United States Radiation Oncology Curriculum Development: The Tail is Wagging the Dog

Quality of Radiotherapy Workforce Training within the USA

The training, competency requirements and scope of practice of professionals within a radiation oncology department vary across countries. The purpose of this review is to shed light on the current status of radiotherapy training in the USA by discussing current benchmarks for medical residency, physics residency, radiation therapy and dosimetry training programmes. Although there are notable strengths, the US radiotherapy workforce training system also faces several challenges when it comes to standardising education to develop a competent workforce that meets societal needs. Continued efforts are needed at a systemic level to improve training in areas such as brachytherapy and proton therapy, promote research involvement and develop trainees who are equipped to form a competent radiation therapy workforce.

Development of a United States Radiation Oncology Curricular Framework: A Stakeholder Delphi Consensus

PURPOSE

A United States (US) radiation oncology curriculum, developed using best practices for curriculum inquiry, is needed to guide residency education and qualifying examinations. Competency-based training, including entrustable professional activities (EPAs), provides an outcomes-based approach to modern graduate medical education. This study aimed to define US radiation oncology EPAs and curricular content domains using a deliberative process with input from multiple stakeholder groups.

METHODS AND MATERIALS

The Radiation Oncology Education Collaborative Study Group Core Curriculum Project Leadership Committee developed initial content domains and EPAs. Following recruitment of stakeholders, a Delphi process was used to achieve consensus. In the first round, content domains and EPAs were reviewed for inclusion and exclusion, clarity, time allocation (content domains), and level of training (EPAs). Participants submitted additional content domains and EPAs for consideration. Any content domains or EPAs 1 standard deviation below the median for inclusion and exclusion underwent Leadership Committee review. All participants completing the first Delphi round were invited to the second round. Percent curriculum time allocated for content domains and a single subdomain were finalized. New EPAs or EPAs undergoing major revisions were reviewed.

RESULTS

A total of 186 participants representing diverse stakeholder groups participated. One hundred fourteen completed the first Delphi round (61.3%). Of 114 invited, 77 participants completed the second round of the Delphi process (67.5%). Overall, 6 of 9 content domains met consensus, 1 content domain was removed, and 2 content domains were combined. Four subdomains of a single content domain were reviewed and met consensus. Consensus on percent time allocated per content domain and subdomain was reached. Of 55 initial EPAs, 52 final EPAs met consensus.

CONCLUSIONS

Deliberative curriculum inquiry was successfully used to develop a consensus on US radiation oncology content domains and EPAs. These data can guide the allocation of educational time in training programs, help inform weighting for qualifying examinations, and help guide clinical training and resident assessment.

A Call for Reform: Variability and Insufficiency in Radiation Oncology Resident Didactics-a Brief Report and National Survey of Program Directors

An informal needs assessment and lack of a national standardized curriculum suggest that there is tremendous variability in the formal teaching of radiation oncology resident throughout the USA. The goal of this study was to characterize formal radiation oncology resident education, in order to identify knowledge gaps and areas for improvement. We developed a 14-item survey consisting of the following domains: program characteristics, teaching faculty, formal teaching time, instructional approaches for formal teaching, curricular topics, and satisfaction with didactics. All 91 accredited US-based radiation oncology program directors received an invitation to complete the survey anonymously by email. Twenty-four (26% response rate) program directors responded. Programs used a variety of instructional methods; all programs reported using lecture-based teaching and only a minority using simulation (38%) or flipped classroom techniques (17%). Other than PowerPoint, the most common electronic resource utilized was quizzing/polling (67%), webinar (33%), and econtour.org (13%). The lack of a national, standardized, radiation oncology residency didactic curriculum promotes variability and insufficiency in resident training. Themes for improvement were diversity in didactic topics, incorporation of evidence-based teaching practices, increased faculty involvement, and sharing of resources across programs. Development of a national curriculum and increased electronic resource sharing may help address some of these areas of improvement.

