Radiation Oncology Residents Research Articles

Cancer Careers a ROECSGXLearnOncology podcast: Increasing Accessibility to Information about Oncology Careers

Purpose In recent years, medical student (MS) applications to U.S. and Canadian radiation oncology (RO) residency programs have declined. The Radiation Oncology Education Collaborative Study Group (ROECSG) recently formed an Undergraduate Medical Education (UGME) committee consisting of attending physicians, residents, and MSs across the globe to further UGME educational efforts. This group identified a need for outreach activities to increase exposure to and interest in RO. Methods In collaboration with LearnOncology, an online, interactive tool to teach oncology skills to learners at all levels, the UGME subcommittee created a structure for a podcast series to highlight oncology careers. This podcast series will be hosted on LearnOncology. Together, these groups identified key topics, informally surveyed MSs, wrote a standardized script, trained interviewers on recording and editing audio content, and set goals for the future scope of the podcast. Results MS and resident interviewers recently completed training and have scheduled initial faculty interviews. Edited podcast episodes will be ≤20 minutes, conducted informally to spotlight both the career and personality of the interviewee. Prominent oncology specialists (e.g. radiation, surgery, medicine, interventional radiology, and physics) will be featured. Listeners will be prompted to complete a brief survey. Interviewers and interviewees will partake in a separate survey to examine the impact of project participation. Podcast analytics and survey data will guide subsequent iterations of podcast episodes. Discussion Podcasts for UGME are a cost-effective teaching method, which gained popularity during the COVID-19 pandemic. We hypothesize that this podcast will be a unique way to positively impact undecided MSs facing the challenge of choosing a career path and increase awareness about oncology specialties. Additionally, this may positively impact mentorship through linking MS and resident interviewers to specialist interviewees. The LearnOncologyXROECSG podcast platform, Cancer Careers, was created to address student questions, anxieties, and excitement related to choosing an oncology career. We expect that this project will increase exposure to oncology and MS interest in oncology careers, including RO. In recent years, medical student (MS) applications to U.S. and Canadian radiation oncology (RO) residency programs have declined. The Radiation Oncology Education Collaborative Study Group (ROECSG) recently formed an Undergraduate Medical Education (UGME) committee consisting of attending physicians, residents, and MSs across the globe to further UGME educational efforts. This group identified a need for outreach activities to increase exposure to and interest in RO. In collaboration with LearnOncology, an online, interactive tool to teach oncology skills to learners at all levels, the UGME subcommittee created a structure for a podcast series to highlight oncology careers. This podcast series will be hosted on LearnOncology. Together, these groups identified key topics, informally surveyed MSs, wrote a standardized script, trained interviewers on recording and editing audio content, and set goals for the future scope of the podcast. MS and resident interviewers recently completed training and have scheduled initial faculty interviews. Edited podcast episodes will be ≤20 minutes, conducted informally to spotlight both the career and personality of the interviewee. Prominent oncology specialists (e.g. radiation, surgery, medicine, interventional radiology, and physics) will be featured. Listeners will be prompted to complete a brief survey. Interviewers and interviewees will partake in a separate survey to examine the impact of project participation. Podcast analytics and survey data will guide subsequent iterations of podcast episodes. Podcasts for UGME are a cost-effective teaching method, which gained popularity during the COVID-19 pandemic. We hypothesize that this podcast will be a unique way to positively impact undecided MSs facing the challenge of choosing a career path and increase awareness about oncology specialties. Additionally, this may positively impact mentorship through linking MS and resident interviewers to specialist interviewees. The LearnOncologyXROECSG podcast platform, Cancer Careers, was created to address student questions, anxieties, and excitement related to choosing an oncology career. We expect that this project will increase exposure to oncology and MS interest in oncology careers, including RO.

Lessons Learned from Multi-Institutional Medical Physics Animated Video Production

Background Medical physics education is a vital part of radiation oncology (RO) residency. However, its instruction is heterogenous across training programs. We present the results of a pilot series of high-yield videos, with special focus on lessons learned for future educational pilots. Methods The ASTRO Core Curriculum was used to choose 4 high-yield topics to cover in 5-10 minute animated videos. Scripting was done by ROs, reviewed by medical physicists, and graphics created by university broadcasting specialist; there were 8 active team members. Participants were recruited through social media and AROPC emails over the course of 1 month with aim of 80 participants. Demographic information was collected for each participant and the surveys were sent to eligible registrants sequentially, such that video 2 would be sent once survey assessment of video 1 was complete. Video evaluation was developed based off validated technology acceptance model (TAM) questionnaires composed of a series of Likert style questions. Results Creation of the four pilot videos took 7 months, with multiple iterations of scripting and storyboarding. Video cost was estimated to have been nearly 10x the quoted and agreed upon fee due to significant time needed to communicate graphic designer regarding complexities of radiation physics. Ultimately, 169 unique participants enrolled in the pilot from across the country which was 211% of the targeted cohort size. Of this cohort, 108 initiated the series and 85 completed the pilot resulting in a 78% completion rate. Videos were watched for a median duration of 6:38 out of ∼10 minutes. All participants reported the use of graphic animation improved understanding across all videos. 93% agreed with a need for additional resources geared specifically towards RO and 100% would recommend these videos to other residents. Discussion The Hi-Phy pilot series was a successful in developing videos that were effective in teaching RO physics concepts. As RO residents report a need for free and high quality standardized educational resources, it is important to learn from this experience. Medical physics education is a vital part of radiation oncology (RO) residency. However, its instruction is heterogenous across training programs. We present the results of a pilot series of high-yield videos, with special focus on lessons learned for future educational pilots. The ASTRO Core Curriculum was used to choose 4 high-yield topics to cover in 5-10 minute animated videos. Scripting was done by ROs, reviewed by medical physicists, and graphics created by university broadcasting specialist; there were 8 active team members. Participants were recruited through social media and AROPC emails over the course of 1 month with aim of 80 participants. Demographic information was collected for each participant and the surveys were sent to eligible registrants sequentially, such that video 2 would be sent once survey assessment of video 1 was complete. Video evaluation was developed based off validated technology acceptance model (TAM) questionnaires composed of a series of Likert style questions. Creation of the four pilot videos took 7 months, with multiple iterations of scripting and storyboarding. Video cost was estimated to have been nearly 10x the quoted and agreed upon fee due to significant time needed to communicate graphic designer regarding complexities of radiation physics. Ultimately, 169 unique participants enrolled in the pilot from across the country which was 211% of the targeted cohort size. Of this cohort, 108 initiated the series and 85 completed the pilot resulting in a 78% completion rate. Videos were watched for a median duration of 6:38 out of ∼10 minutes. All participants reported the use of graphic animation improved understanding across all videos. 93% agreed with a need for additional resources geared specifically towards RO and 100% would recommend these videos to other residents. The Hi-Phy pilot series was a successful in developing videos that were effective in teaching RO physics concepts. As RO residents report a need for free and high quality standardized educational resources, it is important to learn from this experience.

