By Shauna Campbell, DO
In comparison with most medical specialties, radiation oncology offers a more family friendly schedule, for both a trainee and practicing physician. However, the board certification process is extensive, including four individual examinations spanning an average of three years. This prolonged process often leaves early career physicians trying to coordinate major life events, such as family planning, with the intensive study required to obtain board certification. From 2018 to 2020, there were several unfortunate events that left a divide between many young physicians and the ABR. This included an unprecedented failure rate in the basic science examinations, examinees who reported their request for accommodations were not fulfilled and cancellations due to the COVID-19 pandemic. In response, there has been a concerted effort by several stakeholder organizations, including the ABR, ARRO, ADROP, SCAROP and ASTRO, to improve the board certification process. As we emerge from the COVID-19 pandemic, I would like to highlight the recent changes that have been implemented.
- As of 2021, all ABR written and oral examinations are now virtual. The ABR should be commended for creating this platform on such a limited timeline, as well as their commitment to continuous improvement.
- Candidates taking the oral examination are no longer required to travel to Tucson, Arizona, limiting the time and financial burden of board certification.
- Candidates are now able to take the written and oral examinations in the environment of their choice, improving the ease of special accommodations.
- The ABR now has improved ability to schedule examination dates based on feedback from stakeholder organizations, as it is no longer dependent on a third-party company for examination administration.
- This change made the extra April 2021 basic science and clinical written examinations possible.
- ARRO has provided feedback requesting the clinical written examination be permanently moved from July/August following graduation to May of PGY-5. This feedback was received favorably by the ABR, and the 2022 examination dates will be released in early June.
- ABR personnel now have direct access to the examination platform and no longer depend on a third-party administrator to implement special accommodations, such as longer breaks or increased testing time.
- Residents are now eligible, with the permission of their program director, to sit for the medical physics and/or radiation and cancer biology examination at the beginning of PGY-4. This is one year earlier than previous requirements and provides residents with personal choice and flexibility to accommodate other life events with board certification.
Family & Medical Leave Policy:
- The ABR is expected to announce their official family and medical leave policy in early June 2021. All medical boards under the American Board of Medical Specialties were called to establish a maximum amount of time away permitted during residency before extension of training is required, as of July 1, 2021.
- The ABR has been responsive to feedback from stakeholder organizations informing this policy, and in the latest draft has introduced a leave policy inclusive of 28 weeks’ leave over four years for radiation oncology trainees. This policy accounts for time away, inclusive of vacation, family, medical and caregiver leave.
- There is also consideration for additional leave, without extension of training, for residents deemed competent by their program director and with special permission of the ABR.
- The ABR will be a leader among medical boards should it finalize this contemporary policy, which is consistent with the recent editorial published in Radiology, Family and Medical Leave for Diagnostic Radiology, Interventional Radiology, and Radiation Oncology Residents in the United States: A Policy Opportunity, which was endorsed by ARRO and ADROP. If this policy is finalized as proposed, it would be in agreement with Resolution 48, passed at the 2021 ACR meeting, recommending all residents receive 12 weeks of family and medical leave during residency, with additional time at the discretion of the program director and the ABR.
As we emerge from a difficult few years, the board certification process in radiation oncology has undergone substantial modernization. The changes implemented thus far represent a collaborative effort by several organizations and significant dedication by the ABR to support the growing workforce of radiation oncologists. Continued collaboration and improvement in board certification will help ensure radiation oncology continues to attract talented and diverse physicians that represent the future of our specialty.
Join us on the Gender Equity community on the ROhub to continue the conversation. What future changes do you think should be considered for the continuous improvement of board certification in radiation oncology?”
For additional information, read the ASTRO letter to the ABR on parental leave. This page also includes a link to SCAROP’s letter to the ABR.
Shauna Campbell, DO, is a PGY-5 resident at Cleveland Clinic and immediate past chair of the ARRO Executive Committee.
Posted: May 25, 2021
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By Thomas Eichler, MD, FASTRO, ASTRO Chair
After more than a decade of enjoying the prestige of being one of the most highly sought-after specialties in the medical student match process, there have been troubling signs in the past few years that something was amiss. In 2019, the number of medical students who initially matched into radiation oncology declined with multiple slots unfilled. At the time, there was speculation about whether this was an anomaly or the beginning of a trend that had been forecast years before. In 2020, the field saw a larger decline in the number of medical students who matched, coupled with an increase in the number of people who then entered the field through the Supplemental Offer and Acceptance Program (SOAP) process. In fact, radiation oncology had the highest percentage of spots filled through the SOAP of any medical specialty.
