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Results of the 2005-2008 Association of Residents in Radiation Oncology Survey of Chief Residents in the United States: Clinical Training and Resident Working Conditions
Int. J. Radiation Oncology Biol. Phys., Vol. 81, No. 4, pp. 1120–1127, 2011 Copyright Ó 2011 Elsevier Inc. Printed in the USA. All rights reserved 0360-3016/$ - see front matter
doi:10.1016/j.ijrobp.2010.07.018
CLINICAL INVESTIGATION
Residency Training
RESULTS OF THE 2005-2008 ASSOCIATION OF RESIDENTS IN RADIATION ONCOLOGY SURVEY OF CHIEF RESIDENTS IN THE UNITED STATES: CLINICAL TRAINING AND RESIDENT WORKING CONDITIONS VINAI GONDI, M.D.,* JOHNNY RAY BERNARD, JR., M.D.,y SIAVASH JABBARI, M.D.,z JENNIFER KEAM, M.D.,{ KAREN L. DE AMORIM BERNSTEIN, M.D.,x LUQMAN K. DAD, M.D.,** LINNA LI, M.D.,yy MATTHEW M. POPPE, M.D.,zz JONATHAN B. STRAUSS, M.D.,{{ xx AND CASEY T. CHOLLET, M.D. FOR THE ARRO EXECUTIVE COMMITTEE Department of *Radiation Oncology, University of Wisconsin Comprehensive Cancer Center, Madison, Wisconsin; yMayo Clinic Jacksonville, Jacksonville, Florida; zUniversity of California San Francisco, San Francisco, California; {Memorial Sloan-Kettering Cancer Center, New York, New York; xAlbert Einstein College of Medicine, Bronx, New York; **SUNY Roswell Park Cancer Institute, Buffalo, New York; yyFox Chase Cancer Center, Philadelphia, Pennsylvania; zzUniversity of Utah Huntsman Cancer Hospital; {{ Northwestern University Feinberg School of Medicine, Chicago, Illinois; and xxLoyola University Medical Center, Maywood, Illinois Purpose: To document clinical training and resident working conditions reported by chief residents during their residency. Methods and Materials: During the academic years 2005 to 2006, 2006 to 2007, and 2007 to 2008, the Association of Residents in Radiation Oncology conducted a nationwide survey of all radiation oncology chief residents in the United States. Chi-square statistics were used to assess changes in clinical training and resident working conditions over time. Results: Surveys were completed by representatives from 55 programs (response rate, 71.4%) in 2005 to 2006, 60 programs (75.9%) in 2006 to 2007, and 74 programs (93.7%) in 2007 to 2008. Nearly all chief residents reported receiving adequate clinical experience in commonly treated disease sites, such as breast and genitourinary malignancies; and commonly performed procedures, such as three-dimensional conformal radiotherapy and intensitymodulated radiotherapy. Clinical experience in extracranial stereotactic radiotherapy increased over time (p < 0.001), whereas clinical experience in endovascular brachytherapy (p <0.001) decreased over time. The distribution of gynecologic and prostate brachytherapy cases remained stable, while clinical case load in breast brachytherapy increased (p = 0.006). A small but significant percentage of residents reported receiving inadequate clinical experience in pediatrics, seeing 10 or fewer pediatric cases during the course of residency. Procedures involving higher capital costs, such as particle beam therapy and intraoperative radiotherapy, and infrequent clinical use, such as head and neck brachytherapy, were limited to a minority of institutions. Most residency programs associated with at least one satellite facility have incorporated resident rotations into their clinical training, and the majority of residents at these programs find them valuable experiences. The majority of residents reported working 60 or fewer hours per week on required clinical duties. Conclusions: Trends in clinical training and resident working conditions over 3 years are documented to allow residents and program directors to assess their residency training. Ó 2011 Elsevier Inc. ARRO, Association of Residents in Radiation Oncology, Radiation oncology residency, Residency training, Survey.
INTRODUCTION
from 1986 (1), 1989 (2), 1992 (3), 1993 (4), 2000 to 2002 (5), 2003 (6), and 2004 (7) have been published previously. These surveys have provided unique insights into the perceived quality of residency training in radiation oncology in the United States. Surveys have also enabled professional
Founded in 1982, the Association of Residents in Radiation Oncology (ARRO) has represented all radiation oncology residents in the United States and has conducted surveys of these residents for almost 3 decades. Results of these surveys
Acknowledgment—We thank Eugene Kim, Steven Smith, and Kathy Thomas of the American Society of Radiation Oncology for administrative assistance; Anita R. Kharwadkar for technical assistance; Paul M. Harari, M.D., for manuscript review; and 189 recently graduated chief residents for their participation. Received May 10, 2010, and in revised form June 24, 2010. Accepted for publication July 2, 2010.
Reprint requests to: Vinai Gondi, M.D., University of Wisconsin Comprehensive Cancer Center 600 Highland Ave., Madison, WI 53792. Tel: (608) 263-8500; Fax: (608) 262-6256; E-mail: [email protected] Presented at the 52nd Annual Meeting of the American Society of Radiation Oncology, Chicago, IL, November 1-5th, 2009. Conflicts of interest none. 1120
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85.2 83.3 77.8 79.6 86.4 85.7 90.7 83.3 86.1
Lymphoma Pediatrics Sarcomas GI
90.3
96.3 98.3
96.3 96.7 93.1 88.9 91.7 95.8 94.4 91.7 95.8 96.3 100.0 97.1 96.3 98.3 98.6 96.3 95.0 98.6
Lung Gyn Head & Neck CNS Breast GU 0
20
40
60
80
100
Percentage of Respondents 2005-06
2006-07
2007-08
Fig. 1. Percentage of respondents who reported receiving adequate clinical experience in particular disease sites. Year-to-year differences, using chi-square statistics, were not statistically significant for any of these disease sites. Numbers at the end of the bars are percentages of respondents in each category. GI = gastrointestinal; Gyn = gynecologic; CNS = central nervous system; GU = genitourinary.
societies, such as the American College of Radiology Standards and Accreditation Committee, the American Society of Radiation Oncology (ASTRO) and the Accreditation Council of Graduate Medical Education’s Residency Review Committee in radiation oncology, to review issues pertinent to residency training. Since 2003, the ARRO Executive Committee has disseminated a separate survey exclusively to chief residents for the purpose of ascertaining their perspectives on their residency programs. This 43-question survey is designed to assess breadth and depth of clinical training, resident working conditions, and other issues pertinent to residency training. The first and only prior report of chief resident survey results was based on the survey administered during the academic year 2003 to 2004 and published in 2005 (6). Since then, the field of radiation oncology has witnessed multiple changes, including wider availability of newer radiation therapy technologies (8), evolving roles of radiation therapy in the treatment of various malignant and nonmalignant diseases (9), expansion of a number of academic radiation oncology departments (10), and increasing competitiveness among medical students seeking specialty training (11–14). These and other changes are likely to have impacted multiple facets of residency training, further highlighting the importance of updating our understanding of the current residency training environment. Herein, we present results from the chief resident survey from academic years 2005 to 2006, 2006 to 2007, and 2007 to 2008, with a particular emphasis on clinical training and resident working conditions. METHODS AND MATERIALS During the academic years 2005 to 2006, 2006 to 2007, and 2007 to 2008, surveys were distributed to chief residents at each radiation oncology training program in the United States. Surveys consisted of 43 questions assessing clinical experience, availability of educa-
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tional resources, research experience, program policies, and working conditions. Chief residents were initially contacted by electronic mail, postal mail, and, if necessary, by telephone to encourage response and ensure a maximal response rate. Each residency training program completed only one questionnaire. Statistical analyses were performed using SPSS version 14.0 software (SPSS Inc., Chicago IL). Chi-square statistics were used to compare responses by year.
