% and 31%, respectively) stating that they felt both methods are equally effective (P = .28, Fig 1B). Teaching sessions were reported to be resident-led ≥ 75% of the time by 50% of CRs versus 18% of PDs (P b .01). When asked, CRs differed from PDs on the type of moderator (faculty or resident) felt to be most effective: 26% of PDs versus 63% of CRs felt that faculty-led teaching conferences were more effective than resident-led conferences, with 53% versus 32% of PDs and CRs, respectively, stating that they are equally effective (P b
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Figure 2 Bar chart comparing perceived efficacy of faculty-led versus resident-led conferences.
.01, Fig 2). Regarding protection of resident learning time, 40% of CRs reported that educational time is moderately/ frequently interrupted, whereas 14% of PDs responded this way (P b .01, Fig 3).
Discussion This is the first survey to report on US academic radiation oncology programs’ overarching curricular structure and the first to compare perspectives among radiation oncology PDs and CRs as to the strengths and efficacy of various approaches. Publications discussing the educational environment of US residency programs are relatively rare, particularly in the field of radiation oncology. Shakespeare et al in 2005 described their work in establishing the first dedicated radiation oncology training program in Singapore, reporting that “educational research is not well documented in clinical medical journals [in general, which] also appears to be true for radiation oncology specialty training, despite the attention it has received in recent years.” 7 Using the terms “residency program structure in [a given field]” via PubMed search generated 36 results for general surgery, 78 for internal medicine, 42 for pediatrics, 24 for radiology, and only 3 for radiation oncology. Despite the relatively small size of the field of radiation oncology, this remains a low number for a specialty whose explicit educational component is crucial in light of the very minimal exposure to this field trainees receive prior to residency. Residents typically enter this specialty after a 1-year internship with minimal to no background in the
Practical Radiation Oncology: Month 2016
Figure 3 Bar chart comparing chief resident and program director perceptions of how often protected resident educational/ conference time is compromised by clinical duties.
software and technology used to implement care. Furthermore, principles in physics and radiobiology serve as the core of treatment methods, yet most residents have not been trained in these principles since their undergraduate education. For these reasons, the didactic structure of radiation oncology programs becomes exceedingly important to provide residents in training with a solid foundation for the remainder of their careers. Also lacking in the literature is a comparison of the perspectives of CRs and PDs, with only 2 discovered via PubMed search, 1 in the field of pediatrics and another in psychiatry. 8,9 These findings compelled us to disseminate a survey characterizing the educational structure at radiation oncology programs around the country and to divide responses into those provided by PDs and CRs to better understand where their views converge and differ. Our findings suggest that the clinical learning environment among the majority of radiation oncology programs is quite robust, with many attending physicians showing significant investment in the day-to-day clinical education of residents. This is evidenced by N 50% of PDs and CRs agreeing that evidence-based management is discussed more than three-quarters of the time, and N 60% in both groups agreeing that contours were reviewed with residents with the same high frequency. Both PDs and CRs also stated that mock oral examinations were completed on a regular basis. There were 3 notable findings that may elucidate some facets of clinical radiation oncology education that could be improved. First, a minority (20% of PDs and CRs) responded that Socratic methods were a predominant component of their program, whereas approximately 50%
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Practical Radiation Oncology: Month 2016
Survey on U.S. radiation oncology residency education
in each group felt that a Socratic conference style is more effective than a purely didactic style. This suggests that question-based, interactive learning could be greater used. Small-group, problem-based learning methods have been discussed extensively in medical education over the past 2 decades, particularly in the medical school setting. 10-15 Henry Walton of the World Federation for Medical Education wrote that “small group work enables participants to gain a great deal from their fellows, in a type of communication which cannot take place in a lecture hall.” 16 This is a central concept in the adult learning theory first pioneered by Malcolm Knowles at the University of Chicago in the 1950s. It has continued to be discussed in the realm of medical education over many decades and has contributed to the restructuring of many US medical colleges’ curricula over the past several years. In 1 study that documented the transition from lecture-based to small group, question-based learning, both students and faculty reported increased satisfaction with the change but acknowledged the increased time necessary to make this transition. 17 That said, average National Board of Medical Examiners test scores improved from 55% to 61% (P = .04) following the intervention. 