Applied Radiation Oncology’s latest blog covering today’s issues in oncology
Nadia Saeed, BA, is a fourth-year MD candidate at Yale School of Medicine, Class of 2022. She serves as the Medical Student Representative for Applied Radiation Oncology.
Rethinking the Preliminary Year: The Argument for an Integrated Residency in Radiation Oncology
There has been a progressive shift toward adopting an integrated residency program structure among many specialties that had traditionally required a separate internship year;1 however, this element of the radiation oncology training landscape has remained largely unchanged. Although a small number of radiation oncology programs have a linked intern year and are thus considered categorical, most begin at the PGY-2 level, requiring applicants to apply to internships separately. While the transition toward integrated internships has been gradual and largely program-dependent in many specialties, some recent examples of a consolidated effort link the PGY-1 year with advanced training. For example, the Accreditation Council for Graduate Medical Education (ACGME) has requested all ophthalmology residency programs become integrated or joint by July 2023.2 There are several potential advantages to similarly implementing a universal integrated program structure in radiation oncology.
Preliminary year training is currently heterogenous among radiation oncology residents, who have the option to complete their internship in any number of specialties including internal medicine, family medicine, surgery, obstetrics and gynecology, pediatrics, or with a transitional year.2 An integrated program structure could introduce standardization across PGY-1 training and, more importantly, could be leveraged to tailor the first year of residency toward clinical experiences considered valuable for radiation oncology. For example, surgical exposure and gross anatomy education have been identified as valuable competencies for radiation oncology but are not typically included in the standard residency curriculum.3-6 Similarly, many radiation oncology residents have reported a need for dedicated diagnostic radiology training during residency.7 A PGY-1 year tailored specifically for radiation oncology could provide the opportunity for formal education in these areas. It should be noted that a minimum of 9 months of direct patient care during the preliminary year is required by the ACGME;2 still, it is likely that many of the rotations beneficial for a career in radiation oncology (such as surgical oncology, ENT, medical oncology, etc.) would fall under this heading.
One might also consider the possibility of earlier introduction to radiation oncology during the intern year. For example, PGY-2 ophthalmology residents who completed ophthalmology training time during their internship reported greater preparedness in formulating ophthalmic diagnoses and performing the ophthalmic exam.8 The ACGME currently allows for up to 3 months of radiation oncology rotations during the preliminary year, although typically only transitional year programs include the substantial elective time needed to capitalize on this (even then, not all programs have an affiliated radiation oncology department and many also have their own requirements for how elective time can be spent).2,9 Standardizing radiation oncology exposure during the PGY-1 year may be advantageous, especially with the continued emergence of newer treatment modalities.
Additionally, completing the preliminary year at the same institution as radiation oncology residency could facilitate earlier mentorship and research opportunities. Given the longitudinal nature of clinical research, such a program structure may enhance productivity while allowing residents to explore different research interests ahead of their dedicated research blocks—something that would be particularly beneficial in residencies with less dedicated nonclinical time.10 Moreover, a linked PGY-1 year would also allow for earlier integration into the hospital system where one’s advanced training will be completed. Prior familiarity with the electronic medical record (EMR), hospital layout, and other departments and services one will be working with and consulting on would likely ease the immense transition from the PGY-1 to PGY-2 year.
It should also be highlighted that linking the intern year with advanced training would help reduce the significant financial and logistical burden associated with applying to residency. Medical students currently spend hundreds—even thousands—of dollars on residency applications;11 for students pursuing radiation oncology, this includes the cost of additional applications for separate internship programs. While the switch to virtual interviews in the wake of the COVID-19 pandemic has helped mitigate the substantial overall cost of the residency application process, the cost of the application itself should not be ignored—especially if some form of in-person interviewing eventually resumes. Reducing the overall number of applications necessary to submit would be a step closer to decreasing the significant economic barriers inherent in this process. Additionally, the cost of potentially moving twice—once for internship and again for advanced training—should be considered as well.
Some advantages to maintaining a residency structure with separate internship and advanced training are worth noting. First, while there is likely an overall benefit to introducing standardization across the PGY-1 year, the current flexibility in choice of internship type allows residents to tailor their training to align with their clinical interests. Additionally, residents may capitalize on the geographic flexibility of a non-integrated internship to explore a different region of the country or spend a year close to home or family. Moreover, many argue that a full year of internal medicine or surgery provides the opportunity to build broad clinical skills before embarking on a highly specialized career trajectory. Still, these factors should be weighed against the many educational, financial, and logistical benefits of transitioning toward an integrated program structure in radiation oncology similar to that of many other specialties.