RESULTS Demographics Surveys were completed by representatives from 55 programs (response rate, 71.4%) in 2005 to 2006, 60 programs (75.9%) in 2006 to 2007, and 74 programs (93.7%) in 2007 to 2008. The majority of respondents were male (69.1% in 2005-2006, 83.3% in 2006-2007, and 62.2% in 2007-2008), married or in domestic partnerships (68.6% in 2005-2006, 65.0% in 2006-2007, and 73.4% in 20072008), and in their fourth year of radiation oncology training (73.6% in 2005-2006, 68.3% in 2006-2007, and 65.2% in 2007-2008). Proportions of 56.3%, 48.3%, and 48.4% of respondents during 2005 to 2006, 2006 to 2007, and 2007 to 2008, respectively, had or served as a guardian for one or more children. Clinical experience in disease sites Figure 1 demonstrates the percentage of respondents who reported receiving adequate clinical experience in particular disease sites. Disease sites for which >90% of respondents reported receiving adequate clinical experience in all 3 years analyzed included genitourinary (96.3%, 95%, and 98.6% in 2005-2006, 2006-2007, and 2007-2008, respectively), breast (96.3%, 98.3%, 98.6%, respectively), central nervous system (96.3%, 100.0%, 97.1%, respectively), head and neck (94.4%, 91.7%, 95.8%, respectively), lung (96.3%, 96.7%, 93.1%, respectively), and gastrointestinal malignancies (96.3%, 98.3%, 90.3%, respectively). During two of the 3 years analyzed, greater than 90% of respondents reported adequacy of clinical experience with gynecologic malignancies (88.9%, 91.7%, 95.8%, respectively). At least 9% of respondents reported inadequacy of clinical experience with sarcoma cases (9.3%, 16.7%, 13.9%, respectively) and lymphoma cases (14.8%, 16.7%, 22.2%, respectively) during all 3 years analyzed. Year-to-year differences were not statistically significant for any of these disease sites. Clinical experience in radiotherapy procedures Figure 2 demonstrates the percentage of respondents who reported receiving adequate clinical experience with particular radiation oncology procedures. A total of 90% or more respondents reported receiving clinical experience in threedimensional conformal radiotherapy (100.0%, 98.3%, and 98.6% in 2005-2006, 2006-2007, and 2007-2008, respectively), intensity-modulated radiotherapy (100.0%, 98.3%, 98.6%, respectively), cranial stereotactic radiosurgery (96.3%, 100.0%, 98.6%, respectively), high-dose rate brachytherapy (98.1%, 98.3%, 95.9%, respectively), and
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Table 1. Average number of brachytherapy cases performed per resident during the course of residency Site
Fig. 2. Percentage of respondents who reported receiving clinical experience in particular radiation oncology procedures. Chi-square statistics showed increasing availability of clinical experience in extracranial stereotactic radiotherapy (p < 0.001) and decreasing availability of clinical experience in endovascular brachytherapy (p < 0.001) during the time period analyzed. IORT= Intraoperative radiotherapy; SRS = stereotactic radiosurgery; TBI = total body irradiation; HDR = high-dose-rate; LDR = low-dose rate; IMRT = intensity-modulated radiotherapy; 3D-CRT = three-dimensional conformal radiotherapy.
unsealed sources (90.7%, 96.7%, 90.5%, respectively) during all 3 years analyzed. During the 3 years analyzed, the majority of respondents received no clinical experience in intraoperative radiotherapy (65.4%, 73.3%, 71.6%, respectively), hyperthermia (83.0%, 78.3%, 87.8%, respectively), and particle beam therapy (86.3%, 83.1%, 79.7%, respectively). Clinical experience in extracranial stereotactic radiotherapy increased during the years analyzed (62.3%, 71.7%, 86.5%, respectively; p < 0.001). However, a diminishing percentage of respondents gained clinical experience in endovascular brachytherapy over the time period analyzed (41.5%, 33.3%, 17.8%, respectively; p < 0.001).
Clinical experience in brachytherapy Table 1 shows details of the average number of cases reported by respondents to be performed per resident during the course of residency at their respective programs. All respondents reported performing gynecologic brachytherapy, and most residents saw more than 10 cases during the course of residency (78.9%, 91.7%, and 79.4% in 2005-2006, 2006-2007, and 2007-2008, respectively). Most residents performed more than 10 prostate brachytherapy procedures during their course of residency (67.9%, 83.3%, 63.1%, respectively). A significant percentage of programs did not offer clinical experience in breast brachytherapy (28.3%, 28.3% 26.5%, respectively). However, where breast brachytherapy was available, case loads seemed to be increasing, with an increasing percentage of residents reporting taking on more than 30 cases over the course of residency (1.9%, 10.0%, 19.1%, respectively; p = 0.006). Clinical experience with endovascular brachytherapy was offered at fewer programs (32.7%, 32.7%, 14.7%, respectively; p = 0.034).
Gynecologic No. of cases 2005–2006 2006–2007 2007–2008 Prostate No. of cases 2005–2006 2006–2007 2007–2008 Breast No. of cases 2005–2006 2006–2007 2007–2008 Endovascular No. of cases 2005–2006 2006–2007 2007–2008 Head and Neck No. of cases 2005–2006 2006–2007 2007–2008 Other* No. of cases 2005–2006 2006–2007 2007–2008
Percentage of respondents None 0 0 0
1–10 21.1 8.3 20.6
11–30 48.1 51.7 48.5
None 3.8 1.7 2.9
1–10 28.3 15.0 33.8
11–30 45.2 46.7 33.8
None 28.3 28.3 26.5
1–10 54.7 35.0 47.1
11–30 15.1 26.7 7.4
None 67.3 68.3 85.3
1 or more 32.7 32.7 14.7
None 47.2 43.3 36.8
1–10 47.2 46.7 51.5
>10 5.7 10.0 11.8
None 11.5 10.5 14.7
1–10 78.8 73.7 69.1
>10 9.6 15.8 16.2
p = NS >30 30.8 40.0 30.9 NS >30 22.7 36.6 29.3 p = 0.006 >30 1.9 10.0 19.1 p = 0.034
NS
NS
Abbreviation: NS = Non-significant. * Included, e.g., sarcoma, eye, lung, brain, anal, and other disease sites. Chi-squared statistics were used to compare responses by year.
Head and neck brachytherapy and other forms of brachytherapy (e.g., for sarcoma, eye, lung, brain, and anal therapy) remained limited to a minority of institutions. Clinical experience in pediatric oncology During all 3 years analyzed, a significant minority of respondents reported receiving inadequate clinical experience in pediatrics (14.3%, 13.6%, and 20.4% in 2005-2006, 2006-2007, and 2007-2008, respectively) (Fig. 1). A small but significant percentage of residents (18.9%, 6.7%, 8.8%, respectively) reported treating 10 or fewer pediatric cases during their course of residency (Fig. 3). Year-to-year differences were not statistically significant. Clinical Experience in Satellite Facilities Table 2 details residents’ responses to questions regarding the role of satellite facilities in resident clinical experience. At least two-thirds of programs surveyed were associated with a satellite facility for radiation treatment outside of the main facility. Among those programs that did have satellite facilities, the majority of them incorporate resident rotations at the satellite facilities as part of clinical experience, with most residents spending more than 20 weeks over the course
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Fig. 3. Percentage of respondents who reported receiving 1 to 10, 11 to 20, or >20 pediatric cases, on average, during the course of residency. Year-to-year differences, using chi-square statistics, were not statistically significant.
of their residency at the satellite facilities (Fig. 4). Among residents who participated in these satellite rotations, more than 85% found them valuable for their clinical training. As many as 5.4% to 13.0% reported being left alone at the satellite facility without a staff radiation oncologist on site for more than 4 hours while patients were being treated.