Preferences Amongst Radiation Oncology Residents for Virtual and In-Person Radiation Treatment Planning Review

<h3>Background</h3> Broadly, medical education e-learning is equivalent to in-person in student satisfaction, knowledge, skills, and outcomes. However, when e-learning is best used, and in what form is still being determined. For instance, e-learning with greater interactivity, practice, and feedback is associated with improved learner satisfaction and outcomes. Considering the computer-basis of radiation treatment planning, radiation oncology residents plausibly may prefer virtual treatment planning and review formats. We aimed to assess resident use of Virtual, In-Person, or a combination of Both review formats, to elicit their format preferences, and reasons for their preferences. We theorized virtual-preferring residents would endorse areas previously associated with enhanced e-learning outcomes more than in-person peers. <h3>Methods</h3> Online questionnaires were emailed to current PGY1-PGY5 residents in Canadian radiation oncology programs. Questionnaires examined level of training, typical review format, preferred format, and reasons for format preference. Chi-square tests compared differences in format preference and reasons for preference. <h3>Results</h3> 52 respondents were included for analysis; PGY1s were excluded due to limited treatment planning exposure. 76.9% of residents typically review with Both virtual and in-person formats, significantly more than 17.3% who review In-Person (p<0.0001) or 5.8% who review Virtually (p<0.0001). When asked which format they preferred, 44.2% preferred Virtual, 36.5% In-Person, and 19.2% preferred a combination of Both. Preference was significantly greater for Virtual versus Both (p=0.006) and In-Person versus Both (p=0.049). Reasons for preference were thematically grouped, reflecting focus upon Interactivity, Practice, Feedback, Convenience, and Teaching Quality. Significant differences were not found between In-Person and Virtual-preferring respondents in terms of Feedback, Interactivity, or Practice. However, significant within-group differences existed between Convenience versus Teaching Quality (Virtual-preferring: 84.3%>61%, p=0.0198; Both-preferring: 76.7%>40%, p=0.0324; In-person-preferring: 25%<63%, p=0.00214), and between Feedback versus Interactivity (Virtual-preferring: 66.7%>45.4%, p=0.0048; In Person-preferring: 59.7%>37%, p=0.00634). <h3>Discussion</h3> Our results suggest residents review contours and treatment plans with a combination of virtual and in-person formats, more than either format alone, despite low resident preference for this approach. While use of either format appears acceptable to residents, differences in emphasis on convenience with virtual-preferring and teaching quality in residents preferring in-person review suggests that educational priorities may differ between residents. Feedback more than interactivity seems important for residents irrespective of preferred format. Thus, residents and attendings should identify a format that best meets resident's educational needs and priorities. Further research should explore attending preferences.

Experience from a hypofractionation curriculum pilot: Overcoming education as a barrier to implement hypofractionation

<h3>Background</h3> Hypofractionation has equivalent oncologic outcomes to conventional fractionation, with the advantage of shortening treatment time. This is beneficial for health systems in low-to-middle income countries (LMICs); however, little is known about how to promote its adoption globally. <h3>Methods</h3> The non-profit Rayos Contra Cancer developed a hypofractionation e-learning program to pilot in Colombia, free of charge, and shared through the Colombian Association of Radiation Oncology. Two electronic surveys were distributed, one before and one after the completion of the course. Physicians were asked questions regarding their attitudes to hypofractionation. Different sections focused on clinical scenarios related to breast, prostate, rectal, and CNS gliomas, asking current practices regarding conventional fractionation, hypofractionation (15-20 fractions), and ultra-hypofractionation (5 fractions). To measure the impact of the curriculum, we categorized physicians' use of hypofractionation with a numerical score from 0 to 12 (12 = More conventional, 0=more hypofractionation). <h3>Results</h3> Across 19 cities in Colombia, 149 participants enrolled: 61 radiation oncologists, 59 medical physicists, 7 radiation oncology residents, 18 physics residents, 1 technologist, and 1 dosimetrist. 33 physicians responded both surveys. More respondents chose hypofractionation after the curriculum for all scenarios (mean "pre-curriculum" score=5.9, vs. "post-curriculum" score = 4.15, p=0.03). For breast cancer, hypofractionation use after N0 lumpectomy increased by 24.2% for older patients (51% to 75%, p=0.766) and 18.2% for younger patients (42% to 60%, p=0.00), and for locally advanced postmastectomy increased by 12.1% (76% to 85%, p=0.435). For prostate cancer, use for unfavorable intermediate-risk patients increased by 15% (67% to 82%, p=0.176), for favorable intermediate-risk by 12.1% (76% to 85%, p=0.00), and for high-risk by 12.1% (42% to 54%, p=0.52). For rectal cancer, the increase in hypofractionation for T3N1 and T4N1 mid-rectal patients was 24.2% and 21.2%, respectively. In CNS high-grade gliomas respondents increased the use of hypofractionation in older patients with poor performance status (18.2%). At baseline, education was perceived as a barrier for the use of breast (ultra-hypo/hypo), prostate (ultra-hypo/hypo), rectal, and CNS hypofractionation in 69.7%, 45.5%, 78.8%, 63.6%, respectively. These percentages decreased by 24.2%, 9.1%, 18.2% and 12.1%. When asked if the course had increased their confidence and knowledge towards hypofractionation 100% of respondents said yes. <h3>Discussion</h3> Education is a perceived barrier for the use of ultra-hypofractionation schedules in a LMIC with a bundled payment system. An E-learning approach appears to be feasible and effective at reducing the educational barrier and increasing the use of hypofractionation.