17 Though it is unknown whether other educational initiatives were undertaken at the time that might have confounded this result, it nevertheless suggests that not only is question-based learning more satisfactory, but also may actually be more efficacious. These transitions should not be limited to undergraduate medical education: in a review article investigating the efficacy of continuing medical education among 50 randomized controlled trials, inherently directed at postgraduate medical professionals, authors concluded that “workshops which provide more opportunity for case discussion and rehearsal of practice behaviors are considerably more effective than are more didactic programs.” 18 The second important finding of this survey that could lend itself to further optimization of radiation oncology residency programs is the stark difference in the perceived efficacy of resident- versus faculty-led conferences. As stated previously, more than double the number of CRs versus PDs felt that faculty-led teaching conferences were more effective. This knowledge may encourage program leadership to solicit more faculty participation in leading and/or moderating educational sessions when available. The third and perhaps most important finding of this survey was that, overall, there were several important educational domains in which PD and CR perceptions diverged. Nearly 20% more PDs than CRs estimated that faculty implemented mock oral examinations with their residents on a regular basis; more than 30% more CRs than PDs reported that academic conferences were more commonly resident- rather than attending-led; more than double the percentage of CRs than PDs (62% vs 27%) felt that faculty led teaching was more effective; and nearly triple the number of CRs than PDs reported that protected educational time is moderately/frequently interrupted.
These findings suggest that CRs have a number of concerns about the way education is implemented at their respective programs, and PDs may not be aware of the discordant perceptions. Enhanced communication between PDs and CRs may help bridge this gap in perception and can facilitate changes that can better serve residents and faculty alike. There are several limitations to this study. We received responses from just over half of US radiation oncology programs, and reporting bias may exist. Furthermore, we cannot confirm that the comparison in responses between PDs and CRs represents views from the same institutions and thus the contrasting responses may be less robust. In addition, the limited overall sample size may have underestimated differences between PD and CRs that were nominally quite different but did not reach statistical significance. Despite these limitations, the results of this survey provide valuable information for PDs and CRs to improve their interpersonal communication as well as the quality of teaching and learning in radiation oncology residency programs around the United States.
Conclusions This survey highlights the considerable variability in the perceived structure and effectiveness of resident education in US radiation oncology residency programs. Although there is strong agreement regarding the perceived efficacy of Socratic teaching methods, only a minority of programs use this approach on a consistent basis. PDs and CRs differ in their perceptions of the efficacy and frequency of resident- versus faculty-led educational conferences. This heterogeneity represents an opportunity for improvement in radiation oncology residency training. More thorough and frequent communication between the PD and CR at each program may narrow the gap in perception and foster the dialogue needed to accomplish improved alignment and meaningful change in the educational methods used.
References 1. Labranche L, Johnson M, Palma D, et al. Integrating anatomy training into radiation oncology residency: Considerations for developing a multidisciplinary, interactive learning module for adult learners. Anat Sci Educ. 2015;8:158-165. 2. Cabrera AR, Lee WR, Madden R, et al. Incorporating gross anatomy education into radiation oncology residency: A 2-year curriculum with evaluation of resident satisfaction. J Am Coll Radiol. 2011;8:335-340. 3. 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. 4. Radiation Oncology Education Collaborative Study Group, Radiation Oncology Education Collaborative Study Group Writing
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C. Berriochoa et al Committee, Golden DW, et al. Multi-institutional implementation and evaluation of a curriculum for the medical student clerkship in radiation oncology. J Am Coll Radiol. 2016;13:203-209. Jagadeesan VS, Raleigh DR, Koshy M, et al. A national radiation oncology medical student clerkship survey: Didactic curricular components increase confidence in clinical competency. Int J Radiat Oncol Biol Phys. 2014;88:51-56. Golden DW, Spektor A, Rudra S, et al. Radiation oncology medical student clerkship: Implementation and evaluation of a bi-institutional pilot curriculum. Int J Radiat Oncol Biol Phys. 2014;88:45-50. Shakespeare TP, Back MF, Lu JJ, et al. Design of an internationally accredited radiation oncology resident training program incorporating novel educational models. Int J Radiat Oncol Biol Phys. 2004;59:115711-115762. Dabrow SM, Harris EJ, Maldonado LA, et al. Two perspectives on the educational and administrative roles of the pediatric chief resident. J Grad Med Educ. 2011;3:17-20. Yudkowsky R, Elliott R, Schwartz A. Two perspectives on the indicators of quality in psychiatry residencies: Program directors' and residents'. Acad Med. 2002;77:57-64. Mann KV, Kaufman DM. A comparative study of problem-based and conventional undergraduate curricula in preparing students for graduate medical education. Acad Med. 1999;74:S4-S6.