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Fig. 4. Among programs where satellite rotations are incorporated into clinical training, percentage of respondents who reported spending 1 to 10, 11 to 20, or >20 weeks, on average, at the satellite facility during the course of residency. Year-to-year differences, using chi-square statistics, were not statistically significant.
moonlighting occurred at less than 20% and 26% of programs, respectively. DISCUSSION
Resident work hours Figure 5 details resident responses to questions regarding hours spent per week on required clinical duties (Fig. 5A) and hours spent per week on tasks that were considered to have little or no educational value and that could be performed by a nonphysician staff member (Fig. 5B). The majority of residents reported working 60 or fewer hours per week on required clinical duties and 15 or fewer hours on tasks with little or no educational value. Year-to-year differences were not statistically significant. Locum tenens and moonlighting Table 3 summarizes residents’ responses to questions regarding locum tenens and moonlighting. At least 20% of residents surveyed could not identify a defined departmental policy on moonlighting and locum tenens. In general, during the years analyzed, resident participation in locum tenens or Table 2. Response to satellite experience in resident clinical training Institutions That have satellite facilities That require residents to rotate at satellite facilities* Where residents find satellite rotations valuable* Where residents are alone at the satellite for >4 hours*
2005-2006 2006-2007 2007-2008 70.9% 66.7%
66.7% 75.0%
81.8% 79.6%
92.6%
91.7%
85.1%
7.4%
5.4%
13%
* These questions were asked only of residents who reported that their institutions were associated with satellite facilities. Thus, percentages are reported as a function of the number of institutions associated with satellite facilities.
This paper reviews results of surveys administered to chief residents in radiation oncology from the academic years 2005 to 2006, 2006 to 2007, and 2007 to 2008, with a particular focus on clinical training and resident working conditions. These reports represent only the second publication of chief resident data since inception of the surveys in 2003 (6) and provide an opportunity to assess the breadth and depth of clinical experience and resident working conditions for recently graduated residents over a 3-year period. During the years analyzed, the Program Requirements set out by the Radiation Oncology Residency Review Committee (RRC) of the Accreditation Council of Graduate Medical Education (ACGME) went into effect in 2003 (15), with revisions rendered effective in July 2007 (16) and then again in January 2009 (17). In terms of clinical experience, residents have been required to simulate no fewer than 450 patients for external beam radiotherapy during the course of their residency (ACGME Program Requirement V.F.1 in 2003 [15]; and IV.A.5.a.1 in 2007 and 2009 versions [16, 17]). This has included gaining a diverse clinical experience in the treatment of lymphoma and leukemia; gastrointestinal, gynecologic, genitourinary, breast, soft tissue and bone, skin, head and neck, lung, pediatric, and central nervous system tumors; and benign conditions for which radiotherapy is utilized. Residents have been required to be trained in the use of external beam modalities and to personally perform technical procedures, including simulation, treatment planning, and placement of intracavitary and interstitial brachytherapy instruments. In terms of brachytherapy experience, in the 2003 (V.F.2.d) and 2007 (IV.A.5.a.5) versions of ACGME program requirements (15, 16), no fewer than five interstitial
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Fig. 5. According to year of residency training, percentage of respondents who reported working (A) 50 or fewer, 51-60 or >60 hours per week on required clinical duties and (B) 10 or fewer, 11-15, or >15 hours per week on tasks that are considered to have little to no educational value. Year-to-year differences, using chi-square statistics, were not statistically significant.
implants in at least 5 patients and 10 intracavitary implants in at least 5 patients were required of residents during their training. In addition, residents were required to observe an additional 5 interstitial implants and 10 intracavitary implants. In July 2009 ACGME program requirements (IV.A.5.a.2 [17]), the requirement for observational cases was eliminated, and the intracavitary implant case minimum was increased to 15 cases. From 2003 to 2007, residents were required to administer no fewer than six radiopharmaceutical therapies or unsealed radioactive sources (V.F.2.d [15]). The 2007 revision reduced this requirement to no fewer than five such procedures (IV.A.5.a.5 [16]), but this requirement has been increased to six such procedures in the most recent, 2009, revision (IV.A.5.a.3 [17]). Residents have been required to treat at least 12 pediatric patients, of whom at least 9 have solid tumors, in the 2003 (V.F.2.e), 2007 (IV.A.5.a.6), and 2009 (IV.A.5.a.4) versions of the ACGME program requirements (15–17). Since 2003, duty hours have been restricted to 80 hours per week, averaged over a 4-week period and inclusive of all in-house call activities (VI.B in 2003 (15); and VI.D in 2007 and 2009 (16, 17)). Clinical experience in the more commonly encountered disease sites, such as genitourinary, breast, central nervous
system, head and neck, lung, and gastrointestinal sites, were noted to be adequate in the majority of programs. However, for sarcomas and lymphomas, 9% to 22% of chief residents reported inadequacy of clinical experience. Inadequate exposure to treatment of sarcomas may relate to the relative infrequency of sarcoma cases nationwide, where annual incidences of soft tissue and bone sarcomas are estimated at approximately 9,500 and 2,400 cases, respectively (18). Inadequate clinical experience with lymphomas may be related to diverse practice patterns. For instance, in an analysis of the National LymphoCare Study, therapeutic approaches used for follicular lymphoma were noted to be widely disparate, with radiotherapy for stage I follicular lymphoma frequently omitted, contrary to practice guidelines (19). Similarly, varied practice patterns have been reported in other types of non-Hodgkin’s lymphoma (20) and in Hodgkin’s lymphoma (21). In terms of radiotherapy procedures, adequacy of clinical experience was reported by the majority of programs in frequently encountered therapeutic modalities, such as threedimensional conformal radiotherapy, intensity-modulated radiotherapy, cranial stereotactic radiosurgery, high-dose rate brachytherapy, and unsealed sources. However,
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Table 3. Resident participation in locum tenens or moonlighting Institutions With departmental policy on moonlighting and locum tenens Approved Approved in later years Not approved No defined policy Number of current residents who have done locum tenens None 1 2 or more No. of current residents moonlighting None 1 2 or more
2005–2006 2006–2007 2007–2008
14.6% 22.9% 39.6% 22.9%
23.3% 13.3% 38.3% 25.0%
21.2% 13.6% 45.5% 19.7%
83.3% 7.4% 9.3%
86.7% 13.3% 0%
84.8% 13.6% 1.5%
74.1% 14.8% 11.2%
75.0% 11.7% 13.3%
74.2% 12.1% 13.6%
radiotherapeutic modalities that involve high capital costs, such as intraoperative radiotherapy or particle beam therapy, or infrequent usage, such as hyperthermia, remain limited to a few select institutions. At the time this survey was conducted (2005-2008), ACGME program requirements specified minimum limits for the number of brachytherapy and pediatric cases but did not specify a minimum number of cases required for other types of procedures. Paralleling the increase in extracranial stereotactic radiotherapy publications, an increasing percentage of programs reported receiving adequate clinical experience in extracranial stereotactic radiotherapy, such that by 2007 to 2008, 87% of residents reported receiving adequate experience in extracranial stereotactic radiotherapy. This increase likely reflects the wider applicability and further development of stereotactic body radiotherapy during this time period (22). Notably, effective January 2009, the Program Requirements set out by the RRC were revised to include managing at least 10 cranial radiosurgery cases over the course of residency (IV.A.5.a.6 [17]). A similar requirement for five extracranial stereotactic radiotherapy cases is under review by the radiation oncology RRC and may be implemented at a later date (23). In contrast, fewer programs offered adequate clinical experience in endovascular brachytherapy, potentially reflecting the wider use of drug-eluting stents to prevent in-stent re-stenosis (24). The majority of residents reported performing therapy for more than 10 cases each of gynecologic and prostate brachytherapy during the course of residency. However, since the survey did not query residents specifically regarding interstitial and intracavitary implants, correlating these data with ACGME case requirements for 2005 to 2008 is not feasible. We anticipate changing future chief resident survey questionnaires to allow for a more precise comparison to current ACGME requirements. During the time period analyzed, partial breast irradiation became increasingly popular (25). In