From a treatment perspective, many factors, including the decreased use of radiation for some disease sites and an increased use of hypofractionation, bring into question the long-term viability of our specialty. Despite the many positive aspects of radiation oncology, there are growing concerns about the future of the workforce. There has been an increase in the number of available trainee positions despite the apparent decline in medical student interest and concern regarding patient volume projections. These issues contribute to forecasts of declining income streams and anxieties about the future given the recently proposed ― and now delayed ― radiation oncology alternative payment model. The worrisome trend in the SOAP percentages for radiation oncology underscores some of these negative perceptions about the field among students and residency applicants, which are in turn amplified on social media platforms. Not surprisingly, many students are confused about what career path to choose and may be discouraged to pursue radiation oncology before they even truly explore it.
ASTRO leaders have sought to be forthright with our members about challenges in the field (see previous blog posts below) and ASTRO’s role in addressing them. While there are strict anti-trust principles ASTRO must abide by, the Board of Directors felt compelled to issue a definitive statement so that there is no ambiguity about our position.
ASTRO Position Statement on the U.S. Radiation Oncology Workforce
- Radiation oncology has long been a critical component of multidisciplinary cancer management, driven by clinical and scientific innovation. Recent advances in technology and our understanding of cancer biology have allowed radiation oncologists to offer more accurate and effective therapies, often in fewer total treatments than before, resulting in improved patient care. ASTRO has observed growth in residency training positions over the past two decades. With more efficient treatment delivery, fewer radiation oncologists may be needed in the coming years. Residency training positions should be reserved for those who are enthusiastic about the field and should reflect the anticipated societal need for radiation therapy services. As we prepare the next generation of radiation oncologists for independent practice, we encourage stakeholders to carefully consider these aspects affecting our specialty as they review the size and scope of their training programs.
Additionally, ASTRO acknowledges the continued need to grow and nurture diversity within the next generation of our workforce. We serve diverse peoples, and our trainees and faculty should reflect that diversity. We are committed to addressing all aspects of bias as we seek to ensure equity and inclusion within our specialty and to improve health outcomes for all our patients.
While we acknowledge that this statement will not magically solve the issues impacting the field, we do want to be clear with our current and future members about ASTRO’s stance on this critical issue. We also strive to keep the lines of communication open with all members, including our residents. We listen to and appreciate the insights and perspectives from Association of Residents in Radiation Oncology (ARRO) to better understand their perceptions and experiences. Results from a survey of the class of 2020 found that residents had an average of five job interviews, received at least two job offers and, perhaps most significantly, 89% of residents were satisfied with the offers they received. While there are some vocal naysayers on social media, the direct response from residents gives us confidence and hope about the current realities in the field.
Radiation oncology has always sought the best and the brightest minds for our field because we know it is a truly rewarding area of cancer treatment. That will not change. We have deeply meaningful interactions with our patients, curing many of their cancers, alleviating suffering and extending life. Technology continues to play a large role in the field with novel and groundbreaking synergies between radiation and systemic agents, including immunotherapeutics, and many contemporary research questions are emerging, ripe for exploration and clinical trials. The field is also expanding due to innovations in radiopharmaceuticals and theranostics, offering radiation oncologists exciting new ways in which to help patients. While the future is unpredictable, we unequivocally believe in the continued impact and relevance of our specialty going forward, and perhaps more importantly, have unshakeable faith in the dedicated professionals who have made radiation oncology fundamental in the fight against cancer.
Read previous posts:
A Commitment to the Field - Dr. Theodore DeWeese, March 10, 2020
The Residency Training Landscape, Continued - Dr. Paul Harari, May 28, 2019
The Residency Training Landscape - Dr. Paul Harari, March 20, 2019
Posted: January 5, 2021
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By Theodore DeWeese, MD, FASTRO, ASTRO Board Chair
Next week, the National Resident Matching Program® kicks off Match Week, which will culminate with Match Day on March 20. This is an important and exciting day for both students and training programs and represents the first glimpse at the future leaders of our field. We are fortunate to recruit outstanding resident physicians to our field, a group who values the key role radiation oncology plays in the care of patients and who can pursue the future of research in oncology. We anticipate that like last year, there will be an imbalance between the number of programs offering positions and the number of students who match into the radiation oncology specialty. Radiation oncology was not the only specialty to experience a market correction last year, and there are numerous factors that contributed to the expected gap this year. We also recognize that over the last decade there has been a gradual but steady expansion in residency programs and positions, and it is unlikely for this imbalance to be corrected in just a year or two. While outside factors such as board certification exams, program-level training issues and institutional hiring practices are beyond ASTRO’s direct control, there are a number of things that we as a membership society did in the past year to address some of the field’s challenges, and I want to share some of what has been done to-date.
Exams and Training
As a normal course of business, the ASTRO Board regularly discusses the future of the field with an eye toward new treatment options such as theranostics to expand the role of radiation oncologists as leaders in oncology care. With this and other opportunities in mind, ASTRO submitted comments to the ACGME last spring to help shape future training requirements for residents. As the field continues to mature, so too the ACGME Radiation Oncology Program Requirements should evolve. The ASTRO Board also publicly supported the proposal that the ABR make the radiation oncology examination blueprint accessible on its website, including topics and the percentage of the examination dedicated to a topic. We understand the ABR has agreed to develop these blueprints, and this transparency will provide important guidance for trainees, allowing them to focus their studying efforts.