Ten-year trends in Canadian female medical student interest in radiation oncology: an analysis of data from the Canadian Resident Matching Service (2012-2021)

<h3>Background</h3> Canadian medical student (MS) interest in Radiation Oncology (RO) residency training has varied over the last decade. Concerns related to post-training job availability, employment location flexibility, and extended fellowship training may have affected MS perceptions of RO, potentially deterring past applicants. With recent job market improvements, there has been increased MS interest in the specialty. However, despite recent years showing no gender differences in successfully matching to first-choice overall nonsurgical disciplines, the number of women entering RO residency remains low. This study examines 10 years of resident match data to assess trends in gender-specific interest and match characteristics in RO. <h3>Methods</h3> Publicly available Canadian Resident Matching Service (CaRMS) data from 2012 to 2021 were compiled. Gender-based analysis focused on Canadian medical graduates (CMGs) ranking RO as their first-choice discipline in the match's first iteration. No applicant gender data were available for the 1 to 8 first-year residency positions carried over to the second iteration that occurred in 7 out of 10 matches over the study period. Pearson's chi-square test was used to evaluate whether the number of female applicants differed significantly from what could be expected if RO applicant gender breakdown reflected Canadian CaRMS participant demographics. <h3>Results</h3> Numbers of applicants ranking RO as their first-choice discipline have recently increased. 2018-2021 saw 23-28 RO-preferring applicants, while 2012-2017 saw 9-18. Total applicants ranged from 24-51 per year over the study period. Numbers of female RO-preferring applicants have remained largely unchanged, with a 10-year average of 7 women per year, ranging from 2/15 (13%) in 2016 to 12/27 (44%) RO-preferring applicants in 2018. Overall, 190 CMG applicants ranked RO as their first choice over the last 10 years, comprising 73 females (38%) and 117 males (62%). During this period, 56% (17696/31618) of CMG applicants who participated in the CaRMS match were female. ​​Rates of female applicants to RO were significantly lower compared to rates of female applicants to all specialties combined (p < 0.01). <h3>Discussion</h3> While recent years have had more RO-preferring applicants overall, numbers of RO-preferring female applicants have remained low, and disproportionately less than rates of female CaRMS participants. Findings highlight the need for greater understanding of the factors influencing female medical students' career selection and CaRMS ranking decisions to develop strategies to improve female representation in RO.

Evaluating a structured applied physics case-based course for radiation oncology and radiation physics residents

Background We supplemented applied physics textbook learning and clinic learning with case-based discussions. The purpose of this study was to review this applied physics course, in terms of structure and teaching evaluations. Methods We reviewed the 6 year applied physics teaching experience (2016-2021) in a multi-hospital site university affiliated accredited training program. A unique component of the course is the intentional inter-professional education, due to the inclusion of both radiation oncology and medical physics learners and faculty. This course ran weekly from September to May for a total of 29 weeks. All sessions were 1 hour long and case based except for 5 didactic sessions. Each session was taught by a pair of faculty members (one radiation oncologist and one medical physicist). The cases in the syllabus were reviewed yearly by teaching faculty and adjusted for updated clinical management and technological changes. A final examination was given to each trainee consisting of 3 clinical case scenarios, with written and oral questions on applied physics concepts learned throughout the course. In 2020 and 2021, during the pandemic, the applied physics course syllabus was shortened to 8 weekly video sessions (2 hour class per week) and given from April to May. Results The number of trainees who took the course ranged from 7-14 per year. Ninety-four percent of trainees passed the final exam. Trainees who did not pass the final exam were given a supplemental exam. Feedback was given to each trainee who did not pass the first exam. All trainees who did not pass the final exam, were successful in passing the supplemental exam. For the years 2016-2021, the mean and median teaching evaluation scores were 4.65 and 5 respectively, where 1 represents the worst teaching quality and 5 represents the best. In 2020-2021, due to the covid-19 pandemic, the teaching evaluations administered included 2 questions regarding the virtual format of the course. For these 2 questions relating to the virtual format of the course, the mean and median responses were 4.14 and 5 respectively. Discussion The structured syllabus of cases, case based questions and discussions were ranked highly by the trainees for teaching effectiveness. The success of this course is also dependent on faculty who demonstrate excellent teaching skills. Our experience indicated that the nature of this course was adaptable to a virtual format and could be useful for small programs without a structured applied physics curriculum. We supplemented applied physics textbook learning and clinic learning with case-based discussions. The purpose of this study was to review this applied physics course, in terms of structure and teaching evaluations. We reviewed the 6 year applied physics teaching experience (2016-2021) in a multi-hospital site university affiliated accredited training program. A unique component of the course is the intentional inter-professional education, due to the inclusion of both radiation oncology and medical physics learners and faculty. This course ran weekly from September to May for a total of 29 weeks. All sessions were 1 hour long and case based except for 5 didactic sessions. Each session was taught by a pair of faculty members (one radiation oncologist and one medical physicist). The cases in the syllabus were reviewed yearly by teaching faculty and adjusted for updated clinical management and technological changes. A final examination was given to each trainee consisting of 3 clinical case scenarios, with written and oral questions on applied physics concepts learned throughout the course. In 2020 and 2021, during the pandemic, the applied physics course syllabus was shortened to 8 weekly video sessions (2 hour class per week) and given from April to May. The number of trainees who took the course ranged from 7-14 per year. Ninety-four percent of trainees passed the final exam. Trainees who did not pass the final exam were given a supplemental exam. Feedback was given to each trainee who did not pass the first exam. All trainees who did not pass the final exam, were successful in passing the supplemental exam. For the years 2016-2021, the mean and median teaching evaluation scores were 4.65 and 5 respectively, where 1 represents the worst teaching quality and 5 represents the best. In 2020-2021, due to the covid-19 pandemic, the teaching evaluations administered included 2 questions regarding the virtual format of the course. For these 2 questions relating to the virtual format of the course, the mean and median responses were 4.14 and 5 respectively. The structured syllabus of cases, case based questions and discussions were ranked highly by the trainees for teaching effectiveness. The success of this course is also dependent on faculty who demonstrate excellent teaching skills. Our experience indicated that the nature of this course was adaptable to a virtual format and could be useful for small programs without a structured applied physics curriculum.