Applications of Virtual Learning to Diversify the Radiation Oncology Workforce
Significant deficits in gender and racial/ethnic representation are well documented in the radiation oncology (RO) workforce. Females comprise less than one-third of faculty positions in RO, lagging behind other oncologic subspecialities.1 Only 3.2% of the RO trainee pool in 2016 was comprised of Black residents.2 Hispanic trainees too are significantly underrepresented in RO compared with other specialties.3 Medical students who are underrepresented in medicine (UIM) and/or female face a number of barriers to entering the field, including but not limited to insufficient or late exposure to RO, deficits in mentorship, low numbers of female and UIM role models owing to inadequate representation in the field, and interpersonal bias at many levels.4 Moreover, the substantial financial investment required for the residency application process hinders students who are economically disadvantaged from pursuing the specialty.
While a growing number of initiatives has been undertaken in recent years to advance diversity in RO, there remains a critical need for innovative solutions to address barriers to representation in the field—particularly when considering the overall decline in RO applicants in recent years.5 The COVID-19 pandemic accelerated the development of new virtual educational and professional resources in RO in response to disruptions in medical education. Looking ahead to the post-pandemic era, an essential question becomes how these resources can be used to promote female and UIM recruitment into RO to diversify the future workforce.
Virtual RO rotations are among these new resources. RO electives let students not only gain hands-on experience in the field but also obtain letters of recommendation and meet potential future mentors. UIM students are significantly less likely to attend medical schools with an affiliated RO program, hindering access to this crucial component of residency application.6 This also places even greater importance on away rotations, which may pose significant financial barriers in terms of travel and housing, creating structural inequalities in the application process. Virtual electives created during the pandemic in response to canceled away rotations may serve to reduce some of these inequities by increasing access to RO experiences. Moreover, many virtual electives are two weeks rather than the usual four weeks for in-person rotations, allowing for the possibility to rotate at more programs which may be especially valuable for those without a home RO department. These virtual electives should continue to be offered post-pandemic, in addition to providing greater financial assistance for in-person away rotations.
Virtual rotations should also be used as a springboard for formal RO clinical experiences specifically targeted toward female and UIM students to support recruitment into the field. In response to the cancelation of away rotations, an intensive virtual shadowing experience (RISE) was recently developed at two academic medical centers for fourth year UIM students, complete with a 1-week disease-specific curriculum, mentorship, and capstone experience.7 Compact two-week virtual electives can be adapted to create similar institution-specific initiatives aimed at providing comprehensive RO experiences for students underrepresented in the field; moreover, these should be offered earlier in medical school, such as the summer between first and second year, to facilitate longitudinal mentorship and research experiences.
While targeted experiences for UIM and female students are needed to diversify the applicant pool, increasing general exposure to RO in the medical school curriculum may also be beneficial.8 Currently, most medical schools do not cover radiation oncology in either the standard pre-clinical or clinical years. The condensed materials used in virtual electives—including interactive didactics, treatment planning seminars, and multidisciplinary tumor boards—may be integrated at different stages to ensure all students are aware of RO as a career option. For example, a mandatory one- or two-week oncology rotation that includes time in the RO clinic may be integrated into the clerkship year; similarly, didactics and workshops adapted from virtual RO electives could be included in the pre-clinical oncology unit to introduce the specialty early in medical school. In addition, online educational resources, which were expanded during the pandemic, improve access to foundational RO knowledge. For example, the Radiation Oncology Virtual Education Rotation (ROVER) held a series of case-based site-specific seminars for medical students in the summer of 2020.9 Such initiatives shift learning to an open-access platform, reducing some of the barriers that limit diversity in the field.
Female and UIM students also face hurdles when it comes to mentorship opportunities. Lack of access to a home RO department—as has been shown to be more common among UIM students—creates challenges in finding mentors and securing research projects. In addition, a lack of representation in the field creates a gap in female and UIM faculty available to mentor students. Since it has been shown that the gender and racial/ethnic composition of faculty affects recruitment,10 current deficits in representation in the RO workforce act to perpetuate further disparities in the field. Moreover, studies have shown that interpersonal bias by gender and race can also influence selection for mentorship opportunities in science and medicine.11-13 Amid the pandemic, new opportunities in online networking and mentorship emerged, which can be leveraged to address some of these disparities. For example, the Radiation Oncology Education Collaborative Study Group (ROECSG) organized a virtual networking session to connect third- and fourth-year medical students with residents and attendings across the country; many programs also held institution-specific meet-and-greets for prospective applicants. The Society for Women in Radiation Oncology (SWRO) began a remote mentorship program in 2018 to pair members with a mentor who is one level higher in training. More recently, ASTRO established the online program Mentor Match. These virtual initiatives should be continued post-pandemic and used to provide networking and mentorship for students from groups underrepresented in RO. These would be particularly effective during the early part of medical school to facilitate longitudinal professional relationships.
Lastly, it should be emphasized that continuing to expand the RO pipeline, such as through modified virtual resources, alone is insufficient to reduce the lack of diversity in the workforce. Further efforts are needed to support female and UIM faculty retention, identify and eliminate interpersonal bias, and promote diversity within RO leadership.14 It is critical to tackle these barriers head-on to create a future RO workforce that reflects the diverse patient population it aims to serves.