Practical Radiation Oncology: Month 2016 11. Schmidt HG, Dauphinee WD, Patel VL. Comparing the effects of problem-based and conventional curricula in an international sample. J Med Educ. 1987;62:305-315. 12. Zhao B, Potter DD. Comparison of lecture-based learning vs discussion-based learning in undergraduate medical students. J Surg Educ. 2016;73:250-257. 13. Moore GT, Block SD, Style CB, et al. The influence of the New Pathway curriculum on Harvard medical students. Acad Med. 1994;69:983-989. 14. Vernon DT, Blake RL. Does problem-based learning work? A meta-analysis of evaluative research. Acad Med. 1993;68:550-563. 15. Kaufman DM, Mann KV. Comparing achievement on the Medical Council of Canada Qualifying Examination Part I of students in conventional and problem-based learning curricula. Acad Med. 1998;73:1211-1213. 16. Walton H. Small group methods in medical teaching. Med Educ. 1997;31:459-464. 17. Cendan JC, Silver M, Ben-David K. Changing the student clerkship from traditional lectures to small group case-based sessions benefits the student and the faculty. J Surg Educ. 2011;68:117-120. 18. Davis DA, Thomson MA, Oxman AD, et al. Evidence for the effectiveness of CME. A review of 50 randomized controlled trials. JAMA. 1992;268:1111-1117.
www.practicalradonc.org
Basic Original Article
Program director and chief resident perspectives on the educational environment of US radiation oncology programs Camille Berriochoa MD, Michael Weller MD, Danielle Berry BS, Chandana A. Reddy MS, Shlomo Koyfman MD, Rahul Tendulkar MD ⁎ Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH Received 13 April 2016; revised 26 May 2016; accepted 1 June 2016
Abstract Purpose: Our goals were to examine the educational approaches used at radiation oncology residency programs nationwide and to evaluate program director (PD) and chief resident (CR) perceptions of their educational environment. Methods and materials: We distributed a survey regarding curricular structure via email to all identified US radiation oncology residency PDs and CRs. Pearson χ 2 test was used to evaluate whether differences existed between answers provided by the 2 study populations. Results: The survey was disseminated to 200 individuals in 85 US residency programs: 49/ 85 PDs (58%) and 74/115 (64%) CRs responded. More than one-half of PDs and CRs report that attending physicians discussed management, reviewed contours, and conducted mock oral board examinations with the residents. At nearly 50% of programs, the majority of teaching conferences use a lecture-based approach, whereas only 20% reported predominant utilization of the Socratic method. However, both PDs (63%) and CRs (49%) reported that Socratic teaching is more effective than didactic lectures (16% and 20%, respectively), with the remainder responding that they are equally effective. Teaching sessions were reported to be resident-led ≥ 75% of the time by 50% of CRs versus 18% of PDs (P = .002). Significantly more CRs than PDs felt that faculty-led teaching conferences were more effective than resident-led conferences (62% vs 26%, respectively; P b .001). There was a difference in perception regarding the protection of educational time, with 85% of PDs versus 59% of CRs reporting this time as being “never” or “infrequently” compromised by clinical duties (P = .005). Conclusions: There is considerable variability between PDs and CRs in the perceived structure and effectiveness of resident education in US radiation oncology residency programs. These data suggest opportunity for improvement in radiation oncology residency training, such as encouraging more faculty-led, Socratic-based teaching conferences. Increased communication between PDs and CRs can better align perceptions with educational goals. © 2016 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
Supplementary material for this article (http://dx.doi.org/10.1016/j.prro.2016.06.001) can be found at www.practicalradonc.org. Conflicts of interest: None. ⁎ Corresponding author. Department of Radiation Oncology, Desk T28, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail address: [email protected] (R. Tendulkar). http://dx.doi.org/10.1016/j.prro.2016.06.001 1879-8500/© 2016 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
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Introduction Radiation oncology is a unique field within medicine, with residents having little exposure to the specialty before commencement of their training. Physics and radiation biology are integral components of clinical practice and represent 2 of the 4 areas of examination required to pass for board certification. The general curriculum structure of radiation oncology residency programs has not been well-characterized in the literature. However, of the few published relevant studies, most have shown that the development of explicit radiation oncology and oncoanatomy curricula improve learner satisfaction and knowledge retention. 1-6 These findings, though limited in scope, suggest that the way in which curriculum is implemented has an important impact on outcomes in radiation oncology education. By disseminating an anonymous online survey, we sought to quantify and characterize the academic structure employed by radiation oncology programs nationwide. Given the potential for varying perceptions in describing the educational environment of each of their programs, we divided our study population into 2 cohorts, chief residents (CRs) and program directors (PDs). Each cohort received identical surveys. Areas of agreement and difference in the responses between these 2 populations were identified.
