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When should radiation oncology become a separate department?
Editorials
When Should Radiation Oncology Become a Separate Department? LUTHER W. BRADY, MD”
u ‘YFIL:I.SITEI) SKATES,radiation
therapy has generalI>. evolved within a department of radiology. In many institutions, it continues as a part of that department even though now there is a tendency for separate departments of diagnostic radiology and departments of radiation therapy to be created. Since radiation therapy continues as a part of numerous departments of radiology, many of the characteristics of diagnostic radiology practice persist and lead to serious misunderstandings on the part of other physicians, hospital administrators, deans of medical schools, patients, and third party payers regarding the nature and scope of radiotherapeutic services. These misunderstandings often lead to serious difficulties in obtaining adequate staff and equipment, admission privileges, reimbursement for services and may have well played a part in hindering the development of radiation oncology in comparison with other oncologic specialties. After the discovery of x rays by Wilhelm Conrad Rktgen,’ their application in the treatment of malignancy was rapid, the first case of cancer cured by x rays was reported in 1896.’ Thereafter, radiation therapy was largely an empiric practice of medicine. The growth and development of radiation oncology has been greatest during the last ten years; the rapid development of new megavoltage equipment, a better understanding of the basic biologic basis for radiation therapy, and the application of physics and computer techniques to treatment planning, have contributed to this growth. The number of full time practicing radiation onI
* Department of Radiation Therapy and Nuclear Medicine, Hahnemann Medical College and Hospital, Philadelphia, Pennsylvania.
cologists has grown from 30 in 1959 to the present total of nearly 1,000 physicians practicing radiation oncology as a full time specialty.” Related to these developments has been a trend to establish academic departments of independent, radiation oncology within medical schools. The number of independent academic departments has grown from less than five in the 1960s to more than 26 such departments of radiation oncology within the 125 medical schools of the United States.” New medical schools anticipate establishing independent academic departments of radiation oncology in addition to departments of diagnostic radiology. National trends in cancer care are affected by the development of independent departments of radiation oncology because of their major contributions in the treatment of cancer patients and in the trend toward multidisciplinary oncology programs. Moreover, independent departments can establish basic broad research programs and support them by funds from various national sources. Medical school committees charged with the responsibility for reviewing potential departmental status for radiation oncology should give careful and deliberate consideration to the following questions: I) Is the radiation oncology service large enough to be viable? 2) Does the clinical service provide a meaningful teaching experience for medical students and house staff? 3) Is there a sufficient volume of paticnts cared for both on an inpatient and outpatient basis? 4) Is there an adequate research program either in the basic sciences or in the clinical field? 5) Does the radiation oncology service
174 deal with a constellation of diseases or anatomic systems not dealt with by other departments? 6) Does the radiation oncology service have an organized graduate teaching program or a specialty board designation? 7) Is the radiation oncology service strong enough to have innovative ideas, plans, and programs? 8) Is there a demonstrated need for separate administrative powers or considerations which will assure growth or increase strength of the service? If the answers to these questions are positive, radiation oncology qualifies for departmental status. A clinical radiation oncologist needs a thorough grounding not only in the clinical characteristics of cancer care, but also in the basic sciences and related clinical fields such as radiation physics, radiation biology, immunology, clinical treatment planning, computer techniques and their applications in dosimetry, pathology, and chemotherapy. Knowledge also is required of the application of surgical techniques in the management of the cancer patient, of the basic background in gynecologic oncology necessary to the appropriate management of the cancer patient, as well as basic information in anatomy, physiology, microbiology, and pharmacology. Primary care of the cancer patient should also be included in training programs. The creation of a department of radiation oncology attract a medical faculty of high professional standing, and can lead to a major and significant contribution in the overall program for cancer within the institution. Rapid changes are taking place within the cancer programs of medical schools: at this time, radiation oncology should be represented on the higher councils of the schools so that it may make a significant contribution to the actions of these councils, particularly regarding cancer care. The chairman of radiation oncology should be informed quickly and directly of new or pending developments. There-