Measuring resident/faculty contour concordance as a potential tool for quantitative assessment of residents' performance in target volume delineation: a feasibility study

<h3>Background</h3> Accurate target delineation/contouring is essential for radiation treatment planning and the clinical efficacy of radiation therapy. Clinical trial data has demonstrated the importance of quality contouring and treatment planning for optimal survival outcomes. As a result, improving the quality of target delineation is an important goal in the education of radiation oncology residents. However, there is limited quantitative data on the quality of residents' contours. Therefore, it would be beneficial to track performance and improvement in resident target delineation during residency. The purpose of this study was to determine if it was feasible to track the concordance of radiation oncology residents' contours with faculty physicians' contours. <h3>Methods</h3> Residents were asked to contour target volumes (GTV, CTV, ITV, PTV, etc.) based on patient history, physical exam, clinical stage and fused diagnostic imaging and were allowed to use any available outside resources, including textbooks, review articles, consensus guidelines, and online atlases. Resident contours were saved as separate structures. Finalized, faculty physician-approved contours were also saved. Saved contour structures and data from October 2019 through June 2020 were reviewed for feasibility. <h3>Results</h3> In total, 209 structures had both resident and faculty versions saved within Eclipse and were available for analysis. The Boolean Operations Tool in Eclipse (Varian Medical Systems, Palo Alto, CA, USA) was used to create an intersection volume of the resident/faculty contours. Separately, the Boolean Operations Tool was used to create a union volume of the resident/faculty contours. Based on these two volumes, the Jaccard Concordance Index (JCI) was calculated by dividing the intersection volume (in cubic centimeters [cc]) by the union volume (cc). The JCI could be successfully calculated for 203 (97.1%) of the 209 structures. For 6 structures (2.9%), both the intersection and union volumes could not be calculated because the volumes were too small for Eclipse to determine. All 6 of these structures were small brain metastases. <h3>Discussion</h3> Tracking and comparing the concordance of resident contours and faculty physician contours is feasible using available tools in Eclipse. Additional data collection and assessment is necessary before this technique can be more widely utilized.

Design and implementation of a radiation oncology standardized letter of evaluation (RO-SLOE) for the evaluation of medical students and radiation oncology residency applicants

<h3>Background</h3> Prior research has shown that clerkship grades and letters of recommendation for radiation oncology residency applicants are susceptible to grade inflation and bias, both of which diminish the utility of these criteria when evaluating prospective candidates. This is especially pertinent in light of the shift of USMLE Step 1 to Pass/Fail and recent initiatives in our field to better promote diversity, equity, and inclusion. Other fields such as emergency medicine have implemented a standardized letter of evaluation (SLOE) to address these and other concerns. This project will seek to design and adopt a new radiation oncology SLOE (RO-SLOE). <h3>Methods</h3> Members of the Radiation Oncology Education Collaborative Study Group (ROECSG) Undergraduate Medical Education (UGME) working group designed a survey to assess attitudes regarding the efficacy and design of a RO-SLOE. This is conditionally approved under an educational IRB waiver and pending full IRB approval. The survey population will be members of the Association of Directors of Radiation Oncology Programs (ADROP), current residency program directors, and medical school clerkship directors. <h3>Results</h3> Our data will provide a contemporary snapshot of residency admissions practices, willingness of residency programs to consider the RO-SLOE in the admissions process and provide a framework to design novel questions for inclusion on a final RO-SLOE. We anticipate that a RO-SLOE would transparently reflect applicant's level of preparedness for residency compared to their peers, reflect institutional and evaluator grading practices, and allow for narrative feedback to qualify these objective metrics. <h3>Discussion</h3> We expect that the RO-SLOE will offer a novel, easily adaptable means to provide both actionable feedback to medical students and a standardized admissions criterion to residency programs to better discriminate between applicants. A RO-SLOE may promote greater diversity in the residency admissions process by minimizing sources of bias in clerkship evaluations and encouraging a shift to more holistic candidate review. By working with stakeholders, we hope to facilitate the RO-SLOE's incorporation into medical school clerkship evaluations and the residency application process.

Developing the Next Iteration of Radiation Oncology Milestones: How to Make Assessment More Useful for Both Residents and Faculty