Practical Radiation Oncology: Month 2016
survey and to guarantee the anonymity of responses. Multiple responses from the same internet protocol address were prohibited. Three online reminders were delivered between February 11, 2015, and March 10, 2015, with an open response period of approximately 3 months. No cash awards, raffles, or other incentives were offered to solicit responses. The complete survey is in Appendix EI (available as supplementary material online only at www.practicalradonc.org).
Statistics Pearson χ 2 test was used to evaluate whether statistically significant differences existed between answers provided by the 2 study groups (ie, PD and CR), with P b .05 considered statistically significant. To simplify the way in which responses were categorized, responses on either end of the Likert scale (eg, “moderately” and “frequently,” “rarely” and “infrequently,” respectively) were combined before statistical analysis. Statistical analysis was performed using JMP Pro V10 software (SAS Institute, Cary, NC).
Results Response rates and demographics
Methods and materials Survey creation This survey was created to specifically address 3 domains: (1) clinical resident education, (2) the conference structure employed during dedicated educational time, and (3) the resident’s weekly academic and clinical responsibilities. To assess the demographic information as it relates to the respondent’s program, respondents were asked to describe their residency program (community hospital, tertiary care center, university-based hospital) and the size of the program both in number of residents and number of clinical faculty.
Survey dissemination We distributed our 21-question online survey regarding curricular structure and culture via email to all identified 2014-2015 PDs and CRs of US radiation oncology residency programs. E-mail addresses of the individuals serving these roles during this academic year were verified by contacting program coordinators if the published contact information was noted to be out of date. An institutional survey software program entitled Class Apps SelectSurvey.Net (Microsoft 2008) was used to deploy the
The survey was disseminated to 200 individuals in 85 US residency programs as some programs identified more than 1 CR. Overall, 49/85 PDs (58%) and 74/115 (64%) CRs responded. Among PDs and CRs, 88% and 85% described themselves as practicing at a university-based hospital, respectively. There were no significant differences between the 2 groups of respondents in terms of program size or description (community, tertiary care, university-based) (Table 1). Select results are described in the following section, with complete results available for review in the eTable.
Weekly resident duties More than 60% of programs report dedicating at least 5 hours per week for educational conferences (73% per PDs, 62% per CRs; P = .19). In terms of preparation for each educational conference, 77% of CRs responded that residents devoted 2 hours or less preparing for each conference. Among PDs, 51% perceived that residents spent 2 hours or less preparing for these conferences, with 27% stating that they are unsure of how much time residents spend doing so. At more than half of programs, residents are required to cover multiple attending physicians in clinic within the same week (53% per both PDs and CRs). At approximately 30% of programs, residents
Practical Radiation Oncology: Month 2016 Table 1
Survey on U.S. radiation oncology residency education
3
Composition of respondents Program director (N = 49)
Chief resident (N = 74)
% (N)
% (N)
Residency program setting Community hospital 2% (1) Tertiary care hospital 10% (5) University-based hospital 88% (43) Number of clinical faculty in program 7 or fewer 27% (13) 8 to 11 29% (14) 12 or more 45% (22) Number of residents in program 7 or fewer 35% (17) 8 to 11 37% (18) 12 or more 29% (14)
P value
.68 0% (0) 15% (11) 85% (63) .95 28% (21) 30% (22) 42% (31) .85 39% (29) 32% (24) 28% (21)
are required to find co-resident cross-coverage when they are away from clinic (31% per CRs, 27% per PDs).