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parallel, where available, the breast brachytherapy case load increased significantly during the years analyzed, such that by 2007 to 2008, 19% of chief residents reported treating more than 30 breast brachytherapy cases over the course of residency. Clinical experience with rarer forms of brachytherapy, such as brachytherapy for head and neck malignancies or sarcoma, remain limited to a small minority of institutions. ACGME requirements during the time period analyzed included simulation of 12 pediatric cases over the course of residency. The ARRO chief resident survey used intervals of 1 to 5, 6 to 10, 11 to 15, and so on, to determine average numbers of pediatric cases managed by residents over the course of residency. As a result, precise correlation of these data with ACGME requirements is not feasible. However, at least 80% of residents reported treating more than 10 pediatric cases over the course of residency. This suggests, however, that between 10% and 20% of residents may not have received the minimum number of pediatrics cases, as defined by ACGME. This finding is shown in Fig. 1, demonstrating that 13% to 20% of residents reported receiving inadequate clinical experience in pediatric oncology. Given these data, further analysis of the quality and quantity of residency training in pediatric radiation oncology, and policies to increase the number of visiting rotations or fellowship opportunities at national centers of pediatric oncology, may be warranted. ‘‘Integrated’’ institutions has been defined by ACGME program requirements as institutions where the residency program director (1) determines all rotations and assignments of residents and (2) is responsible for the overall conduct of the educational program in the integrated institution (II.B.1.b in 2003 [15]; I.B.7 in 2007 [16]; and I.B.4 in 2009 [17]). A written agreement stating these provisions is necessary between the parent institution and the integrated institution and must be approved by the RRC. Once approved, rotations at these integrated institutions are not limited in duration. In the interpretation of these chief resident survey data, ‘‘integrated’’ institutions were considered synonymous with satellite facilities. The majority of surveyed programs reported an association with a satellite facility. Among those programs, 67% to 80% of programs reported residents were required to rotate through the satellite facilities as a component of clinical training, in which most residents would spend more than 20 weeks over the course of their residency. Importantly, more than 85% of chief residents who trained at programs where satellite rotations were required found these satellite rotations valuable to their clinical training. Presumably, these rotations may provide residents with an opportunity to train in a community environment, which may involve a varied spectrum of pathology and/or treatment techniques compared to their central academic site. Given these favorable chief resident responses, opportunities to increase resident training in satellite facilities may be worthy of consideration. The ACGME has restricted duty hours to 80 hours per week as a common program requirement for all medical residencies and fellowships, regardless of specialty (VI.B in
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2003 (15); and VI.D in 2007 and 2009 [16, 17]). The majority of radiation oncology residents reported working 60 or fewer hours per week on clinical duties, with 15 or fewer hours devoted to tasks with little to no educational value. In terms of moonlighting and locum tenens, resident participation occurs at a minority of programs. According to ACGME requirements, moonlighting should not interfere with a resident’s ability to achieve the goals and objectives of the educational program (VI.D in 2003 [15]; and VI.F in 2007 and 2009 [16, 17]). The observation that at least 20% of residents surveyed could not identify a defined departmental policy on moonlighting and locum tenens suggests that communication of these ACGME requirements may warrant closer attention. One limitation of such a survey analysis is that not all chief residents were surveyed during each year. Thanks to the avid participation of 189 recently graduated chief residents, rates of responses to the chief resident surveys exceeded 70% during each of the 3 years analyzed, with an excellent 94% response rate during the most recent year (2007-2008). This relatively high response rate improves the sensitivity of these data to capture important trends in radiation oncology residency training. For instance, nationwide trends in the clinical practice of radiation oncology, such as the wider use of extracranial stereotactic radiotherapy and breast brachytherapy and the less frequent use of endovascular brachytherapy, were reflected in temporal changes in resident responses to survey questions. However, an important limitation in assess-
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ing clinical experience by number of cases is the subjectivity with which respondents may estimate average case numbers at their respective programs. For the question regarding pediatric cases, the option of ‘‘5-10 cases’’ on the survey questionnaire may have seemed adequate for those residents not familiar with the ACGME 12-case minimum. Nonetheless, the correlation of these case-specific data with resident responses regarding the adequacy of clinical experience in pediatrics suggests that these case-specific data may be accurately capturing nationwide trends. Another limitation of this study was the absence of survey questions pertaining to radiology and medical oncology training experience. We anticipate including such questions in future surveys. Finally, although much of these data provide a quantitative assessment of residency training, quality of residency training can be affected by myriad factors not captured by the chief resident survey. Thus, caution is advised in the interpretation of these data. CONCLUSIONS The ARRO Chief Resident survey provides an opportunity to document and analyze trends in residency training with respect to clinical experience and residency working conditions. It is our hope that this report can be used by residents, program directors, the ACGME, and others interested in resident education, to continue to improve residency training in radiation oncology.
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10. Wasserman TH, Smith SM, Powell SN. The growth of academic radiation oncology: A survey of endowed professorships in radiation oncology. Int J Radiat Oncol Biol Phys 2009;74:338–340. 11. Wilson LD, Yu JB, Haffty BG. National Residency Matching Program (NRMP) results for radiation oncology: 2007 update. Int J Radiat Oncol Biol Phys 2007;69:326–327. 12. Wilson LD, Haffty BG. National Residency Matching Program results for radiation oncology: 2006 update. Int J Radiat Oncol Biol Phys 2006;66:321–322. 13. Wilson LD, Haffty BG. National Residency Matching Program results for radiation oncology, 2005 update. Int J Radiat Oncol Biol Phys 2005;63:3–4. 14. Wilson LD, Haffty BG. National Residency Matching Program (NRMP) results for radiation oncology, 2004 update. Int J Radiat Oncol Biol Phys 2004;60:689–690. 15. Residency Review Committee (RRC) in Radiation Oncology. ACGME program requirements for graduate medical education in radiation oncology. Chicago: Accreditation Council for Graduate Medical Education; 2003. 16. Residency Review Committee (RRC) in Radiation Oncology. ACGME program requirements for graduate medical education in radiation oncology. Chicago: Accreditation Council for Graduate Medical Education; 2007. 17. Residency Review Committee (RRC) in Radiation Oncology. ACGME program requirements for graduate medical education in radiation oncology. Chicago: Accreditation Council for Graduate Medical Education; 2009. 18. Ries LA, Harkins D, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2003. Bethesda, M.D: National Cancer Institute; 2006. 19. Friedberg JW, Taylor MD, Cerhan JR, et al. Follicular lymphoma in the United States: first report of the
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national LymphoCare study. J Clin Oncol 2009;27:1202– 1208. 20. Cronin DP, Harlan LC, Clegg LX, et al. Patterns of care in a population-based random sample of patients diagnosed with non-Hodgkin’s lymphoma. Hematol Oncol 2005;23:73–81. 21. Ng AK, Li S, Neuberg D, et al. Factors influencing treatment recommendations in early-stage Hodgkin’s disease: A survey of physicians. Ann Oncol 2004;15:261–269. 22. Lo SS, Fakiris AJ, Chang EL, et al. Stereotactic body radiation therapy: a novel treatment modality. Nat Rev Clin Oncol 2010;7:44–54.