Purpose Radiation Oncology Milestones 1.0 was developed in 2011 using the Accreditation Council of Graduate Medical Education's (ACGME) 6 core competencies to standardize the competency-based assessment of radiation oncology medical residents conducted by Clinical Competency Committees biannually. Critiques of Milestones 1.0 included the lack of clear progression between levels of the subcompetencies, and the complex language made it difficult to interpret by residents and faculty. The development of Milestones 2.0 aimed to simplify the language, clarify the expected progression of residents' competence, and provide supplemental resources for implementation. Methods The ACGME assembled a 9-member working group (academic radiation oncologists, residents, community members) to compose Milestones 2.0 for Radiation Oncology using a modified Delphi method consisting of multiple asynchronous small-group meetings interspersed with four web-based whole-group meetings until consensus was reached for each competency. Results Milestones 2.0 replaced disease-specific Patient Care subcompetencies (e.g., Lymphoma, Genitourinary) with those that emphasize the care delivery pathway (e.g., Consult, Simulation, Contouring and Target Delineation, Treatment Planning and Plan Evaluation, Treatment Delivery, Follow-up), restructured the Medical Knowledge competency, revised all subcompetency descriptions to chart a clear progression between levels, removed research from level 5 criteria, and provided a supplemental guide to aid implementation. Patient Care subcompetencies in Milestones 1.0 limited direct assessment of residents to specific rotations while revised subcompetencies in Milestones 2.0 can be assessed on every rotation. Level 5 in each subcompetency now reflects skills exhibited by the top 10% of residents and includes items such as "leads the multidisciplinary care team" under Consult. Previously, Medical Knowledge was an assessment of Medical Physics and Radiation/Cancer Biology. This has been modified to include Applied Sciences and Evidence-Based Foundations of Radiation Oncology with specific constructs to guide assessment. The supplemental guide gives real-life examples for each level within the subcompetencies to promote consistency in the implementation of Milestones 2.0 across residencies. The guide is designed as a living document to be tailored by programs to align with individual practices and allow for a shared mental model for faculty expectations. Discussion Milestones 2.0 builds on the foundation laid by Milestones 1.0 by aligning subcompetencies with clinical practice and represents a comprehensive approach to assessing core competencies necessary to succeed as a competent clinical radiation oncologist. The new framework will be put into practice in July 2022. Real-time feedback and additions to the supplemental guide will continue to refine and improve assessment of radiation oncology residents' clinical competence. Radiation Oncology Milestones 1.0 was developed in 2011 using the Accreditation Council of Graduate Medical Education's (ACGME) 6 core competencies to standardize the competency-based assessment of radiation oncology medical residents conducted by Clinical Competency Committees biannually. Critiques of Milestones 1.0 included the lack of clear progression between levels of the subcompetencies, and the complex language made it difficult to interpret by residents and faculty. The development of Milestones 2.0 aimed to simplify the language, clarify the expected progression of residents' competence, and provide supplemental resources for implementation. The ACGME assembled a 9-member working group (academic radiation oncologists, residents, community members) to compose Milestones 2.0 for Radiation Oncology using a modified Delphi method consisting of multiple asynchronous small-group meetings interspersed with four web-based whole-group meetings until consensus was reached for each competency. Milestones 2.0 replaced disease-specific Patient Care subcompetencies (e.g., Lymphoma, Genitourinary) with those that emphasize the care delivery pathway (e.g., Consult, Simulation, Contouring and Target Delineation, Treatment Planning and Plan Evaluation, Treatment Delivery, Follow-up), restructured the Medical Knowledge competency, revised all subcompetency descriptions to chart a clear progression between levels, removed research from level 5 criteria, and provided a supplemental guide to aid implementation. Patient Care subcompetencies in Milestones 1.0 limited direct assessment of residents to specific rotations while revised subcompetencies in Milestones 2.0 can be assessed on every rotation. Level 5 in each subcompetency now reflects skills exhibited by the top 10% of residents and includes items such as "leads the multidisciplinary care team" under Consult. Previously, Medical Knowledge was an assessment of Medical Physics and Radiation/Cancer Biology. This has been modified to include Applied Sciences and Evidence-Based Foundations of Radiation Oncology with specific constructs to guide assessment. The supplemental guide gives real-life examples for each level within the subcompetencies to promote consistency in the implementation of Milestones 2.0 across residencies. The guide is designed as a living document to be tailored by programs to align with individual practices and allow for a shared mental model for faculty expectations. Milestones 2.0 builds on the foundation laid by Milestones 1.0 by aligning subcompetencies with clinical practice and represents a comprehensive approach to assessing core competencies necessary to succeed as a competent clinical radiation oncologist. The new framework will be put into practice in July 2022. Real-time feedback and additions to the supplemental guide will continue to refine and improve assessment of radiation oncology residents' clinical competence.