To address resident training and education, ADROP, the Association for Directors of Radiation Oncology Programs, created an information exchange network. This allows programs to share resources, including curricula, with radiation oncology residency program directors, assistant program directors and associate program directors. In addition, leaders of the Society of Chairs of Academic Radiation Oncology Programs (SCAROP) discuss resident issues during their monthly leadership calls and at their Annual Meeting, keeping the topic and the well-being of the field top of mind.
And we continue to listen. During ASTRO19, the ASTRO Board invited the ARRO Chair to share trainee perspectives on priority issues including the board examination processes. The Board also met with leaders from the ABR and ADROP to talk more about resident physician training. We also wanted to hear from recent residents who matched into the specialty about their experiences. I am heartened by residents like Amishi Bajaj, MD, who matched into radiation oncology in 2018 at the McGaw Medical Center of Northwestern University. As she noted, “I matched at my dream program in my dream institution. I absolutely love my department and my institution, and I am endlessly inspired by my attendings and coresidents, who are not only brilliant physicians but also wonderfully kind people.”
As a way to support the next generation of researchers and to improve outcomes and quality of life for cancer patients, ASTRO created two new Research Training Fellowships with industry partners AstraZeneca and Varian. The Fellowships are designed to advance the field of radiation oncology by providing new research opportunities in an industry setting. The program will allow each Fellow to gain experience in medical affairs, clinical research and research/development from an industry perspective. We received many high-quality submissions and nominations, and we will be making the announcement about the two Fellow recipients in the weeks to come.
Commitment to Diversity and Inclusion
In an effort to introduce radiation oncology to students from historically underrepresented groups, ASTRO led an effort to connect with Chicago-area high school and college students and invited budding scientists to come to ASTRO19. The students met a range of ASTRO members, including radiation oncologists, residents and medical physicists. The students were also given a tour of the Exhibit Hall where they met leaders from a variety of companies to learn more about the latest medical advances. Because most medical schools do not require a rotation through radiation oncology, it is our hope that introducing young women and men from underrepresented minority groups to our field at this formative stage of their education will inform their future career decisions.
Addressing Patient Needs
We have heard concern about the job market and the timing of job offers for those completing residency, and we understand that many residents seek to work in academic settings. In fact, a recent Red Journal article, “Top Concerns of Radiation Oncology Trainees in 2019: Job Market, Board Examinations and Residency Expansion,” by Kahn, et al noted that “graduates strongly prefer jobs that are located in large cities (population >500,000) and that specific geographic regions, such as the Midwest, are considered to be less desirable.” Those preferences are certainly consistent with previous resident graduates. Interestingly, and importantly from a job search perspective, an analysis done for the ASTRO Rural Task Force revealed that 15% of Americans live in a non-metro area with only 6% of radiation oncologists practicing in these non-metro areas. Such information is not widely known and may help future residents consider these opportunities. Working in non-metro and smaller community settings can have tangible and direct impact where there is high patient need for quality oncologic care.
Volunteering Makes the Field Stronger
We want our field to grow in a healthy way, and the best way to change the course of the field or ASTRO as a membership society is for you to get involved. By serving as a volunteer on a committee or task force, your voice and perspective have more impact and weight.
One thing we continue to hear is that many medical students aren’t introduced to the specialty or have minimal exposure to what radiation oncology entails. As Mudit Chowdhary, MD, chief resident at Rush University Medical Center noted, “In hindsight, I realize how lucky I was to have learned about radiation oncology. Like many, I had never heard of this field even after two years of medical school. During this time, my future brother-in-law matched into a radiation oncology residency program and encouraged me to learn more about the specialty.” Another thing you can do without joining a formal committee is take the opportunity to educate your peer physicians or the medical students you encounter. The volunteers in ASTRO’s Communications Committee recently released updated slide decks that all ASTRO members can access to introduce or educate your colleagues and patients about the latest advances in radiation therapy. There is one RT overview presentation for the general public and two presentations for medical professionals: a general overview and the first in a series of disease-site specific trainings, this one focused on lung cancer treatments.
Amishi noted in her essay: “To the medical students out there who similarly identify as lovers of medicine in all its forms: Don’t forget to consider radiation oncology. You really can have it all.” As we look ahead to the Match results to come, we remain thankful to all those who are currently practicing and training in radiation oncology, and for the commitment of medical students seeking to help cancer patients by joining the radiation oncology field. ASTRO will continue to be an advocate for the field and do its best to influence how the scope of the specialty continues to evolve.
Read previous posts:
The Residency Training Landscape
(posted March 20, 2019)
The Residency Training Landscape, continued
(posted May 28, 2019)
Posted: March 10, 2020
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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.
Posted: May 28, 2019
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