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23. Residency Review Committee (RRC) in Radiation Oncology. RRC News Radiation Oncology. ACGME Newsletter. Chicago: Accreditation Council for Graduate Medical Education; 2009. 24. Van Limbergen E, Trepuraneni P. Is this the swan song of endovascular brachytherapy? Radiother Oncol 2007;82: 1–4. 25. Smith BD, Arthur DW, Buchholz TA, et al. Accelerated partial breast irradiation consensus statement from the American Society for Radiation Oncology (ASTRO). Int J Radiat Oncol Biol Phys 2009;74:987–1001.
doi:10.1016/j.ijrobp.2010.07.018
CLINICAL INVESTIGATION
Residency Training
RESULTS OF THE 2005-2008 ASSOCIATION OF RESIDENTS IN RADIATION ONCOLOGY SURVEY OF CHIEF RESIDENTS IN THE UNITED STATES: CLINICAL TRAINING AND RESIDENT WORKING CONDITIONS VINAI GONDI, M.D.,* JOHNNY RAY BERNARD, JR., M.D.,y SIAVASH JABBARI, M.D.,z JENNIFER KEAM, M.D.,{ KAREN L. DE AMORIM BERNSTEIN, M.D.,x LUQMAN K. DAD, M.D.,** LINNA LI, M.D.,yy MATTHEW M. POPPE, M.D.,zz JONATHAN B. STRAUSS, M.D.,{{ xx AND CASEY T. CHOLLET, M.D. FOR THE ARRO EXECUTIVE COMMITTEE Department of *Radiation Oncology, University of Wisconsin Comprehensive Cancer Center, Madison, Wisconsin; yMayo Clinic Jacksonville, Jacksonville, Florida; zUniversity of California San Francisco, San Francisco, California; {Memorial Sloan-Kettering Cancer Center, New York, New York; xAlbert Einstein College of Medicine, Bronx, New York; **SUNY Roswell Park Cancer Institute, Buffalo, New York; yyFox Chase Cancer Center, Philadelphia, Pennsylvania; zzUniversity of Utah Huntsman Cancer Hospital; {{ Northwestern University Feinberg School of Medicine, Chicago, Illinois; and xxLoyola University Medical Center, Maywood, Illinois Purpose: To document clinical training and resident working conditions reported by chief residents during their residency. Methods and Materials: During the academic years 2005 to 2006, 2006 to 2007, and 2007 to 2008, the Association of Residents in Radiation Oncology conducted a nationwide survey of all radiation oncology chief residents in the United States. Chi-square statistics were used to assess changes in clinical training and resident working conditions over time. Results: Surveys were completed by representatives from 55 programs (response rate, 71.4%) in 2005 to 2006, 60 programs (75.9%) in 2006 to 2007, and 74 programs (93.7%) in 2007 to 2008. Nearly all chief residents reported receiving adequate clinical experience in commonly treated disease sites, such as breast and genitourinary malignancies; and commonly performed procedures, such as three-dimensional conformal radiotherapy and intensitymodulated radiotherapy. Clinical experience in extracranial stereotactic radiotherapy increased over time (p < 0.001), whereas clinical experience in endovascular brachytherapy (p <0.001) decreased over time. The distribution of gynecologic and prostate brachytherapy cases remained stable, while clinical case load in breast brachytherapy increased (p = 0.006). A small but significant percentage of residents reported receiving inadequate clinical experience in pediatrics, seeing 10 or fewer pediatric cases during the course of residency. Procedures involving higher capital costs, such as particle beam therapy and intraoperative radiotherapy, and infrequent clinical use, such as head and neck brachytherapy, were limited to a minority of institutions. Most residency programs associated with at least one satellite facility have incorporated resident rotations into their clinical training, and the majority of residents at these programs find them valuable experiences. The majority of residents reported working 60 or fewer hours per week on required clinical duties. Conclusions: Trends in clinical training and resident working conditions over 3 years are documented to allow residents and program directors to assess their residency training. Ó 2011 Elsevier Inc. ARRO, Association of Residents in Radiation Oncology, Radiation oncology residency, Residency training, Survey.
INTRODUCTION
from 1986 (1), 1989 (2), 1992 (3), 1993 (4), 2000 to 2002 (5), 2003 (6), and 2004 (7) have been published previously. These surveys have provided unique insights into the perceived quality of residency training in radiation oncology in the United States. Surveys have also enabled professional
Founded in 1982, the Association of Residents in Radiation Oncology (ARRO) has represented all radiation oncology residents in the United States and has conducted surveys of these residents for almost 3 decades. Results of these surveys
Acknowledgment—We thank Eugene Kim, Steven Smith, and Kathy Thomas of the American Society of Radiation Oncology for administrative assistance; Anita R. Kharwadkar for technical assistance; Paul M. Harari, M.D., for manuscript review; and 189 recently graduated chief residents for their participation. Received May 10, 2010, and in revised form June 24, 2010. Accepted for publication July 2, 2010.
Reprint requests to: Vinai Gondi, M.D., University of Wisconsin Comprehensive Cancer Center 600 Highland Ave., Madison, WI 53792. Tel: (608) 263-8500; Fax: (608) 262-6256; E-mail: [email protected] Presented at the 52nd Annual Meeting of the American Society of Radiation Oncology, Chicago, IL, November 1-5th, 2009. Conflicts of interest none. 1120
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85.2 83.3 77.8 79.6 86.4 85.7 90.7 83.3 86.1
Lymphoma Pediatrics Sarcomas GI
90.3
96.3 98.3
96.3 96.7 93.1 88.9 91.7 95.8 94.4 91.7 95.8 96.3 100.0 97.1 96.3 98.3 98.6 96.3 95.0 98.6
Lung Gyn Head & Neck CNS Breast GU 0
20
40
60
80
100
Percentage of Respondents 2005-06
2006-07
2007-08
Fig. 1. Percentage of respondents who reported receiving adequate clinical experience in particular disease sites. Year-to-year differences, using chi-square statistics, were not statistically significant for any of these disease sites. Numbers at the end of the bars are percentages of respondents in each category. GI = gastrointestinal; Gyn = gynecologic; CNS = central nervous system; GU = genitourinary.