Clinical resident education More than half of PDs and CRs agreed that attending physicians discussed evidence-based management following patient consults ≥ 75% of the time (53% per PDs, 55% per CRs). More than 60% of both PDs and CRs reported that attending physicians personally review contours with residents ≥ 75% of the time (74% per PDs, 61% per CRs; P = .14). Seventy-three percent of PDs responded that faculty conduct mock oral examinations ≥ 50% of the time while only 56% of CRs responded likewise (P = .04). Regarding visiting professors, 48% of CRs and 51% of PDs responded that their programs host a visiting professor ≥ 3 times per year, whereas 12% of both PDs and CRs stated that their program never invites a visiting professor.
Conference structure PDs and CRs were asked whether academic conferences were most frequently didactic-based (ie, lecture) or Socratic-based (ie, question and answer). Respondents agreed that at nearly 50% of programs, the majority of teaching conferences use a didactic lecture-based approach (49% of PDs, 46% of CRs, respectively), whereas only 20% of programs have the majority of conferences conducted in a Socratic manner (22% of PDs, 19% of CRs, respectively; P = .78; Fig 1A). Approximately 30% of each group (29% of PDs and 35% of CRs) reported an equal distribution of Socratic- and lecture-based approaches. Regarding efficacy of teaching methods, 63% of PDs and 49% of CRs felt that Socratic teaching is more effective and 14% of PDs and 20% of CRs felt that
Figure 1 Bar chart comparing perceptions of frequency (A) and efficacy (B) of lecture-based versus Socratic-based teaching methods.
lecture-based teaching was more effective, with the remainder (23% and 31%, respectively) stating that they felt both methods are equally effective (P = .28, Fig 1B). Teaching sessions were reported to be resident-led ≥ 75% of the time by 50% of CRs versus 18% of PDs (P b .01). When asked, CRs differed from PDs on the type of moderator (faculty or resident) felt to be most effective: 26% of PDs versus 63% of CRs felt that faculty-led teaching conferences were more effective than resident-led conferences, with 53% versus 32% of PDs and CRs, respectively, stating that they are equally effective (P b
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Figure 2 Bar chart comparing perceived efficacy of faculty-led versus resident-led conferences.
.01, Fig 2). Regarding protection of resident learning time, 40% of CRs reported that educational time is moderately/ frequently interrupted, whereas 14% of PDs responded this way (P b .01, Fig 3).
Discussion This is the first survey to report on US academic radiation oncology programs’ overarching curricular structure and the first to compare perspectives among radiation oncology PDs and CRs as to the strengths and efficacy of various approaches. Publications discussing the educational environment of US residency programs are relatively rare, particularly in the field of radiation oncology. Shakespeare et al in 2005 described their work in establishing the first dedicated radiation oncology training program in Singapore, reporting that “educational research is not well documented in clinical medical journals [in general, which] also appears to be true for radiation oncology specialty training, despite the attention it has received in recent years.” 7 Using the terms “residency program structure in [a given field]” via PubMed search generated 36 results for general surgery, 78 for internal medicine, 42 for pediatrics, 24 for radiology, and only 3 for radiation oncology. Despite the relatively small size of the field of radiation oncology, this remains a low number for a specialty whose explicit educational component is crucial in light of the very minimal exposure to this field trainees receive prior to residency. Residents typically enter this specialty after a 1-year internship with minimal to no background in the
Practical Radiation Oncology: Month 2016
Figure 3 Bar chart comparing chief resident and program director perceptions of how often protected resident educational/ conference time is compromised by clinical duties.