Analyzing Resident Perceptions of Current Radiation Oncology Evaluation Methods

Background In an effort to facilitate positive change in radiation oncology (RO) resident evaluations, we collect and report resident familiarity and perceptions of current evaluation methods. We hypothesize familiarity with evaluation methods is predictive of the perceived utility of evaluations, stress or intimidation of evaluations, and behavioral changes. Methods A survey with Likert-scale questions was distributed to RO residents at 13 institutions. Questions assessed resident familiarity with evaluation methods, satisfaction and utility of different aspects of evaluations, stress, or intimidation of receiving evaluations, and likelihood of changing post-evaluation. Likert-type scales included: 1) not familiar=1; extremely familiar=5; 2) extremely unsatisfied=1; extremely satisfied=5; 3) strongly disagree=1; strongly agree=5; 4) extremely unlikely=1; extremely likely=5. Summary statistics are reported as (median, IQR). Regression analysis was used to analyze relationships between different variables. Results Eight of 13 programs responded to the survey with a response rate of 50% (52/104 residents). Surveyed residents reported being "not familiar" with the Next Accreditation System (1, 1-1) and "slightly familiar" with the six Core Competencies and the factors use to assess them (2, 2-3). Satisfaction with aspects of the resident evaluations was variable: frequency (3, 3-4), timeliness (3.5, 3-4), clarity of strengths or areas of improvement (4, 3-4). Overall, residents agreed that evaluations were useful in informing them of their competence, progress, strengths, and areas of improvement (median 4). Residents were neutral when asked whether they agreed with the statement, "receiving evaluations intimidates me," although 24/52 (46%) reported either "somewhat" or "strongly" agreeing with the statement (3, 2-4). Most residents agreed that receiving evaluations was stressful (4, 2-4). Additionally, residents indicated they were "very likely" to change behaviors and practices following evaluations (4, 4-5). Resident-reported familiarity with the evaluation methods was not found to be a significant predictor of the utility of evaluation methods (coefficient= -0.02, p=0.83), stress (coefficient= -0.11, p=0.62), or intimidation of receiving evaluations (coefficient= -0.06, p=0.792), or the likelihood of changing post evaluation (coefficient= 0.41, p=0.204). Discussion Familiarity with evaluation methods is not correlated with perceptions or behavioral changes necessitating further investigation of alternative predictor variables. Despite the low familiarity with evaluation tools, most residents reported that evaluations were useful and likely to elicit changes in their behaviors and practice, highlighting the value of current evaluation methods. This study is a part of a larger multi-institutional project that aims to consolidate evaluation methods across different institutions and develop interventions to improve the training process for the RO trainees. In an effort to facilitate positive change in radiation oncology (RO) resident evaluations, we collect and report resident familiarity and perceptions of current evaluation methods. We hypothesize familiarity with evaluation methods is predictive of the perceived utility of evaluations, stress or intimidation of evaluations, and behavioral changes. A survey with Likert-scale questions was distributed to RO residents at 13 institutions. Questions assessed resident familiarity with evaluation methods, satisfaction and utility of different aspects of evaluations, stress, or intimidation of receiving evaluations, and likelihood of changing post-evaluation. Likert-type scales included: 1) not familiar=1; extremely familiar=5; 2) extremely unsatisfied=1; extremely satisfied=5; 3) strongly disagree=1; strongly agree=5; 4) extremely unlikely=1; extremely likely=5. Summary statistics are reported as (median, IQR). Regression analysis was used to analyze relationships between different variables. Eight of 13 programs responded to the survey with a response rate of 50% (52/104 residents). Surveyed residents reported being "not familiar" with the Next Accreditation System (1, 1-1) and "slightly familiar" with the six Core Competencies and the factors use to assess them (2, 2-3). Satisfaction with aspects of the resident evaluations was variable: frequency (3, 3-4), timeliness (3.5, 3-4), clarity of strengths or areas of improvement (4, 3-4). Overall, residents agreed that evaluations were useful in informing them of their competence, progress, strengths, and areas of improvement (median 4). Residents were neutral when asked whether they agreed with the statement, "receiving evaluations intimidates me," although 24/52 (46%) reported either "somewhat" or "strongly" agreeing with the statement (3, 2-4). Most residents agreed that receiving evaluations was stressful (4, 2-4). Additionally, residents indicated they were "very likely" to change behaviors and practices following evaluations (4, 4-5). Resident-reported familiarity with the evaluation methods was not found to be a significant predictor of the utility of evaluation methods (coefficient= -0.02, p=0.83), stress (coefficient= -0.11, p=0.62), or intimidation of receiving evaluations (coefficient= -0.06, p=0.792), or the likelihood of changing post evaluation (coefficient= 0.41, p=0.204). Familiarity with evaluation methods is not correlated with perceptions or behavioral changes necessitating further investigation of alternative predictor variables. Despite the low familiarity with evaluation tools, most residents reported that evaluations were useful and likely to elicit changes in their behaviors and practice, highlighting the value of current evaluation methods. This study is a part of a larger multi-institutional project that aims to consolidate evaluation methods across different institutions and develop interventions to improve the training process for the RO trainees.

Progression of citation-based scholarly activity from postgraduate year one to postgraduate year two in a current resident class.

Recent work has demonstrated multiple measures of citation-based scholarly activity. Measures including Hirsch index (h-index), h-index limited to first author manuscripts (hf), h-index limited to first or second author only manuscripts (hs), and g-index have been associated with radiation oncology resident choice of academic versus private practice career. To date, there has been no evaluation of the progression of citation-based scholarly activity during residency. A list of United States radiation oncology residents from the graduating class of 2022 [postgraduate year two (PGY-2) academic year of 2018-2019] was obtained through internet investigation. Citation-based scholarly activity was collected and calculated from searches of the Scopus bibliometric citation database for h-index, hf, hs, and g-index for each resident as previously described. Calculations were derived in June 2018 for the postgraduate year one (PGY-1) year, and in June 2019 for the PGY-2 year. Fisher's exact test was used for statistical analysis. Analysis of 195 residents from the 2022 class revealed that the citation-based scholarly activity significantly increased from PGY-1 to PGY-2 for h-index (2.6 to 3.2; P=0.047) and g-index (4.0 to 5.1; P=0.045), but not for hf (1.0 to 1.3; P=0.170) or hs (1.5 to 1.9; P=0.065). Underrepresented minority race/ethnicity (African-American/Hispanic) did not impact the significance of the h-index and g-index findings. From the PGY-1 to PGY-2 academic year, residents significantly increased in citation-based academic productivity, with an increase in the proportion of residents with a cited first-or-second author manuscript. Further study is necessary to determine how this trend persists in future years.

Can We Identify Predictors of Success in Contouring Education for Radiation Oncology Trainees? An Analysis of the Anatomy and Radiology Contouring Bootcamp

PurposeAlthough several different contouring instructional programs are available to radiation oncologists and trainees, very little is known about which methods and resources benefit learners most, and whether some learners may need alternate forms of instruction. This study aimed to determine the factors that were predictors of learners’ success in anatomy, radiology, and contouring education. Methods and MaterialsParticipants in the online and face-to-face Anatomy and Radiology Contouring (ARC) Bootcamp completed pre- and postintervention evaluations that assessed anatomy/radiology knowledge, contouring skills, self-confidence, and spatial ability. Baseline factors were assessed as predictors of outcomes across multiple educational domains. ResultsOne hundred and eighty (face-to-face: n = 40; online: n = 140) participants enrolled in the ARC Bootcamp, and 57 (face-to-face: n = 30; online: n = 27) participants completed both evaluations. Of the participants enrolled, 37% were female, and most were radiation oncology residents (62%). In the anatomy/radiology knowledge testing, all quartiles (based on baseline performance) improved numerically; however, the largest improvements occurred in learners with the lowest baseline scores (P < .001). At the end of the Bootcamp, learners with lower-performing scores did not reach the level of learners with the highest baseline scores (Bonferroni-corrected P < .001). Regarding the contouring assessment, improvements were only evident for the participants with lower-performing baseline scores (P < .05). Spatial anatomy skills, as measured by the spatial anatomy task, were correlated to contouring ability. Overall, the greatest improvements were seen for learners in postgraduate year 1 to 3, those with no previous rotation experience in a given discipline, and those who attended from other programs (ie, medical physics residents and medical students). ConclusionsThe ARC Bootcamp improved all levels of performers’ anatomy and radiology knowledge but only lower-performers’ contouring ability. The course alone does not help lower-performing learners reach the abilities of higher-performers. The ARC Bootcamp tends to be most beneficial for participants with less radiation oncology experience. Curriculum modifications can be made to help support ARC Bootcamp participants with lower performing scores.

