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Towards a unified specialty: Unity holds the key to diversity
Clinical Oncology(1998) 10:279-280 © 1998 The RoyalCollegeof Radiologists
Clinical Oncology
Editorial T o w a r d s a Unified Specialty: Unity Holds the Key to Diversity* M. D. Mason I and P. G. de Takats 2 1University of Wales College of Medicine, Cardiff and 2Addenbrooke's NHS Trust, Cambridge, UK
The recent open meeting of the Joint Council for Clinical Oncology held in London on 4 June 1998 to discuss the future relationship between clinical and medical oncology created such fall-out that those who attended are still trying to make sense of the unexpected turn of events. The meeting had been eagerly anticipated. After years of discussion and significant positive feeback from recent direct questioning of members of both disciplines, the time seemed right to address in detail the mechanism by which the specialities could unite with common purpose concerning training and clinical practice. Yet high hopes were dashed, with the working parties placed on hold to allow wounds to be licked. In retrospect, why should a 'merger' not have been a realistic hope? After all, the diversity that exists between oncological specialties is no more marked than in other fields, such as cardiology, paediatrics or urology. It should theoretically be possible to stop worrying about 'labels' and start moving the specialty forward in a way that would equip it for the challenges of the twenty-first century. So what went wrong? Unification would be simple if the clinical territories of clinical and medical oncologists were entirely separate. The fact that they overlap is the basis for much disharmony, making each a potential threat to the other. To date, this perceived threat has been the single largest factor in hindering the potential benefits of a merger. Yet, those of us with experience of joint oncology clinics have been enlightened to find that our different skills, interests and knowledge base are in fact complementary, enhancing patient management, registrar training and, interestingly, mutual respect. What was most striking about the recent debate was that the most heated arguments and counter arguments on all sides amounted to the same theme: that of wishing to preserve professional identity. For both groups, it seems there are important questions to address. For medical oncologists, will a merger mean Correspondence and offprint requests to: Prof. M. D. Mason, Section of Clinical Oncology,Departmentof Medicine,University of Wales College of Medicine, Velindre Hospital, Whitchurch, Cardiff, CF4 7XL, UK. *The views expressed in this Editorial are those of the authors, in their capacity as young stakeholders in the future of clinical and medical oncology.They do not represent any officialview of the Royal Collegeof Radiologists,the Royal Collegeof Physicians,or the Journal.
that they are unable to maintain their research-based practice, forsaking specialization for generalization, or will maintaining an academic bias threaten the expansion of new specialist consultant posts in peripheral hospitals? For clinical oncologists, will a merger mean that they are forced to become pure 'radiation oncologists', giving up the broader-based approach that attracted them into the field in the first place? These concerns are more than understandable and they are a mark of the commitment that clinicians feel to their chosen speciality. Small wonder, then, that the disagreements over training surfaced as a major concern, since the training process will determine the nature of future oncologists. If training serves to undermine the important differences between different types of oncologist, will it not pose a threat to professional identity? It is important to recognize that, when considering the value of a unified specialty, subspecialists with very different interests will continue to exist. Any hidden agenda - which would be doomed to failure in any case - to create a single 'clone' of oncologist, would surely stultify the future of oncology practice in this country. Our existing clinical diversity should be encouraged, not diminished, since it is in fact our greatest strength. If we believe this statement, why change the system at all? The answer is that, if we are to plan for the future, we can expect to see a massive expansion of activity in cancer management in the coming years: new radiation techniques, cytotoxic, biological and molecular biological modalities, with potential benefits for treatment, prognosis and perhaps prevention of cancers, are going to be entering clinical practice. We need to prepare to embrace greater diversification than ever before and to build a training programme that allows for this. We cannot afford to feel threatened by disease site versus treatment modality specialization and its implications for practice, when we need to be united with a common strategy to increase manpower overall and encourage greater subspecialization within our different, yet contemporary, fields. Clearly, therefore, we cannot strait-jacket trainees into programmes that are perceived as combining medical and clinical oncology as a single discipline. Why should future medical oncologists feel that they have to practice (albeit in a limited way) radiotherapy? Why should clinical oncologists feel that they have to practice high dose chemotherapy or