software and technology used to implement care. Furthermore, principles in physics and radiobiology serve as the core of treatment methods, yet most residents have not been trained in these principles since their undergraduate education. For these reasons, the didactic structure of radiation oncology programs becomes exceedingly important to provide residents in training with a solid foundation for the remainder of their careers. Also lacking in the literature is a comparison of the perspectives of CRs and PDs, with only 2 discovered via PubMed search, 1 in the field of pediatrics and another in psychiatry. 8,9 These findings compelled us to disseminate a survey characterizing the educational structure at radiation oncology programs around the country and to divide responses into those provided by PDs and CRs to better understand where their views converge and differ. Our findings suggest that the clinical learning environment among the majority of radiation oncology programs is quite robust, with many attending physicians showing significant investment in the day-to-day clinical education of residents. This is evidenced by N 50% of PDs and CRs agreeing that evidence-based management is discussed more than three-quarters of the time, and N 60% in both groups agreeing that contours were reviewed with residents with the same high frequency. Both PDs and CRs also stated that mock oral examinations were completed on a regular basis. There were 3 notable findings that may elucidate some facets of clinical radiation oncology education that could be improved. First, a minority (20% of PDs and CRs) responded that Socratic methods were a predominant component of their program, whereas approximately 50%
5
Practical Radiation Oncology: Month 2016
Survey on U.S. radiation oncology residency education
in each group felt that a Socratic conference style is more effective than a purely didactic style. This suggests that question-based, interactive learning could be greater used. Small-group, problem-based learning methods have been discussed extensively in medical education over the past 2 decades, particularly in the medical school setting. 10-15 Henry Walton of the World Federation for Medical Education wrote that “small group work enables participants to gain a great deal from their fellows, in a type of communication which cannot take place in a lecture hall.” 16 This is a central concept in the adult learning theory first pioneered by Malcolm Knowles at the University of Chicago in the 1950s. It has continued to be discussed in the realm of medical education over many decades and has contributed to the restructuring of many US medical colleges’ curricula over the past several years. In 1 study that documented the transition from lecture-based to small group, question-based learning, both students and faculty reported increased satisfaction with the change but acknowledged the increased time necessary to make this transition. 17 That said, average National Board of Medical Examiners test scores improved from 55% to 61% (P = .04) following the intervention. 17 Though it is unknown whether other educational initiatives were undertaken at the time that might have confounded this result, it nevertheless suggests that not only is question-based learning more satisfactory, but also may actually be more efficacious. These transitions should not be limited to undergraduate medical education: in a review article investigating the efficacy of continuing medical education among 50 randomized controlled trials, inherently directed at postgraduate medical professionals, authors concluded that “workshops which provide more opportunity for case discussion and rehearsal of practice behaviors are considerably more effective than are more didactic programs.” 18 The second important finding of this survey that could lend itself to further optimization of radiation oncology residency programs is the stark difference in the perceived efficacy of resident- versus faculty-led conferences. As stated previously, more than double the number of CRs versus PDs felt that faculty-led teaching conferences were more effective. This knowledge may encourage program leadership to solicit more faculty participation in leading and/or moderating educational sessions when available. The third and perhaps most important finding of this survey was that, overall, there were several important educational domains in which PD and CR perceptions diverged. Nearly 20% more PDs than CRs estimated that faculty implemented mock oral examinations with their residents on a regular basis; more than 30% more CRs than PDs reported that academic conferences were more commonly resident- rather than attending-led; more than double the percentage of CRs than PDs (62% vs 27%) felt that faculty led teaching was more effective; and nearly triple the number of CRs than PDs reported that protected educational time is moderately/frequently interrupted.
These findings suggest that CRs have a number of concerns about the way education is implemented at their respective programs, and PDs may not be aware of the discordant perceptions. Enhanced communication between PDs and CRs may help bridge this gap in perception and can facilitate changes that can better serve residents and faculty alike. There are several limitations to this study. We received responses from just over half of US radiation oncology programs, and reporting bias may exist. Furthermore, we cannot confirm that the comparison in responses between PDs and CRs represents views from the same institutions and thus the contrasting responses may be less robust. In addition, the limited overall sample size may have underestimated differences between PD and CRs that were nominally quite different but did not reach statistical significance. Despite these limitations, the results of this survey provide valuable information for PDs and CRs to improve their interpersonal communication as well as the quality of teaching and learning in radiation oncology residency programs around the United States.
Conclusions This survey highlights the considerable variability in the perceived structure and effectiveness of resident education in US radiation oncology residency programs. Although there is strong agreement regarding the perceived efficacy of Socratic teaching methods, only a minority of programs use this approach on a consistent basis. PDs and CRs differ in their perceptions of the efficacy and frequency of resident- versus faculty-led educational conferences. This heterogeneity represents an opportunity for improvement in radiation oncology residency training. More thorough and frequent communication between the PD and CR at each program may narrow the gap in perception and foster the dialogue needed to accomplish improved alignment and meaningful change in the educational methods used.
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