societies, such as the American College of Radiology Standards and Accreditation Committee, the American Society of Radiation Oncology (ASTRO) and the Accreditation Council of Graduate Medical Education’s Residency Review Committee in radiation oncology, to review issues pertinent to residency training. Since 2003, the ARRO Executive Committee has disseminated a separate survey exclusively to chief residents for the purpose of ascertaining their perspectives on their residency programs. This 43-question survey is designed to assess breadth and depth of clinical training, resident working conditions, and other issues pertinent to residency training. The first and only prior report of chief resident survey results was based on the survey administered during the academic year 2003 to 2004 and published in 2005 (6). Since then, the field of radiation oncology has witnessed multiple changes, including wider availability of newer radiation therapy technologies (8), evolving roles of radiation therapy in the treatment of various malignant and nonmalignant diseases (9), expansion of a number of academic radiation oncology departments (10), and increasing competitiveness among medical students seeking specialty training (11–14). These and other changes are likely to have impacted multiple facets of residency training, further highlighting the importance of updating our understanding of the current residency training environment. Herein, we present results from the chief resident survey from academic years 2005 to 2006, 2006 to 2007, and 2007 to 2008, with a particular emphasis on clinical training and resident working conditions. METHODS AND MATERIALS During the academic years 2005 to 2006, 2006 to 2007, and 2007 to 2008, surveys were distributed to chief residents at each radiation oncology training program in the United States. Surveys consisted of 43 questions assessing clinical experience, availability of educa-
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tional resources, research experience, program policies, and working conditions. Chief residents were initially contacted by electronic mail, postal mail, and, if necessary, by telephone to encourage response and ensure a maximal response rate. Each residency training program completed only one questionnaire. Statistical analyses were performed using SPSS version 14.0 software (SPSS Inc., Chicago IL). Chi-square statistics were used to compare responses by year.
RESULTS Demographics Surveys were completed by representatives from 55 programs (response rate, 71.4%) in 2005 to 2006, 60 programs (75.9%) in 2006 to 2007, and 74 programs (93.7%) in 2007 to 2008. The majority of respondents were male (69.1% in 2005-2006, 83.3% in 2006-2007, and 62.2% in 2007-2008), married or in domestic partnerships (68.6% in 2005-2006, 65.0% in 2006-2007, and 73.4% in 20072008), and in their fourth year of radiation oncology training (73.6% in 2005-2006, 68.3% in 2006-2007, and 65.2% in 2007-2008). Proportions of 56.3%, 48.3%, and 48.4% of respondents during 2005 to 2006, 2006 to 2007, and 2007 to 2008, respectively, had or served as a guardian for one or more children. Clinical experience in disease sites Figure 1 demonstrates the percentage of respondents who reported receiving adequate clinical experience in particular disease sites. Disease sites for which >90% of respondents reported receiving adequate clinical experience in all 3 years analyzed included genitourinary (96.3%, 95%, and 98.6% in 2005-2006, 2006-2007, and 2007-2008, respectively), breast (96.3%, 98.3%, 98.6%, respectively), central nervous system (96.3%, 100.0%, 97.1%, respectively), head and neck (94.4%, 91.7%, 95.8%, respectively), lung (96.3%, 96.7%, 93.1%, respectively), and gastrointestinal malignancies (96.3%, 98.3%, 90.3%, respectively). During two of the 3 years analyzed, greater than 90% of respondents reported adequacy of clinical experience with gynecologic malignancies (88.9%, 91.7%, 95.8%, respectively). At least 9% of respondents reported inadequacy of clinical experience with sarcoma cases (9.3%, 16.7%, 13.9%, respectively) and lymphoma cases (14.8%, 16.7%, 22.2%, respectively) during all 3 years analyzed. Year-to-year differences were not statistically significant for any of these disease sites. Clinical experience in radiotherapy procedures Figure 2 demonstrates the percentage of respondents who reported receiving adequate clinical experience with particular radiation oncology procedures. A total of 90% or more respondents reported receiving clinical experience in threedimensional conformal radiotherapy (100.0%, 98.3%, and 98.6% in 2005-2006, 2006-2007, and 2007-2008, respectively), intensity-modulated radiotherapy (100.0%, 98.3%, 98.6%, respectively), cranial stereotactic radiosurgery (96.3%, 100.0%, 98.6%, respectively), high-dose rate brachytherapy (98.1%, 98.3%, 95.9%, respectively), and
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Table 1. Average number of brachytherapy cases performed per resident during the course of residency Site
Fig. 2. Percentage of respondents who reported receiving clinical experience in particular radiation oncology procedures. Chi-square statistics showed increasing availability of clinical experience in extracranial stereotactic radiotherapy (p < 0.001) and decreasing availability of clinical experience in endovascular brachytherapy (p < 0.001) during the time period analyzed. IORT= Intraoperative radiotherapy; SRS = stereotactic radiosurgery; TBI = total body irradiation; HDR = high-dose-rate; LDR = low-dose rate; IMRT = intensity-modulated radiotherapy; 3D-CRT = three-dimensional conformal radiotherapy.
unsealed sources (90.7%, 96.7%, 90.5%, respectively) during all 3 years analyzed. During the 3 years analyzed, the majority of respondents received no clinical experience in intraoperative radiotherapy (65.4%, 73.3%, 71.6%, respectively), hyperthermia (83.0%, 78.3%, 87.8%, respectively), and particle beam therapy (86.3%, 83.1%, 79.7%, respectively). Clinical experience in extracranial stereotactic radiotherapy increased during the years analyzed (62.3%, 71.7%, 86.5%, respectively; p < 0.001). However, a diminishing percentage of respondents gained clinical experience in endovascular brachytherapy over the time period analyzed (41.5%, 33.3%, 17.8%, respectively; p < 0.001).
Clinical experience in brachytherapy Table 1 shows details of the average number of cases reported by respondents to be performed per resident during the course of residency at their respective programs. All respondents reported performing gynecologic brachytherapy, and most residents saw more than 10 cases during the course of residency (78.9%, 91.7%, and 79.4% in 2005-2006, 2006-2007, and 2007-2008, respectively). Most residents performed more than 10 prostate brachytherapy procedures during their course of residency (67.9%, 83.3%, 63.1%, respectively). A significant percentage of programs did not offer clinical experience in breast brachytherapy (28.3%, 28.3% 26.5%, respectively). However, where breast brachytherapy was available, case loads seemed to be increasing, with an increasing percentage of residents reporting taking on more than 30 cases over the course of residency (1.9%, 10.0%, 19.1%, respectively; p = 0.006). Clinical experience with endovascular brachytherapy was offered at fewer programs (32.7%, 32.7%, 14.7%, respectively; p = 0.034).
Gynecologic No. of cases 2005–2006 2006–2007 2007–2008 Prostate No. of cases 2005–2006 2006–2007 2007–2008 Breast No. of cases 2005–2006 2006–2007 2007–2008 Endovascular No. of cases 2005–2006 2006–2007 2007–2008 Head and Neck No. of cases 2005–2006 2006–2007 2007–2008 Other* No. of cases 2005–2006 2006–2007 2007–2008
Percentage of respondents None 0 0 0
1–10 21.1 8.3 20.6
11–30 48.1 51.7 48.5
None 3.8 1.7 2.9
1–10 28.3 15.0 33.8
11–30 45.2 46.7 33.8
None 28.3 28.3 26.5
1–10 54.7 35.0 47.1
11–30 15.1 26.7 7.4
None 67.3 68.3 85.3
1 or more 32.7 32.7 14.7
None 47.2 43.3 36.8
1–10 47.2 46.7 51.5
>10 5.7 10.0 11.8
None 11.5 10.5 14.7
1–10 78.8 73.7 69.1
>10 9.6 15.8 16.2
p = NS >30 30.8 40.0 30.9 NS >30 22.7 36.6 29.3 p = 0.006 >30 1.9 10.0 19.1 p = 0.034
NS
NS
Abbreviation: NS = Non-significant. * Included, e.g., sarcoma, eye, lung, brain, anal, and other disease sites. Chi-squared statistics were used to compare responses by year.