Editorials fore, it is important that the relationship between the dean and the chairman of radiation oncology be clear, direct, and personal. It should not be opacified by placing between the two another administrative officer whose primary interest may include many other areas of the medical school. A number of objections can be raised to departmental status for radiation oncology. Some are related to the fact that the care of the cancer patient is a highly specialized area of endeavor and that most physicians know when to refer patients for radiation therapy. Another objection raised to departmental status is that the dean can only keep in touch with a limited number of departments. This statement is misleading since no sudden increase in demands on the dean’s time is envisioned. With the expansion of cancer programs, the dean’s office invariably has become involved in various aspects of the enlarged oncology services. Another objection is that radiation oncology is an additional clinical field and that its inclusion in the executive committee of the medical school will dilute preclinical strength. Radiation oncology, however, has a strong orientation toward the basic sciences, collaborating actively in teaching and research with the preclinical departments. Also, it is a rigorous intellectual discipline with an allegiance to many different points of view which are neither partisan nor parochial. The change of radiation oncology to de-partmental status has opened new avenues for support from state, federal, and private sources, in large measure, requirements for departmental status are supported by funds from the federal level. Creation of a department of radiation oncology is not divisive, but instead actively contributes to a more effective and significant program in cancer care and research. The arguments in favor of according departmental status for radiation oncology are major and require the attention of medical faculties and deans of medical schools, as well as the active participation
175
Editorials
of
the
director
of
the
radition
oncologv
program. Indeed,
the
concept
status
for
radiation
whose
time
has come.
oncologv
is an
idea
of a departmental
REFERENCES
1. W. C. RBntgen. Uber eine neue Art von Strahlen. Pt. I. Sitzumgsber. Phvs. Med. Ges. Wiirzburg. 132-141, Dec. 28, 1895; Pt. 2, ibid., March 9, 1896. 2. A. Voigt. Behandlung eincs inoperablen
pharynxkarzinoms mit RGntgenstrahlen. Arztlichen verein i. Hamburg, Nov. 3, 1896. 3. Crisis in radiation therapv training and practice. Final Report to the National Cancer Institute from the Committee for Radiation Therapy Studies, Sept. 1, 1972.
When Should Radiation Oncology Become a Separate Department? LUTHER W. BRADY, MD”
u ‘YFIL:I.SITEI) SKATES,radiation
therapy has generalI>. evolved within a department of radiology. In many institutions, it continues as a part of that department even though now there is a tendency for separate departments of diagnostic radiology and departments of radiation therapy to be created. Since radiation therapy continues as a part of numerous departments of radiology, many of the characteristics of diagnostic radiology practice persist and lead to serious misunderstandings on the part of other physicians, hospital administrators, deans of medical schools, patients, and third party payers regarding the nature and scope of radiotherapeutic services. These misunderstandings often lead to serious difficulties in obtaining adequate staff and equipment, admission privileges, reimbursement for services and may have well played a part in hindering the development of radiation oncology in comparison with other oncologic specialties. After the discovery of x rays by Wilhelm Conrad Rktgen,’ their application in the treatment of malignancy was rapid, the first case of cancer cured by x rays was reported in 1896.’ Thereafter, radiation therapy was largely an empiric practice of medicine. The growth and development of radiation oncology has been greatest during the last ten years; the rapid development of new megavoltage equipment, a better understanding of the basic biologic basis for radiation therapy, and the application of physics and computer techniques to treatment planning, have contributed to this growth. The number of full time practicing radiation onI
* Department of Radiation Therapy and Nuclear Medicine, Hahnemann Medical College and Hospital, Philadelphia, Pennsylvania.