Challenges in the transition to independent radiation oncology practice and targeted interventions for improvement

Numerous radiation oncology residents and junior attendings have identified common weaknesses in residency training that hinder the transition from training to independent practice. Recurrent themes include not only general autonomy but also proficiency in technical skills, such as treatment plan review and image verification, and nontechnical skills, such as leadership, mentorship, and education. While multiple strategies to address these deficiencies have been investigated, many are not widely available or may be difficult to implement. We aim to summarize the frequently cited challenges in the transition to independent radiation oncology practice as well as the pertinent interventions that have been explored.

Radiation and Cancer Biology Educators of Radiation Oncology Residents and the Courses They Teach1

The purpose of this study was to characterize today's radiation and cancer biology educators of radiation oncology residents, and the biology courses they teach. An e-mail list of 133 presumptive resident biology educators was compiled, and they were invited to participate in a 46-item survey. Survey questions were designed to collect information about the educational and academic backgrounds of the educators, how they self-identify, characteristics of the courses they teach, the value that they assign to their teaching activities, their level of satisfaction with their courses and how they see these courses being taught in the future. Findings of this survey were compared and contrasted with prior surveys of biology educators (conducted 12 and 20 years ago, respectively), and with more recent surveys of radiation oncology residents and radiation oncology residency program directors conducted in 2018 and 2019. A total of 67 survey responses were received. Biology educators range in age, academic rank and years of teaching experience from junior (18%) to quite senior (45%). Only about 40% self-identify as radiation biologists, biophysicists or chemists, compared to 56% in 2001. The majority of the others consist of cancer biologists (15%), radiation oncologists (15%) and radiation oncology physician-scientists (16%). Educators prioritize their resident teaching as important or very important. Biology courses are widely variable in contact hours between programs and have not changed significantly over the past 20 years. About 75% of the courses are team-taught, including 15% involving multiple training programs. An average biology course consists of about 42% foundational ("classical") radiobiology, 28% clinical radiobiology and 28% cancer biology. While biology educators and radiation oncology program directors are highly satisfied with their biology courses, approximately a third of residents report being not very, or not at all, satisfied. That fewer biology educators are radiobiologists by training and their courses have remained quite variable in length and content over long periods point to the need for a consensus core curriculum for resident education in radiation and cancer biology. Both current educators and program directors also support making online teaching resources available, diversifying course instructors and consolidating biology teaching across multiple training programs.

Radiation Oncology Initial Certification Qualification Examinations: The Resident Experience in 2019

PURPOSE

To characterize the resident experience preparing for the 2019 American Board of Radiology initial certification (IC) qualifying examinations in radiation oncology.

METHODS AND MATERIALS

The Association of Residents in Radiation Oncology distributed a survey to 360 radiation oncology residents from the 2019 and 2020 graduating classes covering topics pertinent to preparation for the medical physics (MP), radiation and cancer biology (RCB), and clinical radiation oncology (CRO) qualifying examinations.

RESULTS

The response rate was 58% (n = 210). In the 12 weeks before the MP and RCB examinations, first-time examinees studied a median of 160 hours (interquartile range, 96 to 270). Residents reported a "moderate" or "significant" negative effect on research productivity (3 [2-4]), mental health (3 [2-4]), clinical development (3 [2-4]), and family life (3 [2-4]). Half of surveyed residents (52%, n = 110) used a protected research or elective block to study while an additional 21% (n = 45) used a median of 5 (3-20) vacation days. Residents overall "agreed" (4 [2-4]) that their program's physics course was "important" for their preparation but were "neutral" (3 [2-4]) regarding the value of their program's radiobiology course. Question-based educational resources were most frequently rated as "important" study resources. Respondents "strongly" endorsed the development of a consensus radiation oncology curriculum (5 [4-5]) and "agreed" (4 [3-4]) that consolidation of the MP, RCB, and CRO qualifying examinations into a single written examination would be preferred.

CONCLUSIONS

Radiation oncology residents dedicate substantial time preparing for the IC examinations at the expense of training- and health-related outcomes. Residents report a wide range in quality of internal program didactic courses in physics and radiobiology, endorse development of a consensus radiation oncology curriculum, and prefer consolidation of the three qualifying examinations into a single written IC examination. We caution the high pass rates seen on the 2019 examinations do not obviate the need for ongoing improvement in radiation oncology graduate medical education and the board certification process.