By Bruce Haffty, MD, FASTRO,1 Chair; Chirag Shah, MD,2 and Pranshu Mohindra, MD,3 Co-chairs, ASTRO Workforce Task Force
Issues around the state and future of the radiation oncology workforce have taken on more urgency in the recent years given the imbalance in residency positions secured during the Match and Supplemental Offer and Acceptance Program (SOAP) process. In an effort to better inform medical students about the specialty, ASTRO updated the medical student section of the website to include a Journals collection, which provides a range of studies and perspectives specific to the specialty, including workforce issues. Additionally, recognizing and respecting diverse viewpoints, ASTRO offers many channels for thoughtful and transparent debates and discussions, including ROhub, the ASTRO Blog and ASTRO’s suite of scientific journals.
The ASTRO Board of Directors has long shared our concerns about the future radiation oncology workforce. In fact, in each of the past three years, the Chair of the ASTRO Board provided updates to members about why addressing workforce issues are critical to the health of the specialty. Links to past Chairs’ remarks are at the end of this post. In January 2021, the Board released a position statement that was shared with ASTRO members, and it is worth revisiting.
- ASTRO Position Statement on the U.S. Radiation Oncology Workforce (January 2021)
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.
Recognizing that more could be done, the ASTRO Board approved the creation of a task force to analyze the current and projected future status of the radiation oncology workforce, the potential oversupply of radiation oncologists and ways to inform and attract an appropriate number of interested medical students to the field. The task force, which we co-chair, includes representatives from ASTRO’s Workforce Subcommittee, ADROP, ARRO, CHEDI and SCAROP, as well as community practices.
Our first recommendation to the Board was to authorize a Request for Proposal (RFP) for an outside, independent analysis of the future requirements for the radiation oncology workforce. We felt an external independent analysis by professionals experienced in these complex studies would minimize bias and provide the most credible data to assess the supply and demand over the coming decade. The ASTRO Board approved the RFP, and we are pleased to report that after a national search, the Workforce Task Force recommended, and the Board approved, the funding and selection of an independent firm, Health Management Associates, to execute the study.
The task force also crafted a supplement to the ASTRO Position Statement, which provides more context about issues impacting residency training programs, including the size, selection process and scope of training programs. This new position statement is:
- ASTRO Statement on the U.S. Radiation Oncology Workforce (February 2022)
ASTRO continues to support the critical role of high-quality residency training to optimally educate and prepare our future workforce. It is a foundational principle that residency training positions should be filled by qualified candidates who are enthusiastic about the field. To that end, we encourage stakeholders to carefully consider the following factors as they evaluate the size, selection process and scope of their training programs:
- The quality and extent of each candidate’s interest in radiation oncology.
- How the specialty, as a whole, as well as individual programs, can engage, recruit and retain diverse applicants.
- Availability of sufficient resources for clinical operations so that the priority for residents is education.
- The future expected need for radiation oncologists.
- Whether participation in the SOAP is warranted and in the best long-term interest of providing quality training, innovation and patient care.
The ASTRO Board is committed to maintaining distance from the analysis to ensure that there are no perceptions of any internal influence. It is the intention of the ASTRO Workforce Task Force to regularly update ASTRO members about the progress of the study while maintaining the boundaries required to ensure that the analysis and recommendations remain the independent domain of the outside firm. Until then, we hope that programs take our updated position statement into consideration as they plan their programs for the years ahead.
Read previous posts:
The Future of our Field – Dr. Thomas Eichler, January 5, 2021
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
1. Robert Wood Johnson and NJ Medical School, New Jersey
2. Cleveland Clinic, Cleveland, Ohio
3. University of Maryland School of Medicine, Baltimore, Maryland
Posted: March 1, 2022
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By Rachel B. Jimenez, MD;1 Curtiland Deville, Jr., MD;2 Chelsea C. Pinnix, MD, PhD;3 and Iris C. Gibbs, MD4
When embarking on the residency selection process for your training program, it is important to recognize that attracting applicants with relevant attributes and experiences is vital for shoring up the strength of our specialty while meeting the needs of an increasingly diverse patient population. A holistic review, applied at all stages of the selection process, can be an effective way to ensure that qualified applicants are not overlooked. Below, we provide some do’s and don’ts to consider during each phase of the recruitment season, followed by additional resources for context and further reading.
- Be consistent:
- Use standardized questions across all interviewees to promote fairness and uniformity in an interview setting.
- Identify the most important skills and attributes of desirable applicants in advance of the residency selection process.
- Consider which skills and attributes are trainable or acquirable through your training program (e.g., research skills) and which are not trainable and constitute proficiencies expected upon entry (e.g., empathy, communication skills).
- Generate a rubric of selection criteria. Circulate the rubric among members of the selection committee for their feedback and encourage use of the rubric in all phases of the selection process from screening and interviews to final selection.
- Promote awareness:
- Provide implicit bias training for all members of the residency selection process to promote awareness and mitigate the effects of unconscious bias.
- Educate the committee about local, institutional and national representation trends and strategies to enhance diversity and inclusion.
- Encourage multiple perspectives:
- Form a diverse residency selection committee (ethnicity/race, sexual orientation, gender identity, religion, academic level, position focus) that offers broad and multi-faceted perspectives on the applicant pool.
- Foster an environment of open communication that allows members of the selection committee to offer their opinions in a safe and respectful manner.
- Context matters:
- When evaluating the strengths/weaknesses of an applicant’s experiences (e.g., strength of prior research experience or prestige of a letter writer), consider the opportunities available to that applicant in their given training environment and if they have made the most of the opportunities to which they reasonably have access. Reward distance traveled.
- Avoid inappropriate questions:
- Do not inquire about an applicant’s racial or ethnic identity, marital status, sexual orientation, gender identity, age or parental status. At times, a candidate may voluntarily share this information so you may simply acknowledge it and move on to the next question. It is not a good practice to ask follow-up questions, even if it is volunteered by the applicant. Similarly, avoid commenting on someone’s physical appearance or inquiring about where else the applicant applied or where they plan to rank your program. This information should have no bearing on the applicant’s candidacy as a resident physician.
- Don’t anchor:
- Avoid focusing on a single strength or weakness in a candidate’s application. If an applicant meets screening criteria for an interview, despite fewer strengths in one domain or because of a particular accomplishment, avoid drawing upon that same item for subsequent considerations of their candidacy.
- Diversity is not a quota:
- Resist the pitfalls of “checking a box.” Invest in individuals and be inclusive.
For additional reading:
Best Practices for Conducting Residency Program Interviews
Diversity Trends by Sex and Underrepresented in Medicine Status Among U.S. Radiation and Medical Oncology Faculty Over 5 Decades
Impact of Holistic Review on Student Interview Pool Diversity
Linguistic Biases in Letters of Recommendation for Radiation Oncology Residency Applicants from 2015 to 2019
Potential Implications of the New USMLE Step 1 Pass/Fail Format for Diversity Within Radiation Oncology
1. Assistant Professor and Associate Residency Program Director, Harvard Radiation Oncology Program; President, Association for Program Directors in Radiation Oncology
2. Associate Professor of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University; ASTRO Board Representative Ex-officio, Health Equity, Diversity and Inclusion.
3. Associate Professor and Residency Program Director, The University of Texas MD Anderson Cancer Center; Vice-president, Association for Program Directors in Radiation Oncology
4. Professor of Radiation Oncology and Associate Dean of MD Admissions, Stanford Medicine; former Director of Education and Residency Program Director, Stanford Department of Radiation Oncology
Posted: February 9, 2022
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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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