Head and neck brachytherapy and other forms of brachytherapy (e.g., for sarcoma, eye, lung, brain, and anal therapy) remained limited to a minority of institutions. Clinical experience in pediatric oncology During all 3 years analyzed, a significant minority of respondents reported receiving inadequate clinical experience in pediatrics (14.3%, 13.6%, and 20.4% in 2005-2006, 2006-2007, and 2007-2008, respectively) (Fig. 1). A small but significant percentage of residents (18.9%, 6.7%, 8.8%, respectively) reported treating 10 or fewer pediatric cases during their course of residency (Fig. 3). Year-to-year differences were not statistically significant. Clinical Experience in Satellite Facilities Table 2 details residents’ responses to questions regarding the role of satellite facilities in resident clinical experience. At least two-thirds of programs surveyed were associated with a satellite facility for radiation treatment outside of the main facility. Among those programs that did have satellite facilities, the majority of them incorporate resident rotations at the satellite facilities as part of clinical experience, with most residents spending more than 20 weeks over the course
2005-2008 ARRO survey d V. GONDI et al.
Fig. 3. Percentage of respondents who reported receiving 1 to 10, 11 to 20, or >20 pediatric cases, on average, during the course of residency. Year-to-year differences, using chi-square statistics, were not statistically significant.
of their residency at the satellite facilities (Fig. 4). Among residents who participated in these satellite rotations, more than 85% found them valuable for their clinical training. As many as 5.4% to 13.0% reported being left alone at the satellite facility without a staff radiation oncologist on site for more than 4 hours while patients were being treated.
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Fig. 4. Among programs where satellite rotations are incorporated into clinical training, percentage of respondents who reported spending 1 to 10, 11 to 20, or >20 weeks, on average, at the satellite facility during the course of residency. Year-to-year differences, using chi-square statistics, were not statistically significant.
moonlighting occurred at less than 20% and 26% of programs, respectively. DISCUSSION
Resident work hours Figure 5 details resident responses to questions regarding hours spent per week on required clinical duties (Fig. 5A) and hours spent per week on tasks that were considered to have little or no educational value and that could be performed by a nonphysician staff member (Fig. 5B). The majority of residents reported working 60 or fewer hours per week on required clinical duties and 15 or fewer hours on tasks with little or no educational value. Year-to-year differences were not statistically significant. Locum tenens and moonlighting Table 3 summarizes residents’ responses to questions regarding locum tenens and moonlighting. At least 20% of residents surveyed could not identify a defined departmental policy on moonlighting and locum tenens. In general, during the years analyzed, resident participation in locum tenens or Table 2. Response to satellite experience in resident clinical training Institutions That have satellite facilities That require residents to rotate at satellite facilities* Where residents find satellite rotations valuable* Where residents are alone at the satellite for >4 hours*
2005-2006 2006-2007 2007-2008 70.9% 66.7%
66.7% 75.0%
81.8% 79.6%
92.6%
91.7%
85.1%
7.4%
5.4%
13%
* These questions were asked only of residents who reported that their institutions were associated with satellite facilities. Thus, percentages are reported as a function of the number of institutions associated with satellite facilities.
This paper reviews results of surveys administered to chief residents in radiation oncology from the academic years 2005 to 2006, 2006 to 2007, and 2007 to 2008, with a particular focus on clinical training and resident working conditions. These reports represent only the second publication of chief resident data since inception of the surveys in 2003 (6) and provide an opportunity to assess the breadth and depth of clinical experience and resident working conditions for recently graduated residents over a 3-year period. During the years analyzed, the Program Requirements set out by the Radiation Oncology Residency Review Committee (RRC) of the Accreditation Council of Graduate Medical Education (ACGME) went into effect in 2003 (15), with revisions rendered effective in July 2007 (16) and then again in January 2009 (17). In terms of clinical experience, residents have been required to simulate no fewer than 450 patients for external beam radiotherapy during the course of their residency (ACGME Program Requirement V.F.1 in 2003 [15]; and IV.A.5.a.1 in 2007 and 2009 versions [16, 17]). This has included gaining a diverse clinical experience in the treatment of lymphoma and leukemia; gastrointestinal, gynecologic, genitourinary, breast, soft tissue and bone, skin, head and neck, lung, pediatric, and central nervous system tumors; and benign conditions for which radiotherapy is utilized. Residents have been required to be trained in the use of external beam modalities and to personally perform technical procedures, including simulation, treatment planning, and placement of intracavitary and interstitial brachytherapy instruments. In terms of brachytherapy experience, in the 2003 (V.F.2.d) and 2007 (IV.A.5.a.5) versions of ACGME program requirements (15, 16), no fewer than five interstitial
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Fig. 5. According to year of residency training, percentage of respondents who reported working (A) 50 or fewer, 51-60 or >60 hours per week on required clinical duties and (B) 10 or fewer, 11-15, or >15 hours per week on tasks that are considered to have little to no educational value. Year-to-year differences, using chi-square statistics, were not statistically significant.
implants in at least 5 patients and 10 intracavitary implants in at least 5 patients were required of residents during their training. In addition, residents were required to observe an additional 5 interstitial implants and 10 intracavitary implants. In July 2009 ACGME program requirements (IV.A.5.a.2 [17]), the requirement for observational cases was eliminated, and the intracavitary implant case minimum was increased to 15 cases. From 2003 to 2007, residents were required to administer no fewer than six radiopharmaceutical therapies or unsealed radioactive sources (V.F.2.d [15]). The 2007 revision reduced this requirement to no fewer than five such procedures (IV.A.5.a.5 [16]), but this requirement has been increased to six such procedures in the most recent, 2009, revision (IV.A.5.a.3 [17]). Residents have been required to treat at least 12 pediatric patients, of whom at least 9 have solid tumors, in the 2003 (V.F.2.e), 2007 (IV.A.5.a.6), and 2009 (IV.A.5.a.4) versions of the ACGME program requirements (15–17). Since 2003, duty hours have been restricted to 80 hours per week, averaged over a 4-week period and inclusive of all in-house call activities (VI.B in 2003 (15); and VI.D in 2007 and 2009 (16, 17)). Clinical experience in the more commonly encountered disease sites, such as genitourinary, breast, central nervous
system, head and neck, lung, and gastrointestinal sites, were noted to be adequate in the majority of programs. However, for sarcomas and lymphomas, 9% to 22% of chief residents reported inadequacy of clinical experience. Inadequate exposure to treatment of sarcomas may relate to the relative infrequency of sarcoma cases nationwide, where annual incidences of soft tissue and bone sarcomas are estimated at approximately 9,500 and 2,400 cases, respectively (18). Inadequate clinical experience with lymphomas may be related to diverse practice patterns. For instance, in an analysis of the National LymphoCare Study, therapeutic approaches used for follicular lymphoma were noted to be widely disparate, with radiotherapy for stage I follicular lymphoma frequently omitted, contrary to practice guidelines (19). Similarly, varied practice patterns have been reported in other types of non-Hodgkin’s lymphoma (20) and in Hodgkin’s lymphoma (21). In terms of radiotherapy procedures, adequacy of clinical experience was reported by the majority of programs in frequently encountered therapeutic modalities, such as threedimensional conformal radiotherapy, intensity-modulated radiotherapy, cranial stereotactic radiosurgery, high-dose rate brachytherapy, and unsealed sources. However,
2005-2008 ARRO survey d V. GONDI et al.