280 biological therapy? Both would be fundamentally wrong. Equally, it is wrong to think that the only way to preserve identity is as a 'modality specialist' rather than as a 'tumour site specialist'. To be sure, there is room for both, but site specialization need not, and must not, mean that oncologists must be able to use all therapeutic modalities in the management of that disease. Furthermore, a third dimension of the specialization of oncology service provision settings needs now to be considered as better equipped facilities are developed in cancer units, permitting greater complexity of treatments to be delivered at the local level. Theoretically, this should provide job opportunities for both oncology disciplines. The benefits of a dual presence are manifold and should serve further to discourage non-oncologists from handling cytotoxics, encourage clinical trial recruitment in oncology units, and facilitate speed of referral to cancer centres for patients with rare tumours or those requiring highly specialized treatments. There is, unfortunately, more than enough work to go round for everyone. The core curriculum for oncology must be carefully reconsidered. We suggest that trainee medical oncologists do not need to know detailed radiation physics, and trainee clinical oncologists do not need to undertake the detailed pharmacological study that their medical oncology counterparts do. It was disheartening at the meeting to hear trainees extend their anxieties into a general resistance to studying other modalities at all. How can the study of pharmacology by a 'pure' radiation oncologist, or the study of radiotherapy by a 'pure' medical oncologist somehow 'pollute' their minds, and prevent them from practising their own modality as well? Was it so long ago that one of the country's foremost medical oncologists used to astound clinical oncology trainees by his knowledge of technical radiotherapy? Did that knowledge make him a 'worse' medical oncologist? Let us suggest those subjects that might be valuable as core subjects for any trainee oncologist; perhaps, to begin with, they should be exclusive rather than inclusive. So, for example, a core curriculum might contain: 1. 2. 3. 4. 5.
Basic tumour pathology and tumour behaviour Cancer statistics Basic cell and molecular biology of cancer Basic pharmacology and therapeutics Tumour proliferation kinetics (extracted from the current radiobiology syllabus) 6. Basic principles of radiotherapy
M.D. Mason and P. G. de Takats The more advanced selective modules for a subsequent year might include: 1. Clinical management of tumours (by site) 2. Radiation physics, biology and radiotherapy planning 3. Advanced pharmacology and therapeutics 4. Biological response modifier therapy 5. Molecular biological therapeutic modalities In the short-term, could the core curriculum perhaps run in parallel to, rather than as a replacement for, the existing FRCR Part I course and examination? This might allow its development as an adjunct to the existing programmes for both medical and clinical oncology. Maybe this would give us all a breathing space and, hopefully, allow our trainees time to feel comfortable with the new arrangement. We all need to think long and hard about the value of specialist examinations. One key characteristic that runs deep at the very heart of oncology is its research base. In an increasingly abbreviated training programme, should we not be encouraging opportunity for innovation rather than confining minds to personal study until the eve of consultancy? Finally, the theoretical aspects of the core curriculum need to be thoughtfully integrated with the clinical practice of oncology. Is it too great a sea change to conceive of all (medical and clinical oncology) specialist registrars rotating through the same modules of clinical and ward work as part of core training? The clinics attended should be selected to be suitable for both types of trainee, giving a broad spectrum of exposure to the management, primarily, of the common cancers. Beyond the core, trainees would be expected to differentiate and focus their training in areas of particular interest to their specialty and, ultimately, to themselves. The onus is on the current consultant oncologists of each institution to take a huge leap of faith and radically reconsider current clinical training programmes if we are to secure the best possible future for our specialty and the patients treated within it. In summary, we have a moral imperative to equip the specialty of oncology for the challenges of the next century. Let us rejoice in the diversity of the 'oncologist'; it is a strength, not a weakness. Let us also respect and protect the professional identities of our component parts. Unless we have a common purpose, which, after all, should be to improve the future of our cancer patients, we will never achieve unity, and divided we shall fall!