Breast cancer awareness among Afghan refugee women in Turkey.

SummaryBackground Refugees and asylum-seekers have lower levels of cancer awareness and this contributes to low rates of screening and more advanced cancers at diagnosis, compared to non-refugee populations, due largely to reduced access to medical information and care. The global Afghan refugee population is rapidly increasing with the ongoing Afghan political crisis. The present study investigates breast cancer (BC) awareness among Afghan refugee women.MethodsA cross-sectional survey of Afghan refugee women residing in Turkey was performed in September 2021. A validated BC patient awareness assessment, the Breast Cancer Awareness Measure (BCAM), was used to assess participants’ knowledge of seven domains of BC: symptoms, self-examination, ability to notice breast changes, age-related risk of BC, urgency of addressing changes in the breast, BC risk factors, and BC screening. BCAM was translated into patients’ native language and administered verbally by a physician with the assistance of an official interpreter. Routine statistical methods were employed for data analysis.FindingsA total of 430 patients were recruited to the study. The response rate was 97·7% (420 patients). The median participant age was 35 years (range: 18 to 68 years). The majority of participants (84%) had no formal education. Most participants (96%) were married, and most (95%) were not employed. Awareness of warning signs of BC was low: only seven to 18% of participants recognized 11 common warning signs of BC. Participant use of breast self-exam (BSE) was low, with 82% of participants stating they rarely or never complete BSE. Zero of 420 patients reported ever seeing a physician for a change in their breasts. Awareness of risk factors for BC was also low: only 15% of participants recognized increasing age as a risk factor for BC, and other risk factors were only recognized by four to 39% of participants.InterpretationBC awareness among Afghan refugee women is critically low. There is an urgent need to target this population for practical interventions to increase BC awareness, in addition to screening and earlier diagnosis. Evidence-based interventions include educational sessions in patients’ native language and use of BSE and clinical breast examination for screening.FundingAmerican Society for Radiation Oncology (ASTRO) – Association of Residents in Radiation Oncology (ARRO) Global Health Scholar Grant, Dana-Farber Cancer Institute Jay Harris Junior Faculty Research Grant.

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.

Educative Impact of Automatic Delineation Applied to Head and Neck Cancer Patients on Radiation Oncology Residents.

To evaluate the educational impact on radiation oncology residents in training when introducing an automatic segmentation software in head and neck cancer patients regarding organs at risk (OARs) and prophylactic cervical lymph node level (LNL) volumes. Two cases treated by exclusive intensity-modulated radiotherapy were delineated by an expert radiation oncologist and were considered as reference. Then, these cases were delineated by residents divided into two groups: group 1 (control group), experienced residents delineating manually, group 2 (experimental group), young residents on their first rotation trained with automatic delineation, delineating manually first (M -) and then after using the automatic system (M +). The delineation accuracy was assessed using the Overlap Volume (OV). Regarding the OARs, mean OV was 0.62 (SD = 0.05) for group 1, 0.56 (SD = 0.04) for group 2M - , and 0.61 (SD = 0.03) for group 2M + . Mean OV was higher in group 1 compared to group 2M - (p = 0.01). There was no OV difference between group 1 and group 2M + (p = 0.67). Mean OV was higher in the group 2M + compared to group 2M - (p < 0.003). Regarding LNL, mean OV was 0.53 (SD = 0.06) in group 1, 0.54 (SD = 0.03) in group 2M - , and 0.58 (SD = 0.04) in group 2M + . Mean OV was higher in group 2M + for 11 of the 12 analysed structures compared to group 2M - (p = 0.016). Prior use of the automatic delineation software reduced the average contouring time per case by 34 to 40%. Prior use of atlas-based automatic segmentation reduces the delineation duration, and provides reliable OARs and LNL delineations.

ASTRO's Framework for Radiopharmaceutical Therapy Curriculum Development for Trainees

In 2017, the American Society for Radiation Oncology (ASTRO) board of directors prioritized radiopharmaceutical therapy (RPT) as a leading area for new therapeutic development, and the ASTRO RPT workgroup was created. Herein, the workgroup has developed a framework for RPT curriculum development upon which education leaders can build to integrate this modality into radiation oncology resident education. Through this effort, the workgroup aims to provide a guide to ensure robust training in an emerging therapeutic area within the context of existing radiation oncology training in radiation biology, medical physics, and clinical radiation oncology. The framework first determines the core RPT knowledge required to select patients, prescribe, safely administer, and manage related adverse events. Then, it defines the most important topics for preparing residents for clinical RPT planning and delivery. This framework is designed as a tool to supplement the current training that exists for radiation oncology residents. The final document was approved by the ASTRO board of directors in the fall of 2021.