cologists has grown from 30 in 1959 to the present total of nearly 1,000 physicians practicing radiation oncology as a full time specialty.” Related to these developments has been a trend to establish academic departments of independent, radiation oncology within medical schools. The number of independent academic departments has grown from less than five in the 1960s to more than 26 such departments of radiation oncology within the 125 medical schools of the United States.” New medical schools anticipate establishing independent academic departments of radiation oncology in addition to departments of diagnostic radiology. National trends in cancer care are affected by the development of independent departments of radiation oncology because of their major contributions in the treatment of cancer patients and in the trend toward multidisciplinary oncology programs. Moreover, independent departments can establish basic broad research programs and support them by funds from various national sources. Medical school committees charged with the responsibility for reviewing potential departmental status for radiation oncology should give careful and deliberate consideration to the following questions: I) Is the radiation oncology service large enough to be viable? 2) Does the clinical service provide a meaningful teaching experience for medical students and house staff? 3) Is there a sufficient volume of paticnts cared for both on an inpatient and outpatient basis? 4) Is there an adequate research program either in the basic sciences or in the clinical field? 5) Does the radiation oncology service
174 deal with a constellation of diseases or anatomic systems not dealt with by other departments? 6) Does the radiation oncology service have an organized graduate teaching program or a specialty board designation? 7) Is the radiation oncology service strong enough to have innovative ideas, plans, and programs? 8) Is there a demonstrated need for separate administrative powers or considerations which will assure growth or increase strength of the service? If the answers to these questions are positive, radiation oncology qualifies for departmental status. A clinical radiation oncologist needs a thorough grounding not only in the clinical characteristics of cancer care, but also in the basic sciences and related clinical fields such as radiation physics, radiation biology, immunology, clinical treatment planning, computer techniques and their applications in dosimetry, pathology, and chemotherapy. Knowledge also is required of the application of surgical techniques in the management of the cancer patient, of the basic background in gynecologic oncology necessary to the appropriate management of the cancer patient, as well as basic information in anatomy, physiology, microbiology, and pharmacology. Primary care of the cancer patient should also be included in training programs. The creation of a department of radiation oncology attract a medical faculty of high professional standing, and can lead to a major and significant contribution in the overall program for cancer within the institution. Rapid changes are taking place within the cancer programs of medical schools: at this time, radiation oncology should be represented on the higher councils of the schools so that it may make a significant contribution to the actions of these councils, particularly regarding cancer care. The chairman of radiation oncology should be informed quickly and directly of new or pending developments. There-
Editorials fore, it is important that the relationship between the dean and the chairman of radiation oncology be clear, direct, and personal. It should not be opacified by placing between the two another administrative officer whose primary interest may include many other areas of the medical school. A number of objections can be raised to departmental status for radiation oncology. Some are related to the fact that the care of the cancer patient is a highly specialized area of endeavor and that most physicians know when to refer patients for radiation therapy. Another objection raised to departmental status is that the dean can only keep in touch with a limited number of departments. This statement is misleading since no sudden increase in demands on the dean’s time is envisioned. With the expansion of cancer programs, the dean’s office invariably has become involved in various aspects of the enlarged oncology services. Another objection is that radiation oncology is an additional clinical field and that its inclusion in the executive committee of the medical school will dilute preclinical strength. Radiation oncology, however, has a strong orientation toward the basic sciences, collaborating actively in teaching and research with the preclinical departments. Also, it is a rigorous intellectual discipline with an allegiance to many different points of view which are neither partisan nor parochial. The change of radiation oncology to de-partmental status has opened new avenues for support from state, federal, and private sources, in large measure, requirements for departmental status are supported by funds from the federal level. Creation of a department of radiation oncology is not divisive, but instead actively contributes to a more effective and significant program in cancer care and research. The arguments in favor of according departmental status for radiation oncology are major and require the attention of medical faculties and deans of medical schools, as well as the active participation
175
Editorials
of
the
director
of
the
radition
oncologv
program. Indeed,
the
concept
status
for
radiation
whose
time
has come.
oncologv
is an
idea
of a departmental
REFERENCES
1. W. C. RBntgen. Uber eine neue Art von Strahlen. Pt. I. Sitzumgsber. Phvs. Med. Ges. Wiirzburg. 132-141, Dec. 28, 1895; Pt. 2, ibid., March 9, 1896. 2. A. Voigt. Behandlung eincs inoperablen
pharynxkarzinoms mit RGntgenstrahlen. Arztlichen verein i. Hamburg, Nov. 3, 1896. 3. Crisis in radiation therapv training and practice. Final Report to the National Cancer Institute from the Committee for Radiation Therapy Studies, Sept. 1, 1972.