Clinical Oncology
Editorial T o w a r d s a Unified Specialty: Unity Holds the Key to Diversity* M. D. Mason I and P. G. de Takats 2 1University of Wales College of Medicine, Cardiff and 2Addenbrooke's NHS Trust, Cambridge, UK
The recent open meeting of the Joint Council for Clinical Oncology held in London on 4 June 1998 to discuss the future relationship between clinical and medical oncology created such fall-out that those who attended are still trying to make sense of the unexpected turn of events. The meeting had been eagerly anticipated. After years of discussion and significant positive feeback from recent direct questioning of members of both disciplines, the time seemed right to address in detail the mechanism by which the specialities could unite with common purpose concerning training and clinical practice. Yet high hopes were dashed, with the working parties placed on hold to allow wounds to be licked. In retrospect, why should a 'merger' not have been a realistic hope? After all, the diversity that exists between oncological specialties is no more marked than in other fields, such as cardiology, paediatrics or urology. It should theoretically be possible to stop worrying about 'labels' and start moving the specialty forward in a way that would equip it for the challenges of the twenty-first century. So what went wrong? Unification would be simple if the clinical territories of clinical and medical oncologists were entirely separate. The fact that they overlap is the basis for much disharmony, making each a potential threat to the other. To date, this perceived threat has been the single largest factor in hindering the potential benefits of a merger. Yet, those of us with experience of joint oncology clinics have been enlightened to find that our different skills, interests and knowledge base are in fact complementary, enhancing patient management, registrar training and, interestingly, mutual respect. What was most striking about the recent debate was that the most heated arguments and counter arguments on all sides amounted to the same theme: that of wishing to preserve professional identity. For both groups, it seems there are important questions to address. For medical oncologists, will a merger mean Correspondence and offprint requests to: Prof. M. D. Mason, Section of Clinical Oncology,Departmentof Medicine,University of Wales College of Medicine, Velindre Hospital, Whitchurch, Cardiff, CF4 7XL, UK. *The views expressed in this Editorial are those of the authors, in their capacity as young stakeholders in the future of clinical and medical oncology.They do not represent any officialview of the Royal Collegeof Radiologists,the Royal Collegeof Physicians,or the Journal.
that they are unable to maintain their research-based practice, forsaking specialization for generalization, or will maintaining an academic bias threaten the expansion of new specialist consultant posts in peripheral hospitals? For clinical oncologists, will a merger mean that they are forced to become pure 'radiation oncologists', giving up the broader-based approach that attracted them into the field in the first place? These concerns are more than understandable and they are a mark of the commitment that clinicians feel to their chosen speciality. Small wonder, then, that the disagreements over training surfaced as a major concern, since the training process will determine the nature of future oncologists. If training serves to undermine the important differences between different types of oncologist, will it not pose a threat to professional identity? It is important to recognize that, when considering the value of a unified specialty, subspecialists with very different interests will continue to exist. Any hidden agenda - which would be doomed to failure in any case - to create a single 'clone' of oncologist, would surely stultify the future of oncology practice in this country. Our existing clinical diversity should be encouraged, not diminished, since it is in fact our greatest strength. If we believe this statement, why change the system at all? The answer is that, if we are to plan for the future, we can expect to see a massive expansion of activity in cancer management in the coming years: new radiation techniques, cytotoxic, biological and molecular biological modalities, with potential benefits for treatment, prognosis and perhaps prevention of cancers, are going to be entering clinical practice. We need to prepare to embrace greater diversification than ever before and to build a training programme that allows for this. We cannot afford to feel threatened by disease site versus treatment modality specialization and its implications for practice, when we need to be united with a common strategy to increase manpower overall and encourage greater subspecialization within our different, yet contemporary, fields. Clearly, therefore, we cannot strait-jacket trainees into programmes that are perceived as combining medical and clinical oncology as a single discipline. Why should future medical oncologists feel that they have to practice (albeit in a limited way) radiotherapy? Why should clinical oncologists feel that they have to practice high dose chemotherapy or
