By Paul Harari, MD, FASTRO, ASTRO Board Chair
In the seven years that I have served on the ASTRO Board in various capacities, our leadership has heard from key stakeholders and discussed and debated many important issues. We’ve discussed the future of brachytherapy and the emerging promise of theranostics and artificial intelligence along with the variability of radiation and cancer biology faculty and the need for common curriculum across residency training programs.
Given the attention this year to residency and training issues, I want to continue the discussion about matters that impact our field. Earlier this year we learned that the ACGME residency training requirements would be updated and that part of the deliberation process included public comments. Given the impact that ACGME rules have within our departments and practices, ASTRO did provide comments on a range of topics.
While we think that by and large the current radiation oncology training requirements are good, we feel there are areas that could be adjusted. Knowing that any changes in ACGME’s residency requirements will impact future residents and the field, I want to give some context to ASTRO’s position on ACGME’s proposed changes to the radiation oncology residency program requirements.
Does Program Size Matter?
ASTRO appreciates the difficulty of identifying the right mix between faculty and residents, particularly when some programs are quite large and others small. The three factors that impact this balance are minimum number of faculty, minimum number of residents, and the faculty-to-resident ratio. We recognize that numeric rules do not guarantee success when it comes to education and training, and that minimum requirements are simply an attempt to strike the best balance.
At one point in time, ASTRO thought the idea of increasing both the minimum number of faculty and the minimum number of residents might be a worthy approach. But after further analysis and discussion, we concluded that there is insufficient data at this time to support an increase in the minimum number of residents. If ACGME elects to share anonymized data about key factors such as ABR pass/fail rates or case logs with information about program size, that may shed further light on the question of whether program size matters. In the absence of such clear data, ASTRO believes four residents is an acceptable minimum.
We do have concerns, however, about the current faculty to resident ratio. We fully support that both the cancer biologist (or radiobiologist) and the medical physicist be considered core faculty. We think that given the increasing complexity of multidisciplinary cancer care, at least four different clinical faculty are needed to provide guidance and knowledge transfer for residents to develop the depth of understanding required for practice. Thus, we recommend that the faculty:resident ratio be increased from 0.67:1 to 1:1 and that it be further clarified that this ratio applies to clinical physician faculty. We think that this size-agnostic metric would help improve quality across all programs.
As I stated in my March blog post, ASTRO has an eye toward the future health and growth of the specialty. From this perspective, we are supportive of many of the proposals to update residency program’s case minimums and curriculum.
- ASTRO supports the proposal to require disease-specific clinical rotations. As multidisciplinary, multimodality treatments and increased sophistication of radiation delivery continue to expand and define the standard of care for many cancer patients, we believe this training is imperative.
- As we look to the future, we anticipate the need for radiation oncologists to be prepared to manage patients who are receiving theranostics and other radiopharmaceuticals. The ongoing use of Xofigo®, the recent approval of Lutethera® and the imminent approval of a PSMA-targeted radioligand and other novel radiolabeled agents in the pipeline lead us to believe that the current requirements are likely insufficient. We are supportive of this update to increase the minimum number of cases.
- We have significant concerns about the levels of brachytherapy training, particularly in light of recent reports showing underutilization of brachytherapy for patients with cervical cancer and an associated decline in cure rates. We are concerned that the current intracavitary requirements could be met with vaginal cylinders only and without exposure to tandem-based insertions for cervix or endometrial cancer. We wholeheartedly support this proposed change.
- We agree with the update for resident scholarly activity to require that the results of investigative projects be submitted for publication. We are hopeful that if residents must submit a manuscript during their residency training, faculty at the institution will provide mentorship guidance to help further residents’ scholarly skills.
While ASTRO heard concerns about many of these topics, we had not heard concerns that the current resident training requirements are insufficient for external beam cases. After discussion, ASTRO leadership agreed that the focus in the current requirements related to a maximum of 250 treated patients per year is an appropriate upper limit. We have several concerns with changing the definition of the upper limit to 350 simulations per year. First, this could be ambiguous (e.g., is this initial simulation only or does it include adaptive simulation or verification simulation or boost simulation or even simple/block check simulation)? Second, we are concerned that more than 250 initial simulations (i.e., more than 250 treated patients as per the current definition) will not afford residents ample time to read and learn from each simulated case. In many academic practices, full-time attending physician workload does not exceed 250 initial simulations per year, and thus we think this is a reasonable benchmark for the upper limit of patients treated by a resident.
Looking Towards the Future
Radiation oncology has attracted many hundreds of truly outstanding residents to the field over the last several decades. Despite the most recent match challenges, I strongly believe that the discipline remains vibrant, dynamic, intellectually and emotionally rewarding, and a wonderful blend of cancer biology, technology and compassionate cancer care for cure and/or palliation. The more we engage the voice of our trainees and early career practitioners in the dialogue, the stronger our field can become for future generations of providers and cancer patients.