Establishing a Deaf and American Sign Language Inclusive Residency Program

Improving diversity in residency programs has been increasingly emphasized as a means to address gender, racial, and ethnic disparities in medicine. However, limited attention has been given to the potential benefits of training physicians with differences other than gender or race and ethnicity. Americans with a disability represent about 27% of the U.S. population, whereas 1%-3% of physician trainees report having a disability. In 2013, a national survey identified only 86 physicians or trainees reporting deafness or hearing loss as a disability. To date, there are no published strategies on how to create an inclusive program for Deaf trainees. Herein, the authors report on the development of a Deaf and American Sign Language (ASL) inclusive residency program that can serve as an academic model for other programs, in any medical specialty, seeking to create an accessible training program for Deaf physicians and that can be adapted for trainees with other disabilities. In March 2017, the radiation oncology residency program at Johns Hopkins University matched an ASL-signing Deaf resident who would begin the program in July 2018. In preparation, department leadership engaged key stakeholders and leaders within the university's health system and among the department faculty, residents, and staff as well as the incoming resident to create an ASL inclusive program. A 5-step transition process for the training program was ultimately developed and implemented. The authors focused on engaging the Deaf trainee and interpreters, engaging health system and departmental leadership, contracting a training consultant and developing oral and written training materials for faculty and staff, and optimizing the workspace via accommodations. Through collaborative preparation, a Deaf and ASL-signing resident was successfully integrated into the residency program. The proposed 5-step transition process provides an effective, engaging model to encourage other institutions that are seeking to employ similar inclusivity initiatives.

La phase socle en oncologie : retour d’expérience sur les trois premières années d’application de la réforme du troisième cycle

Since the establishment of the reform of medical studies' third cycle in 2017, the first two residency semesters define the "phase socle" whose objective is to provide the basic knowledge of the specialty. We have carried out a declarative survey, submitted in 2020 to all French residents in Oncology whose "phase socle" had taken place during the first 3 years of the reform. The main objectives of this survey were to evaluate the theoretical teaching of oncology as well as the practical hospital training provided during this phase. The response rate was 44% (among 355 residents, 155 answered). In terms of theoretical training, the level of satisfaction with the national teaching courses of the Collège National des Enseignants en Cancérologie and the distant learning courses on the SIDES-NG platform was considered satisfactory (average visual analog scale of 6.7/10 and 5.7/10, respectively). There was greater heterogeneity in the organization of local courses, of which only 50% of base phase residents benefited. In terms of practical training, the training value of the medical oncology and radiation oncology residencies was good (visual analogue scale 7.9/10 and 6.7/10, respectively), with educational objectives adapted to the base phase, but with a greater workload for medical oncology. This study provides feedback that shows the success of this reform in oncology. It also offers suggestions, which could be the basis to improve the formation of oncology residents.

Radiation Oncology Residency Training in Latin America: A Call to Attention

PurposeDespite the call to increase the number of radiation oncologists in Latin America, the quality, similarity, and number of residency training programs are unknown. We seek to describe the current state of residency programs in radiation oncology in Latin America. Methods and MaterialsLatin American Residents in Radiation Oncology performed a cross-sectional analysis of universities and training centers for radiation oncologists in Latin America. Latin American Residents in Radiation Oncology members identified and contacted current residents and specialists at each center to obtain information and documents that described their training curricula. ResultsAs of 2020, 13 of 23 (56.5%) Latin American countries have radiation oncology training. Seventy-three training centers were identified (59 active and 14 inactive), associated with 28 universities. On average, each active center trains 2.6 new residents per year, and in total, 156 residents are trained annually. The average length of training programs is 3.6 years. Brazil and Mexico comprise 31 (52.5%) and 7 (11.9%) of active programs, respectively, and 64 (41.8%) and 50 (32.7%) residents, respectively. Training is available in 38 cities in 13 countries, and outside Brazil and Mexico, only 13 cities in 11 countries (9 capitals and 4 noncapital cities). Individualized curriculum documents were provided by 20 (83.3%) of 24 non-Brazilian programs, while 1 standardized guideline was provided for Brazilian training programs. These demonstrated variation between subjects taught, their devoted time, outside specialty rotations, and experiences in modern techniques. Seventy-five percent include volumetric modulated arc therapy, 70% stereotactic radiosurgery, and 55% stereotactic body radiation therapy training. One-hundred percent include gynecologic brachytherapy education and <50% brachytherapy education in other disease sites. ConclusionsTraining is highly centralized in capital cities. The number of trainees is insufficient to close the current human resource divide but is limited by available job openings. Over 50% of training programs now include technological training in stereotactic radiosurgery, stereotactic body radiation therapy, or volumetric modulated arc therapy; however, substantial variation still exists. The development of radiation oncology specialists must be improved and modernized to address the escalating demand for cancer care.

A Survey to Assess and Delineate Approaches to Medical Student Outreach to Promote Diversity at Academic Radiation Oncology Programs

The aim of this study was to assess how academic radiation oncology departments engage medical students who are either female and/or from racial and ethnic demographic groups that are underrepresented in medicine. An electronic survey was sent to all 83 radiation oncology residency program directors (or if applicable medical student directors) whose department is affiliated with an on-site medical school. Questions assessed whether any faculty in the participants' department offer exposure in radiation oncology specifically to medical and premedical student groups whose members are typically women and others underrepresented in medicine, or promote the American Society for Radiation Oncology's Minority Summer Fellowship Award. Barriers to these types of involvement were also assessed. A representative from 54 out of 83 programs responded (response rate 65%). Faculty from 83% of departments had given a presentation to an oncology or radiation oncology medical student interest group. However, faculty from only 18% of departments had given a presentation to a Student National Medical Association chapter, 9% to a Latino Medical Student Association chapter, and 11% to an American Medical Women's Association chapter. Faculty from 15% of departments actively promote the Minority Summer Fellowship to the general student body, and 24% promote it to any minority students who express interest in radiation oncology. Faculty from 22% of departments had given a presentation to a premedical student group, 10% to an undergraduate student group focused on minority or female students, and 20% to a pipeline program for high school (or younger) women or other students who are underrepresented in medicine. Lack of awareness of the existence of such programs, or not being invited, were the most common barriers to participation. Most academic radiation oncology departments do not offer educational outreach specifically targeting women or minority students or promote the Minority Summer Fellowship. Further efforts are needed to break from the status quo and attract a more diverse workforce.