280 biological therapy? Both would be fundamentally wrong. Equally, it is wrong to think that the only way to preserve identity is as a 'modality specialist' rather than as a 'tumour site specialist'. To be sure, there is room for both, but site specialization need not, and must not, mean that oncologists must be able to use all therapeutic modalities in the management of that disease. Furthermore, a third dimension of the specialization of oncology service provision settings needs now to be considered as better equipped facilities are developed in cancer units, permitting greater complexity of treatments to be delivered at the local level. Theoretically, this should provide job opportunities for both oncology disciplines. The benefits of a dual presence are manifold and should serve further to discourage non-oncologists from handling cytotoxics, encourage clinical trial recruitment in oncology units, and facilitate speed of referral to cancer centres for patients with rare tumours or those requiring highly specialized treatments. There is, unfortunately, more than enough work to go round for everyone. The core curriculum for oncology must be carefully reconsidered. We suggest that trainee medical oncologists do not need to know detailed radiation physics, and trainee clinical oncologists do not need to undertake the detailed pharmacological study that their medical oncology counterparts do. It was disheartening at the meeting to hear trainees extend their anxieties into a general resistance to studying other modalities at all. How can the study of pharmacology by a 'pure' radiation oncologist, or the study of radiotherapy by a 'pure' medical oncologist somehow 'pollute' their minds, and prevent them from practising their own modality as well? Was it so long ago that one of the country's foremost medical oncologists used to astound clinical oncology trainees by his knowledge of technical radiotherapy? Did that knowledge make him a 'worse' medical oncologist? Let us suggest those subjects that might be valuable as core subjects for any trainee oncologist; perhaps, to begin with, they should be exclusive rather than inclusive. So, for example, a core curriculum might contain: 1. 2. 3. 4. 5.
Basic tumour pathology and tumour behaviour Cancer statistics Basic cell and molecular biology of cancer Basic pharmacology and therapeutics Tumour proliferation kinetics (extracted from the current radiobiology syllabus) 6. Basic principles of radiotherapy
M.D. Mason and P. G. de Takats The more advanced selective modules for a subsequent year might include: 1. Clinical management of tumours (by site) 2. Radiation physics, biology and radiotherapy planning 3. Advanced pharmacology and therapeutics 4. Biological response modifier therapy 5. Molecular biological therapeutic modalities In the short-term, could the core curriculum perhaps run in parallel to, rather than as a replacement for, the existing FRCR Part I course and examination? This might allow its development as an adjunct to the existing programmes for both medical and clinical oncology. Maybe this would give us all a breathing space and, hopefully, allow our trainees time to feel comfortable with the new arrangement. We all need to think long and hard about the value of specialist examinations. One key characteristic that runs deep at the very heart of oncology is its research base. In an increasingly abbreviated training programme, should we not be encouraging opportunity for innovation rather than confining minds to personal study until the eve of consultancy? Finally, the theoretical aspects of the core curriculum need to be thoughtfully integrated with the clinical practice of oncology. Is it too great a sea change to conceive of all (medical and clinical oncology) specialist registrars rotating through the same modules of clinical and ward work as part of core training? The clinics attended should be selected to be suitable for both types of trainee, giving a broad spectrum of exposure to the management, primarily, of the common cancers. Beyond the core, trainees would be expected to differentiate and focus their training in areas of particular interest to their specialty and, ultimately, to themselves. The onus is on the current consultant oncologists of each institution to take a huge leap of faith and radically reconsider current clinical training programmes if we are to secure the best possible future for our specialty and the patients treated within it. In summary, we have a moral imperative to equip the specialty of oncology for the challenges of the next century. Let us rejoice in the diversity of the 'oncologist'; it is a strength, not a weakness. Let us also respect and protect the professional identities of our component parts. Unless we have a common purpose, which, after all, should be to improve the future of our cancer patients, we will never achieve unity, and divided we shall fall!