Table 3. Resident participation in locum tenens or moonlighting Institutions With departmental policy on moonlighting and locum tenens Approved Approved in later years Not approved No defined policy Number of current residents who have done locum tenens None 1 2 or more No. of current residents moonlighting None 1 2 or more
2005–2006 2006–2007 2007–2008
14.6% 22.9% 39.6% 22.9%
23.3% 13.3% 38.3% 25.0%
21.2% 13.6% 45.5% 19.7%
83.3% 7.4% 9.3%
86.7% 13.3% 0%
84.8% 13.6% 1.5%
74.1% 14.8% 11.2%
75.0% 11.7% 13.3%
74.2% 12.1% 13.6%
radiotherapeutic modalities that involve high capital costs, such as intraoperative radiotherapy or particle beam therapy, or infrequent usage, such as hyperthermia, remain limited to a few select institutions. At the time this survey was conducted (2005-2008), ACGME program requirements specified minimum limits for the number of brachytherapy and pediatric cases but did not specify a minimum number of cases required for other types of procedures. Paralleling the increase in extracranial stereotactic radiotherapy publications, an increasing percentage of programs reported receiving adequate clinical experience in extracranial stereotactic radiotherapy, such that by 2007 to 2008, 87% of residents reported receiving adequate experience in extracranial stereotactic radiotherapy. This increase likely reflects the wider applicability and further development of stereotactic body radiotherapy during this time period (22). Notably, effective January 2009, the Program Requirements set out by the RRC were revised to include managing at least 10 cranial radiosurgery cases over the course of residency (IV.A.5.a.6 [17]). A similar requirement for five extracranial stereotactic radiotherapy cases is under review by the radiation oncology RRC and may be implemented at a later date (23). In contrast, fewer programs offered adequate clinical experience in endovascular brachytherapy, potentially reflecting the wider use of drug-eluting stents to prevent in-stent re-stenosis (24). The majority of residents reported performing therapy for more than 10 cases each of gynecologic and prostate brachytherapy during the course of residency. However, since the survey did not query residents specifically regarding interstitial and intracavitary implants, correlating these data with ACGME case requirements for 2005 to 2008 is not feasible. We anticipate changing future chief resident survey questionnaires to allow for a more precise comparison to current ACGME requirements. During the time period analyzed, partial breast irradiation became increasingly popular (25). In
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parallel, where available, the breast brachytherapy case load increased significantly during the years analyzed, such that by 2007 to 2008, 19% of chief residents reported treating more than 30 breast brachytherapy cases over the course of residency. Clinical experience with rarer forms of brachytherapy, such as brachytherapy for head and neck malignancies or sarcoma, remain limited to a small minority of institutions. ACGME requirements during the time period analyzed included simulation of 12 pediatric cases over the course of residency. The ARRO chief resident survey used intervals of 1 to 5, 6 to 10, 11 to 15, and so on, to determine average numbers of pediatric cases managed by residents over the course of residency. As a result, precise correlation of these data with ACGME requirements is not feasible. However, at least 80% of residents reported treating more than 10 pediatric cases over the course of residency. This suggests, however, that between 10% and 20% of residents may not have received the minimum number of pediatrics cases, as defined by ACGME. This finding is shown in Fig. 1, demonstrating that 13% to 20% of residents reported receiving inadequate clinical experience in pediatric oncology. Given these data, further analysis of the quality and quantity of residency training in pediatric radiation oncology, and policies to increase the number of visiting rotations or fellowship opportunities at national centers of pediatric oncology, may be warranted. ‘‘Integrated’’ institutions has been defined by ACGME program requirements as institutions where the residency program director (1) determines all rotations and assignments of residents and (2) is responsible for the overall conduct of the educational program in the integrated institution (II.B.1.b in 2003 [15]; I.B.7 in 2007 [16]; and I.B.4 in 2009 [17]). A written agreement stating these provisions is necessary between the parent institution and the integrated institution and must be approved by the RRC. Once approved, rotations at these integrated institutions are not limited in duration. In the interpretation of these chief resident survey data, ‘‘integrated’’ institutions were considered synonymous with satellite facilities. The majority of surveyed programs reported an association with a satellite facility. Among those programs, 67% to 80% of programs reported residents were required to rotate through the satellite facilities as a component of clinical training, in which most residents would spend more than 20 weeks over the course of their residency. Importantly, more than 85% of chief residents who trained at programs where satellite rotations were required found these satellite rotations valuable to their clinical training. Presumably, these rotations may provide residents with an opportunity to train in a community environment, which may involve a varied spectrum of pathology and/or treatment techniques compared to their central academic site. Given these favorable chief resident responses, opportunities to increase resident training in satellite facilities may be worthy of consideration. The ACGME has restricted duty hours to 80 hours per week as a common program requirement for all medical residencies and fellowships, regardless of specialty (VI.B in
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2003 (15); and VI.D in 2007 and 2009 [16, 17]). The majority of radiation oncology residents reported working 60 or fewer hours per week on clinical duties, with 15 or fewer hours devoted to tasks with little to no educational value. In terms of moonlighting and locum tenens, resident participation occurs at a minority of programs. According to ACGME requirements, moonlighting should not interfere with a resident’s ability to achieve the goals and objectives of the educational program (VI.D in 2003 [15]; and VI.F in 2007 and 2009 [16, 17]). The observation that at least 20% of residents surveyed could not identify a defined departmental policy on moonlighting and locum tenens suggests that communication of these ACGME requirements may warrant closer attention. One limitation of such a survey analysis is that not all chief residents were surveyed during each year. Thanks to the avid participation of 189 recently graduated chief residents, rates of responses to the chief resident surveys exceeded 70% during each of the 3 years analyzed, with an excellent 94% response rate during the most recent year (2007-2008). This relatively high response rate improves the sensitivity of these data to capture important trends in radiation oncology residency training. For instance, nationwide trends in the clinical practice of radiation oncology, such as the wider use of extracranial stereotactic radiotherapy and breast brachytherapy and the less frequent use of endovascular brachytherapy, were reflected in temporal changes in resident responses to survey questions. However, an important limitation in assess-
Volume 81, Number 4, 2011
ing clinical experience by number of cases is the subjectivity with which respondents may estimate average case numbers at their respective programs. For the question regarding pediatric cases, the option of ‘‘5-10 cases’’ on the survey questionnaire may have seemed adequate for those residents not familiar with the ACGME 12-case minimum. Nonetheless, the correlation of these case-specific data with resident responses regarding the adequacy of clinical experience in pediatrics suggests that these case-specific data may be accurately capturing nationwide trends. Another limitation of this study was the absence of survey questions pertaining to radiology and medical oncology training experience. We anticipate including such questions in future surveys. Finally, although much of these data provide a quantitative assessment of residency training, quality of residency training can be affected by myriad factors not captured by the chief resident survey. Thus, caution is advised in the interpretation of these data. CONCLUSIONS The ARRO Chief Resident survey provides an opportunity to document and analyze trends in residency training with respect to clinical experience and residency working conditions. It is our hope that this report can be used by residents, program directors, the ACGME, and others interested in resident education, to continue to improve residency training in radiation oncology.
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